MILD CONCUSSIONS don’t get the respect they deserve—for how debilitating they can be, and for how many weeks, months or years the brain can take to recover completely. Four months after hitting her head on a pole while rushing to get off a Metro train, DC artist and teacher A.M. still struggled, at first mostly with headaches and facial pain focused in her jaw.
But A.M.’s eyes caused her the most trouble in the presence of any light, indoors and outside. Reading was difficult— black print on white pages—but especially anything on an electronic screen. In addition to its bright lights, a screen also continually flickers, making the eyes work harder.
“Sensitivity to light is the worst,” she said, “because everything involves light.” Most of the time, even indoors, she wore two or three pairs of dark glasses.
A.M. also had trouble with noise, both the uncontrolled ringing of tinnitus and the amplification of voices, including her own, which sounded like a recording blasted through a loud speaker inside her head.
At the four-month mark, she received an official diagnosis of post-concussion syndrome with ocular-motor difficulties, a prescription for vision therapy and the prognosis that these could take months or even years to heal.
With a concussion, severity and recovery time are often unrelated to the original impact or its immediate effects, such as blacking out. It’s almost impossible to detect how far the initial damage has spread, and every concussion is unique.
“Imagine you have a mason jar that is full of thick liquid and just big enough to accommodate a peach,” writes Lori Fox about her girlfriend’s head injury. “If you shake the jar violently, the peach sustains multiple impact points. When you take the peach out, the bruised places are visible. If you cut into the bruise, you will see the damage spreads beyond the area around the impact sites.”
“I just saw someone the other day who had a dog toy thrown at their head by their toddler,” said clinical neuropsychologist Alicia Sufrinko at the University of Pittsburgh Sports Medicine Concussion Program. “The injury comes from the brain shifting inside the skull and affecting your nervous system.”
“Usually it’s only in retrospect that you can say how severe a concussion is,” according to Vanderbilt neurosurgeon Andrew Gregory.
Bruising caused when the brain moves back and forth inside the skull often affects the frontal lobes. These are responsible for cognitive functions, also called “executive functions,” such as attention and completing tasks; planning and organization; inhibition and emotions. Head injury can also cause fatigue, irritability, anxiety and insomnia.
Most people, including physicians, are unaware that sufferers should avoid triggers such as bright lights, loud noises and physical or mental exertion until the symptoms are gone, Gregory pointed out.
Said Sufrinko, “We give people a structured rehab program, and we follow up with them and make sure they get to 100 percent before we discharge them.”
Few physicians are also aware that, for symptoms that persist after three to four weeks, more aggressive interventions should begin, including vision therapy for eye problems, vestibular therapy for balance problems and cognitive therapy for difficulties with concentration and multi-tasking. As with a stroke, undamaged areas of the brain can take over tasks from the damaged areas but need therapy and practice to master those tasks.
What can help predict recovery time is the total number of specific early symptoms, such as sensitivity to noise or light, difficulty concentrating, insomnia and balance issues. Others that appear less relevant include amnesia, tinnitus, loss of consciousness and hyper-excitability. Researchers are working on algorithms to help with these predictions.
According to a meta-analysis of more than 100 research studies, the likelihood of a lengthy recovery is also linked to the “development of subacute problems with headaches or depression,” as well as to a history of mental health issues such as depression. Other red-flag symptoms include neck pain, double vision and weakness or tingling in the arms and legs.
The strongest predictor of a lengthy recovery from a mild traumatic brain injury is painful headaches in the days immediately following the impact. For the first time in her life, A.M. had migraine headaches over a period of several weeks. (Her family history of migraines made these more likely with a head injury.) She had surgery to remove impacted wisdom teeth and treatment for TMJ. After the migraines stopped, she continued having tension headaches and jaw pain.
The one effect of head injury with an unquestionable prognosis is loss of smell, because impact can completely sever the brain connections involved, and their functions cannot be replaced.
Once A.M. received her diagnosis, she started therapy for her brain to relearn how to coordinate the information received by her two eyes, needed for all visual activities, notably for tracking lines of print on a page for reading. Simply receiving the post-concussion diagnosis helped her to obtain accommodations at work and to make other adjustments. The only regret: that getting an accurate diagnosis and starting treatment had taken so long.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.
DIRECTLY CONTRADICTORY advice on calcium and vitamin D supplements appeared on facing pages in last week’s New York Times Science Times.
Meanwhile last year, a U.S. government-appointed panel of physicians recommended “against daily supplementation with 400 IU or less of vitamin D and 1000 mg or less of calcium for the primary prevention of fractures” in postmenopausal women.
In April of 2014, my post on supplements and bone health described annual checkups with both my internist and my gynecologist, mistakenly scheduled within a few weeks of one another. Because my blood levels were good, my internist advised me to stop taking both supplements, while my gynecologist reminded me that, because of my mother’s severe osteoporosis, I should be taking the maximum doses.
Five years later, not much has changed. On the left-hand page of the Science Times spread, research linked the commonly recommended daily amounts of calcium and vitamin D respectively (1,000 or more mg and 400 IU or more) with “an increased risk of death from cancer” and “increased cancer death and death from any cause.”
The same study—referred to as NHANES, involving more than 30,000 American adults—linked other vitamins and minerals with reductions in mortality but “only when the substances came from food, not supplements.” In fact, most studies showing benefits of calcium/vitamin D supplements are observational, failing to consider diet, exercise and other important variables.
An osteoporosis diagnosis begins with a DEXA or DXA scan that measures the mineral content of bones as an indication of bone strength. Those with bone density scores T-scores of -2.5 or below, as a group, have a 33% chance of fracturing a hip compared with a 16% risk with a score of -1. These scores, along with a history of fracture, can help determine individual risk. For those with borderline scores, urine testing can help determine the need for drug treatment.
Decreasing bone density occurs over time when bone resorption exceeds bone formation, which is controlled by hormones, such as estrogen and parathyroid hormone, as well as by specific proteins in the bone.
Bisphosphonate drugs can inhibit bone resorption by blocking the osteoclasts that cause breakdown, in turn allowing osteoblasts to create more new bone. Other osteoporosis drugs affect parathyroid hormone levels or create antibodies to proteins in the bone to encourage bone growth.
Side effects of these drugs, however, include gastrointestinal problems as well as increased risk of stress fractures and deterioration of specific bones. The numbers of osteoporosis patients and their doctors who “have turned their backs on bone-protecting medicine” have led to a plateauing of hip fractures since 2012, following 10 years of declining rates, Brody noted. One study of 126,188 women, all of whom had Medicare Part D drug coverage, found fewer than one-third started drug therapy within a year of diagnosis.
In her 2015 article,“12 Minutes of Yoga for Bone Health,” Brody described research by Columbia University physiatrist Loren Fishman that found yoga increased bone density in the spine and femur. “Yoga puts more pressure on bone than gravity,” Fishman told her. “By opposing one group of muscles against another, it stimulates osteocytes, the bone-making cells.”
“Yoga for osteoporosis,” offered at Circle Yoga off Chevy Chase Circle and elsewhere, concentrates on the 12 poses used in Fishman’s study, with the recommendation to hold each pose for 30 seconds—a routine that takes closer to 20 minutes than 12—and poses are adjusted for individual bodies.
The worst outcomes for osteoporosis sufferers come, not from brittle bones themselves, but from the increased risk of falling for which the best protection is good balance. Yoga for osteoporosis focuses on balance in most of the poses—not just tree pose (standing on one leg).
In Northwest Washington, a “forum” of four friends—after comparing DXA scan results, diagnoses of osteoporosis and prescriptions for osteoporosis drugs—determined to find ways to strengthen their bones without taking drugs or relying on supplements.
They wanted to avoid the side effects. Even calcium/vitamin D supplements can cause gas and bloating, as well as constipation. Also supplements may increase the risk of serrated polyps, precursors to colon cancer. These concerns aside, there is abundant medical research and professional statements advising against supplements.
The group started when two friends broke bones—one her wrist, the other her hip. Calling themselves Gimpy and Limpy, the two commiserated and, with two others, began sharing research on bone health. While some take small amounts of supplements, they try to get most of their calcium from diet—notably dark, leafy greens and bone broth.
One member, MH (Limpy), continues with a low-inflammation diet, which includes less dairy, sugar and processed foods, and more vegetables, fruits and grains.
Exercise choices varied. For the first time ever, MH, a former runner, signed up for twice-weekly personal training sessions for almost four months. The sessions worked on strength and flexibility, with a particular focus on her feet. Because she had already been doing Gyrotonics—exercises involving a series of circular, flowing movements—MH added Gyrotonics-related PT, which includes weights, all at Elements Center in Georgetown.
In the three years since they began, several members have not just leveled off but improved their DEXA scores. It may help that they have each other to compare notes and scores, and even egg each other on. But their success in improving bone strength is enough to inspire someone like me, wavering between opposing doctors’ recommendations, finally to let go of calcium supplements and see what I can do for myself—with diet, exercise, and yoga whenever possible.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.
SCHIZOPHRENIA is no longer a blanket diagnosis with a poor prognosis, and one day may become as outdated as “dropsy.” The main reason is the growing list of its possible causes, from childhood trauma and central nervous system infections to genetic variants, cannabis use and cats.
Diagnosing psychosis today is a far cry from the early 1980s when Susan Sheehan’s book, Is there No Place on Earth for Me?, about a schizophrenic patient in her 30s with the pseudonym Sylvia Frumkin, won a Pulitzer Prize. At the time, the diagnosis was a life sentence with debilitating symptoms that could only get worse and made living outside a mental health facility nearly impossible.
Even in 2013, skepticism arose over University of Southern California law professor Elyn Saks’s memoir, The Center Cannot Hold: My Journey Through Madness (describing her ongoing delusions and repeated hospitalizations) as to whether her diagnosis of schizophrenia could be correct and, if so, how anyone with this diagnosis could accomplish so much.
