26/02/2019

Don’t take fatigue lying down

Sure, everyone gets tired sometimes, and often bounces back after a quick rest or a good night’s sleep. However, if bouts of fatigue occur more often and last longer, you shouldn’t ignore them.

“Older adults may chalk up fatigue to aging, but there is no reason you should battle ongoing tiredness,” says Dr. Suzanne Salamon, a geriatric physician with Harvard-affiliated Beth Israel Deaconess Medical Center.

Here are signs that you should take your tiredness seriously:

    inability to do activities you enjoy
    waking up exhausted, even after a good night’s sleep
    not feeling motivated to begin the day
    sudden bouts of exhaustion that go away and then return
    shortness of breath.

This type of fatigue can affect your health in many ways. You may have less energy to exercise. You may have trouble concentrating, staying alert, and remembering things. You may anger easily and become more socially isolated.
It’s worth checking in with your doctor

Fatigue also could signal a medical condition, according to Dr. Salamon, and you should consult your doctor to see if you have any of the following issues.

    Anemia. This occurs when your blood has too few red blood cells or those cells have too little hemoglobin, a protein that transports oxygen through the bloodstream. The result is a drop in energy levels.
    Heart disease. Heart disease can cause the heart to pump blood less efficiently and lead to fluid in the lungs. This can cause shortness of breath and reduce the oxygen supply to the heart and lungs, making you tired.
    Sleep problems. Sleep apnea is characterized by pauses in your breathing, often lasting several seconds, or shallow breathing while you sleep. It is common among older adults and those who are overweight. Another sleep-related issue is an overactive bladder, which forces repeated nighttime bathroom trips. Either of these can disturb your sleep enough to leave you feeling tired during the day.
    Medication. Certain medications can make you feel tired, such as blood pressure drugs, statins, antidepressants, antihistamines, nonsteroidal anti-inflammatory drugs, and cold medications. “People react to medications differently and they often end up taking more as they get older,” says Dr. Salamon. Check with your doctor, especially if you have added a new medication or recently increased your dosage. “Sometimes it helps to take certain medicines, which may cause fatigue, at night rather than in the daytime,” she says.
    Low-grade depression or anxiety. Mental health issues often drain energy levels. “You may suffer from depression or anxiety and not even know it,” says Dr. Salamon.
    Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). This is a complex disorder that causes unexplained extreme fatigue, which can worsen after physical or mental activity and does not improve with rest. Its cause is unknown, but may be linked to one or more underlying issue.

Some simple ways to boost energy levels

For regular, everyday fatigue, try these tips:

    Drink a cup of coffee or tea. A little caffeine can jump-start your day, she says. “You don’t need more than that, but it can offer a mental and physical lift, especially if you have trouble with morning fatigue.”
    Go for a 30-minute walk. “If you can’t get outside, walk around your house in bouts of 10 to 15 minutes, two to three times a day,” says Dr. Salamon.
    Take a nap. A midday nap can help overcome tiredness later in the day. Keep naps to about 20 to 30 minutes, as studies have suggested that napping for 40 minutes or longer can have the opposite effect and leave you feeling groggy rather than refreshed. “Also, don’t nap too late in the day or in the early evening, when it could interfere with your normal sleep schedule,” says Dr. Salamon.
If you Google “coconut oil,” you’ll see a slew of stories touting the alleged health benefits of this solid white fat, which is easy to find in supermarkets these days. But how can something that’s chock-full of saturated fat — a known culprit in raising heart disease risk — be good for you?

Coconut does have some unique qualities that enthusiasts cite to explain its alleged health benefits. But the evidence to support those claims is very thin, says Dr. Qi Sun, assistant professor in the Department of Nutrition at the Harvard T.H. Chan School of Public Health.

“If you want to lower your risk of heart disease, coconut oil is not a good choice,” he says. It’s true that coconut oil tends to raise beneficial HDL cholesterol more than other fats do, possibly because coconut oil is rich in lauric acid, a fatty acid that the body processes slightly differently than it does other saturated fats.
Coconut oil’s effect on cholesterol

But there’s no evidence that consuming coconut oil can lower the risk of heart disease, according to an article in the April 2016 Nutrition Reviews. The study, titled “Coconut Oil Consumption and Cardiovascular Risk Factors in Humans,” reviewed findings from 21 studies, most of which examined the effects of coconut oil or coconut products on cholesterol levels. Eight were clinical trials, in which volunteers consumed different types of fats, including coconut oil, butter, and unsaturated vegetable oils (such as olive, sunflower, safflower, and corn oil) for short periods of time. Compared with the unsaturated oils, coconut oil raised total, HDL, and LDL cholesterol levels, although not as much as butter did.

These findings jibe with results from a study by Dr. Sun and colleagues in the Nov. 23, 2016, issue of The BMJ, which examined the links between different types of saturated fatty acids and heart disease. Compared with other saturated fats (like palmitic acid, which is abundant in butter), lauric acid didn’t appear to raise heart risk quite as much. But that’s likely because American diets typically don’t include very much lauric acid, so it’s harder to detect any effect, Dr. Sun notes.
Tropical diets are different

Coconut oil proponents point to studies of indigenous populations in parts of India, Sri Lanka, the Philippines, and Polynesia, whose diets include copious amounts of coconut. But their traditional diets also include more fish, fruits, and vegetables than typical American diets, so this comparison isn’t valid, says Harvard Medical School professor Dr. Bruce Bistrian, who is chief of clinical nutrition at Beth Israel Deaconess Medical Center.

Some of the coconut oil available in stores is labeled “virgin,” meaning that it’s made by pressing the liquid from coconut meat and then separating out the oil. It tastes and smells of coconut, unlike the refined, bleached, and deodorized coconut oil made from the dried coconut meat used in some processed foods and cosmetics. Virgin coconut oil contains small amounts of antioxidant compounds that may help curb inflammation, a harmful process thought to worsen heart disease. But to date, proof of any possible benefit is limited to small studies in rats and mice, says Dr. Bistrian.
Unsaturated fats

In contrast, there’s a wealth of data showing that diets rich in unsaturated fat, especially olive oil, may lower the risk of cardiovascular disease, Dr. Sun points out. The evidence comes not only from many observational studies (like those in the aforementioned BMJ report) but also a landmark clinical trial from Spain, which found that people who ate a Mediterranean-style diet enhanced with extra-virgin olive oil or nuts had a lower risk of heart attack, stroke, and death from heart disease than people who followed a low-fat diet.

Of course, there’s no need to completely avoid coconut oil if you like the flavor. Some bakers use coconut oil instead of butter in baked goods, and coconut milk is a key ingredient in Thai cooking and some Indian curry dishes. Just be sure to consider these foods occasional treats, not everyday fare. High-grade cancer that’s still confined to the prostate is generally treated surgically. But a third of the men who have their cancerous prostates removed will experience a rise in blood levels of prostate-specific antigen (PSA). This is called PSA recurrence. And since detectable PSA could signal the cancer’s return, doctors will often treat it by irradiating the prostate bed, or the area where the gland used to be.

In February, researchers reported that radiation is a more effective treatment for PSA recurrence when given in combination with androgen-deprivation therapy (ADT). ADT interferes with the body’s ability to make or use testosterone, which is the hormone (or androgen) that makes prostate tumors grow more aggressively. It targets rogue cancer cells in the body that escape radiation.
Here’s what the study found

The newly published study randomly assigned 760 men with detectable PSA after surgery to one of two groups. One group got radiation plus ADT and the other group got radiation plus a daily placebo tablet. The study recruited patients between 1998 and 2003, and after an average follow-up of 12 years, 5.8% of men in the combined treatment group had died of prostate cancer, compared to 13.4% in the radiation-only group. Rates of metastatic prostate cancer were also lower among men treated with ADT: 14.5% compared to 23% among the placebo-treated controls.

“The take-home message is that ADT has a major and beneficial impact on the risk of death from prostate cancer when added to radiation for PSA recurrence,” said Ian Thompson, M.D., a professor of oncology at the UT School of Medicine, in San Antonio, Texas, and the author of an editorial accompanying the newly published findings.

Men in this study received a high dose of the ADT drug bicalutamide, which doctors use less frequently for PSA recurrence today, instead favoring other testosterone-suppressing medications that have since been shown to be more effective. Therefore this is an instance of a long-term study reporting results after treatment standards — in this case the selection of a specific ADT regime — have changed.
A new treatment standard

Still, some men have difficulty tolerating ADT, and not all of them should get it, particularly if they’re older and more likely to die of something other than prostate cancer. “I’d reserve ADT for younger men with a long life expectancy ahead of them who were diagnosed initially with high-grade or late-stage disease,” Thompson said. As a primary care physician at Massachusetts General Hospital (MGH), I am profoundly grateful for my 10 years in recovery from opiate addiction. As detailed in my memoir Free Refills, I fell into an all too common trap for physicians, succumbing to stress and ready access to medications, and became utterly and completely addicted to the painkillers Percocet and Vicodin. After an unspeakably stressful visit in my office by the State Police and the DEA, three felony charges, being fingerprinted, two years of probation, 90 days in rehab, and losing my medical license for three years, I finally clawed my way back into the land of the living. I was also able to return, humbled, to a life of caring for patients.

