28/01/2019

Comparing medications to treat opioid use disorder

My first day returning to work after being treated for a severe opiate addiction was one of the most daunting moments of my life. Everyone in the office, from my manager to the administrative assistants, knew that forged prescriptions and criminal charges were the reason I had been let go from my previous job. My mind was spinning. What would my coworkers think of me? Who would want to work alongside an “addict”? Would they ever come to trust me? Did I even deserve to be here?

When my life was crashing and burning due to my addiction (detailed in my memoir Free Refills: A Doctor Confronts His Addiction), a return to work seemed like a distant prospect, barely visible on a horizon clouded by relapses, withdrawal, and blackouts. My finances, my professional reputation, and my family life were in terrible shape due to my drug-seeking behavior. Working was not a tenable option until I received treatment and established a solid track record of recovery, which a potential employer could rely on.

The fact that I was now in recovery was a great development, and it was further ratification of my progress that I had landed a job and was returning to work. So, why wasn’t I feeling overjoyed?
How stigma affects the return to work

As it turns out, the transition back to work after someone is treated for an addiction can be profoundly stressful. People recovering from addiction already tend to suffer disproportionately from guilt, shame, and embarrassment, and these feelings are often brought to the forefront during the unique challenges of returning to work.

Stigma is what differentiates addiction from other diseases, and is primarily what can make the return to work so difficult. If I had been out of work to receive chemotherapy or because of complications from diabetes, I certainly wouldn’t have felt self-conscious or self-doubting upon resuming my employment. With addiction, due to the prejudices that many people in our society hold, the return is psychologically complex and anxiety-producing. As I entered my new office, I was walking right into the fears, preconceptions, and potential disdain that my new officemates might share toward people suffering from a substance use disorder. For all I knew, I was the “dirty addict” that they now, against their wishes, had to work with.
“Bring your body and your mind will follow”

What I was taught in recovery, to deal with situations like this, is to “just keep your head up” and to “put one foot in front of the other.” Or, “bring your body, and your mind will follow.” When I first heard these phrases, I thought that they were mere platitudes, phrases without content, provided to motivate us through dark times. Now, I think they hold a great deal of wisdom.

As I walked through the door on my first day back, I did feel everyone’s eyes on me, and I did wonder if they were judging and criticizing me, but I made it to my desk without incident, and managed to power through my self-consciousness and get into the flow of my work. Every day, it became easier as I did a good job, deepened my connections with my colleagues, and accumulated good will, which would eventually replace any negative images that may have accompanied my arrival. Within weeks this was a non-issue, though at office get-togethers, my co-workers still somewhat awkwardly don’t know whether to put a wine glass at my place setting.

With all I had learned in recovery about communication, about humility, about connecting with others, I feel that I was in a better position to thrive in my workplace than I was before my addiction started in the first place. As more of my brothers and sisters in recovery return to employment, and as we succeed, the more difficult will it be for people to hold on to their negative attitudes and prejudices about substance use disorders. We can defeat the stigma by confronting it, putting one foot in front of the other, one step at a time.
This one got by me. I’d never heard of “man flu” but according to a new study of the topic, the term is “so ubiquitous that it has been included in the Oxford and Cambridge dictionaries. Oxford defines it as ‘a cold or similar minor ailment as experienced by a man who is regarded as exaggerating the severity of the symptoms.’”

Another reference called it “wimpy man” syndrome. Wow. I’d heard it said (mostly in jest) that if men had to carry and deliver babies, humankind would have long ago gone extinct. But wimpy man syndrome? I just had to learn more.
What is man flu?

As commonly used, the term man flu could be describing a constitutional character flaw of men who, when felled by a cold or flu, embellish the severity of their symptoms, quickly adopt a helpless “patient role,” and rely heavily on others to help them until they recover. Another possibility is that men actually experience respiratory viral illnesses differently than women; there is precedent for this in other conditions. Pain due to coronary artery disease (as with a heart attack or angina) is a good example. Men tend to have “classic” crushing chest pain, while women are more likely to have “atypical” symptoms such as nausea or shortness of breath. Perhaps the behavior of men with the flu is actually appropriate (and not exaggerated), and based on how the disease affects them.

Here are the highlights from the study:

    Influenza vaccination tends to cause more local (skin) and systemic (bodywide) reactions and better antibody response in women. Testosterone may play a role, as men with the highest levels tended to have a lower antibody response. A better antibody response may lessen the severity of flu, so it’s possible that vaccinated men get more severe symptoms than women because they don’t respond to vaccination as well.
    In test tube studies of nasal cells infected with influenza, exposure to the female hormone estradiol reduced the immune response when the cells came from women, but not in cells from men. Treatment with antiestrogen drugs reduces this effect. Since flu symptoms are in large part due to the body’s immune reaction, a lessened immune response in women may translate to milder symptoms.
    In at least one study reviewing six years of data, men were hospitalized with the flu more often than women. Another reported more deaths among men than women due to flu.
    A survey by a popular magazine found that men reported taking longer to recover from flu-like illnesses than women (three days vs. 1.5 days).

Taken together, these findings suggest that there may be more to “man flu” than just men exaggerating their symptoms or unnecessarily behaving helplessly. While the evidence is not definitive, they suggest that the flu may, in fact, be more severe in men.
If it’s true that men get sicker with the flu, why?

Some have suggested that early man evolved to require more prolonged rest while sick to conserve energy and avoid predators. In more modern times, the advantage of a longer recovery time is less clear beyond the obvious. When you don’t feel well, it’s nice to be taken care of. Of course, that’s true for women as well.
The bottom line

Diseases can look different in men and women. That’s true of coronary artery disease. It’s true of osteoporosis, lupus, and depression. And it may be true of the flu. So, I agree with the author of this new report, who states “…the concept of man flu, as commonly defined, is potentially unjust.” We need a better understanding of how the flu affects men and women and why it may affect them differently.

Until then, we should all do what we can to prevent the flu and limit its spread. Getting the flu vaccination, good handwashing, and avoiding others while sick are good first steps. And they’re the same regardless of your gender. Using medications to treat opioid use disorder is a lifesaving cornerstone of treatment — much like insulin for type 1 diabetes. The flawed but widely held view that medications like methadone or buprenorphine are “replacing one addiction for another” prevents many people from getting the treatment they need. In actuality, people successfully treated with these medications carefully follow a prescribed medication regimen, which results in positive health and social consequences — as in patients with many types of chronic medical conditions.

However, even among those who embrace treating opioid use disorder (OUD) with medication, there is a difference of opinion as to which medications are most effective. A new study offers important insight into the advantages and disadvantages of the two medications for OUD that can be prescribed in a doctor’s office (that is, on an outpatient basis). These medications are buprenorphine and extended-release (ER) naltrexone. This study was widely covered in the press, and many of the sound bites and headlines reporting the two treatments to be equally effective were a bit misleading.
The advantages and disadvantages of buprenorphine (Suboxone, Subutex, Zubsolv, Probuphine, Sublocade)

Buprenorphine is a partial opioid agonist medication. This medication activates the same receptors in the brain as any opioid, but only partly. Because its effects are long-lasting, it can be taken once a day to relieve cravings, prevent withdrawal, and restore normal functioning in someone with opioid use disorder. Because it is a partial agonist, it has a ceiling effect. This means once all the receptors are occupied by the medication, even if a person takes 20 more tablets she wouldn’t feel any additional effect or be at risk of overdose.

Any doctor who has completed special training (a primary care provider, addiction specialist, OB/GYN, etc.) can prescribe buprenorphine. The advantage is, theoretically, that a person with OUD could receive treatment from any provider he or she might see for a routine health issue. I say theoretically because, despite its availability, only about 4% of physicians have done the necessary training to be able to prescribe it. The research on buprenorphine is robust, with multiple studies showing it reduces the risk of death by more than 50%, helps people stay in treatment, reduces the risk that they will turn to other opioids (like heroin), and improves quality of life in many ways.
The advantages and disadvantages of naltrexone (Vivitrol, Revia)

Naltrexone is a pure opioid antagonist. It sticks to an opioid receptor, but instead of activating it to relieve craving and withdrawal it acts as a blocker, preventing other opioids from having any effect. The research on naltrexone has been mixed. Naltrexone in pill form is basically no better than placebo because people simply stop taking it. Studies on extended-release naltrexone are more promising and have shown it to be better than no medication at all. However, there has never been a US trial comparing extended-release naltrexone to either methadone or buprenorphine, until this study.
The X-BOT study: Comparing buprenorphine and extended-release naltrexone

This study enrolled individuals with opioid use disorder who had voluntarily gone to a detoxification program. Researchers then randomly assigned them to either daily buprenorphine or monthly extended-release naltrexone. Both groups were followed for 24 weeks, to see how many people relapsed.

One of the most important things investigators learned is just how hard it was to get participants onto extended-release naltrexone, revealing a potential barrier to its usefulness. Before a person can start taking ER naltrexone, they must be completely off opioids for seven to 10 days. Only 72% of the group assigned to ER naltrexone even got the first dose, and among those who were randomized during the detoxification process, only 53% started the medication. In contrast, 94% of the group assigned to buprenorphine started the medication.

The other important finding was what happened with relapses. The researchers analyzed their data using an “intention to treat analysis.” This means that once a person is randomly assigned to a treatment (or placebo), their data counts even if they don’t stick with the treatment. Here’s why this is important: if you don’t include that data, then you miss other important outcomes that influence how effective a treatment really is. Thanks to this type of analysis, researchers learned that relapse was significantly more likely in the extended-release naltrexone group (65% compared to 57% in the buprenorphine group).

Immediate relapses were even more likely in the naltrexone group due to failures to start the medication — 25% of the naltrexone group had a relapse on day 21, compared to 3% in the buprenorphine group. Overall there were more overdoses in the naltrexone group, but no difference in fatal overdoses between the groups. Most of the overdoses occurred after the study medication was stopped, highlighting the lifesaving importance of getting on, and staying on, treatment. The naltrexone group also had a longer length of stay in inpatient detoxification programs, which may be an important consideration when we think about overall healthcare costs.

