The role of our minds in the avoidance of falls

A few years ago, my grandmother suffered a fall and broke her hip. She has never fully recovered and is now constantly fearful of falling, and has significantly limited her activities to prevent a fall from ever happening again. As a scientist focused on translational research in mobility and falls in older adults, of course I asked her how she fell. She stated that she was standing in the kitchen and reading a recipe when the phone rang. When she turned and started to walk over to the phone, her feet “weren’t in the right spot.” She fell sideways and unfortunately, her hip was unable to absorb the impact without breaking.

For older adults, falls are a leading cause of hip and wrist fractures, concussions, mobility disability, loss of independence, and even death. As it turns out, the circumstances leading up to my grandmother’s fall were typical. In fact, the majority of falls occur when an individual is “dual-tasking;” that is, standing or walking while at the same time performing a separate cognitive task (such as reading), a motor task (carrying groceries), or both (walking while talking and carrying a cup of coffee).

Why does dual-tasking (or multitasking) often lead to falls in older adults?

It turns out that the seemingly simple acts of standing upright, or walking down an empty, well-lit hallway, are quite complex. To complete these tasks, we must continuously stabilize our body’s center of mass — a point located just behind our sternum — over the relatively small base of support that we create by positioning our feet on the ground. This control requires quick reflexes, as well as strong muscles of the trunk, hips, legs, ankles, and toes. However, to avoid falling we also need to pay attention to our body and environment, predict and perceive unsafe movements of our body, and adjust accordingly. Our brains need to quickly make sense of information coming from our eyes, ears, and bodies to produce patterns of muscle activity that appropriately adjust our body’s position within the environment.

Therefore, tasks of standing and walking are in fact cognitive tasks, and these tasks require more and more cognitive effort as we grow older and our senses and muscles no longer work as well as they once did. For my grandmother and many others, dual-tasking led to a fall because it diverted shared cognitive resources away from the critical job of controlling her body’s center of mass over her feet on the ground.

The role of our minds in the avoidance of falls is striking

Older adults who are cognitively impaired are more than two times as likely to fall compared to those who are cognitively intact. A recent study by researchers at the Albert Einstein College of Medicine has shown that even subtle differences in the brain’s ability to dual-task when walking are predictive of future falls in healthy older adults. Specifically, the researchers asked their volunteers to walk while completing a word-generation task in their laboratory, and used a technology called functional near-infrared spectroscopy to measure brain activity. Those volunteers who required more brain activity (mental effort) to complete these tasks were more likely to fall during a four-year follow-up period.

Thankfully, these startling studies have a silver lining: they suggest that cognitive function is a promising — and largely untapped — target for the prevention and rehabilitation of falls. In fact, there are several large-scale clinical trials currently underway that are testing the effects of computer-based cognitive training on balance, mobility, and falls in older adults (see here and here). There is also strong evidence that a physical therapy program that asks patients to balance while completing cognitive tasks like counting backwards significantly reduces the incidence of falls in stroke survivors.

It seems like only a matter of time before cognitive and dual-task training become mainstays of fall prevention programming in older adults. In the meantime, if you are worried about falling, or feel like your balance is slipping, you might consider the following:

• Be aware of your surroundings. Try to minimize distractions if and when you find yourself standing in a crowded room, walking down an uneven sidewalk, or in a hurry to get to an appointment. In these situations, avoid answering your cellphone, keep conversations light, and prioritize your balance above all else.
• Keep your mind sharp. Cognitive decline is not an unavoidable consequence of aging. There are evidence-based tips for maximizing your mental abilities into older age.
• Consider joining a group activity class focused on tai chi, yoga, or dance. These safe mind-body exercises have proven effective for improving balance and even reducing falls in numerous populations of older adults.
• Remember that falls rarely occur due to a single factor, like poor muscle strength, fatigue, or reduced vision. Instead, they usually occur when multiple factors combine to cause an irrecoverable loss of balance. Multifactorial strategies therefore appear to be the best “medicine” for the avoidance of falls over time.

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What’s new with the Nutrition Facts label?

The Nutrition Labeling and Education Act of 1990 (NLEA) mandated nutrition labeling on most packaged foods. These include canned and frozen foods, breads, cereals, desserts, snacks, beverages, and a variety of other foods that line the aisles of grocery stores. Food labels — officially called Nutrition Facts labels — are intended to help consumers choose healthy foods. It is the FDA’s responsibility to make sure that foods are properly labeled.

Over the years there have been many changes to the initial law, and to the label. The newest version of the food label rolled out on January 1, 2020 for larger food manufacturers; smaller manufacturers have until January 1, 2021 to introduce the new labels.

Here’s a rundown of features you’ll encounter on the new food labels.

Serving size

The new food label shows “servings per container” and “serving size” in a larger font size and a bolder type. Per the NLEA, serving sizes must be based on the Reference Amounts Customarily Consumed (RACCs) — that is, the amounts that people are actually eating, not what recommendations suggest they should be eating. The amounts that people eat and drink have changed since 1993, when the previous serving size requirements were published. For example, in 1993 the reference amount used for a serving of soda was 8 ounces; it will now be 12 ounces. A serving of ice cream has also increased, from 1/2 cup to 2/3 cup.

For packages that are between one and two servings, such as a 15-ounce can of soup, the label will now treat the package as a single serving, since people usually consume it at one time.

Certain foods and beverages that are larger than a single serving but could be eaten in one sitting will now display two columns: one showing calories and other nutrients per serving, the other showing the same information for the entire package.

Calories

Calories will now be displayed much more prominently on the label. But you’ll no longer see “calories from fat” on the food label, since research has shown that the type of fat in a food is more important than the amount of fat.

Added sugars

One of the biggest changes is that the new food labels will specify the amount of added sugar — sugars that are added during food processing. Added sugars are a bigger concern than natural sugars, which occur naturally in all foods that contain carbohydrates, including fruits and vegetables, grains, and dairy products.

Research shows that it is difficult to meet nutritional needs while staying within calorie limits if you consume more than 10% of your total daily calories from added sugar (added sugars will appear on the label in both grams and percent daily value). Too much added sugar can also lead to weight gain and other health problems, including diabetes and heart disease.

Dietary fiber

The FDA definition of fiber, which is used as a guideline for what appears on food labels, includes both naturally occurring fibers and fibers added to foods that show a physiological health benefit. Fiber is naturally present in vegetables, whole grains, fruits, cereal bran, flaked cereal, and flours. In addition, some nondigestible carbohydrates that are added to food also meet the FDA’s definition of dietary fiber, and are accounted for in the dietary fiber value on the new food label.

Nutrients and daily values

The list of nutrients that appear on the food label has been updated. Vitamin D and potassium will now be required; vitamins A and C will no longer be required, since deficiencies of these vitamins are rare today. Calcium and iron will continue to be required. Manufacturers must declare the actual amount, in addition to percent daily value, of vitamin D, calcium, iron, and potassium. In the old food label, manufacturers only needed to include percent daily value of these nutrients.

Daily values are reference amount of nutrients to consume or not to exceed, and are used to calculate the daily value percentages on the label. This can help the consumer use the nutrition information in the context of a total daily diet. They are based on 2,000 calories, which is a reference number of calories for general advice. Individuals may need less or more than 2,000 calories per day depending upon their specific needs.

The daily values for nutrients like fiber, sodium, vitamin D, and potassium have all been updated based on the most recent research from the Institute of Medicine, and the 2015 Dietary Guidelines Advisory Committee Report used in the development of the 2015–2020 Dietary Guidelines for Americans.

With its more realistic measure of serving size and emphasis on calories and added sugars, the new food label has the potential to help consumers make healthier food choices.

Source: FDA

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As coronavirus spreads, many questions and some answers

The rapid spread of COVID-19 has sparked alarm worldwide. The World Health Organization (WHO) has declared a global health emergency, and many countries are grappling with a rise in confirmed cases. In the US, the Centers for Disease Control and Prevention (CDC) is advising people to be prepared for disruptions to daily life that will be necessary if the virus spreads within communities.

Below, we’re responding to a number of questions about COVID-19 raised by Harvard Health Blog readers. We hope to add further questions and update answers as reliable information becomes available.

Does the virus spread person-to-person?

What is the incubation period for the virus?

What are the symptoms?

Can people who are asymptomatic spread the virus?

