Wellness Wednesday: The Importance of Neighborhood

Right now I am in the middle of something big with my neighborhood. We are rallying and banding together to prevent the development of a huge water bottling plant in our agricultural and research oriented riverside neighborhood. Yeah, I know ! Outrageous isn’t it ? More on that later. 

I am learning what good people I have around me. I have truly been blessed. My neighbors are educated, considerate, flexible, and well spoken. They are from old to young. They come from a variety of economic and social backgrounds. They have a wide range of politics. But one thing’s for sure, we have some shared values. Those include feelings of stewardship for good soil and our pristine aquifer. 

It goes deeper. I have a sense of having a neighborhood of people who would help me if I had a flat tire. I have seen random busy people stop their cars to help shoo someone’s cows back into a pasture. I would never worry about my kids walking to school. But not everyone has these types of advantages. 

A Rand foundation report called “ Neighborhoods and Health”  indicates the following:

“ Just as conditions within our homes have important implications for our health, conditions in the neighborhoods surrounding our homes can have major health effects. Social and economic features of neighborhoods have been linked with mortality, general health status, disability, birth outcomes, chronic conditions, health behaviors and other risk factors for chronic disease as well as with mental health, injuries, violence and other important health indicators."

reference:

http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf70450

Did you know, for example, that heath habits or disease habits are contagious ? That’s right, things like obesity, smoking, or on the other side, jogging and gardening are contagious too ? Neighborhoods can influence health in this way. 

Even the physical layout of a neighborhood can have its effects. Are there sidewalks, playgrounds and good lights ? A “ bad neighborhood” where it is not safe to walk or play outside severely constrains people’s ability to be active. It keeps people inside with the shades drawn, and bad behaviors like drinking can potentially go unchecked because there is no social accountability.  Such a lonely hostile environment greatly contributes to people’s stress, and of course stress truly contributes to many disease processes. 

Green spaces in neighborhoods turn out to be especially important. These serve as places to congregate and places to play. They also expose people to nature in places where it may be scarce, and research tells us that exposure to nature is beneficial to health in specific measurable ways. Please see my 2015 post on Nature and Health HERE. I remember being delighted with the particulars of what I unearthed when I did the research for this post. 

Here is a strange, wondrous and reproducible statistic:

An increase of ten additional trees on a city block on average, increases self reported health equivalent to a $10,000 annual increase in income or being 7 years younger. That’s right, adding ten trees to your block will add seven years to your life, at least from your perspective. The health they are talking about here is “cardiometabolic conditions” such as heart disease and diabetes. Several studies have tried to determine how this works. It seems to start by getting people outside, more active, with lower stress and lower blood pressure. More green space also seems to help reduce aggression and crime. 

What about the food environment of a neighborhood ? Is there local food ? Is food grown and sold ? Are there bars, grocery stores or convenience stores ? There is such a thing as a “ food desert” and I don’t mean dessert. A food desert is place which has nowhere to easily get healthy affordable food. The food environment has a huge obvious effect on food choices and health. 

Have you ever heard of a Ciclovia ? A Ciclovia is a open street programs that closes major roads to motor vehicles so they can be used exclusively by bicyclists and pedestrians. Ciclovias are being studied in large urban centers like Los Angeles in an effort to increase physical activity and sense of community in urban areas. 

What about sense of community ? What does that do ? This goes back to my original description of our neighborhood. It involves trust. There is trust and accountability in the continuity of these neighborhood relationships. Dan Beuttner, in his book Blue Zones, speaks of the decade-spanning friend groups of Japanese women, the “ moai” and their role in promoting the extreme healthy longevity of these women. The trust and connection of these long relationships provide a basis for the best things in life, such as celebration. 

These neighborhood relationships also uphold us when the going gets tough. I can remember nearly 27 years ago, I was between med school and residency, when I was pregnant with Forest. I had preterm labor and was put on bedrest. I was living in this same rural neighborhood, but in a tiny aging cottage which has since been torn down. I had a four year old, and my husband worked long days. Neighbors I barely knew, from newly married young women to aging matriarchs arrived with casseroles and pies. When it snowed, the drive just got plowed. These people became friends, and some have since passed. But their kindness left a permanent mark. 

In my search of Pub Med, which is the US National Library of Medicine at the National Institutes of Health, I found a fairly recent article stating “ The study of neighborhood health effects has grown exponentially over the past 15 years. “ Do not think for a minute that this is not real science nor that there are not real monetary and human resources being devoted to it. 

Neighborhoods affect the physical and mental health of their constituents. One study from the Archives of Psychiatry introduced me to some useful terminology as they highlighted the effects of neighborhoods on health. “ Concentrated disadvantage” was strongly associated with mental health problems for children. On the other hand, collective efficacy (the ability of neighbors to work together) and organizational participation mediated the effects of concentrated disadvantage on the effects of children. 

My neighborhood is demonstrating collective efficacy and organizational participation at its best. We have got our Facebook and Twitter pages for our cause and a great many of us plan to show up at the County Commissioners’ Office  to register our thoughts on the matter. I anticipate the group will bring some scientific and oratorial firepower to bear. 

It turns out that bad neighborhood environments generate their own vicious cycle and good neighborhood environments generate an even stronger virtuous cycle. Understanding this dynamic gives people a handle on how to make things better, no matter where they are starting from. 

How do you make things better ? Twenty two years ago I purchased an unconventional poster to decorate my office. It was shrink-wrapped, and backed in cardboard. When my practice got going, we had it framed and glassed. I still see its message every day. It is by an artist named Karen Kerney, and I will share it with you through an Amazon link. It is titled, “ How to Build Community”. It is for everyone who does not yet have a nice neighborhood to live in. It was ahead of its time. The folk wisdom it contained has now been largely validated by the science on neighborhoods and health.  I hope you enjoy it. 

Medical Monday : Breaking News from the World of Obstetrics and Gynecology 

As per recent precedent and priority, we start with the Zika news. 

Three of nineteen traps in the Miami area have trapped mosquitos which have tested positive for the Zika Virus. New readers will note that this virus is transmitted to humans through mosquitos bites and sex. If a pregnant women acquires the virus, it often leads to severe brain damage to the baby most notably in the form of microcephaly, which means small brain. It also leads to hearing loss. Dr. Anthony Fauci of the National Institute of Allergy and Infectious Disease Control and Prevention warned that microcephaly may be “ the top of the iceberg” and that the full impact of Zika may not be apparent until they grow older. Thus it is of paramount public health important especially with regards to the care of pregnant and potentially pregnant women. 

Zika virus infection can also increase the risk of post viral paralysis,Guillain-Barre syndrome, in those who are infected. New research published in the New England Journal of Medicine has confirmed the association with Guillain-Barre in seven different countries.

The FDA has recommended that all donated blood be screened for Zika, even in places where the virus is not present. Zika testing is currently expensive and time consuming, but officials feels this is necessary, given the seriousness of the infection and the fact that many Zika infections are asymptomatic. 

The mosquito vector which carries the Zika virus has a territory spanning only part of the United States. For this reason, officials believe the sexual route of transmission may become more important here that mosquito transmission. 

The director of the CDC (Centers for Disease Control) has stated that federal funds to fight the Zika virus will be exhausted by the end of September. It has already spent $194 million of the $222 million it was allocated. Congress must then act to provide funding to fight the virus effectively.

