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Aspirin for primary prevention of cardiovascular disease, part 2

Update

In March 2019, the American College of Cardiology (ACC) and the American Heart Association (AHA) released new guidelines that suggest that most adults without a history of heart disease should not take low-dose daily aspirin to prevent a first heart attack or stroke. Based on the ASPREE, ARRIVE, and ASCEND trials, the ACC/AHA guidelines concluded that the risk of side effects from aspirin, particularly bleeding, outweighed the potential benefit.

The new guidelines do not pertain to people with established cardiovascular disease, in whom the benefits of daily aspirin have been found to outweigh the risks.

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Well, it seems as though not even a week can go by without more data on aspirin! I recently reviewed the ARRIVE trial and the implications for primary prevention — that is, trying to prevent heart attacks and strokes in otherwise healthy people. Since then, yet another large clinical trial — the ASPREE study — has come out questioning the use of aspirin in primary prevention. Three articles pertaining to this trial were published in the prestigious New England Journal of Medicine, which is an unusual degree of coverage for one trial and highlights its immediate relevance to clinical practice.

Aspirin still strongly indicated for secondary prevention

Nothing about any of the new aspirin data, including ASPREE, pertains to secondary prevention, which refers to use of aspirin in patients with established cardiovascular disease. Examples include a prior heart attack or certain types of stroke, previous stents or bypass surgery, and symptomatic angina or peripheral artery disease. In general, in patients with a history of these conditions, the benefits of aspirin in reducing cardiovascular problems outweigh the risks. Chief among these is a very small risk of bleeding in the brain, and a small risk of life-threatening bleeding from the stomach.

ASPREE study suggests no benefit from aspirin in primary prevention

ASPREE randomized 19,114 healthy people 70 or over (65 or over for African Americans and Hispanics) to receive either 100 milligrams of enteric-coated aspirin or placebo. After an average of almost five years, there was no significant difference in the rate of fatal coronary heart disease, heart attack, stroke, or hospitalization for heart failure. There was a significant 38% increase in major bleeding with aspirin, though the actual rates were low. The serious bleeding included bleeding into the head, which can lead to death or disability. Again, the actual rates were very low, but they are still a concern when thinking of the millions of patients to whom the ASPREE results apply.

Rates of dementia were also examined, and again, there was no benefit of aspirin. Quite unexpectedly, there was a significantly higher rate of death in the patients taking aspirin. This had not been seen in prior primary prevention trials of aspirin, so this isolated finding needs to be viewed cautiously. Still, with no benefits, increased bleeding, and higher mortality, at least in this population of older healthy people, aspirin should no longer be routinely recommended.

Another unexpected finding in ASPREE was a significantly higher rate of cancer-related death in the people randomized to aspirin. The prior thinking had been that aspirin might actually prevent colon cancer, though generally after many more years of being on aspirin. The ASPREE trial was terminated early due to lack of any apparent benefits. And even though five years is a relatively long period of follow-up, it may not have been long enough to find a benefit on cancer. Thus, the increase in cancer deaths may be a false finding. Nevertheless, the overall picture from this trial is not a compelling one for aspirin use for prevention of either cardiac or cancer deaths.

Should healthy people take a daily aspirin?

In general, the answer seems to be no — at least not without first consulting your physician. Despite being available over the counter and very inexpensive, aspirin can cause serious side effects, including bleeding. This risk goes up with age. So, even though it seems like a trivial decision, if you are healthy with no history of cardiovascular problems, don’t just start taking aspirin on your own.

However, there are likely select healthy patients who have a very high risk of heart attack based on current smoking, family history of premature heart attacks, or very elevated cholesterol with intolerance to statins, for example, who might benefit. Therefore, the decision to start aspirin should involve a detailed discussion with your physician as part of an overall strategy to reduce cardiovascular risk. If you are already taking aspirin for primary prevention, it would be a good idea to meet with your physician and see if you might be better off stopping.

Follow me on Twitter @DLBHATTMD

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How to prevent poisonings in children — and what to do if they happen

March 17–March 23, 2019 is National Poison Prevention Week

Every day in the United States, over 300 children under the age of 20 are seen in an emergency room because of poisoning, and two of them die. What is most heartbreaking is that poisonings are preventable — and quick action can save lives when they happen.

Poisoning prevention

Here are some tips from the Centers for Disease Control and Prevention and the American Academy of Pediatrics to prevent poisoning in children:

Keep medicines, cleaning and laundry products, paints and varnishes, as well as pesticides, out of sight and reach of children. If possible, lock these products away.

Always keep these products in their original containers, which makes it less likely that they will be ingested by accident.

While laundry and dishwasher detergent pods can be convenient, stick with the standard liquids and powders if there are young children in the house. The pods just look too much like candy.

Have safety caps for all medications, but don’t rely on them (meaning keep medications out of reach and sight).

Make sure you know the correct dose of any medication you give your child, and always use a medication syringe or spoon to measure it (ask your pharmacist for one if you don’t have one).

Get rid of any old or unused medicines or cleaning products. The less around, the better.

If you use e-cigarettes, only buy nicotine refills in safety containers and keep them out of sight and reach. Nicotine can be very dangerous.

If you have a gas, kerosene, coal, or wood-burning stove, make sure it is in good working order.

Have smoke and carbon monoxide detectors, and check them regularly to be sure they are working.

Know what devices in your home use button cell batteries, and keep them out of reach of children. Don’t buy children’s books or toys that have these batteries; it’s not worth the risk.

Make sure you know all the types of plants you have in your house or yard. If any are poisonous, either keep your child away from them, or better yet, get rid of them.

What do to should a poisoning happen, or if you think it might have

If the child is having any trouble breathing, is unconscious, or has what you think even might be a serious injury, call 911 right away.

For a swallowed poison, have the child spit out whatever isn’t swallowed. Do not use ipecac or anything else to make them vomit. If your child has any symptoms, call 911 or bring your child to a local emergency room. If your child doesn’t have symptoms, call 1-800-222-1222, the nationwide poison control center number. Have the container with you when you call, and be ready to tell the person you talk to how much your child swallowed (or your best guess).

For something that gets on the skin, take off any clothing and run water over the affected area for 15 minutes. While you are doing that, call the poison center.

If anything gets in the eyes, hold the eye open and run room-temperature water on the eyes (aim for the inner corner) for 15 minutes. Call the poison center while you do — or call 911 if a lot got into the eyes or the child is in a lot of pain — but don’t stop flushing the eyes.

If a child swallows a button cell battery, or puts it in his nose or ear, take him immediately and directly to an emergency room. They can do damage quickly.

If a child has inhaled a poison, or you think that she might have, get her out into fresh air. Call 911 if she is unconscious or having any trouble breathing.

Keep the Poison Center number in your phone and posted in your house so that it is always handy. You can and should also call the number — or your doctor — if you think your child might have gotten into something, but you aren’t sure. It’s always better to be safe than sorry.

Follow me on Twitter @drClaire

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How long does a joint replacement last?

Joint replacement surgery represents one of the biggest and most life-changing advances in modern medicine. It has meant the difference between disability from crippling arthritis and nearly normal mobility for millions of people in recent decades. The hip and knee are, by far, the most commonly replaced joints, and they have the most reliable results. In the US each year, more than 300,000 hips and 700,000 knees are replaced, and the results are generally good. But every time a joint is replaced, an important question looms: how long will it last?

