prevention

Food Friday: Carbohydrate Intolerance

“ Hey wait, I thought food Friday was supposed to be a celebration of good food and eating !” Of course it still is. I just want to talk a little bit about how to understand your own metabolism and to leverage it for your health and for your enjoyment. Bear with me for a little science.

Carbohydrate or carbs is a term we hear frequently in popular media. But what exactly are they? A carbohydrate is a compound that contains carbon, hydrogen and oxygen. These molecules are linked together in such a way as to store energy. In their simplest form, they are sugars like glucose. When they are linked together like Legos they become starch, which is really just a storage form of glucose. 

Glucose is the body's principal energy source, its fundamental fuel. But as with most things,too little or too much is a problem. A young, healthy, non-pregnant body will manage its fuel very efficiently. The silent internal workings of the body's physiology will keep circulating levels of glucose within a close ideal range, even during periods of dietary excess and periods of dietary scarcity. The main regulators here are insulin and glucagon. Insulin is a pancreatic hormone that brings glucose from the circulation into the cell where it can be used for fuel. Glucagon has the opposite effect. When blood sugar levels go low, though lack or food or periods of high demand, glucagon goes into action and mobilizes stored starch to be broken down releasing glucose into the bloodstream. 

When we become overweight or pregnant or older, this process works less well. In particular, the cells do not respond as well to insulin. I am not speaking of diabetics here. This tendency is true of everyone. When we do not process our blood glucose efficiently, specifically when we become less sensitive to our own insulin, we are said to be carbohydrate intolerant.

A vicious cycle can then ensue. When we cannot bring glucose from the bloodstream into the cell by the action of our insulin, the concentrations of glucose in the bloodstream becomes abnormally high. This leads to the formation of fat in our tissues and in particular our arteries. This of course, leads to cardiovascular disease.

Under these circumstances, our insulin levels also become chronically high in an attempt to bring the blood sugar down. This is called hyperinsulinemia, and it is thought to be a precursor of type 2 diabetes. Moreover, hyperinsulinemia alone is associated with “ Metabolic Syndrome” , the unholy quartet of hypertension, obesity, high cholesterol ( or triglycerides) and glucose intolerance. 

How can you short-circuit this vicious cycle? Well, no one can avoid aging if they're lucky, and many people choose to become pregnant. Avoiding obesity is the best way to avoid carbohydrate intolerance because, as you have no doubt gathered by now, obesity leads to carbohydrate intolerance, and carbohydrate intolerance leads to more obesity, a vicious cycle. That is one of the reasons why it is so hard for people to lose weight once they have become obese. It is far easier to avoid obesity in the first place than it is to correct it after the fact.

But there are many obese people who are intent on losing their weight and getting healthy. Here's the good news for them, and for the rest of us wanting to prevent these problems. If we minimize sugars and simple carbohydrates (like starch) in our diet and keep a steady intake of meals and snacks with high quality fruits, vegetables, proteins and fiber, our blood sugar levels will trend toward the steady and normal, both necessary to avoid the development of carbohydrate intolerance.

If we add steady increasing levels of physical activity every day and, as a result develop increased exercise tolerance and increased muscle mass, we will have synergistically increased our metabolic rate. We will feel more energetic, and as a result be more active. A virtuous cycle will set in! 

Here's the real newsflash: I am asking all my patients to pay more attention to food. In fact, I am almost certainly asking them to eat better food, in greater quantities, more frequently. In fact I would be thrilled if all of my patients made healthy food a lifelong hobby. Sourcing high quality food, searching for recipes, trying new things, and entertaining with healthy recipes is a lot of fun.

So with the holidays approaching, do not worry. Get excited about finding some great healthy recipes. And maybe plan a frosty family walk outside on your Thanksgiving morning, or between dinner and pie. 

 

 

Wellness Wednesday: How to Start Your Fitness Routine 

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There are people out there who experience lasting fitness breakthroughs. They all have to start somewhere. This week's post is about how you can start your fitness regimen. 

How do you break out of your rut? By creating a new rut. A lot of people have good intentions and a lot of people have brute force discipline. But that's not really what it takes.

What does it really take? It takes a good set up. You have to set yourself up for success.

 

As with any goal, your goal of starting fitness needs to be SMART.  

SMART means: 

  • SPECIFIC
  • MEASURABLE
  • ATTAINABLE 
  • RELEVANT
  • TIME BOUND 

 

1. Specific- Decide what you are going to do. I suggest beginners either go to a class at an accredited health center, gym or, as a lower cost alternative get a selection of appropriate fitness DVDs for home use. One great regimen is every other day at the gym interspersed with every other day at home with a DVD. Always take at least one or two days off a week. On those off days you may do gentle yoga to perpetuate your habit and stay limber. 

Being specific also means that you know exactly what you are going to wear and exactly what you are going to do to start the workout. For me, this means coming home from work, changing into my exercise clothes, turning on my DVD player, grabbing a glass of ice water, and then putting on my workout shoes. By then, the workout is as good as done. I do it the same way every time to create and reinforce a habit loop.

2. Measurable-Consult with your doctor about how many days a week you should work out. I suggest no less than three and no more than six, preferably 5 to 6 days per week. When you are a beginner the duration of your exercise should be no more than 30 minutes and possibly closer to 20.

Very importantly decide on a method of recording your exercise episodes. This can be as simple as making a mark on the calendar or as complicated as using a fitness tracker on your smart phone. Don't make a big deal out of the recording, just do something simple and quick. Then your exercise becomes measurable.

