5 winning ways for kids burn energy

Could your kids power the electrical grid, if you could only figure out how to tap that energy? Someday, all the hours spent cooped up at home will be a memory, not a daily reality. But if your children are bouncing off the walls with schools and day care still closed and summer coming, here are five active ideas to safely channel their energy. Pandemic or not, preschoolers benefit from active play throughout the day, and children ages 6 to 17 should rack up at least 60 minutes of activity daily, according to the Centers for Disease Control and Prevention. And since regular activity boosts health and lifts mood, everyone stands to benefit.

Pick a card

Annelieke Rietsema, an employee health coach and fitness specialist at Newton-Wellesley Hospital, suggests this simple strategy. Take a pack of playing cards and assign different exercises to each suit. For example, hearts could be jumping jacks or bear crawl; diamonds could be burpees or somersaults (if you have room); spades could be mountain climbers or cat-cow; clubs could be knee pushups or squats. Now shuffle or mix up the cards (face down), then start going through the deck. Kids do the number of each exercise on cards numbered 2 to 9. They do 10 of an exercise if a card is an ace, jack, queen, or king. So, a jack of hearts in the spades suit could equal 10 mountain climbers. For an exercise without discrete repetitive movements, like the bear crawl, try assigning a number of seconds based on the card selected (a five of hearts equals five seconds of bear crawl).

Children can do the shuffling and assign exercise choices, even picking simpler or harder exercises depending on age or ability.

Top of the hour

Five-minute or 10-minute energy burns at the top of each hour may help keep the peace. Have kids set a timer and choose easy exercises: running in place, jumping jacks, skipping rope, practicing sit-ups and squats. Children can compete with each other or with friends — from one week to the next, is it getting easier to do certain exercises? Can you do more than you could before?

Creature moves

Challenge younger children to think up and enact the moves of animals and other creatures: waddle like a duck, small hops like a bunny, giant hops like a kangaroo, slither like a snake, jump high like a frog, crawl-walk like a bear, inch forward like a turtle, waggle-dance like a honeybee, flap arms like a bird, crawl sideways like a crab, and so on. Set up indoor races for the quieter moves (crab, duck, snake) and occasional outdoor races for louder critters, to see who reaches the finish line in the least and most time. Extra points for unusual choices.

Personal best

Record how long a child can hop or balance on one foot or the number of push-ups, sit-ups, jumping jacks, or other exercises a child can do in a row. Practice three times a week and track the results once weekly.

Teens and some younger children may enjoy setting goals and logging progress in virtual races. The Healthy Kids Virtual Running Series for children in pre-K to grade 8 has a state-by-state locator to find local races. Many charities are encouraging people of all ages to raise money while walking, running, biking — or even dancing — in virtual events.

Yoga and fitness classes online

Two engaging options are Cosmic Kids, which combines yoga and storytelling into a calming, enjoyable workout for many children, and Go Noodle, which has high-energy video or app games to get kids moving and silly costumes to amuse them. Or you can find free online options, or sample classes available through local gyms, recreation centers, or YMCAs. Be sure to screen fitness videos aimed at children, to check if they are appropriate for your child.

Whatever you choose to help children burn energy, do give a thought to your neighbors. Quieter exercises are best if you live above someone, and mixing in safe outdoor time is good for everyone, parents included. If there’s enough room to move freely while maintaining safe distances, a game of tag or soccer, a bike ride, or just a run, skip, or kangaroo-hop to the end of each block could be fun.

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Can forest therapy enhance health and well-being?

The beauty of the outdoors naturally encourages people to go outside, inhale fresh air, listen to the birds, take a walk, or watch the wind animate the branches of the steadfast neighboring trees. The pull toward the natural world is present even in normal times. Now, as we’re confined indoors by the coronavirus pandemic, often spending hours in front of inanimate screens, the urge to be outside is ever more acute. One way to satisfy these urges while improving our health and well-being is forest therapy, a practice growing in popularity around the world.

What is forest therapy?

Inspired by the Japanese practice of shinrin-yoku, or “forest bathing,” forest therapy is a guided outdoor healing practice. Unlike a hike or guided nature walk aimed at identifying trees or birds, forest therapy relies on trained guides, who set a deliberately slow pace and invite people to experience the pleasures of nature through all of their senses. It encourages people to be present in the body, enjoying the œsensation of being alive and deriving profound benefits from the relationship between ourselves and the rest of the natural world.

Shinrin-yoku started in Japan in the 1980s in response to a national health crisis. Leaders in Japan noticed a spike in stress-related illnesses, attributed to people spending more time working in technology and other industrial work. Certified trails were created to guide people in outdoor experiences. Decades of research show that forest bathing may help reduce stress, improve attention, boost immunity, and lift mood.

How does forest therapy affect the body?

Stress raises levels of the hormone cortisol. Long-term stress and chronic elevations in cortisol play a role in high blood pressure, heart disease, headaches, and many other ailments. In test subjects, levels of cortisol decreased after a walk in the forest, compared with people who walked in a laboratory setting.

Trees give off volatile essential oils called phytoncides that have antimicrobial properties and may influence immunity. One Japanese study showed a rise in number and activity of immune cells called natural killer cells, which fight viruses and cancer, among people who spent three days and two nights in a forest versus people who took an urban trip. This benefit lasted for more than a month after the forest trip!

Don’t worry if you don’t have three days to spend in the forest. A recent study in the United Kingdom of nearly 20,000 people showed that spending at least 120 minutes a week in nature improved self-reported health and well-being. It doesn’t matter whether the 120 minutes represents one long trip, or several shorter visits to nature. So, even as we are honoring physical distancing, we can get outside for 20 minutes every day and enhance our well-being.

Some research suggests exposure to natural tree oils helps lift depression, lowers blood pressure, and may also reduce anxiety. Tree oils also contain 3-carene. Studies in animals suggest this substance may help lessen inflammation, protect against infection, lower anxiety, and even enhance the quality of sleep.

Even people confined to a hospital bed may benefit from viewing nature. A small study published decades ago compared people who recovered from gallbladder surgery in a room with a window onto a natural outdoor view with people who recovered from the same surgery in a hospital room with a view of a brick wall. People who could see nature recovered more quickly and needed less powerful pain medication than people who could not see nature.

And one intriguing study found benefit in green roofs. Participants were asked to look at nature in a green roof or concrete for 40 seconds while the researchers measured attention. According to this study, green spaces are restorative and boost attention, while viewing concrete worsens attention during tasks.

Finding a forest therapy guide

The Association of Nature and Forest Therapy trains and certifies forest therapy guides across the world. Guides help people forge a partnership with nature through a series of invitations that allow participants to become attentive to the forest, to deepen their relationship with nature, and allow the natural world to promote healing and well-being.

Ultimately, guides support what the forests have to offer us, inviting participants into practices that deepen physical presence, pleasure, and partnership with nature. When we connect with nature in this way, we are connecting with ourselves.

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Can celiac disease affect life expectancy?

Celiac disease (CD), triggered by the ingestion of gluten, occurs in people genetically predisposed to develop the chronic autoimmune condition.

During the past few decades, doctors have learned much about how the disease develops, including genetic and other risk factors. However, results from studies on whether people with CD have an increased risk of premature death linked to the condition have been mixed. A recent study shows a small but statistically significant increased mortality rate.

Celiac disease can affect the entire body

Until recently, CD was considered a mainly pediatric gastrointestinal disorder, associated with symptoms of abdominal pain, diarrhea, constipation, and bloating, and characterized by damage to the villi of the small intestine. (Villi are tiny, fingerlike projections lining the small intestine that help the body absorb nutrients.)

With the development of accurate blood tests and large-scale screenings, we have identified CD as a truly systemic disorder that can develop at any age and affect nearly any tissue or organ in the body. People with CD may experience joint pain, osteopenia or osteoporosis, bone fracture, rash, and psychiatric symptoms such as anxiety and depression.

The environmental trigger for CD — gluten — is known. When we remove gluten (a protein found in wheat, rye, and barley) from the diet of people with CD, they usually experience an improvement or resolution of symptoms. Their blood tests return to normal and their small intestine heals.

