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WHAT’S IMPORTANT to know about the sneeze is: never try to stop one.  Squeezing the nostrils risks a sudden rise in blood pressure in the brain that could cause a stroke or, at the least, a busted eardrum. And keeping the mouth closed can direct the sneeze’s force against membranes of the nose and middle ear, risking congestion, pain, nosebleeds and ringing in the ears.

At the other end of the spectrum, releasing the sneeze — i.e., sneezing — is reputed to lead to orgasm, especially the magic number of seven sneezes.  And sneezing during or following sex is not uncommon, perhaps due to the stimulation of the parasympathetic (involuntary) nervous system involved in both sex and sneezing.  Other sneeze-producing stimulations are strong odors and sudden chills.

Even without the sexual connection, the pleasure of sneezing for some is evident in the popularity of snuff, among both women and men until its social acceptance waned, and among many sniffers today.

Sneezes can spew from 2,000 to 40,000 droplets of moisture, moving anywhere between 70 to 100 miles an hour, and containing up to 100,000 bacteria and viruses that can remain in the surrounding air for up to 45 minutes.  Although most of these germs are benign, sneezers are advised to direct their sneezes into the crook of the elbow to catch as much as possible.  Sneeze-free periods occur only during REM sleep when reflex signals are dulled.

The most common causes of sneezing are allergies, followed by colds.  Environmental triggers from pollen to dust to dry air and any kind of foreign particle or irritant — black pepper for some— entering the nose can all provoke a sneeze.  Exercise causes sneezing when dry air makes the nose run, and genetics are responsible for both photic sneezes, in response to sunlight, and sneezes due to a full stomach after a large meal.

Emotions, especially when repressed, can emerge as sneezes. Fear can cause the nasal membranes to shrink, while frustration, apprehension, grief, anguish and resentment can cause these membranes to swell.  Excitement and joy provoke sneezing through the same stimulation pathways as sex.  In one medical journal report, treatment-resistant sneezing was blamed on psychological factors in 31 of 38 cases.  Likewise, folk remedies to stop sneezing —pressing on the upper lip or sniffing garlic, witch hazel or alcohol — probably work when they do via the emotions rather than for physical reasons.  Anti-anxiety medication can also help.

Producing a sneeze involves muscles from the eyelids to the diaphragm. Sneezes begin with a signal from the nose, where stimulated nasal mucosa causes the release of histamines that irritate the nose’s nerve cells.  The signal travels down to the brain stem, causing the chest muscles to expand, the diaphragm to contract and the lungs to fill with air; muscles in the throat, eyes and mouth also contract. Then the chest muscles contract, the throat relaxes, and air is forced out of the body through the mouth and nose, sometimes explosively.

To clear irritants from the airways, sneezes sometimes come in threes: number one loosens or dislodges the offender; number two gets it to the front of the nose; and out it goes with number three.  Although the sneezing signal closes the eyes, it’s possible to purposefully keep them open, for example while driving. The force of sneezing can sometimes be lessened safely by strongly exhaling air from the lungs through the mouth prophylactically or by massaging the neck or abdomen.

Because the system of trigeminal nerves throughout the face that can play a role in initiating sneezing is close to the optic nerve, signals from two can cross, called “cross talk,” so that, for example, plucking the eyebrows can spur a sneeze.

Though rare, the greatest dangers from sneezing are strokes in people with weakened blood vessels and epileptic seizures in those with a history of epilepsy — though it’s possible for sneezing to be the result and not the cause in both cases.

The sneeziest animals are iguanas, who sneeze to rid their bodies of excess salt.  Sneezing is common among mammals as a primitive reflex to protect the nose by eliminating foreign objects that could interfere with the passage of air. The longest human sneezing attack lasted 978 days.

Finally, sneezes have given rise to myths and rhymes.  From the days when it was thought that a posey, or sac of herbs, worn around the neck protected wearers from the plague comes Ring-around-a-rosy, with rosy referring to a rosy rash and ending with sneezes  “atches, atches [sneezes], we all fall down” — dead.

Another rhyme is thought to refer to the legend that multiple sneezes in a row can end in spontaneous orgasm: “Once — A wish; Twice — A kiss; Three times — A letter; Four times —Something better.”  The God-bless-you given sneezers comes from the belief that the sneeze is a near-death experience; the blessing should prevent death by keeping the soul from leaving the body.

— Mary Carpenter
Mary is the Well-Being editor of MyLittleBird.com. Read more about Mary here.
Her last post was on DNA testing. 

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I HESITATED, then I watched my friends go for it, and finally I shelled out the $200 for 23andMe genetic testing — more curious about my health risks, less about my ancestry. 23andMe sent the kit, and I spat into the tube and mailed it back. Slightly worried that nothing would happen, I waited several weeks for the promised results.

Since its launch in 2007, 23andMe has had an uneven run, starting with test results that included risk factors for everything from obesity and alcoholism to breast cancer and Parkinson’s, along with guidance on how to change negative outcomes. In 2013, charging lack of evidence, the FDA put a halt to the risk analyses and left only the ancestry break-down.

23andMe relaunched in the fall of 2015 with health-risk analyses severely curtailed. For medical information,  the FDA allowed only 36 “carrier status” reports, all of which in my case came up “no variant detected,” meaning I was not carrying anything from cystic fibrosis to familial dysautonomia. Not very useful.

But here’s the genius of 23andMe: It’s like a high-tech horoscope with the same appeal — it’s all about ME!!!

And further analysis of your sample is plentiful from other sites that use raw data from 23andMe. For an additional $5, I chose Promethease, which provided results in five minutes. When downloaded and copied into a Word document, they filled 290 pages: too much information. I pulled back, re-sorted for fewer conclusions and have since spent more hours than I like to admit deep-diving the mounds of information.

DNA test results are based on genetic variations — the differences among people — also called “single nucleotide polymorphisms” (SNPs). Promethease ranks your SNPs by magnitude (how much interest each SNP has garnered from the “community” of other Promethease users) and frequency in your population, which for me is Caucasian/European. Promethease results include paragraphs on each SNP, with links to SNPedia (a DNA Wikipedia), where more links lead to published research, and on and on.

Luckily, Promethease also provides colorful borders around each SNP description — red for “bad,” green for “good” and gray for “not set” — and, for each sorting of SNPs, creates a corresponding colored pie chart. Despite my overwhelming total of 19,489 SNPs, my pie looks pleasingly green and gray with just a sliver, 2%, of red.

Genetic test results come with plenty of caveats. Having a variant indicates merely an increased or decreased risk that you could have a specific health issue, and not that you do or will definitely have it. Also, a variant means the specific gene is working at an efficiency level that is altered but not necessarily better or worse. Finally, whether and how much a genetic variant is ultimately expressed depends on epigenetic (lifestyle) variables such as diet, exercise and environment. Many experts believe genetic test conclusions are too poorly substantiated to be of much value. So, maybe not any more reliable than playing the horses.

Currently, the best use of DNA testing may be to maximize the effects of specific medications based on an individual’s rates of metabolism and response for that drug. The indication by one SNP that aspirin can reduce my risk of colon cancer was reassuring, especially when my doctor was not supportive.

Although my recent MyLittleBird article, “The Ideal Diet for your DNA,” cites several experts who tailor individual diet and exercise regimens to DNA profiles, my Promethease diet and exercise results come with the caveat “interesting hypothesis but not well-validated.”  Nonetheless, I was interested to find that better weight loss for me could be achieved with high-energy exercise and low-fat diets. (NutraHacker offers more extensive diet information, but at a higher price tag of about $20 for each report on different dietary issues, which could add up quickly.)

The few results now permitted for 23andMe can seem silly, obvious and/or wrong. Among my “physical responses,” for example, 23andMe gave me an only average tendency to sneeze after eating dark chocolate, based on my Neanderthal ancestry, but corroborated my photic sneezing (in response to sunlight). Also well known to me, I have a 75% chance of being able to detect the “funny smell in urine” after eating asparagus.

In the category of wrong conclusions, I am 72% more likely to have wavy, slightly wavy or straight hair — don’t I wish? In fact it’s very frizzy. Also my muscle composition makes me more likely a sprinter than an endurance athlete: not true.

On the other hand, I was intrigued to find that I likely have more “periodic limb movements” per hour of sleep compared to the average of about 10. I do not have the variant linked to “deep sleep,” making my sleep typically but not excessively deep. Also, based on a SNP for a protein that transports fatty substances, I have a 93% chance of wet earwax (compared to dry and flaky) that, more important, is linked to less body odor.

On caffeine, 23andMe found my consumption 37% higher than those who are genetically similar to me, while Promethease labeled me a “fast metabolizer” of coffee — which decreases its effect — but on the other hand, to have “significantly higher anxiety levels after moderate caffeine consumption.” Both sites agree that I have a high likelihood of not tasting certain bitter compounds — in coffee as well as in vegetables like broccoli or Brussels sprouts.

