Sunday, April 28, 2019

Ultra-rapid treatment reduces odds of post-stroke disability

Nearly a third of Americans will develop osteoarthritis of the knee before age 70. With no “cure” beside knee replacement on the horizon for this painful joint condition, relief often has to come from pain pills. Assistive devices such as wedge insoles are often prescribed as a less drastic, side effect-free treatment option. But do they really work? A research review published today in JAMA indicates that these shoe inserts do little—if anything—to relieve arthritis pain.

The review looked at the use of lateral wedge insoles for medial knee osteoarthritis, which affects the inner part of the knee. Lateral insoles are thicker at the outer edge of the foot. Slightly tilting the foot is thought to reduce the load on the inner knee joint.

Walking directs more force to the inside part of the knee (the medial aspect) than the outside part (the lateral aspect). The medial compartment is where osteoarthritis usually appears first. “A lateral wedge insole is intended to reduce pressure transmitted through the lower leg to the medial compartment of the knee during walking,” explains Dr. Robert Shmerling, clinical chief in the Division of Rheumatology at Beth Israel Deaconess Medical Center, and associate professor of medicine at Harvard Medical School.

To see whether lateral wedge insoles actually relieve arthritis pain, an international team of researchers evaluated the results of 12 different shoe-based clinical trials that included a total of 885 participants. Trials comparing the lateral wedge insole to a neutral insole didn’t find a significant improvement in pain.

The findings echo new osteoarthritis treatment guidelines released by the American Academy of Orthopaedic Surgeons (AAOS) in May. Based on current research, the AAOS said it couldn’t recommend lateral wedge insoles for people with medial knee osteoarthritis.
Is it worth wearing insoles?

Doctors who recommend these inserts for their patients may want to re-evaluate their decision based on the most current research, says Dr. Shmerling. Yet you don’t need to toss out lateral wedge insoles if they’ve worked for you, because everyone’s response to treatment can be different. “I think it makes sense to recommend insoles on a case-by-case basis, because even though the average response was no different between wedge insole users and non-users, individual response can vary,” Dr. Shmerling says.

You just might not want to splurge on the priciest options at first. The cost of lateral wedge insoles can range from $10 for ones you buy off the shelf at your local pharmacy or shoe store to $500 for a pair of custom-made insoles your podiatrist or orthopedist orders for you. “Considering the results of this study, I think it’s hard to justify a big investment in wedge insoles solely to treat knee pain from osteoarthritis,” Dr. Shmerling says. “My advice would be to go with inexpensive insoles, and if you’re no better, and if nothing else is working, you could consider seeing a podiatrist or orthotist for higher-end options.”

An alternative to inserts is using a cane to improve your stability. So can buying the right shoes. There is evidence that wearing flat-heeled, flexible shoes—especially ones that mimic the natural movement of walking barefoot—may do more to slow knee osteoarthritis than any insert you stick inside them. When it comes to treating stroke, time is brain and every minute counts. That tenet was supported yet again by an international study showing that the sooner clot-busting treatment is begun, the greater the chances of surviving a stroke without a disability.

Writing in the journal Stroke, researchers led by Dr. Daniel Strbian, an associate professor of neurology at Helsinki University Central Hospital in Finland, reported that giving the clot-busting drug alteplase within 90 minutes of the start of stroke symptoms was more effective at preventing long-term problems than giving the drug within 4.5 hours. Current guidelines recommend that a clot-dissolving drug (generally known as a tissue plasminogen activator [tPA]) be administered within 4.5 hours of the onset of symptoms. After 4.5 hours, these drugs are less effective and the risk of bleeding outweighs the small risk of benefit.
Stroke types

Each year, nearly 800,000 Americans have a stroke. Most of them are ischemic strokes. That means they are caused by something blocking blood flow to part of the brain. That something is usually a blood clot. The clot may form in a blood vessel within the brain (causing a thrombotic stroke), or it may form elsewhere in the body and travel to the brain (causing an embolic stroke).

Types of stroke About 10% of strokes occur when a blood vessel in the brain bursts. This causes bleeding in the brain, and also cuts off blood flow to part of the brain. These are called hemorrhagic strokes.

In the study published in Stroke, patients were divided into three groups based on the severity of their stroke: minor; mild-to-moderate; and moderate-to-severe. Those with mild-to-moderate strokes got the most benefit from ultra-rapid treatment. Less benefit for rapid treatment was seen in those with minor strokes, because they are already at low risk of disability, and in those with severe strokes, probably because their blockages were extensive and more resistant to tPA therapy.

But that’s not to say that patients with severe stroke symptoms shouldn’t be hustled to the hospital and receive early treatment. They, too, should always be considered for intravenous tPA therapy.

In addition to patients’ delaying a call to 911 or trip to the hospital, there’s another factor that can slow the delivery of tPA. A doctor must be sure that the stroke is not caused by bleeding into the brain. To determine that, an MRI or CT scan must first be done.
Brain attack

Strokes, even “minor” ones, are a medical emergency similar to heart attacks. That’s why many experts call stroke a “brain attack.” When one strikes, brain cells die quickly. The faster you recognize a stroke and get to the hospital, the faster treatment can begin. And the greater your chance of near or complete recovery, especially if the symptoms are mild to moderate.

If you suspect that you or someone you are with is having a stroke, think FAST:

    Face: Ask the person to smile. Is one side drooping?
    Arms: Ask the person to lift both arms. Does one drift back down?
    Speech: Ask the person to repeat a simple sentence. Is it slurred or incomplete?
    Time: If one or more stroke signs are present, act quickly. Call 911, and get the person to the nearest hospital with an emergency department. If possible, it should be a hospital with a stroke center.

If you think a stroke is in progress, the best thing to do is to dial 911 or your local emergency number. Let the person on the other end of the line know that you suspect a stroke is happening. That way the emergency department can be ready to do a brain scan. During the summer, I take much of my speech-language therapy practice out of the classroom and office and move it to summer camp. It can be a treat to help preschoolers develop language and social skills with their peers outside on warm summer days.

Around late July, my preschoolers who are heading to kindergarten often need some extra attention. Kids are pretty smart about these transitions and sense the unpredictability of going to a new classroom. They wonder about making new friends and getting used to a new teacher—will they be able to find the bathroom, where will they eat snack, how will they fit in?

Some children, like 5-year-old Kara, are very direct about expressing their fears. One day she climbed out of her kayak and dashed across the dock to greet me. She crossed her arms across her chest, stood in front of me with a wide stance, and said, “Ann, I’m so scared. I have to go to kindergarten soon!” (You can read the entire conversation with Kara below.)

Other children aren’t quite as direct about their worries. Another one of my rising kindergartners dumped a bucket of water on my head (I was not dressed for swimming). I knew his behavior wasn’t because he was in the mood for a good prank, but rather because he had something he wanted to talk about and wanted my full attention. The topic was going to kindergarten.

If you have a child headed to kindergarten in September, here are some ways you can help ease the transition.

    Try to do some play therapy at home. Small figures, stuffed animals, or puppets will do. Have your “actors” experience a transition to a new place. Don’t forget to “act out” coping strategies, for example, “Mr. Elephant feels scared. So what can he do? Maybe he could tell his teacher!”
    Talk about the transition to your child in a positive way and try not to let your own anxiety about the change show too much.
    Visit the school as soon as you can this summer. If your school offers visiting days, do your best to have your child attend. If your child’s kindergarten provides a daily schedule of activities ahead of time, go over it with your son or daughter. Take photos of the school, the classroom, and the new teacher, if possible.
    See if you can find out some of your child’s new classmates, and set up a play date. Some schools offer late summer playground dates for incoming kindergarteners.
    Role play as much as you can (dramatic play is very important to help preschoolers learn how to accept change and how to begin new roles).
    Tell your child how you felt when you had to go to kindergarten—and what made you feel better and how it turned out okay (that is if you can remember!)
    Ask your child’s siblings to tell her/him about their experience.
    Remind your child “It’s okay to be afraid. But, you’ll feel better each day that you’re there. Lots of kids feel just like you do.” It can be tempting to try to brush off a child’s fear (after all, you know it will be okay). Instead try to acknowledge your child’s fear as real and appropriate while offering reassurance.
    Preschoolers need to feel that their parents believe how they feel is true.
    Give your child time to talk to you about their fears.
    With your child, write a story about his or her first day at kindergarten (with your child as the main character!) Include logistics, feelings, etc.
    Read to your child about starting kindergarten. Some good choices are The Night Before Kindergarten (Reading Railroad Books) Paperback, by illustrators Natasha Wing and Julie Durrel; Miss Bindergarten Gets Ready for Kindergarten, written by Joseph Slate and illustrated by Ashley Wolff; Kindergarten Rocks! by Katie Davis; Look out Kindergarten, Here I Come! by Nancy Carlson; and I Am Too Absolutely Small for School (Charlie and Lola), by Lauren Child.

Talking with Kara about starting kindergarten

One of the camps I work with is in a large wooded area with tall trees, a lake and a boat dock. Kara, a 5-year-old, climbed out of her kayak, and dashed across the dock to greet me. She crossed her arms across her chest, stood in front of me with a wide stance, and said, “Ann, I’m so scared. I have to go to kindergarten soon!”

I told her, “I know it’s so hard at first, but it gets better!”

She looked down at the ground and then around at her camp friends, looking for support. One friend offered an idea, “Why don’t we have a longer summer?”

I said, “Well, I’d love to spend more time swimming at the pond, but in the fall we all have to go to work to learn.”

Kara, spun around and said, “Ann, I just can’t go. I won’t have my friends there. I miss my preschool teacher!”

I responded, “Have you met your new teacher, yet?”

Kara, looking down again answered in a small voice, “No.”

I asked, “Why don’t you ask your mom if you can visit your new school and meet that teacher before school starts? Some schools let kindergarteners do that.”

Kara, “Okay. Maybe. But, I’m still scared.”

I asked, “What scares you the most?”

Kara whispered, “I don’t know what it’s like. Will I get to play a lot? Do I have to do a lot of work? What if I can’t do the work? I can’t read yet, and a ton of my friends can read!”