Postmenopausal hormone therapy is back in the news. Current practice is largely dictated by a landmark study called the Women’s Health Initiative (WHI), which was released in 2002. One of the principal investigators of the WHI, Dr. JoAnne Manson, said the “ WHI findings have been seriously misunderstood and misinterpreted. She indicated that the benefits still outweigh the risk for women of average risk for breast cancer." Aye there’s the rub. To calculate risk, you will need to have a good history taken, including a family history, a physical exam, a mammogram, and maybe even a visit to the genetics counselor. The plot thickens. 

Texas maternal mortality rates have doubled in the last four years and no one knows why. Numerous commentators have now published about this, and most have noted the political and funding challenges to women’s health care there and in the whole bible belt. There is serious speculation as to whether slashing funding for women’s health and the increase in maternal mortality is related.  Some would say that amidst the ardor to defund clinics which provide reproductive health care services like abortion and contraception, that Texas has also weakened its ability to care for pregnant women. In effect, Texas may have shot itself in the foot. It is believed that family planning clinics are an entry point into health care for many women of modest means. It is often the place where pregnancy is diagnosed. Without these clinics, prenatal care is delayed or absent. An editorial in the Dallas Morning News indicated that if were Texas a country, it would rank 31st in the OEC (Organization for Economic Cooperation and Development) for maternal mortality.

Unpacking this further we see that this jump in mortality is predominantly occurring in black women. Heart problems, prescription drug overdoses, and hypertensive disorders of pregnancy like preeclampsia (aka toxemia) are the leading causes of death in these women. I can tell you that to properly follow a women with cardiovascular or blood pressure problems in pregnancy is big undertaking. It involves frequent if not weekly visits, fetal monitor strips, serial Ultrasounds, and social support so the patient can rest. Maternal mortality is the worst complication one can imagine. Complications can happen anywhere, but deaths should be a rarity if care is adequate. According to research in the Journal Obstetrics and Gynecology, Texas maternal mortality rates are the worst in the nation and among the worst in the developed world. Truthfully it’s a disgrace. 

In the practicing medicine without a license department, Ohio passed a law in 2011 stipulating that providers of medical abortion had to use a FDA ( Food and Drug Administration) protocol for the doses of the 2 medications involved, mifepristone and misoprostol. Basically the law required them to follow the package insert, or “ the labelling”. This protocol was developed in 2000. By 2003, specialist organizations such as the American College of Obstetricians and Gynecologists and the World Health Organization, found shortcomings with the protocol and recommended changes in the package insert, allowing for the simpler and more effective dosing protocol, but also the evidence based extension of the gestational age for which the drug would be effective, and the ability for women to take the medication at home. However these changes weren’t made due to political reasons.  It now appears that since the law was enacted, women taking the suboptimal dose are more than three times more likely than before to have complications requiring additional intervention, often surgical. In other states without this law, medical providers would simply follow the most up to date recommendations of their professional governing body, including an up to date dosing protocol, regardless of the FDA labelling. This is called “ off-label use” of FDA approved medications. In many cases, in many fields of medicine, off label use is common and necessary to take the best care of patients. Up until May of this year, however, it was illegal to do so in Ohio. I wonder what they did to the rebel caregivers who gave the correct doses ? It would be tough to be a doctor in this climate. If the law didn't get you for off label use of meds, the lawyers could for knowingly giving a potentially unsafe dose of a medication to a patient. 

In May of this year, the FDA corrected the package labeling to reflect the most up to date science on the subject. Regardless of how you feel about abortion, you would not want to give a patient part of a dose of medication to only evacuate her uterus partially, since this can cause hemorrhage and infection !  Dangerous !

You may recall that a few weeks past I reported on the decline in teen pregnancy. At that time we were not precisely sure why. However, now, parsed the data and we have nailed it down. Drum roll please…..It’s…. you guessed it…. contraception !!! It turns out sexual activity did not vary in that time frame. Use of contraception did. It increased from 86% use from 78%. Science !

Perform labor is in the news. The causation of preterm labor has remained a bit of a mystery. To show you how nascent is our science, I present the findings of two recent studies, both retrospective. The first, published in the Maternal and Child Health Journal examined 400,000 births. Resistance to preterm labor seemed to be conferred by three things: birth spacing, optional weight at the beginning of pregnancy, and appropriate weight gain in the pregnancy. Pretty vague, I grant you. Next, is an NIH(National Institute of Health) study of 200,000 women. In this group  they were able to unearth the uncanny fact that women exposed to extremes of temperature early in pregnancy were more likely to deliver preterm. OK. What if they wore appropriate clothing and used climate control devices ? Gosh that is unhelpful information. Whereas, any old crusty Obstetrician can spot preterm labor risk as it walks through the door. She or he might notice the frenzy with which the patient blew in, the smell of cigarettes, the poor nutritional status, or poor dentition (teeth). We need studies which tell us about factors we can change - not the weather ! 

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

Food Friday: Feeding the Unwell

The natural follow up to Wellness Wednesday’s post about visiting the unwell is one about feeding them. I guess I am a true Jewish mother in this regard, since feeding people is one of my love languages. 

I wrote a post about “ Food for Healing” last February (HERE) when I was talking care of my son who was recovering from a femur fracture. I am inspired to write again, since is dear friend is recovering from surgery, and I am in the role of support person instead of physician. 

When people are under the weather their tolerance for food and drink becomes limited. There may be very little tolerance at all, such as when they are nauseous. Or, their doctor may have made them “NPO” or ordered that they take nothing by mouth. This may be because they need to have a empty stomach before surgery. If they do not have an empty stomach before surgery, theyhave an increased risk of aspirating stomach material into the lungs while under anesthesia. After surgery, the doctor may have prescribed that they advance their diet slowly and stepwise. Be sure you know their status before you go bringing them food. 

For those that are NPO, I like to bring something for them to partake, even if they cannot eat. Often I bring aromatherapy oils to apply. These are the natural kind, since synthetic fragrance can provoke nausea, headache, or allergies. I favor lavender, which seems to help nausea, and the citrus oils, since they have been shown to improve mood. 

Also for the early post op, I like to provide a source of music. Numerous studies have shown music helps the healing process and decreases requirements for post op pain medication. Shakespeare, the great bard, said that music is “ the food of love” so it is no wonder that it helps. Patients these days still maintain control of their smart phones, so what they tend to lack for is a bluetooth speaker. There are many great ones on the market now which are small, high quality, inexpensive and even waterproof. Buy one and lend it, or make it a gift. To spend less, lend a pair of earbuds which they may have forgotten. To learn more about music and healing, check HERE

Those that are just beginning to advance their diet are usually placed on “ clear liquids”. This means just what it says. Their virtue is that they are easy to absorb, are generally not irritating, provide hydration, and will not cause serious problems if they are accidentally aspirated into the lungs. People wake up groggy, and could choke on food or drink if they are too medicated or groggy.

When a patient “ goes to sleep” from anesthesia, her bowels go to sleep too. To function, the intestines need to move. This is one important way that they accomplish digestion and move material down the line. If a patient advances their diet too quickly and puts bulky foods into a sleepy gut, digestion cannot happen properly and the patient feels worse. 

Clear liquids in the hospital are sometimes very sugary. I find homemade or store bought organic broths are a better choice. Herbal tea is ideal. Also, some people like a little sweetness by mixing 100% fruit juice diluted with water, herb tea or club soda. Regardless, it all should be given in small portions. Post op patients are often very tired, and sitting in a reclined position, so straws are helpful, and they are usually provided by the hospital. 