So, why did many headlines claim extended-release naltrexone was as effective as buprenorphine? Well, that was the finding of a separate analysis that looked only at people who successfully started each medication. When the data was viewed that way, there was no difference between the two medications, but that’s just part of the picture. If it’s harder to get a person to successfully start and stick with a medication, that should factor in evaluating its “effectiveness.”
Take-home messages from X-BOT

This is an incredibly important study. The findings are generally consistent with what I see in my clinical practice. Overall buprenorphine is a more effective treatment for opioid use disorder, in part because it’s easier to get patients started on it and they are more likely to stick with it. Extended-release naltrexone may be as good for people who can successfully complete the detoxification required before starting on it. Both medications have a place, but as with so many conditions and treatments, one size does not fit all.
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Another option for life-threatening allergic reactions

It’s a new year, the gyms are unusually busy, and many of us started a new physical activity. Several health clubs are offering fun, interactive, and dynamic exercises such as whole-body workouts, functional training, CrossFit, high-intensity interval training, spinning, etc.

Some of these classes are incorporating intense workouts, which was a hot topic in exercise physiology in 2017. There is significant enthusiasm around these programs among my friends, family, and patients. Some of these classes have loud music, lights, and trainers whose job is to push you to a new level. Increasing the intensity of a workout may bring significant health benefits for some; however, lately we are starting to see cases of a potentially life-threatening disease as a result of these activities. It’s called rhabdo.

The other day I saw someone wearing a shirt that said “Pushing until Rhabdo.” That made me cringe. And I realized that, although rare, some people do not understand how serious rhabdo can be.
What is rhabdo?

Rhabdo is short for rhabdomyolysis. This rare condition occurs when muscle cells burst and leak their contents into the bloodstream. This can cause an array of problems including weakness, muscle soreness, and dark or brown urine. The damage can be so severe that it may lead to kidney injury. Intense physical activity is just one of the causes. Others include medication side effects, alcohol use, drug overdose, infections, and trauma/crush injury. Fortunately, most people who have rhabdo do not get sick enough to require hospitalization. But if you develop any of these symptoms after a hard workout, it’s a good idea to set up an appointment with your doctor. A simple blood and urine test could help establish the diagnosis.
How to avoid rhabdo

I know you are probably excited about your new exercise program, and you want to excel. And that’s great. But take it easy, especially if this is a new exercise routine. You want to challenge your body, but avoid extremes. If you are working with a trainer, make sure you tell him/her where you stand in terms of fitness level and health concerns. In addition:

    Drink lots of water. That will help prevent problems and help flush your kidneys.
    Avoid using anti-inflammatory medications such as ibuprofen and naproxen. These drugs may worsen kidney function.
    Avoid drinking alcohol. Alcohol is a diuretic, which means it will make you more dehydrated. You need more fluids in your system, not the opposite.

If you experience intense pain and fatigue after your workout, you should call your doctor. Most cases of rhabdo are treated at home simply by increasing fluid intake. If muscle enzyme levels are high, or if there are signs of kidney problems, IV fluids may be needed. In some cases, we have to admit patients to the hospital and even to the ICU for close monitoring and further treatment.
Ramping up safely

Be smart and train your muscles to adapt to new activity. Exercise is better if it is enjoyable and entertaining, and I have to say that some of these classes are incredibly fun. But make sure that you listen to your body. Watch out for trainers who may push you too hard to the point of exhaustion. That should not be your goal when you are first starting a brand-new routine, especially if you haven’t been active for a while. A good trainer should get to know you and will tailor the exercise routine to your level of fitness. Adding a new workout to your day is probably one of the healthiest habits you can incorporate in 2018, but don’t “push until rhabdo.” Instead push slowly but consistently, challenging your body toward wellness and better function. Attention deficit hyperactivity disorder, or ADHD, is very common — according to the most recent statistics, one in 10 children between the ages of 4 and 17 has been diagnosed with this problem. So it’s not surprising that when parents notice that their child has trouble concentrating, is more active or impulsive than other children, and is having trouble in school, they think that their child might have ADHD.

But ADHD isn’t the only problem that can cause a child to have trouble with concentration, behavior, or school performance. There are actually lots of problems that can cause symptoms that mimic ADHD, which is why it’s really important to do a careful evaluation before giving that diagnosis. Here are five common problems that parents and doctors should always think about:

1.  Hearing problems. If you can’t hear well, it’s hard to pay attention — and easy to get distracted. Now that more newborns are being screened for hearing problems before leaving the hospital, we are able to catch more cases early, but some slip through the cracks, and children can also develop hearing problems from getting lots of ear infections. Any child with behavioral or learning problems should have a hearing test to be sure their hearing is normal.

2.  Learning or cognitive disabilities. If children don’t understand what’s going on around them, it’s hard for them to focus and join in classwork. Children who have trouble understanding may also have difficulty with social interactions, which can be very quick, complex, and nuanced. Any child who is doing poorly in school should be evaluated and given the help they need. All public schools have a process for evaluating children and creating an Individualized Education Program, or IEP, for those who need help. Even if a child goes to an independent school, they can still get an evaluation through the public schools. Parents should talk to their child’s teacher and their pediatrician for guidance.

3.  Sleep problems. Children who don’t get enough sleep, or whose sleep is of poor quality, can have trouble with learning and behavior. Any child who snores regularly (not just with a bad cold) should be evaluated by their doctor, especially if there are any pauses in breathing or choking noises during sleep. Parents of teens should be sure that their children are getting at least eight hours of sleep and aren’t staying up doing homework or on their phones. In general, any time a diagnosis of ADHD is being considered, it’s important to take a close look at a child’s sleep and make sure there aren’t any problems.

4.  Depression or anxiety. It is hard to concentrate when you are sad or worried, and it’s not uncommon for a depressed or anxious child to act out and get in trouble. More than one in 10 adolescents has suffered from depression, and the numbers are higher for anxiety. Even more alarming, both depression and anxiety often go undiagnosed — and untreated — among children and adolescents. As part of any evaluation for ADHD, a child should also be evaluated for other mental health issues, not just because they can mimic ADHD, but because other mental health issues can occur with, or because of, ADHD.

5.  Substance abuse. This is something that should always be considered in an adolescent, especially if the ADHD symptoms weren’t present earlier in childhood (by definition, you have to have the symptoms before age 12 to get the diagnosis). Nobody wants to think that their child could be using drugs or alcohol, but by 12th grade about half of youth have tried an illicit drug at least once, and for some, it can turn into a habit — or worse. For some people, many foods, medicines, and bee stings mean life-threatening allergic reactions that require immediate treatment with injectable epinephrine. For many people, January means the start of a new drug deductible to be met. In June 2017 the FDA approved a new form of emergency epinephrine called Symjepi, which may be good news for people who must be prepared in the event of a life-threatening allergic reaction.
The seriousness of a severe allergic reaction

Severe allergic reactions affect anywhere from 5% to 70% of persons, depending on age and prior exposure. Anaphylactic or “type 1” (immediate hypersensitivity) reactions are the most severe forms of allergic reaction to a substance: insect venom, foods, or some drugs. People who have had prior exposure to an allergic substance are “sensitized” and when they are re-exposed, can have a reaction within seconds to minutes. Anaphylactic reactions are caused by the release of histamine and other chemicals throughout the body, resulting in leaky blood vessels that contribute to swelling of tissues in the mouth and airway and very low blood pressure. These symptoms can lead to difficulty swallowing and speaking, wheezing and severe shortness of breath, and death.
Treating severe allergic reactions

The treatment for severe allergic reactions is the administration of epinephrine (adrenaline) at the first sign of symptoms. Epinephrine is one of the chemicals in the body that raises blood pressure and heart rate. Epinephrine can be administered through an IV in the hospital, but since the 1980s, epinephrine has been available as a pre-filled syringe that can be obtained with a prescription and immediately injected into the thigh muscle when severe allergic symptoms are recognized.

The prevalence of severe allergies has been increasing since 2000. Anaphylaxis to some external chemical or allergen occurs in 2% of the population, and it is estimated that approximately 500 people die from anaphylactic reactions per year in the US. Because of this, more and more people need to have epinephrine available wherever they are (home, school, when traveling). So it is no surprise that the manufacture and marketing of pre-filled epinephrine syringes has been big news in the last two years.
Keeping epinephrine at the ready

Spring-loaded autoinjectors that contain epinephrine have been manufactured by several companies since 1987. In the last 30 years, changes in pharmaceutical companies and patent transfers resulted in a near-monopoly in the production of pre-filled epinephrine products. From 2009 to 2016, one company with a 90% market share dramatically increased the consumer cost for epinephrine injectors, resulting in an investigation and eventual settlement with the US Department of Justice.

Although not a spring-loaded autoinjector, Symjepi consists of two single-dose, pre-filled syringes of epinephrine, for the emergency treatment of anaphylactic and severe allergic reactions in adults. Each pre-filled syringe contains 0.3 mg epinephrine, the recommended initial dose for emergency treatment of anaphylaxis.

At an anticipated lower cost and small size, Symjepi could be an attractive addition to this slice of the pharmaceutical world. In November 2017, the company also submitted a second new drug application to the FDA for a junior version (0.15 mg dose for children between 33 and 65 pounds).
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A rare but serious complication of… exercise

Sore throats happen all the time in childhood — and most of the time, it’s nothing to worry about. Most of the time, they are simply part of a common cold, don’t cause any problems, and get better without any treatment.

Sometimes, though, a sore throat can be a sign of a problem that might need medical treatment. Here are four examples:

Strep throat. This infection, caused by a particular kind of streptococcus bacteria, is quite common. Along with a sore throat, children may have a fever, headache, stomachache (sometimes with vomiting), and a fine, pink rash that almost looks like sandpaper. All of these symptoms can also be seen with a viral infection, so the only way to truly know if it’s strep throat is to swab for rapid testing and/or a culture. Strep throat actually can get better without antibiotics, but we give antibiotics to prevent complications, which, while rare, can include heart problems, kidney problems, and arthritis.

Peritonsillar or retropharyngeal abscess. This is a collection of pus either behind the tonsils (peritonsillar) or at the back of the throat (retropharyngeal) and can be dangerous. Redness and swelling on one side of the throat, or a bad sore throat with fever and neck stiffness, can be signs.

Stomatitis. This is caused by viruses, and leads to sores in the mouth and throat. It gets better by itself, but it can make eating and drinking very uncomfortable, which is why some children with stomatitis (especially very young children) end up with dehydration. There are medications that can help coat the sores and make drinking easier, to help prevent dehydration.