It’s a fair question. After all, no one wants to go through the risk, discomfort, and recovery time required for a major operation only to need it again in a short time.

The usual estimate: 10 to 15 years

When I was in medical school, the commonly quoted estimate was that a replaced knee or hip should last about 10 to 15 years, but hopefully much longer. That was an average, of course. Rare complications requiring re-operation can occur soon after surgery; for others, a replaced joint can last two decades or more. And since it takes many years to know whether improved surgical techniques and materials have led to longer joint life, it’s hard to know at any given time how long a replaced joint might last.

Why is this so important? Estimates of joint replacement longevity are helpful to the person who is uncertain about whether joint replacement is worth pursuing. But in addition to whether to have surgery, these numbers can help people decide when to have it done. For example, a person in their 30s might be looking at two or more revisions (the surgeon’s term for replacing a previously replaced joint). Some younger joint replacement surgery candidates have been advised to wait until symptoms are more severe in the hopes of reducing the need for multiple revisions in the future.

A new study provides new estimates

In February 2019, two large analyses were published in the medical journal Lancet regarding the longevity of replaced hips and knees, that included nearly 300,000 total knee replacements and more than 200,000 total hip replacements. They found encouraging results:

Nearly 60% of hip replacements lasted 25 years, 70% lasted 20 years, and almost 90% lasted 15 years.

Total knee replacements lasted even longer: 82% lasted 25 years, 90% lasted 20 years, and 93% lasted 15 years.

These estimates are quite a bit higher than prior ones and may reflect improvements in surgical technique and materials, general medical care around the time of surgery, or more aggressive mobilization and physical therapy that starts right after surgery. The study authors also suggest that these numbers reflect “real life” patients (including all patients in multiple medical centers who were having their knees or hips replaced), rather than a small number from a single medical center.

Some caveats are worth noting:

These surgeries were performed in New Zealand, Australia, Denmark, Finland, Norway, and Sweden. The results might be different in the US or other countries.

Detailed information was not available regarding which patients were considered eligible for total joint replacement and which were denied surgery because they were considered at high risk for failure or complications. These factors can affect the success of joint replacement surgery.

Surgery is usually the last (and sometimes best) option

When a hip or knee has worn out and no longer functions as it should, medications, physical therapy, various injections, and other nonsurgical treatments can only do so much — often they can’t do much at all. For those who are healthy enough to have major surgery (and willing to go through with it), total joint replacement is often the only option that offers a good chance at significant pain relief and improved function. Joint replacement surgery for arthritis is considered a treatment of last resort. But even though replaced joints may not last forever, they may last longer than we’d thought.

Follow me on Twitter @RobShmerling

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Something else to avoid in pregnancy: Phthalates

Most pregnant women know that they should avoid things like alcohol and tobacco while they are pregnant, as well as certain foods like sushi and soft cheeses. But not many pregnant women think about avoiding lipstick, perfume, or lotions — and it turns out that they probably should.

The problem is a type of chemical called phthalates. It’s nearly impossible to avoid phthalates entirely, as they are quite literally everywhere. They are in plastic products including packaging, in toys and garden hoses, as well as in cosmetics and other personal care products. They can act like hormones and interfere with male genital development, as well as increase the risk of cardiovascular disease and diabetes.

The risks of phthalates, though, begin before birth. A study showed that children whose mothers were exposed to phthalates during pregnancy were more likely to have problems with motor skills, the skills that we use not just in sports but also in everyday activities, and another showed that the children of mothers exposed during pregnancy had problems with language development.

Even if it’s impossible to avoid phthalates entirely, there are ways women can decrease their exposure:

Limit exposure to plastics, especially anything with the number 3 or 7 on them. Use glass, ceramic, or metal containers for food and drink.

Try to buy foods that don’t come in plastic packaging.

If you have to use plastic, don’t microwave it, and wash it by hand rather than in the dishwasher to limit the leaching out of chemicals.

Avoid anything with fragrance in it, as phthalates are commonly used in making fragrances.

Look into handmade cosmetic and personal products that don’t use any chemicals (and skip the products entirely when you can). The Environmental Working Group has a database you can use to learn more about commercial products.

Go DIY. Things like honey, coconut oil, baking soda, vinegar, and salt can be used in place of many commercial beauty products. Do a little research — you may find that it’s easier than you think to make a moisturizer, a shampoo, or a perfume.

Wash your hands often with soap and water.

Once the baby is born, continue to be mindful about chemicals that can cause harm. Look for fragrance-free products that are as all-natural as possible, keep up with DIY including for cleaning products, and limit plastics in the house, especially baby bottles and toys. We can’t escape all the harmful chemicals around us, but by getting back to basics, we can make things safer for our children.

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Banishing dry winter skin

Do you have dry, itchy winter skin? You’re not alone. During the winter months, many of my patients come into clinic asking about the right cream to use to cure their dry skin. But dry skin care is about so much more than just moisturizers.

Here are some dermatologist-recommended tips for preventing and relieving dry skin:

Harsh soaps are not your friend. Many people love the feeling of being “squeaky-clean” after using harsh soaps in the shower. But these soaps strip your skin of essential lipids (fats) that keep the skin moisturized. Instead, try a gentle, fragrance-free cleanser and limit its use to cleaning the underarms and groin, or skin that is visibly soiled.

Warm showers, not hot. I look forward to a steaming-hot shower at the end of a cold winter day as much as the next person. But hot water and long showers can irritate and dry out the skin. So can saunas, hot tubs, and Jacuzzis. Especially when your skin is dry, try turning the temperature knob down slightly so that the water is warm rather than hot, and limit showering to once a day for no more than 10 minutes.

When you moisturize matters. The best time to moisturize is when your skin is still damp, such as right after a shower. Pat your skin dry gently, then slather up with a good moisturizer from head to toe. Not only is it more effective, it may also feel less greasy on your skin as the moisturizer traps existing moisture on your skin.

The thicker the better. Ointments or creams are much more effective at moisturizing than lotions. Ointments are typically petroleum or lanolin based, and creams tend to be thicker than lotions. Additional moisturizing ingredients to look for include shea butter, olive oil, and jojoba oil. If your skin is flaky, look for exfoliating ingredients such as lactic acid or urea, but be careful using these ingredients if you have sensitive skin.

Go gentle all around. Use skincare products that are gentle and unscented, including deodorants and hypoallergenic laundry detergent. Gentle or hypoallergenic products minimize the chance of skin irritation; avoiding irritation can help maintain the healthy skin barrier needed to retain water from the inside.

Consider a humidifier. During the dry winter months, using a humidifier to keep the humidity above 30% can make a big difference for your skin.

Nature versus nurture. Some people have a genetic mutation in the fillagrin gene. This gene is very important in the formation of the outer layer of the skin, which forms a barrier that helps the skin retain moisture. This mutation predisposes the affected individuals to eczema and persistently dry skin. It is especially important for people with this mutation to follow all the tips above to prevent and manage dry skin.

