SINCE Mary Carpenter’s 2014 post on napping, new health benefits of naps, as well as napping methods and tips, keep popping up for the almost one-third of Americans who partake. But nothing has made a news splash like the recent New York Times editorial, “Work is a False Idol,” by Cassady Rosenblum.
“Lying flat is justice,” Rosenblum quotes Chinese former factory worker Luo Huazhong); and “Rest is not only resistance, it is also reparation,” from Atlanta-based Nap Ministry head Tricia Hersey. Casey Gerald, author of the essay, “The Black Art of Escape,” exhorts: “Miss the moment. Go Mad, go missing, take a nap…”
More than naps alone, these writers advocate opting out of “996”—9am to 9pm, six days a week —careers to choose instead simply working for sustenance. Rosenblum herself opted out—of the “cacophony of the 24-hour news cycle” as an NPR producer—to sit on her parents’ porch in West Virginia.
Before the lying-flatters came a long line of famous nappers, including Winston Churchill, John F. Kennedy and Thomas Edison. Most well known, particularly for his napping technique, is Albert Einstein —who sat after lunch with his heavy wristwatch in one hand, which he dangled over the edge of his chair until the watch fell, and the noise woke him up—nap over.
Among napping tips, the most popular may be consuming a caffeine drink before a 15-minute nap to help avoid “sleep inertia” upon awakening—because caffeine kicks in about 15 minutes after consumption, according to myclevelandclinic. But because caffeine’s effects can last as long as 10 hours, timing the nap for early afternoon may be important for getting a good night’s sleep.
Restorative or replacement naps make up for sleep loss due to poor sleep—but become less useful after a string of sleep-deprived nights, according to Sleep.org. And missing just one hour of sleep can require many nights of restorative sleep to compensate.
The ideal nap length “is long enough to be refreshing but not so long that sleep inertia occurs,” according to the Sleep Foundation, which recommends 10 to 20 minutes as “the ideal length.”
But the length of a nap is “very personal,” according to Chevy Chase Center for Sleep and Wake Disorders Medical Director Helene Emsellem. “For some a five-to-10-minute nap can provide improvement for the next few hours. And a nap in the 20- to 30-minute range can reset you.”
Besides the so-called “recovery” nap, people may take an appetitive nap—“for the enjoyment of napping,” according to the Sleep Foundation. The appetitive nap seems to create less sleep inertia—because the napper is either better accustomed to the timing and to waking up, or is simply less sleep-deprived.
Other nap categories include the prophylactic nap —in preparation for sleep loss; the essential nap—needed during illness, when the immune system requires extra energy to fight infection; and the fulfillment nap —usually for children, to fill their greater sleep needs.
The most oft-touted health benefit of napping is lowered risk of cardiovascular problems. In a Swiss study of nearly 3,500 adults ages 35 to 75 tracked over five years, those who napped once or twice a week were 48 percent less likely than non-nappers to suffer serious heart attack, stroke or heart failure. The length of naps made no difference nor did napping more often than a couple of times a week.
Napping may also increase memory retention—as in the phrase “you should sleep on it”—especially if aligned with the natural sleep cycle. For this reason, nap lengths of 60 minutes that include “slow wave” sleep may be better for cognitive memory processing. And napping for the full sleep cycle of 90 minutes may bolster both memory and creativity.
But even shorter naps can help move information to more permanent storage in cortical areas of the brain from temporary storage in the hippocampus, which in turn clears the hippocampus of recent learning to make room for new information. In a multi-country study, napping resulted in not just “strengthening of rote memories but also the binding of items that were not directly learned together, reorganizing them for flexible use at a later time.”
In addition, naps can decrease the risk of general cognitive dysfunction, strengthen the immune system and even reduce symptoms of sleep disorders, including hypersomnia and insomnia.
For some people, however, naps are unhelpful and disruptive to nighttime sleep. And lengthy or excessive napping may lead to diminished productivity, while sleep inertia following naps can increase the risk of human error. Some research has also linked long naps to higher mortality among older adults.
My own almost-daily, about 15-minute naps started as efforts to do short, mindful meditations along with resting my aching back— lying flat, years before the napping boon. But mine may also be recovery naps, based on the finding that dreaming during short naps can be a sign of sleep deprivation—and because, instead of meditating, I fall asleep so easily I must set an alarm.
Finally, though, my naps may have become “appetitive”—as the Sleep Foundation explains, because “people who enjoy napping sometimes make it a habit.”
—Mary Carpenter regularly reports on topical subjects in health and medicine.
DURING A recent encounter with fully vaccinated friends, a woman in her early 70s backed away from the group saying, “My antibody count is very low: 160.” Looking puzzled, no one else knew their antibody numbers—or even their general low or high levels—although many had received “positive” results from blood tests that assess the presence of vaccine-induced antibodies.
In response to the Delta variant’s rampage among fully vaccinated people, booster shots in the U.S. are now available for the moderately to severely immune-compromised—those with specific diseases or recent stem or bone marrow transplants. Awaiting approval from the FDA and CDC, everyone who received mRNA vaccines (Pfizer and Moderna) may have a third booster shot eight months after their last vaccine, starting September 20—at the same location where they received their earlier doses.
But at pharmacies with vaccines in stock, about a million Americans have skipped ahead—by driving out of state or concealing their identity—to get a third shot, according to an internal CDC memo. Besides being unable to record the not-yet-recommended third dose on personal vaccine cards, people receiving early booster shots may have no response or possibly develop serious problems.
Israel now offers mRNA boosters to those age 50 and above. For the Johnson & Johnson vaccine, the U.S. is awaiting more research, while Iceland recommends a booster eight weeks after receiving the vaccine. The main purpose of existing Covid vaccines is to prevent severe infection and hospitalization.
But increasing hospitalizations in Israel (the world’s most-vaccinated population), breakthrough Covid in those fully vaccinated with the Pfizer vaccine helped spur the new U.S. recommendations. According to Israeli data, the Pfizer vaccine had become less than 55% effective against serious disease for those age 65 and older.
In Iceland, an excellent Covid surveillance system provides total numbers of cases—including asymptomatic cases no longer counted in the U.S.—and 71% of the population is fully vaccinated. In the current Covid wave, 1,300 people have developed infections, with 65 admitted to the hospital—among whom 60% (39 patients) were fully vaccinated.
But getting a third shot too soon risks overstimulating the immune system, which could make the body less adept at fighting Covid infection, as happens with malaria, Washington University immunologist Marion Pepper told The Atlantic. Pepper explained that the immune system “needs some time and space to calm down in between seeing one infection and the next one” —to develop its pathogen-detection skills.
In addition, only very preliminary research confirms that specific levels of antibodies in the blood are a good indication of how well protected people are from severe Covid. And Pfizer’s clinical booster trials measured only whether antibodies had increased, rather than specific levels, and tracked participants for only one month after their third dose.
The Delta variant is still too new for answers to many ongoing questions, notably what’s responsible for its rampage. The cause could be waning antibody levels or minimal antibody responses in so-called “low-responders.” Alternatively—or simultaneously—the particular contagiousness and/or virulence of the Delta variant could be spurring the 10-fold spike in severe Covid cases in the U.S. since early summer.
Quantitative antibody tests, also called “immunity trackers” —such as the one mentioned above by the woman with the 160 antibody count—identify neutralizing antibodies that prevent the virus from entering cells and replicating, writes Helen Thomson in the New Scientist. Thomson took the quantitative antibody test made by Roche, for which she paid 49 pounds or $66.75.
While a typical antibody level 21 days after the second dose of the Pfizer/BioNTech vaccine is 1,000 to 2,000 units/milliliter, a “positive” antibody test result comes with any level above 0.8 U/ml. Thomson’s level was 15-20 U/ml, considered “low ”—but it’s unclear whether her vaccine’s protectiveness had begun to wane or she had been a “low-responder” from the outset.
The usefulness of qualitative antibody tests is complicated, Thomson points out, due to the “intricacies of the immune response to a virus.” Besides neutralizing antibodies spurred by vaccines, the body’s B cells make additional antibodies, and different T-cells kill virus-infected cells directly—not so much preventing the infection as modulating or terminating it. With ongoing reduced severity and hospitalizations, “this is exactly what we are seeing,” explains Alessandro Sette, immunologist at the La Jolla Institute in California.
In addition, tests measuring antibodies in a laboratory may be “meaningless” in predicting real-world activity, according to London virologist George Kassiotis. As a result, quantitative antibody results could create either false reassurances of protection or unnecessary fears, Thomson concludes.
On the other hand, a small data set collected using a different antibody-quantifying test has linked waning immunity to the risk of breakthrough Covid. Of 107 individuals who took the test, which rates an individual’s levels from “very high” to “low,” those with low or medium levels became “negative” for antibodies over a year and some got Covid in the second wave —compared to people with high or very high levels in April 2020 who are “all still positive today.”
And last week, pre-print results from a large multicenter study showed that antibody levels can provide “correlates of protection.” Said Christopher Houchens, one author of the paper and a biologist at the U.S. Biomedical Advanced Research and Development Authority, “We saw a very clear correlation that the higher the level of antibody produced by vaccines, the less likely you were to become sick.”
For me, the most worrisome risk of breakthrough infections is long Covid, with symptoms including severe fatigue, brain fog and sleep problems—which sound a lot like those I had for years following Lyme disease in 2008. Recently—though in a very small data set—among 1,497 fully vaccinated health care workers, 39 developed breakthrough infections—and of 36, seven had persistent symptoms six weeks later.
For now, I am heeding the personal views of epidemiologists in a STAT survey, who in general plan to avoid indoor movies and restaurants for the foreseeable future. And I will seek out any possible protection—notably the hoped-for booster after September 20.
ON THE TRAIL of mysterious illnesses, The Medical Detectives — the title of collected New Yorker articles dating from the late 1940s by Berton Roueché —must diagnose puzzling symptoms and afterwards pinpoint the origin. Their work becomes especially urgent if symptoms begin to worsen or spread—to prevent an epidemic and to forestall future outbreaks.
Searching for the origin of the novel coronavirus, hundreds of researchers around the world continue to pursue two trails, both starting in Wuhan, China: a “lab leak” from biological researchers studying coronaviruses and “natural spillover” from wet markets selling live animals.
The search for Patient Zero, however, is ongoing and extends as far away and back in time as Italy, September 2019, when more than 10% of blood samples collected for a cancer-screening trial tested positive for coronavirus antibodies. Although the WHO requested retesting by a different laboratory in the Netherlands, results have not yet become available.
In Roueché’s “Eleven Blue Men,” the source of cyanotic (blue) coloring— indicating insufficient oxygen in the blood— in 11 sick men turned out to be the salt sprinkled on oatmeal from a single shaker in a public cafeteria, which had had been mistakenly filled with sodium nitrite— familiar as a meat curing agent but poisonous in high doses.
But origins can remain forever unverifiable, as in “The Liberace Room,” where investigators looking into high fever and other symptoms in elementary school students and one teacher in Missouri first suspected bird-borne psittacosis from the class parakeet named Liberace. But when the diagnosis turned out to be the fungal infection histoplasmosis, suspicions centered on a load of coal deposited close to the window of the most-infected classroom—and a recent cave-in at the local strip mine buried any potential evidence.