There is one question that I invariably get asked, by my doctors, colleagues, friends, family members, and at lectures and book talks: now that you are in recovery from opiates, what are you going to do when you are in a situation such as an accident or surgery, when you might need to take opiates again? I have blithely answered this question with platitudes about how strong my recovery is these days, and how I will thoughtfully cross that bridge when I come to it. In other words, I punted consideration of this difficult issue into some unknown future time.

Unfortunately, that future is now, and that bridge is awaiting my passage.

Last week I slipped on my top outside step, which was covered in ice, went into free fall, and managed to completely tear my left quadriceps tendon. This required a surgical repair in which doctors drilled three holes into my kneecap and then tethered what was left of my quadriceps muscle to the kneecap. Taking Tylenol or Motrin for this kind of pain is kind of like going after Godzilla with a Nerf gun. I was sent home with a prescription for one of my previous drugs of choice: oxycodone.

My leg was hurting beyond belief. I literally felt as if it were burning off. But, I had spent the last 13 years of my life conditioning myself, almost in a Clockwork Orange kind of way, to be aversive to taking any and all opiates.

What is a person who used to suffer from a substance use disorder (SUD) to do? There are millions of us in this country who may eventually face this choice.

Fortunately, I am not the first person who has confronted this issue. There exist safeguards one can put in place. It is important that all of your doctors know about your history of SUD. It is also helpful if you have a significant other or partner at home who can manage the pills for you, and dole out two of them every four to six hours as directed, to avoid the temptation to take more than prescribed in order to get high. (Old habits die hard.) Finally, the key to all addiction treatment is being open and honest. It is critical to check in with one’s support network about medications, cravings, and fears, and to use all of the recovery tools that are available to you, such as asking for help if you need to, and not trying to control things that can’t be controlled.

In the end, my level of pain was so great that there really wasn’t any choice but to take the oxy. My nerve receptors made the decision for me. I’m sure there are Shaolin monks somewhere who can block out high levels of pain, but that just isn’t me.

I am reassured, and even pleasantly surprised, by several aspects of having taken the oxycodone. First, it worked well for the pain. Second, I did not get high from the pills. I guess that taking two pills is different from taking (or snorting) 10 or 20, as we tend to do when we are addicted. Finally, it was very easy to stop taking them, and I have had absolutely no cravings or dreams about using since stopping.

This is a critical issue. It would be cruel and inhumane to not sufficiently treat any patient’s pain, especially after surgery, and it is important not to discriminate against people with SUDs. There are millions of people in recovery from opiates in the United States alone, and they are as deserving of pain control as anyone else.

Finally, I am grateful beyond belief to have survived my opiate addiction, and to not have become one of those all too common overdose stories we all read about in the newspapers. I am also grateful to my excellent doctors at MGH for fixing my wounded knee, and for providing me adequate pain control. Fortunately, my recovery and my pain control do not seem to have been mutually exclusive.
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A strengths-based approach to autism

You hear your spouse breathing nearby and you instantly get angry. Your 6-year-old yawns and it triggers a fight-or-flight reaction in you. You avoid restaurants because you can’t stand the sound of chewing. Sounds other people don’t even seem to notice, drive you up a wall. You might have misophonia.
What is misophonia?

People with misophonia are affected emotionally by common sounds — usually those made by others, and usually ones that other people don’t pay attention to. The examples above (breathing, yawning, or chewing) create a fight-or-flight response that triggers anger and a desire to escape. This disorder is little studied and we don’t know how common it is. It affects some worse than others and can lead to isolation, as people suffering from this condition try to avoid these trigger sounds. People who have misophonia often feel embarrassed and don’t mention it to healthcare providers — and often healthcare providers haven’t heard of it anyway. Nonetheless, it is a real disorder and one that seriously compromises functioning, socializing, and ultimately mental health. Misophonia usually appears around age 12, and likely affects more people than we realize.
What causes misophonia?

New research has started to identify causes for misophonia. A British-based research team studied 20 adults with misophonia and 22 without it. They all rated the unpleasantness of different sounds, including common trigger sounds (eating and breathing), universally disturbing sounds (of babies crying and people screaming), and neutral sounds (such as rain). As expected, persons with misophonia rated the trigger sounds of eating and breathing as highly disturbing while those without it did not. Both groups rated the unpleasantness of babies crying and people screaming about the same, as they did the neutral sounds. This confirmed that the misophonic persons were far more affected by specific trigger sounds, but don’t differ much from others regarding other types of sounds.

The researchers also noted that persons with misophonia showed much greater physiological signs of stress (increased sweat and heart rate) to the trigger sounds of eating and breathing than those without it. No significant difference was found between the groups for the neutral sounds or the disturbing sounds of a baby crying or people screaming.
The brain science of misophonia

The team’s important finding was in a part of the brain that plays a role both in anger and in integrating outside inputs (such as sounds) with inputs from organs such as the heart and lungs: the anterior insular cortex (AIC). Using fMRI scans to measure brain activity, the researchers found that the AIC caused much more activity in other parts of the brain during the trigger sounds for those with misophonia than for the control group. Specifically, the parts of the brain responsible for long-term memories, fear, and other emotions were activated. This makes sense, since people with misophonia have strong emotional reactions to common sounds; more importantly, it demonstrates that these parts of the brain are the ones responsible for the experience of misophonia.

The researchers also used whole-brain MRI scans to map participants’ brains and found that people with misophonia have higher amounts of myelination. Myelin is a fatty substance that wraps around nerve cells in the brain to provide electrical insulation, like the insulation on a wire. It’s not known if the extra myelin is a cause or an effect of misophonia and its triggering of other brain areas.
There is some good news

Misophonia clinics exist throughout the US and elsewhere, and treatments such as auditory distraction (with white noise or headphones) and cognitive behavioral therapy have shown some success in improving functioning. For more information, contact the Misophonia Association. We are in the midst of an unprecedented epidemic, with several million people currently addicted to opiates in the United States, including both prescription drugs and heroin. Much discussion has been devoted to the visible tragedy of overdoses, which are killing dozens of people every day. Less attention has been paid to a more subtle, but damaging and painful, component of this epidemic: how a person suffering from opiate addiction affects his or her family members.
The effects of substance use disorder on loved ones

Substance use disorders (SUDs) are brain diseases that can negatively affect a person’s behavior and fundamentally alter one’s personality. It is not uncommon for people suffering from SUDs to act in a way that is alienating and destructive to their friends and families. For example, a common scenario is theft of property or money to purchase drugs. Families can feel hurt and betrayed by this behavior, especially if they don’t understand that addiction is a disease. Family members can feel lied to, cheated, manipulated, and at times even threatened. With any signs of progress, with each stay in rehab, they become hopeful, only to have their hopes dashed again and again.

What can you do if you have a loved one addicted to opiates? This question has no easy answers, but does have several distinct schools of thought.
The “tough love” approach

A common belief is that a “tough love” approach will help family members avoid enabling the addiction. The thinking is that a family member can make an addiction worse by removing or cushioning the natural consequences of the addicted person’s actions, so that they do not have an incentive to recover. For example, if a person spends all his or her money on drugs, and you give them more money for food, you have enabled their addiction. Otherwise, presumably, they would go hungry, and would start to understand the connection between their drug use and their hunger.

In this example, the tough love approach suggests that the thieving offender be forced to “find their bottom,” or become miserable enough to understand the inescapable need to seek treatment. This response would also serve the purposes of protecting the family’s finances and property and setting up physical and psychological boundaries, so that the members of the family can move on with their lives.

Unfortunately, with our current opiate crisis, “finding your bottom” all too commonly can mean death from overdose, especially with our streets being flooded with fentanyl, a deadly opiate that people often mistakenly buy, looking for heroin.
Plain old love as an approach

Gradually, a more nurturing and supportive approach to substance users is supplanting the tough love approach. This is partly in response to the sheer number of overdose deaths. It is also due in part to the increasing awareness of addiction as a disease that needs to be met with empathy, rather than a moral failing that deserves scorn and punishment. Instead of tough love, people are simply using plain old love to try to coax their family member back into the fold, and hopefully encourage them to seek treatment. Each slip or relapse is met with support and patience, as families increasingly understand the chronic and relapsing nature of addiction. Many believe that this is a safer and more humane way to respond to addiction.

A tenet of 12-step ideology is that addiction is a “disease of isolation,” with its hallmarks being secrecy and disconnection. Therefore it makes sense that human connection would be an important component of treating addiction, and that a strategy of loving engagement might be more effective than one that shuns the sufferer or blames the victim. Through engagement and connection, a lifeline to treatment can be offered.
And about the suffering of family and friends…

It is essential to pay attention to the well-being of the family members themselves during all of this, as having a loved one with a substance use disorder can be profoundly stressful and disruptive, even traumatic. Every situation is different, but certain general principles apply. Psychologically, it is critical to be as open with your social community as you feel comfortable being, and to rely on the support of others. Many people find getting involved in a recovery group such as Al-Anon or Nar-Anon to be invaluable. Sometimes suffering alone can be the worst type of suffering. Family therapists and addiction specialists may also be helpful.

