Posted on Leave a comment

The rising tide of dementia and the need for nondrug therapies

senior man in a wheelchair interacting with a small dog held by a care facility staff member

The human and financial cost of Alzheimer’s disease is devastating. More that 55 million people are living with Alzheimer’s disease and other causes of dementia, rising to 78 million by 2030 and 139 million by 2050. In the United States alone, the Alzheimer’s Association estimated that in 2020, more than 11 million unpaid caregivers provided 15.3 billion hours of assistance (valued at $256.7 billion) to 6.2 million people with dementia. That estimate does not include the $51.2 billion in Medicaid payments for Americans ages 65 and older living with dementia.

Pharmacological solutions to slow down Alzheimer’s disease

For years, most Alzheimer’s clinicians, researchers, and advocacy groups have pinned their hopes on a pharmaceutical solution to this crisis, yet there has been failure after failure. Last year, amid considerable professional debate, the FDA approved the first medication thought to be able to slow the accumulation of Alzheimer’s disease pathology in the brain. The theory, as yet unproven, is that if such a drug is given early enough — before there are any symptoms — the disease progression will be so gradual that people will be able to live out their lives without developing disabling dementia.

A looming crisis

Although this hoped-for trajectory is logical and laudable, the immediate effect may be costly. The vast majority of new medications being developed for Alzheimer’s disease — including the one the FDA approved — are being evaluated in people who already have symptoms, such as memory loss. These new disease-modifying drugs will therefore first be used in millions of individuals with mild Alzheimer’s symptoms. Because these drugs slow down (but not stop) the accumulation of pathology, individuals with symptomatic Alzheimer’s disease will continue to progress, and — if the therapies are successful — they will progress more slowly. Instead of the mild stage of dementia lasting about three years, it might last four, five, or six years. Instead of the moderate stage lasting about four years, it might last five, six, or seven years. This means that, for the foreseeable future, disease-modifying drugs will not decrease the numbers of individuals living with dementia — it will hugely increase them.

For this reason, it is critical that the US and other countries invest in not only pharmacological but also nonpharmacological treatments for Alzheimer’s disease and other dementias. Although many strategies have been developed to improve memory in those patients with mild memory symptoms, few, if any, of these interventions have undergone large clinical trials to prove (or disprove) their efficacy.

The potential benefit of nonpharmacologic memory-boosting strategies in the mild stages

One study from a group of Boston researchers examined 32 individuals with mild memory problems, half with mild cognitive impairment and half with mild Alzheimer’s disease dementia. They found that both groups improved their memory by simply thinking about the following question when learning new information: “What is one unique characteristic of this item or personal experience that differentiates it from others?” Another study by Boston researchers found that 19 individuals with mild cognitive impairment could improve their ability to remember items at a virtual supermarket by simply thinking systematically about whether items were already in their cupboard before putting them in their shopping cart. Larger studies are needed, however, to determine if such memory strategies are generalizable.

Music, pets, robots, and the environment in the moderate to severe stages

Similarly, there are many nonpharmacological treatments that appear to provide comfort and reduce agitation in individuals with moderate to severe dementia, but larger and more rigorous studies are needed to prove or disprove their efficacy, and thereby promote more widespread utilization.

  • A group of Portuguese clinicians and researchers reviewed more than 100 studies evaluating music-based interventions for people with dementia who had agitation or other behavioral and psychological symptoms of dementia, finding that the vast majority were efficacious with little or no side effects.
  • A team of neurologists from Florida reviewed the effects of dog therapy and ownership, finding that both were safe and effective approaches to treat chronic and progressive neurological disorders.
  • Other researchers found reductions in anxiety and psychoactive medication use when robot pets were given to individuals with dementia.
  • A review of the built environment (the architecture of the home or facility) concluded that “specific design interventions are beneficial to the outcomes of people with dementia.”

Education for families

Educating families and other caregivers about how to manage the different stages and facets of dementia is also critical. One pilot study by Brazilian clinicians invited caregivers to participate in educational sessions and found a high rate of program satisfaction. Unfortunately, these types of caregiver education interventions are rarely studied in large clinical trials.

Enormous potential savings

If strategies in the mild stages prove effective enough to save just one hour each week of a caregiver’s time for the roughly two million people in the US with mild dementia, it could save 104 million hours valued at $1.7 billion each year. That extra hour might, for example, allow a “sandwiched caregiver” to help their child with homework while their parent with mild dementia takes medications or pays bills independently.

If nonpharmacologic interventions in the moderate to severe stages saved just one month of nursing home care for the roughly four million people with moderate to severe dementia in the US, it would save more than $31 billion dollars (based on a semi-private nursing home room costing $93,075 per year). And that financial savings is in addition to the social and emotional benefit to individuals with Alzheimer’s disease and their families.

New models of reimbursement

Finally, once nonpharmacological treatments have been proven efficacious, new models of reimbursement will be needed to pay for their implementation, as traditional insurance payments are geared toward medications. The only way the US — and the world — will be able to cope with the rising numbers of people with dementia will be for nonpharmacological approaches to be used along with pharmacological therapies.

Posted on Leave a comment

Can flavonoids help fend off forgetfulness?

273f3f0f-cd86-4609-92f7-b0cac45703db

The foundation of a healthy diet is a vibrant rainbow of fruits and vegetables, like rosy red strawberries, dark green spinach leaves, or sunny yellow peppers. Their colors often come from flavonoids, powerful plant chemicals (phytochemicals) that appear to contribute to many aspects of health. And now a large Harvard study published online in Neurology in July suggests that flavonoids may also play a role in protecting cognition.

The investigation

Scientists evaluated the health data and self-reported diet information of more than 77,000 middle-aged men and women, collected over 20 years.