3. Attainable-Make sure the first three months of your workout are easy. Your workouts should be so easy that they provoke nothing more than some light breathing. They should not hurt, burn, or exhaust you. The first three months of what you do is simply to let your body and your mind adjust to the idea of regular exercise. You are building a habit. You will almost certainly want to modify the routines you see in the easiest of your DVDs, but this is perfectly okay. 

4 Relevant-The first three months of your fitness workout should focus on light cardio and light resistance combined. This is the most relevant form of exercise according to current Sports Medicine evidence. You do not want to undertake long distance running or powerlifting or anything so specialized or extreme.

5 Time bound-You know your schedule. Carve out precisely 30 minutes for a 40 minute work out getting yourself five minutes on either side to change clothes. Know exactly where the workout is going to be placed in your day for the entire next week. Be realistic… you have 30 minutes. Everyone does, but this might mean you need to be more efficient overall, and there is nothing wrong with that. It also might mean that you have to cut things out, Such as Facebook, Pinterest or even Big Bang Theory.

 

You really want it. You know it will make you feel good. You know it will enhance your health. You know it will set a good example for your family. I'm here to tell you that fitness is not hard. In fact, it's fun and satisfying. Take these SMART steps today and start your fitness routine.

 

 

 

 

 

Medical Monday: Weekly News Update in Obstetrics and Gynecology

Good Monday.

A new study presented at the annual meeting of the American Society of Anesthesiologists suggested light meals during labor may be safe for most women. Ordinarily we would like to restrict intake to clear liquids nothing at all depending on the risk level of the woman. The main concern here is the risk of aspiration which means inhaling food particles from the stomach into the respiratory tract. Pregnant women are at increased risk for aspiration compared to non-pregnant women due to  the pressure from the baby and the relaxation of the esophageal muscles. Moreover, women are often nauseous during labor, increasing risk. The highest concern comes if the patient needs to go to cesarean section. In this instance she needs to be on her back with only a slight tilt, and this increases the risk of aspiration even further. It is unfortunate that the lay reporting makes it sound like we fear that women might aspirate during normal labor. Our concern is mostly having to do with the chance that they will go to cesarean section on a full stomach. 

Shots Blog on NPR covered this interesting tidbit: Babies and mothers exchange cells each others circulation during pregnancy labor and delivery, And they are maintained in circulation thereafter. These are believed to have implications for cancer and auto immune diseases that affect women. It is unclear whether these are beneficial, harmful, or both, depending on the circumstances. 

We know that when people have more testosterone in their system that they are more assertive or aggressive. But we are now finding is that the converse is also true. According to a study published in the Proceedings of the National Academy of Sciences, our testosterone levels rise in response to assertive behavior such as the use of power in a work situation. Study noted that this is especially true in women.

Did you know that tobacco use before pregnancy and in pregnancy is associated with cleft palette and congenital heart defects? The CDC's National Center on Birth Defects and Developmental Disabilities performed a meta-analysis which indicated that 6% of oral clefts and 1.4% of non-syndromic heart defects are attributable to maternal smoking in the first trimester. 

Yet another study underscores the fact that drinking alcohol increases a woman's risk of breast cancer.

Got cold sores? Don’t feel bad. The World Health Organization estimates that half of the world’s population under 50 does too. 

Stay tuned for more news from the world of obstetrics and gynecology, Next week on Medical Monday.

 

Medical Monday: Weekly News Update in Obstetrics and Gynecology

Good Monday !

I am returning from a great five days back at Stanford with our son Forest, who is now also an alumni. We attended “ Classes without Quizzes” and enjoyed ourselves immensely. We learned about numerous things, including a little about the way the brain functions during early language development, the latest in nutrition research, and a MMOG, yes, a massive multiplayer online game called EteRNA which has become a powerful tool in the design of tiny RNA machines which may be used to treat disease. We also took a yoga Piyo Hip Hop Fusion class, went on a pro multi-ethnic eating tour and saw tons of old friends. 

So now we return inspired, excited to move the needle forward in everything we do, including Medical Mondays ! 

Flibanserin went on sale this last Saturday. Flibanserin is of course the pill to treat low libido in women. It goes by the name Addyi. Does anyone know how to pronounced this ? Someone got paid to think of that name, you know. I can’t wait to see the commercials. For some real information about this drug, please see my prior post HERE

This week, in a 2000 word opinion piece in the New York Times, a political scientist Courtney Jung, criticized breast feeding activists for putting too much pressure on women to breastfeed. She states broad based research indicates the benefits of breastfeeding are  “ modest”. Could this op ed have anything to do with the fact that she is releasing a sensational new book called “Lactivism” next month ? Imagine running a 2000 word ad for your upcoming book in the New York Times. I wonder if they even paid her for her ad.

Her subtitle includes many of us: 

How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy

I am just going to go out here on a limb and disagree and say that I do not think breastfeeding is bad policy. I guess I’m kind of a rebel that way. 

The American Academy of Pediatricians has come out saying that "no amount of alcohol is safe for unborn babies". The new guideline “identifies prenatal exposure to alcohol as the leading preventable causes birth defects and intellectual disabilities in children.” It was previously thought that "a small amount" of alcohol is okay in pregnancy. According to the CDC (The Centers for Disease Control), about 10% of women self-report that they drink alcohol in pregnancy. So in my simplistic mind this means that if women comply with this recommendation, 10% of the entire next crop of babies could be significantly developmentally better off than the last group. Wouldn’t this have staggeringly good effects on the population ? 

The American Cancer Society has revised its recommendations for mammograms once again stating that they should start at age 45 in a patient of average risk, and go to every other year at the age of 55, provided that the woman is expected to live at least 10 more years. The purpose here is to "eliminate false positives and over treatment’.