According to the current prognosis, however, the majority of schizophrenia patients improves over time. For every five people, within five years of experiencing the first signs, one will get better; three will get better but have periods of bad symptoms; and one will having ongoing debilitating symptoms.
And some experts are challenging the view of schizophrenia as one distinct disease. “I expect to see the end of the concept of schizophrenia soon,” British psychiatrist Robin Murray told MedicalXpress. In 2013, the most recent DSM V (Diagnostical and Statistical Manual of mental conditions) changed the description of schizophrenia to eliminate previously listed subtypes such as paranoid schizophrenic and to add the word “spectrum.”
Symptoms of schizophrenia spectrum include the “positive,” such as hallucinations and delusions, which alter the sense of what is real; and “negative,” such as loss of affect and inability to experience pleasure. Anti-psychotic drugs are most useful for treating positive symptoms.
A newer therapy called “internal family systems” (IFS) – in which therapists encourage dialogue among different voices inside a patient’s head—has been successful, particularly with patients whose schizophrenia appears related to childhood trauma and who do less well in general with drug treatment.
Understanding is growing about how different treatments can work better depending on the factors linked to an individual’s symptoms—in contrast to the earlier belief that all symptoms arise from increased levels of dopamine, which should thus be the target for all treatment.
“The potential for different treatments to work for different people further explains the schizophrenia wars,” according to MedicalXpress—between those who see schizophrenia as genetically or physiologically based versus those who view it as a response to psychosocial factors, such as adversity.
IFS, used for an array of psychological issues, begins with the belief that we all have multiple personalities and many inner voices, Harvard psychologist Richard Schwartz told the Psychotherapy Networker Symposium held recently in DC. But the experience of childhood trauma can push helpful voices into dysfunctional roles, leading to symptoms of schizophrenia.
Schwartz showed the video of a TED talk, “The Voices in My Head,” by Manchester, England psychologist Eleanor Longden, who traces her recovery from schizophrenia to therapists willing to converse with her most troublesome voices. In another video, a young man who appears disturbed and almost catatonic begins to recover as therapists encourage his voices to speak up.
“There’s nothing inside of anyone that can hurt if they’re not afraid of it,” said Schwartz. “It has no power if you’re not afraid.” He described a survey by the Hearing Voices Network (comprised of some 200 groups worldwide) of 450 people, among whom one-third said they had no trouble with their voices.
Viewing schizophrenia as a healing journey and encouraging patients to act out—in response to inner voices or compulsions—has a long history. In the 1960s Scottish psychiatrist and author R.D. Laing became a counterculture hero for his clinic, Kingsley Hall, where patients could act out in safety, notably his patient Mary Barnes who became a successful painter.
Besides links to childhood trauma, early exposure to Toxoplasma gondii, transmitted to humans from cats, may trigger schizophrenia. But the odds may be much lower than those for other risk factors, such as childhood viral infections of the nervous system, autoimmune disorders and certain genetic variants.
And some research has found a higher incidence of psychosis in those U.S. cities with the most easily available marijuana. “But you cannot say that cannabis causes psychosis,” says Columbia University psychiatrist Diana Martinez. “It’s simply not supported by the data.” Psychotic disorders such as schizophrenia are complicated disorders, and overall incidence has not gone up despite increasing numbers of people using marijuana.
About her diagnosis of schizophrenia, Elyn Saks writes, “We can’t all be Nobel laureates like John Nash in the movie A Beautiful Mind. But the seeds of creative thinking may sometimes be found in mental illness, and people underestimate the power of the human brain to adapt and to create.” Saks won a MacArthur Foundation “genius award” to write about her experiences.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.
I WISH I’d had a few more good responses after “I’m sorry” upon hearing my friend’s recent bad news about a family member.
What comes next can be challenging—and people often avoid uncomfortable circumstances out of fear they might say the wrong thing, according to Rutgers sociologist Deborah Carr.
Avoidance is the wrong approach, Carr said in a Live Science panel, because social support is “the most important factor” for helping people cope with any problem from terminal illness to divorce. To help the sufferer feel less alone in their grief, share any positive memories you have if the news concerns someone you know or knew.
When sending condolences, do it “as soon as you learn,” advises etiquette expert April Masini on her website Ask April.
In a panel convened by the New York Times, Masini warned against using social media because comments there can look like the writer’s attempt to get credit for themselves, while “comforting the bereaved becomes a secondary goal.”
Wake Forest sociologist Amanda Gengler on Live Science disagreed: Contact the person as you normally would, including by phone or email.
Also, make specific offers to help—anything from bringing dinner on Tuesday to binge-watching Netflix—and when possible ask “if they want company or if they would rather have some time alone,” said Gengler.
What should be more general are expressions of concern such as “how are you doing this week?” said Cleveland State University sociologist Linda Francis. This way you’re telling the person you’re there while allowing them to take control of the conversation and share as much or as little as they want.
Asking questions is always better than offering answers. Questions give people “a chance to share their experiences and voice their concerns without judgment,” writes Suzanne Leckie on Sane.
Empathy— awareness that the other is suffering —is what you want to convey, rather than pity, which can make a sufferer feel more helpless. But empathy can be overdone: identifying too closely with the other can cause you to imagine suffering that is not theirs. Also, taking on another’s sadness can make you feel too depressed to take helpful action.
The long list of what not to say begins with: don’t minimize or invalidate the other person’s feelings with comments or clichés, such as “look on the bright side.” Forced cheerfulness can make the speaker feel better, rather than the sufferer, and risks shutting down the conversation.
It’s good to be encouraging as long as you’re not being unrealistic, said Francis.
Also don’t make it about you, Massini advised. “Avoid referring to your own experiences with the death of a loved one.” Definitely do not try to one-up sufferers by telling them about someone who is worse off.
Another big don’t: unsolicited advice. Someone who’s heard a bad diagnosis is getting enough information from their doctors, who know the facts of their condition—and from the questions they themselves ask. The best solutions are generally reached by the sufferer, according to Leckie.
When depression is the problem, though, it can be helpful to mention changes you’ve noticed, such as someone being more reluctant to make plans with you.
All communication should include “no need to reply.” Sufferers can be overwhelmed or exhausted by so many emotional messages and so many offers to help. And they can feel pressured when those with the best intentions seem competitive about being the most helpful.
Anyone at a loss for words can find inspiration from sympathy cards or in sample condolences online. Or from condolence expert Emily McDowell, creator of “Empathy Cards,” on her website or in her books, including the recent There’s No Good Card for This.
The key here is that individuals are so different—both bearers and receivers of bad news. When asked, a close friend told me her favorite response was food left on her porch, something that didn’t spoil like trail mix—so she didn’t feel the obligation to see or talk to anyone that she would if given advance notice of plans to drop something off. She would rather choose the friend and the time that works best for her—when she’s ready to talk.
I wish I’d known about her preferences earlier when she was suffering. People who’ve been through painful experiences can help friends by talking about what helped them the most.
The most challenging for me is the surprise at hearing bad news—almost always the case—that makes me forget everything I’ve learned to say. Hence a new plan: Collect responses I might want to give and keep copies close at hand.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.
SUPPLEMENTS TO improve memory or stave off dementia are ineffective based on current research, with the possible exception of omega-3 fatty acids, Jane Brody wrote in last week’s Science Times.
But the specific supplements currently giving highest hopes to many —L-serine and NAD+— although they may be equally unsupported by evidence, do not appear on Brody’s list of ineffectuals. That list includes gingko biloba, coenzyme Q10, huperzine A, caprylic acid and coconut oil, and coral calcium.
What continues to spur both research and personal use of supplements to combat age-related dementia and Alzheimer’s Disease (AD) is the repeated failure of drugs designed to combat formation in the brain of the beta amyloid protein plaque associated with AD.
Since 2003, despite more than 300 clinical trials, the FDA has approved no new drugs for AD, and the five approved before that offer only limited, temporary relief.
The experiment, halted last week, on the most recent hopeful, aducanumab, cast more doubt on the importance of these plaques in causing dementia associated with AD. The drug, tested on patients showing very early signs of disease, was the most recent bet for removing plaques.
Besides these drugs, some of the best results to date—reversing symptoms of AD about half of patients—come from the 36-recommendation protocol that includes a list of supplements, elucidated in Dale Bredesen’s 2017 book, The End of Alzheimer’s. Bredesen’s protocol is based not on the amyloid hypothesis, but on the idea that an array of age-related changes are to blame for deterioration of cognitive functioning.
As a result, his program focuses on controlling blood sugar, reducing inflammation and correcting other imbalances that occur with aging. Among the program’s diet restrictions are those dubbed KetoFlex 12/3: keto to help control blood sugar levels; flex, because the allowed food groups can flex from paleo to vegan; and 12/3, restricting eating to a 12-hour window and leaving at least three hours between the last meal and bedtime, according to Minnesota Integrative Health practitioner Karen Vrotchka.
Among supplements arousing enthusiasm, L-serine is an amino acid produced by the body and consumed in soy, eggs, meat and other foods. Although Fortune magazine in February deemed L-serine worthy of 20 pages, research has not yet linked its levels to cognitive function, and postmortem studies have found no differences in levels in the brains of AD patients compared with those of healthy people.
Excitement comes from the discovery of an odd hybrid of ALS and AD symptoms in people living on Guam, which is blamed on their consumption of the chemical BMAA from eating bats. High levels of BMAA, traced to cycad plants in the bats’ diet, appeared to replace L-serine in sufferers’ brain cell membranes, creating a deficiency of the amino acid that was linked to cognitive deterioration: there is a possibility that BMAA from other sources could be doing the same thing elsewhere, such as in the U.S.