The information included how often participants ate many types of flavonoid-rich foods and whether participants reported cognition changes in their 70s, such as difficulty

  • remembering recent events or a short list of items
  • remembering things from one second to the next
  • understanding instructions
  • following a group conversation or TV plot
  • finding their way around familiar streets.

Researchers then calculated participants’ intake of six classes of flavonoids:

  • flavonols (such as quercetin in onions and kale)
  • flavones (such as luteolin in green chile peppers and celery)
  • flavanones (such as naringenin in grapefruit and oranges)
  • flavan-3-ol monomers (such as catechins in red wine and strawberries)
  • anthocyanins (such as cyanidin in blackberries and red cabbage)
  • polymers (such as theaflavins in black tea).

What the study found

After accounting for factors that could have affected cognition (such as age, weight, physical activity, alcohol intake, depression, and non-flavonoid nutrient intake), scientists found that people with the highest daily flavonoid intakes were 19% less likely to report trouble with memory and thinking, compared to people with the lowest daily flavonoid intakes.

"Our results are exciting because they show that eating foods high in flavonoids could help prevent or slow down decline in memory and other cognitive processes in late life," says Dr. Walter Willett, one of the study’s authors and a professor of epidemiology and nutrition at the Harvard T.H. Chan School of Public Health.

"We noticed that earlier consumption of flavonoid-rich foods seemed to improve the protective effect on the brain. But even participants who began eating more flavonoids later in life saw benefits," says Dr. Tian-Shin Yeh, the study’s lead author and a postdoctoral research fellow in the Harvard-Oxford Program in Epidemiology and the department of nutrition at the Harvard T.H. Chan School of Public Health.

The study was only observational, relying on what people remembered about their diets and noticed about cognition, and didn’t prove conclusively that flavonoid intake kept people sharp in older age. But smaller or shorter-term studies have also found a link between flavonoids and cognitive health benefits.

Flavonoid superstars

Some flavonoids in particular appeared to have protective effects on the brain:

  • Flavones were associated with a 38% lower risk for self-reported cognitive decline.
  • Flavanones had a 36% lower risk for self-reported cognitive decline
  • Anthocyanins had a 24% lower risk for self-reported cognitive decline.

Click here (note: automatic download) for a USDA list of top choices for these three types of flavonoids.

The fruits and vegetables in the study most associated with beneficial cognitive effects, listed from strongest to weakest, were:

  • Brussels sprouts
  • strawberries
  • cauliflower
  • raw spinach
  • yams/sweet potatoes
  • blueberries
  • yellow/orange winter squash
  • cooked spinach
  • cooked carrots
  • peaches/apricots/plums
  • cantaloupe
  • tomato juice
  • applesauce
  • green/red/yellow peppers
  • broccoli
  • cabbage
  • tomato sauce
  • romaine lettuce
  • tomatoes
  • grapefruit
  • celery
  • beets
  • iceberg lettuce
  • baked/boiled/mashed potatoes
  • orange juice
  • raw carrots
  • apples/pears
  • grapefruit juice
  • bananas
  • oranges
  • onions
  • apple juice/cider
  • tea
  • white wine
  • grapes/raisins
  • red wine.

What’s the magic in flavonoids?

We don’t know for sure why flavonoids might play a role in protecting cognition. But we do know that flavonoids are powerful antioxidants, which may fight brain inflammation and the accumulation of amyloid — a hallmark of Alzheimer’s disease.

Antioxidants may also play a part in

  • keeping the blood vessels healthy (which keeps blood flowing to the brain)
  • increasing the production of brain-derived neurotrophic factors, chemicals that repair brain cells, strengthen their connections, promote new brain cell growth, and enlarge the size of your hippocampus (a part of the brain involved in the storage and retrieval of memories).

Plus, we know that flavonoids are associated with fighting inflammation and tumor growth, and in lowering blood pressure.

Setting simple flavonoid goals

With so many potential flavonoid benefits, you may be wondering what kind of levels you should aim for in your diet. In the study, flavonoid intakes ranged from low — about 150 milligrams (mg) per day — to high — about 620 mg per day.

But tracking flavonoids is complicated. They vary greatly depending on the food. For example, half a cup of blueberries contains about 165 mg of anthocyanins; half a cup of peppers contains about 5 mg of flavones. And many fruits and vegetables contain several types of flavonoids, along with many other phytochemicals.

So don’t stress about it. Just eat a diet with a wide variety of fruits and vegetables — the sooner you start, the better. Try to reach the five-a-day fruit and vegetable goal (recent evidence suggests that the most effective combination is two servings of fruits plus three servings of vegetables per day).

Then, as you enjoy foods like strawberries, blueberries, peppers, celery, apples, bananas, oranges, and grapefruit, remember they’re not only tasty and good for general health, but potentially helpful for your brain, too.

"It’s been called ‘eating the rainbow,’ and can lead to a healthier, more delicious diet; and it’s another reason why we should ensure that everyone has access to fresh fruits and vegetables," says Dr. Deborah Blacker, a study co-author and professor and deputy chair of epidemiology at the Harvard T.H. Chan School of Public Health.

Posted on Leave a comment

Thinking of trying Dry January? Steps for success

Let’s file this under unsurprising news: many American adults report drinking more since the pandemic began in March 2020, according to a survey on alcohol use in the time of COVID-19. If you’re among them, you might want to start 2022 on a healthy note by joining the millions who abstain from alcohol during Dry January. Your heart, liver, memory, and more could be the better for it.

What did this survey find?

The researchers asked 832 individuals across the US about their alcohol intake over a typical 30-day period. Participants reported drinking alcohol on 12.2 days and consuming almost 27 alcoholic drinks during that time. More than one-third reported engaging in binge drinking (consuming five or more drinks for men and four or more drinks for women in about two hours).

