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Saturday, 31 October 2020
Friday, 30 October 2020
Heavy Metals in Fish & Seafood: Should We Be Worried?
I am a huge seafood fan, so when I hear concerns from you about whether seafood is safe to eat, I definitely want to talk about it! One of the biggest concerns about seafood is the bioaccumulation of heavy metals from pollution in the oceans. It can be confusing to know what fish or seafood …
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Intermittent fasting: Does a new study show downsides — or not?
Intermittent fasting (IF) is an approach to eating based on timing. The idea is that fasting for long enough allows insulin levels to fall low enough that our body will use fat for fuel. Growing evidence in animals and humans shows that this approach leads to significant weight loss. When combined with a nutritious, plant-based diet and regular physical activity, IF can be part of a healthy weight loss or maintenance plan, as I described in an earlier blog post.
Now, a randomized controlled trial published in JAMA claims that IF has no significant weight loss benefit and a substantial negative effect on muscle mass. News outlets picked up the story and ran headlines like A Potential Downside of Intermittent Fasting and An Unintended Side Effect of Intermittent Fasting.
But what did this study actually look at and find?
In the study, 141 patients were randomly assigned to 12 weeks of either a time-restricted eating plan (TRE) that involved fasting for 16 hours and eating only during an eight-hour window of the day, or a consistent meal timing (CMT) eating plan, with three structured meals a day plus snacks.
Neither group received any nutrition education or behavioral counseling, nor was physical activity recommended. There was no true control group (meaning a group that did not receive any instructions about meal timing).
Interestingly, both groups lost weight. Given the headlines, I had to read and reread the results several times, because they show that the IF group lost a statistically significant amount of weight from beginning to end — which wasn’t true in the CMT group. The researchers reported: “There was a significant decrease in weight in the TRE group (−0.94 kg; 95% CI, −1.68 kg to −0.20 kg; P = .01) and a nonsignificant decrease in weight in the CMT group (−0.68 kg; 95% CI, −1.41 kg to 0.05 kg; P = .07).”
Translated into plain English, the IF group lost more weight than could be due to chance: between half a pound and 4 pounds, or an average of 2 pounds. The structured meals group also lost some weight, although the amounts lost could have been due to chance: between 0.1 and 3 pounds, or an average of 1.5 pounds. The upshot was that there wasn’t a significant difference in weight change between the two groups. And the researchers saw a loss of muscle mass in the IF group that didn’t occur in the CMT group.
Diving deeper into the study
By the way, all of these folks may have been eating fried or fast foods, and sugary sodas and candy — we don’t know. The study doesn’t mention quality of diet or physical activity. This isn’t how IF is supposed to be done! And yet the IF folks still lost between half a pound and 4 pounds.
Importantly, the structured meals group also lost weight. While not significant enough to prove it was due to this intervention, for some participants it was enough to make structured meal weight loss differ little from IF weight loss. But think about it: structured meals are an intervention. After all, some people eat more than three times a day, consuming multiple small meals throughout the day. Telling people to limit their eating to three mealtimes plus snacks may actually be helping some to eat less.
The authors very well could have concluded that IF was indeed successful. They might also call for a follow-up study with a true no-intervention control group, as well as behavioral counseling, guidance on a healthy diet, and recommended activity levels for IF and CMT groups.
Does additional support make a difference?
Prior studies of IF that have provided behavioral counseling, and guidance on nutrition and activity, have definitely shown positive results. For example, in a previous blog post I described a 2020 American Journal of Clinical Nutrition study in which 250 overweight or obese adults followed one of three diets for 12 months:
- IF on the 5:2 protocol, which means drastically reducing food intake for any two of five days of the week (down to 500 calories for women and 700 calories for men)
- Mediterranean, which emphasized fruits and vegetables, legumes, nuts, seeds, whole grains, and olive oil with moderate fish, chicken, eggs, and dairy, and with an allowance of one glass of wine per day for women and two per day for men
- Paleo, which emphasized fruits and vegetables, animal proteins, coconut products, butter, and olive oil, along with some nuts, seeds, and legumes.
- And this is key: all participants were provided education on behavioral strategies for weight loss, stress management, sleep, and exercise.
Everyone lost weight. The IF group lost more than anyone with an average of 8.8 pounds, Mediterranean next at 6.2 pounds, and Paleo last at 4 pounds. Adherence was better with the Mediterranean diet (57%) and IF (54%) than with the Paleo diet (35%), and better adherence resulted in one to three pounds more weight loss. The Mediterranean and IF groups also saw significant drops in blood pressure, another good result.
What about the loss in muscle mass that occurred in the IF group in the JAMA study? While this needs to be studied further, it’s important to note that other research on IF that included guidance on physical activity did not show any loss of muscle mass.
The bottom line
What’s the takeaway here? A high-quality diet and plenty of physical activity — including resistance training — are critical for our good health, and nothing replaces these recommendations. IF is merely a tool, an approach that can be quite effective for weight loss for some folks. While this one negative study adds to the body of literature on IF, it doesn’t reverse it. We simply need more high-quality studies in order to have a better understanding of how to most effectively incorporate IF into a healthy lifestyle.
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Thursday, 29 October 2020
Keeping your family safe this Thanksgiving
So much is different and hard during this pandemic — including planning for the holidays.
It’s understandable to want to gather with friends and family. We are all so worn out by the COVID-19 pandemic, and need some cheering up. And most of us have friends and family that we haven’t been able to really spend time with — or haven’t seen at all — for months.
But gathering with friends and family can bring real risks during the pandemic, especially with cases rising all over the country. All it takes is one sick person — who may not even realize that they are sick — to infect others and spread the virus even more.
