Thursday, September 5, 2019

The inconvenient truth of vaccine refusal of Health

There’s been a lot of back-and-forth recently about how much sleep we really need, with recent studies suggesting that some long-held notions about this may be outdated. For example, a recently published study challenged the widely held belief that adults need an average of eight hours of sleep a night to function well. The researchers found that members of pre-industrial societies, free of the technological distractions that often keep us up at night, tend to get an average of 5.7 to 7.1 hours of sleep per night (more on that in a bit).

However, while the actual amount of sleep required to function optimally may vary from person to person, it is still very clear that not getting enough sleep — whatever that “magic number” is for any specific individual — can have serious consequences. This is especially true in children and adolescents, whose developing brains are very sensitive to insufficient sleep.
Studying the effects of sleep deprivation in teens

This was borne out in a new study published in this month’s issue of Sleep. Researchers from Singapore compared two groups of high school students before, during, and after a week in which half were allotted nine hours sleep per night and the other half only five hours per night. Not only did the sleep-deprived kids exhibit impaired cognitive function, alertness, and mood during their week of five-hour nights as compared with their peers, but it took them more than two nights of “recovery sleep” to catch back up again.

One way of looking at this is that not only do you suffer the day after not getting enough sleep, but that the idea of skimping on sleep during the week with the plan to somehow “catch up” on the weekend isn’t a good one: it simply doesn’t work. Even after getting lots of sleep on the weekend, you’ll still be far away from where you could — and probably should — be as far as sharpness and mood go.
Setting up a great night’s sleep for your child

One way of helping kids get the sleep they need is by eliminating some of those things that tempt them into staying awake. There is a lot of evidence that kids with televisions in their bedrooms, for example, not only sleep less but also have poorer-quality sleep. (Increased screen time is also associated with higher rates of obesity and with less time spent reading, but that’s a topic for another post.) The same is probably true for computers, tablets, and smartphones as well. Removing electronic media devices from the bedroom will make it more likely that your child will fall asleep sooner — and sleep better — than she will with the world at her fingertips.

Another way of helping kids fall asleep sooner and with greater ease is by removing stressors from their bedroom and encouraging them to relax before bedtime. This means, for example, not doing homework in the bedroom (and never in bed!), but at the dining room table instead. This creates a distinct boundary between the pressures of the day and the comforting space of the bedroom, which is so important for falling asleep. It may also have the added benefit of keeping them focused on the task at hand instead of the distractions of YouTube, Snapchat, and texting that can turn one hour of homework into a three-hour ordeal. Likewise, ending the day with 20-30 minutes of mindfulness practice, yoga, or quiet reading can help your teen redirect himself to a different plane as he gets ready to sleep.

Finally, keeping to a regular sleep schedule, seven days a week, with fixed wake-up and bed times will help keep your teen’s internal clock synchronized with the external one, preventing the development of a circadian phase delay between the two that may interfere with his or her being able to fall asleep at their appointed bed time on week nights. Do you know your BMI? Increasingly, people know theirs, just as they know their cholesterol.

If you don’t know your BMI, you can use a BMI calculator available online, including this one at Harvard Health Publishing. All you need is your height and weight. Or, you can calculate it yourself, using this formula:

BMI = (Weight in Pounds x 703) / (Height in inches x Height in inches).

So, now that you know your BMI, is it worth knowing? What are you going to do with it?
What your BMI means

To understand what your BMI means, it’s useful to take a step back and understand what it’s measuring and why it’s measured.

BMI is a calculation of your size that takes into account your height and weight. A number of years ago, I remember using charts that asked you to find your height along the left side and then slide your finger to the right to see your “ideal weight” from choices listed under small, medium, or large “frame” sizes.

These charts came from “actuarial” statistics, calculations that life insurance companies use to determine your likelihood of reaching an advanced age based on data from thousands of people. These charts were cumbersome to use, and it was never clear how one was to decide a person’s “frame size.”