Moreover, nearly two-thirds of the participants said their drinking had increased compared to their consumption rates before COVID. Their reasons? Higher stress, more alcohol availability, and boredom.

But we can’t blame COVID entirely for the recent rise in alcohol consumption. Even before the pandemic, alcohol use among older adults had been trending upward.

Why try Dry January?

If you recognize your own behavior in this survey and wish to cut down on your alcohol intake, or simply want to begin the new year with a clean slate, join in the Dry January challenge by choosing not to drink beer, wine, or spirits for one month. Dry January began in 2012 as a public health initiative from Alcohol Change UK, a British charity. Now millions take part in this health challenge every year.

While drinking a moderate amount of alcohol is associated with health benefits for some people in observational studies, heavier drinking and long-term drinking can increase physical and mental problems, especially among older adults. Heart and liver damage, a higher cancer risk, a weakened immune system, memory issues, and mood disorders are common issues.

Yet, cutting out alcohol for even a month can make a noticeable difference in your health. Regular drinkers who abstained from alcohol for 30 days slept better, had more energy, and lost weight, according to a study in BMJ Open. They also lowered their blood pressure and cholesterol levels and reduced cancer-related proteins in their blood.

Tips for a successful Dry January

A month may seem like a long time, but most people can be successful. Still, you may need assistance to stay dry in January. Here are some tips:

  • Find a substitute non-alcoholic drink. For social situations, or when you crave a cocktail after a long day, reach for alcohol-free beverages like sparkling water, soda, or virgin beverages (non-alcoholic versions of alcoholic drinks.)

    Non-alcoholic beer or wine also is an option, but some brands still contain up to 0.5% alcohol by volume, so check the label. "Sugar is often added to these beverages to improve the taste, so try to choose ones that are low in sugar," says Dawn Sugarman, a research psychologist at Harvard-affiliated McLean Hospital in the division of alcohol, drugs, and addiction.

  • Avoid temptations. Keep alcohol out of your house. When you are invited to someone’s home, bring your non-alcoholic drinks with you.
  • Create a support group. Let friends and family know about your intentions and encourage them to keep you accountable. Better yet, enlist someone to do the challenge with you.
  • Use the Try Dry app. This free app helps you track your drinking, set personal goals, and offers motivational information like calories and money saved from not drinking. It’s aimed at cutting back on or cutting out alcohol, depending on your choices.
  • Don’t give up. If you slip up, don't feel guilty. Just begin again the next day.

Check your feelings

Sugarman recommends people also use Dry January to reflect on their drinking habits. It’s common for people to lose their alcohol cravings and realize drinking need not occupy such an ample space in their lives. If this is you, consider continuing for another 30 days, or just embrace your new attitude toward drinking where it’s an occasional indulgence.

If you struggle during the month, or give up after a week or so, you may need extra help cutting back. An excellent resource is the Rethinking Drinking site created by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). For the record, NIAAA recommends limiting alcohol to two daily drinks or less for men and no more than one drink a day for women.

Be aware of problems that might crop up

Dry January can reveal potential alcohol problems, including symptoms of alcohol withdrawal ranging from mild to serious, depending on how much you usually drink. Mild symptoms include anxiety, shaky hands, headache, nausea, vomiting, sweating, and insomnia. Severe symptoms often kick in within two or three days after you stop drinking. They can include hallucinations, delirium, racing heart rate, and fever. "If you suffer alcohol withdrawal symptoms at any time, you should seek immediate medical help," says Sugarman.

Posted on Leave a comment

Can ALS be caused by traumatic brain injury?

ALS, Amyotrophic Lateral Sclerosis acronym spelled out on sticky notes with stethoscope next to it.

Amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease) is a neurologic disease that damages nerve cells in the spinal cord and brain, causing widespread muscle wasting and weakness. It strikes without warning, usually beginning between the ages of 55 and 75. As it worsens, ALS disables a person’s ability to move, speak, eat, or breathe. Although two FDA-approved medications can modestly slow its progress, death generally occurs within three to five years of diagnosis.

Decades of research have failed to come up with a definite cause. However, one new study supports a link between playing professional football and ALS.

Why is ALS called Lou Gehrig’s disease?

Since it was first described in the 19th century, much about ALS has remained mysterious. It’s quite rare, affecting about two in 100,000 people. It might have remained a disease you’d never heard of if not for Lou Gehrig, the Hall-of-Fame baseball player who played for the New York Yankees in the 1920s and 1930s. He developed ALS at age 36 and died of the disease two years later. Since then, ALS has often been called Lou Gehrig’s disease.

In recent years, widespread social media campaigns, such as the Ice Bucket Challenge, have raised awareness and funding for ALS research.

Searching for a cause of ALS

Some research suggests that risk factors for ALS include:

  • Genetics: Genes passed down through families contribute to about one in 10 cases
  • Smoking: In one study, the heaviest smokers had a 26% higher risk of developing ALS compared with those who had never smoked
  • Pesticide exposure, such as pesticides used on crops
  • Unusual infections with certain bacteria or viruses
  • Bodily injury severe enough to impair activities of daily living
  • High levels of physical exertion, as is common for elite athletes or members of the military
  • Head trauma, including concussions and repeated, less severe head injuries. While chronic traumatic encephalopathy (CTE) has been closely tied to head injuries, the role these injuries play in developing ALS is less certain.

New research links playing professional football with ALS

A new study published in JAMA Network Open might help us better understand the cause of at least some cases of ALS. It strongly suggests that playing professional football may be a risk factor for the disease.

