Monthly Archives: June 2013
You might eat them in a sauce alongside your Christmas turkey or drink them juiced, perhaps with a shot of vodka. But the sweet, tart cranberry is also well known as a remedy for preventing urinary tract infections (UTIs). Cystitis – an infection and inflammation of the lining of the bladder – is the…
You might eat them in a sauce alongside your Christmas turkey or drink them juiced, perhaps with a shot of vodka. But the sweet, tart cranberry is also well known as a remedy for preventing urinary tract infections (UTIs).
Cystitis – an infection and inflammation of the lining of the bladder – is the most common form of UTI, with symptoms including:
- the frequent urge to pass urine
- a stinging or burning sensation when passing urine
- smelly urine
- cloudy or blood urine
- pain in the low abdomen or pelvis.
This condition occurs frequently in women, with one in three experiencing cystitis at least once in their life. As a general practitioner, it would be unusual for me to not see a case of cystitis most weeks. In most cases, cystitis is easily treated with a course of antibiotics.
As a folk remedy with a long history among Native Americans, cranberry juice was dismissed for years by the medical establishment. But this changed in the 1980s and 1990s when it was discovered that cranberry juice contained chemicals that seemed to stop E. coli (the most common bacteria causing UTIs) from sticking to the lining of the bladder.
Conceptually, if bacteria cannot attach to the bladder lining, then it would be flushed out with the urine and thus not cause an infection.
This thinking has been popularised in the last couple of decades. Cranberry juice and capsules have been widely recommended and promoted as a treatment for preventing bladder infections, particularly for women who suffer from recurrent infections. Health literature aimed at consumers, including high-quality sources, often advise that cranberry products can be used to reduce the frequency of UTI episodes.
In such a setting, it would be natural to believe that cranberry products were a proven therapy! Indeed, I was taught in medical school that cranberry was effective, and have personally prescribed it for my patients in the past.
Curiously, although there appears to be good scientific reasons why cranberry products could work in preventing UTIs, evidence that it does in real patients has been rather murky.
A 2009 Cochrane Library systematic review, which independently analysed all the available evidence, noted that there was some evidence that cranberry products might work, but it wasn’t clear what the “optimum dosage or method or administration” was.
The large number of dropouts from the available trials also suggested that it might not have been an acceptable treatment over a longer period of time.
This review was updated in October 2012 with the inclusion of newer and larger studies. Disappointingly, this revised appraisal of the empirical evidence seems to suggest that cranberry does not reduce the likelihood of a recurrence of UTIs in women.
I doubt that we have heard the last word on cranberry and there are studies in the pipeline.
But the weight of evidence, especially those from larger and better-designed trials, points towards the likelihood that cranberry products are ineffective for preventing UTIs.
Greater Happiness in 5 Minutes a Day
Might be that sitting with your legs crossed repeating stuff like “May all beings be free from suffering,” is a little too far-out for you. I’m a scientist for crying out loud, so you can imagine how I might feel meditating while surrounded by prominent neuroscientists, which I once did on a 7-day silent meditation retreat. Except that I actually didn’t feel silly.
Because research demonstrates the incredible power of loving-kindness meditation: No need to be self-conscious when this stuff might be more effective than Prozac. Also called metta, loving-kindness meditation is the simple practice of directing well-wishes towards other people.
Here’s How to Do It
The general idea is to sit comfortably with your eyes closed, and imagine what you wish for your life. Formulate your desires into three or four phrases. Traditionally they would be something like this:
May I be healthy and strong. May I be happy. May I be filled with ease. Loving-kindness meditation is a simple repetition of these phrases, but directing them at different people. I do this with my kids before bed. We visualize together who we are directing the metta towards, and at first I say something (May you be happy) and the kids repeat it after me. After a few repetitions, we start saying them in unison. The phrases we use are “May you be healthy and strong. May you be happy. May you be peaceful.“
1. Start with by directing the phrases at yourself: May I be happy.
2. Next, direct the metta towards someone you feel thankful for or someone who has helped you.
3. Now visualize someone you feel neutral about—people you neither like nor dislike. This one can be harder than you’d think: Makes me realize how quick we can be to judge people as either positive or negative in our lives.