BMI does something similar — it expresses the relationship between your height and weight as a single number that is not dependent on “frame size.” Although the origin of the BMI is over 200 years old, it is fairly new as a measure of health.
What’s a normal BMI?

A normal BMI is between18.5 and 25; a person with a BMI between 25 and 30 is considered overweight; and a person with a BMI over 30 is considered obese. A person is considered underweight if the BMI is less than 18.5.

As with most measures of health, BMI is not a perfect test. For example, results can be thrown off by pregnancy or high muscle mass, and it may not be a good measure of health for children or the elderly.
So then, why does BMI matter?

In general, the higher your BMI, the higher the risk of developing a range of conditions linked with excess weight, including:

    liver disease
    several types of cancer (such as those of the breast, colon, and prostate)
    high blood pressure (hypertension)
    high cholesterol
    sleep apnea.

Current estimates suggest that up to 365,000 excess deaths due to obesity occur each year in the U.S. In addition, independent of any particular disease, people with high BMIs often report feeling better, both physically and psychologically, once they lose excess weight.
And here’s why BMI may not matter

It’s important to recognize that BMI itself is not measuring “health” or a physiological state (such as resting blood pressure) that indicates the presence (or absence) of disease. It is simply a measure of your size. Plenty of people have a high or low BMI and are healthy and, conversely, plenty of folks with a normal BMI are unhealthy. In fact, a person with a normal BMI who smokes and has a strong family history of cardiovascular disease may have a higher riskof early cardiovascular death than someone who has a high BMI but is a physically fit non-smoker.

And then there is the “obesity paradox.” Some studies have found that despite the fact that the risk of certain diseases increases with rising BMI, people actually tend to live longer, on average, if their BMI is a bit on the higher side.
Should we stop giving so much “weight” to BMI?

That’s exactly what’s being asked in the discussion generated by a new study. For this study, researchers looked at how good the BMI was as a single measure of cardiovascular health and found that it wasn’t very good at all:

    Nearly half of those considered overweight by BMI had a healthy “cardiometabolic profile,” including a normal blood pressure, cholesterol, and blood sugar.
    About a third of people with normal BMI measures had an unhealthy cardiometabolic profile.

The authors bemoaned the “inaccuracy” of the BMI. They claim it translates into mislabeling millions of people as unhealthy and also overlooking millions of others who are actually unhealthy, but are considered “healthy” by BMI alone.

Actually, this should come as no surprise. BMI, as a single measure, would not be expected to identify cardiovascular health or illness; the same is true for cholesterol, blood sugar, or blood pressure as a single measure. And while cardiovascular health is important, it’s not the only measure of health! For example, this study did not consider conditions that might also be relevant to an individual with an elevated BMI, such as liver disease or arthritis.
Bottom line

As a single measure, BMI is clearly not a perfect measure of health. But it’s still a useful starting point for important conditions that become more likely when a person is overweight or obese. In my view, it’s a good idea to know your BMI. But it’s also important to recognize its limitations. In the United States, the national drinking age is 21. States can make it younger, but if they do they lose federal highway funding. The idea is that youth less than 21 are more likely to run into trouble if they drink, and that having them wait until they are older is better. You can argue about whether this actually works, but the idea is a good one.

And yet when it comes to tobacco, as far as the federal government is concerned, you just have to be 18. Which, for anyone who knows anything about what happens when youth smoke, makes no sense at all.

It was really Mothers Against Drunk Driving (MADD) that drove the national drinking age legislation. It’s true that smoking doesn’t cause immediate impairment in the way alcohol does; one can smoke a couple of cigarettes and drive. But the longer-term impacts of tobacco use are staggering. Cigarette smoking is the leading preventable cause of death in the United States, causing more deaths each year than HIV, illegal drug use, alcohol use, motor vehicle injuries, and firearm-related incidents combined. Even if it doesn’t kill you, smoking markedly increases your risk of heart disease, cancer, lung disease, rheumatoid arthritis, and diabetes, among other health problems. When pregnant women smoke, their babies are at higher risk of being born small, prematurely, or having birth defects. When parents smoke, it’s more likely that their baby will die of sudden infant death syndrome, or SIDS.