Even when patients advance to regular diets, their capacity to eat will probably be reduced. Do not get too excited and bring big baked creations unless there are plenty of healthy helpers, guests or family to feed. Stick to simple items like fresh fruit in small bites with plain yogurt. Offer soups, such as chicken soups, as it is full of electrolytes, vitamins and protein. For more help with chicken soup, check HERE and HERE

Visiting the sick and helping the to get their strength back with appropriate foods is a great way to show you care. 

 

Wellness Wednesday: How to Visit Someone in the Hospital 

On first glance this seems self-explanatory. However, a few tips may make things easier. 

If you are uneasy about visiting the hospital, figure out why. Are you afraid of embarrassing the patient ? Do you not like hospitals ? Do you fear illness yourself ? Figure out your reasons and decide if they are reasonable. Remember that the visit is for the benefit of the patient, and that it is an act of care. People in hospitals can very easily feel isolated, as though everyone else is out there living life to the fullest…but them. 

Call beforehand. Based on circumstances, call the patient, her significant other, or perhaps the nursing station of the ward that she is on. Find out the visiting hours, if there are any, and whether or not a visit is appropriate. When you call, ask if the patient needs anything from home or from the store. Sometimes little things can make a big difference, i.e. gum, or their iPad. 

Consider bringing a small gift of your own. However, when considering gifts of or drink, make sure you know the patient’s dietary limitations. In the hospital, dietary restrictions are common, such as during the time before and after surgery, or stroke. When considering flowers, make sure they are permitted. Some units cannot have them because of infection risk. If the patient can do things to pass the time, consider bringing activities that he or she will like, such as card games. 

When you arrive, check in at the nursing station and with the patient’s nurse. Wash your hands. Once in the patient’s room, it is important to suss things out. It may be a time for visiting and joking, but it also may be a time to just be present in silence. Either way, it is a comfort. Even without a lot of conversation, just being there is very beneficial. On the other hand, patient’s still like to hear about what is going on in their friend’s lives as they would normally. If the patient is too tired to read, they might like having the paper read to them. Do remember that hospitalized patients are almost always tired. Watch carefully so that you do not stay too long, to that there are so many guests that the patient feels overwhelmed. 

Do not ask prying or personal questions about the patient or the illness. If the patient wants to talk about them, be a good listener. Even then, do not pry. Do not ask the nurses, doctors or other staff about the patient’s condition. They are not permitted to discuss the case without the patient’s permission, and asking right then might be uncomfortable. 

When you are there, consider offering material help to the patient or to her helpers. She may need kids shuttled, dogs walked, or lawns mowed. You could even offer to set up a google doc or some equivalent to coordinate the helpers if the need is extensive. 

Consider helping your friend after they transition back to home. Getting around will not be the same even if they are stable enough for discharge. Plus, hospitalized patients get a lot of attention to help them through. To have that come to a screeching halt upon discharge would not be all that fun. Connection, not isolation, is essential to healing. 

Most major religions, certainly Judaism and Christianity, include visiting the sick as a formalized duty. It represents the best of society, and embodies compassion. The secret is, it blesses the visitor as much as the visited. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology 

Zika again dominates the news in Ob/Gyn. As of Friday, a storm system was approaching the subtropical state of Florida, where 43 are confirmed infected with the Zika Virus. Authorities think the storm may help spread the virus which is transmitted by mosquitos and sex. Meanwhile, the CDC (Centers for Disease Control) does not have enough Zika testing resources. I myself experienced this last week when I was told a specimen we sent to the CDC would take “weeks” to result. We Ob/Gyns are not able to effectively work in time frames like this, and so this week we will have being having some words with the powers that be. 

A new study published in Radiology has shown that Zika can cause many other brain defects besides microcephaly. They have thus far identified 8 major defects. One of the most common was ventriculomegaly, or enlarged ventricles and thinning cortex. 

Thus far the Florida outbreak has been clustered around Miami. However Thursday, an isolated case showed up some 250 miles to the north in Tampa Bay, Pinellas county. It is still unclear how this occurred. On the bright side, modeling done by researchers at the University of Florida has indicated that the total outbreak should limited to under 400 individuals or less, considering all the southern states. They also believe winter will stop the outbreak, which would then recur next summer the same way. It is estimated that 20,000 pregnant women in the Miami area are taking extreme measures such as confinement indoors or moving to avoid Zika infection. 

NewYork officials are noting that travel restrictions to Zika affected area not being properly observed by pregnant or pre conceptual women. How do they expect people to take these restrictions seriously when they gave full sanction to people traveling to the Olympics in Rio? 

Dr. Kristyn Brandi writes that Zika is spreading more rapidly than anticipated in Puerto Rico, and that resources of information and contraception are not adequately available. 

The chair of ACOG (American College of Obstetricians and Gynecologists) has written a strongly worded piece which has criticized how politics has prevented the funding of an adequate Zika response. He and co author, Dr. Didi Saint Louis of Morehouse School of Medicine have called for the full funding of comprehensive reproductive health care to allow women to avoid or delay pregnancy. They have called on Congress to reconvene to deal with this. 

In the non-Zika news, HPV virus is in the spotlight. This virus is responsible for abnormal paps, and cervical cancer, among other things. It has an effective vaccine which is meant for young people between the ages of 9 and 26. However parents remain wary to give it to their children. Research is being done regarding the prospect of putting it on the list of already mandatory vaccines which must be done before school entry. Surveys show that parents would accept this as long as there was an opt out provision. As of 2014, only 40% of girls and 20% of boys were vaccinated. It will be interesting to see if there will be those who decline the Zika vaccine once it gets developed. 

Breastfeeding is practiced by about 80% of all American women when they leave the hospital. However less than a third keep it up for the recommended time. The American Academy of Pediatrics has recommended that infants should get nothing but breast milk for six months, and that breastfeeding should continue one year. 

Co-sleeping beyond six  months has been shown to produce significant stress on women. Researchers at Penn State note this may be related to fragmented sleep and less time with partner. Perhaps this is related to the falloff in breastfeeding. 

In the everyone-already-knows-this department, researchers at UCLA have discovered that menopause accelerates aging. In all fairness, what they have determined is that methylation increases in menopause, accelerating cellular aging about 6 %.

And in the we-should-have-known department, the “ baby simulator” program in high schools designed to deter teen pregnancy may actually be encouraging it. Graduates of the program with over third more like to have a teen pregnancy. 

Stay tuned next week for more news from the amazing world of Obstetrics and Gynecology.  

Wellness Wednesday: Back to School 

Parents all over the world are experiencing one of the biggest transitions of the year: back to school. Whether you have grade schoolers, high schoolers or kids bound for the university, it is bound to have a big effects on your routines of daily life. And that in turn, has effects on your health and the health of the family. 

Summer can be a relaxing time when people are more physically active. Or it can be hectic with guests, vacations, and the routines can go out the window. Take a moment to assess your summer. Determine how you would like to capitalize on the transition back to school. 

For families with kids of any age, getting back on a good sleep wake schedule is key. Start at least a week early. Get back on a good meal and snack time schedule. You should be on that schedule anyway ! 

Sit down with kids of any age and go over their school supplies. Let kids have as much independence as possible in picking their supplies. These are important expressions of individuality. 

For university students, sit down and discuss finances. Establish a realistic budget regardless of where the money is coming from. Make sure they know how to balance a bank account and look up any card balances. Discuss expectations well in advance. 

