As If PMS Weren’t Bad Enough, Study Links It To Later High Blood Pressure

(Newton Free Library/Flickr Creative Commons)

(Newton Free Library/Flickr Creative Commons)

By Dr. David Scales

As if the symptoms of PMS itself weren’t bad enough – the hot flashes, dizziness, cramping, trouble sleeping — now researchers have found a possible link to high blood pressure.
Currently, doctors are naturally aware of Premenstrual Syndrome, but are not thinking about it as a warning sign that a patient is at risk for developing health problems down the line. A new study by Dr. Elizabeth Bertone-Johnson, an epidemiologist at UMass, and her colleagues may soon change that.

They studied over 1,200 women – all part of a well-known and long-followed group called the Nurses’ Health Study – who developed at least moderate PMS. The researchers matched them to twice the number of women without PMS symptoms and looked for links to the diagnosis of high blood pressure.
Their analysis, published this week in the Journal of Epidemiology, found women with moderate-to-severe PMS had a 40% higher risk of developing high blood pressure over the next 20 years than the control group that experienced few PMS symptoms.
The researchers took into account factors we already know lead to hypertension, such as obesity, smoking, or a lack of exercise.
Still, the study had a number of limitations, so it will need to be repeated to make sure the link between PMS and high blood pressure holds up to scrutiny.
Dr. Bertone-Johnson and her colleagues are also looking into ways to prevent the symptoms of PMS. So far, they have found that high dietary intake of certain vitamins like thiamine, riboflavin or vitamin D as well as calcium can lower the risk of developing PMS. Another study by Bertone-Johnson’s group suggested increased iron and zinc intake may be protective.
These studies are preliminary, though, so I wouldn’t go out and load up on vitamins, iron and zinc –- but they do suggest that PMS may be treatable, and that treatment might help prevent some of its potentially harmful downstream consequences.

Sorry, Intriguing Studies Are No Excuse To Skip The Flu Shot This Year

 (Rick Wilson/AP Images for NCOA)

(Rick Wilson/AP for NCOA)

By Alison Bruzek

Warning: You may be tempted to use some of the following information to rationalize skipping your annual flu shot. But in fact, you’re out of luck. The message from public health authorities is absolutely clear: roll up your sleeve (or prepare your nasal passages) and get your flu vaccine.

“Just do it now, would be my advice,” said Dr. Larry Madoff, director of epidemiology and immunization at the Massachusetts Department of Public Health. “There’s always a benefit to getting the flu vaccine.”

Granted, you wouldn’t be entirely crazy for thinking otherwise, thanks to recent headlines like these:

From USA Today last winter: “Flu shots only 23% effective this season.

From CBS News: “Flu vaccine might be less effective in statin users.”

And on the front page of The Boston Globe earlier this month: “Repeated flu shots may lose potency.” (The story came from STAT, the Globe’s new online sibling publication covering medicine and bioscience, which used the headline, “Getting a flu shot every year? More may not be better.”)

The STAT story reports in its third paragraph that public health officials “still believe an annual vaccination is better than skipping the vaccines altogether.” But its primary emphasis is on a “growing body of evidence” that with flu vaccines, “more may not always be better.”

As one mother wrote on Facebook, “[It’s] very upsetting for someone like me, who has had their kids vaccinated every year.”

The message is confusing, even for someone well aware of the recommendation from public health authorities that everyone over six months old should get a flu vaccine unless there’s a medical reason to avoid it. Flu is no joke: It kills thousands, and probably tens of thousands, of Americans a year, the CDC says.

So what to do if you’re still worried?

To begin with, listen to the author of the study, Dr. Edward Belongia, an epidemiologist at the Marshfield Clinic Research Foundation. The STAT story notes he still strongly encourages everyone to get their flu vaccine.

As Dr. Belongia told me about his study: “At this point there really aren’t any implications for the general public.” Rather, it’s a jumping-off point for future research. Furthermore, the study was presented as a poster in October at an infectious diseases conference; it hasn’t yet been through the rigorous peer review required for publication in a scientific journal.

The study itself is intriguing — it concluded that children who had gotten a flu shot in two previous years, for a specific strain of the flu, were more likely to contract that flu than kids who had just been vaccinated for the first time.

