All posts by Richard Saint Cyr MD

Alcoholism: A Family Scourge

I miss my father. He should be around to be granddad to my wonderful boys, helping me raise them to be good men. But he’s not around, dying far too early, from alcoholic cirrhosis of the liver. Only in his mid-60’s, he was a wonderfully warm-hearted man with a deep belly laugh, very much the average-guy Martin Crane to my Frasier Crane-like stuffiness. But he was also an alcoholic who slowly drank himself to death.

I have countless fond memories of us over the years, but I also have nightmare memories of holding his hand as he died in the hospital, in a coma, his skin yellow and lungs filled with fluid as his kidneys and liver finally gave up from the years of toxic abuse. These are memories that no child should have — but so many do.

My father

Why is alcoholism such a scourge to society? When compared to many other common diseases such as heart disease, alcoholism has a much more devastating social effect — not just on that person, but also their family, who painfully watch for years, helplessly, as their loved one slides into decline. Yes, many diseases are terrible and affect others; smoking can cause secondhand smoke diseases to family members. But alcoholism is a sad disease, and it’s those bad memories that really haunt families of alcoholics — memories of being afraid as we weave across wintry roads as dad drives home tipsy; memories of mom crying as dad refuses to hand over the car keys; memories of watching his belly get bigger and his memory weakening as his liver starts to fail.

So as we honor Alcohol Awareness Month this April, I’d like to use this opportunity to spread the word about alcoholism, hopefully to help a few people out there.

The first step, as anyone in 12-step programs will tell you, is to admit there may be a problem. If you’re not sure, just answer these four simple questions:

  1. Have you ever felt you needed to Cut down on your drinking?
  2. Have people Annoyed you by criticizing your drinking?
  3. Have you ever felt Guilty about drinking?
  4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

If you’ve answered “yes”  to 2 or more, then you indeed may have a problem with alcoholism and may already be causing liver damage. These questions above are called the “CAGE questionnaire” and are used by doctors as a screening tool for alcoholism.

What If You May Be Alcoholic?

First of all, congratulations if you’re honest enough to admit you may have a problem. Secondly, you need to know that you are not alone, and many people and organizations can help you:

  • Your family doctor can check out your liver and kidney health.
  • Some newer medicines, like naltrexone, may actually help you quit drinking; your doctor can discuss these with you.
  • Twelve step programs such as Alcoholics Anonymous aren’t for everyone, and there’s contradictory evidence as to how effective they are. But for many recovering alcoholics, they’ve been a source of strength, all over the world. You can find a list of AA sites in the US here.
  • Psychologists and psychiatrists can help you in many ways, from quitting drinking to processing underlying stresses and depression, to fixing family and job problems related to your drinking.

    dad on the twins second birthday
    My dad with us, at 2 years old. That’s me on the right (I think)

My Dad’s Legacy

Clearly, living through my dad’s illness has had a profound influence on me as a doctor, and I do find myself drawn to these patients. I’m sure it’s partly an effort to make up for what I couldn’t do for my own dad.

But despite all the pain of those later years, my strongest memories are the good ones. I will always remember his laugh, and to this day I vividly remember how he could light up a room. I’d like to end with a poem from Ralph Waldo Emerson, which we used at his wake:

To laugh often and much;
to win the respect of intelligent people
and the affection of children;
to appreciate beauty;
to find the best in others;
to leave the world a bit better
whether by a healthy child,
a garden patch, or a redeemed
social condition; to know even
one life has breathed easier
because you have lived.
This is to have succeeded.

Diabetes: Healthy Lifestyle Choices Are Key

I’ve been a family doctor for fifteen years, and one of the more dramatic changes I’ve noticed is a big spike in the incidence of prediabetes and diabetes, in all age groups. I had worked in China for ten years until last summer, and all us family doctors at my Beijing clinic weren’t surprised at all with the 2013 paper published in JAMA confirming the frightening reality in China: more than half of all adults in China now are prediabetic. Even worse, 11.2% have diabetes, giving China the dubious distinction of having the highest prevalence of diabetes in the world — higher than in the USA, an extraordinary statement given the far higher rate of obesity in the USA. As this epidemic spreads,  I felt a timely urgency to share my advice on how to avoid this disease – or at least to slow it down.