Celiac disease may affect life expectancy

Studies evaluating CD and mortality have had conflicting results, with some studies showing up to a twofold increase in mortality, and others showing no increased risk. In addition, we have not yet identified how CD may alter life expectancy. Some think that it might be partly related to chronic inflammation, leading to the development of osteopenia and bone fractures, complications from associated conditions such as type 1 diabetes, or rarely, the development of intestinal lymphoma (a type of cancer).

A recent study published in JAMA found a small but significant increased risk of mortality in people with CD. Interestingly, people with CD were at an increased risk of death in all age groups studied, but mortality was greater in those diagnosed between the ages of 18 and 39. Researchers found that the risk of death was increased in the first year after diagnosis, but this persisted even 10 years later. The increase in mortality in patients with CD was related to cardiovascular disease, cancer, respiratory disease, and other unspecified causes.

Dietary changes and routine medical care may help reduce risks

The slight increase in mortality risk does not suggest that we need to manage CD differently. However, these findings do highlight areas for patients and physicians to focus on in an effort to possibly reduce these risks.

For example, research suggests that inadequate intake of whole grains, along with insufficient fiber intake, is a leading cause of disease and death worldwide. Specifically, lower intake of whole grains is associated with increased risk of cardiovascular disease. Given the limitations of a gluten-free diet, it is possible that people with CD eat fewer whole grains than those on an unrestricted diet. Thus, individuals with CD should consume a diet rich in whole grains that do not contain gluten, such as oats, quinoa, and amaranth.

In addition, patients with CD were found to have an increased risk of death related to respiratory disease. As part of routine care after diagnosis, patients should speak with their doctor about pneumococcal vaccines, which can reduce the risk of some respiratory infections. This is not yet common in most healthcare practices, so ask your doctor about this if he or she does not bring it up.

Chronic inflammation is likely a factor in the association of CD with increased mortality. With this in mind, physicians should consider a repeat intestinal biopsy to look for ongoing inflammation, even though this study did not find an increased risk of death in people whose intestine did not heal on a gluten-free diet.

After the intestine has healed, patients should visit their physician and dietitian yearly to review their gluten-free diet, undergo evaluation for other possible autoimmune conditions, and to discuss the need for vitamin supplementation. Routine follow-up care, pneumococcal vaccination, and a diet rich in whole grains, fiber, fruits, and vegetables should also help.

Follow me on Twitter @celiacdoc

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Collaborative care: Treating mental illnesses in primary care

Like most people, you probably do not enjoy going to the doctor only to be referred to a specialist in a different practice. Unfortunately, fragmented care is often the reality among people suffering from common mental illnesses such as depression or anxiety. Wouldn’t it be nice to have both your behavioral and physical health needs addressed at the same time and in the same place?

Comprehensive physical and behavioral health care

In medicine, illnesses of the brain are often treated in specialized settings, separate from the rest of medical care. However, we know that there is a strong link between mental illnesses and numerous medical conditions including heart diseases, lung diseases, immune function, and pain. Mental illnesses can cause or exacerbate physical illnesses, but the reverse is true as well: physical illnesses can result in psychological distress or illness through common pathways such as inflammation. Treating mental illnesses in the primary care setting improves access to mental health care and reduces stigma. Although the burden of mental illnesses in primary care settings is high, many primary care physicians do not feel comfortable managing these conditions alone.

What is collaborative care?

Collaborative care is a team-based model of integrated psychiatric and primary care that can treat mental illnesses in the primary care setting. In our practice, a multidisciplinary “teamlet” of a behavioral health coach, a social worker, and a psychiatrist work together in a coordinated fashion to provide treatment to the patient, and to provide recommendations for the patient’s primary care physician. Treatment is truly patient-centered, and the clinicians often use motivational interviewing to help a patient identify and achieve their behavioral health goals. This model of care is time-limited, generally six sessions every other week for 12 weeks, followed by three monthly maintenance sessions.

Collaborative care helps you meet your goals

Patients may enroll in collaborative care to receive treatment for anxiety or depression, to receive treatment for substance use disorders, or to learn skills to manage stress at work or at home. Goals may include increasing physical activity, setting a quit date for smoking, or practicing mindfulness to reduce anxiety. In addition to behavioral health coaching, the teamlet may also connect a patient to resources (financial, support groups, housing) or provide medication recommendations. To ensure that the patient improves during treatment, collaborative care uses patient-reported outcome measures to drive clinical decision-making, such as symptom rating scales.

Collaborative care during COVID-19

The psychological toll of the pandemic on people infected with the virus and their loved ones is profound. The collaborative care team at our institution has adapted to this surge of distress by providing additional support to patients and their families. Through virtual coaching (by phone or video), coaches have broadened their repertoire to provide specific cognitive behavioral therapy (CBT) interventions to address COVID-19 related anxiety and mood symptoms. Patients have access to COVID-19 workbooks, and they may enroll in internet-based CBT modules that focus on managing anxiety or depressive symptoms related to the pandemic.

What else can help me during this pandemic?

Whether collaborative care is offered at your doctor’s practice or not, there are many available resources to help you and your loved ones cope during these difficult times. In addition to the resources available at health.harvard.edu, there are the free and evidence-based COVID Coach mobile application, the free online course Coping during the pandemic, and the free online meditation resources for times of social distancing/COVID-19 — all wonderful tools to support your mental health. Lastly, there is a reason why behavioral health coaching often involves physical activity — it remains one of the best ways to rapidly improve your mood, decrease anxiety, and boost your overall brain health.

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If cannabis becomes a problem: How to manage withdrawal

Proponents of cannabis generally dismiss the idea that there is a cannabis withdrawal syndrome. One routinely hears statements such as, “I smoked weed every day for 30 years and then just walked away from it without any problems. It’s not addictive.” Some cannabis researchers, on the other hand, describe serious withdrawal symptoms that can include aggression, anger, irritability, anxiety, insomnia, anorexia, depression, restlessness, headaches, vomiting, and abdominal pain. Given this long list of withdrawal symptoms, it’s a wonder that anyone tries to reduce or stop using cannabis. Why is there such a disconnect between researchers’ findings and the lived reality of cannabis users?

New research highlights the problems of withdrawal, but provides an incomplete picture

A recent meta-analysis published in JAMA cites the overall prevalence of cannabis withdrawal syndrome as 47% among “individuals with regular or dependent use of cannabinoids.” The authors of the study raise the alarm that “many professionals and members of the general public may not be aware of cannabis withdrawal, potentially leading to confusion about the benefits of cannabis to treat or self-medicate symptoms of anxiety or depressive disorders.” In other words, many patients using medical cannabis to “treat” their symptoms are merely caught up in a cycle of self-treating their cannabis withdrawal. Is it possible that almost half of cannabis consumers are actually experiencing a severe cannabis withdrawal syndrome — to the point that it is successfully masquerading as medicinal use of marijuana — and they don’t know it?

Unfortunately, the study in JAMA doesn’t seem particularly generalizable to actual cannabis users. This study is a meta-analysis — a study which includes many studies that are deemed similar enough to lump together, in order to increase the numerical power of the study and, ideally, the strength of the conclusions. The authors included studies that go all the way back to the mid-1990s — a time when cannabis was illegal in the US, different in potency, and when there was no choice or control over strains or cannabinoid compositions, as there is now. One of the studies in the meta-analysis included “cannabis dependent inpatients” in a German psychiatric hospital in which 118 patients were being detoxified from cannabis. Another was from 1998 and is titled, “Patterns and correlates of cannabis dependence among long-term users in an Australian rural area.” It is not a great leap to surmise that Australians in the countryside smoking whatever marijuana was available to them illegally in 1998, or patients in a psychiatric hospital, might be substantively different from current American cannabis users.

Medical cannabis use is different from recreational use

Moreover, the JAMA study doesn’t distinguish between medical and recreational cannabis, which are actually quite different in their physiological and cognitive effects — as Harvard researcher Dr. Staci Gruber’s work tells us. Medical cannabis patients, under the guidance of a medical cannabis specialist, are buying legal, regulated cannabis from a licensed dispensary; it might be lower in THC (the psychoactive component that gives you the high) and higher in CBD (a nonintoxicating, more medicinal component), and the cannabis they end up using often results in them ingesting a lower dose of THC.

