Younger kindergarteners more likely to be diagnosed with ADHD

Younger kindergarteners more likely to be diagnosed with ADHD

In a class of kindergarteners, a child born in August is about
30% more likely to be diagnosed with attention deficit
hyperactivity disorder (ADHD), and 25% more likely to be treated
for it, than a child born in September — if you have to be 5
years old by September 1st to start kindergarten.

These were the findings of a study
published in the New England Journal of Medicine. They didn’t
find such a difference between any two other months — and in
schools that didn’t have a September 1 cutoff for entry, the
difference between August and September disappeared.

It’s not a Leo versus Virgo thing: it’s age. In schools with
a September 1 cutoff, children born in August are a full year
younger than children born in September. For children who are only
5, a year is a lot, especially when it comes to maturity, and the
ability to stay focused and engaged on academic subjects. While
some children might be naturally more mature than others, a child
who is turning 6 is likely going to be able to sit still and focus
more than a child who just turned 5.

But that doesn’t mean that the 5-year-old has ADHD; it means
that the 5-year-old is acting normally for his or her age. And
that’s what is worrisome about the study: it suggests that at
least in some cases, teachers and doctors are mistaking normal
behavior for a problem. Even worse, some children are getting
medications that they really don’t need — or they wouldn’t
need, if they were just a little bit older or the classroom demands
were a little bit different.

Some families may see this study as proof that they should
“red-shirt” their child. (The term is borrowed from school
sports when a high school or college student is kept out of varsity
sports for a year to gain skills while still keeping their
eligibility to play; apparently they wear red shirts to set them
apart from other new players.) When parents red-shirt their child,
they wait an extra year before starting kindergarten. Parents are
more likely to do this when their child has a spring or summer
birthday, especially if their child is a boy. It’s thought that
the extra year gives them more time to mature and be ready for

There are certainly some children who benefit from a bit more
time before starting kindergarten, which has become increasingly
focused more on academics than on socialization and play. But I
would argue that parents shouldn’t have to do it — and many
families simply can’t afford to pay for another year of preschool
or childcare.

As a pediatrician, I see two big take-homes from this study.
First, teachers and doctors need to do a better job of factoring in
a child’s age and maturity level when assessing their behavior;
just because they are different from their classroom peers
doesn’t always mean that they have a psychiatric diagnosis, let
alone need medication. Some do, of course, but many just need

Second, we need to do a better job of accommodating the relative
differences in ages and maturity levels that exist in a perfectly
normal kindergarten classroom. We need to be able to meet children
where they are, and help each child get where they need to be —
with patience and support, not labels or medications. That
definitely means more support for teachers, but it also may mean
that we need to rethink kindergarten curricula. Maybe we had it
more right when we focused more on socialization and play. If a
child needs to be 6 to do what we are asking a 5-year-old to do,
maybe the problem isn’t with the child. Maybe it’s with us.

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Younger kindergarteners more likely to be diagnosed with ADHD

appeared first on Harvard Health Blog.


Can watching sports be bad for your health?

Can watching sports be bad for your health?

As the new year begins, sports fans rejoice! You’ve had the
excitement of the college football bowl games and the national
championship, the NFL playoff games are winnowing teams down to the
Super Bowl contestants, and basketball and hockey seasons are in
full swing. There’s even some early talk of spring training for
the upcoming Major League Baseball season.

While I hate to rain on anyone’s parade, the truth is that
there can be health risks associated with watching sports. I’ve
seen it firsthand while working in a walk-in clinic near Fenway
Park, where people would show up bleeding from cuts that needed
stitches (from trips and falls at the stadium), broken bones (from
trying to catch a foul ball or after an altercation with another
fan), dehydration, or other minor problems.

The problems can be more serious. In fact, studies have shown
that watching sports — whether live at the stadium or on
television — can have dire health consequences.

The big game may come with a big cost

Doctors and nurses often describe how quiet things get in the
emergency room during a World Series game or the Super Bowl. But
once the game ends, things get busy. It seems that many people with
chest pain, trouble breathing, or other symptoms of a potentially
serious problem delay seeking care until after the game.

Of course, there’s another possibility: the game itself —
especially if a game is close and particularly exciting — might
cause enough stress on the body that heart attacks, strokes, or
other dangerous conditions develop.

A number of studies support the idea that watching sports can
lead to health problems. For example, a 2017 study found
that spectators of Montreal Canadiens hockey games experienced a
doubling of their heart rate during games. The effect was more
pronounced for live games than televised games, but even the latter
experience led to faster heart rates similar to that during
moderate exercise.

