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Friday, 31 July 2020
Lifestyle changes are important for managing atrial fibrillation
Atrial fibrillation (afib) is a common heart rhythm disorder in which the upper chambers of the heart (the atria) beat fast and irregularly. Afib commonly causes recurrent symptoms, usually palpitations and shortness of breath, and can negatively affect quality of life. Afib also substantially increases the risk of stroke, and is also associated with heart failure, high blood pressure, and diabetes. People with afib routinely require lifelong treatment with blood thinners, to prevent blood clots that can lead to strokes.
Doctors are only recently understanding the importance of lifestyle factors in treating afib. Modifiable lifestyle factors are so important and under-recognized that the American Heart Association (AHA) recently released a scientific statement summarizing the latest research on this topic. The AHA wants both doctors and patients to understand the relationship between lifestyle and afib, and to work as a team to put these lifestyle factors into practice. Following is a discussion of important lifestyle factors, how they may impact afib, and what you can do.
Obesity
One of the strongest factors associated with afib is body weight. Obesity (defined as body mass index [BMI] > 30) has been shown in multiple studies to be linked to the development of afib. Obesity is associated with changes to electrical signaling within the atria, as well as structural changes to the heart’s upper chambers. Overeating can also cause inflammation via changes in hormone and cell-signaling pathways in the atria. Several studies have shown that as we gain weight, fat is deposited in the heart (as well as other places throughout the body), and this can trigger arrhythmias, most commonly afib.
Obesity can also be a cause of new or worsening hypertension (high blood pressure), which promotes further structural changes in the heart. Obesity also can cause obstructive sleep apnea and diabetes, both of which independently increase risk of afib.
The good news is that for people who are overweight or obese, just a 10% reduction in weight seems to improve symptoms related to afib.
Exercise
For decades cardiologists have encouraged people to exercise, because exercise reduces the risk of dying from cardiovascular causes. Not only is exercise good, but physical inactivity is actually detrimental; a sedentary lifestyle contributes to afib and may actually be an independent predictor of this condition. The AHA recommends 150 minutes per week of moderate-intensity aerobic exercise, or 75 minutes per week of vigorous-intensity aerobic exercise, to improve cardiovascular health. Regular exercise helps to prevent atrial fibrillation and, if you already have afib, reduces symptoms and improves afib-related quality of life.
If you are not already exercising, talk to your physician about starting a low-intensity exercise program. Brisk walking is a great form of moderate exercise and allows for physical distancing. Start with 20 minutes a day and gradually increase your pace and duration to achieve at least 150 minutes per week of moderate-intensity activity.
Sleep disorders
Obstructive sleep apnea (OSA) is a sleep disorder in which people stop breathing for short periods while they are sleeping. It is the most common form of sleep-disordered breathing and is strongly associated with cardiovascular disease. There is also a very high prevalence of OSA in people with afib, and recurrence of afib symptoms is higher in people with more severe OSA.
Cardiologists now routinely screen people with recurrent afib symptoms for OSA. Treating OSA with continuous positive airway pressure (CPAP) appears to improve afib symptoms.
If you experience afib symptoms, ask your doctors if you should have a sleep study to check for OSA.
Alcohol
Alcohol is a known risk factor for atrial fibrillation, and there is mounting evidence that the old adage “less is more” may be true for drinking if you have afib. A recent study in the New England Journal of Medicine found less afib when patients decreased or abstained from alcohol.
If you have afib, try cutting back on alcohol, or even not drinking at all. Talk to your doctor if you are having trouble reducing your alcohol consumption.
Diabetes
The risk of afib is higher in patients with type 2 diabetes. While the mechanism is not well understood, it’s likely that elevated blood sugars directly damage the heart and promote structural, electrical, and autonomic changes within the heart tissue.
The good news is that better blood sugar control improves both the severity and frequency of afib symptoms. Lifestyle changes that promote exercise and limit inactivity can also help with weight loss and blood sugar control.
Diet
Dietary changes can translate into weight loss, and also help to control blood sugar if you have diabetes. Changing your diet can be challenging, but eating less processed foods and more fresh vegetables and fruit is a good starting place. Target bad habits, like snacking or eating out of boredom. And consider transitioning to a Mediterranean diet, which helps control weight, blood sugar, and blood pressure.