Cannabis withdrawal symptoms are real

 All of this is not to say that there is no such thing as a cannabis withdrawal syndrome. It isn’t life-threatening or medically dangerous, but it certainly does exist. It makes absolute sense that there would be a withdrawal syndrome because, as is the case with many other medicines, if you use cannabis every day, the natural receptors by which cannabis works on the body “down-regulate,” or thin out, in response to chronic external stimulation. When the external chemical is withdrawn after prolonged use, the body is left in the lurch, and forced to rely on natural stores of these chemicals — but it takes time for the natural receptors to grow back to their baseline levels. In the meantime, the brain and the body are hungry for these chemicals, and the result is withdrawal symptoms.

Getting support for withdrawal symptoms

Uncomfortable withdrawal symptoms can prevent people who are dependent or addicted to cannabis from remaining abstinent. The commonly used treatments for cannabis withdrawal are either cognitive behavioral therapy or medication therapy, neither of which has been shown to be particularly effective. Common medications that have been used are dronabinol (which is synthetic THC); nabiximols (which is cannabis in a mucosal spray, so you aren’t actually treating the withdrawal); gabapentin for anxiety (which has a host of side effects); and zolpidem for the sleep disturbance (which also has a list of side effects). Some researchers are looking at CBD, the nonintoxicating component of cannabis, as a treatment for cannabis withdrawal.

Some people get into serious trouble with cannabis, and use it addictively to avoid reality. Others depend on it to an unhealthy degree. Again, the number of people who become addicted or dependent is somewhere between the 0% that cannabis advocates believe and the 100% that cannabis opponents cite. We don’t know the actual number, because the definitions and studies have been plagued with a lack of real-world relevance that many studies about cannabis suffer from, and because the nature of both cannabis use and cannabis itself have been changing rapidly.

How do you know if your cannabis use is a problem?

The standard definition of cannabis use disorder is based on having at least two of 11 criteria, such as: taking more than was intended, spending a lot of time using it, craving it, having problems because of it, using it in high-risk situations, getting into trouble because of it, and having tolerance or withdrawal from discontinuation. As cannabis becomes legalized and more widely accepted, and as we understand that you can be tolerant and have physical or psychological withdrawal from many medicines without necessarily being addicted to them (such as opiates, benzodiazepines, and some antidepressants), I think this definition seems obsolete and overly inclusive. For example, if one substituted “coffee” for “cannabis,” many of the 160 million Americans who guzzle coffee on a daily basis would have “caffeine use disorder,” as evidenced by the heartburn and insomnia that I see every day as a primary care doctor. Many of the patients that psychiatrists label as having cannabis use disorder believe that they are fruitfully using cannabis to treat their medical conditions — without problems — and recoil at being labeled as having a disorder in the first place. This is perhaps a good indication that the definition doesn’t fit the disease.

Perhaps a simpler, more colloquial definition of cannabis addiction would be more helpful in assessing your use of cannabis: persistent use despite negative consequences. If your cannabis use is harming your health, disrupting your relationships, or interfering with your job performance, it is likely time to quit or cut down drastically, and consult your doctor. As part of this process, you may need to get support or treatment if you experience uncomfortable withdrawal symptoms, which may make it significantly harder to stop using.

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Combining different biopsies limits uncertainty in prostate cancer diagnosis

Are prostate cancer biopsies reliably accurate?

Not always.

The most common method, called a systematic biopsy, sometimes misses tumors, and it can also misclassify cancer as being either more or less aggressive than it really is. During systematic biopsy, a doctor takes 12 evenly-spaced samples of the prostate, called cores, while looking at the gland with an ultrasound machine.

A new method, called MRI-targeted biopsy, guides doctors to suspicious abnormalities in the prostate, and emerging evidence suggests that it’s better at detecting high-grade, aggressive tumors that need immediate treatment. These biopsies require doctors to get an MRI of the prostate first. Computer software then fuses the high-resolution MRI scan with ultrasound images gathered in real time during the biopsy procedure. Since doctors only sample from where the MRI reveals possible evidence of cancer, they can take fewer cores.

Some experts are now saying that systematic biopsies should be replaced by the MRI-targeted approach, even though it requires specialized training, and is generally available today only in large academic cancer centers.

However, new evidence suggests that the best way to reduce diagnostic uncertainties is to take both biopsies together. The findings come from a study performed at the National Cancer Institute in Bethesda, Maryland.

Investigators enrolled 2,103 men with suspected prostate cancer based on abnormal PSA readings and digital rectal exams. Each was given an MRI-targeted biopsy, followed immediately by a systematic biopsy. Cancer was detected in 1,312 of the men, and 404 of them were surgically treated. The investigators wanted to compare the two biopsy methods in terms of being able to find cancer and classify it correctly as high- or low-grade. The surgically removed prostate specimens provided a final confirmation.

As it turned out, 208 more cancers were detected by giving both biopsies together than by giving systematic biopsies alone, and 59 of the additional cancers were in high-risk categories. MRI-targeted biopsies by themselves detected 91% of the high-risk cancers identified by both techniques combined. But they also made some incorrect calls: 123 men classified by MRI-targeted biopsies as having low-risk prostate cancer actually had intermediate-risk disease. And 41 men classified by the MRI approach as having low- or intermediate-risk tumors actually had high-risk cancer.

The investigators emphasized these figures in their conclusion. The combined biopsy, they wrote, “has high predictive value… reduces the likelihood of misdiagnosis, and should translate to decreased diagnostic uncertainty.”

“This is an important study, as it adds significantly to the ongoing evolution of identifying the roles and limitations of traditional systematic biopsies, MRI-targeted biopsies, and the combination of both,” says 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. “Again, as with many ultra-sophisticated technologies, significant training and expertise is needed in both the actual performance of the MRI-targeted biopsy itself and its interpretation.”

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When dieting doesn’t work

At any given time, more than a third of Americans are on a specific diet, with weight loss as a leading reason. Most are going to be disappointed, because even when successful, lost weight is frequently regained within a few months.

While most weight-loss diets can help you lose weight, they may be unsuccessful over the long run for a number of reasons. Some people don’t follow their diets carefully and don’t lose much weight even from the start. Others may go off the diet entirely after a while, because it’s too restrictive or the foods aren’t appealing. Some may engage in less physical activity as they consume fewer calories. But who hasn’t heard of someone doing everything right and still losing minimal weight, or regaining lost weight over time? Perhaps that someone is you.

Even when research studies confine study subjects to a research setting — with carefully-controlled calories, food types, and physical activity, and with intensive counselling, teaching, and monitoring — the lost weight and other health benefits (such as improved cholesterol and reduced blood pressure) tend to disappear soon after the study ends.

You can’t pick the right diet if none of them work

According to a new study, popular diets simply don’t work for the vast majority of people. Or more accurately, they are modestly effective for a while, but after a year or so the benefits are largely gone.

In a large systematic review and meta-analysis, recently published in the medical journal The BMJ, researchers analyzed 121 trials that enrolled nearly 22,000 overweight or obese adults who followed one of 14 popular diets, including the Atkins diet, Weight Watchers, Jenny Craig, DASH, and the Mediterranean diet, for an average of six months. The diets were grouped into one of three categories: low-carbohydrate, low-fat, and moderate-macronutrient (diets in this group were similar to those in the low-fat group, but with slightly more fat and slightly less carbohydrate). Loss of excess weight and cardiovascular measures (including cholesterol and blood pressure) while on one of these diets were compared with other diets or usual diets (one in which the person continued to eat as they usually do).

While weight, blood pressure, and cholesterol measures generally improved at the six-month mark, results at the 12-month mark were disappointing, to say the least.

• While low-carbohydrate and low-fat diets both resulted in weight loss of about 10 pounds at six months, most of the lost weight was regained within one year. People in the moderate macronutrient group tended to lose less weight than those following the other diets.
• Blood pressure and cholesterol results improved modestly at six months, but generally returned to where they started after a year. One exception was noted: reduced LDL (“bad”) cholesterol levels while on the Mediterranean diet persisted at one year.
• There were no major differences in other health benefits between the various diet programs.

All is not lost

Based on this new report, you might be tempted to throw up your hands and give up on weight-loss diets altogether. But there’s another way of looking at this: it probably matters less which plan you pick (whether low-carb, low-fat, or something in between) than whether you stick with it.

The average duration of the studies included in this analysis was six months. What if they’d lasted 12 months, or two years, or a lifetime? The benefit would likely have been greater and more long-lasting. The trick is to pick a diet with foods you actually like so that it’s not so hard to stick with it.