Unresolved investigations give rise to finger-pointing and sometimes to conspiracy-like theories—that have included lab leaks. Michael C. Carroll’s Lab 257 traces the emergence of Lyme disease to a poorly secured, biological-weapons research lab on Plum Island, New York. The lab, staffed in the 1940s and ’50s by Russian scientists who specialized in tick-borne diseases, appears close to the epicenter on some early Lyme disease maps.
Close to the center for SARS-CoV-2 on some early maps is the Wuhan Institute of Virology (W.I.V.), where scientists have been studying coronaviruses for years and where safety lapses were the focus of a November 19, 2019, meeting, although the institute has not responded to questions about the lapses or whether these led to accidents.
Fueling suspicions were rumors about W.I.V. coronavirus studies involving “gain of function” —altering a virus’s genotype in ways that could make it more contagious and more virulent, with the goal of better understanding virus-host interactions and the virus’s ability to replicate — especially after the U.S. State Department prohibited mention of U.S. funding for this research, reported by Vanity Fair.
In a related theory of the novel coronavirus’s origin, a W.I.V. researcher might have contracted the virus on a field expedition to study bats, or while processing a virus at the lab, according to Rutgers molecular biologist Richard Ebright.
But University of Arizona virologist Michael Worobey insists that there were “no early cases cluster anywhere near the W.I.V.” Worobey recently switched his support to the natural spillover theory after researchers found that the Wuhan wet market sold civets and raccoon dogs, which can act as intermediate hosts for coronaviruses moving from bats to humans.
Also, Worobey points to the animal market’s location “right at the epicenter of the outbreak.” (Other scientists including Ebright, however, disagree about the significance of both the recent animal studies and the locations involved.)
But the strongest evidence for the natural spillover theory may be the “uncanny similarity” between the Covid and SARS pandemics, according to UC San Diego virologist Joel Wertheim. Both viruses emerged in China in late fall, with early cases occurring close to animal markets in cities —Wuhan for Covid and Shenzhen for SARS.
In the search for Patient Zero, researchers at France’s National Institute for Health and Medical Research along with other institutes found seven serum samples testing positive for the coronavirus in a retrospective examination of more than 9,000 samples collected starting in November 2019, and banked as part of a public health project.
Also, beginning in October 2019, China was in the midst of its “worst flu season in more than a decade,” leading to suspicions that early Covid-19 cases could have been missed. Around the same time in October 2019, Wuhan hosted the Military World Games—for which blood samples were collected but no information has yet been made available, despite requests from the WHO.
While some experts doubt that the virus could have circulated for long enough to include these early samples—especially those from France and Italy—others explain that early appearances of new viruses can “fizzle out,” which happened two-thirds of the time in simulations of early Covid-19 outbreaks.
“We have entered a new pandemic era,” write tropical medicine and virus experts collaborating on the September, 2020 paper ,“The Origin of Covid-19 and Why It Matters.” With recent emergences and re-emergences of Ebola fever, Lassa fever, chikungunya, Zika, HIV and other diseases, they warn that “future coronavirus transmissions into humans are not only possibly but likely.”
While science has the ability to control pandemic viral emergencies within 2 to 3 years, it is “dramatically insufficient to prevent and control their emergences in the first place,” the scientists warn. To lower future risks, they call for more aggressive surveillance of coronavirus hot spots and of human behaviors that “bring us into contact with bats, including risks from wet markets, bat cave tourism, and capturing and eating bats.”
To establish the provenance and early infection path of a new disease can take years under the best conditions—and to date China’s government has limited access to biological samples and original records, even from the WHO–which in turn has been slow to release information, according to the Post. U.S. intelligence agencies are now working on an end-of-summer deadline to report to President Biden.
THE BENEFITS of meditation—well supported by research—range from anxiety reduction to total life improvement. But recent investigations have revealed unpleasant or unwanted effects in around 25% of participants; the incidence is lower among women and those with strong religious beliefs.
Psychotic symptoms—hallucinations, delusions and disordered thought and speech—are among meditation’s worst risks. A 2019 Harper’s article tells the story of Megan Vogt, whose psychotic symptoms and suicidal thoughts increased over 10 days of an intense meditation retreat.
More than 50 published studies have documented meditation-induced psychosis, mania and dissociation, according to Harper’s. And “not-uncommon” adverse effects—including anxiety, depression and cognitive impairment—arose during 65% of studies reviewed by a Scandinavian journal in 2019.
Among 342 experienced meditators surveyed in the first large study, 25.4% reported “unwanted or “adverse” reactions—more likely when practicing alone and associated with the length of meditation. And a later survey of 1,232 regular meditators found 315 (25.6%) reporting similar “unpleasant experiences.”
“Every meditation center had at least a dozen horror stories,” said Brown University neuroscientist and psychologist Willoughby Britton, one of the first to investigate meditation’s risks. The most-debilitating meditation experiences occurred during multiday retreats, like the one Vogt did, that include fasting and sleep deprivation—with activities beginning before dawn and lasting 10 or more cumulative hours—along with restrictions on exercise and interactions with other meditators.
“The brain is accustomed to a certain amount of activity,” Harvard neuroscientist Matcheri Keshavan told Harper’s. When someone sits motionless with their eyes closed for 10 or more hours a day, neurons can start firing on their own—that “might lead to unusual phenomena, which we call psychosis,” said Keshavan.
Negative psychological effects are more likely to emerge with the “focused-attention” (FA) meditation commonly practiced at long retreats. As in the Vipassana meditation at Vogt’s retreat, FA practitioners concentrate on tasks like mental scans of the body and different methods of breathing with the goal of clearing their minds of everything else—and specifically of restricting mind wandering.
“Open monitoring” (OM) meditation, on the other hand, encourages mind wandering and paying attention to that as well as to sensations in the body. “Mindfulness meditation” includes both focused-attention and open-monitoring.
Both kinds of meditation reduce activation of the brain’s “default mode network” (DMN), the so-called “emotional brain” where feelings, behavior and motivation—everything from depression to creativity —arise. The DMN may also produce rigid habitual thinking, obsessions and addictions.
As a result, DMN functions may generate “awareness of the self”—in the moment and in different environments. The brain regions involved in the DMN operate on “a plethora of introspection-related functions, including self-reflection, mind wandering, autobiographical memory recollection, mental time travel to the future and imagination more broadly,” according to Robin Carhart-Harris and colleagues at London’s Psychedelics Research Group.
Not just a goal of meditation, bypassing the DMN can also facilitate psychedelic therapy—an experience called “drug-induced ego dissolution”—putting the ego out of commission by dissolving boundaries between self and the world, according to Johns Hopkins psychologist Matthew Johnson, who researches the effects of psilocybin (magic mushrooms).
Meditation research, however, is fraught with challenges: reliance on studies of individual cases rather than evidence from large groups and dependence on surveys taken following meditation experiences. Among hundreds of meditation surveys published each year, very few include questions about negative effects. In the only prospective study (as of 2019) of meditation-related difficulties, two (7%) of 27 participants, enrolled before participating in a Vipassana retreat, reported “profound adverse effects” leading them to discontinue the meditation.
A significant problem is the unreliability of self-reports by meditators. A 2014 Carnegie Mellon University study found that meditators who reported decreased stress actually had increased levels of the stress hormone cortisol. And among 12 subjects who reported sleeping better since beginning five-day per week meditations, six who meditated longer than 30 minutes had shallower sleep and woke more often than a control group. Sleep quality improved only for those who meditated for 30 minutes or less.
Disagreement about negative meditation experiences centers on whether these occur exclusively in individuals with pre-existing, underlying psychiatric conditions or vulnerability. Says Jeffrey Lieberman, past president of the American Psychiatric Association: “I don’t think meditation by itself can cause this.”
But in Britton’s study of 60 experienced meditators, 43 had “moderate to severe impairment” of their day-to-day functioning, with 10—most of whom had no pre-existing psychiatric condition—requiring inpatient hospitalization. ”It’s easy to assign a latent vulnerability after the fact,” Britton told Harper’s, “but we are seeing people who really had no indicators.”
The Scandinavian review also concluded that adverse effects “may occur in individuals with no previous history of mental health problems.” And a Dutch systematic review of 19 reports of “potentially meditation-induced psychosis” found that in half of the 28 cases, 14 had no prior diagnosis.
In most studies, length of meditation is a key variable in cases of adverse effects—with participants meditating for 30 minutes or less reporting positive experiences compared to those who meditated for longer periods. Other variables related to difficult meditation experiences include relationships (isolation of participants), health behaviors (restrictions on sleep, diet and exercise) and practitioner vulnerability.
What may be most important for safe meditation experiences is the quality of instructors—notably the relationships they establish with participants, both before and during the meditations, which should include learning about each individual’s strengths and vulnerabilities.
Britton and other meditation researchers have created a “safety tool-box” for meditation leaders. For meditators in trouble, the online support group Cheetah House based at Brown University and facilitated by Britton offers resources and support, including first-hand accounts of “meditation-induced medical emergencies.” One poster wrote on the site, “Cheetah House literally saved my life.”
During her retreat, Megan Vogt appeared to lose her sense of self and to dissociate from reality —goals of the meditation but devastating to her. More than 60 hours after she began having symptoms and had gone days without sleeping, the staff failed to contact Megan’s therapist (who had agreed to be available) but finally called her family to come take her home. Despite having in-patient psychiatric treatment and cautious, watchful family members, within months of the retreat Vogt committed suicide.
For an eight-week Mindfulness Based Stress Reduction (MBSR) class at the Insight Medication Community of Washington,” I received a long, chatty introductory phone call from the class instructor Bill Mies—which in hindsight probably included an assessment of me. By our first class, Mies appeared on familiar terms with most of the students. Perhaps that’s why, also in hindsight, that first night I felt unworried by the serious-sounding mental health issues described by some of the students—and comforted by the easy familiarity that Mies created for the class.
—Mary Carpenter regularly reports on topical issues in health and medicine.
SYMPTOMS OF diverticulitis—inflammation in the colon — can spiral quickly from digestive discomfort blamed on recently consumed foods to life-threatening infection accompanied by debilitating pain and cramping, with bloating that makes the abdomen feel hard as stone.
When local DC-area fundraiser T.L. found herself lying on the couch with nausea and severe belly pain for the second straight day, she knew it was time to go to the ER —even though that meant leaving a vacation house to drive more than an hour back home. Admitted right away to the hospital, T.L. received antibiotics and nutrients through an IV tube for five days while her doctors evaluated the need for surgery.
Recent colon surgery on the Pope has cast new light on the progression of diverticulitis over time. Each episode of inflammation causes scarring and thickening of the colon wall, eventually shrinking the colon by as much as 90 percent, to “just one quarter of an inch—the diameter of a No. 2 pencil,” according to Apoorva Mandavilli in the New York Times.
Surgery becomes the only option in cases of severe infection, bleeding, intense pain, blockage or perforation—or when the patient has suffered many attacks of diverticulitis. “By the time it gets to the point where [the colon is] scarred down and too narrow, we don’t have a lot of medical options,” said University of Washington, Seattle, surgeon David R. Flum.
But when inflammation or infection are too widespread, surgeons will instead connect the bowel through an opening in the abdomen to a colostomy bag for evacuation—at least temporarily until the colon heals.
Diverticulosis, which is the precursor to diverticulitis, is a usually benign collection of pouches in the colon wall that can cause either no symptoms at all or some abdominal pain. Diverticulosis affects about two of every three people older than 60; some 10 to 15% of diverticulosis cases progress to diverticulitis, when the pouches become blocked, inflamed and infected.