The best thing to do, honestly, is to celebrate the holiday with just the people you live with, and to skip in-person sporting (or other) events, or in-person Black Friday shopping. That’s truly the best way to keep everyone safe. Just hunker down, check in virtually, and make plans for next year, when things will hopefully be much better.
Still planning to gather for Thanksgiving?
While experts advise skipping gatherings this Thanksgiving, here are some recommendations to help limit risks for people who plan to celebrate the holiday with others.
Plans to make beforehand
- Travel safely if you are traveling. The safest way is by car with just the people you live with, but if that requires an overnight stay somewhere, a direct flight is likely safer. If you do fly, look for flights that space people apart, wear a mask, and bring hand sanitizer and wipes.
- Keep the numbers low. This is just not the year for a big family gathering.
- Keep the party short. This is not the year for a long family gathering either.
- Agree on “no symptoms” and “no exposure.” Make sure that everyone understands that anyone who has any symptoms of COVID-19, or has been exposed to someone with the virus, cannot come. That needs to be non-negotiable.
- Agree to socialize outside if possible. If you have to be inside, do everything you can to improve ventilation, like opening windows (but understand that this is not as safe as being outside).
Seating and food
- Arrange seating so that there is at least six feet between family members who don’t live together.
- Be mindful of risks as you plan the meal:
- Ideally, everyone should bring their own food and not share.
- If some people will be cooking, ask them to wear gloves and masks. And limit the people involved in preparing shared food.
- No buffets this year. Think pre-served plates of food that people can grab and bring to their seat.
- If you are serving food, have one person wearing a mask and gloves do all the serving.
- Try to use single servings of condiments (like packets of salt and pepper) so that people are not all touching the same container.
- Use disposable plates, cutlery, and cooking ware, when possible.
- Use touchless garbage cans or pails.
Masks, physical contact, and sanitizing hands and surfaces
- Wear masks when you aren’t eating and when you cannot be six feet apart. I know this feels weird and hard at a family gathering, but it’s crucial.
- No hugs or other physical contact between people who don’t live together. Even elbow bumps are not a good idea. Not this year.
- Everyone should wash their hands often. Have hand sanitizer available.
- Wipe down surfaces regularly (keep wipes in the bathroom, for example).
Finally, don’t go to any crowded sporting events or shopping venues. Again: not the year for that. It’s just not worth the risk.
For more information on keeping your family safe this holiday season, visit the website of the Centers for Disease Control and Prevention or the Harvard Health Publishing Coronavirus Resource Center.
Follow me on Twitter @drClaire
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Talking to your doctor about an abusive relationship
When Jayden called our clinic to talk about worsening migraines, a medication change was one potential outcome. But moments into our telehealth visit, it was clear that a cure for her problems couldn’t be found in a pill. “He’s out of control again,” she whispered, lips pressed to the phone speaker, “What can I do?”
Unfortunately, abusive relationships like Jayden’s are incredibly common. Intimate partner violence (IPV) harms one in four women and one in 10 men in the United States. People sometimes think that abusive relationships only happen between men and women. But this type of violence can occur between people of any gender and sexual orientation.
Experiencing abuse can be extremely isolating, and can make you feel hopeless. But it is possible to live a life free from violence. Support and resources are available to guide you towards safety — and your doctor or health professional may be able to help in ways described below.
What is intimate partner violence?
Intimate partner violence (IPV) isn’t just physical abuse like kicking or choking, though it can include physical harm. IPV is any emotional, psychological, sexual, or physical way your partner may hurt and/or control you. This can include sexual harassment, threats to harm you, stalking, or controlling behaviors such as restricting access to bank accounts, children, friends, or family.
If this sounds like your relationship, consider talking to your doctor or health care professional, or contact the National Domestic Violence Hotline at 800-799-SAFE.
What does a healthy relationship look like?
Media images show us uniformly blissful relationships, but perfect relationships are a myth. This culture can make it difficult for us to recognize unhealthy characteristics in our own relationships. Respect, trust, open communication, and shared decisions are part of a healthy relationship. You should be able to freely participate in leisure activities or see friends without fear of your partner’s reaction. You should be able to share your opinions or make decisions without fear of retaliation or abuse. Sexual and physical intimacy should include consent — meaning that no one uses force or guilt to compel you to do things that hurt you or make you feel uncomfortable.
How can a health professional help me?
Health professionals like doctors or nurses can take a history and assess how the abuse may be affecting your health, well-being, and safety. Trauma from IPV can cause visible symptoms, like bruises or scars, as well as more subtle symptoms, like abdominal pain, headaches, trouble sleeping, or symptoms of traumatic brain injury. Health professionals can also provide referrals to see specialists, if needed.
With your consent, health professionals can take a detailed history, examine you, and document the exam findings in your confidential medical record. Let them know if you are concerned that your partner will view your medical record, so measures can be taken to keep it confidential. This documentation can help to strengthen a court case if you decide to pursue legal action in the future.
Additionally, you may be at risk for pregnancy or certain sexually transmitted infections (STIs). A health professional can perform tests for STIs or pregnancy and offer birth control options. Some forms of birth control are less easily detected by your partner, like an IUD, or a contraceptive implant or injection.
Health professionals can help you develop a safety plan if you feel unsafe. They can also help connect you with social services, legal services, and specially trained advocates. If you would like, health professionals can also connect you with law enforcement to file a report.
What is a sexual assault exam?
If you have experienced sexual assault within 120 hours (five days), you may be offered a sexual assault medical examination. This exam is voluntary. It is performed by a trained health professional and may include a full body exam, including your vagina, penis, or anus. It may also include taking blood, urine, or body surface samples and/or photographs that could be used during an investigation or legal action. You may be prescribed medication that could prevent infections or a pregnancy. You can click here to learn more about the sexual assault exam.
What can I expect if I talk to a health care professional about IPV?