A similar observation had been made in the 1990s by researchers
spectators of live Scottish football matches
: blood pressure
and heart rate rose dramatically compared to baseline measures
while at home. The maximal heart rates were recorded just after a
goal had been scored by the favored team.

Perhaps these observations explain why other studies have linked
hospital admission for heart failure
and even cardiac arrest
with watching sporting events. The former study (in New Zealand)
only found higher rates of heart failure admissions among women,
and the latter study (in Japan) only found higher rates of cardiac
arrest among older men. The gender differences remain

Keeping it in perspective

It’s worth emphasizing that most people who choose to watch
sports enjoy it and do not experience any health problems during or
afterwards. My sense is that people with no health problems are at
little risk even if they get worked up while watching sports, but
there may be some small risk (similar to what might accompany
moderate or vigorous exercise) for people who have cardiovascular

What’s a sports fan to do?

The obvious recommendation is to remember, it’s only a game.
But, ask anyone who cares about sports, sporting events, or a
particular team — it’s much more than that.

It’s also easy to suggest being careful about how much you
drink, to avoid overeating (especially salty junk food), and to be
aware of your surroundings. For example, if you’re at a baseball
game, pay attention to the game so you’ll at least have a chance
of getting out of the way of a line-drive foul ball. Notice where
the railings are and avoid leaning over dangerous ledges. And, of
course, avoid altercations with hostile fans. Stay well-hydrated if
you’re out in the heat for hours — remember that although beer
is a liquid, it can actually make you more dehydrated.

For people who have cardiovascular disease, don’t forget to
take your medications, even when there’s a big game on. Ask your
doctor about how much exercise your heart can take, and whether you
have any conditions that restrict your ability to exercise. If you
do, improving your cardiac fitness might help improve your ability
to exercise — and it might also make it safer to enjoy watching
the sports you love.

Follow me on Twitter @RobShmerling

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Can watching sports be bad for your health?
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Harvard Health

Fatty liver disease: What it is and what to do about it

Fatty liver disease: What it is and what to do about it

Non-alcoholic fatty liver disease (NAFLD), a condition of extra
fat buildup in the liver, is on the rise — it now affects roughly
20% to 40% of the US population. It usually doesn’t cause any
symptoms, and is often first detected by accident when an imaging
study (such as an abdominal ultrasound, CT scan, or MRI) is
requested for another reason. A fatty liver may also be identified
on an imaging test as a part of investigating abnormal liver blood
tests. NAFLD is intimately related to conditions like diabetes and
obesity. It’s also linked to an increased risk of cardiovascular
disease. Understanding NAFLD and its causes, consequences, and
treatment options is still a work in progress.

The many faces of fatty liver disease

There are lots of medical terms related to fatty liver disease,
and it can get confusing. The main medical umbrella term NAFLD
refers to a fatty liver that is not related to alcohol use. NAFLD
is further divided into two groups:

  • Non-alcoholic fatty liver (NAFL), otherwise known as simple
    fatty liver, or
  • Non-alcoholic steatohepatitis (NASH)

Why the type of fatty liver disease matters

Distinguishing between simple fatty liver and NASH is important.
Why? Because for most people, having simple fatty liver doesn’t
cause sickness related to the liver, whereas those with NASH have
inflammation and injury to their liver cells. This increases the
risk of progression to more serious conditions like fibrosis
(scarring) of the liver, cirrhosis, and liver cancer. NASH
cirrhosis is expected to be the number one reason for liver
transplant within the next year. Luckily, most people with NAFLD
have simple fatty liver and not NASH; it is estimated that 3% to 7%
of the US population has NASH.

It takes a liver biopsy to know if a person has simple fatty
liver or NASH. But the possible (though infrequent) complications
and cost of a liver biopsy make this impractical to do for everyone
with NAFLD.

Scientists are trying to find noninvasive ways to identify who
is at the greatest risk for fibrosis, and thus who should go on to
have a liver biopsy. Possible approaches include biomarkers and
scoring systems based on blood tests (such as the NAFLD fibrosis
score and Fibrosis-4 index), as well as elastography (a technology
which uses soundwaves to estimate fibrosis based on the stiffness
of the liver).

Keeping your liver healthy

If you have been diagnosed with fatty liver disease, it is
important to keep your liver as healthy as possible and avoid
anything that can damage your liver. Here are some important things
you should do.

  • Don’t drink too much alcohol. How much is too much remains
    controversial, but it’s probably best to avoid alcohol
  • Make sure that none of your medications, herbs, and supplements
    are toxic to the liver; you can crosscheck your list with this
    LiverTox Even acetaminophen
    (the generic ingredient in Tylenol and some cold medicines) may be
    harmful if you take too much for too long, especially if you have
    liver disease or drink alcohol heavily.
  • Get vaccinated to protect against liver viruses hepatitis A and
  • Control other health conditions that might also affect your
    liver, and check with your doctor if you might have other
    underlying, treatable diseases contributing to your fatty
  • Get regular screening tests for liver cancer if you already
    have cirrhosis.