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Thursday, 30 July 2020
Can appealing to teenagers’ vanity improve sun-protective behaviors?
As the summer warmth lures us outside, parents may be struggling to get their teenagers to follow sun protection guidelines. It can be challenging to catch the attention of younger people, for whom health concerns such as skin cancer feel like a lifetime away. One promising strategy for educating teens about sun-protective behavior is to appeal to their vanity and meet them where they are — on their smartphones.
Mobile app reveals possible effects of UV exposure
A recent study in JAMA Dermatology looked at the impact of using a face-aging mobile application on sun-protective behaviors in a group of Brazilian high school students. The face-aging mobile app used in the study, called Sunface, allows the user to take a selfie and shows what they might look like in five, 10, 15, 20, and 25 years, based on three levels of exposure the user selects: sun protection, no sun protection, and weekly tanning.
The face-aging mobile app modifies selfies by adding skin changes from chronic ultraviolet (UV) radiation exposure, such as from the sun or tanning beds. Signs of photoaging (premature aging of the skin from chronic sun exposure) include brown spots, increased facial wrinkles, uneven skin pigmentation, enlarged or broken blood vessels, and actinic keratoses (gritty rough spots that are precursors to skin cancer). While the accuracy of the face-aging app algorithm is unclear, it creates a reasonable facsimile of the effects of chronic sun exposure.
Study finds teens may be motivated by vanity
The JAMA Dermatology study authors divided the high school students into two categories. One group of students was shown the effects that UV exposure could have on their future faces via the app. The app also provided information about sun protection. The control group did not receive any intervention or sun protection education. At the start of the study, the researchers collected information from all study participants about their sunscreen application, tanning bed use, and performance of skin self-examinations. They then followed the students over six months to re-assess for changes in baseline behaviors. The study was led by the app developer.
In the face-aging app group, the percentage of students using sunscreen every day increased from 15% at the start of the study to 22.9% at the six-month follow up. There was no increase in sunscreen use in the control group. There was also an increase in the proportion of students in the face-aging app group who performed at least one skin self-examination during the six months of follow-up. There was no corresponding increase in the control group. Finally, while use of tanning beds had decreased in the mobile app group at the three-month follow up, tanning bed use returned to nearly baseline six months after students used the face-aging app. This is troubling, because indoor tanning increases the risk of skin cancers, including the deadliest form, melanoma.
The face-aging app had greater impact on high school girls, meaning boys were less likely to be motivated by appearance-based educational efforts. Over a lifetime, men are more likely than women to develop and die from melanoma, so other methods are needed to promote sun-safe behaviors in teenage boys.
One limitation of the study is that because students in the control group did not receive any basic sun protection education, it is not 100% clear whether the app’s face-aging simulation, the UV protection information provided by the app, or some combination of the two was responsible for the study findings.
Early sun-protective behaviors can have a lasting impact
Early sun-protective behaviors can have a lasting impact on the development and appearance of photoaging, and can reduce the risk of developing skin cancer. Beginning in infancy, children should be kept out of direct sunlight and covered with sun-protective clothing with an ultraviolet protective factor of 50+. Sunscreens are safe for infants starting at 6 months.
During adolescence and beyond, a tanned appearance is often associated with youthfulness and health. Instead of using a tanning bed, opt for a sunless tanning cream to achieve a similar effect — but be sure to apply a sunscreen, since tanning creams generally don’t contain sun-protective factor unless explicitly stated on the label. Another option is to apply a tinted sunscreen.
The following tips can help reduce photoaging and risk for skin cancer.
- Avoid peak hours of the sun’s intensity (generally between 10am and 2pm) and seek shade when outdoors.
- Wear sunscreen, even when it’s cloudy, raining, or snowing:
- broad-spectrum UVA/UVB coverage
- SPF 30+, which blocks 97% of the sun’s rays (no sunscreen blocks 100% of the rays)
- water-resistant (be sure to reapply every two hours when outside or after getting wet or toweling off)
- Wear sun-protective clothing (UPF 50+) like broad-brimmed hats, long-sleeved shirts, and pants.