(Belly pain can also occur with inflammatory bowel disease (IBD), autoimmune disease, including Crohn’s disease and ulcerative colitis; and irritable bowel syndrome (IBS), with no inflammation but physical issues like trapped gas and intestinal spasms causing pain.
Constipation, a common cause of diverticulosis, can result from a diet too low in fiber compounded by not drinking enough water, which leads to straining and pressure in the colon that in turn causes the colon lining to pouch out. Food particles that become wedged in the pouches and can lead to infection include, notably, seeds from fruits and vegetables, including cucumbers, tomatoes and strawberries.
As the colon becomes narrower, trapped gas can contribute to bloating. Gas-producing foods include those that are fried or spicy or have high fiber or fat content; also carbonated beverages and artificial ingredients in low-carbohydrate and sugar-free products, such as sorbitol.
Known for producing gas, the category of food called FODMAPS are short-chain carbohydrates like legumes that escape digestion. When fermented by gut bacteria, these produce methane and hydrogen—which is expelled as flatus (gas). Other factors exacerbating gas issues are overeating, eating too fast and swallowing air while eating.
Strategies for reducing gas include sitting down during meals and post-prandial exercise, such as walking. Certain yoga poses have reputations for helping to release air. While not always condoned, allowing yourself to fart can be healthy.
The recommended diet following diagnosis with diverticular disease involves keeping fluid intake up around nine cups per day; lowering fat to decrease pressure in the colon; and increasing fiber to above 25 grams/day—but gradually over time to minimize GI discomfort.
Conversely, during periods of inflammation, the best diet is high in protein to inhibit contractions in the colon, and “low-residue”—soft foods like puddings—to minimize undigested and unabsorbed food that remains in the large intestine following digestion and decreases fecal volume. All diets related to diverticular issues restrict nuts, seeds and hulls.
After five days in the hospital, T.L.’s abdomen began to feel softer and the pain subsided. She left the hospital with strict dietary instructions and three antibiotic prescriptions for the next month. What lasted were fatigue and nausea, especially with any exertion like working in the garden, probably due to a combination of weakness—from weight loss and stress on her body during the acute illness—and general stress and worry about having such serious symptoms, along with the heavy load of antibiotics.
—Mary Carpenter regularly reports on topical issues in health and medicine.
Since My Little Bird’s 2017 post reported on Bessel van der Kolk’s book The Body Keeps The Score—about body-focused therapies like yoga for treating mental health issues—the 2015 book has been on the New York Times Paperback Nonfiction Bestsellers List for the past 140 weeks and on the (all) Nonfiction Bestsellers list for 44 weeks; and is number one on both lists —as of Sunday July 11. And therapists who specify the kinds and combinations of therapies they use often include “somatic” therapies, alongside others that incorporate physical components, such as touch.
Last year in Los Angeles, 30-something entrepreneur T.J. found a new therapist, who told him her practice included Cognitive Behavior Therapy (CBT)—along with somatic and IFS (internal family systems) therapies, both of which incorporate physical components, including movement, touch and breath work. Somatic therapy is “based on the idea that traumatic experiences cause dysfunction in a person’s nervous system [that] prevents them from processing” talk-therapy sessions, writes Jessica DuBois-Maahs on Talkspace .
Somatic therapy aims to “help individuals develop new thinking patterns and behavior to better respond to various experiences or emotions as they come up,” writes Dubois-Maahs—by making them “notice physical sensations stemming from their mental health issues and use that awareness to work through painful feelings and emotions.” (For some patients, especially those who have suffered physical abuse, physical contact can be triggering or uncomfortable.)
In the 1990s, Antonio Damasio’s “somatic marker hypothesis” pointed to the role of the insula, located in the brain’s cerebral cortex, in processing bodily sensations that influence decision making—for example, queasiness in the stomach when deciding not to walk down a dark side street at night, or not to move to a different state—although much about the insula remains unknown.
“When you get to the point in struggling with a problem that you think, ‘I’m sick of talking about this,’” then it’s time to focus on your body, said Jonathan Foust, senior teacher at the Insight Meditation Community of Washington (IMCW). In a DC day-long workshop on “Body-Centered Inquiry: Mindfulness, Focusing and the Power of Questions,” Foust was only partly joking as he quipped: “Your issues are in your tissues.”
According to Bessel van der Kolk, when a child’s needs have been ignored by caretakers, their body remains in a state of high alert: brain imaging studies show effects in the insula, deep in the brain “where they cannot be eliminated by reason or understanding”—hence the need for work with the body along with cognitive therapies.
“Dr. van der Kolk writes that there are three avenues for recovery: ‘top down, by talking, (re-) connecting with others and allowing ourselves to know and understand what is going on with us’; ‘taking medicines that shut down inappropriate alarm reactions’; and ‘bottom up, by allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage or collapse that result from trauma,’” according to the New York Times review. “Survivors usually need some combination of the three methods, writes Dr. van der Kolk, but the latter— the mind-body connection—is most neglected.”
As a researcher at Harvard and Boston University for more than four decades, van der Kolk studied the impact of childhood trauma on brain development and emotional regulation, as well as the effectiveness of yoga, theater, the drug MDMA “and other methods for treating trauma,” writes productivity consultant Tiago Forte.
Another of T.J.’s therapies, IFS, divides consciousness into distinct “parts” —one being “firefighters” that offer protection from depression and pain by redirecting the sufferer’s attention to work, sex, alcohol or drugs —for example, to the part of the brain that wants to stay out drinking vs. another part that’s aware such behavior will make tomorrow’s workday more difficult.
The goal of IFS is to access the wounded parts—from childhood or other trauma—to better balance consciousness, for example, to obviate the need for such firefighters. In particular with therapy called “Somatic IFS,” learning to use more effective breathing techniques can lead to relaxation and eventual mental clarity, along with the ability to sense which of your parts wants to keep drinking and try to understand the negative emotions involved.
While the goal of mindfulness exercises involving breath and body awareness focus on “being,” CBT uses the mind to reframe negative, anxious or obsessive thoughts with the goal of “doing,” or acting, differently.
Self-talk: to “approach, personify, exaggerate and talk directly” to their anxiety — to ask yourself, how can I create some anxiety here; how can I practice being willing to be anxious?—is the first homework UNC psychiatry professor Reid Wilson gives his patients. Worrying and avoiding stress heighten physical reactions by raising adrenaline levels, Wilson explains; whereas looking directly at and moving toward fears can be calming.
For the 2020s, CBT is also the therapy offered by Woebot, an app that relies on algorithms to “take someone through a standard CBT process,” according to University of Louisville psychiatrist Jesse Wright. But MIT clinical psychologist Sherry Turkle, who writes about technology and relationships, is skeptical—pointing out that, for therapy to heal, the therapist must empathize with a patient’s pain: “An app cannot do that.”
In fact, for most people, the best therapy occurs when they can form a relationship with the therapist—which happened for T.J. And the most effective therapists —whether or not they specify which therapies they are using—employ a variety of techniques with the goal of responding differently to the needs of each individual patient.
—Mary Carpenter regularly reports on topical issues in health and medicine.
Mary Carpenter has covered breathing in recent MyLittleBird posts – in January of 2019 and of 2021. But recent reader queries about Breath the New Science of a Lost Art ($16.75) by James Nestor led to a different take on the topic, along with personally helpful advice.
“IF I HAD to limit my advice on healthier living to just one tip, it would be simply to learn how to breathe better”—naturopath and healer Andrew Weil, quoted in the Epilogue of James Nestor’s Breath.
In Breath Nestor links almost all bodily functions —along with possibilities for their improvement—to breathing. What the book does most helpfully is collect the research “all together in one neat package…along with an appendix of breathing exercises,” according to writeoutloud. To date, the book’s popularity has boosted sales of its recommended products—from the most inexpensive sleep strips to very pricey, personally fitted mouth retainers.
In Nestor’s self-improvement journey as a “pulmonaut,” he sometimes seems to go too far: as noted by one complainer on Amazon, “cure scoliosis by breathing through your nose…supposedly cure ADHD!” (To be fair, here Nestor is reporting other people’s experiences, not drawing conclusions.)
Among serious errors, Nestor confounds lung capacity and lung function—and incorrectly credits the Framingham Study with discovering that “greatest indicator of life span…was lung capacity…smaller [lungs] meant shorter [life].” In fact, many analyses of the Framingham data found that even “vital capacity” (the total amount of air you can forcibly expel from your lungs) was not a significant risk factor for heart disease.
But Nestor’s contentions about the health benefits both of breathing solely through the nose and of lengthening the exhaled breath have gained recent prominence. The nose warms and moistens the air, which improves its passage into the lungs, as well as slowing the breath.
And longer exhales make more room for incoming air, as well as slowing the breath to give the lungs more time to absorb oxygen. Exhaling through the nose can slow the breath by more than 50%, thereby lowering the respiratory rate (breaths per minute), writes Nestor.
While mouth breathing is usually faster and expels more carbon dioxide, nose-breathing decreases the ratio of oxygen intake to carbon dioxide output—seen in a recent study of 10 runners at Colorado State University. “You’re doing less work of breathing to get the same oxygenation,” said health sciences professor and the study’s lead author George Dallam.
Higher CO2 levels help dilate blood vessels to provide better transport for oxygenated blood and release oxygen from blood cells as they travel through the body—especially important for endurance. And CO2 buildup in the blood can stimulate the parasympathetic nervous system —as can lengthening the outbreath —to create a relaxing effect.
Nose-breathing “allows you to use your diaphragm better,” explains Dallam. Both diaphragm and lungs fall into the use-it-or-lose-it category: lungs lose an average of 12 percent of capacity between ages 30 and 50, and the loss continues over time. But individuals can expand their lung capacity—with the most extreme example being freedivers, who can increase theirs by 30 to 40%, according to Nestor.
“A typical adult engages as little as 10 percent of the range of the diaphragm when breathing,” writes Nestor, “which overburdens the heart, elevates blood pressure and causes of rash of circulatory problems.” Increasing the amount of air that enters the diaphragm can help slow the breathing and improve its effectiveness over time.
What also decreases with age is saliva production—by as much as 40% over age 65. Nestor rephrases this statistic to conclude that “mouth breathing causes the body to lose 40% more water”—but he focuses on its nighttime effects: exacerbating dehydration and, conversely, increasing the need to urinate.
Optimal slow breathing may be close to 5.5 breaths a minute, and some recommend adding a breath-hold. Among many formulae for this, for example, “box breathing” involves taking four seconds for the inbreath, four more to hold the breath, followed by four for the outbreath, with a final four-second hold.
Nestor advocates breath limitation techniques—extending exhales “far past the point of what feels comfortable, or even safe,” while reducing inhales. Also called hypoventilation, breathing too slowly or too shallowly to meet the needs of the body has helped athletes, notably swimmers, reduce their oxygen needs and improve performance.
Nestor also supports breathing methods originating in the practice of yoga, notably alternate-nostril breathing by closing one nostril at a time. Breathing through the left nostril alone can help with relaxation, via the parasympathetic nervous system—while breathing only through the right side of the nose activates the sympathetic nervous system to increase alertness and energy.