Here’s why it’s so crucial to stop youth from smoking: 90% of all smokers tried their first cigarette by 18, and 99% started by age 26. Three-quarters of teen smokers end up smoking into adulthood, even if they intend to quit. And here’s another important fact: most youth under the age of 18 get cigarettes from someone under 21.

If we make it so that nobody under 21 can buy tobacco, the impact could be enormous. And, according to an editorial just published in the New England Journal of Medicine, the time for Tobacco 21 laws may have come.

The editorial quotes a study from the Institute of Medicine that says that if we were to increase the national smoking age to 21, it would lead to, among other benefits:

    20-30% less smoking among 15 to 17-year-olds
    12% fewer smokers overall
    249,000 fewer premature deaths, with 4.2 million fewer lost life years
    286,000 fewer preterm births
    4000 fewer cases of SIDS

That’s pretty astounding. Many states have already made this change — and yet some, like New Jersey, have balked. Which is interesting, as according to the editorial most people support the idea — especially current and former smokers (66.5% and 73%, respectively). It is also indisputable that raising the smoking age to 21 would lead to huge health care savings. The biggest obstacle? Special interest groups. The tobacco industry has deep pockets and clearly doesn’t want to lose its future smokers, so it has lobbied hard.

It’s pretty difficult to come up with arguments against federal Tobacco 21 legislation. You could say that it infringes on personal rights. But unlike other rights, the right to an addiction that can kill you and those around you, well, that’s a bit hard to justify — especially among our youth. We have a responsibility to set them on the path to the healthiest life possible.

You could say — and those who fight this legislation do — that it will hurt businesses that sell tobacco products, especially small stores that rely on cigarette sales for income. That’s certainly true. But who are we as a country if we value the health of small businesses over the health of our people?

There is abundant evidence that cigarettes are bad for you — so much evidence that nobody disputes it. If we can’t come together to stop youth from smoking, and in doing so prevent so much disease and death, we should be ashamed. While it is obvious that your feelings can influence your movement, it is not as obvious that your movement can impact your feelings too. For example, when you feel tired and sad, you may move more slowly. When you feel anxious, you may either rush around or become completely paralyzed. But recent studies show that the connection between your brain and your body is a “two-way street” and that means movement can change your brain, too!
How exercise can improve mood disorders

Regular aerobic exercise can reduce anxiety by making your brain’s “fight or flight” system less reactive. When anxious people are exposed to physiological changes they fear, such as a rapid heartbeat, through regular aerobic exercise, they can develop a tolerance for such symptoms.

Regular exercise such as cycling or gym-based aerobic, resistance, flexibility, and balance exercises can also reduce depressive symptoms. Exercise can be as effective as medication and psychotherapies. Regular exercise may boost mood by increasing a brain protein called BDNF that helps nerve fibers grow.

For people with attention-deficit disorder (ADHD), another study showed that a single 20-minute bout of moderate-intensity cycling briefly improved their symptoms. It enhanced the participants’ motivation for tasks requiring focused thought, increased their energy, and reduced their feelings of confusion, fatigue, and depression. However, in this study, exercise had no effect on attention or hyperactivity per se.

Meditative movement has been shown to alleviate depressive symptoms. This is a type of movement in which you pay close attention to your bodily sensations, position in space, and gut feelings (such as subtle changes in heart rate or breathing) as you move. Qigong, tai chi, and some forms of yoga are all helpful for this. For example, frequent yoga practice can reduce the severity of symptoms in post-traumatic stress disorder to the point that some people no longer meet the criteria for this diagnosis. Changing your posture, breathing, and rhythm can all change your brain, thereby reducing stress, depression, and anxiety, and leading to a feeling of well-being.
The surprising benefits of synchronizing your movements

Both physical exercise and meditative movement are activities that you can do by yourself. On their own, they can improve the way you feel. But a recent study found that when you try to move in synchrony with someone else, it also improves your self-esteem.