What about drug therapy?

Unfortunately, there are no FDA-approved medications for fatty
liver disease. So far, the two best drug options affirmed by the

American Association for the Study of Liver Diseases
biopsy-proven NASH are vitamin E (an antioxidant) and pioglitazone
(used to treat diabetes). However, not everyone will benefit from
these treatments, and there has been some concern about safety and
side effects. If you have NASH, it’s best to speak to your doctor
about whether these treatments are appropriate for you, as they are
not for everyone. There are more drugs in the pipeline, some with
promising initial study results.

The most effective treatment: lifestyle changes

The good news is that the most effective treatment so far for
fatty liver disease does not involve medications, but rather
lifestyle changes. The bad news is that these are typically hard to
achieve and maintain for many people. Here’s what we know

  • Lose weight. Weight loss of roughly 5% of your
    body weight might be enough to improve abnormal liver tests and
    decrease the fat in the liver. Losing between 7% and 10% of body
    weight seems to decrease the amount of inflammation and injury to
    liver cells, and it may even reverse some of the damage of
    fibrosis. Target a gradual weight loss of 1 to 2 pounds per week,
    as very rapid weight loss may worsen inflammation and fibrosis. You
    may want to explore the option of weight loss surgery with your
    doctor, if you aren’t making any headway with weight loss and
    your health is suffering.
  • It appears that aerobic exercise also leads to
    decreased fat in the liver, and with vigorous intensity, possibly
    also decreased inflammation independent of weight loss.
  • Eat well. Some studies suggest that the
    Mediterranean diet may also decrease the fat in the liver. This
    nutrition plan emphasizes fruits, vegetables, whole grains,
    legumes, nuts, replacing butter with olive or canola oil, limiting
    red meat, and eating more fish and lean poultry.
  • Drink coffee, maybe? Some studies showed that
    patients with NAFLD who drank coffee (about two cups every day) had
    a decreased risk in fibrosis. However, take into consideration the
    downsides of regular caffeine intake.

Even though it can be difficult to make these lifestyle changes
and lose the weight, the benefit is immense if you have fatty
liver, so give it your best effort! And remember, the greatest risk
for people with a fatty liver is still cardiovascular disease. Not
only can some of these lifestyle changes improve or resolve your
fatty liver, they will also help keep your heart healthy.

The post
Fatty liver disease: What it is and what to do about it

appeared first on Harvard Health Blog.

Surgery for appendicitis? Antibiotics alone may be enough

Surgery for appendicitis? Antibiotics alone may be enough

I remember when my best friend in fifth grade couldn’t make
our much-anticipated end-of-the-school-year camping trip because he
had just undergone surgery for appendicitis.
Now I prevent kids from participating in their school activities
for four to six weeks after I remove their appendix. But what is
the appendix, why do we have an organ that causes so many problems,
and do you need surgery for appendicitis?

Role of the appendix is unclear

The appendix is a fingerlike tube, about three to four inches
long, that comes off of the first portion of the colon. It is
normally located in the lower right abdomen, just after the small
intestine (needed for digestion and absorption) turns into the
colon (whose purpose is to reclaim water and remove waste

The true function of the appendix remains unknown today, but one
debated theory is that the appendix acts as a storehouse for good
bacteria, to reboot the digestive system after a diarrheal illness.
Other experts believe the appendix is just a useless remnant from
our evolutionary past. Surgical removal of the appendix appears to
cause no observable health problems.

Today, appendicitis is usually treated with surgery

In the medical community, the suffix “-itis” refers to
inflammation (think arthritis, which is inflammation of a joint).
Many times, “-itis” is due to an infection — pharyngitis, or
strep throat, for example. After much research and debate, the
cause of “-itis” of the appendix is still unclear. However, it
appears that most causes of appendicitis are infectious agents,
such as bacteria, viruses, parasites, or fungi.

Whatever the cause, whenever there is an obstruction of the
entrance to the appendix — either from swelling or inflammation,
or from mechanical blockage, like a hard piece of stool or a tumor
— appendicitis may ensue. The real danger from appendicitis comes
from the potential of the appendix to perforate, or burst, which
can spread infection throughout the abdomen.