Can the virus live on fabric, carpet, and other soft surfaces? What about hard surfaces?

Should I wear a face mask? Should my children?

Should someone who is immunocompromised wear a face mask?

Should I accept packages from China?

an I catch the virus by eating food prepared by others?

Should I travel on a plane with my children?

Is there a vaccine available?

Is there a treatment available?

How is this virus confirmed?

How deadly is COVID-19?

What should people do if they think they have the virus or their child does? Go to an urgent care clinic? Go to the ER?

Can people who recover from the virus still be carriers and therefore spread it?

Does the virus spread person-to-person?

Yes, the virus can spread from one person to another, most likely through droplets of saliva or mucus carried in the air for up to six feet or so when an infected person coughs or sneezes, or through viral particles transferred when shaking hands or sharing a drink with someone who has the virus.

Often it’s obvious if a person is ill, but there have been some cases where people who did not yet feel sick had the virus and could spread it.

Basic steps for avoiding flu and other infections—including steps for handwashing shown in this video—are likely to help stop the spread of this virus. The CDC has a helpful list of preventive steps.

Quarantines and travel restrictions now in place in many counties, including the US, are also intended to help break the chain of transmission. Public health authorities like the CDC may recommend other approaches for people who may have been exposed to the virus, including isolation at home and symptom monitoring for a period of time (usually 14 days), depending on level of risk for exposure. The CDC has guidelines for people who have the virus to help with recovery and prevent others from getting sick.

What is the incubation period for the virus?

An incubation period is the time between catching an illness and showing symptoms of the illness. Current estimates suggest that symptoms of COVID-19 usually appear within around five days or less in most cases, but the range could be between one and 14 days.

What are the symptoms?

Fever, dry cough, trouble breathing, and sometimes pneumonia are the common symptoms of COVID-19. There have been some reports of gastrointestinal symptoms (nausea, vomiting, or diarrhea) before respiratory symptoms occur, but this is largely a respiratory virus.

Those who have the virus may have no obvious symptoms (be asymptomatic) or symptoms ranging from mild to severe. In some cases, the virus is life-threatening or fatal.

Currently, it seems that most people who get sick will recover from COVID-19. Recovery time varies and, for people who are not severely ill, may be similar to the aftermath of a flulike illness. People with mild symptoms may recover within a few days. People who have pneumonia may take longer to recover (days to weeks). In cases of severe, life-threatening illness, it may take months for a person to recover, or the person may die.

Can people who are asymptomatic spread the virus?

A person who is asymptomatic may be shedding the virus and could make others ill. How often asymptomatic transmission is occurring is unclear.

Can the virus live on fabric, carpet, and other soft surfaces? What about hard surfaces?

Currently, there’s no evidence that the virus can be transmitted from soft surfaces like fabric or carpet to humans.

It’s possible that the virus could be on frequently-touched surfaces, such as a doorknob, although early information suggests viral particles would be likely to survive for just a few hours, according to the WHO. This also assumes that someone who is sick with the virus has touched a surface after sneezing or coughing into their hand or rubbing their eye. That’s why personal preventive steps like frequently washing hands with soap and water or an alcohol-based hand sanitizer, and wiping down often-touched surfaces with disinfectants or a household cleaning spray, are a good idea.

Should I wear a face mask? Should my children?

Follow public health recommendations where you live. Currently, face masks are not recommended for the general public in the US. Your risk of catching the virus in the US is likely to be low, since there is little evidence of community transmission at this time. At this writing, only one confirmed case in the US is unrelated to travel to China or close contact with travelers from China.  Even though there are some confirmed cases of COVID-19 in the US, you’re much more likely to catch and spread influenza (the flu). (So far this season, there have been nearly 30 million cases of flu and 17,000 deaths.)

Some health facilities require people to wear a mask under certain circumstances, such as if they have traveled from the city of Wuhan, China or surrounding Hubei Province, or have been in contact with people who did or with people who have confirmed coronavirus.

If you have respiratory symptoms like coughing or sneezing, experts recommend wearing a mask to protect others. This may help contain droplets containing any type of virus, including the flu, and protect close contacts (anyone within three to six feet of the infected person).

The CDC offers more information about masks. The WHO offers videos and illustrations on when and how to use a mask.

Should someone who is immunocompromised wear a mask?

If you are immunocompromised because of an illness or treatment, talk to your doctor about whether wearing a mask is helpful for you in some situations. We are currently in the middle of a flu epidemic in the US. By contrast, we have limited cases of COVID-19 and no evidence of sustained person-to-person transmission in our communities. At this time, it wouldn’t make sense for someone who is immunocompromised to wear a mask when in public to decrease risk for catching COVID-19. However, if your healthcare provider advises you to wear a mask when in public areas because you have a particularly vulnerable immune system, follow that advice. But if masking has not been recommended to you to protect against the flu and numerous other respiratory viruses, then it doesn’t make sense to me to advise wearing a mask to protect against COVID-19 at this time.

Should I accept packages from China?

There is no reason to suspect that packages from China harbor COVID-19. Remember, this is a respiratory virus similar to the flu. We don’t stop receiving packages from China during their flu season. We should follow that same logic for this novel pathogen.

Can I catch the virus by eating food prepared by others?

We are still learning about transmission of COVID-19. It’s not clear if this is possible, but if so it would be more likely to be the exception than the rule. That said, COVID-19 and other coronaviruses have been detected in the stool of certain patients, so we currently cannot rule out the possibility of occasional transmission from infected food handlers. The virus would likely be killed by cooking the food.

Should I travel on a plane with my children?

Keep abreast of travel advisories from regulatory agencies and understand that this is a rapidly changing situation. At this writing, most travel throughout the world is unrestricted (exceptions include China and now South Korea). I recently flew with my son and his friend and did not bring any type of masks.

Of course, if anyone has a fever and respiratory symptoms, that person should not fly if at all possible, but anyone who has a fever and respiratory symptoms and flies anyway should wear a mask on an airplane.

Is there a vaccine available?

No vaccine is available, although scientists are working on vaccines. In 2003, scientists tried to develop a vaccine to prevent SARS but the epidemic ended before the vaccine could enter clinical trials.

Is there a treatment available?

Currently there is no specific antiviral treatment for COVID-19. Treatment is therefore supportive, which means giving fluids, medicine to reduce fever, and, in severe cases, supplemental oxygen. People who become critically ill from COVID-19 may need a respirator to help them breathe. Bacterial infection can complicate this viral infection. Patients may require antibiotics in cases of bacterial pneumonia as well as COVID-19.

Antiviral treatments used for HIV and other compounds are being investigated.

There’s no evidence that supplements, such as vitamin C, or probiotics will help speed recovery.

How is this virus confirmed?

A specialized test must be done to confirm that a person has COVID-19. Most testing in the US has been performed at the CDC. However, the goal is to send test kits to state laboratories so testing can be performed locally.

How deadly is COVID-19?

We don’t yet know. However, signs suggest that many people may have had mild cases of the virus and recovered without special treatment.

Very early in this epidemic, it looked like about 20% of cases were severe. People developed acute respiratory distress syndrome (ARDS), which causes tiny air sacs in the lungs to fill with fluid, crowding out air so that not enough oxygen can reach the bloodstream.

As of February 25, 2020, the reported confirmed cases and deaths in China suggest the mortality rate is roughly 3%. It is important to remember that early on in an epidemic there is a “tip of the iceberg” phenomenon where we overestimate more severe cases and mild or asymptomatic cases go unrecognized, so the mortality seems higher than the reality. That may be happening when we speak of up to 3% mortality. By contrast, SARS had a mortality rate of around 10%; the MERS mortality rate is closer to 30% to 40%. There appear to be many more COVID-19 cases confirmed than there were with SARS and MERS.

What should people do if they think they have the virus or their child does? Go to an urgent care clinic? Go to the ER?

If you have a health care provider or pediatrician, call them first for advice. If you live in the US, it’s far more likely to be the flu or another viral illness.

If you do not have a doctor and you are concerned that you or your child may have COVID-19, contact your local board of health. They can direct you to the best place for evaluation and treatment in your area.

Only people with symptoms of severe respiratory illness should seek medical care in the ER. Severe symptoms are rapid heart rate, low blood pressure, high or very low temperatures, confusion, trouble breathing, severe dehydration. Call ahead to tell the ER that you are coming so they can be prepared for your arrival.