Health professionals should listen to you supportively and without judgement. While not all health professionals are trained in trauma-informed care, it is your right to be treated with respect and empathy to help you feel safe and empowered. You should not be pressured to do anything you don’t want to do. And this shouldn’t change the care you receive. You have the right to decline any care you are not comfortable with. You get to decide how you want to proceed after you share information with your healthcare professional, whether that means seeking out legal support, making a safety plan to leave the relationship, or choosing to stay in the relationship and be connected to ongoing support. And you can choose not to share information about abuse at all.
Will the conversation be private and confidential?
These discussions should occur with you and your health professional in a private space. If your abusive partner accompanies you to your appointment, your health professional may ask them to leave the examination room for a period of time so that you have the privacy to talk openly. You can also ask to speak with the health professional alone.
In most cases, discussing your experiences with your health professional is confidential under HIPAA. All states have laws that protect children, elders and people with disabilities from abuse of any kind. Your health professional is obligated in certain circumstances to report abuse, such as violence against a minor or vulnerable adult. However, only a few states require health professionals to report intimate partner abuse.
Where can I find more resources on IPV?
Want to learn more about IPV and how to seek help?
If you or someone you know you is at risk, call the National Domestic Violence Hotline at 800-799-SAFE (7233) or 800-787-3224. This hotline is for anyone, regardless of race, sex, ethnicity, gender identity, sexual orientation, religion, or ability.
If you are unable to speak safely, you can visit thehotline.org or text LOVEIS to 22522. They are available 24/7 by phone or with a live chat, and can work with you to find help in your area.
- RAINN (national resource for sexual assault and violence)
- Love Is Respect (national resource for dating violence)
- WomensLaw.org (legal information for women experiencing domestic violence)
- LGBT National Help Center (LGBTQ+ resources, including chat and peer counseling).
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387: Ask Katie Anything: Protein, Supplements, Sleep, Parenting, and Shoes
You all ask so many great questions that I like to do a solo episode once in a while to answer some of the things on your mind. Of course I’m not a doctor, but I am a mom who’s been totally immersed in health for the last 15 years! I try to answer most …
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Wednesday, 28 October 2020
Mind-body medicine in addiction recovery
As someone who struggled with a miserable opiate addiction for 10 years, and who has treated hundreds of people for various addictions, I am increasingly impressed with the ways in which mind-body medicine can be a critical component of recovery from addiction. Mind-body medicine is the use of behavioral and lifestyle interventions, such as meditation, relaxation, yoga, acupuncture, and mindfulness, to holistically address medical problems. Mind-body treatments can be integrated with traditional medical treatments, or used as standalone treatments for certain conditions. Mind-body medicine is now being studied by the National Institutes of Health and effectively used in the treatment of addiction, and it will likely play a role in addiction recovery programs in the future.
Mind-body principles are not new to the recovery movement
Mind-body principles have been around since the start of the recovery movement in 1937, and they are a big part of Alcoholics Anonymous. The 12 Steps of AA feature concepts such as surrender, meditation, gratitude, and letting go — all critical components of mind-body medicine. Most 12-step meetings end with the Serenity Prayer: “God, grand me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” Mutual help groups play a role in recovery for many people, and the principles of mindfulness that are part of these programs — in addition to the social support — shouldn’t be overlooked.
My experience with mind-body therapies for addiction
When I was sent to rehab for 90 days by the medical board due to my addiction, we participated in a lot of activities that seemed to be meant to approximate mind-body medicine, but they were haphazard and not particularly scientific, and I don’t believe they had the intended effect or were at all therapeutic. For example, we did shrubbery mazes (I’d get lost); we sat meditatively in silence (everyone around me chain-smoked, triggering my asthma); we had repeated lectures about “letting go and letting God” (I still have no idea what this means); we’d spend 30 minutes staring at a red square projected onto a screen (this gave me a migraine); and we went to a local acupuncture place where they hooked up extra electric current to the needles to give us extra “chi” (I felt like I was being cooked for dinner). Given that rehab is a $50 billion industry, I felt this was a lost opportunity to utilize mind-body medicine in a way that wasn’t superficial or trivial.
Formal mind-body therapies for addiction are being rigorously studied
Fortunately, there are now several scientifically-based mind-body medicine options for people in recovery. Mindfulness-Based Relapse Prevention (MBRP) is a technique that uses meditation as well as cognitive approaches to prevent relapse. It aims to cultivate awareness of cues and triggers so that one doesn’t instinctively turn to using drugs. It also helps people get comfortable sitting with unpleasant emotions and thoughts —their distress tolerance, a person’s ability to tolerate emotional discomfort — without automatically escaping by taking a drug. Improving distress tolerance is a common theme to many, if not all, approaches to addiction recovery, as a large part of the appeal of drug use is replacing a bad emotion with a good emotion — for example, by using a drug.
Mindfulness-Oriented Recovery Enhancement (MORE) is another technique to address addiction in recovery. MORE attempts to use both mindfulness and positive psychology to address the underlying distress that caused the addiction in the first place. There are three main pillars of MORE: it has been proven to help with distress tolerance; cue reactivity (the way people with addiction respond to cues, such as seeing a bottle of prescription drugs, which often trigger cravings); and attentional bias (the way an addicted brain will pay extra, selective attention to certain things, such as a pack of cigarettes when one is quitting smoking).
Mindfulness-Based Addiction Therapy (MBAT) is a technique that uses mindfulness to teach clients how to notice current emotions and sensations, and how to detach themselves from the urge to use drugs. This is called “urge surfing,” and we practiced it extensively in rehab. The aim is to break the automatic link between feeling uncomfortable, craving drugs, and, without thought or reflection, taking a drug to alleviate that discomfort.
