Hearing loss may affect brain health

Hearing is a complex sense that provides us with awareness of environmental sounds and, more importantly, the ability to communicate. The ear is the organ responsible for perceiving sound, but it may not be so obvious that the brain is responsible for processing the sound. It is necessary that both organs work properly for hearing to occur.

The link between hearing loss and cognition is not fully understood

In recent years, there has been extensive research examining how age-related hearing loss and brain function (cognition) are associated. There are some general concepts that might contribute to the association between hearing loss and cognition. One theory is that hearing loss leads to a decreased input to the brain, so there is less processing that occurs, which contributes to cognitive decline (a “bottom-up” approach). Another theory is that early cognitive deficits may impact a person’s ability to process sound, and thus contribute to hearing loss (a “top-down” approach). Irrespective of which theory is correct, it is clear that the association between hearing and cognition is very real. This association emphasizes the need to improve our approach to testing and treating hearing loss.

How is hearing loss measured, and what’s considered a deficit?

Most audiologists and otolaryngologists define normal hearing as someone being able to hear any level above 25 decibels. This value is somewhat liberally designated, and largely based on the average range below which most people in a population experience hearing trouble. Most clinicians who manage patients with hearing loss will admit that conventional hearing tests are imperfect, despite the important information they provide. The imperfections in conventional hearing tests are due to the fact that it is a simple measure that is trying to quantify a complex process. For example, hearing tests present simple tones and words, but hearing in real-life situations involves sentences, speech, and language, which is much more complicated to hear and would require more complicated testing to evaluate.

Researchers and clinicians who specialize in hearing loss have considered that the current standard for normal hearing may be too liberal. Additionally, research suggests there may be a role for new definitions of normal hearing that account for people who are experiencing symptoms of hearing loss, but are considered to have normal hearing by current standards. These people might be considered as having “borderline hearing loss” or “subclinical hearing loss.”

New research highlights the need to improve our approach to subclinical hearing loss

A recent article in JAMA Otolaryngology highlights this need. In this article, researchers reviewed two large population databases of 6,451 people who had had hearing and cognitive testing. The research showed that those who were 50 or older had cognitive scores that seemingly declined even before they reached clinically defined hearing loss (subclinical hearing loss). The research also noted that the association between hearing and cognition is stronger among subjects with normal hearing compared to those with hearing loss. For example, in the population they analyzed, cognition scores dropped in the normal hearing population faster than in the population with hearing loss. This result is somewhat counterintuitive, and suggests that maybe what we currently define as normal hearing may in fact include some people with hearing deficits. It also challenges what clinicians have accepted as standard classifications for hearing loss on hearing tests.

What does this mean if you are concerned about hearing loss?

First, it is worth clarifying that the new research does not in any way suggest that hearing loss is going to lead to cognitive decline. Just because these things are associated, does not mean they are causally related. Next, what these findings make clear is that it is important to have hearing tested if you notice problems with your hearing, such as challenges hearing when in social settings, requiring the radio or television at higher volumes, or constantly requiring people to repeat themselves.

The coordinated functions of the ear and the brain place a new priority on addressing hearing loss

Do not ignore symptoms of hearing loss, because you do not want to miss an opportunity to address hearing deficits. In addition, do not hesitate to ask your provider specific details about your hearing results. Often patients can be afraid to ask for details about their results because they do not want to admit that they do not understand the result, and it is important to raise concerns about your hearing even if your hearing test is normal. By taking care of your hearing, you are addressing an obvious issue (hearing loss) with not-so-obvious consequences (cognition).

Unfortunately, hearing aid use is very low despite the high incidence of hearing loss. Ask your provider about options to rehabilitate your hearing with hearing aids. Depending on the type of hearing loss you have, other options may be available to you as well, such as procedures to improve the hearing.

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Food allergy, intolerance, or sensitivity: What’s the difference, and why does it matter?

Chances are that you or someone you know has experienced unpleasant symptoms after a meal or snack. Maybe you experienced some degree of sneezing, wheezing, rashes, brain fog, joint pain, nausea, bloating, diarrhea, or another symptom. This may have led you to believe you have a food allergy — and maybe you do. But it’s also possible that you have a food intolerance, celiac disease, or a food sensitivity. This is important, because some of the reactions can range from just annoying to life-threatening.

Food intolerances

Food intolerance refers mostly to the inability to process or digest certain foods. The most common food reaction appears to be lactose intolerance. As we get older, our ability to digest dairy decreases. That’s because, with age, our intestines make less of the enzyme (lactase) that processes lactose, a type of sugar present in milk and dairy products. As a result, we have more lactose sitting in the digestive tract, which can cause stomach bloating, inflammation, and diarrhea. Research has found that only about 35% of people worldwide can digest lactose beyond the age of about seven or eight.

Lactose intolerance is not a serious disease, but it can be quite uncomfortable. Avoiding dairy products is a surefire way to avoid symptoms; some, like milk, tend to produce more severe symptoms than others, like yogurt and cheese. Over-the-counter lactase enzyme supplements can also help.

Food allergies

A more severe problem happens when someone develops a true allergic reaction, an overblown response by the body’s immune system against a seemingly harmless substance — in this case, a food. The classic example is the potentially life-threatening difficulty breathing and low blood pressure following exposure to peanuts or seafood. Food allergies can show up at any time in our lives, even during older adulthood.

If you think you may have a food allergy, consider allergy testing and treatment, especially if your symptoms are severe (significant rashes, feeling of passing out, facial swelling, and problems breathing). Scrupulously reading ingredient labels is wise. And carrying epinephrine shots in case of accidental ingestion or contact with the food in question is essential and can be lifesaving.

Celiac disease

Celiac disease affects about 1% of the Western population. In this autoimmune condition, the ingestion of gluten initiates a complex inflammatory reaction that can make people with celiac disease very sick. Celiac disease is not a true allergy; eating gluten once does not cause an immediate life-threatening problem. However, prolonged and continuous ingestion can cause diarrhea, weight loss, and malnutrition.

Avoiding gluten is the only solution to this problem. Gluten is found in a variety of grains, including wheat, rye, barley, semolina, bulgur, and farina. Many processed foods also contain gluten. People with celiac disease must also be careful about cross-contamination, when a gluten-free food comes into contact with a gluten-containing food.

Food sensitivities

After eating certain foods, a large part of the population experiences symptoms that are not related to food intolerances, food allergies, or celiac disease. These are referred to as food sensitivities. Though there is controversy around what exactly happens in the body of someone with a food sensitivity, it appears that exposure to specific foods may create an immune reaction that generates a multitude of symptoms. The symptoms are not life-threatening, but they can be quite disruptive and include joint pain, stomach pain, fatigue, rashes, and brain fog. Gluten is probably the best-known trigger of food sensitivities.

The best tool we have to identify food sensitivities is a process of careful observation and experimentation. Removing certain foods believed to cause reactions from the diet for two to four weeks, reintroducing them one by one, and watching for symptoms is the current gold standard to pin down what may be causing symptoms. This so-called “elimination diet” is not high-tech, and it is far from perfect. A physician or nutritionist can provide guidance for undertaking an elimination diet, and can help you understand limitations and avoid possible pitfalls. Removing certain foods can help stave off undesirable symptoms and improve your quality of life.

Food reactions, especially sensitivities, can also fade away with time. Our bodies, immune systems, and the gut microbiome are continually changing, and what may not sit well today may be fine to have later on in life. At some point, you may consider reintroducing small amounts of a food that you have been sensitive to, to see what you may be able to tolerate.

The bottom line

Though food reactions are common, they can be challenging to understand. Identifying the cause can be difficult and time-consuming, but it is worth the time and effort. Once you’ve identified the problem, and the food or foods that trigger it, a nutritionist or a physician can help you develop the most comprehensive diet that is safe for you.

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Are you getting enough sleep… or too much? Sleep and stroke risk

The importance of getting enough sleep has been emphasized by hundreds of studies in recent years, and we’ve covered the topic many times on this blog.

Inadequate sleep has been linked to obesity, heart disease, diabetes, high blood pressure, and other health problems. And, according to the National Highway Traffic Safety Administration, up to 72,000 car accidents and 6,000 deaths occur each year due to sleep-deprived drivers.

But what about too much sleep? Could that be bad for you, too? According to a new study, the answer may be yes.

More sleep, more strokes?

Researchers publishing in the December 11, 2019, online issue of Neurology describe an analysis of stroke risk among nearly 32,000 adults with an average age of 62. The study’s authors compared rates of stroke with study subjects’ self-reported sleep habits.

