How to Boost Your Energy Easily and Naturally

Monotony rules where there is lack of variety and interest. It not only snatches away the flavor of life but devoid us from relishing the sweet giggly moments as well. A tedious routine or any repetitive activity leaves behind nothing but a passive mind and a fettered soul. Being mechanical, we become oblivion to the beauties of nature, and all bestowed blessings. Not only, we neglect the people around but our own precious selves. Novelty and creativity seems to be superseded by robotic servility, what remains behind is not an energetic entity but only a heap of flesh and blood without spirit. Therefore, it is time to break up from uniformity and replenish with a boost of vitality in order to meet the challenges of life.

There are a number of ways to fight it out. I always suggest music of one's own taste as an immediate recourse or a few moments of solitude away from all the hustle and bustle of life. Venture of your choice or some time for your own self is a way to fortify the crumbling strength. Forget about every burden and think only of, whatever or whoever makes you happy. Break or rest is necessary to regain the lost spark and spirit. A well -planned and mutually agreed upon weekend trip always proves to be a great boost for the victim of monotony. Hindrances in such planning are the budget as well as the right destination, which may prove to be a treat for everyone. Such difficulties can be overcome by proper information available on different websites. Distance from the dull and hectic routine and spending some happy moments with the loved ones always remove deadliness.

At times, a few changes in the interior décor bring a fresh breeze of air to our mind through eyes. It does not mean replacing the whole old lot with the new one but only a few thing will do. Sometimes switching of some articles or furniture can be equally useful, if it has done keeping in view the comfort of family.

Change is the key weapon against monotony. A variety may help to eliminate this evil, which badly affects our efficiency. Feeling of futility pervades in an uneventful and flat continuous work. The same twenty-four hour spans rust the hidden potential. Confining the human potential to limited jobs is unjust. Learning new skills, exploring the world around, settings up realistic goals, pursuing them with refreshing breaks provide us the opportunity to realize our existence. Productivity makes you happy and helps to repower your brain. Brain thrill or learning something new rejuvenates our static selves. Sparing time for the hobby of your taste or for some creative work is never wastage of time. if you are good at any kind of creative work, no matter how mundane is this,never be reluctant to practice which will serve as a tonic for your withering mind. Life is a journey not a race so cool down and move with a moderate pace enjoying the pleasures of life rather than adhering to stiff and hard robotic routine.
Despite all these healthy options, it is almost too easy to rely on sugar and caffeine to boost us when we are feeling down or lethargic. Instead, here are some healthier energy booster ways which will sustain better energy levels over the long term as well as in the short term. Furthermore, these will improve overall health rather than providing a quick fix which can be instead detrimental to health.

The first recommended natural energy booster is getting more sleep. This can seem a very difficult thing to do when we are excessively busy, but this does not stop it from being one of the healthiest habits that you can get into that will not only give you greater mental and physical energy, but will also help heal your tired body.

The body repairs and restores itself at night, and sleep is also necessary for our minds to process what we have been doing throughout the day. Therefore, a good, long sleep every night will leave us brighter, less stressed, and with our body performing at its best.

Of course, this can be difficult to achieve if we have very busy, demanding lives. For this reason, it is necessary to put in place several small practices which can boost the quality and length of your sleep. This can include setting a strict curfew every night, using essential oils such as lavender on your pillow, or having a warm, relaxing shower every night before bed.

These steps you take to relax, wind down and be in bed by the right time every night will help you sleep better, even if initially these will take some getting used to. It is said that, it takes twenty-one days to form a habit, so commit to a better sleep routine for this length of time and see how your energy levels and life quality can change.

Our next recommendation is using herbal and mineral drinks as a regular energy booster on a daily basis. There are several excellent herbal remedies on the market nowadays in drink form, all of which contain unique ingredient lists of herbs and minerals that have been used for centuries to improve health.

Some of these ingredients - such as iron and magnesium - actively will boost your energy levels, and with other herbs will work to boost your overall health. As mentioned above, better overall health can make you feel a million dollars and generally have much higher energy levels.

If you want to do something good for your health and have more energy, try a herbal supplement drink, preferably with added minerals such as iron or magnesium, which humans can tend to become deficient in. Replace one of your daily coffees or colas with this and your body will reap the health benefits.

Lastly, cut down on unhealthy energy boosters which will give you energy in the short term but will cause you to crash afterwards and put you in an unhealthy cycle of ups and downs. These include endless teas, coffees and sugary and high carb snacks to keep you going.

It is often impossible to give these up completely, and many enjoy one or two of these as a treat every day. However, ensure that you do not rely on them, instead replacing most of them with healthy options such as a herbal energy booster and fresh fruit, and put in place a healthier sleep routine to make you feel brighter and in better health overall.
Now-a-days, we can see that the market is flooding with Incontinence products be it for kids or adults. But do we really know what incontinence is?

Basically it is loss of urine from bladder or bowel motion accidentally or unknowingly due to medical problems in the body. Incontinence can be treated as well as managed. The range of severity varies from small leakage to complete loss of bladder or bowel control. The problem is widespread all over the world. It is most common among elderly people. Half of the elderly people living at home or in long-term care facilities are incontinent. These people can go through emotional as well as physical distress.

People are shy about discussing this but remember this it is a medical situation not a defect. It is not a topic of being shy but rather taking action. Even according to the research by National Association for Continence, nearly 25 million Americans struggle with bladder control. Products like adult Diapers or Bedliners are there to avoid the embarrassment people feel due to the leakage. The most common reason people fail in their lives is because they think they can't win.

Any medical situation can be cured or managed by drugs or medicines but sometimes we can treat it by changing something. Incontinence can be treated or reduced by few regular exercises, lifestyle changes, natural remedies, etc. You can try to coach your bladder as well.

At this moment you have a clear picture of what is incontinence? But knowing the problem is not the solution for it, either it can be treated or managed. To manage it there are various products like Adult Diapers, Bedliners, Washable Liners, etc. To support these there are few hygiene products like wet wipes, Vinyl Gloves, etc.

Products like overnight briefs are easy to use with a touch of comfort for the consumers. These adult diapers absorb the leakage easily even when you are tossing in your sleep without leaving stains or other after effects.

Under pads are the protectors of your furniture or linen on bed. These under pads are available in various shapes and sizes and absorbencies. These under pads can be disposable or washable depending your needs. These protectors are waterproof and are designed in such a way that it protects the mattress from the contamination.

These products are made of hygienic as well soft material which avoids skin problems among the consumers. Companies dealing with these products know it's a private matter, that's why some of them also provide discreet home delivery services. Companies, medical associations are working day night to give you comfort, it's your choice take a step ahead and embrace the solutions.

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Tips to Selecting the Best Gym

There is absolutely no rocket-science involved in selecting the best gym. It's easier than you would think, provided you followed some tips. In order to select the best gym, you should first do an assessment of the goals or targets to achieve there. You should be sure of the reason of joining one gym or another as without clarity, results would deviate too. It's good that you want to stay fit and healthy, but for that, you need to follow some steps. The first step is prioritizing the fitness targets as based on that, your next steps will follow.

Fitness goals tend to vary from individual to individual; for some, a toned or chiselled body can be the ultimate achievement while for others, gaining total health can be the driving force. You will get specific fitness classes to serve every purpose of yours and you needn't join classes without understanding the health goals. If you want to gain core strength, you can then join weights classes. Aerobic exercises will help a great deal when the purpose is to burn calories and bring the body back into shape by countering weight problems. Target-specific fitness classes are a great investment of time and energy.

Similarly, you can enrol for a combination of circuit training and weights classes if the idea is to rub shoulders with a bodybuilder. There are health-crazy people who are driven to achieve their targets yet unsure of the ways of reaching there. For them, the best strategy is to consult a health expert and get a fair assessment of fitness goals. A good gym often has experts or trainers to guide people towards achieving superior fitness results. Based on the inputs of experts, you can decide to join indoor or outdoor activities. The same inputs can be used to join group classes or one-to-one sessions.

Group sessions are perfect for those who want to achieve fitness goals without that much of investment while tailor-made classes are for those who are ready to stretch their fitness budget further. More so, one can base their daily or weekly or monthly fitness schedules based on the inputs shared by experts. In a way, a standard system is followed where one has to be sure of the goals to achieve from fitness classes. The selection of a right gym is to ensure that fitness goals find right place and tools to be realized in a timely manner.