Has anyone ever considered asking the question, How bad is the badness of a false positive? And what do they mean by overtreatment? Do they mean biopsies which turn out to be benign or do they mean lumpectomies or mastectomies? Most physicians do not consider a biopsy to be a treatment. Most patients consider a benign result a great relief. I have never heard of a patient saying ”Doctor, my biopsy was benign. It looks like I really didn't need that biopsy after all ”. If biopsies were taken out of the “over treatment “ calculations would there really be any unnecessary “treatments” left to lament ?

The American College of Obstetricians and Gynecologists (ACOG) has maintained their stance on mammograms every one to two years from the age of 40 forward. It also recommends a clinical breast exam annually. The American Cancer Society is dropping their recommendation for an annual clinical breast exam since it has not"been shown to save lives.” They say nothing about whether it extends lives. Is important for readers to know that there are many studies designed to determine whether or not a certain intervention prevents death in the course of the study. Preventing death is the same thing as saving life, no matter if you die at one year or ten years after treatment.  Studies geared to show an interventions ability to save life do not necessarily have the power to show it extends life. ACOG keeps its position on mammograms and clinical breast exams because earlier more frequent mammograms and clinical breast exams are associated with earlier diagnosis and longer life after breast cancer. 

I had better stop writing since there is steam coming out of my keyboard and my ears again. 

Stay tuned for more news from the wacky world of OB/GYN next week on Medical Monday. 

Food Friday: Travel Food

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As I recently wrote in my post on travel wellness, discretion and restraint is advised in matters of travel food. Nonetheless, I think it is incumbent upon all travelers to try as much of the local cuisine as possible.

​How is this accomplished? For one, through small portions and for me as you will see, through photography. I need not eat my food to enjoy it, though I certainly do my fair share of  eating. 

For me, travel food also encompasses experiencing food with people. That is to say, the people are part of the recipe, part of the menu. For me, even the food preparation, the utensils and even the dishtowels add to the experience.

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 ​And so, since I am traveling, I will share with you some of my food experiences.

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Medical Monday: Weekly News Update in Obstetrics and Gynecology 

Did you know that some insurance companies offer rebate incentives to get indicated mammograms ? A recent editorial in the Journal of the American Medical Association called this “ an ethically disconcerting distraction”. What do you think ? I think advanced breast cancer is far more expensive than early cancer caught and cured. 

A new study from the University of Minnesota School of Public Health has shown that less than half of new mothers returning to work have adequate space and time to pump. Meanwhile, in related news, the Army now requires commanders to allow breastfeeding soldiers to have time and space to pump. To clarify, many soldiers stay stateside or in non-hostile countries with family on bases and serve in technical or support positions. 

One article and two more separate recent studies indicate a higher infant mortality for non- hospital births than hospital births. ACOG estimates risk at two to threefold across the board. Remember there is also evidence demonstrating a 14 fold incidence of first Apgar of ZERO in those delivering their first baby at home. All this seems self evident to me given all my eyes have seen. 

The American College of Physicians has come out against routine pelvic exams in the the asymptomatic woman. The American College of Obstetricians and Gynecologists has made it clear it supports annual pelvic exams. Recall that pelvic exams need not always include a pap, since a pap is the collection of cells from the cervix to be evaluated in the lab. Pelvic exams confer a wealth of information about infection, pelvic relaxation, masses in the uterus, masses in the ovaries, etc. Ask any ob/gyn; They will tell you they find significant things on pelvic exams in asymptomatic women all the time. It looks like this needs to be formally studied. 

Uh oh, more bad news for Essure, those little coils placed in the tubes for sterilization. (Darn it, this seemed so promising. ) A new study in the British Medical Journal evaluated over 52,000 women sterilized with Essure. These women were 10 times more likely to go to surgery in the following year than those that were sterilized with a traditional tubal sterilization procedure. It is interesting to note that the FDA ( Food and Drug Administration) did NOT require documentation of Essure’s performance though a RCT ( randomized controlled trial). 

A study in the Journal of the National Cancer Institute has shown 61% of women obtaining mammograms will have at least one false positive report. They are advocating that physicians do more to educate and reduce anxiety associated with these results. 

In the good news and empowerment department, a Norwegian Study reports that pregnant women who exercise regularly in the three months prior to pregnancy report less pelvic pain in pregnancy that their non exercising counterparts. And this is making me smile: High impact exercise was the most strongly associated with decreased pain. So, did these women go through life feeling less pain to begin with thus tolerate exercise and pregnancy better, or did the performance of the exercise change something about the way they perceive pain ? A study like this cannot answer these questions, but they are interesting to ask. 

Stay tunes for more news form the world of OB/GYN next week on Medical Monday. 

Structure Sunday: The Structure of Prevention 

Here’s a simple question: Is it hard or easy to stay well ? 

Staying well is two things: avoiding disease and optimizing health. I’ll be the first to tell you that there are some diseases you simply can’t avoid. I’ll also be the first to tell you that most diseases are a preventable. 

What is prevention ? Is prevention hard or easy ? Prevention is not one thing. It is collection of different actions. Most importantly, these are done over time, on a meaningful schedule, and so we call them habits. I find that lots of people do certain few healthy things once in a while. Oftentimes these same people wonder why they do not see gains in health or fitness. What they are missing is the element of time. Taking one, two or ten habits and performing them in perpetuity over time is what makes the changes. If I could change just a few ideas in my patient’s minds, this would be one of them. 

Prevention requires you to harness the element of time. Time gives your actions power. Most prevention habits are simple easy acts in and of themselves. By themselves they don’t so much. Multiply them by months and they make significant and long lasting changes. 

Here are some super simple acts which you can multiply over time. 

Mind: 

Record three things for which you are grateful before you go to bed. 

Read them upon arising. 