Is there good evidence for mind-body medicine approaches to recovery?
While there is promising research that mind-body treatments for addiction are effective, some of the research is contradictory. According to a meta-analysis in the Journal of Substance Abuse Treatment, mindfulness is a positive intervention for substance use disorders, it has a significant but small effect on reducing substance misuse, a substantial effect on reducing cravings, and, importantly, it is a treatment that has a large effect on reducing levels of stress.
However, not all studies of mind-body medicine for addiction have shown overwhelmingly positive results. Some studies showed that the treatment gains diminish over time. Some randomized controlled trials did not show that mind-body medicine was better than cognitive behavioral therapy in decreasing alcohol and cocaine use, or in abstaining from cigarette use.
The National Center for Complementary and Integrative Health did a thorough review of much of the current literature surrounding mind-body medicine as it applies to addiction treatment, and summarized the impact of certain mind-body treatments as follows:
- Acupuncture is generally safe, and may help with withdrawal, cravings, and anxiety, but there is little evidence that it directly impacts actual substance use.
- There was some evidence that hypnotherapy my improve smoking cessation.
- Mindfulness-based interventions can reduce the use of substances including alcohol, cocaine, marijuana, cigarettes, opiates, and amphetamines greater than control therapies do, and are also associated with a reduction in cravings and risk of relapse. But the data in several studies are not strong.
At this time, we need more and better evidence, and more definitive conclusions, about how helpful, ultimately, mind-body medicine will be in helping to treat addiction in different treatment settings. But a takeaway message is that mindfulness-based treatments are certainly quite effective as adjunct treatments for addiction, in that they can help people with their anxiety, distress tolerance, and cravings, and quite plausibly will turn out to help people put down the drink or the drug, and to avoid relapsing, once they have managed to get themselves into recovery.
Mind-body interventions to prevent addiction
If mind-body medicine can significantly reduce stress, then one must ask if it can also help us prevent addiction by helping our society deal with the chronic, overwhelming stress that it is facing. Addiction is in large part considered to be a “disease of despair.” Important contributors to addiction are untreated anxiety and depression, unresolved childhood trauma, social isolation, and poor distress tolerance. If all of us can learn, or be trained, to be more mindful, grateful, present, and connected, perhaps the need, and eventually the habit, of fulfilling our most basic needs with the false promise of a chemical that merely wears off — and leaves us worse off — will become less of a problem in our society.
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How to Make Rose Water
Rose water is not only beautifully fragrant but extremely versatile. It has an extensive range of uses including facial toner, hair perfume, cooling mist, and linen freshener. Rose petals are edible and rosewater has a place in the culinary world as well. I use rose water to replace some or all of the water in …
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Tuesday, 27 October 2020
What your skin should expect when you’re expecting
Are you pregnant or thinking of becoming pregnant? You’re probably prepared for morning sickness, weight gain, and an expanding belly. But did you know your skin can also undergo a variety of changes when you’re expecting? These changes are due to normal alterations in hormones that occur during pregnancy. Rest assured, most skin conditions that develop or worsen during pregnancy are benign, and tend to improve following delivery.
Darkening of the skin
A large majority of women experience darkening of their skin due to hormone shifts that occur during pregnancy. You may notice that the areas around your thighs, genitals, neck, armpits, and nipples darken. Many women also develop linea nigra, a dark line extending between the belly button and pubic bone. It is also not uncommon for women to experience darkening of their pre-existing moles and freckles. (If you are concerned that a spot on your body is growing or changing more than you’d expect, see a dermatologist for further evaluation.) However, most pigmentary changes tend to return to normal following childbirth, but may take many months to do so.
Melasma, the “mask of pregnancy”
Perhaps the most cosmetically distressing pigmentary change to occur in pregnancy is melasma, also known as the “mask of pregnancy.” Melasma, which can appear as dark patches on the forehead, cheeks, and upper lip, develops in approximately 70% of pregnant women. Melasma is exacerbated by exposure to sunlight. To help prevent it, consistently use sunscreens with sun protection factor (SPF) greater than 50, wear sun-protective clothing and hats when spending time outdoors, and avoid too much direct sunlight.
Melasma can sometimes persist after delivery, though it tends to improve after childbirth. If you wish to treat melasma after delivery, there are many treatments that can be prescribed or performed by a dermatologist, including skin lightening agents, chemical peels, and certain types of lasers. Hydroquinone, which is one of the most commonly used lightening agents on the market, is not safe to use during pregnancy or while breastfeeding. If you want to use a cream that has brightening properties while pregnant, look for glycolic acid or azelaic acid in the ingredient list.
Stretch marks
Stretch marks, also called striae gravidarum, are pink or white streaks of thin skin that develop in up to 90% of pregnant women. They occur due to expansion and stretching of skin during pregnancy, and they are most frequently seen on the abdomen, breasts, buttocks and hips. Stretch marks tend to develop in the late second and third trimester.
Many treatments, including vitamin E-containing oils, olive oil, and cocoa butter, have been used for prevention and treatment of striae, but unfortunately there is limited data to suggest the that any of these products are truly effective. These pink or red marks tend to fade to skin color following delivery, although they rarely disappear entirely. Evidence suggests that topical hyaluronic acid, tretinoin, and trofolastin can be used, with varying degrees of success, after delivery. If topicals are not effective, research has shown that several laser treatments, energy-based devices, and microneedling can lead to visible improvement in striae by increasing production of collagen (a structural component of skin) and decreasing blood flow to the lesions.
Acne… again?!