In overall, one should try to join from the best of fitness gyms around as substandard ones hardly deliver superior results. A well-equipped gym with different classes can be a place to be as here, you can benefit from yoga, Pilates, tabata, tai chi etc. A quality gym is one where dance and music are an integral part of workouts. More so, one should look for a place where the entire focus is not dedicated to physical body alone. After all, staying fit should not only be fun but it must also include the virtues of total health.
Proteins are long chains of amino acids that can be found in a wide range of foods. They are stored within our body by a multitude of peptide bonds. If you don't have enough protein in your diet, you will have to deal with a deficiency of various amino acids. The results are unfortunately very bad, because you will face a low concentration, memory loss, mood swings, a low energy level, a low muscle mass, an unstable blood sugar level and at the same time it will be hard for you to lose weight as well.

There are 20 types of amino acids out there and some of them are more useful than others for the human body. It all comes down to finding the right protein category for your body, but usually having one with lean meat can help. When it comes to the benefits of protein, there are quite a lot of them, as follows:

* You get to improve your muscle mass, because proteins are helping your ligaments, tendons and other body tissues build up and work properly. If you lack amino acids in your diet you will not have strength and energy, however once you add proteins into the mix the result is a lot better.

* You can easily manage your weight. Thankfully proteins are known to help address one of the many issues that most modern people have, and that's fat accumulation. As long as you keep yourself within the recommended amounts, you will have no problem enjoying their benefits and lose weight!
Orthopedic surgeries are those that deal with the muscles and skeleton in the human body. This kind of surgery corrects problems that arise in the skeleton, attachments, ligaments and tendons. Some other common problems arise from injury to the spine or damage due to aging. The range of treatments includes traction, amputation, hand reconstruction, spinal fusion, joint replacement etc.

Some of the other type of ailments that orthopedics treat are broken bones, strains, sprains and dislocations. Most of the times, orthopedic surgeries include adding foreign material to the body such as screws, wires, pins, tongs etc. to hold the bone or the artificial bone in place. With advanced technology, there are plenty of improvements made in the replacement of bones and joints and the materials used for replacement.

Here are the most common orthopedic surgeries:

Total Joint Replacement Surgery

Those diagnosed with severe arthritis or severe joint pains are advised to go or total joint replacement surgery. This surgery enables the patient to gain increased range of motion. After recovery, the patient experiences lesser pain and can resume normal life as soon as possible. During the treatment, your surgeon assesses the damaged parts o your joint and replaces it completely with metal or plastic parts that are shaped with near to natural perfection to enable normal movement without pain.

Total Shoulder Replacement

Total shoulder replacement greatly helps reduce pain and improves the joint movements over a period of time. Damaged parts of the bone and cartilage are replaced with metal or plastic. This surgery greatly improves the range of motion too.

Spine surgery

Spine surgery is very complicated. There are many ailments that lead to spine surgery. One of the most common reasons cited is severe back pain. This back pain is so severe that it hampers day to day life of the patient. Once the surgery is complete, the patient experiences diminished pain and a dramatic improvement in movement and activity. One of the most common types of back surgeries are spinal fusion. During this procedure, the orthopedic surgeon joins two vertebrae of the back bone together. This restricts the motion and reduces stress on the spinal cord, hence reducing the pain.

ACL Reconstruction

ACL stands for Anterior Cruciate Ligament. This is one of the major ligaments that stabilize the knee movements. This ligament needs to be reconstructed when it ruptures. An orthopedic surgeon can easily reconstruct this ligament by using your own tissues or by using tissues from a donor and a new ACL is constructed. The new ligament is secured in place with screws and other devices.

Overall, orthopedic surgeon can replace, reconstruct or cure ailments that are connected to your musculoskeletal system. The results of these treatments ensure that the patient can resume day to day life with diminished pain and increased capability of movement. With advanced technology, near to natural reconstructions are possible and after the patient recovers, he can resume routine life soon.

Take these eight steps to heart and live longer, enjoy life more, and feel good in your body and mind all of the time.
Routine screening
You cannot know what the solution is unless you know the problem. Routine screening for cancer, cardiovascular disease, kidney disease, and diabetes can prevent complications that are costly to your health and your wallet. Set up a schedule of routine screening with your physician or take advantage of the free ones offered by many hospitals.
Weight
One-third of the world is considered to be overweight or obese. Being overweight can lead to stroke, diabetes, heart disease, and kidney disease. Weight can be controlled and reduced. You do not have to spend a fortune on programs to lower your weight if you need to.
Activity
Your body wants you to exercise. Physical activity produces a cascade of chemicals in the body that not only make you feel good physically but also make your mood better. Physical activity is more important as you age. You cannot grow lost muscle after you are 50 but activity will allow you to keep the muscle and strength you have.
Diet
Everything in your body, brain, and even your emotions is a product of your diet. You need a diet that minimizes the amount of fat, cholesterol, processed sugars, and salt. Be sensible about your diet from the perspective of wanting a long useful life. A little cake once in a while does no harm but eating a whole cake in a day will.
Mood
You must learn to manage your mood. Your mood can make your brain change chemically and can make your body feel differently. You have to learn to recognize your moods and use a tool like meditation or simply talking to someone to work through the damage bad moods can do to you.
Stress
Stress is rated as a more frequent killer than car crashes or terrorists. Excess stress damages the heart and brain. You lose your ability to be creative due to stress. There are many stress management techniques that work. Pick the method that reduces your stress level and use it every time you feel stressed and you will live longer.
Relationships
Relationships can heal you and kill you. Most relationships have patterns. You must learn to recognize the relationship patterns that cause stress and anger. Learning how to change your mood or response can save your life and relationship. You will get angry with your spouse or children but that anger cannot control you. Friends can heal you simply by talking to you.
Sleep
Your body demands eight hours of sleep. The healing mechanism that is in your body does not work unless you get enough sleep. Rest is just as important. You need to relax and enjoy things to be mentally and physically healthy.
Challenge your mind
You can avoid dementia and other mental issues by keeping your mind active. Try a new activity that forces you to use your mind to the fullest. Stimulating your creativity, emotions, and thinking regenerates abilities that you may have thought that you had lost.

There are other health issues that are important for you to have good health. Here at EMK Marketing LLD we have found Himalayan Salt Lamps to be very beneficial to purifying air. The dust, pollen, smoke, and pet dander collect with moisture in the air. When these droplets come in contact with the heated Himalayan Salt Lamps they are destroyed as a result of being dehumidified. It will develop negative ions that enhance your mood and sense of well being. The wide variety of cleansing salt crystal lamps can be found at [http://www.himalayansaltlampsplus.com]. Choose the lamps that best fits your individual preference and experience cleaner air, lessened health issues, increased energy, health, and well being.

Article Source: http://EzineArticles.com/9382700

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steps toward a successful exercise resolution

Writing in the October 10, 2018 New England Journal of Medicine, Eve Rittenberg, MD, assistant professor at Harvard Medical School and practicing physician at Brigham and Women’s Fish Center for Women’s Health, reflects on the impact the Kavanaugh hearing and #MeToo movement have had on patients who have experienced sexual violence. Important principles of trauma-informed care—including ways to ask permission, offer control, and find support—described in her article and in Monique Tello’s post below can make a real difference to many women and health care professionals alike.

Many years ago, when I was a trainee, I helped take care of patients at a family medicine clinic.* One day, a school-aged brother and sister came in for their annual physicals. They were due for vaccines. Neither wanted any shots, and they were both quite upset. “You’ll do what the doctor tells you, is that clear?” ordered the mother. She and the nurse worked together to hold the sister’s arm down. But just as the nurse was about to deliver the injection, the young girl jerked her arm away and ran to the opposite corner of the room, crying. The brother then ran over and stood in front of her, his arm outstretched, guarding, and yelled “Get away! Leave her alone!” At first, the focus was on forcing them to have their shots, which were required for school. But it only made things worse. The young girl screamed, the boy fought, no one could calm them, and everyone was annoyed.

One of the senior doctors finally conceded: Let them go, we’ll have to work on this. But that family never returned.

Months later, we learned that the children had been removed from the home by the Department of Children and Families, for parental abuse. I could only imagine what had been happening.