4. Ironically, the next one can be easier: visualizing the people you don’t like or who you are having a hard time with. Kids who are being teased or bullied at school often feel quite empowered when they send love to the people making them miserable.
5. Finally, direct the metta towards everyone universally: “May all beings everywhere be happy.“
In this 3-minute video, Sylvia Boorstein, author of Happiness is an Inside Job, teaches how to do this. Another good resource is Sharon Salzberg—she wrote Loving-Kindness: The Revolutionary Art of Happiness. Doing this with kids of all ages doesn’t need to be complicated; most are good at using their imaginations to send love and well-wishes. You don’t really need to read books about this: loving-kindness meditation is as simple it seems. People write books about it because it is so powerful.
Here’s What You Get When You Send Love
Loving-kindness meditation does far more than produce momentary good feelings. Over a nine week period, research showed that this type of meditation increased people’s experiences of positive emotions. (If you are working on improving your ratio of positive to negative emotions, start with metta!) The research shows compellingly that it actually puts people on “trajectories of growth,” leaving them better able to ward off depression and “become ever more satisfied with life.” This is probably because it increases a wide range of those resources that make for a meaningful and successful life, like having an increased sense of purpose, stronger social support, and less illness. Research even shows that loving-kindness meditation “changes the way people approach life” for the better.
I’ve blogged before about social connections and how important they are for health and happiness. Doing a simple loving-kindness meditation can make us feel less isolated and more connected to those around us: one study showed that a SINGLE SEVEN MINUTE loving-kindness meditation made people feel more connected to and positive about both loved ones and total strangers, and more accepting of themselves. Imagine what a regular practice could do!
© 2012 Christine Carter, Ph.D.
In Medicine, the Cochrane centre is considered the gold standard for advising on medical issues. The Cochrane centre consists of the best experts around the world in a particular field advising on issues after studying all the research on a particular topic. They are independent and not swayed by vested interests. I have promoted probiotics for my patients after antibiotics for many years, and the research now shows this to be correct. In fact, Doriann and I take them daily for good health irrespective of whether we have had antibiotics or not.
Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children
Published Online: 31 MAY 2013
Assessed as up-to-date: 21 FEB 2013
Plain language summary
The use of probiotics to prevent C. difficile diarrhea associated with antibiotic use
Antibiotics are among the most prescribed medications worldwide. Antibiotic treatment may disturb the balance of organisms that normally inhabit the gut. This can result in a range of symptoms, most notably, diarrhea. Clostridium difficile is one particularly dangerous organism that may colonize the gut if the normal healthy balance has been disturbed. Clostridium difficile-related disease varies from asymptomatic infection, diarrhea, colitis, and pseudo-membranous colitis to death. The cost of treatment is expensive and the financial burden on the medical system is substantial.
Probiotics are organisms thought to improve the balance of organisms that inhabit the gut, counteract disturbances to this balance, and reduce the risk of colonization by pathogenic bacteria. They are becoming increasingly available as capsules and food supplements sold in health food stores and supermarkets. As “functional food” or “good bacteria”, probiotics have been suggested as a means of both preventing and treating C. difficile-associated diarrhea (CDAD).
This review includes 31 randomized trials with a total of 4492 participants. Twenty-three studies (4213 participants) assessed the effectiveness of probiotics in preventing CDAD in participants taking antibiotics. Our results suggest that when probiotics are given with antibiotics they reduce the risk of developing CDAD by 64%. Side effects were assessed in 26 studies (3964 participants) and our results suggest that probiotics decrease the risk of developing side effects. The most common side effects reported in these studies include abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance. The short-term use of probiotics appears to be safe and effective when used along with antibiotics in patients who are not immunocompromised or severely debilitated
Menstruation is a reproductive quirk that humans share with only a few other mammals. But even stranger is the fact that women stop menstruating when they have a whole third of their lives left to live. All animals have a finite reproductive life. But more often than not, their reproductive system winds…
Menstruation is a reproductive quirk that humans share with only a few other mammals. But even stranger is the fact that women stop menstruating when they have a whole third of their lives left to live.
All animals have a finite reproductive life. But more often than not, their reproductive system winds down at roughly the same time as every other system in the body – the menopausal killer whale is a notable exception.
