Medical Monday: Breaking News from the World of Obstetrics, Gynecology and Women’s Health

The HPV vaccine has recently been vetted at the European Medicines Agency (EMA, the equivalent of the FDA). The EMA concluded that the benefits of Cervarix and Gardisil outweigh the risks. CDC (Center for Disease Control) Director Tom Frieden estimates that increasing the HPV vaccination rate to 80% would prevent 50,000 cases of cervical cancer in women.

Echoing results from last week, a study published in the Journal Hypertension has shown that those who had high blood pressure in pregnancy double their risk to develop the condition later in life. For diabetes, the risk quadruples.

Our largest and most foundational study on postmenopausal hormone therapy, the Women's Health initiative, (2002) was noteworthy for the fact that overall “estrogen plus progestin hormone replacement therapy" increased risk of "heart disease and breast cancer”.

Well the devil is always in the details, and sometimes angels too. It turns out that age makes a big difference the development of heart disease risk. If you “unpack" the data, you will see that women between the ages of 50 and 59 actually had a protective benefit to using hormone therapy, while women over 60 did not have the same advantage. Is interesting to remember that in this study all study participants  had never before taken any postmenopausal hormone replacement therapy. Therefore those who were 60 and older entering the study were beginning their hormone therapy approximately 10 years after the onset of menopause. Some researchers believe that it is that block of time after menopause but before initiation of hormone therapy in which silent atherosclerotic developed. If this is true then cardiovascular disease manifesting during the course the study would not really have been caused by the hormone replacement under study. Optimistic speculation leads us to wonder if women over 60 would do as well as their younger counterparts if they're hormone therapy has been started at the onset of menopause. It would be nice to know whether or not it is the youth of the women that caused them to do well with hormone therapy in their 50s or the fact that they started their hormone therapy immediately after the beginning of menopause.

It is interesting to note that age at the beginning of the study did not affect a woman's risk of breast cancer. Use of "estrogen plus progestin hormone replacement therapy” was and is clearly associated with increasing risk of breast cancer. (The same cannot be said for those who are able to use estrogen alone as their hormone therapy.) The lead investigator in this most recent study, Dr. Joanne Manson, indicated that "for every 1000 women per year not using hormone therapy, about 3 develop breast cancer” versus 4 out of “every 1000 women” using combined estrogen plus progestin hormone therapy.

A recent study has shown that only about half of women visited the dentist during pregnancy. Dental care in pregnancy is critical since many oral and tooth diseases have a direct impact on the pregnancy including increased risk of preterm labor.

Former Republican representative from Georgia Phil Gingrey has criticized the recent US Preventive Services Task Force (USPSTF)  recommendations on mammography citing the differing recommendations of the USPSTF, the American Cancer Society, and the American College of Obstetricians and Gynecologists. He has urged for more time to study the basis of these differing recommendations, so that we can "analyze the research and arrive at a medical consensus”. He has introduced a bill entitled “Protect Access to Life-saving Screenings”, (PALS). This bill would place a two year moratorium on the USPSTF recommendations.

I am all for this and I dare say a great deal of unpacking the data will be necessary here. What will be important in the conversation is identifying the “harms" of screening. And please don't talk to me or the breast cancer survivors in my life about fear of and pain from mammograms, which have been cited by the USPSTF as harms. Besides this, it will also be imperative to study endpoints, not only survival, meaning and lack of death, but years of life. It seems like a subtle distinction but it seems to have been lost on the US Preventive Services Task Force thus far.

Support has come out for treatment of subclinical hypothyroidism (low thyroid) in pregnancy. A new study presented at the International Thyroid Congress has shown that treatment with synthroid or Levothyroxine in pregnancy for those with subclinical hypothyroidism “was associated with decreased low birth weight and Apgar scores". It was not however associated with a significant decrease in miscarriage. This will probably tip the wobbling scales in favor of universal thyroid testing in pregnancy. 

Any study recently published in the December issue of Obstetrics and Gynecology has shown that yoga is safe even late in pregnancy. Study participants were put through various yoga postures and measurements were taken of heart rate, blood pressure and other vital signs for mother and or baby. Although mothers often opted for various modifications of their poses, no ill effects were found.