Ingestion. Little children are curious and don’t have the best self-preservation skills. If they drink something that is a strong acid or alkali, it can burn the mouth and throat as it goes down. Household products such as bleach, drain cleaners, toilet bowl cleaners, some detergents, and even some beauty products such as hair straighteners, can do terrible damage. If an adult didn’t witness the ingestion, all they might know is that the child is suddenly complaining of mouth and throat pain.
There are few subjects that can stir up stronger emotions among doctors, scientists, researchers, policy makers, and the public than medical marijuana. Is it safe? Should it be legal? Decriminalized? Has its effectiveness been proven? What conditions is it useful for? Is it addictive? How do we keep it out of the hands of teenagers? Is it really the “wonder drug” that people claim it is? Is medical marijuana just a ploy to legalize marijuana in general?

These are just a few of the excellent questions around this subject, questions that I am going to studiously avoid so we can focus on two specific areas: why do patients find it useful, and how can they discuss it with their doctor?

Marijuana is currently legal, on the state level, in 29 states, and in Washington, DC. It is still illegal from the federal government’s perspective. The Obama administration did not make prosecuting medical marijuana even a minor priority. President Donald Trump promised not to interfere with people who use medical marijuana, though his administration is currently threatening to reverse this policy. About 85% of Americans support legalizing medical marijuana, and it is estimated that at least several million Americans currently use it.
Marijuana without the high

Least controversial is the extract from the hemp plant known as CBD (which stands for cannabidiol) because this component of marijuana has little, if any, intoxicating properties. Marijuana itself has more than 100 active components. THC (which stands for tetrahydrocannabinol) is the chemical that causes the “high” that goes along with marijuana consumption. CBD-dominant strains have little or no THC, so patients report very little if any alteration in consciousness.

Patients do, however, report many benefits of CBD, from relieving insomnia, anxiety, spasticity, and pain to treating potentially life-threatening conditions such as epilepsy. One particular form of childhood epilepsy called Dravet syndrome is almost impossible to control, but responds dramatically to a CBD-dominant strain of marijuana called Charlotte’s Web. The videos of this are dramatic.
Uses of medical marijuana

The most common use for medical marijuana in the United States is for pain control. While marijuana isn’t strong enough for severe pain (for example, post-surgical pain or a broken bone), it is quite effective for the chronic pain that plagues millions of Americans, especially as they age. Part of its allure is that it is clearly safer than opiates (it is impossible to overdose on and far less addictive) and it can take the place of NSAIDs such as Advil or Aleve, if people can’t take them due to problems with their kidneys or ulcers or GERD.

In particular, marijuana appears to ease the pain of multiple sclerosis, and nerve pain in general. This is an area where few other options exist, and those that do, such as Neurontin, Lyrica, or opiates are highly sedating. Patients claim that marijuana allows them to resume their previous activities without feeling completely out of it and disengaged.

Along these lines, marijuana is said to be a fantastic muscle relaxant, and people swear by its ability to lessen tremors in Parkinson’s disease. I have also heard of its use quite successfully for fibromyalgia, endometriosis, interstitial cystitis, and most other conditions where the final common pathway is chronic pain.

Marijuana is also used to manage nausea and weight loss, and can be used to treat glaucoma. A highly promising area of research is its use for PTSD in veterans who are returning from combat zones. Many veterans and their therapists report drastic improvement and clamor for more studies, and for a loosening of governmental restrictions on its study. Medical marijuana is also reported to help patients suffering from pain and wasting syndrome associated with HIV, as well as irritable bowel syndrome and Crohn’s disease.

This is not intended to be an inclusive list, but rather to give a brief survey of the types of conditions for which medical marijuana can provide relief. As with all remedies, claims of effectiveness should be critically evaluated and treated with caution.
Talking with your doctor

Many patients find themselves in the situation of wanting to learn more about medical marijuana, but feel embarrassed to bring this up with their doctor. This is in part because the medical community has been, as a whole, overly dismissive of this issue. Doctors are now playing catch-up, and trying to keep ahead of their patients’ knowledge on this issue. Other patients are already using medical marijuana, but don’t know how to tell their doctors about this for fear of being chided or criticized.

My advice for patients is to be entirely open and honest with your physicians and to have high expectations of them. Tell them that you consider this to be part of your care and that you expect them to be educated about it, and to be able to at least point you in the direction of the information you need.

My advice for doctors is that whether you are pro, neutral, or against medical marijuana, patients are embracing it, and although we don’t have rigorous studies and “gold standard” proof of the benefits and risks of medical marijuana, we need to learn about it, be open-minded, and above all, be non-judgmental. Otherwise, our patients will seek out other, less reliable sources of information; they will continue to use it, they just won’t tell us, and there will be that much less trust and strength in our doctor-patient relationship. I often hear complaints from other doctors that there isn’t adequate evidence to recommend medical marijuana, but there is even less scientific evidence for sticking our heads in the sand. We are fortunate to have a country home in the Catskills where we can escape city life. An eight-year-old neighbor often crosses our meadow or bikes over to stop by for a visit. While I’d like to think I’m the featured attraction, his visits are not just to see me; of much greater interest is our basement with its shelves of toys and games. Particularly appealing to this lad is the sports equipment: hockey sticks, goalie pads, a goal to shoot on, baseball mitts, a batting helmet, a catcher’s mask, soccer balls, and more. Name the sport and it is most likely we have equipment for it, even in different sizes.

I’ve given my young friend a few items: retaping a hockey stick that’s the right size for him, a pair of batting gloves, a cracked bat from a Bat Day at Yankee Stadium. He knows these were things that belonged to my son. Visits have been frequent, offering a chance to go to the basement so we could play some more floor hockey, or perhaps do a review of our inventory again, maybe hoping to catch me in a generous frame of mind. Downstairs amongst the gloves and balls and pads, waiting to be discovered, was The Question. “Where is your son, where is William?”

Knowing that sooner or later The Question that would come up, I had a conversation with his parents. Who explains William’s permanent absence to the young fellow? What is age-appropriate detail? Is there a better time for the discussion?

The Answer is, sadly, that William died from an accidental heroin overdose. At the time my wife and I became aware that William was using heroin, he was 22. He was already seeing a psychotherapist. Over the next two years we added an addiction psychiatrist, outpatient treatment, treatment with Suboxone, inpatient detox, inpatient treatment, outpatient treatment, outpatient detox, treatment with Vivitrol, more outpatient treatment, another inpatient treatment, more outpatient treatment, a revolving door of well over a dozen trips to and from the emergency rooms of at least four different hospitals, an attempt to work with another addiction psychiatrist, Alcoholics Anonymous, Narcotics Anonymous, and a home life fraught with tension, despair, sometimes hope during intermittent periods of sobriety, and always filled with the apprehension of misfortune.

That apprehension became fact when William accidentally overdosed shortly before his 24th birthday. Just four days prior he had gone to a hospital to ask to be admitted to inpatient detox. His insurance company denied the request as “not medically necessary.” Six weeks of comatose and/or heavily medicated hospitalization followed before the ultimate realization that William was consigned to a persistent vegetative state.

When we decided to permanently remove him from a respirator we attempted organ donation. Organ donation in William’s condition required an expedient demise within a tight one-hour time frame once removed from the respirator. William continued on and survived for another 21 hours before breathing his last in our arms. Ultimately, we made an anatomical donation of his body to Columbia University’s College of Physicians and Surgeons.

Once, William was young, curious, engaging, and adventuresome, much like our eight-year-old neighbor. I continue to question, puzzle, and agonize over the path that takes a boy from building with Legos, playing catch, bocce on our lawn, snow forts, an entertaining sense of humor, late night talks, fierce and courageous loyalty to friends, right-on-the-money analysis of people, situations, and numbers, a flash of the pads for a save, and the sweetness, strength, inspiration, and love that was William… to a death certificate that reads death due to “complications of acute heroin intoxication.”

One thing I do know. When my young neighbor asks about William, I have to answer him openly and honestly. There’s more of William to share than some old hockey sticks and baseball bats. William’s story, like that of so many others, has to come out of the basement so that it can be the cautionary tale every growing boy should hear.
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17/01/2019

Going Mediterranean to prevent heart disease

Medical myths die hard. Maybe that’s because there’s no agreement on whether a common belief is indeed a myth.

For example, there’s the longstanding belief that weather affects arthritis pain. Many of my patients notice a clear connection; some are so convinced of the link, they believe they can predict the weather better than the TV meteorologists. And maybe that’s true.

But that’s not what the science says. A recent study finds no connection between rainy weather and symptoms of back or joint pain. This conclusion was based on a staggering amount of data: more than 11 million medical visits occurring on more than two million rainy days and nine million dry days. Not only was there no clear pattern linking rainy days and more aches and pains, but there were slightly more visits on dry days.

Still not convinced? That’s understandable. Maybe it’s not rain or shine that matters — maybe it’s barometric pressure, changes in weather, or humidity that matters most. Or maybe the study missed some key information, such as when symptoms began or got worse — after all, it can take days or even weeks after symptoms begin to see a doctor.
What does past research say about weather and arthritis pain?

The question of whether there’s a link between weather and aches and pains has been studied extensively. While a definitive answer is nearly impossible to provide — because it’s hard to “prove a negative” (prove that something doesn’t exist) — researchers have been unable to make a strong case for a strong connection.

For example, a 2014 study in Australia found no link between back pain and rain, temperature, humidity, or air pressure. This study collected data regarding features of the weather at the time of first symptoms, and compared it to the weather a week and a month before. But, an earlier study found that among 200 patients followed for three months, knee pain increased modestly when temperature fell or barometric pressure rose.
Does research matter when you have personal experience?

That’s a fair question. And it’s something I’ve even heard in TV commercials about headache medicines: “I don’t care about the research. I just know what works for me.” But it’s worth remembering that humans have a remarkable tendency to remember when two things occur or change together (such as wet, gloomy weather and joint pain), but remember less when things do not occur together. That rainy day when you felt no better or worse is unlikely to be so notable that you remember it. If you rely solely on memory rather than on more rigorous, data-based evidence, it’s easy to conclude a link exists where, in fact, none does.
There is a mountain of high-quality research supporting a Mediterranean-style diet as the best diet for our cardiovascular health. But what does this diet actually look like, why does it work, and how can we adopt it into our real lives?
What is a Mediterranean diet?

The Mediterranean diet is not a fad. It is a centuries-old approach to meals, traditional to the countries bordering on the Mediterranean Sea. The bulk of the diet consists of colorful fruits and vegetables, plus whole grains, legumes, nuts and seeds, fish and seafood, with olive oil and perhaps a glass of red wine. There is no butter, no refined grains (like white bread, pasta, and rice), and very little red or processed meat (like bacon). There is also an emphasis on sitting down and enjoying a meal among family and friends, as well as avoiding snacking, and getting plenty of activity. It’s not just about the food: it’s a way of being.
What’s a Mediterranean-style diet?

