Tuesday, March 6, 2018

The Mind Diet – Rush University Medical Center

Rush University Medical Center dates back to March 2, 1837, when Rush Medical College received its charter. The college is named for Benjamin Rush, a signer of the Declaration of Independence and a Pennsylvania physician, who counted George Washington among his patients. He became a medical and humanitarian leader after the Revolutionary War. He was also a social activist, a prominent advocate for the abolition of slavery, for scientific education for the masses— including women—and for public medical clinics to treat the poor.

The Mind Diet, created by researchers at Rush University Medical Center, may help substantially slow cognitive decline in stroke survivors, according to preliminary research presented on Jan. 25 at the American Stroke Association's International Stroke Conference 2018 in Los Angeles. The findings are significant because stroke survivors are twice as likely to develop dementia compared to the general population.

The MIND diet is short for Mediterranean-DASH Diet Intervention for Neurodegenerative Delay; it is a hybrid of the Mediterranean and DASH (Dietary Approaches to Stop Hypertension) diets. Both have been found to reduce the risk of cardiovascular conditions such as hypertension, heart attack and stroke.

"The foods that promote brain health, including vegetables, berries, fish and olive oil, are included in the MIND diet," said Dr. Laurel J. Cherian, a vascular neurologist and assistant professor in Rush's Department of Neurological Sciences. "We found that it has the potential to help slow cognitive decline in stroke survivors." Cherian is the lead author of the study, which was funded by the National Institute of Aging. "I was really intrigued by the results of a previous MIND study, which showed that the people who were most highly adherent to the MIND diet cognitively functioned as if they were 7.5 years younger than the least adherent group," Cherian said. "It made me wonder if those findings would hold true for stroke survivors, who are twice as likely to develop dementia compared to the general population." "The Mediterranean and DASH diets have been shown to be protective against coronary artery disease and stroke, but it seems the nutrients emphasized in the MIND diet may be better suited to overall brain health and preserving cognition."  Cherian said that studies have found that folate, vitamin E, omega-3 fatty acids, carotenoids and flavonoids are associated with slower rates of cognitive decline, while substances such as saturated and hydrogenated fats have been associated with dementia. "I like to think of the MIND diet as a way to supercharge the nutritional content of what we eat. The goal is to emphasize foods that will not only lower our risk of heart attacks and stroke, but make our brains as resilient as possible to cognitive decline.”  Cherian cautions, however, that the study was observational, with a relatively small number of participants, and its findings cannot be interpreted in a cause-and-effect relationship.

Study co-author Martha Clare Morris, ScD, a Rush nutritional epidemiologist, and her colleagues developed the MIND diet based on information from years of research about what foods and nutrients have good, and bad, effects on the functioning of the brain. The diet has been associated with reduced Alzheimer's risk in seniors who adhered to its recommendations. Even people who moderately adhered had reduced risk of AD and cognitive decline.

Rush, in Chicago, is currently seeking volunteers to participate in the study, which aims to show whether a specific diet can prevent cognitive decline and brain changes with age. From 2004 to 2017, Cherian and colleagues studied 106 participants of the Rush Memory and Aging Project who had a history of stroke for cognitive decline, including decline in one's ability to think, reason and remember. They assessed people in the study every year until their deaths or the study's conclusion, for an average of 5.9 years, and monitored patients' eating habits using food journals.

The researchers grouped participants into those who were highly adherent to the MIND diet, moderately adherent and least adherent. They also looked at additional factors that are known to affect cognitive performance, including age, gender, education level, participation in cognitively stimulating activities, physical activity, smoking and genetics. The study participants whose diets scored highest on the MIND diet score had substantially slower rate of cognitive decline than those who scored lowest. The estimated effect of the diet remained strong even after taking into account participants' level of education and participation in cognitive and physical activities. In contrast to the results of slower decline with higher MIND diet score, stroke survivors who scored high on the Mediterranean and DASH diets, did not have significant slowing in their cognitive abilities. "This is a preliminary study that will hopefully be confirmed by other studies, including a randomized diet intervention study instroke survivors," say the authors. "For now, I think there is enough information to encourage stroke patients to view food as an important tool to optimize their brain health."