In more happy news, the United Nations and the World Bank jointly issued a report Thursday noting that maternal death rates have dropped 43% worldwide since 1990. This is attributed to better access to higher quality health and sex education services.

Stay tuned for more news from the world of OB/GYN and women's health, next week on Medical Monday.

Wellness Wednesday: Gratitude is at the Center of Wellness

Most people think of gratitude as a feeling. Actually, it is a practice. Did you know that there is a science of gratitude?

Major academic centers the world are investing in gratitude. Gratitude is studied as a part of a relatively new branch of Psychology called Positive Psychology. A landmark study in the Journal of Personality and Social Psychology, 2003, volume 84 number 2, entitled “Counting Blessings versus Burdens: an experimental investigation of gratitude and subjective well-being in daily life." This research suggested that”...a conscious focus on blessings may have emotional and interpersonal benefits”.

Much more recent research since then has also underscored the physical health benefits of gratitude. Most of us understand by now that the mind and body are connected on a neurophysiologic level, and while it is fascinating, it is no surprise that a mental practice such as gratitude could go on to have concrete benefits to physical health. 

What is gratitude, the practice?

Prof. Robert Emmons, the author of”Gratitude Works !" recommends establishing a full on gratitude ritual. These can include the following:

Gratitude Works!: A 21-Day Program for Creating Emotional Prosperity

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• Make a resolution or vow to practice gratitude. 
• Make a plan to practice gratitude. 
• Have a morning gratitude ritual. Examples would be glancing over your gratitude journal or meditating for a few minutes about what you are grateful for. 
• Adopt the physical habits of gratitude such as smiling and making eye contact, saying hello,, saying please and thank you, and making a physical gesture such as handshaking if appropriate.
• Send written expressions of gratitude such as emails and thank you notes in paper.
• Place objects or other visual cues in your house, office, or where you can see them to remind you of something for which you are grateful.
• Keep a gratitude journal. Make it brief but make it regular. If you keep it by your bed you can glance at it first thing in the morning.
• Go out of your way to remember good times.

What will a practice of gratitude do for you?

There is an enormous body of science from a variety of sources that indicate the following effects of gratitude:

• Stress reduction
• Improvement of a immune function as measured in the bloodstream.
• Better recovery from loss, i.e. Better resilience
• Higher levels of life satisfaction.
• For students,better grades.
• It makes you a better friend to others.
• Improved sleep.
• Strengthens interpersonal relationships
• Improves team functioning 
• Greater alertness
• Greater enthusiasm
• Greater goal attainment.
• Lower levels of depression
• Enhanced capacity for empathy
• Improved self esteem
• Reduced aggression
• Decreased loneliness
• Greater tendency to act with generosity and compassion
• Increased energy.

Gratitude

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This is not just new age foo foo nonsense. Institutions such as Stanford, Harvard, and Penn, not to mention Google have thrown serious money, time, and entire departments into the pursuit of the evidence based effects of gratitude.

So this Thanksgiving, capitalize on this most important of national holidays. Find your gratitude, and keep it going. 

References and Additional Reading: 

Pass the Gratitude: Recipe for a happy Thanksgiving, From Huff Post Los Angeles

In praise of gratitude, from the Harvard Mental Health Letter

Seven scientifically proven benefits of gratitude that will Motivate you to Give Thanks Year-round from Forbes

Expanding the Science and Practice of Gratitude, From the Greater Good Science Center at the University of California, Berkeley

Why gratitude is Good for You, From the Stanford Social Innovation Review

Medical Monday: Breaking News from the World of Obstetrics, Gynecology and Women’s Health

Happy Monday ! This week, in addition to reading the news and doing your normal workweek, you get to start seriously preparing for the holidays.  Enjoy the process !

Postpartum depression is in the news again, and this is a good thing. “ Shots” blog by NPR ( National Public Radio ) has run a story about a woman, Paige Bellenbaum,  who went through this. She has since recovered and has become an activist on the subject, and helped to write a bill in New York “ aimed at educating more families on the symptoms of maternal depression.” The bill also promotes screening through the Pediatrician's office. Early treatment for postpartum depression is, of course, more effective. 