NAD+— nicotinamide adenine dinucleotide plus hydrogen—occurs naturally in the body and produces energy used in cognitive function and memory. Supplements of the chemical have shown no side effects as well as some evidence of benefits.
Because NAD+ levels decline with age, supplements might inhibit this decline and thereby forestall age-related conditions such as dementia. To date, though, only animal studies have found supplemental NAD+ to counter the effects of age or specifically to improve specific cognitive functions.
NAD+ supplements in human trials have reduced blood pressure, lowered cholesterol, helped with chronic fatigue syndrome and increased nerve signals in those with Parkinson’s disease. Currently medical professionals give NADH injections and people take the supplements to boost mental clarity and athletic performance, as well as to treat everything from depression to jet lag.
In the same Science Times as Brody’s article, another titled “Moonshot for the Brain” describes a hormone called Klotho. In mice, Klotho has enhanced healthy brains and protected those with symptoms of AD from further cognitive decline.
Also far in the future is the brain implant, a “cognitive prosthetic” that boosts memory being developed at the University of Pennsylvania and Thomas Jefferson University. The central concept of the device is similar to the effects of caffeine: “that goosing a wandering brain can make it somewhat sharper.”
People with excellent memories are especially good at “attentional control,” measured, for example, by the Stroop test: color names are written in a variety of colors, and subjects must name the color of each name—difficult, for example, when “red” is written in purple letters.
Success at the Stroop test can improve with practice, as it can with brain games, but the improved abilities rarely extend beyond the specific task. The Federal Trade Commission has challenged claims of overall memory improvement by the brain game company Lumosity.
Besides the usual recommendations for diet and exercise, what appears to cut risk for mild cognitive impairment—in research by the Mayo clinic in Phoenix following 2,000 adults age 70 and older over four years—is computer use by 30%, and engaging in crafts by 28%.
The study’s result most encouraging to me, although I use a computer every day, was the reduction of risk by 22% for playing games. Though less than for the other activities, that finding offers hope that my Words-with-Friends habit is not a complete waste of time.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.
IF YOU BELIEVE the current best-selling novel, There, There, by Tommy Orange, in-home 3-D printers costing just a few thousand dollars could produce plastic guns that work. In fact, commercial printers are currently making everything from guns to shoes and car parts. Personal models might someday allow people to print their own prescription drugs.
Lower-cost “biologics,” drugs made from biological sources, which have to date led to breakthroughs against cancer, rheumatoid arthritis and other serious diseases are also something to hope for in the high-tech medication future.
By definition, biologics include anything produced from a biological source and used in the prevention, treatment or cure of a disease or condition of human beings, including vaccines, blood products, antitoxins, gene therapy and tissues.
The first true “biologic,” human insulin—developed in the early 1980s using recombinant DNA—mimics the body’s natural patterns of insulin release. Biologic formulations developed since then have targeted the immune system and include anti-inflammatories for the treatment of rheumatoid arthritis (RA) and Crohn’s disease, and cancer drugs.
Compared to conventional drugs, biologics can suppress activity of specific immune system components— for example, different white blood cells or inflammatory chemicals —affording both more focused effects and fewer side-effects.
But the current high costs of these drugs are an obstacle to widespread use. The “biologic” classification, along with the way the formulations are produced (using large vats of living protein, with complicated standards and ingredients) make approval of similar, cheaper versions called biosimilars trickier than that of generics, the drug equivalent.
Because it was created before the adaptation of the label “biologic,” biosynthetic insulin is considered a drug and thus regulated differently from biologics. But even for insulin, costs are soaring—up almost 200% from 2002 to 2013 and doubling since then—to the extent that patients ration insulin supplies by taking less than their needed dose, risking serious long-term health consequences.
Commercial 3-D printers are the hoped-for solution to producing drugs in small batches, both at home as needed by individuals—using widely available starting compounds—and for orphan diseases (conditions that affect fewer than 200,00 people nationwide).
In 2015, the FDA approved the first and currently only bio-printed tablet on the market. It’s a high-dose reformulation of an anti-epileptic seizure drug that dissolves instantly, useful for patients who struggle to swallow pills. The drug, Spritam, has a layered, porous structure difficult to achieve using traditional manufacturing methods.
“We can print tens of thousands of tablets a day,” said Tim Tracy, chief executive at Aprecia Pharmaceuticals, which developed the drug—on printers the size of a room.
Meanwhile, healthcare’s most prolific use of 3-D printers is the production of hearing aids, along with prosthetics, orthotics, orthodontics and implants. Researchers are working to get printers to create blood vessels. The major challenge is to print living cells quickly enough before the already printed cells die.
But even if personal 3-D printers become easily available, regulators will try to retain control of some of the component parts or ingredients. In There, There, the 3-D printed weapons still needed bullets purchased at a store and then, to avoid metal detectors, be transported in socks and thrown over a wall before the guns could kill.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.
NEW YORK journalist M.W. noticed an itchy, raised rash developing on the back of her forearms below the elbows. Though she tried not to scratch, when distracted by work or during an intense conversation, she sometimes found her fingers doing just that.
“Pain’s creepy bedfellow” is how Duke University cardiology fellow Haider Warraich describes itching: “the sensation of itchiness which is perceived by some of the same skin receptors that are on the lookout for pain…like pain it can be alleviated through distraction.”
Also like pain, itching is closely linked to mental health issues such as depression and obsessive compulsive disorder. One clue for the mental component of itching, also called localized pruritis, is seeing someone else scratch can make you itch.
As with itching, “after a pain signal reaches the brain, it undergoes significant reprocessing,” Warraich writes.
Another commonality between itching and pain: capsaicin, the chili pepper extract, applied topically, causes both—and in turn, is said to help combat both, although many studies of topical capsaicin for pruritis have found insufficient evidence of effect.
More familiar as a general analgesic, capsaicin sends impulses to the brain that produce sensations of warming, tingling, itching, stinging or burning—and can diminish these responses in a process called “defunctionalization.”
Contact dermatitis is among the most common causes of itching. In M.W.’s case, a wool sweater most likely caused the initial itching, and then she scratched, which caused the rashes and bumps—which in turn caused more itching, more scratching and more reactions, until the layers of bumpy rash began to look serious.
Irritant contact dermatitis is a nonallergic skin reaction to a substance that damages the skin’s outer protective layer, and it usually develops within minutes to hours of exposure. An allergen—poison ivy, the mango plant, nickel, formaldehyde—can provoke a similar reaction.
Whatever the initial cause, repeated scratching can lead the bumps to ooze, creating a good place for bacteria or fungi to grow and cause infection. Independently, fungi can also cause itching—as in athlete’s foot.
In very cold weather, itching can arise in exposed areas of skin. With “frostnip,” the body’s first reaction,” skin turns pale or red—followed by red, white or yellow patches, itching, pain and prickling—which can proceed to frostbite.
Among other common causes of itching, eczema and psoriasis are both “atopic”—hypersensitivity reactions that occur in a part of the body not in contact with an allergen. Both are traced to a combination of genetics and environmental causes, such as pollen. Psoriasis causes itching that is similar to that of eczema but less intense. It’s often accompanied by a stinging or burning sensation, compared to that produced by fire ants.
Lichen sclerosus (LS), with symptoms of white spots and pain along with itching, is usually blamed first on an “overactive immune system.” When traced to previous trauma or infection, LS qualifies as an autoimmune disease in which the body’s immune system attacks healthy tissue, causing inflammation and damage.
Finally, the nerve disorder notalgia paresthetica (NP) can produce an intense and sometimes painful itching on the back, often between the shoulder blades and usually on an area of skin just past reach. Usually, NP occurs in patients with a history of upper back or neck pain.
NP can begin when bones or muscles trap and put pressure on nerves—caused initially by a back injury or herniated disc, or shingles. Scratching the itch of NP can create patches of darker colored skin. Topical capsaicin is often the first treatment.
Besides capsaicin, treatment for all itching can include pain relievers like lidocaine as well as corticosteroid creams. Particular bacteria, applied topically, may kill the bacteria that plays a role in some cases of eczema as well as in acne. For many people like M.W., in addition to cortisone cream, the crucial component of treatment is often the most arduous: to stop scratching.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.
PERSONALIZED DIETS created by A.I. (artificial intelligence) and based on analysis of an individual’s gut bacteria will prescribe the healthiest specific foods for each person, according to California-based cardiologist Eric Topol. Still in the early stages of development, complicated algorithms will pull together microbiome analysis results along with other variables—including physical activity, sleep, stress, medications, family history and existing medical conditions.
Groundbreaking research by two Israeli investigators in 2014 found that the bacteria populating an individual’s microbiome had a much greater influence on blood-sugar spikes than did specific food or diets. The finding contracted decades of dietary research, including the largest nutrition study ever, which concluded that the Mediterranean diet provides optimal long-term health for everyone.
Blood-sugar spikes can increase the risk of cardiovascular disease as well as the insulin resistance that causes weight gain and is a precursor to diabetes. Insulin resistance occurs over time when high circulating blood sugar levels put an increasingly heavy load on the pancreas to produce more insulin—which the body needs for metabolizing glucose to produce energy.
Foods that create high blood-sugar levels are considered to have a heavy “glycemic load.” According to two meta-analyses of dozens of studies, people who consumed lower-glycemic load diets were at lower risk of developing type 2 diabetes and heart disease than those eating foods with higher glycemic loads.
Unprocessed whole carbohydrates—even a boiled potato—generally have a much lower glycemic load than an equivalent quantity of processed carbohydrates, like a hamburger bun, according to Toronto kidney disease specialist Jason Fung. He uses such comparisons to criticize the common focus on macronutrients—proteins, carbs, fats—rather than on specific foods to create a healthy diet. Among carbohydrates, fructose has a “deadly effect,” he notes.
