Medical Monday: Are there really any low risk pregnancies ?

In today's post I report on some recently presented work which questions the validity of classifying pregnant women into either low risk or high risk groups. 

These categories have been important to women and their caregivers since they have used the information to determine the most appropriate site for delivery, from freestanding birth center, to community hospital to university medical center. 

But while Obstetricians have gone along with the use of the category " low risk", we know from anecdotal experience that ANY patient can unexpectedly have complications with out any warning or risk factors. A cross sectional investigation published in the American Journal of Obstetrics and Gynecology, February 7th, 2015, has shown us in precise numerical terms just how often this happens. 

Please note that in this study, those with no prenatal risk factors were classified as low risk. Those with one or more risk factors were classified as high risk. 

Here are their results: 

Of 10,458,616 pregnancies analyzed, 38% were identified as low risk, and 62 % as high risk. 

It turns out that 29% of those classified as low risk had unexpected complications. 

It is not surprising that high risk pregnancies had complications. It turns out that 57% percent of them did. However, 29%, almost a third of the low risk patients had complications. For certain outcomes, like use of vacuum, forceps, meconium and infection, so called low risk pregnancies had a higher incidence than those in the high risk group. 

If you look at all pregnancies and add the 62% who are high risk to begin with and the 29 % of the remaining low risk 38% group who ended up having complications despite their low risk designation, it adds up to 73% of the total group. 

So, according to this large study, 73% of all pregnant women can either be classified as high risk from the get go, or are low risk and going to have a complication. This 73% of all pregnant women are those that belong in the care of Obstetricians or Certified Nurse Midwives working in the hospital under the care of Obstetricians.

Here's the problem. While we can select out those in the high risk group for higher level hospital care, it is not so easy with those classified as low risk. When we consider the low risk group, who are over the third of the whole group, we know about a third of them will have complications. WE JUST DONT KNOW WHICH WOMEN THEY WILL BE. That is the problem. That is why, in my mind, all women deserve access to a high level of care in a congenial but fully equipped setting...the hospital. 

It is imperative that birth be congenial but even more critical that it be safe... 100% of the time. To achieve both does not require taking birth out of the hospital realm, instead it means transforming the hospital birth environment to be all that it needs to be.. comfortable, accommodating, beautiful, as well as fully equipped for any medical or surgical contingency. 

Here is the link to this current research: 

http://www.ajog.org/article/S0002-9378(15)00268-9/fulltext

Structure Sunday: The Structure of Grocery Shopping

I am interested in grocery shopping since it has a great deal to do with what we eat. What we eat has a lot to do with our health. Since this is all so very important I am going to break it down into ridiculous but useful detail. The following is a primer on how to go grocery shopping. 

First reflect: 

First and foremost, think about your nutrition goals for the week. Remember that Dr. Gina wants you to consume primarily meat, fish, chicken, vegetables and fruits in three meals and three snacks every day. Review our Nutrition section if you have questions. Think about some of the awesome healthy dishes you would like to make. Include those ingredients on your list. 

Inspect, tidy and make lists: 

Be brave and look into the depths of the fridge. Find any science projects (spoiling food in containers) and get rid of them. If you consolidate things like ketchup bottles and wipe out the refrigerator shelves a little bit it will make you feel so much better. You will see that feeling better is actually important, since it will help you avoid buying things you don’t need. Look in the freezer, and all the cabinets too. Make room for the new groceries. Go to your laundry room and your bathrooms, and check and tidy there as well. After you are done inspecting and tidying, make your lists of all the things you need to buy. You can group them any way you want, either by store like I do, or by store section. Make your list on paper or on your phone. I tend to lose paper lists. 

The idea here is that with a list you will buy only what you need, and nothing that you don’t need. Sure enough, you may run into excellent and discounted produce you didn’t know was in season, and that I believe is a legitimate reason to go off list, but just any old bargain is not. 

Prepare yourself to shop: 

Research clearly shows that we often suffer from “needs confusion”. When we are tired, hungry, bored or angry, we soothe ourselves with retail therapy. Buying, like many pleasant things, produces a surge of potent neurotransmitter, not dissimilar to those felt with accomplishment or good fortune. In unpleasant states, we are more vulnerable to marketing ploys and subliminal suggestion, and we are anxious to resolve our uncomfortable state. So, I suggest that you work out, shower, dress and eat at least a healthy snack before going out to shop, hereby calling up happy neurotransmitters in more legitimate ways.  

Pack for the trip: 

Make sure and collect all your reusable and attractive shopping bags. Get rid of the ugly downer bags, my goodness. Life is too short for ugly shopping bags.

Bring healthy snacks so you will not fall prey to the samples. Bring all the equipment and healthy snacks you need to keep kids happy. This will help both kids and parents resist child-initiated impulse buying. 

When to go: 

I am a firm believer in twice per week shopping. Any more is onerous and any less results in a lack of fresh food, which is so important. I have chosen Sundays and Wednesdays since that is easiest for me. 

Where to go: 

Assuming you have already gone to your own garden, your own freezer, and your own farmer’s market first, you must then consult your list. To get exactly what I want (and I am very picky) I have to go to at least two stores. Usually one is Costco, which has more organic food all the time. The other is my local organic/natural/whole food store. 

 

Once you get there:

Understand that everything in the store environment is designed to get you to buy. This goes from the print, the colors, the displays and the music. Use your own mind. You have already decided what you need.

• Be skeptical, stick to your list, and be a label reader.
• Be wary of health claims on product packaging.
• Stick to real fresh food, which is mostly located on the periphery of the store. Stay out of the middle of the store without good reason.
• Be cautious about budget brands. They may be cheaper for market reasons, or because they use cheap fillers which are not healthful. 
• Be cautious about coupons and sales. Do not let these cause you to buy something you don’t need or more than you can use. 