On Promethease, I have a “stronger bones” SNP as well as the conflicting SNP for “increased risk of low bone mineral density disorders” — but my pleasing pie chart showed six green good results vs. only five red bad ones. Most surprising was the long list of SNPs indicating my risk for Type 2 diabetes, which has appeared nowhere in my family but could be affected by my sugar consumption over the years — though that risk pie chart actually looked quite green as well.

Of my two favorite Promethease results, both marked bright green, one indicates “better avoidance of errors,” “women have higher persistence” and “lower obesity due to increased pleasure response to food.” The other is “[worrier] advantage in memory and attention tasks…more difficult to hypnotize…placebo is more effective…more efficient at processing information,” also “enhanced vulnerability to stress,” based on what’s known as the “warrior/worrier hypothesis,” which I intend to investigate further.

What is worrisome to many is the privacy issues of genetic testing sites. 23andMe makes no bones about being out to collect personal information: With a current database of more than one million customers, it is noted that each additional sample helps improve everyone’s results. Among more private alternatives, the Genophen platform can be ordered by private physicians through Base Health at $130 and is reputed to give better information on the interaction of an individual’s genotype with diet, exercise, lab results and family history.

For some, though, genetic testing sites provide anonymity — I am not obliged to discuss the findings with anyone, not even my doctor — along with links for endless ferreting throughout the Web, time to reflect on the results, and experts at the ready for questions: When I emailed the site to challenge my high-risk SNP for male-pattern baldness, the answer came quickly, the error acknowledged.

— Mary Carpenter
Mary is the Well-Being editor of MyLittleBird.com. Read more about Mary here.
Her last post was on hiccups and yawns. 

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BOTH HICCUPS AND YAWNS can be triggered by the way air enters the body.  Also, both are related to activity of the vagus nerve, which regulates the body’s organs — in particular the heart and blood vessels — and conveys information about them to the central nervous system.

The vagus nerve meanders up the body to affect bodily functions including heart rate, sweating and speech; also the inner portion of the outer ear — creating an ear-throat connection that explains why clearing earwax can cause coughing.  (The vagus nerve comprises more than 80% of the body’s afferent nerves, which affect the subject, as opposed to efferent nerves that allow the subject to effect change.)  Breathing more quickly or slowly can alter vagus nerve activity, which in turn can cause fainting.

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Hiccups can erupt when eating too fast causes air to get trapped between pieces of food: the compressed air physically impacts the vagus nerve as it runs up from the diaphragm. Long-term hiccups can be traced to vagus nerve damage or to local irritation, for example, when something in the ear like a hair touches the eardrum.  (The longest attack of hiccups lasted 68 years, estimated at 430 million hiccups, according to Guinness World Records.)

Found only in mammals, hiccups may be an evolutionary remnant of earlier amphibian respiration.  Or because they are more common in infants and become rarer with age, hiccups may have evolved to release air trapped in nursing infants’ stomachs.

Holding the breath or breathing into a paper bag can stop hiccups by raising carbon dioxide levels and inhibiting diaphragmatic activity.  Alternatively, swallowing dry bread or crushed ice can irritate the pharynx, which in turn stimulates the vagus nerve to stop the hiccups.  Folk remedies include drinking a glass of water upside down, gargling, being frightened, eating peanut butter and placing sugar on or under the tongue.

Anecdotal evidence supports applying lidocaine (2-3% is recommended) to the inner ear canal, or squirting vinegar into the nostrils.  Stronger drugs can help with more serious cases.

Birds, fish and snakes, as well as mammals, yawn.  Excessive yawning can be related to the degree that chemicals, such as dopamine and serotonin, are activated in the brain as a result of, for example, intense concentration or creative thinking.  Yawning, which expands the passage from the back of the throat to the eardrums, can also be caused by problems in the heart or blood vessels that stimulate the vagus nerve.

In addition to intense thinking, sleep deprivation, including that due to narcolepsy and hypersomnia, causes brain temperature to rise. Yawns increase blood flow to the brain to move heat away.  Yawns cause the sinuses to act like bellows that cool the brain, according to Gary Hack of the University of Maryland and Andrew Gallup of Princeton University.

With the understanding that yawning is often contagious, the researchers found that subjects who applied cold packs to their heads yawned less often in reaction to others’ yawning, and those who breathed through their noses did not yawn responsively at all —compared to 48% of mouth breathers.

Contagious yawning — also called social yawning — increases around age 4 along with the development of empathy, lessens in old age, and is more common among friends and family members. Men yawn more than women, possibly because women are more “socially aware,” explains psychiatry professor Walter Smitson at the University of Cincinnati.

On the other hand, groups with greater immunity to social yawning include psychopaths and children on the autism spectrum — due both to lack of empathy and to fearlessness, according to Baylor University researchers.  The more coldhearted — on the psychopathy — scale, i.e., the less empathetic — the more immune people were to others’ yawns.   And those who are less fearful — measured as less likely to startle — are less likely to catch yawns.  Physiologically, yawning boosts your blood pressure and heart rate. Paratroopers often yawn just before jumping.

Because yawning is seen as an expression of negative emotions — anger, boredom, disagreement or rejection — and thus ill-mannered, polite yawners cover their mouths with their hands, and people search for ways to catch yawns before the need-to-stifle stage. In anticipation of a potentially yawn-inducing event, the most efficient strategy is to cool the brain: drink or eat something cool, keep the environment cool or apply a cool compress to the head for a minute or two ahead of time.  In the absence of foresight or cooling options, a few deep breaths through the nose, exhaling through the mouth, can help.

Yawns last an average six seconds. The technical name for a yawn is disambigulation; yawning and stretching at the same time is pandiculation, according to Ward Degler in the Zionsville Times Sentinel.  Degler tells about his childhood experiences of trying to hide yawns by pulling his shirt over his face or covering his face with a pillow — about as successful as hiding hiccups.

Although hiccups are unpleasant for the person experiencing them, yawns bother other people more.  Spreading the word about the paratroopers, as well as that yawns indicate serious thinking might someday make them a welcome sign of bravery, intelligence and creativity.

— Mary Carpenter
Mary is the Well-Being editor of MyLittleBird.com. Read more about Mary here.
Her last post was on gadgets that help you relax. 

WHETHER YOU PREFER to go through your heart or brain to de-stress, there are gadgets trying to make it easier for you.

For the heart, the emWave Personal Stress Reliever (HeartMath) works like a portable biofeedback device to encourage a smooth heart rate variability (HRV), the interval between consecutive heartbeats that is constantly changing from irregular when stressed to regular and “coherent.”

As you press your thumb on the metal device — about the size and shape of an EZ-pass transponder— the indicator light changes from red to blue to green as your stress diminishes.  Remaining sufficiently de-stressed will produce a consecutive series of green bars, tapping into the competitive natures of some users: one friend, who has several advanced degrees, swears by the emWave.

The emWave can help you “quickly and easily reach a state of high coherence,” according to Julie Strietelmeier, an initially skeptical reporter for The Gadgeteer.

“Coherence” is created by signals sent from the heart to the brain-stem via the vagus nerve, causing alteration in brain function.  For more than 30 years, HRV biofeedback has been used as treatment for disorders including asthma and depression, as well as for performance enhancement.   Heartmath, developer of the emWave, emphasizes that “coherence is not relaxation:” while coherence includes the lower HRV of relaxation, activity in the brain and nervous system is not decreased but rather becomes more harmonic and better synchronized.

Although Strietelmeier personally finds it easy to de-stress by simply taking several deep breaths, she writes that “seeing that green LED has a positive effect that just closing your eyes and breathing deeply does not.”  Responses to her article include: “Trust me — if you are a golfer, try it out!”

(EmWave2 is available from HeartMath as well as from Amazon, starting at $199; less expensive devices provide biofeedback using other measurements including respiratory rhythm and galvanic skin response.)

For the brain, portable biofeedback devices pair smartphone apps with electroencephalography (EEG) headsets — like fitness trackers for the brain, according to an article by Wall Street Journal Technology Editor Michael Hsu.  With growing acceptance that meditation is the great stress reducer, Hsu wanted to find a way to “meditate less but better.”

Among several products, he found the one offering “the most pleasant experience overall” was the Muse:  Four sensors on a headband that goes over the ears measure stress to which the Muse responds by producing sounds, such as ocean waves and rainfall.  “When the app thinks your mind is wandering, the sounds become more turbulent.  Ocean waves roar; rain falls harder,” Hsu writes.

Although he had meditated for years, Hsu found the focused-attention technique assessed by the Muse difficult to master until hearing his “first chirp” of success got competitive juices flowing, and then he wanted to do it over and over — which the manufacturers call “Musing.”  And soon a “greater sense of awareness” spread to his everyday life.  (He also notes that the minute-long initial calibration exercise each time you put on the headset can be annoying.)