Can people who recover from the virus still be carriers and therefore spread it?

People who get COVID-19 need to work with providers and public health authorities to determine when they are no longer contagious.

Reliable resources:

• WHO coronavirus web site and answers to frequently asked questions
• WHO coronavirus mythbusters page
• CDC coronavirus web site and answers to frequently asked questions

Also, read our earlier blog posts on coronavirus:

• The new coronavirus: What we do — and don’t — know
• Be careful where you get your news about coronavirus
• Coronavirus: What parents should know and do

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New study compares long-term side effects from different prostate cancer treatments

Prostate cancer therapies are improving over time. But how do the long-term side effects from the various options available today compare? Results from a newly published study are providing some valuable insights.

Investigators at Vanderbilt University and the University of Texas MD Anderson Cancer Center spent five years tracking the sexual, bowel, urinary, and hormonal status of nearly 2,000 men after they had been treated for prostate cancer, or monitored with active surveillance (which entails checking the tumor periodically and treating it only if it begins to grow). Cancers in all the men were still confined to the prostate when diagnosed.

Dr. Karen Hoffman, a radiation oncologist at MD Anderson and the study’s first author, said the intent was to provide information that could help men choose from among the various therapeutic options. “Surgical and radiation techniques have changed significantly in the last few decades, and at the same time, active surveillance has become an increasingly acceptable strategy,” she said. “We wanted to understand the adverse events associated with contemporary approaches from the patient’s perspective.”

Roughly two-thirds of the men enrolled in the study had “favorable risk” cancer, which is nonaggressive and slow-growing. A quarter of these men chose active surveillance, and the rest were treated with one of three different methods:

• nerve-sparing prostatectomy (an operation to remove the prostate with the intent of sparing the nerves required for erections)
• external beam radiation therapy (EBRT)
• low-dose rate brachytherapy, which is a method for destroying cancerous tissues with tiny radioactive beads implanted inside the prostate gland.

Men with favorable risk cancer who chose EBRT or active surveillance tended to be older than men who choose surgery, likely because increasing age and illness make prostatectomy harder to tolerate.

The rest of the men in the study were diagnosed with “unfavorable risk” tumors that were more likely to spread. These men were treated either with prostatectomy, or with EBRT combined with drugs that block testosterone (a hormone that fuels growing prostate tumors).

What the results showed

After five years, there were no significant differences in survival associated with any of the selected treatments. Just one man in the favorable risk category died from prostate cancer during the study, and there were eight deaths from the disease in the unfavorable risk group.

Many men in the study had initial problems with sexual, bowel, urinary, and hormonal functioning. Brachytherapy caused more irritative urinary problems during the initial six months than the other treatments, but then those symptoms steadily improved. Brachytherapy and EBRT were associated with minor bowel symptoms such as urgency, bleeding, frequency, and pain that resolved within a year in men from both risk groups.

After five years, differences in side effects between the treatment options had disappeared, with a notable exception: about half the surgically treated men in both the favorable and unfavorable risk groups still had difficulty achieving erections sufficient for intercourse, and between 10% and 13% of them reported ongoing problems with urinary leakage and incontinence. “However, I don’t want anyone to walk away from this analysis thinking they should not get a prostatectomy,” Dr. Hoffman emphasized. “Side effects will differ from person to person.” Furthermore, radiation side effects may still develop even after five years, “and this is something we’re continuing to monitor,” she said. “Our hope is that doctors will use this information to counsel men on expected side effects so they can make an informed choice that is right for them.”

Dr. Marc Garnick, Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, agreed the study provides a valuable resource that adds to existing information. Yet he cautioned against brachytherapy, warning that this particular treatment in some cases has long-term urinary side effects that can significantly alter a patient’s quality of life. “I do not routinely recommend brachytherapy,” Garnick said. “This is especially true in patients with a pre-existing history of urinary tract infections or prostatitis.”

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Dopamine fasting: Misunderstanding science spawns a maladaptive fad

The dopamine fast, created by California psychiatrist Dr. Cameron Sepah, has very little to do with either fasting or dopamine. As Sepah told the New York Times, “Dopamine is just a mechanism that explains how addictions can become reinforced, and makes for a catchy title. The title’s not to be taken literally.” Unfortunately, with such a snazzy name, who could resist? This is where the misconceptions begin.

What’s the thinking behind a dopamine fast?

What Sepah intended with his dopamine fast was a method, based on cognitive behavioral therapy, by which we can become less dominated by the unhealthy stimuli — the texts, the notifications, the beeps, the rings — that accompany living in a modern, technology-centric society. Instead of automatically responding to these reward-inducing cues, which provide us with an immediate but short-lived charge, we ought to allow our brains to take breaks and reset from this potentially addictive bombardment. The idea is that by allowing ourselves to feel lonely or bored, or to find pleasures in doing simpler and more natural activities, we will regain control over our lives and be better able to address compulsive behaviors that may be interfering with our happiness.

The six compulsive behaviors he cites as behaviors that may respond to a dopamine fast are: emotional eating, excessive internet usage and gaming, gambling and shopping, porn and masturbation, thrill and novelty seeking, and recreational drugs. But he emphasizes that dopamine fasting can be used to help control any behaviors that are causing you distress or negatively affecting your life.

You can’t “fast” from a naturally occurring brain chemical

Dopamine is one of the body’s neurotransmitters, and is involved in our body’s system for reward, motivation, learning, and pleasure. While dopamine does rise in response to rewards or pleasurable activities, it doesn’t actually decrease when you avoid overstimulating activities, so a dopamine “fast” doesn’t actually lower your dopamine levels.

Unfortunately, legions of people have misinterpreted the science, as well as the entire concept of a dopamine fast. People are viewing dopamine as if it was heroin or cocaine, and are fasting in the sense of giving themselves a “tolerance break” so that the pleasures of whatever they are depriving themselves of — food, sex, human contact — will be more intense or vivid when consumed again, believing that depleted dopamine stores will have replenished themselves. Sadly, it doesn’t work that way at all.

Fasting may simply be a technique to reduce stress and engage in mindfulness-based practices

Sepah recommends that we start a fast in a way that is minimally disruptive to our lifestyles. For example, we could practice dopamine fasting from one to four hours at the end of the day (depending on work and family demands), for one weekend day (spend it outside on a Saturday or Sunday), one weekend per quarter (go on a local trip), and one week per year (go on vacation).

This all sounds sensible, if not necessarily new or groundbreaking. In fact, it sounds a lot like many mindfulness practices and good sleep hygiene, in the suggestion of no screen time before bed.

However, people are adopting ever more extreme, ascetic, and unhealthy versions of this fasting, based on misconceptions about how dopamine works in our brains. They are not eating, exercising, listening to music, socializing, talking more than necessary, and not allowing themselves to be photographed if there’s a flash (not sure if this applies to selfies).

Misunderstanding science can create maladaptive behaviors

When you think that none of this is actually lowering dopamine, it’s kind of funny! Especially since avoiding interacting with people, looking at people, and communicating with people was never part of Sepah’s original idea. Human interaction (unless it is somehow compulsive and destructive) is in the category of healthy activities that are supposed to supplant the unhealthy ones, such as surfing social media for hours each day. In essence, the dopamine fasters are depriving themselves of healthy things, for no reason, based on faulty science and a misinterpretation of a catchy title.

Taking time out for mental rejuvenation is never a bad thing, but it’s nothing new

The original intent behind the dopamine fast was to provide a rationale and suggestions for disconnecting from days of technology-driven frenzy and substituting more simple activities to help us reconnect us with ourselves and others. This idea is noble, healthy, and worthwhile, but it’s certainly not a new concept. Most religions also suggest a rest day (for example, the Jewish Sabbath) or holidays without technological distractions, so that you can reflect and reconnect with family and community, Thousands of years of meditation also suggests that a mindful approach to living reaps many health benefits.

Unfortunately, the modern wellness industry has become so lucrative that people are creating snappy titles for age-old concepts. Perhaps that is how to best categorize this fad, if only we can get its proponents to look at us or speak to us, without disturbing their dopamine levels, in order to explain this to them.