On a practical level, one must protect one’s finances, and you may need to change passwords or secure valuables if theft is an issue. If living with your addicted loved one is just too stressful, alternative living arrangements may be necessary. Some families may need to change their locks. Families must decide whether they truly wish to go deeply into debt to fund a second or third stint at rehab.

One of the most difficult situations that families can face is coping with a loved one who is actively abusing opiates. With our current epidemic, it is becoming distressingly common. This situation is always replete with guilt, shame, and stigma for everyone. A frequently used metaphor (borrowed from airline safety videos, yet commonly employed in recovery centers) is that it is critical that you put on your own oxygen mask before trying to help others do the same, so that you are able to remain functional in order to help. This fully pertains to addiction. We suffer alone, but we recover together. At our son’s 18-month checkup five years ago, our pediatrician expressed concern. Gio wasn’t using any words, and would become so frustrated he would bang his head on the ground. Still, my husband and I were in denial. We dragged our feet. Meanwhile, our son grunted and screamed; people said things. Finally we started therapy with early intervention services.

A few months later, after hundreds of pages of behavior questionnaires for us and hours of testing for Gio, we heard the words: “Your son meets criteria for a diagnosis of autism spectrum disorder…”

Our journey has taken us through several behavioral approaches with many different providers. Today, Gio is doing very well, in an integrated first grade in public school. He can speak, read, write, and play. His speech and syntax can be hard to understand, but we are thrilled that we can communicate with him.
The difference between typical and functional

Longtime autism researcher Laurent Mottron wrote a recent scientific editorial in which he points out that the current approach to treating a child with autism is based on changing them, making them conform, suppressing repetitive behaviors, intervening with any “obsessive” interests. Our family experienced this firsthand. Some of our early behavioral therapists would see Gio lie on the ground to play, his face level with the cars and trucks he was rolling into long rows, and they would tell us, “Make him sit up. No lying down. Let’s rearrange the cars. Tell him, they don’t always have to be in a straight line, Gio!”

To me, this approach seemed rigid. We don’t all have to act in the exact same way. These kids need to function, not robotically imitate “normal.”
Why not leverage difference rather than extinguish it?

We naturally gravitated towards Stanley Greenspan’s “DIR/Floortime” approach, in which therapists and parents follow the child’s lead, using the child’s interests to engage them, and then helping the child to progress and develop.

Mottron’s research supports Greenspan’s approach: study the child to identify his or her areas of interest. The more intense the interest the better, because that’s what the child will find stimulating. Let them fully explore that object or theme (shiny things? purple things? wheels?) because these interests help the developing brain to figure out the world.

Then, use that interest as a means to engage with the child, and help them make more connections. Mottron suggests that parents and teachers get on the same level with the child and engage in a similar activity — be it rolling cars and trucks, or lining them up. When the child is comfortable, add in something more. Maybe, make the cars and trucks talk to each other.

But, don’t pressure the child to join the conversation. Let them be exposed to words, conversations, and songs, without forced social interaction. This is how early language skills can be taught in a non-stressful way, acknowledging and aligning with the autistic brain. The ongoing relationship and engagement will foster communication.

Basically, what both Greenspan and Mottron are advocating are methods of teaching autistic children to relate, adapt, and function in the world, without “forcing the autism out of them.”

The concept of accepting autistic kids as they are, and incorporating the natural ways they think into educational and therapeutic techniques, feels right to me. Gio is different from most kids, and really, he’s not interested in most kids. Our attempts to push him to participate in “fun” group activities like soccer, Easter egg hunts, and birthday parties have all been spectacular failures. Maybe the real failure was ours: by pushing him to “fit in,” we deny his true nature. Yes, the way he thinks is sometimes mysterious to us, but he clearly has great strengths: a remarkable ability to focus and persevere, to experiment with his ideas, and to follow his vision.

World-renowned autism expert and animal rights activist Temple Grandin (who is herself autistic, and very open about her preference for animal rather than human companionship!) sums up Mottron’s approach perfectly: “The focus should be on teaching people with autism to adapt to the social world around them while still retaining the essence of who they are, including their autism.”
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Tips for using this versatile piece of exercise equipment

Sodium is an essential part of our diet. It helps nerves and muscles function as well as hold onto water. Sodium in the blood is what keeps it viscous, but too much sodium means your body could retain too much liquid. This surge in volume increases blood pressure, which is the root of many serious ailments including heart and kidney disease. Experts estimate that we could save 280,000 lives in the United States if we lowered the average daily sodium intake by 40% for the next 10 years. And that’s just because lowering blood pressure protects the heart.

The average American consumes 3,409 milligrams of sodium each day, according to a new report from the Centers for Disease Control and Prevention. That’s way above the amount we should be getting per day: 1,500 mg. It means we’re ingesting 1.5 teaspoons of salt each day, when we really need only a third of that. And most of that sodium comes from prepared and processed foods — 75%, actually. Salt helps to preserve and add flavor to food, which is great when you want that strawberry Pop-Tart to taste the same whether you eat it the day after you buy it or a month after. But the CDC recently published a list of the 10 most sodium-dense foods in our diets. You know what’s at the top? Yeast bread, pizza, and sandwiches. The good stuff, the convenient stuff, the stuff like Pop-Tarts.
Dialing back the sodium

Cutting back on sodium in our prepared foods has been made easier by the increase in packaged food companies’ creating reduced-sodium versions of them, like low-sodium chicken broth. While that sounds simple, sodium lurks in some unexpected places. Kathy McManus, director of the Department of Nutrition at Brigham Health/Brigham and Women’s Hospital, says there are some ways to cut back on sneaky salt.

McManus says a good way to reduce the amount of sodium you eat is to focus on natural and whole foods. Preparing your own food, while sometimes inconvenient, can cut down on a lot of the sodium you consume. For instance, a frozen dinner of Marie Callender’s Vermont White Cheddar Mac and Cheese contains more sodium in one meal than you’re supposed to have in an entire day. But it’s not that hard to prepare a decadent mac and cheese yourself with Barilla pasta, your own white cheddar cheese, and a little cream. The sodium count comes out to around 715 mg. That is much more manageable when watching your sodium intake. It’s less convenient, but it works.

Buying low-sodium products and then adding salt to them is still better than buying the regular version. Cooking techniques can also help compensate for flavor lost when cutting back on salt. McManus suggests playing around with grilling or stir-frying with healthy oils to change the flavor. You can also add fresh or dried herbs to enhance taste. Over time, your taste buds will adjust. Your palate will change. You’ll be less accustomed to salt and less desensitized to it, so a little bit will travel farther in terms of flavor.

Restaurants remain at the top of the list for sodium-dense meals. Looking at the menu online ahead of time can help you prepare and research your options, but so can keying in on words that indicate healthier options. Look for baked, grilled, or steamed as a description for lean meats like fish or poultry. Keep an eye out for sides that are prepared simply, like vegetables. Avoid soups or pastas with sauces. Put salad dressing on the side, and definitely avoid the bread basket.
Top 10 high sodium foods

Nutrition is not a one-size-fits-all kind of science, but it does get us thinking about what we eat and how it affects us. You could never cut sodium completely out of your diet, nor would you want to, but you can be more aware of the sodium in the foods you eat. To see the complete list of high-sodium foods, check out the table below. Seasonal allergies can be frustrating. When spring crawls in, many people begin to experience all-too-familiar itchy and watery eyes, runny nose, and congestion. Symptoms of seasonal allergies are the result of an immune system in overdrive in response to pollen and other allergens. Those bothersome symptoms are intended to protect you from unwanted foreign particles, but in this situation they end up causing misery. There are quite a few options when it comes to controlling allergy symptoms, but we want to watch out for a few that can be quite dangerous when used incorrectly.
Nasal steroids

The first-line treatment for seasonal allergies is an intranasal corticosteroid such as fluticasone propionate (Flonase). These sprays are available without a prescription and you can use them as-needed. Nasal steroid sprays have been shown to help with both nasal symptoms of runny nose and congestion, as well as eye symptoms. When using these sprays, it is important to direct the spray away from the nasal septum, as there have been some cases of nosebleeds from using these sprays. If this happens, stop using the medication and let your doctor know.

To date, most studies looking at the effect of intermittent use of nasal steroids on growth in children have been inconclusive. However, a large study reported a slight reduction in the rate of growth when nasal steroids were used daily over 52 weeks by children before puberty. Therefore, it’s a good idea to discuss steroid nasal sprays with your doctor if you find your child needs it on a more regular basis.
Oral antihistamines

Antihistamines such as diphenhydramine (Benadryl), loratidine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra) can also be quite helpful. The key is to take the medicine before symptoms develop, such as early in the morning. Another important thing to remember is that some of these medications can cause drowsiness and should be used cautiously during the day, especially if you are driving.
Decongestants

Nasal decongestant sprays such as phenylephrine and oxymetazoline (Afrin) should be used cautiously. Although they may work well in the short term when used occasionally, if used regularly for more than a few days (approximately five days), you may find your nose more congested than usual. This is called rebound congestion or rhinitis medicamentosa. I usually recommend patients not use these products for more than three days. Using these sprays too often causes a biochemical change in certain receptors on your cells, resulting in a vicious cycle of dependence — the more you use it, the worse your symptoms, and the more you need to use it. If this happens, stop using the medication, and talk to your doctor about switching to another type of nasal spray (intranasal glucocorticoid spray) which has been shown to help with this condition.