Focused attention might sound like mindfulness.  But when Hsu took a more elaborate EEG test at the Center for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts Medical School (founded by Jon Kabat-Zinn, who spearheaded the mindfulness movement in the U.S.), he found that the Muse techniques he had used were “completely different” from those required by these EEG sensors.  Instead of focused attention, the U. Mass EEG measured “effortless awareness,” less of an exertion and more of a “letting-go,” as Hsu explains it.

On the other hand, Richard Davidson, founder of the Center for Healthy Minds at the University of Wisconsin-Madison and a “dedicated meditator,” told Hsu that he opposes any kind of EEG feedback for meditation training.  Davidson pointed out that meditation in Sanskrit means “familiarization,” referring to one’s increasing familiarity with the nature of one’s own mind — so that focusing on external signals can be a distraction from learning about ourselves and becoming more effective meditators.

We don’t know enough about what brain signals to look for in a meditative state, says Davidson, and so “the effort at this point is absurd.”  Other practiced meditators agree with the criticism that external devices direct attention away from our inner selves.

Even the skeptical concede, however, that using these devices can be an important first step.  Because everyone’s hearts and brains are different, such devices might help precisely those individuals who most need help to relax or focus.

— Mary Carpenter
Mary is the Well-Being editor of MyLittleBird.com. Read more about Mary here.
Her last post was Less Medicine, More Health?

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“COLONOSCOPIES AND OTHER cancer screening tests are out — and before [age] 75…65 will be my last colonoscopy.” Those words spoken by University of Pennsylvania oncologist Ezekiel Emanuel in the October 2014 issue of Atlantic magazine, were music to my ears. Stop the hated colonoscopies, yes!  Turns out it’s not so simple.

Emanuel’s article “Why I Hope to Die at 75” makes the point that a cancer diagnosis at that age usually leads to unpleasant treatment providing little gain in enjoyable or productive years. (The article elaborates on the decline in overall quality of life after that age.) His thesis was compelling for many, but at least the same number had stories about screening and/or treatment saving their life or that of someone close to them, and about the wonderful experiences they had or are having ever since.

Although many articles and books use statistics to show that screening does not save lives in the long run, these statistics need to be examined closely and personal situations seriously considered.  Dartmouth Medical School professor Gilbert Welch is one spokesperson for avoiding excessive medical care, with three books on the subject, including the most recent Less Medicine, More Health.

On colon cancer, Welch cites the “Minnesota Colon Cancer Control Study — another herculean study of roughly 50,000 people followed for 15 years to conclude that “screening didn’t help people live longer.  Not even a little bit.”

He acknowledges that the study didn’t focus on colonoscopies, but instead evaluated the “fecal occult blood” screening test, which detects hidden blood in the stool — but is not the most effective even among noninvasive tests.

In fact, a similarly herculean study looked at 57,600 patients in the Kaiser Permanente Northern California health care system who had colonoscopies, “unequivocally best at finding cancer and precancer,” according to an April 16 New York Times story by Jane Brody.  The Kaiser study put the lifetime colon cancer risk among those not screened at more than 34 per 1,000 compared to those who had colonoscopies by the most skilled doctors at under 13 per 1,000 — which comes out to “a 50 to 60% lower risk for colon cancer and colon cancer fatalities over a patient’s lifetime,” according to a June 2015 article in HealthDay.

Welch makes many useful points about early and overdiagnosis, as well as about treatments later disproven and about how taking action may not always be the best choice.  Blood pressure recommendations had remained the same for years, he notes, until in 2012 they were changed by the American Diabetes Association to raise the systolic goal from under 130 to under 140 — because prescribing medication to get pressure below a certain point had led to patient deaths.

In 1998, the respected Journal of the American Medical Association initiated the ongoing series “Less is More,” with entries that support less medical intervention.  One describes a patient with Type 2 diabetes, whose doctor’s efforts to reduce his blood sugar to the prescribed level led to an episode of severe hypoglycemia, “associated with cardiovascular events, cognitive impairment, fractures and death,” after which the patient’s target level was individualized to the higher level of 7.0% (% of hemoglobin A1C, which reflects average blood sugar levels over several months).

In the ubiquitous physical exam, however, doctors generally use much the lower level of 5.7% to diagnose “pre-diabetes,” and for those with higher levels recommend dieting to decrease sugar consumption.  Doctors now also commonly diagnose pre-osteoporosis, called “osteopenia,” with accompanying warnings.  But “pre” anything actually means you have nothing, and while moderate changes in lifestyle might lead to better health, medical treatment for these conditions can cause more stress and worry than improved health.

For breast cancer, on the other hand, a “pre” diagnosis may be a life-saver. Ductal carcinoma in situ (DCIS), the most often-targeted in discussions about cancer overtreatment, is considered stage 0 cancer because it has not yet spread outside a breast duct.  (The duct is where most breast cancer begins.)  Also because DCIS was a rare diagnosis before mammography screening, health care professionals complain that regular mammographies lead to over-treatment and that DCIS should not be called cancer at all, or that it should not be treated.  On the other hand, with DCIS, cancerous cells are still completely contained — in the duct — and surgery, in many cases accompanied by radiation, will completely remove the cancer as well as all future risk of cancer from that site.

Welch notes that population-wide breast cancer screening might help one in 1,000 women…”we’d all do it for the chance to be that 1, if nothing bad happened to the others…if there were no harms.  But there are.”  In his opinion, number one is fear — which leads to a rate of double mastectomies that Welch considers overtreatment.  Of U.S. women who develop cancer in one breast — but who do not have the genetic mutation that dramatically increases breast cancer risk — about one-quarter of those now ask for both breasts to be removed, with a 30-day mortality rate after mastectomy at about a quarter of one percent.

Although DCIS is stage 0, in fact each woman receives the additional measurement of “nuclear grade,” referring to condition of the tissue.  One woman whose tissue was graded 2-3 (out of 3) and “nasty,” opted for lumpectomy and radiation.  Another with DCIS chose a double mastectomy and was relieved both that she had eliminated all risk, and that she would never need another mammography.

What’s difficult is how personal this process ends up being — with the burden on each individual to gather information and then weigh and sort according to their knowledge of themselves.  The received wisdom is that you never know what you will decide until faced with a particular medical decision. When someone in their 70s refuses treatment for a life-threatening condition, doctors protest and tongues wag — but what should be remembered is: maybe that woman simply knows herself very well.

— Mary Carpenter
Mary is the Well-Being editor of MyLittleBird.com. Read more about Mary here.
Her last post was on flatulence.
 

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I RECENTLY TOOK an online WebMD quiz titled “All About Farts” and failed miserably — to my surprise, because gas is an issue to which I’ve paid considerable attention over the years. (I’m taking advantage of WebMD’s story title as permission to employ the word “fart,” instead of the medical “flatus,” with abandon.)

What I learned from my quiz errors: Air travel can make you fart, because air pressure can make gas worse if you’ve recently eaten whichever foods make you gassy; a person eating a normal diet passes gas 13 to 21 times a day; foods high in carbs are more likely to produce gas compared with those higher in fat or protein (more on this below); anti-gas medications such as Gas-X use enzymes that help break down sugar, which helps food get digested more easily; and the best way to get rid of a fart is by opening a window — not lighting a match.

The few answers I got right: Bad-smelling farts do not mean you’re sick; exercise can help you fart less by getting rid of extra air in your system; gassiness increases with age because your digestive system slows down; and chewing gum can make you gassy, as can anything that causes you to swallow air, including fizzy drinks and eating too fast.

The main cause of gas is the breakdown of food in the digestive system. Although different foods cause gas in different people, most notorious gas-producers are among the healthiest, plant-based foods, such as beans, fruits, vegetables and whole grains. More obvious villains are sugary foods, such as cakes, soft drinks and candy — and anything made with high-fructose corn syrup.

Lists of high gas-producing foods vary, and elimination diets are the best way to determine which foods are the gassiest for you. Before embarking on those, digestive issues can be minimized by taking smaller bites, chewing thoroughly and eating slowly — to make it easier for the stomach to break down food; and by drinking liquids beforehand rather than during the meal, because too much liquid can dilute stomach acids and disrupt digestion. On the other hand, eliminating high-gas foods, which are often high in fiber, can cause constipation, in which case drinking more water is advised.

Gas-causing foods are grouped under the acronym FODMAP, referring to a collection of molecules that are poorly absorbed in some people, according to Kris Gunnars on the Authority Nutrition website. (FODMAP stands for Fermentable Oligo-, Di-, Mono-saccharides and Polyols.)