For school clothes, don’t go crazy. Start by asking kids to tidy up their room and go through their things. Younger ones will need help with this, but let them do as much as they can by themselves. Encourage them to get rid of as much as they can, but go through it later yourself for things you might need to keep for younger children or other kids whom you know. Establish a habit of giving to Goodwill, and likewise, regardless of your finances, teach kids that it is reasonable to check second hand stores for things they might need. This should be given a air of boho environmental cachet, as well as frugality. After that, establish a budget and go shopping, but just get basics until your child reinvents themselves again for that year. 

Make it easy for kids to stay organized. Have an area such as a mudroom with hooks and cubbies for kids to put their things. Additionally, each child, whether large or small should have a desk area of their own if at all possible, even if they have to share a bed. This can be organization central for them. Consider having a family wall calendar, so everyone can see what family activities are coming. 

Teaching kids early on to have a routine will save them tons of stress. There are routines for sleep, eating, exercise, homework, after school activities, family time and play. Teach kids by example. Make sure you have good habits yourself. Then everyone will have a productive, low stress, enjoyable school year. 

 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

In sobering news, results from a study using mice as a model indicate that children's and adult's brain cells which are critical to learning and memory might be susceptible to the Zika virus. Zika may be able to infect neural progenitor cells which serve to replenish normal neurons over the course of a lifetime.

Meanwhile, a second local Zika out break may be beginning in Miami Beach Florida. Louisiana is bracing for Zika in the wake of recent flooding since flooding affords more mosquito breeding grounds. Finally Puerto Rico has declared a state of emergency due to the Zika outbreak. Zika has infected about 10 thousand people there including over 1000 pregnant women. The CDC (Centers for Disease Control) estimates that 10,000 pregnant women could be affected before the end of the season. 

The head of ACOG (American College of Obstetricians and Gynecologists) has written a piece highlighting Florida as the worst place to be a pregnant woman. He cited the combination of three things: the threat of Zika, restrictive abortion laws, and the lack of funding to fight the virus. 

CDC director Tom Frieden has indicated that there is now thought to creating a $300 million dollar “ rapid response reserve fund” to combat infections disease such as Zika. 

The CDC is becoming concerned that sexual transmission of the virus can spread beyond its natural geography beyond the territory of the Aedes mosquito. The CDC estimates that the public underestimates the risks of transmitting Zika sexually. 

Brazil has been on the leading edge of the Zika epidemic. Fifty years ago they once combatted this virus. However, they fear this time it will not be so easy. They do believe their mosquito control efforts are yielding results. However, they are beginning to discover the long term medical consequences of Zika. 

According to researchers a the University of Kansas, Zika is unlikely to spread the the majority of North America, however is could plausibly spread to Africa and Southeast Asia. 

In other news, OB/GYNs are in short supply and the supply is due to become even shorter incoming years. Although the field is rewarding in many ways, there are also many disincentives associated with it as well, such as risk of lawsuit and grueling hours. 

The US fertility rate has plummeted to the lowest point on record. Some factors are that women are delaying pregnancy, teens are having fewer pregnancies, and more women are choosing to have no children at all. The first quarter of 2016 saw 60 births per 1000 women, half that of the 1950s. Forty years ago, women had their first baby at 21, on average. In year 2000 it was about 25. Now it is over 26 years of age. It is speculated that the economic downturn may bear on this. It is also speculated that women are increasingly concerned with stability, turning attention to being financially solvent, with adequate education, good jobs, and lower debt. 

 

Stay tuned next week for more breaking news from the world of Obstetrics and Gynecology.  

Food Friday: A More Complete View of Workout Nutrition

Last week we talked about the basics of targeted workout nutrition. This week we will get specific. And we will not talk about all the glossy prepackaged products on the shelves of stores. It turns out that some simple inexpensive choices which anyone can get at an ordinary grocery store make ideal workout supplements. 

It turns out to be good to divide workout nutrition into three categories: pre work-out, during the work out, and post workout. It is also useful to differentiate between nutrition for mostly weight workouts from that for mostly cardio workouts. 

Many of these differences are summarized nicely in an infographic on Greatist.com, which they have encouraged people to repost. I have included it here since I think it is clever, useful and attractive. 

Get health and fitness tips at Greatist.com

Wellness Wednesday: Unpacking the Seven Principles 

Last week in the post entitled “ Couple’s Wellness “ I referenced the work of Julie and Stuart Gotten of the esteemed Gotten Institute and the Seattle Love Lab. I introduce their book entitled “ The Seven Principles for Making Marriage Work”. However we didn’t really go into what those principals really are. This week I will give you a thumbnail sketch of each in the hopes that you will be interested enough to pursue more study. They are as follows: 

  1. Enhance Your Love Maps
  2. Nurture Your Fondness and Admiration
  3. Turn Toward Each Other Instead of Away
  4. Let Your Partner Influence You
  5. Solve Your Solvable Problems
  6. Overcome Gridlock
  7. Create Shared Meaning 

Enhance Your Love Maps

The love map is a term for the area of the brain which holds all the information about your partner. The Gottmans propose that having a detailed love map of your partner enables you to love better, and weather challenges more easily. This is done by concerning yourself with all the things that are important to your partner and keeping up to date with what is going on in their life. 

Nurture Your Fondness and Admiration

Fondness and admiration usually exist at the beginning of any relationship. However, as time passes and life’s difficulties are encountered, they may diminish. Expending effort to deliberately keep these past memories and present feelings of fondness and admiration alive will prevent bad feelings from developing in their place. In particular, the Gottmans state that fondness and admiration are the antidote to contempt. 

Turn Toward Each Other Instead of Away

A couple’s connection is built of many small connections throughout the course of everyday life. When one partner reaches out even slightly in speech or gesture, the Gottmans call this a bid. If the other partner turns away from (disregards) the bid, the bidder is slighted and some degree of detachment or irritation takes place. However, if the partner turns toward the bid responsively, their connection is strengthened. The Gottmans teach that a tendency to turn toward your partner’s bids build trust, goodwill and emotional connection. 

Let Your Partner Influence You

The Gottmans have found that partners who share power are more likely to have happy and long lasting marriages. Part of sharing power is allowing influence to flow back and forth. In these marriages conflict prompts a search for common ground. 

Solve Your Solvable Problems

This sounds hard at first but the Gottmans break it down as follows: 

  1. Soften your start-up. 
  2. Learn to make and receive repair attempts.
  3. Soothe yourself and each other.
  4. Compromise.
  5. Prices any grievances so they don’t linger. 

These are the features that an effective problem solving session needs to have. They liken good problem solving to that done between respectful professionals or esteemed guests. 

Overcome Gridlock

The Gottmans assert that gridlocked issues in a marriage touch on deeply held beliefs or wishes, or each partner’s dreams for their life. If partners sit down with each other and try to discern the real basis of the tightly held position, then perhaps a common ground can be found. 

Create Shared Meaning 

The Gottmans assert that a real marriage is more than the sum of its parts. By parts I mean living or loving each other, raising kids competently, and having sex. Instead, they argue, the couple must create a their own unique culture, which incorporates both partners' closely held beliefs and dreams. The Gottmans have identified four aspects of creating shared meaning:

  1. Rituals of connection, such as a family sit down dinner 
  2. Support for each other’s roles
  3. Shared goals 
  4. Shared values and symbols.

This will give us all a lot to think about until next week on Wellness Wednesday. 

 

 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

We continue to learn more about the way Zika virus affects babies.  It turns out Zika can affect babies late in pregnancy. In fact, Zika related brain changes may not become apparent until months after they are born. The reason for this is that the baby continues to grow all except the brain, which does not. 

