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Thursday, January 31, 2019

Things to know about ticks and Lyme

Have you ever noticed that you tend to get a lot angrier on the road with other drivers than you do with people in the rest of your life? To a large degree, the experience of road rage is universal, and can be explained by the emotional distance that is created between drivers when there is both physical separation and a high potential for perceived slights and wrongdoing. The relative anonymity of driving leads to an exaggerated emotional response when feeling slighted or threatened, in part because all you may know of the other driver is that he or she just cut you off. It makes sense that you might react more angrily in that situation than if the same interaction occurred in another real-life setting.

Now if you accept the premise that separation and relative anonymity increase the potential for rage, imagine what the anonymity and dehumanization of the Internet does to virtual interactions. It is well documented that online comment sections too often become a hub for threats, heated arguments, and name calling.

Let’s explore why this might happen.

In 2016, FiveThirtyEight.com performed an extensive survey of 8,500 commenters to better understand the nature of their behavior. It found that commenters tended to be younger than 40 and predominantly male. Commenters also stated that they commented primarily in order to correct an error, add to the discussion, give their personal perspectives, and represent their views. Less often, they were trying to be funny, praise content, ask a question to learn, or share their own thoughts. So, we can acknowledge that there is a certain self-selection in the Internet commentary world that will lead to many comments being oppositional, even if most readers do not perceive the article this way.

But why do online commenters so often seem rageful in their opposition?

One explanation begins with the knowledge that the content most likely to elicit impassioned responses is on the very subjects that people feel affect them personally. The majority of Internet commenters know something about the topics being discussed, and often their personal experience does not align with the viewpoint of the author. Put another way, they may feel that this firsthand experience makes them more knowledgeable than the author, while the author may only have theoretical experience or none at all. Because commenters so often identify personally with the topic for this reason, the magnitude of their emotional response can be amplified, sometimes leading to stronger language than they would use in the real world. This is the case even when topics are written by so-called experts. This may be attributed to a principle in psychology known as the “backfire effect” — that is, people often become counterintuitively more entrenched in their position when presented with data that conflicts with their beliefs.

Even when commenters read entire articles, hostile comments are often formed out of defiance rather than ignorance of evidence presented by the author. The Dunning-Kruger effect may be at play here. This principle states that a person’s perception of what they have read and the content they’ve actually read often do not align well. In other words, a person may read an article whose focus is on one area, but become attentionally derailed by a strong emotional response provoked early in the piece. The provocative nature of Internet headlines are in fact designed to elicit such emotional responses in order to gain additional page views. One result is that many readers come away very quickly feeling attacked or misrepresented by information when that was not necessarily the article’s objective or focus. With the inherent anonymity and seclusion of Internet use, it is not hard to see how reasonable online decorum so often fails to hold under such circumstances.

There is little that you as an individual can do about the nature of the Internet, but you can choose how you interact with it. Good mental health around Internet use likely revolves around limiting your use to content arenas that promote your best self by allowing you to be productive and enjoy the time you spend on the web. If sites or posts seem to make you rageful, it may not be worth continuing to engage in this way. This is one aspect of online interactions where you have a lot of control.
Naturally fermented foods are getting a lot of attention from health experts these days because they may help strengthen your gut microbiome—the 100 trillion or so bacteria and microorganisms that live in your digestive tract. Researchers are beginning to link these tiny creatures to all sorts of health conditions from obesity to neurodegenerative diseases.

Fermented foods are preserved using an age-old process that not only boosts the food’s shelf life and nutritional value, but can give your body a dose of healthy probiotics, which are live microorganisms crucial to healthy digestion, says Dr. David S. Ludwig, a professor of nutrition at the Harvard School of Public Health.
Not all fermented foods are created equal

The foods that give your body beneficial probiotics are those fermented using natural processes and containing probiotics. Live cultures are found in not only yogurt and a yogurt-like drink called kefir, but also in Korean pickled vegetables called kimchi, sauerkraut, and in some pickles. The jars of pickles you can buy off the shelf at the supermarket are sometimes pickled using vinegar and not the natural fermentation process using live organisms, which means they don’t contain probiotics. To ensure the fermented foods you choose do contain probiotics, look for the words “naturally fermented” on the label, and when you open the jar look for telltale bubbles in the liquid, which signal that live organisms are inside the jar, says Dr. Ludwig.
Try making your own naturally fermented foods

Below is a recipe from the book Always Delicious by Dr. Ludwig and Dawn Ludwig that can help get you started.

Spicy pickled vegetables (escabeche)

These spicy pickles are reminiscent of the Mediterranean and Latin American culinary technique known as escabeche. This recipe leaves out the sugar. Traditionally, the larger vegetables would be lightly cooked before pickling, but we prefer to use a quick fermentation method and leave the vegetables a bit crisp instead.As the weather gets better and school vacations begin, along with sunburns and water safety there is something else parents need to think about: ticks and Lyme disease.

Lyme disease is spread by the bite of the blacklegged tick. While there are cases in various parts of the country, it’s most common in the Northeast and mid-Atlantic states, as well as around the Great Lakes. The early symptoms of Lyme include fever, body aches, and a bull’s-eye rash. It’s very treatable with antibiotics, but if not caught and left untreated, it can lead to serious health problems.

Here is information from the Centers for Disease Control and Prevention on four things that everyone should know and do:
1.  Prevention is key

As is true with all health problems, preventing them in the first place is always best. Be mindful of where your children play, as brush and tall grasses are where the ticks hang out. As much as possible, try to keep to the center of paths. Use a repellent with DEET (at least 20%), picaridin, or IR3535 on exposed skin (the Environmental Protection Agency has a great online tool that can help you choose the best insect repellent), and spray clothing (including socks and shoes) and gear like backpacks with permethrin.
2. Do tick checks at the end of every day

Even if your kids were just playing outside in the yard, get in the habit of looking them over. Ticks like warm, moist areas like the armpits, groin, and scalp, so you should particularly check there. Be sure to look carefully, because the blacklegged tick often transmits when it’s in the nymph stage, and nymphs are really tiny.

If you find an attached tick, grab it at the base with a tweezer and pull it upward with steady pressure. You can get rid of a live tick by wrapping it tightly in something or flushing it down the toilet.

Along with checking your human family members, be sure to check pets that have been outside, as they can carry ticks inside with them. You should also check clothing. Anything that isn’t going into the wash can be thrown into the dryer for 10 minutes or so (when washing clothes, be aware that if they aren’t washed in hot water, they may need extra time in the dryer to kill any ticks on them).
3. Be on the lookout for symptoms

If you do tick checks at the end of every day you should be fine, because it takes at least 24 hours — more often 36 to 48 hours — for an infected tick to transmit Lyme. This is a really important point that many people don’t know.

The classic rash of Lyme is an expanding bull’s-eye rash at the site of the bite. The rash is present in 70% to 80% of cases. Of course, that means it isn’t present in 20% to 30% of cases, so if someone in your family had a tick on them for more than 24 hours, or if you live in an area where there are many cases of Lyme and there may have been a tick bite, you should call your doctor if the person has a fever, chills, aches and pains for no clear reason, along with swollen lymph nodes or swelling of one or more joints. While having these symptoms doesn’t mean for sure that a person has Lyme, it’s worth getting checked out, as early treatment generally leads to a complete cure.
4. Be a cautious consumer of information when it comes to testing and treatment of Lyme

As with many conditions, there is a lot of misinformation out there about Lyme testing and treatment. It’s important to use laboratories that use evidence-based norms and processes. There are many advertised tests for Lyme disease, but some of them are simply not reliable — and it’s really important to have reliable information when making a diagnosis. It’s also not recommended to do testing for Lyme in someone who does not have clear symptoms of Lyme disease.

Most people recover completely after treatment of Lyme, but there are some people who have chronic symptoms such as fatigue, pain, or joint swelling after Lyme disease. This is called post-treatment Lyme disease syndrome or post-Lyme disease syndrome. The cause of these syndromes is unknown. Prolonged use of antibiotics is not recommended. Studies have shown that it doesn’t help, and there can be serious health problems when antibiotics are taken for prolonged periods of time.
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Dairy: Health food or health risk

For 30 years, I have talked to people about their memories and, as a neuropsychologist interested in amnesia, I am very interested in brain areas that mediate learning and forgetting.
How memories work

A core brain structure for memory is the hippocampus. The hippocampus (the Greek word for seahorse) is shaped like its namesake. It plays a key role in the consolidation of new memories and in associating a new event with its context (e.g., where it took place, when it happened). For example, you might hear the name Princess Diana. The hippocampus may activate verbal associations (e.g., she was part of the Royal Family), as well as memories of particular images or experiences. When I hear the name Princess Diana, I recall my brother telling me of her death as I descended the stairs of his home on Cape Cod. I can picture that moment in my “mind’s eye.” Despite my age, my (relatively) intact hippocampus allows me to retrieve a complex set of images and ideas that remind me where I was and who I was with when I heard the sad news of Princess Di’s death.
Memories that last

Some memories seem to age well. Recall of specific “flashbulb” events, such as the death of John F. Kennedy, or where you were on September 11th, 2001, seems unblemished and unchanged over time. However, in reality all memories, even flashbulb events, are malleable; they change as a result of the passage of time. They shift each time you call a memory to mind, as they are affected by other memories that have overlapping elements. As a student of memory, I am just as interested in long-term forgetting as I am in remembering. I am particularly intrigued by changes that take place with regard to autobiographical memory. Autobiographical memory is the foundation on which we derive a sense of who we are, what we find rewarding, and how we define our world. It is integral to how we construct meaning and purpose in our lives.
Autobiographical memory as we grow older