 The MIND diet has 15 dietary components, including 10 "brain-healthy food groups" and five unhealthy groups.
Foods to enjoy include
1) green leafy vegetables – 2 cups raw or one cup cooked, daily.
2) Berries – at least 2 cups a week.  Bananas count as a berry.
3) Vegetables and fruit – at least one serving daily -2 cups raw vegetables or one cup cooked, one cup fresh fruit or ½ cup dried.  An apple equals one cup.
4) Nuts  - almonds, pecans, walnuts et al. 1-2 ounces at least 3 times a week
5) Whole grains – 3 servings a day.  Oats, quinoa, spelt, rye, brown rice, whole grain pasta, buckwheat, 100% whole grain bread.
6) Seafood – at least one serving a week of salmon, sardines, trout or other seafood you enjoy.  4-6 ounces.
7) Beans – a serving every other day – fresh or cooked.  Wash canned beans to eliminate extra salt.  Unsweetened non-dairy milk: soy, almond, cashew or rice milk.
8) Poultry – at least 2 four  ounce servings a week, skin removed.  Poultry provides protein and vitamin B12, iron and zinc, important for cognitive health. 
9) Olive Oil – Use as primary oil for cooking and for salads and cooked vegetables.  Olive oil has many anti-oxidant and anti-inflammatory properties.  Use low to moderate heat when cooking with olive oil.  Grapeseed oil is also good for cooking and can be used at higher heat.
10) Wine – one 5 ounce serving of wine – containing alcohol or not. Wine has micronutrients such as resveratrol that help prevent degenerative diseases.  Red or purple grape juice may have same effects of wine on health – to be verified.

The diet also specifies limiting intake of the designated unhealthy foods
1) Red meat – beef, lamb, pork and duck – limit intake to 3 ounces less than 4 times per week. Look for lean, organic an/or grass fed options.  Avoid all cured and processed meats.
2) Pastries and Sweets – less than 5 servings a week – such as one small cookie.  Try to enjoy whole fruit instead.
3) Butter and stick margarine – Avoid any fat that is solid at room temperature, including palm oil, coconut oil and other shortenings.  No hydrogenated oil.  Limit butter to less than 1 ½ teaspoons daily.
4) Full-fat cheese – limit to 1.5 ounces, less than once a week.  Try low or no fat options, or vegan cheese.
5) Fried or fast food – limit to one small serving of fries twice a month at most.

Greenwood’s addenda:  1) Studies from Oxford University and elsewhere have shown that levels of vitamin B12 decrease with age and low levels can affect leaning and memory adversely.  B12 is only found in animal food.  Supplements are advisable in vegans and older people.  50 micrograms a day should suffice.
2) Alcohol use disorders are the most important preventable risk factors for the onset of all types of dementia, especially early-onset dementia, according to a nationwide observational study of over one million adults diagnosed with dementia in France.  Red or purple grape juice my have the same effects as wine on health – to be verified.
3 ) A cookbook based on the Mind Diet by Kristin Diversi is published by Ulysses Press: The Mind Diet Cookbook

Sadja Greenwood, MD, MPH   Past issues at sadjascolumns.blogspot.com

Monday, January 8, 2018

Children may Benefit from Omega 3 Fatty Acids in Fish

 According to a new report from the University of Pennsylvania, children who eat fish at least once a week sleep better and have IQ scores that are 4 points higher, on average, than those who consume fish less frequently or not at all. These findings were recently published in Scientific Reports, a Nature journal.

Previous studies showed a relationship between omega-3s, the fatty acids in many types of fish, and improved intelligence, as well as omega-3s and better sleep. But they've never all been connected before. This work, conducted by Jianghong Liu, Jennifer Pinto-Martin and Alexandra Hanlon of the School of Nursing and Penn Professor Adrian Raine, reveals sleep as a possible mediating pathway, the potential missing link between fish and intelligence.

"This area of research is not well-developed. It's emerging," said Liu, lead author on the paper and an associate professor of nursing and public health. "Here we look at omega-3s coming from our food instead of from supplements." For the work, a cohort of 541 9- to 11-year-olds in China, 54 percent boys and 46 percent girls, completed a questionnaire about how often they consumed fish in the past month, with options ranging from "never" to "at least once per week. They also took the Chinese version of an IQ test called the Wechsler Intelligence Scale for Children-Revised, which examines verbal and non-verbal skills such as vocabulary and coding (!).

Their parents then answered questions about sleep quality using the standardized Children Sleep Habits Questionnaire, which included topics such as sleep duration and frequency of night waking or daytime sleepiness. Finally, the researchers controlled for demographic information, including parental education, occupation and marital status and number of children in the home. Analyzing these data points, the Penn team found that children who reported eating fish weekly scored 4.8 points higher on the IQ exams than those who said they "seldom" or "never" consumed fish. Those whose meals sometimes included fish scored 3.3 points higher. In addition, increased fish consumption was associated with fewer disturbances of sleep, which the researchers say indicates better overall sleep quality.
"Lack of sleep is associated with antisocial behavior; poor cognition is associated with antisocial behavior," said Adrian Raine, who has appointments in the School of Arts and Sciences and Penn's Perelman School of Medicine. "We have found that omega-3 supplements reduce antisocial behavior, so it's not too surprising that fish is behind this.