Zika also appears to produce joint deformities. This may take the form of curved or crooked legs or arms. 

We are also learning more about the sexual spread of Zika. Men may be able to spread Zika for longer than six months, longer than previously reported. The Obama administration has shifted another $81 million dollars from the Department of Health and Human Services to continue development of a Zika vaccine.

Florida officials continue to deal with more local spread of Zika in the Miami area. Aggressive spraying programs are underway to reduce mosquito populations. Additionally there are plans to release genetically modified mosquitos which will mate with the natural Aedes Aegypti and render their offspring sterile. This has reportedly reduced the Aedes populations in Brazil, Panama and the Cayman islands by 90%. 

Various commentators are now starting to focus on how abortion politics played a role in the Congressional failure to develop a funding plan for Zika. It continues to play a role. Since Zika produces grave birth defects in babies which usually live, it is a condition for which some women might chose abortion. Marc Rubio (Republican from Florida)  has come out this week saying that he “doesn’t believe a pregnant woman infected with the Zika virus should have the right to an abortion-even if she had reason to believe the child would be born with severe microcephaly. “ A recent STAT Harvard poll indicates that 59% of Americans believe that a women should have a right to end a pregnancy after 24 weeks of testing showed a serious possibility that the fetus had microcephaly caused by the mother’s Zika infection. The same poll also showed most Americans are unaware that Congress left for vacation without securing Zika funding. Meanwhile women and health care workers in Puerto Rico are trying to overcome historical cultural barriers to contraception in a territory at very high risk for Zika. 

The Obama administration has shifted another $81 million dollars from the Department of Health and Human Services to continue development of a Zika vaccine in Phase 2 trials. Stage 1 is preclinical development, in labs and on animals. Stage 2 is when the vaccine is first tested on humans. This second stage proceeds first to study safety and then, if it passes, to effectiveness. 

In other news, ACOG (The American College of Obstetricians and Gynecologists) has updated its opinion on home births. New data has prompted the revision. The new Committee Opinion Document states that babies are twice as likely to die and more than three times as likely to have seizures soon after birth, compared to hospitals. I would point out that this is case even when most home birth attendants chose low risk patients to deliver at home. I would also point out that the literature on which this is based only reported on two of the worst outcomes, death and seizures. The many lesser but still significant complications like subsequent learning disability remain unquantified. 

In other sobering news, the US maternal death rate has increased. Between 2000 and 2014, the death rate increased from 19 per 100,000 to 24 per 100,000. It is unclear as to why though more thorough reporting methods are believed to account for much of the increase. However some of the increase is real, and authorities speculate that it is because women having babies are older and more likely to be obese than in the past. This gives rise to more complications such as maternal hypertension and diabetes. 

Many including me are cheering the relaxation of rules surrounding marijuana research. It is currently being used legally in several states without evidence of its effectiveness. New studies should be able to “ weed” out the legitimate from the bogus uses of which I suspect there are many. 

Stay tuned next week for more breaking news from the world of Obstetrics and Gynecology.

Food Friday: Pre and Post Work Out Food and Drink 

Young attractive woman doing exercises for the triceps.jpg

This is actually called nutrient timing in the hallowed halls of medicine. When I initially started looking into this, I found a number of sources calling it bunk, and just as many others touting it earnestly. I wanted to get to the truth of the matter. 

To understand the rationale for pre and post workout food and drinks, one must understand the concepts of catabolism and anabolism. These are the two basic metabolic modes that the body can be in. 

Catabolism is the state of breaking down.

Make no mistake, all exercise is, by design, a teardown or at least a strain, on body parts. What makes exercise more than just trauma is that it is done in such a way to be just enough strain to stimulate new growth, or anabolism. Moreover, it is balanced between upper and lower body, as well as between flexor and extensor muscle systems of the body. Exercise is a well designed program of strategic strains on the body so as to stimulate a growth and strengthening of the systems. 

Anabolism is a state of building up that one will hopefully achieve in the aftermath of exercise. 

Clearly this state of anabolism is resource requiring, even resource intensive. We need certain amounts of water, carbohydrates and fats for energy, and protein to build body parts. 

Review of the literature reveals a shortage of good studies on the effectiveness of pre and post exercise supplements. However a number of general insights can be gained. 

  • Gains after exercise are greater when exercise is in initiated in a non fasting state. 
  • A meal should not be closer than 1.5 to 2 hours before a workout. 
  • The so called post exercise window when one can benefit from this supplementation is not as small nor as soon as was previously believed.
  • To maximize anabolic effect, pre and post meals should be separated by no more than 4 hours. 
  • Good nutrition spread throughout the day also supports continued anabolism. 
  • The post exercise interval is more important than the pre-exercise interval, but supplements at both times appears to confer some benefit in optimal anabolic gain and have little risk. 
  • Carbohydrate is needed as well in the post exercise interval in order to replace glycogen, but the carbohydrate need is met by meeting the normal daily requirement for carbohydrate distributed throughout the day. 
  • Protein supplementation pre and post workout should be about 0.5 g/kg of Lean body mass (LBM) For example, a 50 kg person would consume 25g of protein a couple hours before a workout and a couple of hours after a workout. 
  • Pre and post exercise supplements seem to confer a greater percentage gain in the untrained versus the already trained. 
  • Pre and post workout supplements need not be expensive or prepackaged. Protein powder in milk will do nicely. 

Good for you if you are interested in both fitness and nutrition. Now you can leverage them both for some serious gains. Ladies, remember, muscles do not make you look big. They make you look toned and sleek. And they burn more calories than fat. Best yet, they let you do fun things like carry backpacks, ride horses and play sports. 

 

reference: 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3577439/

Wellness Wednesday: Couples Wellness

This last weekend our adult kids cross examined us about when we had last done something with just the two of us as a couple. As a result we ended up taking our own hike in Glacier Park, something we had not done in years. This got me thinking about the ever increasing amount of evidence demonstrating how critical relationships are to health. I put two and two together. 

More attention should be given to relationships in the context of health. Primary care physicians including Ob/Gyns should include relationship assessment in their broader health history. They should be able identify serious problems and refer patients for couple’s counseling or whatever it is they need to correct the problems. 

All this can happen in the context of the doctor’s visit. But discussion about the health of our relationships should be a common one, because it is important. We talk about kale, yoga, cardio and even mindfulness. Why shouldn’t the conversation extend to interpersonal skills and healthy relationships ? 

I have spent the last few days reviewing material on the subject of relationships and what can be done to make them healthier. This extends beyond partner relationships to friendships and family relationships. The core skill set in all cases is the same, with variations depending on the relationship. 

Two particular sources were the most helpful. 

The first is an article in Psychology Today which pointed me toward a sweeping review out of UCLA on the effectiveness of couples' therapy. The conventional wisdom in the lay press seems to be that couple's therapy does not work well. This research study served to shed light on this question. It was a major review of the past 40 years of research on couples therapy. It turns out that certain therapy worked, and certain therapy did not. The conclusion of the study was that couple's therapy does demonstrably work IF it follows 5 particular principles : 

  1. The therapist must be willing to ask both partners to step back and look more objectively at the facts and patterns of the relationship and actually be willing to change how they each think of the relationship. (The individual partner’s views are not sacrosanct.) 
  2. To be effective, a therapist must be wiling and able to change actual behavior in the individuals. They must be able to take concrete steps to prevent one partner from harming the other. This includes psychological services, anger management, or substance abuse treatment. (The therapist must have teeth.) 
  3. Effective therapists must bring out the emotions of each partner. 
  4. Effective therapy must include the teaching of good communication skills. This includes active listening and responsible “I statements”. 
  5. Effective therapy must focus on strength and build resilience. 