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Co-parent adoption: A critical protection for LGBTQ+ families

Every child deserves to be part of a loving family, and establishing a secure legal relationship known as parentage between parents and their children is critical to the well-being of all families. This provides stability and security for children and allows parents to care for their children, including making important medical decisions. For LGBTQ+ families, co-parent adoption ensures that parents have a secure legal relationship to their child.

What is co-parent adoption?

Co-parent adoption (also called “second parent adoption”) is the legal process of adopting a partner’s biological or legal child, when a person is not biologically or legally related to the child. This may be the case if the parents used donated sperm or eggs to create their family, or if one partner had children prior to the relationship, either through adoption or biological means. Co-parent adoption can be used to establish a legal relationship in any of these cases. (This post focuses on families created with donated sperm or eggs.)

Why is co-parent adoption important?

Because adoption decrees must be honored in all US states and jurisdictions, they are the best way to ensure that the legal status of both parents is recognized. Birth certificates are not considered as legally strong as adoption decrees. If a co-parent is on a state birth certificate due to marriage, but hasn’t legally adopted their child, the co-parent might not be treated as a legal parent outside of the state where the child was born. This may be critical in certain situations, such as when a child needs emergency health care.

Why is co-parent adoption especially important for families with same-gender parents?

Because of outdated assumptions about parents and families, the parental rights of same-gender parents may be questioned more often than those of a family with a mother and father — even when one parent is not genetically related to the child.

Consider the following scenario: A married same-gender female couple has a baby using sperm from a donor. Both mothers are listed as parents on their child’s birth certificate because they are married to one another. When the child is 5 years old, the family is traveling in another US state and there is a car accident. The gestational mother and child are both hurt. While the gestational mother is in surgery and unable to give consent, time-sensitive medical decisions must be made about their child. In the state the family is visiting, the nongestational mother’s legal relationship to her child is questioned, because she did not give birth to the child and that state does not honor a birth certificate with two mothers listed as the parents. Because the hospital questions the nongestational mother’s right to consent for her child’s treatment, the doctors decide the course of treatment.

All states must honor an adoption decree, so the nongestational mother in this scenario would be able to make medical decisions for her child if she had adopted the child through co-parent adoption.

And even though some states now allow unmarried parents to sign a Voluntary Acknowledgment of Parentage so they can both be on their child’s birth certificate, most unmarried parents also need to complete a co-parent adoption to ensure that the nongestational parent has a legal relationship to their child.

Is co-parent adoption an option for same-gender parents in every state?

Fewer than 20 US states and territories currently permit co-parent adoptions for same-gender parents. In those states, the process varies widely. In Massachusetts, the paperwork is simple enough that parents can file it themselves without the help of a lawyer. In Rhode Island, a family lawyer must file the paperwork, and the nongestational parent must complete numerous steps before the whole family goes to court. Required steps might include: a physical exam; submission of tax returns; fingerprinting for a criminal background check; character letters; a lengthy questionnaire about the parent’s own childhood and parenting beliefs; an advertisement posted in a newspaper to find the donor; and a visit from a social worker to assess the safety of the family’s home.

The co-parent adoption process creates numerous barriers for LGBTQ+ families. Co-parent adoptions may not be financially feasible for some families. The process may also be psychologically difficult, especially if a nongestational parent has planned for the birth of their child and cared for them since birth. To have to prove their commitment to their child may feel unnecessary and invasive. Having a social worker visit the family’s home may make both parents feel vulnerable.

Improving co-parent adoption laws

GLBTQ Legal Advocates & Defenders and others are working to legalize co-parent adoptions in states where it is not yet available, and simplify the process in states where it is available. As one example, a group of parents in Rhode Island is currently working to simplify the co-parent adoption process to make it more attainable for families. You can help these efforts by

• educating yourself about laws on parentage and co-parent adoption in your state
• writing letters to state legislators or testifying at the statehouse when co-parent adoption laws are being considered
• sharing your story if you have gone through the co-parent adoption process, or faced barriers to securing a legal relationship to your child
• providing emotional or financial support to families going through the co-parent adoption process.

For more information

National Center for Lesbian Rights

Family Equality Council

Academy of Adoption & Assisted Reproduction Attorneys can help with finding a qualified adoption lawyer

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Puffing away sadness

Ask a smoker what they get out of cigarettes and they are likely to talk about pleasure, contentment, and an overall good feeling. Nicotine, the active ingredient in cigarettes, is a stimulant. Used in low doses like those delivered by combustible cigarettes, stimulants activate the nervous system, resulting in enhanced arousal and alertness. Nicotine binding in the limbic system — the part of the brain that houses the pleasure and reward center — releases dopamine, resulting in feelings of euphoria. These effects combine to give smokers a boost in their mood.

In this context, new research from a team at Harvard University, that found that when smokers feel sad they reach for cigarettes and inhale longer and deeper, is not surprising. Cigarettes are a “solution” to the “problem” of sadness that smokers seem to learn to use effectively. This new research is the first to show that sadness elicits nicotine use much more than other negative emotions, and that sad feelings are not only associated with smoking, but can actually cause it.

Smoking may blunt an adaptive and necessary emotion

Sadness is a basic emotion, typically felt in response to loss. The experience of sadness and the underlying neurobiology is universal. Sadness that is too intense or too prolonged — i.e., depression — is a disorder that results in dysfunction. But normal sadness has an adaptive function: people experiencing sadness focus their attention internally and become better problem solvers.

The expression of sadness is physiologically determined. Humans can reliably read sadness on each other’s faces independent from cultural cues, and these signals provoke empathy from others — another benefit to the individual who is sad. In this regard sadness, while unpleasant, has its upsides; its universality is an indication of its survival advantage.

While smokers get immediate relief from sadness with a cigarette, that may come at a cost if they also lose these adaptive benefits. “Treatment” of sad emotional states with nicotine over time may also impair innate restorative responses, just as treatment of chronic pain with opioids results in many patients experiencing hyperalgesia, a pathologically heightened response to painful stimuli. Indeed, this may help to explain the association between smoking and depression.

Part of maturing is learning to manage emotions

Compared with adults, adolescents experience emotions more strongly; with maturity they transition from the emotional reactivity typical of this age group to the more tempered presentation of adults. When it comes to sadness, reactivity and response are age-dependent: the triggering content of sadness is less tightly coupled with physiologic responses in the young compared to mature adults. Experience appears to be a crucial component of the maturational process.

What happens when adolescents use nicotine to blunt their sadness?

Does smoking interrupt emotional maturation, making young smokers susceptible to depression? Does disruption in emotional maturity make adolescent smokers more likely to use other drugs? The short answer to all of these questions is that we do not know, but there is reason to be concerned, because we do know that smoking is associated with increased risk of depression, marijuana use, binge drinking, and use of other drugs including opioids. Since most smokers start using cigarettes during their teen years, these questions have real salience.

After 20 years of dramatic decline in the rates of smoking among high school students, and a more gradual decline among adults, e-cigarettes and vaping devices have begun to reverse these trends. The new findings demonstrating the linkage between sadness and smoking should give us all pause. While the health impacts of smoking have been well documented over the past 50 years, we are still learning about the impacts of nicotine.

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Hands or feet asleep? What to do

We’ve all been there. You awaken in the morning and one of your hands is completely numb. It feels dead, heavy, and simply won’t work. Perhaps there’s some tingling as well. Or, you arise from a long dinner or movie and one of your legs feels that way. Then over a few minutes — maybe you shook your hands, stamped your foot — everything goes back to normal. Until the next time.

The first time this happened, it might have been worrisome. But, now that you know it’s temporary and happens to everyone, it may not bother you. But did you ever wonder why in the world this happens? Read on!

When the nerves are not happy

When someone complains to me about their hand or leg falling asleep, I reassure them. I usually explain, “The nerves are not happy.” In general, numbness, tingling, and other symptoms called paresthesia are most commonly due to abnormal nerve function. And when this is intermittent, temporary, and related to holding one position for a long time, it’s rarely anything to worry about. The cause in these cases is simply pressure on one or more nerves travelling into the hands or feet. When you remove the pressure (by changing position, for example), the problem goes away.

However, many other causes of nerve problems — more than 100, in fact — can cause similar, though more prolonged and persistent, symptoms, as noted below. If you have one of these conditions, you’re far from alone: an estimated 20 million people have a form of peripheral neuropathy that might make hands or feet numb or tingly.