Their findings were surprising (at least to me) and included:

• Those who reported sleeping nine or more hours each night had a 23% higher risk of stroke than those sleeping less than eight hours each night.
• Stroke risk was 25% higher among those who took midday naps for at least 90 minutes compared with those napping for less than 30 minutes.

Poor sleep quality was also linked to higher stroke risk

Combinations of these factors had an even more dramatic effect on stroke risk, including an 85% higher risk among those who slept at least nine hours each night and also took midday naps for at least 90 minutes. Similarly, an 82% higher stroke risk was observed among those who slept longer at night and also reported poor sleep quality.

Does this mean too much sleep causes strokes?

If you are a person who sleeps more than nine hours each night, takes long midday naps, and feels your sleep quality is poor, these results may be troubling. But before trying to change your sleep habits, keep in mind this study did not conclude that more sleep actually causes strokes.

This study found an association between stroke risk and longer sleep, longer midday napping, or poor sleep quality. But an association is not the same as causation. Rather than longer sleep duration causing strokes, there are other possible explanations for the findings. For example, people who sleep more at night or nap more during the day may have other risk factors for stroke, such as:

• A higher incidence of depression. Excessive sleeping or poor sleep quality may be symptoms of depression, and prior studies have noted higher stroke rates among depressed individuals.
• A more sedentary lifestyle. Those who are not active may sleep or nap more and also have more cardiovascular risk factors (such as smoking or hypertension) than those who exercise regularly. Past research has noted less favorable cholesterol levels and larger waist circumference among long sleepers and nappers.
• Sleep apnea. Longer sleep duration, more napping, and poor-quality sleep may be more common among people with sleep apnea, a condition linked to an increased risk of stroke. This new study did not ask subjects about sleep disorders such as sleep apnea.

In addition, this study had weaknesses that could call its findings into question or limit its applicability. These include reliance on self-reported sleep habits and quality, and inclusion only of middle-aged and older Chinese adults without prior cancer or cardiovascular disease; the results might have been quite different if others were included in the study.

The bottom line

Sleep is a mysterious thing. It’s often unclear why some people sleep more or less than others, or why certain sleep disorders (such as insomnia or sleep apnea) affect so many people while sparing others. At a time when there’s so much media emphasis on the importance of getting enough sleep, this new study raises the possibility that more sleep may not always be a good thing. Still, we’ll need additional research on the question of whether more sleep is hazardous before making any firm recommendations to limit sleep duration.

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How safe is exercise during pregnancy?

Two lines on a home pregnancy test, a flickering heartbeat on ultrasound, and suddenly your world has changed: you’re pregnant! Regardless of where this new path takes you, you may start to examine your daily decisions in a new way as you discover an intense drive to protect the growing baby inside you. Even your exercise routines may come under scrutiny, particularly if late-night Googling has you second-guessing everything that you believed you knew.

Just how safe is exercise during pregnancy?

The short answer? Exercise during pregnancy is not only safe, it’s encouraged. An overriding principle for pregnancy is: what is good for mom is good for baby. The American College of Obstetricians and Gynecologists (ACOG) and the US Office of Disease Prevention and Health Promotion note that exercising during pregnancy may reduce

• weight gain
• risk for gestational diabetes, particularly in overweight or obese women
• risk for cesarean delivery.

Plus, it helps pregnant women prevent or manage inevitable aches and pains. Regular physical activity during pregnancy may help psychological well-being and possibly even reduce depression and anxiety during the postpartum period. Additionally, women who exercise during pregnancy may recover more quickly after the birth.

How active should you be?

Best-laid plans aside, the ACOG recommends engaging in moderate activity for 20 to 30 minutes on three to seven days per week throughout your pregnancy. It is safest to avoid exercising for longer than 45 minutes in one session to prevent hypoglycemia (low blood sugar).

The best time to boost your activity level is before you conceive. Generally, you can safely continue to exercise at the level of strenuous activity you practiced before your pregnancy. So, if you enjoyed moderate activity, stick with that rather than ramping up during your pregnancy. If you enjoyed vigorous activity, you may be able to continue this, though it’s safest to check with your obstetric team to be sure.

Of course, many women become pregnant without an established exercise routine in place. If this is true for you, start slowly and ramp up gradually. For example, try walking a few more times per week, then add to the amount of time you walk. Finally, you might step up intensity by walking more quickly.

What types of exercise can you do?

The best exercises to engage in are activities you actually enjoy doing. Pregnant women can generally do brisk walking, swimming, stationary cycling, low-impact aerobics, yoga or Pilates, and running. Most of these activities can be modified for your growing belly.

There are some activities you should avoid, including:

• contact sports that could cause injury, such as basketball, hockey, or soccer
• sports that are risky or likely to cause falls, such as skiing, surfing, or gymnastics
• scuba diving
• hot yoga or hot Pilates, because increases in body temperature might harm a fetus.

What if you have a high-risk pregnancy?

What if your pregnancy is not straightforward? High-risk pregnancies come in a variety of forms. Often, they occur when women have complex medical conditions (such as epilepsy or lupus), develop a condition that could affect the pregnancy (such as a short cervix or placenta previa), or if the fetus has a complex condition (such as a heart defect).

Usually, doctors recommend mild activity like walking or stretching, because it isn’t linked to poor outcomes, such as inadequate growth or preterm delivery. Even if you have a high-risk condition where vigorous activity is discouraged, you and your doctor can come up with an individualized plan for light, safe activities.

Although bed rest was advised in the past for certain high-risk conditions, it hasn’t been shown to improve outcomes. And unfortunately, bed rest can put you at a higher risk for blood clots, loss of bone density, and deconditioned muscles, which could further complicate your pregnancy. The mood-boosting benefits of exercise may be even more critical in high-risk pregnancies.

The bottom line

Whether you are new to exercise or a lifelong athlete, physical activity is generally safe and well tolerated in pregnancy. With rare exceptions, mild to moderate exercise offers physical and psychological benefits. If you have a high-risk pregnancy, your obstetrician can help you choose activities that will be safe for you and your baby. Pregnancy is the first step along the journey of parenthood. Let regular physical activity now become part of a lifetime of dedication to good health for your family.

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Beyond heart health: Could your statin help prevent liver cancer?

Liver cancer is hard to treat. It’s a top-five cause of cancer-related death worldwide and a growing cause of cancer-related deaths in the United States. Since liver cancer is often found at a late stage, when treatment has limited benefit, there has been increasing interest in prevention. That’s where statin medications might come in.

Liver cancer is usually caused by chronic liver disease, so an important way to prevent liver cancer is to treat the underlying trigger. For example, curing hepatitis C infection — an important cause of chronic liver disease — reduces the risk of liver cancer. However, if the liver disease has progressed to an advanced stage, the risk of liver cancer remains high even after removing the underlying cause.

Statins and liver disease: what’s the connection?

Statin medications are widely known to lower cholesterol levels and decrease the risk of cardiovascular disease. When statins first came on the market, there was great concern that statins might injure the liver. It turns out that not only are significant side effects rare, but statin medications are likely beneficial for the liver. In fact, research has shown that for people with liver disease, statins are associated with a reduced risk of liver failure, liver cancer, and death (see this study, this study, and this study).

It turns out that some statins may be better at preventing liver cancer than others. Specifically, lipophilic statins (those that dissolve more readily in lipids such as oils and fats) may be more effective for preventing liver cancer than hydrophilic statins (those that dissolve more readily in water). This suspected difference is supported by observations that lipophilic statins can more easily get into diseased liver cells, passing readily through cell walls, which are made mostly from lipids. Once inside cells, lipophilic statins may do a better job interfering with cancer formation.

Lipophilic statins include atorvastatin (Lipitor), simvastatin (Zocor), Fluvastatin (Lescol), and lovastatin (Altoprev). Hydrophilic statins include pravastatin (Pravachol) and rosuvastatin (Crestor).

Study links lipophilic statins to reduced risk of liver cancer

A recent study published in Annals of Internal Medicine took a closer look at the effect of different statin types on liver cancer risk. In the largest and most comprehensive study on the topic to date, the study researchers examined liver cancer risk over 10 years in a group of more than 16,000 adults with viral hepatitis (a possible cause of chronic liver disease). Based on records from the Swedish national registry, their results demonstrate that individuals who took a lipophilic statin (in this case atorvastatin or simvastatin) were at a significantly lower risk of developing liver cancer than those who were not taking a statin (3.3% versus 8.1%). In contrast, the study did not find a statistically significant benefit in liver cancer risk for individuals taking hydrophilic statins (rosuvastatin or pravastatin) compared to those not taking a statin. Taking either type of statin was associated with a lower risk of death compared to not taking a statin at all.