Enjoy yourself: 

Your nervous system is right. You have every reason to feel a thrill right down to your neurotransmitters when you pick up you a big crate of ripe strawberries. Eating is one of the great joys of life. To be able to acquire beautiful varied foods as we do is unprecedented in human history. Think about what it takes to bring us this food: all of the people and places and knowledge that come into play. It is nothing short of amazing. 

 

 

 

For more reading : 

How to Buy Food, at Bon Appetite

The Psychology of Shopping: How Grocery Stores Make Rational Shopping Nearly Impossible

Supermarket Psychology, by Weight Watchers 

Surviving the Psychology of Sneaky Supermarkets, at National Geographic 

A Few More Ways that Supermarkets Mess with Your Mind, at Business Insider 

11 Psychological Tricks of the Supermarket Trade, at Food Network

Ten Ways your Local Grocery Store Hijacks Your Brain, by Psychology Today 

Food Friday: Cool Dinners for Hot Days

It’s summer and the weather is hot. It’s great to turn to festive cold dishes. But they often contain lots of simple carbohydrates, which most of us should avoid. Here are some tips to help you avoid the same old sandwiches, crackers and pasta salads. 

Some recipes, especially these which are high in protein, require a little preparation in advance. 

With advance cooking: 

• Prepare any kind of meat, chicken or fish in surplus. Use in any of the following ways: 
• Season liberally and toss into a leafy green salad for a balanced meal, e.g Taco salad. Serve with fresh corn rather than chips.
• Season liberally and toss with firm vegetables such as cubed carrots, steamed broccoli, carrots, peas, corn, peppers, tomatoes. Dress with a vinaigrette in advance to marinate, flavor and soften. Add raw nuts to any salad but be sure about allergies. 
• Make wraps and include vegetable, garnishes, salsas and condiments. Consider rice, seaweed or iceberg lettuce wraps with toothpicks. 
• Use hard boiled eggs as a protein rich garnish to leafy salads, or mix with olive oil vinegar, mustard lemon and spices to make a rich dressing. Traditional Cobb Salad and Salade Nicoise are made this way. 
• Make an egg salad with lots of vegetables like celery, pickles, relishes, peppers, etc. 
• Make “meat” balls of chicken, meat or even fish (called gefilte fish traditionally), and serve on sticks with flavorful cold sauces for dipping. Find recipes that have high flavor since flavor is more subtle in cold dishes. 
• Make chicken salads, e.g. curried chicken salad or Waldorf salad. 

With no advance cooking: 

( Remember, deli meats are not for pregnant women.) 

• Meat deli trays.  
• Cheese Deli trays. 
• Smoked fish or poultry platter. Any of these can go with all the trimmings, i.e.fruits, vegetables, condiments. Try not to resort to all the crackers. Build hor d’oevres on slices of cucumber, small tomatoes halves or slices of firm cheese.
• Toss cubes of feta, mozarella or other cheese with leafy or firm vegetable salads. Dress attractively with flavored vinaigrette or a creamy homemade dressing. 
• Make cold fruit soup with a yogurt or kefir base. 
• Use canned salmon or your favorite canned meat fish or chicken to make spreads, dips and additions to salad. Think "tuna salad” but better. 

Once you’ve got a protein rich cold main dish figured out, it’s easy to think of cold side dishes. Make any kinds of fruit or vegetable salads; try your hand at a cold Gazpacho. Those who can tolerate legumes (beans, tofu, etc) can make many more protein rich dishes, though one must bear in mind that to constitute complete protein, legumes must be combined with whole grains. 

To keep your cool dinner healthy, steer clear of soda, fruit juices and excess alcohol. Lightly sweetened herbal iced teas flavored with lemon wedges and mint leaves are always appreciated. You can also use just a splash of fruit juice with cold and very economical club soda, at a fraction of the price of commercial gourmet sodas. 

Finally, cool desserts are easy. Try fresh berries, melon or pitted fruit with cow’s milk or coconut cream. If you are feeing ambitious, prepare an exotic sorbet. Simple reliable ice cream makers are commonly available these days at any big box store, and make your recipe into ice cream in 45 minute or less. Just remember to freeze the cylinder well in advance of using it. 

Wellness Wednesday: Creativity and Health

Yes! There is substantial connection between creativity and health. I started thinking about it today when my creative son Vale said he needs different parts in his day: some hardworking, others restful, and then finally, a creative time. The creative time is when he really recharges. I feel the same way. I crave that creative time almost as one would crave food or drink. 

What is the science behind this? To answer this, we need to remember that, on one level, we live in our nervous system. Our nervous system has two main parts: electrical and chemical. Chemical messengers called neurotransmitters convey information between neurons, long nerve cells, which then conduct electrical signals down their lengths. All our sensory input and thought output occurs this way. When we are creative, the brain is utilized in broad new ways, in a process that is both effort-requiring and pleasant. New neural networks are formed and older ones are kept healthy. More neurotransmitters are released. In fact, a Yale study (1) found that older "creatives"  have measurably more robust white matter of the brain, and tend to live substantially longer than non-creatives. Ok, so creativity seems to keep brain tissue healthy, which seems to be associated with longevity. 

It turns out that creativity also seems to impact the immune system. This was suggested in a small study of HIV patients, wherein writing was utilized as a therapy. Emotional writing versus non emotional writing was associated with a significant rise in CD4+ white cell counts. (2)

All form of creativity seem to be associated with positive health outcomes, from music, movement, to the graphic arts.