But Nestor’s most dramatic recommendations are aimed at correcting early dental work that, he contends, have damaged breathing in as many as half of orthodontic patients. Specific instructions for remedies include steps to improve “oral posture” and a complicated tongue-extending exercise called “mewing.”
What made the biggest difference for Nestor was the Homeoblock, a retainer-like device personally fitted to expand mouth size that he wore for a year, created by New York City orthodontist Theodore Belfor.
Along with more than a dozen “breathing methods” and exercises, Breath’s appendix lists devices, including Belfor’s “POD” (Preventive Oral Device) and other “palatal expansion” devices that “expand the palate and open airways.” Obtaining most of these requires consulting a dental professional, preferably one specializing in “functional orthodontics.”
On the lengthy list of personal health benefits for Nestor of better breathing: lower blood pressure and resting heart rate, higher heart rate variability (an indicator of cardiovascular fitness); increased blood CO2 levels, and reduced sleep problems (including snoring and apnea), along with specific improvements such as increased bone in the mouth and jaw areas, better aligned jaw position—widened airways—and greater exercise capacity.
My efforts to lengthen the exhale and to breathe solely through the nose seem to help with relaxation and sleep. But working on nose-breathing led me to Nestor’s drastic-sounding yet personally most useful recommendation: a thin strip of surgical tape to shut my lips at night. Besides seeming to make my sleep deeper and keep me from waking as often, enforced nose-breathing has been the best remedy so far for dry mouth, which always worsens in summertime.
—Mary Carpenter regularly reports on topical issues in health and medicine.
“THE MAN That Was Used Up,” Edgar Allan Poe’s story from 1836, describes an extremely vain man with a seemingly perfect body that’s discovered to be a total ruse by an early morning visitor, who finds only a small pile of clothing on the floor: the artificial parts have all been removed for sleeping.
In the 21st century, replacement body parts keep improving, even the more prosaic joints—most recently knees, with minimally invasive surgery (MIS) that can be performed using a robot and often as an outpatient procedure. Similar to anterior hip arthroplasty—revolutionary 20 years ago—MIS allows surgeons to enter through a smaller incision in the front of the joint and spare important muscles, compared to older methods.
But the 2021 documentary film They Say It Can’t be Done highlights an era of an ever-worsening shortage of donor organs for transplantation—and ongoing obstacles to 3D organ printing, as one of four humanity-rescuing innovations currently held up in regulatory bureaucracy.
More than 100,000 Americans at any one time are waiting on very long lists for organ transplants, with more than 20 people dying every day. For most transplantations, organs of deceased donors must match a recipient’s blood type and body size, although kidneys and parts of the liver can come from a living donor, if the tissues match sufficiently and if that person is willing to undergo major surgery.
Among the newest replacement-part possibilities, bioprinting allows for the creation of full-scale 3D components of the human heart and lungs, using new “bioink” gel to create an extracellular matrix that helps suspend the cells. The first transplanted lab-grown human bladder, developed by Anthony Atala at Wake Forest University, allowed Luke Massella to play high school sports, followed by college and a career as a wrestling coach and jewelry event planner, without needing dialysis. But Massella’s transplantation took place 15 years ago; as of today, only about 10 people have benefited from replacement bladders.
Meanwhile the FDA has failed to create a framework for reviewing and approving artificial body parts, despite promising in 2017 to get to work on this. In contrast to the FDA’s bailiwick —mass-produced products like drugs and medical devices—3D-printed and lab-grown organs are one-of-a-kind creations, tailor made for each patient.
Resistance to opening the floodgates to artificial organs comes from many directions, as it does for the three other innovations in the film, including aquaculture to save the oceans. According to Cardwell’s Law, golden eras tend to move towards an “absorbing barrier of technological stagnation”—created by groups believing they will lose something as a result of change.
As the field of tissue engineering was “beginning to coalesce” 30 years ago, experts expected the ability to create brand new organs within several decades. But, said Rice University bioengineer Jordan Miller, “Growing new organs turned out to be a little further off than anyone thought” —though it is now in “striking-distance.”
“You can grow billions of cells in a lab…hundreds of billions of cells at the bottom of a petri dish,” said Miller. What’s usually missing is the architecture, scaffolding needed for a three-dimensional organ: “If you don’t have it, you can’t get nutrients to cells and cells will die.” Miller expects the first applications of any new technology to be in “bridging treatments,” to keep patients with failing organs alive until a donor organ is available.
The organ procurement process in the U.S. can prove unwieldy from the start. To get on the national list, patients who need transplants must visit a transplant hospital to be evaluated by a multidisciplinary team. When an organ becomes available, the United Network of Organ Sharing generates a list of potential recipients based on blood type, tissue type, organ size and medical urgency of the patient’s illness—as well as time already spent on the waiting list and geographical distance between donor and recipient.
Potential organ recipients need to stay close to a medical center because transplantation must take place within hours of removal to preserve the organ. But obtaining consent from donors or donors’ families can be both time-consuming and challenging. And transplanted organs have high failure rates, with acute rejection episodes occurring in 15% of patients within the first week, and more than half of all organ transplants failing within 10 to 12 years.
For live donations of kidneys or liver parts, individual transplant centers make the arrangements. Among organs and tissues that can be transplanted are the liver, kidney, pancreas, heart, lung, intestine, corneas, middle ear, skin, bone, heart valves and connective tissue. A deceased donor can save up to eight lives and enhance over 75 more.
Recently I learned about the possibility of having a MIS knee replacement—which avoids trauma to the quadriceps muscle, the most important muscle group around the knee. Compared to traditional knee surgery, MIS can result in less postoperative pain as well as helping to reduce time spent on recovery as well as rehab and therapy.
At the first knee replacement discussion 10 years ago, my physician advised waiting until the pain or dysfunction was much worse, saying, “Otherwise, you will not be pleased.” His point: Replacing body parts requires cutting into the body — and that means it will take time and hard work for that body to recover.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
THE RECEDING Covid pandemic is leaving behind a tsunami of new research that focuses on different individuals’ immune responses to the virus, offering the hope of one day creating personal, immunity-response profiles that could lead to better treatment decisions early on, for Covid and for other infections, such as the flu.
Driving this research are questions about why Covid infections in patients—who are of similar age, background and health status—can follow “wildly different trajectories,” according to NBC News; or why some patients develop long-lasting post-Covid symptoms.
“One thing that was surprising to us was the large percentage of asymptomatic patients that are in that category of long Covid,” said Robin Gelburd, president of the non-profit FAIR Health, which tracked health insurance records of nearly two million Americans.
Also surprising, more than half of patients hospitalized with severe Covid in a Belgian study had “rogue” antibodies, autoantibodies that can disable immune system proteins and attack other organs affected by Covid—which “should make us rethink dozens of diseases, if not hundreds,” according to David Lee at New York University Langone Health. “I’m like, ‘How is anybody not seeing this?’”
This “autoimmunity might be the real culprit behind deadly destruction that continues after the coronavirus has cleared,” said Lee. According to the Nature report, “scientists are very interested in whether autoimmunity is linked to long Covid.”
Although women with Covid infections have less severe symptoms and fewer deaths, they experience long-haul problems at more than four times the rate of men. (Women are also more likely to have autoimmune diseases, such as lupus, MS and rheumatoid arthritis.) On the other hand, the international Covid Human Genetic Effort study of patients with life-threatening Covid pneumonia found dangerous auto-antibodies in only 2.6% of women but in 12.5% of men, for whom they may be the cause of the more severe infections and higher numbers of deaths.
Other reasons for the severity of Covid in men could be that obesity poses a greater risk to men who have the infection; or that testosterone puts men at greater risk—or women’s estrogen levels help protect them.
Important Covid-immunity research comes from so-called “supertasters”–people who have a strong response to bitterness, for example, in coffee and broccoli, and who appear practically immune to Covid infection. In past research, the “supertaster gene” TaR38 has correlated with a stronger immune response to bacterial infections in the sinus and lungs.
Taste strips assessing individual levels of bitterness response were close to 95% accurate in predicting the risk of infection, severe disease and need for hospitalization —in a recent study of 1,935 people exposed to Covid but with no evidence of infection, by ENT researchers in Baton Rouge and at UC San Diego. While more research is needed, taste-strip tests could provide a simple contribution to personal immunity profiles.
Other unusual responders to Covid include those who develop severe infections but produce no antibodies at all. About one-third of 9,785 severe Covid patients in the UK’s large Recovery trial failed to produce any antibodies in response to coronavirus infection—in some cases, because underlying health conditions had weakened their immune systems; but in others, for no clear reason.
In the Recovery research, among patients who received a new cocktail of two genetically engineered monoclonal antibodies, 24% died, compared with 30% of those who received standard care. The Regeneron cocktail is the same as the one given to former President Trump, explained Scripps Research Translational Institute Director Eric Topol. “Who knows what might have happened at his age, with his morbid obesity and all the other risk factors he had” without the cocktail.
At a different extreme of the immunity spectrum are the patients who produce autoantibodies, which, in addition to blocking immune function, attack organs—blood vessels, heart and brain —and phospholipids that affect blood clotting, all of which can be affected by Covid. Most hospitalized Covid patients have neurological symptoms.
While many people have a few rogue antibodies— perhaps due to genetic predisposition—the first evidence that autoantibodies against the body’s immune system might put people at higher risk of infectious disease came in 1984, said Rockefeller University researcher Jean-Laurent Casanova. With the Covid pandemic, now “people understand the problem.”
Down the road, creating personal immunity profiles could help with treatment decisions, such as whether to supply missing antibodies to bolster a patient’s immune system or to protect a patient against the creation of rogue autoantibodies—or to determine which patients should be hospitalized and which ones can just go home.
Finally, but still not well understood are the long-haul Covid symptoms, which affect around one-fourth of all Covid patients—hundreds of thousands of Americans, including children and those with mild or asymptomatic Covid— and can last for months following coronavirus infection. In addition to brain fog and intense fatigue, lasting symptoms can include parosmia and phantosmia—distortions in the senses of smell and taste.
Some observers speculate that Covid’s severe toll on men may help lead to better attention for its symptoms—including for the enduring brain fog and fatigue, even though these affect more women than men—than has occurred for other infections, notably Lyme disease. In common with Covid, Lyme has early non-specific flu-like symptoms, as well as the post-infectious fatigue and brain fog.
In general, Covid has put Lyme disease and its enduring effects under a new spotlight—after years of little attention as well as funding. In a loose comparison, the government has so far authorized $3.7 trillion for all Coronavirus support vs. $14 million in FY 2020 for Lyme and other tick-borne diseases, but dedicated entirely to prevention and control.
For me, Lyme disease is the reason that, despite knowing that those who are fully vaccinated against Covid have a very small risk of being infected and that they should expect only a mild or even asymptomatic course of disease, I remain cautious about Covid exposure from unvaccinated people.
Since the acute infection in 2008, peripheral neuropathy in my legs and feet can interfere with walking and balance, and my cholesterol levels have remained more than 100 points higher than previously. When my knee doctor recently said it was time for replacement, he blamed Lyme-related arthritis for hastening the deterioration.
But the doctor was also very cheerful about the declining Covid statistics, as well as about the possibility that his office will dispense with mask requirements on July 1.
AS BILLS to decriminalize marijuana circle through Congress, consumers interested in its potential health benefits—better sleep, relief of chronic pain—are asking: how are specific health effects determined for each product; how can buyers be sure which products will achieve the desired benefits; and how can they be sure what’s in the products they get?