*This vignette is based on a composite of several cases I have been involved with over the years. All potentially identifying details have been changed to protect patient privacy.
The prevalence of trauma

The CDC statistics on abuse and violence in the United States are sobering. They report that one in four children experiences some sort of maltreatment (physical, sexual, or emotional abuse). One in four women has experienced domestic violence. In addition, one in five women and one in 71 men have experienced rape at some point in their lives — 12% of these women and 30% of these men were younger than 10 years old when they were raped. This means a very large number of people have experienced serious trauma at some point in their lives.

Medical exams by definition can feel invasive. They often involve asking sensitive questions, examining intimate body parts, and sometimes delivering uncomfortable — even painful — treatments. So, it is important that healthcare providers are mindful of the fact that so many people come to that healthcare interaction with a history of trauma.
Could the case I described have been handled differently?

There have been some recent news articles about a relatively new (and improved) way for health professionals to approach patients. This is called trauma-informed care. Dr L. Elizabeth Lincoln is a primary care physician at MGH who has trained medical professionals and students about approaching patient care with an understanding of trauma. She explains: “Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing. A medical office or hospital can be a terrifying experience for someone who has experienced trauma, particularly for childhood sexual abuse survivors. The perceived power differential, being asked to remove clothing, and having invasive testing can remind someone of prior episodes of abuse. This can lead to anxiety about medical visits, flashbacks during the visit, or avoidance of medical care.”
What does trauma-informed care look like?

The first step is to recognize how common trauma is, and to understand that every patient may have experienced serious trauma. We don’t necessarily need to question people about their experiences; rather, we should just assume that they may have this history, and act accordingly.

This can mean many things: We should explain why we’re asking sensitive questions. I might say, “I need to ask you about your sexual history, so I know what tests you may need.” We should explain why we need to perform a physical exam, especially if it involves the breasts or genitals. If someone is nervous, we can let them bring a trusted friend or family member into the room with them. I’ve had many female patients hold someone’s hand during a pelvic exam. We can tell them that if they need us to stop at any time, they can say the word. If someone refuses outright to have a certain exam or test, or if they’re upset about something (like having vaccinations), we can respond with compassion and work with them, rather than attempting to force them or becoming annoyed.

For someone who has experienced trauma, the hospital or doctor’s office can be a scary place. Dr. Lincoln explains: “Patients often do not volunteer such information about prior experiences, because of guilt or shame. Medical professionals often ask about safety in a patient’s present relationships, but few ask about past experiences. A simple question such as, “Is there anything in your history that makes seeing a practitioner or having a physical examination difficult?” or, for those with a known history of sexual abuse, “Is there anything I can do to make your visit and exam easier?” can lead to more sensitive practices geared to developing a trusting relationship. Patients can advocate for themselves by explaining to physicians their anxiety about medical visits, why this is so, and what they have found helpful or harmful in prior healthcare encounters.”
Trauma comes in many forms

It is also important to note that there are many types of trauma. A colleague of mine has a child who survived a life-threatening illness. Prior to his ICU stay, he never flinched at vaccines; since his hospitalization, any needle sticks make him extremely anxious. Another colleague describes how after years of invasive infertility treatments, and despite becoming a mother, she sobbed uncontrollably at her simple routine gynecologic exam, because it touched such a nerve of helplessness and failure. Trauma-informed care is the open-mindedness and compassion that all patients deserve, because anyone can have a history that impacts their encounter with the medical system.

We as providers need to recognize that many, many patients have a history of physical, sexual, and/or emotional abuse, as well as serious illnesses and negative experiences in the medical setting, and we need to learn to respond with empathy and understanding.All too many women recognize the signals of a urinary tract infection, or UTI: pain and burning when urinating, coupled with a frequent urge to do so. A simple change in behavior could help prevent a common UTI known as recurrent cystitis in women, according to a randomized controlled study published in JAMA Internal Medicine in October 2018. The study showed that drinking more water daily led to fewer episodes of recurrent cystitis and less need for antibiotics.
What is cystitis and what causes UTIs?

Cystitis refers to an infection in the bladder, which most women know as a urinary tract infection. Cystitis is extremely common among women, partly because female anatomy increases the risk of infection due to the proximity of the urethra to the anus. Additional risk factors for cystitis include sexual intercourse, diaphragm use, spermicides and spermicide-coated condoms, and a prior history of cystitis. Women with diabetes and those who have abnormalities of the urinary tract are also at increased risk for cystitis.

The vast majority of infections (up to 95%) are caused by one bacteria, E. coli. Signs and symptoms of an infection include pain with urination, increased frequency of urination, and an increased urge to urinate.
What is the treatment?

Cystitis is treated with antibiotics for three to five days, depending on the antibiotic used.
Can UTIs be prevented?

If you’ve ever had cystitis, you may have heard suggestions that are mostly based on anecdotal evidence. To decrease risk for cystitis, women are advised to urinate after intercourse, drink cranberry juice, drink more fluids in general, and keep the perineal area that lies between the urethra and the anus clean. Evidence is mixed on whether these steps may help prevent cystitis. This study sought to provide direct evidence of the benefits of drinking extra fluids.
What did the study tell us?

The study participants were 140 premenopausal women who experienced three or more episodes of cystitis in one year and reported that they drank less than 1.5 liters of fluids daily, which is about 6 1/3 cups. The average amount participants drank daily was a bit over a liter (1.1 liters, or about 4 1/2 cups).

The women were randomized to one of two groups. Every day, one group drank their usual amount of fluids plus an additional 1.5 liters of water. The control group drank just their usual amount of fluids. The women kept journals recording the type and amount of fluids they drank in a day. Their urine was periodically measured for volume and tested for hydration status. The study discovered that women who drank an additional 1.5 liters of water had 50% fewer episodes of recurrent cystitis, and required fewer antibiotics than women who did not drink additional fluid.
Is it safe to drink this much fluid?

While the amount of extra fluids tested in the study may seem like a lot, the Institute of Medicine recommends that women have 2.2 liters daily, which is about 9 cups. Not all of this needs to come just from water — or even fluids. Fruits and vegetables, which are part of a healthy diet, contain a lot of water.

This study used a rigorous scientific method to evaluate the benefits and risks of an inexpensive and safe anecdotal treatment. While it has been suggested that substances in cranberry juice can decrease the risk of urinary tract infection, no studies have conclusively demonstrated its benefits. Water may be the best means to increase hydration because it is inexpensive and has no calories. Although this study focused on women who had recurrent cystitis, its results could be extrapolated for a lower-risk population as well.

If you’re a woman with symptoms of cystitis, such as pain or burning with urination, increased urgency and frequency, try to drink more fluids, but also call your health care team for evaluation. A simple urine test in conjunction with the symptoms you describe may provide enough information for your health care provider to confirm an infection and start you on a brief course of antibiotics.

Better still, going forward, you may be able to decrease the chance that you will develop an infection by drinking more water daily. It’s a simple solution readily available for prevention — and now supported by evidence!6 steps toward a successful exercise resolution
Many people have decided to try the ketogenic diet for weight loss. The most recent evidence shows that reducing your carbohydrate intake to a minimum may help you shed a few pounds, at least in the first few weeks to months. However, we don’t really know whether, over the long term, achieving and maintaining ketosis is better for weight loss than other diets. Almost any intervention can cause undesirable consequences, and the ketogenic diet is no different. One of the most well-publicized complications of ketosis is something called “keto flu.”
What is keto flu?

The so-called keto flu is a group of symptoms that may appear two to seven days after starting a ketogenic diet. Headache, foggy brain, fatigue, irritability, nausea, difficulty sleeping, and constipation are just some of the symptoms of this condition, which is not recognized by medicine. A search for this term yields not a single result on PubMed, the library of indexed medical research journals. On the other hand, an internet search will yield thousands of blogs and articles about keto flu.

It is tricky to describe exactly what happens after the diet change, because we are left with only our own observations and experiences. These symptoms may not even be unique to the ketogenic diet; some of my patients describe similar symptoms after they cut back on processed foods, or decide to follow an elimination or an anti-inflammatory diet.
What causes keto flu?

Well, we don’t really know why some people feel so bad after this dietary change. Is it related to a detox factor? Is it due to a carb withdrawal? Is there an immunologic reaction? Or is this a result of a change in the gut microbiome? Whatever the reason is, it appears the symptoms attributed to the keto flu may happen, not to everyone but to some people, after “cleaning up” their diet.