As we age our personal memories become fragile. They become less accurate and lose context. People with neurodegenerative conditions such as Alzheimer’s disease are particularly vulnerable to the loss of personal memories, due to the combined effects of their neurological condition and the aging process. They no longer have the same access to important milestones that helped define them. The importance of autobiographical memory is often overlooked. People come to me to ask for assistance with memory skills. I teach them all I know about mnemonic techniques to enhance face–name associations. I review cognitive strategies for new learning. I rarely talk about old memories… their first day of school, their first kiss, music from teenage years.
Tending to autobiographical memory

More recently I shifted my focus in conversations with people who want to talk about memory. Together with a therapist colleague, I started the “memoir project.” Why? I want to help highlight the important role of personal memories in maintaining a strong sense of self. People, even those with mild dementia, are encouraged to review important life events by using personal timelines to identify, for example, key events, food, music, and people who contributed to their sense of self. They may contact childhood friends, college roommates, and family members to remind them of shared experiences and to augment past memories. They often receive memory “gifts” as a result of these conversations — filling in the gaps in a memory that was beginning to fade. And of course, documentation and journaling are critical strategies. The stories people have shared with me have been fascinating. More important is the joy of reminiscence they experience.
If you’re the kind of person who avoids public bathrooms at all costs, you may feel validated, as well as disturbed, by a new study from researchers at the University of Connecticut and Quinnipiac University. They suspected that hot-air hand dryers in public restrooms might be sucking up bacteria from the air, and dumping them on the newly washed hands of unsuspecting patrons.

To test this theory, scientists exposed petri dishes to bathroom air under different conditions and took them back to the microbiology laboratory to look for bacterial growth. Petri dishes exposed to bathroom air for two minutes with the hand dryers off only grew one colony of bacteria, or none at all. However, petri dishes exposed to hot air from a bathroom hand dryer for 30 seconds grew up to 254 colonies of bacteria (though most had from 18 to 60 colonies of bacteria).

Were the bacteria multiplying inside the hand dryers, or were they being pulled into the hand dryers from the air inside the bathroom? To answer this question, the researchers attached high-efficiency particulate air (HEPA) filters to the dryers, which would eliminate most of the bacteria from the air passing through the dryer. When they exposed petri dishes to air from the hand dryers again, the quantity of bacteria in the dishes had fallen by 75%. As well, the researchers found minimal amounts of bacteria on the nozzles of the hand dryers. They concluded that most of the bacterial splatter from the hand dryers had come from the washroom air.

How did the bacteria get into the air in the first place? Unfortunately, every time a lidless toilet is flushed, it aerosolizes a fine mist of microbes. This fecal cloud may disperse over an area as large as six square meters (65 square feet). Aerosols from flushed toilets may be especially harmful in the hospital setting as a means of spreading Clostridium difficile.

Is there any good news from this study? Well, the vast majority of the microbes that were detected do not cause disease in healthy people, with the exception of Staphylococcus aureus. Some of the bathroom bacteria, such as Acinetobacter, only cause infections in people in the hospital, or in those with weak immune systems. The others that were found are relatively harmless. In addition, air from real-world bathrooms may contain fewer bacteria than the bathrooms in the study. The sampled restrooms were located in a university health sciences building, and at least some of the bacteria came from experiments going on in laboratories within the building.

So what’s a person to do to avoid picking up bacteria in a bathroom? You should still dry your hands, as not drying them after washing them helps bacteria to survive on them. Paper towels are the most hygienic way to dry your hands. For this reason, use of paper towels is already routine in health care settings. You may also wish to avoid jet air dryers, which have also been associated with the spread of germs in bathrooms. And remember that your chances of picking up a serious pathogen in a restroom are small. Direct contact with other people is much more likely as a means of acquiring infection.
The idea of using marijuana to mitigate the opiate crisis may seem counterintuitive to many people in the medical community. Some healthcare providers ask questions like, “Aren’t we just replacing one drug with another?” and “Doesn’t marijuana present its own set of dangers, such as addiction, dependency, and other health concerns?”

Medical marijuana is a divisive issue, and many intelligent, thoughtful people voice these concerns. Other people view cannabis research as an open and exciting field of discovery, and they want to advance marijuana as a safer option for patients who are managing chronic pain.
There is some common ground

People from both pro and con sides of the medical marijuana debate agree we need to study the medical benefits, safety, and dosing of marijuana, so that we can use it for difficult-to-manage diseases, such as opiate addiction and chronic pain. We now have data on how access to marijuana via medical marijuana dispensaries affects opioid use, and it’s positive. According to two studies recently published in JAMA Internal Medicine, the rate of opiate prescriptions is lower in states where medical marijuana laws have been passed.
Let’s look more at research

One of the studies, a longitudinal analysis of the number of opioid prescriptions filled under Medicare Part D, showed that when medical marijuana laws went into effect in a given state, opioid prescriptions fell by 2.21 million daily doses filled per year. When medical marijuana dispensaries opened, prescriptions for opioids fell by 3.74 million daily doses per year. These reductions in daily opioid doses were particularly notable for hydrocodone (Vicodin) and morphine prescriptions.

The other study analyzed Medicaid prescription data from 2011 to 2016, and that analysis showed that states that have implemented medical marijuana laws have seen a 5.88% lower rate of opioid prescribing, and when they implemented adult-use (i.e., recreational use) marijuana laws, there was a 6.38% reduction in opiate prescribing.

In the editorial accompanying these studies, the authors noted, “We do not know whether patients actually avoided or reduced opioid use because of increased access to cannabis (marijuana).” However, given that millions of prescriptions for opiates were not written, and consequently there were millions fewer bottles of prescription opiates consumed, sold, diverted, or abused, it does not seem to be too big a leap to infer that opiate use was avoided, or at least reduced.

In the same editorial, the authors make two more important points. The first alludes to research that shows opiates and cannabinoids (the active molecules in marijuana) use overlapping signaling systems in the body having to do with drug tolerance, pain, and dependence. This common mechanism would support and help explain stories of patients who describe a decreased need for opiates to treat chronic pain after starting to use medical cannabis. Second, the authors cited a 2014 study, also published in JAMA, which showed that “states with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate compared with states without medical cannabis laws.” The fact that opioid overdose deaths appear to be falling in states with medical marijuana laws complements this new research that suggests that fewer opiates are being prescribed.
Doctors and their patients can discuss medical marijuana

Just as there is disconnect among different members of the medical community about fundamental conceptions of marijuana, there is a large disconnect between patient and physician approval ratings of medical marijuana. Patients are loudly clamoring for more and better quality information from their doctors. An April 2017 Quinnipiac University poll showed that 94% of Americans support “allowing adults to legally use marijuana for medical purposes, if their doctor prescribes it.”

Healthcare providers, whether they are pro-, neutral, or anti-medical marijuana, need to leave their prejudices outside the exam room. Physicians need to create a climate where patients feel they can be open with us, so that we can know if and how they are using medical marijuana. Physicians can be in a position to advise them on the risks and benefits of safe usage, and meaningfully contribute to the conversation (assuming that we ourselves have a modicum of education on this issue). Once we are all on the same page, guided by evidence in new studies about reduced opiate use and adding medical marijuana to the pain relief arsenal, we can start helping patients to minimize their use of opiates.
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Ways to help get more children immunized


Fibromyalgia is a common condition that causes chronic body-wide pain and affects millions of people. The cause is unknown, and medications approved to treat it often aren’t effective, cause side effects, or both. To say we need better treatments for fibromyalgia is an understatement.

Non-medication treatment of fibromyalgia — especially exercise — is an essential part of treatment. But the last thing people with this condition want to do is exercise! Their pain and fatigue, so typical of this disease, make physical activity more wishful thinking than reality for most fibromyalgia sufferers. Even so, studies suggest that as long as people start “low and slow” (exercising at low intensity and for short duration, and very gradually increasing both), physical activity can be tolerated and even enjoyed.
Is there a “best” type of exercise for fibromyalgia?

A new study compared two types of physical activity among people with fibromyalgia: aerobic exercise (such as brisk walking, as commonly recommended) and tai chi, an ancient form of martial arts often practiced for health benefits. Past studies have demonstrated that tai chi can be effective for people with fibromyalgia.

Researchers enrolled 226 adults with fibromyalgia and randomly assigned 151 to learn and practice tai chi (once or twice a week for 12 or 24 weeks), while 75 were assigned to participate in standard “moderate intensity” aerobic exercise (twice a week for six months, with an aim of raising the heart rate during exercise to an aerobic range). Study subjects were representative of “real world” patients who varied in age, had other health problems, and took a number of medications.
What did the study show?

Compared with aerobic exercise, study participants assigned to the tai chi groups:

    attended their assigned exercise classes more reliably
    reported significant improvement on a standard survey of fibromyalgia symptoms when asked six months after treatment began
    had less anxiety
    felt better able to cope and had higher self-efficacy (a belief that they were able to improve their symptoms through their own actions)
    reported more improvement after 24 weeks of tai chi (vs. 12 weeks of tai chi)

Both groups reduced their use of pain relievers to a similar extent. And no serious injuries or side effects of the treatments were reported.
Does this mean everyone with fibromyalgia should try tai chi?

As is true for most treatments, there is not a single best option in all circumstances. It may not work well for those who don’t like tai chi (or don’t give it a chance), or feel they cannot participate due to poor balance, weakness, or other health problems.