Research findings presented at the NCI ( National Cancer Institute’s) annual conference underscored that increasing parity ( the more children you have ) reduces risk of ovarian cancer. The first child reduces the change of this cancer10% and each subsequent birth reduces it 8% more. While no one would decide the number of children they wanted based on this, it is interesting and may spur further research about how ovarian cancer comes into being the first place. Hopefully this will ultimately yield clues on how to prevent and treat this awful disease. 

New research published in the Journal of Diabetes Care indicates that women with central obesity (higher levels of abdominal fat) are more likely to develop pregnancy associated diabetes here. Of course it is also known that women who get gestational ( pregnancy associated diabetes) are more likely to get Type 2 Diabetes later in life. Moral of the story: Get in good shape and at your correct weight before pregnancy and in-between each delivery. 

Also hot on the trail of gestational diabetes (GDM), s study presented at the Conference of the Society for Endocrinology indicates that women who are sedentary in the first trimester are more likely to get GDM. They defined sedentary as sitting more than 6.5 hours per day. Has anyone ever tried a standing desk ? Personally I think the best thing at work is to alternate siting and walking about at frequent intervals. Also naps, mid afternoon. Wouldn’t that be cool ? 

The CDC ( Center for Disease Control) reports that half of pregnant women are gaining too much weight in their pregnancy. IOM ( Institute of Medicine ) recommendations indicate women with a normal BMI ( body mass index) gain about 18.5 an 24.9pounds. Smaller women should gain more and larger women should gain less. 

Wow this week's news sure had some common themes. 

To help you stay in the know very quickly, don’t miss Medical Monday.

Food Friday: Carbohydrate Intolerance

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

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

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

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

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

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

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

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

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

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

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

Wellness Wednesday: How to Start Your Fitness Routine

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

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

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

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

SMART means: 

• SPECIFIC
• MEASURABLE
• ATTAINABLE 
• RELEVANT
• TIME BOUND 

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

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

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

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

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

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

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

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

Medical Monday: Weekly News Update in Obstetrics and Gynecology

Good Monday.

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

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

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

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

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

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

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

Structure Sunday: The Structure is Changing !

As of today, I have done precisely one year of regular blogging four days per week. Medicine, Fitness and Nutrition lend themselves to easily written useful blog posts, and they are also easy to illustrate. Structure Sunday, however, is rather bookish. It requires more thought, and is probably worth more in the long run, but it is not as easy or convenient to read. 

For this reason, I am going to streamline down to three blog posts per week, continuing all on schedule except Structure Sunday. This energy and this material is going to go toward books. I have several planned or partly written, and with some allotted days to work on them, they will come to completion. When this type of longer material is put in book form, only people who want these longer pieces will get it. 

I would love to know what you think about the change ! 

I am also curious about any subject you would like to see become books. 

Finally, do you prefer your ebooks as Kindle or Ibooks ? 

Looking forward to your feedback, 

Dr. Gina 

Wellness Wednesday: The Wellness of Being Yourself

My new T shirt 

As most of you know I recently returned from my alma mater, nerd nation, the mothership, Stanford University. Here is a group of misfits so diverse and enthusiastic that they just might save the world.

Wikipedia defines nerds as follows:

Nerd (adjective: nerdy) is a descriptive term, often used pejoratively, indicating that a person is overly intellectual, obsessive, or lacking social skills. They may spend inordinate amounts of time on unpopular, obscure, or non-mainstream activities, which are generally either highly technical or relating to topics of fiction or fantasy, to the exclusion of more mainstream activities.[1][2][3]

The Wiki goes on further to add the following:

"Nerdy" interests[edit]

Some interests and activities that are likely to be described as nerdy[by whom?] are:

• Intellectual, academic, or technical hobbies, activities, and pursuits, especially topics related to science, mathematics, engineering, linguistics, economics, literature, sociology, geography, mythology, history, and technology.[citation needed] (See below)
• Hobbies, games, and activities that are described as obsessive and "immature", such as trading cards, comic books, fantasy and science fiction novels, television programs and films, role-playing games, tabletop games, and video games and anime.[citation needed] (See below)
• Interest in the fine arts, non-mainstream music such as classical, progressive rock, techno, or folk music, hobbies (i.e., collecting), or other "obscure" interests.[citation needed]
• Heavy obsession with a topic that would otherwise be mainstream (such as a popular TV show or a sport).[citation needed]

Reality Is Broken: Why Games Make Us Better and How They Can Change the World

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Jane McGonigal writes convincingly in her book “Reality is Broken" that the gaming community is full of people with great capacity to focus, as well as a passion for adventure and righting wrongs. She proposes to harness this energy for good and not just for gaming. This nerdy passion for adventure and justice combined with an intense capacity for focus was just what I saw at Stanford.