As with all studies, this one had some limitations. They include only looking at individuals from Sweden, only those with liver disease from viral hepatitis (as opposed to other causes of liver disease), and having relatively fewer data points for people taking hydrophilic statins, which might have made it harder to find a benefit.

A cause-and-effect relationship?

While a strong connection has been drawn between lipophilic statins and decreased liver cancer risk, research has not yet proven that these medications prevent liver cancer. Demonstrating a cause-and-effect relationship would require a study where people with chronic liver disease are randomized to receive either a lipophilic statin or a control medication.

It is possible that other unmeasured factors could actually account for the observed difference in cancer risk. These factors might include differences in liver disease severity, or other differences in treatment that correlate with statin prescribing patterns. However, the Annals study did demonstrate that higher doses of lipophilic statins were associated with a lower risk of liver cancer, implying a cause-and-effect relationship may indeed be present.

Weigh risks and benefits with your doctor

Further evidence is needed before recommending that individuals take statins specifically for liver disease. While there may be a benefit, there is also a small but real risk of side effects and the consideration of cost.

If you have liver disease and are planning to start a statin for cardiovascular disease, it would be worth discussing with your doctor the risks and benefits of selecting a lipophilic statin such as atorvastatin or simvastatin. In the meantime, ongoing and future studies will help to define the precise role of these medications for preventing liver cancer and the progression of liver disease.

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The new coronavirus: What we do — and don’t — know

A rapidly evolving health story broke in late December when a novel illness originating in Wuhan, China made the news. Reports of the number of infected people swiftly rose, and isolated cases of this new coronavirus — dubbed 2019-nCoV by scientists — have appeared in several countries due to international travel. At this writing, almost 1,300 confirmed cases and over 40 deaths have occurred in China, according to an article in the New York Times.

Fortunately, public health officials in many countries, including the US, have put measures in place to help prevent further spread of the virus. These measures include health screenings at major airports in the US for people traveling from Wuhan. In China, travel restrictions are in effect.

With information changing so quickly and every news report about the virus seeming to raise the stakes, you may be wondering how worried you should be. Here’s a primer on what we do — and don’t — know about this virus and what it may mean for you. While there is much we don’t yet understand about the virus, public health officials, medical experts, and scientists are working in collaboration to learn more.

What is a coronavirus?

Coronaviruses are an extremely common cause of colds and other upper respiratory infections. These viruses are zoonoses, which means they can infect certain animals and spread from one animal to another. A coronavirus can potentially spread to humans, particularly if certain mutations in the virus occur.

Chinese health authorities reported a group of cases of viral pneumonia to the World Health Organization (WHO) in late December 2019. Many of the ill people had contact with a seafood and animal market in Wuhan, a large city in eastern China, though it has since become clear that the virus can spread from person to person.

What are the symptoms of this coronavirus?

The symptoms can include a cough, possibly with a fever and shortness of breath. There are some early reports of non-respiratory symptoms, such as nausea, vomiting, or diarrhea. Many people recover within a few days. However, some people — especially the very young, elderly, or people who have a weakened immune system — may develop a more serious infection, such as bronchitis or pneumonia.

How is it treated?

Scientists are working hard to understand the virus, and Chinese health authorities have posted its full genome in international databases. Currently, there are no approved antivirals for this particular coronavirus, so treatment is supportive. For the sickest patients with this illness, specialized, aggressive care in an intensive care unit (ICU) can be lifesaving.

Should you worry about catching this virus?

Unless you’ve been in close contact with someone who has the coronavirus — which right now, typically means a traveler from Wuhan, China who actually has the virus — you’re likely to be safe. In the US, for example, only two cases of the virus have been confirmed so far, although this is likely to change.

While we don’t yet understand the particulars of how this virus spreads, coronaviruses usually spread through droplets containing large particles that typically can only be suspended in the air for three to six feet before dissipating. By contrast, measles or varicella (chickenpox) spread through smaller droplets over much greater distances. Some coronaviruses also have been found in the stool of certain individuals.

So it’s likely that coughs or sneezes from an infected person may spread the virus. It’s too early to say whether another route of transmission, fecal-oral contact, might also spread this particular virus.

Basic infectious disease principles are key to curbing the spread of this virus. Wash your hands regularly. Cover coughs and sneezes with your inner elbow. Avoid touching your eyes, nose, or mouth with your hands. Stay home from work or school if you have a fever. Stay away from people who have signs of a respiratory tract infection, such as runny nose, coughing, and sneezing.

In the US, the average person is at extremely low risk of catching this novel coronavirus. This winter, in fact, we are much more likely to get influenza B — the flu — than any other virus: one in 10 people have influenza each flu season. It’s still not too late to get a flu shot, an easy step toward avoiding the flu. If you do get the flu despite having gotten the vaccine, studies show that severe illness, hospitalization, ICU admission, and death are less likely to occur.

The bottom line

Given the current spread of this virus and the pace and complexity of international travel, the number of cases and deaths will likely to continue to climb. We should not panic, even though we are dealing with a serious and novel pathogen. Public health teams are assembling. Lessons learned from other serious viruses, such as SARS and MERS, will help. As more information becomes available, public health organizations like the Centers for Disease Control (CDC) in the US and the World Health Organization (WHO) will be sharing key information and strategies worldwide.

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Think hard before shaming children

As a parent, it’s easy to slip into shaming your child. It can happen so easily, as you blurt out what you are thinking:

“Do you really want to go out looking like that?”
“You let your teammates down during that game.”
“Why can’t you get good grades like your sister?”
“Why do you hang out at home all the time instead of going out like other kids?”
“Why are you crying? It’s not that bad.”

As we blurt out such things, we usually don’t think of them as shaming. We think of them as something that might help our child recognize a problem — and perhaps motivate them to change. We think of them as constructive criticism.

The line between criticism and shaming

The problem is that there is a fine line between criticism and shaming — and shaming is a bad idea. Here’s why:

• Sometimes children truly cannot change what is being shamed. Not everyone is a star student or athlete, we all make mistakes despite our best efforts, and some children are more sensitive or introverted than others, for example. We also can’t always change how we look, which is why fat-shaming is a terrible idea.
• Sometimes what is being shamed is part of a child’s identity. Clothing choices are a good example, especially for teens. So is how and with whom a child chooses to spend their time.
• Shaming may make children feel like they cannot change. Rather than motivating them, it may make them feel like they aren’t capable. And as a corollary and consequence…
• Shaming may make children feel bad about themselves. When the people you love the most, and whose opinion matters most, say bad things about you, it can be more than hurtful — it can affect your self-esteem in ways that can become ingrained and permanent.

How to put a stop to shaming

To prevent shaming, we need to stop and think before we speak. There are two things you should always ask yourself if you are about to criticize your child:

• Is this something they can change?
• Is it important that they change it?

Be really honest with yourself about the answers, especially to the second question. If the answer to either one is no, then it’s not something to criticize, end of story. Don’t take the risk of shaming or hurting your relationship with your child — and don’t waste your time or energy.

If the answer to both is yes, then ask yourself these questions:

• Is this a good place and time to say anything?
• Do they want to change this behavior?

Criticizing a child in public may be important, especially if they have been rude or hurtful to someone, or done something that could be unsafe. But outside of those circumstances, public criticism is shaming. It also may not be a great idea to criticize when a child is already upset, or when they are in a situation where they need to keep their composure or not be distracted; that’s less about shaming and more about being kind and effective.

If a child really doesn’t want to change a behavior, then you are going to have to think of a different way of managing it than just pointing it out. Which leads to the last and most important question:

• Is there a better way of changing this behavior?

The answer to that is most likely going to be yes.

We do best as parents when we take the time to understand why our children do what they do — and find collaborative, supportive ways to help them make safe, kind, and healthy choices. As parents, our words have power; as much as we can, we need to use that power for good.

Follow me on Twitter @drClaire

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The hype on hyaluronic acid

As dermatologists, we often hear questions from patients about ingredients in beauty and skincare products. Recently, hyaluronic acid (HA) has been hitting the shelves in a variety of products, from serums and moisturizers to sheet masks, night creams, and lip products. So what is HA? What benefits does it offer? And what are the most effective ways of using this ingredient?

What is hyaluronic acid?