In addition, the study itself is not the last word on which activities are best for people with fibromyalgia. Not everyone will have access to high-quality tai chi instructors (though in this study, results were consistent across three instructors). Skeptics will point out that since study subjects knew which treatment they were getting, the placebo effect could account for the findings. And, of course, there are countless other exercise programs that were not included in this study.
Stand by for more on exercise and other treatments for fibromyalgia

This new research suggests that instead of current recommendations to get aerobic exercise (as with taking brisk walks), tai chi might be just as good or better for many people with fibromyalgia.

In the near future, it’s likely that we’ll have better ways to diagnose and treat fibromyalgia. In addition, a better understanding of why it develops in the first place could lead to preventive approaches. Until then, I’ll keep telling my patients what I’ve been telling them for years: when fibromyalgia gets better, it’s usually because of something the patient is doing, not because of a medication I prescribed. Being physically active does seem to be a particularly necessary part of the approach. Based on the results of this latest research, tai chi may be a good place to start.
It’s almost May and here in the Northeast, front-of-the-pharmacy aisles are filled with myriad brands and types of sunscreen. While sunscreen is essential to lowering your risk for skin cancer, there are other simple, over-the-counter options you can incorporate into your summer skin protection routine.
Nicotinamide may help prevent certain skin cancers

Nicotinamide is a form of vitamin B3 that has been shown to reduce the number of skin cancers. In a randomized controlled trial performed in Australia (published in the New England Journal of Medicine), the risks of basal cell carcinoma and squamous cell carcinoma were significantly reduced — by 23%. Nicotinamide has protective effects against ultraviolet damage caused by sun exposure. The vitamin is safe and can be purchased over the counter. We recommended starting the vitamin (500 mg twice a day) to all our patients with a history of a basal cell carcinoma or squamous cell carcinoma, or with extensive skin damage due to sun exposure. One caveat is that the vitamin must be taken continuously, as the benefits are lost once stopped.
Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs, such as ibuprofen and aspirin, may have a modest effect on skin cancer prevention. A systematic review showed that the risk of squamous cell carcinoma was reduced by 15% with non-aspirin NSAIDs, and by 18% with any NSAID. Some studies of melanoma have also shown positive results; one found a 43% reduction in melanoma with continuous aspirin for five years, while other studies have failed to show any risk reduction. NSAIDs are known to inhibit an enzyme responsible for inflammation and pain, known as COX-2, which is overexpressed in squamous cell carcinomas. A limitation to many of the studies on NSAIDs in skin cancer is that the amount of NSAID taken varied. Especially at higher doses, NSAIDs are associated with other side effects, such as ulcers, and so I do not routinely recommend that my patients take these drugs to lower skin cancer risk.
Polypodium leukotomos

Polypodium leukotomos is a tropical fern found in Central and South America that has antioxidative, immunomodulatory, and anti-inflammatory effects, and is being marketed as an oral “sunscreen.” A recent small study of 22 patients showed that the fern extract altered the effects of UVB light (the more carcinogenic form of ultraviolet light) in 17 of the 22 patients to varying degrees. However, it is important to recognize that there are limitations to this study. First, it was unable to evaluate UVA light, which also causes skin cancer. Second, it is difficult to determine the most appropriate dose from the study. The participants received two doses of 240 mg of polypodium leukotomos two hours and one hour before ultraviolet exposure, but it is not clear how best to advise patients to use it. So, you may wonder whether I recommend this to my patients. The answer is, not yet. But I do plan to try the extract myself and on my husband (who has a history of skin cancer) this summer. Just keep in mind, this does not replace sunscreen and sun-protective clothing.
Watch your alcohol intake

Although alcohol is not a classic “over-the-counter” product, it has been in the spotlight in the past year, as alcohol is estimated to be responsible for 3.5% of all cancer deaths. Two meta-analyses suggested an association between skin cancer and alcohol intake. One study found that the risk of basal cell carcinoma increased by 7% and squamous cell carcinoma by 11% for every standard beer or small glass of wine each day. Another study showed a 20% increase in melanoma in drinkers, and the risk increased with the number of drinks. However, these studies didn’t take into account other factors that could affect the results, some of which cannot be measured. One example is that ultraviolet light is the main factor that increases basal cell carcinoma and squamous cell carcinoma, and alcohol consumption has been associated with behaviors that increase one’s risk of getting a sunburn. So what is the recommendation? The American Cancer Society recommends limiting alcohol consumption to one drink per day for women and two drinks per day for men.
And you still need sunscreen!

Since we have yet to find a magic pill that completely prevents sunburns and eliminates skin cancer risk, this is my plug for good old-fashioned sunscreen. Sunscreen has been shown to reduce both melanoma and squamous cell carcinoma. Randomized prospective studies in Australia showed that individuals who used daily sunscreen had a 50% reduction in melanoma and a 40% reduction in squamous cell carcinoma, compared to individuals who used sunscreen intermittently. So when the sun and warm weather beckon, remember to apply a broad-spectrum sunscreen with at least SPF 30 prior to going out in the sun, reapply every two hours, and apply liberally: 1 teaspoon to each arm, head and neck, front torso, and back; and 2 teaspoons to each leg.
Substance use disorders affect millions of Americans, and overdose is now the leading cause of accidental death in the United States. The need for treatment and recovery services has never been greater. This increasing demand has led to rapid growth in the number of detox and treatment service providers, which has burgeoned into a $35 billion a year industry. Most of these service providers work hard to provide honest, quality care to save lives.

Yet historically, addiction treatment and recovery services have been largely unmonitored, and remain so. As a result, the field is riddled with its share of corruption that seeks to exploit vulnerable individuals in desperate need of medical care. Because the news is saturated with stories about rehab scams and various patient abuses, it’s easy to think that “ one bad apple spoils the whole bunch.”
Unethical marketing of addiction treatment

Common unscrupulous practices include:

Patient brokering. This can take several forms. Lead selling involves paying brokers a finder’s fee or kickback for referring patients to their treatment facility (e.g., financial compensation of $500 to $1000 per patient or special future consideration). This is happening not only with patients new to treatment, but also in agreements made between recovery residences and treatment centers, or between two separate treatment centers. Lead buying is another approach. Call centers generate commission based on the number of placed referrals. Call center agents pose as caregivers, and unbeknownst to the patient, auction him or her off to the highest bidding treatment center. Treatment facilities that appear as separate centers may all route to the same call center. Finally, “addiction tourism” is the practice of sending a patient to a treatment facility in a state other than his or her home state.

Patient enticement. This is providing unethical incentives (money, gifts, free rent, flights, food, or other amenities) to get patients to enter, stay, or switch addiction treatment facilities.

Listing hijacks. Google Business or Google Maps listings can be altered through the suggested edits feature. Unaffiliated individuals can go into an organization’s profile and change listed phone numbers to reroute calls and online correspondences to other treatment programs or call centers, and change listed addresses to deceive patients about the actual location.

Misleading language or misrepresentation of services. Treatment facilities may deny their affiliations to other facilities or organizations; inaccurately portray the services they provide, their accreditation status, the types of conditions they treat, the credentials of clinical staff, accepted insurances; or misrepresent facilities, locations, and amenities in various ways.

Patient privacy violations. It isn’t unusual for unethical treatment centers to use a patient’s personal information — without his or her permission — as part of a sales or marketing pitch. This is in violation of HIPAA and other laws intended to protect sensitive personal health information.

Insurance overbilling and fraud. This is the process of billing insurance companies excessively for unnecessary treatment or services. A common instance is urine drug screens. For example, $10 drug tests are performed every two days and billed at $1,000. Under the guise of free insurance or care, patients may be enrolled in insurance plans utilizing false addresses to take advantage of the “change in address” exception, which allows a person to get coverage outside the open enrollment period. Unethical facilities may also enroll patients, without their knowledge, in premium plans with generous coverage (e.g. out-of-network coverage and low out-of-pocket costs) so that the treatment center gets reimbursed at a higher rate than from other plans or providers.
Fighting unethical addiction treatment marketing practices

Awareness is the first step in combating unethical addiction marketing practices, and has led to new legislation and increased scrutiny of addiction treatment providers by law enforcement, and even for-profit corporations such as Google.

Beyond ongoing criminal investigations led by local and state law enforcement agencies, the National Alliance for Recovery Residences (NARR) officially established a code of ethics for recovery residences in 2016. More recently, in an attempt to thwart aggregate call centers, Google has temporarily ceased the sale of pay-per-click advertisements on thousands of rehab-related search terms that previously generated over $100 per click. And beginning this year, the Joint Commission on Accreditation of Healthcare Organizations will require evidence-based practices in order for treatment facilities to be accredited.

Protecting patients from corrupt addiction marketing practices is necessary in order to provide honest and effective treatment for substance use disorder. While decisions on what treatment facility to enter are often made in states of distress, it is important to emphasize that individuals and families should protect themselves by learning about what constitutes quality addiction treatment, where to find trusted local providers, and how to choose the right option for them.
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Should you carry the opioid overdose rescue drug naloxone

There is much to celebrate during National Infant Immunization Week this year. More than 90% of children 19 to 35 months have received all the recommended doses of vaccines for their age against polio, measles, mumps, rubella, chicken pox, and hepatitis B — and more than 80% have received all the recommended protection against diphtheria, tetanus, pertussis, pneumococcus, and Haemophilus influenzae.

But there are also reasons to be concerned. Only 72% have had all the recommended vaccines, which means one in four children is missing at least one. Even more concerning, studies show that there are geographic clusters of underimmunized or unimmunized children — and it’s within these clusters that vaccine-preventable diseases can sprout up, and spread, quickly.

Vaccines save lives. They have dramatically decreased the incidence of many diseases that used to cause real harm and even death. Illnesses that used to be dreaded are now becoming almost forgotten. But vaccines don’t work if children don’t get them.