If your skin does not improve after making these changes, you may need to see a dermatologist. Sometimes, severe dry skin can be relieved by a prescription ointment or cream. Dry skin can also indicate a more serious skin condition; a dermatologist can evaluate your skin and decide on the regimen that can help you the most.

Follow me on Twitter @KristinaLiuMD

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Can exercise extend your life?

Exercise provides a remarkable variety of health benefits, which range from strengthening bones to positive effects on mood and helping to prevent chronic illnesses such as diabetes and heart disease. Research dating back to the late 1980s has consistently shown that aerobic fitness may help extend lives. Yet a few studies on athletes examining whether habitual vigorous exercise might harm the heart made some experts wonder how hard people ought to push when exercising (see here and here).

Do cardiorespiratory fitness levels affect longevity?

A retrospective study in JAMA attempts to answer this question. The study explores the association between long-term mortality and various levels of cardiorespiratory fitness (CRF). CRF is a measure of how well your heart and lungs pump blood and oxygen throughout the body during prolonged bouts of exercise. The more fit you are, the higher your level of CRF. Regular exercise, and vigorous exercise, can both boost CRF.

The researchers looked at over 122,000 patients at a large academic medical center who underwent exercise testing on a treadmill, an objective measure of CRF. While the average age was 53, participants ranged in age from 18 to over 80. Similar to findings of previous studies, being fit was associated with living longer. This held true at any age. The researchers also saw a relationship between CRF and survival rates: the higher the level of fitness, the higher the survival rate. This was especially notable in older people and people with high blood pressure. And the survival benefit continued to climb with no upper limit.

What does this mean for all of us?

Unless there is a clear medical contraindication, we should all strive to achieve and maintain high levels of fitness. Current guidelines recommend 150 to 300 minutes per week of moderate aerobic activity (walking, running, swimming, biking), or 75 minutes of vigorous activity, or a mix of both. Twice-weekly resistance training to strengthen muscles is also recommended. Unfortunately, only about one in five adults and teens gets enough exercise to maintain good health.

Wondering where to start?

There’s a place to start for everyone regardless of age or current fitness level.

First, think safety.Walking and other low levels of exercise are generally safe for most people. But check with your doctor before starting or making changes to an exercise routine if you have a history of heart disease, or any other medical condition that might impact your exercise tolerance.

Start small.You’ll be more successful if you set the bar low. For example, start with a simple routine of walking 10 to 20 minutes three times per week. Every week or two, add five minutes per walk until you reach a goal of 30 minutes. Then, every week or two, add a day until you reach at least 150 minutes per week. Over time you can try to increase intensity. Remember, small goals are more achievable, and these little victories will continue to fuel your motivation.

Don’t be afraid of exercise or the gym. Any movement is good and is a step in the right direction. The gym intimidates many folks — perhaps you’re overweight or inexperienced, and worry that others might stare or judge you. Everyone was new to exercise at one point in time. Focus on your purpose and avoid wasting energy on things that do not matter.

Plan ahead. To maximize your success in adopting a long-term lifestyle change, plan ahead. Every week, look at your calendar ahead of time and commit to when you will exercise that week. Think of your opportunity to exercise as an appointment, rather than “I’ll get to it if I have time.”

Expect to lose some battles. Keep in mind that realistically, most people will get derailed at some point as they work on a behavioral change. Do not let this crush your motivation. Instead, identify obstacles that may have interfered, strategize a solution moving forward, and try again.

Trying to get back into physical activity after a hiatus?

Take the first week to ease back into exercising. Avoid building up to your previous level of fitness too quickly to avoid injuring yourself.

Already active and wondering how to reap more benefits?

Many people fall short on resistance training and are mostly focusing on cardio. Resistance training helps you build strength, thereby improving your overall cardiovascular fitness and performance.

If you’re short on time, consider a high-intensity interval workout. This will get you more bang for your buck.

Vary your exercise routine to keep yourself challenged physically.

Too often, our health takes a back seat in the midst of busy careers and the multitude of responsibilities we take on in our lives. Optimizing your health through highly nutritious food choices and by getting enough sleep and exercise takes time and dedicated effort. But it is certainly worth it, and only gets easier over time as these new habits become ingrained.

Follow me on Twitter @MarwaAhmedMD

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Just do it… yourself: At-home colorectal cancer screening

Colorectal cancer (CRC) is the fourth leading cause of death worldwide. Yet despite the ability of CRC screening to detect colon cancer early, and to find and remove potentially precancerous growths called polyps, screening rates remain low, below 60%. Experts generally agree that people should be screened for CRC at regular intervals beginning by age 50.

Colonoscopy is considered the gold standard for CRC screening. In this procedure, a doctor examines your entire colon through a colonoscope, a flexible tube outfitted with a small video camera and a light.

But concern around pre-colonoscopy bowel cleaning, which can be uncomfortable and unpleasant, may contribute to low screening rates. Your bowel needs to be completely empty during colonoscopy to give your doctor a clear view of your intestinal wall; preparing for the test involves drinking a liquid that triggers bowel-clearing diarrhea.

CRC screening tests: Other options

So, while colonoscopy remains the gold standard, the best test is the one that gets done or gets the process started. A recent meta-analysis found that fecal blood tests, which are available by prescription and can be done at home, are associated with increased screening rates. (Patients still need a colonoscopy if there is an abnormal result, to diagnose cancer or remove polyps to prevent cancer.)

In 2016, the United States Preventive Services Task Force updated its CRC screening recommendations to state that patients and physicians can choose among available screening tests.

Currently, three types of at-home CRC screening tests are approved by the Food and Drug Administration (FDA):

Guaiac FOBT (gFOBT) uses a chemical to detect a component of hemoglobin, a blood protein in the stool.

Fecal immunochemical test (FIT or iFOBT) uses antibodies to detect hemoglobin shed by polyps or colorectal cancer.

Multitarget stool DNA test (FIT-DNA) detects trace amounts of blood and DNA from cancer cells in the stool.

For all of these tests, you collect a stool sample at home using a kit, then mail the sample to a doctor or to a laboratory for testing. None require the bowel-clearing prep required for colonoscopy. Amazon sells screening tests: FOBT for $10 and FIT for $25. These are available without a prescription but are not as well studied or standardized as those available through your physician.

Pros and cons of at-home CRC screening tests

A review published in JAMA concludes that all three home tests may be an efficient first-step for low-risk patients. However, all the kits, as well as colonoscopy, can miss polyps, which can and should be removed at the time of the colonoscopy.

The FIT screening test has been in use for about 10 years. It should be repeated annually in case the cancer or polyp isn’t bleeding at the time of the test. (Colonoscopy is recommended once every 10 years for low-risk patients.) The FIT test detects cancer with 79% accuracy, with about 5% false positive results (suggesting cancer where none exists), which warrant a colonoscopy for further testing.

Studies have shown that the multitarget stool DNA test (Cologuard is currently the only FDA-approved brand) detects cancer with 92% accuracy. However, 14% of tests deliver a false positive result, which is higher than the FIT test. Health experts recommend repeating the test every one or three years.

For years we have used the gFOBT to detect microscopic amounts of blood in the stool that is not visible to the naked eye. It is less accurate than either the FIT or the DNA stool test, identifying only 20% to 50% of cancers. This test has a limited role today.