"There is evidence that engagement with artistic activities, either as an observer of the creative efforts of others or as an initiator of one's own creative efforts, can enhance one's moods, emotions, to other physiological states as well as have a salient impact on important physiologic parameters. " (3) 

Music has even been shown to help control pain. (3) 

Both being creative and experiencing the creative efforts of others improves measures of well being. On this basis, 

"... the arts are also being used to create safer hospital environments, introduce nature into medical settings and enhance aesthetics through hanging art on previously sterile space. And guess what? Patient/caregiver stress is measurably reduced, quality of care is increased, and costs of treatment go down. (4)

Numerous observational studies have shown associations between being creative  and the following outcomes: 

• increased happiness/enhanced mood
• less anxiety
• increased resilience
• better problem solving and mental acuity
• improved self confidence
• decreased tendency toward dementia
• increased longevity

What of the person who says they are not creative? First of all I think this is misconception. Creativity may be something you are, but it is also some thing you do, and something you can develop. Though I cannot tell you exactly how to be creative, I can give you a few hints. Creativity involves the following two traits/practices: 

1. openness- meaning mental flexibility and willingness to entertain new ideas

2. conscientiousness - which means carefulness and perseverance. Malcolm Galdwell has postulated that 10,000 hours at something is required to achieve mastery, and of course mastery is associated with that pinnacle of creative states, FLOW, but that is a topic for another day. 

Meanwhile have a look at my latest creative endeavor: 

References: 

http://www.ncbi.nlm.nih.gov/pubmed/21840401

 http://www.ncbi.nlm.nih.gov/pubmed/22807062

(1) http://www.jneurosci.org/content/29/16/5319.full

(2) Psychosom Med. 2004 Mar-Apr;66(2):272-5. 37 pts 

(3) Am J Public Health. 2010 February; 100(2):254-263. 

(4)https://www.psychologytoday.com/blog/arts-and-health/201004/arts-in-healthcare-creativity-the-health-it

Medical Monday: For the Autoimmune Among Us

Chances are, you know someone with an autoimmune condition. This might be Lupus, Rheumatoid Arthritis, inflammatory bowel disease, Multiple Sclerosis, or many others. I decided to post about this on my site since autoimmune disease affects so many women. 

I received a diagnosis of autoimmune disease (Lupus) in 1995, but probably had it long before that. And yet, I am fit and healthy. I believe my health habits have helped with this.

If you have received a diagnosis of autoimmune disease, be encouraged. How you do will depend on your unique disease process, but will also depend tremendously on how well you take care of yourself. Those with autoimmune disease and those that care about them can learn more HERE. 

Structure Sunday: The Structure of a Weekend

Did you know the the weekend as we know it is only about 100 years old ? I can't imagine life without the weekend. There is no natural correlate to the 7 day week. It is entirely man made and was probably designed in ancient Babylon. From there it was exported to the ancient Israelites and continued through the Jewish people through the idea of the Sabbath. 

However, it wasn't until 1908 in a car factory owned by Henry Ford, that Jewish and Christian cultures combined to give us the weekend. Before that time, workers would labor untold hours. Early labor rights were established after the French revolution, but even then their workweek was ten days on with one day off. Meanwhile in England, Sunday had evolved into the " Lord's Day" for rest and worship. 

In the late 1800s Europe was becoming more and more hostile to Jews. Immigration of Jews to America increased, and they entered the work force. Accordingly, the work force in Henry Ford's factory was composed of both Christians and Jews. The Christians took Sunday off, and the Jews observed Saturday as the Sabbath. To make everyone happy, the clever and diplomatic Mr. Ford created the two day weekend. Not only that, Mr. Ford popularized the weekend road trip... driving what ? You guessed it, his Model T. 

How did fewer working days effect commerce and productivity ? Somewhat paradoxically, research on the subject consistently shows that fewer work hours lead to greater productivity overall. Some say the sweet spot is a four day 8 hour work week, but that remains to be demonstrated. 

References: 

The Atlantic

American Public Media

Here is a rough version of what has been our ideal weekend routine: 

Friday evening: Dinner with family (with reference to the Jewish Sabbath)  something fun afterwards

Saturday morning: Catch up on sleep, brunch with family, outings, projects

Saturday evening: entertain 

Sunday Morning: brunch with family, clean house,  projects

Sunday evening: family dinner and get ready for the week

Here are some fantastic resources on having a great weekend: 

Lifehack

Reader's Digest

The Muse

Fast Company

Forbes

Entrepreneur

Pinterest 

Medical Monday: One step closer to a " female Viagra"

There is no doubt that female sexual dysfunction (FSD) is a problem in need of solutions. FSD takes many forms. The drug Flibanserin, the so-called "female viagra"  is under evaluation for treating hypoactive sexual desire disorder (HSDD). It is worth taking a moment to define HSDD. 

• "Persistent or recurrently deficient (or absent) sexual fantasies and desire for sexual activity."
• This state must cause "marked distress and interpersonal difficulty "
• This state must not be caused by "another...disorder, ...a substance (e.g.drugs of abuse, a medication) or a general medical condition." 

DSM IV, the Diagnostic and Statistical Manual of Mental Disorders 

When the FDA evaluates a drug, it must demonstrate both safety and efficacy. After three go rounds at approval, Flibanserin has been marginal on both counts. On June 4th, during this third round, it has passed recommended from the Bone , Reproductive and Urologic Drugs Committee to the Drugs Safety, and Risk Management Advisory Committee. 

Currently there are no drugs approved by the FDA to treat any form of female sexual dysfunction. There is a need. So it makes sense that Big Pharma  would submit some candidate drugs.