It helps me to think of diabetes as a modern lifestyle disease, mostly caused by all developing countries’ gains in weight, less physical activity, and changes in diet. Diabetes now is a global pandemic. Tens of millions of people have diabetes, and many people are undiagnosed because they’ve never been tested. There are two types of diabetes, and type 2 diabetes accounts for 90 to 95 percent of diagnosed diabetes in adults.

Prediabetes concerns us doctors because it means you are at extremely high risk of developing diabetes in the next few years. Studies show that a prediabetic person has a 25% risk of developing diabetes within three years, and a majority within ten years. The greatest risk factor by far is overweight and obesity. Having a BMI under 23 is ideal, and a BMI of 25 increases your lifetime risk of diabetes by 600%. A BMI of 30 increases your risk by 4,000% — that’s 40 times the risk! That’s an extraordinary number which should worry us all, since in the USA over two thirds of adults are overweight and over a third are obese.

But here’s the good news: the crucially important message for everyone is that you have great control over whether or not you develop full diabetes. You should think of prediabetes as an early warning sign by your body, a major wake up call that whatever you’ve been doing to your body isn’t too healthy. Most people with prediabetes fit one or more of these three major risk factors: body mass index (BMI) over 25; lack of enough exercise; and unhealthy food choices as well as portion sizes.

So let’s say that you’re one of the many people who has prediabetes: what can you do right now to help? If you follow the three lifestyle steps below, you can lower your risk more than half! One of the most important public health research studies ever, the Diabetes Prevention Program, proved that lifestyle changes worked better than pills in reducing progression to diabetes. Lifestyle changes lowered a prediabetic person’s risk by 58% over three years — much better than the 31% improvement with a daily pill (metformin).

So what are these magic steps? Without further ado:

  1. Lose weight. Weight gain and obesity are the top causes of type 2 diabetes, and losing weight is now proven to be the most effective prevention. In the DPP study, the goal was to lose at least 7% of your body weight. Your goal should be to lose 5-10% of your body weight.
  2. Exercise. Exercise may not directly cause much weight loss, but exercising muscles absorb sugars much more effectively. This is why exercising is crucial to help control sugars, both in a prediabetic as well as in diabetics. How much exercise is enough? We usually recommend 150 minutes a week of moderate exercise, but any amount is better than nothing. Also, as I mentioned in an earlier column, shorter, more intense workouts can help as much as moderate exercise.
  3. Proper diet. Healthy food choices also are crucial to control your sugars. One of the most common misperceptions about diabetes and prediabetes is that it’s “a sugar problem” and you must cut down on sweets and desserts. The bigger culprit are total starches — pastas, breads, rice and potatoes. In all these cases, processed versions are never as healthy as the originals.

Here are a few quick tips on nutrition:

  • Brown is always better than white: Processed white bread and flour have lost all the nutritious fiber which helps regulate your bowels as well as your sugar spikes after a meal. If you love your carbs, at least try to switch to whole wheat pastas, breads and rice.
  • Portion control: Total calories are also important, as most likely you are taking in a bit more than you realize. These extra calories will get deposited as fat, which leads to more risk of diabetes.
  • Cut back on sodas, beer and juices: All of these are empty calories, full of processed sugars which stress out your liver and pancreas. These unhealthy carbs, especially in sodas, are a major cause of obesity and diabetes in both children and adults.

Type 2 diabetes is partly genetic, so no matter how healthy you are, it still may be inevitable. But these above steps are always good advice for all of us. Another great thing about these healthy life changes is that they also dramatically reduce your risk of heart disease, many cancers, and early deaths from all causes.

Don’t get discouraged — you have control over the next steps!

Not Sleeping Well? Here’s My Advice.

