Archive For: Wellness

Dementia and Alzheimer’s: Updates from a Leading Geriatrician

Senior Moments Or Something More?

As Baby Boomers continue the inexorable journey deep into their senior years, preserving cognitive function understandably tops the list of worries. While Alzheimer’s Disease and related dementias are seen in just 5% of people over 65, that number jumps to 30% for people age 85 and over. Questions abound: is forgetting a name a sign of normal aging or an indicator of a more serious memory disorder? Are any nutritional supplements or pharmaceutical treatments available that are proven to stave off memory loss? Most importantly, what steps can be taken to modify individual risk?

To better understand how to identify and manage dementia and Alzheimer’s disease, we asked one of the country’s leading experts, R. Sean Morrison, MD, for his informed perspective on this growing concern for seniors, their families and caregivers. A practicing geriatrician, palliative medicine physician and health researcher for almost three decades, Dr. Morrison has earned numerous awards and recognition for his work, and currently serves as the Chair of the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai and as Director of the Hertzberg Palliative Care Institute.

Is memory loss an inevitable, natural sign of aging?

Dr. Morrison: The good news is that not all cognitive functions decline with age. The ability to maintain attention, language comprehension, usage, and vocabulary does not decrease. Knowledge learned years ago like how to ride a bike, or brush your teeth, also stays intact. Additionally, when you learn something new and can remember it, you won’t forget it any more rapidly than when you were younger.

The not so good news is that it will take greater effort to learn those new things; more attention, repetition and use of memory-enhancing strategies will be needed. The ability to multitask is also diminished, as processing information takes longer and reaction times are slower. People may experience poorer performance when working under time pressure, and find it more difficult to manipulate information in the brain, such as calculating a tip in a restaurant or figuring out a route to travel from one place to another.

How do you distinguish between a “senior moment” lapse in memory and a sign of Alzheimer’s disease?

Dr. Morrison: So many people experience that temporary inability to remember a name. But if you are able to recall things with a cue or can pick it out from a list of possibilities, that’s evidence of a problem with retrieval but not with storage. You can be reassured that it doesn’t indicate Alzheimer’s disease but a “senior moment” because the information has been successfully stored in your memory.

Is routine screening for dementia recommended in older adults?

Dr. Morrison: The U.S. Preventive Services Task Force does not recommend for or against routine screening, saying no interventions are proven to have a significant effect in people with earlier detected cognitive impairment. However, it is required as part of Medicare’s yearly assessments, and most primary care physicians consider dementia screenings an essential part of their annual wellness exam.

What types of screening tests do you recommend?

Dr. Morrison: At least a dozen tests are available, each with their own benefits and drawbacks. I recommend the following for their ease of use and proven sensitivity and specificity in diagnosing cognitive impairment:

  • Mini-Cog is a quick, three-minute evaluation. Patients are asked to repeat three words, draw a clock with hands at a specific time, and then recall the initial three words.
  • Memory Impairment Screen assesses free and cued word recall. Patients are read four unrelated words from four categories (e.g. Red Cross, saucer, checkers, telegram) and after a few minutes of diversion, asked to recall the words in 20 seconds, either with no prompting or cued by category.
  • Animal Fluency Test. Patients are asked to name as many animals as possible in a 60-second period.

Are there any risk factors for dementia and Alzheimer’s disease that can be controlled by patients?

Dr. Morrison: Quite a few risk factors are modifiable with lifestyle changes and non-pharmaceutical treatments. These include:

  • Address hearing and visual impairments, with eyeglasses, hearing aids and other assistance
  • Prevent and manage hypertension and diabetes
  • Maintain a healthy weight
  • Stop smoking
  • Seek treatment for depression
  • Prioritize regular exercise and physical activity
  • Avoid social isolation
  • Explore cognitive training

The best advice I can give to people in their 50s to 70s looking to prevent or delay progression of dementia and Alzheimer’s disease: exercise, exercise, exercise and rigorously control your blood pressure.

How are the symptoms frequently experienced by people with dementia – sleep disturbance, mood disorders, agitation – best addressed?

Dr. Morrison: There are a number of non-pharmaceutical interventions that have proven effective. Use adaptive clothing and assistive devices to help eliminate distress around bathing and dressing. Create a reassuring familiar structure to the day with a regular routine and activities. Optimize the sleep environment with a comfortable temperature, the right amount of light, a warm milky drink and a bath or shower before bed; avoid stimulating medications, drinks containing caffeine and alcohol, and exercise too close to bedtime. Pharmaceutical treatments can also be considered, including antidepressants to improve cognition and ameliorate agitation and aggression, and melatonin and melatonin antagonists to help with sleep disorders. Of note: medications such as benzodiazepines (BZD), non-BZD hypnotics, mood stabilizers and antipsychotics are no longer routinely recommended as side effects can outweigh possible benefits.

Are there any benefits to nutritional supplements or appetite stimulants?

Dr. Morrison: Nutritional supplements can help with weight gain in patients with anorexia or cachexia (‘wasting’ syndrome) but have no meaningful impact on survival. And while appetite stimulants such as cannabinoids and steroids are often given to help patients with dementia, there is no consistent data regarding their safety and efficacy.

What medications are available to treat or stop the progression of dementia?