HA is a humectant — a substance that retains moisture — and it is capable of binding over one thousand times its weight in water. This substance is naturally found in many areas of the human body, including the skin, eyes, and synovial fluid of the joints. HA used in beauty and skincare products is primarily made by bacteria in a lab via a process called biofermentation.

As we age, the production of key substances in the skin, including hyaluronic acid (along with collagen and elastin) decreases. As a result, our skin loses volume, hydration, and plumpness.

Lotions, potions, and injectable HA

Many skincare products containing HA claim to increase hydration within the skin. But is this true? The answer requires a closer look at the type of HA in the product. HA comes in different molecular sizes. Larger HA molecules, despite being the best at binding water and offering hydration, cannot penetrate into the skin. When applied topically (to the skin), these molecules sit on top of the skin, offering hydration only at the very surface. Smaller HA molecules, which bind less water than larger HA molecules, can penetrate deeper into the skin (though only into the epidermis, the topmost layer of skin). For maximum surface hydration, look for a product that contains HA molecules in a variety of sizes.

HA is also used in dermal fillers, many of which are composed of HA in an injectable gel form. HA fillers add volume by physically filling the area where they are placed, as well as by drawing water to enhance the filling effect. HA fillers can be used to address a multitude of cosmetic concerns, including lifting the cheeks, softening deeper folds and creases around the mouth and chin, improving the look of sunken, dark, undereye circles, hydrating and enhancing the lips, and rejuvenating the hands and earlobes.

HA hope or hype?

So is topical HA worth the hype? First, let’s establish that topical HA will never be as effective as an injectable HA filler for replacing lost volume, even though some topical HA products are misleadingly marketed as topical “fillers.” Topical HA is an excellent moisturizer. However, if the goal is to improve volume loss and laxity of the skin that naturally occurs with aging, injectable HA, rather than topical HA, is the preferred treatment method.

Topical HA has many positive attributes: it is generally well tolerated; it does not frequently cause allergic reactions or irritate sensitive skin; and it is safe to use on the skin during pregnancy and while breastfeeding.

For individuals with dry skin, or for those who crave a more dewy, moisturized feel to their skin during the cooler months, a serum or moisturizer containing HA can be a great choice. But keep in mind that topical HA will provide hydration on a surface level, not deep within the skin.

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What can you do to reduce the risk of birth defects?

You’ve done it! You’ve taken that last birth control pill, removed your IUD, or stopped using your contraceptive method of choice. You’ve made the decision to try to conceive a pregnancy, and while this is an exciting time in your life, it can also feel overwhelming. There is so much advice around fertility and pregnancy, and sifting through it all just isn’t possible. For many mothers, their goals crystallize around ensuring that their baby is healthy.

Evidence-based steps that may prevent birth defects

January is Birth Defects Prevention Month, so we want to focus on things you can do to reduce the risk of birth defects. I always encourage my patients to think about the steps they can take to make sure their baby is healthy. Scheduling a preconception visit is a good place to start. At that visit, we can review any medical problems women have, which medications they are taking, and which medications they can continue during pregnancy. While many medications are safe during pregnancy, there are others that should be stopped prior to conception, as those are known to cause birth defects. It is particularly important that women with other medical problems, such as diabetes, attend a preconception counseling visit, as having better control of their diabetes can decrease their risk of birth defects.

Get vaccinated

It is also important that women are up to date with their vaccinations, including the ones for measles, mumps, and rubella (MMR), influenza, and varicella (chicken pox, which some women may be naturally immune to if they had it as a child). Rubella exposure and infection can cause birth defects, and rarely chicken pox can develop into a severe infection in some pregnant women, as can the flu, so protecting yourself and your baby by ensuring that you are adequately vaccinated is extremely important.

Lifestyle changes can help prevent birth defects, especially taking folic acid daily

This preconception visit can also encourage women to maintain a healthy weight and lifestyle. I counsel all of my patients that they will gain weight in pregnancy, and so they should start the pregnancy at a healthy weight. I encourage regular exercise even prior to becoming pregnant, and then continuing that level of activity during pregnancy. Being at a healthy weight prior to conceiving and maintaining a healthy weight throughout pregnancy can help decrease your risk of developing diabetes or elevated blood pressure during pregnancy. Having a body mass index (BMI) of 30 or above can also increase your risk of birth defects, which is why maintaining a healthy weight is also important.

All women who are trying to get pregnant should start a daily prenatal vitamin containing at least 400mcg of folic acid, at least one month prior to attempting to conceive. Folic acid helps to decrease the risk of certain birth defects, such as neural tube defects. Another risk factor for neural tube defects is increased core body temperature in a pregnant woman, particularly during the first trimester. I recommend that all of my patients avoid hot tubs, saunas, and hot yoga, and that they treat any fever promptly with acetaminophen (which is safe during pregnancy, unlike ibuprofen).

Reduce substances that can increase the risk of birth defects

Similarly, it is important to avoid substances that increase the risk for birth defects, such as alcohol, tobacco, drugs, and retinoid medications. There is no safe limit of alcohol use during pregnancy, and while it is known that binge drinking during pregnancy increases the risk of fetal alcohol syndrome, there has been no clear definition of the amount of alcohol intake that is connected to fetal alcohol syndrome. I recommend that my patients abstain from alcohol during their pregnancies.

If you are smoking or using alcohol or other drugs, an ideal time to quit is prior to pregnancy. Planning for a pregnancy can be a powerful motivator to quit unhealthy habits, not just during pregnancy but beyond. There are many resources that can help you quit smoking, including medication and nicotine replacement. There may be clinics that specialize in recovery from drug use for pregnant women in your area; starting the conversation with your doctor will help you better understand how to ensure a safe pregnancy for you and your baby.

Doing all you can to ensure a healthy baby

Unfortunately, knowing and following these guidelines does not guarantee that your baby will not have a birth defect. Many birth defects are detected by specialized ultrasounds of the fetal anatomy, although some may not be detected until birth. At the very least, following these recommendations will help ensure that you have done all that you can to ensure a healthy pregnancy and baby.

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Is your cell phone dangerous to your health?

Have you ever been walking along while looking at your cell phone and nearly run into someone or something? If so, you’re not alone. It happens to me all the time. If I veer into another person’s path, I move aside, apologize, and promise myself I’ll be more careful. And then I return to whatever I was doing on my phone.

Maybe there’s a message in this I’m missing. That’s certainly the suggestion of a new study on head and neck injuries linked to cell phone use.

Which injuries are most likely — and where do they occur?

Using data from 100 hospitals in the US, researchers reviewed injuries to the head and neck related to cell phone use affecting more than 2,500 people over the last 20 years. Analysis of these injuries showed that:

• About 40% of these injuries occurred at home.
• A “direct mechanical injury” (such as being struck by a cell phone or an injury related to an exploding battery) accounted for 47% of cases, while use-related injuries accounted for 53%. However, this varied by age. Direct injury was much more common among those younger than age 13Injuries directly related to use (such as distraction while texting) were more common among older individuals.
• About 10% of injuries occurred while a person was driving and using a cell phone, about 7% occurred while walking, and only about 1% were reported while the user was texting.
• 94% of those who did get injured required no treatment or were treated in the ED and released. While cuts and bruises accounted for over half of these cases, 18% were more serious, including traumatic brain injury.
• The rate of these injuries has increased dramatically since 2007, when the Apple IPhone was introduced.

If the experience of these hospitals is representative of the nation as a whole, it translates to an estimated 76,000 people suffering head and neck injuries related to cell phone use over the last two decades. Even though this number is large, it’s less than two injuries per 100,000 cell phone users each year.

No study is perfect

This study may be the first to provide details regarding the relationship between cell phone use and head and neck injuries. However, it had some significant limitations. Keep in mind that the study focused on head and neck injuries. People with multiple injuries or more serious injuries (such as a heart attack or an ankle fracture) might not have been included in the count. Individuals who sought care at their doctor’s office or urgent care centers would also be excluded from this study.

In addition, information about the circumstances of an injury can be incomplete. Embarrassment or concerns about legal liability might have discouraged some from disclosing information about cell phone use when their injury occurred. Finally, information about what happened after the emergency room visit was not reported, so this study provides no insight into the long-term impact or cost of these injuries.

Some final thoughts

Cell phones are amazing. They are an instant source of information, communication, and documentation. Health apps can encourage and track healthy behaviors. GPS tracking can help parents keep their kids safe. Phoning for help in an emergency can be lifesaving.