I asked, “Kindergarten is a place where lots of kids learn to read. It’s okay.”

Kara snapped back, “Oh, yeah, but they’ll know I can’t read. Well, I can read a little, a few words, like “cat” and “bat”, but I can’t REALLY read, like a whole book!”

I suggested, “What if your mom got some of the classroom books to read to you at the end of summer?”

Kara, “Yes. That would be good.”

I asked, “Have you seen your classroom, yet? That will help you think about what your new school will be like.”

Kara whispered again, “Okay. I’ll ask my mom. But, what if the school says no?”

I responded, “They might, but you can at least try!”

Kara paused, looked at me, and announced, “Okay, but I might cry!”

I answered, “It’s okay to cry and feel lost at first. It’s okay.”

Kara snapped again, “No! It’s not. I have to be ‘grown up’ now and I don’t want to.”

I tapped her shoulder and said, “I think you are a little grown up already. You can talk about how you feel. That’s good. You can tell your teachers and parents how you feel.”

Kara crouched down to the dock and sat “criss-cross, applesauce.” She rested her arms on her kayak paddle. I sat down near her and put my hand on the paddle. We looked at the water and watched the boats move and bump the dock. When they hit, we moved a little, too. I waited until she spoke.

She whispered, “Will you visit me in kindergarten?”

“Yes and I can’t wait to hear all about it!” I answered.
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Lyme disease 10 times more common than thought

It’s easy to think of heart disease and stroke as an almost inevitable part of aging in a developed country like the United States. After all, they are our leading causes of death and disability. But the truth is that these are largely preventable conditions.

New estimates from the Centers for Disease Control and Prevention (CDC) indicate that one-quarter of all deaths from heart disease and stroke are preventable. And that is almost certainly an underestimate.

According to the report, published online yesterday in Morbidity and Mortality Weekly Report, among American adults under age 75, approximately 200,000 of deaths caused each year by heart disease, stroke, and high blood pressure (hypertension) are preventable. Surprisingly, more than half of those preventable deaths occurred among individuals under age 65.

During a press conference to present the study results, CDC director Dr. Tom Frieden said, “As a doctor, I find it heartbreaking to know that the vast majority of people who are having a heart attack or stroke, under the age of 65 in particular, and dying from it didn’t have to have that happen.”

It’s possible that the rate of preventable deaths is lower among those over age 65 because they are covered by Medicare, and so may be more likely to see doctors and receive preventive treatment.

Other factors also influenced the rate of preventable death. Sex is one: men were twice as likely to die from a preventable heart attack or stroke as women. Race and ethnicity also matter: blacks were twice as likely to die from a preventable heart attack or stroke as whites.

Geography is another influence. “Longevity may be more likely to be influenced by your ZIP code than by your genetic code,” said Dr. Frieden. Preventable deaths were more common in southern states, as shown by the map below.
Rates of avoidable deaths due to heart disease, stroke, and high blood pressure by U.S. county, 2008 to 2010. (Source: Centers for Disease Control and Prevention)

Rates of avoidable deaths due to heart disease, stroke, and high blood pressure by U.S. county, 2008 to 2010. (Source: Centers for Disease Control and Prevention)

The good news is that the rate of preventable deaths declined 29% from 2001 to 2010, the last year for which there are complete statistics.
An underestimate

The CDC came up with its estimates using mathematical modeling. It essentially identified “avoidable deaths” as those occurring among men and women under age 75 who had been diagnosed with heart disease, stroke, or high blood pressure. Such people, so the thinking goes, can be treated to prevent the condition from killing them.

Preventing these conditions in the first place could lead to even greater reductions. Harvard School of Public Health researchers followed nearly 85,000 women in the Nurses’ Health Study, all free of cardiovascular disease, cancer, and diabetes at the study’s start in 1980. After 14 years of follow-up, 1,128 had experienced a heart attack or died of heart disease. Women with a healthy lifestyle (nonsmoker, healthy body weight, moderate-to-vigorous physical activity an average of at least half an hour per day, and a healthy diet) were far less likely to have had a cardiovascular problem than women who didn’t. In fact, the researchers estimated that 82% of the coronary events in these women could be attributed to aspects of an unhealthy lifestyle. The study was reported in the New England Journal of Medicine.
Do-it-yourself approach

No matter what your age and how good things look today, your future risk of heart disease, stroke and other related diseases is high. It’s true for all of us.

That’s why it’s so important to do all you can to lower your risk:

    Don’t smoke. If you smoke, it’s never too late to quit. Your risk of a heart attack starts to decrease within weeks of quitting.
    Aim for or maintain a healthy weight.
    Take steps to help keep your blood pressure in the healthy range. Eat a diet rich in fruits and vegetables and limit salt intake. If lifestyle changes aren’t enough to do the job, there are a number of medicines that work.
    Reduce your consumption of saturated and trans fats. This will help improve your LDL (bad) cholesterol level. Instead use more olive oil and other unsaturated oils. Some people may also need a statin drug to lower LDL.

Over the next 10 years, we have the knowledge and means to greatly increase the number of preventable deaths from heart disease, stroke, and from many other diseases as well. As a nation we could take a huge step forward by becoming more physically active and adopting other healthy lifestyle changes. No time in your busy schedule for a long workout? No problem. Combining brief bouts of moderate to vigorous exercise over the course of the day also add up to good health, an interesting new study suggests.

Most guidelines—such as those of the American Heart Association—call for at least 30 minutes of moderate plus vigorous physical activity five days a week in bouts of at least 10 to 15 minutes. Some experts call for even more. Exercise specialist Aaron Baggish, MD, assistant professor of medicine at Harvard-affiliated Massachusetts General Hospital, says people wishing to be in tip-top shape should strive to get in an hour of exercise five days a week.

Many people have trouble finding that kind of time. Is it possible to cram exercise into shorter bursts?
Every minute of exercise counts

To find out how we can squeeze more exercise into our lives, researchers led by Jessie X. Fan, PhD, professor of family and consumer studies at the University of Utah, analyzed data on 4,511 U.S. adults age 18 to 64 collected by the National Health and Nutrition Examination Survey. Fan’s team identified people who accumulated at least the minimum recommended amount of exercise, but in shorter-than-recommended bouts of 10 minutes or fewer. They found that people who accumulated exercise in very short bursts and who got at least 30 minutes of moderate activity five days a week had a lower body mass index (BMI, a measure of weight versus height) than those who didn’t get 150 minutes of exercise a week.

“We are talking about a brisk walk at three miles per hour, or anything of higher intensity like going up and down a flight of stairs or jumping rope,” Dr. Fan says. “This doesn’t change the recommendation of 150 minutes of brisk exercise a week or 30 minutes on five days. It is just a different way of accumulating this.”

The findings reinforce suggestions that people should look for simple ways to get short bouts of exercise: for example, by parking at the far end of the lot and walking briskly to the entrance, by taking the stairs quickly instead of riding the elevator, or by plugging in your earbuds and dancing energetically to a favorite song.

If you are a professional working a desk job at a computer, set a timer and every half hour get up and do a minute or two of something energetic, Dr. Fan suggests.

The Fan study isn’t the first to suggest that a little exercise is better than none, and that accumulating shorter bouts of exercise is better than not missing exercise days due to lack of time for a longer workout.

“This is a story that has been developing over some time,” says Dr. Daniel Forman, associate professor of medicine at Harvard-affiliated Brigham and Women’s Hospital. “Now people have no excuse for not exercising.” The 30,000 cases of Lyme disease reported to the Centers for Disease Control and Prevention (CDC) each year are just the tip of the iceberg. According to a new CDC estimate, more than 300,000 Americans are diagnosed with the tick-borne disease each year. The new number was presented at the 2013 International Conference on Lyme Borreliosis and Other Tick-Borne Diseases, being held in Boston.

Although the new numbers may be an overestimate, they still provide a clearer picture of the impact of Lyme disease in the United States, says Dr. Robert H. Shmerling, a rheumatologist at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School.

Instead of relying mainly on cases reported by doctors, a standard public health approach, CDC researchers are trying to get a more complete picture of Lyme infections by sifting through health insurance claims, analyzing data from clinical laboratories (which do the tests necessary to diagnose Lyme disease), and surveying the public for self-reported Lyme disease.

“We know that routine surveillance only gives us part of the picture, and that the true number of illnesses is much greater,” said Paul Mead, M.D., chief of epidemiology and surveillance for CDC’s Lyme disease program, in a statement. “This new preliminary estimate confirms that Lyme disease is a tremendous public health problem in the United States, and clearly highlights the urgent need for prevention.”

Although Lyme disease has been diagnosed in almost every state, most cases reported to the CDC are in the Northeast and upper Midwest—96% of cases come from 13 states.
The aftermath of a tick bite

Lyme disease is a zoonotic disease, meaning a disease spread between animals and humans. It is caused by a bacterium called Borrelia burgdorferi, which lives in mice and deer. These corkscrew-shaped bacteria, called spirochetes, get into black-legged ticks when they feed on an infected animal. They migrate to the tick’s salivary glands, and, if the tick bites a person, are injected into the bloodstream. An excellent illustration by The Boston Globe depicts this life cycle.

In some people, the immune system destroys the bacteria before they can do any damage. In others, they grow and multiply, causing an infection. Symptoms include a bull’s-eye-shaped rash, fever, headache, and fatigue. Treatment with antibiotics can usually prevent any short- or long-term repercussions, says Dr. Shmerling.

If the infection isn’t treated, problems can develop in other parts of the body, including the joints, heart, and nerves. It can also cause arthritis that persists months or years after the tick bite.

Some people with Lyme disease and some doctors have argued that Borrelia burgdorferi can somehow evade courses of antibiotics and become a chronic infection that needs long-term antibiotic treatment—even though conventional antibody tests are negative. Chronic Lyme disease has been blamed for causing pain, fatigue, muscle aches, loss of memory and thinking skills, and a host of other problems.