Here are three ways we can work together to save more lives:

1.   Make sure that all children have access to health care. It isn’t just vaccine hesitancy that gets in the way of vaccination. For many families, it’s more about not having a doctor nearby — or not having health insurance or other means of paying for health care. While there are programs that help with the cost of the vaccines themselves, they don’t cover the cost of the doctor’s visit and other well-child care that usually comes along with vaccines. Health care access and coverage is important for all aspects of child health, of course — vaccines are just one part, but an important part.

2.   Make sure that all parents have access to accurate information about vaccines. There are a lot of rumors out there, such as that vaccines cause autism (they don’t) or that spacing out vaccines is better for babies (it’s not). With the rise of the Internet, it has become easier for misinformation to spread — and once parents are afraid, that can be hard to undo. There is lots of good scientific evidence to show that vaccines are both effective and safe, and we need to do a better job of getting that information to parents. It’s not always possible to have a really full discussion at a 15-minute well-child visit, so we need to think more creatively about how we can proactively get information to parents — and make better use of social media and other communities to spread facts instead of rumors.

3.   Make sure that we understand the concerns of vaccine-hesitant parents. Research on vaccine hesitancy has shown that there are lots of different reasons why parents worry about or refuse vaccines, and just telling people it’s a good idea isn’t going to do the trick. For example, an interesting study published in Nature Human Behavior used moral foundations theory to explore how parents make decisions about vaccines, and found that vaccine-hesitant parents placed a high value on personal liberty and purity. That means that arguments about avoiding harm (by vaccinating against harmful diseases) or fairness (saying it’s not fair to put others at risk by not vaccinating) simply weren’t as important to them as their arguments that forcing them to vaccinate violates their personal liberty, or that vaccine additives are impure (this is another area where misunderstandings are common). If we want to be successful, we need to take the time to understand and address all the reasons behind vaccine hesitancy.
Pharmacology has changed the practice of medicine. Scientists are continually working on new and better drugs to manage medical conditions, from high blood pressure to autoimmune diseases to cancer. The mechanism of a drug — how it actually works on the condition it is mean to treat — is one important factor, but drug delivery, meaning how the medication arrives at the target it is meant to affect, is also key.

As a patient, it’s your right to understand everything about a medication prescribed for you. That doesn’t mean you have to become a scientist or pass an exam about pharmacology. But you can and should ask your doctor to explain to you why she has selected this medication for you, how it works, and what side effects you should expect. An article in Pharmacy World and Science explores what medications mean to patients and why it’s important to think about these concepts. Do I need this medicine? How will it impact my body? What control do I have over the effects of the drug?
Find out why this particular medication

No matter what the health condition is, there is always more than one choice of medication to treat it. Ask why the one your doctor recommends is the best choice for you. You want to know what the medicine is expected to do and how that will be monitored. Will you be expected to keep a log of your pain, symptoms, blood pressure, or blood sugars? Is this a medicine your doctor has used before and is familiar with? It’s a red flag if he says, “Well, I haven’t tried it before with a patient, but it seems like the right choice.”

Sometimes a physician will try a drug that is new to the market, but you need to know exactly what makes this medicine special for your condition. Be wary of medicines that are “brand name only.” That means they are newer to medical practice, will likely be more expensive, and that there is less experience using them. Sometimes, a newer brand name drug is a great choice, but if your doctor just heard about it and isn’t yet familiar with potential side effects and clinical response, you need to know that.
Be sure you know how to take the medication

Morning or evening? Empty stomach or after a meal? What if you miss a dose? Can you have a glass of wine while taking this medicine? Is it okay to drink grapefruit juice (which interacts with many medicines)? Will you need to “titrate up” (meaning to increase slowly until you get to the right dose)?
Your doctor should carefully review medication side effects

All drugs have potential side effects, even acetaminophen (Tylenol). Fatigue, weight gain, and headache are common, but there are lots of others. Some drugs can make your urine turn a different color — scary unless you know to expect it. Your GI system may move more quickly, resulting in diarrhea. Hair loss is an unpleasant drug side effect that can sometimes be prevented by taking supplements with the medicine. Tremor is another side effect that can limit how much of a medicine you’re able to tolerate.

Whatever you experience is real, so make sure you keep a list and let your doctor know. Anyone can be allergic to a medicine (and sometimes it’s just a simple rash that fades when you stop the drug), but a more serious and potentially life-threatening side effect is anaphylaxis. That means that you can actually stop breathing as your body goes into crisis mode. Don’t ignore any new symptoms when you start a drug.
Keep track of your experience and ask questions

It’s often useful to keep a list of questions in a notebook you take to medical appointments, or on your phone. Phone apps are great ways to track responses and side effects, so be sure to ask about options. Make sure you have all the answers about your medication, including how long you’re expected to try it before an adjustment or change.

Medicine can be life-altering. Taking medication prescribed for you can help you feel better or prevent health problems down the road (or both). But if a drug isn’t working for you or you are concerned about new symptoms or side effects, speak up. Your doctor needs to know in order to change the drug or dose, or consider other options.

New choices offer patients incredible options to improve their health. Your job is to understand your medicine and to tell your doctor if you can’t tolerate it or don’t want to take it. Medication adherence starts with you, but treatment is a partnership, so ask the questions you need to understand your treatment. Although most people know that regular exercise is vital to good health, many find that it’s a hard habit to maintain. Just over half of adults in the United States meet the recommended advice to do moderate-intensity exercise (such as brisk walking) at least 30 minutes a day, five days a week.

Two of the main reasons people say they don’t exercise are 1) not having enough time, and 2) having joint pain, fatigue, or a chronic health condition. Even people who aren’t working full-time can still find it hard to make time for exercise. They may be caring for an ill spouse, taking care of their grandchildren, doing volunteer work, and filling their days with other pursuits. However, for some people in their 60s and 70s, reaching retirement age comes with a revelation.

“People wake up to the idea that exercise is a worthy thing to do. They make time for it because they realize it can help them enjoy a healthy life for as long as possible,” says Dr. Edward Phillips, assistant professor of physical medicine and rehabilitation at Harvard Medical School.
Practice piggybacking to get your exercise in

He encourages people to find creative ways to “piggyback” activity onto things you’re already doing regularly. One simple trick is to stand or walk every time you’re on the phone. Get earphones or a headset, which you can also use to listen to podcasts or audiobooks during a daily walk.

When you go shopping, don’t circle in your car looking for a spot near the store entrance — make it a habit to park far away. “You’ll get in some extra steps without spending much more time,” says Dr. Phillips, who also directs the Institute of Lifestyle Medicine at Spaulding Rehabilitation Hospital. If you can, walk or ride a bike to do your errands. Or park in a central location and walk to as many places as possible. “My 80-year-old mother-in-law does this and gets in nearly a mile’s worth of steps by walking to the post office, bank, and pharmacy rather than driving from place to place,” says Dr. Phillips.

You can even use toothbrushing time to get in a little balance exercise, as Dr. Phillips does. He uses an electric toothbrush that buzzes every 30 seconds, which prompts him to switch from standing on one leg to the other leg.

Think of the exercise guidelines as a goal to reach over time. If you haven’t been very active for a while, start slowly. Not sure you can commit to walking for 10 minutes at least four days of the week? Aim lower. Start with a goal of two days a week. When that becomes easy, add another day. Then start adding two more minutes to your walk, and then five minutes. Eventually, you’ll reach the goal of walking for 30 minutes, five days a week.
Exercising with physical limitations

Physical limitations from health conditions (especially arthritis) often make people reluctant to exercise. In fact, exercise nearly always makes you feel better, not worse — provided you make the right modifications, says Dr. Phillips. Do you have joint pain in your knees, hips, or ankles? Stick to non-weight-bearing exercises, such as swimming or doing water aerobics, or low-impact exercise, such as using an exercise bike or an elliptical machine.

Strengthening the muscles that support your joints can help ease pain. A physiatrist, physical therapist, or personal trainer experienced in working with people who have arthritis can help you choose and adapt activities that will work for you.

If you’ve never had a formal exercise program, or if you’ve allowed your exercise routine to lapse over the years because of illness, time pressures, or family obligations, check out Harvard Health Publishing’s online course Starting to Exercise. This program will help you create a safe, well-rounded exercise plan — one that fits your life and that you will be likely to stick with. You’ve heard it a million times — exercise benefits your body, your brain, and your quality of life. You’re sold, but the problem is it can be hard to carve the needed time out of a busy day. If your schedule is putting the squeeze on your workouts, there may be a way to get the same fitness benefits in less time: interval training.

Interval training uses short bursts of strenuous activity to ramp up your heart rate and boost your fitness. The word strenuous probably sounds a little scary if your fitness level is closer to couch potato than super athlete, but interval training can work for almost anyone.

“If done properly, it can be safe for the vast majority of people,” says Dr. Meagan Wasfy, an instructor in medicine at Harvard Medical School and a cardiologist at Massachusetts General Hospital.

The trick is to define “high intensity” based on your fitness. For an elite athlete, high intensity might mean grueling wind sprints, but if you’re not that fit, it might be as simple as incorporating a few brief periods of speed walking or slow jogging into your morning walk.
Getting started with interval training

While interval training is safe for most people, it might not be appropriate for those with heart problems, breathing disorders, or other medical conditions. So, as with any new exercise regimen, it’s always a good idea to get clearance from your doctor before you begin. Once you get the go-ahead, you can start incorporating intervals into your fitness program a little at a time.