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11 Natural Remedies to Stop Thinning Hair
Between postpartum hair loss (six times!) and Hashimoto’s, I saw too much hair go down the drain in the past. I use castor oil for hair growth and this hair growth serum, but there’s a lot more to how to stop thinning hair. Here I cover how to care for thin hair and encourage hair …
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361: Homeschooling and Raising Entrepreneurs With Nathan Barry
I am here with Nathan Barry, a friend of mine and also the founder of a business called ConvertKit which powers the email and newsletter that many of you subscribe to. He like me was homeschooled and dropped out of college. He now runs a hundred million dollar company. In this episode, we delve into …
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Wednesday, 29 July 2020
I can’t tolerate CPAP, what can I do?
Continuous positive airway pressure, or CPAP, is the most common treatment prescribed for obstructive sleep apnea (OSA). CPAP involves wearing a mask that fits into the nostrils, underneath or over the nose, or over the nose and mouth, through which pressurized air is delivered via tubing from a machine to keep the upper airway open during sleep. CPAP is recommended by the American Academy of Sleep Medicine (AASM) as the initial treatment for moderate or severe OSA, and in mild cases of OSA when associated with insomnia, disrupted sleep, or excessive daytime sleepiness. When used consistently, and when treatment is effective, CPAP improves daytime sleepiness, quality of life, and it can have positive impacts on cardiac and metabolic health.
The effectiveness of CPAP depends on using the device correctly and consistently, since OSA is a chronic disease that requires long-term treatment. Most sleep doctors, myself included, recommend that patients with sleep apnea use their treatment whenever they sleep, in order to derive optimal benefit. While there are many patients who love their CPAP machines and report the treatment to be life-changing, and are unable to sleep without CPAP, there are others who learn to accept and tolerate CPAP because they appreciate either the functional benefits (such as better mood and less daytime sleepiness) or medical improvements they get from using the device. However, many patients struggle with CPAP.
CPAP is not easy and there are common complaints
Despite the many potential benefits, CPAP adherence estimates from clinical data and insurance groups suggest that about 50% of CPAP users either do not reach minimum adherence criteria or discontinue the treatment. Each patient is unique and may have individual struggles with CPAP; however, there tend to be similar themes among users. Some of the common complaints I hear from patients who have trouble tolerating CPAP include
- mask issues, including mask discomfort, skin irritation or marks, feelings of claustrophobia, or discomfort with the appearance of wearing a mask
- dryness, especially waking with a dry mouth
- removing the mask during sleep
- pressure intolerance, from either too much pressure or not enough pressure; trouble exhaling against the CPAP pressure; or swallowing air (aerophagia)
- breathing that feels out of sync
- noise from the machine bothering the patient or their bed partner.
Troubleshooting issues with CPAP tolerance
First and foremost, patients should partner with their doctor and healthcare team. OSA is a serious disease that warrants treatment. Before starting treatment, patients should be educated about OSA, learn about all treatment options and new technologies, and know what to expect with CPAP. Patients benefit from close clinical follow-up, including a review of data from their CPAP device (which may also be important for continued insurance coverage). Family and/or partner support is also important, as friends or family can help encourage and support CPAP use.
Other tips to improve adherence:
- Behavioral and medication interventions. Cognitive behavioral therapy or short-term use of sleep medications can help people adjust to CPAP.
- The right mask. If the mask does not fit, the treatment may not work well. There are many mask sizes and types, including nasal masks that fit over or under the nose, nasal pillows that fit in the nostrils, full face masks that cover the mouth and nose, hybrid masks that sit under the nose and cover the mouth, and even helmet masks that cover the face. A mask fitting is advised when patients start treatment, and several fittings may be needed.
- Mouth breathing is another mask-related factor to consider. When a patient sleeps with their mouth open, the pressure from the CPAP leaks out the mouth. This causes dryness, and also prevents CPAP from keeping the upper airway open. Mask leak can also result in noise and mask removals during sleep. A mask that covers the mouth will probably be needed, though sometimes adding a chinstrap can keep the jaw closed and prevent mouth breathing.