Even before 1886, when Dr. Reginald Fitz, a Harvard pathologist,
first described appendicitis as a surgical disease, physicians had
dealt with the pain and complications stemming from this tiny,
menacing organ. Today, the standard of care for the treatment of
appendicitis remains surgical removal of the appendix
(appendectomy), along with intravenous fluids and antibiotics. In
fact, appendectomy is one of the most common abdominal operations
in the world. It is also the most common emergency general surgical
operation performed in the United States. Most appendectomies are
performed by the laparoscopic technique, also known as
“keyhole” or minimally invasive surgery. Patients usually
remain at the hospital for less than 24 hours post-operatively.

Emerging evidence suggests antibiotics alone may be enough to treat

Many studies have demonstrated that surgery may not be necessary
for all cases of appendicitis. A paper published in June 2015
received international visibility and challenged the status quo
when antibiotic therapy was compared with surgery for the treatment
of appendicitis. The conclusion of the APPAC
(APPendicitis ACuta), which ran in Finland from November
2009 to June 2012, was that most patients who were treated with
antibiotics for uncomplicated acute appendicitis did not require
surgery during the one-year follow-up period. (Uncomplicated
appendicitis refers to those cases in which there is no evidence of
perforation or abscess formation, and in which the inflammation is
mostly confined to the appendix.) Those who eventually did require
appendectomy after failure of the antibiotic regimen did not
experience significant complications.

In 2018, the APPAC authors published a follow-up
in which they concluded that six out every 10 patients who were
initially treated with antibiotics for uncomplicated acute
appendicitis remained disease-free at five years. They again
concluded that antibiotic treatment alone appears feasible as an
alternative to surgery for uncomplicated acute appendicitis. Many
additional studies also support a nonoperative approach to
appendicitis. (And having spent almost 15 years in the navy, I know
that for sailors suffering from appendicitis at sea, the use of
powerful antibiotics has been the standard of care for decades when
access to a surgeon is not readily available.)

As is always the case in scientific research, these studies have
many limitations, including basic study design, multiple
confounding variables, misinterpretation of results, and intrinsic
flaws known to anyone using statistics. You can also find many
articles and rebuttals describing the problems with using
medication for a “surgical disease.” So as of now, while we
eagerly await more data on the integrity of antibiotics for the
safe use and definitive treatment of uncomplicated appendicitis,
surgery remains the gold standard.

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Surgery for appendicitis? Antibiotics alone may be enough

appeared first on Harvard Health Blog.

Heart disease and breast cancer: Can women cut risk for both?

Heart disease and breast cancer: Can women cut risk for both?

Very often I encounter women who are far more worried about
breast cancer than they are about heart disease. But women have a
risk of dying from heart disease 
than from all cancers
combined. This is true for women of all races and ethnicities. Yet
only about
50% of women
realize that they are at greater risk from heart
disease than from anything else.

Currently in the US, three million
are living with breast cancer, which causes one in 31
deaths. Almost 50
million women
have cardiovascular disease, which encompasses
heart disease and strokes and causes one in three deaths.

Here’s what’s really interesting, though: heart disease and
breast cancer share many of the same risk factors. What’s more,
there are two big risk categories that we can do something about:
exercise and diet.

Heart disease and breast cancer: How much exercise is needed?

have shown that the less physically active a woman is,
the higher her risks are for cardiovascular disease and breast
cancer. Of course, the flip side is that the more physically active
she is, the lower her risks.

How much physical activity is recommended? Well, the latest
government physical
activity guidelines
for Americans and the
American Heart Association guidelines on activity
both call for
at least 150 minutes of moderate physical activity weekly. That’s
only 21 minutes daily. More is better. But by current statistics,
less than 18% of women are meeting that minimum of 21 minutes a
day. Everything counts! Walking, gardening, taking the stairs,
dancing around, cleaning house. Exercise does not have to be at the
gym. Avoiding long periods of time sitting is key. So, sit less,
move more.

Heart disease and breast cancer: How can diet help?

Research also shows that a diet high in fruits and vegetables,
whole grains, and healthy protein (like seafood, tofu, or beans)
and low in refined grains, added sugars, and red and processed
meats is associated with a lower risk of both heart disease and
breast cancer. The American Cancer Society
nutrition guidelines for cancer prevention
and the American
Heart Association
nutrition guidelines for heart disease prevention
essentially the same:

  • DO Eat mostly plants, meaning fruits and vegetables; aim for
    plant proteins like beans, lentils, nuts, and seeds; eat whole
    grains like brown rice, quinoa, and corn instead of refined grains;
    if you’re going to eat meat, eat fish or poultry.
  • DON’T eat refined grains (things made with white flour; white
    rice); avoid added sugars and sugary beverages; try not to eat red
    or processed meats or other processed foods with chemicals (like
    fast foods or frozen dinners).

What else is important to know?