The finding that the healthiest foods are different for each individual —“the first major development” in the field of nutrition, according to Topol—comes from research by Eran Segal, Eran Elinav and colleagues at the Weizmann Institute of Science, first published in the journal Cell as “Personalized Nutrition by Prediction of Glycemic Responses.” The Weizmann Institute offers online access to diets based on microbiome analysis.
For his own personal gut inspection, Topol donned a blood-glucose sensor and provided a stool sample. The results showed an unusual preponderance of one type of bacteria and advised a list of foods that were healthier—mixed nuts, bratwurst, and cheesecake, for example —and less healthy, like oatmeal and squash. Still in an early state, the algorithm missed at least one important variable, Topol’s pre-existing kidney stones—a condition exacerbated by eating mixed nuts.
An earlier effort to create personalized diets, called nutrigenomics, used genetic profiling to determine an individual’s food choices for ideal health.
While the method failed to garner reliable data, research increasingly supports the “no single diet that’s right for everyone” statement on Berkeley Wellness: Some people do well on low carb/high protein, while others do well on different combinations “partly due to genetic reasons.”
Whatever the diet, individuals also differ in the best way to proceed with healthy prescriptions. For calorie-counting diets, for example, some people do better using a point system while “others prefer a more mindful approach,” according to Berkeley Wellness.
And while some people prefer to go it alone, many do better by choosing a partner, consulting a dietician or joining a structured weight-loss program. Among the longest-enduring of these, Weight Watchers offers an extensive app-based rating system for different foods—but for many members, what matters most is the weekly weigh-ins, and for some the crucial addition of an ongoing support group.
More structured, the residential program offered by the Pritikin Program educates participants on eating for health and weight loss –- and provides a mound of take-home recipes and exercise regimens, according to Florida-based environmental educator K.R., who recently spent a week there. While the high-carbohydrate, very low-fat diet is strict, K.R. appreciated the program’s suggestions for leeway, such allowing an occasional off-diet meal but following that with one that adheres closely.
Like the microbiome algorithm, Pritikin focuses on the effect on insulin levels of different foods and the consequences for weight loss and risk of metabolic syndrome, according to Fung. Saying “any diet that lowers insulin will show incredible benefits,” he also includes Atkins, Paleo and Mediterranean—and supports “intermittent fasting,” eating within a limited time period (usually 8-10 hours) and fasting during the hours that remain.
Even with sophisticated algorithms, some universal diet advice may hold true —for example, that people over 65 may need more protein. “During stressful periods, aging bodies process protein less efficiently and need more of it to maintain muscle mass and strength,” writes Kaiser news columnist Judith Graham.
In a 2018 study that followed more than 2,900 seniors, those who ate the most protein were 30 percent less likely to become functionally impaired —unable to climb stairs —than those who ate the least amount. The current protein recommendation for older adults is more than a gram of protein for every kilo of body weight —for a 150-pound woman, 70 grams or more of protein spread throughout the day, which is a 20 to 50% increase over the RDA (based on studies that rarely include older adults).
The microbiome approach has its detractors. “Most people do not need personalized diets,” Dean Ornish, UCSF medical professor and long-time low-fat diet champion, wrote in response to Topol’s New York Times article. “To say that artificial intelligence is needed to design a diet based on your microbiome is incorrect since a healthy diet can quickly change your microbiome in beneficial ways.” Ornish is especially critical of the recommendation that Topol eat bratwurst, “which the World Health Organization defined as [a] potent carcinogen.”
But even for people who have figured out the best diet for them, an easily accessible algorithm is an appealing means to get a quick health grade for specific foods and could simplify daily dietary choices.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news that affects our everyday lives.
TWO WOMEN in their 60s have similar blood pressures and cholesterol levels (LDL and HDL) —variables used to assess the 10-year risk of heart disease in those with no prior heart attack or stroke by the various risk calculators.
Viewing scores from their demographics, labs and personal histories (diabetes and smoking), the physicians treating each woman prescribed cholesterol-lowering statins. But then Woman#1 found a new doctor, who reviewed her numbers, considered the statin side-effects of muscle pain that she’d experienced and took her off the drugs.
Prescribing guidelines recommend statins when the 10-year risk of developing Atherosclerotic Cardiovascular Disease (ASCVD) is 7.5% and over—though that can vary between 5% and 10%—for patients 40 to 75 years of age, with no clinical heart disease or diabetes, and whose LDL cholesterol levels range from 70 to 189 mg/dl.
The algorithm used by the ASCVD Heart Risk Estimator focuses on variables that can be controlled: levels of cholesterol and blood pressure, as well as smoking and uncontrolled diabetes. Like most calculators, however, it doesn’t add in important variables such as diet, exercise, obesity, and “uncontrolled stress and anger,” as listed by WebMD.
The crucial element missing from most algorithms is family history. Woman#2’s father died from a heart attack at age 60; Woman#1 not only had a family history without heart disease but her own cholesterol levels had been very good until a bout with Lyme disease caused a puzzling and dramatic rise in her late 50s.
Of the 20 or so calculators currently in use, most are based on the Pooled Cohort Equations (PCE) published in 2013, but a recent NIH-funded study found the results to be “way too high or low for some patients,” according to Stanford University professor Sanjay Basu, lead author of the study.
The PCE overestimated heart disease risk in about 20% of individuals –- indicating approximately 11.8 million fewer Americans at risk than originally determined, Basu told Medscape Medical News. This finding “substantially” reduced the numbers of people who should be taking statins or antihypertensive agents or even aspirin.
Over-estimations occurred most often in older persons without long-standing risk factors; those with a ten-year risk below 10%; and those with higher socioeconomic status who were more likely to have a healthy lifestyle and be on preventative drug therapy, according to a 2018 special report from the American College of Cardiology (ACC) and the American College of Cardiology and American Heart Association (AHA).
Under-estimations were most likely in African Americans as well as in those with family histories of chronic kidney disease, chronic inflammatory diseases and premature vascular disease—as in the case of Woman #2.
In ASCVD, cholesterol plaque buildup in the arteries leads to heart attack, stroke, peripheral artery disease and other heart issues. The current guidelines also recommend cholesterol-lowering treatment in those with clinical ASCVD—those with LDL levels above 190 mg/dl, and those with diabetes and LDL levels 70 and above.
For women over 50 with borderline profiles —“moderate” risk levels between 5% and 7% and those with low scores who have a family history of heart disease—a heart scan can help determine the need for statins. Also known as a coronary calcium scan, this specialized X-ray of the heart detects and measures calcified plaque in the arteries.
Other red-flag markers for heart disease are high-sensitivity C-reactive protein (hsCRP), which has proved a better predictor for heart disease than LDL cholesterol; high HDL cholesterol, which can cause inflammation in the presence of dietary saturated fat; and insulin resistance as determined by high levels of HgA1c and fasting glucose.
To reduce ASCVD risk, cholesterol-lowering statins counter inflammation throughout the body, including the brain—which might also help protect against dementia. On the other hand, potential side effects include mental fuzziness along with muscle aches—most common in women age 65 and older with a small body frame. Rarely, statins can damage the liver and muscles.
Low-dose aspirin can protect against heart disease for adults with a ASCVD risk lower than the eligibility for statins—in the range of 6% to 10%. For patients older than 50 with no symptomatic ASCVD, the American College of Chest Physicians recommends aspirin, but most experts consider aspirin’s benefits outweighed by increased chance of GI and intracranial bleeding in those with lower risk levels and in anyone age 70 and older who hasn’t taken aspirin before.
Diet advice to counter heart disease risk changed dramatically with new guidelines published in 2015 from imposing an upper limit on cholesterol intake to a focus on trans fats—to be eliminated entirely—and saturated fats. For the latter, experts keep lowering the limits: from a recent general recommendation of 10% or less of daily calorie intake, to further limits from the AHA to 5% to 6% or less—which comes to about 100 calories in a diet of 2,000 calories/day.
Despite the usefulness of algorithms and calculators, talking to a doctor often provides the best assessment of individual risk. In the cases of the two women, each had a personal history—family and Lyme disease—that made the difference.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.
“DRINK MORE WATER” is a repeated refrain. It comes with a few caveats, notably regarding the source. For health, the best option is usually municipal water, which gets high ratings in the DC area.
As for when to drink, the answer is anytime except during meals—when water can dilute the digestive juices.
Before a meal, or when feeling hungry, water can help you feel fuller and improve digestion. Before a workout and before bed, water can protect against dehydration; first thing in the morning, it can jump-start the digestive system; and when feeling fatigued, which can be a sign of dehydration, it can give a quick boost to the brain.
The tide continues to turn away from bottled water—and not just in individual plastic bottles, which are an environmental scourge. It also might not be the healthiest source. At least 25% of bottled water is simply filtered municipal tap water, according to the National Resources Defense Council (NRDC), with labels like “purified” and “distilled” meaning safe—but not necessarily safer than tap water. True “spring water” must use those words on the label.
Tap water is monitored by the EPA—with strict regulations and standards under the Safe Drinking Water Act—and testing performed often hundreds of times a month. Only the FDA regulates bottled water, which doesn’t require lab testing. Looking at 10 popular bottled water brands, the Environmental Working Group found 38 contaminants.
High or low measurements of pH can indicate problems with any water. While “pure” water has a pH of 7, tap water with a pH lower than 5 is likely to be polluted; and more alkaline than 9, it may have an unpleasant smell or taste. Slightly alkaline water with a pH between 8 and 9 has become popular for its potential to help with acid reflux and high blood pressure, and with dehydration caused by exercise.
Water with a pH lower than 5.5 can dissolve enamel, the protective outer layer of teeth. The pH of bottled waters varies among brands due to different filtering processes. In a study at the University of Alabama School of Dentistry, the four bottled brands with pH and fluoride levels safest for teeth were Fiji, Just Water, Deer Park and Evamor.