The ability to bear children gradually declines throughout a woman’s reproductive life. The average age at which a woman’s ability to natural conceive ceases is 38.
But when the fertility free-fall of menopause kicks in between the ages of 45 and 55, complete sterility is the inevitable result. No more ovulation, no more menstruation, and no more opportunities to procreate.
In contrast, males experience only a slight decrease in fertility in their senior years.
Giving kids a head start
Evolutionary theory predicts that life span and reproductive span should synchronise – why go on living if you are unable to go on breeding, bolstering the contribution of your genes to the next generation?
One reason for dialling back reproduction could be to maximise the level of nurturing available for children that already exist. Human infancy is marked for its length and also for the degree of dependence that infants have on their parents. Perhaps menopause is a reproductive compromise to ensure that a woman’s last born makes it out of the nest safely.
But this would only account for a ten or 15 year difference between menopause and death – much less than usually occurs.
Grandmothers and daughters-in-law
Another suggestion – dubbed the grandmother hypothesis – is that menopause enables women to provide for their grandchildren.
In evolutionary terms, a person is said to be “fit” if they are able to pass on their genes to future generations by reproducing. Given that our children bare 50% of our genes – the other 50% from our partner – and our grandchildren share 25% of our genes, a grandmother providing for her grandchildren still results in evolutionary fitness.
The numbers don’t add up, though. The fitness benefit of caring for grandchildren is less direct and, in the end, less potent than if the grandmother were simply able to have more children of her own.
A more recent hypothesis centres on the age-old conflict between women and their mothers-in-law. This intergenerational reproductive argy-bargy is apparently the result of ancestral daughters-in-law joining a partner’s family. The daughter-in-law gains nothing by helping her partner’s mother to reproduce, but the mother-in-law does benefit in an evolutionary sense by helping her own grandchildren to be raised.
Instead of having two competing females in the one clan reproducing, the older female relinquishes her own reproduction in favour of helping her daughter-in-law raise her grandkids.
Similarly to the grandmother hypothesis, the reproductive conflict hypothesis could explain why reproduction ceases at around the same time as a woman reaches the age at which she is likely to become a grandmother.
But a recent study of pre-industrial Norwegian women casts doubt on this reckoning of evolutionary events. The study found that grandmothers who had a reproductive overlap with their daughters-in-law had more grandchildren, not less.
A fluke of nature
So, perhaps it is to happenstance that we must turn for an explanation for menopause. Could it be that menopause is simply an evolutionary hitchhiker; a trait that has come along for the ride without providing any adaptive benefit?
It’s possible, for example, that menopause could be the result of a physiological trade-off that favours efficient reproduction early on.
In searching for an answer to why women live for so long post-fertility, palaeontology has reminded us of a very important fact: old age is actually relatively new age. Early human fossils are invariably young, and it wasn’t until a few thousand years ago that anyone lived into the senior years we have now grown to expect.
It is highly likely, therefore, that our long-lost great-great grannies didn’t live long enough to experience the hot flushes, night swears and yo-yo-ing hormones of the modern-day menopause. They never lived long enough to be denied the children that menopause robbed them of, because they may not have reached menopausal age at all.
We can be thankful for our longer lives, but menopause may be the cost women endure for it.
Welcome to Facts about Flu – Perhaps the misery you feel when ill in winter isn’t the fault of the much-maligned influenza virus after all. RSV, hMPV, CoV… these may all sound like random acronyms, but they are influenza’s less well-known viral cousins. In fact, studies have shown that a lot of illness…
Welcome to Facts about Flu – Perhaps the misery you feel when ill in winter isn’t the fault of the much-maligned influenza virus after all.
RSV, hMPV, CoV… these may all sound like random acronyms, but they are influenza’s less well-known viral cousins. In fact, studies have shown that a lot of illness that we think of being caused by the “flu” is actually due to these other viruses.
Some of them are seasonal, such as respiratory syncytial virus (RSV) and parainfluenza virus. While others, such as coronaviruses (CoV) and rhinoviruses, are found all year around.
And others still are found living in your nose, throat or windpipe, but it isn’t clear whether they do much. These include respiratory polyomaviruses WU and KI (known to those in the field as the “Wookie” viruses). But why is all this important?