Oral decongestants such as pseudoephedrine or phenylephrine may help reduce symptoms as well. You should also use these medications cautiously. They mainly work by constricting blood vessels, and may cause side effects such as increased blood pressure, palpitations, headaches, nervousness, and irritability. These medications should not be used by patients with a history of uncontrolled high blood pressure, heart rhythm problems, strokes, glaucoma, or other conditions.
Alternative therapies

Other therapies that have been shown to be beneficial include nasal saline irrigation. Irrigating the nasal passages with prepared solutions, such as with neti pots, has been shown to improve symptoms of runny nose, congestion, and itchy throat, and to improve quality of sleep in children with acute sinusitis and allergic rhinitis. When using these products, however, make sure you are using distilled, sterilized, purified, or previously boiled water, as there have been rare cases of fatal infections by amoeba when using tap water that was contaminated. Although the evidence for menthol rubs such as Vicks is limited, some patients find that rubbing a little menthol ointment under the nose can sometimes also offer congestion relief.\

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A point in the right direction, or a stab in the dark?

In 2015, motor vehicle accidents claimed the lives of more than 35,000 Americans. Sadly, the toll exacted by motor vehicle accidents has now been eclipsed. Data from the American Society of Addiction Medicine show that more than 52,000 of we Americans lost our lives to opioid overdose in 2015. Here in the Commonwealth, the story is even more grim; even accounting for differences in average age from community to community — younger people are still more likely to be affected than older people — the opioid overdose death rate has climbed to 23 per 100,000 residents as compared to 9 per 100,000 for the nation as a whole. The causes are numerous and a subject for another day. Similarly, approaches to solve the crisis are numerous and no one solution works for everyone who decides he or she has developed an opioid problem.
Medication Assisted Treatment (MAT)

One approach to treat people who are addicted to opioids is Medication Assisted Treatment (MAT) that combines medications to treat addiction with more traditional counseling approaches. One medication often used in MAT programs is buprenorphine-naloxone (trade name Suboxone, among others). This preparation — hereafter BN — combines buprenorphine, an opioid medication with partial activity that blunts cravings, and naloxone, an opioid overdose reversal medication that discourages abuse of the medication. When we compare groups of people addicted to opioids who are treated with and without BN, we see that those who receive the medication have a significantly higher rate of remaining free of other opioids. But how long should one continue the medication? A month? A year? A lifetime? And is it safe to continue the medication? We do not have the full answers yet, but early signals from the research indicate that not only is it safe but that longer treatment is better than shorter treatment.
Long-term treatment for a chronic condition

Many in the medical community have come to view addiction as a chronic disease. And, like many chronic diseases, it is one that can be managed but not yet cured. The thinking goes that just as those of us with high blood pressure take high blood pressure fighting medication each day for years, those of us with addiction would take addiction-fighting medication every day over years. The evidence shows that long-term proper treatment for high blood pressure lowers the risk for heart attack; evidence is now beginning to grow that long-term MAT can similarly decrease risk for relapse in those with addiction. As reported in a 2008 study in the American Journal on Addictions, patients who were successfully stabilized with a short course of BN could then be switched to long-term treatment with the medication. Forty percent of patients remained in treatment at two years and 20% at five years. When we remember that nearly half of people prescribed medication for blood pressure do not take their pills, we see that people on BN are not more likely to skip their medication than are people with better-studied chronic diseases. More importantly, though, greater than 90% of urine samples from those in the study remained free of opioids other than BN.

Long-term treatment with BN works.
How do people do without longer-term buprenorphine-naloxone treatment?

It is one thing to say that someone on a medication has a good outcome, but it is something else to prove that without the medication the person would not do well. Many advocate short-term treatment with BN. Help a person become stable and then taper off the medication. We now have evidence that this approach, however well intentioned, may be misguided. A 2014 study reported in the Journal of the American Medical Association demonstrates that over half of people who continued on BN maintenance remained free of opioids compared to just a third of those who were stabilized on BN and then tapered off. Further, far more of those treated with maintenance BN remained in the study compared to those who were tapered, suggesting that people remain committed to treatment while receiving BN.
Is long-term MAT safe?

Even if many people can be helped by extended BN treatment, it is important to consider possible side effects. Though we do not know the effects of being on BN for many decades, the 2008 American Journal on Addictions study looked for but did not find any serious adverse effects on the people treated. Earlier concerns that BN could cause liver damage also appeared to be unfounded as blood tests did not show signs of liver problems in any of the patients in the study.

More research is needed, of course, but the early evidence suggests that BN can safely help people remain off unwanted opioids over the long term just as blood pressure medication can protect people from the effects of high blood pressure. That is good news because each day off unwanted opioids is a day a person can focus on improving his or her life. Of course, buprenorphine-naloxone maintenance is not for everyone, but when it works it can work well and can give people room to breathe and rebuild their lives. Many people do focused brain exercises to help develop their thinking. Some of these exercises work, while others do not. Regardless, the focus network in the brain is not the only network that needs training. The “unfocus” network needs training too.
The “unfocus network” (or default mode network)

Called the default mode network (DMN), we used to think of the unfocus network as the Do Mostly Nothing network. And this network uses more energy than any other network in the brain, consuming 20% of the body’s energy while at rest. In fact, effort requires just 5% more energy. As you can imagine, this network is doing anything but “resting” even though it operates largely under the conscious radar. Instead, when you turn your “focus” brain off, it will retrieve memories, link ideas so that you become more creative, and also help you feel more self-connected too. Somewhat surprisingly, although the DMN is involved in representing and understanding your self, it also helps you read the minds of others. No wonder then, with all these functions on board, this network metaphorically converts your brain into a crystal ball, allowing you to predict things more accurately too. This is the kind of sharpness that you will develop if you train the DMN.

There are many ways to activate the DMN. Below are some that will give you a good start.
Surprising ways to train the default mode network

Some simple interventions could help you engage this network, depending on your goal.

Napping: If, for example, you are dog tired in the midafternoon, and just need your mind to be clear, a 10-minute nap might be all you need for sharper thinking. But if you have a major creative project ahead of you, whether it is an innovative idea at work, or redecorating your house, you will need at least 90-minutes of napping time. This gives your brain enough time to shuttle around ideas to make the associations that it needs to make.

Positive constructive daydreaming (PCD): It’s hard to imagine daydreaming as a type of training, but it is. It has to be the right type of daydreaming. According to Jerome Singer, who has studied this for decades, slipping into a daydream is not of much use; neither is guiltily rehashing everything that makes you feel bad — like the expense you incurred when you bought the shoes you liked, or the one-too-many drinks that you had at a party. But there is a type of daydreaming that will make you more creative and likely re-energize your brain. Called positive constructive daydreaming (PCD), it is best done while you are engaged in a low-key activity, not when you are fading. And as opposed to slipping into a daydream, which is more like falling off a cliff, you must parachute into the recesses of your mind with a playful and wishful image — perhaps one of you lying on a yacht or floating on your back in a pool on vacation. Then comes the swivel of attention — from looking outside, to wandering inside. With this move, you engage your unfocus brain and all the riches that it can bring.

Physical exercise and free-walking: In the brain, thinking supports movement, and movement supports thinking. In fact, exercise improves your DMN function. It normalizes it in obese people (who have too much of it) and increases connectivity in young healthy people. Even a single session can make a difference. Aerobic exercise can help prevent atrophy of key regions within the DMN, and also help the connectivity between different regions too.

Walking does boost creative thinking, but how you walk matters. One year of walking boosts the connections between the different parts of the DMN too. In 2012, psychology professor Angela K. Leung and her colleagues tested three groups of people. One group walked around in rectangles while completing a mental test; one group walked around freely; and the last group sat down while taking the test. The free-walking group outperformed the other two groups. Other studies have shown that free-walking results in improvements in fluency, flexibility, and originality of thinking. So if you want to boost your creativity, go on a meandering hike on a safe path less traveled. Furthermore, walking outdoors may be even more beneficial than puttering around the house (unless you’re using PCD, of course!) Acupuncture is a treatment that dates back to around 100 BC in China. It is based on traditional Chinese concepts such as qi (pronounced “chee” and considered life force energy) and meridians (paths through which qi flows). Multiple studies have failed to demonstrate any scientific evidence supporting such principles. Acupuncture involves the insertion of thin needles into the skin at multiple, varying locations based on the patient’s symptoms. Once inserted, some acupuncturists hand turn the needles for added therapeutic benefit. Although there are many uses for acupuncture in traditional Chinese medicine, in Western medicine it is primarily used for the treatment of pain.
Acupuncture (im)pales in comparison to Western medicine

At a time when people are increasingly concerned about drug side effects, some consider acupuncture an attractive non-medication option. Unfortunately, many studies show that the potential benefits of acupuncture are short-lived. In my experience, I put acupuncture, massage, and chiropractic interventions in the same bucket. You may feel better for a day or two, but there is limited lasting improvement.

