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Thursday, January 31, 2019

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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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