The food part is similar to most other healthful diet approaches in that it’s plant-based. And the recipes do not have to be Italian or Greek, which is why I refer to it as a Mediterranean-style diet. Every meal should have vegetables and fruits as the base. Any grains should be whole grain, like quinoa, brown rice, corn, farro, or whole wheat. Legumes are an excellent source of plant protein, things like lentils, garbanzo, kidney, cannellini, or black beans. Nuts and seeds have protein and healthy fats, and olive oil provides even more healthy fat. Including fish and seafood is traditional, but not required. I advise people not to stress about dairy, poultry, and eggs; these are okay in small amounts. A glass of wine a day may be beneficial, but not for everyone, and there is no reason for non-drinkers to take it up.
Why does this way of eating produce such impressive health benefits?

In a recent study published in JAMA Network Open, researchers looked at data from over 25,000 women over 45 (with an average age of 55) and with no history of heart disease.

Using the baseline dietary questionnaire, a Mediterranean diet “score” was calculated. Basically, there was one point given for each of these nine main components: higher than average intake of fruits, vegetables, whole grains, legumes, nuts, fish, and healthy fats; healthy level of alcohol intake; and lower than average intake of red and processed meats. Participants were divided into groups based on low, medium, and high Mediterranean diet consumption (scores of 0–3, 4–5, and 6–9).

After 12 years average follow-up time, 1,030 participants had some kind of serious cardiovascular issue (including heart attack, angina with stent placement, peripheral vascular disease requiring intervention, or stroke). The women in the medium and high Mediterranean diet groups had significantly lower risk (23% and 28% lower, respectively).

Higher Mediterranean diet scores were also associated with lower body mass index and blood pressure, as well as more optimal lab data like lower inflammatory markers (high-sensitivity CRP), lower diabetes risk (insulin resistance), and a better lipid profile (higher HDL). These findings suggest the pathways through which the diet benefits the body: by decreasing inflammation and promoting healthy blood cholesterol and sugar levels.
How to “go Mediterranean”

Adopting the Mediterranean diet in our busy, high-tech world may seem daunting. But there are tips and tricks to change your eating habits and reduce your risk of heart disease.

My book, Healthy Habits for Your Heart, teaches you the basics of behavior change, as well as step-by-step methods to make these changes happen in your real life. Chapter 5, “Eat For Your Life: Nutrition Habits” takes you through the science-backed recommendations for adopting a heart-healthy, plant-based Mediterranean-style diet. One suggestion is:
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04/01/2019

Preterm birth and heart disease risk for mom

When I’m dragging and feeling tired during the occasional low-energy day, my go-to elixir is an extra cup (or two or three) of black French press coffee. It gives my body and brain a needed jolt, but it may not help where I need it the most: my cells.
The cellular basis of being tired

What we call “energy” is actually a molecule called adenosine triphosphate (ATP), produced by tiny cellular structures called mitochondria. ATP’s job is to store energy and then deliver that energy to cells in other parts of the body. However, as you grow older, your body has fewer mitochondria. “If you feel you don’t have enough energy, it can be because your body has problems producing enough ATP and thus providing cells with enough energy,” says Dr. Anthony Komaroff, professor of medicine at Harvard Medical School. You may not be able to overcome all aspects of age-related energy loss, but there are ways to help your body produce more ATP and replenish dwindling energy levels. The most common strategies revolve around three basic concepts: diet, exercise, and sleep.

Diet. Boost your ATP with fatty acids and protein from lean meats like chicken and turkey, fatty fish like salmon and tuna, and nuts. While eating large amounts can feed your body more material for ATP, it also increases your risk for weight gain, which can lower energy levels. “The excess pounds mean your body has to work harder to move, so you use up more ATP,” says Dr. Komaroff. When lack of energy is an issue, it’s better to eat small meals and snacks every few hours than three large meals a day, according to Dr. Komaroff. “Your brain has very few energy reserves of its own and needs a steady supply of nutrients,” he says. “Also, large meals cause insulin levels to spike, which then drops your blood sugar rapidly, causing the sensation of fatigue.”

Drink enough water. If your body is short on fluids, one of the first signs is a feeling of fatigue. Although individual needs vary, the Institute of Medicine recommends men should aim for about 15 cups (3.7 liters) of fluids per day, and women about 12 cups (2.7 liters). Besides water and beverages like coffee, tea, and juices, you can also get your fluids from liquid-heavy fruits and vegetables that are up to 90% water, such as cucumbers, zucchini, squash, strawberries, citrus fruit, and melons.

Get plenty of sleep. Research suggests that healthy sleep can increase ATP levels. ATP levels surge in the initial hours of sleep, especially in key brain regions that are active during waking hours. Talk with your doctor if you have problems sleeping through the night.

Stick to an exercise routine. Exercise can boost energy levels by raising energy-promoting neurotransmitters in the brain, such as dopamine, norepinephrine, and serotonin, which is why you feel so good after a workout. Exercise also makes muscles stronger and more efficient, so they need less energy, and therefore conserve ATP. It doesn’t really matter what kind of exercise you do, but consistency is key. Some research has suggested that as little as 20 minutes of low-to-moderate aerobic activity, three days a week, can help sedentary people feel more energized.
When being tired warrants a visit to your doctor

You should see your doctor if you experience a prolonged bout of low energy, as it can be an early warning of a serious illness. “Unusual fatigue is often the first major red flag that something is wrong,” says Dr. Komaroff. Lack of energy is a typical symptom for most major diseases, like heart disease, many types of cancer, autoimmune diseases such as lupus and multiple sclerosis, and anemia (too few red blood cells). Fatigue also is a common sign of depression and anxiety. And fatigue is a side effect of some medications.
If you delivered a baby early, you may want to pay closer attention to your heart health. A study published in the journal Hypertension shows that a history of preterm birth (defined as a birth before the 37th week of pregnancy) may bring health risks for not only for baby, but for mom, too.

The study found that women who delivered a baby preterm were more likely to experience rising blood pressures later, compared to women who delivered closer to term. If they had this pattern, they were also more likely to show signs of coronary artery disease, which is associated with an increased risk of heart attack and stroke.

Because of the unique demands that pregnancy places on a woman’s body, it may serve as a stress test for a woman’s heart, says Dr. JoAnn E. Manson, the Michael and Lee Bell Professor of Women’s Health at Harvard Medical School. Pregnancy-related conditions (for example, gestational diabetes and pre-eclampsia) are known to raise a woman’s risk of developing cardiovascular disease. Preterm birth should now join that list, says Dr. Manson.

“I think this study adds to the mounting evidence that preterm birth is yet another complication of pregnancy that indicates a higher risk of cardiovascular disease in the mother,” she says.
The association between early birth and heart disease risk

The study looked at data from more than 1,000 mothers in several major US cities. Researchers divided the women into three categories — “low stable,” “moderate,” and “moderate increasing” — based on how their systolic blood pressure (the first number in a reading) changed over time. Women who had what was defined as “moderate increasing” blood pressure were 19% more likely to have delivered a baby early than women with “low stable” blood pressure. In addition, more than 38% of the “moderate increasing” group developed coronary artery calcifications (a marker for higher risk of future heart attack), seen on CT heart scans, compared with 12.2% of the “low stable” group. Women who had both a preterm delivery and “moderate increasing” blood pressure had more than double the risk of developing arterial calcifications, compared with women who delivered at term and had a lower blood pressure pattern.

The associations researchers found were stronger in women who experienced high blood pressure conditions during pregnancy, but were also found in women who did not. Interestingly, women who had a “moderate increasing” blood pressure pattern but delivered a full-term baby didn’t seem to have excess risk for artery calcifications.

But not all preterm births bring the same potential heart risks. The study authors found that a preterm birth alone wasn’t enough to raise risk. That happened only when women had both a preterm birth and a pattern of increasing blood pressure in the years that followed. This may be the case because there are other factors that can result in a preterm birth, such as carrying twins or other multiples, or having a physical problem with the cervix, says Dr. Manson. For women with such conditions, a preterm delivery would not be expected to reflect higher cardiovascular risks, says Dr. Manson.
If you gave birth early, pay attention to all heart disease risk factors

Having a preterm birth or other pregnancy-related complications doesn’t mean you are doomed to develop cardiovascular disease. Steps you can take to reduce your risk include the following:

    Discuss your pregnancy history with your doctor. Your doctor should be aware that you delivered preterm and should also know about any other pregnancy-related complications you had, such as gestational diabetes or pre-eclampsia — and should understand that it may raise your risk for future heart disease.
    Track your blood pressure. “Your blood pressure should be monitored closely, at least once a year, and preferably more often,” says Dr. Manson. Self-monitoring using a blood pressure machine monthly at home might also help you spot troubling trends early. Blood pressure should ideally remain below 120/80 mm Hg. If it rises above that level, discuss it with your doctor.
    Maintain a healthy diet and lifestyle. It’s been said a million times before, but eating a well-balanced diet rich in fruits, vegetables, and whole grains can help head off cardiovascular disease. Avoid excess sodium, red meat, and heavily processed foods whenever possible. And of course, don’t smoke, and make time to squeeze in regular exercise.
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Understanding and improving core strength

It may not seem possible to be able to write your way to better health. But as a doctor, a public health practitioner, and a poet myself, I know what the scientific data have to say about this: when people write about what’s in their hearts and minds, they feel better and get healthier. And it isn’t just that they’re getting their troubles off their chests.

Writing provides a rewarding means of exploring and expressing feelings. It allows you to make sense of yourself and the world you are experiencing. Having a deeper understanding of how you think and feel — that self-knowledge — provides you with a stronger connection to yourself. It’s that connection that often allows you to move past negative emotions (like guilt and shame) and instead access positive ones (like optimism or empathy), fostering a sense of connection to others in addition to oneself.
Making connections is key

It’s remarkable that the sense of connection to others that one can feel when writing expressively can occur even when people are not engaged directly. Think of being at a movie or concert and experiencing something dramatic or uplifting. Just knowing that everyone else at the theater is sharing an experience can make you feel connected to them, even if you never talk about it. Expressive writing can have the same connecting effect, as you write about things that you recognize others may also be experiencing, even if those experiences differ. And if you share your writing, you can enhance your connection to someone else even more. That benefit is energizing, life-enhancing, and even lifesaving in a world where loneliness — and the ill health it can lead to — has become an epidemic.