In one study, 249 people with migraines occurring two to eight times per month received either acupuncture, sham (fake/placebo) acupuncture, or were put on an acupuncture waiting list. The two treatment groups received treatment five days per week for four weeks. Twelve weeks after treatment, the acupuncture group had on average 3.2 fewer attacks per month, the sham acupuncture group had 2.1 fewer attacks per month, and the wait-list group had 1.4 fewer attacks per month. These results are modest at best, and carry an approximate treatment cost of $2,000 per month (estimating $100/session x 20 sessions). This figure does not include lost income from time away from work to attend appointments, travel costs, pain from the procedure, and recovery time.

In general, the effectiveness of standard treatment (medication and injectable therapies) is supported by much stronger scientific evidence than acupuncture, including large clinical trials with thousands of subjects. For those averse to medications, physical therapy is a great alternative — one based on actual human anatomy and scientific principles. My patients often complain that they do not feel significantly better after the five to 10 sessions of physical therapy that insurance companies typically approve. I advise them that the true benefit of physical therapy comes when the stretching and strengthening routines taught by the therapist are continued at home on a long-term basis. Expecting an instant and permanent cure from physical therapy is like going to the gym for a week, and expecting to lose 20 pounds — without any chance of regaining the weight. (If any readers find a gym like that, please let me know….)
Stuck with needles, then stuck with a bill

At a cost of around $100 per treatment, and with sessions that can last over an hour, acupuncture treatments can be limited by both time and cost. Some patients may confidently argue that they do not mind the cost, because their insurance plan covers acupuncture. I would caution those same patients that money does not grow on trees, especially in the health insurance forest. If money is spent on one expense, it cannot be spent on something else. A plan that covers acupuncture may include fine print about excessive co-pays or limited coverage for basic medications. In some cases, covering acupuncture or massage may affect other patients in the same pool. Imagine if everybody received free massages, but in turn a cancer patient’s lifesaving chemotherapy becomes unaffordable. Although this is an exaggerated example, it does demonstrate the economics of health insurance.
Skewer side effects?

Side effects are not just limited to medications; procedures can also have negative effects. Acupuncture is relatively safe when the practitioner uses single-use, sterile needles with a clean technique. Side effects can include skin infections, bleeding, and pneumothorax (collapsed lung) if the needles are inserted too deep in the chest. Physicians sometimes perform acupuncture, but medical training is not required, and the qualifications to secure a license to practice acupuncture vary by state. It is probably worth the added expense to have a more experienced and/or highly credentialed acupuncturist.
Needle-less to say, the procedure went well

I fondly recall meeting an elderly lady who had a good experience with acupuncture for the treatment of her migraines, but the benefit only lasted one to two days after each session. After failing multiple treatments, she tried Botox injections with physicians not named Dr. Mathew, which she found effective. Due to scheduling issues, she ended up seeing me for injections. After I explained the risks and benefits of the procedure, she asked, “Dr. Mathew, are you experienced?” I replied, “Well, I trained the other two doctors who performed your previous injections.” She replied, “Well, I guess that makes you experienced. Are you gentle?” I paused and then replied in a stern tone, “Well, I am known as the Butcher of New England.” The woman was mortified, and she actually turned a little pale. I then advised her that I was just kidding, and that I am one of the gentler injectors in the practice. We then proceeded with her treatment. After we were done, she said, “That was the gentlest set of injections I ever received, and my pain is actually better.” I then said, “Please don’t say that… you will ruin my horrible reputation as the Butcher of New England.”
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Long-term treatment for a chronic condition

In 1996 Peter D’Adamo, a naturopathic physician, published a book in which he described how people could be healthier, live longer, and achieve their ideal weight by eating according to their blood type. One’s choice of condiments, spices, and even exercise should depend on one’s blood type. Soon, the book was a best seller and people everywhere were finding out their blood type, revising their grocery lists, and changing how they ate, exercised, and thought about their health.

Here are some of the recommendations according to the “Eat Right for Your Type” diet:

    Those with type O blood should choose high-protein foods and eat lots of meat, vegetables, fish, and fruit but limit grains, beans, and legumes. To lose weight, seafood, kelp, red meat, broccoli, spinach, and olive oil are best; wheat, corn, and dairy are to be avoided.
    Those with type A blood should choose fruit, vegetables, tofu, seafood, turkey, and whole grains but avoid meat. For weight loss, seafood, vegetables, pineapple, olive oil, and soy are best; dairy, wheat, corn, and kidney beans should be avoided.
    Those with type B blood should pick a diverse diet including meat, fruit, dairy, seafood, and grains. To lose weight, type B individuals should choose green vegetables, eggs, liver, and licorice tea but avoid chicken, corn, peanuts, and wheat.
    Those with type AB blood should eat dairy, tofu, lamb, fish, grains, fruit, and vegetables. For weight loss, tofu, seafood, green vegetables, and kelp are best but chicken, corn, buckwheat, and kidney beans should be avoided.

As mentioned, the recommendations for the blood type diets extend well beyond food choices. For example, people with type O blood are advised to choose high-intensity aerobic exercise and take supplements for their sensitive stomachs, while those with type A blood should choose low-intensity activities and include meditation as part of their routine.
But does it work?

High-quality studies about the blood type diet had not been published in peer-reviewed medical literature. Even now, a search in the medical literature for the author’s name reveals no research pertaining to this diet. Studies published in 2013 and 2014 about the blood type diets are worth noting. The 2013 study analyzed the world’s medical literature and found no studies demonstrating benefit from a blood type diet. The 2014 study found that while people following any of the blood type diets had some improvement in certain cardiometabolic risk factors (such as cholesterol or blood pressure), those improvements were unrelated to blood type.
Does it make any sense?

The theory behind this diet is that blood type is closely tied to our ability to digest certain types of foods, so that the proper diet will improve digestion, help maintain ideal body weight, increase energy levels, and prevent disease, including cancer and cardiovascular disease.

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Type O was said to be the original “ancestral” blood type of the earliest humans who were hunter-gatherers, with diets that were high in animal protein. Group A was said to evolve when humans began to farm and had more vegetarian diets. Group B blood types were said to arise among nomadic tribes who consumed a lot of dairy products. And since Group AB blood was supposed to have evolved from the intermingling of people with types A and B blood, type AB recommendations were intermediate between those for people with types A and B blood.

Each of these theories has been challenged. For example, there is evidence that type A was actually the first blood group to evolve in humans, not type O. In addition, there is no proven connection between blood type and digestion. So, in addition to a lack of evidence that the diet works, serious questions remain about why it should work in the first place.
So, what’s the downside?

It’s a fair question, especially since some improvements were seen in people who adopted certain blood type diets (see link above). Eating based on your blood type requires you to know your blood type and then follow a restrictive diet. Personal preferences might be a problem: a vegetarian with type O blood may struggle to stay on the assigned diet, and people who love red meat may be disappointed to learn they have type A blood. Recommended supplements are not cheap; neither are the recommended organic foods. And if you have certain health conditions, such as high cholesterol or diabetes, a nutritionist can make better evidence-based recommendations for you than those determined by your blood type.
Now what?

Advocates of blood type diets may say that while the ideal study has not yet been performed, the absence of evidence doesn’t prove they’re ineffective. And there’s also no proof that these diets are harmful. So, my guess is that interest in the blood type diets will not disappear any time soon. But there’s a reason that bookstores have rows and rows of books on diet, each claiming to be highly effective if not the best. We simply don’t know which diet is best for each individual person. And even if we did, sticking to any single diet is often challenging.
Though it seems Americans don’t agree on much, screening for cancer is an exception. Who wouldn’t support preventing or identifying cancer at an early, more treatable stage, when the alternative is pain, toxic therapies, and a shortened life? That may be why people get confused when news headlines don’t reinforce a “just do it” message. A recent example of the disconnect between public perception and medical evidence is screening for prostate cancer using the prostate-specific antigen (PSA) test. The United States Preventive Services Task Force (USPSTF), a non-governmental expert panel that produces guidelines for primary care providers, proposed new recommendations saying doctors should only order the PSA test for older men after discussing its pros and cons and eliciting preferences for screening.
Screening for prostate cancer with the PSA test: The backstory

To understand the new draft recommendation requires a brief history of this test. Introduced in the 1980s as a way to follow patients already diagnosed with prostate cancer, it began to be used to screen for new cancers. Given that the PSA is an easy blood test to perform, it was quickly adopted — without waiting for evidence that it actually worked. For many years, the USPSTF said there wasn’t enough information to recommend for or against the PSA test.