Dr. Morrison: Until last year, only four medications were approved for treatment of dementia and Alzheimer’s disease, showing only a minimal to modest improvement in cognition. In 2021 a fifth drug was launched – aducanumab – a monoclonal antibody designed to reduce amyloid protein in the brain. Its fast-track approval was quite controversial as the clinical benefits of the drug were not proven during trials, which were stopped early as a result, and some severe side effects were observed. Interestingly, some researchers are now rethinking the idea that targeting amyloid protein plaques will eliminate Alzheimer’s disease, and instead exploring Alzheimer’s as a disease of inflammation. This could be the next fascinating line of research.

How a Memory is Made

Memory begins to form by giving attention to the information received through your senses. Anything that interferes with your ability to pay attention, such as hearing impairment, will affect the formation of a sensory memory. Successful integration of sensory memories into your working memory enables you to temporarily store, organize and manipulate information. These memories are then encoded into long-term memory and finally put into permanent storage.

 

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Tips for Safe Summer Fun

Stay Safe with Sunscreen, Sunglasses and Plenty of Water

The longer, sunshine filled days of summer are upon us and without a doubt, they are one of life’s unrivaled joys, especially when you protect yourself from the powerful impact of ultraviolet rays. With that in mind, we share our tips for safe summer fun; from choosing and using the right sunscreen to staying hydrated.

The debate around sunscreen safety heated up with last year’s recall of some popular consumer products containing chemicals such as benzene, which is absorbed through the skin and into the bloodstream. Yet according to the FDA, the American Academy of Dermatology and other experts, there is minimal evidence that systemic absorption of these ingredients is toxic or harmful to health. There is, however, a mountain of proof regarding the harmful effects of sunburn – most notably its significant contribution to the risk of melanoma.

“Use of a broad-spectrum, SPF 30 sunscreen effectively blocks UVB and UVA rays to prevent sunburn,” says Dr. Andrea Murina, MD, associate professor of dermatology at Tulane University School of Medicine and director of the University Medical Center’s dermatology clinics. “This not only reduces the risk of developing skin cancer but also decreases signs of early aging on your skin (such as wrinkles, age spots, sagging skin) and stops existing melasma from darkening and new patches from appearing.”

According to Dr. Murina, while we know some ingredients in sunscreen do cross over into the bloodstream, most are rated by the FDA as GRASE, meaning generally recognized as safe and effective.

A bit of background: Earlier studies conducted by the FDA showed that common chemical ingredients used in sunscreen, including oxybenzone are absorbed into the bloodstream.

Further research on whether systemic absorption of oxybenzone was an actual concern was suggested. However, no clear links to any health problems in humans were identified.

Nevertheless, the ingredient has been eliminated from most sunscreens currently being manufactured, making it easy to find an oxybenzone-free product.
When applied correctly, a water-resistant, SPF 30 sunscreen is optimal, blocking 97% of UVB rays. “A higher SPF is fine, but only incrementally blocks more rays, and the time and duration of effectiveness is the same,” says Murina.

The best way to protect yourself is by using a combination of measures:

  • Wear sun-protective clothing, including a lightweight, loose-fitting, long-sleeved shirt, pants, a wide-brimmed hat and sunglasses. Darker colors, densely woven cloth, unbleached cotton and shiny polyesters are recommended by the Skin Cancer Foundation.
  • Judiciously apply broad-spectrum sunscreen every two hours on uncovered body parts, such as top of hands, face, neck and ears.
  • Swap out regular SPF 15 foundation for a tinted sunscreen. “There are so many cosmetically elegant ones available today that mimic the look of makeup but offer much more protection,” says Murina. Tinted sunscreens with an SPF of 30 or higher provide protection that blends well with all types of natural skin tones, and help prevent exposure to both UV rays and visible light from the sun.
  • Seek shade when the sun’s rays are strongest, between 10:00 a.m. and 2:00 p.m.

Like sunscreen, sunglasses are vital in blocking the harmful effects of UV radiation. UVA and UVB rays can cause increased risk of conditions such as cataracts, eye cancers and growths on the eye, as well as premature aging of the delicate skin around your eye. Choose sunglasses that block 99% or 100% of all UV light or are listed as having UV absorption up to 400nm. Wear them even when it’s hazy or cloudy, as UV light can pass right through clouds. And although you’ve undoubtedly heard this piece of advice before, it bears repeating: To protect your retina, never look directly at the sun.

Finally, drink up when you’re out in the sun. Water is the elixir of choice, helping to lower your body temperature and replace the fluids you lose through sweating. This is particularly important for older adults whose body’s fluid reserve becomes smaller and thirst sense decreases as they age. Be aware of the most common signs of dehydration – lightheadedness, fatigue, dizziness, less frequent urination, dark-colored urine – and rehydrate promptly with cool water.

Safe Travels
If your summer vacation includes international travel, we recommend some healthy pre-planning that includes the following:

  • COVID-19: Make sure you are up to date with your vaccines and boosters. Get tested for COVID-19 as close to the time of your departure as possible (no more than three days before travel). Do not travel if you have COVID-19 symptoms, if you tested positive or if you are in quarantine due to possible exposure.
  • Check the U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) websites for the most up-to-date travel alerts, advisories and recommendations. Immunizations needed will vary based on your health condition, immunization history, countries and regions on your itinerary, and duration of your visit.
  • Update your routine immunizations to protect against increased risk of exposure to illnesses such as seasonal flu, diphtheria, varicella (chickenpox), measles, mumps and rubella. For quick guidance on additional immunizations you may need, try the online tool at GlobalTravEpiNet.
  • To protect yourself from the serious diseases spread by mosquitos, such as dengue fever and malaria, bring an EPA-registered insect repellent with an active ingredient like DEET or picaridin.
  • Pack your prescription medications and consider bringing over-the-counter medicines, including anti-diarrheal medicine, antacid, antihistamine, hydrocortisone cream, motion sickness medicine, cough medicine, pain and fever medicine, and mild laxative.
  • Also, pack supplies to prevent illness or injury, such as hand sanitizer, water purification tablets, insect repellent and sunscreen; and first aid items such as antibacterial ointment, antiseptic wound cleanser, aloe gel, insect bite cream, a digital thermometer and bandages.