Cost considerations

An additional barrier to CRC screening is the out-of-pocket cost to patients. The Affordable Care Act mandated that insurance plans cover CRC screening tests, including colonoscopy, in full, with no out-of-pocket cost to patients. However, coverage does not apply to colonoscopies that convert from screening to diagnostic when a polyp is detected and removed during the procedure. And coverage does not apply to diagnostic colonoscopies after a positive CRC FIT or DNA screening test result.

This coverage failure means that patients may have to pay thousands of dollars to complete recommended CRC testing.

How can you decide which CRC screening test is right for you?

Ask your doctor and have a frank discussion about your risks and concerns. Most people find colonoscopy less miserable than they anticipate, and it is still the best option overall. Higher-risk people really do need a colonoscopy, usually until age 80. For others, get tested or get the screening process started, and the only wrong answer is ignoring the possibility of colon cancer.

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Aging and sleep: Making changes for brain health

As a neuropsychologist, my research interests have focused on the link between sleep and cognitive health. As I have gotten older, I have personally come to appreciate the restorative power of a good night’s sleep for thinking, memory, and functioning at my best.

Sleep affects our overall health, including our hormones and immune system. Neurobiological processes that occur during sleep have a profound impact on brain health, and as a result, they influence mood, energy level, and cognitive fitness. Numerous studies have shown that structural and physiological changes that occur in the brain during sleep affect capacity for new learning, as well as the strength of memories formed during the day. Sleep promotes the consolidation of experiences and ideas; it plays a pivotal role in memory, and has been shown to enhance attention, problem solving, and creativity.

Specific sleep stages are associated with different types of learning

Over the course of each night sleep unfolds in five different cycles which alternate throughout the night. These include Rapid Eye Movement (REM) and Non-REM stages. REM is the stage when dreaming occurs. This stage of sleep is associated with active eye movements and body paralysis, which assures that a sleeping person is protected from acting out the dream. During REM there is increased activity in limbic structures involved in memory and emotional regulation, whereas there is less activity in frontal brain systems involved in analytic thinking. Fragments of events and memories experienced during the day may be combined in novel and often bizarre ways during REM-based dreaming. REM plays a pivotal role in memory and other cognitive functions. Other sleep stages are also associated with memory. For instance, stage 2 (slow wave) sleep promotes motor skill learning needed for activities such as playing an instrument or keyboarding.

Changing circadian rhythms and sleep disturbances are common

When we get older, we tend to feel sleepy earlier in the evening. This may result in waking up early in the morning as our sleeping hours shift. Older people have less REM and less slow wave sleep. Less slow wave sleep may impede memory consolidation in older adults. In addition to changes in sleep cycles, older people are increasingly vulnerable to sleep disturbances that cause poor sleep and low brain oxygen such as sleep apnea, a medical condition characterized by loud snoring, breathing pauses during sleep, and daytime fatigue. Research has shown that sleep apnea increases amyloid, a protein associated with Alzheimer’s disease. Poor sleep increases amyloid deposition and in turn, amyloid deposition compromises the quality of sleep. In fact, people with Alzheimer’s disease are prone to sleep problems, including insomnia at night and excessive sleeping during the day.

Aging well means prioritizing sleep

We know that a good night’s sleep is good for our brain, especially as we get older. But how do we do this? As a first step you should use a sleep diary to keep track of your sleep schedule for at least two weeks. This will provide objective information regarding the consistency of your sleep routine as well as the association between sleep and your level of alertness during the day.

Recommendations from sleep experts such as Dr. Suzanne Bertisch provide a road map for improving sleep hygiene. The following tips are highlighted:

Consistency matters. Train your body to sleep well by going to bed and getting up around the same time each day (even on weekends).

Only sleep when you are sleepy. Do not spend too much time awake in bed.

Pay attention to your sleep environment. Your bed should be comfortable. The room should be sufficiently dark and quiet. Some people use eye masks to block light. Some use white noise filters or ear plugs when there is noise in or near the bedroom. The temperature of your bedroom should be cool. A cool room with warm blankets is optimal for a good night’s sleep.

Reserve your bed for sleep (and sex). Avoid television, reading, or work activities while in bed.

Avoid (or limit) naps. You need to be tired at bedtime. If you need a daytime nap, do this before 3 PM and for less than one hour.

Avoid stimulants (coffee, cola, chocolate, and cigarettes) for four to six hours before going to bed.

Limit alcohol intake for four to six hours before going to bed. Alcohol disrupts REM and slow wave sleep, which are important for memory.

Avoid electronic devices with LED screens for at least an hour prior to bedtime. The blue light that comes from these screens interferes with the brain’s natural sleep rhythms, and may trick your brain into thinking that it is daytime.

Use rituals. Some people enjoy a hot bath one to two hours before sleep. Others use stretching or mindfulness practices in preparation for sleep.

If you do wake during the night, don’t remain in bed struggling to fall back to sleep. Get up and do something that may increase sleepiness (like reading) for about 20 minutes, and then return to bed and try to initiate sleep.

Sleep is an important aspect of cognitive health, but it is not whole story. Further information regarding brain fitness can be obtained by reading our Special Health Report A Guide to Cognitive Fitness.

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Fat is more than calorie storage

A group of researchers based at the Joslin Diabetes Center and Harvard Medical School just published a paper in the journal Nature Metabolism that tells us something new and amazing, as well as confirms something we all know already.

They studied a protein that is secreted by mouse and human fat cells in response to cardiovascular exercise. The protein, called transforming growth factor-beta 2, or TGFB2, is an adipocytokine (which literally means “fat cell movement”) that seems to lower blood sugars in mice. Previous research has shown that transplanting fat cells from mice of normal weight who exercised on a wheel into mice who were overweight and sedentary resulted in improved blood sugars.

These researchers administered this “fat cell movement” protein to mice with diet-induced obesity for nine days, and found significantly improved blood sugar response to a sugar load as well as increased sensitivity to insulin, both markers of improved metabolism and lower risk for diabetes.

They found that human fat cells also secrete TGFB2 in response to cardiovascular exercise. They hypothesize that TGFB2 could be used as a treatment for the metabolic problems often linked to obesity, such as glucose intolerance, insulin resistance (both of which increase risk for developing diabetes), and diabetes.

But they also state the obvious conclusion: exercise training improves metabolism.

Why take a pill when you can take a walk?

From my perspective, the next step is not to discuss how we can make this protein into a profitable pill, but rather to discuss how we can become more active in our day-to-day lives.

We know that activity — any activity — has multiple health benefits beyond those on blood sugar. This blog has reviewed research showing that exercise lowers cardiovascular risk, relieves stress, improves memory and cognition and mood, prevents dementia, increases longevity, helps treat cancer, and on and on.

Right now, the recommended weekly amount of physical activity for adults is at least 150 minutes of moderate activity (think walking or easy biking) or 75 minutes of vigorous activity (think running or stair climbing). Children and teens should be getting 60 minutes per day of moderate to vigorous activity. These evidence-based recommendations were released by the US Department of Health and Human Services and are supported by many organizations, including the American Heart Association. (Check out our post on the new activity guidelines.)

According to a 2018 CDC study based on survey data from over 150,000 Americans from all 50 states, only 23% of adults meet those activity levels.