A Boston Globe series, “Bitten By Uncertainty,” has been exploring this controversial side of Lyme disease.
Prevention is key

Like most communicable diseases, Lyme disease is largely preventable, says Dr. Shmerling. Avoid being bitten by a blacklegged tick (also known as a deer tick) and you won’t get Lyme disease. There are two main ways to do that—stay out of brush and high grass in and around wooded areas, or get out in nature and protect yourself. Here are six tips for protecting yourself from ticks, adapted from the Connecticut Agricultural Experiment Station’s comprehensive handbook about tick management.

1. Wear light-colored clothing. Light colors make ticks easier to spot, especially tiny deer tick nymphs.

2. Tuck your pants inside your socks. It may not be a flattering look, but it creates a physical barrier against ticks.

3. Use insect repellent. Most of the chemicals that repel mosquitoes are somewhat effective against ticks, although it may take a heavier concentration of DEET—between 30% and 40%—to really keep them away. Permethrin is a stronger chemical that kills ticks as well as repels them. Products containing permethrin should be sprayed on clothes, not on the skin. Picaridin repels mosquitoes and other insects but not ticks.

4. Stay in the middle of the path (or fairway). Ticks can’t fly or jump, so they can only get on you if you come into contact with the kind of environment they live in: moist, often shady, wooded areas, with leaves, low-lying plants, and shrubs.

5. Think sunny. Ticks don’t do well in dry, open areas. Lawn furniture and playground equipment should be set back from the edge of wooded, shady areas. If you’re picnicking, pick a patch of well-tended lawn or some open ground.

6. Inspect yourself and your children (and your pets), especially the legs and groin. Ticks usually get picked up on the lower legs and then climb upward in search of a meal. The odds of contracting Lyme or other tick-borne disease are minimized if a tick is removed soon after it’s attached, and there’s no risk if it’s still crawling around. The shower is a good place to conduct a tick check. Feel for any new bumps on soaped-up skin.

And if you do get bitten by a tick, remove it using the method recommended by the CDC: Use a pair of fine-tipped tweezers to grasp the tick as close to the skin as possible. Then pull it out with a steady motion. Once the tick has been removed, clean the skin with soap and water. Dispose of the tick, which is probably still alive, by placing it in alcohol or flushing it down the toilet. Don’t fall for “home remedies” like covering the tick with Vaseline or touching it with a just-blown-out match.
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Saturday, April 27, 2019

Cholesterol and statins: it’s no longer just about the numbers

Last year, new guidelines from the American Heart Association, the American College of Cardiology, and nine other health organizations lowered the numbers for the diagnosis of hypertension (high blood pressure) to 130/80 millimeters of mercury (mm Hg) and higher for all adults. The previous guidelines set the threshold at 140/90 mm Hg for people younger than age 65 and 150/80 mm Hg for those ages 65 and older.

This means 70% to 79% of men ages 55 and older are now classified as having hypertension. That includes many men whose blood pressure had previously been considered healthy. Why the change?
Behind the numbers

"Blood pressure guidelines are not updated at regular intervals. Instead, they are changed when sufficient new evidence suggests the old ones weren't accurate or relevant anymore," says Dr. Paul Conlin, an endocrinologist with Harvard-affiliated VA Boston Healthcare System and Brigham and Women's Hospital. "The goal now with the new guidelines is to help people address high blood pressure — and the problems that may accompany it like heart attack and stroke — much earlier."

Discover the secrets to lowering your blood pressure and reducing your risk of heart attack, stroke, and dementia!

The new guidelines stem from the 2017 results of the Systolic Blood Pressure Intervention Trial (SPRINT), which studied more than 9,000 adults ages 50 and older who had systolic blood pressure (the top number in a reading) of 130 mm Hg or higher and at least one risk factor for cardiovascular disease. The study's aim was to find out whether treating blood pressure to lower the systolic number to 120 mm Hg or less was superior to the standard target of 140 mm Hg or less. The results found that targeting a systolic pressure of no more than 120 mm Hg reduced the chance of heart attacks, heart failure, or stroke over a three-year period.
More than blood pressure

The new guidelines have other changes, too. First, they don't offer different recommendations for people younger or older than age 65. "This is because the SPRINT study looked at all patients regardless of age, and didn't break down groups above or below a certain age," says Dr. Conlin.

The guidelines also redefined the various categories of hypertension. It eliminated the category of prehypertension, which had been defined as systolic blood pressure of 120 to 139 mm Hg or diastolic pressure (the lower number in a reading) of 80 to 89 mm Hg. Instead, people with those readings are now categorized as having either elevated pressure (120 to 129 systolic and less than 80 diastolic) or Stage 1 hypertension (130 to 139 systolic or 80 to 89 diastolic).

A reading of 140/90 mm Hg or higher is considered Stage 2 hypertension, and anything higher than 180/120 mm Hg is hypertensive crisis.
Check your blood pressure at home

The new guidelines note that blood pressure should be measured on a regular basis and encourage people to use home blood pressure monitors. Monitors can range from $40 to $100 on average, but your insurance may cover part or all of the cost. Measure your blood pressure a few times a week and see your doctor if you notice any significant changes. Here are some tips on how to choose and use a monitor.


    Select a monitor that goes around your upper arm. Wrist and finger monitors are not as precise.

    Select an automated monitor, which has a cuff that inflates itself.

    Look for a digital readout that is large and bright enough to see clearly.

    Consider a monitor that also plugs into your smartphone to transfer the readings to an app, which then creates a graph of your progress. Some devices can send readings wirelessly to your phone.


    Avoid caffeinated or alcoholic beverages 30 minutes beforehand.

    Sit quietly for five minutes with your back supported and your legs uncrossed.

    Support your arm so your elbow is at or near heart level.

    Wrap the cuff over bare skin.

    Don't talk during the measurement.

    Leave the deflated cuff in place, wait a minute, then take a second reading. If the readings are close, average them. If not, repeat again and average the three readings.

    Keep a record of your blood pressure readings, including the time of day.

What should you do?

If you had previously been diagnosed with high blood pressure, the new guidelines don't affect you too much, says Dr. Conlin, as you still need to continue your efforts to lower it through medication, diet, exercise, and weight loss. "However, based on new information in the guidelines, your doctor may propose treating your blood pressure to a lower level," he says.

The larger issue is that many men ages 65 and older suddenly find themselves diagnosed with elevated or high blood pressure, since the new normal is a whopping 20 points lower than before. Does this mean an automatic prescription for blood pressure drugs? Not necessarily.

"They should consult with their doctor about first adjusting lifestyle habits, such as getting more exercise, losing weight, and following a heart-healthy diet like the DASH or Mediterranean diet," says Dr. Conlin.

Medications are recommended to lower blood pressure in Stage 1 hypertension if you've already had a heart attack or stroke or if your 10-year risk of a heart attack is higher than 10%. (You can find your 10-year estimation at For others with Stage 1 hypertension, lifestyle changes alone are recommended. Overeating during the holidays is practically a tradition. “We rationalize that it’s a special time, with foods that aren’t available throughout the year,” says registered dietitian Kathy McManus, director of the Department of Nutrition at Harvard-affiliated Brigham and Women’s Hospital. But overindulging can lead to weight gain, fatigue, and guilt. So how should you approach the holiday buffet? Here are some tactical strategies to get you through the season of eating.

Plan ahead. Find out when you’ll be eating, and plan your day around it. For example, if you know a big dinner will be served at 8 p.m., eat a lighter breakfast and lunch than usual. But also have a healthy snack just before you leave home at 6 p.m. so that you don’t arrive at the party feeling hungry; otherwise you’ll overeat.

Also, ask if you can bring a dish for the buffet. If the answer is “yes,” bring something healthy, such as chicken and veggie skewers or an assortment of fruit.

At the buffet. Grab a salad plate instead of a dinner plate. You’ll fool yourself into maintaining portion control. Avoid foods that are fried, buttered, creamy, or cheesy. Load at least half of your plate with veggies, then add just a taste of other foods. But choose wisely; don’t waste calories on foods that aren’t special. For example, a roll with butter can easily add 200 calories.

At the table. Research shows you’ll eat less food and take in fewer calories if you eat slowly, so pace yourself at holiday meals. Do this by taking small bites, chewing slowly, and sipping water between bites. When you’ve finished, don’t linger at the table, which may encourage more eating. The reason to eat slowly is that it takes at least 20 minutes for your brain to get the message that you’re full. It’s easy to consume many more calories than you need in 20 minutes. In fact, you can consume all the calories you need for a whole day in 20 minutes.

About alcohol. Alcohol adds calories in a hurry, and it can ruin your resolve. McManus advises that you delay drinking until you begin your meal. Set a limit in advance, and ask your host or buddy for help observing the rule.

If all else fails. When temptation trumps resolve, don’t beat yourself up, and don’t feel you’ve failed. Just go back to a healthy eating plan as soon as possible. “Don’t feel guilty about food,” says McManus. “It’s there to enjoy. But you must give your meals some thought.” Think of this planning as a little gift you give yourself. Updated cholesterol guidelines released yesterday by the American Heart Association and American College of Cardiology aim to prevent more heart attacks and strokes than ever. How? By increasing  the number of Americans who take a cholesterol-lowering statin.

The previous guidelines, published in 2002, focused mainly on “the numbers”—starting cholesterol levels and post-treatment levels. The new guidelines focus instead on an individual’s risk of having a heart attack or stroke. The higher the risk, the greater the potential benefit from a statin.

Statins are a family of medications that lower cholesterol. Even more important, they lower the chances of having a heart attack or stroke. Statins include atorvastatin (generic, Lipitor), fluvastatin (generic, Lescol), lovastatin (generic, Mevacor), pitavastatin (Livalo), pravastatin (generic, Pravachol), rosuvastatin (Crestor), and simvastatin (generic, Zocor). The new guidelines recommend a statin for:

    anyone who has cardiovascular disease, including angina (chest pain with exercise or stress), a previous heart attack or stroke, or other related conditions
    anyone with a very high level of harmful LDL cholesterol (generally an LDL above greater than 190 milligrams per deciliter of blood [mg/dL])
    anyone with diabetes between the ages of 40 and 75 years
    anyone with a greater than 7.5% chance of having a heart attack or stroke or developing other form of cardiovascular disease in the next 10 years.