We encourage you to contact your health care provider four to six weeks prior to your trip for personalized guidance … and we wish you a safe and memorable journey!

Sources: FDA, American Academy of Dermatology, Mayo Clinic, American Academy of Ophthalmology, U.S. Centers for Disease Control and Prevention, Skin Cancer Foundation

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Exercise Is Good Medicine

Get Up and Join the Movement

As we emerge from the doldrums of winter hibernation and COVID-19-related inertia, it’s important to remember that exercise is good medicine and there’s no better time than now, to get moving again.

“There isn’t a chronic condition that can’t be better managed with an appropriate dose of exercise,” asserts Dr. Cedric Bryant*, President and Chief Science Officer at the American Council on Exercise. “This requires good interaction with your physician, an ability to listen smartly to your body and the realization that some exercise is always better than none.”

He recommends fostering good muscular fitness and enhancing strength, flexibility and balance with the exercise routine shown below. The 15-minute investment of time needed to complete one set of 8 to 15 repetitions for each exercise provides beginners with “the minimum effective dose needed to elicit a very positive response,” says Dr. Bryant.

Add regular rounds of exercise that build endurance, helping improve the health of your heart, lungs and circulatory system. To achieve the best results, you should have enough breath to talk but not enough to sing during aerobic activities such as brisk walking or jogging, dancing, biking, swimming, climbing stairs, or playing basketball, tennis or the uber-popular pickleball. (Learn more about today’s fastest-growing sport in an upcoming newsletter.) Be sure and check with your healthcare provider before beginning an exercise program.

Dr. Bryant’s Essential Seven

1. Pushups

Benefits: Develop the large muscles of the chest and the back of arms
The basic incline pushup is done using a sturdy table or other solid surface about 3 feet high. Stand facing the table and place your hands on the edge (shoulder width apart) arms straight and elbows not locked. Walk your feet backward until your arms and body are in a straight line. Bend elbows and slowly lower chest to the edge of the table while inhaling. Keep body straight and rigid throughout the movement. Push body away from the table until elbows are extended but not locked. Exhale as you push up.

 


 

2. Bodyweight Squat (we need a little green guy for this one)

Benefits: Strengthens and tones the lower body

Stand with your feet slightly more than hip width apart, toes turned slightly outward, hands at sides with palms facing in. Pull shoulders down and back. Stiffen your core and abdominal muscles. Hold chest up and out, tilt head slightly up, shift weight back onto your heels while pushing hips toward the wall behind you.

Downward phase: Shift hips back then down to create a hinge-like movement at hips and knees. Try to control the amount of forward movement of the shinbones. Maintain tension in the core muscles and keep your back straight. Lower yourself until thighs are parallel or almost parallel with the floor. DO NOT go deep enough to cause pain. Make sure your feet don’t move, ankles don’t collapse in or out, knees remain aligned over the second toe, and body weight is evenly distributed between balls and heels of the feet.

Upward phase: Extend the hips and knees by pushing your feet into the floor. Hips and torso should rise together while heels are flat on floor and knees are aligned over the second toe. Continue extending until you reach the starting position.

Remember to inhale on the way down and exhale on the way back up.


3. Bent-Over Row

Benefits: Targets muscles in the upper and middle back and improves stability of the spine

Holding a small weight in each hand and standing with feet hip-distance apart, bend at the waist. Your back should be parallel to the floor with a neutral, not rounded, spine. Extend arms toward floor, keeping knees slightly bent. Engage abs and squeeze shoulder blades together as you bend elbows back and bring weights to your torso. Keep arms close to your torso. Slowly lower the weights back to the starting position.


4. Modified Single-Leg Deadlift

Benefits: Strengthens and tones gluteals and helps improve balance

Position yourself by a wall or chair. Stand straight, with feet aligned with hips, and shift weight to right leg. Slowly bend forward at the waist while raising your left leg behind you until your torso and leg are both parallel to the floor. Keep your head up and arms straight, perpendicular to the floor. Lower your leg as you return to an upright position. Keep your leg straight at all times. Repeat all reps on one side, then switch legs.


5. Overhead Front Press

Benefits: Increases shoulder strength and engages the core for stability

Stand upright and keep the back straight. Note: Beginners or those with back issues can perform this exercise seated. Hold a small weight in each hand at the shoulders, with an overhand grip. Thumbs are on the inside and knuckles face up. Exhale as you raise the weights above the head in a controlled motion. Pause briefly at the top of the motion. Inhale and return the weights to your shoulders.


6. Calf Raises

Benefits: Strengthen lower leg muscles, increase stability, balance and agility

Start by standing 6 to 12 inches away from a wall, facing it, with feet hip width apart. Extend arms to place your palms on the wall, level with chest or shoulders. Exhale and slowly lift heels off the floor, keeping knees extended without rotating your feet. Use your hands on the wall to support your body. Hold raised position briefly. Inhale and slowly lower heels back to the floor.