That changed in 2012 when the USPSTF released a controversial recommendation against screening. It was based in part on a large US study showing no decrease in prostate cancer deaths among men screened using the PSA test. The recommendation also reflected concern about the test causing a surge in prostate cancer diagnoses, many of which were small, low-risk cancers being treated with surgery or radiation — treatments with common side effects.

I was uncomfortable with this “don’t screen” recommendation and am happy about the proposed change. Here’s why: while the US screening trial was negative, another large study in European men showed a small decrease in prostate cancer deaths after more than 10 years of follow-up. Moreover, specialists had devised new strategies to avoid overtreating low-risk cancers.
Having a conversation about screening with the PSA test

I discuss the pros and cons of the PSA test with my patients and ask about their personal preferences for screening. I tell them that while screening can reduce death due to prostate cancer by 20%, the “bang for the buck” is small. It takes screening of over 1,000 men to prevent one death. I also highlight that the benefit of screening is years off, but the risks of treatment — impotence, incontinence, and bowel problems — occur right away.

I also emphasize the PSA test isn’t very accurate. There can be anxiety due to false positive results, meaning further testing shows no cancer. I mention the potential for diagnosing a low-risk cancer where the treatment may be worse than the disease, and that following them closely without treatment may be preferable. How much a man wants to know something like this can differ — some view it as useful information, others see it as an endless source of worry.

Finally, I share my own perspective. As a medical student in the late 1980s learning about the PSA test, my grandfather was dying from prostate cancer. He was an otherwise healthy man who had many good years left, and I wondered if the PSA test could have helped him. Because of this family history, I have decided to have the PSA test. But I’m also unsure what I would do if I didn’t have that history. The small potential for benefit must be weighed versus the risk of false positives or of finding a low-risk tumor that may never cause harm. I can see how two men without risk factors for prostate cancer could make different decisions.

So, I think the USPSTF got it right. This is a decision best made by a well-informed patient in collaboration with his doctor. The challenge in implementing this is practical: the short time I have with each patient. I could save time by simply ordering the test without a discussion. But in my role as health advisor, I need to be able to not only say when I think we should or should not do something, but also when there is a choice. And when there isn’t one right decision for everyone, my patient is the best person to make the choice that’s right for him. I can state my personal preference, but need to highlight why that may not be the right answer for him. Ever wonder what it would be like to be able to look at people’s entire adult lives? Not asking older people to remember, but starting with them as teenagers and tracking their health and well-being until they die? We’ve been lucky enough to do this for the past 78 years, starting in the late 1930s and early ‘40s with a group of men who agreed to be part of one of the longest studies of adult life ever done.

The Harvard Study of Adult Development has tracked the lives of 724 men from the time they were teenagers into old age — 268 Harvard College sophomores, and 456 boys from Boston’s inner city. Using questionnaires, interviews, medical records, and scans of blood and brains, we’ve monitored their physical and mental health, work lives, friendships, and romances.

Here are five of the big lessons we’ve learned about what contributes to a good life.
Lesson 1: Happy childhoods matter

Having warm relationships with parents in childhood predicts that you will have warmer and more secure relationships with those closest to you in adulthood. We found that warm childhoods reached across decades to predict more secure relationships with spouses at age 80. A close relationship with at least one sibling in childhood predicts that people are less likely to become depressed by age 50. And warmer childhood relationships predict better physical health in adulthood all the way into old age.
Lesson 2: Fostering the welfare of the next generation can ease the sting of difficult childhoods

People who grow up in difficult childhood environments (chaotic families, economic uncertainty) grow old less happily than those who have more fortunate childhoods. But by the time these people reach middle age (ages 50 to 65), those who mentor the next generation — guiding younger adults at home or at work — are happier and better adjusted than those who do not. The kind of maturation needed to nurture younger people also seems to reduce some of the sting of growing up disadvantaged.
Lesson 3: Coping effectively with stress has lifelong benefits

We all have habitual ways of managing stress and relieving anxiety. Some people tend to ignore uncomfortable facts, while others tend to face difficult issues and deal with what is unpleasant. For example, someone who is angry at his boss might “forget about it” but start missing important work deadlines. Alternatively, he might find a way to take up his concerns directly with that boss. We found that the people who cope with stress by engaging more directly with reality rather than pushing it away have better relationships with others. This coping style makes it easier for others to deal with them, which in turn makes people want to help them. They end up having better relationships and more social support, and this predicts healthier aging in your 60s and 70s. People who use these more adaptive coping mechanisms in middle age also end up with brains that stay sharper longer.
Lesson 4: Breaking bad habits earlier in life makes a difference

Watching people’s smoking habits across adulthood, those who quit earlier are less likely to develop lung disease as they grow old. They are also more likely to live longer than people who do not quit smoking or who quit later in life. Our findings differ from some studies that find no change in risk of disease and death once you’re tobacco-free for 15 years or more. Getting off the couch and starting to exercise earlier in life predicts that you’ll stay healthy longer in life, that your brain will stay sharper, and even that your immune system will be stronger.
Lesson 5: Time with others makes us happier

Looking back on their lives, people most often report their time with others as the most meaningful part of life, and what they’re proudest of. Time with other people makes us happier on a day-to-day basis, and time with a close partner buffers us against the mood dips that come with increased physical pain.
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16/02/2019

How to Score Good Grades in your school

Bakery business is one the lucrative businesses all around the world today. With a nation’s population increasing by millions, it shows that people will continually eat and it will be your business to provide the needed meal. Bread is one of the choice fast foods of people across the globe and in Nigeria, its demand is never in short supply. In Nigeria, for example, the amount of people who consume bread on a daily basis proves that the bakery industry is a profitable industry. In this article, you will have the knowledge needed to start up and maintain a profitable bakery business.
High Demand For Bakery Product

Bread as an example of bakery products is a good source of carbohydrates, proteins, and vitamins. Because it has such high nutritional value, it is widely consumed by almost everyone on this planet. For a very long time consumption of bread has been a necessity for human diets and as continuously yielded an increase in consumption over the years. This proves that the market is wide open for anyone to venture into as one can invest in opening a modern bakery to provide the highest in demand bread for consumers.

Nigeria with a large population consumes a lot of bread with locally made meals such as bean cakes, pap, beans etc. Another fraction of the population may require catering services for parties and wedding to provide snacks and pastries etc. However before you launch into the business, there are some few things you must note
Find Mentors Before You Commence Bakery Business

Search for mentors before you start your bakery business as mentors will easily provide you with solutions to difficulties in the business, provide ideas, tips and information necessary to having a successful bakery business. These mentors will serve as a guide to instruct you on among other things the necessary equipment needed, how to get your license, strategies and branding ideas to selling your bread, etc.


The bakery as a highly lucrative business

Nigerian loves baked foods such as the regular “puff puff”, Agege bread, small chops and so on. With all these, there’s is still a huge market to attract as baking has no limitations in terms of age, religion etc. If you can create a creative branding strategy you will definitely find it profitable by the end of the month.

With the huge population in Nigeria, it’s very easy to say every baker is a millionaire if they get to sell to about one million people in the open market in a day. But baking doesn’t grow in such large fashion in a day but requires adequate time in branding and improving on providing crocrowd-pleasing delicious meals at an affordable price and quick accessibility in order to increase sales.

See: How to Start A Successful Farming Business in Nigeria

If you have an intention of baking or you have started your baking business, here are the ways to make it profitable:
Market Survey

Do a proper survey or research to inquire about the demand presently in the market regarding baking products which other bakeries do not offer. In this survey, you can also find out if there is a customer relationship between the producer and the consumer. In this survey y,ou can state what the customer’s demands are and position your business in such a way that meet such demands.
Source for Start-up Capital

Whatever you discover from the demands in the market will affect the budget of your start-up capital and this could be more than your initial budget.
Source for Start-up Capital

The high demand which you have discovered in the market for a particular product will affect the amount of start-up capital you need to start the business.

Furthermore, your start-up capital will determine the materials you would need, the equipment you should buy, your business size, etc. All these would be drawn up into the estimated amount of what to you need to get your business up and running.
Have a Business Plan

The business plan enables you to draw out strategies to be used in the business such analyzing your start-up capital which has been estimated from your feasibility reports, where you want to get your capital from – this could be a loan, from your savings or assistance from family and friends.

This business plan will show marketing and branding strategies to be used to promote your brand, number of staff you need, equipment etc. It is important to start a business with a proper business plan.
Buy Necessary Bakery Equipment

Purchasing the right and necessary equipment is very important. Buying the right equipment depends on the level at which you want to startup the business such as the size of the bakery, capital and so on. Here is the list of equipment needed for a bakery business: mixers, dough molder, large tables, bread pans, display shelves, water proof wrapping sheets, oven, bread slicer, van for delivery and so on.