Your goal should be to perform at least a half-hour exercise session five times a week, with the first five and last five minutes devoted to warm-up and cool-down, says Dr. Wasfy. The actual workout should last 20 minutes, alternating between high and low intensity for whatever activity you are performing. For example, you might swim or cycle more intensely for 30 seconds, and then slow back down for 30 seconds to recover before speeding up again. You can use longer recovery periods initially if you need to.

While these high-intensity intervals that get your heart rate up can be as short as 30 seconds, the goal should be to extend them over time, eventually working up to high-intensity intervals that are at least two minutes long.

Those short bursts of activity can considerably improve the benefits of your workout. Ultimately, “during a 30-minute workout, including warm-up and cool-down, between 10 and 15 minutes will be at high intensity,” says Dr. Wasfy. But it will be a more productive 30 minutes than it would have been using a traditional workout format. “If you think about exercise volume as calories burned or steps taken, you will get more done in the same period of time,” she says. “This is appealing to people who are fitting exercise into a busy schedule.”

Initially, you may not have the endurance to perform interval training during all your weekly workout sessions, but you can slowly build up on that end as well.
Taking cues from your body

In order to successfully incorporate interval training, you have to listen to your body and respond to it accordingly. “The downside of interval training is that any time you are pushing your body to high intensity, you may unmask symptoms of underlying health problems,” says Dr. Wasfy. For example, a heart blockage that might not bother you on a regular walk could produce symptoms during interval training. The same could be true of musculoskeletal problems — a budding knee problem could get worse quickly when you are doing high-intensity intervals. So, be certain to pay attention to your physical needs. If you notice a problem, talk with your doctor.
Fostering fitness gains

Studies show that interval training, performed safely and correctly, may help you achieve more rapid fitness gains. Those short, high-intensity bursts help your body get used to exercising at a higher level, which makes it easier for you to do more at that level over time. If you’re not getting into that zone on a regular basis, your functional fitness will stagnate, says Dr. Wasfy. For example, a brisk daily walk is great, but it won’t improve your fitness beyond a certain point if you’re not moving your body into that higher-intensity range. Challenge yourself to help increase capacity. You’ve got to feel a little uncomfortable to ratchet up your fitness level, she says. Interval training allows you to do this incrementally.

In addition to its other benefits, interval training can reduce blood pressure and other cardiovascular risk factors, as well as improve blood sugar control, research shows. The American Society of Sports Medicine says the practice can also help you lose weight — particularly that troublesome abdominal fat — and maintain muscle mass.
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Yoga for people with back pain

When I was about 10 years old, my mother had me take a puff on an unfiltered Camel cigarette in an effort to discourage me from smoking in the future. Well, needless to say, it worked. After coughing and sputtering for what seemed like hours, I have never touched another cigarette.

While I am in no way suggesting that parents follow in my mother’s footsteps (in fact I would strongly discourage it), as a pediatrician and parent myself I want to ensure that children and teens never take that first puff. But in fact, the majority of smokers in the US begin smoking in their youth.

According to the Centers for Disease Control and Prevention, cigarette smoking remains the leading cause of preventable disease and death in the United States, and tobacco kills more than 480,000 Americans every year. Cancer, heart disease, stroke, chronic lung disease, infertility, pregnancy complications, fractures, cataracts, gum disease — the list of diseases caused or complicated by tobacco use goes on and on. So why do people continue to smoke? Because they can’t quit.
The role of nicotine

Cigarettes contain nicotine, a highly addictive substance found naturally in tobacco. When inhaled, nicotine travels quickly to the brain, causing a variety of pleasurable sensations. Many report an adrenaline “kick.” Others report a feeling of relaxation and improved mood. Some say it makes them more alert and improves their ability to concentrate.

The downside is that nicotine is highly addictive, and once you start smoking it becomes increasingly hard to stop. People who do try to quit can experience profound withdrawal symptoms including cravings, anxiety, depression, irritability, and inattention.

Other than telling young people to stay away from tobacco products, how can we make them less attractive? Less addictive? That is where the US government is now stepping in.
Reducing nicotine in cigarettes

In July 2017, the FDA announced a regulatory plan to explore lowering nicotine levels in cigarettes, and just last month the agency took what FDA Commissioner Dr. Scott Gottlieb called a “historic first step.” It released an “advance notice of proposed rulemaking” which marks the beginning of the agency’s effort to reduce nicotine levels in cigarettes.

To support the effort, the agency pointed to data from an FDA-funded analysis published in the New England Journal of Medicine on March 15, 2018. The statistical model found that cutting nicotine levels to “minimally addictive levels” could slash smoking rates from 15% to as low as 1.4% and lead to a substantial reduction in tobacco-related deaths. In fact, the researchers estimate that such an initiative “could save millions of lives and tens of millions of life-years over the next several decades.”

Previous studies have found that use of cigarettes with very low nicotine levels could result in greater efforts to quit smoking and a decrease in the number of cigarettes smoked per day. This most recent analysis provides even more evidence.

Critics say that smokers will simply compensate by smoking more cigarettes, but some research suggests that’s unlikely. The levels of nicotine will be so low that smokers will no longer have the drive to smoke more.

The “nicotine notice” is just the beginning of the FDA’s effort to regulate tobacco products and protect citizens from the harmful effects of nicotine, and the planned rollout will most certainly take time. The FDA is encouraging public comment for 90 days before further steps are taken. In the meantime, I hope parents will continue to discourage their kids from using tobacco products like my mom did with me, but perhaps with open dialogue instead of an unfiltered Camel. Let’s say you’ve started working out at the gym and you’re wondering what you can do for your aching muscles. How does this sound? Put on a pair of gloves, shoes, socks, and a protective headband to cover your ears and face — but wear little else. Then step into a cold room for three to four minutes. By “cold” I mean really cold: between −100° C and −140° C (which is −148° F to −220° F)!

If that sounds good to you (really?), you may already be using whole body cryotherapy (WBC). And if it sounds terrible to you (or just strange), perhaps you haven’t heard of this increasingly popular “treatment” for sports injuries and a host of other conditions. It’s become even more popular in recent years as celebrities and professional athletes have embraced it. (I’m going to resist the temptation to namedrop here… okay, just a few: Justin Timberlake, Jennifer Aniston, and LeBron James reportedly engage in WBC. If you feel compelled, you can Google “cryotherapy celebrities” to find out about others).

The idea comes from the simple observation that applying ice or other types of cryotherapy (cold treatment) can provide pain relief for inflamed, injured, or overused muscles. Another version of cryotherapy is to soak a sore area (such as an arm or leg) or the entire body in cold water (called cold water immersion, or CWI).
The claimed benefit of whole body cryotherapy

According to websites promoting whole body cryotherapy, it may be recommended for “anyone who wants to improve their health and appearance” — which by my estimation would be just about everyone — as well as for

    recovering from a painful sports injury
    a chronically painful condition such as rheumatoid arthritis
    athletes who want to improve their performance
    weight loss
    improved mood or reduced anxiety.

And the list goes on. However, the escalating claims of benefit and rising popularity led the FDA to warn consumers recently that, “If you decide to try WBC, know that the FDA has not cleared or approved any of these devices for medical treatment of any specific medical conditions.”
Does whole body cryotherapy actually work?

Good question! One website offering WBC services recommended that customers perform their own search of the medical literature. That doesn’t exactly inspire confidence. Another provided links to dozens of studies that varied so much it was hard to know what to make of them. For example, the temperatures of the cold chambers varied, as did the duration and number of treatments across studies. Some assessed elite athletes or active adults who were generally young and fit, but still others enrolled people with chronic illnesses, such as rheumatoid arthritis and multiple sclerosis. And then there’s the question of how to define success. Each study had its own way of assessing the response to treatment.

A recent review of the evidence found that WBC may lower skin or muscle temperatures to a similar (or lesser) degree as other forms of cryotherapy (such as applying ice packs)
    may reduce soreness in the short term and accelerate the perception of recovery after certain activities, though this did not consistently lead to improved function or performance
    could be helpful for “adhesive capsulitis” (frozen shoulder), a condition marked by severe loss of shoulder motion that may complicate certain injuries; there are no long-term studies of WBC for this problem
    did not alter the amount of muscle damage (as reflected by blood tests) after intense exercise.
Local irritations, including skin burns, have been reported, although these should be avoidable with proper preparation.

Perhaps the biggest downside is cost. While first visits may be offered at a discount, a single session may run $20 to $80, and a course of treatment can cost several hundred dollars (and is not typically covered by health insurance in the US).
The bottom line on whole body cryotherapy

From the available evidence, it’s hard to know if whole body cryotherapy reliably prevents or treats any particular condition, or if it speeds recovery or improves athletic performance. And even if it did, there’s little proof that it’s more helpful than much less expensive cryotherapy options, such as simply applying ice to a sore area.

My guess is that the lack of convincing evidence that WBC works is unlikely to diminish its popularity. As long as people are convinced it’s helping (and as long as they can afford it), WBC is here to stay… at least until the next “big thing.” To date, official recommendations on when and how often a woman should have a screening mammogram, have been based on risk factors (such as age, a family history of breast cancer, a personal history of radiation to the chest), genetic testing (the BRCA test, for example), or troubling results from a previous biopsy. Race and ethnicity have not officially factored into the equation — yet.
Does race matter when it comes to screening mammograms?

A recent study by Harvard doctors at Massachusetts General Hospital reinforces prior data suggesting that race and ethnicity can be a separate risk factor for breast cancer, and should be taken into account when advising women on when and how often to have a screening mammogram.