In addition, there are factors other than diet that can have a big impact on weight. For example, everyday physical activity, regular exercise, and sleep are important in helping to maintain a healthy weight.

Rather than following a highly restrictive or named diet, I endorse the Mediterranean diet. It’s among the best studied, performs well when compared with other diets (as in this analysis), and was the only diet in this analysis to have long-lasting effects on LDL cholesterol levels.

The bottom line

Losing weight is not easy. If you’re struggling with your weight, talk to your doctor, a nutritionist, and perhaps a health coach. Review this study with them and, together, decide on dietary and other lifestyle changes that appeal to you. Then stick with them. Remember, you’re most likely to stick with lifestyle changes you actually like.

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Reducing your risk of changes in thinking following surgery

Cognition is an important function of the brain that enables us to acquire and process information, to enhance our understanding of thoughts, experiences, and our senses. Any condition that affects our ability to think, reason, memorize, or be attentive affects our cognitive ability. Some cognitive decline is a normal part of aging, but there are many things you can do to prevent or forestall cognitive changes as you age, including when planning for surgery.

Older adults are having more surgical procedures

As our population ages and medicine and healthcare advances, more older adults are likely to develop serious conditions (like heart problems) and undergo surgical procedures to treat or manage these conditions. Recent surveys suggest that progress in surgical techniques and control of anesthesia has increased surgical procedures in older people, with approximately 30% of all surgeries being conducted in people over the age of 70.

While advances in medicine may help people live longer, older adults are more likely to develop complications due to surgery. Some research suggests approximately one-quarter of those over 75 undergoing major surgery will develop significant cognitive decline, and about half of those people will suffer permanent brain damage.

Why do surgery and anesthesia cause problems with thinking for older adults?

There are degenerative changes in the brain with aging that predispose people to cognitive changes from surgery. Hence, age is a risk factor that needs to be considered when making decisions about surgery. Education level, mental health, and pre-existing medical conditions are also factors that affect an older person’s postsurgical cognitive functioning. People with higher levels of education tend to have more active brains due to regular mental stimulation. Mental and social activities promote brain health and decrease the risk of dementia and cognitive decline with normal aging.

Pre-existing medical conditions such as obesity, hypertension, coronary artery disease, diabetes, chronic kidney disease, stroke, and dementia predispose older adults undergoing surgery to more risk of postoperative cognitive decline. The reason these diseases cause cognitive decline is related to systemic inflammatory markers in the blood — proteins that are released into the bloodstream as a result of inflammation in the body. These markers enter the brain following a break in the blood-brain barrier (protective membrane) during the postoperative period, resulting in inflammation in the brain. This blood-brain barrier dysfunction is frequently seen in older people (even in the absence of surgery), and has been seen in approximately 50% of patients undergoing cardiac surgery.

Does the type of surgery and anesthesia matter?

Many surgical factors and techniques, blood pressure fluctuations during surgery, and longer time in surgery can adversely affect the cognitive function of older patients. Each factor affects cognitive functioning in a unique way. Younger patients tend to respond better to surgical stresses compared to older people.

Minor surgical procedures such as skin biopsies, excision of cysts, suturing of lacerations, and related procedures performed on an outpatient basis are unlikely to result in cognitive decline. However, as the complexity of a surgical procedure increases, with longer operative periods and greater exposure to more anesthesia medication, the likelihood of postoperative cognitive decline increases. This is especially true for cardiac surgery.

Studies suggest that incidence of postoperative cognitive decline is approximately 30% to 80% after cardiac surgery, while for noncardiac surgeries the prevalence is approximately 26%. While all major surgeries (such as orthopedic, abdominal, or gynecological) pose a risk for cognitive decline, cardiac surgeries have a much higher proportion of cognitive decline after surgery. The most common determinants of cognitive decline involving cardiac surgical procedures are the presence of pre-existing cognitive dysfunction and the use of bypass machines to replace the function of the heart and lungs during the surgery.

Anesthesia management before and during surgery affects what happens after surgery

The perioperative period refers to the time span of a surgical procedure, and includes three phases: preoperative, operative, and postoperative. Anesthesia management encompasses all three phases. The type and dose of anesthesia medication, the use of opioid analgesics, fluid, and glucose management can all influence a person’s cognitive function in the perioperative period. The use of multimodal anesthesia (where a combination of intravenous medications is used, instead of only inhaled agents) may protect against some cognitive dysfunction, as may using non-opioid analgesics for pain management in the postoperative period.

Are there strategies to avoid cognitive decline in the postoperative period?

Benjamin Franklin once said, “An ounce of prevention is worth a pound of cure.”  No other condition exemplifies this saying better than preventing postoperative cognitive decline.

The following are some strategies you and your caregivers can use to prepare for surgery.

Before surgery is scheduled:

• Eat healthy, balanced meals. Foods rich in polyunsaturated fatty acids are protective for your brain health.
• Exercise regularly, or as much as allowed by your cardiac conditions. Physical activity promotes brain health.
• Maintain a healthy weight.
• Remain socially active and connected.
• Reduce stress. Meditation significantly reduces stress and promotes a sense of calm and overall well-being.
• Practice good sleep habits and try to get six to eight hours of sleep a night.

When surgery is scheduled:

Schedule a comprehensive geriatric assessment. This enables your physician to diagnose reversible aspects of frailty preoperatively (if they exist) and take adequate measures in a timely manner, such as altering medications you may be taking, and/or postponing surgery if you are extremely frail, to improve nutrition and incorporate lifestyle changes.

Talk to your surgeon about the risks and complications of the procedure. If you are having heart surgery, ask if a cardiopulmonary bypass machine will be used, and whether it is important to your surgery.

Talk to your anesthesiologist about

• The types of medications they plan to use, and if there are alternatives for those medications. Have a conversation about need for opioid analgesics, and if alternative non-opioid pain medication can be used to decrease the risk of postoperative cognitive decline.
• The methods of measuring medications that can reduce your risk of cognitive changes. For example, use of EEG machines during surgical procedures enhances the anesthesiologist’s ability to monitor the depth of anesthesia. Anesthesia depth is the degree to which the central nervous system is depressed by an anesthetic medication. EEG monitoring will result in adequate usage of anesthetic agents, avoid overuse, and reduce risk for postoperative cognitive decline by reducing anesthesia exposure.
• Gather relevant information on your perioperative management. Discuss which medications you currently take and should continue taking, and which ones should be avoided.

After surgery and during recovery:

• Make sure you have adequate control of pain with medications, and consider trying mind-body therapies, including meditation.
• Keep active (walking, physical therapy, rehab), which prevents postoperative complications.
• Have friends and family around to enhance recovery and provide social stimulation.
• Practice behaviors that are help improve sleep, even when you’re recovering in the hospital.

Caregivers need to be informed about the need for keeping their loved one active and following physical rehab recommendations, and providing mental stimulation in the postoperative period. Puzzles, sudoku, board games, books, etc., will keep someone entertained while simultaneously providing them with some brain activity.

Finally, it is necessary to understand that although there is no cure for postoperative cognitive decline, preventive strategies and pre-planning with your team of surgeons, anesthesiologists, and geriatricians can help reduce the risks of cognitive problems that older adults often face following surgery.

References

Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis. The American Journal of Surgery, August 2019.

Postoperative cognitive dysfunction — current preventive strategies. Clinical Interventions in Aging, November 8, 2018.

Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms. Anesthesiology, October 2018.

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Are there benefits of cardiac catheterization for stable coronary artery disease?

One of the main causes of chest pain is a blockage of blood flow down the coronary arteries, the blood vessels that deliver oxygenated blood to our heart muscle to allow it to beat. Depending on how fast the blockage forms, it is labeled as either a stable or unstable blockage.

Unstable blockages occur quickly when an atherosclerotic plaque ruptures within the coronary artery and a clot forms on top of it. The clot, along with the plaque, can obstruct blood flow, deprive heart muscle of oxygen, and lead to a heart attack. This is called an acute coronary syndrome, and it frequently requires a minimally invasive procedure called a cardiac catheterization to diagnose the blockage and then provide options to treat it.

When the buildup of plaque in the coronary arteries occurs gradually, most patients have little to no symptoms. As the blockage expands over time, patients can experience chest pain with activity that usually goes away with rest. When a blockage causes this predictable pattern of chest pain, it is called stable coronary artery disease (CAD). A cardiac catheterization may or may not be needed to manage stable CAD.