Complications of respiratory viruses
For most of us, respiratory viral infections are an annoyance that, at worst, require us to take a day or so off work. Occasionally, complications ensue in otherwise healthy people for reasons that aren’t entirely clear to doctors.
In recent years, we’ve found that around a quarter of the people are admitted to hospital with influenza don’t have an obvious reason for ending up there (that is, they don’t have an identifiable medical risk factor).
In addition to secondary bacterial pneumonia, which is known as a complication of the flu, some studies suggest that influenza might trigger heart attacks and strokes.
In some people, “ordinary” respiratory viruses are known to be dangerous. These include asthmatics, those whose underlying severe medical problems, and those with impaired immune systems.
In young children, viral infections can cause diseases such as croup, which sometimes requires hospitalisation. In Indigenous children, we think that there’s an interplay between viral infections and more serious bacterial infections such as middle ear disease, an important cause of impaired hearing.
So, there’s clearly a real need for effective vaccines and treatments for some of these other viruses.
Indeed, some of these respiratory viruses are really nasty. SARS, a coronavirus that emerged in China, was known to have affected 8,096 people and resulted in the deaths of at least 775 (including many health-care workers caring for infected patients). It was estimated to cost around A$40 billion.
On a different scale, a related novel coronavirus is currently the focus on attention in the Middle East, where a hospital outbreak in Saudi Arabia has been known to involve 13 patients. Seven of these people have died and over 50 cases have been reported in total.
What ails thee
For most of us, what we think of as “the flu” (fever, with a runny nose, sore throat or cough, and body aches and pains) is actually not due to influenza virus infections. In fact, studies have shown that of those with this syndrome, only about 40% have influenza – even in the middle of winter.
There don’t appear to be any simple ways to tell what’s due to the influenza virus and what’s due to other viral infections. The currently available tests aren’t that useful because they’re relatively expensive and the results aren’t available for at least a day or so.
This is important for our perception of the effectiveness of influenza vaccines and treatment. While this vaccine is reasonably effective in preventing influenza, it isn’t anywhere as good at preventing flu-like symptoms generally (because it only prevents those due to influenza).
There is some evidence that the protection of influenza vaccines may be inferior to that produced by natural infection. This is the rationale for a new generation of “live attenuated” vaccines that provide protection but without causing significant illness.
Antivirals are also only effective for influenza and some would say that even this is debatable. To have any effect, they need to be started soon after the onset of symptoms – both these factors dilute out the effectiveness of treatment.
Other than influenza, there’s no proven effective treatment against respiratory viruses, although there are some expensive preventative agents and antivirals we often try for patients who are critically ill or who are at very high risk of getting really ill.
Remarkably, respiratory viruses, which are essentially little particles of genetic material that arguably aren’t even alive, continue to cause all this misery.
This is the eighth article in our series Facts about Flu. Click on the links below to read other instalments in the series.
Facts about flu – Today, Ian Barr considers advice about who should get a flu shot. Questions about who should be vaccinated against influenza are asked each year as the winter (and influenza) season approaches. Even though influenza vaccines have been used since the 1940s, there’s still much confusion…
Facts about flu – Today, Ian Barr considers advice about who should get a flu shot.
Questions about who should be vaccinated against influenza are asked each year as the winter (and influenza) season approaches. Even though influenza vaccines have been used since the 1940s, there’s still much confusion about their use and effectiveness.
In most Western countries, vaccines are widely used by public health authorities, workplaces and individuals to reduce the risk of contracting the flu.
So what is the risk of being infected with influenza each year? This figure is variable and can be as low as one in 100 or as high as one in three.
It depends on many factors such as:
- if you have young children,
- if your children attend daycare or school,
- if you use public transport,
- if you live in an institution such as a nursing home or boarding school,
- your vaccination status, and
- the (constantly-changing) virus itself.
Try working out your odds (it’s a difficult task, let me assure you). And assuming your risk of infection is relatively low, what will be the outcome if you do become infected? Again, the answer is: “it depends”.
The pyramid of illness
Influenza is generally a mild disease. Many people, especially children, won’t even know they’ve been infected with the flu. We call these people asymptomatic. Other healthy children and adults might be somewhat indisposed by a seasonal influenza infection, missing a week’s school or work.