The researchers see strong potential for the implications of this study. "It adds to the growing body of evidence showing that fish consumption has really positive health benefits and should be something more heavily advertised and promoted. Children should be introduced to it early on. That could be as young as 10 months, as long as the fish has no bones and has been finely chopped, but should start by around age 2.  Introducing the taste early makes it more palatable. It really has to be a concerted effort, especially in a culture where fish is not as commonly served or smelled. Children are sensitive to smell. If they're not used to it, they may shy away from it."

Given the young age of this study group, Liu and colleagues chose not to analyze the details participants reported about the types of fish consumed, though they plan to do so for work on an older cohort in the future. The researchers also want to add to this current observational study to establish, through randomized controlled trials, that eating fish can lead to better sleep, better school performance and other real-life, practical outcomes.

For the moment, the researchers recommend incrementally incorporating additional fish into a diet; consumption even once a week moves a family into the "high" fish-eating group as defined in the study.
"Doing that could be a lot easier than nudging children about going to bed," Raine said. "If the fish improves sleep, great. If it also improves cognitive performance -- like we've seen here -- even better. It's a double hit."  

Families who are vegetarians may consider making an exception and giving their children chewable fish oil capsules. 

Dear Reader – I will be going away for a month, so my columns will not resume until late in February. Past issues are at sadjascolumns.blogspot.com. Call me with any questions – I’m in the Bolinas Yellow pages, and you can get my cell phone from that number.   Sadja Greenwood, MD

Monday, January 1, 2018

Colon Cancer Survival Helped by Nut Consumption

 A new study sponsored by the Dana Farber Cancer Institute in Boston looked at people diagnosed with colon cancer, and found that eating tree nuts  lowered their chances of cancer recurrence. An observational study of 826 patients with stage III colon cancer showed that those who consumed two ounces or more of nuts per week had a 42% lower chance of cancer recurrence and 57% lower chance of death than those who did not eat nuts. The questionnaire was given after completion of chemotherapy in a study that began in 1996.  Stage III colon cancer is defined as cancer that has spread to surrounding lymph nodes.
 “Basic healthy eating can often be overlooked during cancer treatment. This study shows that something as simple as eating tree nuts may make a difference in a patient's long-term survival," said Dr. Daniel F. Hayes. "Nut consumption and a healthy diet are generally factors that clinicians and patients should perhaps pay attention to as they design the approach to treatment for colorectal cancer." A secondary analysis revealed the benefit of nut consumption was limited to tree nuts. Tree nuts include almonds, walnuts, hazelnuts, cashews, and pecans, among others. There was no associated reduction in cancer recurrence and death among patients who consumed peanuts or peanut butter. According to the authors, the reason may be that, being legumes, peanuts have a different metabolic composition than tree nuts
"Numerous studies in the fields of heart disease and diabetes have shown the benefits of nut consumption, and we felt that it was important to determine if these benefits could also apply to colorectal cancer patients," said lead study author Temidayo Fadelu, MD, a clinical fellow in medicine at Dana Farber Cancer Institute. "Patients with advanced disease who benefit from chemotherapy frequently ask what else they can do to reduce their chances of recurrence or death, and our study is an important contribution to the idea that modifying diet and physical activity can be beneficial."
Researchers were particularly interested in nut consumption because it has been linked to lower incidence of obesity, type 2 diabetes, and reduction in insulin resistance. These health conditions are each associated with a higher risk of recurrence and death from colon cancer. The benefit of eating nuts was consistent across known factors that can influence cancer recurrence, including patient age, body mass index, gender, and common genomic changes in the tumor.

"It should be emphasized that the authors are not suggesting that eating nuts should be considered a substitute for standard chemotherapy and other treatments for colon cancer, which have dramatically improved survival," said Dr. Hayes. "Rather, patients with colon cancer should be optimistic, and they should eat a healthy diet, including tree nuts, which may not only keep them healthier, but may also further decrease the chances of the cancer coming back."