Many women experience breakouts during their pregnancies, especially those who had acne prior to pregnancy. This typically occurs in the first trimester and is related to the surge of estrogen causing overproduction in oil glands. Guidelines for the treatment of acne during pregnancy are scarce due to the lack of safety data. Dermatologists often recommend a combination of topical azelaic acid and/or benzoyl peroxide. If these treatments are not effective, topical antibiotics such as erythromycin or clindamycin can be added in some cases. Oral antibiotics, including erythromycin, azithromycin, and cephalexin, may be used for persistent cases. Oral and topical retinoids, normally a mainstay of treatment for moderate to severe acne, can result in birth defects and should be avoided during pregnancy.
If you develop any skin eruptions during pregnancy that cause concern, you should be evaluated by a dermatologist prior to starting any medications.
Follow me on Twitter @KristinaLiuMD
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Cumin Coriander Fennel Tea (for Digestion and Weight Loss)
After a surgery my husband had years ago (with resulting secondary infection and IV antibiotic use), his gut needed a little extra help. A gut rehabilitation he was following at the time (see below) suggested he try making a cumin coriander fennel tea to help his bloating and digestive problems. It worked! Now we are …
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Monday, 26 October 2020
386: What the Current Data Says About Viral Risk, Immune Function, and Herd Immunity With Dr. Chris Masterjohn PhD
This episode has been a long time coming, but I knew it was important to make sure we had reliable data available first! Now that some studies have come out, it’s time for a deep dive into COVID and who better to walk us through it than one of the researchers I highly, highly respect …
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Making special education work for your child during COVID-19
Even in normal times, parents wrestle with decisions about how best to support their children’s development. Now, however, parents are faced with nearly-unprecedented choices, and problems with no clear solutions: What if in-person schooling is better for emotional health, but remote schooling is better for physical health? How can children foster social skills without typical social interactions? How can parents select among learning environments when all the options have clear downsides?
These concerns and choices are even more difficult for parents of children with disabilities, who are among the most vulnerable students and who are at increased risk of regression during school disruptions.
Special education: One size does not fit all
Of course, students who receive special education are not a uniform group. They range in age from 3 to 22, attending preschool through post-secondary placements. They include students with a wide variety of mild to severe cognitive, physical, social, emotional, and behavioral disabilities.
But students with disabilities share a need for special services, accommodations, or both, in order to fully access the school curriculum, and to make meaningful progress appropriate to their ability. At a time when schools are scrambling to deliver regular education in a novel and frightening new context, parents and educators must also work together to select and design appropriate programs for students with special needs.
Remote learning
Remote learning has two obvious benefits. First, it is the safest choice from a physical health perspective; it may indeed be the only choice for students who are medically fragile. Second, remote learning is less likely to be disrupted or changed over the course of the school year. Students who struggle with transitions or anxiety may benefit from the relatively predictable course of remote learning.
But remote learning also carries risks, some of which are particularly acute for students with disabilities. When children are at home, educators may not be able to deliver some services or accommodations. It may be more difficult, or even impossible, to work toward some goals, especially those that require proximity to or interaction with others, such as independently toileting, or purchasing lunch in the school cafeteria without adult support.
Remote learning also requires flexibility in parents’ schedules, and intensive parental participation. Even with parental involvement, students vary in how effectively they can engage with remote learning. And students who struggle with attention, intellectual functioning, language, self-regulation, or a combination of these challenges may have great difficulty learning efficiently from a remote platform. The lack of peer models may lead some children to regress behaviorally or academically.
In-person learning
In-person or hybrid (a combination of remote and in-person learning) models offer most of the benefits that remote options lack. These include a social environment with peers, and access to services and accommodations in as normal an environment as possible. Students who require intensive support, hands-on services, or who are working on skills specific to the school or vocational environment may require in-person learning opportunities in order to fully access the curriculum.
However, in-person models carry one major and obvious risk: the potential of increased exposure to COVID-19. All parents must be wary of this dangerous disease, and parents of medically complex children may deem such a risk unacceptable, despite potential academic or social benefits.
In-person models are also likely to evolve as the pandemic progresses. As a result, students will require greater flexibility in order to be successful at a physical school.
What should parents do?
Parents and educators will need to approach this challenge with creativity, flexibility, and collaboration. Parents should request to meet with their child’s educational team as soon as possible, and should plan to meet regularly thereafter to monitor their child’s progress, and to update the educational program as needed. When parents meet with their team, they should consider each goal and service with an open mind, discussing multiple options for how a goal could be met, and how a service or accommodation could be delivered.
Some adaptations are easy: for example, large print, screen-reading software, and speech-to-text are all immediately available in a remote context. Other adaptations pose challenges, but not necessarily insurmountable ones. A behavior analyst could offer coaching through a video call, for example. Or a teacher certified in intensive special education could deliver discrete trials instruction remotely by positioning two tablets in the child’s home, one for the child to use, and one as a screen to watch the child’s responses. An aide or behavioral support could join a child’s virtual classroom, and chat with or break out with the child as needed to offer support.
Now is the time for innovation, and many schools and families are discovering great new ways to deliver special education instruction safely and effectively.
Put schooling in perspective
While it can seem like there are no great options for school, parents should try to take comfort in accepting that this year, “good enough” is truly enough.
We should also strive to prioritize the things that children require even more than schooling: physical and emotional safety, a responsive adult, and unconditional love and acceptance. Children who feel safe and loved will emerge from this pandemic resilient, and ready to overcome other challenges in their future — and they may even have learned a thing or two along the way.
Resources
Autism Speaks COVID Resources
Child Trends (includes multiple excellent articles about supporting children through COVID-19)
Harvard’s Center for the Developing Child Guide to COVID-19 and Early Child Development
Helping Traumatized Children Learn, a collaborative work of MA Advocates for Children and Harvard Law School
Learning Policy Institute Resources and Examples
US Department of Education resources for schools, students and families
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Sunday, 25 October 2020
Saturday, 24 October 2020
The Best Tents for Family Camping
We love camping as a family for uninterrupted quality time out in nature (which has real health benefits!). For a long time, my husband and I were camping purists. Camping meant carrying everything you needed, including the biodegradable toilet paper, deep into the woods far away from peasantries like running water and bathrooms. Someday, I’ll …
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Friday, 23 October 2020
Aspirin and breast cancer risk: How a wonder drug may become more wonderful
Aspirin has been called a wonder drug. And it’s easy to see why.