In a conversation, listen first then respond with “I” statements. 

Think and take two full breaths before responding during a conflict. 

Meditate for 10 minutes per day. 

Have about 6 close friends. 

Consider having a partner. 

Have a pet of whom you take good care. 

Ensure your work is meaningful. 

Don’t overspend. 

Take your allotted vacations. 

 

Body: 

Wash your hands at work and when you get home. 

Get your required vaccinations. 

Sleep at least 7-8 hours a night. 

Wear seat belts. 

Use sunscreen.

Eat three meals and three snacks each with protein and produce. 

Avoid simple refined carbohydrates. 

Use olive oil and green tea. 

Ban soda, smokes and drugs. 

Limit to one wine or beer per day. 

Drink 3 liters water per day. 

Brush twice a day, floss and use a peroxide mouthwash before bed. 

Exercise for half hour 5-6 times per week combining cardio and light resistance. 

Incorporate yoga every week. 

 

Super basic, right ?

Super powerful.

That’s what these habits are when repeated over time. 

Prevention doesn’t hurt, it’s not expensive, and you can do it anywhere. It does take a plan to carve out the small slots in the day to do these things, but it really isn’t hard. Just keep the list handy, do the items, and you will wake up in a few months and notice some pleasant changes. 

 

 

 

 

 

 

 

 

 

 

Weekly News Update in Obstetrics and Gynecology 

Good Monday news readers. 

This week, card carrying Ob/Gyns the world over are going all green on us. The World Health Organization and no less than 6 other international Ob/GYN professional societies have “ come out” calling for “ providers to incorporate environmental health screening as a part of routine practice." They have also asked that clinicians become active on a local, national, and global levels to advocate against exposure to toxic chemicals in the environment. 

In sensational news, a Finnish study reports that discontinuation of hormone therapy may increase the risk of cardiovascular death. This news comes as one of many postscripts to the large Women’s Health Initiative (WHI) study designed to assess the effects of two forms of hormone therapy (HT): combined therapy with conjugated estrogens plus synthetic progesterone, and unopposed estradiol in those with a hysterectomy. Until the WHI, conventional wisdom was that HT prevented heart disease, but fostered breast cancer. Surprisingly the WHI showed women in the combined HT group had small but significant increased risks of both heart disease and breast cancer. Those in the estradiol alone group had neither. 

In Finland, which has a highly regulated and uniform brand of socialized medicine, the use of HT took a steep dive upon the release of the WHI. ( It did in the US too.) Examination of this time period a few years ago in Finland has yielded these new insights. No one knows precisely why this is the case, but the authors speculated that it is because only estradiol, either with or without progesterone, is used in Finland. No conjugated estrogens are used. 

 It turns out that the average age of the women in the WHI was 63, a good 12 years older than the average age of natural menopause. These were women who might have accumulated atherosclerotic disease before even starting the HT. Authors of a related recent Finnish study speculated that estrogen may be good for clean vessels, but bad for atherosclerotic ones. This is physiologically plausible since estrogen encourages turnover of the vascular lining, which is where plaques happen. The plot on HT thickens again, but maybe in a good way. Stay tuned. 

Cup half full or half empty ?  The CDC reports that there has been a 44 % increase since last year of hospital policy driven encouragement of breastfeeding within one hour of birth. The trend is good ! However, the respected blog “ Shots”  at NPR ( National Public Radio) decried the findings, pointing out that most hospitals still are not doing a good enough job promoting breastfeeding and most hospitals give formula despite mothers wishes.The cup has some water in it….errr milk. 

Aren’t there some animals who ovulate in response to intercourse ? Kitty cats ? Animal lovers help me here. A new study in the Journal Fertility and Sterility has identified intercourse induced changes the immune system that are pregnancy favorable. Researchers have stated “... sex outside the fertile window is still important for triggering important changes in a woman’s body that may promote a healthy pregnancy.' Meow. 

Stay tuned for more news from the world of Ob/Gyn next week in Medical Monday. 


Wellness Wednesday: When NOT to work out

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Last week I “exercised” poor judgement. I knew it right away, since my natural consequences were swift and sure. 

I had an exhausting week at work. I had kept up on my regular workouts, and got a moderate amount of sleep. Then one morning very early, really in the wee hours of the night, I had to go do an emergency delivery. This dovetailed right into the day. As I worked into the afternoon, not surprisingly, I felt off, a little ill. However, it was the night of the big Zumba Master class, with the awesome teacher from out of town. It was not to be missed. 

I felt like it was all I could do to get my zumba clothes on. Maybe that was a sign. If you can’t get your sports bra on you should not work out. Anyhow, I got there, and it was packed. A nurse friend of mine told me I looked tired. She told me I’d feel better after the workout. Then the new instructor started  in and she was dynamite. It was great dancing; stuff I had not seen before. I did feel better. 

Somehow I had gotten into a little clutch of instructor types in my section of the crowd and everybody could actually dance. That made it even more fun, but you had to really put out. And put out I did. By the end I was drenched, which is unusual for me. My face was red as a beet, also unusual. And then I stepped into the cold night air and felt sick. Weird sick. I was pretty sure I had whacked my electrolytes. 

When I got home I felt strangely weak, and super thirsty. I drank slowly, ate some chips and salsa for salt, and soaked in a tub. I got better, but it took until the next afternoon for me to feel ok. 

Moral of the story ? Remember that working out is for health. If doing it will not be good for you then don’t. Other moral ? Listen to your body. 

So I thought I would take this occasion to give you ( and me) some reasonable criteria for postponing your workout. 