7. Plank Pose

Benefits: Strengthens the core and abdominals while increasing stability and balance

Modified version: Start in tabletop position with hands and knees on the floor. Walk your hands so your forearms and palms are facing down, keep shoulders and elbows aligned. Walk your knees away from your body until you feel your core and abdominals engaged. Keep torso straight and rigid, your body in a straight line from ears to knees with no sagging or bending, and with shoulders down, not creeping up toward your ears. You may keep your toes on the floor for extra support. Hold position for 10 seconds. Walk your knees back in, repeat. Over time, work up to 30, 45 or 60 seconds.


*As President and Chief Science Officer at the American Council on Exercise, Cedric X. Bryant, PH.D and Fellow of the American College of Sports Medicine, stewards the organization’s exercise-science and behavior-change education. He earned both his doctorate in physiology and master’s degree in exercise science from Pennsylvania State University, where he received the Penn State Alumni Fellow Award, the school’s highest alumni honor.

Sources/refer to these websites for more detailed descriptions on the exercises: American Council on Exercise, Verywell Fit, Women’s Health

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What’s Keeping You Up at Night?

Breaking the Cycle of Anxiety, Insomnia and Sleep Anxiety

A good night’s sleep does more than refresh and revitalize. It’s essential to your health, so make it a priority to understand what’s keeping you up at night.

“Healthy sleep is as important as proper nutrition and regular exercise for our physical and mental well-being,” says Kannan Ramar, MD, sleep medicine physician at the Mayo Clinic’s Center for Sleep Medicine and immediate past president of the American Academy of Sleep Medicine. “Lack of sufficient sleep is associated with increased risks of type 2 diabetes, high blood pressure, cardiovascular disease, depression and anxiety.”

The sleepless nights and drowsy days previously experienced by one out of three Americans with insomnia rose to pandemic highs of almost 60% in 2021, sounding a wake-up call to address this treatable condition which profoundly impacts both mental and physical well-being.

Sleep disturbance is intricately interconnected with the presence of issues such as anxiety and depression, each influencing the others, so it’s not always possible to determine which came first. Behavioral changes that result from chronic insomnia include feelings of being overwhelmed, inability to concentrate, irritability, nervousness, restlessness, and a sense of impending danger or doom.

Of adults diagnosed with depression, 75% experience insomnia and 20% have obstructive sleep apnea. Similarly, anxiety can make it harder for the body to relax and fall asleep.

Research suggests that anxiety can also affect rapid eye movement (REM) during slumber and trigger vivid, disturbing dreams that wake the sleeper.

Completing the loop is sleep anxiety — apprehension or fear about going to sleep — which is commonly seen in those with insomnia, narcolepsy, sleep apnea or restless legs syndrome.

While insomnia can seem never-ending, a number of strategies can effectively break the cycle.

The Basics:

  • Set boundaries for blue light exposure by turning off tv, tablets and phones at least 30 minutes before bedtime.
  • Limit large meals, caffeine and alcohol within 3 to 4 hours of bedtime, which can disrupt sleep. Alcohol allows you to fall asleep quickly but not stay asleep throughout the night.
  • Establish a consistent wake-up time seven days a week.
  • Ensure your bedroom is a designated place of sleep by keeping it dark, cool and quiet. And turn around your clock so you can’t see the time if you’re tossing and turning in the middle of the night.
  • Pursue support if you are experiencing chronic insomnia, defined as difficulty sleeping three or more times per week for at least three months. “We know that the longer insomnia lasts, the more difficult it is to treat,” says Dr. Ramar.

Support can include:

  • Cognitive behavioral therapy for insomnia (CBTI), a form of talk therapy focused on learning how to create an optimal sleep environment with positive bedtime routines and avoidance of factors that trigger anxiety and negative thinking. Requiring up to 12 weeks to see results, the key is shifting from “trying hard to sleep” to “allowing sleep to happen,” according to Stanford Health.
  • Prescription sleep hypnotics, such as Ambien or Lunesta. Hypnotics can be considered in conjunction with CBTI, but patients must be closely monitored for adverse effects and a buildup of tolerance to the medication’s effects. Low doses of Trazodone, an antidepressant, are sometimes used, as it causes drowsiness.
  • Light therapy, which is especially helpful for those who need to reset their circadian rhythms; e.g., a night owl who wants to function better with an early morning rising time.

If you are experiencing too many wakeful nights, please let your healthcare provider know. It may be helpful to keep a sleep diary for several weeks to help pinpoint the habits affecting your ability to fall and stay asleep. In some cases, we may recommend a polysomnography (sleep study), where you’ll be monitored for blood oxygen levels, body position, breathing, electrical activity in the brain, eye and leg movements, heart rates and rhythms, sleep stages and snoring during an overnight stay in a sleep lab.

Finally, keep in mind that the amount of sleep needed per night – typically 7 or 8 hours on average – varies by individual. “If you function well and are fully alert during the day, you can be confident your sleep needs are being met,” says Dr. Ramar.

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What Does BMI Really Tell Us?

Definitive Diagnostic Tool or Part of a Greater Health Matrix?

It’s an easily understood calculation: Body Mass Index, popularly known as BMI, computes an individual’s measure of body fat as weight in kilograms divided by height in meters squared. Levels are defined as Underweight if less than 18.5, Normal weight if between 18.5 and 24.9, Overweight if between 25.0 and 29.9, and Obese if above 30. But what does BMI really tell us?