FODMAPs generally pass through most of the intestine unchanged until they reach the far end, where they are broken down, or fermented, by a certain kind of gut bacteria that produces hydrogen (instead of methane, produced by most by bacteria).  Hydrogen can cause gas, bloating and sometimes pain. (In contrast, low gas-causing foods are digested earlier, primarily in the stomach.) FODMAPs are osmotic, meaning they pull water into the intestinal tract, which also slows digestion.

Sadly, the high-FODMAP list includes some of the most delectable foods: artichokes, apples, mangos, bananas, garlic, onions, breakfast cereals, milk, ice cream and chocolate. Most high-fiber foods are on this list, so low-FODMAP diets can create their own digestive issues. Oatmeal is an exception: It’s low in FODMAPs but high in fiber.

The best way to figure out which FODMAPs are causing an individual’s gas is to start with a six-week low-FODMAP diet, eliminating almost everything from dairy and gluten to many fruits and vegetables, after which foods can be added one at a time back into the diet. The Stanford University Low-FODMAP diet avoids fructose (fruits, honey); lactose (dairy); fructans (wheat, garlic); galactans (beans, lentils) and polyols (artificial sweeteners, along with “stone fruits” including avocadoes, cherries and peaches). At the end of six weeks, add high-FODMAP foods one at a time to identify personal triggers.

An alternative is to start by eliminating “The Top 10 Vegetables That Cause Gas,” from Flatulence Cures, which can be divided into several groups: Peas and beans have high levels of soluble fiber and oligosaccharides, and produce mostly odorless gas; broccoli, cabbage, cauliflower and Brussels sprouts are high in sulfur compounds, which can produce the rotten-egg gas smell; and onions, asparagus, mushrooms and artichokes have an array of different gas-producing compounds. (Meat can also cause unpleasant-smelling gas.)

“Cruciferous” vegetables, such a broccoli and cauliflower, can be digested more easily if they are eaten regularly to build up intestinal tolerance; and a mix of vegetables is less likely to cause problems than a large plate of just one kind, according to flatulencecures.com. Low gas-producing vegetables include carrots, tomatoes, zucchini and leafy greens like spinach — and, beneficial as always, kale — although these sometimes appear on FODMAP-villain lists as well.

Also recommended on Flatulence Cure are daily probiotics; fennel, ginger or peppermint tea; activated charcoal, and finally, a broad- spectrum digestive enzyme called Veganzyme ($49.95), to be taken just before a “potentially hard to digest meal”— if you are good at anticipating such things. (Read listed warnings on all products.)

If all this sounds like too much work, the last quiz question I got wrong asks what to do if you feel a fart coming on.  I checked “sit down and clench muscles.” The right answer is “stand up and relax everything.”

— Mary Carpenter
Mary Carpenter is the Well-Being Editor of MyLittleBird. Read more about Mary here.
She last wrote about Confronting Anxiety. 

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I THOUGHT I UNDERSTOOD Cognitive Behavior Therapy (CBT), or had certainly heard enough about it, until making a mistake in reading a schedule unexpectedly landed me in an anxiety workshop at the recent Psychotherapy Networker Symposium in D.C. At first I took random notes without understanding if anything new was being said.

Then came two videos of actual therapy sessions showing the speaker, Reid Wilson, psychiatry professor at the UNC School of Medicine, putting into practice the concepts he was explaining.  The videos were a revelation.

Anxiety disorders, the most common type of mental illness, are mental conditions in which intense, irrational feelings of fear and anxiety are expressed frequently and to a debilitating degree.

Because anxiety disorders are disorders of uncertainty, Wilson warned the auditorium full of therapists: patients “can’t trust you but must act as if they do.”  As Wilson’s patients spoke about their fears — in front of a video camera for public consumption, no less — they appeared to grow more comfortable and more sincerely trusting.  While Wilson’s responses made the CBT formula appear somewhat simple and obvious, they also suggested a proficiency gained over decades of practice.

The first video’s patient had generalized anxiety disorder (GAD), the most common in a list that includes social anxiety, phobias, panic attacks and obsessive-compulsive disorder.  She was a middle-aged woman who worried often about her grown son, newly on his own in a big city.  Following Wilson’s suggestion to “step back” and examine what’s going on, she figured out that the days she worried most about her son were also the days when she felt insecure about work or concerned about personal health issues.

Wilson urged her to separate the worries about her son from her own concerns — which he calls separating the signal (the immediate cause of anxiety, something that could benefit from action) from the noise (background worries, for which no imaginable action would help).  “Separating the signal from the noise” at first sounded jargonny and confusing.  But after the patient did just that — and then breathed a sigh of relief, sat up straighter, looked more in control, and sounded as if she could, quite suddenly, think more clearly — CBT began to make more sense and to seem like something worth trying before signing on to more time-consuming traditional therapy.

Recognizing our own insecurities or unhappy feelings can be unpleasant, Wilson explained, because as children we were told not to pay attention to ourselves.  Worriers learn to avoid their fears, whereas he urges them to seek out and be okay with feeling insecure or clumsy or awkward or even panicked.

(Wilson acknowledged that worry has its uses: “When worry plays a role in helping us to solve our problems, it does a fantastic job. But when it becomes a bothersome noise in your head, it has no redeeming value.”)

Mindfulness — also recommended for anxiety — is fine, he said, but insufficient. The first homework Wilson gives his patients is “self-talk:” to “approach, personify, exaggerate and talk directly” to their anxiety — to ask yourself, how can I create some anxiety here; how can I practice being willing to be anxious?  Worrying and avoiding stress heighten physical reactions by raising adrenaline levels, he said, whereas looking directly at and moving toward fears can be calming.

The second patient, Mary, had a 10-year history of claustrophobia: in elevators, airplanes, parking garages, she worried that she might suffocate or have a heart attack.  Wilson explained how to use the content of fears (the parking garage) to stimulate doubt and distress — the by-now familiar habituation therapy for phobias.  Exchanging the old response of “look how shaky I became” for the new “I did this!” can “change the prefrontal cortex,” he said.

In Mary’s first of just two sessions, she described her fear that a parking garage could collapse and crush her, with the worst damage occurring if her car was parked in a dark, interior spot.  Wilson advised Mary to change her interpretation of the fears: instead of pushing them away, to say to herself, “I want these feelings.”

At the second session, Mary described making a trip on purpose to a parking garage; driving to the darkest place she could find, a challenge with the Southern California sun streaming in; and trying “to make it as unpleasant as I could” — while at the same time telling herself, “it’s not going to collapse.”

As she spoke, Mary appeared pleased by her success as well as more relaxed and actually prettier.  Wilson noted the importance of Mary preparing herself ahead of time by repeating reassuring phrases and by anticipating that the garage would be hot and crowded, both of which replaced her accustomed approach of waiting for panic to strike.  Short clips from the sessions are available online.

The strategies of CBT are paradoxical: the patient must “purposely and voluntarily choose to seek out uncertainty and distress,” according to Wilson’s latest book “Stopping the Noise in Your Head.”   In his books and lectures, Wilson creates diagrams of a stick figure pushing a child’s swing, with each push causing the swing to gather strength and come back more strongly than before.  Pushing away whatever is worrisome serves only to strengthen the anxiety for the next time that situation arises.

— Mary Carpenter
Mary Carpenter is the Well-Being Editor of MyLittleBird. Read more about Mary here.
See last week’s post on back pain. 

IN AN INTERVIEW with NPR, Harvard cancer specialist and New Yorker writer Jerome Groopman described his 20-year long battle with “excruciating” and sometimes “explosive” back pain.  The ordeal included two surgeries that failed to allay his suffering — and this is someone with access to the best medical resources.

What ultimately helped was back pain “boot camp,” created at New England Baptist Hospital in Boston by Dr. James Rainville, who explains that pain often has nothing to do with the mechanics of the spine.  “It’s a change in the way the sensory system processes information.  Normal sensations…produced by movements are translated by the nervous system into a pain message,” says Rainville.

As many as 25% of patients with acute back pain are in an endless loop of pain due to persistent hypersensitivity of the nervous system.  As a result, addressing the brain issues can often alleviate back pain better than direct treatment of the back itself (see  MyLittleBird’s story on the pain-brain connection.

A compelling reason for treating the brain first is that the back presents thornier problems.  Even when MRI scans reveal abnormalities, those are not necessarily the cause of pain.  For more than 95% of those with back pain — for many of whom the pain is “age-related” — surgery is not the best treatment.  In addition, back surgery can lead to more pain over time, compared to leaving the problem untreated.  And among back pain sufferers who have surgery, one in five ends up having more surgery.

Cognitive behavioral therapy (CBT), which appears at the top of Google lists for “back pain,” can help control how the mind manages pain by transforming negative thoughts, for example from “I hate this pain” to “I have dealt with this pain before.”  Other therapies directed at the brain include meditation and deep breathing.  Tai chi and yoga work on both mind and body:  one study group who took 12 weeks of yoga classes had fewer pain symptoms than a control group.