In brief, therapy can be effective if it

  1. Fosters objectivity
  2. Changes behavior
  3. Handles emotions
  4. Teaches communication
  5. Enhances strengths

My second source led me to the famous Gottman Institute founders John and Julie Gottman. They provided a piece in the recently published " Time Special Edition, The Science of Relationships" . As lay reading goes, it is superb. I picked mine up in Costco. In it, they discussed their work and the “ Seattle Love Lab” where they evaluate and treat couples. They also referred to their most recent book, "The Seven Principles of Making Marriage Work”. In this book they present the distilled result of their observations of hundreds of successful “ emotionally intelligent” marriages. They too identified the common patterns in these relationships and have presented them for our consideration. 

They seven principals at work in successful marriages are as follows: 

  1. Enhance Your Love Maps
  2. Nurture Your Fondness and Admiration
  3. Turn Toward Each Other Instead of Away
  4. Let Your Partner Influence You
  5. Solve Your Solvable Problems
  6. Overcome Gridlock
  7. Create Shared Meaning 

You could map each of these lists uno the other and find that they line up pretty well. I find it interesting that both research groups chose to study what worked, and that the features held true over large numbers of couples and long periods of time. Finally, it seems that the social sciences are catching up to the medical sciences in prescribing evidence based treatments. 

I encourage you to delve into this literature, regardless of the type or the state of your relationships.

Check these valuable resources out at your local library, your local booksellers, Amazon.com, or even Costco.

 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Florida has an ongoing Zika outbreak in a Miami neighborhood of Wynwood. The CDC (Centers for Disease Control) has confirmed local transmission there for several days. In response, Florida Governor Scott has pledged that Zika tests will be free for all pregnant women. Apparently there is a Zika test kit shortage and physicians' offices have waiting lists for their use. Pregnant residents in Florida are beginning to curtain their activities and travel in their home towns. Other women are delaying pregnancies, freezing eggs for later, or leaving the area when pregnant.

California has the seen the first births of Zika infected babies. These cases have been from mothers who travelled to Zika affected areas. 

Texas Medicaid has decided to cover the cost of mosquito repellant to women of reproductive age. 

President Obama has asked Congress to reconvene early to work on Zika. Meanwhile the CDC has itself provided an additional  $16,000,000 to 40 states to combat Zika. They had already given $25,000,000 in July. This comes out to and additional $400,000 per state on average and does not sound like much in the scheme of things. The money is meant for developing programs to collect and track data on both the mothers and the babies affected by Zika. I have to say that when money is short, as it is, that making the choice to fight the virus with information seems like the wisest first step. When more money comes in, which hopefully it will, it can go to bigger ticket items like better mosquito control and vaccines. Current mosquito control techniques are poor against the mosquito since it can live indoors or outdoors, can hatch in a tiny amount of water, can bite multiple people, and has eggs which can last for months. 

The CDC has clarified that all pregnant women need to be assessed for risk of Zika. They do not necessarily need to be tested, but their travel history and the travel history of their partner or partners should be assessed. 

The CDC has reviewed data which show that the use of Long Acting Reversible Contraceptives (LARCS) is low in Zika affected States. LARCS are among the most effective means of contraception and considered safe for most all women. 

Finally in encouraging Zika news, The Journal Science has reported that three different Zika vaccines have worked “to perfection” in rhesus monkeys. Each of these vaccines works by a different mechanism to stimulate the immune system to combat the virus. One vaccine uses dead virus, but the other two use two different viral DNA subunits to stimulate an effective immune response. 

In other news, the CDC has reported that adults across the board are about 15 pounds heavier than they were 20 years ago. Boys and girls weigh more as well, though boys' heights have gone up. Girls' hights have stayed the same. The average 5’4 woman weighs 168.5 pounds, which qualifies as a BMI (Body Mass Index)  of 29, nearly going from overweight to obese at a BMI of 30. Normal BMI is somewhere between 19 and 25. See the NIH (National Institute of Health) BMI calculator HERE: 

http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Vitamin D is in the news again. Apparently Vitamin D levels decrease by 20 % after cessation of oral contraceptives (OCs). This has potential consequences not only for women but for any pregnancies that ensue. Because of his new finding, it might be appropriate to check Vitamin D levels after OCs are stopped or before pregnancy is considered. 

In the close-to-science-fiction department, we turn our attention to telomeres. What is a telomere ? Tasciences.com quotes Blackburn and Epel from the Journal Nature, saying that

“ Telomeres are the end caps at the end of each DNA strand that protect our chromosomes, like the plastic tips at the end of shoelaces. Without the coating, shoelaces become frayed until they can no longer do their job, just as without telomeres, DNA strands become damages, and our cells can’t do their job.”.

Telomere length is therefore a marker of cell aging. Cell lifespan shortens as telomeres shorten. We are born with a certain telomere length. The majority of telomere shortening occurs in the first 4 years of life. Little is known about why telomeres shorten. It turns out that early exclusive breastfeeding for just 4-6 weeks is associated with longer telomere length at age 4-5 years. This may have consequences for long term health and overall longevity. The CDC has reported that just about half of all postpartum women are breastfeeding at 6 months. Less than a third were still breastfeeding at a year. The American Academy of Pediatrics has recommended that women breastfeed for at least 6-12 months. 

The Journal Pediatrics reports that “ Breast milk give a boost to premature babies mental and physical development.” Those who received breast milk during the first 28 days of life had measurably better IQ, math, memory and motor skills at age 7 compared to those who received less breast milk. I will comment that to pump breast milk for 28 days while your premature baby is in the NICU (newborn ICU) requires a high level of dedication. Perhaps it is difficult to factor out this maternal dedication as a factor in the better outcomes of the breastfed babies in their study.  These breastfeeding mom’s of preemies either are or become some of the most dedicated and resourceful moms out there, due, at least in part, to what they have to deal with. Maybe the better outcomes are born of the mother’s overall dedication. Hat’s off to you…. dedicated NICU moms. 

 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology next week on Medical Mondays.  

Food Friday: Campfire Cooking 

Summer is in full swing and this is the weekend to be out by a campfire. That is because the weather is fine, the nights are mild and the Perseid meteor shower is coming. 

Cooking on a fire is truly gratifying from a five senses point of view. The crackling fire is beautiful, the smell is delicious and the taste is unmatched in the kitchen.

It is hard not to be relaxed by a fire. You just can’t rush it. If you try, you’ll literally get you or your food burned. 

Those unfamiliar with fire making need to start by checking their local agencies regarding fire regulations. These my vary by your season and location. You may need to go to a public park or a campground. Or you may need to use a barbecue. Whatever you do, keep it simple and friendly, since that is part of the charm. If possible, give each person some hands on responsibility for their food. 

How is food on the fire cooked ? Well for starters, the same rules of food safety apply over a fire. Keep cold food cold and hot food hot. Check the link below for more details on that. Meanwhile, consider all the ways you can cook over a fire: 

  • Food goes on skewers and is set on a grill.
  • Food goes directly on a grill. 
  • Food is placed on skewers and held over the fire.
  • Food is cooked in a pan on a grill. 
  • Food is cooked in a Dutch Oven in coals. 
  • Food is cooked in foil packets or in its own skin in coals. 