How is this different from the previous guidelines? They recommended specific cholesterol targets for treatment. For example, people with heart disease were urged to get their LDL cholesterol down to 70 mg/dL. The new guidelines essentially remove the targets and recommend basing treatment decisions on a person’s heart risk profile.

In other words, anyone at high enough risk who stands to benefit from a statin should be taking one. It doesn’t matter so much what his or her actual cholesterol level is to begin with. And there’s no proof that an LDL cholesterol of 70 mg/dL is better than 80 or 90 mg/dL. What’s important is taking the right dose based on heart attack and stroke risk.

There are a few reasons for these new “risk-focused” guidelines:

    Statins are the best drugs to lower LDL cholesterol.
    Statins also have benefits above and beyond cholesterol lowering. We have long known that statins lower the risk of premature death, heart attack, and stroke, even among individuals with relatively normal cholesterol levels—who are not exempt from having heart attacks or stroke.
     A statin dose tailored to the individual appears to be more important than reaching a particular target number.

Putting guidelines into practice

Will these guidelines change how your doctor checks and treats your cholesterol? Yes and no. Many physicians are already focusing on the balance of benefits and risks when making decisions about treatment. I, for one, am already prescribing statins to patients of mine at high risk of heart disease even when their cholesterol levels are close to normal. What will be new for me is making sure my patients are on an effective dose and no longer focusing on how low their LDL drops.

These new guidelines, while meant for doctors, contain a lot that each of us can do. Here are some examples.

    Go beyond the numbers. When talking with your doctor, instead of focusing on your cholesterol “number,” ask about your risk for developing cardiovascular risk. That appears to be a better guide as to whether you should be on a statin. Your doctor should have tools to help you estimate that. The new AHA/ACC guidelines recommend replacing the Framingham Risk Score with a new way to estimate risk.
    Consider the risks. No treatment is without some risk. Statins can cause muscle pain, and in a small number of individuals, more significant muscle injury and rarely liver problems. They have also been associated with increases in blood sugar, which in some cases leads to a diagnosis of diabetes. Some reports have linked statin use to memory issues, but the evidence is unclear. In the end, it’s a matter of balancing the low risk of these side effects with the potential benefit of lower risk of heart disease, stroke, and death. Have an open conversation with your doctor to consider your personal benefits and risks.
    Remember the other stuff. These new guidelines are quick to remind us that there is more to lowering cardiovascular risk than just taking a statin. We need to remain focused on living healthy as well—eating right, getting exercise, not smoking, and maintaining a healthy weight.

Other guidelines released this week—assessing cardiovascular risk, lifestyle management to reduce cardiovascular risk, and management of overweight and obesity in adults—can help us do this.
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Do “energy boosters” work?

Move over, apples: A handful of nuts a day keeps the doctor away—and might help you live longer, according to new results from two long-running Harvard studies.

“We found that people who ate nuts every day lived longer, healthier lives than people who didn’t eat nuts,” said study co-author Dr. Frank Hu, professor of nutrition and epidemiology at the Harvard School of Public Health. The report, in tomorrow’s New England Journal of Medicine, showed that daily nut-eaters were less likely to die of cancer, heart disease, and respiratory disease. Overall, the daily nut-eaters were 20% less likely to have died during the course of the study than those who avoided nuts. (Peanuts, which are actually legumes, counted as nuts in this study).

The findings were gleaned from nearly 120,000 participants in the Nurses’ Health Study and the Physician’s Health Study. All answered questions about their diets at the beginning of the studies in the 1980s and then every two to four years during 30 years of follow-up. The researchers classified the participants into six categories that ranged from never eating nuts to eating them seven or more times per week. The more often people ate nuts, the lower their risk of premature death.

The findings echo those of earlier studies, according to Dr. Penny Kris-Etherton, professor of medicine at the University of Pennsylvania, who highlighted nut research at this week’s American Heart Association meeting in Dallas, Texas. “Eating nuts lowers LDL (“bad” cholesterol), raises HDL (“good” cholesterol) and also lowers blood pressure and blood pressure responses to stress,” said Dr. Kris-Etherton. Her research also shows that nut consumption helps boost a process called reverse cholesterol transport, by which HDL particles in the blood sweep away fatty plaque from clogged arteries. The Harvard researchers pointed out that the composition of nuts—fiber, healthy fats, vitamins, minerals, and phytochemicals—may provide “cardioprotective, anticarcinogenic, antiinflammatory, and antioxidant properties.”

Worried that eating nuts might make you fat, since they’re high in fat? In fact, frequent nut eaters were less likely to gain weigh in this and other studies. “Nuts are high in protein and fiber, which delays absorption and decreases hunger,” said Dr. Hu, adding that nuts contain mostly unsaturated healthy fats.
No “perfect” nut

Are certain nuts better than others? “Everybody is searching for the perfect nut,” says Dr. Kris-Etherton. But the health benefits hold true for a variety of nuts, including walnuts, almonds, peanuts, and pistachios, so eat your favorite. Or, as Kris-Etherton recommends, try mixed nuts—and be sure to choose unsalted over salted. She offered the following tips for making nuts part of your regular diet:

    spread nut butter on your morning toast instead of butter or cream cheese
    sprinkle chopped nuts on cereal or yogurt
    toss nuts into a salad or stir-fry
    top fruit or crackers with nut butter
    try nut-encrusted fish or chicken, such as pecan-encrusted trout
In many ways, women are different from men. One way in which they are alike is how they “feel” a heart attack: with similar kinds of chest pain. Other heart attack symptoms may differ, but chest pain is pretty standard, according to a large new study from Europe.

This study focused on nearly 2,500 men and women being evaluated in one of seven emergency departments for a possible heart attack. In such a situation, doctors typically ask a few standard questions about chest pain. For this study, the researchers asked 34 detailed questions about chest pain or discomfort, such as:

    When did it start?
    How long did it last?
    Where specifically in the chest do you feel the pain?
    How large is the spot where you have pain?
    Does the pain extend into any other part of the body – the neck, throat, back, one arm, both arms, etc.?
    What does the pain feel like (pressure, stabbing, burning)?
    Does the pain get worse with a deep breath, cough, sneeze, or movement?

No differences in chest pain were seen between men and women except for two characteristics. Pain that lasted two to 30 minutes and decreased in intensity reduced the chance that the symptoms were caused by a heart attack in women. This was not true for men—the pain of a heart attack could be of short duration. And women with heart attacks tended to have longer lasting pain, 30 minutes or greater, compared to men. The results were published yesterday in JAMA Internal Medicine.

The kind or duration of chest pain didn’t help tell a heart attack from some other problem. The conclusion? A careful medical history, an electrocardiogram, and blood tests are the best way to diagnose a heart attack in men and women.
Recognizing a heart attack

During a heart attack, more than three-quarters of men and women experience chest pain or discomfort. In the run-up to a heart attack, chest pain with exertion is a more common warning sign in men, while women often have other types of symptoms.

Surveys of women who have had heart attacks have shown that up to 95% said they noticed something “wasn’t right” in the month or so before their attacks. Two of these early warning symptoms, fatigue and disturbed sleep, were especially prominent. Some women, for example, said they were so tired they couldn’t make a bed without resting. Women who do feel something unusual in the chest often describe the sensation as discomfort, aching, tightness, or pressure rather than as pain.

Some heart attacks are unmistakable. Others aren’t easy to detect because the symptoms are subtle or masquerade as something else. The faster a heart attack is diagnosed and treated, the greater the likelihood it won’t cause long-lasting damage. If you feel any of the symptoms below, or see them in someone you are with, call 911 or your local emergency number right away:

    pain or discomfort in the center of the chest
    pressure, aching, or tightness in the center of the chest
    pain or discomfort that spreads to the upper body, especially the shoulders, back, arms, neck, throat, or jaw
    unusual sweating
    sudden dizziness
    unusual shortness of breath
    unusual fatigue or weakness
    unexplained nausea or vomiting
It’s been a topsy-turvy few days in the world of heart health and disease. Last week the American Heart Association and American College of Cardiology released new guidelines that upended previous recommendations for who should take a cholesterol-lowering statin. A few days later, two Harvard physicians challenged the accuracy of the calculator included in the guidelines, saying it would cause many people to unnecessarily take a statin. The story made headlines in The New York Times and prompted a closed-door review by the guidelines committee.

The controversy over the calculator should serve to improve this useful tool. I just hope it doesn’t make people mistrust the guidelines, which I think will help prevent more heart attacks, strokes, and premature deaths than the earlier ones.
How the new guidelines change things

The previous guidelines recommended that individuals take a statin if the level of their harmful LDL cholesterol was above a certain number. The guidelines also recommended that many people get their LDL level down to 70 milligrams per deciliter (mg/dL), even if that meant taking a statin plus other medications, a strategy never proven to prevent heart attack or stroke.

The new guidelines no longer focus on “the numbers,” but instead focus on the risk of heart disease or stroke risk. Taking a statin is now recommended for:

    anyone who has cardiovascular disease, including angina (chest pain with exercise or stress), a previous heart attack or stroke, or other related condition
    anyone with a very high level of harmful LDL cholesterol (generally an LDL above greater than 190 mg/dL)
    anyone with diabetes between the ages of 40 and 75 years
    anyone with a greater than 7.5% chance of having a heart attack or stroke or developing other form of cardiovascular disease in the next 10 years.

The calculator included in the guidelines aims to gauge an individual’s chances of developing atherosclerotic cardiovascular disease (ASCVD) over the next 10 years. ASCVD includes arteriosclerotic heart disease (heart attack, stroke, the chest pain known as angina, or severely narrowed coronary arteries), peripheral artery disease, and stroke or transient ischemic attack. The calculator uses nine pieces of information—sex, age, race, total cholesterol, HDL cholesterol, systolic blood pressure, current treatment for high blood pressure, diagnosis of diabetes, smoking habit—to do this. The new guidelines recommend a statin for seemingly healthy people with a risk of 7.5% or higher.