Maybe it’s time to pay greater attention to expressive writing as one important way to enhance a sense of connection to others. Social connection is crucial to human development, health, and survival, but current research suggests that social connection is largely ignored as a health determinant. We ignore that relationship at our peril, since emerging medical research indicates that a lack of social connections can have a profound influence on risk for mortality, and is associated with up to a 30% risk for early death — as lethal as smoking 15 cigarettes a day. Social isolation and loneliness can have additional long-term effects on your health including impaired immune function and increased inflammation, promoting arthritis, type 2 diabetes, cancer, and heart disease.
How expressive writing battles loneliness

Picking up a pen can be a powerful intervention against loneliness. I am a strong believer in writing as a way for people who are feeling lonely and isolated to define, shape, and exchange their personal stories. Expressive writing, especially when shared, helps foster social connections. It can reduce the burden of loneliness among the many groups who are most at risk, including older adults, caregivers, those with major illnesses, those with disabilities, veterans, young adults, minority communities of all sorts, and immigrants and refugees.

Writing helps us to operate in the past, present, and future all at once. When you put pen to paper you are operating in the present moment, even while your brain is actively making sense of the recalled past, choosing and shaping words and lines. But the brain also is operating in the future, as it pictures a person reading the very words you are actively writing. When expressing themselves in writing, people are actually creating an artifact — a symbol of some of their thoughts and feelings. People often can write what they find difficult to speak, and so they explore deeper truths. This process of expression through the written word can build trust and bonds with others in unthreatening ways, forging a path toward a more aware and connected life.

When people tell their personal stories through writing, whether in letters to friends or family, or in journals for themselves, or in online blog posts, or in conventionally published work, they often discover a means of organizing and understanding their own thoughts and experiences. Writing helps demystify the unknown and reduce fears, especially when we share those written concerns with others.
Write for your health

As a poet, I’ve personally experienced the benefits of expressive writing. The skills it sharpens; the experience of sharing ideas, feelings, and perceptions on a page; the sensations of intellectual stimulus and emotional relief — all are life enhancing. I’d like more people to discover that expressive writing can contribute to well-being, just as exercise and healthful eating do.

I’ve documented some of the research being done in the area of healing and the arts. After reviewing more than 100 studies, we concluded that creative expression improves health by lowering depression and stress while boosting healthy emotions. So pick up a pen, and start to write creatively. For the mind and the body, writing is a strong prescription for good health.
The rate of type 2 diabetes is increasing around the world. Type 2 diabetes is a major cause of vision loss and blindness, kidney failure requiring dialysis, heart attacks, strokes, amputations, infections and even early death. Over 80% of people with prediabetes (that is, high blood sugars with the high risk for developing full-blown diabetes) don’t know it. Heck, one in four people who have full-blown diabetes don’t know they have it! Research suggests that a healthy lifestyle can prevent diabetes from occurring in the first place and even reverse its progress.
Can a healthy diet and lifestyle prevent diabetes?

The Diabetes Prevention Program (DPP), a large, long-term study, asked the question: we know an unhealthy diet and lifestyle can cause type 2 diabetes, but can adopting a healthy diet and lifestyle prevent it? This answer is yes: the vast majority of prediabetes and type 2 diabetes can be prevented through diet and lifestyle changes, and this has been proven by 20 years of medical research.

Researchers from the DPP took people at risk for type 2 diabetes and gave them a 24-week diet and lifestyle intervention, a medication (metformin), or placebo (a fake pill), to see if anything could lower their risk for developing diabetes. The very comprehensive diet and lifestyle intervention had the goal of changing participants’ daily habits, and included: 16 classes teaching basic nutrition and behavioral strategies for weight loss and physical activity; lifestyle coaches with frequent contact with participants; supervised physical activity sessions; and good clinical support for reinforcing an individualized plan.

Perhaps not surprisingly, the diet and lifestyle intervention was incredibly effective. After three years, the diet and lifestyle group had a 58% lower risk of developing diabetes than the placebo group. Participants aged 60 and older had an even better response, with a whopping 71% lower risk of developing diabetes. The diet and lifestyle effect lasted: even after 10 years, those folks had a 34% lower risk of developing diabetes compared to placebo. Men, women, and all racial and ethnic groups had similar results (and almost half of participants represented racial and ethnic minorities). These results are not surprising to me or to other doctors, because we have all seen patients with prediabetes or diabetes get their sugars down with diet, exercise, and weight loss alone.

Meanwhile, the medication group had a 31% lower risk of diabetes after three years, and an 18% lower risk after 10 years, which is also significant. It’s perfectly all right to use medications along with diet and lifestyle changes, because each boosts the effect of the other. Studies looking at the combination of medication (metformin) with diet and lifestyle changes have shown an even stronger result.
Dietary recommendations to prevent diabetes (and even reverse it)

    Decrease intake of added sugars and processed foods, including refined grains like white flour and white rice. This especially includes sugary drinks, not only sodas but also juices. The best drinks are water, seltzer, and tea or coffee without sugar.
    Swap out refined grains for whole grains. Whole grains are actually real grains that haven’t been stripped of nutrients in processing. Foods made from 100% whole grain (like whole wheat) are okay, but intact whole grains (like farro, quinoa, corn, oatmeal, and brown rice) are even better. Swapping out grains for starchy veggies (like potatoes) is also okay, as long as these veggies aren’t in the form of french fries!
    Increase fiber intake. High-fiber foods include most vegetables and fruits. Legumes are also high in fiber and healthy plant protein. Legumes include lentils, beans, chickpeas, peas, edamame, and soy. People who eat a lot of high-fiber foods tend to eat fewer calories, weigh less, and have a lower risk of diabetes.
    Increase fruits and vegetables intake. At least half of our food intake every day should be non-starchy fruits and vegetables, the more colorful the better. Cruciferous vegetables like broccoli, cauliflower, and Brussels sprouts, and high-fiber fruits like berries of all kinds, are especially healthy. All fruits and vegetables are associated with living a significantly longer and healthier life!
    Eat less meat, and avoid processed red meat. Many studies have shown us that certain meats are incredibly risky for us. People who eat processed red meat are far more likely to develop diabetes: one serving a day (which is two slices of bacon, two slices of deli meat, or one hot dog) is associated with over a 50% higher risk of developing type 2 diabetes. Eating even a small portion of red meat daily (red meat includes beef, lamb, and pork), like a palm-sized piece of steak, is associated with a 20% increased risk of type 2 diabetes. This may be because of the iron in red meats, and the chemicals in processed meats. As a matter of fact, the less meat you eat, the lower your risk of diabetes. People who don’t eat red meat at all, but do eat chicken, eggs, dairy, and fish, can significantly lower their risk of developing type 2 diabetes, by about 30%; those who eat only fish, 50%; those who eat only eggs and dairy, 60%; those who are vegan, 80%.
    Eat healthier fats. Fat is not necessarily bad for you. What kind of fat you’re eating really does matter. Saturated fats, particularly from meats, are associated with an increased risk of diabetes and heart disease. Plant oils, such as extra-virgin olive oil and canola oil, carry less risk. Omega-3 fats, like in walnuts, flax seeds, and some fish, are actually quite good for you.

Diet and lifestyle changes that can help prevent diabetes

Diet and lifestyle changes are so effective for diabetes prevention that as of April 2018, insurance companies are now covering these programs for people at risk. The CDC’s Diabetes Prevention Program, used in many clinics, is a free tool to help you learn and stick with the healthy diet, physical activity, and stress management techniques that reduce your risk of diabetes.

One helpful tool is the Harvard School of Public Health Nutrition Source Healthy Eating Plate, which shows you what your daily food intake should look like: half fruits and vegetables, about a quarter whole grains, and a quarter healthy proteins (plant protein is ideal here), with some healthy fats and no-sugar-added beverages. The Harvard Health Blog also offers many articles with recipes and cooking videos to help you create a healthier, diabetes-free lifestyle. When most people think about core strength, they think about an abdominal six-pack. While it looks good, this toned outer layer of abdominal musculature is not the same as a strong core.
What is the “core” and why is core strength so important?

The core is a group of muscles that stabilizes and controls the pelvis and spine (and therefore influences the legs and upper body). Core strength is less about power and more about the subtleties of being able to maintain the body in ideal postures — to unload the joints and promote ease of movement. For the average person, this helps them maintain the ability to get on and off the floor to play with their children or grandchildren, stand up from a chair, sit comfortably at a desk, or vacuum and rake without pain. For athletes, it promotes more efficient movement, therefore preventing injury and improving performance. Having a strong or stable core can often prevent overuse injuries, and can help boost resiliency and ease of rehab from acute injury. The core also includes the pelvic floor musculature, and maintaining core stability can help treat and prevent certain types of incontinence.
The problem with a weak core

As we age, we develop degenerative changes, very often in the spine. The structures of the bones and cartilage are subject to wear and tear. Very often, we are able to completely control and eliminate symptoms with the appropriate core exercises. Having strong and stable postural muscles helps suspend the bones and other structures, allowing them to move better. Scoliosis, a curving or rotation of the spine, can also often be controlled with the correct postural exercises. Having an imbalanced core can lead to problems up and down the body. Knee pain is often caused by insufficient pelvic stabilization. Some runners develop neck and back pain when running because the “shock absorbers” in their core could use some work.
Finding the right core strengthening program for you

A good core program relies less on mindless repetition of exercise and focuses more on awareness. People with good core strength learn to identify and activate the muscles needed to accomplish the task. Learning to activate the core requires concentration, and leads to being more in tune with the body.

There is no one method of core strengthening that works for everyone. Some people do well with classes (though it can be easy do the repetitions without truly understanding the targeted muscle groups). Others use Pilates or yoga to discover where their core is. Physical therapists are excellent resources, as they can provide one-on-one instruction and find a method that works for any person with any background at any ability level. It sometimes takes patience for people to “find” their core, but once they do, it can be engaged and activated during any activity — including walking, driving, and sitting. While building the core starts with awareness and control, athletes can further challenge their stability with more complex movements that can be guided by athletic trainers and other fitness specialists.
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Orthorexia: The extreme quest for a healthy diet

One of the best parts of being a geriatrician (a specialist caring for older adults) is to meet individuals who are aging successfully, taking care of themselves, and taking their health seriously. Well-informed individuals usually like to know if their chronic health conditions are well controlled or not.

With improved public education, it is now common knowledge that uncontrolled diabetes leads to damage to the major organs of the body, such as the heart, kidneys, eyes, nerves, blood vessels, and brain. So, it is important to ask how tightly blood glucose (also called blood sugar) should be controlled to decrease the risk of harm to these organs.
Blood sugar: too high, too low, or just right?