The authors studied almost 40 years of data in a massive, publicly available US research information bank called the Surveillance, Epidemiology, and End Results (SEER) Program, and identified over 740,000 women ages 40 to 75 with breast cancer. They wanted to know if the age and stage at diagnosis differed by race.

It did. White women’s breast cancers tend to occur in their 60s, with a peak around 65. However, black, Hispanic, and Asian women’s breast cancers tended to occur in their 40s, with a peak around 48. In addition, a significantly higher proportion of black and Hispanic women have advanced cancer at the time of diagnosis, when compared to white and Asian women.

This fits with prior studies, including a separate analysis of data from SEER as well as the Center for Disease Control’s National Program of Cancer Registries (NPCR). They found that non-Hispanic white women tend to have the least aggressive breast cancer type, while black women tend to have the most aggressive type, as well as more advanced disease at diagnosis.

Basically, there are reliable data to suggest that we take race and ethnicity into account when we counsel patients about when to start mammograms and how often to have them. While many doctors are aware of the data and are sharing this information with patients, it’s not part of “official” guidelines.
So what are the official guidelines for screening mammograms?

Well…

Breast cancer screening has become an area of some controversy, with at least six different US organizations offering varying opinions, more or less in the same ballpark (give or take 10 years, that is). For the average woman without the risk factors listed above, the recommendations range from

Every woman over age 40 should have a mammogram every year, but, it’s a shared decision-making process so talk about it first (American College of Obstetrics and Gynecology)

This variability seems confusing, but what is consistent is that all guidelines recommend a shared decision-making process. That means a woman should talk with her doctor to determine when to first have a screening mammogram, and how often she should have one.
Reasons a woman might not want to start screening mammograms at age 40

Apart from some awkwardness and discomfort, why wouldn’t a woman want to start screening mammograms at age 40? Every screening test carries some risk, including unnecessary additional imaging and biopsies. The idea is that by starting screening later, the likelihood of catching cancer early isn’t outweighed by the risks of screening. Many of my patients have gotten that dreaded callback after their mammogram: “We see something that may be cause for concern and need you to return for additional images.” This is nerve-racking and involves additional radiation exposure. If the area is still worrisome, then a biopsy may be done. Most biopsies are negative, and even when positive, we don’t know for sure that all low-grade, localized cancers are going to progress. We treat them when we find them for sure, but it’s possible that not everyone will benefit from lumpectomy and radiation or mastectomy.
What do women need to know about screening mammograms?

Doctors should counsel women accurately about their risks and benefits for cancer screening, and while guidelines are helpful, they are only guidelines. We need to know where the guidelines came from, what data was used to create them, and — most importantly — what data were not used to create them. In the case of breast cancer screening, race and ethnicity have not yet been formally included in the existing guidelines, and women need to be aware of that and what it means for them. Whenever my lower back gets tight (which happens more often than not after being glued to my work chair for hours on end), I sit on the floor and slowly move into my favorite yoga pose: half lord of the fishes, also known as a seated spinal twist. Just a twist to the left and right never fails to restore my sore back.

Yoga is one of the more effective tools for helping soothe low back pain. The practice helps to stretch and strengthen muscles that support the back and spine, such as the paraspinal muscles that help you bend your spine, the multifidus muscles that stabilize your vertebrae, and the transverse abdominis in the abdomen, which also helps stabilize your spine.

But unfortunately, yoga is also the source of many back-related injuries, especially among older adults. A study published in the November 2016 Orthopedic Journal of Sports Medicine found that between 2001 and 2014, injury rates increased eightfold among people ages 65 and older, with the most common injuries affecting the back, such as strains and sprains. So, the question is this: how can you protect an aching back from a therapy that has the power to soothe it?
Proper form is especially important for people with back pain

The main issue with yoga-related back injuries is that people don’t follow proper form and speed, says Dr. Lauren Elson, instructor in medicine at Harvard Medical School. “They quickly ‘drop’ into a yoga pose without gradually ‘lengthening’ into it.”

This is similar to jerking your body while lifting a dumbbell and doing fast reps instead of making a slow, controlled movement, or running on a treadmill at top speed without steadily increasing the tempo. The result is a greater chance of injury.

In yoga, you should use your muscles to first create a solid foundation for movement, and then follow proper form that slowly lengthens and stretches your body. For example, when I perform my seated twist, I have to remember that the point of the pose is not to rotate as fast and far as possible. Instead, I need to activate my core muscles and feel as though my spine is lengthening. Then I can twist slowly until I feel resistance, and hold for as long as it’s comfortable and the tension melts away.
Starting yoga if you have back pain

Talk to your doctor first about whether it’s okay to begin a yoga program if you suffer from low back pain. Dr. Elson suggests staying away from yoga if you have certain back problems, such as a spinal fracture or a herniated (slipped) disc.

Once you have the green light, you can protect your back by telling your yoga instructor beforehand about specific pain and limitations. He or she can give you protective modifications for certain poses, or help guide you through a pose to ensure you do it correctly without stressing your back. Another option is to look for yoga studios or community centers that offer classes specifically designed for back pain relief.

Remember that the stretching and lengthening yoga movements are often what your low back needs to feel better, so don’t be afraid to give it a try. “By mindfully practicing yoga, people can safely improve their mobility and strength while stretching tight and aching back muscles,” says Dr. Elson.
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Giving antacids and antibiotics to babies can lead to allergies

There are two main types of cholesterol: high-density lipoprotein (HDL) and low-density lipoprotein (LDL). (Lipoproteins are made of fat and protein, and serve as vehicles for your cholesterol to travel through the blood.) Cardiologists are often asked about low-density lipoprotein (LDL) versus high-density lipoprotein (HDL). The difference is important to understand.
What does HDL cholesterol do?

HDL clears from the body via the liver. HDL may therefore prevent the buildup of plaque, protect your arteries, and protect you from atherosclerotic cardiovascular disease. It is considered the “good” cholesterol, and higher levels are better. A good goal to aim for is higher than 55 mg/dL for women and 45 mg/dL for men. The higher your HDL cholesterol numbers, the lower your risk is for heart disease, vascular disease, and stroke.
How to increase HDL cholesterol

Although HDL levels are driven by family genetics, you can improve HDL levels in three key ways:

    If you are a smoker, research clearly shows that quitting smoking can increase HDL.
    Adopting a heart-healthy diet low in fat and high in fiber can also modestly raise your HDL.
    Aerobic exercise can also have positive effects on HDL. Have trouble exercising? Find a buddy; research shows it helps motivate you. That exercise can be as simple as increasing the amount of walking you do (for the sake of exercise, not a stroll) each week.

Lastly, although primarily used to decrease high LDL, some statin medications may potentially increase HDL levels moderately. Any medical treatment option should be discussed with your doctor. Importantly, high HDL does not protect you from the untoward effects of high LDL.
What does LDL cholesterol do?

LDL is considered the “bad” cholesterol. It carries cholesterol to your arteries, where it may collect in the vessel walls and contribute to plaque formation, known as atherosclerosis. This can lead to decreased blood flow to the heart muscle (coronary artery disease), leg muscles (peripheral artery disease), or abrupt closure of an artery in the heart or brain, leading to a heart attack or stroke. Over a third of the US population has high LDL cholesterol. Diagnosis is made via blood testing, so if you don’t check, you won’t know.

For LDL, the lower the number the better. A good goal to keep in mind is less than 130 mg/dL if you don’t have atherosclerotic disease or diabetes. It should be no more than 100 mg/dL, or even 70mg/dL, if you have any of those conditions or high total cholesterol. It’s very important to set your own target cholesterol levels with your doctor. Obesity, a large waist circumference, a sedentary lifestyle, or a diet rich in red meat, full-fat dairy, saturated fat, trans fats, and processed foods can lead to high LDL cholesterol.
How to lower LDL cholesterol

Lifestyle and diet changes are the main ways to prevent or lower high LDL. A trial of eating a low-fat diet, regular aerobic activity, maintaining a healthy weight, and smaller waist circumference is an appropriate first step. It is best to set a timeline to achieve your goals with your doctor. In some cases, if those lifestyle changes are not enough, your physician may suggest a cholesterol lowering medication, such as a statin. If you are considering over-the-counter herbal or ayurvedic medications for cholesterol, please discuss those with your physician first as well.

Rarely, very high LDL is genetic and passed down in families. This is called familial hypercholesterolemia and is caused by a genetic mutation that decreases the liver’s ability to clear excess cholesterol. This condition can lead to very high LDL levels, and heart attack or stroke at a young age in multiple generations. Those individuals may require special medical treatment for prevention and treatment of atherosclerotic cardiovascular disease.

Remember, knowledge is the first step. If you don’t know your cholesterol levels, get tested. That will give you and your physician a starting point for lifestyle changes and medications if needed. In the meantime, adopt a heart-healthy lifestyle, and do it with friends and family no matter their ages. There’s no time like the present to prevent heart disease. With the opioid epidemic worsening and with no end in sight, as it continues to shorten the life expectancy of our citizens, we must do everything we can to lower the barriers that physicians face to treating addiction. The lowest-hanging fruit is the emergency department. For every fatal overdose, there are roughly 30 non-fatal overdoses, so this is an ideal “captive audience” to embrace, connect with, and engage in treatment.

Buprenorphine (Subutex, Suboxone) is a mainstay of medication-assisted treatment (MAT) for opiate addiction, where a safer opiate is provided for daily consumption in order to supplant the use of illicit opiates, which are all too often deadly. Buprenorphine is often the preferred option as an opioid replacement because it is a partial opioid agonist, meaning that it only partially stimulates the opioid receptors, causing a “ceiling effect” that makes it much more difficult to overdose on compared to other opioid drugs. Buprenorphine has been shown to cut overdose deaths in half, and to allow people to resume productive and fulfilling lives.