A word on nerve terminology

So, what is peripheral neuropathy? It’s worth clarifying some commonly used medical terms.

• Neuropathy means nerve disease.
• Peripheral neuropathy is a condition affecting nerves in the peripheral nervous system, which includes nerves outside of the brain and spinal cord. Nerves of the legs and arms are part of the peripheral nervous system, and tend to be the first ones affected by diseases of peripheral nerves.
• Compression (or entrapment) neuropathy develops because of pressure on a nerve. Carpal tunnel syndrome, which occurs when a nerve becomes compressed in an already tight channel in the wrist, is one well-known example. Having your hand or foot fall asleep is another. Fortunately, this is quite temporary, while carpal tunnel syndrome is often chronic.
• Paresthesia is a sensation of pins and needles, numbness, or another abnormal sensation, often tied to peripheral neuropathy. Having your hand or foot fall asleep is a temporary paresthesia.

When to see your doctor

If you’re hands or feet fall asleep occasionally and normal sensation quickly returns, that’s fine. No need to contact your doctor.

But call your doctor promptly if you have persistent numbness, tingling, or other unusual sensations in your hands or feet. This is especially important if these sensations cause trouble with walking or holding onto things. Your doctor should investigate further and will likely consider possible causes of peripheral neuropathy, including the following:

• Diabetes is the most common identifiable cause of peripheral neuropathy, accounting for nearly a third of cases. Sometimes it’s the first indication that a person has diabetes.
• diseases of the liver, kidney, and thyroid
• nutritional deficits, such as vitamin B₁₂ deficiency or other vitamin deficiencies. Vitamin B₆ is unique in this regard because too little or too much can cause neuropathy; too little is quite rare, but it’s possible to get excess B₆ from supplements.
• alcohol and other toxins. Alcohol ingestion is probably the most common cause of toxic neuropathy. Alcoholics may also have nutritional deficiencies that can cause neuropathy.
• Certain medications, including some antibiotics and chemotherapy drugs, or lead, mercury, and other chemical and industrial toxins, may be culprits.
• vascular disease, which occurs when the blood supply to a peripheral nerve is impaired, as with atherosclerosis. The nerve becomes unhealthy or dies.

Additional causes of neuropathy are infection, compression or trauma to nerves, and inflammatory or autoimmune conditions that affect nerves. It’s worth noting that nearly a third of cases have no clear cause — a problem known as idiopathic neuropathy.

The bottom line

The causes of peripheral neuropathy are many, and range from the harmless and annoying to the intolerable and dangerous. When in doubt, see your doctor. But try not to worry when your hands or feet fall asleep due to holding your arms or legs too long in one position, as long as this resolves within minutes and doesn’t happen often. These things happen.

And the next time you see a movie, don’t forget to change positions, stretch, and fidget a bit — even if the movie is really good.

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C. difficile (C. diff): An urgent threat

Clostridioides (previously Clostridium) difficile (C. diff) is the most common cause of diarrhea among hospitalized patients and the most commonly reported bacteria causing infections in hospitals. In a 2019 report, the CDC referred to C. diff as “an urgent threat.”

Who is most at risk?

C. diff infection (CDI) occurs more commonly following antibiotic therapy or hospitalization, and among older adults or patients with weakened immune responses. In 2002, an epidemic strain of C. diff emerged, causing more severe disease with inflammation of the colon (colitis) and an increase in deaths. This strain adheres better to the intestine and produces more toxin, which is responsible for causing illness. Non-epidemic strains may cause less severe disease.

What makes C. diff so difficult to treat?

A high relapse rate poses challenges to treating people with CDI. Recurrence of diarrhea following initial treatment occurs in about 20% of cases. The risk of yet another relapse is even greater in the weeks following treatment for a recurrent CDI.

C. diff produces spores (dormant cells capable of surviving harsh conditions for prolonged periods) that can contaminate the environment. Spores are hearty and resistant to routine cleaning. But enhanced protective measures — careful hand washing, isolation precautions for infected patients (private room, gown, and gloves), and cleaning with agents capable of killing C. diff spores — are effective ways to prevent transmission and control CDI.

Antibiotics disrupt the healthy gut bacteria (microbiome), which then provides suitable conditions for ingested spores to flourish and result in CDI.

Hospitalized patients are at greater risk, although healthy individuals in the community who have not been treated with antibiotics can also become infected.

The World Society of Emergency Surgery released updated clinical practice guidelines in 2019, focusing on CDI in surgical patients. Surgery, particularly gastrointestinal surgery, is a known risk for CDI. (Ironically, surgery is also a potential treatment option for severe CDI.)

What is the difference between C. diff colonization and C. diff infection?

Up to 5% of people in the community, and an even greater percentage of people who are hospitalized, may be colonized with C. diff bacteria, but not experience any symptoms. The risk of progressing to disease varies, since not all C. diff strains produce toxin that makes you sick. People colonized with a non-toxin-producing strain of C. diff may actually be protected from CDI.

CDI is diagnosed based on symptoms, primarily watery diarrhea occurring at least three times a day, and stool that tests positive for C. diff. A positive test without symptoms represents colonization and does not require treatment. Patients colonized with toxin-producing strains are at risk for disease, particularly if exposed to antibiotics.

How is C. diff treated?

The most common antibiotics used to treat CDI are oral vancomycin or fidaxomicin. Extended regimens, lasting several weeks, have been used successfully to treat recurrences. Vancomycin enemas and intravenous metronidazole, another antibiotic, are also used in severe cases.

Fecal microbiota or stool transplant (FMT) from screened donors is an effective investigational treatment for those who do not respond to other treatment. However, it is not without risk. FMT capsules are effective and logistically easier.

Patients with severe CDI not responding to therapy may benefit from surgery, typically a colon resection or a colon-sparing procedure.

What can you do to prevent CDI?

Though there are no guarantees, there are many things you can do to help reduce your risk of CDI, particularly if you are scheduled for hospitalization or surgery.

If you are scheduled for surgery, discuss routine antibiotics to prevent infection with your surgeon. In most cases, according to the CDC, one dose of an antibiotic is sufficient. If you have an established (non-C. diff) bacterial infection, several recent studies show that shorter antibiotic courses are effective and may also reduce your risk of CDI. You should also ask your doctor about avoiding antibiotics that are more likely to result in CDI (clindamycin, fluoroquinolones, penicillins, and cephalosporins).

If you are hospitalized with CDI, you should use a designated bathroom and wash your hands frequently with soap and water, particularly after using the restroom. In the hospital, encourage staff to practice hand hygiene in your line of sight, and express appreciation to hospital staff for keeping your environment germ-free. If you are at high risk for a CDI recurrence (you are 65 or older, have a weakened immune response, or had a severe bout of CDI), discuss the potential value of bezlotoxumab with your provider. This monoclonal antibody can help to further reduce risk of recurrent CDI in those who are at high risk for recurrence.

There are other preventive measures that you can take whether or not you are hospitalized. Limit the use of antacids, particularly proton-pump inhibitors (PPIs). Don’t ask your doctor for antibiotics to treat colds, bronchitis, or other viral infections. Request education about side effects of prescribed antibiotics from your doctor or dentist, and discuss the shortest effective treatment duration for your condition. Let your doctor know that you want to minimize your risk for CDI. Practice exceptional hand hygiene before eating, and especially before and after visiting healthcare facilities.

For more information, visit the Peggy Lillis Foundation and the Centers for Disease Control and Prevention.

Follow me on Twitter @idandipacdoc

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Five healthy habits net more healthy years

Are healthy habits worth cultivating? A recent study suggests healthy habits may help people tack on years of life and sidestep serious illnesses, such as diabetes and cancer. After all, if you’re going to gain an extra decade of life on this earth, you want to enjoy it!

What did this research focus on?

Researchers from the Harvard T.H. Chan School of Public Health looked at data from more than 73,000 women enrolled in the Nurses’ Health Study (NHS) who were followed for 34 years, and more than 38,000 men enrolled in the Health Professionals Follow-up Study (HPFS) who were followed for 28 years.