 In three different studies on Flibanserin, two primary endpoints were studied: sexual desire, and satisfying sexual endpoints (SSEs). 

Study results in summary: 

1. SSEs increase from a baseline of 2-3 per month by 0.5-1, meaning on average, there was half to one more SSE per month when flibanserin was taken, compared to controls. 
2. Desire increased minimally. 
3. Distress regarding sexual dysfunction decreased minimally. 

Concerns and side effects that surfaced:

1. hypotension (abnormally low blood pressure) 
2. syncope (fainting) 

The FDA states that concomitant use with alcohol was especially risky: 

"Hypotension anad syncope can occur with Flibanserin alone and the risk is amplified by drug interactions and concomitant alcohol intake. " (reference) 

So...Flibanserin does not seem like an ideal solution, but may be, like many medications, one tool in the toolbox to treat a given disorder. 

Sexual function is complex and sexual dysfunction is most generally multifactorial. It may involve physical, psychological and interpersonal factors. Check with your Ob Gyn if you have challenges in this sensitive area. 

Wellness Wednesday: Workplace Bullying

All the data I could find indicates that the vast majority of people, have at one time or another, experienced workplace bullying. As I have become a more careful observer of the years, I have learned to ask my patients questions about their work environment. 

What are the tip offs? When I notice increasing blood pressure, more frequent illnesses, less self confidence, more digestive problems, and hear about increasing stress, depression, anxiety and work problems, I suspect workplace bullying. 

When I ask about work, and get into the particular details, I often hear about a situation which would qualify as workplace bullying. But the surprise is this: Much of the time, the patient doesn't even realize that bullying is what is going on. 

What is bullying ? 

Workplace bullying is a systematic pattern of behavior that harms, intimidates, shames, undermines, offends, degrades or humiliates an employee, possibly in front of other employees, clients or customers. It is an abuse of power and a form of emotional abuse. It is a threat to health, livelihood and relationships. 

Once a patient realizes what it is, and a name has been put to it, she can begin to take steps to deal with it. But bullying is a complex human behavior and it is challenging to counteract. It is best to get outside help to deal with it. Most of the time it involves not only the one bully, but an overall workplace environment that is permissive of it. This is because it is difficult for bystanders to call out the bully, lest they become a target themselves. It is also difficult since bullies are generally highly ranking in organizations. Targets often fear for their jobs. Employers, when informed, are in a hard place, since they have not usually witnessed the behavior and moreover, they have an interest in keeping their more highly ranked employees. 

Nonetheless, bullying takes a toll on people and organizations. While bullies are more highly ranked, targets are often up and coming, and they pose a threat or perceived threat to the bully. Targets are often very productive likable workers. Organizations with bullies often start losing their best people. 

As a physician it is very important to me that my patients know about workplace bullying. I would like all of them to be in supportive home and work environments. Failing that, I would like them to have the tools to speak up against this form of abuse, whether it is done to them or to their co-workers. 

The references in this blog post are especially informative. Please take a few minutes to have a look at the resources on this very important topic. 

Stop Workplace Bullying 

Workplace Bullying 

What Workplace Bullying Looks Like in 2014--And How To Intervene

Workplace Bullying Institute

Wellness Wednesday: Quantify Yourself

I have always said that knowledge is power. This is especially true in this digital age since we have access to so much searchable knowledge. I have also always said that one of our primary goals in our medical practice is to empower women to take charge of their own health.  It is therefore natural that I am very interested in helping women to empower themselves through the use of technology.

It turns out that one of the most powerful things we can do to take control of and change our own behaviors is to observe, record and track them. This habit is called quantification. People who do this regularly as a part of their self improvement are participating in the "quantified self’ movement. Livescience.com defines the quantified self movement as a “movement which aims to measure all aspects of our daily lives with the help with technology.” 

Quantifying ones habits such as hours of sleep, minutes of exercise, or calories eaten, does not necessarily need to be done with a high tech device. It can be done with paper and pencil. However, since smart phones are nearly ubiquitous, these records are most often kept on these small powerful personal devices.  Of course there is a proliferation of different apps for this, one for every topic and several for many parameters. Not only is there a proliferation of different software apps to help with quantification, there is a proliferation of different hardware such the Apple watch and the FitBit. 

If the patient and I decide to follow some detail of her health such as her blood sugar, we begin some sort of record keeping. The patient makes the measurements, records them and naturally evaluates them herself as she goes through the week. This alone often results in substantial improvement in her numbers, since she can begin to discern patterns and the reasons behind them. Taking measures to push the data toward better performance is gratifying day by day. It becomes like a game that the patient is determined to win. This is called ”gamification" and it too, it is powerful in behavior change.

When the patient comes in to review her data, she can get even more benefit when we analyze her data together. If we add another layer such as her diet, and superimpose it graphically on the blood sugars in her records, we can see a cause and effect relationship between what she eats and her blood sugars over time. Sometimes a third layer of data such as activity can be added into her records and we can use this variable to improve her blood sugar control even more. 

This kind of record keeping puts the facts and the control in the hands of the patient. It is much more effective than a doctor simply telling her to eat better and exercise more. It has been my consistent observation that all sorts of patients have success with this type of approach. Moreover, in reading about this "quantified self movement" it seems apparent that this technique can be used for many types of conditions, like weight, exercise, autoimmune activity, sleep problems and even mood disorders. It can also be used for broader issues of life performance, in relationships and on the job. 

I hope this introduction into the quantified self movement has inspired you to learn more. Here are some fun references which makes for very interesting reading.