"We need to look at the potential positive impact of nut consumption on survival at other stages of colon cancer, particularly stage IV. (Stage IV colon cancer is defined as cancer that has spread to other organs, such as liver or lungs.) Ultimately, we need to understand how nuts confer this protective effect, as well as possibly conduct a randomized, controlled clinical trial where diet recommendations are given at the start of the study to prove that tree nuts can reduce recurrence and death after treatment for colon cancer," said Dr. Fadelu.
Here’s a take-home message from this positive finding.  It’s a good idea to put nuts into your diet now – they can also help to prevent overweight, diabetes and heart disease.  Peanuts have also been found to have positive effects on our health.  If they fill you up with healthy fat, you’ll be ahead when it comes to super-sweet deserts!
Sadja Greenwood, MD, MPH

Thursday, December 14, 2017

More Good News about Coffee

 A recent paper, published in the British Medical Journal (BMJ), looked at over 200 studies on coffee drinking and health outcomes.  The work was done at the University of Southampton (England) and the University of Edinburgh.  Researchers reviewed over 200 observational studies across many countries.  Drinking coffee was consistently associated with a lower risk of death from all causes and from heart disease, with the largest reductions at 3 cups a day, compared with non-coffee drinkers.  Drinking more than 3 cups daily was not associated with harm, but the beneficial effect was less pronounced. There was less evidence for the positive aspects of decaf coffee, but it had similar benefits for a number of outcomes.  Some but not all of the studies corrected for factors that may be associated with coffee drinking, such as smoking, that may influence health outcomes.

Coffee was also associated with a lower risk of several cancers, including prostate, endometrial (uterine), skin and liver cancer, as well as type 2 Diabetes, gallstones, gout and cirrhosis of the liver. Finally, there seemed to be beneficial associations between coffee use and Parkinson’s disease, depression and Alzheimer’s.  

The authors concluded that coffee drinking seems safe within usual patterns of use, except during pregnancy and in women with increased risk of fracture.  They also wrote that there is substantial uncertainty about the effects of higher levels of intake.  It may be a trigger for rapid or irregular heartbeat in some people.  Additionally – coffee is often consumed with sugars and unhealthy fats  which may not be beneficial.

The warnings about coffee during pregnancy are based on an English and Swedish study showing that caffeine use may be associated with lower birth weight babies and an increased risk of miscarriage.    Caffeine from coffee, tea, chocolate , soft drinks and some medicines should be counted.  The authors suggest limiting caffeine use  - a cup of coffee contains about 100 mg of caffeine, while tea may have half that amount.  It may be prudent not to exceed one cup a day in pregnancy.  Avoid colas, whether sweetened with sugars or chemicals. In addition do not smoke during pregnancy and limit alcohol use to one small glass of wine once a week.  It is best to avoid alcohol completely, since studies on minimal amounts have not been done.  Binge drinking is associated with serious harm to the fetus.

Warnings against caffeine use in post-menopausal women come from a few studies looking at osteoporotic fractures and diet.  A 2001 study from Creighton University showed that a caffeine intake of more than 300 mg daily was associated with decreased bone density of the spine in women with a particular genotype influencing vitamin D receptors.   There is currently no test for this problematic vitamin D receptor.   The authors suggest that postmenopausal women at risk of osteoporosis decrease caffeine intake (no more than 3 cups daily) and use vitamin D supplements.

Ways to Avoid Overeating during the Holidays!
*Include lean protein sources at every meal – such as chicken (minimal skin), beans and fish.  Protein triggers a hormone that signals the brain to slow down emptying of the stomach.  This hormone also acts to decrease  the hunger promoting hormone called ghrelin. 
*Choose minimally processed, high fiber carbohydrates, such as whole grains and vegetables. You will feel full more quickly, and help your microbiome!
*Chew your food thoroughly, don’t gulp!  Eating more slowly allows you to know when you’ve had enough.
*Get enough sleep. Inadequate sleep is associated with increased levels of hunger and weight gain.

Sadja Greenwood, MD, MPH

Tuesday, November 21, 2017

Mushrooms and Your Well-being

Mushrooms are in the news.  They may contain unusually high amounts of two antioxidants that could help to fight aging and increase health, according to research done at Penn State University.  Penn State has a Center for Plant and Mushroom Products for Health. The antioxidants are ergothioneine and glutathione..  When we use food to produce energy, we produce ‘oxidative stress’ as free radicals are formed.  These free radicals are oxygen atoms with unpaired electrons that can cause damage to cells throughout the body.  Antioxidants such as ergothioneine and  glutathione can reduce this damage. 

The amounts of these compounds vary greatly between mushroom species. Porcini mushrooms contain the highest amounts.  White button mushrooms have less, but still higher amounts than most other foods.  Cooking mushrooms does not significantly affect the antioxidants.  Countries that have more of these antioxidants in their diet, such as France and Italy, have lower incidents of neurodegenerative diseases like Parkinson’s and Alzheimer’s.  This could be merely correlation and not causation, but is something to be noted.  About 5 white button mushrooms per day would give an amount of antioxidants that could be helpful, according to Penn State researchers.  Mushrooms are also good sources of vitamin D and B vitamins.