At this point, “more research is needed into cannabinoids, marijuana’s active chemical compounds,” notes UC San Diego Pain Medicine Department Chair Mark Wallace. In addition to a range of effects that depend on the different strains, other variables can play a role in effects of products, including chemical compounds, potency, delivery methods (smoking, edibles, tinctures) and the user’s age.
Cannifornian reported a 250 percent rise in marijuana use by Americans 65 and older between 2006 and 2016—though the total number was still only 1.4 percent of that population. The many variables and the resulting unpredictability of products help explain the dearth of scientifically rigorous studies on marijuana’s health effects —and the inability to do anything like “precision prescribing.”
The Importance of Trustworthy Sources
After reading the research along with informative websites such as Leafly, I found the best advice from two younger-generation marijuana growers whom I know personally: one, a co-founder of a Colorado marijuana business; and the other, a DC backyard gardener. In turn, these two rely on professionals in the business: “samplers,” who work for grow-operations and elsewhere, and reviewers at sites like the Cannifornian.
Early on, I depended on salespeople at dispensaries (in Colorado and California, and in DC during the year I had a marijuana card), also considered trustworthy sources by the two young growers for the same reasons that apply to samplers and reviewers: because each of these people has tried the products, and because their reputations and business success depend on the reliability of their judgments.
Professional evaluations are especially helpful because of the extreme variability in marijuana products even within a single batch of the same strain—due to variations in growing methods, including soil, sunlight and nighttime temperatures. But even after products receive professional ratings, individuals can have varying responses due, for example, to habituation after long-time use.
Genetics determine each strain’s “unique profile of terpenes and cannabinoids… that play off each other” in what’s called an entourage effect, according to Leafly. Terpenes are the flavor chemicals, such as the most common, myrcene, believed to boost pain relief; or limonene (and other citrus flavors), thought to “promote an uplifting and energetic high.”
Cannabinoids are similar to the body’s own endocannabinoids, which have corresponding receptors throughout the body—and affect, for example, various aspects of circadian rhythms, such as appetite, alertness and sleepiness. THC, the primary psychoactive cannabinoid, creates the “high.”
The genetic profile helps explain “why one sativa strain helps you focus while another has you bouncing off the wall instead,” according to Leafly. Sativa and indica refer generally to the two categories of effects—with sativa linked to alertness and higher energy, and indica to calming and relaxation.
What’s the THC Percentage?
For most marijuana consumers, potency—based on THC content — is the key rating of interest. When I sought an edible marijuana product for sleep during stressful times—and secondarily for chronic pain— my number one request was for low THC to minimize the high. Starting out low is especially important for edibles, because these can take as long as two hours before effects set in, making it risky to up the dosage any sooner.
On my visit to San Francisco’s Apothecarium, the salesperson suggested Petra mints from the Kiva Company, at 2.5 milligrams of THC each. Eating one mint before bed has helped me sleep. When I checked for reviews, the Cannifornian rates the “Effects: 10 out of 10 for relief from mild aches and pains, emotional turbulence, and other low- grade ailments.”
[The mints] “benefit from Kiva’s extraordinary attention to detail in terms of taste and efficacy,” writes the cannifornian reviewer, who felt about an hour and fifteen minutes after eating, that two mints “get into the task of smoothing my jagged edges and I felt noticeably more cheerful after two hours passed.”
THC can alter sleep architecture, the nightly structure of sleep—specifically lengthening periods of the “deep sleep” state, which is believed to be the most restorative and restful. In turn, however, comes a reduction in the amount of REM sleep — characterized by rapid eye movements; the phase when dreaming occurs; and important for healthy immune and cognitive functioning, specifically for the consolidation of memories.
Potency levels on labels can be unreliable—and, more importantly, have little or no relationship to the [entourage] effects of the different products, explains chemist Josh Wurzer, co-founder of SC Labs, which tests cannabis products. On the other hand, scientists still disagree about the existence or importance of the entourage effect.
Until the passage of a national bill, the FDA has no role in marijuana regulation, and oversight remains up to individual states. Massachusetts, for example, requires testing by “certified labs” of “all cannabis harvested for commercial and medical use, as well as all marijuana products” —for “cannabinoid profile and potency,” as well as for contaminants such as pesticides.
The Risk of Side Effects
The greatest risk of marijuana for some people is side effects— anxiety, paranoia, delusions, and psychosis —mainly linked to THC. Despite a common belief that the non-psychoactive ingredient CBD can block psychiatric effects —especially as CBD levels approach a 1 to 1 ratio with THC —a systematic review of research found “no consistent evidence” of this.
Another risk, specifically with THC edibles—because the kick-in time is unreliable —is a longer-than-intended effect that causes grogginess the following day. As a result, edibles are best ingested at least an hour before bedtime, according to Harvard Medical School marijuana therapeutics expert Jordan Tishler.
In addition to psychiatric side effects, a worrisome risk for the typical novice comes from imbibing an excessively high dose, which can create feelings of being out of control, a racing heart or a panic attack.
Milder effects include “couch-lock,” which “some want while others don’t,” explained one of the young growers. I’m in the latter category—neither seeking what sounds like inertia, nor hoping for the “noticeably more cheerful” effect described by the Petra mints reviewer.
But I probably will never know any of these effects because I restrict my consumption to near bedtime—being slightly fearful of the high, also worrying about any interference with my nighttime reading—and I go to sleep shortly afterwards. Although the mints seem to provide better “deep sleep,” I restrict them to weekends because I need a lot of that memory-enhancing REM sleep at least as much.
Mary Carpenter regularly reports on topical issues in health and medicine.
SUN, SWIMMING, air conditioning—summer can produce dry-skin problems not so different from those due to cold winter air. The best advice: When indoors, turn thermostats up to diminish the drying effects from air conditioning; and outside in the sun, use cosmetic skin protection, avoid midday exposure and moisturize afterwards. After swimming almost anywhere, shower and shampoo as soon as possible.
Another scourge of summer can be the poison plants, or toxicodendrons —ivy, oak and sumac. Even people who’ve experienced debilitating outbreaks of poison ivy since infancy can find it challenging to recognize the “versatile” shape-shifting plant, despite its ubiquitous “leaves of three.”
(For example, poison ivy bears small berries, but only briefly; can form a hairy vine, but typically has a common thin green stem; and it can climb trees but often crawls along the ground. The “leaflets can be smooth, rounded or spiny… are green in the early season but will turn bright red in the fall… are often waxy and shiny, but may appear dull, particularly after it rains.”)
To prevent contact dermatitis from poisonous plants: wash as soon as possible after any encounter—using dishwashing or laundry soap, or rubbing alcohol—including under the nails; also wash everything you might have touched, particularly gardening tools. People can spread poison ivy’s “tenacious” urushiol oil to others, though the rash itself is not contagious. Cortisone ointments can help with intense itching, but when the rash spreads to the face or is unbearably aggressive, a five- or fifteen-day course of prednisone can be the only salvation.
While pool chlorine dries the skin, swimming anywhere else has its own risks. Swimmer’s itch —also called clam digger’s itch—comes from lakes, ponds and oceans where water parasites, often from bird droppings, can burrow into the skin to cause welts or blisters on areas that bathing suits don’t cover. A brisk towel rubdown can help remove critters when washing is unavailable.
Conversely, seabather’s eruption—or pica-pica— appears on areas of the body covered by bathing attire, including flippers and masks, when newly hatched jellyfish or sea anemones get trapped inside, most commonly in the waters off Florida and Long Island, NY.
Summer warmth can provoke prickly heat— miliaria or heat rash— when blocked sweat glands cause sweat to build up under the skin, producing itchy bumps. While sunburn appears uniformly red and only on exposed skin, heat rash occurs anywhere moisture can get trapped, particularly under the arms. Bursting bumps release sweat to create a prickly sensation. Common-sense advice suggests trying to avoid profuse sweating—for example, by reducing exertions during the hottest or most humid periods of the day.
Melasma, which looks more like sunburn, is a disorder that produces gradual pigmentation of the skin. Sunlight can provoke flares in summertime, while the condition can improve in the winter.
Another ongoing skin condition that becomes worse in summertime is folliculitis—also known as “hot tub folliculitis” — that occurs when hair follicles become infected and often resembles pimples. To alleviate problems, change out of tight workout clothes whenever possible or wear looser-fitting options. Also, stay out of hot tubs, which can have irritating high chlorine and acid levels.
DSAP (disseminated superficial actinic porokeratosis) causes dry, scaly patches; it can be inherited. Generally, it first appears among those in their 30s and 40s— and is also most likely to arise on sun-exposed areas of the skin, with lesions most prominent in the summer. While DCAP is usually benign, carcinomas can develop within the patches.
But small, scaly skin patches are most often actinic keratosis—also called solar keratosis— the most common early-warning sign of skin cancer. (Actinic refers to chemical changes produced by radiant energy—described as photochemical reactions, as in photography.) The two main non-melanoma or keratinocyte carcinomas are basal cell, occurring mostly on the face and neck, from which 80% of skin cancers develop; and squamous cell, found all over the body and accounting for 20% of skin cancers. The most dangerous skin cancer is melanoma, which can spread throughout the body.
Beachgoers incur additional risks in summertime. Pathogens that lurk in the sand include dermatophytes that can cause ringworm and athlete’s foot. In addition, hookworms and roundworms can enter the body through bare feet, or bare skin, but usually die after about six weeks.
The most familiar sand-borne bug, Staphylococcus aureus, or S. aureus, usually lives benignly on the skin but can penetrate through a cut or lesion. The most worrisome, antibiotic-resistant MRSA (multi-resistant staph aureus) has appeared in samples of sand and seawater from southern California beaches, although it’s unclear whether that bacteria has led to infections.
Milder staph infections can cause the skin sores of impetigo, which commonly afflict children and can run rampant on local beaches. For me, although I’d had severe bouts of poison ivy, ringworm and dry skin, the worst summer skin experience involved being asked by a lifeguard to leave a private beach after someone reported seeing, near my bared waist, weeping impetiginous sores.
Mary Carpenter regularly reports on topical issues in health and medicine.
“WHEN a wound doesn’t heal, something else is going on,” Jule Crider, past executive director of an association of wound care specialists, told MyLittleBird.
So that patients don’t have to “schlep around” from one specialist to another, Crider explained, wound centers bring together teams of physicians who can select and provide the best treatments—such as hyperbaric oxygen (HBO), negative pressure therapy, surgery, medication —because each individual’s non-healing, or chronic, wound is different. The teams can include foot and ankle surgeons, orthopedic surgeons, plastic surgeons and vascular specialists, along with specialists in limb salvage and wound care.
A wound typically becomes “chronic” after 30 days without measurable improvement or 90 days without complete healing—or when healing begins and then stalls, commonly between two to four weeks after the initial injury, said Crider. The “gray areas” that occur at these points can be difficult for most physicians to recognize or treat.
The “art and science of wound care” involves a combination of detective work—asking all the important questions—along with hands-on attention, and both can be time-consuming for a busy general practitioner, explained Crider. Chronic wound care can also require specialized tools and supplies not commonly found in doctors’ offices.
But because wound centers may not always be well known in their communities, many physicians initiate treatment without having the resources to provide the best option— for example, podiatrists who are trained to treat only below the ankle.