But Dr. Madoff at the Massachusetts Department of Public Health said the idea that vaccines may bring diminishing returns isn’t new. In fact, it’s been around since the 1990s. And the bottom line, he said, is that “the return may diminish but there’s always a benefit to getting vaccinated.”

Or as a spokesperson for the CDC said, “This is an interesting new finding and CDC will be looking into it further. For now, the CDC recommendation for vaccination remains unchanged.”
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Elder Hunger: New Efforts To Combat Surprisingly Common Malnutrition Among Seniors

Meals on Wheels, a national home-delivery meals program, has helped some seniors manage their dietary needs as rates of malnutrition among the elderly population rises. (Jeff Gentner/AP)

Meals on Wheels, a national home-delivery meals program, has helped some seniors manage their dietary needs as rates of malnutrition among the elderly population rises. (Jeff Gentner/AP)

By Nell Lake

After her stroke, a 95-year-old woman in New York State found that she could no longer taste her food. She was also unable to feel hunger, so she didn’t know when she was supposed to eat. As a result, the woman began losing weight, grew weak and wasn’t getting the nutrients she needed.

Enter Meals on Wheels, a national home-delivered meals program established by the 1965 Older Americans Act. The woman (who asked that her name not be used) began receiving meals at her home five days a week. This, she says, helped her remember to eat regularly. Her weight improved, and so did her general health.

Malnutrition like hers is surprisingly common. Six percent of the elderly who live at home in the United States and in other developed countries are malnourished, according to a 2010 study in the Journal of the American Geriatric Society. The rate of elder malnutrition doubles among those in nursing homes is 14 percent, according to the same study.

And rates skyrocket among elderly populations in rehabilitation facilities and hospitals: Various measures show an astonishing one third to one half of seniors are malnourished upon being admitted to the hospital.

“Malnutrition is a serious and under-recognized problem among older adults,” says Nancy Wellman, a nutritionist and instructor at Tuft University’s Friedman School of Nutrition Science and Policy.

It’s not a new problem. But growth in the elderly population, and concerns about healthcare costs, have helped renew efforts by nutritionists and other advocates to establish screenings for malnutrition in medical settings, and to improve interventions that can prevent or reverse the issue.

Nutrition Complexities

Most basically, malnutrition means not getting enough nutrients for optimal health. In older adults, the causes are complex, experts say. Illness, disability, social isolation, poverty — often a combination of these — can all contribute to malnutrition. An older person may become malnourished because she has trouble chewing or swallowing. The medications she takes may suppress appetite. She may be unable to get to a grocery store. She may live alone, be depressed, or simply be uninterested in eating.

It’s important to know, says Connie Bales, a dietician and faculty member at Duke University Medical Center, that obese and overweight seniors can be malnourished, too. Eating too many calories doesn’t necessarily mean you’re getting the right nutrients for maintaining muscle and bone. “One can be quite malnourished, yet not be skinny,” Bales says.

High Costs 

Whatever the cause, malnutrition leads to further trouble. It increases older adults’ risk of illness, frailty and infection. Malnourished people visit the doctor and are admitted to the hospital more often, have longer hospital stays and recover from surgery more slowly.

The association between malnutrition and hospitalization goes both ways, say Wellman and other experts: The sick are more likely to become malnourished, and the malnourished are more likely to get sick. Continue reading

Why To Exercise (During Pregnancy) Today: Ob-Gyns Say It's Best Time To Boost Health

il-young ko/Flickr

il-young ko/Flickr

Yes, they’ve told us this before: If you’re pregnant, you needn’t refrain from exercise. But now, the influential (and fairly conservative) professional group of U.S. obstetricians and gynecologists is saying it even more forcefully: If you’re pregnant and facing no complications, you really should exercise — it’s the ideal time to improve your health, including your weight.

In an updated committee opinion, the group, the American College of Obstetricians and Gynecologists (ACOG)says: “Women with uncomplicated pregnancies should be encouraged to engage in physical activities before, during, and after pregnancy.”

The list of recommended activities includes: walking, swimming, stationary cycling, low-impact aerobics, yoga (modified and not hot), pilates (also modified), running, jogging, racket sports and strength training, and all with the usual caveats to check with your doctor first.