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Behavioral weight loss programs are effective

Growing up I had to wear glasses. Back then it was considered socially unacceptable, but necessary to be able to see. Sixty years later, everyone wears glasses and they are a fashion statement. Now as an aging adult, I need to wear hearing aids. This was and still is in many age groups considered socially unacceptable — a sign of being old and maybe a little senile. But it appears that hearing aids are in the process of a similar transformation. A pared down, more affordable category of products — personal sound amplification products (PSAPs) — may lead to greater use of hearing enhancers at a younger age.
Hearing aids: Enhanced hearing, at a price

One of the major complaints about hearing aids is that they are expensive; they can run from $1,000 to $6,000 apiece. Their average lifespan is about five years, making this a recurring expense. Not everyone can afford or wishes to spend that amount to improve their hearing, especially if their hearing loss is mild and they can get by without aids.

There is a large segment of the population that has such a mild hearing loss. They struggle in certain situations, such as when there is a lot of background noise — in noisy restaurants, large crowds, and large rooms. They do fine in quiet situations with small groups or one-on-one conversation. They could benefit from “readers” for the ears — inexpensive help that they can use occasionally, or even continuously, for a little boost.

Until recently, the laws have been a barrier for development of such help. Hearing aids have been defined by law and regulated. High certification costs have served as a barrier to market entry. Hearing aid prices have not come down much over the years, though the quality of the aids and the sophistication of the instruments have improved as fast as any electronic device available. What you get now for the same price you would have paid 10 years ago is a far superior device. What’s more, the cost to dispense, service, and maintain the devices has increased with the cost of living. All of this has led to a gap between the demand for and supply of inexpensive hearing aids.
PSAPs: A more affordable option

Along come PSAPs, which have the potential to fill a large gap in the existing hearing aid product offerings. They provide a lesser certified, less feature-filled, but lower-cost entry for hearing loss sufferers. PSAPs cannot be called or marketed as “hearing aids,” as they do not meet the definition and rigorous manufacturing and safety standards of hearing aids.

PSAPs range from simple volume amplification devices to more sophisticated devices that can do many of the simpler tasks that hearing aids can perform. They are self-fitting and can be self-programmed using a smartphone or computer app. They are sold over the counter, and thus eliminate the expense of fitting. They are not as electronically sophisticated as hearing aids, and so can be sold cheaper. Lowering the cost of entry will allow most people to enjoy better hearing at a younger age.

PSAPs are not a replacement for hearing aids. They cannot replace the sophistication of hearing aids, or the skill in fitting them that audiologists bring to the job. They are devices that can fill the need for those with mild hearing loss, who just need a little more volume in certain situations. The good ones — the ones you should try — will be marketed as hearing aids in the near future.
Getting started with your PSAP

Suppose you want to try a PSAP. How do you know you are getting what you are being told you are getting? How do you know that what these products advertise is actually what they deliver? How do you know that they are safe? The FDA has stepped in to regulate this new market. Legislation was passed in 2017 and goes into effect in 2020 to allow for marketing of these low-end hearing aids to be advertised as such, if they meet certain (still-to-be finalized) criteria on performance and safety. Many of the devices are on the market today without any such oversight. That will change in 2020 to allow those devices that meet the established criteria to be marketed as hearing aids and not PSAPs.

Many of the new devices require some sophistication in setup and maintenance. You become the dispenser, fitter, and maintainer of the devices. You provide yourself with the services that an audiologist provides for hearing aids. YouTube videos and online support can resolve most if not all issues that may come up. Mandated trial periods can allow for return of goods when the issues cannot be resolved.
Better hearing, younger

In countries where hearing aids are free, more than half of the people who could use hearing aids do not use them. Money is clearly not the only issue preventing hearing aid use. Starting people earlier in the process and giving them control over the use of such devices can only encourage a greater long-term acceptance and usage of hearing aids as we age. Having more people use the devices eliminates the social stigma that has surrounded hearing aids.

I am hopeful that PSAPs are the intermediate steps that will lead to greater hearing aid use for the majority of us who should be using hearing aids, but do not. It’s a gorgeous weekend and you are playing a game of basketball with friends. You take a jump shot, scoring two points, but twist your right ankle on landing. You feel immediate pain and stop playing. After resting for an hour, you notice increased swelling and are having difficulty walking, so you go to the nearby urgent care center. The physician comes to see you, introduces herself, then introduces the medical scribe, who moves to the corner of the room in front of the computer. As the doctor starts asking you questions, the scribe begins typing.

Scribes are becoming increasingly common in doctor’s offices. But what do they do, what type of training do they have, and why are they gaining in popularity?
What are medical scribes?

Scribes are assistants to physicians and other healthcare providers. Their roles include entering electronic documentation (notes) into the computer, including patient history, physician examination findings, test results, and other information pertinent to your care. While the scribe’s primary role is to enter medical documentation, they may also check for test results and assist with assigning diagnoses and billing. The physician is then responsible for carefully reviewing the scribe’s notes, correcting any misinformation or omissions, and signing the notes.

Scribes are often college students or recent college graduates seeking additional exposure to the healthcare field before applying to medical school or other graduate training programs; however, scribing can also be a full-time career. They receive training on how to document as well as on medical coding and billing rules. In general, scribes do not have healthcare provider training or certification. Unless your scribe is also a nurse, medical assistant, or other certified medical professional, they should not be providing medical advice or delivering care to you.

Scribes are members of the healthcare delivery team, and are therefore accountable to all applicable institutional policies and are expected to act professionally. For example, scribes are held to the same standards to protect patient privacy as other health care professionals. Scribes should be introduced to the patient when they enter the room. If you are uncomfortable with a scribe being present during your visit, you should request to be seen by the healthcare provider privately.
Why are scribes gaining popularity?

The practice of medicine requires a large number of administrative tasks, including thorough documentation of all patient visits. As the majority of US hospitals and physician offices have now transitioned to electronic documentation, physicians are spending an increasing amount of time on the computer instead of with the patient.

Adding a scribe to the team enables physicians to spend more time directly talking with patients, while the scribe documents the visit. Scribes are being used in all care settings, including the primary care office, specialist offices, urgent care, emergency departments, and inpatient hospitals. A recent study in the primary care setting found reductions in the amount of time spent with electronic documentation and improvements in physician productivity and work satisfaction associated with the use of medical scribes.
The future of scribes

Today, scribes typically accompany the physician and patient in the room. In-person scribes are also being supplemented by virtual scribes, where the scribe is not physically present in the room with the patient. For example, physicians may use a recording device to capture their interview and examination of the patient. The electronic recording can then be sent to the scribes (who are offsite), and then transcribed and entered into the computer. Newer video teleconferencing software and smart glasses are also being used to allow the scribe to view and transcribe the visit into the computer from an offsite location. The latter technology has the benefit of allowing the scribe to work in real time, asking clarifying questions to the providers, and entering the notes faster. Importantly, with both these scenarios, physicians are still responsible for the content of the notes and must review and sign off on the notes.

The US Centers for Medicaid and Medicare Services, which oversees federal health insurance programs, is currently working to reduce documentation requirements for billing, which may help decrease physician workload. In addition, advances in technology may one day completely automate documentation of patient visits.

In the meantime, scribes provide the ability for physicians to focus more on the patient relationship and interaction and less on computer data entry. The US Preventive Services Task Force (USPSTF) is a team of volunteer experts from various primary care medicine and nursing fields. They identify big medical problems, review the research, and translate it into action plans (called practice recommendations) for doctors like me.

Just this fall, they tackled obesity, with the goal of identifying effective ways we in primary care can help people to lose weight.

And it’s not about aesthetics. This is about disease prevention, especially diabetes, high blood pressure, and heart disease, which are particularly associated with obesity.

They were NOT looking at surgeries or other procedures, only research trials involving either behavioral or medication-based weight loss programs.

The task force analyzed 89 behavioral weight loss program trials from all over the world, and these included participants of both genders as well as many racial and ethnic groups, with ages between 22 and 66, and body mass index between 25 and 39.
What was involved in a behavioral weight loss program?

The programs studied lasted between 12 and 24 months, and involved at least 12 sessions (face-to-face, group meetings, or web-based). A variety of specialists were involved (behavioral therapists, psychologists, registered dietitians, exercise physiologists, lifestyle coaches, as well as physicians) who provided counseling on basics like nutrition, physical activity, and self-monitoring, as well as psychological components like identifying obstacles, planning ahead, problem solving, and relapse prevention. Email, telephone, and/or peer support were typically included. Basically, these are intensive programs that focus on lasting diet and lifestyle change.