Stress tests

A stress test can be used to determine the likelihood of having a coronary artery blockage. The main goal of the test is to see how your heart works during physical activity. Because exercise makes your heart pump harder and faster, an exercise stress test can reveal problems with blood flow within the coronary arteries. Certain types of stress tests can even detect how much of the heart has ischemia, or inadequate blood supply.

A stress test usually involves walking on a treadmill or riding a stationary bike while your blood pressure, heart rate and rhythm, and symptoms are closely monitored. (Some patients are given medications that imitate the effects of exercise because they are unable to exercise.) Depending on the type of stress test, some patients are given a radioactive tracer to help create an image of how well blood is reaching different parts of their heart muscle, both during exercise and while at rest, to detect ischemia. If the stress test is abnormal, patients may need cardiac catheterization to confirm the presence of any potential blockages, and possibly even undergo invasive treatment of them.

What is cardiac catheterization?

Cardiac catheterization is a diagnostic procedure that involves taking a long, thin tube called a catheter and threading it within an artery in the arm or leg to get to the coronary arteries. The coronary arteries are then injected with contrast dye to look for blockages.

Depending on the location and severity, the blockages can be treated with medications alone; with angioplasty plus stent placement (expanding a balloon located at the end of the catheter to open the blockage and placing a stent), which can be done during the cardiac catheterization procedure; or with open-heart surgery to reroute blood around the blockage (coronary artery bypass surgery, or CABG).

Studies have shown that cardiac catheterization, followed by angioplasty and stenting or CABG, can improve survival and decrease heart attacks in patients with acute coronary syndromes. But what are the benefits of cardiac catheterization in stable CAD?

Cardiac catheterization or medications only to treat stable CAD?

An older trial, known as the COURAGE trial, found that in patients with stable CAD, stenting plus medication therapy did not reduce the risk of death, heart attack, or other major cardiovascular events compared to medication therapy alone. However, stenting did provide symptom relief much quicker than medication therapy alone.

More recently, the ISCHEMIA trial, published in the New England Journal of Medicine, examined a subset of stable CAD patients with moderate to severe ischemia on stress testing. The researchers compared outcomes in patients who underwent cardiac catherization, along with angioplasty with stenting or CABG when feasible, plus medications, to patients who received medication therapy alone. The study found that there was no difference between the two groups in the primary endpoint (a combination of death from cardiovascular causes, heart attack, cardiac resuscitation, or hospitalizations for unstable chest pain or heart failure).

The ISCHEMIA trial did find that there was a small increase in procedural heart attacks (damage to the heart muscle caused by an interruption in blood flow to the heart during the procedure) in patients who underwent cardiac catheterization. But there was an even greater increase in spontaneous heart attacks in patients who did not undergo cardiac catheterization. The study also found that patients who underwent cardiac catheterization had more symptom relief than medication therapy alone.

The bottom line

The ISCHEMIA trial failed to show an outright benefit of cardiac catheterization (along with angioplasty with stenting or CABG when feasible, plus medications), compared to medications alone. As a result, treatment guidelines continue to recommend that all patients with stable CAD should first have their medications increased to maximally tolerated doses. However, cardiac catheterization would be very appropriate if such patients continue to have unacceptable symptoms, have poor tolerance to their medication therapy, or both.

Follow me on Twitter @DrDarshanDoshi

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Some healthcare can safely wait (and some can’t)

Among the many remarkable things that have happened since the COVID-19 pandemic began is that a lot of our usual medical care has simply stopped.

According to a recent study, routine testing for cervical cancer, cholesterol, and blood sugar is down nearly 70% across the country. Elective surgeries, routine physical examinations, and other screening tests have been canceled or rescheduled so that people can stay at home, avoid being around others who might be sick, and avoid unknowingly spreading the virus. Many clinics, hospitals, and doctors’ offices have been closed for weeks except for emergencies. Even if these facilities are open, there’s understandable reluctance to seek medical care where an infected person may have been just before you. So which health concerns can safely wait — and which should not?

What can wait?

It’s safe to put off some healthcare for a number of weeks or months.

• Routine screening tests. For example, a mammogram may be recommended every year or two for women at average risk of breast cancer. In that situation, it’s unlikely that having that test a few months late will affect your health. Similarly, if you’re due for a screening colonoscopy because you’ve turned 50 or your last one was 10 years ago, having it a few months late is not a risky delay. For some tests, there are alternatives you could have in the meantime. For example, there is home testing available for colon cancer screening that checks the stool for blood or abnormal DNA (findings that could indicate the presence of cancer). Each person’s situation is a bit different, so if you’re due for a screening test and can’t have it due to the pandemic, call your doctor about how to proceed.
• Routine vaccinations. Usually, it’s safe for adults to briefly put off routine vaccinations. Ask your doctor which vaccinations are time-sensitive and which can wait. For example, a shingles vaccine requires a second dose within a specific window of time after the first dose.
• Routine physical examinations. If you are feeling well and you have no pressing health concerns, delaying your exam for a few weeks or months is fine. In fact, the usefulness of routine annual physical examinations has been debated for some time, so even if you skip a year, it might not matter.
• Elective surgery. A good example is knee replacement for osteoarthritis: if you had surgery planned in April, there’s a good chance it was cancelled. That might be fine if you are able to get around and can tolerate the arthritis pain with medications. Hopefully, you can reschedule within a few weeks of the original date. But some elective surgery is more urgent than others, so review the timing with your doctor.

Thank goodness for telehealth

Video conferencing and telephone visits with doctors, nurses, and other healthcare professionals have filled the healthcare void admirably. We are realizing that a lot can be accomplished without coming into the office or hospital. Especially with the help of home equipment (such as a blood pressure cuff), you can be monitored well for hypertension, diabetes, asthma, and a host of other conditions with virtual visits. Mental health care can often be successfully provided by telehealth.

Sometimes your presence is required

Of course, some medical care simply cannot be provided by telehealth. Your doctor cannot perform procedures (such as draining an abscess) or an operation without your physical presence. A physical examination to feel a lump or search for an enlarged liver, an x-ray or other imaging test, and most blood tests require you to come in. It can be hard to evaluate a rash, look in your throat, or assess a sore joint without your being there. And if you had an abnormal test (such as a mammogram), you may be encouraged to come in for follow-up testing or evaluation. While a month or two of delay may not matter for some of these issues, for others it does.

Some healthcare cannot wait

What problems should prompt you to seek medical care even during a pandemic?

In recent months, reports from news media and healthcare providers in some parts of the US suggest that fewer people are coming to the emergency department with heart attacks, strokes, and other non-COVID health problems (see here, here, and here).

How can this be? Some problems, such as injuries from car accidents, may have become less common because people are staying in and driving less. But many conditions that land people in emergency rooms don’t go away during a pandemic. So what happened to the people having these problems?

The answer is almost surely that they are staying home and riding it out, avoiding exposure to those who might be infected with the new coronavirus, or wanting to do their part to limit emergency room overcrowding. Some may be concerned they’ll be turned away if they do show up.

But it’s risky to put off medical care for potentially serious problems, such as those on the list below. Complications of these conditions can be life-threatening, and a trip to the emergency room or urgent care is warranted.

When to seek emergency care

Call 911 or seek emergency medical care right away if you experience

• trouble breathing
• persistent chest pain or pressure, especially if you have a history of heart problems
• persistent and severe pain, such as abdominal or pelvic pain
• unexplained loss of consciousness, confusion, or a change in mental state (such as being unusually agitated or speaking incoherently)
• unexplained and persistent weakness in muscles of your arms, legs, or face that affects your ability to move or speak
• loss of vision
• an accident that impairs function, such as falling and then not being able to bear weight on your hip
• uncontrollable bleeding
• coughing up or vomiting blood
• suicidal feelings or acts.

Use your own experience as a guide. If you’ve had a serious illness in the past and now have the same worrisome symptoms, seek medical attention.

Thinking of heading to the ED?

Many emergency rooms and hospitals are crowded right now. It’s a good idea to call ahead, so the emergency providers know you’re coming and can give you advice about where to show up. If there’s time, put on a mask and wash your hands once more before leaving for the ED.