Importantly, the opinion says: “Some patients, obstetrician–gynecologists, and other obstetric care providers are concerned that regular physical activity during pregnancy may cause miscarriage, poor fetal growth, musculoskeletal injury, or premature delivery. For uncomplicated pregnancies, these concerns have not been substantiated…” Continue reading

Opinion: Why The WHO Botched Ebola, And How Proposed Fixes Miss The Mark

A World Health Organization worker trains nurses on how to use Ebola protective gear in Freetown, Sierra Leone last year. (AP)

A World Health Organization worker trains nurses on how to use Ebola protective gear in Freetown, Sierra Leone last year. (AP)

In the latest Lancet, a report from an independent panel of experts lambastes the World Health Organization for its handling of the Ebola outbreak. The panel makes 10 recommendations to help get the WHO in better shape for the next global epidemic alert.

I wish I could tell you not to worry, that the WHO will heed these recommendations and handle its next epidemic much better, so that the outbreak will never get as widespread and disturbing as Ebola was last year.

But I did my PhD dissertation on how the WHO plans for and responds to health problems like infectious diseases that don’t respect borders, and my sad conclusion is: Not gonna happen.

I agree wholeheartedly with many of the new recommendations — like that the WHO should focus on supporting countries with technical advice, and create a dedicated center for outbreak response. But if the WHO carries out even one of the 10, it will be a miracle.

Why should you care? Well, it’s widely thought that the WHO botched the Ebola outbreak: It was late in releasing information, and was even called out by Doctors Without Borders for its lackadaisical response.

And why did it botch the response? Because it is not built to rapidly balance politics with medicine, which is exactly what’s required in an epidemic. It can’t be helpful doctor and tough enforcer at the same time.

The independent panel, launched by the Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine, includes world health experts and former high-level WHO officials, but it seems to forget how the WHO works. The experts have made pie-in-the-sky recommendations that the WHO is unlikely and probably even unable to implement, making it more likely that it will repeat its mistakes.

I spent close to four years working on my dissertation, which had the riveting title “Exit, Voice and (Trojan) Loyalty: The World Health Organization and the Dynamics of International Disease Control.” Luckily for you, you don’t need to read it (not even my mom has, to be honest). There are just two quotes you need to understand pretty much everything about my dissertation and how the WHO responds to infectious disease risks.

Quote No. 1: “Our clients are our member states.”

A WHO official told me this during my first week researching in the archives. You might think the WHO works for the health of the people. Unfortunately, that’s a common misunderstanding. The WHO’s first priority is to the governments of its member states. Understanding that allows you to make sense of the WHO’s actions (or lack thereof) during an epidemic.

It also makes many of the recommendations from the panel impractical. The panel is basically asking the WHO to go rogue and bite the hands that feed it, criticize sensitive and capricious governments that, if threatened, will simply throw the WHO and all of its officials out of the country. Continue reading

More On ‘Sundowning,’ And The Agitation That Can Grip Seniors After Dark

(edward musiak/Flickr)

(edward musiak/Flickr)

Our post last week on “sundowning” — a syndrome in which seniors’ behavior changes dramatically after dark — generated an outpouring of stories from patients, caregivers and people working in hospitals, in hundreds of comments on Facebook.

Many brought up the fact that delirium and sundowning are related. While sundowning is thought to happen in elderly patients with advanced dementia, many people described seeing sundowning in others — like a relative after surgery. While experts aren’t sure how much sundown syndrome and delirium overlap, they agree that not everyone who gets confused at night is sundowning.

Delirium is very common and also gets worse at night. So the first time someone experiences delirium they should be checked for underlying and reversible causes like infections or mind-altering medications.

People also pointed out that sundowning can happen at home as well as in the hospital. For people with severe dementia like Alzheimer’s, this is especially true.

Some commenters referenced “The Visit,” a recently released horror movie where two children are visiting their elderly grandparents who exhibit erratic and violent behavior each night. I haven’t seen it myself, but it seems to be taking the concept to the extreme in the most frightening way possible.

Many of the stories on Facebook were particularly moving. We thought we’d share a few: Continue reading


Mass. Moves To Adjust Controversial Medical Marijuana Testing Standards

There are currently four medical marijuana dispensaries open in Massachusetts — in Salem, Brockton, Northampton and Ayer. But patients aren’t able to buy the full 10 ounces every 60 days that is allowed by state law because most of the marijuana grown by these facilities is not passing state testing standards, which dispensaries say are too strict and not realistic. Now the state is proposing a fix.