To answer this question, first let’s discuss how diabetes is different than other chronic health conditions. For example, a doctor can tell you that your cholesterol levels need to be below a certain number to lower the risk of heart disease. Diabetes is different. Diabetes is a unique condition in which both high and low glucose levels are harmful to the body.

Diabetes control is measured as A1c, which reflects average blood sugar levels over the past two to three months. High glucose levels (A1c levels greater than 7% or 7.5%) over a long period can cause damage to the major organs of the body. However, medications and insulin that are used to lower glucose levels can overshoot and lead to glucose levels that are too low. Low glucose levels (known as hypoglycemia) can result in symptoms such as rapid heartbeat, excessive sweating, feeling dizzy, difficulty thinking, falling, or even passing out.

So, both high and low glucose levels are harmful. Thus, diabetes management requires balancing the risk of high and low glucose levels, and requires constant assessment to see which of these glucose levels is more likely to harm an individual patient.
Different blood sugar goals over a lifetime

The next consideration in answering the question about tight glucose control is to understand why younger and older adults need different goals. In younger individuals, longer life expectancy means a higher risk of developing complications over many decades of life. Younger adults typically recover from hypoglycemic episodes without severe consequences.

On the other hand, people in their 80s or 90s may not have several decades of life expectancy, and so the concern about developing long-term complications due to high glucose levels is decreased. However, hypoglycemia in these individuals may lead to immediate consequences such as falls, fractures, loss of independence, and subsequently a decline in quality of life. In addition, tighter control of diabetes frequently requires complicated treatment regimens, such as multiple insulin injections at different times of the day or a variety of glucose lowering pills. This further increases the risk of hypoglycemia, as well as stress, to both older patients and their caregivers at home.
Identifying the “why” of blood sugar control

Thus, when considering goals for blood glucose in older adults, it is important to ask why we are managing diabetes. As the reason to tightly control diabetes is to prevent complications in the future, tighter control of diabetes could be a goal in an older adults who are in good health and have few risk factors for hypoglycemia. Hypoglycemia risk factors include previous history of severe hypoglycemia that required hospital or emergency department visits, memory problems, physical frailty, vision problems, and severe medical conditions such as heart, lung, or kidney diseases.

In older individuals with multiple risk factors for hypoglycemia, the goal should not be tight control. Instead, the goal should be the best control that can be achieved without putting the individual at risk for hypoglycemia.

Lastly, it is important to remember that health status is not always stable as we get older, and the need or the ability to keep tight glucose control may change over time in older adults. Goals for all chronic disease, not just blood sugar control, need to be individualized to adapt to the changing circumstances associated with aging.
The pursuit for the healthiest diet continues. Just as I was finishing writing this blog post, a new study came out suggesting that both low-carb and high-carb diets may shorten lifespan. In the 1980s and ‘90s, we were following the low-fat trend. These days, the ketogenic diet and the very-low-carb diet are all the rage. And if you think there is controversy about the right amount of carbohydrates, fats, and proteins you should eat, the conversation can get downright ugly if we start talking about specific items like gluten. Research continues to look for insight into the best diet for humans. But the relentless focus on diet and health may lead some people to obsessively seek a perfect “utopian” diet, a condition called orthorexia.
The difference between healthy eating and orthorexia

Orthorexia, although not yet recognized as a disease, is the obsessive fixation on healthy food and healthy eating. People with orthorexia are often on a stringent diet and may have anxiety about how much they eat, how certain foods are prepared, and where those foods came from. This behavior has hints of obsessive-compulsive disorder and anorexia nervosa. Some people feel very guilty if they do not follow the rigid plans they originally designed to have a healthy diet. Their lives are too focused on healthy eating, and they hardly ever have dinner with friends. They prefer starvation to eating “impure” foods. The result is social isolation and hours spent preoccupied and anxious about what to eat. It is important to note that people who choose to eat a specific diet for religious or environmental reasons, or to protect animal welfare and agricultural sustainability, are not considered to have orthorexia.
Cultural shifts about healthy eating

Growing up in the ‘80s, I hardly knew anyone who had dietary restrictions. Today it is very common to know people who strictly avoid certain foods. There are several theories to explain this new phenomenon: exposure to more toxins and chemical products in our foods; the advent of genetically modified organisms; the modern, more hygienic way of living (which is also blamed for the rise of allergies, asthma, and autoimmune diseases). But others think it may be partially related to the increased recognition and awareness of healthier habits and the significant influence of social media, blogs, health magazines, and clinicians who pontificate ideas of what is right and wrong in the nutritional world. All these factors, added to the avalanche of contradictory studies published almost daily about what we should eat, create the perfect storm for those who may have anxiety about health and avoiding illness.
When the quest for a healthy diet leans toward orthorexia

For those who have documented medical reasons to do so (for example, food allergies or celiac disease), a restricted diet is essential and sometimes lifesaving. But if you do not have much reason to support a restricted diet, and a rigid eating pattern negatively impacts your life and relationships with friends and family, consider looking for medical help, ideally a mental health clinician with whom you can talk about your concerns and underlying fears. Relaxation training, behavior modification strategies, and medications may also help with obsessive and compulsive thoughts. Try to avoid reading blogs and books from people who have radical opinions regarding specific food items. The information era has brought great advancement in publicizing tips about a healthy lifestyle, but the broadcast of extreme views may not be so healthy. Of course, eating a lot of sugar, flour, and red meat every day, all day, will not help you live a long and healthy life, but it doesn’t mean you can never touch them.

Most of the population will never need to avoid specific foods. If you suspect you might have a problem with a specific food item, before you make a final decision about eliminating it, first consult with your doctor. The aspiration to eat a healthy diet is not a problem in itself, but when these thoughts are excessive it may undermine the original goal. Food is one of the great pleasures in life; it is connection, it is culture, it is something to cherish. We should avoid going overboard toward notoriously unhealthy items, but we should be able to eat the most comprehensive diet possible. For most of us, eating nutritionally dense whole foods, mostly vegetarian and non-processed, rarely causes problems.
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03/01/2019

Alcohol and your health: Is none better than a little?

I was called to your room in the middle of an overnight shift. There you were, breathing quickly, neck veins bulging and oxygen levels hovering despite the mask on your face. I placed my stethoscope on your back and listened to the cacophony of air struggling to make its way through your worsening pneumonia.
“We’re going to place a tube down your throat to help you breathe,” I told you.
Your eyes were pleading, scared. “We’ll put you to sleep. It’ll help you breathe more comfortably. Okay?”
You nodded. You had already told the doctors who cared for you during the day that if your breathing worsened, you would agree to intubation to allow more time to treat your pneumonia. So I called for the anesthesiologists. Minutes later, you were sedated and intubated, silenced — maybe forever.
I thought about you recently, when I read a poignant Perspective in JAMA Internal Medicine: “Saving a Death When We Cannot Save a Life in the Intensive Care Unit.” In this piece, critical care doctor Michael Wilson relates the story of a woman in the ICU who was electively intubated for a procedure and then died, without ever having had the opportunity for her loved ones to say goodbye.
Fueled by his feelings of regret over this and similar cases, Wilson argues for a different approach to intubation, which he likens to the talk a parent has with a child who is going off to war. Of course, these parents hope their children will come back safely, but they are given the chance to say what they want to say — knowing the conversation might be their last. Wilson suggests that we might build a similar pause into our protocols before intubation, lest we unwittingly deprive our patients of the opportunity for a final exchange with their loved ones. “Stealing the opportunity for meaningful last words is precisely the kind of avoidable complication that ought to be visible to us in the ICU,” Wilson writes. “My intubation checklist now includes this step.” In doing so, Wilson suggests that we might be able to “save a death” even if we are ultimately unable to save a life.
Reading this piece, I’m left with the image of Wilson’s patients — both the one who never had the chance to say goodbye, and another woman he describes who was given the chance to say “I love you” to her husband — and also of my own patients. It is too easy, in the heat of the moment, to forget that this patient before us is a person. How many times have I decided on intubation, ordered the appropriate medications, prepared for complications, but not taken pause to allow my patient to talk to a loved one?
I only took care of you for the night, as the physician on call. Though I remember your face, I do not remember your name and I don’t know what happened to you. Maybe the breathing tube came out in a day or two, and you were able to talk to your family once again. Or maybe it did not. Maybe your pneumonia worsened and you died, there in our ICU. It has been months since that night, and I can’t know. But I do wish, now, that I had paused and given you that chance. Well, it seems as though not even a week can go by without more data on aspirin! I recently reviewed the ARRIVE trial and the implications for primary prevention — that is, trying to prevent heart attacks and strokes in otherwise healthy people. Since then, yet another large clinical trial — the ASPREE study — has come out questioning the use of aspirin in primary prevention. Three articles pertaining to this trial were published in the prestigious New England Journal of Medicine, which is an unusual degree of coverage for one trial and highlights its immediate relevance to clinical practice.
Aspirin still strongly indicated for secondary prevention

Nothing about any of the new aspirin data, including ASPREE, pertains to secondary prevention, which refers to use of aspirin in patients with established cardiovascular disease. Examples include a prior heart attack or certain types of stroke, previous stents or bypass surgery, and symptomatic angina or peripheral artery disease. In general, in patients with a history of these conditions, the benefits of aspirin in reducing cardiovascular problems outweigh the risks. Chief among these is a very small risk of bleeding in the brain, and a small risk of life-threatening bleeding from the stomach.
ASPREE study suggests no benefit from aspirin in primary prevention

ASPREE randomized 19,114 healthy people 70 or over (65 or over for African Americans and Hispanics) to receive either 100 milligrams of enteric-coated aspirin or placebo. After an average of almost five years, there was no significant difference in the rate of fatal coronary heart disease, heart attack, stroke, or hospitalization for heart failure. There was a significant 38% increase in major bleeding with aspirin, though the actual rates were low. The serious bleeding included bleeding into the head, which can lead to death or disability. Again, the actual rates were very low, but they are still a concern when thinking of the millions of patients to whom the ASPREE results apply.

Rates of dementia were also examined, and again, there was no benefit of aspirin. Quite unexpectedly, there was a significantly higher rate of death in the patients taking aspirin. This had not been seen in prior primary prevention trials of aspirin, so this isolated finding needs to be viewed cautiously. Still, with no benefits, increased bleeding, and higher mortality, at least in this population of older healthy people, aspirin should no longer be routinely recommended.