The Quantified Self, a TED talk by Gary Wolf

The Quantified Self at Livescience.com

The Beginners Guide to Quantified Self, at Technori

Why You Should be tracking Your Habits ( and how to do it well) at Lifehacker.com

The Quantified Self: How Cold Hard Data Improves Lives, at Bloomberg.com

The Data Driven Life, at the New York Times 

How Self-Tracking Apps Exclude Women, at The Atlantic

Medical Monday: Skin Deep

What does it take to be beautiful ? I mean physical beauty. It it feels so awkward to even ask this since, in general, beauty is mostly a matter of the heart.

 You might be surprised to hear about my idea of physical beauty. Basically, to me, physical beauty equates with health. Every face, every age, every body type, hair type or skin color is beautiful when it is healthy. 

Skin is especially telling. It is the first thing we see. The skin of the face is vulnerable and worthy of our protection. It is sun season again, and I would love to see everyone take pride in and care of their skin. 

What are the main steps to beautiful skin ? 

• Optimize your fitness, nutrition and hydration. 
• Cleanse and moisturize twice per day. 
• Exfoliate once per week.
• Sun (UV) protect ardently. 
• Never tan. Never. 
• Be assured sunscreen is safe.
• Chose a broad spectrum sunscreen with SPF 30 or greater. 
• Chose a water resistant brand. 
• Apply 15 minutes before going out so it will soak in. 
• Reapply every 2 hours. 
• Consider a hat or SPF clothing. 
• Get a partner to "watch your back" for any suspicious moles. 
• See your dermalogist for any concerns. 
• Enjoy summer. 
• Be beautiful. 

Food Friday: The Joy Lunch Club

Who doesn't look forward to lunch during a busy day tending kids at home or a hard day at work? I look forward to lunch. However, when I interview patients about their eating habits, I find all too often that patients skip meals, especially breakfast and lunch. 

I understand. We're busy. Sometimes we're not even hungry. We think skipping meals will help us lose weight. But as I have mentioned before, skipping meals actually causes us to lose muscle and slow down our metabolism and our thinking, making us feel sluggish and perform poorly. If we skip breakfast we are even less hungry than we would be had we jumpstarted our metabolism with a good breakfast. 

So, I have decided to promote the idea of a homemade workday lunch by issuing a challenge called the Joy Lunch Club. I will give the readers of this blog two weeks to submit a picture of their awesome lunch on a typical busy day. The best workday lunch photo at the end of two weeks will receive a custom "yoga girl" lunch box complete with containers and ice. To qualify, the lunch must be healthy, contain protein and produce like fruit or vegetables, be homemade, and if  brought to work, be in suitable containers. Photos may contain the lunch itself or you with the lunch. They should be posted to my office Facebook page linked to this website. Finally, to be eligible for the prize, you have to be subscribed to the site. (Please see the "Subscribe and Comment" section in the menu.)  At the end of the two weeks I will announce the winning photo, who's owner will then need to Facebook message me for the prize. Unfortunately I need to limit this offer to the US and Canada.

Others can order this unique lunch box through our Zazzle Store found HERE. Have fun, enjoy your lunch and good luck! 

Wellness Wednesday: How to have a Healthy Argument

I would like to say that couples and families can get to a point where they do not have arguments. However I believe that is unrealistic. Instead, I would present to you a list of rules which will help the arguments that do occur be fair, responsible and healthy. 

Click HERE to learn more.

Medical Monday: You asked for it… Endometriosis

Women are curious about endometriosis because it is a curiosity. The causes of endometriosis are not precisely understood but we have a good working knowledge.

We do know that it involves endometrial tissue being extruded out of fallopian tubes and into the pelvis. There, in a subset of women, the tissue implants and becomes active. Then, in a subset of these patients, this tissue secretes inflammatory mediators. Finally, some of these women develop autoantibodies. Pain and infertility can result from all of the inflammation and the damage that it causes. Cysts full of liquid can form; scarring can block tubes and distort anatomy. 

Treatments are of two types: medical and surgical. Medical therapy makes good sense because we know that endometriosis is hormonally responsive. Conservative surgical therapy is helpful to drain cysts, cauterize lesions, and release adhesions such as the ones in the photo. Definitive surgical therapy includes removal of the tubes, uterus and ovaries. 

Recently I was asked to review a blog post posted on my Facebook page. (See blog post HERE)  It was by a naturopathic doctor who was proposing a different approach to endometriosis. She was postulating endometriosis as an autoimmune disease. Apparently she had read a speculative literature review article, (Reference HERE) which noted an increased prevalence of inflammatory mediators and auto antibodies in those with endometriosis. Despite anything like a high level of evidence, (See levels of evidence HERE) she drew a causal relationship between these findings in the occurrence of endometriosis.

I think the authors of the study would consider these findings noteworthy associations, but would not feel entitled to draw any further conclusions such as causality.  I myself would say her blog post thesis is a case of confusing eggs with chickens. In other words, endometriosis probably causes inflammatory mediators to arise and fosters the development of autoantibodies, not the other way around as she proposes. Some people are more immunologically reactive than others, and those that are will likely develop more autoimmunity of whatever type. 

It is important to note that the author of the blog post draws a conclusion from this paper from which no conclusion can legitimately be drawn. She goes on to propose therapy, including modifications in diet, i.e. going off dairy and gluten. She then suggests her book which further discusses endometriosis and the "natural immune-modulating treatments" which she offers. 

I see two main differences between legitimate medical websites and others. First, legitimate medical websites are evidence based. This  means that not only must they cite medical research, but that they must cite it correctly, and not draw unfounded or speculative premature conclusions for associations which may be suggested. Secondly, legitimate medical websites are realistic. Others are boundlessly optimistic, offering readers and customers results that invariably surpass conventional treatments. 