Carbonated water can also erode tooth enamel, traced to the carbon dioxide added to make bubbles, which leaves weak carbonic acid in the water that increases acidity. Some experts argue, however, that added flavorings are the real villain in bringing pH too low. In addition, carbon dioxide can trigger the hunger hormone ghrelin, blamed for weight gain. In one study, people who drank sparkling water had six times the ghrelin level of those drinking still water.
Choosing bottled water, people have learned to avoid BPA, bisphenol A, which is thought to increase risk factors contributing to heart disease, such as high blood pressure. In a 2015 study of adults drinking from containers tainted with BPA, blood pressure rose almost immediately. Softer bottles can also contain estrogen-like compounds with an array of harmful effects.
Bottled water samples sent to be tested in the film “Tapped” contained phthalates—used to make plastic more flexible—and styrene, both risking harmful health effects. New bottles overheated during shipping had the highest levels. And plastic bottles that are refilled and used repeatedly break down, creating small cracks that can harbor bacteria causing colds and flu.
Microplastics (tiny pieces of plastic), found in more than 90% of bottled water samples in a 2018 study at the State University of New York in Fredonia, are worrisome for their accumulated pollutants, such as polychlorinated biphenyls (PCBs). While these can be absorbed by the gut, health consequences for humans are not known and might depend on the quantity ingested and how quickly they pass through the body.
The most commonly occurring microplastic found was polypropylene, used to make bottle caps. In one bottle of Nestle Pure Life, microplastic concentrations were as high as 10,000 plastic particles/ liter of water. Even the brand “Boxed Water,” which comes in a box, contained high levels of plastic fibers.
The main objections to tap water concern odor and taste—from chlorine added to remove contaminants—as well as occasional local upsurges in lead levels. Microplastics in tap water are traced to airborne microfibers, notably from factories manufacturing synthetic fabrics for clothes. And despite frequent testing, a recent study found Chromium-6 in water from all 50 states—though the risk of cancer, explained in the film “Erin Brockovich,” from the levels measured may be very low. The worst location for unsafe tap water is Florida, where “boil-only” warnings have become a regular occurrence.
For those concerned about contaminants as well as disagreeable tastes and odors, water filters come in “pour through” pitchers, tap attachments, and whole-house systems, with different brands filtering different contaminants. The most popular pitcher-filter brands are Brita for best taste and PUR for more complete removal of contaminants. Consult evaluation review sites—which don’t always agree—before making a choice.
Water for other uses than drinking often needs special treatment as well. In a neti pot (a container designed to rinse debris or mucus from your nasal cavity), for example, water should be either distilled or cooled after boiling for one minute. The next best option is a filter that includes cyst reduction or removal, or that reads NSF53 or NSF58. More than one person has died from brain-eating amoeba after using a neti pot, one after using a Brita Purifier.
For a personal filter purchase, I will rely on my sister, who works with water and environmental issues, and uses a PUR pitcher filter. Until then, what has worked well for our family for decades is Deer Park water, in three- to five-gallon plastic bottles, chilled by a dispenser. While clearly marked “spring water,” with an acceptable acidity of 6.3 and on lists of water unlikely to destroy tooth enamel, Deer Park may be filtered less well than highly rated DC water and may contain microplastics. For convenience, but maybe more for nostalgic reasons or sheer inertia, I am not yet ready to move on.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.
BUNNY BOOM, rabbit explosion—some say bunny rabbits are becoming as common in DC as pigeons in New York City and deer in Northern Virginia. In the District, selected streets—notably Ingomar Street off Connecticut Avenue in Northwest, and all over Southwest—and gardens appear to be awash in bunnies.
A large acorn drop in the fall of 2018, along with increased rainfall that fuels vegetation growth, may be driving the proliferation by providing more food for hungry bunnies. And as one community gardener said, the rabbits don’t run…they don’t have any fear of humans.”
While gardeners complain about the rabbits’ voracious appetites for lettuce and carrots, a serious risk is tularemia—rabbit fever. Although the numbers of DMV region cases are low, averaging around two/year, a recent surge in four U.S. states (Colorado, Nebraska, South Dakota and Wyoming) included one death, and another man died last summer on Martha’s Vineyard.
Tularemia spread by rabbits is “well entrenched on Martha’s Vineyard,” according to Tufts University infectious disease professor Sam Telford, who reports between three and 15 cases of tularemia on the Vineyard every year going back to 1999.
Potentially scary, tularemia is one of five diseases including anthrax considered to have the greatest potential for use in biological warfare. But the most serious ongoing threat is to landscapers and gardeners, who breathe in the bacteria after mowing or digging in the area where an animal has been sick or died.
Tularemia infections vary in seriousness depending on where the bacteria enters the body: the lungs, breathing in bacteria airborne from disrupted lawns and garden soil; or the skin, through a tick bite—the most common source in the U.S. (Mosquitoes are the main vectors elsewhere.) Symptoms, including fever and chills, muscle or joint pain, sore throat or trouble breathing, usually appear three to five days after exposure, although it could take longer.
Antibiotics can treat both forms; the more threatening is the lung-borne disease, which requires immediate treatment, and most victims recover.
Where bunnies are booming, face masks can protect gardeners who are digging, mowing or clearing brush, although the CDC advises avoiding mowing in areas where sick or dead animals have been reported. Keep pets away from wild animals that might be carrying ticks, or sick or dead ones that might be infected.
Precautions against tularemia-carrying ticks are the same ones for Lyme disease: Wear long pants and high socks, use DEET, check for ticks after undressing. Another beneficiary of the acorn drops, squirrels are also multiplying—though they rarely live more than four years because they carry so many diseases and are also hosts for tularemia-carrying ticks.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.
HAVE TO sit for long periods—on planes, in meetings? Get up often and walk around. In between, don’t cross your legs and do foot exercises. Raise and lower the heels on both feet and then the toes. Drink water and wear loose-fitting clothes. For many people, compression socks can help.
What you’re trying to avoid is deep vein thrombosis (DVT), clumping or clotting of the blood cells that can occur when blood moves too slowly through veins, most often in the legs. Over time, a clot in the legs can cause chronic swelling and pain, and cellulitis, a skin infection.
But the biggest risk comes from a clot that travels to the lungs where it can block blood flow and cause life-threatening pulmonary embolism (PE). However, PE occurs about 50% of the time with no symptoms. Signs include sudden shortness of breath, lightheadedness, chest pain and a rapid pulse.
DVT rates rise with age, increasing after age 45 from 1/1,000 to 5 to 6/1,000 people by age 80. In addition to prolonged immobility (standing, sitting and bed rest), DVT is more likely after injury or surgery that damages blood vessels.
“When we walk, our muscles contract and push the blood back to the heart,” explains Baton Rouge vascular surgeon Andrew Olinde. “Usually it’s a predisposing factor that caused you to get [DVT]—you had surgery or were immobile. Once active again, the risk of getting DVT again is low.”
DVT is also linked to hormone replacement therapy that includes estrogen and to low vitamin D levels. It occurs more often with obesity, with a family history of DVT or clotting disorders, and with Inflammatory Bowel Disease and cancer.
In athletes, especially endurance runners, DVT symptoms are likely to include bruises and stabbing Charley-horse pain. Exercise, on the other hand, lowers the risk of blood clots, especially in those who must sit for hours.
The clearest signs of DVT occur in only one leg: persistent swelling; feeling of warmth in the leg; red, blue or otherwise-discolored skin especially below the back of the knee; and pain that feels like cramping, soreness or ache, more likely during standing or walking, and often occurring in the back of the calf—rather than on the outside where injured muscles cause pain.
DVT symptoms get worse over time, rather than dissipate as they would with a pulled muscle, even after the leg has been elevated.
When a clot is suspected, the affected leg is checked for pain and swelling as well as for knots that are sometimes felt with a clot. Ultrasound can diagnose DVT and show if clots are in the deep, larger veins, where they are more dangerous than those in superficial veins.
DVT is usually treated with blood thinners, such as heparin or warfarin, for up to six months. An alternative, a tiny filter inserted in the inferior vena cava—the largest vein in the body —can catch a large clot before it reaches the lungs. In the case of severe symptoms, clot-dissolving medications can help—sometimes in combination with a balloon-catheter procedure called isolated thrombolysis.
Compression socks or stockings that are tight at the ankle and looser toward the knees help push the blood upwards, against gravity, to prevent pooling in the veins. The socks can also improve the flow of lymph to help reduce swelling. In healthy people, they can keep legs feeling warmer on airplanes and offer relief for leg fatigue.
Doctors recommend compression socks after surgery as well as for those who take estrogen or have a family history of DVT. And people who must sit for long periods find them helpful. But their promotion to prevent symptoms in people with an acute DVT lacks evidence—as does their use by athletes to improve performance. However, there is some evidence showing that the socks speed recovery and reduce soreness following a workout.
Those with peripheral neuropathy might have trouble feeling when compression socks are too tight and could impede circulation. In cases of peripheral artery disease (narrowing of the arteries that can cause pain when walking), the socks can interfere with oxygen delivery in arteries with impaired blood flow. Certain skin conditions or infections can also react badly to the socks.
The best recommended choices on Amazon have the highest compression rating—20 mmHg and above, considered “medical-grade”—and are touted to improve blood flow for upping athletic performance and promoted as combinations like “best stockings for running, medical, athletic”… as well as “best graduated athletic fit running.” But at this pressure, the socks can feel too tight and leave red marks on the legs.
Healthy people and anyone sitting or standing for long hours should choose the lightest compression rating —under 15 mmHg—produced for medical suppliers in neutral colors, but also in fun designs by Dr. Motion, Different Touch and others (available at the Amazon link).