Proper installation and maintenance should be given to the skilled technicians to monitor and control.
Baking Materials

The major materials needed for baking are baking flour, baking soda, butter flavors, water and so on.
Get Approval from Government and Regulatory Bodies

If the law requires any form of payment to a regulatory body, kindly comply and pay every necessary dues and get your government approval and license, in order to carry out your business smoothly.
Get a Good Location

Find a good location that will promote sales. Location close to the buyers will improve sales on a regular basis which will mean constant production that will keep you in business. Without demand, there would be no business therefore get a place with enough traffic to keep yourself ib business.
Safety of Lives and Property

Nigerians have no regards about this matter, they rely more on spiritual matters when asked to get insurance. It is important to note that safety of lives and property is as important as the sales you want to make. Therefore, fix every necessary gadget or appliance for preventing major disaster to your establishment.
Recruit the Best Staff

After your business plan, your staff are also important, therefore, make sure you recruit the best hands with relevant experiences on the job. The recruited staff should not be bakers only but also individuals who understand marketing and distribution in order to promote sales.

See also: Establishing a Profit-Making Fish Farming Business
How is Bakery Business Profitable?

Bakery business is profitable if you start up with the right capital, inculcate and promote good customer relations, have the right team working with you; that is a team that understands the level of business and so on and so forth.

To venture into the profit side of the business, take note of the following:
Bakery Products Sales and Distribution:

If your product has the right branding and it’s properly packaged with a delicious taste, people will buy it.

Make sure that your products are fresh and attractive fonts or images pleasing to the consumer eyes.

Your distributors can include wholesalers, retailers as they bring your products closer to the consumers
Offer Trainings

You can offer training to a number of persons and charge from as low as 20,000 Naira and if you have 10 students, that’s 200,000 Naira. This student can also help in production of more products after completing the training.
Offer Event Catering Services

This is the most popular avenue used to make money in Nigeria. A lot of event are usually held on weekly basis and most of them require services of bakers to provide them some tasty meals.

For example a wedding cake costs about 50,000 to 500,000 Naira depending on the number of tiers and decoration. This is also similar to small chops which can be priced at 500 Naira per guests. If your production and packaging is top notch you will get referrals and lots of events will be needing more of your services.
Go on TV Shows

You could have the opportunity to host your personal baking show on TV which could bring more sponsorship deals and brand endorsement, creating a total uniqueness to your brand.

To get to this platform, you must be ready to invest all, that is your time, money and so on but at the end it’s definitely profitable.

Be very open to criticism so you can correct mistakes and do not allow anyone tell you it can’t be done, constantly press on to be better on every side. Turn your business into a money making venture.
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See: 3 Months Study Plan for NEET 2019

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How to learn some langauge in collage

Hello, what's happening folks. So today we will cover six critical procedures for enhancing your dimension of self-control. Presently before we get into the bare essential, I would like to take a concise minute to characterize what precisely self-restraint is. Since when I asked you all to inform me regarding your with control on Twitter a few days ago, I found a great deal of solutions extending from inspiration to diversions to wireless dependence, a wide range of things in the middle of, and what every one of these answers are genuine issues. I don't assume that every one of them fit conveniently into the class of self-restraint, where they do fit in the more extensive classification of conduct change. What's more, that is the enormous objective for the majority of us. We need to change our practices to be progressively lined up with our objectives and our long haul wants. Also, with regards to that general mission, to change our practices, I see four fundamental territories that we have to concentrate on. One of which is simply the development discipline, which we're going to handle in this video, yet additionally the working of new propensities which can make that conduct programmed, the customization of our condition which can evacuate barriers and help us oppose enticements by essentially expelling them and obviously, the utilization have however much Brando as could reasonably be expected since it is the initially meet later.

Yet, as you may have speculated, this video is just about that first territory self-restraint. Furthermore, where I need to begin is by asking and noting two inquiries. Number one, what precisely is self-restraint? What's more, number two? How can it contrast from inspiration? Since I think many individuals get these two terms befuddled.

To begin, I need to share a statement from the essayist Samuel Thomas Davies, since it really answers both those inquiries in a truly clean manner. self-control is tied in with inclining toward obstruction making a move regardless of how you feel living by plan, not naturally, however in particular it's acting as per your considerations, not your sentiments. Be that as it may, another way inspiration is your general dimension of want to accomplish something Reza discipline is your capacity to do it paying little respect to how you feel. What's more, for any of you who've ever woken up supposing I don't feel like it, which is every one of you, myself notwithstanding. You can see now how essential self-control is. It's building that benchmark that enables you to act as per your long haul objectives.

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Regardless of how spurred you feel. So, how about we spread six essential techniques for building your self-restraint. Also, we're going to begin with one that doesn't appear to be truly unmistakable or noteworthy at first. Yet, stay with me here, on the grounds that this is an outlook move that I discovered more accommodating than some other personal growth strategy. I've attempted in late memory.

To say it basically, when you're attempting to change your conduct, disregard the objective, you're endeavoring to accomplish the outside result, and rather center around the adjustment in character you need to occur. This is an idea that I originally found out about in James Claire's book, nuclear propensities, which I very suggest, coincidentally, and there's this section close to the start of the book that truly exemplifies it well so I'm simply going to peruse it to you here envision two individuals opposing a cigarette when offer to smoke the principal individual says not this time I'm attempting to stop it sounds like a sensible reaction however this individual is still trusts they are a smoker who is endeavoring to be something different they're trusting that their conduct will change will bearing similar convictions the second individual to customers by saying No much appreciated. I'm not a smoker.

It's a little distinction. In any case, the announcement flags a move in character. Smoking was a piece of their previous life, not their present one, they never again recognize as somebody who smokes. So the general thought here is that once you've grasped the adjustment in your character, you're going to end up acting in arrangement with that change. Furthermore, in case you're asking why precisely this occurs, the third section of Robert youngsters' book affected the brain research of influence has an extraordinary clarification for it. Basically, people feel this common impulse to act reliably with their past choices. As he writes in the book. When we have settled on a decision or standing firm, we will experience individual relational weights to act reliably with that dedication. Those weights will make us react in manners that legitimize our prior choice. Also, moving my outlook along these lines, has been extraordinarily useful in the recent months. What's more, the primary way that I actualized it was by beginning to consider myself a competitor. Presently, I've generally been a truly dynamic individual, and I've had a clothing rundown of athletic objectives on my site for a significant long time now, however I never truly took the jump and kind of reasoning of myself as a competitor and there was some fraud disorder explanations behind this yet as

In the wake of perusing that entry in the book, I chose to take the jump and begin considering myself a competitor, not similarly as someone who acts of things. What's more, that move in attitude has done miracles for my dimensions of self-restraint in a wide range of zones from setting off to the rec center all the more reliably preparing more diligently while I'm there to enhancing my eating routine, which has been significantly superior to anything it used to be over the recent months. So truly, in the event that you don't take anything else from this video, I'm putting this first for a reason, begin pondering conduct change as far as the character that you need to epitomize, instead of the objectives that you need to accomplish.

OK. System number two is to as often as possible help yourself to remember for what reason you're being taught in any case by the day's end. We must have a solid why for our activities on the off chance that we need to do them reliably. Furthermore, every time I consider this idea, I'm helped to remember a tale about the performing artist Jim Carrey and it goes like this after he had touched base in Hollywood. Furthermore, he was still sort of a devastated performing artist. One day he took out a napkin and he drew himself a look at made to himself for $10 million and post dated for a long time and

The future and after that you put that check in his wallet so every time you draw out his wallet, he could see it and help themselves to remember why he was buckling down what he was really going after. What's more, this is something that you may discover accommodating to do also. Take a stab at recording your objective or the personality you need to expect and put it possibly on a sticky note by your work area or by your PC so you can see it each and every day and realize this is for what reason I'm building myself discipline. This is the explanation behind all the work I'm putting in.

Good. Procedure number three is to discover approaches to grasp distress and grasp the opposition you feel towards accomplishing something that takes diligent work or that is upsetting. Much the same as setting off to a genuine rec center and lifting loads improves you at lifting loads later on and ready to lift more weight whenever you go in. Each time you grasp distress, you're basically completing a rep of the activity that is self-control since it is an ability that can be scholarly. It is a muscle that can be worked after some time. This is for what reason I'm such a defender of scrubbing down on the grounds that a virus shower is something that a great many people would prefer not to do. It's most certainly not

Entirely open to remaining underneath that surge of super cold water. Also, that is the point each morning that you get into the shower, and you turn that handle to cold. Rather than hot, you are grasping uneasiness, you're inclining toward the opposition, and that improves you at doing as such later on, paying little mind to what the errand is. So as you experience your day by day life, discover approaches to grasp uneasiness.

It could be cold showers, it could be setting up for 6am ROTC wellness class, it tends to take the stairs rather than the lift. Essentially, whatever your mind hurls, that I don't feel like a reason. That is a chance to construct that self-restraint muscle you should take

Alright, we are on to thing number four of our rundown, which is to focus on the essentials first, and by the basics. I mean the natural necessities of life, your rest, your nourishment, and your activity propensities. These are for the most part pivotal to focus on the grounds that the piece of your cerebrum that handles official working part that controls your wants and your driving forces requires a great deal of vitality and customary rest to work at pinnacle levels. Keep in mind forget that you are most importantly an accumulation of organic frameworks, all of which require the correct information sources on the off chance that you need to get the best yields out of them.