It’s inexpensive, its side effects are well-known and generally minor. And since it was developed in the 1890s, it’s been shown to provide a number of potential benefits, such as relieving pain, bringing down a fever, and preventing heart attacks and strokes. Over the last 20 years or so, the list of aspirin’s potential benefits has been growing. And it might be about to get even longer: did you know that aspirin may lower your risk of several types of cancer?
Studies of aspirin and cancer
A number of studies suggest that aspirin can lower the risk of certain types of cancer, including those involving the
The evidence that aspirin can reduce the risk of colon cancer is so strong that guidelines recommend daily aspirin use for certain groups of people to prevent colon cancer, including adults ages 50 to 59 with cardiovascular risk factors, and those with an inherited tendency to develop colon polyps and cancer.
And what about breast cancer? A number of studies in recent years suggest that breast cancer should be added to this list.
Studies of aspirin and breast cancer
One of the more convincing studies linking aspirin use to a lower risk of breast cancer followed more than 57,000 women who were surveyed about their health. Eight years later, about 3% of them had been newly diagnosed with breast cancer. Those who reported taking low-dose aspirin (81 mg) at least three days a week had significantly fewer breast cancers.
- Regular low-dose aspirin use was associated with a 16% lower risk of breast cancer.
- The reduction in risk was even greater — about 20% — for a common type of breast cancer fueled by hormones, called HR positive/HER2 negative.
- No significant reduction in risk was found among those taking regular-dose aspirin (325 mg), or other anti-inflammatory medications such as ibuprofen.
Another analysis reviewed the findings of 13 previous studies that included more than 850,000 women and found
- a 14% lower risk after five years of taking aspirin
- a 27% lower risk after 10 years of aspirin use
- a 46% reduction in risk after 20 years of aspirin use.
How does aspirin affect breast cancer risk?
These studies did not examine why or how aspirin might reduce breast cancer risk. So we really don’t how it might work.
In animal studies of breast cancer, aspirin has demonstrated anti-tumor properties, including inhibiting tumor cell division and impairing growth of precancerous cells. In humans, researchers have observed an anti-estrogen effect of aspirin. That could be important, because estrogen encourages the growth of some breast cancers. It’s also possible that aspirin inhibits new blood vessel formation that breast cancers need to grow. And the particular genetics of the tumor cells may be important, as aspirin’s ability to suppress cancer cell growth appears to be greater in tumors with certain mutations.
Now what?
It’s too soon to suggest that women should take aspirin to prevent breast cancer. Studies like these can show a link between taking a medication (such as low-dose aspirin) and the risk of a particular condition (such as breast cancer), but cannot prove that aspirin actually caused the reduction in breast cancer risk. So we’ll need a proper clinical trial — one that compares rates of breast cancer among women randomly assigned to receive aspirin or placebo — to determine whether aspirin treatment lowers the risk of breast cancer.
Warning: All drugs come with side effects
Keep in mind that all medications, including aspirin, can cause side effects. While aspirin is generally considered safe, it can cause gastrointestinal ulcers, bleeding, and allergic reactions. And aspirin is usually avoided in children and teens, due to the risk of a rare but serious condition called Reye’s syndrome that can harm the brain, liver, and other organs.
Stay tuned
Low-dose aspirin is often prescribed to help treat or prevent cardiovascular disease, such as heart disease and strokes. A 2016 study estimated that if more people took aspirin as recommended for cardiovascular disease treatment or prevention, hundreds of thousands of lives and billions of dollars in healthcare costs would be saved. That might be an underestimate if the drug’s anti-cancer effects are confirmed. But aspirin is not beneficial for everyone — and some people need to avoid taking it. So, ask your doctor if taking aspirin regularly is a good idea for you.
Follow me on Twitter @RobShmerling.
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Thursday, 22 October 2020
14 Festive & Healthy Halloween Recipes (Kids Will Love)
Our family loves Halloween! It’s true, in the early days we were trick-or-treating holdouts (all that sugary artificial candy… shudder!). Now that my kids are older and we’ve figured out a healthy balance, times have changed. We just buy candy with better ingredients (and make sure to have non-candy treats too). Reinventing our dinner plan is another way …
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Promoting equity and community health in the COVID-19 pandemic
Editor’s note: Second in a series on the impact of COVID-19 on communities of color, and responses aimed at improving health equity. Click here to read part one.
In early March 2020, as COVID-19 was declared a public health emergency in Boston, Mass General Brigham began to care for a growing number of patients with COVID-19. Even at this early stage in the pandemic, a few things were clear: our data showed that Black, Hispanic, and non-English speaking patients were testing positive and being hospitalized at the highest rates. There were large differences in COVID-19 infection rates among communities. Across the river from Boston, the city of Chelsea began reporting the highest infection rate in Massachusetts. Within Boston, several neighborhoods, including Hyde Park, Roxbury, and Dorchester, exhibited infection rates double or triple the rest of the city. COVID-19 was disproportionately harming minority and vulnerable communities.
Working toward an equitable response to COVID-19
From the start, our work was driven by examining COVID data by race, ethnicity, language, disability, gender, age, and community. As the COVID crisis intensified in Massachusetts, we sought ways to improve health equity and extend support within the communities we serve. We designed and deployed initiatives aimed at our patients, community members, and employees. Below are examples of tools to enhance equity that we found useful.