How can we make that happen?

On an individual level, we can realize that all activity counts, and it doesn’t have to be at the gym.

On a family level, we can make playtime more active by encouraging more outdoor play (basketball, biking, jumping rope) and discouraging indoor sitting time (video games, television). We can make family time more active by taking walks, hiking, or doing sports together.

On a community level, we can work to make walking or biking to school safer for kids, and organize or get involved with activities like town soccer leagues.

There’s more, of course, a lot more, and all of it is better (and safer) than taking another pill.

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Can vaping help you quit smoking?

It’s hard to overstate the dangers of smoking. Nearly 500,000 people die of tobacco-related disease each year in the US. Over the next decade, estimates are that around eight million people will die prematurely worldwide each year due to tobacco use. The list of tobacco-related diseases and conditions is long and growing. It includes:

cardiovascular disease, including heart attack and stroke

emphysema, bronchitis, and asthma

lung and other types of cancer

tooth decay

weathering of the skin

having a low-birthweight baby

diabetes

eye damage (including cataracts and macular degeneration).

And there are others. The point is, if you smoke, you should try hard to quit. And if you don’t smoke, don’t start!

While the dangers of smoking are clear, the best way to quit is not. In fact, there is no single best way. And most people who quit for good have to try more than once before they succeed.

What about e-cigarettes?

Users of electronic cigarettes (e-cigarettes) inhale an aerosol created by heating nicotine, flavorings, and other substances. There seems to be general agreement that vaping(the term often used to describe use of e-cigarettes) is safer than smoking cigarettes. That said, vaping can cause mouth or throat irritation, nausea, and coughing, and the long-term effects are not yet known.

E-cigarettes have been in the news a lot lately because of concerns that they are being marketed to kids, with flavor options such as cotton candy, cupcake, and tutti-fruiti. One survey found that about 80% of middle school students had seen ads for e-cigarettes. Since we know that nicotine is highly addictive and the long-term risks to kids of vaping are not known, the rising popularity of vaping among young people might create a host of unforeseen health problems in the future.

And that’s not an idle concern. Animal studies and limited human research have shown that vaping can lead to changes in the airways that are similar to those caused by smoking. And some of the same chemicals detected in the flavorings have been removed from food products because they’ve been linked with health problems. There are also concerns that teenagers who become addicted to nicotine by vaping may be more likely to smoke cigarettes as adults or try other addictive drugs such as opiates. Finally, “dual use” of tobacco products — vaping and smoking cigarettes — is not rare. A 2015 survey cited by The Truth Initiative (an anti-tobacco organization) found that nearly 60% of e-cigarette users also smoked cigarettes.

What about vaping to help you quit smoking?

Advocates of vaping have promoted it as a way to help cigarette smokers to quit. Although giving up nicotine products altogether might be the ultimate goal, there may be health benefits to a smoker who becomes a long-term vaper instead, though this remains unproven.

A new study compares vaping with other common nicotine replacement approaches as a way to help smokers quit. The findings support the idea that vaping may help some smokers.

Researchers recruited nearly 900 people who wanted to quit smoking, and randomly assigned half to receive e-cigarettes and the other half to receive other nicotine replacement products (such as nicotine patches and gum). All of the study participants received weekly individual counseling for four weeks. After one year, smoking cessation was confirmed by measures of exhaled carbon monoxide (which should be low if you’ve quit but high if you’re still smoking).

Here’s what they found:

Among those assigned to vaping, 18% had stopped smoking, while about 10% of those using nicotine replacement therapy had quit.

Among successful quitters, 80% of those in the e-cigarette group were still vaping; only 9% of those in the nicotine-replacement group were still using those products.

Reports of cough and phlegm production dropped more in the e-cigarette group.

So, while e-cigarette use was associated with nearly twice the rate of smoking cessation, more than 80% of smokers entering this study continued to smoke a year later. One other caveat to note: the e-cigarettes used in this study contained much lower levels of nicotine than found in some common brands used in the US (such as Juul). The importance of this difference is unclear, but a higher nicotine level could contribute a higher rate of addiction to the e-cigarette.

Recommended ways to quit smoking

If you’re trying to kick the habit, you’ll get lots of advice. Many people try to quit cold turkey, but success rates are quite low. Hypnosis and acupuncture seem to work for some people, but these remain unproven. The best studied smoking cessation strategies include:

behavioral therapy, such as individual counseling

nicotine replacement therapy, such as a long-acting nicotine patch and short-acting nicotine gum

medications to reduce the urge to smoke, such as varenicline (Chantix) or bupropion (Zyban).

In studies of these approaches, quit rates were around 20% to 25% over six to 12 months. While these may seem low, they’re significantly higher than observed among people trying to quit on their own.

What’s next?

While I think concerns about vaping are appropriate (especially regarding use among youth), this study demonstrates that it could help people quit smoking. So, vaping could soon get approval from the FDA as a smoking cessation aid, but even if that happens, it should not be the first choice given how much is still unknown. It’s possible we’ll see regulations and legislation on vaping in this country, including a higher age limit on its use, a ban on its marketing to young people, a limit to nicotine concentrations, and even a ban on flavored e-cigarettes altogether.

Ultimately, we’ll need good studies to assess the long-term safety of vaping, to confirm that when used to aid smoking cessation we aren’t just replacing one bad habit with another.

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Do you really have a penicillin allergy?

Chances are, you or someone you know is one of the 10% of Americans with a documented penicillin allergy. But just because you were told you had a penicillin allergy, or had one in the past, does not mean you have one now. People with a penicillin allergy history have their allergy disproved with allergy testing more than 90% of the time.

Penicillin: a primer

Penicillin is part of a larger drug class called beta-lactam antibiotics, which include the common penicillins and cephalosporins.

Common penicillins include ampicillin, amoxicillin, and Augmentin. Among other uses, penicillins are often used to treat ear infections, strep throat, sinus infections, and to prevent dental infection. Cephalosporins are used for similar reasons. Certain intravenous (IV) cephalosporins are important for hospitalized patients.

What is a true penicillin allergy?

True allergies can result from any medication. Symptoms can range from mild, like itching, to severe, like anaphylaxis, which can involve low blood pressure and difficulty breathing. If a reaction to penicillin included skin redness, itching, rash, or swelling, there may have been a penicillin allergy, but these symptoms can also occur for other reasons. Shortness of breath, wheezing, fainting, and chest tightness are all reactions that may indicate anaphylaxis. These reactions can be safely evaluated by a trained medical professional. Even patients with severe penicillin allergy histories are often able to take penicillins safely again, because penicillin allergy often does not persist for life.

Rarely, people have reactions to drugs, such as peeling or blistering skin, or liver or kidney injury, that are so troubling that we recommend avoiding the medication in the future.

Side effects like fatigue, nausea, and vomiting are not allergies, but because side effects are recorded in the “allergy” section of health records, their documentation contributes to confusion surrounding what is a true penicillin allergy.

Why does it matter if I have a true penicillin allergy or not?