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news that affects our everyday lives.
BELLY PAIN—a label sounding slightly less unpleasant than abdominal distress and covering more (physical) ground than stomach aches or cramping—includes these abdominal issues as well as the constipation or diarrhea that may accompany them.
Most often the diagnosis is irritable bowel syndrome (IBS), which affects from 7% to 25% of American adults and grows more common with age. IBS is not considered a disease but a “functional disorder,” like chronic fatigue syndrome, and can be traced to physical issues like trapped gas and intestinal spasms.
IBS is usually a “diagnosis of exclusion”—made in the absence of clinical signs of disease—but positive diagnosis can be made based on the “Rome criteria.” The criteria are specific about time: abdominal pain occurring at least one day/week for at least three months, with symptoms starting at least six months earlier. Symptoms must include two of the following: change in frequency and in appearance —either harder or looser—of bowel movements.
(Confusingly, the label IBS is similar to that of inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, autoimmune diseases that often have a genetic link. IBD always involves involve inflammation, which is not present with IBS; usually begins before age 30; and can cause serious health difficulties.)
Because IBS is almost always exacerbated by stress, treatment can include relaxation techniques such as meditation, exercise and yoga. Medications such as Levsin and Bentyl can reduce intestinal spasms.
“Dietary and lifestyle changes seem to help the most,” according to Healthline. “Avoid aggravating the condition with fried and fatty foods and caffeinated beverages.”
Fatty foods appear on bad-food lists for most abdominal symptoms, because fat slows passage of food through the digestive system. When it remains in the intestines too long, fat can provoke IBS symptoms. While lingering in the stomach, it can cause GERD, or acid reflux, that includes heartburn, trouble swallowing and a dry cough.
For IBS, other categories of foods to avoid are “high-gas”—carbonated and alcoholic beverages, caffeine, raw fruit, and vegetables such as cabbage, broccoli and cauliflower. Also, FODMOPS (certain grains, vegetables, fruits and dairy products). For IBS with diarrhea, eliminating gluten can help.
“Disorders of gut-brain interaction” and “changes in how the brain sends and receives” signals from the gut are updated wording in the 2016 Rome IV criteria to reflect the role of the brain. Another change is minimizing use of the word “functional,” because it is “potentially stigmatizing”—that is, suggesting that mental health issues and not physical disease are the cause.
Clinical testing for suspected IBS checks for infection or problems with malabsorption and rules out other diagnoses. Endoscopy can pinpoint areas of trapped gas and spasm. Flexible sigmoidoscopy and colonoscopy allow visual examination of the colon. X-rays and CT scans produce images of the abdomen and pelvis—with ingestion of barium before X-rays, often called a lower GI series, aiding visualization of problem areas.
Diverticulosis, another cause of belly pain, can have some of same symptoms as IBS—or no symptoms at all—and the two can be difficult to differentiate. Both respond to the antibiotic rifaximin (Exifaxan), and both are increasingly common with age: diverticulosis occurs in some 50% of people over 60.
In diverticulosis, small pouches form in the walls of the digestive tract, possibly caused by muscle spasms or straining during bowel movements that builds pressure against walls of the colon. Past blame focused on insufficient dietary fiber, but recent studies have not confirmed the link.
In 10% to 25% of sufferers, infection or inflammation in these pouches, called diverticulitis, causes severe abdominal pain and fever. Prevention includes drinking a lot of water and eating a low-fat diet to speed digestion. Prunes or laxative medication can help with constipation.
Inflammation is also the villain in IBD, in this case caused by the body’s immune system mistaking food, bacteria and other materials in the GI tract for foreign substances and sending white blood cells to attack. Symptoms of diverticulitis and Crohn’s disease can be similar, with the chronic inflammation of Crohn’s disease causing fever, fatigue, persistent diarrhea, pain and rectal bleeding.
Crohn’s disease can lead to scarring and swelling and risk blockages throughout the GI tract, which over time can requiring surgery. Ulcerative colitis (UC), another IBD, leads to fewer complications and almost never requires surgery. In UC, the inflammatory immune reaction is confined to the colon (large bowel), with symptoms including urgent bowel movements and anemia. Ultrasound—which shows thickened loops of the intestines—as well as colonoscopy, CT or MRI, can diagnose IBD.
NSAIDs can be prescribed for these conditions to relieve pain caused by inflammation. But these drugs can also cause the so-called N-SAD stomach, because inhibiting inflammation can also reduce the body’s production of prostaglandins, which help protect the gut from the corrosive effects of digestive acids.
Some gut symptoms are anodyne. In addition to pain and constipation, 60s-something swimmer and Indian clothes designer L.K. felt lightheaded and, most worrisome to her, noticed what looked like blood in her urine. Examining her, the GI doc suspected trapped gas in the colon was causing spasms as waste passed through, which in turn caused lightheadedness, all of which should be alleviated by diet and laxatives.
And while blood in the urine accompanied by lower abdominal pain can indicate bladder problems like cystitis, reddish urine is often easily explained by recent consumption of beets or rhubarb. That symptom of L.K.’s vanished overnight.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news that affects our everyday lives.
GENETICS, culture, personal experience and sometimes nutritional needs can affect strong taste preferences—for cilantro and beer; vanilla, licorice and cinnamon; turnips and watercress; sugar and salt. But sufficient motivation can change intense dislike, which also generally diminishes with age.
“Every new experience causes the brain to update and enlarge its set of patterns, and this can lead to a shift in how we perceive a food,” according to Northwestern University neuroscientist Jay Gottfried, who studies how the brain perceives smells.
Taste buds containing receptors for the five basic tastes—sweet, sour, salty, bitter and umami (from glutamate, in broth, etc.)—are distributed in small bumps called papillae throughout the tongue, roof of the mouth, and throat. They number around 10,000 at birth and start to decrease after age 50.
Ethnic Europeans have fewer taste buds, while in some parts of Asia, South America and Africa, 85% of native populations are “highly sensitive” or “supertasters.”
Unborn and breastfed babies “taste what their mothers eat…and have been shown to develop early affinities to certain flavours in their mothers’ diets,” according to The Guardian. Learning plays a role in taste. Vanilla in the West is associated with sweet foods and is used to enhance the perception of sweetness (adding vanilla is a low-calorie way to sweeten plain yogurt). But in East Asia where vanilla is used in savory dishes, it doesn’t taste sweet.
While European cuisine combines similar flavors, Asian cooking does the opposite. And Europeans generally dislike cinnamon, turning up their noses at carrot cake and fleeing from the aroma in U.S. coffee shops. For licorice, the search is still on for why it’s widely disliked, although this seems to be something people are born with. Meanwhile, too much black licorice can cause high blood pressure and heart disease.
Senses of smell and taste evolved to evoke strong emotions because they were critical to finding food and mates and avoiding predators…so when “a flavor fits into a pattern that involves chemical cleaning agents and dirt or crawly insects,” we avoid it, Gottfried explains. For some, cilantro’s odor suggests soap and/or stink bugs.
Bitterness is the taste linked to the greatest number of genes and thus to the greatest variation in preferences. Although only two genes affect how we perceive sweetness and two affect umami, at least 25 and maybe 40 affect bitterness, explains Nicole Garneau, director of the Genetics of Taste Lab at the Denver Museum of Nature and Science.
For the 25% of the population who can’t taste bitterness, genes change the shape of bitterness taste receptors to prevent binding with bitter food molecules. Among the 75% who can detect bitterness, different combinations of genes lead some to like grapefruit but not kale, quinine but not coffee, or “hoppy beer” ( bitterness comes from hops).
“Flavor consequence” and “conditioned taste aversion” refer to the effects of experience on taste and help explain how bitter beer, including especially bitter IPAs, have become popular. “Hardly anyone likes bitter beer the first time they try it,” says John Hayes, director of the Sensory Evaluation Center at Penn State. But if they get “positive post-ingestion consequences like having a good time with friends,” they might keep trying it and like it more with every pint.
The discovery of a genetic link to bitter perception began in the 1930s with a chemical compound known as PTC. That led to subsequent research on individual reactions to similar compounds in foods—for example, turnips and watercress, which are more appealing to genetically insensitive people than to people who find them bitter.
Bitterness also plays a role in the taste of cilantro—the most famously disliked herb—which has an especially vocal group and its own website “I Hate Cilantro.” This distaste was first traced to a group of olfactory-receptor genes that pick up on the smell of aldehyde chemicals that are found in cilantro, as well as in soap and stink bugs.
In twin studies, identical twins are more similar in their reaction to bitterness than fraternal twins. Questioning 527 sets of twins about cilantro, scientists at the Monnell Chemical Senses Center in Philadelphia found three more genes that play a role: two for tasting bitter foods, and one that detects pungent compounds like those in wasabi.
Cilantro preference, however, has “only a small underlying genetic component,” according to California-based geneticist Nicholas Eriksson. To build an appreciation for the herb, the common suggestion is to start with cilantro pesto, because crushing the leaves releases enzymes that convert the soapy compounds into more mild aromas.
Gottfried, a “former cilantrophobe,” found that after eating “all kinds of things” and experiencing pleasure from sharing with friends: “It can still remind me of soap but that association fades into the background.”
Liking sugar can also be linked to the bitterness gene: those with one or two copies of the gene were more likely to favor foods and beverages with high sugar content. Conversely, those who don’t care much for sweets could be supertasters, who have inherited a greater number of taste buds and thus taste all flavors more intensely.“These people tend to shun strong-flavored foods including rich deserts…and may explain why supertasters are more likely to be slim,” according to Smithsonian magazine.
Craving sugar and fat can also be linked to mood. Carbohydrate consumption increases the release of the neurotransmitter serotonin, which plays a role in mood control: depression can increase a craving for carbohydrates in an effort to feel better. On the other hand, eating protein can help stabilize blood sugar levels to offset sugar cravings.