Yet there are clearly downsides to cell phone use: distracted driving leading to automobile accidents may be the most obvious example, but as this new research shows, other injuries can be linked to cell phone use as well. There are also concerns about possible connections between cell phone use and  upper back and neck pain, as well as an increased cancer risk (an area of controversy and active research).

Perhaps cell phones should have warning labels about how to use them responsibly. Of course, this would likely just sound like common sense: put the phone away while driving, walking, running, or doing anything that requires your attention to avoid injury.

My guess is that short of legislation banning cell phone use in specific circumstances, or other major changes in our daily lives such as self-driving cars, injuries related to cell phone use will continue to rise. So, if you’re reading this post on your cell phone while walking or otherwise on the move, please put your phone away and watch where you’re going!

Follow me on Twitter @RobShmerling

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LDL cholesterol: How low can you (safely) go?

Elevated low-density lipoprotein (LDL, or “bad”) cholesterol is a clearly established risk factor for the development of cardiovascular disease (CVD). Lowering LDL with medications and/or lifestyle changes has been shown to lower CVD risk. Just how far to lower LDL, however, has remained controversial.

Current guidelines developed by the American Heart Association, American College of Cardiology, and several other professional organizations recommend lowering elevated LDL levels to 70 milligrams per deciliter (mg/dL) in people with high-risk CVD. However, recent studies have suggested that CVD risk may continue to drop as LDL is lowered beyond these targets, leading some cardiologists to believe that our current guidelines are not aggressive enough. Others are concerned that lowering LDL too much may lead to harm.

No apparent danger of very low LDL cholesterol

LDL is a key component of many hormones and all cell membranes, which allow cells to communicate with each other. Earlier studies had raised concerns that lowering LDL too far might interfere with normal cellular functions, especially in organs that have higher lipid concentrations, such as the brain and reproductive organs. And there have been reports of a slightly increased risk of osteoporosis and brain bleeding in patients treated with high doses of statin medications.

Well-known side effects in people who use statin medications include muscle aches and a slightly increased risk of diabetes, especially when high doses of medication are used. Whether these risks are due to the statin medications themselves or the lowering of LDL is not entirely clear.

However, people with rare inherited disorders in which LDL levels are extremely low (often less than 30 mg/dL) from birth appear to have normal fertility and no major organ dysfunction. Therefore, an extremely low LDL by itself does not appear to be dangerous in these unusual cases.

Study suggests lower LDL cholesterol is better

A recent meta-analysis published in JAMA Cardiology suggests that it is both safe and effective to lower LDL below 70 mg/dL. The authors reviewed a large database of CVD patients with LDL levels averaging 70 mg/dL or less at the start of the studies. On average, there was a 20% drop in CVD risk seen for every 39 mg/dL drop in LDL cholesterol. In other words, a drop in LDL from 70 mg/dL down to 31 mg/dL was associated with 20% fewer CVD events such as heart attack or stroke.

The benefit was consistent regardless of the medications used to lower cholesterol. The JAMA Cardiology meta-analysis looked at studies in which LDL was lowered with a statin drug, which works by lowering LDL production in the liver, or with a different type of medication, including ezetimibe (Zetia), which interferes with absorption of LDL from the intestine, or PCSK9 inhibitors, newer injectable medicines that increase uptake of LDL from the bloodstream into the liver. The drop in CVD risk was in line with previous studies of patients who started with LDL levels around 130 mg/dL, and saw a drop in CVD events of about 22% for every 39 mg/dL drop in LDL.

In this study, there was no increased risk of adverse outcomes (including muscle aches, liver dysfunction, new onset of diabetes, cancer, and bleeding strokes), even when LDL was lowered to as low as 20 mg/dL. Although statin medications themselves have been linked to side effects, especially at high doses, it appears that extremely low LDL concentrations are not responsible for side effects.

In other words, lowering LDL beyond our previous target of 70 mg/dL appears to be not only safe but beneficial, in patients with CVD.

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Menopause and insomnia: Could a low-GI diet help?

Sleep disturbances such as insomnia are extremely common, especially in women after menopause. According to data from the National Institutes of Health, sleep disturbance varies from 16% to 42% before menopause, from 39% to 47% during perimenopause, and from 35% to 60% after menopause.

Insomnia is a serious medical problem defined by frequent difficulty falling or staying asleep that impacts a person’s life in a negative way. Hormone changes around menopause can lead to sleep problems for many reasons, including changing sleep requirements, increased irritability, and hot flashes.

What menopausal women eat could have an impact on their risk of developing insomnia

Researchers recently looked at detailed dietary data from over 50,000 postmenopausal women (average age 63) enrolled in the Women’s Health Initiative study between 1994 and 2001. Carbohydrate intake was measured in several ways: glycemic index (GI) and glycemic load (GL), measures of added sugars, starch, total carbohydrate, and dietary fiber, and specific carbohydrate-containing foods such as whole grains, processed or refined grains, whole fruits, vegetables, and dairy products. They then looked at each participant’s risk of developing insomnia after three years of follow-up.

They found that the risk of developing insomnia was greater in women with a higher-GI diet, as well as in women who included more added sugars in their diet. Added sugars included white and brown sugar, syrups, honey, and molasses. The risk of developing insomnia was lower in women who ate more whole fruits and vegetables.

The researchers accounted for and adjusted for many potentially confounding factors, including demographic (education, income, marital status), behavioral (smoking, alcohol, caffeine intake, physical activity), psychosocial (stress, social connection), and medical factors (body mass index, various medical diagnoses, hormone therapy, snoring).

What is the glycemic index of food, and how could this affect sleep?

The glycemic index (GI) is a ranking of foods on a scale from 0 to 100 according to how much they raise blood sugar levels after eating them. I’ve written previously about planning meals with knowledge of the GI and the glycemic load of foods. High-GI foods are those that are rapidly digested, absorbed, and metabolized, and cause spikes in blood sugar and insulin levels. Some examples of high-GI foods include anything made with processed grains (bread, pasta, baked goods, white rice) and anything containing added sugars (sugary beverages, sweets).

Low-GI foods don’t cause your blood sugar and insulin levels to spike, and include plant foods such as most fruits and vegetables, legumes and beans, nuts, seeds, and whole grains. Even plant foods that have a high GI — such as bananas and watermelon — are not likely “bad” for you when eaten in moderation.

Researchers hypothesize that high-GI foods cause insomnia because of the rapid spike and then crash of blood sugar levels. Essentially, what goes up must come down, and after blood sugar and insulin levels peak, they tend to drop, which can cause a lot of symptoms, including awakening from sleep. The researchers of this new study cite multiple studies supporting this theory.

Nutrition is critical for so many aspects of our health, including sleep

Endless research connects the quality of our diet with our risk for heart disease, strokes, dementia, depression, and cancer. This new research notes that diet can also impact our risk for certain sleep problems. It’s not just about eating the obviously healthy foods, but also about avoiding the obviously unhealthy foods.

So how can you apply these findings?

In addition to practicing good sleep habits, here are some additional ways postmenopausal women can incorporate what we have learned from this study to sleep better (and be all-around healthier):

• Go for low-GI foods as much as possible. This means aiming to eat fruits and vegetables, beans and legumes, nuts and seeds, whole grains, and lean protein instead of anything made of processed grains or with added sugars. Think plain yogurt with berries and nuts instead of cereal or bagels for breakfast; a big plate of roasted vegetables and grilled salmon instead of pasta and meatballs for dinner.
• Never eat large meals close to bedtime. As a general rule, a large meal should be eaten at least three to four hours before lying down, maybe more. You do not want to go to bed with lots of food in your intestines!
• If you have to have a little something closer to bedtime, avoid sugars and processed grains. A sliced apple with a little almond butter; some blueberries and nut milk; or maybe hummus and carrots. Those are all well-balanced, plant-based snacks.

References

Insomnia: Definition, Prevalence, Etiology, and Consequences. Journal of Clinical Sleep Medicine, August 2007.

National Institutes of Health State-of-the-Science Conference Statement: management of menopausal symptoms. Annals of Internal Medicine, June 21, 2005.

High glycemic load and glycemic index diets as risk factors for insomnia: analyses from the Women’s Health Initiative. The American Journal of Clinical Nutrition, December 11, 2019.

Sleep Disorders in Postmenopausal Women. The Journal of Sleep Disorders and Therapy, August 2015.

About Glycemic index. The Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders and Charles Perkins Centre at the University of Sydney.