And intensive diet and lifestyle programs work well for weight loss. Participants had significant weight loss compared to controls, averaging between 1 and 20 pounds, with an average weight loss of 5 pounds overall, and were more likely to have lost 5% of their total body weight at 12 to 18 months. Thirteen trials looked at diabetes risk, and pooled results showed that participants had a significantly lower risk of developing diabetes.

Here’s the most important part: the risks of participating in these studies were minimal. This is a major plus to behavioral interventions: no side effects or drug complications.
How did behavioral programs compare with medications?

That is considerably different from studies featuring weight loss medications. Thirty-five studies looking at a variety of medications (like liraglutide, lorcaserin, naltrexone and bupropion, orlistat, and phentermine-topiramate) had stringent inclusion criteria and high dropout rates. Why? Because of the many medical contraindications of some of these medications, and the side effects, some quite serious.

Yes, the medication studies demonstrated significant weight loss, ranging from 2 to 13 pounds. But in the end, the USPSTF has to weigh effectiveness as well as potential risks, and they concluded that “intensive, multicomponent behavioral interventions in adults with obesity can lead to clinically significant improvements in weight status and reduce the incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels …[]… and that the harms of intensive, multicomponent behavioral interventions (including weight loss maintenance interventions) in adults with obesity are small to none.”

Basically, intensive behavioral programs aimed at lasting lifestyle changes work well for weight loss, and are extremely low-risk to boot.
So where can you sign up for such programs?

Okay, here’s where the gap between science and practice comes in.

Few of these behavioral weight loss programs exist, and not everyone meets the criteria for insurance to cover them. So for most people, unless they can afford to pay out of pocket, these programs are only available through research studies.

For example, the Diabetes Prevention Program (DPP) is an excellent intensive lifestyle change behavioral weight loss program that has been studied for literally decades and works very well. It’s a year-long commitment including 22 learning sessions (in-person or online) and frequent contact with a lifestyle coach. Insurance will cover this program for people who have a BMI over 25 and a confirmed diagnosis of prediabetes. Not diabetes, only prediabetes. The DPP curriculum is available for free on the Centers for Disease Control (CDC) website. Anyone could establish a program.

But a program has to meet a lot of requirements over a significant amount of time before it’s officially recognized by the CDC, and insurance companies won’t cover a program until it’s recognized by the CDC. Even then, reimbursement rates can vary. As a result, there aren’t many of these programs up and running, but there are some. To find a recognized DPP program in your state or online, check out the CDC’s registry.

Many hospitals offer less intensive, shorter behavioral lifestyle change programs, but these are pay-out-of-pocket and generally cost upwards of $500.
What can you do if you can’t access a behavioral weight loss program?

You can work with your doctor and create your own program by consulting with relevant specialists (for example, a nutritionist, personal trainer, and therapist), following your own progress (for example, at the doctor’s office or using an app), and arranging your own peer support (ask friends and family to join you on your health journey, or join a group like Weight Watchers). I have had patients who have succeeded in making lasting lifestyle changes — including weight loss — using this approach.

Mobile phone apps are a relatively new but promising tool. In one 2015 research review, studies of various weight loss phone apps, used for six weeks to nine months, showed a significant average weight loss of 2.2 pounds. Some free, widely available apps include MyFitnessPal, Lose It, Noom, Weight Watchers, and Fooducate (note that these were not necessarily the ones studied in that review article).

I am hopeful that soon, guidelines-based intensive lifestyle change programs will become more widely accessible to everyone who needs this support.

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Creating recovery-friendly workplaces

If you can’t stop picking your skin, you may have a very common condition called skin picking disorder (SPD). We all pick at a scab or a bump from time to time, but for those with SPD, it can be nearly impossible to control those urges. Apart from the cosmetic impact of recurrent skin lesions and scarring, SPD can lead to serious infections, shame, depression, and anxiety.

You may be feeling alone or embarrassed, but you should know that this condition affects at least five million Americans. A diagnosis of SPD, also known as excoriation disorder, is made when there are repeated attempts to stop picking, and the skin picking is either distressing or interfering with social or work functioning. SPD is one of a group of disorders that is related to obsessive-compulsive disorder (OCD).

You already know that it is not a matter of will — trying to stop is the equivalent of telling one not to have high blood pressure. The good news is that therapy, medication, and dermatologic treatments can help. For most, though, no one treatment will be curative, and you will experience remission and recurrence.

Having realistic expectations and arming yourself with a variety of skills for skin picking flares will make this condition much more manageable. Here are four tips that can help you tackle your picking.
1. Know your triggers

You may be tempted to pick for a variety of reasons, from boredom, itch, or negative emotions, to blemishes or simply looking at or feeling your skin. You may even find the experience of picking itself pleasurable. Understanding your triggers can be a first step in deciding which treatments to pursue. For example, if your picking is triggered by a skin condition such as acne or itch, you might be best served by first seeing a dermatologist. If, however, your picking is triggered by depression, anxiety, or more of an urge, you should consult with a mental health professional with expertise in skin picking.
2. Make it harder to pick

One simple strategy to reduce picking, called stimulus control, involves changing your environment to make it harder to pick. Examples of this technique include keeping your nails short, wearing gloves at times when you are most likely to pick, and making the skin more difficult to access by wearing tight-fitting clothing or long-sleeve shirts. You can also try distracting your hands with any number of items including silly putty, stress balls, fidgets, and tangle toys. Once you have found an item that works for you, make sure to have one everywhere you spend time such as work, home, and your bag, so you are fully covered.
3. Get therapy

Cognitive behavioral therapy (CBT) is a structured type of psychotherapy that aims to produce healthier behaviors and beliefs by identifying unhelpful thoughts and behaviors. A specialized type of CBT has been developed for SPD. This type of CBT includes more of the stimulus control techniques described above, as well as habit reversal training, in which individuals are taught to engage in a harmless motor behavior (like clenching one’s fists) for one minute when triggered to pick. Clinical trials have demonstrated that skin-picking for CBT can be extremely effective. But because it is different than other types of CBT, it will be important to work with a therapist who is trained in treating SPD. You can find skin-picking experts at the TLC Foundation for Body-Focused Repetitive Behaviors.
4. Consider medication with your providers

While no medication has been formally approved by the FDA to treat SPD, there is evidence to suggest that selective serotonin reuptake inhibitor (SSRI) antidepressants and N-acetylcysteine (NAC), an antioxidant supplement, can be helpful. Owing to the limited and evolving research on medication treatments for SPD, you may find that your provider is not up to date on current skin picking treatments. If you or your provider would like more information about these medication treatments and others, you can look here.

Please be aware that even over-the-counter, well-tolerated supplements like NAC should always be taken under the supervision of a medical professional for guidance on dosing, duration of treatment, drug interactions, and side effects.
Our country’s ongoing opioid crisis has many faces, from teenagers on Cape Cod to middle-aged parents in West Virginia. A recent report from the Massachusetts Department of Public Health provides another demographic affected by opioids: people who work in the trade industries, namely construction. The report broke down overdose deaths by industry, and construction workers were involved in almost a quarter of overdose deaths recorded in the state over five years. Farming, forestry, and hunting, along with fishing, are the next most dangerous industries. And there are relatively high overdose death rates for women working within health care support and food services.

This research supports what we have seen in our own work treating patients for substance use disorders who work in manual labor jobs. On-the-job hazards and related injuries are common, and pain medications of all kinds tend to be readily available as workers informally share and sell them on worksites.
The need for recovery-friendly workplaces

A recent National Safety Council report found that 70% of surveyed employers have been impacted by prescription drug misuse, but fewer than 20% feel extremely prepared to deal with it. The financial cost to employers in lost productivity is significant: in Massachusetts alone, opioid addiction cost businesses $2.5 billion annually from employees who aren’t functioning at full capacity, and $5.9 billion in lost productivity from people who can’t join the workforce due to addiction. Opioid use disorder has kept nearly 33,000 people in Massachusetts from participating in the labor force each year, on average, over the past five years.

But what could a recovery-friendly workplace look like? Drawing inspiration from models like Supported Employment, an evidence-based intervention for individuals with serious mental illness, and recovery high schools, we describe five key features of a recovery-friendly workplace:

Available counseling for scheduled and on-demand recovery support. Manual labor workers with varying schedules often have trouble making appointments in traditional healthcare settings, which tend to be offered only during normal business hours. Missed work equals lost income, which is harmful to workers and employers alike. An onsite counselor for large worksites or availability of remote telehealth counseling on-demand during work breaks could encourage participation in these programs.