However you cook it, the same rules of safe cooking apply. You must ensure fire safety and food safety. Make sure you have a source of water and that you are not at risk of losing control of your fire. Make sure you have all the right tools so that you will not be tempted to use your hands and burn yourself. Regarding food safety, you must stack the deck in your favor to make sure all foods are thoroughly cooked and yet not burned. Some of you will recall that black char contains unhealthy chemicals. More on that in the link below.

http://drginanelson.com/drginablogs/2015/6/11/food-friday-healthy-barbecue-grilling-and-picnics?rq=barbecue

How can this be accomplished ? 

  • Precook foods that take a long time. 
  • Cut foods into easily cooked piece sizes. 
  • Do not mix short and long cooking foods in one packet. 

Here is my modest album of campfire recipes on my Pinterest: 

https://www.pinterest.com/drginanelson/campfire-recipes/

Truthfully, I am not much of a recipe user anymore. Dutch oven recipes are like crock pot recipes but take less time. Foil packets for grilling are pleasing single serving mixes of fruits vegetables and meats cut small and generally marinated with a basic vinaigrette or butter. Grilled food is similar, but more lightly dressed so as not to burn, and placed on a skewer or on a grill directly. Oh and, if Pinterest is any indication, everything is wrapped in some sort of bacon.  Dessert and treats are less familiar to me, although I have made nice s’mores with good chocolate in my day. Even more intriguing are fruits dipped in marshmallow cream or doughs wound onto skewers and roasted directly over the fire, things I have yet to try. 

About the real dessert: the Perseids are an annual meteor shower, my favorite. It is generated as we pass through the tail of the comet Swift -Tuttle. The shower comes out of the northeast, and as the name suggests, out of the sky in the region of the constellation Perseus. If you are not familiar with the night sky, I recommend getting an app to help. I have had several such apps, but right now am using SkySafari, the cheap version. With it, you can point your screen of your device ( phone or tablet) at the sky and see the same segment of virtual sky, but WITH LABELS ! This year the Perseid forecast is for 200 meteors per hour, which is at least twice the typical average. This is because, this year earth orbit is nearer to the center of the comet tail than usual. 

So take advantage of this good fortune and check out the beauty of the summer sky. And get back to the primitive pleasure of sitting around the fire with friends and family to eat good food and relax. 

 

Wellness Wednesday: Exercise Specs

Today’s post will keep it simple, portraying just a few simple keys to successful exercise. With the books, shows and classes out there, it is easy to get confused about what you need to do to start getting fit. My simple reminders will hopefully bring it down to earth and help you get started or stay consistent with your exercise regimen. 

Accept your present state.

Back in the day, in some challenging yoga classes, I was, at once, encouraged to master harder and harder poses, but, somewhat paradoxically, I was taught be “ be where I am”. This mean I had to be real about what I could actually do properly at the present moment. I was not to fight or strain my way into a new pose. I was to practice as best I could until it came naturally. This was a very hard concept to grasp. 

At the same time, I want you to embark on exercise in a spirit of happy acceptance. Whatever you do is a plus. You should not make it hard, or certainly not painful. When beginning, it should just feel like mild exhilaration. It should not exhaust you. You are just letting your body and brain get used to the movements and the routine. It takes months to adjust. You will advance in intensity when you want to. You will want to when you are ready. 

Start easy and short.

Research I mentioned on this last Medical Monday indicated that 2.5 hours of moderate exercise a week has measurable effects on heart disease risk in women. This translates into 25 minutes a day 6 days a week. It is true that some fit people exercise for longer for fewer days per week. However I prefer beginners and the inconsistent to workout for less time more frequently since it reinforces the habit more effectively. 

Value initiation over endurance.

Woody Allen once side that 80% of life is showing up. This is certainly true of exercise. You can make things easier on yourself by observing a fairly steady routine. Remember Mr. Rogers ? On his TV program he would arrive home from work and immediately change from his work jacket to his house sweater, thereby prompting him to shift gears and relax. Me, I change into workout gear and somehow there is no going back. Next I get the glass of water, and off I go. Get yourself to start, and you will finish. 

 

 

Take one break day per week.

Exercise is to transform your body so that it is healthier, more efficient, stronger and more functional. So give it some time to transform. Never skip your break day. And if you are feeling wiped out, take an extra break day or just choose a milder workout. Having said that, ordinary everyday fatigue should not prevent you from working out. Your exercise will actually help your fatigue, ten times out of ten. If you are feeling overly fatigued after what feels like a mild workout, check in with your doctor. Additionally you should make sure you are giving your body adequate hydration and nutritional support to transform. 

 

Stay tuned next week for more Wellness Wednesday tips.  

Medical Monday: Breaking News from the World of Obstetrics and Gynecology 

About 1.6 million pregnant women are at risk for Zika virus infection in South and Central  America. Now, health officials are concerned that local transmission of Zika virus has begun in southern Florida. This means the virus was acquired in Florida, instead of being acquired elsewhere while a person was traveling. This means that some of the mosquitos in Florida carry the virus.

In related news, the blood supply in South Florida is now considered to be potentially contaminated with Zika virus. The FDA ( Food and Drug Administration) has asked that all blood donations from South Florida halt until all donations can be screened for Zika virus.

In even more striking news, the CDC ( Centers for Disease Control)  is recommending that all pregnant women be screening for the Zika virus. 

As most of you know, Congress left for its seven week vacation without coming to an agreement on Zika funding. The President of the American College of Obstetricians and Gynecologists has written a strongly worded letter to Congress on this matter. 

http://www.acog.org/About-ACOG/News-Room/Statements/2016/ACOG-Statement-on-Congress-Failure-to-Take-Action-on-Zika

Proceedings from the National Academy of Sciences include research that indicates that women who enter menopause early age faster than other women. They were able to quantify this, saying that menopause speeds up cellular again about 6 %. They also indicated that poor sleep can trigger similar aging type changes. 

In related news, women who start menstruation late and who have menopause late compared to average are more likely to achieve 90 years of age. Information like this is useful in that it helps identify factors tied to longevity. 

Research from the Journal Circulation has indicate that only 2.5 hours of moderate exercise per week has measurable effects on heart disease risk in women. Let’s see, taking one day off per week leave six days for exercise. Divide that into 2.5 hours to get the time per day needed for exercise. Only 25 minutes per day needed to reduce cardiac risk ! 

Stay tuned next week for more breaking news from the world of Ob/Gyn and women’s health.

Food Friday: Delicious Dietary Fiber 

We have all heard of the health benefits of fiber. You would be surprised by just how much fiber can do for you. But to get the benefits of fiber, you will have to learn a little about what it is and how it works. 

Fiber is a complex carbohydrate from plants. We are unable to digest it. But before you write it off as empty filler, consider how and works. Remember too, that our systems evolved to process our foods in the presence of lots of fiber. 

Fiber comes in two kinds, soluble and insoluble fiber. As the names suggest, soluble fiber mixes with or absorbs water, and insoluble fiber just passes through the system unaltered. 

What good could this possibly do? 

Soluble fiber

Soluble fiber softens the stool and helps it pass smoothly.  In this way it prevents constipation and all the complications from that. It binds cholesterol helps more it be eliminated. In this way, soluble fiber is heart healthy.

Soluble fiber buffers blood sugar spikes and may help control diabetes. And yes, it makes you feel full so you eat less. 

Good sources of soluble fiber are oatmeal, nuts, beans, apples and blueberries. 

Insoluble fiber 

Insoluble fiber is what your parent used to call roughage. It makes you feel full and helps discourage overeating. It bulks up the stool and protects against both diarrhea and constipation. 