This week, March 6 – 13, is National Sleep Awareness Week, so it’s a good time to review healthy sleep habits. I see a lot of adults and teens in my clinic who are chronically tired and have troubles sleeping — both falling asleep and staying asleep.

How Much is Enough?

According to the National Sleep Foundation’s research, here’s the amount of sleep we need:

  • Newborn (0-3 months): 14-17 hours
  • Infant (3-12 months): 12-15 hours
  • Toddler (1-2 years): 11-14 hours
  • Preschool (3-5 years): 10-13 hours
  • School age (6-13 years): 9-11 hours
  • Teenager (14-17 years): 8-10 hours
  • Adult (18-64 years): 7-9 hours
  • Older adult (>65 years): 7-8 hours

One of the main problems with insufficient sleep is the daytime sleepiness, an obvious consequence of not sleeping enough. A fascinating series of tests in children showed that insufficient sleep and daytime sleepiness both lead to worse school performance. Most of these children went to bed at 9-9:30 am and almost all got up at 7 am, causing a daily sleep debt of 1/2-1 hour for many children. While that may seem like a small amount, like any debt, it must be paid back, and most children cannot recover all of this lost time by sleeping late on weekends.

One good bit of news from the same study describes how delaying school start times even by just a half hour can significantly improve sleep duration and daytime sleepiness. In their interventional study with six primary schools in Shanghai, delaying school openings from 7:30 to 8 or 8:30 gave the children almost an hour of extra sleep — and more importantly, less complaints of daytime sleepiness. This fits with studies in other parts of the world and supports the growing movement, led by pediatricians, to delay school opening times to 8:30 am. Just doing this could allow better sleep and improved test scores for all students!

Besides school performance, poor sleep also leads to an increased risk of overweight and obesity in children (as well as adults). A 2007 meta-analysis of 36 studies across the world showed a strong, independent association between short sleep duration and weight gain in children, which continues into adulthood.

For adults,  poor sleep can cause long-term problems with high blood pressure, depression, diabetes and obesity. It can also cause dangers such as sleeping behind the wheel or more errors at work (medical training and internships are notorious for this, as are night shift workers driving home).

My tips for sleeping well

Get all screens out of the bedroom. Technology is changing so quickly that it’s difficult for research to keep up. But it’s clear that many people are having a lot more sleeping troubles when using their iPads and cell phones at bedtime. It’s partly because their backlight alters our sleep hormones, but also it’s distracting us with answering text messages even after lights out. I think a great general rule, for adults and kids, is no screen time two hours before bedtime (that includes TV), and definitely get all screens out of your bedroom while you sleep.

Exercise often — but early. Exercise has been shown to improve sleep habits, but only if done at least four hours before bedtime. Otherwise, you still may have too much metabolic energy and will have trouble falling asleep. This is also a good tip for kids who are having sports practices late into the night.

Avoid alcohol and smoking before sleeping. Alcohol is a major cause of insomnia for many. Drinks will certainly make you sleepy, but your body will rebound and wake you up in the middle of the night. It’s far better to have only a drink or two, at least 2 hours before bedtime. Smoking causes the same problems; that initial relaxation quickly wears off and the nicotine stays in your system for hours.

Caffeine is another major cause of poor sleep. As we get older, we cannot handle the triple-shot cappuccinos which we had in college, and it’s very common to have poor sleep with any caffeine drinking after lunchtime. So if you’re having light sleep, definitely take a look at your caffeine habits first; any tea, sodas or coffee after lunch may be keeping you awake. If you must have your afternoon coffee, at least try to switch to decaf.

Other tips include not staying in bed if you can’t sleep. If you can’t fall asleep, after 20 minutes of trying you should get up and try to relax in another room. Staying longer in bed generally makes you more anxious, making it even harder to fall back asleep.

Take a nap. Napping, even if only 20-30 minutes when needed, has been shown to have great benefit for short term memory and concentration. As I get older, I definitely lag more in the afternoon, and a 15 minute power nap at lunch really helps me get through a busy clinic afternoon (as does a lighter lunch).