This simple formula has nonetheless sparked controversy and continued questioning: Is BMI a quick, easy and efficient way to identify weight problems and associated risk of disease in adults? Or is it an inaccurate measure because it doesn’t consider body composition, age, sex or ethnicity?

Years of debate, research and analysis now point to using BMI in a more nuanced way, suggesting that it is best employed as just one part of an initial health screening for individuals, and not as a diagnostic tool. Much more meaningful is how BMI fits with other essential measures of an individual’s health — blood pressure, blood sugar, cholesterol levels, heart rate, inflammation, physical activity, diet, cigarette smoking and family history.

Looking at BMI alone can be misleading when you consider that:

  • Women tend to have more body fat than men.
  • Older adults have more body fat than younger ones. Aging is associated with an unhealthy increase in body fat and an associated increased risk for prediabetes and type 2 diabetes.
  • At the same BMI, the metabolic risks for people of Asian descent are higher than for Caucasians.
  • People who engage in strength training two or more times per week have higher lean muscle mass than nonathletes, which can result in a higher BMI but not necessarily a higher risk of disease.

Additionally, knowing where the fat is distributed is essential in determining disease risk. The pear shape associated with women means subcutaneous fat around the hips, thighs and buttocks; more dangerous is the apple shape, which indicates visceral fat in the abdomen (waist circumference of more than 40 inches for men or more than 35 inches for nonpregnant women), which is linked to higher risk of heart disease and type 2 diabetes.

An influential study published in Nature further revealed the flaws in categorizing people as “unhealthy” or “healthy” based on BMI alone. The authors found that more than 74 million American adults were miscategorized. Nearly half of people considered overweight and 29% of those categorized as obese were actually metabolically healthy, with normal blood pressure, cholesterol and blood glucose levels. Meanwhile, 30% of those considered “normal weight” had metabolic or heart issues.

The origins of BMI help explain its limitations. In the 1830s Belgian mathematician Lambert Adolphe Jacques Quetelet developed a test intended to identify the “l’homme moyen,” or the “average man,” by taking the measurements of thousands of Western European men and comparing them to find the ideal weight. More than a century later, American physiologist and dietician Ancel Keys promoted Quetelet’s Index as the best available way to quickly screen for obesity, identifying certain BMI ranges as associated with greater risk of disease and poor health outcomes. However, like Quetelet, Keys didn’t account for different body types or ethnicities.

One other point to consider: While more intrusive and not as commonly available, methods such as measuring skinfold thicknesses, bioelectrical impedance, underwater weighing, abdominal CT scans (for visceral fat) and dual-energy X-ray absorption are more accurate than BMI for estimating body fat.

So is BMI still meaningful?
As a discussion point, or as one tool used in combination with other assessments of metabolic and skeletal health, it can be useful.

Most importantly, body fat is just one of many factors considered when evaluating individual health and risk of disease.

We encourage you to call your healthcare provider to discuss your personal wellness profile.

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Pandemic Stress Likely Compounded by Seasonal Affective Disorder

 

Coping With Sad This Winter

As we continue to weather the storm of COVID-19, seasonal affective disorder, or SAD, is once again on our radar. More subtle than an arctic blast, SAD is just as real, with just as much potential to have a chilling effect on our mood, productivity and wellness. Similar to last winter, the emotional stress and ongoing uncertainty that come with a global pandemic is unfortunately creating an ideal climate for SAD. Not surprisingly, mental health experts are expecting to diagnose and treat an increased number of people with SAD in 2022.

First discovered in the 1840s, SAD was not officially recognized as a disorder until the early 1980s, when Dr. Norman Rosenthal coined the term and categorized it as a form of clinical depression. We now know that SAD affects at least 5% of Americans; is more likely to affect women than men, those with other forms of depression or family members with the condition; and is far more common in northern regions, due to reduced natural sunlight. New research has advanced several theories as to why some people develop SAD, including: sluggish transmission of serotonin (which helps regulate mood and the body’s circadian rhythms; reduced sensitivity of the eyes to environmental light; a combination of these factors; or other reasons yet to be uncovered).

A deeper understanding of what triggers SAD and its impact on mental health has inspired a growing number of clinical treatments that can effectively neutralize its effects.

Chief among them:
Healing light.
Sitting in front of a bright light box for 30 to 45 minutes daily has been a treatment of choice for more than three decades, helping SAD patients with either 10,000 lux of white fluorescent or full spectrum light that shines 20 times brighter than ordinary indoor illumination. Dawn simulation, another form of light therapy, begins in early morning before patients awake by emitting a low level of light that gradually increases over 30 to 90 minutes to recommended room light level (approximately 250 lux). Enhancing indoor lighting with regular lamps and fixtures is also recommended).

Talk therapy.
Newer studies from the University of Vermont suggest that cognitive behavioral therapy (CBT), a psychological treatment aimed at providing patients with tools to change negative thoughts and behaviors, may be as effective as light therapy for treating SAD. According to the National Institute for Mental Health (NIMH), CBT adapted for SAD focuses on behavioral activation, helping SAD sufferers identify and engage in enjoyable seasonal activities to combat the ennui and fatigue they typically experience in winter.

Sleep hygiene.
Creating a consistent light-dark, sleep-wake cycle is important for SAD patients, who often experience hypersomnia (excessive daytime sleepiness) and insomnia (trouble falling or staying asleep).
Antidepressant medications. Because SAD is associated with disturbances in serotonin activity, antidepressant medications have been effectively used to treat symptoms.
Active days. Keep moving with daily walks outside, even on cloudy days, and aerobic exercise. Both can help alleviate symptoms of SAD.