Peer support groups built into the daily schedule. Like individual appointments, therapy groups often occur during the business day. Open and safe discussions with crewmates who are also in recovery can help build a culture of mutual support. Onsite peer support by recovery coaches in the industry might be particularly impactful.

A supervisor who understands the challenges and needs of people in recovery. Slip-ups are part of the recovery process, and a positive drug test should signal the need for more counseling support and closer monitoring, not automatic termination of employment.

Support for medication-assisted treatment. We’ve heard anecdotally about certain union health insurance plans that deny coverage of buprenorphine (Suboxone), a medication for opioid use disorder that calms cravings and halves the risk of overdose death. This kind of discrimination is a federal crime, and for good reason — imagine employer-based health insurance refusing to pay for insulin for workers who have diabetes. Unfortunately, stigma and fear of retribution may keep union workers from speaking out to claim their rights.

Onsite drug testing (where appropriate) and telepsychiatry. Regular drug testing could help make construction sites safer and indicate when people need more support. Crews often share transportation to and from worksites, making it hard for an individual to leave in the middle of the day for a medication appointment or to provide required toxicology testing for their program. Telepsychiatry visits in a secure room on a worksite could allow people to get assessed more regularly and prevent missed doses of recovery medications like buprenorphine.
Recovery-friendly workplaces may lower healthcare costs

Employers in all kinds of industries should consider how establishing recovery-friendly workplaces may help them access an underutilized workforce while addressing a vital social need. People in recovery from opioid use disorder commonly describe their core recovery goals as needing to keep busy, to achieve financial self-sufficiency, and to recapture the dignity of being a working member of society. Our clinical work can go only so far in supporting our patients’ recovery, but with the right kinds of partnership across sectors, we can make great strides together.

Given the high prevalence of substance use disorders in certain sectors, investing in supported employment with recovery support and medication-assisted treatment might reduce costs associated with missed work as well as employee hiring and retraining, improving overall work quality while also lowering overall healthcare costs. Finally, substance use is rampant on construction and manual labor worksites, so investing in recovery support and treatment might improve the relationship of workers with management and unions and reduce risk for accidental injuries in the future.

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Giving babies and toddlers antibiotics can increase the risk of obesity

In my experience, most people dealing with infertility would say that their longing for a child brings sadness year-round. Still, there are times and seasons when the pain intensifies.

This may be in spring or early summer when the world is in bloom, winter coats are off and pregnant bellies are out, when greeting card companies and florists ambush airwaves to promote Mother’s Day and Father’s Day.

Similarly, the winter holidays present an ever-lengthening stretch during which many women and men who are struggling with infertility feel pummeled. Bookended by Thanksgiving and New Year’s, this has become a season of holiday cards spotlighting happy children, and loud messages of merriment in stores and public places. Short days, dark nights, cold, snow, and clouds further conspire to tell those who are struggling with infertility that ‘tis hardly the season to be jolly.
Approaches to coping with infertility

So, how best to get through the holidays when you are enduring infertility? You might wish to set sail for an island paradise and remain there until the January blizzards take everyone’s focus off babies and young children. An escape could be sweet, but for many, the desire to share holidays with loved ones coexists with the pain of being infertile.

Rather than isolating yourself or disconnecting from those you love, you may simply want to hurt less. One way to do so is to find ways to claim some modicum of control during the winter holidays. Here are some ideas that have worked for people I’ve counseled over the years.

    Develop a strategy for opening holiday cards. For anyone going through infertility, the contents of each envelope may bring pain. While you have endured a year — or yet another year — of longing and disappointment, other people’s children have grown. Some cards hurt more: announcements of a new baby entering the world. One coping strategy is collecting the cards and opening a batch with a partner or a close friend who “gets it.” It can help a lot to feel that you are doing this as a team, letting fly with dark humor or sarcasm to fortify you in the process. Celebrate when the last envelope has been opened. For some, a bottle of wine or a nice dinner to enjoy afterwards eases sadness.
    Host a holiday gathering? Or just make a cameo? No one going through infertility wants to feel trapped in a holiday gathering with no way to escape. But how to avoid this? Surprisingly, one way is to host the party. Yes, it’s a lot of work, but you set the timing and format, and can shape content for the occasion to focus guests on something other than family chatter. A Yankee swap? A wine, cheese, or olive oil tasting?

    Alternatively, leave the heavy lifting to others and participate in their events on your terms. Agree on an escape clause — a reason to depart from a gathering early. That way, you know you can leave if someone announces a new pregnancy or is gushing about his children — or worse, grumbling about them and seemingly oblivious to her good fortune in having children. If you like, you can share your strategy with your host. The key, as with opening holiday cards, is to find pathways to control.

    Decide what to share. One way to claim some control at family holiday gatherings — and in general during infertility — is to manage information and communication. What do you want people to know? What is too much information? For example, you may feel it’s important that people you care about know you want to have a baby and are seeking medical help. Yet they need not know exact treatments, timing and outcomes of treatments, or the doctors you are seeing. Providing basic information protects you from being misunderstood, or the subject of queries. Offering detailed information invites commentary and advice.
    Consider how it might feel to acknowledge pain without showing it. Acknowledging pain might sound like this: “This has been a hard year. We’ve had some disappointing fertility treatments and gone through tough times, but we’re so happy to be here welcoming a new year with all of you.” Showing pain might sound like this: “It’s too hard for me to be here with all the children. I need to leave now.”

Giving back

Infertility draws us inward, prompting us to focus on our bodies, our sadness, our longings, and our helplessness. It blurs time and strains relationships, even when we do our best to stay connected. The holiday season, for all its commercial fanfare, is also a time when we remember those in need and those whose suffering eclipses ours.

Think perhaps of the holiday lights: Hanukah, the festival of lights, Kwanzaa, with seven glowing candles in the kinara, and Christmas, with its illuminated trees and homes, remind us that light in darkness is far more beautiful than light in light. At the risk of sounding preachy — which is not my intent — I think that doing good in dark times alleviates some of the seasonal pain of infertility. It reminds us that we do have some control, that the holidays are not simply a time to escape from, and that in helping others, we help ourselves.
Are you counting down the days until you find yourself face-to-face with certain family members or friends who know exactly where your buttons lie and push them, repeatedly? While we all long for an abundance of good cheer, an overflow of ready affection, and easy conversations, handling challenging relationships during the holidays can trip up even the best-intentioned. So, how to navigate the gatherings ahead?
Simple tips to help you navigate

Here are some simple tips to keep in mind:

Prepare. Sometimes we can avoid what we fear by anticipating and accepting what is. Why would Aunt Bertha be any different this year than last? Why set yourself up for disappointment or frustration? Identifying one or two traits that you appreciate about her (okay, one) can help you adopt an attitude of tolerance in your interactions.

Let awareness and acceptance lead to useful action. What kind of time are you willing to spend with those you find most challenging? Do you get along best with one sibling while doing the dishes together at the end of the meal? Is an after-dinner walk the best way to engage with another? Group versus one-on-one time? Think ahead about when and how you want to engage with others, then look for those opportunities.

Be curious. We can’t always control the conversations that arise, especially around the dinner table. Uh-oh, who just brought up politics? If there’s genuine curiosity about others’ points of view, the conversation may be terrific. But being curious takes a willingness to not be right and to listen simply to understand. Listening takes the discipline and desire to stay in the moment without formulating your rebuttal while another person is talking. It also takes a kind of humility to recognize that you might learn something new. And if you don’t think that’s possible — for you or for others — sometimes a simple “no politics” (or “no whatever-is-too-controversial”) rule is helpful with challenging relationships.

Redirect. And what about the 27th retelling of a hackneyed family story, maybe even one where you — or someone else — come out looking a little worse for wear? Intentional, light-hearted interruption and redirection may be just what’s needed. Keep the focus on the speaker to minimize the potential that they will feel slighted. “That was a horrid day at the beach. Did I hear you’re planning a trip to Spain in February?”
Time for a difficult conversation?