It’s critical to understand your risk factors for heart
disease — and what you can do to lower those risks. Sixty-four
percent of women who die of heart disease never have any symptoms
beforehand. Beyond an unhealthy diet and physical inactivity, other
major risk factors include smoking, obesity, diabetes, high
cholesterol, high blood pressure, growing older (particularly
post-menopause), and a family history of heart disease. It may be
important to check your “numbers” (blood sugars, cholesterol,
blood pressure) in order to know if any of these are a problem. For
women who have risk factors, we can screen for any heart disease
with a coronary artery CT scan.

It’s also important to know that women can have different
symptoms of heart disease than men. In my own practice, most of my
female patients who have had heart attacks thought they had acid
reflux. They experienced a burning feeling in their chest,
accompanied by nausea and even burping. One was even seen in urgent
care and told that she had acid reflux. The clue in all cases was
that the sensation was brought on by activity, not eating.

Mammograms are very important for breast cancer screening. What
age to start them and how often to have them is
somewhat controversial
. It should be individualized to the

I encourage everyone to meet with their doctor and discuss their
risks for heart disease and breast cancer, as further testing may
be required.

What’s the bottom line?

Physical activity and a healthy, plant-based diet are key for
heart disease and breast cancer prevention. Also, cardiovascular
disease and cancer treatment outcomes are better in patients who
adopt healthy lifestyle habits, especially
regular exercise
. Basically, a plant-based Mediterranean diet
and plenty of physical activity are sensible measures that are
important for prevention and even treatment of cardiovascular
disease and breast cancer — both major health issues for

Follow me on Twitter @drmoniquetello

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Heart disease and breast cancer: Can women cut risk for both?

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Long-term statin use protects against prostate cancer death

Long-term statin use protects against prostate cancer death

Statins and other drugs that lessen cardiovascular disease risk
by lowering blood lipids rank among the world’s most prescribed
medications. And for the men who take them, accumulating evidence
has for years pointed to another added benefit: a lower risk of
developing prostate cancer.

Now researchers are reporting that long-term statin use (more
than 10 years) can also reduce the odds of a prostate cancer death.
The new findings come from a study led by
Alison Mondul, a cancer epidemiologist at the University of
Michigan School of Public Health.

Mondul says that most men develop slow-growing, indolent
prostate cancers that will never become clinically relevant. Her
goal with this new study, she says, was to look more specifically
at whether statins protect against fatal prostate cancers.

Here’s what the researchers did

Since death from prostate cancer can take many years to occur,
Mondul and her team needed a dataset with an adequate duration of
follow-up. And the study they went to for data — the
Atherosclerosis Risk in Communities Study (ARIC)
— fit the
bill with a launch date of 1985. The ARIC study enrolled nearly
16,000 men and women between the ages of 45 and 64, and monitored
their heart disease outcomes until 2016. Mondul’s team zeroed in
on 6,518 men from the ARIC cohort who had enrolled between 1990 and
1992 — the beginning of the statin era. Approximately 25% of
those men were African Americans, and none of them had prostate
cancer when they entered the study.

Like all the ARIC participants, each of these men returned every
three years for an extensive physical exam, during which they also
supplied answers to questions about their medical history,
demographic and lifestyle factors, and medication use. By 1996, 21%
of the white men and 11% of the African Americans were using
lipid-lowering drugs, mostly statins. And by 2012, 750 of the men
had developed prostate cancer, and 90 of them had died of the

This is what they found out

Mondul’s investigation showed men who used lipid-lowering
drugs for more than 10 years were 33% less likely to develop a
fatal prostate cancer and 32% less likely to be diagnosed with
prostate cancer in the first place. Moreover, the protective
benefits were similarly evident among both white and African
American men.

Just why statins and other lipid-lowering drugs might protect
against prostate cancer isn’t clear. Mondul says some evidence
suggests accumulating lipids in cancer cells trigger altered,
pro-tumor signaling. “Statins are also anti-inflammatory, and
inflammation is a cancer hallmark,” she says.

More research is needed. Meanwhile, Mondul emphasizes that men
shouldn’t take statins (which can induce side effects including
headache, drowsiness, insomnia, and muscle aches) solely to guard
against prostate cancer. “But if men choose to take a statin for
cardiovascular benefits, then they should feel good about
influencing their prostate cancer risk in a positive way,” she

The post
Long-term statin use protects against prostate cancer death

appeared first on Harvard Health Blog.

NSAIDs: How dangerous are they for your heart?

NSAIDs: How dangerous are they for your heart?