There is controversy about the safety of eating raw mushrooms, because of tough cells walls and a possible toxin that disappear with cooking .  I suggest cooking first.    The cooking techniques that preserve most of the benefits of mushrooms include microwaving and grilling.  However you use them, mushrooms greatly enhance the flavor of your food.

Many people buy dried porcini mushrooms in bulk, or use mushroom powder to sprinkle on their food.  Be exceedingly careful to check the species of mushroom you may collect in the wild after a rain.  Many species are poisonous, deadly poisonous.  Consult a book and an expert.

Sadja Greenwood, MD, MPH

Champiñones y tu bienestar 

Los hongos están en las noticias. Pueden contener cantidades inusualmente altas de dos antioxidantes que podrían ayudar a combatir el envejecimiento y aumentar la salud, según una investigación realizada en la Universidad Estatal de Pensilvania. Penn State tiene un Centro de productos de hongos y plantas para la salud. Los antioxidantes son ergotioneina y glutatión. Cuando usamos alimentos para producir energía, producimos "estrés oxidativo" cuando se forman radicales libres. Estos radicales libres son átomos de oxígeno con electrones desapareados que pueden causar daño a las células en todo el cuerpo. Antioxidantes como la ergotioneína y el glutatión pueden reducir este daño.

 Las cantidades de estos compuestos varían mucho entre las especies de hongos. Los hongos Porcini contienen las cantidades más altas. Los champiñones blancos tienen menos, pero aún cantidades más altas que la mayoría de los otros alimentos. Cocinar setas no afecta significativamente los antioxidantes. Los países que tienen más de estos antioxidantes en su dieta, como Francia e Italia, tienen menores incidentes de enfermedades neurodegenerativas como el Parkinson y el Alzheimer. Esto podría ser simplemente una correlación y no una causalidad, pero es algo que debe tenerse en cuenta. Alrededor de 5 setas de botón blanco por día daría una cantidad de antioxidantes que podrían ser útiles, de acuerdo con los investigadores de Penn State. Los hongos también son buenas fuentes de vitamina D y vitamina B. 

Existe controversia sobre la seguridad de comer champiñones crudos, debido a las paredes resistentes de las células y una posible toxina que desaparecen con la cocción. Sugiero cocinar primero. Las técnicas de cocción que conservan la mayoría de los beneficios de los hongos incluyen el microondas y la parrilla. Sin importar cómo los use, los champiñones mejoran en gran medida el sabor de su comida.  Muchas personas compran setas porcini secas a granel, o usan polvo de setas para rociar sobre sus alimentos. Sea extremadamente cuidadoso para controlar las especies de hongos que puede recolectar en la naturaleza después de una lluvia. Muchas especies son venenosas, mortales venenosas. Consulte un libro y un experto.
Sadja Greenwood, MD. MPH

Talking to Your Children About Sex

Last week I wrote a column about Nurx, an app or website that helps women order birth control or ‘morning after’ pills by mail. Women can order these drugs by using the app, answering a series of health questions, providing basic demographic information, and having their information reviewed by a physician.  They then choose their pills of choice, either birth control (pills or a vaginal ring) or emergency contraception (Plan B or Ella) after unprotected sex.  The doctor reviews their information, writes a prescription and the drug is delivered to the patient’s home or local pharmacy.  The service is available to women over the age of 12.

Young girls can use the app without parental knowledge, in situations when they feel they cannot talk with their parents about sex, either because of strict religious views or strong parental discomfort with the subject.  Here are some books that could help parents and children talk about sexual feelings and actions.   These books are recommended by The School Library Journal, a national monthly magazine with articles and reviews for school librarians, and public librarians who work with young people.   The books include Sex is a Funny word, which is filled with cartoons and is for younger kids, and Doing it Right: Making Smart, Safe and Satisfying Choices about Sex, which is for high school girls and boys.  These books, and others on the recommended list, reassure readers that developmental differences are quite normal.  They account for differences in gender, family makeup, and sexuality. Often the best way to a difficult topic is through fiction, and this is certainly the case with teen romance and sex.  The School Library Journal suggests:
·       The Fault In Our Stars, by John Green
·       Graceling, by Kristin Cashore
·       Finding Audrey, by Sophie Kinsella
·       *Aristotle and Dante Discover the Secrets of the Universe, by Benjamin Alire Sáenz
·       Love and First Sight, by Josh Sundquist
·       Goodbye, Stranger, by Rebecca Stead
·       Marcello In the Read World, by Francisco X. Stork
·       The Absolutely True Diary of a Part-Time Indian, by Sherman Alexie
·       Stargirl, by Jerry Spinelli
·       *Lily and Dunkin, by Donna Gephart
·       Fangirl, by Rainbow Rowell
·       *Tell Me Again How a Crush Should Feel, by Sara Farizan
Although issues of romance and love -- and teen angst! -- are universal and often transcend sexuality, books with an * will be of particular interest to LGBTQ readers.
Sadja Greenwood, MD, MPH