I returned from nerd nation inspired and encouraged. However I also found myself with a number of questions. Have I had enough faith in myself and the world? Have I tried enough new things ? Have I developed myself to my fullest potential? Have I done enough to make the world a better place ?

There is the temptation for these questions to become very heavy. However, in nerd nation, there is the acknowledgment that everyone is unique and that everyone has something unique to contribute. It was provocative nonetheless to meet a considerable selection of people who are doing things that could actually change the world, and by change the world I mean things like discover life on other planets or cure cancer. It is even more provocative to consider that most of these nascent accomplishments were not that hard. Rather than coming from brute force of mind, they came from unencumbered creative thinking, an environment supportive of trial and error, and steady efforts in a collegial team environment. 

On balance the visit was more empowering than daunting. This is where the connection to wellness becomes evident. I have written before about the connection between wellness and creativity. I have also written about the connection between learning and wellness. There is clearly a connection between wellness and altruism. I write now to encourage all of us to have a little more faith, a little more creativity, maybe some continuing education, maybe a little travel to get us out of our own heads, and more drive to make the world a better place.

Get your nerd on people.

Food Friday: Travel Food

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

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

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

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

Medical Monday: Weekly News Update in Obstetrics and Gynecology

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

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

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

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

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

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

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

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

Structure Sunday: The Structure of Prevention

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

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

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

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

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

Mind: 

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

Read them upon arising. 

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

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

Meditate for 10 minutes per day. 

Have about 6 close friends. 

Consider having a partner. 

Have a pet of whom you take good care. 

Ensure your work is meaningful. 

Don’t overspend. 

Take your allotted vacations. 

Body: 

Wash your hands at work and when you get home. 

Get your required vaccinations. 

Sleep at least 7-8 hours a night. 

Wear seat belts. 

Use sunscreen.

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

Avoid simple refined carbohydrates. 

Use olive oil and green tea. 

Ban soda, smokes and drugs. 

Limit to one wine or beer per day. 

Drink 3 liters water per day. 

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

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

Incorporate yoga every week. 

Super basic, right ?

Super powerful.

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

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

Weekly News Update in Obstetrics and Gynecology

Good Monday news readers. 

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

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

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

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

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

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

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

Structures Sunday: the Structure of Studying

I'm a perpetual student. You may not realize it but in certain circles this was considered an insult. I now realize it is good thing. Indeed life long learning is the only way to go.

I have already blogged about the importance of reading and creativity. Those of you who know me realize I have a number of serious creative pursuits, Since we are approaching Halloween, I am deep in preparation to sew a detailed costume. For these sorts of things as well as my work, I have to study. That's right, study.

For my costume I have had to research everything from specialized sewing machine feet to the thermal properties of craft foam. For my amateur photography I have had to research telescope eyepieces and how to connect a old school serial port to a USB port.

Tonight for example I am deep into my annual board review preparation. Every year we have to review research articles and take tests, But every 10 years or so we have to take a big test and that is what I am preparing for this week.

Additionally, I am aware of many of my friends and their adjustment to the new school year. Bottom line: all parents home school, even those parents whose kids go to public or private school. That's how I felt anyway when my kids were in grade school and high school. Every day when I would come home from work I would simply change hats and I would turn from OB/GYN to homeschool teacher. I would check in with each of my kids to see what they had to do for homework and upcoming tests. I would check in on how their classes were going. I might take a some time and give them a little supplemental information on a topic if I happened to know something about it. Finally I would monitor their study habits. As much as I think they found it irksome, I think even they would admit it has served them well. 