  • Between 1960 and 2019, 19,423 men played in the National Football League (NFL). During that time period, 38 were diagnosed with ALS and 28 died of the disease.
  • Among these current and former football players, the risk of developing ALS and dying of the disease was nearly four times higher than that of men in the general population.
  • NFL players who developed ALS had a longer average football career (seven years) than those without the disease (4.5 years).
  • Many NFL players were in their mid-30s at the time of their ALS diagnosis. This is quite a bit younger than is typical for ALS.

Importantly, this study did not assess why there might be a relationship between ALS and playing professional football. The study authors speculate that traumatic brain injury might be to blame.

How certain are these findings?

This was an observational study. Observational research can identify a link between a possible risk factor (in this case, playing in the NFL) and a disease (ALS). However, it cannot prove that the risk factor caused the disease.

For studies like this, it’s always possible that a confounder — a factor not studied or accounted for — might explain the connection. For example, this study did not collect information about head injuries, pesticide exposure, smoking, or family history. This means it can’t provide insight into whether these factors played a role in ALS risk.

In addition, the study identified diagnoses of ALS among NFL players only through Google News reports and obituaries. The diagnoses weren’t confirmed by a review of the players’ medical records. Therefore, cases of ALS could have been missed or misdiagnosed.

It’s also possible that the study missed cases of ALS among less famous players whose health news or deaths might be overlooked by the media. To account for this, the researchers logged indicators of NFL fame (including selection to the NFL Pro Bowl and Hall of Fame). They found no difference in ALS risk among more famous and less famous players.

The bottom line

Public health experts and researchers are trying to sort out which sports harm brain health, and to recommend ways to protect against brain injuries. Expert recommendations for contact sports have evolved to include protective equipment, changes in game rules, limiting participation by younger players, and discouraging participation after a head injury until recovery is complete.

As noted, studies have strongly linked brain injury from concussions and repetitive head injuries. This latest study suggests some cases of ALS may also be caused by brain trauma.

Lou Gehrig reportedly had multiple concussions over the course of his sports career. Regardless of whether he actually had Lou Gehrig’s disease or CTE with features of ALS, this new research raises the possibility that his demise might have been due to traumatic brain injury. And that should serve as a reminder that even as we cheer on those with inspiring athletic talent and win-at-all-costs determination, protecting the health of sports participants should be even more important.

Posted on Leave a comment

Are poinsettias, mistletoe, or holly plants dangerous?

Last winter, my wife shooed the dog and visiting toddlers away from our poinsettia plants, saying "they’re poisonous, you know."

I did not know. But it turns out that the belief that poinsettias are deadly is widespread. The same could be said for mistletoe and holly. But are their reputations for danger well-deserved? Since these plants are especially popular to brighten up homes or give as gifts during the holidays, I decided to look into it.

The risks of poinsettia

Could a plant so common and so well-liked in the winter holidays also be so dangerous? If it is dangerous, what problems does it cause? Must it be eaten to cause problems, or is it harmful to just be nearby? And if it’s not dangerous, why does the myth live on?

The answers to these questions are not easy to find. In fact, the bad reputation may have started in 1919, when an army officer’s child reportedly died after eating part of a poinsettia plant. It is unclear if the plant was responsible, though: many other reports describe mild symptoms, such as nausea or vomiting, but no deaths.

Decades ago, a study in the American Journal of Emergency Medicine analyzed nearly 23,000 cases of people eating poinsettia and found

  • no fatalities
  • nearly all cases (96%) required no treatment outside the home
  • most cases (92%) developed no symptoms at all.

According to one estimate, a 50-pound child would have to eat more than 500 poinsettia leaves to approach a dose that could cause trouble. Similarly, pets may develop gastrointestinal symptoms after eating poinsettia, but these plants pose no major threat to animals.

The risks of mistletoe

The story is much the same for mistletoe. It’s not particularly dangerous, but may cause an upset stomach if eaten. In fact, mistletoe has been used for centuries as a remedy for arthritis, high blood pressure, infertility, and headache. The evidence isn’t high-quality for any of these uses, though.

Interest also centers on this plant’s potential as an anticancer treatment. Some extracts of mistletoe contain chemicals shown to kill cancer cells in the laboratory and to stimulate human immune cells. For example, a substance called alkaloids has similar properties as certain chemotherapy drugs used in the past to fight leukemia and other forms of cancer. However, a two-part 2019 review found that adding mistletoe extracts to conventional cancer treatments did not improve survival or quality of life.

No one suggests it's a good idea to eat this plant, accidentally or otherwise. But eating one to three berries or one or two leaves is unlikely to cause serious illness, according to the authors of a 1986 review of multiple studies. And no significant symptoms or deaths were described in one report of more than 300 cases of eating mistletoe. However, some sources warn that serious problems or even death may occur if enough is ingested. The specific dose required to cause death is unknown but, fortunately, it appears to be so high that consuming enough to be lethal is extremely rare.

The risks of holly

This plant can be dangerous to people and pets. The berries of holly plants are poisonous. If eaten, they may cause crampy abdominal pain, drowsiness, vomiting, and diarrhea. While no one would recommend eating holly, it is unlikely to cause death. And for at least one type of holly, knowing the Latin name would be enough to discourage ingestion: the yaupon holly is also called Ilex vomitoria.

The bottom line

No one should eat poinsettias, mistletoe, and holly, but if small amounts are consumed, they are unlikely to cause serious illness. It seems to me that the dangers of these plants appear to be vastly overestimated.

Perhaps the most dangerous thing about mistletoe and poinsettias is the choking hazard the berries pose for young kids, although that risk is not unique to plants: any small object poses similar risks. Try to keep holiday plants out of the reach of small children and pets. And keep in mind that berries may fall from these plants and wind up on the floor.