Chronic wounds most commonly start as ulcers but can begin with something benign like a blister. A surprisingly frequent, problem-causing wound occurs from tripping over the dishwasher door—linked to diminished balance, vision and ambulation that can occur with aging, said Crider.
That underlying “something else” mentioned by Crider is most often diabetes, peripheral artery disease (PAD) or obesity—especially in combination and especially in those with tissue-thin skin that tears easily and heals slowly. In adults ages 65 and older, diabetes and/or PAD occur in close to 20%—as well often as inadequate nutrition, poor hydration and decreased immunity.
On the other hand, even among people who are younger, healthy, active, non-smokers, with no vascular disease, and not obese, two to three percent end up with wounds that fail to heal in 30 days, Jule Crider said.
A wound begins to heal seconds after injury—starting with hemostasis that stops blood flow with the creation of a clot, which both plugs the wound and creates a provisional matrix. The next three phases, which can overlap, are inflammation, proliferation and tissue remodeling— with the final phase taking as long as a year.
The first steps in early wound treatment are cleaning with soap and running water, applying antibiotic ointment and covering with a bandage, plus using pressure to stop any bleeding. For a wound that is large, deep, won’t stop bleeding or is on the face or over a joint, stitches can speed healing but must be done in the first eight hours after the injury—before bacteria has a chance to enter and before the body’s own healing response begins.
Common signs that a wound is becoming infected include nearby skin becoming redder or more painful, or the wound becoming warm, swollen or oozing. More serious indicators are chills, fever over 100 degrees and red streaks near the wound.
Moisture-retentive dressings help keep wounds hydrated and enhance the migration of healthy cells to the site—a reversal from the older belief in keeping wounds dry. “Desiccation,” when a scab or crust forms over the wound site, can impede healing, as can infection and swelling.
Another important “standard care” tool is debridement—controlled removal of dead or unhealthy skin to provide a clean surface for healing. For chronic wounds, debridement can keep the wound in “active” stage —as if reminding the body to do more healing—or jumpstart the process. Other tools in “standard care” are pressure stockings to improve circulation and skin grafts.
Hyperbaric oxygen can help heal “from the inside out,” according to the University of Rochester’s Strong Wound Healing Center website —especially useful for younger patients based on health status and other factors, and for locations without a wound care center. The pressurized chambers, usually located in hospitals, can increase the concentration of oxygen in the blood, which can help reduce swelling, fight infection and build new blood vessels to improve circulation.
But HBO can be cumbersome because it requires series of treatments, often five times a week for four to six weeks. In the case of post-surgery wounds, some experts believe the best results occur when HBO is used right away, though national guidelines mandate waiting 30 days. But others caution against the overuse of HBO and recommend it only as a last resort to avoid amputation, and only in combination with other methods to achieve complete healing.
Medications to thin the blood or to relax the blood vessels can also help, especially for older patients, when the body’s “plumbing is clogged up enough,” says Crider. And negative-pressure wound therapy, using a vacuum pump to create suction, can remove excess fluid from the wound.
But not all wounds will heal, warns Crider—especially in those patients with more serious underlying conditions. These wounds get to maximum healing and, after that, require palliative care.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
IN MY Little Bird’s Part Two look at old diseases, literature of the 18th and 19th centuries begins to include—and sometimes comes up with original names for—these conditions, along with many now-outdated treatments, following their earlier listings in 17th-century “Bills of Mortality.”
Charles Dickens “achieved an almost matchless status as a definer of medical conditions,” Russel Chesney writes in a JAMA (Journal of the American Medical Association) review.
Dickens became known as a “syndrome spotter,” for example, with Pickwickian syndrome —an imbalance of carbon dioxide (too much) and oxygen (too little) in the blood of overweight patients, who are unable to breathe well while sleeping. What’s now called obesity hypoventilation syndrome —sleep apnea and obesity—in The Pickwick Papers caused a “wonderfully fat boy..standing upright..his eyes closed as if in sleep.”
The constant “writhings” of Uriah Heep in David Copperfield gave rise to Uriah Heep syndrome, most likely dystonia —repetitive movements that result from the involuntary contraction of muscles. As Miss Trotwood exclaims in Heep’s presence, “If you’re an eel, Sir, conduct yourself like one. If you’re a man, control your limbs, Sir! Good God!”
But Tiny Tim is the Dickens character whose medical issues have inspired the most speculation and research—with possible diagnoses of cerebral palsy, spinal dysraphism (congenital abnormal structure of the spine) and renal tubular acidosis (when the failure of kidneys to remove acids from the blood causes impaired growth in children).
Alternatively, Tiny Tim may have suffered from a “crippling” combination of rickets and tuberculosis, according to the JAMA review, as these two conditions were prevalent among London’s children—in about 60% for rickets and 50% for TB.
With rickets, insufficient vitamin D—needed for the body’s absorption of calcium and phosphorous—can cause a softening or weakening of bones in children, leading to delayed growth, bow legs, weakness and pain. While crowding and poor nutrition were contributing causes, the soot and particles in coal smoke darkened London’s skies and absorbed ultraviolet rays needed for vitamin D synthesis.
Tuberculosis, a lung infection eventually treated with antibiotics, appeared often in Dickens’s novels and in literature through the 20th century, famously in Thomas Mann’s The Magic Mountain. Also caused by a mycobacterial infection like TB, but not contagious, Lady Windemere syndrome got its name from the Oscar Wilde character whose Victorian manners kept her from coughing. Failure to cough was deemed a cause of the condition, characterized by an accumulation of phlegm.
Scurvy—the result of severe, prolonged vitamin C deficiency, which killed three times as many people as those who died fighting in the Civil War—appeared often in novels of the sea, notably Moby Dick. Another common vitamin deficiency, pellagra resulted from low levels of niacin (vitamin B3) and could lead to dementia, diarrhea and dermatitis—with the exacerbation of dermatitis by the sun causing its link to vampire literature, in particular to Count Dracula.
Cures for ancient ills were often worse than the symptoms, notably the mercury ointment used for skin diseases like scabies–which could lead to kidney damage and death.
Though most ancient treatments are now forgotten, leeches and maggots are “the only two living animals approved as medical devices in the U.S.,” writes Kate Golembiewski in Discover Magazine. Both “critters that clean up wounds by eating flesh and blood” can help treat infection.
Medical-grade maggots consume dead tissue to clean infected wounds. And leeches drink blood—an anesthetic is used first to numb the area and then an anticoagulant added to increase blood flow—in areas where pooling blood causes swelling “and the lack of fresh, oxygenated blood causes skin tissues to die.”
Another enduring treatment is the straitjacket, used on England’s King George III (who appeared recently in the musical “Hamilton”). His most likely diagnosis for “madness” was the genetic blood disorder porphyria (pronounced por-FEAR-e-uh), according to the BBC’s HistoryExtra.
In fact, a kind and industrious king who fathered 15 children and founded the Royal Academy, George III suffered from violent convulsions, terrible insomnia, hallucinations and mania, according to HistoryExtra. He once planted “a beef steak in the ground, fully believing it would grow into a beef tree.”
Of two forms of porphyria —both causing urine to turn red or brown, sometimes described as “bluish”—King George likely had an “acute” porphyria, caused by deficient production of heme, which is a component of hemoglobin. Symptoms can include pain, gastrointestinal problems and seizures. With the other “cutaneous” porphyrias, extreme sun sensitivity causes skin blisters and pain.
Besides the straitjacket, King George’s treatments included “arsenic-based powders applied to his skin… a method thought to draw the illness out,” according to HistoryExtra. Also, he was starved, bled and given freezing cold baths as a way of “shocking” the illness from his body. And “purgatives such as rhubarb, castor oil and senna were used to treat his constipation and cause diarrhoea, while emetics were given to make him vomit, purging him of disease.”
Some ancient diseases are still around, with others expected to return, according to NYU physician Marc Seigel, who is concerned about the “‘rise in diseases not seen since the Middle Ages,” including leprosy.
Seigel pinpoints homeless individuals as creating a “perfect cauldron for a contagious disease…Transmitted by nasal droplets and respiratory secretions with close repeated contact.” Los Angeles physician Drew Pinsky worries about “what usually comes on the heels of typhus,” which he has seen in this population: Yersinia—bubonic plague.
—Mary Carpenter regularly reports on topical issues in health and medicine.
OPTMISM has become a buzzword for the current state of the pandemic, while insecurity and caution are replacing fear—and people are beginning to grasp their new normal.
Among other reasons for optimism: L.A. County—with a population of 10 million where more than 200 people were dying every day just a few months ago—reported zero new deaths on two days last week. And Broadway has scheduled the reopening of full-capacity shows for September 14— a few on for now and more coming soon.
Swartzberg also finds reasons for insecurity, such as the randomness of the virus’s ongoing spread as hotspots arise unpredictably. He points to Washington State’s recent increase in case numbers and hospitalizations, despite rising vaccination numbers and ongoing restrictions in most parts of the state limiting restaurants and other businesses to 50% capacity.
Increased case numbers in some locations have created concern about the greater contagiousness of variants—notably the B.1.1.7 variant first seen in Britain and responsible for close to 60% of cases in states with recently spiking infections, such as Michigan and Tennessee.
Research on variants, on the other hand, has also led to optimism about the effectiveness of some vaccines, as well as the potential for an early warning system for spiking infections: Genetic sequencing of 20,000 cases in the United Kingdom showed that the appearance of new variants preceded higher levels of transmission.
Breakthrough infections, a concern for some, had as of April 30, occurred in about 1% of fully vaccinated adults—in 10,000 of almost 100 million people—with about 64% in women, as opposed to early higher rates of Covid among men. Also, 46% occurred in people 60 years old or older; about 9% were hospitalized (900); and 1% died.
(The statistics on hospitalizations and deaths may be affected by the difficulty pinpointing the virus as the primary cause and may be skewed because the majority of vaccinations have been given to older age groups, who are more prone to serious cases and death from Covid.)
Breakthrough infections, on the other hand, can be also illuminating, for example, as indicators of circulating virus levels within a community, according to Kawsar Talaat, infectious disease specialist at Johns Hopkins. And circulating virus levels, in turn, depend on the degree—and highlight the importance of — “herd immunity.”
When large numbers of people have developed immunity— either from the vaccine or the virus —if someone develops Covid, the people around them are protected, making it harder for that infection to spread—and “therefore transmission stops,” Talaat told CNN.
While nearly half of American adults (148 million) have received at least one dose of the vaccine, numbers are leveling off in several states—with Texas, Mississippi and Louisiana reporting closer to one third of the population having had one shot. A recent poll found almost one-fourth of U.S. adults probably or definitely will not get inoculated.
Among various unfounded criticisms of the vaccine, the private Centner Academy in Miami cites risk of “shedding” for its refusal to employ vaccinated teachers—based on reports from “tens of thousands of women [of] adverse reproductive issues from…close proximity with those” who have received the injections. (Shedding is impossible with Covid vaccines, which contain no live virus.)
True herd immunity for the coronavirus—estimated to begin when anywhere from 65 to 90% of the population is protected—may be out of reach, according to former FDA commissioner Scott Gottlieb. “I think [the virus] is always going to circulate at a low level.”
Breakthrough infections can also highlight the effectiveness of different vaccines and the wide variations in individual responses. One study has suggested that protection from severe Covid-19 holds steady while that from infection can drop “significantly”—depending on varying durations of strength of the different vaccines, writes retired Harvard infectious disease expert William Hazeltine.