I am a practicing primary care doctor who is now 10 years into recovery from opiate addiction. I was recently asked to recount my story to a room full of emergency medicine physicians, as part of a program to inspire them to get “waivered” to prescribe buprenorphine.

To get this waiver, doctors need eight hours of training and a special US Drug Enforcement Administration (DEA) license. (Nurse practitioners and physician assistants can also get a waiver, but they need more training.) The DEA oversees office-based buprenorphine treatment and has the right to inspect physicians’ buprenorphine practices at any time. The DEA conducts unscheduled and random audits, which may intimidate doctors; however, only a minority of practices that prescribe buprenorphine are visited by the DEA annually. The DEA also puts limits on how many patients a doctor can prescribe buprenorphine for. Thus, it requires some additional motivation for doctors to prescribe buprenorphine, another task piled on top of physicians who are often already working past their capacity, at a burnout-level pace, for no extra compensation.

Asking doctors to get waivered must also be considered in the context of the other obstacles that doctors face treating patients who are suffering from substance use disorders. Treating addicted patients is time-consuming and can be frustrating. Relapse is a common, if not an intrinsic, part of the perilous transition from addiction to recovery. Treating the same patient for multiple overdoses can start to feel incredibly futile, and adds to feelings of burnout and discouragement. When a patient is impaired or withdrawing, they are not always on their best behavior. Having been on both sides of this equation, I can vouch for the fact that these interactions aren’t always easy or pleasant.

Sadly, many physicians share the same biases toward addicted patients that the rest of society does, and would rather not interact with them. Stigma inhabits the occupants of white coats who wear stethoscopes around their necks, too. This can lead to substandard care. It needs to change.
MAT treatment in the ER saves lives

At first blush, a busy emergency department may not seem to be the ideal place to start treatment for a chronic, complex disease such as addiction, with the hustle and bustle of the ER, the pressures to move patients along to clear beds for the next emergency, and the fact that there isn’t much, if any, long-term personal connection between patients and ER caregivers.

However, studies have shown that starting buprenorphine in the emergency department significantly increased engagement in addiction treatment, reduced self-reported illicit opioid use, and decreased use of inpatient addiction treatment services. Starting MAT treatment in the ER works. So is it happening? Not much. A 2017 study in JAMA showed that among people who had overdosed on heroin, buprenorphine treatment increased by only 3.6 percent, though a more recent analysis published in Health Affairs shows the use of any medication-assisted treatment to be only as high as 10.8% after overdose and treatment in the ER, which is abysmally low.
How can we support physician training?

The obvious answer is to facilitate the process of emergency room doctors getting waivered — and motivated — to start buprenorphine after overdoses in the emergency department. We need to provide more resources to support these already beleaguered physicians, to encourage them to take on the intimidating prospect of treating opiate addiction.

If, for example, emergency departments were set up with access to fully-equipped addiction consult teams, complete with recovery coaches and navigators, who had the ability to arrange follow up within a week, and make the “bridge” with a primary care doctor or with an addiction clinic, then essentially, all an overworked emergency room doctor would have to do is stabilize the patient, educate, and prescribe buprenorphine. This would make treating addiction feel much more doable. It could create a transformative pipeline from overdose into treatment across the country, which is essential given that the vast majority of people suffering from opiate use disorders are not currently receiving treatment.

Above all else, we need to reduce the stigma of addiction. Anyone can get addicted. Recovery from addiction is about much more than just not taking drugs. It is about humility, mindfulness, and connecting to other people. People who overdose and who come to the emergency department, even repeatedly, deserve a chance at a new lease on life. The emergency department is an ideal point of entry to start a proven, lifesaving treatment, which is just a waiver away. Allergies are on the rise, especially food allergies. While nobody knows for sure why this is happening, a leading theory is that we may be doing things that mess up our natural microbiome.

Our microbiome is the trillions of organisms that live on and in our bodies, such as bacteria, archaea, fungi, and viruses. We generally think of these organisms as “germs” that can cause illness — and while they can, in some situations it turns out that the right organisms in the right balance actually help keep us healthy. Our microbiome affects how we digest foods, stay at a healthy weight, fight infection, and stave off diseases like diabetes. Through its link to our immune system, our microbiome is thought to be linked to our risk of allergic reactions.

Two common types of medications, antacids and antibiotics, can mess up our microbiome. Antibiotics do it by killing not just the bacteria that make us sick, but also the bacteria that help keep us healthy. As for antacids, by making the stomach less acidic they make it more likely that bacteria from the mouth (that are normally killed by the acid in the stomach when swallowed) make it down into the intestine. Those mouth bacteria can crowd out the bacteria that our intestines need to function normally.

In a study published in JAMA Pediatrics, researchers studied almost 800,000 children from birth to about 4 years of age. They looked to see if the children got antacids or antibiotics in the first six months of life, and then tracked to see if they went on to have any allergic conditions. They found that children who got antacids were twice as likely to have food allergies as those who didn’t, and children who got antibiotics were twice as likely to have asthma as those who didn’t. Children who got either antacids or antibiotics showed an increased risk of other kinds of allergic conditions, from hay fever to severe allergic reactions.

This does not mean that infants should never get antacids or antibiotics. Antibiotics can be lifesaving for infants with bacterial infections, and there are situations when antacids can be extremely useful. But both medications are often overused. Antacids are often used in babies with reflux, or fussiness with feeding; while they can be helpful, the symptoms can be managed in other ways and usually resolve with time. Antibiotics are often used for upper respiratory infections, even though most upper respiratory infections are caused by viruses and don’t need antibiotics.

Moving forward, doctors need to be thoughtful and careful about how they prescribe antacids and antibiotics to infants, only doing it when truly necessary. Parents of infants need to be informed consumers. When given a prescription for either antacids or antibiotics, they should ask if it is truly necessary — and whether there are any alternative treatments that might be tried.

It’s about breaking old habits, and thinking about treatments in different ways based on what research is telling us. The more we learn, the more we can keep our children healthy, not just now but for the rest of their lives.
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Why we shouldn’t demonize formula feeding

Much has been made of the recently published results of the DIETFITS (Diet Intervention Examining the Factors Interacting with Treatment Success) study. Most of the headlines emphasized the fact that the two diets involved — low-fat and low-carb — ended up having the same results across almost all end points studied, from weight loss to lowering blood sugar and cholesterol.

What’s most interesting, however, is how these two diets are similar.

The authors wanted to compare low-fat vs. low-carb diets, but they also wanted to study genetic and physical makeups that purportedly (their word) could influence how effective each type of diet will be for people. Previous studies had suggested that a difference in a particular genetic sequence could mean that certain people will do better with a low-fat diet. Other studies had suggested that insulin sensitivity may mean that certain people will do better with a low-carb diet.
What DIETFITS revealed about weight loss

The study began with 609 relatively healthy overweight and obese people, and 481 completed the whole year. For the first month, everyone did what they usually did. Then, for the next eight weeks, the low-fat group reduced their total fat intake to 20 grams per day, and the low-carb group reduced their total carbohydrate intake to 20 grams per day. These are incredibly restricted amounts, considering that there are 26 grams of carbs in the yogurt drink I’m enjoying as I write this, and 21 grams of fat in my half of the dark chocolate bar my husband and I split for dessert last night.

That kind of dietary restriction is impossible to maintain over the long term and, as this study showed, unnecessary. Participants were instructed to slowly add back fats or carbs until they reached a level they felt could be maintained for life. In addition, both groups were instructed to

    eat as many vegetables as possible
    choose high-quality, nutritious whole foods and limit anything processed
    prepare food themselves at home
    avoid trans fats, added sugars, and refined carbohydrates like flour.

People were not asked to count calories at all. Over the course of a year, both groups attended 22 classes reinforcing these very sound principles — and all participants had access to health educators who guided them in behavioral modification strategies, such as emotional awareness, setting goals, developing self-efficacy (also known as willpower), and utilizing social support networks, all to avoid falling back into unhealthy eating patterns.

Participants in both groups also were encouraged to maintain current US government physical activity recommendations, which are “150 minutes of moderate intensity aerobic physical activity (2 hours and 30 minutes) each week.”
Two different diets that are not so different after all

Get all that? Basically, the differences between groups were minimal. Yes, the low-fat group dropped their daily fat intake and the low-carb group dropped their daily carb intake. But both groups ended up taking in 500 to 600 calories less per day than they had before, and both lost the same average amount of weight (12 pounds) over the course of a year. Those genetic and physical makeups didn’t result in any differences either. The only measure that was different was that the LDL (low density lipoprotein) was significantly lower in the low-fat group, and the HDL (high density lipoprotein) was significantly higher in the low-carb group.

I love this study because it examined a realistic lifestyle change rather than just a fad diet. Both groups, after all, were labeled as healthy diets, and they were, because study investigators encouraged eating high-quality, nutritious whole foods, unlimited vegetables, and avoiding flours, sugars, bad fats, and processed foods. Everyone was encouraged to be physically active at a level most Americans are not. And — this is a big one — everyone had access to basic behavioral counseling aimed at reducing emotional eating.
When it comes to diet, everything old is new again

This whole study could just as well be called a study of sustainable healthy lifestyle change. The results jibe very much with prior research about healthy lifestyle. The end message is the same one that we usually end with:

The best diet is the one we can maintain for life and is only one piece of a healthy lifestyle. People should aim to eat high-quality, nutritious whole foods, mostly plants (fruits and veggies), and avoid flours, sugars, trans fats, and processed foods (anything in a box). Everyone should try to be physically active, aiming for about two and a half hours of vigorous activity per week. For many people, a healthy lifestyle also means better stress management, and perhaps even therapy to address emotional issues that can lead to unhealthy eating patterns. To screen or not to screen for prostate cancer? This remains an important question. Screening relies on a highly imperfect measure, the prostate-specific antigen (PSA) blood test, which is prone to false-positive results. And with mounting evidence that survival benefits from screening pale in comparison with the harms from overtreatment — particularly incontinence and impotence — the pendulum has steadily swung away from it. Still, screening research continues, in the hopes that some lifesaving benefits may be found.