In 2014, psychologist Joanne Lumsden and her colleagues conducted a study that required participants to interact with another person via a video link. The person performed a standard exercise — arm curls — while the participants watched, and then performed the same movement.

The “video link” was in fact a pre-recorded video of a 25-year-old female in a similar room, also performing arm curls. As part of the experiment, participants had to either coordinate their movement or deliberately not coordinate their movement with the other person’s arm curls. They filled out a mood report before and after each phase of synchronizing or falling out of synchrony. They also reported on how close they felt to the other person.

The results were interesting. When subjects intentionally synchronized their movement with the recording, they had higher self-esteem than when they did not. Prior studies had shown that synchronizing your movement with others makes you like them more. You also cooperate more with them and feel more charitable toward them. In fact, movement synchrony can make it easier to remember what people say and to recall what they look like. This was the first study to show that it makes you feel better about yourself, too. That’s probably why dance movement therapy can help depressed patients feel better.
Putting it all together

Your mind and body are intimately connected. And while your brain is the master control system for your body’s movement, the way you move can also affect the way you think and feel.

Movement therapies are often used as adjunctive treatments for depression and anxiety when mental effort, psychotherapy, or medication is not enough. When you are too exhausted to use thought control strategies such as focusing on the positive, or looking at the situation from another angle, movement can come to the rescue. By working out, going on a meditative walk by yourself, or going for a synchronized walk with someone, you may gain access to a “back door” to the mental changes that you desire without having to “psych yourself” into feeling better. Alzheimer’s disease often strikes fear in people’s hearts because it gradually erodes a person’s ability to remember, think, and learn. There is no cure, and available treatments alleviate symptoms only temporarily. An estimated 5.3 million Americans currently have Alzheimer’s disease, yet this brain disorder is far less common than heart disease. More than 85 million people in the United States are living with some form of cardiovascular disease or the after-effects of stroke, which also affects brain function.

Many people don’t realize that Alzheimer’s and heart disease share a genetic link: the apolipoprotein E gene, also known as ApoE. Genetic testing for ApoE — which is done mainly in research settings and isn’t yet widely available — cannot predict whether a person will develop Alzheimer’s disease, only whether they may be more likely than others to do so. The results of ApoE testing can be distressing for people who discover they carry a potentially a worrisome variant of the gene, but a recent Harvard study revealed a surprising silver lining.
Understanding the ApoE gene

The ApoE gene provides instructions for making a protein that transports cholesterol in the bloodstream. It comes in three different forms: e2, e3, and e4. Everyone inherits two variants, one from each parent. More than half of people in the general population have two copies of the most common variant, e3, which doesn’t appear to affect the risk of either heart disease or Alzheimer’s disease. The potentially problematic variant is e4. Having at least one copy of the e4 variant increases blood levels of both harmful LDL cholesterol and triglycerides by about 10 points. This translates to a slightly higher risk of cardiovascular disease.

“It’s a well-proven association. But the effect of the e4 variant on Alzheimer’s disease risk is stronger,” notes Dr. Kurt Christensen, instructor of medicine at Harvard Medical School. Exactly how the e4 variant is related to Alzheimer’s disease remains a mystery. But the variant seems to hamper the clearance of amyloid plaque, the clumps of protein found in the brains of people with Alzheimer’s. Amyloid plaque is thought to destroy brain cells, causing the disease’s devastating symptoms, says Dr. Christensen.

People who inherit one copy of e4 face a two-fold higher risk of developing Alzheimer’s than those without the e4 form. Those who inherit two copies of the e4 form have up to a four-fold higher risk. But it’s important to understand that these people won’t necessarily develop Alzheimer’s disease, and that people without the e4 variant can still get the disease. In fact, up to 60% of people with Alzheimer’s disease don’t have an e4 variant.
What the new study found

Dr. Christensen and colleagues recently published a study in the Annals of Internal Medicine that included 257 people who were interested in knowing their genetic risk of Alzheimer’s disease. Nearly 70% had a parent or sibling with the disease. All received information about their genetic risk of Alzheimer’s. But half were randomly assigned to get additional information about ApoE’s connection to heart disease, along with suggested strategies to lower their risk, including quitting smoking, eating a healthy diet, losing weight, treating high cholesterol, and exercising (with a doctor’s permission).