Carpe diem. When we live far from others, we sometimes need to seize the rare in-person moment to talk about challenging matters. A few words of guidance:

    Give your intended recipient advance notice. “When we get together, I’d really like to talk about the argument we had at Thanksgiving so that we can do better in the future.”
    Find the right time and place for your conversation. Try to ensure you’ll have enough time to talk things through.
    Take responsibility for your contributions to a problem. An apology, when sincere, can go a long way.
    Frame your concerns in neutral, non-blaming language. Try leading with “I” instead of what often sounds like an accusatory “you.” “I felt really betrayed when I found out you told Joe I lost my job,” versus “You are so untrustworthy, telling Joe I lost my job when you promised to keep it confidential.”
    You’ve got two ears and one mouth. Reflect that ratio in how you use them. Listen twice as hard for feelings and concerns, and speak to acknowledge what the other person shared.
    Stay focused on your goals. If you’re clear that your goals are mutual understanding, resolution, and harmony, your intentions will help guide your actions and keep you on track.

Be the light

As much as you might wish to choreograph a perfect holiday gathering — who doesn’t? — you probably know deep down that the only person you can control is yourself. With awareness, preparation, and discipline, you can, in fact, be the light no matter what else is swirling around you. And when all else fails, there’s always refuge behind the locked bathroom door on the second floor.

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Gut feelings: How food affects your mood

We spend our days interacting with the world around us through our senses of sight, sound, and touch. But anyone who has developed complete nasal obstruction from an infection or severe allergies has experienced what it’s like to be without one of our most basic senses: our sense of smell.
The many functions of smell

In other animals, the sense of smell is absolutely crucial for survival, reproduction, and rearing of young. Although humans can survive without smell, research has shown that losing the sense of smell negatively impacts quality of life, even driving some people toward clinical depression. Just as other animals depend on the sense of smell as an alarm system for danger, we also depend on smell to warn us of the hazards of smoke from a fire, natural gas leaks in the home, and spoiled food.

On a daily basis, smell rounds out our experiences and is often an integral part of our memory of events from years gone by. Memories of a perfume worn by your spouse or the bread being baked at your grandmother’s house when you were a child last for decades, and are often intricately tied in with strong emotions.

The flavor of a meal depends heavily on the ability to smell, and without it, eating is just a bland means to dispel hunger. With so much of our social activity involving congregating at restaurants, bars, and cafes, it is understandable how someone losing the sense of smell can develop a sense of alienation.
Impact of smell disorders

Smell disorders affect 19% of the population over the age of 20 and 25% of the population over 53. If smell loss from aging alone is considered, one out of eight people between 53 and 91 will be affected over a five-year period. The detrimental effect of smell loss on flavor of food could significantly impact the elderly population, where diet and nutrition are already often a concern.

The sense of smell (olfaction) is dependent on millions of specialized nerve cells that are located in a deep protected recess high in the nasal cavity. Remarkably, these nerve cells normally die and are replaced throughout our lifetime. Therefore, the system has the capacity to repair itself after injury, but this isn’t always possible or complete.

The most common causes of prolonged smell loss occur as a result of upper respiratory infection, head injury, chronic sinus disease, and aging. However, other conditions such as Alzheimer’s disease, Parkinson’s disease, and tumors can be associated with smell loss.

In some cases, the loss of smell is complete (anosmia), while in other cases there is only a partial loss (hyposmia). In many instances where smell loss occurs, remaining smells are distorted. The distortions are either experienced as odors smelling dramatically different from what was remembered (parosmia) or smelling an odor that isn’t present (phantosmia).

Perhaps if they were pleasant, these distortions of smell might not be as distressful. However, in almost all instances, the experienced smells are unpleasant, with “smoke,” “swamp-like,” “musty,” “garbage,” or “chemical-like” among some very common descriptions. The odor is usually hard for people to describe, since it is not like anything they have experienced before.
Treating smell disorders

In cases where smell loss results from sinus disease, we have had some success in treating the condition. Oral and topical steroids often provide relief. Sometimes surgery is required to reduce the obstruction of odors to the sensory nerve cells. Sinus disease usually requires long-term management, and fluctuations in the ability to smell are common.

In contrast to chronic sinus inflammation, success in treating people with loss of smell resulting from head injury, upper respiratory infection, or aging is poor. The natural ability of the olfactory system to repair itself allows for some patients to regain the sense of smell after a respiratory infection-related loss or head injury. This recovery can take over a year, and can be so gradual that people have difficulty recognizing the change. Predicting whether recovery will occur in an individual is usually not possible, but overall any improvement that occurs within a one-year period increases the chances of recovery.

If you experience any persistent change in your sense of smell, visit your doctor for an evaluation. Some rare forms of smell disorders may result from tumors in the brain, neurodegenerative disease, or infection. These conditions should be diagnosed expediently for proper management and treatment. In addition, your doctor should talk to you about risks, such as depression and nutritional concerns that may stem from loss of smell.

Although therapies are currently lacking, there is hope for future breakthroughs. Ongoing scientific work is investigating how stem cells in the nose replace dying olfactory nerve cells. In the future, we will be able to add medication in the nose to trigger these cells to make more neurons, or replace missing stem cells to regenerate the neurons. Or we may be able to electrically stimulate a sensation of smell using an artificial implant. Continued research advances in this field will someday allow us to restore this important sensory system to those unfortunate enough to experience smell disorders, and provide them with the ability to once again fully experience the world around them.
It’s the holiday season, time for buying toys for the children in our lives. As we do, the American Academy of Pediatrics (AAP) encourages us to think about buying toys that can actually help children as they grow and develop.

Play is the work of children. That doesn’t mean it can’t be fun; of course play should be fun. But play is at its best when it encourages learning and development, and when it encourages interaction with other people. So many gifts these days are full of bells and whistles and cool electronic gadgets, but don’t really help children (and are often quickly discarded). The AAP thinks that when buying gifts for children we should think more about getting back to basics, and suggests we think about toys from traditional toy categories:

    Symbolic/pretend play. These toys are the building blocks for imaginative play. They are things like dolls, animals, dollhouses, kitchen sets, tool sets, dress-up costumes, or puppets. Children can use them to create their own stories, doing it differently each time. Simple is best: toys don’t need to walk or talk or do anything, really. It’s better to leave that up to children.
    Fine motor/adaptive/manipulative. These are things like actual building blocks and other building sets, train sets, or puzzles. These are toys that not only encourage children to build and create, but also encourage fine motor skill development and early math (and even engineering) skills. There are apps that allow kids to build things digitally, but using their hands is best; nothing outdoes the three-dimensional approach.
    Art. Nothing encourages creativity and fine motor skills better than drawing, painting, and building with clay. So buy paper, crayons, markers, paint and paintbrushes — and modeling clay. They are inexpensive gifts that can keep children happy for hours. There is something very powerful for development when children have to start a project from scratch, like a drawing from a blank piece of paper.
    Language and interaction. This is where books come in — there is nothing better for learning new words, and appreciating words, than books. And when they are read aloud, in someone’s lap, they encourage interaction, which helps children flourish. Games encourage interaction too; traditional board games can be fun for everyone, and bring people together.
    Gross motor. In general, we are a sedentary nation — and most children do not get the recommended hour of physical activity every day. So make it easier for them. Buy them a bike or a trike, or a basketball and a net, or a soccer ball or a jump rope. Anything you do to get them moving not only builds strength and skills, it builds habits that can keep children healthy for the rest of their lives.
The human microbiome, or gut environment, is a community of different bacteria that has co-evolved with humans to be beneficial to both a person and the bacteria. Researchers agree that a person’s unique microbiome is created within the first 1,000 days of life, but there are things you can do to alter your gut environment throughout your life.
Ultra-processed foods and gut health

What we eat, especially foods that contain chemical additives and ultra-processed foods, affects our gut environment and increases our risk of diseases. Ultra-processed foods contain substances extracted from food (such as sugar and starch), added from food constituents (hydrogenated fats), or made in a laboratory (flavor enhancers, food colorings). It’s important to know that ultra-processed foods such as fast foods are manufactured to be extra tasty by the use of such ingredients or additives, and are cost effective to the consumer. These foods are very common in the typical Western diet. Some examples of processed foods are canned foods, sugar-coated dried fruits, and salted meat products. Some examples of ultra-processed foods are soda, sugary or savory packaged snack foods, packaged breads, buns and pastries, fish or chicken nuggets, and instant noodle soups.

Researchers recommend “fixing the food first” (in other words, what we eat) before trying gut modifying-therapies (probiotics, prebiotics) to improve how we feel. They suggest eating whole foods and avoiding processed and ultra-processed foods that we know cause inflammation and disease.
But what does my gut have to do with my mood?