Now the latest study once again casts doubt on PSA screening as an effective public health tool.

British scientists divided more than 400,000 men between the ages of 50 and 69 into two groups: one was screened for prostate cancer with a single PSA test, and the other wasn’t tested for the disease at all. After an average of 10 years of follow-up, prostate cancer death rates in both groups were nearly identical. Cancer was detected more often in the screened group, but mostly it was low-grade, with a questionable need of treatment.

“This was the largest study of PSA screening to date, and the results don’t support it,” said Dr. Michael J. Barry, a professor of medicine at Harvard Medical School, and author of an editorial accompanying the published study.

Called the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP), the study’s approach of giving men a single PSA test differs from the more traditional strategy of testing men repeatedly every few years. However, prior studies investigating repeated PSA tests have reached similar conclusions. One European study with 162,000 men, for instance, concluded that for every life saved by screening, 27 men would be diagnosed and treated for prostate cancer that wouldn’t have been lethal if left undetected.

During the CAP study, 189,386 men were assigned to screening and 219,439 men were assigned to a non-screening control group. After 10 years on average, 549 of the screened men had died from prostate cancer, compared to 647 men in the control group who hadn’t gotten a PSA test. The number of prostate cancer deaths among the controls was higher, but so was the number of men in that group to begin with. So the researchers adjusted for the different sample sizes with a statistical tweak: they compared death rates in terms of person-years, or the total number of years that men in either group had participated to the study. Analyzed that way, the study revealed 0.30 prostate cancer deaths per 1,000 person-years in the screened group, and 0.31 deaths from prostate cancer per 1,000 person-years in the controls, which amounts to a negligible difference.

Dr. Barry, member of the US Preventative Services Task Force, an influential group of independent experts who make evidence-based recommendations about clinical preventive services, emphasized that most men who opt for the test get it more than once. And with each additional PSA test, he said, the odds of being diagnosed with prostate cancer grow higher. “But is repeat screening worth the risk of a low-grade cancer diagnosis and all the treatment complications that come with it?” he asked. “It’s hard for us as clinicians to make those decisions for our patients. We need to make them with our patients to determine if they feel those risks are worth taking on.”

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, agreed. “This study adds to the discouraging screening literature, and again, simply does not support screening of asymptomatic individuals,” he said.

Fortunately, Garnick added, men diagnosed with prostate cancer following a PSA test may not have to be treated either in the short or long term. Depending on tumor characteristics, some can opt to have their cancer monitored with active surveillance, which relies on periodic prostate biopsies or MRI to look for new signs that treatment may be necessary. “Hopefully, current research that uses sophisticated genetic testing or biomarkers of prostate cancer may help provide more precise information about those who are likely to most benefit from screening and treatment,” Garnick said. “But we are not there yet.” Improving your diet can seem like a lofty goal, one that people often think requires rigid self-discipline and sacrifice. Cupcakes out, pizza out, treats out, sigh.

But it doesn’t really have to be that way. Sometimes making better decisions for your body can be about adding — not taking away. This may create a more palatable option for those looking for a health boost that feels like a bonus, not a burden.

But what to add? I asked Teresa Fung, adjunct professor in the department of nutrition at the Harvard T.H. Chan School of Public Health for her advice on what foods pack the biggest nutritional punch to a daily diet. Below is her list of five well-balanced options that she says you should eat every day — or at least as often as possible.

1.  Salmon. This oily fish, known for its bright pink color, is rich not only in healthy protein but also in omega-3 fatty acids, which benefit both your heart and your brain. It also provides you with bone-building vitamin D. Still, serving up salmon every day would be a stretch for most people. Aim instead to eat it at least once a week to reap the health benefits, says Fung.

2.  Brussels sprouts. These crunchy little green balls, which look like mini-cabbages, are nutrient-dense and low in calories — only 28 in half a cup. They offer up a well-rounded group of vitamins, including vitamin A, vitamin C, vitamin K, potassium, and folate. Like other cruciferous vegetables, Brussels sprouts feature bioactive compounds, such as antioxidants, which are chemicals that help prevent cell damage inside your body. Taste-wise, Brussels sprouts may be a controversial pick, because while they’re certainly cute, some people find them bitter. If you’re firmly in the “dislike” camp, you can substitute other green vegetables for Brussels sprouts to get a similar nutritional boost. But keep an open mind. You can reduce the bitterness of Brussels sprouts by roasting them with a spritz of olive oil. Add some chopped nuts to the top for a little extra crunch and flavor (as well as extra benefits; see below).

3.  Blueberries. These dark-colored little berries are high in antioxidants, particularly vitamin C, says Fung. Weighing in at 56 calories for 100 grams, blueberries also offer up a good dose of vitamin A and fiber. While most grocery stores will stock blueberries year-round, feel free to substitute another dark-colored fruit — like pomegranates or cherries — if blueberries aren’t in season. Or for some variety, swirl up some frozen blueberries, which taste good at any time of year, with plain yogurt (see below) to make a smoothie.

4.  Nuts. Crunchy and satisfying, nuts not only are filling but also provide an infusion of healthy oils, protein, and vitamin E. Choose any type of nuts: almonds, walnuts, even peanuts (technically a legume), or grab a handful of mixed nuts. Just make sure they’re unsalted, says Fung. But keep in mind these are a high-calorie treat. Depending on the type of nut you choose, an ounce can ring in at 200 calories or more — so limit daily intake to a sprinkling to get the benefits without packing on any extra pounds.

5.  Plain yogurt. This creamy treat gives you a dose of probiotics, which are healthy bacteria that help keep your gut working properly and contribute to better overall health. Yogurt is a nutrient-rich food that fuels your body with protein, calcium, magnesium, vitamin B12, and some key fatty acids that your body needs to stay healthy. And if you choose a high-protein yogurt, it can keep you feeling full, which may help you trim your waistline. While you may prefer flavored yogurts, it’s better to stick with plain. “The problem with flavored yogurt is some of the brands out there have way too much sugar,” says Fung. Sugar negates many of the health benefits of yogurt. Plain yogurt too tart? Toss in some blueberries for added sweetness, says Fung, or add nuts for some crunch. These simple additions can improve the taste, and you can check off three of the foods on this list in one easy snack. Breast is best — we pediatricians say this all the time, because it’s true. Breast milk was uniquely designed for human babies, and many studies have shown its health benefits. In our quest to increase breastfeeding rates here in the US, which are not as high as we want them to be, we encourage new mothers not to use any formula. Hospitals are encouraged not to feed new babies with formula during those first few days before the mother’s milk comes in, and not to send mothers home with samples of formula.

This is all good, as often, if we can get mothers and babies through those first few days and weeks without formula, they can both get used to breastfeeding and make it work. But as we encourage breastfeeding, we need to be careful to keep the big picture in mind and not demonize formula feeding.

In a study recently published in the Journal of Pediatrics, researchers studied babies who had lost a significant amount of weight after birth, which, while common, can be dangerous. They randomized the babies into two groups: one got a small amount of formula after each breastfeeding until the mother’s milk was fully in, and the other group did not. They found that the babies that got the formula were less likely to be readmitted to the hospital, and were no less likely to be breastfeeding a month out.

Exclusive breastfeeding is natural, but not always easy — and when there is a glitch like a delay in the milk supply coming in, inverted nipples, or inadequate milk supply, babies can run into trouble. It’s also not always easy for mothers who don’t have a lot of support from family and health care providers, especially first-time mothers who are feeling overwhelmed, who get sore nipples, who worry that their babies aren’t getting enough to eat. Breastfeeding works best when mothers have a knowledgeable and nurturing community to help them work through the inevitable questions and problems, as well as a supportive work environment, but not every mother has this.

I am not arguing against encouraging breastfeeding. I encourage it with all of my patients, and am lucky enough to have lactation consultants readily available to my practice. I breastfed all six of my children; the last three got only breast milk, while the first three got formula as well, due to logistical and medical issues.

That’s the thing: life and parenting can be complicated. We want more mothers to breastfeed, and we have work to do to make that happen. We need paid parental leave. We need to make lactation consultants and breast pumps available to every mother. We need to educate and inform and build communities (including work communities) that support breastfeeding.

But as we do all this, we need to remember that formula isn’t evil. In fact, sometimes it can be a tool to support breastfeeding — by supplementing newborns that have lost a risky amount of weight, by supplementing the milk supply of mothers who would otherwise give up entirely, by allowing working mothers who can’t pump enough milk for all their hours of work to keep breastfeeding as long as they would like. It’s better that babies get some breast milk than none at all, but if we make it an all-or-none proposition, we may inadvertently cut breastfeeding short.

When we demonize formula we also run the risk of shaming women who, for any number of good reasons, choose not to breastfeed. There are many other ways besides breastfeeding to help babies grow and be healthy; it’s important to keep that perspective.

As valuable as breastfeeding is, there is much more to parenthood than breastfeeding. It’s important to keep the big picture in mind for each mother and baby, and help them both flourish.
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