But some other people and groups run a higher risk of a more serious illness following an influenza infection. These include very young children, the elderly, pregnant women, asthmatics and, cancer and organ transplantation patients. A small proportion of these people will be hospitalised, and some will die.
In the most recent 2012-3 US influenza season, for instance, some 12,343 people were hospitalised with about half of these being elderly (65 years or older) along with 217 pregnant women. There were also 146 children (18 years old or younger) and thousands of adults and elderly who died from influenza or its complications. These findings are likely to be proportionally similar in Australia (that is, about one-tenth of these numbers).
So a reasonable case can be made for avoiding infection from influenza for a number of people. But short of becoming a hermit, living in a remote location and avoiding people or taking drugs (Tamiflu or Relenza) every day for months on end, vaccination is the most viable option currently available.
From the experts
Various groups have considered the question of who should get the influenza vaccine. In April 2012, the World Health Oganization’s (WHO) Strategic Advisory Group of Experts (SAGE) on immunisation recommended that pregnant women were the most important risk group for seasonal influenza vaccination.
It also supported the recommendation – in no particular order of priority – for vaccination of:
- health-care workers,
- children six months to 59 months of age,
- the elderly, and
- those with high-risk conditions.
Annual influenza vaccination is recommended for any person ≥6 months of age for whom it is desired to reduce the likelihood of becoming ill with influenza.
It also strongly recommends vaccination for similar groups to SAGE with some additions such as Aboriginal and Torres Strait Islander people aged 15 years or older.
Other groups such as the US-based Advisory Committee on Immunisation Practices (ACIP) have, since 2010, continued to recommend annual influenza vaccine for all children aged six months or older.
Vaccine safety and effectiveness
Unfortunately, the performance of influenza vaccines in achieving robust protection is far from perfect, especially among the elderly. This age group has a deteriorating immune system due to ageing, which results in reduced responses to vaccinations, including the influenza vaccine.
For many years, scientists have tried to find the Holy Grail of influenza vaccines – a vaccine that is long lasting, works well in all age groups, fully protects against all circulating viruses, and provides protection from influenza viruses that don’t normally circulate in people.
Not one of these aims has been achieved despite around 80 years of effort, experimentation and clinical trials. While some progress has been made, they are relatively minor and are yet to replace or substantially improve the current practice of annual vaccination.
The good news is that while the protection offered by current flu vaccines could be improved, their safety profile is generally very good, with very few serious adverse reactions. There have been a few exceptions to this, such as with the CSL’s vaccine for children in 2010.
This brand is no longer approved or given to children under ten years of age and has been successfully replaced with non-CSL brands by other influenza vaccine manufacturers.
What to do?
The range of influenza vaccines available overseas currently is larger than Australia. In the United States, for example, they have the choice of inactivated virus vaccines, live attenuated (or crippled) virus vaccines and recombinant protein vaccines (made by modern molecular techniques).
In Australia, only the inactivated influenza vaccines, delivered by injection, are currently available. These vaccines are made by growing influenza viruses in embryonated hens eggs, which are then purified, inactivated and formulated into the finished vaccine.
That’s a bit of background (there is a lot more available, for example, on the US Centers for Disease Control website), but the question for you is – do I get the influenza vaccine this winter?
It’s not too late as the peak time for influenza in Australia is usually in August. But like many things to do with the flu we can’t be sure of this. So if you do decide to get vaccinated, the sooner you do it, the better. And remember, it will take approximately two weeks before your body will reach its maximum level of protection following vaccination.
As for me, given that I work with influenza viruses continually, I have chosen to get the influenza vaccine each year for the past 13 years. But the chances of me running into an influenza virus is a daily possibility, a somewhat higher risk than most of you!
Wired to want stuff? Neuroscience can explain kids’ holiday gimmes
I’ll never forget a holiday moment a few years ago, when I found myself in a negotiation with my younger daughter over her gift list. (Which, by the way, I don’t believe in. In theory, I’ve never wanted my kids to make lists of things they want for Christmas and Hanukkah. But we did “go see Santa” when they were younger, and they did prepare to ask him for a gift, so I’ve never really put my money where my mouth is.)