Another unexpected finding in ASPREE was a significantly higher rate of cancer-related death in the people randomized to aspirin. The prior thinking had been that aspirin might actually prevent colon cancer, though generally after many more years of being on aspirin. The ASPREE trial was terminated early due to lack of any apparent benefits. And even though five years is a relatively long period of follow-up, it may not have been long enough to find a benefit on cancer. Thus, the increase in cancer deaths may be a false finding. Nevertheless, the overall picture from this trial is not a compelling one for aspirin use for prevention of either cardiac or cancer deaths.
Should healthy people take a daily aspirin?

In general, the answer seems to be no — at least not without first consulting your physician. Despite being available over the counter and very inexpensive, aspirin can cause serious side effects, including bleeding. This risk goes up with age. So, even though it seems like a trivial decision, if you are healthy with no history of cardiovascular problems, don’t just start taking aspirin on your own.

However, there are likely select healthy patients who have a very high risk of heart attack based on current smoking, family history of premature heart attacks, or very elevated cholesterol with intolerance to statins, for example, who might benefit. Therefore, the decision to start aspirin should involve a detailed discussion with your physician as part of an overall strategy to reduce cardiovascular risk. If you are already taking aspirin for primary prevention, it would be a good idea to meet with your physician and see if you might be better off stopping. Surprisingly, one of the most controversial areas in preventive medicine is whether or not people without known cardiovascular disease should take a daily aspirin for primary prevention. That is, should you take aspirin to reduce the risk of heart attack, unstable angina, stroke, transient ischemic attack, or death from cardiovascular causes? You would think that we would know the answer by now for a medicine as commonly used as aspirin.
Aspirin has unquestioned benefit for secondary prevention

Before considering the impact of aspirin in people without cardiovascular disease, it is first important to clarify uses for aspirin that are not up for debate. In people who have had a heart attack or certain types of stroke, the use of aspirin to prevent a second event — potentially a fatal one — is firmly established. These uses of aspirin are called secondary prevention. Similarly, in people who have had stents or bypass surgery, lifelong daily aspirin is typically warranted. While there is a very small risk that aspirin can cause bleeding in the brain, and a small risk it can cause life-threatening bleeding such as from the stomach, in general the risks are worth it in the setting of secondary prevention.
ARRIVE study suggests no benefit from aspirin in primary prevention

Primary prevention refers to trying to prevent the first event, such as heart attack or stroke (or dying from these causes). In this setting, the actual risks of a cardiovascular event are much lower, though the bleeding risks persist. Therefore, the margin of potential benefit is much more narrow.

Recently in Munich, at the European Society of Cardiology conference — now the world’s largest cardiology meeting — important results pertaining to aspirin in primary prevention arrived in the form of the ARRIVE trial. This clinical trial randomized over 12,000 patients to either 100 milligrams (mg) of coated aspirin daily or to a placebo (a blank). Overall, after an average of five years of following these patients, the trial did not show a significant benefit for aspirin, though there was a significant increase in gastrointestinal bleeding. There were no significant differences in the rates of deaths, heart attacks, or strokes.

Digging a bit more deeply into the results, the enrolled patients ended up being at much lower cardiovascular risk than the researchers had intended. Thus, it is possible that in a higher-risk population with a greater rate of cardiovascular events, aspirin may have been useful. Furthermore, many patients stopped taking their aspirin, diluting the potential to see a benefit. In patients who actually took their assigned aspirin, there was in fact a significant reduction in the rates of heart attack. However, these types of “on treatment” analyses should be viewed cautiously, as it would of course exclude patients who had bleeding complications or other side effects that may have led to aspirin discontinuation.

Aspirin is not currently labeled for use in primary prevention. In fact, based on trials prior to ARRIVE, the US FDA did not feel the data were robust enough to give aspirin this indication for use. It seems unlikely that they will change that opinion on the basis of ARRIVE.

One notable group excluded from ARRIVE was people with diabetes. A separate randomized trial called ASCEND was presented at the European Society of Cardiology conference. This study did find a significant reduction in adverse cardiovascular outcomes with daily aspirin in people with diabetes, though there was also a similar magnitude of increased major bleeding. Still, many people would rather be hospitalized for bleeding and get a transfusion versus being hospitalized for a heart attack that causes permanent damage to the heart. Others may not see much difference between the two types of events and may prefer not to take an additional medication.
Should you take a daily aspirin?

So, where does this leave the average person who is worried about a heart attack and wants to do everything they can to reduce that risk? Again, for people with cardiovascular disease — secondary prevention — nothing about ARRIVE pertains to you. For otherwise healthy people at elevated risk for heart disease or stroke, make sure not to smoke, maintain a healthy weight and diet, and control elevated blood pressure and cholesterol with medications if needed. If you have diabetes, make sure that is controlled with diet and medications if diet alone is insufficient.

The decision to start daily aspirin in otherwise healthy people is quite complex, with potential benefits and actual risks that on average are rather similar. Serious bleeding may occur. Online risk calculators (such as www.cvriskcalculator.com) might be somewhat useful in more objectively calculating the degree of cardiovascular risk. However, in the absence of diabetes, most otherwise healthy people should probably not be taking a daily aspirin to prevent heart attacks.

In the future, if randomized evidence supports it, imaging tests that gauge the degree of silent atherosclerosis (plaque buildup in the arteries that is not causing symptoms) may help decide if a patient should be reclassified from primary to secondary prevention. Other analyses from the large ASPREE trial are ongoing, should report soon, and may further tip the scales. For now, healthy people without atherosclerosis should not just take aspirin on their own without consulting their doctor first.
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Conflict of interest in medicine

Just the idea of packing a lunch elicits a stress response in so many of us. Maybe we’re packing lunch for our kids, maybe it’s for us, but the pressure is on to create a simple yet satisfying, healthy yet hearty, easily transportable meal. This seemingly impossible task is daunting to many people. So much easier to rely on the school cafeteria, lunch trucks, and takeout, right?

Wrong! Let us consider the short- and long-term effects of poor choices at lunchtime. Yes, the school cafeteria may offer some healthy-ish options. I can count on my kids not to choose any of them. Likewise our workplace food trucks and fast food/delivery services: it’s a dietetic disaster out there, folks, and not packing a lunch is akin to heading out to the battlefield in a bathing suit.

My kids would eat mostly carbs, fats, and sugars, if given the chance, and their trays would be piled with pizza, pasta, burgers, hot dogs and fries, chips, juice, and dessert. The downtown lunch scene features pretty much the same choices. Almost all options include refined grains and added sugars, foods with a high glycemic index and load. These will cause a spike in blood sugar, which triggers a surge in insulin. The insulin grabs all that sugar and brings it to the fat cells to be stored away, causing a nice late-afternoon blood sugar crash.

Studies show that people who eat meals prepared at home, including brown-bag lunches, tend to consume significantly more fruits and vegetables and have a lower body mass index than those who do not. If we pack a lunch, we can make better choices: a meal higher in fiber, protein, complex carbohydrates, and healthy fats has a lower glycemic index and load, and will keep our blood sugar steady — no crash! So in the short term, we can be productive through the afternoons. A little planning goes a long way: in the long term, studies show that a healthier diet is associated with improved cognition through the elder years.
How to build a healthy lunch

There’s a basic formula to follow: Primarily plants (actual fruits and vegetables) and protein (like legumes, lentils, tofu, seafood, chicken), with some complex carbohydrates (think: whole grains) and healthy fats (think: nuts and nut butters, seeds and seed butters, avocado, healthy oils).

If the bulk of the meal is plants, like actual fruits and vegetables, you’ll get plenty of fiber. Protein and healthy fats are satisfying. If you include whole grains, you’ll get complex carbohydrates. All of these are absorbed slowly, preventing that blood sugar spike and crash (and also inhibiting fat formation).

But what do these healthy options look like? Below are some simple lunches that follow the basic formula, and that our family actually eats.

Everyone loves dipping and stacking their food, not just kids — this is why those prepackaged boxes of processed food sell so well. So we make our own healthy versions of these with things that can be simply thrown into a “bento box”-style container, without requiring much prep. Here are a number of suggestions that are easy, inexpensive, require slicing at most, and travel well:

Build-Your-Own Gourmet Pizza: Sliced cherry tomatoes; mozzarella cheese; fresh basil; marinara sauce; mini whole-wheat pita breads or pizza dough rounds; orange sections.

Nacho Lunch Muncher: Strips of bell peppers; pinto beans; slices of cheddar cheese; whole-grain chips; low-sodium salsa; sliced peaches.

Breakfast-As-Lunch Box: Sliced strawberries and fresh raspberries, blackberries, and/or blueberries; healthy yogurt; sliced almonds or unsalted sunflower seeds; low-sugar granola or toasted oats cereal.

Hummus Dipper: Carrot sticks and bell pepper strips; container of hummus; whole-grain crackers; unsalted pistachios; apple slices tossed with cinnamon.

Deconstructed Tuna Sandwiches: Cucumber slices; container of tuna salad (tuna, lemon juice, touch of mayo); whole-grain bread squares or crackers; cantaloupe chunks.

Nut Butter Dips and Mini-Wraps: Apple and banana slices (spritz with lemon juice to prevent browning); small container of almond, cashew, peanut, or sunflower seed butter; raisins; whole-wheat wrap cut into fourths. On the surface, your own brain may be your furthest consideration when you are trying to improve your relationships. Yet it is the very place that processes where you perceive, understand, remember, evaluate, desire, and respond to people.

The somewhat bizarre fact of life is that the people who are in our lives are not simply who they actually are. They are some interesting mix of who they are and what we make of them in our brains. If we understand the ways in which relationships impact our brains, we can likely change our brains to alter the ways in which we interact with others too.
Transference

Transference is a psychological phenomenon in which conversational or relational partners activate earlier memories. As a result, we may unconsciously repeat conflicts from the past that have nothing to do with the current relationship.

For instance, you may be having an off day and may be a little short with a colleague. The colleague may snap at you in a way that is out of proportion to your actual interaction, since your manner may remind them of a conflictual and bossy relationship earlier in their lives. These kinds of knee-jerk responses occur in the brain due to the brain’s propensity to make non-conscious predictions based on early life experiences. They may be unwarranted, but we are usually not aware of them.

What you can do: To prevent this kind of situation, introduce new self-reflections, and possibly even points of discussion when you find yourself engaged in a conflict. Ask yourself, “Am I responding to this person, or am I mixing them up with someone from the past?” This can also make for an interesting discussion when you are trying to resolve a conflict.
Emotional contagion

Our emotions can be easily transferred to another person without us even knowing about this. This can also happen through large-scale social networks without in-person interactions or nonverbal cues.