“With this new … approach, we’re able to specify the amount of exposure and the intended use, similar to what you’d see on a bottle of Tylenol.”

– Marc Nascarella, director of the environmental toxicology at DPH

Revised draft testing standards released Friday by the Department of Public Health (DPH) propose changing the amount of marijuana — and in turn possible contaminants — regulators expect heavy users to consume.

The current assumption is up to 1 ounce a day. That’s a lot of marijuana — in the range of 40 joints, depending on the size. If you smoke 40 joints a day you’re much more likely to inhale a dangerous amount of lead, mercury or arsenic than if you smoke 12 to 15 joints a day, which is what the state would assume (using a very rough ounce to joint translation) under the new proposed standards.

To be more precise, the state’s revised standards are based on the assumption that patients would inhale or ingest 0.35 ounces a day, or 10 grams.

“The department is shifting away from a worst case risk assessment style approach and more to a pharmaceutical industry based approach,” said Marc Nascarella, director of the environmental toxicology program at DPH.

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Paleo And Vegan Can Be Friends: 11 Points Of Consensus On What We Should Eat

(J. Scott Applewhite/AP)

(J. Scott Applewhite/AP)

By Rebecca Sananes

For healthy eating fans, it was the All-Star Game. Pick your preferred diet — vegan, paleo, Mediterranean, you name it — and the scientist, clinician or academic behind it was at the table in Boston this week. Think Dean Ornish, S. Boyd Eaton and T. Colin Campbell.

They all gathered at the Finding Common Ground Conference, convened by the nonprofit Oldways, to hammer out a consensus on healthy eating — an antidote to what can seem like endless flip-flops on dietary research. And amazingly enough, they did.

What they found was that despite all the food fights, the prevailing theories of nutrition and healthy eating actually have more in common than you’d think. (Though it’s a bit more complex than Michael Pollan’s classic, “Eat food. Not too much. Mostly plants.”)

After two days of presentations on the latest research, debates over ethics and attempts to differentiate between nit-picky nuance and important distinctions, Harvard’s Walter Willett sums up the consensus like this in a press release: “The foods that define a healthy diet include abundant fruits, vegetables, nuts, whole grains, legumes and minimal amounts of refined starch, sugar and red meat, especially keeping processed red meat intake low.”

So there you have it. But for a more granular look, here’s my take on the 11 principles these top scientists and nutritionists agreed should be the guiding principles when thinking about what and how we eat:

1. Yes to the federal guidelines

From the consensus statement:

The Scientists of Oldways Common Ground lend strong, collective support to the food-based recommendations of the 2015 Dietary Guidelines Advisory Committee, and to the DGAC’s endorsement of healthy food patterns such as the Mediterranean Diet, Vegetarian Diet and Healthy American Diet.

The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meats; and low in sugar-sweetened foods and drinks and refined grains.

Additional strong evidence shows that it is not necessary to eliminate food groups or conform to a single dietary pattern to achieve healthy dietary patterns. Rather, individuals can combine foods in a variety of flexible ways to achieve healthy dietary patterns, and these strategies should be tailored to meet the individual’s health needs, dietary preferences and cultural traditions. Current research also strongly demonstrates that regular physical activity promotes health and reduces chronic disease risk.

The Dietary Guidelines Advisory Committee is a group of scientists handpicked by the government to create a report detailing nutritional and dietary guidelines. Every five years, their report is reviewed by the USDA and the Department of Human Health Services before being voted on by Congress and implemented as the American Dietary guideline — the public policy informing public school lunches, military food and food industry regulations. The official vetted guidelines are due out by the end of the year.

Along with endorsing that committee’s report, the Oldways Common Ground Committee also backed Mediterranean and vegetarian diets.

2. We have to think about the planet when we eat

Form the consensus:

We emphatically support the inclusion of sustainability in the 2015 DGAC report, and affirm the appropriateness and importance of this imperative in the Dietary Guidelines for Americans because food insecurity cannot be solved without sustainable food systems. Inattention to sustainability is willful disregard for the quality and quantity of food available to the next generation, i.e., our own children.