Over six weeks of regular visits to back pain “boot camp,” physical therapists trained in Rainville’s methods give exercises at slowly increasing intensities to improve the back’s strength and flexibility, while at the same time getting patients to believe their backs can sustain such increasing intensity.

Before heading to professionals, the common recommendation is to try DIY remedies for about three months.  Even when the pain first hits, bed rest is advised for only the most severe cases and then for three days max.  But 15-minute breaks to lie with the back flat can help at any point.

Some advocate ice under the back for the first 48 hours after an injury, then switching to heat.  Others suggest alternating the two — first one and then the other: cold reduces inflammation and acts as a local anesthetic by slowing nerve impulses; heat stimulates blood flow while inhibiting pain messages sent to the brain.

Another-inflammation reliever is NSAIDS (non-steroidal anti-inflammatories), among which the best for some is a “medical dose” of Alleve, two pills in the morning and two at night.  As spasms subside, gentle exercises can begin with cat/camel: arching the back in both directions, convex and concave, as well as to one side and the other like a wagging dog’s tail.

Next come low-impact exercises like walking and swimming.  As with the heat-cold combo, the best approach may be a trifecta that combines exercise and stretching along with yoga and massage.  (Acupuncture might help, although one study on several hundred people found that those who received simulated acupuncture, using toothpick taps, had the same relief as those getting the real thing — but both did better than patients who had nothing comparable.)

Strengthening the “core” is a major focus of back pain-relieving exercises, because “the torso is a combination of many muscle groups working together,” Frank Wyatt, exercise physiology professor at Missouri Western State University, told WebMD.  “When we strengthen the abdominals, it often reduces the strain on the lower back.”

Many Pilates exercises work on the core, as do back-pain programs such as “Foundation Training,” a regimen of exercises developed by chiropractor Eric Goodman, available on DVDs and YouTube.  The McKenzie Method uses core muscle contractions as well as arm motions to stabilize the trunk and extend the spine.

Some of the more difficult-to-follow advice for back pain sufferers includes avoiding whatever strenuous exercise caused the original pain, including gardening.  Also avoid excessive sitting, bending your neck toward your phone for too long and carrying excess weight.

Also hard to follow are pillow-placement recommendations for sleeping:  back sleepers should put pillows under their knees; side sleepers should place pillows between their knees; and stomach sleepers should switch to one of the other two positions.

With persistent pain, it might be time to target the pain’s source. A cortisone injection, called a nerve root block, can relieve irritated nerves.

If six months of “aggressive conservative treatment” fails, and if the pain makes it difficult to complete daily activities, surgery can treat herniated or bulging discs, which create cushions between the vertebrae, according to spine-health.com.  Surgery is advised especially when painful discs cause conditions like sciatica, in which pain radiates down the leg.

One surgical option, spinal fusion, creates a direct bony connection between the vertebrae to prevent painful motion of the discs. A recent alternative for some patients is artificial disc replacement, which removes painful discs and uses prosthetic implants to maintain motion.

One more focus for treating back pain is depression and anxiety.  Australian research found a 60% greater incidence of back pain among people with deep depression compared to those without the symptoms, possibly due in part to poor sleep and lack of exercise.  Explains Alex Moroz, associate professor of Rehab Medicine at NYU Langone Medical Center, on spine-health.com., “Your emotional state colors the perception of pain.”

— Mary Carpenter
Mary Carpenter is the Well-Being Editor of MyLittleBird. Read more about Mary.

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CONFLICTING MEDICAL advice abounds: different doctors advise either taking more calcium or less; other professionals recommend either walking with a weighted vest to increase bone strength or losing weight to preserve my troubled knees. But the most adamant docs weigh in on opposite sides of daily low-dose (81 mg) aspirin.

Reasons against taking it for me include evidence of slight GI bleeding and low ferritin (precursor to iron), which together might be causing fatigue. Aspirin increases the risk of stomach irritation and bleeding as well as of developing a stomach ulcer. It can also cause problems with breathing, indigestion, tinnitus (ringing in the ears) and hearing loss.

But the reasons in favor keep growing. Number one is protection against colon cancer, for which I’m at risk based on my mother’s cancer and on occasional polyps found during colonoscopies.

For the first time in the fall of 2015, the U.S. Preventive Services Task Force (USPSTF) recommended the use of aspirin for adults in their 50s and older with risk factors for colorectal cancer; until then, it had been recommended for people at risk of cardiovascular disease, including heart attacks and strokes.

“The change in recommendations by the USPSTF reflects the accumulation of scientific evidence linking aspirin with a lower risk of colorectal cancer,” a USPSTF spokesperson told Elizabeth Mendes on the American Cancer Society site. “There is now definitive evidence that long-term daily aspirin use, even at low doses, will lower risk of developing colorectal cancer, probably by approximately 40%,” the spokesperson said. Even the possible delay of “several years” before the benefit “kicks in” was built into the risk-benefit calculations.

Soon after this recommendation came out, even stronger evidence emerged, based on analyzing data from 135,965 health-care professionals followed for over 30 years. Participants who took aspirin, including low-dose versions, at least twice a week were 19% less likely to have gotten a colorectal cancer diagnosis, and 15% less likely to have developed any gastrointestinal cancer. “The researchers noted that the apparent cancer-protective benefits of aspirin required at least six years of regular use,” according to The Washington Post.

In the same study, the overall risk of developing cancer was 3% less for those who regularly took aspirin. Other researchers have noted the risk-lowering effect of regularly taking aspirin on developing cancers of the esophagus and stomach, and there is some evidence for breast cancer — although that has not yet been supported by randomized trials.

For cardiovascular disease, aspirin reduces the ability of the platelets to clump and clot, lowering the risk of heart attack or stroke. While it can help prevent a clot-related (ischemic) stroke, however, aspirin could also increase the risk of a bleeding (hemorrhagic) stroke.

Additional evidence suggests the salicylic acid in aspirin can help block the development of neurodegenerative diseases, including Alzheimer’s. Similar to the action of one anti-Parkinson’s drug, salicylic acid can bind with the enzyme GAPDH, interfering with its role in cell death and thereby helping maintain healthy levels of intracellular signaling.

GAPDH’s more familiar role is in glucose metabolism, and higher blood glucose levels have been associated with the risk of dementia. Although cause and effect relationships are not yet clear, the brain is clearly a “target organ for damage by high blood sugar,” according to Dr. Medha Munshi at Joslin Diabetes Center in Boston.

Another target of salicylic acid is the protein HMGB1, which causes inflammation associated with arthritis, as well as certain cancers and atherosclerosis. Even more potent than the salicylic acid in aspirin is a natural form found in the Chinese medical herb licorice.

Finally, aspirin appears to increase protection against dying from staph infection, associated in one small study with a 42% lower risk of death. While aspirin is not advised for healthy people with no risk of GI cancer or cardiovascular disease, because of the risk of GI bleeding, I consider myself fortunate to be in the recommended group for all of the possible additional benefits listed above.

— Mary Carpenter
Mary Carpenter is the Well-Being Editor of MyLittleBird.
Read more about Mary.

Photo by Antonio Diaz / iStock

DAYLIGHT SAVINGS TIME, which began this past Saturday at 2 a.m, can interfere with the ability to fall asleep and to wake up at the desired times. The one-hour time change can exacerbate difficulties of people with chronic sleep problems such as insomnia and sleep apnea. And insufficient sleep over time can have a wide range of negative effects on everyone.

The association of sleep loss with increased risk of overeating, poor food choices and weight gain has recently been explained as the same system “targeted by the active ingredient of marijuana,” according to Eric Hanlon, PhD, research associate at the University of Chicago. “Sleep restriction boosts a signal that may increase the hedonic aspect of food intake” — that is, brings on the munchies.

Blood levels of the chemical messenger 2-AG (the endocannabinoid 2-arachidonoylglycerol) are typically low overnight and slowly rise during the day, peaking just after noon. Compared to when study subjects had a full night’s sleep, with insufficient sleep their 2-AG levels rose about 33% higher and remained elevated through the evening. During those periods, they expressed greater desire to eat and, when offered snacks, chose foods providing 50% more calories, including twice the amount of fat.

Previous studies have linked high levels of the appetite-boosting hormone ghrelin and low levels of the fullness-signaling hormone leptin to reduced sleep time and increased appetite. The Chicago research for the first time also measured blood levels of 2-AG, which stimulates the endocannabinoid system and enhances the desire for food intake.
Hanlon explained, “If you have a Snickers bar, and you’ve had enough sleep, you can control your natural response. But if you’re sleep deprived, your hedonic drive for certain foods gets stronger and your ability to resist them might be impaired.”