So what are good study habits? There are numerous books written on the subject which are beyond the scope of this blog post and well worth reading. I just want to emphasize that you should stay intellectually and creatively active as a part of your overall good health. I also want to empower you to get involved in your children's academic life. So here are a few basic tips for studying that will serve you as a parent coaching children, a student, or simply as an adult keeping her intellectual and creative life healthy.

• Get an overview of the task at hand. Even grade school children should know that school goes in semesters or quarters. They should know when the tests and quizzes are given, and when their assignments are due. Both children and adults should have a simple clear system for writing this down. It can be either digital or paper. Their should be a daily and weekly routine for referring back to this schedule. That makes for no surprises and less procrastination. 
• Prepare. It does not matter whether you are preparing for a book report in seventh grade or a board exam when you are a doctor, preparation is key. Learn to channel your anxiety and concern into an early jump start on your project. This is imperative because it alleviates stress and gets the job done.
• Know how to study. Here is a general method for low stress, effective preparation. 

1. Scan the material for an overview.
2. Read the material thoroughly.
3. Highlight the material thoroughly.
4. Make your own handwritten notes from your highlights.
5. Make index cards from your handwritten notes, using a brief description on one side and more complete details on the other.
6. Quiz yourself on your index cards. Do it out loud. When you do, put the ones you know well in one pile and the ones you need to review in another pile. Repeat your index card quiz, this time only with the pile that you need to review. Again, put the ones you fully understand in the good pile and the ones you need to review in the bad pile. Repeat the process until there is nothing in your bad pile.

It turns out that getting as many senses involved in your learning helps. The technique described above involves several senses, sight, touch, and hearing. Reading, writing with your own hand, and seeing what your own hand has written or hearing yourself read what you're own hand has written reinforces the learning of information on multiple levels, indeed in multiple areas of brain.

This is all well and good if you simply need to learn facts. However, if you need to know how to work problems, that comes next. Work on all the problems you can two or three days before they are due. That way you have a chance to go in and ask questions well before the problems need to be turned in. If you are a parent supervising children with homework like this, be sure that they do their assignments at least two days before they are due. You will ingrain this kind of habit in them for the rest of their life, and that will serve them well. And don't forget to lead by example.

If you're working with older children who will be taking tests, coach them a little bit in test preparation. Emphasize early and repeated contact with material as well as working of every problem that the teacher has handed out. Encourage students to use practice tests that have been provided to them and that are available on the Internet. Encourage them to fill in their understanding with information they find on reputable Internet sites such as Khan Academy. Have them try finishing the test preparation the day before the test is given so that they can spend that day asking the remaining questions. Tell them not to be afraid of being like Hermione Granger and having their hand in the air all the time. 

Make sure you and your children have a good night’s rest before any tests. I realize this is easier said than done but it is sound advice. In fact, make sure they are well rested before any school day. This will maximize their ability to learn. Equally important is a good protein rich breakfast, especially before tests.

It is important that if you are parents supervising children in their studying or their homework that you be supportive not harsh. Regardless of what you may think of their teachers, encourage courtesy toward the teacher. To do otherwise is a disservice to your child. 

Is very important to remember that if you are helping someone with their work, you're principally helping them to understand how to do the work themself. Under no circumstances do you do the work for them. You may work a similar problem for them to see, since that is different.

A healthy creative and intellectual life has been proven to benefit health. This is true for both adults and children. I hope these tips help make your studies easy and fun.

Food Friday: Soup is Soul Food

Every cook should know how to make homemade soup, especially those on a budget and those interested in eating healthy.

Two weeks ago I wrote an unusual post about how to make soup stock. It might seem like an unusual post for blog on Obstetrics, Gynecology, and healthy lifestyle, but not when you take a closer look.

One pillar of healthy lifestyle is healthy eating and another pillar is a healthy home life. Home cooked food can help with both. Soup is one of the most comforting and potentially healthy home cooked foods. It is also one of the easiest, of course once you know how. Homemade soup is also one of the thriftiest things to make since you can utilize leftovers and assorted ingredients from the refrigerator, garden, or pantry.

How to start? As always, start by cleaning up any stray dishes in the kitchen, organizing, and assembling your ingredients. Thaw any broth you have frozen. If you have not made frozen broth you can obtain good organic broth in three different flavors at any natural food store. You can also get a jarred  broth concentrate, also organic, at most grocery stores and at Costco as well.