What about natural medicines and non-prescription pills? Many people use over the counter pills such as Tylenol PM. It does work well, in the short term, for many people — but I strongly advise not taking it regularly, as the Tylenol component is totally unnecessary and can cause liver problems if taken chronically. If you must use this medicine, please buy only the active ingredient, diphenhydramine (Benadryl) separately and only use that. As for natural medicines, melatonin works for some types of insomnia but is rarely very effective. Others may consider an herbal capsule with valerian and other compounds such as passionflower, hops or lemon balm.

 

 

Don’t Skip Breakfast! Here’s Why.

Did you know that the U.S. Center for Disease Control predicts that one third of all Americans will have diabetes by the year 2050? This scary statistic is not just an American phenomenon; many Western countries’ modernized diets have led to a diabetes epidemic. The main culprits are what you would expect: obesity and an unhealthy diet. These lifestyle patterns are set as children, and are very difficult to change later on.

So what steps can we take to prevent this? As we recognize National School Breakfast Week, one crucial step is to always have breakfast. Most of the 20-30% of children and teens skipping breakfast may think it’s no big deal, but the long-term consequences of skipping breakfast can be serious enough to warrant a big family discussion. We all know instinctively that eating breakfast is important, and research can help parents convince their kids to eat breakfast — as well as eat it themselves!

Most kids are very focused on the present, and they just won’t be motivated with any talk about health risks decades down the line.  But they’re much more open to data showing how breakfast-skippers not only gain more weight, but they also do worse in school. So if you have an overachiever child who runs out the door in the morning without breakfast, show them the studies showing that breakfast skippers perform worse in school exams.

And here’s an important tip for parents whose child is terrified of gaining weight and skips breakfast: children who skip breakfast actually end up more obese than those who eat breakfast! The main reason for this is mostly because breakfast-skippers get very hungry by lunchtime and end up binge-eating more, usually with less healthy mid-morning snacks and bigger lunch portions. Also, because their metabolism is in a partial fasting mode without breakfast, the body stores more energy from foods as fat, instead of just breaking it down to glucose for your brain and muscles.

Adults also don’t get a pass for skipping breakfast, as they get the same slow weight gain as kids do. The importance of eating breakfast was impressively covered in the Childhood Determinants of Adult Health Study. In this fascinating study from Australia, researchers asked 2,000 school children about their breakfast habits, then followed up with them 20 years later and assessed their health. The results were striking; those kids who skipped breakfast all those years had a larger waist — by 2 inches! These same kids as adults also had higher insulin levels, which leads to more diabetes. They also had higher total cholesterol and the “bad” cholesterol, LDL — both of which cause clogging of the arteries and lead eventually to heart attacks and strokes. Another long term study, this time from Japan, followed 82,000 people for 15 years and found that the breakfast-skippers have a 14% increased risk of heart disease and 18% higher risk of strokes.

And for those of you worried about diabetes, or told you are prediabetic, it’s very important to follow the usual advice to have small, frequent meals instead of one or two large meals. Another excellent study, the Health Professionals Follow-Up Study, followed 29,000 American men for 16 years, and found that the breakfast skippers had a 21% increased risk of developing diabetes.

The type of breakfast is also important. The main research suggests what is obvious to parents — that simple sugars in sweetened cereals are much less healthy than high-fiber, more complex whole-grain cereals as well as fruits, nuts, and dairy products. Those quick energy bursts from the sugary cereals give kids a quick “high” which just as quickly wears off, and their brains and body are dragging along come lunchtime.

My advice for those of you who skip breakfast because “I have no time”: at least try to have a cup of yogurt with some fresh berries and cereal in the morning. You can throw it in your bag, along with a banana, and eat it on the way to school or work. Yogurt by itself is a superfood with its calcium and probiotics, and daily yogurt actually helps you to keep your weight stable. And blueberries are packed with healthy antioxidants and fiber.

So, the next time your kids are trying to run out the door before breakfast, sit them down in front of a bowl of Wheaties with yogurt and tell them how breakfast helps with better grades as well as better health — now, and in their futures.