Winterize your mental health
Be proactive in safeguarding your mental wellness over the coming months. Most importantly, know the symptoms of SAD and call our office for help if you’re experiencing:

  • Diminished interest in things that were once enjoyable
  • Low energy or overwhelming fatigue
  • Difficulty with concentration or focus
  • Worthless or helpless feeling
  • Sleep issues: too much sleep, or not enough
  • Changes in appetite or weight; increases in carbohydrate and sugar cravings
  • Agitation

Experts advise those who’ve previously experienced episodes of seasonal depression to try to get in front of it this year. Call our office for guidance regarding medications or CBT sessions. For many, reprogramming their mindset can help restore proper circadian rhythms and eliminate the psychological dread of winter. Try enrolling in an online class, taking up a new hobby or creating a new routine to optimize daylight exposure. Or keep it even simpler. As Dr. Rosenthal told the New York Times, “A 20-minute early morning walk in the sun can be as good as commercial light therapy.”

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A Novel Approach to Behavior Change

How to Replace Bad Habits with Healthy, Sustainable Behaviors

For entrepreneur physician Kyra Bobinet, MD, the typical reasons behind a failed diet served as the impetus for developing a novel approach to behavior change.

“I was doing so well. I knew what to eat, when to eat, how to eat, and then I just stopped doing it…and I don’t know why.”

Her answer to a patient’s familiar lament above, called the Iterative MindsetTM, is now used by the U.S. Centers for Disease Control and Prevention (CDC) to enhance its diabetes prevention program.

Drawing on her neuroscience and medical training at the UCSF School of Medicine and Harvard T.H. Chan School of Public Health, Bobinet conducted years of field research aimed at eliminating the inevitable gap between intention and action. What she discovered was a way to change even the most intractable bad habits and permanently replace them with healthy, sustainable ones.

The Iterative Mindset, Bobinet asserts, is the key to people who succeed despite seemingly insurmountable odds. In her early work helping frontline Walmart employees manage conditions such as obesity, cardiac disease and diabetes, she observed that only a small percentage of people were able to achieve the necessary lifestyle changes. Notably, they faced every possible headwind of financial and social stress – single parenting, senior caregiving, food insecurity and lack of healthcare access.

“Nonetheless, they somehow were able to lose weight, get off their medications, and dramatically improve their health,” she recounts. “We looked and looked, but the only common link between them was the Iterative Mindset, a resilient way of approaching behavior change like an experiment – with curiosity, innovation and no failure or blame if it doesn’t work out as planned.”

It’s a stark contrast with the way most people view their failure to change longstanding habits. Bobinet describes why: “The habenula, a recently characterized area of the thalamus, has two functions – detecting failure and then, if you think you failed, suppressing your motivation to keep trying. By activating whenever you believe you’ve failed to reach a goal, the habenula places you in a state of learned helplessness, associated with higher depression and low self-efficacy. This is when most people give up and bad choices ensue.”

She posits that those who form new habits by continually trying again in different ways, or iterating, are able to bypass that switch in the brain. An iterative mindset can succeed where the performance mindset, used for SMART (specific, measurable, achievable, relevant, time-based) goals or tracking steps with wearable devices, sometimes cannot.

“Performance mindset works well to motivate for tasks that are short-lived, and for optimization, such as athletes who have already experienced a substantial success and want to strive for the next level,” says Bobinet. “However, it can be detrimental when used to modify behaviors in more vulnerable people, setting them up for an eventual win or lose situation that triggers feelings of failure and causes loss of motivation to keep trying.”

True change only happens when a new behavior turns into a habit, repeated so frequently it grows to be automatic, and by definition becomes part of your lifestyle, says Bobinet. The process can take up to two years, with multiple relapses an expected part of the process.

“It’s completely natural to relapse when you’re stressed or distracted; it’s how fast you get back in motion that counts. And you cannot fail as long as you iterate,” emphasizes Bobinet. “Don’t blame yourself, blame what you tried—it wasn’t the right thing right now. Think of it as an experiment that needs tweaking and continue to version until you find the right fit for you.”

If you’re interested in trying this mindset approach to behavior change, Dr. Bobinet offers a free basic Fresh Tri app through the Apple App Store and Google Play.

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Staying Well in the New Year A Proactive Guide

In the spirit of starting 2022 with healthy intention, we’ve taken a page from the U.S. Preventive Services Task Force (USPSTF) latest recommendations, long considered the gold standard for clinical preventive services, and prepared the following proactive guide to staying well in the new year.

Back in 1903, Thomas Edison predicted where we were headed: “The doctor of the future will give no medicine but will instruct his patient in the care of the human frame, in diet, and the cause and prevention of disease.”

While we have yet to reach the future envisioned by Edison, preventive care, relegated to the back seat during the pandemic, is in full gear once again.

Since 1984, the USPSTF team of volunteer, independent experts in internal medicine, family medicine, pediatrics, behavioral health, obstetrics/gynecology and nursing has conducted rigorous assessments of the scientific evidence for the effectiveness of a broad range of preventive screening, counseling and medications. Their findings, published in the Journal of the American Medical Association, laid the foundation for preventive medicine in primary care, from when to get your first colonoscopy to whether an aspirin a day is really the best way to keep a heart attack at bay.