- The right pressure. Some people require vastly different pressure when on their back vs. on their side, or in one sleep stage vs. another. While a pressure range can be helpful, if the range is too wide, the machine cannot adjust rapidly enough to meet the pressure requirements. Weight changes may also impact pressure requirements. Following device data and/or evaluating with a treatment sleep study in a sleep lab can help identify the best pressure.
- Address coexisting conditions. Some people use CPAP consistently, tolerate it, but are still sleepy. CPAP is not a substitute for inadequate sleep. Sleep apnea can coexist with other sleep problems that might contribute to daytime sleepiness. Sometimes CPAP is not tolerated because sleep is poor, or fragmented due to other issues such as anxiety, PTSD, insomnia, poor sleep habits, or circadian disorders. These other problems need to be addressed.
- Consider alternative treatments. CPAP is the first-line treatment, but not the only treatment for OSA. Consider combining treatments or pursuing an alternative treatment if CPAP is not tolerated or is not desired.
New CPAP innovations can help
A variety of technological advances may improve CPAP comfort and adherence. Some of these include
- heated humidification, a comfort intervention that can help with nasal congestion and dryness
- ramp-up features that allow the machine to start off at a low or minimal pressure as the patient adjusts and falls asleep
- expiratory pressure relief, where the pressure from the machine decreases slightly during exhalation, which is especially helpful when a higher pressure setting is needed to keep the airway open
- auto-titrating CPAP machines, which allow for a range of pressures to be set; the machine self-adjusts the pressure when it senses that more or less pressure is needed to keep the airway open. This is helpful for those who require higher pressures in one body position (back vs. side) or sleep stage (dream/REM sleep vs. nondream/NREM).
- modems that allow the machine to transmit data (either cellular or by wi-fi), so both the patient and their doctor can determine the effectiveness of the treatment.
The bottom line
CPAP is an effective treatment for OSA. If you are struggling with CPAP tolerance, do not give up, but rather talk to your clinician. Proper education, support, personalized troubleshooting, new technologies, and close clinical follow-up can improve adherence and optimize treatment outcomes.
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Tuesday, 28 July 2020
100% Real Cheese Crisps Recipe (Grain Free)
Ever miss that crunchy texture that foods like chips and crackers used to provide? This easy cheese crisps recipe will hit the snacking spot! Best of all, most cheese crackers, the 1-ingredient list is 100% real food! The next time you need a healthy alternative to crackers or a break from carrots and celery for dipping …
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Avoiding COVID-19 when following the guidelines seems impossible
By now, we all know the drill: Maintain physical distance. Wear a mask. Wash your hands. Avoid people who are sick and stay away from others if you are sick. While these measures may seem simple enough, they are not easy to keep up month after month. Yet they are likely to be with us for a while.
But what about those who cannot comply? Certain conditions can make the standard measures to stay safe during the pandemic seem impossible. At the same time, some of those likely to have the most trouble following the guidelines — such as older people with dementia — are at higher risk for illness and death if they do become ill. And the risk for spreading infection to others by not wearing face coverings, washing hands regularly, and observing physical distancing remains very real.
Mitigation efforts are harder for some than others
People who may have the most trouble complying with pandemic-related restrictions include those with
- Dementia. Without constant supervision and reminders, people with cognitive problems may take off their masks or wear them incorrectly, and fail to maintain distance from others.
- Breathing problems. Although for healthy people there is no evidence that commonly worn cloth masks lower your oxygen levels or raise your carbon dioxide levels, those who have lung disease (such as asthma, emphysema, or cystic fibrosis) may find it particularly uncomfortable trying to breathe through a mask.
- Claustrophobia. Wearing a mask may make people with claustrophobia feel panicky or smothered. And this not a rare problem: claustrophobia is the most common phobia, affecting 5% to 10% of the population.
- Depression and anxiety. For people who struggle with mood or excessive worry, concerns about one’s health and the health of loved ones, and the limitations placed on social interactions, may make these conditions worse. According to recent National Center for Health Statistics data, symptoms of anxiety or depression have more than tripled since this time last year.