Rubber Ducky You’re The One — To Cause Diabetes and Cancer?

My boys are now both over two years old, but they still like the occasional chew on their toys, which are mostly made of plastic. Rubber duckies, Lego men, Brio trains — it’s still a ton of fun to put in their mouths if it makes mommy and daddy really mad. I choose my battles with them, but I try to stop them partly because I’m worried about the chemicals in the plastic. Surely, microscopic parts of that plastic must be getting into their systems? One set of bath toys was very typical, made in China but exported to America, from a company vowing they are “safe and dependable”, with standards that “meet and exceed” US laws. What exactly does that mean? What are these laws? Should I be worried? And just how well can I or any parent protect our children from all environmental harms?

When I think about our modern world’s reliance on chemicals and plastics, I’m reminded of what Donald Rumsfeld called the “known unknowns” – we know that we understand almost nothing about the safety of the 80,000 consumer chemicals created since World War II, because they’ve never been required to be tested on humans. As the WHO states in their 2012 report State of The Science of Endocrine Disrupting Chemicals, “the vast majority of chemicals in current commercial use have not been tested at all.

bathtoy

The chief concern is that some of these chemicals are endocrine disruptors, which are chemicals whose molecular structure is similar to our natural hormones. With this mimicry, they can bind to the same receptors that our natural hormones do, thus altering our normal endocrine activities which control  just about every aspect of our health. We are mostly worried about children because these endocrine disruptors could cause permanent damage during our most sensitive growth spurts: while still developing in the womb, and later during puberty. The most notorious example of an endocrine disruptor is diethylstilbestrol (DES), a synthetic estrogen which was given to many pregnant women in the decades after World War II as a treatment to prevent birth complications. But slowly it became clear that many newborn girls of these mothers were getting a rare vaginal cancer, and DES was banned and declared a carcinogenic — but even right now many of these same “DES daughters” are continuing to have reproductive health problems both for themselves as well as in their own children, which means some endocrine disruptors can permanently alter our DNA, affecting generations.

The US Endocrine Society published an even more damning document, their 2015 Scientific Statement on Endocrine-Disrupting Chemicals, which concludes that

…there is strong mechanistic, experimental, animal, and epidemiological evidence for endocrine disruption, namely: obesity and diabetes, female reproduction, male reproduction, hormone-sensitive cancers in females, prostate cancer, thyroid, and neurodevelopment and neuroendocrine systems.

The prestigious JAMA Pediatrics published their own review of endocrine disruptors in 2012, essentially agreeing with the WHO’s assessment that while hard data on humans isn’t very strong, there’s enough concerning data to conclude that “efforts to reduce EDC exposure as a precaution among pregnant women and children are warranted.” Chemicals such as BPA, PVC and phthalates are most often mentioned as causing harm in boys and girls, associated with infertility, obesity, cancers and neurodevelopmental problems such as behavioral issues and a lower IQ.

Plastic ID Codes and Properties. Source: tinyurl.com/o487x9o
Plastic ID Codes and Properties. Click to enlarge. Source: tinyurl.com/o487x9o

So what can we all do to protect ourselves? After all, everything we touch almost literally has plastic as part of it. I’ve found a few consumer groups and blogs that offer helpful advice for worried parents. My favorite is The Soft Landing blog, which has a very useful collection of safer product shopping guides. The Pediatric Environmental Health Specialty Unit also offers similar advice. Here’s a small summary of what most are advising:

  • Try to buy products (especially for babies) that are free of BPA, phthalates and PVC (The Soft Landing website has great blog lists).
  • Switch all your plastic food containers to glass.
  • With the Plastic Coding System, avoid numbers 3, 6 and 7 and try to use numbers 1,2,4 or 5.
  • Consider buying organic produce to reduce exposure to pesticides..
  • If you must use plastic cling wrap, only use PE wrap; minimize contact of cling wrap plastic with the food; and try not to microwave with the plastic on it. Especially don’t let the plastic sit on top of liquids, whether cold or hot.
  • Reduce indoor dust exposure by cleaning carpets and dusty surfaces regularly using a vacuum cleaner with a high-efficiency particulate air (HEPA) filter.
  • Always immediately transfer your restaurant leftovers into glass containers at home, and never reheat your leftovers or eat directly from takeaway plastic containers.