Determine the vegetables you want to include. I'm a fan of great variety, But you can also make a vegetable flavored soup and emphasize one or two flavors such as red pepper. Prepare all of the vegetables by washing trimming and cutting them to the appropriate size.

I try to ask my patients to emphasize the protein in their diet. Decide what the protein in your soup will be. Consider chicken, red meat, fish, seafood,or even eggs. Cut your choice into bite-size pieces.  If you can tolerate legumes like beans and peas and can handle the carbohydrate that they bring, those can be included as well. Prepare all these ingredients so that they are ready to put in the pot.

I like to try to make my soup with only one pot. Choose your pot based on the volume that you want to make. Make sure it is extra large so that when you stir it with a long wooden spoon nothing will spill out.

Use a good cooking olive oil to sauté your first ingredients.These would include garlic, onions, or chilies if they are in your recipe. You will do them first so that they will flavor the oil. Make sure to use enough olive oil on the bottom of the pan. After this, Add your meat, chicken, or fish. Sauté until golden brown, but not fully done. I like to add fairly heavy spices to the cooking meat at this point since the flavor seems to penetrate better than adding it later. Then add your vegetables one by one and cook them until partially done, going from the hardest such as carrots to the softest such as spinach at the last.

When everything seems partially and evenly done, add liquid. I usually add a a half a cup of either red or white wine first. This adds to the depth of flavor. Then I add my broth, at least enough to cover all the hard ingredients, and usually more. I may or may not add a can of diced or stewed tomatoes, depending on the flavor I want to achieve. All you have to do at that point is bring it to a boil briefly, then simmer until the hardest vegetables are fork tender. If you intend for your meats to get very tender, they will have to simmer at least a couple hours. 

This is a good general recipe for a variety of different kinds of soup. You can make it with a large variety of different vegetables and if you add beans and a little pasta it turns out like a minestrone. If you add only a few vegetables and a lot of beans, tomato paste as well as onions and chilies, you have chili. You can pick a vegetable theme such as green vegetables and limit yourself to just a few onions, leeks, spinach, and kale. If you make a broth-y chicken soup with napa cabbage, ginger and green onions, you can drop whisked eggs into it and have egg drop soup. You can do the classic pumpkin soup especially at this time of year. Or you can go with the popular roasted red pepper soup.

If you have athletes, children or adolescents in the home, you can afford to serve this soup with a good whole-grain bread. Otherwise, it should stand on its own. You can always add a side salad and cold glasses of milk, to round it out.

Have fun with your soup and add some garnish. Garnishes can be anything from grated cheese or sour cream to minced green onions, parsley, crumbled hard-boiled eggs, sliced almonds or Siracha sauce. 

You will find that people tend to gather around a kitchen table with a good homemade soup. Having a sitdown family dinner with soup is good for health and good for the soul. 

Wellness Wednesday: When NOT to work out

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

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

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

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

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

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

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

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

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

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

References: 

WebMD

Greatist

MayoClinic 

Medical Monday: Weekly news updates in Ob/Gyn

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Structure Sunday: The Structure of Family

What is family and what does it do for us ? I have had a family focused type of weekend and I wanted to share some numbers and thoughts about the issue of family. 

• The nuclear family: Two parents and their children.
• The blended family: which is remarried or re-partnered parents each with their own children under one roof.
• The extended family: such as sisters, uncles, grandparents, and non relatives either living in the home or elsewhere.
• The single parent family
• The childless family.

Consider all these and more. Add in non married partners, good friends and neighbors. All these people bear on how we live, our health and our happiness. 

Here are some illuminating data from census.gov.

About 50 years ago, 80 % of households included a married couple. Now this is down to 50 %. Some households are made up of non family members, and these are up from 10 % to about 33% in the same last 50 years. 

Two parents households with children have decreased about 15%in the last 50 years to 70% of all households with children. About 25% of all household with children only have a mother. Father only households are up to about 4% of all households with children. 

Among all households with or without children, a steady 30 % are childless. 10% of all households are single parent households with children. Households which are traditional, meaning married with children are half of what they were over about the last 50 years, going from 40 to 20 % . 