Anyway, my daughter was in the back of the car rattling off all the things she wanted for Christmas, excitedly, as though it were a done deal and she would soon be receiving everything she ever hoped for. And I was anxiously trying to do damage control: Santa only brings one toy (“Nah-ah, Mom, he brought Ella THREE last year!!”); Santa can’t bring live animals (she passionately wanted a live llama); if your grandparents get you Uggs instead of Payless knock-offs, you won’t get any other presents from them (economic logic lost on a seven-year-old).
I thought I was going to lose my mind. I’d been trying to create special holiday traditions that foster positive emotions like gratitude and altruism—traditions that would bring meaning, connection, and positive memories. And it all seemed to be falling on deaf ears. My children had wish-lists longer than they were tall. Even my parents were fighting me on going to church Christmas Eve, because they thought it would cut into the gift exchange.
I know I’m not alone; nearly all of my coaching clients have expressed similar dismay. So if we don’t want our children to be whipped into a consumer frenzy, and we value other things, why does this happen, year after year?
One answer, of course, is that on some level our society has come to believe that our economy depends on a gift giving extravaganza, and that the holidays wouldn’t be fun without all the gifts. I’ve been reflecting on this, and on the other forces at work this time of year. Here’s why I think we want, want, want so much stuff come the holidays.
(1) We systematically confuse gratification, which is fleeting, with real joy or lasting happiness. It’s a complex concept for a seven-year-old (and sometimes, for a 37-year-old): We can feel gratified when we get something new—we might even get a hit of pleasure—but that gratification isn’t really the same thing as happiness.
Think of how gratitude feels—or compassion, inspiration, or awe. Think of how you feel when you are madly in love with your new baby, or amorous towards your longtime spouse. Those are deep positive emotions—and to me, they’re the positive emotions that are at the foundation of a happy life.
Gratification still feels good. It is central to our brain’s reward and motivation systems. But when we confuse it with actual happiness, we think that we can’t really be happy—or that our kids won’t be happy—without all the gifts and shopping.
(2) Our brains are hardwired to pursue rewards. Happiness is a reward. It’s not that we aren’t built to pursue happiness, because we are. But the key word here is pursue: Our brain’s built-in reward system motivates us toward all the carrots, large and small, that are dangling out there. We’ll pursue anything that seems like a reward, and our kids will, too.
When our brain identifies a possible reward, it releases a powerful neurotransmitter called dopamine. That dopamine rush propels us toward the reward. Dopamine creates a very real desire for the carrot dangled in front of us.
It makes us more susceptible to other temptations as well, which is why when we decide that we want a cashmere sweater, that cookie over there suddenly looks pretty good, and so do those cute Pottery Barn dishes. High dopamine levels amplify the appeal of immediate gratification (which is why you suddenly can’t stop checking your email), and makes us less concerned about long-term consequences (like your credit card bill).
Unfortunately, our brain doesn’t distinguish between rewards that actually will make us happier and the things that won’t. Dopamine just motivates us to chase them all.
(3) All the carrots being dangled out there are dizzying. They don’t call it neuro-marketing for nothing—believe me, the advertisers know how to stimulate that dopamine rush in our children.
And how does a kid pursue a reward in December? They put it on their wish-list, then endlessly nag us until we break down and concede that, yes, sometimes Santa does bring more than one gift. Or that every night of Hanukkah can bring a “little something.”
So when our kids seem greedy or materialistic at this time of year, it doesn’t mean that we’ve failed to instill good values in them, or that they are spoiled and bratty. It means that they are human, and that they are under the siege of a marketing-induced dopamine rush.
This is an important lesson for our kids to learn! Here’s how we can help: We can teach them to recognize what makes them want, want, want. We can teach them to realize when they are being manipulated by advertisers.
This is hard, but I’ve seen that it’s possible: The other day, my older daughter was barely watching a distant TV in a Thai restaurant, and she said, “Wow, I know that commercial was meant to make me want those pants, and it WORKED. I really want those pants. I feel like I might be happier if I had THOSE PANTS.” She still wanted the pants, of course, but at least she was gaining some insight into her desire. She couldn’t prevent the dopamine rush, but she could react to it.