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Diabetic retinopathy: Understanding diabetes-related eye disease and vision loss

Over 30 million people in the United States live with diabetes, and approximately 7.7 million people have diabetic retinopathy, making it the most common cause of vision loss in working-aged adults. The prevalence of diabetic retinopathy has increased significantly over the past 20 years, due to the rise in the number of people diagnosed with diabetes.

How does diabetes affect the retina?

The retina is the light-sensing component located in the back of the eye. It is composed of blood vessels, nerve cells (neurons), and specialized cells called photoreceptors that are involved in directly sensing light. The ability of the retina to sense light requires energy, which is dependent on the oxygen supplied by blood circulating through blood vessels.

In diabetes, elevated blood sugar levels damage the blood vessels of the retina. These damaged blood vessels leak fluid, bleed, and do not provide adequate oxygen to the retina, leading to retinal ischemia. As a result, retinal cells begin to die and the retina is unable to function properly. In addition, diabetes also damages the neurons of the retina directly. Together, these effects cause diabetic retinopathy.

Vision loss associated with diabetic retinopathy may initially affect central vision due to a condition called diabetic macular edema. This swelling of the macula, a portion of the retina responsible for sharp, central vision, can lead to blurry vision and distortion of images.

Advanced diabetic retinopathy is characterized by the formation of irregular blood vessels that can bleed inside the eye, causing a rapid loss of vision. This results in a sudden, curtain-like vision loss as blood fills up the inside of the eye. Further worsening of advanced diabetic retinopathy can lead to retinal detachment, which requires urgent surgical intervention and can result in permanent, irreversible vision loss if not promptly treated.

What can I do to prevent diabetic retinopathy?

The American Diabetes Association recommends that most people with diabetes keep their A1c level (a measure of average blood sugar levels over the previous two to three months) below 7% to prevent the risk of complications. As blood glucose directly damages retinal blood vessels, there is strong epidemiological evidence that blood sugar control translates to decreased incidence and severity of diabetic retinopathy.

In order to reduce the cardiovascular and microvascular complications of diabetes, which include retinopathy, nephropathy (kidney disease), and neuropathy (nerve damage), it is recommended that people achieve and maintain a normal blood pressure. Blood pressure reduction can delay the onset of diabetic retinopathy, but it is unclear if controlling blood pressure can alter the course of established diabetic retinopathy. Similarly, managing cholesterol is advocated for overall diabetes management, but it is not clear whether doing so reduces the risk of diabetic retinopathy.

How can I find out if I have diabetic retinopathy?

An ophthalmologist can diagnose and begin to treat diabetic retinopathy before sight is affected. In general, people with type 1 diabetes should see an ophthalmologist once a year, beginning five years after the onset of their disease. People with type 2 diabetes should see an ophthalmologist for a retinal examination soon after their diagnosis, and then schedule annual exams after that. You may need to see an ophthalmologist more frequently if you are pregnant or have more advanced diabetic retinopathy.

What can I do to prevent or slow down vision loss if I have diabetic retinopathy?

As mentioned above, damage to the blood vessels deprives the retina of oxygen. Insufficient oxygen leads to production of a signal protein called vascular endothelial growth factor (VEGF). VEGF and its role in eye disease were first discovered at Harvard Medical School.

Currently, there are medications that can bind VEGF and subsequently improve the symptoms of diabetic retinopathy. These “anti-VEGF” agents are injected directly into the eye and can improve diabetic macular edema, and can even improve the severity of diabetic retinopathy. In some people, steroids injected directly into the eye may also improve diabetic macular edema. In some advanced cases of proliferative diabetic retinopathy (the most advanced form of diabetic retinopathy), patients may require retinal laser therapy or retinal surgery to stop or slow bleeding and leakage, to shrink damaged blood vessels, or to remove blood and scar tissue.

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Coming clean: Your anesthesiologist needs to know about marijuana use before surgery

Given the increasing prevalence and legalization of marijuana, many patients have come to think that marijuana use is not worth mentioning to their physicians. After all, they reason, I would not necessarily tell my doctor that I had a glass of wine last night, so why should I disclose that I smoked marijuana yesterday? Unfortunately, this reasoning is flawed. Because marijuana has a variety of effects on the body and on anesthesia medicines, it is crucial that anyone undergoing a preoperative evaluation disclose their marijuana use. Don’t worry that your anesthesiologist is judging you. That’s not our job! Our job is to understand your health and body in order to provide you with the safest and most pain-free procedure. This information is part of your confidential medical record, and accurate information is crucial to helping doctors provide good care.

Marijuana can affect the type and amount of anesthesia

The way(s) you use marijuana (smoking, edibles, etc.), how often you use, and how much all can affect how your body responds to anesthesia. Since marijuana and anesthesia both affect the central nervous system, people who use marijuana regularly may need different amounts of anesthesia medicines. In order to know which medicines and how much to use, your doctor needs to know ahead of time how much and how often you use marijuana.

Regular users of marijuana generally need larger doses of anesthesia medicines in order to achieve the same degree of sedation. If you don’t tell your anesthesiologist how much marijuana you smoke, he or she may underestimate how much anesthesia will be needed for you to “go to sleep” and stay asleep during your procedure. For example, compared to nonusers, regular marijuana users (daily to weekly) need over three times as much more propofol to achieve adequate sedation for endoscopies. That is a huge increase in dose that your doctor would want to be prepared to administer.

The higher anesthesia dose required for regular marijuana users can lead to an increased risk of complications, such as decreased blood pressure and delayed awakening from anesthesia.

Marijuana use before surgery can increase the risk of complications

Other side effects of regular marijuana use can lead to serious complications of anesthesia. Inhaled marijuana can affect your lungs and increase phlegm, coughing, wheezing, and the risk of respiratory infections. These lung issues can lead to breathing problems during your anesthetic, such as increased airway sensitivity when the breathing tube is put into or taken out of the airway. This may feel like an asthma attack, with a sensation of difficulty breathing and decreased oxygen getting into the lungs. Regular users of marijuana can also have increased postoperative pain, which leads to higher opioid use during and after surgery. This puts regular marijuana users at risk for opioid use disorder after surgery.

Don’t use marijuana the day of surgery — especially edibles

No matter how worried you are about your procedure, don’t use marijuana to relax — you may end up with your surgery rescheduled or with serious complications. Regardless of how often you usually use marijuana, anesthesiologists agree that you should skip it completely on the day of surgery. You should not smoke or inhale marijuana the day of your surgery, and certainly you should avoid any edible marijuana the day of surgery, since the American Society of Anesthesiologists’ guidelines for preoperative fasting do not allow any solid food for six to eight hours prior to anesthesia, in order to decrease the risk of food getting inhaled into your lungs. This can lead to aspiration pneumonia, a very serious complication that may cause death in some patients.

The physical effects of marijuana can increase the risk of complications, especially if consumed within an hour or two of anesthesia. Marijuana can raise your heart rate and lower your blood pressure. These changes are even more serious in patients with heart disease. In selected patient populations, this combination of decreased blood pressure and increased heart rate can cause ischemia (lack of blood supply) to the heart muscle, commonly known as a heart attack.

There are still many unknowns about marijuana

Your anesthesiologist needs accurate information about your marijuana use in order to plan safe anesthesia, and we know that no one should use marijuana on the day of surgery. Because of marijuana’s classification as a drug of abuse, we cannot do medical research on marijuana without legislation to allow that research, and this includes research about how marijuana affects surgical procedures and aspects of anesthesia. The American Society of Anesthesiologists (ASA) has urged the federal government to allow medical studies and has endorsed bills to expand research in marijuana.

Your anesthesiologist just wants to keep you safe

The ASA has a list of eight things that you should tell your physician and anesthesiologist before surgery, and the use of marijuana is one of them. Please don’t be afraid to disclose your use of marijuana to your physician, as it will not affect what we think of you. You will help us manage and adjust your anesthetic, prevent complications, and keep you as safe and healthy as possible.

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What to do when your child swears

Young children are constantly reminding parents that they pay attention. They’ll do this in surprising ways, offering up new thoughts, actions, and especially words. Sometimes the choices are funny and impressive. Other times, what comes out of the mouths of children between ages 5 and 8 is not as adorable.

Namely, they swear.

It might be one word. They may not know what it means. You may not know where they heard it. Unfortunately, unwanted language is everywhere. “You can’t prevent them from being exposed to it,” says Dr. Jacqueline Sperling, clinical psychologist and instructor at Harvard Medical School. A 2013 study found that by 8 years old, children know 54 taboo words. At that age, the most frequently used words are along the lines of “stupid” and “god.” But by 11 and 12, there’s a shift where the top two become decidedly more adult-like.