  • The neck rule: You may do a light or “ recovery “ workout if you have the simple sniffles or head cold (cold above the neck) and you are otherwise healthy. 
  • You should pass if your respiratory infection is below your neck in your chest or you feel systemic symptoms such as body aches and fever. 
  • If you have actual Influenza, do not work out. 
  • Do not work out if you are having an asthma flare. Consult with your physician on how to treat your flare and when to return to exercise. 
  • Do not work out after a concussion until your doctor releases you. 
  • If an old injury is acting up don’t just tough it out. Perhaps do a workout where it is not involved at all, or just get in to be treated. 
  • If you went without sleep, i.e. less than 5 hours… then just do a light session, eat, shower, then hit the hay. 
  • If you are really sore from a prior workout, go light on some different type of workout. 
  • If you are dehydrated, then hydrate up, wait a couple hours, then you should be ok. 
  • If you are pregnant without complications, you should be able to continue to exercise, but you will have to modify in later weeks. Consult with your physician about this. 

If you work out in a gym it is particularly important to stay away when you are sick, to prevent the spread of your illness. Likewise it is prudent to wash hands, use sanitizer and avoid touching your face so you don’t get what others have brought. Consult with your doctor about this season’s immunizations. 

Regular moderate exercise stimulates the immune system in a good way. But hard exercise to “ get you to the next level” can actually temporarily suppress immune function. During mild illness, a light workout or yoga session will not result in you losing fitness. When you are under the weather, switch your emphasis from training to self care. You’ll be glad you did. 

References: 

WebMD

Greatist

MayoClinic 

Medical Monday: Weekly news updates in Ob/Gyn

Did you know that not all breast cancer is the same? Breast cancer is of course cells from the breast which have become abnormal and behave in an unregulated destructive manner. We can study specific breast cancer cells to determine their particular nature, for example, whether or they have hormone receptors. When we study breast cancer cells for their particular traits what we are really trying to determine is what therapies would be the most effective against that particular breast cancer cell type.

Some tests we do on breast cancer cells are gene tests. A new gene test called Oncotype DX "accurately identifies a group of women whose cancers are so likely to respond to hormone blocking drugs that adding chemo would do little if any good while exposing them to side effects and other health risks”. This test allows certain patients identified by this gene test to skip chemotherapy, and have results which are basically just as good as the corresponding patients who did have to get chemotherapy.

You may have heard that there is increasing support for homebirth in the United Kingdom. The United Kingdom of course has socialized medicine and a completely different medical care and medicolegal  infrastructure than the United States. For example, British homebirth midwives are highly trained graduate-level professionals who have trained with Obstetricians in hospitals. They use modern equipment, can prescribed medications, and are constrained to doing homebirth in very close proximity to hospitals with emergency capabilities. More importantly, they are very careful at patient selection. Finally, medical malpractice liability is handled through the National Health Service. 

None of this can be said for homebirth professionals in the United States where only a high school degree or GED is required along with an online test, care of home birth clinic patients and an observation of a small number of homebirths by a similarly trained person. These “direct entry” or “lay” midwives in the US are not required to carry liability insurance. 

For many reasons including all of this, the American College of Obstetricians and Gynecologists (ACOG) maintains that the safest place to give birth is the hospital or a birthing center. It is interesting to note that because of medical privacy laws and reporting laws of the state, complications of homebirth are vastly under reported and understudied. Those of us who manage complications from unsuccessful home births are very concerned about these things.

Has anybody noticed that the brouhaha over Planned Parenthood has not prevented the government from continuing to function?

A meta-analysis study out of New Zealand  and published in the British medical Journal has once again raised the question of whether or not calcium supplements are useful for strengthening bones. Their study indicates that while supplemental calcium is indeed associated with increases of bone density up to 2%, they conclude this increase was not enough to meaningfully reduce a person's risk of fracture. It is worth noting that in this study they did not actually measure fracture occurrence in the groups over time.

A second study in the the same journal actually showed a slight reduction in people’s fracture risk with calcium supplementation but researchers concluded the change was not enough to make a statement about the effect. Of course the media reported both of these studies as saying that calcium did not strengthen bones. Oversimplify much ? 

In the conventional wisdom department, new research suggests that women who"begin hormone therapy toward the beginning of menopause may have a lower risk of developing heart disease”. Apparently women who start hormone replacement therapy within five years at menopause stayed free heart disease for a longer time than non-users.".

This is exactly what we thought would take place before we studied the matter in the large very important Women's Health Initiative study, which released in 2002. The Women's Health Initiative study or WHI, demonstrated that those on combined estrogen and progesterone hormone replacement therapy actually had slightly increasing cumulative risk of adverse cardiovascular events after menopause. This was not what researchers expected. Conventional wisdom had always been the hormones like estrogen protected against cardiovascular disease, accounting for the commonly observed phenomenon of that premenopausal women rarely had heart attacks, compared to men or postmenopausal women. Unfortunately the Women's Health Initiative was a bit of a lumper, (as opposed to a splitter) in that it evaluated postmenopausal women of all ages all at once. Moreover, the average age of the test subjects was 63. Thus these women for far more than five years after the average age of menopause which is 51. These women would be likely to have already developed pre-existing cardiovascular disease, in the years after the onset of menopause but before the onset of their research protocol hormone replacement therapy.

Many researchers have speculated that there is something disadvantageous about starting hormone replacement therapy once the patient is long into menopause. Conversely clinicians everywhere have noticed positive effects on health and well-being in those who are able to take hormone replacement from the beginning of menopause and into old age. It will be interesting to see if evidence based quantitative science catches up with or remotely matches the conventional wisdom on the streets.

The Federation Internationale of Gynecology and Obstetrics (FIGO) is stepping up its research on the relationship between toxic environmental chemicals like BPA and problems like miscarriage and cancer.