Finally, by creating meaningful traditions, we can teach our kids what truly will bring them lasting happiness during the holidays — like starting a gratitude tradition or helping others. Those are the things that they really will remember.
What strategies have worked for you in reducing the “gimmies” at this time of year?
Cross-posted from Christine Carter’s blog, Raising Happiness (tag line: Science for Joyful Kids and Happier Parents).
I have on many occasions seen the results of tests gone wrong, or a false test leading to other tests, which lead to various procedures, which lead to harm, or unnecassary treatment. If something is not wrong, don’t fixit can often be the best advice. And also, don’t go looking for trouble! You might find it!
Harvard Health Blog » “Just in case” heart tests can do more harm than good
Here’s an important equation that all of us—doctors included—should know about health care, but don’t:
More ≠ Better
“More does not equal Better” applies to diagnostic procedures, screening tests meant to identify problems before they appear, medications, dietary supplements, and just about every aspect of medicine.
That scenario is spelled out in alarming detail in the Archives of Internal Medicine. Clinicians at the Cleveland Clinic describe the case of a 52-year-old woman who went to her community hospital because she had been having chest pain for two days. She wasn’t having symptoms of a heart attack, such as shortness of breath, unexplained nausea, or a cold sweat, and her electrocardiogram and other tests were fine. The woman’s doctors concluded that her chest pain was probably due to a muscle she had pulled or strained during her recently begun exercise program to lose weight.
A cardiac CT scan can show a blockage in a section of a coronary artery.
To “reassure her” that she wasn’t having a heart attack, the emergency department team recommended she have a CT scan of her heart. This noninvasive procedure can spot narrowings in coronary arteries and other problems that can interfere with blood flow to the heart. When it showed a suspicious area in her left anterior descending artery (a key artery nourishing the heart), she underwent a coronary angiogram. This involves inserting a thin wire called a catheter into a blood vessel in the groin and deftly maneuvering it into the heart. Once in place, equipment on the catheter is used to make pictures of blood flow through the coronary arteries.
During the angiogram, the woman’s aorta was torn. Emergency bypass surgery was needed to fix this tear. The bypass graft failed, and she had several wire-mesh stents implanted to hold open the graft. A blood clot formed inside one of the stents, causing a heart attack and complete heart failure. She ultimately needed a heart transplant.
Such an unfortunate chain of events is rare. But it highlights the fact that things can, and do, go wrong in medicine—as in every other aspect of life and business. No test, no procedure, no drug or dietary supplement is 100% safe.
Readers of the Harvard Heart Letter often write asking if they should have an exercise stress test or a coronary calcium test or a scan of their carotid arteries “just in case,” even though they feel fine and are in generally good health. In theory, such information could warn about an impending heart attack or stroke. The answer from cardiologists on the newsletter’s editorial board is a resounding “No.” Why? Because the chances of causing harm—physical, emotional, or financial—often far exceed the limited diagnostic information and advice for management the test provides.
Tests and procedures are justified when there are solid, evidence-based reasons for performing them, when the anticipated benefits exceed the likelihood of risk, and when their results will clearly change how a person’s care is managed. Reassurance and “just in case” don’t fill the bill.
Fatness and lack of fitness are easily misconstrued
It’s really all about fitness!! Fatness and lack of fitness are easily misconstrued. It is possible to be heavy, strong and healthy. And, it is possible to be unhealthy, underweight and weak. As we and others have shown, with proper exercise and sound nutrition it is possible to make major changes in fitness parameters and risk factors for chronic diseases without major changes in body weight.
My personal view that in many instances, overemphasis on body weight and dieting (meaning food restriction) are destructive, and counter-productive. Even athletes seeking to cut body weight by dietary restriction can set themselves up for long-term disability. Rather, people need to be educated about, and encouraged to pursue healthful dietary and physical activity habits. As well, people need to be educated about the hazards of contemporary lifestyles that discourage movement, keep us from interacting with the environment and surround us with too much and poor quality food.