Children imitate swearing in others

“Imitation is a big part of development,” Sperling says. Children see and hear what’s said after someone stubs their toe or yells at another driver, and they decide to try it. Part of this is emulating a sibling or parent; part is attention; part is the reaction. Does it get people upset or get a laugh? The feedback can be encouraging, which is why it’s good to remain initially neutral, she says.

Home is also a safe place to get upset. That’s why children have meltdowns when they get back from school. After a day of following rules, they need to let go, says Gene Beresin, MD, executive director of the Clay Center for Young Healthy Minds at Massachusetts General Hospital and professor of psychiatry at Harvard Medical School.

How can you handle swearing?

Fortunately, children this age are becoming more socialized, particularly through school. They know that adults act in ways that kids can’t. For example, Grandpa yells expletives at the television while watching a football game. They also know that there are different rules for different places — they don’t go to school or the supermarket without their pants on. “They understand context,” Beresin says.

So, consider context. If swearing is rampant, you most likely would have heard from their teacher or principal. Still, it’s not something to encourage. Kids still need occasional reminders of rules to live by.

When you hear swearing, try these guidelines:

• Take a beat before you say anything. You don’t want to give unwanted behavior too much attention, Sperling says.
• Ask why. Then, suggests Beresin, follow up with, “What were you feeling when you said that?” You might tease out that they were angry or frustrated.
• Problem-solve together. How else could you say that? What are some mad words? What would you say if you were at school or Grandma’s house? “You’re building their repertoire. Our job of parenting is to give them tools of what to do and say in different settings,” Beresin says.
• Explain acceptable behavior. If the word was directed at someone else, clearly express that this isn’t acceptable. “It’s an assault, and we don’t assault other people with words or physically. It’s out of the question,” Beresin says. Also explain that people make mistakes and apologize for them.
• Encourage understanding through questions. How do you think that word made the person feel? How would you feel? How would it make you feel if they said sorry? It all helps build empathy. When they show empathy, praise them. Support the behavior that you want to see, Sperling says.
• Be concrete. “Younger kids don’t understand subtleties, but they understand good/bad, yes/no, that’s the way things are,” Beresin says. Keep it simple: Swearing is something that adults do. It’s done at home, not in the store, a friend’s house, or the doctor’s office. Give examples of school rules they already know to reinforce context: You don’t cut in line. You don’t get up from the lunch table. The teacher doesn’t swear.

Building blocks for future success

Along with curbing bad language, you’re creating an environment to talk about feelings and building their social and emotional learning. Beresin says it’s an area that gets neglected, even though it’s essential for future success. “People lose jobs because of social gaffes and conduct,” he says.

Your exchanges don’t have to be perfect. Kids can fumble with their language; parents can as well. It’s important that you’re modeling appropriate behavior, you apologize if you slip, and that the dialogue stays open and supportive. That consistency will help as conversations become more complex as children get older.

“We want our kids to be able to reflect and talk about their emotions and behavior, and be able to consider other’s people emotions and behavior,” says Beresin. “The earlier we start on this stuff, the better it is as a building block for their future.”

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Are polypills and population-based treatment the next big things?

Cardiovascular disease (CVD), such as heart attack and stroke, is a leading cause of death and disability in the US. High blood pressure and high cholesterol are major risk factors for CVD, and even though they are quite common and highly treatable, they tend to be undertreated. This is especially true among those who are poor or members of a minority. It’s estimated that thousands of lives could be saved each year if more people with high blood pressure and high cholesterol received treatment for these conditions.

The appeal of the polypill

One reason that high blood pressure and high cholesterol are poorly treated is that medications prescribed to treat them aren’t reliably taken as prescribed (the common medical expression for this is poor medication adherence). Among the most important reasons for this are that these conditions usually cause no symptoms, it’s hard to remember to take multiple medications or multiple doses of medications each day, medications may cause side effects, and they may be expensive.

One potential way to improve medication adherence is to combine one or more medications into a single pill, or polypill. Advantages to this approach include:

• Lower doses of each medication may be needed, possibly reducing the incidence of troublesome side effects.
• Multiple medications (in low doses) may be more effective than higher doses of a single medication.
• Fewer doses are easier to remember.
• Depending on the specific medications and doses, a polypill could be less expensive than taking several individual medications.
• Fewer pills and lower doses of medications may require fewer office visits, blood tests, and other monitoring.

Potential downsides of the polypill

While the potential advantages of a polypill are clear, they could be outweighed by their downsides, including:

• Side effects. Taking multiple medications, even at low doses, may lead to higher rates of side effects. If a side effect does occur, it may be impossible to know which of the medicines in the polypill is responsible.
• Drug interactions. When combined, medications can interact, causing serious problems such as too much or too little potency, allergic reactions, or combined side effects.
• Overtreatment. Some people need only one or two medications to treat a condition; polypills may provide more medication than is needed.
• Cost. A polypill may be more expensive than the individual medications they contain.
• Less dosing flexibility. Polypills have fixed doses of several medications, so it may not be possible to adjust the dose of one medication without adjusting them all.

A new polypill study focuses on those who might benefit the most

A recent study in the New England Journal of Medicine reported positive results for people taking a polypill to lower blood pressure and cholesterol. Researchers enrolled 303 people without known CVD but who were considered high-risk based on being members of a minority and having low income: 96% were African American and 75% had incomes less than $15,000/year. As a group, their estimated 10-year risk of CVD was estimated at 13%.

Half of the study subjects were randomly assigned to receive a polypill containing low-dose atorvastatin (to lower cholesterol) and three medications to lower blood pressure (amlodipine, losartan, and hydrochlorothiazide). The other half were randomly assigned to “usual care” (as recommended by their personal physicians) and compared to the polypill group after one year.

Those assigned to the polypill group had

• larger reductions in blood pressure
• larger drops in LDL (“bad”) cholesterol
• excellent medication adherence. 86% of study subjects faithfully took their medication as prescribed. This is much higher than is typically observed in routine practice. Part of this high adherence might have been due to a financial incentive: all study subjects received $50 for each clinic visit, and at each visit those in the polypill group knew their remaining pills would be counted to monitor adherence. Medication adherence in the usual care group was not reported.

There were no serious medication-related side effects reported in either group. The cost of the polypill was low — just $26 per study subject per month — and it was provided free or nearly free of charge to study participants. However, the cost in a non-research setting could vary based on a person’s insurance coverage, location of care, and which medications are included in the polypill.

While there were too few cardiovascular events in this one-year trial to know if the polypill could reduce them, the authors estimated that based on the observed reductions in blood pressure and cholesterol levels, treatment with the polypill could reduce cardiovascular events by 25%. Indeed, another recent study, this one published in The Lancet, found a reduction in major cardiovascular events with a different polypill (which included aspirin).

A word about population-based treatment

It’s worth emphasizing that for those receiving the polypill in the NEJM study, researchers used “population-based treatment.” That means every member of a particular (generally high-risk) population was treated regardless of their individual characteristics. This is quite different from the usual approach in which physicians make treatment recommendations based on an individual’s risk profile.

Population-based treatment may make sense for people who don’t have access to regular medical care. But it also means that certain individuals in the population may be treated for risk factors or health conditions they don’t have.

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Vaccines for women: Before conception, during pregnancy, and after a birth

The rise of vaccine-preventable illnesses, such as measles and hepatitis, in the United States and around the globe has been alarming in recent years. For women — especially those hoping to become pregnant, as well as women who are pregnant or have recently had a baby — vaccines can be a worrisome topic. There are many misconceptions about vaccine safety in and around pregnancy that can lead to confusion and unnecessary fear of a lifesaving medical tool. As a practicing ob/gyn, I often discuss vaccines with my patients and help them sort out fears versus facts.

Which vaccines should you consider before conception?

The preconception period offers a unique opportunity to find your immunization records and review them with your primary care provider. Some vaccines should be considered for all women who are hoping to conceive. Others are recommended based on additional medical issues.

Influenza: Getting your flu shot in anticipation of pregnancy will help protect you during flu season. Flu shots are generally available each year from late August through March, to correspond with the influenza season (though timing may vary by region). You can get a flu shot at your doctor’s office or at many pharmacies. If you could be pregnant, ask for the inactivated influenza vaccine. The nasally administered live vaccine (LAIV, Flumist) is not recommended for women who may be pregnant, although children in your home can safely have this version of the vaccine.