In a previous study using the same data, these researchers had found that five low-risk lifestyle habits are critical for a longer life expectancy. The more of these habits people had, the longer they lived. The habits were:

• a healthy diet, which was calculated and rated based on reports of regularly eating healthy foods like vegetables, fruits, nuts, whole grains, healthy fats, and omega-3 fatty acids, and avoiding less healthy or unhealthy foods like red and processed meats, sugar-sweetened beverages, trans fat, and excess sodium
• a healthy physical activity level, measured as at least 30 minutes a day of moderate to vigorous activity, like brisk walking
• a healthy body weight, defined as a normal body mass index (BMI), which is between 18.5 and 24.9
• never smoking, because there is no healthy amount of smoking
• low-risk alcohol intake, measured as between 5 and 15 grams per day for women, and 5 to 30 grams per day for men. Generally, one drink contains about 14 grams of pure alcohol. That’s 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of distilled spirits.

Even if they had only one of these habits, participants lived two years longer than if they had none. And if by age 50 they regularly practiced all five, women lived an extra 14 years and men lived an extra 12. That’s over a decade of extra life!

Are those extra years healthy?

In this new study, researchers wanted to know if those extra years were also healthy years. Participants were asked in follow-up questionnaires if they had developed medical problems like type 2 diabetes, cardiovascular disease (heart disease and strokes), or cancer. The answers were verified by a review of medical records.

The study found that having at least four of the five healthy habits gave people significant protection against developing any of these illnesses: on average about a decade more of life free of these diseases.

Why is that important? These chronic diseases are associated with illness, hospitalizations, and even needing nursing home care. Diabetes, for example, can lead to disabling conditions, including blindness, amputations, and kidney failure requiring dialysis. The top 10 diagnoses resulting in nursing home care include strokes, heart disease, and obesity, according to the National Association of Health Data Organizations. These conditions are strongly associated with diet and lifestyle.

Steps for a longer, healthier life

If you’re approaching middle age, you can take steps to enjoy a longer and healthier life, one with a lower chance of becoming disabled or ending up in a nursing home:

1. Eat mostly plants, most of the time. That means fruits, vegetables, beans and lentils, nuts and seeds, and whole grains. Avoid eating fast or fried foods, sweets and sugary beverages, and red and processed meats (like cold cuts) as much as possible.
2. Move your body every day as much as you can. Walking for 30 minutes a day (15 in the morning, 15 in the evening, maybe?) would give you the benefits these researchers found. But even as little as ten minutes of movement per week has been shown to have health benefits.
3. Do the best you can to get to a healthy weight. And remember, even a little bit of weight loss, just a few pounds, is associated with real, positive health outcomes, like a lower risk of diabetes in people at risk.
4. Quit smoking — or vaping! Though this particular study looked at never having smoked, we know that there are significant health benefits to quitting at any time. It’s never too late to quit and enjoy a healthier life.
5. If you drink any alcohol, keep the recommended limits in mind: one drink per day max for women, two drinks per day max for men.

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Can light therapies help with bipolar disorder?

Bipolar disorder is a mood disorder characterized by episodes of both depressed and elevated mood. It typically begins in the late teens to early 20s. During depressive episodes, people experience low mood, loss of self-confidence, hopelessness, and impaired sleep and appetite. Manic episodes are marked by an increase in energy, euphoric or irritable and rapidly changing mood, higher self-confidence, and decreased need for sleep. People may experience a mood episode every few years, or as frequently as several times a year.

Bipolar disorder can be treated with medications and psychotherapy. Certain chronotherapies — approaches designed to harness and normalize the body’s natural rhythms, such as light therapies — may help too, according to a recent systematic review of research.

Why might light therapies help?

Circadian rhythms, our natural 24-hour clocks, are disrupted in bipolar disorder. In addition, people with bipolar disorder seem to be more sensitive to light.

One way of treating bipolar disorder is to manipulate the circadian rhythm. This can be achieved with bright light therapy, dark therapy, sleep deprivation, and certain types of psychotherapy.

Bright light, dark light, and sleep deprivation

• Bright light therapy. Animals and humans experience seasonal and daily rhythms of body function and behavior that are influenced by light, among other environmental factors. Light activates the retina in the eye, resulting in a stimulus being transmitted from the eye to the hypothalamus in the brain. The hypothalamus helps regulate mood. In bright light therapy, a light box using fluorescent bulbs that emit 7,000 to 10,000 lux of UV-filtered bright white light is placed on a table at about eye level. (There are also head-mounted units or light visors.) Depending on the light output, time required is between 30 minutes and two hours a day. It’s reasonable to consider this treatment to help prevent or treat episodes of depression. It may be especially useful if a person has trouble tolerating medications.
• Dark therapy. Just as light therapy can improve mood, decreasing light can dampen manic symptoms. For treatment of mania, amber glasses that block blue light are worn in the evenings.
• Sleep deprivation. Onset of antidepressant effects can be rapid and striking. In total sleep deprivation, one is kept awake for 36 hours, all night and the following day. In partial sleep deprivation, one sleeps only four to five hours at night. Unfortunately, improvement in mood is short-lived. Switches to mania have been reported, so it should only be used in combination with a mood stabilizer.
• Though widely used, at this time there is little evidence to support the use of the supplement melatonin in bipolar disorder, according to the researchers.

Typically, light therapies are combined with other treatments for bipolar disorder, including those described below. Less often, they may be effective if used alone.

Additional approaches to changing circadian rhythms

Psychotherapy techniques can help people adjust dysregulated sleep patterns. Indeed, for typical insomnia, cognitive behavioral therapy, not medication, is the treatment of choice. Therapy works by controlling or eliminating negative thoughts and actions that keep one awake.

• Interpersonal and social rhythm therapy. This therapy is centered around the observation that a switch to depression or mania is often associated with a relationship difficulty that results in sleep deprivation. The therapist helps the patient work on regulating routine as well as the interpersonal problem.
• Cognitive behavioral therapy. Originally designed to treat major depression, this therapy aims to mitigate stressful life events that interact with negative cognitive styles to precipitate mania and depression.

These treatments can be combined with each other and used with medications, such as mood stabilizers and antipsychotic drugs. This may allow a person to take a lower dose of an antipsychotic drug than would otherwise be needed to manage symptoms. There are no absolute contraindications to bright light or dark therapies. However, using bright light therapy in the evening may worsen insomnia, and dark therapy should not be used in depression. Sleep deprivation is only used during the depressive phase because it can provoke manic symptoms or worsen them.

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Good news for those with type 2 diabetes: Healthy lifestyle matters

Type 2 diabetes (T2D) is a metabolic disorder of insulin resistance — a reduced sensitivity to the action of insulin — which leads to high blood sugar, or hyperglycemia. Approximately 12% of American adults have T2D, and more than one-third of Americans have prediabetes, a precursor to T2D. This is a major public health concern, as T2D dramatically increases risk for heart disease, including heart attacks, atrial fibrillation, and heart failure.

The development and progression of T2D is affected by many factors. Some, such as a person’s race/ethnicity, age, and gender cannot be modified. Others, including body weight, exercise, and diet can be changed.

Can lifestyle changes help reduce heart disease risk if you have diabetes?

In 2010, the American Heart Association (AHA) published “Life’s Simple 7,” which they defined as “seven risk factors that people can improve through lifestyle changes to help achieve ideal cardiovascular health.” The Simple 7 touched on smoking status, physical activity, ideal body weight, intake of fresh fruits and vegetables, blood sugar, cholesterol levels, and blood pressure.

Subsequent studies found that people in optimal ranges for each of these factors had lower risks of heart disease compared to people in poor ranges. But given the significant increase in heart disease risk in those with T2D, it was not clear if the impact of these modifiable factors would hold true for the T2D population.

Recent study suggests lifestyle changes do benefit T2D and prediabetes

A recent study published in JAMA Cardiology looked at whether the ideal cardiovascular (CV) metrics covered in Life’s Simple 7 translate into improved CV health for those with T2D or prediabetes. The results were exciting, and consistent with other large population-based studies. Patients who had five or more ideal CV measures had no excess of CV events compared with people with normal blood sugar levels. CV events measured in the study included death, heart attack, stroke, and heart failure. Each additional ideal health metric was associated with an additional 18% drop in CV event risk for people with T2D, and an additional 15% drop for those with prediabetes.

This was a prospective, observational study, examining the association of risk factors only. It was not a randomized trial looking at an intervention. As a result, we cannot draw conclusions about cause and effect. Nonetheless, this is the first study to show a positive association between ideal lifestyle factors and CV health in people who are at high risk for CVD due to T2D. These results showcase the importance of our lifestyle choices, suggesting that meeting ideal health metrics can help reduce risk of CV events.