Nurx – the ‘Uber for Birth Control”

There’s an app for birth control and ‘morning after’ pills, called Nurx.  Women can order these drugs by using the app, answering a series of health questions, providing basic demographic information, and having their information reviewed by a physician.  They then choose their pills of choice, either birth control (pills or a vaginal ring) or emergency contraception (Plan B or Ella) after unprotected sex.  The doctor reviews their information, writes a prescription and the drug is delivered to the patient’s home or local pharmacy.  The service is available to women over the age of 12.

 Needless to say, Nurx has run into controversy, because  ‘morning after’ pills are considered abortion-causing drugs by people in Right to Life groups.  They believe that life begins at fertilization of the woman’s egg, even before it has implanted in the uterine wall.  This view is out of step with science , according to Susan Wood, an associate professor of health policy at George Washington University. She says that a fertilized egg is not the same as a pregnancy or the same as a person.  Half of all fertilized eggs never implant in the uterus, and a woman is not pregnant until the egg is implanted and stabilized.  Moreover, there is some evidence that emergency contraceptives may prevent the sperm from fertilizing the egg in the first place.  Dr. Jessica Knox, medical director for Nurx, says that by vetting patients’ information , and asking follow-up questions if needed, the company is going above and beyond the usual prescription of these drugs.  Nurx is available in California (and 15 other states, including Texas) and accepts Medicaid for payment, as well as other forms of insurance.  Nurx will also prescribe Truvada, a medicine for people who are HIV-negative, to reduce the risk of contracting HIV.  People using Truvada should also practice safe sex by always using a condom.
Controversy has also surrounded the prescription of birth control to girls 12 and older without parental consent.  Obviously it is important for parents to talk to their children, boys and girls, about sex and birth control early, as appropriate.  But in cases where there has been no communication about sex, many birth control centers have considered minors to be ‘emancipated’ and have provided birth control to prevent pregnancy at a young age. 
Sadja Greenwood, MD, MPH

Nurx - el 'Uber para control de la natalidad' 
Hay una aplicación para píldoras anticonceptivas y 'mañana después', llamada Nurx. Las mujeres pueden ordenar estos medicamentos usando la aplicación, respondiendo una serie de preguntas de salud, proporcionando información demográfica básica y haciendo que su información sea revisada por un médico. Luego eligen las píldoras de su elección, ya sea anticonceptivos (píldoras o un anillo vaginal) o anticoncepción de emergencia (Plan B o Ella) después de tener relaciones sexuales sin protección. El médico revisa su información, escribe una receta y el medicamento se entrega en el hogar del paciente o en la farmacia local. El servicio está disponible para mujeres mayores de 12 años.   Huelga decir que Nurx ha tenido controversia, porque las píldoras de "la mañana después" son consideradas drogas que causan el aborto por personas en los grupos Right to Life. Creen que la vida comienza con la fertilización del óvulo de la mujer, incluso antes de que se haya implantado en la pared uterina. Esta visión está fuera de sintonía con la ciencia, según Susan Wood, profesora asociada de política de salud en la Universidad George Washington. Ella dice que un óvulo fertilizado no es lo mismo que un embarazo o lo mismo que una persona. La mitad de los óvulos fecundados nunca se implantan en el útero, y una mujer no está embarazada hasta que el óvulo se implanta y se estabiliza. Además, existe cierta evidencia de que los anticonceptivos de emergencia pueden evitar que los espermatozoides fecundan el óvulo en primer lugar. La Dra. Jessica Knox, directora médica de Nurx, dice que al examinar la información de los pacientes y hacer preguntas de seguimiento si es necesario, la compañía va más allá de la prescripción habitual de estos medicamentos. Nurx está disponible en California (y en otros 15 estados, incluido Texas) y acepta Medicaid para el pago, así como otras formas de seguro. Nurx también recetará Truvada, un medicamento para personas que son VIH-negativas, para reducir el riesgo de contraer el VIH. Las personas que usan Truvada también deben practicar sexo seguro utilizando siempre un condón.  La controversia también ha rodeado la prescripción de control de la natalidad a las niñas de 12 años o más sin el consentimiento de los padres. Obviamente, es importante que los padres hablen con sus hijos, niños y niñas, sobre el sexo y el control de la natalidad temprano, según corresponda. Pero en los casos donde no ha habido comunicación sobre el sexo, muchos centros de control de la natalidad han considerado a los menores como 'emancipados' y han proporcionado anticonceptivos para prevenir el embarazo a una edad temprana.  Sadja Greenwood, MD

Wednesday, October 25, 2017


Here’s a surprising story from the San Diego International Airport.  For 10 non-consecutive days, signs were posted at the bottom of a set of stairs and escalators urging people to take the stairs.  The signs read: ‘Please reserve the escalator for those who need it’, or ‘Don’t lose time, lose weight. Use the Stairs’, or ‘Don’t waste Time, trim your Waistline. Use the Stairs’, or ‘You’ll get more stares if you use the stairs’, or ‘If you want to feel younger, act younger. Step it up! Use the stairs.’  On alternating days there were no signs posted. 