Cardiologist Paul Ridker and epidemiologist Nancy Cook, both at Harvard Medical School, say that the calculator likely overestimates ASCVD risk for many people. Such overestimation would mean that millions of otherwise healthy people would take a statin long term with no health benefit, but the real possibility of experiencing harmful side effects.
Deciding who needs a statin

The controversy over the calculator doesn’t affect anyone in categories 1, 2, or 3 above. For them, a significant amount of research has shown that the benefits of taking a statin far outweigh the risks. It does affect those who haven’t yet developed any visible forms of ASCVD.

For example, what if your is LDL high, say 150 mg/dL, and the calculator says you have an 8% risk of developing ASCVD in the next 10 years. The new guidelines say “take a statin.” But guidelines are just that—information to guide a decision, not to mandate it. The best approach for such individuals is to have a discussion with a trusted physician.

Some of my patients in this situation would prefer not to start taking a medication. I would counsel them to try a healthier eating pattern like a Mediterranean-style diet and exercise more. Lifestyle changes should always be a priority—even if a statin is needed. Others will prefer to start taking a statin, and I would go along with that decision.

One of the things the new guidelines have clarified is which statin to use. There are seven on the market: atorvastatin (generic, Lipitor), fluvastatin (generic, Lescol), lovastatin (generic, Mevacor), pitavastatin (Livalo), pravastatin (generic, Pravachol), rosuvastatin (Crestor), and simvastatin (generic, Zocor). The guidelines say that the ones with the best evidence for preventing heart attack and stroke are simvastatin, atorvastatin, and rosuvastatin.

Down the road, genetic testing may help better gauge an individual’s ASCVD risk and refine which statin would work best. Until then, the new guidelines represent a step forward for prevention. Stroll the aisles of any pharmacy or “health food” store and you’ll see a multitude of herbs and other supplements that claim to boost energy. Soft drinks and so-called energy drinks include these products. Yet there is little or no scientific evidence to support the claims for most of these substances. The fact is, the only thing that’ll reliably boost your energy is caffeine or other stimulant—and their effects wear off within hours.

Here’s a look at some of the substances that are commonly touted as energy boosters.

Chromium picolinate. This trace mineral is widely marketed to build muscle, burn fat, and increase energy and athletic performance, but research has not supported these claims.

Coenzyme Q10. This enzyme is found in mitochondria, the energy factories of our cells. Coenzyme Q10 supplements have been shown to improve exercise capacity in people with heart disease, and may do the same in people with rare diseases that affect the mitochondria. In other cases, the effects are not clear. One small European study suggested that people with chronic fatigue syndrome might benefit from supplementation with coenzyme Q10, but more research is needed.

Creatine. The body makes own creatine; it is largely found in muscle. But it is widely sold as a supplement. There is some evidence that taking creatine can build muscle mass and improve athletic performance requiring short bursts of muscle activity (like sprinting). But there is little evidence it can do the same in older adults, or that it can reduce a feeling of fatigue in anyone.

DHEA. Sometimes marketed as a “fountain of youth,” dehydroepiandrosterone (DHEA) is touted to boost energy as well as prevent cancer, heart disease, and infectious disease, among other things. The truth is that this naturally occurring hormone has no proven benefits and some potentially serious health risks. Some research shows that DHEA can damage the liver. It can also lower levels of beneficial HDL cholesterol. And because this hormone is related to estrogen and testosterone, there is concern that it may increase the risk for breast and prostate cancers. By increasing levels of testosterone, it can also encourage acne and facial hair growth in women. Until further research clarifies the side effects, it’s wise to avoid taking DHEA.

Ephedra. Although ephedra was banned by the FDA in 2004 because of major safety concerns, including increased risk of heart attack and stroke, it remains available for sale on the Internet. Any effectiveness that ephedra may have in terms of boosting energy probably results from two substances it contains—ephedrine and pseudoephedrine—which may increase alertness. There is no safe amount of ephedra you can consume. If you want to boost your energy by stimulating your central nervous system, a cup of coffee or another caffeinated beverage will work just as well.

Ginkgo biloba. Derived from the maidenhair tree, ginkgo biloba has been used for centuries in Chinese medicine and is now a common dietary supplement in Western countries. Its effects on cognition (thinking), mood, alertness, and memory have been the subject of many studies, but many of those studies have not been of high quality. A Cochrane Collaboration review found the evidence was too weak to conclude that ginkgo biloba improved cognition in people with Alzheimer’s disease. Regarding memory in people without dementia, the evidence is contradictory. Some studies suggest that ginkgo biloba may improve some aspects of mood, including alertness and calmness, in healthy subjects. By making you more alert and calm, it may increase your sense of energy.

Ginseng. This relatively safe and popular herb is said to reduce fatigue and enhance stamina and endurance. It is sometimes called an “adaptogen,” meaning it helps the body cope with mental and physical stress and can boost energy without causing a crash the way sugar does. Data from human studies are sparse and conflicting. Some studies report that ginseng improves mood, energy, and physical and intellectual performance. Other research concludes it doesn’t improve oxygen use or aerobic performance, or influence how quickly you bounce back after exercising.

Guarana. This herb induces a feeling of energy because it’s a natural source of caffeine. But consuming a lot of guarana, especially if you also drink coffee and other caffeinated beverages, could ultimately lower your energy by interfering with sleep.

Vitamin B12. Some doctors give injections of vitamin B12 as “energy boosters.” But unless they are given to correct anemia that results from a true deficiency of the vitamin, there is little evidence that vitamin B12 treatments boost energy.

Instead of relying on a supplement for energy, I recommend switching to a healthful diet—more vegetables, fruits, whole grains, nuts, lean protein, and unsaturated fats—and exercising more. That’s truly a better way to beat an energy shortage, and it’s one your whole body will appreciate.
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Easy exercises for couch potatoes

I’ve never been much of a tea drinker. To me, the flavor is reminiscent of twigs soaked in warm dishwater. I don’t mean to disparage the tea enthusiasts who “ooh” over their oolong and cherish every drop of their chai. Quite the opposite, in fact. I’m as green as Japanese sencha every time another study emerges, steeped with praise about the health benefits of the beverage I’m not drinking.

This month my envy was particularly strong, when The American Journal of Clinical Nutrition featured not one, but 11 new studies highlighting the many ways in which tea can supposedly improve our well-being. The research was originally presented at an entire symposium devoted to Tea and Human Health, held in Washington, DC.

A few of the highlights:

    Tea drinking appears to lower the risk for heart disease and stroke.
    Natural compounds called polyphenols in green tea might protect against several cancers, including those of the prostate, GI tract, lungs, breast, and skin.
    Caffeine and antioxidants called catechins found in green, oolong, and white teas may increase metabolism and promote weight loss.
    Tea polyphenols are thought to strengthen bones and protect against fractures.
    People who drink tea could see improvements in mood, concentration, and performance.

Is tea uniquely healthy?

Not being a tea enthusiast, I immediately wondered whether any other foods could offer the same health boost. But it looks as though tea is distinctively rich in healthful properties. “Tea is uniquely plentiful in catechins, and especially epicatechins, which are believed to be the component responsible for many of its purported health effects,” says Dr. Howard Sesso, associate professor of medicine at Harvard Medical School and associate epidemiologist at Brigham and Women’s Hospital.

The less processed tea leaves are, the more health-promoting catechins they contain, Dr. Sesso says. Green teas have the most nutritional benefit, followed by oolong and black teas.

I also had to ask whether it’s possible to capitalize on tea’s healthful properties without actually drinking the stuff—say, by popping a pill? “More studies are needed that directly compare the effects of tea drinking versus tea extracts or supplements,” Dr. Sesso says. To harness all the healthful components of tea into a pill, we’d need to know exactly what those components are, and we’re not there yet. Another reason to avoid tea pills, or even to start drinking tea for health, is that although many studies show an association between tea drinking and health, they can’t show cause and effect.
Not your cup of tea?

If you’re a tea drinker, continue to enjoy your Darjeeling, Earl Grey, or Lapsang souchong. If you’re not into tea, don’t use the research as a reason to change your drinking preferences. “It is too preliminary to conclude that everyone should regularly drink tea,” Dr. Sesso says.

It’s not a good idea to resort to additives to make tea more palatable. I’ve heaped in spoonfuls of sugar, and tried the cloyingly sweet facsimiles sold in supermarkets and at Starbucks to make tea go down easier. “Sweetened tea beverages introduce calories, fat, and other ingredients that get away from the basic premise that the tea leaf may be responsible for any health benefits,” Dr. Sesso says. You can add a little honey or lemon to taste without compromising the purity of your tea, but stop there.

If you just can’t stomach the stuff, don’t fear that you’re missing out on a healthy beverage. Coffee—which research is finding may protect against diseases like type 2 diabetes and some forms of cancer—is a perfectly reasonable and possibly equally healthful alternative.
A longer lifespan can be a double-edged sword. You live for more years, but the later years may not necessarily be what you had in mind. A new study suggests that two-thirds of Americans over age 65 need help doing everyday activities such as eating, bathing, and getting in and out of bed or a chair.

We’ve known for some time that about 25% of older Americans can’t perform some activities of daily living without help. But we don’t know much about the other 75%. Are they getting along fine, or do they, too, need some help?

A new report based on data collected as part of the National Health and Aging Trends Study offers more detailed information on the state of seniors. Researchers interviewed more than 8,000 older Americans, most of them living at home, about activities of daily living. The participants also completed tests of physical and mental skills.

From the data, the researchers determined the percentage of older adults in five categories of function or adaptation:

    31% were as mobile as they desired and performed all activities of daily living without any assistance
    25% were as mobile as they desired and performed all activities of daily living but needed help from one or more devices, such as canes or bathroom grab bars
    21% needed someone to help them get around or with one or more activities of daily living
    18% said they had trouble being mobile or performing activities of daily living, even with assistive devices and changes in the home
    6% limited their activities and mobility, even with assistive devices and changes in the home

The study participants’ abilities varied by activity. Among those who said they were fully able, 90% had no trouble with eating. In the other four categories, under 10% said they could eat without help. Similar trends were seen for going to the bathroom, bathing, getting dressed, and getting in and out of bed.