Life’s Simple 7

So what are the lifestyle and metabolic health goals should you strive for, whether or not you have diabetes?

1. Manage blood pressure. 120/80 mm Hg or lower is best.
2. Control cholesterol. Aim for total cholesterol below 200 mg/dL.
3. Reduce blood sugar. Get your HbA1c (an average measure of blood sugar over the past three months) under 5.7% if you have prediabetes, or below 6.5% if you have T2D.
4. Get active. Your goal is 150 minutes per week of moderate-intensity activity or 75 minutes per week of vigorous activity.
5. Eat better. That means at least 4.5 cups of fruits and vegetables per day.
6. Lose weight. You want a body mass index (BMI) of less than 25.
7. Stop smoking. You’ll reap CV benefits, not to mention lowering your risk for cancer, COPD, and much more.

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What’s the best way to manage agitation related to dementia?

You notice your loved one becoming more forgetful. She cannot recall her visit with her granddaughters yesterday. She claims she took her medications this morning, yet you find them untouched in her pill case. You wonder how this mild-mannered woman has become so angry, so quickly. She is often frightened now, disoriented, and unpredictable. Yet she still remembers every detail of your wedding day, the names of your four children, and how to play her favorite piano pieces. When you sing together, time temporarily stands still.

Your loved one received a diagnosis of Alzheimer’s disease. Nights are the hardest time for her. You worry about her safety when she wanders through the house. She almost broke the door last week; you can tell her arm still hurts when you bathe her. She resists and yells at you when you take her to the bathroom. She has started to show behavioral symptoms of dementia.

Aggression and agitation in dementia

Behavioral and psychological symptoms are very common in dementia, and affect up to 90% of people living with dementia. In addition to memory changes, people with dementia may experience agitation, psychosis, anxiety, depression, and apathy. These behavioral symptoms often lead to greater distress than memory changes.

When people with dementia become agitated or aggressive, doctors often prescribe medications to control their behaviors in spite of the known risks of serious side effects. The most frequently prescribed medication classes for agitation in dementia carry serious risks of falls, heart problems, stroke, and even death.

Caregivers, who often experience burnout in managing aggressive behaviors, welcome medications that can temporarily decrease agitation. Unfortunately, aggressive and agitated behavior often contributes to the decision to transition a loved one to an alternative living situation.

New research shows that nondrug therapies are more effective

According to a new study looking at more than 160 articles, nondrug interventions appeared to be more effective than medications in reducing agitation and aggression in people with dementia. Researchers found that three nonpharmacologic interventions were more effective than usual care: multidisciplinary care, massage and touch therapy, and music combined with massage and touch therapy.

For physical aggression, outdoor activities were more efficacious than antipsychotic medications (a class of drugs often prescribed to manage aggression). For verbal aggression, massage and touch therapy were more effective than care as usual. As a result of this study, the authors recommend prioritization of nonpharmacologic interventions over medications, a treatment strategy also recommended by the practice guidelines of the American Psychiatric Association.

Helpful tips for caregivers

To decrease agitation and aggression with dementia, caregivers can help their loved ones in the following ways:

• Find a multidisciplinary team of specialists. This may include a psychiatrist to carefully consider the risks and benefits of medications for managing behavior, a geriatrician to optimize your loved one’s medical situations, and an occupational therapist to consider modifications of a person’s living environment and daily routine.
• Go for a walk or on an outing for a change of scenery. Physical activity has additional benefits on mood, memory, and lowering anxiety.
• Add massage and touch therapy, or just provide a calming hand massage.
• Incorporate music into your loved one’s daily routine.
• Notice the first signs of agitation. Nondrug options work best the earlier they are used.
• Get creative: discover what works and try using different senses. Aromatherapy, an activity such as folding (and refolding) laundry, brushing hair, or dancing can all be calming.
• Consult with your physicians. Medications are often prescribed as first-line interventions despite what we know about the effectiveness of nondrug options.
• Educate all the people caring for your loved one on the interventions that work best, and check in with them about how these approaches are working.

The bottom line

To decrease agitation and aggression in people with dementia, nondrug options are more effective than medications. Physical activity, touch and massage, and music can all be used as tools to manage agitation related to dementia.

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African American and white men who receive comparable treatments for prostate cancer have similar survival

Last year, we reported on two studies showing that African American men respond at least as well as white men to prostate cancer treatments given in clinical trials. Nationally, African Americans with prostate cancer are more than twice as likely to die of the disease as their white counterparts, and that has fueled speculation that genetic or biological factors put them at greater risk. But according to this new research, the survival difference disappears when men of either race get the same cutting-edge treatments.

Now scientists are reporting that African American and white men with prostate cancer live equally as long if they’re treated by the same care delivery system.

Benefits from equal access care

For this study, a team from the University of California at San Diego looked at survival data from 60,035 men who had been diagnosed and treated for prostate cancer by the US Veterans Administration (VA) Health Care System between 2000 and 2015. VA hospitals provide the same subsidized care to all eligible veterans, regardless of their socioeconomic standing. So, African American men cared for by that system don’t experience the delays in diagnosis or treatment that they can often face in the general population.

Of the men included in the study, 18,201 were African American and 41,834 were white. The African Americans tended to be diagnosed at younger ages, lived in areas with lower median incomes, and had less education and more additional health problems than the white men. Yet after adjusting for tumor grade, prostate-specific antigen levels, smoking habits, the types of treatment received, and other factors with an influence on prostate cancer survival, the investigators found that African Americans had slightly better of odds of not dying from the disease than the white men did.

Specifically, the 10-year prostate cancer-specific death rate was 4.4% among African Americans and 5.1% among white men. And among all men in the study who were still alive after 10 years, 81.8% were African Americans and 77.5% were white. According to the investigators, the results are consistent with evidence from other studies showing that racial disparities in prostate cancer survival diminish after men become eligible for Medicare or Medicaid, which also provide equal access care.

Taken together, the results suggest that high mortality from prostate cancer among African American men in the general population is driven less by genetics or biology than by delays in diagnosis and treatment, affirmed Dr. Marc Garnick, Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. Still, the study doesn’t address other mysteries, Dr. Garnick added, such as why more African American than white men develop prostate cancer, and at earlier ages. “More research into these important questions is still needed,” he said.

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Good for your teeth, bad for your bones?

Regular brushing and flossing are the cornerstones of good oral health. But what if you learned that your toothpaste was good for your teeth, but bad for your bones? That possibility has been raised by a recent study. The cause of this unprecedented finding may be triclosan, an antibacterial agent added to toothpaste to reduce gum infections and improve oral health. However, it may actually be causing more harm than good.

Rethinking a popular germ killer

Triclosan is an antibacterial agent that’s been around for decades. Not only has it been used in soaps, hand sanitizers, and deodorants, but it’s found its way into cutting boards, credit cards, trash cans, and, yes, toothpaste.

Adding triclosan to all of these consumer products allowed marketers to slap “antibacterial” on the packaging and emphasize this feature of the product. Though unproven, the implication is that products containing triclosan (or other antibacterial agents) might prevent serious infections.

But for many years, studies done in animals or on human cells in the lab have raised concern about whether all this “cleanliness” might have some unintended — and negative — consequences, including:

• promoting the development of resistant bacteria (see my previous post about this)
• interfering with normal hormonal function: in animal studies, triclosan has been linked with abnormal thyroid function and bone mineral density (a measure of bone health and strength)
• more allergic reactions, perhaps because lowering exposure to bacteria may prevent the immune system from developing as it should
• impaired muscle function, as noted in mice, minnows, and human heart cells in the lab
• uncertain environmental impact, since many products containing triclosan wind up in wastewater and, eventually, into bodies of water. And there’s this disturbing observation: it can survive treatment at a sewage facility.

If triclosan is bad for humans, the problems it causes could be widespread: one study found that more than 75% of the public have detectable amounts of triclosan in their urine. While we are still uncertain of the health impacts of this, if any, the FDA has taken action in recent years to curtail its use.

Triclosan’s fall from grace

First, the FDA asked companies using triclosan in their cleaning products to produce research demonstrating that they were more effective than soap and water. In 2016, when no such proof had been offered, triclosan was banned from soaps sold to consumers. The following year, it was banned from healthcare cleansers. And, in 2019, the FDA announced that triclosan would be banned from consumer hand sanitizers as of April 2020.