Sleep-deprived people also appear to have more trouble expressing and detecting emotions, especially positive ones. According to University of Pennsylvania psychology professor David Dinges, “a sleep-deprived person may say they’re happy but they still have a neutral face.” Also, they might see another’s happy face as neutral, and a neutral face as negative. And they have a low tolerance for disappointment.

The immediate effect of losing two hours of sleep has been compared to that of alcohol intoxication. Over time, sleep insufficiency increases mortality risk more than smoking, high blood pressure and heart disease. And it has been blamed for other chronic diseases such as hypertension, diabetes, depression and obesity, as well as for cancer.

A recently discovered network of fluid channels in the central nervous system called the “glymphatic system” functions as a waste disposal system for the brain. The glymphatic system drains toxins that can accumulate and damage brain cells — including amyloid-beta associated with Alzheimer’s disease — from the brain “at a rapid clip,” according to neuroscientists at the University of Rochester. This system, however, mainly operates during sleep and appears disengaged during wakefulness.

Among suggestions for adjusting to time changes such as daylight savings, the most often heard is to spend time outdoors in sunlight, being physically active when possible. And during the hours before bed, lower the lights and turn off technology including cell phones, iPads, computers and TV. Avoid eating and drinking alcohol too close to bedtime, and warm baths can help.

— Mary Carpenter
Mary Carpenter is the Well-Being Editor of MyLittleBird.
Read more about Mary.

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WHEN A FRIEND’S college-age daughter came home from a gynecological appointment with the diagnosis of an “autoimmune disease,” my friend asked me to look into it. At first, I found the diagnosis, lichen sclerosus (symptoms include white spots, itching and pain), attributed to an “overactive immune system,” which sounded better than an autoimmune disease (AD). But when the condition was also traced to previous trauma or infection, it qualified as an AD.

In autoimmune diseases—the most common being Type 1 diabetes, rheumatoid arthritis and Lupus—the body’s immune system attacks normal, healthy tissue, causing inflammation and damaging or destroying the body’s tissue or organs. Often there is no obvious trigger, although infection and/or trauma appear to play a role because ADs often follow bacterial or viral infections. Multiple Sclerosis (MS) patients are twice as likely to have antibodies to the measles virus compared with those without MS.

ADs can produce effects ranging from severe to mild and barely noticeable: I discovered long after getting to know two friends that one has Hashimoto’s and the other Sjogrens syndrome (affecting the moisture-producing glands).
Women make up about 75% of those afflicted with autoimmune diseases, and ADs represent the fourth-largest cause of disability among women. Ratios of female to male sufferers range from 50:1 for Hashimoto’s syndrome (thyroid deficiency) to 9:1 for Lupus and 2:1 for MS. (Crohn’s disease is one that affects both sexes equally.)

Hormones are thought to play a role in the increased susceptibility of women to AD. Women demonstrate larger inflammatory responses in general compared to men. Also, AD symptoms can vary and intensify depending on estrogen levels; and having been pregnant increases risk for AD. Because estrogen appears to modulate immune activity, declining estrogen production with age can set off a chain reaction leading to increased inflammation.

An overactive immune system, on the other hand, blamed for conditions such as asthma and eczema, is reacting to normally harmless substances in the environment. Called allergens, these include dust, mold, pollen and certain foods.

What is shared by both abnormalities is the suspicion of a genetic component— a susceptibility or vulnerability that makes some people more likely to develop the conditions, often in response to a virus or something in the environment. The propensity can run in families: My friend’s other daughter has a gene strongly correlated with ankylosing spondylitis, a kind of arthritis that can cause inflammation of the spine, discovered when she had backaches during adolescence. In addition, people with one AD are more likely to be diagnosed with another.

Autoimmunity is present to some extent in everyone. According to one theory, low-level autoimmunity may help the body clear away unnecessary or used-up cells. Another role might be to create a rapid response in the early stages of infection, preparing the immune system to fight during the period before enough foreign antigens are present to stimulate a systemic immune reaction. Finally, LDL cholesterol particles that lodge in the lining of an artery can over time trigger low-level inflammation, which eventually causes blood clots that block the artery.

Inflammation is part of the body’s healthy response to outside invaders like infections but at a persistent, low level may contribute to everything from depression to Alzheimer’s disease. Treatment for autoimmune diseases requires reducing immune activity without damping it down too much, which would leave the body unprotected. Until recently, AD treatments—steroids, chemotherapy and immunosuppressants—have been blunt instruments, but newer remedies in the pipeline target the specific malfunctioning parts of the immune system: for example, monoclonal antibodies used to treat rheumatoid arthritis.

ADs are rare in geographic areas where infectious diseases are endemic, possibly because infectious agents such as parasites lower their victims’ immune response in the process of reproducing and spreading infection. The “hygiene hypothesis,” though unproven, posits that the human immune system is designed to respond to certain levels of infection and over-reacts when that level isn’t reached. Another possible explanation is the weakening of the gut microbiome in individuals who take antibiotics or in the presence of absence of certain foods, such as gluten.

Conversely, certain chemical agents and drugs are associated with increased risk of ADs: Cigarette smoking is a major risk factor for the incidence and severity of rheumatoid arthritis.

The NIH estimates that 23.4 million Americans, or as much as 8% of the U.S. population, suffer from autoimmune diseases; while the American Autoimmune and Related Diseases Association puts the number as high as 50 million and counts many more ADs than the NIH. By all counts, the U.S. appears to have the highest prevalence of ADs in the world.

—Mary Carpenter

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THIS YEAR’S FLU season is looking a lot milder than 2014-15. So far, flu-related outpatient visits — one measure of a season’s severity — has remained under 2.5% of the U.S. population, compared to last year when they peaked in late December at around 6%. The reason: in 2014-2015, most of the flu vaccines did not include an especially virulent strain that appeared just weeks after the strains were selected for that year’s vaccine.

Flu vaccines in general work best in healthy young adults and older children. A higher dose shot is recommended for those ages 65 and older because an individual’s immune response to vaccines declines with age, producing up to 75% fewer antibodies than in younger adults, according to one study.

The “Fluzone High-Dose” vaccine has four times the standard dose of antigen, which stimulates the body’s production of flu-fighting antibodies. Although one study showed the high-dose vaccine to be almost 25% more effective in preventing flu in adults over 65, the CDC has not yet published a preference for any flu vaccine for this age group.

The CDC recommends a flu shot for everyone six months of age and older. The vaccine is often available by the end of the summer, and people are advised to get it by October or soon afterwards, because it can take up to two weeks to produce sufficient flu-fighting antibodies. Even when the vaccine fails to target a prevalent strain, it protects against the other two or three which might be circulating and usually comes close enough to lessen the severity of infection in those who get the missing strain.

The biggest challenge in creating the flu vaccine each year is prediction. To allow enough time to produce more than 170 million doses for the U.S. market, the WHO and CDC must decide in February of the preceding year which strains of both the A and B influenza virus will prevail the following fall. The problem is this “production lag,” Dr. Arnold Mondo, a flu expert at the University of Michigan told the L.A. Times.

When prediction is close, the flu vaccine can reach 70% efficiency. The vaccine for 2014-2015 was estimated to be around 50% effective, according to Dr. Joseph Bresee of the CDC. Flu vaccines usually include two strains of influenza A — H1N1 and H3N2 —along with one or two strains of influenza B. In 2014, the strain of H3N2 chosen for the Northern Hemisphere was “Texas,” while the strain “Switzerland” was chosen for the Southern Hemisphere. But Switzerland showed up in the north in March, too late to add it to that year’s vaccine. (Unusually, in 2009-2010, during the H1N1 pandemic (originally referred to as swine flu), people were advised to get an additional vaccination against H1N1 along with the flu vaccine of the season.)

By September of 2014, the prevalence of this mutated Switzerland strain had increased exponentially. And by the time the Northern flu season was in full swing that fall, some 80% of the H3N2 viruses had mutated or “drifted” to the Switzerland strain. The prevalence of H3N2 strains often leads to more severe flu illnesses, hospitalizations and deaths. In addition, the 2014-2015 flu season lasted 20 weeks compared to the average of 13 weeks in the previous 13 flu seasons.

In that 2014-2015 season, 322 out of 100,000 people were hospitalized for flu compared to the previous average of 183 out of 100,000 people. Even in 2007-2008 when the strain of H3N2 was also a “drift variant,” the effectiveness was higher than it was for 2014-2015.

Flu vaccines are available in several forms, with some more highly recommended for specific ages. The traditional vaccine uses “inactivated” viruses — using virus particles grown in the lab and then killed. It is given “intramuscularly” and can include three or four strains — called “trivalent” with three strains, or “quadrivalent” with four. For people who dislike shots, the intradermal vaccine uses a needle 90% smaller than typical vaccination needles, which barely penetrates the surface of the skin and uses 40% less antigen than regular shots.