Based on measurements of neutralizing antibodies, the Pfizer and Moderna vaccines performed best, with an initial efficacy of 95% that didn’t drop to 50% until around day 200, according to Hazeltine. At the other end of the spectrum, the Sinopharm vaccine, with an initial efficacy of 50%, by the 200-day mark offered “next to no protection at all.”
Because duration of antibody response varies so much among individuals, however, the advice remains to take whatever vaccine is available. One Singapore study found a small fraction of individuals experiencing “very long persistence” of antibodies while in another group, “no antibodies at all,” according to Hazeltine.
In the Seychelles, where more than 60% of the population is fully vaccinated, reopening to tourists may have contributed to a recent spike in coronavirus infections—leading to requests for some who received the Sinopharm vaccine to return for a third dose.
Third doses, or annual boosters, look likely to become part of the post-pandemic “normal” for everyone because of such variables as more contagious variants; waning or incomplete vaccine coverage in individuals; and the elusiveness of herd immunity.
And advice that once seemed provisional may become permanent, such as three C’s to avoid—closed spaces, crowded places and close contact; and three conditions, of which two should be met—outdoors, distanced and masked.
For those more resistant to change, like me, preparing for a post-pandemic life means beginning to come to terms with these issues.
Other people, though, have made such momentous changes—in work, home, exercise, friends—that their lives are already a complete do-over, what people are calling a post-pandemic mulligan.
INSOLE MONITORS from Paris-based FeetMe offer real-time gait assessment of variables, such as pressure distribution across the bottom of the foot —making them an exciting new digital health tracker for people with ongoing foot problems. After an endless search for helpful orthotics, real-time evaluations sound like a huge advance over current methods.
“The way people walk under observation in a short amount of time [in the clinic] is not how they walk in real life,” FeetMe co-founder and CEO Alexis Mathieu told ClinicalOMICs news. The insoles also collect and store data for “home-based assessments” of the efficacy of rehabilitation programs and drug treatment in patients with conditions like diabetes and osteoporosis —as well as multiple sclerosis, for which the device is now in clinical trials.
In the “Quantified Self” movement—which includes terms like bio-hacking, self-quantifying, lifelogging —digital devices can offer crucial real-time monitoring of “biomarkers,” defined as indicators of biological events that provide information or clues about current or future health issues. Biomarkers measurable by digital devices provide information on everything from sleep quality, inflammation levels and drug effectiveness, to mental health issues—a big step forward from first-generation health trackers that assessed steps and mileage. (Most of these devices are not yet commercially available in the U.S.)
As early as 2019, 44% of respondents in a digital-health consumer-adoption report tracked some aspect of their health using digital tools and shared that information with their health care providers, according to Rock Health, a seed fund supporting startups focused on digital health technology. “One in three respondents owned a wearable, and one in four wearable owners used it to manage a diagnosis.”
Among the newest options, the CompanionMx app can evaluate four variables relevant to mental health—interest, social isolation, mood and energy levels—by collecting data to find patterns in an individual’s speech as well as in the frequency, diversity and timing of their cell phone use. Studies using the app for suicide prevention are now underway with the U.S. Department of Defense.
The Sweatronics platform from Eccrine Systems analyzes sweat for rapid assessments of drug effects, with the goal of “precision dosing,” especially for medications with a “narrow therapeutic range, like some blood thinners,” explains Eccrine CEO Gavi Begtrup. “The big picture… is to get away from one size fits all dosing and get everyone on the right drug faster.”
Sweat testing also offers rapid adherence-monitoring for opioids, compared to traditional urine tests which take time. And sweat detectors can perform non-invasive testing for inflammation and glucose levels to help monitor diseases like diabetes; and for cortisol levels that indicate stress levels and can be crucial in cases of Addison’s and Cushing’s diseases.
In the case of sweat testing— as with many assessments from wearable devices —the most avid users may be athletes desiring real-time performance data, especially those in serious training for marathon and Olympic competitions.
To determine how hard she can train and whether she can practice her most competitive moves, competitive skater Jeanette Cajide aims for a “good recovery day,” based on her Oura ring’s assessments of resting heart and respiratory rates; continuous glucose monitoring from Levels; and help from a mattress pad programmed to lower middle-of the night temperature for improved heart functioning.
Cajide also wears an Elite monitor to keep track of heart-rate variability (HRV), variance in the length of time between heart beats (greater variance is considered a key real-time indicator of fitness); and an overnight high variance score, an indicator of restorative sleep. The Apollo Neuro, another bio-hacking device, can increase HRV to optimize performance.
Programming the Neuro to “recalibrate the nervous system” using varying-frequency vibrations may speed recovery after physical exertion as well as increase alertness and focus. In an early test, however, endurance mountain biker Chris Bailey concluded that “it helps with focus a little bit, maybe.”
The Covid pandemic has created more interest in tracking biomarkers, Stanford University geneticist Michael Snyder told the Wall Street Journal.” In Snyder’s research, smart watch data on heart rate, steps and sleep have helped detect Covid-19 up to nine days before symptoms appeared. “The seriousness of the pandemic has made people realize that, gosh, isn’t it a good idea to have a sensor?” Snyder said.
Also associated with the pandemic, remote-physician options are upping interest in personal biomarker tracking— as is accumulating evidence that supports better individualizing of health care. Do-it-yourself blood and urine tests and body-fat scans can also help reveal underlying health conditions.
Smartphone and big-data companies like Apple and Google have been developing digital health programs, ushering in a “new class of… software-as-medical-device (SaMD), according to ClinicalOmics, which considers the Apple watch the “the iconic symbol of a SaMD.”
When the Apple Watch Series 4 received FDA clearance for its ECG (electrocardiogram)-monitoring functionality —with the ability to detect elevated heart rates and atrial fibrillation— it became one of the first direct-to-consumer ECG devices on the market. Accuracy of the Apple Watch, however, can vary among individuals; and some find it impossible to get a heart-rate reading at all.
In one study, the Apple Watch detected atrial fibrillation about 40% of the time—considered “fairly good” sensitivity for abnormal arrhythmia—and was more accurate in older patients than younger, according to Morristown, NJ cardiologist and sports medicine specialist Matthew Martinez. Warnings from some doctors, however, concern the risk of overdiagnosis with this function, especially in younger wearers—with a high frequency of false alarms leading to the risk of over-treatment.
“The Apple Watch is in no way a replacement for medical devices,” said Martinez, who instead recommends the AliveCor “medical-grade ECG without the extras of the Apple Watch.” “Medical grade” and “clinical usefulness” are major goals of SaMD’s developers.
Creator of “The Quantified Self” podcast” Laura McClellan—real estate lawyer, self-described “productivity enthusiast” and tech geek—summarizes the advantages of digital biomarker monitors: raising awareness, gathering data about what our bodies and minds are doing; accountability, creating the motivation to be more active; crowdsourced aggregated data; seeing how others are functioning in ways we might like to work on; and improved medical care, using data for better treatment designs.
Among downsides, McClellan describes “cyberchondria,” undue anxiety about health resulting from intense self-tracking. Also: obsession, “unhealthy focus, wasted time;” loss of perspective, forgetting what really matters due to over-focus on numbers; self-criticism, “beating ourselves up or judging ourselves by the results of what we track;” and privacy concerns — “what do the app/website owners do with that data?”
Deeper questions arise about whether the body-hacking movement portends the end of “narrative health” — and “the beginning of examining patients exclusively through data rather than through their personal, needs, worries, expectations or stories,” writes digital health journalist Artur Olesch. “The question ‘how do you feel’ is being replaced by ‘what are the results?’”
Olesch also warns about the new digital divide that could arise as biotracking wearables, most of which are not reimbursable by health insurers, are available only to “digital natives with a higher economic status.” The result: measurement of life signs would be available “not for those who really need it, but for those who can afford it.”
Meanwhile, ongoing questions about the accuracy of wearable monitors extend even to the simplest measurements. But the Apple Watch has come a long way from the early Fitbit—with which one user managed to increase her number of steps by moving her forearm up and down while lying on her bed. And advanced calibrations can now vastly improve the accuracy of data collected by wearable devices, especially by the Apple Watch.
If I could bundle the most appealing lifelogging offerings —only for a few days or nights and mostly out of curiosity rather than medical need — I would choose the following: a continuous blood-glucose monitor, such as the Sweati patch, to find out which favorite foods spike my blood glucose; an HRV monitor to assess the restorative effects of my nighttime sleep; and the Apollo Neuro for staying more alert and focused during Zoom meetings.
Before any of these, however, I’d want to use those FeetMe insole monitors—with the longed-for real-time gait assessments of walking speed, cadence and load—in the hope of acquiring terrific new orthotics that balance my body and end foot pain.
—Mary Carpenter regularly reports on topical issues in health and medicine.
WOMAN A makes promises she can’t keep, lies about her accomplishments and veers from manically active to depressed inertia. Woman B can’t stop shopping or partying—once finding herself in a remote bus station with no money to get home. Both women come from upper middle-class families, have degrees from good colleges and work in the arts.
Both women have also struggled with addiction and sought help from AA and rehab programs —but an occasional drink still sends them over the edge. Both have received “dual diagnoses” of Substance Use Disorder along with Borderline Personality Disorder (BPD) —because the latter includes both impulsivity and a need to self-medicate the mood swings, according to the American Addiction Centers website.
“Borderline” refers to symptoms first thought to be “on the border” between neurosis and psychosis, which can include anxiety, paranoid thinking and anger. People with BPD, according to one theory, are born with a hard-wired disposition toward emotional vulnerability, which is exacerbated during an upbringing that “invalidates the child’s emotional responses by ignoring, dismissing, or punishing them,” writes British Columbia psychologist Andrew Chapman.
The treatment recommended by the National Institute on Drug Abuse specifically for people with both BPD and a co-occurring addiction —as well as for other self-harm behaviors—is Dialectical Behavior Therapy (DBT). Despite the complicated name, DBT therapy employs just two opposing goals: to help patients feel better accepted and at the same time to change their behavior. DBT combines validation of a patient’s thoughts and actions with disagreement that these are the best approach to problem-solving. (In the philosophical concept of dialectics, change occurs only in interaction or conflict between two opposing forces.)
Working to help patients regulate intense emotions and improve interpersonal relationships, DBT differs from therapies like Cognitive Behavior Therapy (CBT) in the “kind of change [each creates] for the client,” according to Indianapolis psychologist Aarika V. White. CBT, with its focus on recognizing and changing patterns of thinking and behaving, may be more helpful for depression, anxiety, OCD and phobias.
DBT evolved when interventions for treating suicidal women were so focused on changing their behaviors that patients felt criticized and misunderstood, and often dropped out of treatment altogether. In the late 1980s, University of Washington psychologist Marsha Linehan and colleagues developed a “standard DBT treatment package”—rather than a single treatment method conducted by a practitioner in isolation—that includes weekly individual therapy along with group sessions focused on skills training with the goal of behavior change.
The four main DBT strategies include mindfulness (sample exercise: pay attention to the breath); distress tolerance (sample, run up and down the stairs or move to a new location); interpersonal effectiveness to become more assertive in relationships while respecting yourself and others (sample: acknowledge another’s thoughts and feelings); and emotional regulation (sample: identify how you are feeling and do the opposite—if sad, plan to visit loved ones.)