A number of USPSTF recommendations have changed significantly over the years, guided by evolving science and clinical experience. In 2021, these changes included lowering the screening age for diabetes from age 40 to 35, lowering the age for colorectal cancer screening from age 50 to 45, and strongly discouraging people over 60 from taking a low-dose aspirin each day to prevent a first cardiovascular (CV) event. As recently noted by the advisory board, this doesn’t represent a flip-flop or misfire, but rather necessary updates based on new research. So, for example, when the latest evidence showed the increased risk of gastrointestinal or brain bleeds in certain populations from taking a daily aspirin to prevent CV disease, the panel reviewed, reconsidered and drafted a revision to its 2016 recommendation. Similarly, when data pointed to the incidence of diabetes increasing at age 35 and the benefits of lifestyle interventions for reducing progression from prediabetes to the more serious type 2, the USPSTF revised accordingly.

What’s on the radar for the USPSTF? Recommendations being studied now for potential updates include statin use for the prevention of CV disease; vitamin, mineral and multivitamin supplementation to prevent CV disease and cancer; behavioral counseling interventions for prevention of CV disease in low-risk adults; hormone therapy to prevent chronic conditions in postmenopausal women; effectiveness of screening for depression, eating disorders, obstructive sleep apnea, skin cancer, osteoporosis, glaucoma and atrial fibrillation; and a comparison of breast cancer screening methods. Stay tuned for new developments.

An Ounce of Prevention

Following are the latest USPSTF preventive medicine recommendations, intended for people without symptoms of the disease. As always, please consult with your healthcare provider for guidance based on your personal health situation.

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Color Your World with Every Hue of Fruit and Vegetable

Eating Your Fruits and Veggies May Help Reduce the Risk of Chronic Disease

Fill your plate with a vibrant, colorful array of fruits and vegetables for a naturally delicious way to meet your daily requirement of vitamins, minerals and nutrients. Plant foods contain thousands of natural compounds called phytonutrients, which may have anti-inflammatory benefits that can help reduce the risk of chronic diseases. Every color has a contribution to make – aim for a few different ones each day, and enjoy the entire spectrum.

Red and pink:

These fruits and vegetables are an abundant source of the carotenoid lycopene, which may help balance free radical activity in the body, offering protection against prostate cancer and heart and lung disease. Additional picks: red onions, persimmons and raspberries.

  • beets
  • cherries
  • cranberries
  • pink grapefruit
  • pomegranates
  • radicchio
  • red radishes
  • red apples
  • red grapes
  • red peppers
  • red potatoes
  • rhubarbs
  • strawberries
  • tomatoes
  • watermelons

Orange and yellow:

Enjoy an extra boost of beta cryptoxanthin, which supports intracellular communication and may help prevent heart disease. Orange and yellow fruits and vegetables also contain vitamin C and carotenoids, including beta-carotene, which is associated with promoting healthy vision and cell growth. Additional picks: pomelos, turmeric root and star fruit.

  • acorn squash
  • butternut squash
  • apricots
  • cantaloupes
  • carrots
  • corn
  • grapefruit
  • lemons
  • mangoes
  • nectarines
  • oranges
  • orange peppers
  • papayas
  • peaches
  • pineapples
  • pumpkins
  • summer squash
  • sweet potatoes
  • tangerines
  • yams
  • yellow apples
  • yellow peppers
  • yellow squash

Green:

These are some of the healthiest fruits and vegetables, rich in chemicals like sulforaphane, isocyanate and indoles, which may inhibit the action of carcinogens. Dark green and leafy vegetables have the highest concentration of both antioxidants and fiber. They’re also packed with potassium, lutein, isothiocyanates, isoflavones and vitamin K, which can be important for vision, bone and blood health. Greens like kale have as much calcium as milk. Additional picks: Swiss chard, arugula, zucchini, edamame, alfalfa sprouts and green herbs (mint, rosemary, sage, thyme and basil).

  • artichokes
  • asparagus
  • avocados
  • bok choy
  • broccoli
  • Brussels sprouts
  • celery
  • collard greens
  • cucumbers
  • green beans
  • green cabbage
  • green grapes
  • green onions
  • green peppers
  • kale
  • kiwis
  • leeks
  • limes
  • mustard greens
  • okra
  • pears
  • peas
  • romaine lettuce
  • snow peas
  • spinach
  • sugar snap peas
  • watercress
  • zucchini

Blue and purple:

Anthocyanins – powerful antioxidants that may help delay cellular aging, block the formation of blood clots and boost urinary tract health – abound in these fruits and veggies. Additional picks: beetroot, radishes and purple cabbage.

  • blackberries
  • blueberries
  • black currants
  • dates
  • eggplants
  • grapes
  • plums
  • prunes
  • purple figs
  • raisins

White:

These foods may not be as brightly hued as the others, but they shine with valuable phytonutrients. These include the potentially anti-tumor properties of allicin and quercetin, found in garlic and onions; the healthy compound sulforaphane in the cruciferous cauliflower; and immune-supporting selenium in mushrooms. Additional picks: leeks, white beans (cannellini, navy beans, lima beans, soybeans), lychees, white peaches and daikon radish.

  • bananas
  • cauliflower
  • garlic
  • Jerusalem artichokes
  • mushrooms
  • onions
  • potatoes
  • parsnips
  • shallots

Sources: American Heart Association, Rush.edu, Harvard Health

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COVID-19 and The Road Ahead

From Boosters & Breakthroughs to Vaccines & Variants: Where Do We Go From Here?

The following reflects an 8/24/2021 discussion; please check the CDC website for real-time updates as the situation continues to evolve.