Among the people who had a higher risk based on their ApoE status, learning about the additional risk to their hearts actually reduced their distress, says Dr. Christensen. And over the following year, something even more unexpected happened: They made a number of healthy behavior changes, such as improving their diets, reducing their stress levels, and being more physically active. And while these habits haven’t been proven to help stave off Alzheimer’s disease, doctors generally agree that what’s good for the heart is good for the brain.

The findings offer reassurance that disclosing genetic information about possible health risks can be helpful — particularly when the knowledge comes with action-oriented suggestions about ways to lessen the impact of that risk. Parents of teenagers, here is another post that I hope will be helpful to you.

Moms and dads of teens — and the doctors who care for these children — know how difficult it can be to identify depression in adolescents. When is your teen simply feeling down or irritable, and when is it something more?

Doctors are receiving better and better training in diagnosing teenage depression, but perhaps the greatest challenge is finding time to make sure it happens. During a typical well-child visit, parents are usually busy trying to address the concerns they have about their child, while at the same time trying to understand what vaccines they need and making sure school forms are filled out. Pediatricians are busy trying to address physical and emotional concerns and anticipate problems that may come up for your child regarding friends, schoolwork, academic work, safe sex, and other risky behaviors.

Where does screening for depression fit in?

Several medical organizations that provide up-to-date, evidence-based guidelines to physicians recommend that we do screen our teens for depression. Among them is the United States Preventative Services Task Force (USPSTF), an agency charged with providing recommendations to the Primary Care community about preventing chronic or difficult-to-detect illnesses. To help us keep our teens as healthy as possible, the USPSTF recently published an updated guideline about screening for Major Depressive Disorder in adolescents.
What is screening?

Screening is the act of checking for a condition that is common in a community but not obvious to doctors unless some sort of testing is done. For example, doctors screen for high blood pressure by checking blood pressure measurements at most visits. Doctors can’t tell, just by looking at a patient, if his blood pressure is high. The same goes for depression. Sometimes it is very difficult to tell if a person is suffering from depression, until it is quite serious. The point of screening is to catch dangerous problems early, before they become severe problems. When doctors elect to screen patients for a condition, typically the following guidelines are met:

    The condition is common, but silent, in the community; lots of people have it.
    The condition is important to a person’s future health.
    Detecting the condition early improves outcomes.
    The condition is something we can treat!
    The testing required is good, easy to administer, and not overly painful or inconvenient.

Can we screen for depression in teens?

Yes, we can, and doctors have been doing so for years, although not necessarily in an organized or systematic way. The USPSTF recommendation is important because it emphasizes this need to test all teens — because depression is common in teenagers, and potentially dangerous.

A few facts about screening for teenage depression:

    Depression is prevalent, but often silent, in adolescents. We don’t have reliable numbers for children 11 or younger, but for children 12-18, rates of depression in the U.S. have been estimated to be around 8%. That means that about one out of every 12 teens will experience an episode of major depression in his or her teenage years!
    The condition is important! Depression in adolescence is associated with depression later in life. It can also lead to poor school performance, substance abuse, early pregnancy, and even suicide.
    Early detection may help prevent long-term, serious problems by allowing your teen to get good treatment in a more timely manner.
    Effective treatment is available. Readers of my last blog post may recall that I discussed how some antidepressant medications have been associated with higher risk of teen suicide. But this is not the case for all medications or all treatments. Psychotherapy, in particular, has been associated with much improved outcomes and little to no risk to a teen’s health.
    The screening test is painless and easy to do. Several simple, short questionnaires exist which have been vetted by experts and proven to be reliable, even when administered to teenagers.

What will screening look like for my teen?