DBT has the strongest empirical support for treating “parasuicidal women with BPD” but has also helped those with binge eating and other eating disorders, with PTSD, and sometimes with depression—in general, conditions that involve emotional vulnerability as well as behavior issues, such as difficulties with social interaction and substance abuse.
Because personality disorders in general are notoriously unresponsive to treatment, however, the BPD diagnosis can be stigmatizing and is often withheld for as long as possible. Meanwhile, many sufferers receive mood-stabilizing drugs to deal with the often-serious consequences of both the excesses of mania and the worrisome intensity of depression. In addition, many also receive prescriptions for anti-depressants, anxiolytics and anti-psychotics.
“Substance use disorder” can involve any “source which is capable of stimulating an individual.” Addiction characteristics listed in the DSM-5 (the manual for psychological diagnoses) include brain-reward dysfunction, preoccupation, risky use and impaired control— as well as causing significant problems in someone’s life, such as health issues or failure to meet responsibilities.
In the absence of psychotropic drugs, behavioral addictions can include gambling, shopping and social media activity. Food addiction remains controversial because its divergence from food enjoyment is inconsistent, and its effects—direct stimulation of the brain versus simply sensory enjoyment—remain unclear. People with a substance use disorder are twice as likely to have a mood or anxiety disorder—and vice versa.
Relapse rates within the first year following treatment for substance use disorder range between 40 and 60%. Medications can help treat specific addictions—to opioids, alcohol and nicotine —but not to stimulants or cannabis, and not behavioral addictions.
Many substance abuse rehab centers offer DBT or programs that incorporate many of the same behavioral elements. But “helping people change must include each individual finding personal and compelling reasons for change, as well as a pathway they can truly endorse,” according to a DC-area DBT-focused center. “While there are clear and specific tools (e.g., CBT, DBT, mindfulness) to be used in making change, they are not effective unless you have made the often very difficult decision to use them.”
Woman B tried DBT with “mixed feelings/results” but received the most help from a psychiatric PA (physician assistant) who reduced her “tangle of drugs” by half, she said. Woman A spent weeks in a behavior-focused residential rehab program but saw no improvement until she began mood-stabilizing medication and slowly created a wide circle of friends and family who could help her. Both women have regular relapses and require ongoing monitoring and support.
—Mary Carpenter regularly reports on topical issues in health and medicine.
NEW YORK-based science writer S.H. headed for the hospital with back pain that, by the time she arrived, felt “as if someone had taken a baseball bat to my back – though at first it felt as if I had pulled a muscle” in a recent ice-skating fall. The cause: pulmonary embolism (PE), a blood clot that had moved to her lungs.
Dangerous blood clots in the brain and abdomen of those who received Covid-19 vaccines— those made by Johnson & Johnson in the U.S. and elsewhere by AstraZeneca—are unusual, if rare, compared to the more familiar dangers of PE. In the vaccine-induced cases, symptoms include severe headache, abdominal pain, leg pain or shortness of breath within three weeks of vaccination.
After six reported cases of blood clots in the brain—all in women ages 18 to 48, one of whom died—the U.S. suspended use of the J&J vaccine for further study. (Also in the U.S., a seventh woman and a man developed clots after receiving the vaccine during its clinical trials.) Three of the women had “large, dangerous clots” in other parts of the body—not just the brain.
Incidence in the U.S. of dangerous post-vaccination blood clots appears to be at least three times more often than would occur naturally in a similar population of women in that age group, but is still “extremely rare,” according to CDC safety expert Tom Shimabukuro. “Vaccine-induced immune thrombotic thrombocytopenia” or VITT—with the prefix thrombo from the Greek word meaning clump or clot—is the complicated label for these blood clots (the clot is a thrombus, and the formation of clots is thrombosis), accompanied by low levels of platelets (thrombocytes).
While the body’s expected response to the SARS-CoV-2 vaccine involves the creation of antibodies against the coronavirus’s spike protein, in rare cases the vaccine also produces antibodies that bind to platelets—causing them to be “activated and also consumed.”
(As of April 4, the AstraZeneca shot—based like the J&J vaccine on an adenovirus vector —had caused 222 similar cases of VITT throughout Europe, or one in 100,000 of those vaccinated: 169 cases of clots in the brain and 53 cases of abdominal clots; and of 86 cases reviewed, 18 were fatal. As a result, several countries have imposed restrictions on administering the vaccine, either limiting it to people over a certain age, like 50 or 60, or halting its use altogether. )
(When J&J privately requested an informal alliance among vaccine makers to study clotting risks linked to vaccines, AstraZeneca expressed interest but Pfizer and Moderna declined to share relevant risk data for recipients of their vaccines.)
Besides providing time for further investigations into VITT and its causes, the U.S. suspension alerted physicians, not just about the risk, but also about the contraindication in these cases of providing the typical clot treatment that involves the blood-thinner heparin. The reason: When blood clots in vaccine-related cases occur together with low platelet counts, the result is a simultaneous risk of clotting and bleeding — which is paradoxical, because clots are usually the result of abnormally high numbers of platelets clumping together. But the combination is similar to a rare side effect of heparin, which makes the drug a dangerous treatment for vaccine-induced clots. With insufficient information to date about the cause of VITT or why certain individuals are affected, there is no way to predict who might be susceptible.
Blood clots are also a side effect of hormonal birth control—at a much higher rate, of 1 to 5 in 10,000—which led to early downplaying of the vaccine-induced clots. But the comparison is like “apples and cashews,” Michigan ob/gyn Jen Villavicencio told The Washington Post’s The Lily. Clotting spurred by the vaccine sounds more like a syndrome, Villavicencio explained —unlike the single blood clotting episodes that can arise with birth control pills.
In addition, blood clots occur commonly after injury or surgery that damages blood vessels, called deep vein thrombosis (DVT), when platelets flood to the site of injury. While the main role of platelets is coagulation to block excess blood loss, their participation in combating microbial threats and other immune responses has led to a more recent view of them as the “underappreciated orchestrator of the immune system.”
In addition to the birth-control pill connection, clots can occur as side effects of several medications and as a result of illness, or bed rest or prolonged sitting — notably following long airplane trips. Clots occurring in the legs can cause chronic swelling and pain, and cellulitis, a skin infection. DVT rates rise with age, increasing from about 1/1,000 before age 45 to 5 to 6/1,000 by age 80.
The risk increases when a clot travels to the lungs, creating a PE that blocks blood flow. A PE can cause shortness of breath, chest pain and a rapid pulse—but occurs 50% of the time with no symptoms. Unusually, dangerous post-vaccination clots have traveled to the brain and to the abdomen.
In the vaccine-related cases, low platelets developed because the vaccines produced antibodies that mistakenly bound to one of the “clotting factors”—13 different proteins that work with platelets to help blood clot. Hemophilia, a genetically inherited condition, involves the absence or low levels of specific clotting factors—most commonly Factor VIII—which causes sufferers to bleed easily, sometimes spontaneously or internally, and require regular transfusions of plasma to replace the missing proteins.
With VITT and most serious blood clots, treatment is usually successful but recovery can take weeks or longer. After science writer S.H. left the hospital, she had so much trouble breathing that she couldn’t walk a block—which continued for more than a month, along with a no-flying ban.
—Mary Carpenter regularly reports on topical issues in health and medicine.
MAKING IT through this pandemic year has inspired medical spruce-ups for some: physical exams and visits to ophthalmologists, dermatologists, gynecologists. But others are choosing more extensive, sometimes holistic, health evaluations—which in the 2020s can include diagnoses like small intestinal bacterial overgrowth (SIBO) and increasingly popular treatments, such as the ionic foot bath.
Thirty-something M.L., who worked as a nurse-practitioner and recently cofounded a new marijuana business, consulted a Denver naturopath to deal with a host of health issues, such as headaches and fatigue, as well as neuropathy from Raynaud’s disease in her fingers, and eczema. But M.L.’s most pressing concern was GI issues that had plagued her for years, resulting in a diagnosis of SIBO, which appears lately to be “much more common than previously thought.”
Bacteria are beneficial as long as they stay in the large intestine, explains the Washington Post’s Cara Rosenbloom. In the case of SIBO, though, these bacteria “end up in the wrong part of the digestive system,” where their proliferation can cause abdominal pain, gas, bloating, constipation and diarrhea—all symptoms that afflicted M.L.
SIBO occurs in those taking proton pump inhibitor drugs like Prilosec to reduce stomach acid—reducing acid allows bacteria to flourish; and in those with diseases of the digestive system, such as irritable bowel syndrome, as well as in people with diabetes and coronary artery disease. It’s also a “common, often undiagnosed cause of malabsorption” in older adults.
The most accessible measure of SIBO is the lactulose breath test—performed after a two-day diet of white rice, eggs and a sugar solution—combined with other assessments. For M.L., the results showed her gut excessively colonized by yeast, which interfered with nutrient absorption—probably related to chronic stress and fatigue that she suspects have been background issues for her since high school.
But the more alarming health check for her was the ionic foot bath, which is enjoying a “surge in popularity.” After the water turned unusual dark colors, M.L. said, it “suddenly began tingling with parasites”—dozens of tiny worms that appeared to emerge from her feet, a not-infrequent experience for ionic foot bathers.
In fact, pinworm (Enterobius) is the most common infection in the U.S., causing restless sleep and anal itching but often symptom- free. The foot bath’s metallic array ionizes the water, giving the hydrogen a positive charge which then purports to work like a magnet to attract negatively charged toxins in the body, such as arsenic and aluminum.
In the most in-depth study by Canadian holistic researchers, the detox bath neither reduced toxins nor stimulated the body to do so, which is another health claim. In general, the body sweats out or excretes toxins like these. But anecdotal reports by foot bathers often mention pinworms; and other research has documented reduced levels of arsenic and aluminum in people following repeated foot bath use.
Holistic practitioners have also found that the specific colors and consistency of the bathing water, typically altered by metals in the array and impurities in the water, also vary with each individual’s health problems to indicate accumulated toxins in certain areas of the body. Among a long list of possible colors, yellow/green suggests urinary tract, bladder and kidney problems; and white, problems in the GI tract, headaches and insomnia.
Many people also have similar experiences with health effects of the baths, at first feeling lousy, often with swollen glands —indicators that the body is fighting infection. In addition to the footbaths, M.L began an anti-parasite diet called “GI synergy” that includes wormwood and berberine, a multi-herb supplement—which made her feel worse at first, as the worms died off.
Along with another very strict diet— no beans, no dairy, very little fruit—M.L.’s regimens focused on treating both the worms and the SIBO. In addition, “intensive psychotherapy” helped her understand that she had felt anxious “my whole life.” Slowly M.L. felt better, at first “in waves” with fewer headaches and less fatigue. And then “all of a sudden” one day, symptoms disappeared, and she felt “great! And hungry!”
Both pinworms and SIBO also have medical treatments: for SIBO, antibiotics such as rifaximin; and for pinworms, anti-parasitic drugs like pyrantel pamoate. But standard treatment for both conditions can also include or rely solely on diet—for SIBO, for example, no snacking between meals.
Ionic foot baths are widely available—at holistic health spas and alternative health practices. For at-home use, model costs range from $40 to $1,000. Comments on Amazon also range widely—from “Rip off!” and “Scam” to many variations on “This really works!”
Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