Their answers may not land lightly, but epidemiologist Jodie Guest, PhD, and drug development expert Michael Kinch, PhD, have been immersed in examining COVID-19 since its first stirrings in early 2020. They share an informed look at the road ahead for us all.

State of Concern

Noting more than 39 million COVID-19 cases nationwide, (as of 9/2/21) Guest projects this will continue to rise rapidly and eclipse one million a week. While “hot spots” for outbreaks clearly correspond to the country’s most lightly vaccinated locales, the impact of the delta variant is being felt in virtually every state. “There’s almost nowhere you can go in the U.S. that you don’t need to be masked indoors, even if vaccinated,” she says. The progressive increase in vaccinated patients with COVID-19 in European hospitals is also troubling, says Kinch, a potential harbinger of what is to come for the U.S.

However, what’s driving the surge is not cases among the vaccinated, known as “breakthroughs.” It’s a term Guest would like to eliminate permanently, given its negative connotation regarding vaccine efficacy. “These type of infections are still rare. More than 90% of those hospitalized with COVID-19 are unvaccinated.” She points out that while viral loads in patients with COVID-19 are the same for vaccinated and unvaccinated patients in the first few days of illness, they drop much faster and further in the vaccinated.

The vaccine, contends Kinch, was never intended to eliminate all possibility of getting COVID-19. “It’s not a suit of armor,” he says, “because no vaccine ever provides 100% protection. But we know they work incredibly well to prevent you from getting very sick or dying.”

The FDA’s recent approval of the Pfizer mRNA vaccine, with Moderna approval expected to follow soon, is pivotal, says Guest, in helping launch vaccination requirements at businesses, schools and other locations. “Don’t underestimate the importance of this approval in providing support for mandates that will protect all of us,” she says. “Recognize that in the entire history of vaccines, there has never been a set more studied than the ones we have now.”
Adds Kinch, “With the enormous amount of data gathered on the vaccines’ efficacy and safety, those who think of themselves as vaccine hesitant may more accurately be described as vaccine resistant.”

Third Doses and Boosters

The recent approval of a third dose of Pfizer or Moderna for immunosuppressed patients who didn’t build sufficient immunity from the first two doses applies to just 3% of the adult population. For everyone else (with the exception of pregnant women), a booster shot six to eight months after the initial series is being considered for approval.

“Right now, that’s how long we believe we can go without significantly diminished immunity,” says Guest. Antibody tests are not proven to be an accurate measure of protection from COVID-19, says Kinch, because the antibody levels vary by individual.

If you received Pfizer or Moderna initially, choose the same for a booster. Notes Kinch: “There’s no difference between these two vaccines—one is not better than the other.” In fact, some studies show no impact on efficacy from switching brands, he says; Johnson & Johnson data is yet to come.

And where does the flu shot fit in this fall? Absolutely essential, both agree, with the only caution that a two-week separation between the two vaccines may be recommended by some healthcare providers to avoid triggering a hyperactive immune response.

Protecting our Children

The best way to keep youngsters under 12 safe is ensuring that everyone around them is vaccinated, says Guest.
“Teachers, caregivers, babysitters and others should be vaccinated, or fully masked whenever they’re with children,” she advises. A different dose is being tested for 5- to 12-year-olds, with approval possible later this year.

The Next Wave of Variants?

While not identified by the Centers for Disease Control (CDC) as a “high concern,” Kinch admits that the lambda variant worries him primarily because not enough is known about its ability to resist vaccines. “One view is that the COVID-19 spike protein can only mutate to a certain point, and if that’s true, lambda could be the end of the virus. The other view is that we don’t know if it stopped mutating,” he says.
“We’re not defenseless, though,” counters Guest, “because we can keep it from getting here by having COVID-19 not circulating in communities. Greater numbers of vaccinated people will prevent us from getting whatever variant might follow delta.”

Stay Safe and Well

One of last year’s most popular signoff lines takes on new resonance as our experts advise on what that now means for the vaccinated in fall 2021.

Mask Up, Indoors and Out.

Masks are increasingly needed outside in crowded areas. Indoors, remember that while a soft, comfortable cloth mask protects others from you, if you need extra protection in certain settings, use a KN95 or N95 mask.

Pass on Indoor Dining, Movies, Concerts and Sporting Events.

Also reconsider full-capacity outdoor events with no masking/distancing/vaccine requirements. (As an alternative, order take-out and support virtual events offered by local venues). And avoid getting together in person with those who are not vaccinated.

Reach out to Every Unvaccinated Person you Know.

“The best action we can take is to keep encouraging every unvaccinated person we know to get the shot, now,” advises Guest. “We’re all in the race against variants and need to work together to defeat them as quickly as possible.” Adds Kinch, “It’s unfortunate that the motivations behind much of the messaging has messed up the message itself. Be completely honest about what is known and not known about the vaccine.”

The Swiss Cheese Respiratory Pandemic Defense.

“Layering prevention messages is crucial because the delta variant has made the holes in the Swiss cheese slice of the vaccine just a bit bigger,” says Guest. “Now masks are more crucial than ever before.”

Dr. Jodie Guest is professor and vice chair of the Department of Epidemiology, Emory University, Atlanta, and award-winning leader of Emory’s Outbreak Response Team for COVID-19.

Dr. Michael Kinch is associate vice chancellor and founder/director of the Center for Research Innovation in Biotechnology and the Center for Drug Discovery at Washington University, St. Louis.

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