Also, I know it's anything but difficult to get your feedback as independent from this as existing in this supernatural domain, yet the main need to feel sources or inspiration and assurance and healthy images, yet the cerebrum needs rest needs exercise, and it needs the correct equalization of supplements, similarly as whatever remains of your body does. So in case you're restless, which, in light of the measure of perspectives on this video, you likely are, or you haven't gotten enough exercise consistently, or your eating regimen is poop. That is the place you should center your control first.

That expedites us to our fifth thing the rundown. What's more, it torments me to state this one since I for one abhor doing it. Be that as it may, you might need to attempt reflection. What's more, the reason you should need to do this is contemplation has been appeared at help individuals enhance their dimensions of self-control. Indeed, the 2013 investigation at Stanford University demonstrated that individuals who experienced sympathy preparing which was a particular reflection program, we're better ready to direct their feelings. a short time later

Module Do you realize how to state this? Or then again that? Or on the other hand these are those in French? All things considered, today to arrive, we're going to rehearse our illustrative modifiers.

OK, along these lines, previously we begin going straight into a little exercise, let me remind you extremely rapidly what an illustrative modifier is. All things considered, in English, it's either this, or that. All these, every one of those, alright? All things considered, in French, we have four diverse methods for saying this, or that or those.

Thus one and what you need to take in thought is that everything concurs incite and numbers with them then they qualify. So by this I imply that you have to know whether you were the word you're utilizing with this definite descriptive word is a ladylike word mescaline with a plural or does it start with a vowel or a H. Presently we should see how we use

The exhibited modifier utilizing a manly Weren't we would state, Sir, would you be able to state that so thus implies this for the manly weren't that pursues So, so take this pen for instance. So Still, if the word is manly yet starts with a H or vowel, it would be set C e t, so set up for instance, this tree. Presently when you utilize a ladylike solitary thing, it would be sent ce e TT E. So you would state this bloom set stream for instance, or you could state set hole the Boston this postcard for instance, and as should be obvious the distinction between specific settings that setters twofold t so it alludes to a female at this point

Alright, presently if you somehow managed to utilize a plural thing and in any case whether it is ladylike or manly, in any case whether it starts with a H of our, you would state Si, si e S. So on the off chance that we use Fleur, once more, recall in a ladylike structure it's set for, however you need to state these blooms on those blossoms, it will be the equivalent. In French, you would state, say Fleur ce e. s, stream, and the focal Afterburn. In any case, you wouldn't state set out, alright, just when it's in particular structure. Be that as it may, in the event that you need to place it in it's plural structure. At that point you utilize the word Si, si E. So you would state, say Zambia and this accentuation to stick you would state these pens will progress toward becoming see stylo. Alright so this is only a brisk update remind that in French we have three unique or four on the off chance that you can set CT of utilizing this. So this alright so we have so we have set CT we have sets e TT E and we have si e s came yet you may state however how would I know without need to utilize a pre roll or will win? It's simple yet how would you realize how to utilize a female or manly when it's very straightforward you must nobody extremely essential principle is that if the words and with a knee or SEO for instance all things considered, the word is ladylike and the rest will probably be mescaline.

In any case, there is no set principle to knowing how where the thing is ladylike or manly. So you simply need to learn it once you know and gain proficiency with the new weren't simply learned with its article or LA female, manly or ladylike if that bodes well now the most ideal path for us is to distinguish them in a sentence. So we should view 10 distinct sentences utilizing them Australia of modifiers. What I might want you to do is view them and attempt to figure which definite modifiers you should use in the hole here. We should view the main sentence.

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The main sentence here says ballad, some day by day sews, lyric, some tasty us so we need to put either C or C or set of set Okay in this hole, however what would it be able to be? Presently we have here a pre move How would I know it's turmoil since it's shown here and I'm going to utilize my pen here Have a look here there is a S.

Thus here there is a paper and not just that, I know more than that, I realize that it's provable and ladylike on the grounds that the word dentistry has been changed into it's plural female structure every day shoes alright and this is a marker here ah alright that it is so predominant currently bomb is Apple however we need to state these apples How might you say that utilizing what I've quite recently let you know so bomb

since it isn't alluding to pre move CET no in light of the fact that the word doesn't start with a vowel or specialty so far as that is concerned so it very well may be so it tends to be set alright CET he surely understood in light of the fact that it has a S OK so it will be C taste on that alludes to endorsement basic some day by day shoes OK so in the event that you take a gander at the word here straightforward it doesn't generally demonstrate whether it's female or manly, however it hasn't.

Sexual orientation, that is what's going to give it away. The E and the S discloses to me that this word isn't just female, however it is so pre roll. Alright, so how about we examine Newman, who do number two is disgrace book who live

and after that exhibited descriptive word. A blade now Jim crazy. Like book with a great deal. I like a ton. What do I like? A ton? The books, Becky. The books. Alright. Goodness, and that methods for,

at that point we need to state this. Alright. Also, a blade, Nick, devise an essayist so however you can say well, how would I realize how would I know what the plan of this word is? Alright. Presently in the event that you base your state from the way that in all likelihood the word finishing with a pleasant woman's rights then here it doesn't finish with me. So we will expect it is manly. So examine the manly

For this it is so well done however

alright however we realize that when the word which is manly start with our Nate, we have to include a TT sir. So we will compose set equal. Alright? So we know two things here that the world is mescaline we realize that currently alright and furthermore that the word has its start with an esteem and consequently we use set alright recollect there's two different ways of utilizing this in manly sex so all set alright so Jim book who leave of the city occasion I like the book of this author. I like this journalists book a ton. That is the thing that it implies. View number three. Presently we have machine new people pee now. Better believe it, we realize that we haven't.

They get to Not that it is important into what we need to do. I'm simply calling attention to out currently no methods not a key know before the action word and after the word demonstrate sent refutation. The action word is here capacity it could be pound also new capacity, new mashup, that does not work. Would could it be that does not work love machine? Also, here it has an E toward the end.

So the weren't having any thought is probably going to be female. So knowing this, what do we put so machine set machine CD set machine CT or debilitated machine? ce e s, not pre roll is it doesn't have a S so here it closes with an E so hence it's probably going to be female and in this manner we would put set machine OK set so what I will do

In reality to assist you with this I'm going to underline the machine as female here to enable you to alright and bomb as ladylike too and the rest here is

manly alright presently how about we view numerical get number four o d and after that inn a period OK we have a trouble here suppose that you don't have the foggiest idea what the rest implies however inn is a basic method to realize it implies lodging OK this word starts with a H OK so with we need to know is it female or manly in such a case that it's met ladylike will be set C e TT e yet in the event that it's ladylike

manly alright it will be CET why since it starts with a demonstration Okay for this situation inn does not have a decent

As it's extremely prone to be manly so in this way we are going to put CET alright Auntie could set up a period better believe it so article is a maxim and it implies individuals state that one says that really it happens that alright This inn is exceptionally great alright so inn is and I will compose it here a manly weren't

presently we should view number five beyond any doubt great name BM Femi definitely OK currently discover me better believe it said that you don't have the foggiest idea what your name implies OK however families and simple approach to know for me is family examine the closure of this world It doesn't require so it is probably going to be female so we realize that for this in ladylike structure is set we're finished

Set alright so set Fermi's this family alright beyond any doubt Columbia set Femi I know this family well and that is the place the word originates from. Would you be able to see that you would apia be able to set Femi so what I will do here I'm going to include a

sticker here to my sticker one you know what I mean? Alright we should examine the following one

see man um. Better believe it what I've said everything implies man. Alright so I'm going to disclose to you now and then I do things I reveal to you can't resist that is a man OK on an instance of the view

on Okay, presently, I think for view see is to look for Have you seen alright Have you seen now here the way to see however it's in its past participle from along these lines it implies perceived how

You seen this man now? What would it be a good idea for it to be here? This man ever take a gander at the rundown again. Simply concentrate and dependably take a gander at the rundown is it's set arrangement of wiped out when

I'm is a man. So however it closes with an almost certainly, the word is strong. Alright state I don't have the foggiest idea why I did that incidentally so it is determined to approve set on in light of the fact that the word is mescaline. Furthermore, it starts with an Ah, alright. Set them I've ever visit them. As I'm going to shading coded in blue only for you. Alright, the following word first class, I blew the skillet such huge numbers of feet later. Blue the band such a large number of feet. So we should envision you don't have the foggiest idea what later blue is. You don't have the foggiest idea what numerous individuals simply base yourself on that word here. gasp. OK.

Presently I realize it has an E toward the end, and I realized that you would probably say it's female, sadly. Furthermore, that is the reason I've picked this precedent is that it has a place with the exemption band as an E toward the end, however is manly. So realizing that band which implies painter is mescaline. What's going on here? Is it so terrible?

This painter set gasp see groups when it very well may be said CT since it doesn't start with a vowel or night. It tends to be provocative TD in light of the fact that I've quite recently revealed to you it is a manly word and it very well may be cc ies since it's not in endorsement structure so it must be so terrible. Alright. So gasp minimal blue. Do some talk such huge numbers of feet the depictions of these painter are grand came only a seemingly insignificant detail here.
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