Researchers from the San Diego State University counted how many people took the stairs versus the escalator on days with and without the signs, and also interviewed people atop the stairs about their health and level of physical activity.  The research was headed by John Bellettiere, at UC San Diego, who is working on ways to help people sit less and move more.   On days when one of the signs was present, about twice as many people took the stairs compared to a no-sign day.  An important finding was that people who never exercised also used the stairs. People used the stairs even if they were in a rush and carrying luggage.  Bellettiere concluded that having even a small amount of exercise early in the day may lead to getting more later.  When people see others taking the stairs they are more likely to do so themselves, creating a ripple effect. 

Social science research has shown that there are many ways we can be ‘nudged’ into acting in ways that may be positive, or negative, for our well being.  Some utility companies get people to conserve power by sending out comparison notices, telling people how their use compares to others in the area who are using less.  This is a carefully designed strategy encouraging people to use less energy, and it has been successful.  If we believe other people are doing the right thing, we will want to do so also. The approach originates from the sociological concept of social norms, which holds that group members will respond to appropriate – or inappropriate  - values and behaviors held by others in their group.  The recent  Nobel Prize winner in Economics, Richard Thaler, wrote about these ideas in a book with Harvard lawyer Cass Sunstein – titled Nudge.  They consider their concepts to be from neither left nor right on many hot button issues, since a nudge does not restrict freedom of choice.

Be on the lookout for ways you are being subtly nudged by the culture around you.  Candy at the checkout counter at Safeway.  Signs urging you to walk up the stairs.  Wait a minute – that’s a good one.  Think of ways you can nudge yourself in a beneficial direction to exercise more.  Form a walking group; tell your friends what you plan to do; pay money to join a gym; write signs in your house that will inspire you to move, eat healthy food, or reach out to friends. 
Sadja Greenwood, MD, MPH  back issues on this blog

Monday, October 2, 2017

Your Microbiome has Circadian Rhythms

We humans have internal clocks; we experience daily changes in our energy, mood, appetite  and sleepiness based on time of day, light and dark, temperature and sleep patterns. These changes are known as circadian rhythms. Microbes in our gut, the so-called ‘microbiome’, have also been found to have circadian rhythms. Our gut bacteria make small rhythmical movements throughout the day and night. In so doing they impact our physiology and affect tissues far away from the gut, such as the liver.  Gene expression in the liver can change in tandem with the microbiome’s rhythm changes, resulting in variations in important liver functions, such as drug metabolism and detoxification. 

The new findings in a paper from the Weizmann Institute of Science in Israel, published 12/1/16 in the journal Cell, show that our circadian rhythms are deeply dependent on the oscillations of the gut microbes. Some of our daily rhythms are maintained but others are disrupted.  Previous work by the authors of this study, Eran Elinay and Eran Segal, showed that disrupting feeding times and sleep-wake patterns in mice induced changes in the gut microbiome.  Understanding more about this relationship could eventually help to find ways to intervene in obesity and it’s related metabolic problems, which are more common when circadian rhythms are disrupted due to shift work or jet lag.  Also, since most drugs, from Tylenol to chemotherapy, are metabolized by the liver, a better understanding of gut/liver rhythms could affect how and when medications are taken or given. According to Eran Segal “What we learned from this study is that there’s a very tight interconnectivity between the microbiome and the host.  We should think of it as one supraorganism that can’t be separated.  We have to fully integrate our thinking with regard to any substance we consume.” 
A take-home lesson from this study is that we should become more aware of our daily patterns of eating and sleeping, and try to keep them as regular as possible.  Eating during the day and letting the gut rest at night is desirable.  Also, remember that your gut microbiome thrives on the fiber found in vegetables and fruits. Think of yourself as a ‘supraorganism.’ !
Sadja Greenwood, MD, MPH  back issues on this blog