We’ve put most of these into practice in our home, so I feel a bit less stressed about this issue.  And the boys’ bath toys? While The Soft Landing blog reassuringly listed them on their list of safer bath toys, their own company rep emailed me to confirm they are “BPA-free, phthalate-free, and non-phthalate PVC”. So I am letting them munch away — for now. Choose your battles…

Obesity in Childhood: How Can We Stop the Pandemic?

obesity in childhoodIt’s no secret that children all over the world are putting on too much weight; in the US, an astonishing 1/3 of children are overweight or obese.  Being overweight as a child can lead to many diseases as an adult, including heart disease, diabetes, arthritis, high blood pressure, and some cancers. Also, overweight kids have lower self-esteem and higher risks for depression. So what can parents, or society really do to stop this epidemic? And how can family doctors and pediatricians help?

The first step parents should take is to find out where your child fits on a Body Mass Index (BMI) chart. Your doctor should be doing this at the well-child exams, but you can easily find childhood BMI calculators online (such as this one) and find out yourself. A child above 85% is considered overweight, and above 95% is obese. Many parents are surprised at finding their child is officially overweight or obese, which is why these objective BMI standards are important for tracking, as well as assessing progress.

There are quite a few weight loss approaches that most doctors can agree on; one major agreement is that diets almost never help, at any age. Any diet plan designed for quick weight loss is almost guaranteed to long-term failure, and many people frequently end up even heavier than before. The healthiest option is always slow and steady weight loss. One pound a week of weight loss for many children, from very conscious changes in diet and exercise routines, is appropriate.

Another major approach involves cutting back on TV time. The American Academy of Pediatrics just published a major policy statement stating that “the evidence linking excessive TV viewing and obesity is persuasive“. They specifically recommend a ban on junk- and fast-food advertising in all children’s TV programs, and they set specific limits of TV time for age groups. They also detail multiple studies showing how having a TV in the bedroom is another independent risk factor for obesity, both as a child and later as adults. They also recommended that “pediatricians need to ask 2 questions about media use at every visit: 1. How much screen time is being spent per day? and 2. Is there a TV set or Internet connection in the child’s bedroom?”

One approach I mentioned before was to have a good breakfast. Many studies have shown that eating a nutritious breakfast is crucial for a child’s physical growth and school performance, and that breakfast-skippers actually end up more overweight, both in childhood and later as adults.

Of course, the main treatments for obesity are the obvious: more exercise and eating proper foods in moderate amounts. It’s important that there be a family effort to help your overweight child lose weight. Parents also need to lead by example; it’s much harder for a child to lose weight if their parents are also overweight and don’t exercise. As for diet recommendations, the most obvious choices to eliminate are sodas and fruit drinks. Sodas truly have almost no redeeming value, especially for children. Any child drinking a daily soda is adding extra pounds of fat each year, and they are also increasing their risk for diabetes as well as teeth problems. Most fruit juices are also quite poor substitutes for natural fruits and should be used at a minimum. For exercise, most kids should be getting 60 minutes a day, but this can be broken up into multiple sessions. The key is finding something they love to do. And don’t forget that any exercise is better than nothing!

Another effort involves reviewing the foods at school. I recently heard the great news that milk producers in America reformulated their flavored milk to have 1/3 less sugars and calories. Many (but not all) nutritionists consider this a positive step, as schools that totally eliminated flavored milk encountered a large drop in milk drinking, which raises the risk of kids not getting enough nutrients such as calcium. What does your school do?

Parents who want to learn more about childhood obesity and how to fight it can find excellent resources at the website healthychildren.org, which is officially run by the American Academy of Pediatrics. And at familydoctor.org, the American Academy of Family Medicine also offers many tips on weight loss for all ages.