When we consider the connection between the brain and the gut, it’s important to know that 90% of serotonin receptors are located in the gut. In the relatively new field of nutritional psychiatry we help patients understand how gut health and diet can positively or negatively affect their mood. When someone is prescribed an antidepressant such as a selective serotonin reuptake inhibitor (SSRI), the most common side effects are gut-related, and many people temporarily experience nausea, diarrhea, or gastrointestinal problems. There is anatomical and physiologic two-way communication between the gut and brain via the vagus nerve. The gut-brain axis offers us a greater understanding of the connection between diet and disease, including depression and anxiety.

When the balance between the good and bad bacteria is disrupted, diseases may occur. Examples of such diseases include: irritable bowel disease (IBD), asthma, obesity, metabolic syndrome, diabetes, and cognitive and mood problems. For example, IBD is caused by dysfunction in the interactions between microbes (bacteria), the gut lining, and the immune system.
Diet and depression

A recent study suggests that eating a healthy, balanced diet such as the Mediterranean diet and avoiding inflammation-producing foods may be protective against depression. Another study outlines an Antidepressant Food Scale, which lists 12 antidepressant nutrients related to the prevention and treatment of depression. Some of the foods containing these nutrients are oysters, mussels, salmon, watercress, spinach, romaine lettuce, cauliflower, and strawberries.

A better diet can help, but it’s only one part of treatment. It’s important to note that just like you cannot exercise out of a bad diet, you also cannot eat your way out of feeling depressed or anxious.

We should be careful about using food as the only treatment for mood, and when we talk about mood problems we are referring to mild and moderate forms of depression and anxiety. In other words, food is not going to impact serious forms of depression and thoughts of suicide, and it is important to seek treatment in an emergency room or contact your doctor if you are experiencing thoughts about harming yourself.

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The new exercise guidelines: Any changes for you?

With the obesity epidemic at an all-time high in the US — close to 70% of Americans are overweight or obese — many people could benefit from losing weight. However, for numerous reasons, weight loss is challenging. In addition, some people are tempted to choose the “diet of the month” or a plan that they have read about online or heard about from friends and family. Unfortunately, these diets are oftentimes not the most nutritious, and even with some weight loss, may not ultimately improve health.

So, is there any benefit from improving the quality of one’s diet without weight loss? The answer is YES. Three randomized clinical trials (the gold standard in nutrition research) have shown that by improving what you eat, you can improve cardiovascular risk factors, such as high blood pressure, LDL (bad) cholesterol, and triglycerides, and improve your health.
Examining the evidence

One study examined the effect of the DASH (Dietary Approaches to Stop Hypertension) Diet on blood pressure. The researchers recruited 460 overweight and obese adults with borderline high blood pressure. They provided the participants with food according to DASH diet guidelines. The DASH diet is defined as: low in saturated fat and dietary cholesterol; rich in potassium, magnesium, calcium, and fiber; emphasizing fruits, vegetables, whole grains, and low-fat dairy products; including fish, poultry, nuts, and seeds; and limiting red meat, sweets, and sugary beverages. To prevent any effect from weight changes on the results, researchers regulated calories to prevent weight gain or weight loss. At the end of the 11-week study, the participants’ blood pressure was significantly reduced compared to their baseline blood pressure.

The second study looked at the already very healthy DASH diet and then added sodium limits. Study participants on the DASH diet who were assigned to the lowest sodium limit (1,500 milligrams per day) experienced drops in blood pressure similar to what a blood pressure medication would achieve.

The third trial examined whether changing a few components of the original DASH diet could result in even greater improvement in risk factors. This study, called OMNI Heart (Optimal Macronutrient Intake to Prevent Heart Disease) examined 164 overweight and obese adults with prehypertension or Stage 1 hypertension, and replaced some of the carbohydrates in the DASH diet with either healthy protein (from fish, nuts, beans, and legumes) or unsaturated fats (from olive oil, nuts, avocado, and nut butters). Again calories were kept neutral to avoid weight gain or loss. Results showed that substituting healthy protein or healthy fats for some of the carbohydrate lowered LDL (bad) cholesterol, blood pressure, and triglycerides even further than the DASH diet alone.
Putting it into practice

In summary, for overweight or obese people with borderline high blood pressure, following a DASH diet with a focus on daily consumption of vegetables, fruits, whole grains, low-fat dairy, nuts, and lean sources of protein could result in a reduction in blood pressure. Limiting high sources of sodium, including any canned, convenience, and processed foods, and high-sodium condiments such as salad dressing, pickles, and soy sauce, can produce even greater reductions in blood pressure. Substituting some healthy fat or healthy protein for some of the carbohydrates in your diet may improve your cardiac risk factors even more by lowering triglycerides and LDL cholesterol.
Salt: without it, food can seem tasteless. It is the reason sea water burns our eyes and skin. Some people enjoy salt water baths. Is it good for us? Is it not? Do we really know?

In modern medicine, we tend to have a generally negative feeling about sodium, the element found in salt. Excessive sodium intake is linked to water retention, and it is also a risk factor for high blood pressure. Both excessive sodium intake and high blood pressure are major risk factors for developing heart failure, and for causing complications in those with existing heart failure. Given that 6.5 million American adults have heart failure, restricting salt intake might profoundly reduce risk for this major medical scourge.

Indeed, we advise our patients with heart failure to restrict the amount of salt they consume per day. For years we have been telling them to stay away from salty fries and Chinese takeout, which may have up to 7,000 mg of sodium in a single meal. We consign patients hospitalized for heart failure to a bland “low salt, heart healthy” diet until discharge. But what do we base the low-salt recommendation on? Is this just anecdotal? Or do we have evidence that guides our recommendations?

In the spirit of open-mindedness, let’s debate this question.
Point: Moderate sodium intake is harmful for people with heart failure

Sodium intake is associated with fluid retention, hence the puffiness and bloating that may follow a very salty meal. And excessive sodium intake may worsen high blood pressure, or hypertension. High blood pressure increases the risk of developing heart failure and can worsen existing heart failure. Hypertension may also lead to other types of heart disease, stroke, or kidney failure. A low-sodium diet may help lower or prevent high blood pressure, and may reduce the risk of such diseases.

High-sodium diets are also usually high in total fat and calories, which may lead to obesity and its many associated complications. Some studies also suggest that there may be a link between sodium intake and osteoporosis and stomach cancer. Additionally, consuming salty foods over a long period of time can accustom your taste buds to the taste, and in turn make you more likely to reach for saltier foods.
Counterpoint: Moderate sodium intake is not harmful for people with heart failure

Cardiologists tend to practice evidence-based medicine, yet many of our recommendations regarding sodium intake for people with heart failure are based on assumptions. Surprisingly, it is hard to say there is enough evidence to state beyond a shadow of a doubt that patients with heart failure should be restricted to the 2,000 mg of salt per day most physicians recommend. And realistically speaking, how many patients abide by this restriction remains unclear, because sodium is in almost everything we consume.

In a systematic review of nine studies recently published in JAMA Internal Medicine, only limited and inconsistent evidence was found supporting any benefit of salt-restricted diets for non-hospitalized people with heart failure. The evidence for salt restriction was inconclusive in patients admitted to the hospital for heart failure. This was a well-done study; only nine of 2,655 studies evaluated were rigorous enough to include in the review. So perhaps most importantly, this review illustrates that regardless of the conclusion, rigorous, evidence-based data regarding sodium restriction in heart failure are not available.

The lives of our heart failure patients are complicated enough as it is. It is imperative that whatever we recommend for our patients does not further worsen the quality of their already difficult lives. Since patients often struggle to maintain adherence to therapies in heart failure, our focus as physicians should be on stressing the things that are evidence-based. This includes adherence to guideline-directed medical therapies and favorable lifestyle interventions, such as more exercise, and care of other relevant medical conditions, such as diabetes.
The verdict: Until we have more evidence, it’s a draw

Take some of what we say with a grain of salt (pun intended). There is not yet enough evidence for either side of the great salt debate to win. And our discussion should not lead patients to consume salt in excess until we know for sure. Indeed, in the absence of good clinical data, one must accept the need for good clinical judgment: avoiding excessive amounts of sodium is a healthy move for all of us, including those with heart failure.

It’s also highly likely that some patients are more salt-sensitive than others. Thus, directing salt restriction to those most vulnerable might be better than a one-size-fits-all approach. Studies in this area are very much needed. Fortunately, clinical trials to address this question are ongoing, so stay tuned!

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