Ability also varied by age. Among those aged 65 to 69, 45% said they didn’t need any help, compared to 4% of those aged 90 or older. The report was published online yesterday in the American Journal of Public Health.
Invest in yourself

Many people begin financial planning for retirement in their 30s and 40s. That’s also the perfect time to begin physical planning for retirement and old age. The key to remaining independent is to stay as free of disability as possible. Although your genes determine part of how well—or how poorly—your body and mind will age, much of that is under your control.

There are a number of things you can do to help ward off becoming frail or disabled, or prevent either from getting worse. These include:

    Staying active. Exercise and physical activity are as close as we can come to preventing disease and disability. It’s best to start early to make physical activity a habit, but you’re never too old or frail to exercise.
    Maintaining a healthy weight and choosing a healthy diet. Eat a variety of healthy foods, and don’t skip meals. If you don’t feel like eating or if you lose weight unexpectedly, see your doctor. The culprit could be illness, medications, depression, or possibly dental problems. Your doctor or a nutritionist may recommend a high-calorie supplement.
    Practicing fall prevention. Frailty can cause falls. But it works the other way, too: falls can lead to frailty. If medications affect your balance or alertness, discuss a lower dose or different medicine with your physician. Have your vision checked regularly. Clear your home of clutter and loose rugs or wires. Good lighting is essential; use night-lights in bathrooms, hallways, and, if needed, your bedroom. Wear flat-soled shoes or boots that grip. In bad weather, exercise indoors.
    Making connections. Relationships can keep you active and help ward off depression. Dining with others may encourage better eating. And an exercise or walking partner can help you stick to your program.
    See your primary care doctor, eye doctor, and dentist regularly. They can identify conditions that contribute to frailty, such as heart disease, and vision or dental problems.

The earlier you start financial planning for retirement, the more money you are likely to have put aside for it. The same holds for physical planning: the earlier you start, the more likely you are to live independently in your later years. I come from a family of champion snorers. Mother, father, brothers—we all broadcast nightly like buzz saws. But by 2006, my snorking and snarking took an unhealthy turn. Instead of merely driving everyone nearby to distraction, I began to stop breathing for short periods. Dozens of times per night, my upper airway fell slack like a worn-out garden hose, which pinched off the flow of air and jarred me awake. Blood oxygen plummeted and adrenaline surged into my bloodstream, making blood pressure swing up and down.

After a sleep study in which I slumbered overnight at a special clinic while wired up to various gadgets, my doctor offered an explanation for my increasing fatigue and mental fog: obstructive sleep apnea (OSA).

Not surprisingly, I read with great interest a study published today in the Journal of the American Medical Association (JAMA) which reported that treating OSA can help people with very hard to control blood pressure. Many people with this so-called treatment resistant hypertension take several medications but their pressures remain stubbornly high. Many people with treatment-resistant hypertension also have OSA.
Healthier BP with CPAP

Could treating their OSA help? To find out, researchers in Spain provided the standard treatment for OSA to nearly 200 men and women for 12 weeks. The treatment was continuous positive airway pressure (CPAP), which uses a facemask and bedside air pump to inflate the upper airways enough to prevent the collapse of soft tissue in the upper throat that obstructs airflow.

After 12 weeks of CPAP, average 24-hour blood pressures in the study participants were a few ticks lower. They also had more healthy nighttime blood pressure patterns.

The improvements, though modest, are still important. Nighttime interruptions in breathing, or “apneas,” starve the brain of oxygen and stress out the cardiovascular system. Inadequately treated OSA comes with a higher risk of heart attacks and strokes. Another hazard is next-day drowsiness that predisposes people to accidents.
What it means for those with OSA

To get the bottom line on the study for OSA sufferers, I talked to Dr. Atul Malhotra, an expert on sleep apnea and associate professor of medicine at Harvard Medical. He’s also the chief of Pulmonary and Critical Care Medicine at the University of California San Diego School of Medicine.

“The wrong message is to say CPAP is weak,” Dr. Malhotra says. “Blood pressure medications offer a bigger bang for the buck to reduce daytime blood pressure, but it’s important to say that when you treat sleep apnea there are a lot of other benefits that are not necessarily related to daytime blood pressure.”

I’ll say! I was absolutely miserable pre-CPAP. But now I sleep like a lamb (well, probably more like an helium-inflated Macy’s Day Parade lamb). Every night I strap on the headgear of what I affectionately call my “astronaut machine.” A small high-tech bedside air pump monitors my breathing and adjusts the flow of filtered, humidified air to my nose. A microchip in the machine tracks my breathing patterns and adjusts the flow throughout the night to compensate for shifts in body position.
Overcoming CPAP roadblocks

But not all of my brother and sister CPAPers are as lucky. Some can’t get used to the mask and tend to tear it off in their sleep or simply don’t wear it at all. But most people can adapt to CPAP.

“Strapping a mask to your head is not ideal, but in some people adherence is extremely good,” Dr. Malhotra says. “They wear it all night every night and couldn’t get to sleep without it. Then they get transformative benefits from it.”

How do you get to that point? A critical factor is mask comfort. “The key is just to find one you like,” Dr. Malhotra says. “It’s like going to Baskin Robbins. There are 31 flavors, and you just have to try different flavors before you find one you like.”

Fortunately, the Baskin Robbins of CPAP is well stocked these days with a variety of mask options. It includes nasal masks, full face masks, and twin tubes that deliver air to each nostril.

Mask fitting can be a trial-and-error process, and you may have to try different ones until you find the right match. “If you try pistachio at Basin Robbins the first time and don’t like it you may never come back,” Dr. Malhotra says, “but some people try pistachio the first time and like it.”

Me, I like vanilla—the smaller, lighter nose-only nasal mask. My brain learned quickly to keep my mouth closed and breath through the nose. Later I found better-designed headgear and an accordion-like mask that maintained its seal better despite my occasional tossing and turning.

Dr. Malhotra urges those going on CPAP not to quit if the first taste isn’t pleasing. “Even if the first experience with CPAP doesn’t go well,” Dr. Malhotra says, “it’s very important to keep trying.” Untreated or inadequately treated sleep apnea can have devastating effects on health and quality of life, but there is usually a solution. If you have trouble finding the motivation to break away from the television and exercise, try couchersizing—staying on or near your couch and exercising during commercial breaks. Why bother? As I write in the December 2013 Harvard Health Letter, a growing body of evidence links the amount of time spent sitting to illness and even death. “Minimizing long periods of inactivity, like exercising during commercial breaks, can help reduce the risk of injury and may even help you live longer,” says Kailin Collins, a physical therapist at Harvard-affiliated Massachusetts General Hospital.

You can work many different muscle groups while seated upright on a couch. Want to get your heart rate up, work the oblique muscles on the sides of the abdomen. To whittle your waist, try twisting your torso from side to side for the length of a commercial break. You can even exercise while lying on the couch: with your legs extended, squeeze the quadriceps on the front of the thigh for a count of 10, then relax. Repeat several times. Try leg lifts while lying flat to build abs, or side lifts to strengthen hip muscles.

Here are more ideas for the couch potato set. Consider trying some of these exercises during the typical three-to-four-minute TV commercial break.
Sit to stand

Why it helps: This exercise works the quadriceps in the front of the thigh and gluteal muscles in the buttocks, which helps protect your ability to get up from a chair, out of a car, or off a bathroom seat. “In addition, it’s possible to use repeated repetitions of this exercise to get your heart rate up,” says Collins.

How to do it: Go from sitting to standing to sitting again, 10 times in a row. Rest for a minute, then repeat.
Calf stretch

Why it helps: “Keeping your calves optimally flexible can keep your walking stride longer, reduce your risk of tripping over your toes, and reduce your risk for common foot injuries such as plantar fasciitis,” says Collins.

How to do it: Sit on the edge of a couch with your feet flat on the floor. With one leg, keeping your heel on the floor, lift and point the toes toward the ceiling, so that you feel a stretch in your calf muscle. Hold for 30 seconds, then do the same with the other leg, three times per leg.
Stand on one leg

Why it helps: “Balance gets better if you practice it, which can decrease the risk of falling,” says Collins.

How to do it: Holding on to the back of a chair for stability, lift one heel toward your buttocks. Hold for 30 to 45 seconds, three times per leg. To improve your balance on unsteady surfaces, try this with shoes off on a balled-up beach towel.
Shoulder blade squeeze

Why it helps: “This can help prevent that rounded, shoulders-forward posture that can develop from many years of sitting, especially at a computer,” says Collins.

How to do it: Pinch your shoulder blades together, but not up (don’t shrug). Hold for 10 seconds, then repeat 10 times.
Hand squeeze

Why it helps: “Keeping your grip strong makes it possible to turn a door knob, open a jar, and grasp a gallon of milk,” says Collins.

How to do it: While seated upright, hold a ball (the size of a basketball) over your lap with both hands, then squeeze the ball as if you’re trying to deflate it. Hold for a few seconds, then release. Repeat 10 times, rest, then do another set of 10 repetitions. You can also improve your grip strength by squeezing a small rubber ball in one hand.
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Fresh fruits and veggies usually pack the most punch nutritionally

On a Saturday morning 50 years ago tomorrow, then Surgeon General Luther Terry made a bold announcement to a roomful of reporters: cigarette smoking causes lung cancer and probably heart disease, and the government should do something about it.

Terry, himself a longtime smoker, spoke at a press conference unveiling Smoking and Health: Report of the Advisory Committee of the Surgeon General of the Public Health Service. That press conference was held on a Saturday in part to minimize the report’s effect on the stock market. After all, in 1964 smoking was common, fashionable, and done everywhere. In the U.S., tobacco was an even bigger business than it is today.