If a child or pet eats leaves or berries from these holiday plants, or any other plants, check in with poison control, your pediatrician, or your veterinarian. But unless a particularly large "dose" is consumed, don’t be surprised if the recommendation is to simply watch and wait.

Still concerned even if you know the risks are low? You can always regift holiday plants you receive to friends with no children or pets, or find other ways to decorate your home for the holidays.

Posted on Leave a comment

5 numbers linked to ideal heart health

How well are you protecting yourself against heart disease, the nation’s leading cause of death? A check of five important numbers can give you a good idea.

“For my patients, I typically look at their blood pressure, blood sugar, LDL cholesterol and triglycerides values, and their waist circumference,” says Harvard Heart Letter editor-in-chief Dr. Deepak L. Bhatt, who directs interventional cardiovascular programs at Harvard-affiliated Brigham and Women’s Hospital. Those values provide a picture of a person’s overall health and, more specifically, what factors they may need to address to lower their chance of a heart attack or stroke, he says.

Below are the ideal values for each measurement, along with why they’re important and targeted advice for improving them. Universal suggestions for improving all five measurements appear at the very end.

How do your heart health numbers stack up?

While the ideal values are good goals for most people, your doctor may recommend different targets based on your age or other health conditions.

Blood pressure

Less than 120/80 mm Hg

Blood pressure readings tell you the force of blood pushing against your arteries when your heart contracts (systolic blood pressure, the first number) and relaxes (diastolic blood pressure, the second number). Your blood pressure reflects how hard your heart is working (when you’re resting or exercising, for example) and the condition of your blood vessels. Narrowed, inflexible arteries cause blood pressure to rise.

Why it matters to heart health: High blood pressure accelerates damage to blood vessels, encouraging a buildup of fatty plaque (atherosclerosis). This sets the stage for a heart attack. High blood pressure forces the heart’s main pumping chamber to enlarge, which can lead to heart failure. Finally, high blood pressure raises the risk of strokes due to a blocked or burst blood vessel in the brain.

What helps: A diet rich in potassium (found in many vegetables, fruits, and beans) and low in sodium (found in excess in many processed and restaurant foods); minimizing alcohol.

LDL cholesterol

Less than 100 mg/dL

A cholesterol test (or lipid profile) shows many numbers. Doctors are usually most concerned about low-density lipoprotein (LDL) cholesterol, particles that makes up about two-thirds of the cholesterol in the blood.

Why it matters to heart health: Excess LDL particles lodge inside artery walls. Once there, they are engulfed by white blood cells, forming fat-laden foam cells that make up atherosclerosis.

What helps: Limiting saturated fat (found in meat, dairy, and eggs) and replacing those lost calories with unsaturated fat (found in nuts, seeds, and vegetable oils).

Triglycerides

Less than 150 mg/dL

Perhaps less well-known than cholesterol, triglycerides are the most common form of fat in the bloodstream. Derived from food, these molecules provide energy for your body. But excess calories, alcohol, and sugar the body can’t use are turned into triglycerides and stored in fat cells.

Why it matters to heart health: Like high LDL cholesterol, elevated triglyceride values have been linked to a higher risk of heart attack and stroke.

What helps: Limiting foods that are high in unhealthy fats, sugar, or both; eating foods rich in omega-3 fatty acids (such as fish); avoiding alcohol.

Blood sugar

Less than 100 mg/dL

High blood sugar defines the diagnosis of diabetes. Type 2 diabetes is most common. It occurs when the body develops insulin resistance (insulin enables cells to take in sugar) and does not produce enough insulin to overcome the resistance.

Why it matters to heart health: High blood sugar levels damage blood vessel walls and cause sugar (glucose) to attach to LDL. This makes LDL more likely to oxidize — another factor that promotes atherosclerosis. Excess sugar in the blood also makes cell fragments called platelets stickier so they’re more likely to form clots, which can trigger a heart attack or stroke.

What helps: Avoiding sugary beverages and foods high in sugar; eating whole, unprocessed grains instead of foods made with refined grains (white flour, white rice).

Waist circumference

Whichever number is lower:

Less than half your height in inches

OR

Women: Less than 35 inches

Men: Less than 40 inches

Measure your waist around your bare abdomen just above your navel (belly button). A big belly — what doctors call abdominal or visceral obesity — usually means fat surrounding internal organs.

Why it matters to heart health: Visceral fat secretes hormones and other factors that encourage inflammation, which triggers the release of white blood cells involved in atherosclerosis.

What helps: Consuming fewer calories, especially those from highly processed foods full of sugar, salt, and unhealthy types of fat.

Universal advice to improve all five measures of heart health

If one or more of your numbers is above ideal levels, you’re far from alone. Most Americans are overweight or obese and have bigger-than-healthy bellies. Excess weight and waist circumference affect blood pressure, LDL cholesterol, triglycerides, and blood sugar. Eating a healthy, plant-based diet can help. Regular exercise also helps: aim for at least 30 minutes of moderate-intensity exercise like brisk walking most days. Other lifestyle habits that can lower your heart disease risk include getting seven to eight hours of sleep nightly and managing your stress level.

Posted on Leave a comment

Stretching studios: Do you need what they offer?

Trainer assisting older woman in a stretch

Boutique or specialty fitness studios offer all sorts of ways to exercise, such as strength training, indoor cycling, and kickboxing. Other popular options, like yoga and Pilates, are less likely to leave you sweaty and breathless, emphasizing flexibility and measured movement. Now a new trend has emerged: studios that focus solely on stretching. What are these studios offering, and will you benefit from this focus?

What are stretch studios offering?