Monday, September 18, 2017

Lower Your Risk of Colorectal Cancer

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A new report from the American Institute for Cancer Research finds evidence that physical activity and eating whole grains lowers the risk of cancer of the colon and rectum, while processed meats increase the risk.   Edward Giovannucci, professor of nutrition and epidemiology at the Harvard School of Public Health, wrote “Colorectal cancer is one of the most common cancers, yet this report demonstrates there is a lot people can do to dramatically lower their risk.”  The new report evaluated scientific research worldwide, analyzing 99 studies that included data on 29 million people, of whom over a quarter million had colorectal cancer.  Risk factors included consuming hot dogs, bacon and other processed meats regularly, eating high amounts of red meat such as beef or pork, being overweight or obese, and consuming two or more daily alcoholic drinks, such as wine or beer.  On the other hand, eating about three servings of whole grains daily, such as brown rice, whole wheat or rye bread, quinoa (actually a seed, but good source of fiber) and other non-refined grains will lower the risk of colorectal cancer.  A higher risk was observed with low intakes of non-starchy vegetables intakes.  Lower risks were seen with fish and foods containing vitamin C, such as oranges, strawberries and spinach. According to Alice Bender, Director of Nutrition Programs for the American Institute of Cancer Research, “Replacing some of your refined grains with whole grains and eating mostly plant foods, such as fruits, vegetables and beans, will give you a diet packed with cancer protective compounds and help you manage your weight, which is so important to lower risk.” 

The most common cancers in the U.S, today are breast, lung, prostate and colorectal.  Factors that reduce the risk of colorectal cancer, as suggested in this column, are also helpful in lowering the risk of breast, lung and prostate cancers.  Maximize your intake of vegetables and fruits, go for varied colors, think fiber, keep your blood sugar low and even, and get yourself, and your dog, out for a walk.    Next week – I’ll report on how the bacteria in your gut – your microbiome,  show subtle movements throughout the 24 hour cycle and influence your metabolism.  If possible, keep a steady sleep schedule in tune with nature’s light and dark.  
Sadja Greenwood, MD, MPH  search this website for back issues 

 Baje su riesgo de cáncer colorrectal
Un nuevo informe del Instituto Americano para la Investigación del Cáncer encuentra pruebas de que la actividad física y comer granos enteros reduce el riesgo de cáncer de colon y recto, mientras que las carnes procesadas aumentan el riesgo. Edward Giovannucci,
profesor de nutrición y epidemiología de la Escuela de Salud Pública de Harvard, escribió que "el cáncer colorrectal es uno de los cánceres más comunes, pero este informe demuestra que hay mucha gente que puede hacer para reducir drásticamente su riesgo". la investigación científica en todo el mundo, analizando 99 estudios que incluían datos sobre 29 millones de personas, de las cuales más de un cuarto de millones tenían cáncer colorrectal. Los factores de riesgo incluyen el consumo de perritos calientes, tocino y otras carnes procesadas regularmente, comiendo grandes cantidades de carne roja como la carne de res o de cerdo, el sobrepeso u obesidad, y el consumo de dos o más bebidas alcohólicas diarias, como el vino o la cerveza. Por otro lado, el consumo de tres porciones de granos enteros al día, como el arroz integral, el trigo integral o el pan de centeno, la quinua (en realidad una semilla, pero buena fuente de fibra) y otros granos no refinados reducirá el riesgo de cáncer colorrectal . Se observó un riesgo mayor con la ingesta baja de ingestas de hortalizas no almidonadas. Menores riesgos se observaron con los pescados y los alimentos que contienen la vitamina C, tales como naranjas, fresas y espinaca. Según Alice Bender, Directora de Programas de Nutrición del Instituto Americano de Investigación del Cáncer, "Reemplazar algunos de sus granos refinados con granos enteros y comer principalmente alimentos vegetales, como frutas, verduras y frijoles, le dará una dieta llena de proteínas protectoras del cáncer compuestos y ayudarle a manejar su peso, que es tan importante para reducir el riesgo ". 

Los cánceres más comunes en los Estados Unidos son el de mama, pulmón, próstata y colorrectal. Los factores que reducen el riesgo de cáncer colorrectal, como se sugiere en esta columna, también son útiles para reducir el riesgo de cánceres de mama, pulmón y próstata. Maximice su consumo de verduras y frutas, opte por colores variados, piense en fibra, mantenga su nivel de azúcar en la sangre bajo e incluso, y consiga que usted y su perro salgan a pasear.  La próxima semana - voy a informar sobre cómo las bacterias en su intestino - su microbioma, mostrar movimientos sutiles a lo largo del ciclo de 24 horas e influir en su metabolismo. Si es posible, mantenga un horario de sueño estable en sintonía con la luz y la oscuridad de la naturaleza.
 Sadja Greenwood, MD sadjascolumns.blogspot.com para los números anteriores