I say, follow the money. Also, if it seems too good to be true, then it probably is. Finally, the proof is in the pudding. 

Click HERE for your internet learning toolbox. 

To learn more about endometriosis, check out our straightforward page on this common disease HERE. 

Structure Sunday: The Structure of Time

For life to be good, we need a rhythm in the day, the week, the month, the season and the year. These circles within circles allow us to feel accomplishment, and to look forward to celebration. These finite periods allow what is overwhelming to become manageable. Structuring time helps us take the one lifetime that is ours, and fill it mindfully. 

I need to feel I am making progress on my long term goals every year. I use the annual holidays like Thanksgiving and New Years for self assessment. I can look back at the same time one year back and see the changes. 

The seasons hold a different joy. Each time I am sad to see the leaves fall, I am, shortly thereafter, shocked by the beauty of frost and snow. I am reminded that all seasons hold beautiful surprises, and that I am foolish to imagine that nothing exciting is around the corner. 

My business cycle is the month. This is how bills are paid, and accounts are balanced. Accountability is examined month by month. Actual money is one representation of work and effort, and as such it is a useful tool to use in gauging how we are meeting our responsibilities. 

My work cycle is the week. I want a chance to get stuff done, and I want to be creative in that work. I try to pace myself all week long, with a lighter day midweek, then forge on to the weekend, when I would hope to be creative. 

My personal cycle is the day. I believe we all thrive with a good day's work. However, in my opinion, this includes some important health and productivity features. Consider the basics:  sleep , nutrition and exercise. Most people need at least 7 hours of sleep. With this, you will have more concentration, stamina and productivity. You might even have a better mood. Life is just more fun and you will be more successful with a modicum of sleep. 

Food is so important! It is your fuel. You should frontload your day with a healthy breakfast of protein, fruits, vegetables, and whole grains. That will turn on your metabolism and your brain. Later in the day, food can give you several healthful recharges: your midmorning snack, your lunch, and your afternoon snack. This way you will not tank your metabolism, feel sluggish, or hardly be able to think. Eating three meals and three snacks per day is a foundational principle of nutrition, and will help you feel better and perform better. 

Somewhere in the course of the day you must carve out at least a half an hour for exercise. It is best to schedule this formally, just like a meeting or an appointment, and to take it just as seriously. The magic of routines will reward you if you persevere. The more you do it, the easier it will be. 

 Everyone from a teen mom to the CEO of a large corporation needs a schedule. To achieve mastery over your time, you must invest in either a paper or electronic system. Smartphones generally come with everything you need in this regard, but the old school day runners can do just as well. But these alone won't do the trick. You must develop a routine of sitting down with the schedule to look it over and fill it in mindfully. I recommend looking at your schedule every Sunday to assess the coming week, and also looking every evening to prep for the next day. Make your schedule check a routine. The habit will stick better if you do it at the same time and place every day. 

Routine lowers stress. Breaking up goals and plotting them over time encourages success. These are among some of the most important things I want for my patients. The particulars I teach them about disease conditions and health maintenance will not help them unless they can follow through on the recommended treatment or prevention steps. Fostering patient success will continue to be a big thrust of this blog and the website in general. 

For more information, please see the hyperlinks in the text. Have a great week ! 

Food Friday: Manage your weight the counterintuitive way !

It seems to make sense that to lose weight we should eat less. On the other hand we all know certain people who seem to eat all day long and are quite slim. Indeed, the French who are known for their small figures, have food as a centerpiece of their culture, a lot of it, and all day long, well into the night. 

How is it possible? It's all about metabolism. It's not about the calories you eat in one sitting, and it's not about the calories you burn in one exercise session. It is about the rate at which you feed calories into your system and your body's ability to utilize them as they come in. 

To have good energy all day, you must have a moderate steady input of calories all day long. If you have a span of time without enough fuel, you body will turn down your metabolic rate and you will feel fatigued and be sluggish. If we eat episodically, then binge, we create a slow metabolism, then overwhelm it with an excess. Such an excess is stored as fat, even though then total number of calories eaten in that day might have been low. This strategy leads to feeling sluggish, losing muscle, and gaining fat all in the course of one day. 

Anyone would rather feel energetic and improve their body composition, but few know how.  Surprisingly, you have to eat more of the right kinds of food, and eat them more often. This produces a steady release of calories. To accomplish a steady release of calories into your system, you need to choose foods which singly, or in combination, release slowly. Unprocessed natural foods tend to release slowly, whereas process foods release quickly. If you combine high quality carbohydrate containing foods like fruits and vegetables with healthy fats or proteins, then you will have energy even longer. 

The rate at which a food digests and release energy in the form of glucose is called the glycemic index. Slow release foods have a low glycemic index, and that is what we should be choosing. If we choose high glycemic foods like sweets or breads, we stimulate a spike in our insulin levels, which leads to cravings. Thus, the less we eat of high glycemic foods, the less we want them. 

Do you want to leverage the system even more? Build up some muscle through a mixture of cardio and resistance. Muscle is lean body mass and has a much higher metabolism than body fat. Either cardio or resistance will increase your metabolism all day long, far beyond your exercise session, but together, they synergize. 

If you are willing to eat three moderate meals and three small snacks composed of some protein, fruits, vegetables, healthy fats and low glycemic grains, you will have more energy and you will drift toward your ideal weight. If you are willing to do a half an hour of cardio and light resistance every day though a gym or a DVD available at any big box store, you will make progress even faster. 

To learn more, see this following section in our website. 