When your adolescent comes to the pediatrician or family doctor’s office for a physical, he or she will be given a short questionnaire, such as the Beck Depression Inventory or the PHQ-A. These questionnaires typically have about nine questions and can be completed in 1-2 minutes. It is important to let your teen complete this questionnaire on his own. Your pediatrician may discuss the answers with your teen privately, but rest assured that if the concern of depression is raised, the pediatrician will never hide from you the fact that your teen is at risk.
A final word…

As parents, you spend much more time with your adolescents than we doctors can during brief office visits. If you notice that your teen has simply not been acting like himself, or if you are worried, please let your pediatrician know! He or she is always ready to help. My elderly dad is sporting a cool new mobile device these days, complete with a sleek design and an aluminum cover. It’s not a smartphone or a laptop or a tablet; it’s a medical alert system, a one-button gadget that can summon emergency help. “Many older people who live alone embrace the devices, because they worry how they would get help if they fell and couldn’t get to a phone. And it’s reassuring for their kids to know there’s a backup system in place,” says geriatrician Dr. Suzanne Salamon, assistant professor at Harvard Medical School.

The devices weren’t always so popular. Once the target of comedians (an issue that kept some seniors from using them), medical alert systems are now in big demand, perhaps due to an aging population, advances in technology, and the reality that one in three adults ages 65 and older might fall one day. Throw in a higher comfort level with mobile gadgets, and it’s not a big surprise that sales of the systems are rising steadily, expected to reach $21.6 billion by 2020, according to some marketing research estimates.
Lots of choices

The popularity of alert systems has resulted in a flood of choices. There are dozens of brands, and each company has several systems available.
Basic models

These typically consist of a pendant or wristband with a large electronic button, and a base unit (similar to a speaker phone) that you plug into your house phone jack. If you get into trouble, you simply press your button, which signals the base unit to call the alert system operators. The operators then talk to you through the speaker in the base unit, and send paramedics if you need help. Most gadgets are waterproof, and have built-in batteries that don’t need recharging; most batteries last for years, and will be replaced free of charge if they run out. Just like a wireless house phone, these buttons can signal the base unit only within a limited range, such as 400 feet. But the buttons don’t provide two-way communication with operators; only the base unit does that.

Typical price: $25-30/month.

This type of model usually come with a base unit and a wearable button, and they also upgrade the technology to include fall detection, an innovation that automatically contacts emergency operators if it detects a fall (handy if you’re unable to push your button).

Original versions of automatic fall detection weren’t the most reliable at discerning if you’d fallen or just leaned over. Newer versions claim to have worked out the kinks, promising much higher accuracy, as much as 95%.

Typical price: $30-40/month
Premium models

These products upgrade the button to top-of-the-line devices that use cellular technology to contact emergency help. The improved communication allows you to use the alert system wherever you go, whether it’s the grocery store or the great outdoors. Unlike the other options, this device has a built-in speaker, so you can talk to an operator through the button. It also features global positioning system technology (GPS), which gives alert system operators the ability to send help to your exact location. This button is thicker and larger than the type worn only at home, so you probably won’t be able to wear it comfortably on your wrist—you’ll have to put it in your pocket or wear it around your neck. Also, it must be charged every few days, just like a cell phone. If you’re not faithful about that, the button won’t work. Typical price: $40-50/month
The fine print

It’s not enough to find the latest and greatest alert system. Make sure that the company you choose has no long-term contracts, low activation fees, no cancellation fees, discounts for add-ons to your service, free replacement for equipment that’s not working, and most important: operators available 24 hours a day. Many alert system companies meet those standards, so it may help to get a recommendation from a friend, your doctor, or even a local hospital.

And remember: no matter what kind of device or deal you get, the alert system will be useless if you don’t wear it. “Not everyone remembers to wear the device, or they’re stubborn about them, or they take them off to take a shower, which is a place people often fall,” says Dr. Salamon.

In my dad’s case, the medical alert system is always around his neck. He has a premium model that looks a lot like a mini-cellphone. But believe me, the peace of mind the device brings to all of us is absolutely super-sized.

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