Background: The DGAC recommended to Congress, for the first time, that nutritional policy should take into account environmental impact. Continue reading

‘Sundowning’: Why Hospital Staffs Dread Nightfall, And How To Help Seniors Avoid It

By Dr. David Scales

The elderly woman had been normal all day, my colleague told me, tolerating it well when a tube was placed in her bladder to measure her urine. But that evening, she was found wandering the hospital halls yelling in Italian, carrying her urine bag under her arm thinking it was her purse, traumatized that hospital staff were trying to take it away.

Another night in the hospital, a female Sri Lankan colleague saw an elderly man who was convinced she was a Nazi soldier. Reassurances and even a plea from the doctor — “How could I be a Nazi? I have brown skin!” — could not persuade him otherwise. The next day the patient was back to normal, incredulous when told about what transpired the night before.

An 80-year-old man — I’ll call him Bill — came to our emergency room after a fall. He seemed fine and his tests were negative, but his family wanted him admitted over night for observation. That evening, he began shouting out, repeatedly wanting to get up and walk to the bathroom (forgetting he had just gone). Our calming efforts only riled him up more.

This erratic nighttime behavior is called “sundowning.” Staff in hospitals and nursing homes always worry what will happen as twilight approaches. As the sun sets, many elderly patients can change drastically: They can become extremely confused, agitated, not know where they are, and even hallucinate. In other words, they exhibit signs of delirium, a confused state that can lead them to do things they otherwise wouldn’t.

Ulrich Joho/Flickr

Ulrich Joho/Flickr

Thankfully, not every elderly patient sundowns, but when one does, it can be emotionally traumatizing for everyone. To be confused or hallucinate, or to see a relative acting out in irrational ways, is frightening and destabilizing. Yet, sundowning seems to be extremely common. So, what is it? Why do people sundown? And what can you do to minimize the risk of sundowning in yourself or a close friend or relative?

Experts agree that confusion and agitation are more common in the evening and at night. But there is surprisingly little scientific consensus on what sundowning actually is.

The debate is in how much sundowning and delirium are related. Some experts think they’re the same thing, others separate but related entities.

It’s hard to study sundowning without a clear definition and diagnostic criteria. Experts can’t even be sure how often it happens. A recent review found a rate of anywhere from 2.4 percent to 66 percent. Continue reading

Study: Risk Of Hidden Cancer In Gynecologic Surgery Higher Than Previously Thought

Undetected cancer among women undergoing a type of minimally invasive hysterectomy or fibroid removal surgery is more common than previously thought, a new study finds. Researchers at Boston Medical Center report that the risk of such hidden cancer is about 1 in 352 women.

The upshot: these women may have had the undetected cancer spread within their bodies inadvertently through a technique that has fallen out of favor called “power morcellation,” which was typically used in these types of surgeries. The technique involves cutting the woman’s uterus or fibroids into small pieces to make them easier to remove during the less invasive laparoscopic procedure.

The new findings (which looked at the cases of more than 19,000 women) support a 2014 estimate by the U.S. Food and Drug Administration that approximately 1 in 350 women undergoing this type of surgery face the risk of hidden cancer. But earlier conventional wisdom was that the risk of undetected cancer for women undergoing this kind of surgery was closer to 1 in nearly 5,000 or more.

“The take-home message of the study is that the true risk of an undetected cancer at the time of gynecologic surgery for what was assumed to be benign disease is about 1 in 352 women,” says Dr. Rebecca Perkins, a practicing gynecologist at BMC and lead author of the new study.

This kind of minimally invasive surgery had “increased greatly” over the past decade, researchers report, because the procedures involved less pain and shorter recoveries, among other benefits.

But power morcellation came under public and regulatory scrutiny a few years ago (in large part due to excellent reporting by Jennifer Levitz at The Wall Street Journal). In 2014, the FDA issued a series of warnings against the use of laparoscopic power morcellators in the majority of women undergoing these types of gynecologic surgeries because of the risk of spreading unsuspected cancer.

At that time, regulators estimated the risk of hidden cancer this way:

Based on an FDA analysis of currently available data, we estimate that approximately 1 in 350 women undergoing hysterectomy or myomectomy for the treatment of fibroids is found to have an unsuspected uterine sarcoma, a type of uterine cancer that includes leiomyosarcoma. At this time, there is no reliable method for predicting or testing whether a woman with fibroids may have a uterine sarcoma.

If laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s long-term survival. While the specific estimate of this risk may not be known with certainty, the FDA believes that the risk is higher than previously understood.

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