- Autism spectrum disorder. Difficulties with social skills, a need for routine, and a reliance on support services such as behavior or speech therapy are everyday challenges for many people with autism spectrum disorder. The pandemic has made these challenges even greater. A heightened sensitivity to touch and difficulty with nonverbal communication can make wearing a mask especially problematic.
Even the experts urging us all to wear face coverings to lower rates of illness and deaths recognize that some cannot comply. Still, there are steps that folks in these situations can take to reduce the risk of becoming infected with the virus that causes COVID-19 and spreading it to others.
What can be done?
There are no easy answers here. I know of at least one memory care center that has largely given up on requiring mask wearing for some of its residents (though staff are still required to wear them). While not ideal, it’s the most practical option. And other measures are still followed: every resident is surveyed about symptoms and has temperature checks daily, chairs and activities are set up to encourage physical distancing, and the number of people in a room is limited. Gentle and frequent reminders and redirection to prevent crowding, increase handwashing, and encourage mask wearing (if possible) are now part of the routine in most nursing homes and long-term care facilities.
The Alzheimer’s Association also recommends extra reminders to wear a mask and wash hands for people living at home with dementia. Visual cues around the home can help. Try tacking up images of people in masks — including their favorite actors or even superheroes — and written reminders in several spots explaining the rationale for all the handwashing and face masks. If possible, try to increase social support (while maintaining physical distance) for those with dementia living at home. For example, if someone living in a memory care center usually talks to family members on the phone once or twice a week, perhaps three or four times a week would be a good idea while social distancing restrictions are in place.
Those with breathing problems may be able to tolerate wearing a mask for short periods. If a particular mask seems too uncomfortable or restrictive, try another type. There are masks of many shapes, sizes, and fabrics out there, and it’s worth trying more than one type of mask before giving up on them. If wearing a mask still seems impossible, conscientious physical distancing and frequent handwashing may make face coverings less necessary. For anyone whose respiratory condition is so severe that wearing a mask is impossible, experts suggest that the safest course of action is to avoid public places rather than relying on “mask exemptions.”
People with depression or anxiety may need to consult more often with their mental health providers during the pandemic. Adjustments in behavioral therapies or medications may help. Claustrophobic people may find that wearing a mask at home for short periods, and gradually increasing the amount of time, may make it easier to consistently wear one in public.
Experts working with people who have autism spectrum disorder recommend a number of ways to help with mask wearing, including education about the rationale for wearing them, demonstrating the use of a mask on a favorite object or person, allowing the person to choose among different types of masks, and wearing the mask for only short periods of time to start. Transparent face masks that make the mouth or face of the speaker visible may be a good option.
The bottom line
While we should not have an expectation that people with certain medical or psychological conditions will be able to follow the guidelines perfectly, that’s one more reason we should maintain high expectations for everyone else.
For more information about coronavirus and COVID-19, see the Harvard Health Coronavirus Resource Center.
Follow me on Twitter @RobShmerling
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Monday, 27 July 2020
The lowdown on the low-FODMAP diet
Irritable bowel syndrome (IBS) is a common intestinal disorder that produces distressing symptoms like abdominal pain, significant bloating, and altered bowel movements that can shuttle between diarrhea and constipation.
While changing what you eat won’t cure you, an evidence-based approach called the low-FODMAP diet is the most frequently prescribed food plan to help relieve IBS symptoms. Studies show it can reduce symptoms for the majority of patients. However, because of certain challenges and risks associated with the low-FODMAP diet, it’s worth talking to an expert before you try it.
FODMAP basics
The low-FODMAP diet addresses four types of fermentable carbohydrates: oligosaccharides, disaccharides, monosaccharides, and polyols (collectively referred to as FODMAPs). While the names sound somewhat abstract, the foods found within these groups are often too familiar to those with digestive woes.
Oligosaccharides are present in foods like wheat, beans, garlic, and onions, while the disaccharide lactose is prevalent in dairy products like ice cream and milk. Monosaccharides refer to foods with excess fructose, and are found in items like apples, mangos, and honey. The final group, sugar alcohols, are found in some artificially sweetened products like chewing gum, and are naturally present in foods like avocados and mushrooms.