Nonsteroidal anti-inflammatory drugs, commonly referred to as
NSAIDs, are one of the most common medications used to treat pain
and inflammation. Ibuprofen, naproxen, indomethacin, and other
NSAIDs are effective across a variety of common conditions, from
acute musculoskeletal pain to chronic arthritis. They work by
blocking specific proteins, called COX enzymes. This results in the
reduction of prostaglandins, which play a key role in pain and
inflammation. There are two types of NSAIDs: nonselective NSAIDs
and COX-2 selective NSAIDs (these are sometimes referred to as

There has been a growing body of evidence that NSAIDs may
increase the risk of harmful cardiovascular events including heart
attack, stroke, heart failure, and atrial fibrillation. Given the
widespread use of NSAIDs, these findings have generated significant
concern among patients and healthcare providers. I am frequently
asked by patients: is it safe to continue to take NSAIDs?

NSAIDs and cardiovascular disease: Minimizing the risks

There are several factors to consider when evaluating the
potential risk of NSAID therapy. The first is the duration of
treatment. The risk of having a heart attack or stroke is extremely
small over a short course of therapy (less than one month), such as
would be the case in treating acute pain from a musculoskeletal
injury like tendonitis. Another important consideration is dose and
frequency. The risk tends to increase with higher doses and
increased frequency. The third factor is whether the person has
existing cardiovascular disease. In people without known
cardiovascular disease, the absolute increase in risk is incredibly
small (one to two excess cardiovascular events for every 1,000
people who take NSAIDs).

My general principles for NSAID use are:

  1. In all patients, I recommend the lowest effective NSAID dose
    for the shortest duration of time to limit potential side
  2. In people without known cardiovascular disease, the increase in
    risk is so minimal that it rarely influences my decision about
    whether to use NSAIDs.
  3. In patients with known cardiovascular disease, I might advise
    an alternative treatment. Many patients with pre-existing heart
    disease can be safely treated with short courses of NSAIDs.
    However, the choice of specific NSAID and dose is more important in
    these patients. I generally recommend the nonselective NSAID
    naproxen or the COX-2 selective NSAID celecoxib, as studies have
    demonstrated that these two drugs may have the best safety profile
    in higher-risk patients.

In summary, although all NSAIDs are associated with an increased
cardiovascular risk, the magnitude of the increased risk is minimal
for most people without cardiovascular disease taking them for
short periods of time. For patients who have heart disease or who
require long-term treatment with high doses of NSAIDs, the
increased risk is more of a concern. If you fall into this
category, discuss your options with your healthcare provider to
determine whether an
alternative therapy
is possible, or to help select the safest
NSAID option for you.

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NSAIDs: How dangerous are they for your heart?
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Working with a disability

Working with a disability

A decade ago, I was completing my master’s degree in
environmental science and policy, and preparing to embark on a
multi-decade career in advocacy and public policy that would have
required not only long hours during the workweek, but frequent
travel and overtime. Unfortunately,
my body had other plans
. Slowly my experiences began to
erode my fantasies, until finally my vision of a flourishing
full-time career evaporated entirely.

The slow toll of disability on work life and goals

This didn’t happen suddenly or all at once. Instead, I
gradually and incrementally began to pull back from applying for
high-energy full-time jobs. As an alternative, I started opting for
part-time jobs while completing freelance work on the side to
supplement my modest income. I was lucky: I did eventually find a
decent-paying, part-time position in the environmental field, in a
municipal government that allowed me a flexible schedule and some
telecommuting opportunities. If I was too sick to work one day, I
could come in the next day or make it up another week. Since I only
had to be in the office two days a week, I didn’t have to
struggle to schedule and make my necessary medical appointments,
either. I held this part-time position for several years before
budget cuts contributed to my layoff. Since then it’s been more
of a struggle for me, as well-paid, part-time positions are
something of a unicorn in the working world in the United

As I’ve mentioned in
past posts
, having a chronic illness is like its own job.
It eats up hours and effort to attend medical appointments, fill
prescriptions, follow up on referrals, and be your own advocate.
This, coupled with the time and energy of dealing with symptoms and
attending to our bodies, can compromise one’s ability to work.
For some, it can limit the hours we can work or what conditions we
can work under — if we can work at all.

Options and legal protections available

In the United States, the American Disabilities Act
makes it illegal to discriminate against potential or
current workers due to disability. In order to be protected under
the ADA, one must have a medical condition — either physical,
mental, or intellectual — that limits a major life activity such
as performing manual tasks, learning, or working. In particular,
employers with 15 or more employees are required to provide
to those employers that have a documented
disability to enable them to carry out the essential functions of
their position. As long as those accommodations don’t cause the
employer a significant hardship or expense to meet, they must
attempt to meet their employee’s requests under the ADA.