People with a penicillin allergy on their medical record are not given penicillins, and may not be given any beta-lactam antibiotics because of concern that the allergy is shared across the antibiotic class. Instead, the antibiotics prescribed may be broader-spectrum. Broad-spectrum antibiotics may be as effective, but they often have more side effects and toxicities, such as increased risk of developing infections like C. diff (Clostridioides difficile, formerly called Clostridium difficile) or methicillin-resistant Staphylococcus aureus (MRSA). Confirming or ruling out a penicillin allergy through allergy testing could justify the risk, or potentially avert it by allowing your doctor to prescribe beta-lactams.

In other cases, your doctor may have to prescribe less-effective drugs than penicillins and cephalosporins because of a documented penicillin allergy.

What does penicillin allergy testing entail?

An allergist can assist in the diagnosis of a penicillin allergy using a skin test. This test involves pricking the skin, usually on the back or on the inside of the forearm, and placing a small amount of allergen on the punctured skin. The allergist will compare how your skin reacts to penicillin versus a positive control (histamine) and a negative control (saline). Anyone with a positive skin test to penicillin — there’s usually itching, redness, and swelling at the site of the skin prick — is allergic and should avoid penicillin.

People who have no reaction to the skin test can safely undergo the amoxicillin challenge. In this test, the allergist gives the person amoxicillin and observes signs and symptoms for at least one hour. This is done under medical supervision.

Although these tests are very useful for diagnosing penicillin allergies that are immediate, there are other types of allergies that may still occur. The most common is a minor drug rash that happens days into the course of antibiotic treatment.

When should I get tested?

I am often asked to evaluate penicillin allergies when a patient needs penicillin or another beta-lactam, and the documented allergy is obstructing the best treatment. However, the best time to have a penicillin allergy evaluated is when you’re healthy.

You can discuss allergies as part of routine health maintenance with a primary care doctor or pediatrician. Clarifying medication allergies is also a good idea before an operation; a penicillin allergy can impact infection risk, and allergies to latex and pain medications can get in the way of a smooth operation and post-operative period. Finally, women of childbearing age who are thinking of conceiving might want to evaluate an allergy to penicillin. Penicillins are used for infections in pregnancy and during deliveries for a variety of reasons. Pregnant patients can also be evaluated safely for a penicillin allergy in their third trimester.

Follow me on Twitter @KimberlyBlumen1

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Diet and exercise limit heart disease risk in men undergoing hormonal treatments for advanced prostate cancer

Men with advanced prostate cancer are typically treated with drugs that prevent the body from making or using testosterone. A hormone (or an androgen, as it’s known), testosterone drives prostate cancer cells to grow faster, so shutting it down is essential to keeping the illness in check. About 600,000 men with advanced prostate cancer in the United States today are undergoing this type of anti-hormonal treatment, which is called androgen deprivation therapy (ADT). But even as ADT helps men live longer, it exerts a toll on the body. Men can lose muscle and bone mass, gain weight, and they face higher risks for heart disease and type 2 diabetes.

The good news is that a few helpful strategies can lessen these metabolic side effects. Engaging in aerobic exercise and resistance training, for instance, has been shown to drop levels of inflammation in the body that might otherwise lead to heart disease. Quitting smoking is similarly beneficial, since tobacco smoke’s toxic effects on the heart are more pronounced in the absence of testosterone.

In a new study, researchers have shown that taking daily walks and eating a low-carbohydrate diet can also lessen ADT’s harms. During the investigation, 42 men who were just starting on ADT were split into two groups: Half the men took daily walks lasting at least half an hour five days a week, and were instructed to limit their carbohydrate intake to no more than 20 grams per day. The other half of the men (the control group) maintained their usual diet and exercise patterns.

After six months, typical weight loss among men in the walking/low-carbohydrate group was about 20 pounds, compared to a nearly 3-pound weight gain among men who stuck to their usual dietary and exercise routines. Men in the walking/low-carbohydrate group also had significantly higher blood levels of high-density lipoprotein (HDL), which removes cholesterol and lessens risks of atherosclerosis and heart disease. And they also had significant improvements in insulin resistance (a pre-diabetic condition), but only at three months and not when the levels were checked again three months later.

The study’s lead author, Dr. Stephen Freedland from Cedars-Sinai Medical Center in Los Angeles, California, says exercise combined with low-carbohydrate diets appears to be a promising strategy in men undergoing ADT that should be studied further. 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, pointing out that weight gain can be a real problem for men that endures even after ADT is discontinued. “The weight loss in the experimental group is encouraging and should be validated in larger studies,” he said. “In the meantime, combining exercise with low-carbohydrate diets is a common-sense strategy that clinicians should recommend to their patients.”

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Infertility: Maintaining privacy, avoiding secrecy

When Michelle Obama’s memoir, Becoming, was released in October 2018, several reviewers noted that her book reveals that the Obamas struggled with infertility. When I was lucky enough to receive a copy as a gift, I learned that Michelle and Barack didn’t simply have a ‘touch of infertility’: they went through IVF in order to have both Malia and Sasha.

Why, some reviewers seemed to wonder, was the public learning this significant piece of the Obamas history now? And, to be bipartisan about it, we learned in Laura Bush’s 2010 memoir, Spoken From the Heart, that she and her husband had endured a long struggle with infertility and were planning to adopt when they found they were expecting twins Jenna and Barbara.

My response is this: The Obamas and the Bushes, so different in so many ways, share the perspective of countless other infertile couples and individuals: infertility is not a secret, but it is private.

One might also say that the Obamas and Bushes acknowledge their infertility because it is in the past. For both couples, it brought them two cherished daughters. I have seen that when people are in the trenches of infertility, questions about what to say, when, and how swirl around in their heads.

Secrets, truth, and privacy

Most people recognize the danger of secrets. Secrets lead to feelings of shame. They distance family and friends and promote misunderstandings. Couples determined to tell no one about their infertility may find others assume they don’t want children, are selfish, or are clueless in thinking they can wait as long as they want. Hence, most people coping with infertility decide to tell others something — the challenge for them is avoiding the pitfalls of too much information.

When counseling infertility patients, I often suggest that they tell a simple truth. Not the whole truth. Not nothing but the truth. Less is more when it comes to talking about infertility.

Couples can think through what they want others to know. In most instances, it is simply that they want children, are having trouble making that happen, and are receiving good medical care. They want others to respect their privacy and to simply stay tuned, knowing that when there is good news to be shared, they will joyfully share it. Specifics of diagnosis, types, and timing of treatments are usually too much information.

Maintaining privacy while avoiding secrecy also arises when individuals and couples are exploring or pursuing other paths to parenthood, such as adoption, egg or sperm donation, or surrogacy. Again, I advise people to share only what others really need to know. Adoption is never a secret these days. But how much do others really need to know while people are waiting for a match with a birth mother or counting down the hours until she signs surrender papers? Often, it adds to the stress of the situation.

Is there an obligation to tell?

Similarly, when people choose egg or sperm donation, do they have an obligation to tell all to others? Years ago, I thought that those who did not acknowledge donor conception were being secretive. Then I realized that fertile heterosexual couples do not tell others how they conceived. Why should it be different for those who participate in third-party reproduction?

On NPR one day, I heard a wonderful interview with an author who had a baby at 50. The interviewer said, “I understand that you had a baby at an older age.”

“Yes, we are so fortunate that there are all sorts of ways to become pregnant these days,” the author responded. She spoke a simple truth and felt no need, it seemed, to tell the whole truth and nothing but the truth.