Everyone knows the saying “ It takes a village.” I would like to point out that this is not just for kids. Adults, married, single or partnered, are happier and healthier if they have strong familial and friendship ties.

Through history, we have developed families, clans and tribes for surviving and thriving. We are wired for it. But in modern times, we are more likely to reach out to friends or coworkers. People sometimes forget to reach out to those closest to them, even those with whom they live. 

I am writing to suggest that people look around and renew ties to those most near. I suggest that this include spouses and partners, children and others in the household, as well as old friends and even neighbors. These relations may not have the cachet of accomplished coworkers, but keeping these relationships healthy has deep benefits. 

It helps us with continuity, and to know our personal history. It helps with feelings of stability, especially for children. Getting along with those closest to us is not really glamourous. But it make us flexible and empathetic. It grounds us. 

Try starting with a phone call, email, or a card in the mail. Then, by all means, plan some sort of get together. The most important thing to remember is that it doesn’t have to be perfect. You don’t have to be perfect, and they don’t have to be perfect. The most important thing to do it to connect. 

Food Friday: Fasting and What To Do Instead

Fasting and cleansing make headlines. They are dramatic trendy measures taken by those seeking improved health. But do they work ? Are they safe ? 

Fasting is generally regarded as going off food for at least a day. Cleansing involves the same but with some sort of liquids and juices added back. Sometimes enemas are part of the “cleanses”.

Proponents state that they get past their hunger, and that they eventually feel good, even high. They state their bowel movements show they are getting cleaned out. Their stomachs flatten and they feel light. Who wouldn’t want all this ? 

Unfortunately, it doesn’t last. Our physical and mental vitality depends on a flux of matter and energy through our body. It is true that our body is designed to weather the temporary hardship of relative drought or famine, but under these conditions it cannot thrive. 

So many people participating in cleanses or fasts are doing so to achieve optimal health and high performance. However, to really thrive, we need optimal nutrition and optimal activity as much of the time as possible. Fasting and cleanses are not compatible with this. 

What do fasting and cleanses really do ? In many cases, they are dehydrating. This can be dangerous, especially if subjects are very young, old, or unwell. The body does burn fat and glycogen for energy, but in more prolonged fasts, muscle mass is lost. This types of metabolism actually produces more “ toxins”. It does not detoxify. 

All this provides a substantial stress on the body. Stress hormones are activated. Neurotransmitters  which help us cope with stress are activated as well, accounting for the feeling of elation and capability. 

Weight does indeed get lost, but mostly in the form of water, stool, fat and and muscle. When a normal dietary and fluid intake is resumed, most of the weight is regained. Muscle of course can be rebuilt, but this requires exercise and surplus protein in the diet. 

Colon cleanses can be dangerous. The colon has a normal bacterial flora. The importance of the balance of this flora is becoming better understood these days. Colon cleanses disturb this balance and can lead to problems with digestion, dehydration and serious electrolyte abnormalities. 

I have noticed that purveyors of these unproven and dangerous methods charge high prices. I have also noticed that they advertise to vulnerable populations, including those undergoing cancer therapy. I find this very concerning. 

The answer to all of this is very simple. It is common sense evidence based medicine and health maintenance. It is Friday, and I am thinking about the weekend. So instead of going on about this downer topic, I would like to tell you my alternative version of a quick health boost. 

I call it a “spa weekend". To me, this means I will arrange to do several key things this weekend in a concerted spirit of boosting wellness. They are as follows: 

• Get the ideal amount of sleep all weekend. 
• Do morning yoga. 
• Drink green tea each day. 
• Drink 3 liters of water each day. 
• Do longer afternoon workouts each day. 
• Have 3 ideal meals and 3 ideal snacks each day all weekend, heavy on protein, veggies and fruit. 
• Soak in the tub each day. 

I might even do my own pedicure. 

That is my idea of a plan to boost wellness. I hope you can take a spa weekend sometime soon. 