Communicating with patients
As new COVID care models were established, we worked on access to clinical communication for all patients and their families. There was a particular focus on language, since COVID greatly impacted non-English speaking communities, and on communication for people with disabilities.
- We linked COVID operations, such as our nurse hotline and telemedicine platforms, to interpreter services or bilingual staff, supported by patient tip sheets in multiple languages. Interpreters, working virtually through enhanced technology and remote communication, supported patients and families with limited English proficiency.
- We collected information on clinical and administrative staff language proficiency, so that multilingual staff could help guide patient care. For example, at two hospitals we established a care model of Spanish-speaking physicians to provide cultural and linguistic support in inpatient and intensive care units that complemented interpreter services.
- As all staff and patients began wearing masks, we ensured that deaf or hard-of-hearing patients would be able to communicate with care teams through the use of masks with a clear window, to allow for lip reading.
Providing up-to-date information for patients and employees
Guidance on how to protect yourself from COVID-19 evolved rapidly. Limited English proficiency, limited access to the Internet or to smartphones and computers, and limited tech savvy are barriers to receiving information for many of our patients and employees. We needed to identify ways to ensure that rapidly changing health information was available to everyone.
- For our patients, we created COVID education in multiple languages, which was distributed through various modes, including brief videos. We also sent text messages with COVID alerts to more than 100,000 of our patients who live in hot-spot communities, or who were not enrolled in our patient portal.
- For our employees, we initially hosted socially-distanced, in-person educational sessions in multiple languages. These sessions provided COVID education and updates on infection control protocol and human resources policies. Our employee educational effort later shifted to a remote model by enrolling 5,500 employees who do not use computers as part of their normal job function (such as environmental services and nutrition and food services staff) into a multilingual texting campaign designed to provide key information.
Expanding equity within communities
Through the COVID pandemic, we were building on our existing presence in, and partnerships with, the communities we serve in eastern Massachusetts in several ways.
- Community members lacked necessary supplies to protect themselves from COVID, such as masks. In April, we launched the production of care kits — packages which included masks, hand sanitizer, soap, and patient education materials — and distributed them within our communities at locations such as COVID testing centers, food distribution sites, and housing authorities. To date, more than 175,000 care kits have been distributed, including more than 1.3 million masks.
- We also partnered with community leaders to provide COVID education. We identified trusted community leaders to record and release brief educational videos over social media to reinforce wearing masks, social distancing, and washing hands.
- Finally, through screening for social determinants of health, it became clear that many of our most vulnerable communities were reporting high rates of food insecurity. We coupled longstanding efforts to address unmet health-related social needs among our patients and communities with our COVID response, by distributing grocery bags and meals at several COVID testing sites.
Looking forward
We made it through the peak of the pandemic in Massachusetts, launching a suite of initiatives to address inequity within Mass General Brigham’s COVID response. However, the battle is by no means over. Now is the time for action. Even in states like Massachusetts, where infections, hospitalizations, and deaths have substantially declined in recent months, we need to ready ourselves for a resurgence — one that is already occurring in parts of the US and Europe. Surveillance and early preparation are key. Increased prevention and mitigation efforts, widespread testing, and identification of emerging hot spots can help curb the impact of a fall and winter resurgence of the virus. Unless we act now, and unless we ramp up efforts aimed at improving health equity, this will once again hit minority communities hardest.
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Communities of color devastated by COVID-19: Shifting the narrative
Editor’s note: First in a series on the impact of COVID-19 on communities of color and responses aimed at improving health equity.
By now we’ve read headlines like these all too often: “Communities of Color Devastated by COVID-19.” Way back in March, available data started to show that vulnerable, minority communities were experiencing much higher rates of infection and hospitalization from COVID-19 than their white counterparts. New York City, New Orleans, Chicago, Detroit, Milwaukee, and Boston, where I live and work, all became ground zeros in our nation’s early battle with the pandemic. The numbers were astounding: Blacks and Latinos were four to nine times more likely to be infected by COVID than whites, even in our nation’s top hot spots. Was I surprised? Absolutely not.
A long view on health disparities
I’m originally from Puerto Rico, and grew up in a bilingual, bicultural home where I had a ringside seat to witness how the issues of race, ethnicity, culture, and language barriers intersected with all aspects of society. Currently, I’m a practicing internist at Massachusetts General Hospital (MGH), where I founded the MGH Disparities Solutions Center in 2005, which I led until becoming the Chief Equity and Inclusion Officer for the hospital last year. I’ve studied and developed interventions to address disparities in health and health care for more than two decades. My career has connected me to more than 100 hospitals in 33 states that are actively engaged in efforts to improve quality, eliminate racial and ethnic disparities in care, and achieve health equity. So, addressing disparities in care isn’t just a job for me; it’s my profession and my passion.
History teaches us that disasters — natural or man-made — always disproportionately harm vulnerable and minority populations. Think of Hurricane Katrina in New Orleans. Those with lower socioeconomic status, who were predominately Black, lived in lower-lying areas with limited protections against flooding, including levees that hadn’t been upgraded or reinforced. Multiple factors converged during and after the storm to rain down unprecedented damage and destruction on these communities, compared with white communities with higher socioeconomic status.
A shifting, yet familiar story of health disparities unspools
Fast-forward to the early months of this devastating pandemic. Working alongside many talented colleagues, I led the combined Mass General Brigham and Equity COVID Response efforts at MGH. Hospitals around the country quickly learned that people with chronic conditions such as diabetes, lung disease, and heart disease, and those of advanced age, had a poorer prognosis once infected with COVID-19.