Nutrition 

Bon appetite! 

Wellness Wednesday: Common Illnesses in Pregnancy

I was inspired to write this post in light of the significant spring cold season we are now finishing. It is common knowledge on the medical hill that this spring's common cold was a bad one.  For most people, the cough lasted several weeks, even though the illness itself was over. It was not pertussis, it was not flu. It was just a garden variety virus that hit hard. 

So I am going to take a moment and talk about prevention. Prevention takes three forms: 

1. Vaccinate for what you can: Pertussis, and Influenza

2. Hand washing and avoiding the sick. 

3. Keeping up on self care with exercise, sleep and nutrition. 

They really are immensely effective. 

Outside of pregnancy, when we get a cold or stomach flu, we doctor it ourselves. But in pregnancy it is different. In pregnancy, it is a good idea to touch base with your doctor about your symptoms if they are anything more than slight. She can give you a few guidelines and recommendations, even if no antibiotics are prescribed. On that note, just as a reminder, most of these common infections are viral, and as such, do not respond to antibiotics. That said, some viral infections can be followed by a bacterial infection. This may be the case if one gets better, and then worse again. Additionally, some viral upper respiratory infections can set off asthma and we can help with this too. 

I set up a page for common illnesses in pregnancy HERE and I couldn't help but notice that in all cases, treatment included, lots of liquids, like tea, soup, and water. Self care included tylenol, since ibuprofen is not recommended in pregnancy, rest and lots of baths and steamy showers.

Perhaps we shouldn't wait for an illness to take good care of ourselves. 

Medical Monday: Gardasil Gets an Upgrade

Most of you are familiar with Human Papilloma Virus, aka HPV. This is the very prevalent virus which causes precancer and cancer of the human anogenital area. When I first started training in gynecology, fighting HPV seems like such an uphill battle, since it spreads so easily and is so prevalent. And then came the idea of a vaccine. It seemed too good to be true. 

Gardasil was developed and released. I am proud to say one of my friends was involved. It protects against two strains of HPV known to cause cancer, and two which cause condyloma or warts. Physicians all over the world rejoiced, but adoption rates weren't what we had hoped. 

Gardasil was initially studied in girls and women since the disease caused in women is more common and more severe. And so it was initially approved only for women. I got all my children vaccinated, and even the boys before it was approved for boys. One of my sons did some research after he got his shot, and approached me later, asking, " Mom isn't this just for girls ? " I reassured him that nothing bad would happen. It works just as well in boys and men, who distribute the virus, usually without having any disease themselves.  It eventually was approved for boys. 

Now Gardasil has been expanded to cover NINE viruses ! It is worth noting who is eligible to receive it: 

Boys ages 9-15.

Girls and women ages 9-26. 

 I expect that the age differential in eligibility between boys and girls is simple a case of what groups have had validating studies done, and I anticipate that the boys group will be expanded to the same age group as girls eventually. 

Chilling statistics anyone? 

" In 2013, coverage of at least one dose of HPV vaccine was 57.3% among adolescent girls and 34.6% among adolescent boys2. According to the CDC, for every year that coverage does not increase, an additional 4,400 women will develop cervical cancer3. Furthermore, if health care providers increase HPV vaccination coverage to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years." 

reference: ACOG Clinical Practice: The 9-Valent HPV Vaccine 

Gardasil has had a very good side effect profile, with just some arm soreness at the site. We believe its benefits far outweigh the risks. 

To learn more about HPV, please see Pap Smears, HPV and Cervical Health. 

Structure Sunday: The Structure of Mothers

In my practice, we do gynecology, surgery, prenatal care and deliver babies.  However, sometimes I think we are helping to make mothers. Usually we spend 30 weeks with a woman and then go through some very intense and uplifting experiences with her. Along the way, we learn all about their background. We help them face challenges that arise. We try to address whatever needs addressing from eating habits to referrals for domestic violence. We try to uplift, we try to empower. We try to help them become good mothers. 

At the beginning, I tend to notice the things I need to address, the problems.  But as the weeks pass, I notice the things that are unique and special about each patient. Somehow, the problems and the virtues are all wound together. These complex dynamic women most always do their best, learn a great deal, and are sent home with a newborn, who will respond to everything they are, and the new world they inhabit.

These worlds are seldom perfect. I think back to my mother, the last of 8 children, born in 1917 in Oklahoma to a poor coal miner's family. Her father, once a foreman, had saved his team of men after an explosion deep in the mine. He suffered severe burns and disfigurement. Thereafter, the family descended into poverty. When she was 14, she was married off to an alcoholic older man. I later learned she endured extensive abuse. 

When I was adopted, she was already 45 and remarried to my dad. She was not easy to be with. Even as a young teen, I knew she was not like my friends' mothers. It was only as a young doctor that I began to understand what she had gone through, and the effect it had on her. Without a doubt, she had PTSD. She was angry, insecure and sold herself short. I could go on. I was angry and disappointed at her for not trying harder in life. 

As my medical career developed, I saw more women like her. As my role as their doctor taught me compassion, I developed a compassion for her. But of course, this was near the time she passed in 1990. At the time I lived with her, dealing with her difficult behaviors made it hard to experience the good things about her. Of course there were good things. I can see them better now.

I can remember the joy she had shopping for nice clothes for me, something she never had when she was a girl. I can remember how she liked high heels and going out to dinner. She made excellent pie crust. She admired Jackie O. She loved the sound of black women singing. She loved Christmas, and carols, and gave lots of gifts. She told me my education would make it so I would never have to rely on any man. 