Finally, in the good news department,  the American College of Obstetrics and Gynecology (ACOG) “recommends pregnant women without obstetrical or medical complications exercise at least 30 minutes a day most if not all days a week, just like the rest of the population.” 

Stay tuned for more fascinating news from the world of obstetrics and gynecology next week on Medical Monday. 

 

 

 

Wellness Wednesday: Getting Real about Wellness Coaches

"Are health coaches a real thing? What do they actually do? Something like that sounds really expensive.” In our survey two weeks ago you said the most helpful thing for your health improvement would be a health coach. Here is the lowdown on this very real and up-and-coming service.

There are a lot of coaches out there. There are a lot of health and wellness coaches out there too. As you know, I have hung out my shingle as an "evidence based" practitioner. Accordingly, if I were to get a wellness coach, I would want one that practiced evidence based coaching. 

I have done a little homework on our behalf, and found that the American College of Sports Medicine certifies only one coaching program in the country at this time, wellcoachesschool.com. Lucky for me, the medical fitness center (health club) associated with my hospital utilizes wellness coaches certified by this school.

However, I too assumed this would be on the expensive side. Here's what I found out. First of all all, prices are cheaper if you are a member of the health club, which stands to reason. Secondly, they offered different packages. The cheapest package without membership was $200 and consisted of eight sessions over eight weeks. This would provide personal training in a small group. This sort of thing would be an out of pocket expense.

On the other hand, I was pleasantly surprised to find out that the more extensive packages involving weight management and wellness coaching for those with serious or chronic medical conditions might be covered by insurance. These programs range from $250-$750 and take place over several months time. Of course any coverage by insurance would have to be determined beforehand and would have to be based on documentation in the patient's medical record by a patient’s physician, someone like me. 

Although I was encouraged by all of this, I did come away from my fact-finding with the impression that my patients who need this most are simply not going to be able to have access to this, afford it or obtain coverage for it. 

This led me to the idea of being your own coach. This is not my idea or a new idea. A simple Google search revealed several reputable sites which deal with this topic. I will share them with you now.  

How to become your own life coach with 14 simple strategies

10 ways to be your own life coach

How to be your own life coach in four easy steps

And my favorite,

Tips from the pros: how to be your own life coach

 

I am thinking about getting wellness coach certification from wellcoachesschool.com. So much of what I do in the course of the day with my patients is wellness coaching. While it is true that I deliver babies and perform female pelvic surgery, I spend a lot of time and energy trying to get my patients to be well. I would like to be as good as this as possible.

I looked into the course curriculum, and I noticed they had two key textbooks, one you get when you register for the classes, and is rather costly. The other is available on Amazon.com for a modest amount of money ( At this time a used one is $0.43 plus $3.99 for shipping. ) It is called "Organize your Mind, Organize your Life” with the subtitle,”Train your brain to get more done in less time”, by Margaret Moore and Paul Hammerness. I think this is a great place to start for people who want to be their own life coach. I know I am going to crack open this book as soon as possible. 

Beyond that I am still going to be giving continued thought to what, in practical every day terms, could help people meet their basic health goals in nutrition, fitness, and stress management.

Stay tuned for more tips on achieving wellness on next weeks Wellness Wednesday. 

Medical Monday: Weekly News Update in Obstetrics and Gynecology 

The Republican dominated House voted to defund Planned Parenthood last Friday the 19th. About a week later, the Senate rejected the same bill by a vote of 52 to 47. It turns out defunding Planned Parenthood would have allowed lawmakers to come in on budget and avoid a government shutdown on October1st. Both sides of the aisle are woking on plans to keep the government going after October 1st. I will say this: that meeting budget and funding Planned Parenthood are really two separate issues and should be treated as such. It is not as though Planned Parenthood is the ONLY straw that could have broken this camel’s back. 

The Food and Drug Administration (FDA) held a public hearing this week about the relatively new method of sterilization called Essure. This procedure involves the insertion of small coils into the inner aspect of the the Fallopian tubes as they open into the uterine cavity. Is is an office procedure without incisions, which is its appeal. However there are now 5k plus reports of complications associated with the device and more pregnancies than were intially advertised. A panel of experts criticized both the maker, Bayer Health Care Pharmaceuticals, and the FDA, in the handling of device’s testing.  A long running social media campaign has influenced the convening of this hearing. 

Long acting reversible contraceptives (LARCs) like IUDs ( intrauterine devices) have been found to be 20 times more effective at preventing pregnancy that all other contraceptive methods. In more good news, almost everyone, even childless women and women with medical conditions, are eligible to use them. Their use is up in the last few years from 1.3% to 7.2 %. The American Academy of Pediatrics recommends that they be first-line contraceptives for sexually active teens.

Most women know there is a vaccine available to prevent cervical dysplasia and cancer. But now a clinical trial from Johns Hopkins University School of Medicine has shown effectiveness in a new genetically engineered vaccine to ERADICATE existing high grade precancerous cervical lesions in half of the test subjects. Wow, fantastic ! 

Stay tuned for more news from the wild world of Ob/Gyn in next’s week Medical Monday. 

Wellness Wednesday: Survey Results for your Biggest Health Challenges

Don't you like getting survey results? It's like getting the punchline to a joke or solving a puzzle. Basically you get to compare your anticipation of the results with the actual results. It's even more fun when the results you get are unexpected. 

Many thanks to those who took the time to complete the survey. The number is small, but it is more than last survey I ran.