One other caveat: if you have typical symptoms of COVID-19 and your symptoms are not severe, call your doctor or local public health officials for guidance. In that situation, it may be best to avoid the emergency room; arranging testing and managing at home may be recommended.

The bottom line

The pandemic is teaching us a lot about what happens when non-urgent healthcare largely shuts down. Some of what we learn will be useful long after the pandemic is over. For example, if virtual visits are proven to be just as effective as an in-person visit, we can expect telehealth to become much more common. We may learn that we can safely take care of many chronic conditions with fewer visits. Years from now, researchers may be able to sort out what types of visits were just as good virtually and which ones were most prone to mistakes. And we might even find out that some medical care previously considered important is actually unnecessary after all.

In the meantime, here’s some advice that’s unchanged by the pandemic: if you have an emergency, seek medical care right away. And if you aren’t sure how to proceed, don’t hesitate to discuss it with your doctor.

Follow me on Twitter @RobShmerling

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How to respond to tantrums

As Murphy’s Law would have it, children’s tantrums seem to happen at the most inconvenient times. Your toddler or independent-minded 3-year-old turns red, screams, stomps, and appears possessed when you’ve finally gotten everyone geared up for a family walk, or wrangled that video call you spent days coordinating with relatives to get everyone live at once — or even worse, when you need silence for your weekly video conference call at work.

“What’s gotten into you? We don’t have time for this!” you might think. Everything you say and do seems to make the tantrum worse, and it takes all of your remaining resources not to throw a tantrum yourself. What can you do instead when your child throws a tantrum? Below is a three-step strategy that can help.

Validate the emotions behind the tantrum

Validating someone’s emotions means acknowledging them. You are not agreeing or disagreeing with the feelings; you are demonstrating that you hear the other person.

You likely have noticed that logic does not go over well with a child throwing a tantrum. For example, let’s say your child throws a tantrum while demanding a cookie before dinner. “Why are you so unhappy? You know you cannot have dessert before dinner,” you point out logically. Most likely, the child’s ears will close, and the tantrum will escalate because they don’t feel heard. Instead, validating their emotions can help them identify how they are feeling, which is one step toward helping them regulate or calm their emotions.

In this case, you can state, “You’re angry with me because I won’t give you a cookie before dinner.” Sometimes, you might just validate the feeling and leave it at that. Other times, a second clause helps illustrate that two opposing statements can be true at the same time: “You’re angry with me because I won’t give you a cookie before dinner, and you can have one after dinner.” If you’re trying this, it’s important to use the conjunction “and” and not “but.” That way, you won’t negate the first part of the clause.

Your child probably won’t smile and agreeably walk away. However, validating can prevent an escalation of the tantrum and curtail the intensity of the emotion.

Actively ignore dandelions

Any behavior that gets attention will continue. Imagine a garden: your child is the rose that needs just the right amount of sunlight and water; the dandelions are the unhelpful behaviors, such as tantrums. If you so much as blink in a dandelion’s direction, you know that you will have a garden full of dandelions. This is why after validating once, the next step is to ignore.

Some parents are concerned that they aren’t doing anything when they ignore. You are; you are ignoring actively, which takes effort. This will be very tough. Expect the behavior to get worse before it gets better (what is known as an “extinction burst”). Remind yourself that you are ignoring the dandelions and not your child. Pay attention to anything else: pick the lint off your sweater, do the dishes, or count the clouds in the sky. Do not water the dandelions, though. If you ignore actively for 10 minutes and then eventually shout at your child or just give the child the cookie, the child will learn that he needs to push longer to get attention or the desired outcome. Then you will have even more dandelions in your garden.

Praise cooperative behavior

The moment your child re-engages in a cooperative manner, praise your child enthusiastically and specifically. For example, “Way to go on joining us at the dinner table respectfully! I am really proud of you.” If you start to hear pleading for a cookie again, go back to ignoring the dandelions. When the rose — your child — returns, provide more praise. You may feel silly bouncing back and forth, but it’s important to water the appropriate flower in the garden — that is, the behavior you want to see.

These strategies apply even when you are in public. Understandably, you may be concerned about what others think of you as a parent while you actively ignore the tantrum. Some parents worry that others are imagining that they do not know how to handle their children. You also might feel utterly humiliated and helpless that you cannot control your child’s behavior.

As you take a deep breath, remember this: you certainly are not the first parent to have a child throw a tantrum in public. Other parents around you likely were in your shoes not long before you. If you feel compelled to do so, you can let others around you know that you are ignoring actively to help your child settle down.

No matter where the tantrums occur, validate your feelings, too. Feeling frustrated or embarrassed is understandable. Remember, though, that the rose will return if you do not water the dandelions.

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I have inflammatory bowel disease (IBD). What should I eat?

One of the most frequent questions that patients with inflammatory bowel disease (IBD) ask is: what should I eat?

It is clear that in addition to genetic factors, certain environmental factors, including diet, may trigger the excessive immune activity that leads to intestinal inflammation in IBD, which includes both Crohn’s disease and ulcerative colitis (UC). However, the limited number and high variability of studies have made it difficult to confidently advise patients regarding which specific foods might be harmful and which are safe or may actually provide a protective benefit.

New IBD dietary guidelines

To help patients and providers navigate these nutritional questions, the International Organization of IBD (IOIBD) recently reviewed the best current evidence to develop expert recommendations regarding dietary measures that might help to control and prevent relapse of IBD. In particular, the group focused on the dietary components and additives that they felt were the most important to consider because they comprise a large proportion of the diets that IBD patients may follow.

The IOIBD guidelines include the following recommendations:

Food	If you have Crohn’s disease	If you have ulcerative colitis
Fruits	increase intake	insufficient evidence
Vegetables	increase intake	insufficient evidence
Red/processed meat	insufficient evidence	decrease intake
Unpasteurized dairy products	best to avoid	best to avoid
Dietary fat	decrease intake of saturated fats and avoid trans fats	decrease consumption of myristic acid (palm, coconut, dairy fat), avoid trans fats, and increase intake of omega-3 (from marine fish but not dietary supplements)
Food additives	decrease intake of maltodextrin-containing foods	decrease intake of maltodextrin-containing foods
Thickeners	decrease intake of carboxymethylcellulose	decrease intake of carboxymethylcellulose
Carrageenan (a thickener extracted from seaweed)	decrease intake	decrease intake
Titanium dioxide (a food colorant and preservative)	decrease intake	decrease intake
Sulfites (flavor enhancer and preservative)	decrease intake	decrease intake

The group also identified areas where there was insufficient evidence to come to a conclusion, highlighting the critical need for further studies. Foods for which there was insufficient evidence to generate a recommendation for both UC and Crohn’s disease included refined sugars and carbohydrates, wheat/gluten, poultry, pasteurized dairy products, and alcoholic beverages.

How would observing these guidelines help?

The recommendations were developed with the aim of reducing symptoms and inflammation. The ways in which altering the intake of particular foods may trigger or reduce inflammation are quite diverse, and the mechanisms are better understood for certain foods than others.

For example, fruits and vegetables are generally higher in fiber, which is fermented by bacterial enzymes within the colon. This fermentation produces short-chain fatty acids (SCFAs) that provide beneficial effects to the cells lining the colon. Patients with active IBD have been observed to have decreased SCFAs, so increasing the intake of plant-based fiber may work, in part, by boosting the production of SCFAs.

However, it is important to note disease-specific considerations that might be relevant to your particular situation. For example, about one-third of Crohn’s disease patients will develop an area of intestinal narrowing, called a stricture, within the first 10 years of diagnosis. Insoluble fiber can worsen symptoms and, in some cases, lead to intestinal blockage if a stricture is present. So, while increasing consumption of fruits and vegetable is generally beneficial for Crohn’s disease, patients with a stricture should limit their intake of insoluble fiber.

Specific diets for IBD?

A number of specific diets have been explored for IBD, including the Mediterranean diet, specific carbohydrate diet, Crohn’s disease exclusion diet, autoimmune protocol diet, and a diet low in fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs).

Although the IOIBD group initially set out to evaluate some of these diets, they did not find enough high-quality trials that specifically studied them. Therefore, they limited their recommendations to individual dietary components. Stronger recommendations may be possible once additional trials of these dietary patterns become available. For the time being, we generally encourage our patients to monitor for correlations of specific foods to their symptoms. In some cases, patients may explore some of these specific diets to see if they help.