What did the new research find?

In the study, researchers reviewed data from more than 1,800 women and found that

• Those with the highest levels of triclosan in their urine had the lowest measures of bone density.
• Osteoporosis (as measured by bone density) was most common among those with the highest urinary triclosan levels. Osteoporosis is a condition in which the bone density is so low that fracture risk from even a minor fall or injury is increased.
• The connection between low bone density and urinary triclosan was stronger for postmenopausal women than among younger women. This may be important, since menopause is a time when bone density often falls dramatically, and postmenopausal women have the highest rates of osteoporosis-related fractures.

Now what?

This is just the latest research to raise concerns about the safety of triclosan. My guess is that it won’t be long before the FDA bans its use in toothpaste, especially if no new studies find that it’s particularly beneficial. The impact of such a ban at this point may not be large; most toothpaste makers have stopped putting triclosan in their products.

To be fair, a previous review of research in 2013 concluded that there was less plaque, gum inflammation, and gum bleeding among users of a toothpaste containing triclosan compared with users of toothpaste without triclosan. However, the authors noted that “these reductions may or may not be clinically important.” There was also a small reduction in dental cavities among users of the triclosan-containing toothpaste, and no safety concerns were raised over a three-year period of use.

Still, the more recent studies may have tipped the balance. Triclosan’s days in consumer products may be numbered.

The bottom line

Check your toothpaste when you next brush. If you see triclosan listed among the ingredients, you may want to switch to a brand without it, at least until you can discuss it with your doctor or dentist.

Follow me on Twitter @RobShmerling

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When is a heavy period too heavy?

It’s common for girls and their parents to wonder if the bleeding with their periods is too often or too much. Especially in the first few years of having a period, any bleeding can feel like too much. Usually, it’s not — but sometimes it is, and it’s important for parents to know what to watch for, and when to call the doctor.

In the first couple of years after periods begin, it’s really normal for periods to be irregular — and for some of them to be heavy. At the beginning, periods aren’t associated with ovulation, and the hormones and hormonal patterns that help regulate periods haven’t fallen into place yet. If it’s just the occasional period that is heavy, that’s usually nothing to worry about.

It’s not always easy to know what counts as a “heavy” period. As I said, for some girls anything is too much. And while we doctors often ask how often the girl changes her pad or tampon, that’s very subjective and dependent on personal preference. Some girls change as soon as there is any blood present or every time they use the bathroom. Others wait until they are completely soaked.

Signs to watch for with heavy periods

Here are some signs that menstrual bleeding may be too heavy, and that you should call the doctor:

• The girl is looking pale and feels dizzy and/or weak. If this is happening, you should call your doctor immediately.
• She needs to change her pad or tampon during the night.
• She is bleeding through her clothes.
• She is passing clots that are bigger than an inch wide.
• Her periods are interfering with her ability to go to school, play sports, or otherwise engage in regular activities.

There are many reasons why girls may have heavy periods. The most common reason is simply that the body is just getting started and getting regulated. If that is the case, it usually gets better with time. However, there are other causes as well, which is why it’s important to see the doctor.

What will the doctor do?

After listening to the story and doing a physical examination, the doctor generally will do some screening blood tests. Basic tests recommended by the American College of Obstetricians and Gynecologists include a complete blood count and some tests to look for bleeding problems. Along with checking to see if her bleeding has caused her to be anemic, it’s important to check to see if there might be a problem such as low platelets, or Von Willebrand disease, or some other condition that might cause her to bleed more heavily than normal. Some of these conditions don’t become apparent until a girl starts menstruating. In retrospect, there is often a history of easy bruising and bleeding, or a family history of heavy periods or other bleeding.

In most cases, doctors will also do a pregnancy test. This may seem like a strange or silly test to do in a young teenager, but pregnancy can cause heavy bleeding — and the reality is that we can never entirely know everything about the lives of young girls. It’s always better to be safe than sorry.

There are many other causes of heavy periods. If initial tests don’t show anything and the bleeding doesn’t get better, the doctor may want to check thyroid function as well as some other hormones, and also do some tests to check overall health. Most of the time, though, more tests aren’t needed.

The treatment of heavy periods depends on the cause — and on whether the bleeding is bad enough to cause anemia. Most of the time, all that’s needed is some extra iron and some patience. So, a multivitamin with iron isn’t a bad idea for any menstruating girl whose diet isn’t always great. Occasionally, more is needed. If there are any warning signs, or if you have any questions, call your doctor.

Follow me on Twitter @drClaire

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Mind-body therapies can reduce pain and opioid use

Our ability to feel pain and react to it is both a boon and a curse, simultaneously. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” This means that pain is highly subjective, and it is informed by a mix of past experiences, our current emotional state, and future expectations. Since pain is an emotional and sensory experience it affects our quality of life immensely, and treatment is complex.

Chronic pain management with opioids is not ideal

Opioids are among the most potent medications used to manage pain. Opioids curb pain by blocking pain signals between the brain and the body. This class of medication also relaxes the brain, providing a sense of calm and euphoria, and there is a high risk of addiction. Opioid misuse is more pronounced in people who have had surgery and been given opioids than in people who have not had surgery. The longer a person uses opioids, the greater risk of their misusing these medications. The ongoing opioid epidemic has led physicians to look for adjunct and nonmedication therapies to help people reduce opioid use and still effectively manage pain.

Mind-body therapies for pain management

Mind-body therapies (MBTs) are integrative practices, and they include breathing exercises and/or body movements aimed at achieving relaxation of mind and body. Some MBTs are Isha yoga, vipassana, mindfulness-based stress reduction, integrative body-mind training, tai chi, guided imagery, cognitive behavioral therapy, and others.

Pain and meditation both alter our senses, thinking, and emotional responses

One MBT is mindfulness meditation, which involves practicing attention control, emotional regulation, and self-awareness. There is increased perception and awareness with mindfulness practices, and meditation addresses both the sensory and emotional components of pain. The interoception center in the brain increases and the amygdala shrinks in size with regular mindfulness practices, which explains better emotional regulation and pain control. The brain’s ability to react to painful stimuli with an emotional response decreases, and a person is more likely to respond calmly to a stimulus instead of having a hasty emotional reaction (hurt, pain, anger, etc.). The increased perception and awareness with regular mediation will make a person feel every sensation, including pain; however, they may choose not to react to it, so practicing meditation can help you better manage pain.

New research on MBTs for pain management and reducing opioid use

A recent paper published in JAMA looked into the use of MBTs as potential tools in addressing the opioid crisis. Researchers reviewed 60 randomized clinical trials with 6,404 participants and found that MBTs had a moderate association with reduction in pain intensity and a small but statistically significant association with reduced opioid dose. These findings suggest that MBTs are an effective nonmedication tool in reducing the experience of pain, and using MBTs may have some benefit in reducing opioid use and misuse. MBTs may also help with cravings for opioids if someone is trying to reduce their dose.

However, a closer look into the analysis reveals that the type of MBT used affects therapeutic efficacy. Often combinations of MBTs are used to treat pain, and it is difficult to be certain which type of MBT is most effective. There is also a lack of conclusive evidence for the benefit of using MBTs in certain clinical scenarios (such as following surgery), due to inconsistent reporting of opioid dosing and durations. Lastly, there is currently a gap in our understanding regarding the right time to implement MBTs, and their effectiveness as an adjunct to opioid-treated pain. All these criticisms do not negate the results of the JAMA study; rather, this work highlights a need for future research to determine what types of MBTs could be most effective in helping with pain and reducing opioids.

Routine mindfulness meditation practices can improve your quality of life

As mentioned, MBTs, particularly meditation, play a huge role in transforming our experience of pain. Meditation allows us to recognize the authenticity of distress and not be overwhelmed by it. Learning and practicing mindfulness-based meditation is a means to deal with pain and the inevitable stresses of life, and to improve your quality of life. However, there is no one-size-fits-all approach and no one MBT that works for everyone.

The array of available MBTs means there is flexibility to choose your level of involvement and time spent in these practices. Our personal experience with meditation and its effects on our lives and the well-being of our patients make us strong advocates of MBTs. As always, discuss all medication changes and new lifestyle practices with your doctor.

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