Nasal spray vaccines, approved for ages 2 through 49 and all quadrivalent, can be more effective because they contain live virus that has been weakened or attenuated. Because these viruses are alive, they can replicate, albeit harmlessly, in the body to create an immune response. Last comes the jet injector, recommended for ages 18 to 64, which uses a high-pressure, narrow stream of fluid instead of a needle to deliver a trivalent vaccine. Developed in the 1960s, it has been used previously in mass inoculations, for example, against smallpox and for military personnel.

The flu vaccine can have side-effects including mild fever and soreness at the site of the injection. A very rare but crippling side-effect is Guillain-Barre Syndrome, which can cause paralysis lasting months or longer.

For the future, flu experts are working on a universal vaccine made using live virus that is collected in the upper respiratory system of from people infected with the flu and then attenuated to prevent it from infecting the lungs. This vaccine would use a newly discovered class of “universal” antibodies found to be as effective as those that are strain-specific and would protect against all strains of flu, even when the virus mutates, according to Matthew Miller, senior author of the study at McMaster’s University in Ontario.

— Mary Carpenter

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One of my most in-shape friends recently began worrying about “pooling fat.” It turns out this fat, also called “belly fat” and “central obesity,” can be a cause for concern. Normal-weight adults with a normal body mass index (BMI) — the ratio of a person’s weight to their height — but an abnormally large waist might be at higher risk of death from cardiovascular disease than those with a high BMI.

“Waist size matters, particularly in people who are a normal weight,” Francisco Lopez-Jimenez, of the Mayo Clinic and senior author on a study analyzing data on more than 15,000 adults over a period of 14 years, told the Washington Post. The study focused on people’s waist-to-hip ratio: a waist measuring larger than the hips reflects excess fat storage around the middle. Central obesity is also defined clinically as a waistline of more than 35 inches in women and more than 40 inches in men, according to the Centers for Disease Control and Prevention.

During the study period, men with “normal-weight central obesity” had twice the mortality risk of men rated overweight or obese by BMI, and had 78% higher risk of death from cardiovascular disease than men with a similar BMI but no central fat. For normal-weight women with belly fat, the risk of death was 32% more than that for obese women without excess pounds around the middle; and central obesity more than doubled their risk of death from heart disease. “We need to talk about waist loss and not weight loss,” Paul Poirier of the Quebec Heart and Lung Institute commented on the study in an email to the Post.

Fifty-four percent of U.S. adults now have central obesity — compared to 46% in 1999-2000 — a body type known as apple-shaped, because the abdomen protrudes in a “pot” or “beer” belly; the alternative kind of fat creates a pear shape, with fat accumulating around the hips and butt. Belly fat consists of deep or visceral fat pooling around the abdominal organs, in contrast to the fat beneath the skin, and can promote inflammation throughout the body, increasing the risk for heart disease, diabetes, stroke and colon cancer.

Although the cause of belly fat is not clear, there is some evidence that low-carbohydrate diets help combat it. On the other hand, a study of people age 65 and older who drank two or more diet sodas a day had waist-size increases six times greater than non-drinkers — about 3.2 inches compared with .8 inches — while people who drank an occasional diet soda gained about 1.8 inches. Belly fat-gain was most pronounced in people who were already overweight.

Artificial sweeteners may behave just like sugar in the body, provoking spikes in insulin levels and shifting the body from burning fat to storing it. Or they may alter gut bacteria, making the body more vulnerable to insulin resistance and glucose intolerance, which can lead to weight gain. Snacking also appears to contribute to abdominal fat — maybe because mid-morning snackers tend to eat more throughout the day than others.
Avoiding snacks is one of “10 daily habits that blast belly fat” as described in the “Zero Belly Diet,” by David Zinczenko. The book also recommends dark chocolate to help shrink abdominal fat, because of the flavonoids, which can fight inflammation. The chocolate must be at least 70% cacao, and not “alkalized.”

As for exercise to pare down belly fat, aerobic exercise seems to work better than interval training. In one study comparing the two kinds of exercise, done three days a week over a 12-week period, those who performed interval training on an exercise bike for 24 minutes each time actually gained .7 percent abdominal fat, while those on the same diet doing 45 minutes of continuous moderate cycling lost nearly 3 percent.

Sedentary women who began moderate exercise twice a week lost about 2% of their total body fat but 10% of the visceral fat, according to a study at the University of Alabama at Birmingham. According to one review, programs combining aerobic exercise with occasional weight training worked better to reduce belly fat than either type of exercise alone. But University of Alabama’s Dr. Gary Hunter warns against one exercise that will not affect the waistline: the situp. “You’re better off going for a walk,” says Hunter.

—Mary Carpenter

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PERSONAL DNA PROFILES can reveal how much salt or coffee your body can handle, which foods your body might need more or less of for better health, and what kind of diet and/or exercise might work the best for losing weight. Using what’s called nutrigenetics – combining genetics and nutritional science – you can also assess personal gene-based food preferences and sensitivities to defend against those friendly food-police who keep pointing out what you should and should not eat.

In early 2015, President Obama announced the creation of a $130 million national database for some one million Americans, with genetic profiles, medical history and other data, from which algorithms could eventually create personalized meal plans. Meanwhile, genetic analysis along with lengthy diet and exercise recommendations can be yours with a mere cheek swab — but the price tag can be high, and skeptics contend that common sense is still the best approach to healthy diet and effective weight loss.

Gluten is the obvious example of gene-based food sensitivity: for people with a gene variant that makes them susceptible to celiac disease, eating gluten can lead to expression of that gene, setting off inflammation throughout the body and a host of health problems. (Besides the 1% of Americans who have genetically based celiac disease, an additional 6% believe they have “non-celiac gluten sensitivity.”)

In addition, processed meat can influence the expression of a genetic variant linked to increased risk of developing colon cancer. Reviewing records of some 20,000 people in four countries – the U.S., Canada, Australia and Germany — about half of whom had colon cancer, researchers at the World Health Organization looked at both genetic differences and at how much processed meat they ate. For the 47% of individuals with one genetic variant, eating more processed meat was associated with greater risk of colon cancer – although the odds may be different in different populations.

Genetic profiling also helps explain why nutrition studies often produce conflicting results. Coffee, for example, is metabolized quickly by about half the population — for whom the four cup limit is set; but for “slow-metabolizers,” drinking more than two cups a day can increase the risk of heart attack.

And, while the Mediterranean diet is generally the healthiest, its levels of salt – in olives, salted nuts, etc. — might be too high for those with the genetic variant that increases sensitivity to salt, according to the Genetic Literacy Project. For these individuals, consuming the same amount of salt is more likely to raise blood pressure to levels considered unhealthy and linked to heart disease.

Conversely, diet recommendations are better adhered to when based on genetic profiles, according to researchers at the University of Toronto. Healthy volunteers divided into two groups received recommendations on salt, caffeine, sugar and vitamin C consumption; but only one group received individual genetic profiles related to these ingredients. That group did better following the salt recommendations, but results weren’t clear for the other foods, because most volunteers were already following healthy guidelines for these.

Italian researchers conducting genome-association studies on more than 4,000 people from Italy and other countries found 17 independent genes that appeared to influence tastes for foods including coffee, artichokes, bacon, broccoli, chicory, dark chocolate, blue cheese, ice cream, liver, orange juice, plain yogurt, white wine, mushrooms and oil or butter on bread. And “none of these genes belonged to genetic categories associated with receptors for the senses of taste or smell,” according to University of Trieste researcher Nicola Piratsu.

In addition to these 17 gene variants, 19 more have been linked to metabolism. In one Italian study of 191 obese study participants, the group of 87 put on a diet customized to their genetic variants for metabolism and taste – accommodating, for example, for liking the taste of fats — lost 33% more weight than those in the control group at the end of two years. Piratsu confessed to being skeptical at first that there would be any difference: “It’s like having two cars which start at the same point and they move in directions which differ for only a degree. At first they will look as though they are parallel, but after 10 km they will actually be far apart.” Piratsu added: “One of the main contributions [to the customized diets’ success] will be in making the diets more pleasurable and thus more acceptable.”

With the understanding that some people are more likely to lower their weight on a low-fat diet, while others do better on low carbs, experts are beginning to rally to the idea of “eating to your genotype.” In a study of 101 obese and overweight women at Stanford University placed on one of four diets, those on a diet matched to their genetic makeup lost 5.3% of their body weight, twice as much as the control group who lost only 2.3%. In addition, those individuals following the lowest-carbohydrate Atkins diet and those following the lowest-fat Ornish diet based on their genetic profiles lost 6.8% of their body weight, compared to 1.4% for those following these diets not matched to their genotype.
Among an array of companies offering genetic profiles, the UK-based DNAFit examines 45 gene variants that reflect the body’s capacity to respond to nutrition and exercise. And Nutrigenomix will create diet and exercise recommendations based on analysis of seven genes that indicate sensitivity to vitamin C, folate, glycemic index, omega-3 fat, saturated fat, salt and caffeine.