Salt craving may be influenced by dehydration or related to the “stress hormone” cortisol. Because stress prompts lower levels of cortisol in people with higher sodium levels, craving salt could be a way the body copes with stress. Cortisol depletion with Addison’s disease is another cause of salt craving.
Some physical disorders can also cause bad tastes. For example, in phantom taste perception, sufferers experience a lingering unpleasant taste after swallowing food. In the case of dysgeusia, bad tastes —foul, salty, rancid or metallic—persist in the mouth, often accompanied by “burning mouth syndrome.” Most often linked to a diminished ability to smell, hypogeusia is a reduced ability to taste. Ageusia is the inability to detect taste, although true taste loss is rare.
Beer is the most common target of personal efforts to change taste perception, which requires motivation—especially for IPAs. For cilantro, however, “Julia Child, an avowed cilantro hater, said she would just pick it out and throw it on the floor.”
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news that affects our daily lives.
SHORTNESS of breath, or dyspnea, both feels unpleasant and can cause low-energy levels. It can signal asthma or more serious lung or heart disease. Or you could be short of breath due to anemia, low blood pressure, too-tight clothes—or, most commonly, anxiety.
Before rushing to the doctor, you can find relief in simple relaxation and breathing techniques. To ease airways by relaxing the neck and shoulders, sit in a chair with elbows resting on knees or chin in hands. Or stand near a wall with hips resting against the wall, body leaning slightly forward and arms dangling. Correcting the position or angle of the head on the neck can also help relax these muscles.
The key to better breathing is the exhale: longer exhales make more room for incoming air and slow the breath to give lungs more time to absorb oxygen before the next round. And slowing the breath—the only function of the autonomic nervous system that can be controlled—has a relaxing effect throughout the entire body, for example, lowering the heart rate.
During exercise, you can ease breathing by exhaling through the mouth with lips pursed (shaped as if for whistling) and inhaling through the nose. Count two for the in-breath and four when breathing out, as slowly as possible.
In general, though, strenuous exercise is the only good reason for mouth breathing, because it speeds the transport of oxygen to the muscles. The downsides include less oxygen in the blood to supply crucial organs—and shallower breathing, the most common respiratory dysfunction.
Inhalation through the nose warms, moistens and conditions the air. The nose offers other advantages, notably via its production of nitric oxide (NO)– dubbed a “pleasant poison” because it’s also an air-pollutant. Released continuously by the nasal passages into inhaled air, NO dilates the airways and blood vessels to improve both the lungs’ ability to absorb oxygen and the transport of oxygen throughout the body. It also kills bacteria.
Exhaling through the nose can slow the breath by more than 50%, resulting in an intake by the lungs of 10 to 20% more oxygen.
The combination of slow in-breath and slower out-breath is the basis of diaphragmatic breathing, also called belly breathing. While sitting relaxed or lying flat, place one hand on the abdomen to feel it expand with the in-breath and empty when breathing out. Diaphragmatic breathing for 5 to 10 minutes daily can change long-established poor breathing habits, especially shallow breathing—which over time damages the lungs.
“Shallow breathing is what we do when we literally hide from a predator…and when we feel like we want to hide,” writes Paul Ingraham on PainScience. “Deep breathing is one of the main practical suggestions for fighting anxiety. It’s a feedback loop.” Deeper breathing is a balm to anxious feelings, which in turn makes it easier to breathe more deeply.
In addition to decreasing anxiety and improving relaxation, changing the breathing patterns can counter depression and nausea, and improve attention and confidence.
“Air hunger,” the shortness of breath most often associated with anxiety, is a feeling—but not a physical problem—that insufficient air is being taken in. “Effort” is the sensation of needing extra work to breathe and is most often associated with COPD (chronic obstructive pulmonary disease).
“Tightness,” a feeling that the airways are constructed, could be due to muscle pain but often occurs in the early stages of asthma attacks—when airways narrow, swell and produce extra mucus. Asthma is the most common reason for emergency room visits due to shortness of breath and affects about 5% of the population.
Besides asthmatic wheezing, shortness-of-breath symptoms that can require medical attention include acute dyspnea—developing suddenly over hours to days; fever or chills; fast-fluttering heartbeats; swelling in feet and ankles; trouble breathing while lying flat (orthnopnea, usually an indication of heart problems); and worsening of breathing problems that interfere with regular daily activities.
Shortness of breath can also be a sign of pneumonia. The lungs can also be affected by HAPE (High-Altitude Pulmonary Edema) that occurs two to four days after ascending quickly to altitudes over 8,000 feet. HAPE causes a cough and fatigue as well as dyspnea that begins with exertion and may progress to dyspnea at rest.
For breathing complaints, a simple test uses a “pulse-ox” (pulse-oximeter), a sensor placed on the finger that employs light to measure the amount of oxygen in the blood. Another device is the spirometer, a mouthpiece connected to a machine—you take a deep breath and blow out as hard as you can—that measures lung capacity and air flow.
An electrocardiogram (EKG) uses electrodes attached to the chest to measure electrical impulses that signal the heart to beat. The EKG can detect heart problems, such as a weakened heart muscle that cannot pump enough blood to meet the body’s needs for blood and oxygen. And chest x-rays can show signs of pneumonia as well as other serious lung problems such as COPD, which affects 90% of American smokers, or a pulmonary embolism (clot).
Medical devices can also help treat shortness of breath. For CART (Capnometry-Assisted Respiratory Training), a capnometer gives feedback on CO2 levels with the goal of reducing hyperventilation, which causes low CO2 and panic symptoms. For treating asthma, inhalers and bronchodilators deliver medication that helps open the airways.
Shallow breathing over time causes the lungs to weaken and stiffen, making deep breathing another use-it or lose-it bodily function. Deepening the breath by slowing it down can thus stave off long-term health problems as well as counter anxiety and improve energy and relaxation throughout the day.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news that affects our everyday lives.
COLDER TEMPS indoors and out—though not too cold—can be healthy. They can improve insomniacs’ sleep, boost the immune system to better fight winter colds, and, despite increasing hunger, burn more calories.
Cold also helps people think more clearly and perform tasks better as well as making them more likely to tackle cognitive problems than warmer temperatures.
“Referential creativity”—better known as thinking outside the box—improves in colder weather as do personal relationships. People tend to reduce their activity level and make fewer but longer phone calls.
Keeping the nighttime temperature between 60 and 67 degrees Fahrenheit —considered “moderately cool”—is ideal for sleeping. Although body temperature drops at night for most people, insomniacs are less able to regulate body heat appropriately. For them, “cooling caps” have helped with falling asleep and provided better quality sleep.
Colder temperatures don’t necessarily make people sick. We get more colds during the winter because we spend more time indoors exchanging germs. And cold viruses can take hold more easily when cold, dry air makes nasal passages drier.
Wintertime runny noses—called “skier’s nose”—are most often unrelated to health but occur when cold weather spurs the respiratory system to produce extra mucus to counter the dry air, and to release more liquid when warmer breath meets colder air.
The effect of cold temperatures on the immune system is unclear. One study found shivering increased the metabolic rate and elevated blood concentrations of catecholamines (hormones released with stress and anxiety) activated the immune system to a slight extent, but the authors make no claims about the biological significance of the changes.
On the other hand, hotter body temperatures can “speed up defenses against tumors, wounds and infections,” according to researchers at the universities of Warwick and Manchester.
What feels cozy to humans is what farmers call the “thermoneutral zone”—the range of temperatures best suited to fattening up animals. That humans in modern society are “buffered from temperature extremes and spend an increasing amount of time in a thermally comfortable state… is hypothesized to contribute to the contemporary increase in obesity rates,” according to nutrition researcher Douglas Moellening at the University of Alabama at Birmingham. He recommends: “exposure to a varied, natural range of ambient temperatures.”
As temperatures drop, while appetite generally increases, energy expenditure must increase to maintain thermal homeostasis. Cooler temperatures may also increase the metabolism of brown fat (considered the “good” fat that our bodies burn for energy), as well as to actually “brown” (also called “beiging”) the white fat, which is the “bad” fat that simply accumulates.
Exposure to 10 hours of 66-degree temperatures at night boosted fat-metabolic activity by 10 percent in a small study, according to diabetes and obesity researcher Philip Kern at the University of Kentucky. (Other options include freezing body fat directly by using a process called cryolipolysis or applying a fat wrap; and wearing something like a “cold shoulder vest” to lower body temperature.)
For some people, though, frequently feeling cold can be a symptom of anemia, hypothyroidism or Raynaud’s syndrome. And ambient temperatures that are too low can cause the core body temperature to drop: at 96 degrees, motor coordination can begin to fail; 95 and below is considered hypothermia.
Thermoreceptors (specialized nerve endings) located beneath the skin create the sensation of hot or cold and respond to ambient temperatures as well as to chemicals like menthol and capsaicin. Cold receptors react to temperatures between 68 and 86 degrees, and warm receptors to between 86 and 104, although heat greater than 113 degrees can make cold receptors fire, a phenomenon called paradoxical cold that remains a mystery to scientists.
Contrary to the view that a warm hat prevents the release of body heat through the head, what works better is covering the back of the neck and lower back, which have the body’s greatest concentration of cold thermoreceptors. Consuming hot drinks stimulates warm thermoreceptors in the stomach. but the effect doesn’t last long after the drink is finished.
Based on the concept that feeling hot or cold has more to do with local temperature sensations than core body temperature, MIT scientists have developed the Embr Wave, a personal thermostat worn on the wrist that costs $300. The Wave produces “maximally effective temperature waves” to make you feel colder or warmer “in minutes.”