After she escaped her first husband and before she married my dad, she worked in a factory assembling bombers. She was a real Rosie the Riveter. After that, she became a bookkeeper at a firm in Los Angeles. She looked ten years younger than her age, even though she picked up smoking as a young women in order to look elegant and independent. She quit smoking cold turkey on post op day one after her quadruple bypass, but died of heart disease anyway eight short years later. 

I am looking back through time so you can too. I am also looking back so perhaps you will look at the present differently. Your mother may not be perfect. But it is still incumbent upon you to see the good with the bad, to see her as a whole person with understanding, compassion, and appreciation.

I also write to remind us that there is a good mother inside all of us. She just may need a little help coming out. 

Structure Sunday: The Structure of a Website and ….YOU

Just last week Google lowered the boom and decreed that sites that are not mobile friendly will suffer in search rankings. At first I felt a little threatened, but after a little research, I have discovered that it is all about….YOU! Yes you. As they say in TRON, “I fight for the users.”. 

I love nothing better than to come into a patient’s room and see her on a smartphone. Do you realize any garden variety smart phone of the present day is literally powerful enough to have run the entire Apollo space program that landed a man on the moon? A smartphone is a very powerful computer and almost every girl and woman I know has one, even the ones of modest means. It is fantastic. Not only do I remember the Apollo missions, but I remember the days when women did not touch technology, not even stereo components. 

Technology is empowering. Information is empowering and the whole world of information is at your fingertips. Patients read about diagnoses, medications, and communicate with others who share their experience. So it is with great satisfaction as I watch my patients as they not only use technology, but make it. I have in my practice graphic designers, filmmakers, website designers, software engineers and IT administrators. I do believe it is technology combined with the goodwill of people, that will solve many of the world’s problems and inequities. As a force in neutralizing gender inequalities, technology is formidable. 

In blogging, and in making this website, I have wanted to provide easy access to what I would like my patients to know. My education has made me  familiar with the best sources of medical knowledge, i.e. institutions like the National Institute of Health (NIH), and the Center for Disease Control (CDC). It has enabled me to tell the legitimate from the bogus. So I feel obliged and enthusiastic to give you all key to all the doors that lead to the best paths to all this valuable information. I want to make it easy, and I want to make it fun. Additionally, I want to make it beautiful. Perhaps this last goal is a universal desire for website designers of all genders, but I think a beautiful website is more welcoming to women. 

And that user experience, in short, is what Google’s directives have been all about. I see from my website analytics that over 50% of you view the site on mobile devices. Had I looked to author my site looked on mobile? Not enough! The main page was cluttered, the font was too small, links were too small to push and you had to scroll way too much. All this gave me a very bad mobile rating on Google. Plus, page loading times were a bit long, and I admit, that is because of the higher definition photos that I chose to upload. This was all a very unpleasant but useful revelation. I felt bad but grateful for all of you devoted readers on mobile who slogged through all of that. 

I read a great deal in Google’s website design and mobile responsive design guidelines. At their heart, the recommendations are meant to enable you, the user, to see the site clearly, and to get the information you want as conveniently as possible. It is all about enhancing the user experience. I spent this weekend changing things around, using fewer main pages, and tucking more within them, so now you will do more clicking and less scrolling. And I promise, if you have a little wait for a photo, it will be a good one. More mobile friendly changes are coming next week. I fight for the users! Those of you who really want to get your geek on can learn the origin of the phrase in this clip from the movie TRON Legacy. 

Food Friday: Food for the postpartum mom

Food is a traditional gift. But, for the postpartum mom, it is best given with some forethought. 

Consider whether it would be best to do a fresh, ready to eat meal or maybe a freezer dinner for later. Make sure to find out about any allergies or food preferences before you prepare. If you do choose a freezer dinner, make sure she has enough room in the freezer. If you need recipes for make ahead meals, there is a wealth of them on food.com, epicurious.com, and of course Pinterest. For a deluxe gift, get together with a few of her friends and assign each person a meal for each day of the week for the first week she is home.  Friends did this for me once and it was so much fun. 

The breastfeeding mom needs between 300 and 500 calories or extra nutrition after the delivery of the baby. She especially needs high quality proteins, healthy fats and fluids. As far as food restrictions because of baby, there really are none. I have always taken the view that baby will to learn to like garlic, chili and chocolate just like I do! There really are no medical reasons to avoid strongly flavored foods when you are breastfeeding. 

Food gifts do not have to be meals. They can be baked goods or even a basket of healthy snacks or a case of healthy drinks like Pellegrino water. 

Gifts do not even have to be food! If you are fairly familiar with the new mom and her home, consider a gift of housekeeping, gardening, pet care or personal shopping on her behalf. You can draw up a cute certificate to present to her if you like, and she can cash it in when she prefers. 

Just remember that the new postpartum mom is bound to be tired. While your gift is almost certainly welcome, your postpartum friend might not be up to a great deal of socializing. So keep your visit short and sweet. 

If you are interested in information about breastfeeding and nutrition, please see the links below at on drginanelson.com. 

Breastfeeding 
Nutrition 

In other news, I am happy to report that all of the pages on drginanelson.com finished. Of course we are still polishing them, adding new handouts, and perhaps an occasional new graphic. Nonetheless, our collection of topics provide a cohesive overview of knowledge from Obstetrics, Gynecology and healthy lifestyle that is up to the minute in accuracy.

In the next week or so, I will be reorganizing the site a bit to make navigating this content simpler and easier, especially for mobile. In all cases, your input about content and ease of use would be most welcome. There is a feedback box you can access in the left menu bar from every page on the site. 

Stay tuned for more posts on Structure Sunday, Medical Monday, Wellness Wednesday, and Food Friday.