Though the FODMAP carbohydrates can trigger digestive discomfort for anyone when consumed in large amounts, much smaller portions can worsen symptoms for those with IBS.
A multiphase approach to a low-FODMAP diet
The low-FODMAP diet is meant to be undertaken in three phases. In the first phase, all high-FODMAP foods are eliminated from the diet for an extended period of time, often four to six weeks. In phase two, you systematically reintroduce restricted foods, noting how well you tolerate increasing quantities of the foods you’re reintroducing. Phase three is the personalization phase, in which you only avoid foods in quantities that cause symptoms.
This multiphase process can be complex and confusing, and requires substantial food knowledge. For instance, most varieties of soymilk are high-FODMAP. Extra-firm tofu, on the other hand, while also made from soybeans, is low-FODMAP. Guidance from a dietitian can be helpful for navigating this diet, but insurance coverage and medical referrals can be barriers to scheduling an appointment. As a result, some patients simply receive a list of low- and high-FODMAP foods.
Risks associated with not reintroducing some high-FODMAP foods
While avoiding high-FODMAP foods can be difficult, adding the carbohydrate groups back systematically to test tolerance can be even more challenging. Some people become hesitant to reintroduce items, especially if they have experienced significant symptom relief during the elimination phase. This increases the potential for nutritional risks. For example, it’s common for people avoiding dairy to have inadequate calcium intake.
Other lesser-known nutrients, like magnesium, are also a concern. Some of the best dietary sources of magnesium come from beans and nuts like almonds and cashews, which are usually restricted during the initial phase of the diet. In addition, people with IBS may already be at increased risk of magnesium deficiency due to digestive symptoms like diarrhea.
There is also concern that long-term restriction of high-FODMAP foods changes the makeup of bacterial colonies in the gut, which may negatively impact intestinal health and possibly worsen digestive issues over time. Oligosaccharides, in particular, are an important energy source for beneficial bacteria. This is particularly worrisome for individuals with IBS, who have been shown to have lower levels of protective intestinal bacteria and higher levels of potentially harmful inflammatory microbes. Probiotics have been suggested to restore such bacterial imbalances, but this remains contentious, and the American Gastroenterological Association recently published guidelines that recommend their use in IBS only when participating in a research study.
Low-FODMAP is not for everyone
The low-FODMAP diet is not intended for individuals without IBS, nor is it appropriate for everyone with the condition. It should be avoided by anyone with an eating disorder, as it may worsen food fears and diet restrictions. This is particularly notable because those with gastrointestinal issues appear to have a higher prevalence of disordered eating compared to the general population. In addition, people with already restricted diets, such as vegans or those with food allergies, may be unable to meet their nutritional needs on the diet. Those who are already malnourished or underweight are poor candidates, as well. The diet is not as well researched for other gastrointestinal conditions, so it’s generally best to avoid the diet if you don’t have IBS, unless otherwise advised by a doctor or dietitian.
Finding an alternative approach
If the low-FODMAP diet is not a good option for you, simply cutting back on high-FODMAP foods in your diet, without entirely eliminating any food groups, may be an alternative. If your diet contains many common offenders like garlic, onions, beans, apples, milk, mushrooms, and wheat, a simple reduction may help decrease symptoms.
To find a list of registered dietitians who can help you to safely make changes, click here. Or contact a nutrition practice to ask if they have someone knowledgeable about the low-FODMAP diet.
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360: Four Questions to Change Your Life & Doing The Work With Byron Katie
I’m here today with Byron Katie, one of my favorite authors and speakers on the topics of mindset, parenting, and about a million other things. She is the author of many books including Loving What Is, I Need Your Love – Is That True?, A Thousand Names for Joy and, A Mind at Home with Itself. In …
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Sunday, 26 July 2020
Saturday, 25 July 2020
The Benefits of Red Light Therapy (Photobiomodulation)
For the past few months, I’ve been standing in front of a red light therapy lamp for about 5 minutes a day. We ordered the red light therapy system when my husband was recovering from surgery since it helps speed wound healing. Now, I’m loving it for its collagen boosting (*wrinkle reducing*), stretch mark reducing, and …
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