In the United States, these chronic conditions disproportionately affect minority populations. So, minorities entered the pandemic with a long history of health disparities that put them at a disadvantage. Structural racism, discrimination, and the negative impact of the social determinants of health — including lower socioeconomic status, less access to education, hazardous environments — continuously undermine the health and well-being of these communities. This is compounded by minorities having less access to health care, and, when they are able to see a health care provider, often engaging with significant mistrust, or language barriers, that make it difficult to obtain high-quality care.
We quickly saw the importance of effective public health messaging, delivered by trusted messengers. However, in minority communities, where mistrust prevails due to historic racism, and limited English proficiency is common, these messages, and the appropriate messengers, weren’t available.
Multicultural media tried its best. But a lack of physicians of color to deliver key messages, and a lot of messages being delivered in English, created a vacuum in good information. Not surprisingly, this was filled by misinformation. So, many communities didn’t get important information early, shared by someone they could trust and easily understand, and presented in their language. Time lost led to lives lost.
Physical structures of systemic inequities helped drive illnesses and deaths
COVID-19 is a respiratory virus that is easily spread from person to person through droplets, and aerosols produced when people breathe, talk, cough, or even sing. This means proximity increases risk, thus the push to social distance, and more recent mandates about wearing masks. To make matters more complicated, a person can have COVID-19 for 10 to 14 days and be asymptomatic, spreading the virus easily and unknowingly to friends, family, coworkers, and those who stood close by on public transportation.
So, what have we learned since last spring about who is at highest risk for COVID-19? It’s those who live in densely populated areas; those who have multiple and multigenerational households in small living spaces; those deemed essential workers — health care support services, food services, and more — who don’t have the luxury to work from home, have groceries delivered, or socially isolate themselves; and those who depend on public transportation to get to work, and thus can’t travel safely in their car, or afford parking when they get to work.
Minorities aren’t more genetically susceptible to COVID-19. Instead, all of the factors described here are the social conditions in which minorities and vulnerable communities are more likely to live and move around in this world every day. Only by building from this understanding can we hope to shift the narrative, and change the headlines before cases surge this winter.
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385: Root Canals, Wisdom Teeth, Remineralizing Teeth, and More With Dr. Kelly Blodgett
This episode is about one of my favorite research topics, oral health. I’m here with Dr. Kelly Blodgett, a recognized leader in holistic dentistry. Dr. Kelly has a fascinating and integrative approach to common dental health questions on topics like root canals, wisdom teeth, remineralizing teeth, gum disease, and a lot more. And some of …
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Wednesday, 21 October 2020
Illness-related fatigue: More than just feeling tired
A common refrain during the COVID-19 pandemic is, “I’m so tired.” After months of adjusted living and anxiety, people are understandably weary. Parents who haven’t had a break from their kids are worn out. Those trying to juggle working from home with homeschooling are stretched thin. Between concerns about health, finances, and isolation, everyone is feeling some level of additional stress during this unusual time, and that’s tiring. We all could use a good, long nap — or better yet, a vacation.
But while a break would be nice, most people — except those who are actually sick with COVID-19 or other illnesses — are able to push through their fatigue, precisely because they aren’t sick. “Tired” is a nebulous word that covers a broad spectrum of levels of fatigue. A crucial distinction, however, is between regular fatigue and illness-related fatigue.
Regular fatigue
Everyday fatigue that is not illness-related starts with a baseline of health. You may feel sleepy, you may in fact be sleep-deprived, or your body and mind may be worn out from long hours, exertion, or unrelenting stress — but you don’t feel sick. Your muscles and joints don’t ache like when you have the flu. You are capable of getting out of bed and powering through the day, even if you don’t want to. A cup of coffee or a nap might perk you up.
This type of fatigue is usually related to external factors: lack of sleep, stress, an extra-hard workout. But internally, your body is working well: your glands and organs are operating properly; infection is not depleting your body of energy; your nervous system may be overtaxed, but it’s not frayed from actual impairment.
Illness-related fatigue
When I was acutely ill with persistent Lyme, babesiosis, and ehrlichiosis (all tick-borne illnesses), as well as chronic Epstein-Barr virus, a good night’s sleep did nothing. Naps were staples of my day that helped me survive but didn’t improve my energy. Drinking a cup of coffee was akin to treating an ear infection with candy. No matter how much I rested, my exhaustion persisted.
I felt like I had the flu, except it lasted for years. My whole body ached. I suffered migraine headaches. I had hallucinogenic nightmares. Exercise was out of the question; at times, I was literally too tired to walk up a flight of stairs or sit at the dinner table. I couldn’t concentrate, unable to read or watch TV. Sometimes I was too tired to talk.
There was no pushing through this level of fatigue, because it was caused by internal factors: illnesses that were ravaging my body. Only when they were adequately treated did I start to get my energy back.
For me, the root causes were bacterial infections (Lyme, ehrlichiosis), a parasite (babesiosis), and a virus (Epstein-Barr). Profound fatigue may also result from a host of other diseases and conditions, including chronic fatigue syndrome, fibromyalgia, and multiple sclerosis.
Is it everyday fatigue or illness-related fatigue?
When determining whether your tiredness is everyday fatigue or illness-related, consider the following questions:
- Do you feel worn out, or do you feel sick?
- Have you experienced this before, or does it feel more extreme or unrelenting?
- When you lessen the load of external factors (work, stress, long days) does the fatigue improve, or does it persist?
- Do you feel refreshed after a good night’s sleep or a nap?
- Can you go about your day, or is it impossible to get out of bed?
- Has the fatigue persisted longer than you would expect?
- Are you experiencing other symptoms that might point to illness?
The bottom line
No one knows your body better than you do. You know what feels normal, and you know what you feel like when you’re sick. If you are not responding to regular fatigue remedies, your fatigue has persisted over time, you have other symptoms, or you just don’t feel right, it’s probably time to call your doctor.
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