These studios, which include StretchLab, StretchMed, LYMBYR, and others, provide assisted stretching sessions, either one-on-one or in small groups. The promised benefits range from reasonable goals of increasing flexibility and range of motion to more questionable assertions, such as preventing injuries and eliminating chronic pain.

“If you participate in certain sports that require flexibility, like dance or gymnastics, stretching may be important to maintain range of motion,” says Dr. Adam Tenforde, associate professor of physical medicine and rehabilitation at Harvard Medical School, and sports medicine physician at Spaulding Rehabilitation and Mass General Brigham.

But if your focus is on improving your overall health, the evidence to support stretching is sorely lacking — especially compared with the wealth of evidence supporting the benefits of regular, moderate physical activity.

“Contrary to popular belief, there’s no consistent evidence that stretching helps prevent injuries,” says Dr. Tenforde. And if you have an existing injury, such as a muscle or joint sprain, aggressively stretching that tissue could actually make the injury worse, he adds.

The “stretch therapists” and “flexologists” at stretching studios may have certain certifications and training, but they’re probably not qualified to recognize and address health-related causes for pain or stiffness. If you have a previous or current musculoskeletal injury, you’re much better off going to a physical therapist who has the expertise and training to treat you correctly.

Feeling tight and stiff?

If you’re free from injuries but just feel tight and stiff, try a yoga class, which can provide added benefits like improving your balance and helping you relax and de-stress. Or consider tai chi, a gentle, meditative form of exercise that can help lower blood pressure and enhance balance. Another option is to get a massage.

If you decide to try assisted stretching offered at a studio, listen to your body, and make sure you communicate how you’re feeling with the therapist working on you, Dr. Tenforde advises.

But you’ll probably do more for your overall health by spending that time taking a brisk walk or some other type of exercise instead, he says. Most Americans don’t meet the federal recommended guidelines for physical activity, which call for 150 minutes per week of moderate-intensity exercise and muscle-strengthening activities twice weekly. “As doctors, we’re dealing more with diseases related to inactivity, not diseases of inflexibility, says Dr. Tenforde.

Want to do your stretching at home?

Three easy morning exercises — an A-B-C routine of arm sweeps, back bend, and chair pose — can help ease morning stiffness. This also works well during the day if you spend too much time sitting.

Stretching at home could save you money and time. These tips can help you get the most out of at-home morning stretches or other flexibility routines.

  • Warm up muscles first. Much like taffy, muscles stretch more easily when warm.
  • Feel no pain. Stretch only to the point of mild tension, never to the point of pain.
  • Pay attention to posture and good form. Posture counts whether you’re sitting, standing, or moving. Photos of stretches tell only part of the story, so read instructions carefully to get form right.
  • Focus on the muscle being stretched. One side of your body often is tighter than the other. Work on balancing this over time.
  • Breathe. Breathe comfortably while stretching rather than holding your breath.
  • Practice often. You’ll make the best flexibility gains if you stretch frequently — daily, or on as many days of the week as possible. At the very least, try to do stretches two or three times a week.

Posted on Leave a comment

POTS: Lightheadedness and a racing heart

217ba476-b737-401b-b57d-c8585005c231

Editor’s note: First in a two-part series on postural orthostatic tachycardia syndrome (POTS). Click here for part two.

This past February, a 57-year-old firefighter came to my cardiology clinic after experiencing a strange set of symptoms. A few weeks earlier, he had gotten COVID-19. Predictably, he lost his sense of smell, developed a low-grade fever, and experienced muscle aches. Within a week his COVID-19 symptoms were gone, but he continued to feel off. And the new symptoms he described — sudden lightheadedness when standing up and an unusually fast heartbeat — made me suspect a condition called postural orthostatic tachycardia syndrome, or POTS.

Below I’ll explain what’s known so far about the triggers and hallmark symptoms of POTS. In a later post, I’ll discuss diagnosis and treatment.

What is POTS?

POTS is a syndrome, which means it’s a collection of symptoms and medical findings that often cluster together. The hallmark of POTS is bothersome symptoms that occur when standing upright. The medical term for these symptoms is orthostatic intolerance.

Most commonly, people report

  • lightheadedness or dizziness with standing (fainting may occur in more severe cases)
  • fatigue
  • shakiness
  • difficulty concentrating (also called brain fog)
  • palpitations (a sense of rapid, pounding, or irregular heartbeat).

People who have POTS also often experience headaches, digestive problems like bloating and constipation, insomnia, heat intolerance, and difficulty exercising due to shortness of breath and fatigue.

Who gets POTS?

POTS most often affects women between the ages of 15 and 50. However, it has recently been diagnosed in other groups of people following infection with COVID-19. People who have long COVID (sometimes called long haulers) may develop several different types of symptoms affecting various organs including the brain, lungs, and kidneys. One subtype of long COVID is POTS.

What is known about recovery?

Research suggests about half of people diagnosed with POTS will recover or improve over a period of a few years.

However, for others, a vicious cycle can develop if POTS goes untreated. The cycle begins because people start to spend more time in bed, avoiding activities that provoke symptoms. As people become far less active, muscle mass in the legs is lost, heart capacity shrinks, and the volume of circulating blood is reduced. These changes make standing upright even more uncomfortable, leading to yet more time spent in bed.

Over time, some people stuck in this cycle can become disabled. They’re unable to perform daily household tasks without becoming dizzy and exhausted. Many take time off from school or work.

What causes POTS?

The underlying cause of POTS is not yet known. It often follows a period of bedrest after an injury such as a concussion, surgery, or a viral illness like mononucleosis or the flu. More recently, POTS has been diagnosed in some people who have had COVID-19. Even after the acute infection resolves, these people may have lingering fatigue, lightheadedness, and a rapid heart rate when upright.