Wellness Wednesday: Getting Real about Wellness Coaches

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

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

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

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

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

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

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

How to become your own life coach with 14 simple strategies

10 ways to be your own life coach

How to be your own life coach in four easy steps

And my favorite,

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

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

Organize Your Mind, Organize Your Life: Train Your Brain to Get More Done in Less Time

$12.96

By Margaret Moore, Paul Hammerness

Buy on Amazon

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

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

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

Structure Sunday: The Structure of My Reading List

Isn’t reading for kids in school ? Who has time for reading ? I hear these types of things all the time. Reading is immensely important to me. Stacks of books and magazines line my home office.

I have already blogged about the scientific evidence on the effect of reading on health in the following post: http://drginanelson.com/drginablogs/2015/2/28/structure-sunday-structure-your-mind?rq=reading

Now I am going to share how I divide my reading pie. 

• Reading the news
• Reading to indulge certain interests 
  •      Things that just pique my interest 
  •      Things I’m trying to do
• Reading for self improvement 
• Reading for Medicine
  •      To deal with a patient problem 
  •      To accomplish my annual board review 
• Reading for business 
• Reading for inspiration 
• Reading for fun

Here are my current examples: 

Reading for News: 

I use Flipboard, a popular customizable news app, my Yahoo homepage which I have tailored to my interests, and News, the new Apple app included in the latest IOS operating system. I also sometimes look at two local paper newspapers. 

Interest Based Reading; 

I am always reading cookbooks, or on cooking sites. I love foodnetwork.com, and epicurious.com. My favorite cookbooks right now are” Paleo”  cookbooks like NomNom Paleo. Pinterest is the best pictorial cookbook in the universe.

I am working on a sewing project and have had to reread some stuff about free motion machine quilting. I am also reading about the work of Natalie Chanin, a designer who revitalized an Alabama community with her handmade heirloom pieces of organic cotton jersey. See alabamachanin.com. I am trying to use one of her beautiful instruction books to make a tunic out of old black t-shirts. 

I am doing quite a bit of reading about small smart energy efficient homes. My family is considering a project with these. On my desk right now is a small beautiful book called “ Convertible Homes”, by Amanda Lam and Amy Thomas. 

Reading for Self Improvement: 

I am about to dig into “ Superbetter”, by Jane McGonigal, a scientist and game designer interested in harnassing the power of gaming for self improvement and medical recovery. I am also excited to ready the giant book on my desk written by my old dorm mate Dan Levitan, The Organized Mind. Good on you, Dan. 

Reading for Medicine: 

The large stack of research articles for American Board of Obstetrics and Gynecology annual board review. I have to have them done by December 15th, but prefer to have them done by October 20th, when I go on vacation. 

Reading for Business: 

I am currently reading “Ask” by Bryan Levesque as an ebook on my Kindle app on my IOS devices. I regularly read Inc. and Entrepreneur magazines. 

Reading for Inspiration: 

I am still working my way through “ Becoming Steve Jobs”, by Brent Schlender and Rick Tetzeli. Wired magazine is a constant reliable source of inspiration. 

Reading for Fun: 

I just finished a new favorite, “ Seveneves”, by Neal Stephenson. I have ordered "Trigger Warning", a short story collection by Neal Gaiman, and just bought  paper copy of “The Martian” by Andy Weir, since I have a feeling I will want to share it. Finally I am savoring “ The Magician’s Land” by Lev Grossman, and author who I was pleased to once meet at a reading.  And yes, my favorite fiction genre is sci-fi. 

You might ask how I learn what’s out there to read. I live in an area THAT HAS NO BOOKSTORE ! I go to Amazon.com and check the recommendations. I also am a member of the online community Goodreads, where I get all kinds of ideas. I read book reviews such as the regular columns in my favorite magazines. I check the NYTIMES review of books, and the books award lists such as the Nebula Awards. Plus, I simply google things like “ The 10 best new cookbooks of 2015” or “ The ten best sci-fi novels of 2015”. 

How can I read so much ? Here’s the secret: I do it all kinds of ways. I read my paper books in the day, books on devices at night, and use Audible.com to listen to books when I drive, jog, cook, sew or do housework. Each method has a different effect and that is ok. Try them all and see what you think. 

Reading stokes the fire in my soul. So take page from this playbook and harness the power and joy of reading for yourself. And don’t be afraid to have a few things going at once.