While it is possible to be fit and fat, given the opportunity to chose one or the other, the obvious choice would be for fitness over fatness. But, such a conclusion still misses the point; this is not an either-or situation. The key thing is to be fit and healthy. The Institute of Medicine panel that I served on reviewed the literature related to nutrition and physical activity; we concluded that daily physical activity in an amount equivalent to 60 minutes of vigorous walking was necessary to promote physical fitness, reduce risks of chronic diseases and control body weight.
Still, questions such as those posted on the blog arise continuously. There are multiple reasons why questions related to fitness and fatness persist, but certainly data from the Centers for Disease Control (CDC) give impetus. The data from the CDC show that we in the U.S. have a growing epidemic in obesity that predisposes us to chronic diseases like diabetes, heart disease and some forms of cancer. On a population-wide basis, Body Mass Index (BMI) data are the most accurate available, but health care professionals can discriminate between athletes and couch potatoes with the same BMI. Most cases health care professionals can make a prediction about a person’s current and future health in minutes simply by measuring abdominal girth and blood pressure. Certainly, blood tests for sugar and lipid contents and other factors are necessary and informative, but with an educated eye a health care professional can make an accurate assessment of a patient in minutes with, or without BMI assessment.
Given the joys of being outside in fresh air and sunshine, hiking in the hills and mountains or along our beaches, riding bicycles along country roads, or partaking in sports and games, it is a wonder that more folks do not participate for sake of their emotional health.
Given the costs associated with treating diabetes, high blood pressure and lipids (cholesterol and triglycerides) in an aging and ever more sedentary and fatter population, we need resurgence in helping and encouraging our citizens to make healthier food and physical activity choices. With the various special interest groups ranging from agribusiness to big pharma and the AARP to placate, Congress diddles and no one asks the question, “who pays for the lack of fitness?”
Q Are Mammograms Unnecessary? I keep hearing conflicting things about mammograms – the latest news that has me worried is that routine screening results in a lot of over-diagnosis. I’m confused. Can you help?
Mammography is a confusing issue and something of a moving target since every new study seems to add to the uncertainty surrounding its use for the routine screening of healthy women for breast cancer. In recent years, we have been hearing more and more about over-diagnosis due to screening – that is, finding tiny tumors that would never cause symptoms or pose a threat to a woman’s life. The latest analysis, from the Harvard School of Public Health (HSPH), using data from Norway, found that between 15 and 25 percent of all cases of breast cancer revealed by mammograms are over-diagnosed. The authors explain that by “over-diagnosed” they mean tumors that would not have grown to threaten a woman’s health in her lifetime. Mammograms can’t distinguish between tumors that will lead to progressive disease and those that will not
The investigators analyzed data from 39,888 women with breast cancer in Norway; of that total 7,793 were diagnosed via the Norwegian Breast Cancer Screening Program, which began in 1996 for women ages 50 through 69. Because this program was phased in over time, the researchers were able to compare the number of breast cancer cases in women who were screened to the number that were found in women who hadn’t had mammograms. Based on this comparison, the researchers estimated that 15 to 25 percent of the 7,793 women diagnosed with breast cancer via the screening program had cancers that never would have grown to pose a threat. Those percentages add up to between 1,169 and 1,948 women. Based on those numbers, the researchers estimated that for every 2,500 women screened, 2,470 to 2,474 never will be diagnosed with breast cancer and 2,499 will never die from breast cancer. Screening all those women will prevent only one breast cancer death, but it will mean that six to 10 women will be needlessly treated with surgery, radiation and, perhaps, chemotherapy.
This was reported in the April 3, 2012 issue of the Annals of Internal Medicine. The lead author of the analysis, Mette Kalager of Norway’s Telemark Hospital and a visiting scientist at HSPH, says that the results suggest that women need to be well-informed about the benefits and risks of mammography, including the fact that screening leads to a significant amount of over-diagnosis and that for the 26 to 30 women out of 2,500 whose mammograms reveal breast cancer, six to 10 of those cases would never prove harmful. She also noted that the study didn’t find a reduction in late-stage breast cancer, which could be expected if early detection via mammography prevents progression of the disease.
Mammography is an imperfect test, and there is widespread medical disagreement about how best to use it. A woman has to base her decision about screening on her understanding of the evidence, how she and her physician view her risk of breast cancer, and her comfort level with the benefits and risks of the procedure. Andrew Weil, M.D.