In the past, accommodations I requested under the ADA and was
granted were the ability to sometimes from work from home or switch
working days as needed, turning off overhead fluorescent lights
above my desk, and taking frequent stretching breaks and snacking
on salty foods (I have very low blood pressure) throughout the work
day. I had a fellow employee request and receive an ergonomic seat
and keyboard setup for her work desk, while I recently had a friend
request a stand-up desk at her office due to disc issues in her
lumbar spine.

Here’s what you can do

If you have an amicable relationship with your supervisor, you
can approach them first with such reasonable accommodation
requests. However, at other times it may be more appropriate to
submit your requests directly through the human resources office.
Some employers may have onsite employee assistance programs (EAPs).
An EAP is a program designed to assist businesses and organizations
in addressing productivity issues by helping employees identify and
resolve personal concerns that affect their job performance —
including working with a disability.

For those employers that don’t have their own EAP, they can
contact the U.S.
Department of Labor’s Office of Disability Employment
, which offers resources — including best practices
and innovative strategies — that support hiring and retaining
employees with disabilities. Every state also has their own version
of a rehabilitation
that offers vocational rehabilitation (VR)
services free of charge to those who apply and are eligible.
Specifically, state VR agencies assist people with disabilities in
locating and maintaining employment, including negotiating
reasonable accommodations with a prospective employer.

Finally, for those who are concerned about working jobs that may
not offer health insurance,
many states enable Medicaid buy-in programs
or opt-in
programs for those who are disabled. For instance, in Massachusetts
there is there is a program through MassHealth (the state’s
Medicaid) called
that people with disabilities can qualify for
as long as they are working, as eligibility is not income-based
(though income is used to determine the monthly premium).

The bottom line

If you are having an issue finding or keeping work — whether
full-time or part-time — due to your disability, please contact
your state government’s rehabilitation commission, or search
online for disability advocacy groups near you for help. Because
those of us with chronic illness should be able to apply our
skills, experience, and training in the workplace and earn a decent

The post
Working with a disability
appeared first on Harvard Health Blog.

Grieving? Don’t overlook potential side effects

Grieving? Don’t overlook potential side effects

Nothing quite prepares you for the heartache of profound loss.
It settles in like a gloomy thrum — sometimes louder, sometimes
softer — with a volume switch you can’t entirely shut off.

For me, that heartbreak arrived this past October, when my
mother died after a long battle with Parkinson’s disease,
dementia, and disability. Now, for the first time in my life, I’m
experiencing real grief. As a health reporter, I know this
emotional experience comes with the risk for physical side effects.
“Most of these side effects are the result of emotional distress
responses,” explains Dr. Maureen Malin, a geriatric psychiatrist
with Harvard-affiliated McLean Hospital.

Whether you’re grieving the loss of a loved one, like I am, or
the loss of a job, a home, or a beloved pet, it’s important to
understand how the process puts your health in jeopardy.

Stress and grief

Grieving takes a toll on the body in the form of stress. “That
affects the whole body and all organ systems, and especially the
immune system,” Dr. Malin says. Evidence suggests that immune
cell function falls and inflammatory responses rise in people who
are grieving. That may be why people often get sick more often and
use more health care resources during this period.

But why is stress so hard on us? It’s because the body
unleashes a flood of stress hormones that can make many existing
conditions worse, such as heart failure or diabetes, or lead to new
conditions, such as high blood pressure or heartburn. Stress can
also cause insomnia and changes in appetite.

Extreme stress, the kind experienced after the loss of a loved
one, is associated with changes in heart muscle cells or coronary
blood vessels (or both) that prevent the left ventricle from
contracting effectively. It’s a condition called stress-induced
cardiomyopathy, or broken-heart syndrome. The symptoms are similar
to those of a heart attack: chest pain and shortness of breath.

Depression and grief

Intense feelings of sadness are normal when we’re grieving.
But some people become depressed. Up to 50% of widows and widowers
have depression symptoms during the first few months after a
spouse’s death. (By the one-year mark, it’s down to
10%). Depression symptoms include:

  • extreme hopelessness
  • insomnia
  • loss of appetite
  • suicidal thoughts
  • persistent feelings of worthlessness
  • marked mental and physical sluggishness.

Dr. Malin says people who are depressed often isolate themselves
and withdraw from social connections, and they often stop taking
care of themselves properly. “You’re not as interested in life.
You fall down on the job, miss doctor appointments, stop
exercising, stop eating properly. All of these things put your
health at risk,” she explains.

Picking up the pieces

It may seem impossible to think about maintaining good health
when it’s difficult to simply get through each day. But Dr. Malin
says it’s okay to just go through the motions at first (fake it
until you make it).