Here are the key results:

Personal trainer and fitness women.jpg
  • Approximately three quarters of respondents felt that their health was only somewhat where they wanted it to be.
  • The biggest health challenges were divided almost equally across nutrition, fitness, weight, and stress.
  • Most everyone who took the survey took the time to write a bit about the biggest obstacle to health maintenance. Time was the most common theme expressed in a variety of different ways. Some people referred to the time demands of their job, partner, kids, house and pets. I doubt very much that these things are ever going to go away. In fact, I hope all of us always have jobs, partners, kids,  houses and pets. It sounds to me that concerted improvements in time management would be helpful across the board.
  • Respondents were uncertain and vague when asked open ended questions about what would help them the most with there health. However when given a choice of specific set of health related products, they were able to clearly choose what would help them the most. This is where the surprise came. It wasn't a product at all. Far and away the most often chosen product was a "health coach." 

Fairly recently I ran into a physician friend of mine who I thought had retired. It turns out she had actually gotten certified as a health coach. She is loving it and and really feels like she's making a difference in her patients' lives. So after I saw the results of my survey I called her up to find out a little bit more. It turns out that health coaches are probably the next big thing in preventive medical care. 

It turns out that there quite a few health coaches out there and it turns out there are a lot of courses you can take in person and online by a great many certifying organizations to become one. However, only one organization is approved by the American College of Sports Medicine, the Wellcoaches School of Coaching. (wellcoachesschool.com) It is an evidence based program which uses up to date behavioral, exercise and fitness science to help people improve their life and their health. Luckily for us, my friend was certified in this manner. She works at out local fitness center. 

All well and good. But I called her later and grilled her about insurance coverage for such services. It turns out that, yes, many insurances do cover some health coaching, which struck me as a pleasant surprise. So I am going to start utilizing her and her team for my patients. I and many other doctors do a lot of office based health coaching, but in the setting of providing specialized medical care I can only give health coaching a limited focus. 

I wonder about those without insurance, those with high deductibles, and those with insurance that does not cover health coaching. I still would like to know what resources would be helpful to people who wish to, in effect, be their own health coach. What do you think ? 

 

 

 

Medical Monday: Weekly News Update in  Obstetrics and Gynecology

It's a mixed week in OB/GYN news, as always.

A Swedish study indicates that women who are overweight or obese at the time of the first pregnancy are more likely to develop diabetes in the next decade or two of their life. The risk of increase is six times baseline.

The eighth circuit court of appeal in St. Louis Missouri has taken the position that forcing employers to cover the cost of contraception through their insurance “ violates the groups religious freedoms".

In other news in the war on contraception, the Congressional Budget Office has estimated that cutting off funds from Planned Parenthood for one year could "reduce healthcare access for about 390,000 people" and at least through the Planned Parenthood budget with sales tax payers about $235 million. They hasten to indicate that defunding the organization could result in"several thousand unplanned births that would drive up government costs elsewhere such as in the Medicaid budget which pays for 45% of all births in this country.

The Census Bureau reports that the percentage of people without health insurance dropped in 2014 to 10.4 % down from 13.3 % the year before.

In the department of general women's health the following finding is rather striking. When comparing the cost of institutional care for male Alzheimer's patients versus women's Alzheimer's patients the following is noted. The cost of caring for women with Alzheimer's is six times greater then for a man with the same diagnosis. This is because when man has Alzheimer’s, female family members put much more time and energy into their care, saving them from expensive institutionalization. The reverse is not true when male family members take care of women with Alzheimer’s.

In other gender gap news, the Journal of the American medical Association reports that the gender gap in academic medicine is alive and well. Despite the fact that half of all medical school graduates are and have been women for sometime, Men are 15 percent more likely to have the rank of full professor. It also shows that women generally do produce less reach her research than men, But that this may be due to lack of mentorship, institutional support, and most importantly research funding through research grants. According to the same study, men received over twice as much research funding from their employers for equipment and labs. Women researchers are also less likely to receive NIH grants than there male colleagues.

For some good news this week we will have to turn to the field of vaccines. The CDC or Centers for Disease Control found that about 90% of children under the age of three were vaccinated against the common disease entities in the years between 1994 and 2013. What did this do for us? The CDC estimates that this will have prevented 732,000 early deaths in United States alone.

Finally, also in the good news department, the flu vaccine may be more effective this year according to the CDC or Centers for Disease Control. It is estimated that it will be nearly 3 times as effective as last year’s preparation. Remember that even if the vaccine doesn't prevent flu entirely, it will decrease the severity of flu which is very important in children and other vulnerable populations.

Stay tuned for more news from the world of OB/GYN next week in Medical Monday.

 

Food Friday: Healthy School Lunches 

Think this is going to be a bunch of recipes ? Think again. Here is what it really takes to have your kids' school lunches be healthy. It's not what you think, and it takes a lot more than a recipe. 

A healthy school lunch that is well received by your grade school child is one of the crowning achievements of parenthood. To engineer this amazing feat, you must be ambitious, disciplined, creative and start very early in the game, like before you are even pregnant with the child. Seriously ?

Most depends on you, and this is both bad and good news. It means the obligation is upon you, but it also means you have the power. While you will see that I am emphasizing a strategy that works best if you start early in a child's life, these strategies can work on older children, teens, and in principle, even husbands !