Privacy and dignity

The word that I have come to pair with privacy is dignity. Perhaps it is my response to living in a time of oversharing. I believe a certain dignity comes with maintaining privacy, especially when it comes to one’s family. Years ago I realized this when a couple I was counseling adopted their son. I was overjoyed for them and filled with questions. They answered some of my questions: where he was born, how long they had to remain out of state. They chose not to answer questions regarding his birth family.

“We feel that’s our son’s story to tell or not tell,” they said. “Until he is old enough to make these decisions for himself, we want to respect his privacy.”

Infertility so often feels like an out of control experience. By actively making decisions about privacy and secrecy, it’s possible for people to take back some of their lost control and gain pride in their ability to tend to and preserve their unfolding family story.

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Should I be eating more fiber?

You probably know the basics about fiber: it’s the part of plant foods that your body cannot digest, and there are two types — soluble fiber and insoluble fiber. Both types of fiber are good for us.

Soluble fiber dissolves in water, forming a gel. It is the form of fiber that helps lower cholesterol levels, reduce the risk of heart disease, and regulate blood sugar levels. Soluble fiber is found in black beans, lima beans, Brussels sprouts, avocado, sweet potato, broccoli, turnips, and pears.

Insoluble fiber passes through the digestive system relatively intact, adding bulk to stools. It is the form of fiber that prevents constipation and regulates bowel movements, removing waste from the body in a timely manner. Insoluble fibers are found in whole wheat flour, wheat bran, cauliflower, green beans, and potatoes.

Despite these health benefits, most Americans get less than half the suggested amounts of daily fiber. The popularity of very-low-carbohydrate diets like the ketogenic or “keto” diet, the Atkins diet, and the Whole 30 diet, which may unintentionally decrease fiber consumption, hasn’t helped matters.

It may be time to give fiber another look.

New evidence confirms protective effect of fiber

A new analysis of almost 250 studies confirmed on a large scale that eating lots of fiber from vegetables, fruits, and whole grains can decrease your risk of dying from heart disease and cancer. Those who ate the most fiber reduced their risk of dying from cardiac disease, stroke, type 2 diabetes, and/or colon cancer by 16% to 24%, compared to people who ate very little fiber. The study also concluded that more fiber is better. For every additional 8 grams of dietary fiber a person consumed, the risk for each of the diseases fell by another 5% to 27%. Risk reductions were greatest when daily intake of dietary fiber was between 25 and 29 grams.

Two observational studies showed that dietary fiber intake is also associated with a decreased risk of death from any cause. Those eating the highest amount of fiber reduced their risk of dying by 23% compared to those eating the least amount of fiber. In these studies, the associations were more evident for fiber from cereals and vegetables than from fruit.

Weight control is another benefit of high-fiber diets. By helping you feel full longer after a meal or snack, high-fiber whole grains can help you eat less. In one large study, adults who ate several servings of whole grains a day were less likely to have gained weight, or gained less weight, than those who rarely ate whole grains.

Fiber: how much is enough?

On average, American adults eat 10 to 15 grams of total fiber per day, while the USDA’s recommended daily amount for adults up to age 50 is 25 grams for women and 38 grams for men. Women and men older than 50 should have 21 and 30 daily grams, respectively.

In general, it’s better to get your fiber from whole foods than from fiber supplements. Fiber supplements such as Metamucil, Citrucel, and Benefiber don’t provide the different types of fiber, vitamins, minerals, and other beneficial nutrients that whole foods do.

When reading a food label, choose foods that contain more fiber. As a rule of thumb, choose cereals with 6 or more grams of fiber per serving, breads and crackers with 3 or more grams per serving, and pasta with 4 or more grams per serving. Another strategy is to make sure that a whole-grain food has at least 1 gram of fiber for every 10 grams of carbohydrate. If you look for a 1:5 ratio, that is even better.

Ignore the marketing on front of the package labels. Just because a bread is labeled “multigrain” or “12 grain” does not mean it is a whole grain. The grains could be refined and the bread may be low in fiber. When you look at the ingredient list, make sure “whole” is the first ingredient.

Easy ways to get more fiber in your diet

Here are some strategies to increase fiber in your diet:

Start your day with a bowl of high-fiber cereal.

Add vegetables, dried beans, and peas to soups.

Add nuts, seeds, and fruit to plain yogurt.

Make a vegetarian chili filled with different types of beans and vegetables.

Add berries, nuts, and seeds to salads.

Try snacking on vegetables such as cauliflower, broccoli, carrots, and green beans. Serve them with a healthy dip such as hummus or a fresh salsa.

Eat more whole, natural foods and fewer processed foods.

A few important tips as you increase your fiber:

Do so gradually to give your gastrointestinal tract time to adapt.

Increase your water intake as you increase fiber.

If you have any digestive problems, such as constipation, check with your physician before dramatically increasing your fiber consumption.

Take a positive approach to eating more high-fiber foods. Beyond reducing risk of chronic disease, eating a variety of whole foods that contain good sources of fiber can be an easy and enjoyable way to keep you fuller longer and help control your weight. Fiber can expand your horizons with different tastes and textures, and can be a bonus to your health.

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Can facial exercises reverse signs of aging?

Patients often come into my office asking, “How can I look younger?” While I always recommend healthy living — a balanced diet and regular exercise — in order to look and feel younger, I have never thought of facial exercises as part of that regimen. That is, until a recent study, published in JAMA Dermatology, showed promising results that routine facial exercise may slow the unrelenting tide of time.

Facial exercises: A fountain of youth for your face?

The rationale behind the study stems from the fact that a major part of facial aging is due to the loss of fat and soft tissue, which leads to sagging and exaggeration of wrinkles. If we can lift weights at the gym and enlarge our biceps, why couldn’t the same be done for muscles in our faces, thereby filling out those contours to create a more youthful countenance?

The concept of facial exercise is not a new one. A simple Internet search will produce a litany of blog posts and books on the subject, touting a variety of programs that promise to be the next fountain of youth. What the JAMA Dermatology researchers did in their study, which was the first of its kind, was to examine this question from a more rigorous scientific perspective. They enrolled 27 women between the ages of 40 and 65 to perform daily, 30-minute exercises for eight weeks, and then continue every other day for a total of 20 weeks.

Dermatologists who did not know the participants were asked to rate their photographs before and after the exercise regimen. The dermatologists found an improvement in cheek fullness and estimated the age of the participants at 51 years of age at the start of the program and 48 at the end of the 20-week study. Furthermore, all the participants felt improvement in their own facial appearance at the end of the study.

While these results seem exciting, the study has some obvious limitations. Of the 27 patients enrolled, 11 dropped out before completing the study. One reason may be that the program was too time-consuming, clocking in at 30 minutes a day. The overall small size of the study also limits its generalizability to the larger population. In addition, there was also no control group, meaning a group of participants who did no facial exercises, which would have helped minimize the possibility that this improvement occurred by chance.

It’s also hard to draw conclusions about the longevity of these results. Presumably the exercises must be continued to maintain their effects. But for how long? And how frequently? Which exercises are most fruitful? More studies are needed to address these questions.