Good sources of insoluble fiber are seeds, whole wheat, brown rice and even popcorn. 

According to the Institute of Medicine, Americans only get 15 grams of fiber per day in their diet. Men should get 38 grams and women should get 25 grams. Perhaps our lack of fiber has contributed to our many digestive complaints and the obesity epidemic.

These portions of fiber seem like a lot. However, if you eat the recommended numbers of servings of fruits vegetables and whole grains in a day, you most likely have it covered.

We have a long way to go, but thankfully high fiber foods such as fruits, vegetables and whole grains are readily available and fun to eat. 

 

References: 

 

http://www.webmd.com/diet/insoluble-soluble-fiber

http://www.healthcastle.com/fiber-solubleinsoluble.shtml

http://www.uccs.edu/Documents/healthcircle/pnc/health-topics/Soluble_Insoluble_Fiber.pdf

http://www.everydayhealth.com/ibs/soluble-vs-insoluble-fiber-for-ibs.aspx

http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/fiber/art-20043983

Wellness Wednesday: Healthy Bowels

What affects our health, how we feel, and how we look, but is rarely discussed ? You guessed it: Bowel movements, or lack or them, or problems with them. Today we will give some attention to the humble colon, indeed the whole female pelvis, as we contemplate the well being of this part of the body. 

Those of us that operate on the female pelvic organs the uterus tubes and ovaries can tell you that they are in close proximity to the bladder and the colon.  In fact, they are sandwiched between the bladder in the front and the colon (large bowel) in the back. Constipation can affect the way the uterus and bladder feel and function, and visa versa. 

Definition

A common definition of constipation is bowel movements less than every three days. The American College of Gastroenterology defines constipation more completely, factoring in all sorts of problems with bowel movements, such as straining, small or hard stools, a sense of not being able to empty the bowels, or difficulty passing stool. Bloating, abdominal pain and excessive gas are also related issues.  

Risk factors

Risk factors for constipation include being a woman, being pregnant, being older, dehydration, low fiber diet, being sedentary. 

Causes

The basic cause of constipation is an unduly slow passage of stool through the bowel such that the stool becomes hard and relatively dry. This slow passage may be caused by a blockage in or near the colon such as a tumor, or a narrowing of the bowel from a stricture or a scarring of an anal fissure.

Since the colon moves stool forward using muscular contractions, poor muscle function can cause constipation. This can be from problems with the nerves that innervate the colon, such as in diseases like MS, stroke, and spinal cord injury. The colon muscles also function poorly if they do not contract and relax normally, or if the surrounding pelvic muscles are weak. Weak pelvic muscles can be caused by injury at childbirth, overweight, poor conditioning, poor posture, or all of the above. Hypothyroidism and diabetes can cause constipation. 

Constipation can also be caused by medications, most famously narcotic pain medications and sedatives. Certain high blood pressure, antidepressant antacid and allergy medications can do it as well. Diuretics like caffeine and alcohol can cause constipation. 

Poor bowel habits can start a vicious cycle of constipation. Ignoring the urge to go for reasons of convenience or modesty leads to more time for water to be extracted from stool, a harder stool, and a more difficult passage. The urge to go may even go away, compounding the problem. 

Poor dietary habits are probably one of the most common causes of constipation. A diet high in saturated fat and sugar can predispose to constipation. A diet low in fruits, vegetables and fiber will surely cause constipation. 

Complications

Untreated constipation may damage the area around the anus, either by producing sore dilated veins (hemorrhoids) or by causing small tears (anal fissures). The pressure and straining associated with constipation will worsen the condition of the pelvic muscles. It may do this to such an extent that the bladder may also start to have problems emptying, holding urine in, or both ! Constipation may even predispose a person to frequent urinary tract infections. 

Evaluation

Persons suffering from constipation should not suffer in silence. Constipation is one of the most common reasons people go to the doctor. The workup of constipation consists of a history, physical exam, and possibly some imaging procedures. 

Treatment

Treatment is determined after the workup is complete. Taking care of serious pathology is critical. But this is less common than lifestyle factors. Dietary and activity changes are front and center in the treatments for most people. Fiber, both soluble and insoluble, are key, along with ample hydration all through the day. Supplements of fiber are widely available if patients just cannot seem to get the right foods into their diet. Finally enemas and medications can be utilized. 

Enemas and suppositories can be used for serious cases. Other classes of medications can be useful, but one must be aware of how they work. 

 

  1. Stool softeners like Colace do just that. 
  2. Bulking agents like Citracel or Metamucil hold additional water. 
  3. Osmotic agents like Milk of Magnesium chemically hold water in the colon. 
  4. Stimulant laxatives like senna or bisacodyl stimulate the colon muscles to contract more. 

 

The first two are generally safe for everyone, but the last two should be used with the supervision of a doctor, since there can be medical consequences. Laxatives should be used with great caution, since they can even be addictive like narcotics, with more and more being required to get the desired effect. 

Those with pelvic floor dysfunction can be treated with pelvic floor physical therapy. More and more medical communities are incorporating this treatment modality into their centers. This is key since these issue disproportionately affect women. These women have often curtailed their work, social lives, or exercise because of problems with bowel and bladder, and this is a significant loss, especially when treatment is available. 

Stay tuned for this week’s Food Friday, when we will explore the dietary remedies for constipation in more detail. 

 

References:

http://www.mayoclinic.org/diseases-conditions/constipation/basics/definition/con-20032773

http://www.emedicinehealth.com/constipation_in_adults/article_em.htm

https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/constipation/Pages/overview.aspx

http://patients.gi.org/topics/constipation-and-defection-problems/

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

The news this week is dominated by virus science.

The first United States baby with Zika related microcephaly has been born in New York City. While this is not surprising, the fact that many women are ignoring Zika related travel warnings is. This summer, over 2000 pregnant women traveled to Zika affected areas and have com back requesting testing. In many cases, they are traveling to the Dominican Republic. AS f the present, cases from the Dominican Republic account for more than a fifth of all US cases. The CDC(Centers fro Disesase Control) and the American Academy of Pediatrics are grappling with how to develop protocols to care for infants who will be born with microcephaly. These infants have serious mental and physical disabilities since the higher portions of the brain are underdeveloped. 

Florida is one of the most vulnerable states in the Union to the Zika virus. Authorities estimates over a quarter of a million women are at risk in Florida. Various research indicates that a Medicaid expansion there would help reduce the risk of pregnancy women to Zika. There is also a push to require employers to take measures to limit their pregnant employees exposure to mosquitos. 

As of mid July the CDC is tracking around 1300 cases of pregnant women with Zika. Fourteen were sexually transmitted, and the rest acquired through travel. 

There is also a Utah case on record this week of a man who acquired Zika through close family contact. He was taking care of an elderly man who had acquired Zika due to travel. 

Hepatitis C is on the rise, both in women of reproductive age, and not surprisingly, in their children under 2. There is no vaccine yet for Hepatitis C, but very recently, a very good treatment has been released. 

In other viral news, work has been done showing that certain vaginal flora (Prevotella BIVIA) make it easier to transmit HIV. However, a silicone ring imbued with antiviral drug may help reduce the risk of transmission. Pregnant women with HIV have now been shown to do better if their therapy is continued postpartum. 

Finally, in some other good news pertaining to viruses, the American Cancer Society has endorse the vaccination of all preteens, boys and girls against HPV (Human papilloma virus.). 

Say tuned for more riveting news from the word of Ob/Gyn next week on Medical Monday.