Many researchers suspect that POTS may be an autoimmune disorder, caused by the body’s immune system becoming overzealous. When this happens, the immune system correctly targets the intruding virus but mistakenly targets the body’s own healthy tissues, causing unwanted damage. In the case of POTS, this damage is thought to affect the lining of the blood vessels, which lose their ability to tighten, or constrict, in response to standing upright.

Three clues: Lightheadedness, changes in heart rate, and the effects of gravity

Before our firefighter, whom I’ll call David, became sick, he kept track of his heart rate on his smartwatch. It was typically about 60 to 70 beats per minute (bpm) at rest. Now, however, his resting heart rate was in the 80s and spiked into the 130s after one flight of stairs. Merely standing up caused lightheadedness and a racing heartbeat. He could no longer get through his usual spin class. He stopped taking hot showers because they made him feel dizzy.

While most of us take for granted the simple act of standing upright, a person with POTS may find it extremely uncomfortable. Why does POTS cause orthostatic intolerance? It helps to first understand the normal response to standing:

  • Gravity causes about one-third of blood volume to instantly pool below the waist.
  • Less blood returns to the heart, so less blood is then pumped out to the body.
  • This leads to a drop in blood pressure to the brain (have you ever experienced a short-lived sense of lightheadedness or “seeing stars” when jumping up quickly after sitting for a long period of time?).
  • The drop in blood pressure is detected by sensors in the heart.
  • These sensors activate the sympathetic nervous system (SNS), instructing the adrenal glands to release an adrenaline-like substance called norepinephrine into the bloodstream to help solve the problem.

How norepinephrine affects the body

Norepinephrine signals the heart to beat more rapidly and forcefully, restoring normal blood flow to the brain. It also signals the blood vessels to tighten, which drives blood to return to the heart instead of pooling in the lower half of the body. Within a few seconds of standing, blood pressure is restored to normal.

However, for reasons not fully understood, this signal is ineffective in POTS, and the blood vessels do not tighten in response to norepinephrine. More blood remains in the lower body, so that less returns to the heart, and therefore less is pumped out to vital tissues and organs. To maintain normal blood pressure, the heart beats faster to compensate for the lower volume of blood pumped with each contraction of the heart.

An overactive flight-or-fight response?

Thousands of years ago, evolution favored those who responded to the stress of physical danger by producing high levels of norepinephrine, allowing them to fight off an attack or run from harm. By releasing norepinephrine into the bloodstream, the nervous system primes virtually every organ for physical activity and potential injury. The pupils dilate; digestion slows; the heart beats quickly. This has been dubbed the fight-or-flight response.

Norepinephrine levels measured in the blood of people who have POTS are significantly higher than in those who do not, leading to an excessively fast heart rate and often a strong, pounding heartbeat. In addition to these effects on the heart, elevated norepinephrine levels can target other organs including the digestive system, causing abdominal bloating and constipation.

If you often experience the symptoms described in this post, you may want to ask your doctor to check you for POTS. A later post will discuss diagnosis, treatment, and living with POTS.

Follow me on Twitter @daraleelewismd

Posted on Leave a comment

5 skills teens need in life — and how to encourage them

Colorful gears forming a human brain together with one red big central cog. 3D rendering isolated on white.

All parents want their children to be successful in life — and by successful, we mean not just having a good job and a good income, but also being happy. And all parents wonder how they can make that happen.

According to Harvard’s Center on the Developing Child, it’s less about grades and extracurricular activities, and more about a core set of skills that help people navigate life’s inevitable challenges. These skills all fall under what we call executive function skills, which we use for self-regulation. Most people who are successful and happy in life have strong executive function skills.

What are five important core skills?

  • Planning: being able to make and carry out concrete goals and plans
  • Focus: the ability to concentrate on what’s important at a given time
  • Self-control: controlling how we respond to not just our emotions but stressful situations
  • Awareness: not just noticing the people and situations around us, but also understanding how we fit in
  • Flexibility: the ability to adapt to changing situations.

While these are skills that children (and adults) can and do learn throughout their lifetimes, there are two time periods that are particularly important: early childhood (ages 3 to 5) and adolescence/early adulthood (ages 13 to 26). During these windows of opportunity, learning and using these skills can help set children up for success. In this post, we’ll talk about that second window of adolescence.

The best way to learn any skill is by actually doing it. Here are some suggestions for parents wondering how to help and when to step back.

Planning

When children are little, it’s natural for parents and caregivers to do the planning for them. But as children grow into teens, they need to learn to do it for themselves.

  • Avoid micromanaging your teen’s life. Instead, set some ground rules — simple ones like: homework needs to get done, they need seven to eight hours of sleep, and regular exercise is important. You may have some other ground rules, like attending family meals or religious services. Then let your teen figure out how to get it done. Step in only if ground rules are clearly being broken consistently.
  • When teens have long-term projects, such as a research project or college applications, sit and talk with them about how they want to get it done. Let them come up with ideas before you do!
  • Involve your teens in planning family activities or vacations, home renovations, or other projects. Let them make some of the decisions (even if you don’t always agree).

Focus

The explosion of device use has caused all sorts of problems with focus in people of all ages. There is an instant gratification to screens that makes it hard to put them aside and focus on less stimulating tasks — so now, more than ever, it’s important to

  • talk about how social media and the Internet can interfere with daily life (and homework), and help them come up with strategies to manage the distraction.
  • have screen-free meals and family time.
  • encourage hands-on activities that don’t involve screens, like cooking, baking, building things, sewing, crocheting, drawing, painting, or gardening.