New guidelines are a good place to start

All patients with IBD should work with their doctor or a nutritionist, who will conduct a nutritional assessment to check for malnutrition and provide advice to correct deficiencies if they are present.

However, the recent guidelines are an excellent starting point for discussions between patients and their doctors about whether specific dietary changes might be helpful in reducing symptoms and risk of relapse of IBD.

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And now for some good news on health

When it comes to health concerns, the COVID-19 pandemic is top of mind for most people right now. And that’s for good reason.

But there is some very good non-COVID health news that may not be getting the attention it deserves. According to the CDC, the rates of six of the top 10 causes of death in this country, which account for about three-quarters of all deaths, have been declining. That’s remarkable. And these improvements are occurring despite an aging population and an obesity epidemic that affects several health conditions.

Six positive health trends

Let’s look at the trends in these conditions and their rank as causes of death in the US:

• Heart disease (#1) and stroke (#5): Deaths due to cardiovascular disease, including heart attacks and stroke, fell by about 36% between 2000 and 2014. The decline for heart disease since 2014 appears to have continued through 2018. After leveling off for several years, stroke-related deaths dropped again (by 1.3%) from 2017 to 2018.
• Cancer (#2): The drop in cancer deaths was about 2% between 2017 and 2018. Over the last 25 years it has dropped by 29%.
• Unintentional injuries (#3), including drug overdoses, and chronic lower respiratory diseases (#4), such as emphysema and asthma: Each of these categories dropped by nearly 3% from 2017 to 2018.
• Alzheimer’s disease (#6): Deaths fell 1.6%, even though the prevalence of this devastating illness is increasing.

The cholesterol connection

Another positive trend is that cholesterol levels across the US population have been moving in the right direction over the last 20 years. About 18% of Americans had a high total cholesterol in 1999; as of 2018, just 10.5% had high levels. Meanwhile, about 22% of the population had low HDL (“good”) cholesterol; that number fell to 16% in 2018. Because high total cholesterol and low HDL cholesterol are risk factors for cardiovascular disease, these improvements may at least partly explain why cardiovascular disease mortality rates are falling.

And fewer people are smoking

There’s also good news with respect to the popularity of cigarette smoking. According to the CDC, the percent of the population that smokes cigarettes is dropping significantly. In 2017 it fell to 14%, an all-time low since such statistics have been collected. This represents a steady drop from 2006, when nearly 21% of people were smokers.

Over time, fewer smokers means lower rates of smoking-related illness, including several of the top 10 causes of death like chronic lung disease, lung cancer, and cardiovascular disease.

Notably, this survey did not include vaping, which has been rapidly gaining popularity in recent years. Some former cigarette smokers are now vaping, as are many adolescents and young adults. So the good news about falling smoking rates could be at least partially offset by potential negative health consequences of vaping, including e-cigarette or vaping-associated lung injury (EVALI).

What about life expectancy?

Life expectancy in the US was estimated to be 78.7 years in 2018, a small increase from 78.6 years in 2017. Between 2014 and 2017 life expectancy had been falling in the US, largely due to suicide and unintentional injury (especially drug overdoses). While the improvement in 2018 is small, it’s still welcome news to see estimated longevity tick upward.

Some caveats

It’s worth emphasizing that the data that demonstrate these positive health trends are at least a year or two old. And, importantly, improvements in life expectancy and certain causes of death are not shared equally among all groups of people: those living in poverty and a number of ethnic and racial groups have experienced less health improvement than the population as a whole.

In addition, these trends preceded the COVID-19 pandemic, a disease that has quickly become a leading cause of death. In fact, as of April 7th, 2020, COVID-19 was the number one cause of death in the US when the number of deaths per day (rather than the yearly number) were considered.

And of course, focusing only on causes of death does not provide a complete picture of a nation’s health. Disability and quality of life are essential measures of health as well, and for many people these are more important than longevity.

The bottom line

The good news is real and reason to celebrate. Yet there is plenty of room for improvement in the health of Americans, especially for four causes of death that are not falling: influenza and pneumonia, suicide, diabetes, and kidney disease. And there is no guarantee that the positive trends will continue. My hope is that we can figure out how to make even more progress more quickly, and to extend that progress more evenly throughout the population.

Follow me on Twitter @RobShmerling

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New warning on coronavirus symptoms in children — what parents need to know

While most children who get COVID-19 have a mild or even asymptomatic illness, there are new reports that some children may have a complication that can be severe and dangerous.

Called pediatric multisystem inflammatory syndrome (PMIS), it can lead to life-threatening problems with the heart and other organs in the body. Early reports compared it to Kawasaki disease, an inflammatory illness that can lead to heart problems. But while some cases look very much like Kawasaki’s, others have been different. Experts think that PMIS is likely a reaction of the body to either a current or past COVID-19 infection — but there is much we don’t understand, including why some children with PMIS have negative tests for COVID-19.

What are the symptoms of the new inflammatory syndrome known as PMIS?

Symptoms of PMIS vary from case to case, but can include

• prolonged fever (more than a couple of days)
• rash
• conjunctivitis (redness of the white part of the eye)
• stomachache
• vomiting and/or diarrhea
• a large, swollen lymph node in the neck
• red, cracked lips
• a tongue that is redder than usual and looks like a strawberry
• swollen hands and/or feet
• irritability and/or unusual sleepiness or weakness.

There are many other conditions that can cause these symptoms. For example, strep throat can cause fever, rash, swollen lymph nodes, and a “strawberry tongue,” and there are plenty of common viruses that cause stomachache, vomiting, and diarrhea. Doctors make the diagnosis of PMIS based not just on these symptoms, but also on their physical examination as well as medical tests that check for inflammation and how organs are functioning.

What parents need to know about PMIS

We are just learning about PMIS. At this point we have many more questions than answers. But here is what parents need to know about this syndrome:

• It is rare. While there is a lot about it in the news, the number of cases is actually low, especially when you consider how widespread COVID-19 has become. Parents should not panic if their child gets one of these symptoms, or if they are diagnosed with COVID-19.
• It is treatable. Doctors have had success using various treatments for inflammation, as well as treatments to support organ systems that are having trouble. While there have been some deaths, most children who have developed this syndrome have recovered.
• It is serious. That’s why it’s important to be vigilant. Call the doctor if your child develops symptoms on the list above, particularly if they have a prolonged fever (more than a couple of days). While it’s especially important to call if your child has been diagnosed with COVID-19 and develops one or more of these symptoms, you should call even if they haven’t. If your doctor isn’t concerned, that’s great — but if the symptoms get any worse or just don’t improve, call again or bring your child to an emergency room.

Many parents are afraid to take their children out of the house during the COVID-19 pandemic, let alone to a doctor’s office or hospital. That’s understandable, but it’s important not to let that fear endanger your child’s health. If you are worried about your child — for this or any reason — call your doctor. Together you can figure out how to get your child the care they need.

Follow me on Twitter @drClaire

For more information on coronavirus and COVID-19, see the Harvard Health Publishing Coronavirus Resource Center.

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SMall Incision Lenticule Extraction (SMILE): It’s what’s new in laser vision correction

The goal of laser vision correction (LVC) is to eliminate or reduce the need for glasses and contact lenses. LVC treats three basic refractive errors: myopia (nearsightedness), astigmatism (blurring of vision due to non-spherical shape of the eye), and hyperopia (farsightedness).

During an LVC procedure, the cornea — the clear dome on the surface of the eye — is reshaped in order to correct the refractive error. The different techniques to perform LVC are laser in situ keratomileusis (LASIK), phototherapeutic refractive keratectomy (PRK), and small incision lenticule extraction (SMILE).

LASIK and PRK

LASIK, the most commonly performed laser vision correction procedure in the US and the most famous of the techniques, was approved by the FDA in 1998. It is well known for its quick recovery. LASIK combines the application of excimer laser and a hinged corneal flap. The excimer laser is a computer-controlled laser that allows precise control over the amounts of tissue that are removed from the cornea. The corneal flap is a layer of the cornea that is folded back to provide access to a deeper layer of the cornea that is reshaped by the excimer laser during the procedure.