Interact with a disgruntled group online, and you are likely to feel disgruntled as well. On the other hand, interacting with a positive group will probably make you feel more positive. Often, our negative emotions such as anger are transferred more easily than positive ones. It’s meant to be to our evolutionary advantage to be able to pick up emotions that quickly, but sometimes it can interfere with relationship dynamics. The culprits responsible for this contagion in the brain are called mirror neurons. They are specialized to automatically pick up the emotions of others.

What you can do: When you are interacting online, ensure that you know that whatever content you are consuming is likely to impact your mood. Be judicious about this depending on what you want to feel.

In interactions with friends, colleagues, or romantic partners, be aware that their negative emotions could throw you into a negative state, even if you do not actually feel negative. Many a fearful dating partner has turned off the other person automatically because they somehow start to feel afraid as well.

Be aware when your partner or colleague “makes” you angry. You may not actually be angry with them, but instead, mistaking their anger for yours when your brain reflects their feeling states.
Cognitive empathy

When you are trying to negotiate with someone, you may think it helpful to reflect their emotions, but this emotional empathy could backfire. In most instances, it’s far more effective to use cognitive empathy instead. When you use cognitive empathy, the other person becomes less defensive and feels heard too. While there is some overlap, cognitive empathy activates a mentalizing network in the brain, which differs from the emotional mirroring mechanisms of emotional empathy.

What you can do: When trying to resolve a conflict, try using cognitive empathy rather than emotional empathy to resolve the conflict. This means that you reflect on what they are saying, and then neutrally paraphrase what they are saying or intending. Paraphrasing can actually decrease their anger and reactivity. It’s a form of cognitive empathy, indicating that you are able to walk in their shoes.

Changing your own brain’s automatic reactions can help you navigate relationships more effectively. By knowing when to examine and explore transference, emotional empathy, and cognitive empathy in different situations, relationships have the potential to deepen too. For many people receiving care in a hospital or emergency room, one of the most common occurrences (and biggest fears) is getting an IV, the intravenous catheter that allows fluids and medications to flow into a vein in your arm or hand.

A trained health professional puts in an IV by sticking a needle that’s inside a thin tube (catheter) through the skin into a vein. Once inside the vein, the needle is removed. The catheter is left in the vein and taped down to keep it from moving or falling out. While IV lines are typically painless, the initial needle stick can be quite painful, especially for those who are a “difficult stick” (when the needle misses the vein, requiring multiple attempts).

IVs can be medically needed when the digestive system isn’t working well, to receive more fluids than you’re able to drink, to receive blood transfusions, to get medication that can’t be taken by mouth, and for a host of other treatments. In cases of massive bleeding, overwhelming infection, or dangerously low blood pressure, IV treatments can dramatically increase the chances of survival.
Drip bars: IVs on demand

And this brings us to a relatively new trend: the option to receive IV fluids even when it’s not considered medically necessary or specifically recommended by a doctor. In many places throughout the US, you can request IV fluids and you’ll get them. A nurse or physician’s assistant will place an IV catheter in your arm and you’ll receive IV fluids right at home, in your office, or at your hotel room. There’s even a mobile “tour bus” experience that administers the mobile IV hydration service. Some services offering IV hydration include a “special blend of vitamins and electrolytes,” and, depending on a person’s symptoms (and budget), an anti-nausea drug, a pain medication, heartburn remedies, and other medications may be provided as well.

And no, it’s not covered by your health insurance — more on the cost in a moment.
Why would anyone do this?

When I first heard about this, that’s the question I asked. Why, indeed? People may seek out IV fluids on demand for:

    hangovers
    dehydration from the flu or “overexertion”
    food poisoning
    jet lag
    getting an “instant healthy glow” for skin and hair

Many of the early adopters of this new service have been celebrities (and others who can afford it) including Kate Upton, Kim Kardashian, Simon Cowell, and Rihanna. Or so I’ve read.
Are IV fluids effective or necessary for these things?

Some people who get the flu (especially the very young and very old) need IV fluids, but they’re generally quite sick and belong in a medical facility. Most people who have exercised a lot, have a hangover, jet lag, or the flu can drink the fluids they need. While I’m no beauty expert, I doubt that IV fluids will improve the appearance of a person who is well-nourished and well-hydrated to start with.

And it’s worth emphasizing that the conditions for which the IVs-on-demand are offered are not conditions caused by dehydration or reversed by hydration. For example, jet lag is not due to dehydration. And while oral fluids are generally recommended for hangover symptoms (among other remedies), dehydration is not the only cause of hangover symptoms.

Finally, there’s a reasonable alternative to IV fluids: drinking fluids. If you’re able to drink fluids, that’s the best way to get them. If you’re too sick to drink and need rehydration, you should get care at a medical facility.
Is it worth going to a drip bar?

I’ll admit I’m skeptical. (Could you tell?) It’s not just that I’m a slow adopter (which is true) or that I’m dubious of costly treatments promoted by anecdotes on fancy websites (which I am). What bothers me is the lack of evidence for an invasive treatment. Yes, an intravenous treatment of fluid is somewhat invasive. The injection site can become infected, and a vein can become inflamed or blocked with a clot (a condition called superficial thrombophlebitis). While these complications are uncommon, even a small risk isn’t worth taking if the treatment is not necessary or helpful.

I can see how the idea of IV fluids at home might seem like a good idea. We hear all the time about how important it is to drink enough and to remain “well-hydrated.” It’s common to see people carrying water bottles wherever they go; many of them are working hard to drink eight glasses of water a day, though whether this is really necessary is questionable.

And then there’s the power of the stories people tell (especially celebrities) describing how great they felt after getting IV fluid infusions. If you have a friend who says they feel much better if they get IV fluids to treat (or prevent) a hangover, who am I to say they’re wrong? The same can be said for those who believe they look better after getting IV fluids as part of getting dolled up for a night on the town.
What about the cost?

While the benefits of IV fluids on demand are unproven and the medical risks are low (but real), the financial costs are clear. For example, one company offers infusions for $199 to $399. The higher cost is for fluids with various vitamins and/or electrolytes and other medications. Keep in mind that the fluids and other therapies offered can be readily obtained in other ways (drinking fluids, taking generic vitamins, and other over-the-counter medications) for only a few bucks.
The bottom line on drip bars

In recent years, more and more options have become available to get medical tests or care without actually having a specific medical reason and without the input of your doctor. MRIs, ultrasounds and CT scans, recreational oxygen treatment, and genetic testing are among the growing list of options that were once impossible to get without a doctor’s order. While patient empowerment is generally a good thing, IV fluids on demand may not be the best example. Some of these services are much more about making money for those providing the service than delivering a product that’s good for your health. Recent news reports described an “ethical lapse” by a prominent New York City cancer specialist. In research published in prominent medical journals, he failed to disclose millions of dollars in payments he had received from drug and healthcare companies that were related to his research. Why is this such a big deal? Disclosing any potential conflict of interest is considered essential for the integrity of medical research. The thinking is that other researchers, doctors, patients, regulators, investors — everyone! — has a right to know if the researcher might be biased, and that measures have been taken to minimize the possibility of bias.
Is it an advertisement or research?

One way to think about the importance of full disclosure regarding medical research is to ask: is the information I’m reading or hearing about coming from a paid spokesperson? If so, it may be the equivalent of an advertisement. Or, is it from a researcher without a financial stake in the results? The answer matters. While the information may be valid either way, the way it’s delivered, how alternative explanations for the results are considered, and the skepticism (or enthusiasm) surrounding the findings can vary a lot depending on whether the source has a vested interest in a study’s results.

One of my favorite examples of how bias can affect how medical information is delivered is the way pain relievers (such as ibuprofen or naproxen) are described in ads. There are more than 20 of them available, and for most conditions their effectiveness is about the same. And that’s exactly how a researcher with no financial ties to the makers of these drugs might describe them: in clinical trials, they are equally effective. But a company’s television ad might claim that “nothing’s proven stronger for your headaches” than their medication. Factually, both ways of presenting the information are true. But knowing the source of the information and whether it might be biased can make a big difference in how you interpret that information.
Why you should care about conflict of interest in medicine

Medical schools, hospital systems, and other institutions that employ doctors generally require disclosure of outside income. But do their patients want to know? Would it matter to you if your doctor accepted gifts, meals, or cash payments from drug companies?

There’s been enough concern about the answers to these questions that the federal government set up a website to post information about payments doctors receive from drug companies, medical device makers, and others. Perhaps you’ve heard of it. It’s called OpenPayments,* a disclosure program mandated by the Sunshine Act that posts these financial relationships online for public viewing. It’s been up and running for several years. But the impact of this program is not clear; many of my patients have never heard of it, and most people have never looked up their own doctors on the site.

*In the interest of full disclosure, my name appears in Open Payments: However, it’s for consulting with the Institute for Healthcare Improvement, an independent healthcare organization. They provided grants to encourage shared decision making and understanding of treatment options for patients with rheumatoid arthritis. A pharmaceutical company sponsored the program but has no role in promoting any particular medication.
Other ethical issues your doctor might face

Even if your doctor doesn’t accept payments from pharmaceutical companies, he or she may have to consider other ethical questions, such as:

    Is it acceptable to own his or her own testing equipment? While it may be more convenient for patients, studies show that when a practice performs (and charges for) its own lab or imaging tests (such as a scanner for osteoporosis screening), more tests tend to be ordered.
    Should he or she meet with representatives from pharmaceutical companies who are promoting their latest drugs? Some physicians get updates regarding new medications from drug reps (along with gifts of minor value, such as pens or lunch), but this may lead to higher rates of prescribing newer, higher priced drugs when older, cheaper options would be just as good.
    Should your doctor attend medical meetings where drug companies sponsor the speaker (complete with dinner in a fancy restaurant)? Again, the information presented may be accurate but biased.
    Is it reasonable for doctors to receive payments to enroll patients in a study sponsored by a drug company? This is a common practice, and it’s likely that the financial arrangement is not always disclosed to the patient.

And these are just a few of the many ethical dilemmas that many doctors face.
What do you think?

Many doctors I know are insulted by the suggestion that they “can be bought” by a charismatic drug rep bearing gifts. But a number of studies show these practices work. Large pharmaceutical companies spend millions on doctors to market, educate, and perform clinical trials. They would not invest so much money if it didn’t work.

Does any of this concern you? Do you think the case of the NYC doctor is unusual and that most doctors navigate the ethical minefields of modern medicine successfully? Let me know!
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