Facial exercises may help, but sunscreen is tried and true

For those who are still skeptical but wish to try something more evidence-based to maintain youthfulness, I have one simple suggestion: use sunscreen. You may roll your eyes at the suggestion of sunscreen from a dermatologist, but there is an enormous body of research that demonstrates the sun’s role in prematurely aging our skin. You can protect your skin from these damaging effects by using broad-spectrum, SPF 30 or higher sunscreen daily, especially on the face. An analogy I often make is to think of a rug of in front of a window in your house. How does it look after five or 10 years? If the sun can fade an inanimate object to such a degree, think of what it can do to your skin.

As for facial exercises, the jury is still out. But unlike youth-preserving cosmetic procedures that require money and time for recovery, facial exercises are free and almost certainly not harmful. So why not try facial exercises if you have the time? If they don’t make you look younger, these goofy moves will, at the very least, make you smile.

Follow me on Twitter @KristinaLiuMD

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Should you try kettlebells?

Kettlebells. There they were in the fitness aisle of my local big box store: cute little candy-colored cannonballs with handles on them. I was drawn to them immediately—adorable pink weights that conjured images of me as an exercise goddess in a sunny meadow, smiling and doing arm workouts with ease (in slow motion of course). Then I lifted one of the weights from the shelf and discovered—record scratch—they’re no creampuffs, they’re heavy workout tools! But apparently they’re all the rage.

How do kettlebells improve fitness?

Kettlebells have been used for centuries, most famously by 19th-century strongmen. Today the weights (which range from 8 to 105 pounds) are featured in exercise classes, gyms, and fitness equipment stores, and for good reason: they work several muscle groups at a time. Holding a lot of weight by a handle engages your arm, leg, shoulder, back, and abdominal muscles. The pull on your muscles helps to strengthen them. The pull on your bones helps stimulate new bone cell growth.

Using kettlebells can also improve your posture. “With the weight in front of you, your back muscles have to straighten up more to counteract the force of the kettlebell pulling you forward,” explains Nancy Capparelli, a senior physical therapist at Harvard-affiliated Beth Israel Deaconess Medical Center.

Swinging a kettlebell also challenges your balance and helps to improve it.

Kettlebell risks

Along with benefits, kettlebells have some risks. One is obvious: dropping the weight on your foot (nothing a goddess would do, but I might by accident). Other pitfalls: lifting too much too soon or lifting a kettlebell the wrong way can lead to muscle strains, rotator cuff tears, and falls.

If you have the bone-thinning disease osteoporosis or its precursor state osteopenia, lifting a heavy kettlebell may increase your risk for fractures, caution some experts. If you’re at risk for falling, using a kettlebell can add to your risk.

Should you try kettlebells?

Using kettlebells should be safe for healthy people as long as they:

Use the appropriate weight. “It depends on the person. Someone who’s five feet tall and 90 pounds will typically use a lighter kettlebell than someone who’s six feet tall and 200 pounds,” Capparelli says.

Learn the proper form from an expert first. “You need to know exactly what to do with the kettlebell and which exercises are appropriate. Otherwise you’ll increase your risk for injury, even with a lighter kettlebell,” Capparelli warns.

It helps to use a kettlebell with a handle wide enough to grip with two hands. Another tip: wear weight-lifting gloves, since the kettlebell handle can get slippery.

Starter exercises

Typical beginner kettlebell exercises include:

The farmer’s walk.Pick up one kettlebell on each side, pinch your shoulders down and back, and walk a distance of 20 feet (across a gym) four times.

The suitcase carry.Pick up a kettlebell with one hand (like you’re carrying a suitcase) and walk a distance of 20 feet (across a gym) four times. Don’t lean to the side. Repeat the exercise while carrying the kettlebell on the other side.

The goblet carry.“Pick up the kettlebell with two hands and hold it in front of you as if you’re taking a sip from it,” Capparelli says. “Then walk 20 feet back and forth a few times. That works your arm muscles, shoulders, biceps, and upper back muscles.”

The kettlebell swing.Hold a kettlebell with both hands, arms extended down in front of you so the kettlebell hangs between your legs. Lean forward, shift your weight onto your heels, and swing the kettlebell back between your legs. Then stand up as you swing the kettlebell forward to chest height. Repeat 10 times.

Getting started

If kettlebells inspire your own images of weightlifting success (meadow optional), try just picking one up in a store or at the gym first to see if you’re interested. Even after my reality check, I am definitely intrigued. But I’ll get some guidance first to avoid accidents and injury.

There are lots of kettlebell classes at local gyms and YMCAs. There are even kettlebell videos online. You can also check out the Kettlebell Workout in the Harvard Special Health Report Strength and Power Training for All Ages.

For me, adding kettlebells to a workout makes sense: anything that draws me to exercise is a winner. And getting a multi-muscle workout with one small (and pretty) tool is a dream come true.

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Got pain? Get better sleep

The cell phone blares out reveille. Your eyes open reluctantly and you realize it’s morning, having only gone to bed four hours earlier because of a late-night party. You creak out of bed to ready yourself for work, arthritic joints hurting much more than usual. A painful day lies ahead even after taking ibuprofen. Does this sound familiar? If it does, you are not alone. Nearly 70% of Americans report getting insufficient sleep on a regular basis, and approximately 20% of Americans suffer from chronic pain. Recently, the intersection between these two conditions has become more apparent.

The association between sleep deficiency or poor quality sleep and increased perception of pain from various medical conditions is well known; poor sleep quality predicts greater intensity of pain from conditions such as back strain, arthritis, and fibromyalgia. In many cases, the relationship is bi-directional. For example, my colleagues and I have documented that heartburn is worse after a poor night’s sleep, and conversely heartburn can result in disrupted sleep.

Recent studies now provide a greater understanding of why pain worsens after poor sleep. In brain imaging studies using magnetic resonance imaging (MRI), there is greater activation of brain regions controlling perception of pain after a poor night’s sleep. In addition, the activity of other brain regions responsible for dampening the sensation of increased pain is reduced. The net effect is that the perception of pain is accentuated after a poor or inadequate amount of sleep. Importantly, this observation is not just a phenomenon confined to the laboratory. In surveys of individuals with chronic pain, a night of poor sleep predicts worse pain.

The relationship between poor quality sleep and worsening pain has important implications for individuals experiencing both acute and chronic pain. More or better sleep may lessen the pain that they are experiencing.

There also is a potential public health message that cannot be ignored. The opioid epidemic is rampant in the United States, related in part to overprescription of opioids for chronic pain. Unfortunately, addiction and inadvertent overdoses are increasingly frequent. How many opioid-related deaths can be avoided if an intervention to improve sleep is implemented? The answer is not known. However, better sleep is inexpensive and generally does not require a physician’s prescription. In addition to other initiatives to address the opioid epidemic, messaging about the benefits of sleep on reducing the perception of pain could be a cost-effective public health investment.

References:

Sleep disturbances and severe stress as glial activators: key targets for treating central sensitization in chronic pain patients? Expert Opinion on Therapeutic Targets, August 2017.

Sleep and pain sensitivity in adults. Pain, August 2015.

Relationships between sleep quality and pH monitoring findings in persons with gastroesophageal reflux disease. Journal of Clinical Sleep Medicine, August 2007.

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