  • That may mean walking for five minutes every day, and then
    gradually increasing the amount of time you walk.
  • And even if you don’t feel like eating, go ahead and eat
    three healthy meals per day anyway. Your body needs calories to
    function, even if you’re not hungry. Eating too little may add to
  • And don’t forget about social connections, which are crucial
    to good health. Stay in touch with friends and loved ones. Try to
    get out of your house and spend time with others, even if it’s to
    talk about your grief.

One step at a time (and your doctor can help)

A good way to stay on top of your health when you’re grieving:
“See your doctor, especially if symptoms worsen, and get back to
a healthy routine as soon as possible,” Dr. Malin suggests. For a
while, at least, you can simply follow your doctor’s instructions
to maintain health, putting one foot in front of the other until
you develop your own routine.

In time — and there is no standard period of grief for anyone
— the sun will come out again, and you’ll feel a little
stronger emotionally and physically each day. I’m counting on
this. But we all need a foundation of good health in order to get
there. Let’s give ourselves that advantage. Our loved ones would
want that for us.

For more information, check out the Harvard Special Health
Grief and Loss: A guide to preparing for and mourning the death of
a loved one

The post
Grieving? Don’t overlook potential side effects
first on Harvard
Health Blog

Acne: What you need to know

Acne: What you need to know

When the teenage years arrive, they often come with those
annoying, distinctive pimples on the face, and often on the chest
and back too. These little skin imperfections tend to go away as we
get older, but for some of us, the painful, red and sometimes
yellow “zits” may last a lot longer into adulthood. Acne is one
of the most common skin problems in teenagers and young adults, and
causes significant emotional distress for many.

Acne is caused by inflammation in the pilosebaceous unit, the
place that harbors the hair follicle and the sebaceous gland. The
sebaceous gland produces sebum, an oily substance that lubricates
the skin. We still don’t know how this inflammation happens, but
it seems that sebum overproduction clogs the sebaceous gland, which
can lead to inflammation and eventually bacterial infection.

Is acne related to diet?

When I was a child, I remember my mother blaming the chocolate I
ate for all the pimples I had. I’ve heard other people say that
dairy products and sodas may cause acne. Although there are a lot
of theories, we still cannot categorically say that specific foods
cause acne. Some studies show an association between acne and
high-glycemic-load diets that include a lot of sugar, sodas,
juices, white bread, pasta, and heavily processed cereals. Small
research trials showed less acne when people eat a
low-glycemic-load diet, or a diet with plenty of whole foods, rich
in fruits and vegetables, and low in processed and refined
products. There is also research linking dairy consumption and
acne. The evidence is still weak, and none of these studies
establish a clear cause and effect, just an association. It is
nonetheless interesting that a pro-inflammatory and processed diet
is associated with more acne. It’s yet another reason to eat more
fruits and vegetables and avoid processed foods rich in sugar and

Treating acne

The first step when treating acne is to determine how bad the
problem is. Severe cases should be handled in the doctor’s
office. You can manage most mild cases with some simple
recommendations and over-the-counter products. What does mild acne
look like? The bumpiness is not widespread and includes just a few
whiteheads, blackheads, and small pimples. The treatment is not
that complicated, but there are no magic bullets. It may take two
to three months before you see improvement. Treat mild acne with
these five simple recommendations:

  • Limit washing your skin to twice a day.
  • Use gentle cleansers for sensitive skin.
  • Remember that skin irritation is common even with
    over-the-counter treatment. The irritation is at its worst around
    two weeks of treatment. After a few months, the irritation and dark
    areas eventually go away.
  • A fragrance-free moisturizer applied on top of the medication
    can reduce the irritation.
  • Using sunscreen is a good idea for people who have dark skin
    zits after treatment. The sunscreen can prevent further

What over-the-counter products should you use?

There is no need to buy expensive online products to treat mild
acne. There are three over-the-counter medications that work very
well: adapalene, salicylic acid, and benzoyl peroxide. (Watch out
if you use benzoyl peroxide, as it can bleach your clothes, linens,
and towels.) All these medications are quite effective for mild
acne, and combining them can work even better. Skin irritation is a
common side effect, and it can be more intense when using two
different products at once. If the irritation is significant, take
a break for a few days before applying again. Your skin will be
happier and thankful.

If mild acne doesn’t improve with home care

If this approach does not work as expected, consider
prescription medication. Primary care physicians and dermatologists
use a stepwise approach to treat acne, trying increasingly
significant treatments (oral medications like antibiotics, retinoid
lotions, or procedures like peels or laser treatments). Acne is not
only a cosmetic problem. People with acne have higher rates of
depression and anxiety, and it can be emotionally devastating for
some. Don’t give up, as there are many treatment options to try.
It can take time to find the one (or ones) that work for you.

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Acne: What you need to know
appeared first on Harvard Health Blog.