I vividly remember hearing about the Surgeon General’s report on the CBS Evening News. At the time, I was a first-year medical student. Between two-thirds and three-quarters of my fellow students were smokers. By the time we graduated, only 10% remained smokers. The report was one big reason why.

The impact of the report was augmented by our experience dissecting cadavers. The lungs of non-smokers were pink. The lungs of heavy smokers were black. That didn’t look healthy, and the surgeon general confirmed that it wasn’t.

I also remember the impression the report had on my mother, who had been smoking for many years. She wasn’t wowed by the science or the weight of the evidence. Instead, she was impressed by the fact that America’s “top doctor” was advising her, and other others like her, to stop smoking. (She didn’t follow his advice right away, but eventually did.)

Smoking-and-Health_coverThe 1964 Surgeon General’s report, and others that followed, have had a profound effect on the health of Americans, despite the tobacco industry’s concerted and continuing efforts to promote smoking. The percentage of Americans who smoke dropped from 42% in 1964 (the peak year for smoking) to 18% today. A new report in JAMA estimates that the decline in smoking prevented 8 million deaths since 1964, more than half of them among people under age 65.

But we still have a long way to go. Some 42 million Americans still smoke, although the majority want to quit. Each year, tobacco use accounts for nearly 500,000 deaths in the United States and 5 million deaths worldwide. And in the developing world, the last statistics I saw said that smoking is on the increase.

We continue to learn about the hazards of smoking and other forms of tobacco use. As CDC Director Thomas Frieden put it in a JAMA editorial, “Tobacco is, quite simply, in a league of its own in terms of the sheer numbers and varieties of ways it kills and maims people.” We also continue to learn about the addictive power of nicotine, and the difficulty of breaking an addiction to it.

The good news is that it’s possible to quit smoking. In the U.S. today, there are more former smokers than current smokers. Some people manage to quit on their own. Others are assisted by nicotine replacement coupled with some form of talk therapy. Stop-smoking medications such as varenicline (Chantix) or bupropion (Zyban) can also help.

I don’t recall hearing about any Surgeon General’s report before Dr. Terry’s 1964 report. In fact, I’m not sure at the time that I knew the U.S. had a Surgeon General. Since 1964, many Surgeon General’s reports have been issued, and many have received a lot of publicity. But probably no subsequent report has had as powerful an impact on the health of Americans.

I have many heroes. I don’t think you can overdo having heroes. Surgeon General Terry, and the epidemiological scientists who collected the evidence that he used, are near the top of my list. I’ll bet the eight million people who didn’t die young because of Dr. Terry’s message, and their loved ones, would agree. My mom began meditating decades ago, long before the mind-calming practice had entered the wider public consciousness. Today, at age 81, she still goes to a weekly meditation group and quotes Thich Nhat Hanh, a Zen Buddhist monk known for his practice of mindful meditation, or “present-focused awareness.”

Although meditation still isn’t exactly mainstream, many people practice it, hoping to stave off stress and stress-related health problems. Mindfulness meditation, in particular, has become more popular in recent years. The practice involves sitting comfortably, focusing on your breathing, and then bringing your mind’s attention to the present without drifting into concerns about the past or future. (Or, as my mom would say, “Don’t rehearse tragedies. Don’t borrow trouble.”)

But, as is true for a number of other alternative therapies, much of the evidence to support meditation’s effectiveness in promoting mental or physical health isn’t quite up to snuff. Why? First, many studies don’t include a good control treatment to compare with mindful meditation. Second, the people most likely to volunteer for a meditation study are often already sold on meditation’s benefits and so are more likely to report positive effects.

But when researchers from Johns Hopkins University in Baltimore, MD sifted through nearly 19,000 meditation studies, they found 47 trials that addressed those issues and met their criteria for well-designed studies. Their findings, published in JAMA Internal Medicine, suggest that mindful meditation can help ease psychological stresses like anxiety, depression, and pain.

Dr. Elizabeth Hoge, a psychiatrist at the Center for Anxiety and Traumatic Stress Disorders at Massachusetts General Hospital and an assistant professor of psychiatry at Harvard Medical School, says that mindfulness meditation makes perfect sense for treating anxiety. “People with anxiety have a problem dealing with distracting thoughts that have too much power,” she explains. “They can’t distinguish between a problem-solving thought and a nagging worry that has no benefit.”

“If you have unproductive worries,” says Dr. Hoge, you can train yourself to experience those thoughts completely differently. “You might think ‘I’m late, I might lose my job if I don’t get there on time, and it will be a disaster!’ Mindfulness teaches you to recognize, ‘Oh, there’s that thought again. I’ve been here before. But it’s just that—a thought, and not a part of my core self,'” says Dr. Hoge.

One of her recent studies (which was included in the JAMA Internal Medicine review) found that a mindfulness-based stress reduction program helped quell anxiety symptoms in people with generalized anxiety disorder, a condition marked by hard-to-control worries, poor sleep, and irritability. People in the control group—who also improved, but not as much as those in the meditation group—were taught general stress management techniques. All the participants received similar amounts of time, attention, and group interaction.

To get a sense of mindfulness meditation, you can try one of the guided recordings by Dr. Ronald Siegel, an assistant clinical professor of psychology at Harvard Medical School. They are available for free at

Some people find that learning mindfulness techniques and practicing them with a group is especially helpful, says Dr. Hoge. Mindfulness-based stress reduction training, developed by Dr. Jon Kabat-Zinn at the University of Massachusetts Medical School in Worcester, MA, is now widely available in cities throughout the United States.

My mom would point you to Thich Nhat Hahn, who offers this short mindful meditation in his book Being Peace: “Breathing in, I calm my body. Breathing out, I smile. Dwelling in the present moment, I know this is a wonderful moment.” A recent article in Parade magazine caught my eye because it has lessons for us all. The article was about Olga Kotelko, a 94-year-old woman, who is a competitive runner and track star. Her age alone is impressive. The fact that she didn’t enter her first Master’s competition until she was 77—an age when many people are hanging up their sneakers—is amazing.

The article offers six lessons that anyone can learn from Ms. Kotelko’s daily life:

Swap Sudoku for sneakers: Yes, challenging brain activities can help protect memory and thinking skills. But so can exercise. And exercise has many other benefits for health.

Stay on your feet: The less you sit each day, the better. That doesn’t mean constantly walking. Try reading, writing letters, or working on a computer at a stand-up desk. If you watch TV, stand or sit and exercise.

Eat real food: Avoid processed foods and eat real ones. Fruits, vegetables, grains, chicken, even red meat sometimes.

Be a creature of (good) habit: Daily rituals are a great way to cement good habits.

Cultivate a sense of progress: We all like rewards. Being able to see improvement—in the distance you can walk or the weight you can lift—can motivate you to exercise daily and follow other good habits.

Lighten up: Stress is bad for the mind and the body. Find ways to ease stress, or nip it in the bud. Exercise is a good stress reliever, as is meditation or other form of invoking the relaxation response.

I’ll add another lesson touched on in the article: It takes a village. Kotelko works with a coach, Harold Morioka, who is himself a gifted Masters athlete. And she regularly works out with a running buddy, 76-year-old Christa Bortignon, who this year won the 2013 World Female Masters Athlete award.

Olga Kotelko can be an inspiration for anyone who wants to start exercising or to exercise more. As I have written before, you are never too old or too frail to start exercising. Getting started is probably the toughest hurdle to overcome. Too often, older or frail individuals have the wrong impression that they are past the point where exercise can do any good. In fact, it can do them a world of good.

Start out with a safe, easy program. Gradually add more and harder exercise. Who knows where you might end—possibly in an event challenging the likes of Olga Kotelko..Fresh fruits and veggies usually pack the most punch nutritionally
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Friday, April 19, 2019

No “best” treatment for common uterine fibroids

The other night, I sat in a restaurant with a group of girlfriends. We shared laughter, good conversation and some great wine. As I looked around, I realized that we were likely to share something else: uterine fibroids. Of the ten women sitting at the table, there was a good chance that seven of us would have uterine fibroids at some point in our lives.

Fibroids are noncancerous tumors that grow in the uterus. They may be smaller than a seed or bigger than a grapefruit. A woman may have only one fibroid or she may have many. Depending on their size, number, and location, fibroids can cause heavy bleeding and long menstrual periods (which can, in turn, cause anemia), pelvic pain, frequent urination, or constipation. Fibroids can also cause infertility and repeated miscarriages.
No “best” treatment

Given how common uterine fibroids are, you’d think there would be a lot of research comparing treatment options. In fact, there are only a few randomized trials to guide treatment. In a clinical practice article in today’s New England Journal of Medicine, Dr. Elizabeth A. Stewart, professor of obstetrics and gynecology at the Mayo Clinic, lays out the options and discusses the factors that women and their doctors should consider when making treatment decisions.

First, are the fibroids causing symptoms? If not — which is often the case — no treatment is needed.

Next, what are the symptoms? These can be broadly divided into two categories: heavy menstrual bleeding and “bulk” symptoms. Bulk symptoms, like pelvic pain and frequent urination, are caused by the presence of large fibroids in the abdomen.

“I consider the severity of symptoms and the impact of those symptoms on a woman’s quality of life to be the foundation of treatment decision making,” says Dr. Aaron Styer, an obstetrician-gynecologist at Harvard-affiliated Massachusetts General Hospital. “For example, is the woman missing work, requiring frequent hospitalizations, or missing out on normal, daily life? If so, that information will guide the treatment I recommend.”

Whether a woman would like to have children, her age, and how close she is to menopause can also ninfluence the treatment decision. Once a woman enters menopause, fibroids often shrink or even disappear. But until menopause, they may continue to form or reappear after they are removed.
Hysterectomy, hold the power morcellation

Removal of the uterus (hysterectomy) is a popular option for women who are done having children. With the uterus gone, new fibroids can’t form. But traditional hysterectomy, in which a surgeon makes a large incision in the abdomen, is major surgery.

In laparascopic hysterectomy, the surgeon removes the uterus through three or four small incisions in the wall of the abdomen. Recovery is quicker and there are usually fewer complications than with a traditional hysterectomy.