LASIK has a much quicker and more comfortable recovery compared to PRK. After LASIK, patients typically experience a scratching and burning sensation that significantly improves within one day. Most patients have excellent vision the day after LASIK. In the first week especially, patients need to be mindful of the corneal flap, which has a small chance of moving or dislocating with rubbing or hard blinking. Even months after the procedure, there is a small risk of flap dislocation with significant trauma.

The most common side effect or risk of LVC is dry eye. Typically, the dryness goes away within a week or two, but in other cases it can require ongoing treatment. The refractive surgeon should screen for dry eye at the preoperative consultation, and treat it prior to the procedure to reduce risk of chronic issues afterward. LASIK is thought to have a slightly higher risk of dry eye compared to SMILE and PRK.

PRK was approved by the FDA in 1995 and was the first type of LVC performed. During PRK, the outer layer of corneal skin cells is removed, followed by the use of the excimer laser to reshape the corneal tissue to correct vision. Patients typically experience 48 to 72 hours of scratching, tearing, burning, and light sensitivity after PRK, often requiring short-term pain medication. Most patients have functional vision during this time, and are able to drive and resume most activities by the fourth or fifth day after the procedure. The PRK recovery is longer and less comfortable than recovery after LASIK and SMILE. The main benefits of PRK are no flap and reduced risk of dry eye. PRK is an excellent option for patients with thinner corneas.

SMILE

The FDA approved SMILE, the latest advance in laser vision surgery, in 2016. It has been shown to be as effective and safe as LASIK, and it is currently available for the treatment of myopia and myopic astigmatism. SMILE combines advantages of PRK and LASIK: it requires only a small incision, does not require a flap, and has a quick, LASIK-like recovery, with the additional benefit of no postoperative restrictions.

With one laser and in approximately 30 seconds, a thin contact lens-shaped layer just beneath the surface of the cornea is created with the laser. This layer is then removed through a tiny 2–3 mm opening, and the surrounding tissues heal together. The procedure is extremely comfortable, with a quick recovery, and requires no postoperative restrictions (unlike LASIK and PRK). It also avoids any potential risk of flap complications, in contrast to LASIK. The SMILE procedure is growing in popularity, but it is currently not as widely available as LASIK and PRK in the US. As surgeons and laser centers continue to adopt the technology, the volume of procedures is expected to grow.

On the day of the SMILE procedure, as with LASIK, most patients experience a sensation that they have something in their eye, as well as tearing and burning for several hours afterward. Visual recovery is quite rapid, and after one to two days most patients have 20/20 vision. With no postoperative restrictions after SMILE, patients are back to all normal activities, including wearing makeup and working out, the next day. One downside of SMILE is that certain prescriptions, including farsightedness, cannot be treated. The most common risks of SMILE are over- or undercorrection of the prescription, dry eye, or more rarely, visual distortions including halos.

SMILE has become a first-choice option for many patients. Many police and army combat personnel are now choosing this flapless option.

Laser vision correction is generally safe and effective

Laser vision surgery is not without risks, and there are times when a patient will experience either an over- or undercorrection of their prescription, as well as issues with healing or dry eye. Everyone’s body can respond differently, and even in a single individual, the left eye may heal differently from the right eye.

Overall, however, all LVC techniques are predictable and safe, with excellent results and minimal risks. It is important to see an experienced surgeon for a consultation. He or she can recommend the best technique for each patient.

The post SMall Incision Lenticule Extraction (SMILE): It’s what’s new in laser vision correction appeared first on Harvard Health Blog.

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Why your sleep and wake cycles affect your mood

It’s no accident that most people tend to sleep at night and are awake during the day. Our sleep-wake cycle is determined by our circadian rhythm, the body’s internal clock. Like old-time clocks, this internal clock needs to be reset every day, and is adjusted by first exposure to light in the morning.

How does circadian rhythm work?

Our circadian rhythms are controlled by multiple genes and are responsible for a variety of important functions, including daily fluctuations in wakefulness, body temperature, metabolism, digestion, and hunger. Circadian rhythm also controls memory consolidation (the formation of long-term memories occurs during sleep); the timing of hormone secretion (for example, the hormones controlling body growth work mostly at night); and body healing.

While the circadian sleep phase typically occurs at night, there are a range of times during which the sleep phase can occur, with some people programmed to sleep from early evening to early morning (known as morning larks), while others stay up late and sleep late (known as night owls). In addition to determining the timing of their sleep, a person’s circadian tendency can also affect their choice of emotional coping skills, such as assertiveness or rationalization, and their predisposition to psychological disorders.

How does your circadian rhythm impact your mood?

An irregular circadian rhythm can have a negative effect on a person’s ability to sleep and function properly, and can result in a number of health problems, including mood disorders such as depression, anxiety, bipolar disorder, and seasonal affective disorder.

A recent study suggested that the night-owl type might have a greater predisposition to psychological disturbances. The authors found that the different circadian types were likely to have different coping styles to emotional stressors, and the ones adopted by the morning larks seemed to result in better outcomes and fewer psychological problems. This was a correlational study, so the reason for adopting different styles wasn’t explained, but this study emphasizes the great impact circadian rhythms have on health and functioning.

Depression and circadian rhythm

Most of the evidence on the relationship between mood problems and circadian rhythm comes from studies of shift workers, whose sleep periods are out of sync with their circadian rhythm. Multiple studies show an increased prevalence of depression in night-shift workers. One meta-analysis showed that night-shift workers are 40% more likely to develop depression than daytime workers. Conversely, circadian rhythm disturbances are common in people with depression, who often have changes in the pattern of their sleep, their hormone rhythms, and body temperature rhythms.

Symptoms of depression may also have a circadian rhythm, as some people experience more severe symptoms in the morning. The severity of a person’s depression correlates with the degree of misalignment of the circadian and sleep cycles.

Many successful treatments of depression, including bright light therapy, wake therapy, and interpersonal and social rhythm therapy, also directly affect circadian rhythms. (For the impact of circadian rhythm on the occurrence and treatment of depression related to bipolar disorder, please see this blog post on light therapy for bipolar disorder.)

Anxiety and circadian rhythm

Misalignment of the circadian rhythm may also provoke anxiety. Shift work results in a sleep disorder when your nighttime work shifts affect your ability to fall asleep and stay asleep, causing you to have excessive sleepiness during the day that in turn results in distress and affects your ability to function normally. Nurses with shift work disorder have increased anxiety scores on questionnaires. In a study on jet lag, in which travel changes the time of the external environment so that it is no longer synchronized with the internal clock and disrupts sleep, travelers had elevated anxiety and depression scores.

Seasonal affective disorder and circadian rhythm

In seasonal affective disorder, people feel down and depressed in the winter months. Researchers believe this is due to changes in circadian rhythms as a result of seasonal changes in the length of daylight. People with seasonal affective disorder feel better using artificial morning light to realign their circadian rhythm with their sleep-wake cycle.

What can I do to alter my circadian type?

There is no way to change your circadian type since it is genetically determined, though there is some natural change that occurs during your lifespan. For example, our circadian sleep phase tends to shift later during adolescence (more owls) and advances earlier as we age (more like the lark).

If you find that your circadian sleep phase is out of sync with your desired schedule, you can either shift your social life to match your circadian rhythm, or try to shift your circadian rhythm to match your social life. It may be easier to try to shift your work and social life to your circadian rhythm: an example would be a person who has a delayed circadian rhythm and likes to sleep late and wake up late switching from a job with a 7 AM start time to a job which allows him or her to start working later — around 10 AM. The other option would be talking to a sleep physician and doing ongoing work to try to shift your circadian rhythm to match your work and social life to an earlier wakeup time.

In general, the best way to improve your mood is to get a good night’s sleep by matching your circadian rhythm to your sleep-wake cycle. Exposure to light in the morning helps synchronize the clock. Exposure to bright light at night, including bright artificial lights and screen time on laptops, tablets, and phones, can cause disruption in circadian rhythm and may contribute to worsening mood and negative consequences for health.

Tips to improve your sleep and mood

• Get a full night’s sleep. Most adults need at least seven to nine hours.
• Get up at the same time each day, seven days a week. A regular wake time in the morning leads to regular times of sleep onset, and helps align your circadian rhythm with your sleep-wake cycle.
• Avoid screen time and bright lights at least 60 to 90 minutes before bedtime. Try activities like reading a book in dim light, listening to audiobooks, guided meditation or mindfulness talks, and soothing music.

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