You must lay the appropriate groundwork in your home. Your parenting should have that " just right" touch which is not too lax and not too firm. Your home should run smoothly, so that kids feel secure. Then you must learn what healthy food is, and learn to prepare it so it is easy to handle and appealing to eat. Then you start thinking about healthy school lunches. Here are your tips: 

  • Start very early on healthy eating habits for the whole family. 
  • Make sure you know about nutrition, and not just what marketers say. 
  • Lead by example, i.e. shop, cook and eat healthy yourself. 
  • Make superb healthy food a family hobby. .  
  •  Know your kids friends.
  • Foster this philosophy among your kids' friends by having them over to do cooking projects. Get them involved in the tradition of really nice healthy food. 
  • Know about school food situation. (Is there a hot lunch ?) 
  • Know about school policy ( Is food trading permitted ? ) 
  • Know the school social scene (Are there bullies ? ) 
  • Be aware of social sensitivity surrounding home packed lunch. ( Is it cool ? Uncool ? ) 
  • Involve children in the school lunch making process. 
  • Look up healthy school lunches online together. 
  • Make a shared Pinterest album of school lunch ideas. 
  • Choose and purchase their lunch containers together. Let the child have a much say as possible.
  • Observe Food safety when packing lunches. Consider a reusable ice block. 
  • Get kids involved the night before in composing and packing their lunch, at the same time you make yours ! 
  • Don’t be a purist. Include some healthier treats like dark chocolate or covered almonds ! 
  • Consider the classic note of encouragement. Consider variations such as riddles or anagrams. 
  • Enjoy the process ! 

 

 

 

 

 

 

Wellness Wednesday : Your Wellness Challenges

This Wednesday I am reaching out to understand your health challenges and what could potentially help you meet them. I work with patients nearly every day and give them information about what can improve their health. Sometimes they are able to work successfully with it and sometimes not. I am fascinated with what separates the two groups. 

I have always tried to make the process of becoming healthy accessible to everyone. I am striving to learn the pertinent behavioral science behind health habits that will enable me to help you actually make those positive health changes. 

I myself am motivated by a variety of things: healthy cookbooks, exercise videos, stories of success, and even inspirational cards that sit on my desk. 

I invite you to take my survey and let me know about your challenges and what you think could help. I am most interested in your response. Click on yoga girl below to access the survey. I promise to publish results next week on Wellness Wednesday. 


Best,

Dr. Gina 

Wellness Wednesday: The Benefit of Trying New Things 

Nutrition, fitness and good relationships can keep us healthy. But... trying new things ? Yes, being adventurous has physical as well as psychological benefits to our health. (1) 

Adventure is a relative thing. For one person it might mean trying a new cookbook (me) while another may need to paraglide to 5000 feet above sea level (my son). But in all cases it means doing something different than your usual, and, for best results, it means getting out of your comfort zone. Comfort zones vary considerably in size.  

Does adventure have to be dangerous ? Of course not. But it should expose you to a new environment and require you to do things you have not done before. So why does it have to be all that? 

Before I explain, lets take a look at the American vacation. It is an endangered species. We are one of the few developing countries without a national policy of paid leave. Those companies who do provide paid leave do not always encourage its use, even though research shows it greatly improves employee productivity and satisfaction. When the companies do provide leave AND encourage its use, employees are reluctant to take it. Why ? Forty percent are afraid of coming back to " a mountain of work" , a third feel no one can do their work but them, a third feel they cannot afford it, and about a fifth feel guilty.  Forty-three percent of adults do not remember the last time they tried to have an adventure. Reasons for avoiding adventure range from lack of money to embarrassment. (2) Fear of one thing or another plays a role in skipping vacations. Ironically, it should be the opposite, since skipping vacations is associated with a measurable and significantly increased risk of heart disease in men and women, according to the Framingham study. (3)

And yet, we bemoan our lack of time off and we make bucket lists all of the things we don't and won't do. We execute what Tim Ferris calls the " deferred life plan". (4) Moreover, we note how every year seems to pass more quickly. 

Enter adventure. If we do get around to it, here is what happens. First, our narrow view of the world opens back up. We experience different ways of living, and see ourselves and others in a new light. Novelty and some degree of challenge have to be a part of it. This way, our confidence and competence is enhanced. A 2015 Study on newly graduated nurses found that a nontraditional outdoors adventure leadership program increased feeings of competence and confidence. When they returned to work, their transformation was felt to have impacted their entire work culture. (5) 

Adventure may even be an antidote for the accelerated passage of time. Dave Engelmann, a neuroscientist, notes that the more familiar the world becomes, the less we remember, and thus the faster times seems to pass. (3). I deduce that novelty and adventure may help us savor the time we have. 

Check out these fun resources: 

30 New Things to Try by Lifehack.com

The Beginner's Guide to Trying New Things

Staying on Top of Your Game

References: 

  1. http://www.huffingtonpost.com/laurie-gerber/are-we-having-fun-yet_b_7948588.html
  2. http://www.huffingtonpost.com/2014/08/19/americans-vacation-days_n_5682576.html
  3. http://www.newyorker.com/magazine/2011/04/25/the-possibilian
  4. http://www.bothsidesofthetable.com/2010/01/10/what-can-you-learn-from-the-4-hour-workweek/
  5. http://www.ncbi.nlm.nih.gov/pubmed/25608096

 

Food Friday: Treats

This is a health oriented blog. And yet, I hope for all my readers to experience a wide range of culinary delights. Food is for celebration and rich sweet treats are served at celebrations. How can you participate without feeling like you’ve eaten poorly ? Here are ten tips to turn nutrition buffs into connoisseurs too. 

 

 

 

 

  1. Eat properly on all regular days. 
  2. Get your workout done before attending your party. 
  3. Fill up on healthy foods before the dessert treats arrive. Savor them as much as the treats to come. 
  4. Fill up on healthy beverages like water, soda water and herb tea before dessert arrives. 
  5. Skip dessert if its not really well done. 
  6. Skip alcohol if you chose a rich dessert. 
  7. Be discriminating. Chose only the best for yourself, e.g. choose chocolate mousse over a cheap candy bar. 
  8. Take a small portion. 
  9. Savor your portion; Eat slowly and mindfully. 
  10. Enjoy !