Self-control

This is one where being mindful of your own reactions to situations is important. How do you react to anger and frustration? Is road rage a problem for you? Remember that our children always pay more attention to what we do than what we say. To help your teen learn self-control, you can:

  • Talk about feelings, and about strategies for managing strong feelings — like taking a deep breath, stepping away from the situation, screaming into a pillow, etc.
  • Debrief after upsets, once everyone has calmed down. What might your teen have done differently? What could they do next time?
  • Talk about how their behavior affects others, and why it’s important to be mindful of that (a practice that also teaches awareness).

Awareness

Teens can be very aware — but mostly of their own world. Help them learn to see beyond that.

  • Talk about current events and stories in the news. In particular, talk about how these affect people, and how different people might see them differently.
  • Go places with your teen — even just a walk in the woods or a visit to a nearby town can give them opportunities to look around them and see things they might otherwise miss.
  • Join community service activities as a family; show teens how they can make a difference.
  • Have rituals of checking in as a family, like at dinner. Give everyone a chance to talk about their day.

Flexibility

Life throws curve balls all the time, and teens need to be able to adjust.

  • Don’t be too rigid about your teen’s schedule. Help them prioritize, and see which things can be missed or postponed when something happens, good or bad.
  • Encourage some spontaneity. This, too, is about learning to prioritize and not getting too stuck in routines.
  • Be a role model. Be spontaneous yourself — and don’t get too upset when plans change. Make new plans.

Any time you let your teen do something, there is a reasonable chance that they will fail. Resist the urge to jump in right away. While it’s important to have your child’s back (now and for the rest of their life), sometimes teens need to fail in order to learn. Give them a chance to figure it out themselves before you offer help. They may just surprise you.

Posted on Leave a comment

How to address opposition in young children

9511a980-5b0e-4a64-98d2-6fc3bfb6d759

"No!"

It might have been endearing as your child’s first word, but dread often kicks in when that word starts to follow parental requests. Experiencing resistance to small or big asks? Stuck in arguments that seem to go in circles and leave you exasperated with unmet requests? The good news is that this pattern can be disrupted. First, you’ll need to identify reasons behind the opposition. Then you can apply relevant strategies to see more helpful behaviors instead.

Below are some examples of opposition drivers and tips to address them.

Difficulty with transitions

If you find that your child resists a request right after engaging in an activity, it might be that your child first needs time to transition. This can be a common experience when parents make requests while children are playing video games or another stimulating activity. One way to manage this is to give your child a five- or 10-minute heads-up (whichever they might need) that you will be asking for the game to stop. This gives your child time to find a place to pause if playing a video game and to transition.

Some families find it helpful to talk with their children before playtime begins to learn what game or activities will be taking place, and how much advance notice might be helpful before the activity would need to stop. This invites collaboration and shows that you respect that not all moments are ideal for stopping a game.

Independent streak

Children almost never are in control, and resistance can show up when that wears on them. Try to fold in elements of choice and control throughout the day for children (that are within a framework you determine) to create more of a balance with your requests. Perhaps you let a young child know that they will need to wear long sleeves and pants because of the weather, but they can pick which top and pair of pants to wear that day. Another idea is to invite your child to pick a side dish for a future dinner from a premade list of a few options.

It also helps to create opportunities for your child to practice being independent. This fosters mastery and offers experiences of feeling in control. This could look like your child preparing any parts of meals that are age-appropriate (for example, a three-year-old could pour cereal into a bowl; a five-year-old could measure ingredients for baking). The kitchen counter may be extra sticky as your child learns new skills. With time, your child will be more adept, and your counters will be cleaner.

Hunger and tiredness

We need both food and sleep to recharge our batteries. When we run low on either or both, it’s extra difficult to be our best selves. If you find that your child is crankier than usual, reflect on when your child last ate and how your child slept the night before (or napped if your child is of napping age). If it’s been a while since your child has eaten and/or your child did not sleep as much as usual, your child may need to recharge before being more receptive to requests. Have your child grab a healthy snack or meal if needed. If sleep is the issue, validate to yourself that this is frustrating that there is no quick fix. Acknowledge privately they are not their usual self at this moment and may be more receptive tomorrow.

Resistance also may crop up when children are coming down with a viral illness, so keep an eye out for any symptoms that may emerge.

Mental health challenges

Everyone has off days, but a persistent pattern of resistance to requests and distress following them may suggest that a child is experiencing mental health difficulties. For example, if a child appears oppositional every morning before school, it could be that they experience anxiety about going to school and are trying to avoid the distress they experience when there. In this case, it is important to ignore the "no" bait and focus on the emotion behind the refusal. Validate or acknowledge how your child is feeling to open the door to learn more. For example, you could say, "You seem really worried about going to school. What about school has been so tough lately?"

Use a similar approach for symptoms of depression, such as withdrawing from and refusing to engage in activities: validate your child’s feelings and invite your child to share more to help you understand their experiences. Discovering what is driving the resistance can allow you to develop a collaborative plan to support your child’s needs and get extra help if needed. Cognitive behavioral therapy is an evidence-based treatment for children experiencing anxiety and/or depression. Your pediatrician can be a helpful resource for mental health treatment referrals. The Anxiety & Depression Association of America also provides treatment resources.

Sometimes, oppositional behavior is pervasive. It can include a frequent loss of temper, irritability, difficulty following the rules, defiance of authority figures, spitefulness, and more. If these behaviors occur at home and also show up in other settings, such as at school, a child may be experiencing symptoms of oppositional defiant disorder. Parent training programs such as parent management training, along with problem-solving skills training, are evidence-based treatments, and pediatricians also may be able to provide relevant referrals.

Your patience understandably can wear thin if you find yourself facing repeated resistance. That experience, though, does not have to continue. You can help shift these patterns once you discover what is driving the "no."