Measles, mumps, and rubella (MMR): Given the ongoing global measles outbreak, the Centers for Disease Control and Prevention (CDC) and American College of Obstetrics and Gynecology (ACOG) recommend assessing measles immunity before a woman becomes pregnant. Your doctor can review your immunization record with you and determine if you have had an adequate number of MMR vaccines. If not, or if you cannot find your immunization record, your doctor can order a blood test to evaluate your immunity and give you a booster shot if needed.

The MMR booster shot is a live-attenuated (weakened) virus vaccine. After a woman receives it, the CDC recommends waiting four weeks before attempting pregnancy because of theoretical risks to the fetus with live vaccines. However, if a pregnancy occurs within the four-week window, do not worry! This recommendation is based on theoretical risks. In fact, there have been no reports of harm to a fetus due to this type of exposure.

Varicella zoster virus (VZV): Many women of childbearing age have either had chickenpox (varicella) or received the vaccine during childhood. Because chickenpox can harm a pregnant woman and her fetus, assessing your immunity to chickenpox is a good idea before conceiving. If you’re not immune, this is a good time to have the vaccine. Similar to the MMR booster, the VZV vaccine is a live-attenuated virus vaccine. A woman should have this vaccine at least four weeks before attempting to conceive, due to the theoretical concern for fetal exposure.

Human papillomavirus (HPV): This vaccine helps prevent new HPV infections and HPV-associated diseases, including cervical cancer. It is recommended for teens and people through age 26, but those ages 27 through 45 years may also benefit. Discuss this with your doctor. While the HPV vaccine is not recommended during pregnancy, inadvertently getting it during pregnancy is not associated with harm for you or your baby.

Additional vaccines to consider: Your doctor can tell you whether it’s especially important for you to consider the hepatitis A, hepatitis B, and pneumococcal vaccines based on health issues, lifestyle, or travel plans that could put you at higher risk.

Which vaccines should you have during pregnancy?

During every pregnancy, the ACOG recommends:

• An influenza vaccine during flu season. This can protect women from severe medical and obstetrical complications, and provide protection for babies during early infancy. It can be safely given any time during pregnancy.
• A tetanus, diphtheria, and pertussis (Tdap) vaccine, given during the third trimester. This protects against pertussis (whooping cough) in pregnant women who might pass it to their babies during delivery, and also protects babies during early infancy when pertussis can be life-threatening. Additionally, Tdap is recommended for anyone who has not received the vaccine and will be in close contact with infants less than a year old, such as grandparents or childcare providers.

Additional vaccines to consider: Hepatitis A, Hepatitis B, and pneumococcal vaccines are recommended if you have certain risk factors, or are midway through a vaccine series that was started before you conceived. Ask your doctor about whether you would benefit from any of these vaccines.

What about vaccines after a birth or if you’re breastfeeding?

If your doctor told you during your pregnancy that you did not have immunity to rubella, measles, or chickenpox, you should receive these vaccines to help protect yourself and your baby. There is no concern about breastfeeding.

If you haven’t had the HPV vaccine, you should start the series if

• you are 26 or younger
• you are over 26 and at risk for HPV exposure.

Finally, ask your doctor if you should consider having hepatitis A, hepatitis B, and pneumococcal vaccines. These are recommended for women with certain risk factors.

What are some myths about vaccines?

Social media and well-meaning friends may spread misconceptions about vaccine safety and efficacy. Below are the most common myths.

• The flu shot makes me sick. While some patients may feel achy or fatigued after the flu shot, this is a sign that your immune system is working in response to the vaccine. Because the flu vaccine is made from a killed virus, you can‘t get the flu from the vaccine.
• I’m young and healthy, so I never get the flu shot. Even healthy pregnant women can become severely ill and die from influenza infection.
• Vaccines cause autism. Many studies have been conducted reviewing mercury (thimerosal), vaccines, and autism. No study has ever shown a positive relationship between vaccines, mercury, and subsequent autism diagnosis.
• Vaccines pose a risk to my unborn baby. Vaccines recommended in pregnancy have proven to be safe in all trimesters. Since 2004 the CDC and ACOG have recommended vaccinations such as influenza during any trimester.
• Vaccines in the first trimester will cause miscarriage. Vaccines such as influenza have been given to millions of pregnant women over decades. No relationship has been shown between influenza vaccination and birth defects and miscarriage.
• I can get my Tdap after the birth. This will not effectively protect your newborn from pertussis. Vaccination during pregnancy gives newborns passive immunity, which protects them from pertussis until they are able to get their vaccination at 2 months.

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What are ultra-processed foods and are they bad for our health?

You hear it all the time: the advice to “eat less processed food.” But what is processed food? For that matter, what is minimally processed food or ultra-processed food? And how do processed foods affect our health?

What are processed and ultra-processed foods?

Unprocessed or minimally processed foods are whole foods in which the vitamins and nutrients are still intact. The food is in its natural (or nearly natural) state. These foods may be minimally altered by removal of inedible parts, drying, crushing, roasting, boiling, freezing, or pasteurization, to make them suitable to store and safe to consume. Unprocessed or minimally processed foods would include carrots, apples, raw chicken, melon, and raw, unsalted nuts.

Processing changes a food from its natural state. Processed foods are essentially made by adding salt, oil, sugar, or other substances. Examples include canned fish or canned vegetables, fruits in syrup, and freshly made breads. Most processed foods have two or three ingredients.

Some foods are highly processed or ultra-processed. They most likely have many added ingredients such as sugar, salt, fat, and artificial colors or preservatives. Ultra-processed foods are made mostly from substances extracted from foods, such as fats, starches, added sugars, and hydrogenated fats. They may also contain additives like artificial colors and flavors or stabilizers. Examples of these foods are frozen meals, soft drinks, hot dogs and cold cuts, fast food, packaged cookies, cakes, and salty snacks.

According to a study published in The BMJ, ultra-processed foods are the main source (nearly 58%) of calories eaten in the US, and contribute almost 90% of the energy we get from added sugars.

How do processed foods affect our health?

A recent study published in the journal Cell Metabolism compared the effects of an ultra-processed diet to the effects of an unprocessed diet on calorie intake and weight gain. The study involved 20 heathy, overweight adults staying at a medical facility. Each study participant received an ultra-processed diet and an unprocessed diet for 14 days each. During each diet phase, the study subjects were presented with three daily meals and were instructed to consume as much or as little as desired. Up to 60 minutes was allotted to consume each meal, with snacks (either ultra-processed or unprocessed, depending on the study phase) available throughout the day.

The meals were matched across the diets for total calories, fat, carbohydrate, protein, fiber, sugars, and sodium. The big difference was the source of calories: in the ultra-processed diet phase, 83.5% of calories came from ultra-processed food; in the unprocessed diet phase, 83.3% of calories came from unprocessed foods.

The researchers found that study subjects consumed about 500 more calories per day on the ultra-processed diet versus the unprocessed diet. The ultra-processed diet period was marked by an increased intake of carbohydrate and fat, but not protein. Participants gained on average two pounds during the ultra-processed diet phase, and lost two pounds during the unprocessed diet phase. The authors concluded that limiting ultra-processed foods may be an effective strategy for preventing and treating obesity.

The study did have several limitations. For one thing, with only 20 participants, this was a very small study. For another, there was significant variation in individual responses to the two diets. Eleven people gained extreme weight on the ultra-processed diet — as much as 13 pounds over 14 days — while a few participants saw no weight gain. It’s also unclear how generalizable the results are to a wider population, because the study did not include people with chronic diseases such as heart disease or diabetes. In addition, the study was done in a clinical research setting, which could have affected their eating behavior (the study subjects may have been more isolated and bored than in their natural environments).

Another study, this one published in The BMJ, examined representative dietary records of more than 100,000 French adults over a five-year period. They found that those who consumed more ultra-processed foods had higher risks of cardiovascular disease, coronary heart disease, and cerebrovascular disease. These results remained statistically significant even after the researchers adjusted for the nutritional quality of the diet (considering factors such as the amount saturated fat, sodium, sugar, and dietary fiber in the diets). Although large observational studies do not prove cause and effect, the research does suggest an association between ultra-processed diets and heart disease.

Learn to identify processed foods

Whenever possible, try to avoid or limit ultra-processed foods. Consider the examples in this table to help you quickly determine if a food is minimally processed, processed, or ultra-processed.

Minimally processed	Processed	Ultra-processed
Corn	Canned corn	Corn chips
Apple	Apple juice	Apple pie
Potato	Baked potato	French fries
Carrot	Carrot juice	Carrot cake
Wheat	Flour	Cookies

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