Laparascopic hysterectomy has historically been accompanied by a procedure called power morcellation. It uses a device to cut the uterus into fragments so it can be removed through the small incisions. But the FDA recently recommended limiting the use of power morcellation because of the small chance that a woman having surgery to remove fibroids may have undiagnosed uterine cancer. If power morcellation is performed in these women, there is a risk that the procedure will spread the cancer throughout the abdomen and pelvis. This is precisely what happened in the much-publicized case of Dr. Amy Reed, an anesthesiologist at Boston’s Brigham and Women’s Hospital.
Treatment options for heavy bleeding

Women with heavy bleeding who do not want to have a hysterectomy can turn to both medical and surgical options. Some medications reduce heavy bleeding by helping blood clot. Hormonal birth control works by thinning the endometrium. This is the nutrient-rich lining of the uterus that is shed during a woman’s period. Medications can relieve symptoms, but they don’t treat the underlying problem.

A surgical option to treat heavy bleeding is hysteroscopic myomectomy. In this procedure, a thin tube called an endoscope is passed through the cervix and into the uterus. The fibroid is shaved and removed, but the uterus is left intact. If a woman does not want to have children, she can opt for endometrial ablation. In this procedure, the endometrium is destroyed, often with heat or cold.
Treatment options for bulk symptoms

When fibroids cause pelvic pain or frequent urination, the goal of treatment is to reduce the size of the fibroids. Medications called GnRH agonists effectively shrink fibroids. However, fibroids grow back once the treatment is stopped, and these drugs are not intended for long-term use.

Myomectomy — this time done through a larger incision in the abdomen — can reduce the size of the fibroids while preserving a woman’s ability to have children. However, fibroids can recur after myomectomy. Another option is uterine artery embolization. This procedure blocks the blood supply to fibroids, causing them to shrink and die. Women are significantly more likely to have a successful pregnancy and delivery after myomectomy than after embolization.

A treatment option that is increasingly being used to treat uterine fibroids is MRI-guided ultrasound surgery. It uses ultrasound waves to shrink fibroids and reduce heavy menstrual bleeding.
Which treatment is right for you?

While there are many treatment options for uterine fibroids, there is no clear winner. That means you and your doctor can choose a treatment based on your preferences and reproductive plans along with other medical considerations.

As you decide, ask your doctor:

    Which treatment gives me the best chances of having a healthy pregnancy?
    Which treatment is most likely to offer permanent removal of fibroids?
    What are my personal risks and benefits of medical versus surgical treatment options?

Let your doctor know:

    whether you plan to have more children
    if you’d prefer to keep your uterus, even if your childbearing days are over
    which symptoms you find most bothersome and how they affect your quality of life.

There may be no “best” treatment for uterine fibroids. But there is a best treatment for you. One morning not long ago, my teenage daughter started to black out. After an ambulance ride to our local hospital’s emergency department, an electrocardiogram, and some bloodwork, she was sent home with a follow-up doctor appointment. We got the good news that Alexa is perfectly healthy, but should avoid getting too hungry or thirsty so she doesn’t faint again. And I’m feeling lucky that she didn’t need to be hospitalized, because a research letter in this week’s JAMA Internal Medicine points out that hospitalization for low-risk fainting can do more harm than good.

Doctors use something called the San Francisco Syncope Rule to identify individuals who are at low risk for serious short-term problems after fainting and who don’t need to be hospitalized. Yet up to one-third of fainters at low risk are still hospitalized. “Most patients in the U.S. are admitted even if they don’t need to be, because doctors worry there might be a life-threatening cause,” says Dr. Shamai Grossman, an associate professor of emergency medicine at Harvard Medical School, who’s conducted about 20 studies on fainting.
The new research

Researchers at Johns Hopkins University followed more than 200 people between the ages of 19 and 97 (average age of 61) who were admitted to the hospital for fainting, also called syncope (SIN-co-pee). This is the sudden loss of consciousness resulting from reduced blood flow to the brain, followed by spontaneous recovery. About one-third of all those admitted were at a low risk for short-term serious problems like heart failure or an abnormal heart rhythm.

Among the low-risk fainters, the average hospital stay lasted almost two days. During that time, they underwent a variety of tests, including CT and MRI scans of the head, ultrasounds of the heart, and imaging of the spine.

Is all that testing and evaluation necessary if you’re at low risk for more serious problems? “Complete loss of consciousness always deserves a thorough medical evaluation,” says Dr. Deepak Bhatt, a cardiologist and the editor in chief of the Harvard Heart Letter. “On the other hand, if someone is feeling lightheaded from not eating or drinking all day on a hot day, that may not be serious, yet may lead to a series of unneeded tests.”
The risks of unnecessary treatment

There were a few people in the study whose hospital stay or follow-up care uncovered a serious condition. But far more often, fainters at low risk for serious problems wound up experiencing more harms than benefits by being hospitalized.

For example, among the low-risk fainters in the study, testing uncovered “incidental findings of unclear significance” in 23 people. In other words, tests revealed other medical conditions that weren’t necessarily helpful to discover, such as calcified lymph nodes, spine fractures that had no symptoms, and changes in white matter in the brain. Those people experienced the inconvenience and expense of testing, only to come away with information that did little to pinpoint the cause of the fainting but that probably caused them anxiety and prompted even more tests.

What’s more, some problems that happened to low-risk fainters during hospitalization could have been prevented. Nine (mostly older) individuals experienced adverse events such as blood transfusion errors, falls, delirium, medication errors, and complications from the placement of an IV drip or a urinary catheter.

Hospitalization isn’t cheap, either. “A recent study suggests the average cost for a syncope admission is $2,420 per day. Being held for observation has an average cost of $1,400 a day,” says Dr. Grossman. In addition, admitting people to the hospital when they’re at low risk for additional problems means that they’re taking up valuable hospital beds that sicker people might need.
Fainting risks

Sometimes fainting is nothing to worry about. It can be caused by stimulation of the vagus nerve. This can happen if you strain while urinating, have blood drawn, get an injection, hear bad news, or even laugh too hard. These kinds of fainting episodes are known as vasovagal syncope; it commonly affects young people.

Sometimes the cause of fainting is never determined. “In about half of the cases, we don’t have a clear cause for fainting. So in low-risk individuals, we send them home and often they get more tests, and even then we still don’t find a cause,” says Dr. Grossman.

But you shouldn’t ignore losing consciousness, especially if you’ve never fainted before or if you have other medical problems or symptoms. For example, chest pain or shortness of breath either before or after fainting could indicate a heart problem. Other serious causes of fainting include a ruptured aneurysm, gastrointestinal bleeding, or a ruptured ectopic pregnancy.

So when should you be hospitalized after fainting? “The problem is that you can’t evaluate yourself, and you should let a physician determine if fainting is worrisome or not,” says Dr. Grossman. “But just because you’re in the emergency department doesn’t mean you need to be admitted to the hospital.”

He recommends that you ask your physician if you’re at risk for a worse event if you go home, and to make sure that if you’re admitted, it’s because there’s a potential serious cause to your fainting that can’t be fully assessed in the emergency department.

In our case, Alexa didn’t need to be hospitalized. But I’m glad she was fully evaluated; it was a relief to know she’s okay. I’ll just have to stay vigilant about keeping her well fed, well hydrated, and well advocated-for if fainting ever lands her in the emergency department again. I never planned on running a marathon, even though I had run for fitness and enjoyed going longish distances. I’ve never been fast, and any run over 8 miles had me wishing I had thought to use the bathroom again before heading out or thinking about how much laundry I could have finished in the time it would take me to finish a route.

But when a friend asked me to train with him to run the Boston Marathon for charity, I decided to go for it. The training was long and sometimes tedious but it was worth it to be part of this extraordinary event. I was pleased to finish in a respectable time, but what made it so rewarding was running “my” marathon (I won’t say race because I was not racing by any stretch).

Here are a few tips I’d like to share with Monday’s marathoners.

    You’ll find this advice in many running resources, but never, ever wear something on marathon day that you haven’t worn for a distance run before. Preferably many times before. That includes socks, definitely shoes, shorts, underwear, watches, sunglasses, hats, you name it. The last thing you need is unexpected discomfort, chafing, or blisters.
    If you have family or friends watching you along the route, try to know in advance where they will be. My best memories of the marathon were being able to hug friends and give my sisters and my husband a kiss on my way. Knowing where they were going to be made it easier for me to see them and to maneuver to the correct side of the road for a sweaty public display of affection.IMG_5213
    “The wall” is real so have a plan. I didn’t. I was quite pleased with myself that I made it through Newton and Heartbreak Hill in relatively good shape. But when I rounded into Cleveland Circle, my body said “I am D-O-N-E, done.” In that moment, I had no idea what to do. If this happens to you, try walking for five minutes or, if you’re running with music, cranking up your most inspiring tunes.

At the rate I was going, walking wouldn’t be that much slower or easier, so I kept shuffling. I could at least say I ran the whole thing. Which I did. But I think I would have been just as satisfied if I had to walk.

    Try to take in the atmosphere—and I don’t just mean breathing hard! The last 4 miles were tough for me. I was running along and looked up and saw a sign that said “Go Nancy.” “Wow,” I thought. “Someone has a sign for someone with my name!” As I glanced up, I saw it was for me. A friend from work had made it and was rooting me on.

But even if it wasn’t for me, I was amazed at all the support and encouragement the crowds offered all the runners. Tune into that goodwill and support. The crowd appreciation can help you keep moving. It really is for you and can help keep you moving.

    Enjoy the camaraderie. As I was turning onto Gloucester Street — the final stretch — a runner I’d never met looked at me and said “I can’t believe we’re here!’ I couldn’t either and it was great to share that moment (especially when you’re one of the back-of-the-pack runners). Throughout the race, don’t hesitate to connect with your fellow runners.

If you are running the Boston Marathon on Monday, I wish you a joyous and rewarding run. No matter how fast you go, how far you make it, or what shape you’re in when you’re done, you’ve been a part of something special. I’ll be cheering you on.
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