In aid of the “thermally underserved,” Embr labs raised more than six times its goal (a total of $636,000) in a 2017 kickstarter campaign for the Wave. Wearing it to a Las Vegas conference—to stay warm in freezing convention centers as well as overly air-conditioned casinos —one user reported: “it worked like a charm.”
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news that affects our everyday lives.
“IT’S NOT quite being alive, but still having to go through all the crappy parts of being alive,” 22-year old Ian Hanley told Time magazine. In the six years since the day in 10th grade when he “lost all desire to get out of bed in the morning,” Hanley tried half a dozen antidepressants as well as combinations of those drugs.
As suicide numbers rise, notably in the 10-34 age group (14,000 in a recent single year, and up by about 50% in adolescents between 2003 and 2016), questions remain about the role antidepressants play. In 2003, these led to a Black Box warning for children about Prozac and other SSRIs (selective serotonin reuptake inhibitor), which was extended in 2007 to include young adults.
Blaming any individual’s suicide on antidepressants is a thorny problem, especially when depression is the leading cause of suicide in young people and these drugs might offer the best hope of combating it. Also, while some studies have found that patients taking antidepressants are more likely to have suicidal thoughts and to commit suicide; others have found no relationship.
A Complex Story
The picture grows more complicated because recovery from severe depression, with or without antidepressants, can follow a devastating natural trajectory. As a patient becomes less depressed, they may still feel miserable enough to believe that family and friends would be better off without them, but without the paralysis of depression, they have enough energy to act on that belief to successfully kill themselves.
In one review of 70 trials of adult volunteers with complaints other than depression, taking antidepressants doubled the occurrence of events defined by the FDA as “possible precursors to suicide and violence.” Middle-aged women taking Cymbalta for stress urinary incontinence had four to five times more of these events than those taking a placebo.
No clear relationship between suicide and antidepressant use in adults was the 2012 “summary of current evidence” published by Indian psychiatrists in Mens Sana. In children and adolescents, on the other hand, the study found an increased risk of suicidal thoughts and attempts but not of completed suicides. It concluded by advising physicians prescribing these drugs to follow their patients very closely.
Another complication is that most research separates subjects by age group, but there is little agreement about when an adolescent becomes an adult. “Late adolescence,” according to several definitions, can last into the 20s.
Guns and Suicide Attempts
And then there are factors, such as having a gun on hand or being able to easily purchase one, that are linked to completed suicides. Over the past decade, the rate of suicide by firearm increased by 19%. Although guns are involved in fewer than 6% of suicide attempts, they are responsible for more than half of deaths by suicide.
Among antidepressants studied, three (trazadone, mirtazapine and venlafaxine) are more often associated with a higher risk of suicide and self-harm attempts, compared to SSRI drugs, such as Prozac. In two UK studies of 238,000 and 300,000 adults respectively, the former found that patients on these three drugs were more likely to commit suicide than those taking SSRIs; the latter found “no meaningful difference in risk for suicide” between the two groups.
The three drugs, however, are often prescribed only after SSRIs haven’t helped. That suggests that these patients may have more intractable depression or have become more depressed during repeated, failed trials of other drugs, and thus more likely to consider suicide.
The Jitters and SSRIs
For SSRIs, the debilitating side effects are most directly linked to suicide. Five days before killing himself, Stewart Dolan had started taking paroxetine, the generic form of the SSRI Paxil, which caused akathisia —acute physical and psychological agitation that sufferers have compared to “jumping out of their skin.”
One review of more than 100 studies of SSRIs found the rate of the “jitteriness/anxiety syndrome” ranged from 4 to 65% among patients who began treatment with these drugs. “Akathisia symptoms so closely resemble symptoms of anxiety and depression that it may be hard for a doctor to distinguish between the underlying illness and what could be a side effect of the drug used to treat it,” UCSF psychiatry professor Joanna Gedzior told the New York Times.
But in the 10 years following the FDA’s highly publicized warnings about SSRIs, the result has been less access to mental health services and a significant reduction in the diagnosis of major depressive disorder in young adults. For adolescent patients, the rate of suicide increased by 50%, while the number of those diagnosed with major depressive disorder decreased by 40%.
Increased Suicide Rates/Fewer Diagnoses
These changes — increased rates of suicide with decreases in diagnoses — occurred at the same time as a 24% and 31% reduction in antidepressant use respectively among adolescents and young adults; as well as comparable increases in “poisonings” from drugs like Valium, often used by young girls in suicide attempts.
By 2018, “suicides and overdoses are, by any objective measure, flat-out boiling,” wrote Zachary Siegel in the New York Times. “Researchers believe…they’re to blame for the nation’s life expectancy actually dropping over the past two years.”
Meanwhile, recent advances in depression research point to different categories of the condition, with each suited to a better tailored treatment. In addition to antidepressants, psychotherapy is increasingly supplemented with advice on exercise and diet as well with acupuncture, yoga and even psychedelics.
Over the past two years, Facebook has attempted to reduce this complex issue to an algorithm that scans posts for risk of depression.For individuals deemed high-risk, FB connects them to friends, sends contact information for help lines, and in 2018 made calls to thousands of local police stations worldwide. However, experts question the algorithm as well as the safety and effectiveness of what may constitute the unlicensed practice of medicine.
New drugs useful against depression include the club drug ketamine, which provided the best relief for Ian Hanley and has been particularly effective in ending suicidal thoughts. Cristina Cusin, head of the ketamine clinic at Massachusetts General Hospital, told Time, “We have patients saying I’m exactly as depressed as I was before. I just don’t want to kill myself anymore.”
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news we can use.
AFTER THOUGHTFULLY removing a dead armadillo from the bike path on a recent trip in northern Florida, the rider learned from fellow travelers that he might have been exposed to leprosy (also called Hansen’s disease), spurring some worrisome and mostly erroneous comments about the possible risk.
Traditionally, leprosy has been spread only by infected, untreated humans. In recent years, though, in more than a dozen southern states, the disease has become a zoonotic infection traced to the nine-banded armadillo—specifically to very close contact with its meat or blood. It’s the only mammal besides humans that can develop the disease.
Of 150 to 250 people with new cases of leprosy reported each year in the U.S., in addition to about 3,600 people being treated for the chronic condition, some two thirds picked up the bacteria while traveling abroad. But starting in 2011, new cases were reported in people who had been in contact with armadillos—with an “unusually high number of cases cropping up in Florida.”
Contracting Hansen’s disease, caused by Mycobacterium leprae, was thought to require close contact over many months —called an inoculation effect —with an untreated sufferer. Like tuberculosis, leprosy is spread through the air when untreated victims cough or sneeze. Once treatment (usually a combination of two or three antibiotics) begins, they are no longer contagious. However, according to the CDC, a complete cure can take six months or longer on the drugs.
An individual’s risk of contracting leprosy in the U.S. is very low, mostly because up to 95% of Americans are genetically immune to the disease. Also, leprosy cannot be spread through casual contact such as shaking hands or hugging—or sexual contact—or passed during pregnancy from mother to unborn child.
The oldest disease associated with humans, leprosy can produce symptoms as much as seven years after infection. These include lesions that start as red swellings or rash and can become disfiguring; and nerve damage that causes sensory deterioration and can progress to psychosis and seizures. Left untreated, leprosy can be life-threatening.
About two million people around the world are permanently disabled due to Hansen’s disease, and new cases continue to occur in tropical countries—related to poverty, unsanitary conditions and lack of health care for victims before disability occurs and before they pass it along to others. Of about 200,000 new cases reported to the World Health Organization in 2016, 60% were in India, 13% in Brazil and 8% in Indonesia.
Among new cases in the U.S. linked to contact with armadillos, one person had killed the animal and gotten blood on his hands. Another had armadillos digging in her flower beds—the bacteria can survive in moist soil, which is how contagion among armadillos is thought to occur.
In humans, leprosy “needs a cut or mucus membrane to enter into the body,” Richard Truman, chief of research at the National Hansen’s Disease Program in Baton Rouge, Louisiana, told Scientific American. “Just by touching an armadillo you’re not going to get leprosy.”
Americans, in fact, come into frequent contact with millions of armadillos (nocturnal animals that emerge from their burrows to forage at dusk) in the southern U.S. The leathery carapaces are made into purses and boots; the animals are kept as pets or in petting zoos and raced at county fairs; and they are hunted and served as barbecue meat.
Because M.leprae cannot be grown in lab dishes, the discovery of leprosy in armadillos gave researchers their first means for studying the disease. Most likely it’s their body temperature of 90 degrees (cooler than most mammals) that makes armadillos susceptible; scientists believe they were originally infected by humans four or five centuries ago.
Although the numbers of armadillos infected with M.leprae are thought to be around 20% of the population, a 2011 study found that 28 of 33 wild-caught southern armadillos showed evidence of a newly described strain of the bacteria.
In 2000, the World Health Organization declared leprosy officially “eliminated” as a public health problem even as new cases continue to arise. Due to traditional ostracism, those with chronic cases continue to isolate themselves, with more than 700 informal leper colonies in India today.
The one remaining leper colony in the U.S., located on the north coast of the Hawaiian island of Molokai, was once home to thousands of victims who built their own community. By 2015 only six leprosy patients remained. That’s also the case for the few residents choosing to stay in the only U.S. “leprosarium” or in-patient hospital for treating the disease, located in Carville, Louisiana. It closed in 1999 and is now the National Hansen’s Disease Museum.
Based on Florida health reporting, leprosy contracted from armadillos is not on the rise: after 29 and 18 cases in 2015 and 2016 respectively, officials confirmed only 16 cases in 2017.
With armadillos continuing to proliferate, however, and their rustling a familiar nighttime sound in places like Georgia’s Cumberland Island, experts recommend avoiding unnecessary contact.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news that affects our everyday lives.