The Nordiska system, developed by Newcastle-based myGenomics, provides diet and exercise advice based on eight genetic variants; in trials of more than 7,000 people, the average weight loss was 11 pounds over four months. A British writer for Men’s Health who tried the system (whose name, oddly, is not on the article) was disappointed to find that Nordiska matched you to only one of four nutritional types: “GI smart”— a diet designed to avoid spiking blood sugar; “Carb smart” — a diet limiting carbs to 40% of food; “fat smart” — a low-fat diet; and “balanced” — prescribed a diet that combines the other three. The writer was also disappointed to be placed in group four, which, he said, led to a “predictable combination” diet. Although, with the Nordiska recommendations for diet and exercise, he lost about 12 pounds in one month.

The roles of inheritance and experience on food-related genes, however, can be complicated. Individuals called “supertasters” inherit more taste buds and receptor cells than others, leading them to use more salt than others to block bitter tastes and to avoid strong flavors, especially sugary deserts. And one gene variant influences how much an individual can detect bitter tastes, causing some people to have a strong dislike of broccoli and other cruciferous vegetables. Finally, the more salt we use on our food, the more we crave it.

“What these tests really measure are what people are currently eating,” according to Catherine Collins of the British Dietetic Association, who is skeptical about the usefulness of expensive genetic profiling. “If you are eating a lot of fat, it will lead to the over-expression of certain genes…but you don’t need these tests to tell you that.”

— Mary Carpenter

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SEATED AROUND a table in an intimate conference room at Sibley Hospital in Northwest Washington, about 30 women, ranging in age from our 40s to our 70s, were smiling a little nervously at one another but generally not making eye contact. The reason? Probably because we had all come to hear about something extremely personal and vaguely embarrassing: vaginal rejuvenation using a technique called MonaLisa Touch from two ob-gyns, Dr. Marilyn Jerome and Dr. Sharon Malone, at Foxhall Ob-Gyn Associates, the first practice to offer the treatment in D.C.

We would also soon be hearing serious discussion of vibrators and dilators—things that many people label “sex toys.”

Among the attendees was Barbara A., a 59-year-old D.C.-based psychotherapist who had the MonaLisa treatment after more than 10 years of trying “everything” to cope with pain during sex, from estrogen creams to different lubricant creams and jellies—as well as hormone replacement therapy, which she still takes.

“Nothing worked,” Barbara A. said, speaking very openly to the group. “Intercourse was incredibly painful, I had a grimace on my face, and I had frequent UTIs [urinary tract infections].” Her relationship suffered, she said: “When sex is so uncomfortable, you’re not up for it, and your partner feels badly. It does put a damper on your sex life.”

The reason she was speaking to the group is that MonaLisa Touch appears to work wonders for women who experience discomfort during sexual intercourse.

Called dyspareunia, discomfort during sexual intercourse is caused by decreased blood flow as well as thinning and stretching of the vaginal walls, as a result of hormonal changes, usually following menopause, as well as after vaginal deliveries. Its proponents say MonaLisa Touch can also help with bladder issues, including frequent infections (UTIs), urgency, nocturia (the need to urinate during the night) and incontinence. These problems are created because the bladder is located next to the vagina and depends on it for support. When the vagina weakens, the bladder can suffer.

The treatment involves five-minute applications, usually performed in a series of three applications six weeks apart, using a laser similar to that used for facial skin rejuvenation. An additional single treatment is recommended yearly or so as needed if problems return.

During the MonaLisa treatment, Barbara A. said, she “felt nothing except being in stirrups and a very light vibration.” After the second treatment, she experienced “a noticeable difference” in her comfort level during intercourse and, after the third, “an enormous difference.” Also, she said, she has had no UTIs since beginning the treatment. (She is happy to speak by phone with anyone interested in discussing her experience: Barbara at 301-455-3185.)

Speaking for Foxhall Ob-Gyn, Dr. Marilyn Jerome said, “For years we had nothing to offer [for sexual discomfort] except vaginal estrogen, along with lubricants and systemic hormone replacement.” But creams and lubricants work for only about 20 to 25 percent of patients. And systemic hormone replacement provides “a lot of hormones just for the vagina,” Dr. Jerome pointed out; and there are many who shouldn’t take or don’t want estrogen.

At first, Dr. Jerome said, she was skeptical about MonaLisa Touch. Then, she said, she looked closely at the research coming out of Italy, where it’s been used since 2012, and was “very impressed” by the reported changes in vaginal tissue after treatment. Dr. Jerome was also reassured that this carbon dioxide laser has been tested over 20 years for facial rejuvenation with no scarring, no side effects, she said. She continued to question medical personnel experienced with the laser, always asking, What can go wrong? The answer, repeatedly: nothing. Foxhall Ob-Gyn has been offering the treatment since the end of October 2015.

About the size of a fat pencil, the laser probe is inserted into the vagina—with a topical anesthetic if requested—where it emits light energy that penetrates the vaginal wall at specific depths as the probe is rotated and withdrawn. The light energy causes a little damage to the cells, Dr. Jerome explained, which triggers a wound-healing process that increases blood flow and causes remodeling of the connective tissue. Afterward, she said, “The tissue looks like it did pre-menopause. The quality of life and self-esteem improve;  the numbers are very good.”

She hears comments like: “I saw results almost immediately,” “I am 90 percent better,” and “intimacy has improved.” While the treatment ($2,100 for all three sessions, or $800 for one treatment or for the annual touch-up) is generally not yet covered by insurance, Dr. Jerome suggested people communicate with their insurers in the hope that, with enough pressure, their positions will change.

Dr. Sharon Malone began her part of the presentation by discussing the libidinal differences between men and women. After menopause, she explained, a woman’s desire decreases faster than her ability—while for men the issue is ability. Viagra improves ability, which is why men today have more interest in intercourse, and why vaginal rejuvenation has become more of an issue.

For women, libido is more complicated, she explained, involving the quality of the relationship, the presence of kids in the house, stress and “mood killers” such as hot flashes in the bedroom. So when sex becomes uncomfortable, women desire sex less often, and then soreness increases. “MonaLisa removes that component,” the problems with physical sensation, Dr. Malone said.

Speaking about libido, Barbara A. noted, “Mine is up because I know I won’t be in pain. You connect better.”

Dr. Malone cautioned that, “If you are not having sex, it’s important to remain sexually active.” The No. 1 tool is lubricant. She demonstrated several options, including Pure Romance Just Like Me and [G] Female Stimulating Gel. 

Finally, Dr. Malone brought out tiny vibrators that look like tuning forks and that can be charged using a USB port. The vibrator, called “Duet,” is designed to be used alone or during intercourse, said Malone: “Everyone will enjoy it.” The “Duet” is offered in either the regular model for about $149 or the Deluxe starting at $349 online.

Dr. Malone also mentioned the drug Addyi, recently approved by the FDA. “It’s supposed to increase desire,” said Dr. Malone, “but the results are underwhelming. And it’s not for post-menopausal women, who would [actually] need it.” In the three months since approval, not one of Foxhall’s patients has asked for it, she said.

But they are asking for the MonaLisa. Before Foxhall Ob-Gyn began offering it, one 80-year-old patient called every week to ask when they would begin. By the end of October, there were 200 machines in the U.S., said Dr. Jerome. Locally, she believes that others, including at least one urologist, are beginning to offer it. There’s no hurry and no age limit, said Dr. Jerome. “You get it when you need it. If you have no problems, don’t get it.”

From the looks on faces around the table and the eager questions, the evening’s participants appeared ready.

–Mary Carpenter
Mary Carpenter is the Well-Being Editor of MyLittleBird.
Read more about Mary.

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POTENTIAL HEALTH benefits aside, I have always loved our cats — from rescues with their darling kittens, to my favorite Maine coon who needed a little too much grooming, and now back to rescues.

So I understand the allure of spending a sociable hour at Crumbs and Whiskers, Georgetown’s cat-visiting cafe for $15, or of taking their cat yoga class. But a holiday-only “kitten delivery” service, including a basket of kittens and a “sleeve” of macaroons for 30 minutes, seemed excessive at $99 – until it sold out in two hours. “We are thinking of doing it again in the future,”  Ambassador of Human Feline Relations Ashley Brooks assured mylittlebird by email.

Because cats are “tough to manage in the laboratory,” according to Julia Calderone in Scientific American Mind, there’s scant evidence of their effects on human health. “The second you take a cat out of its own home, it becomes nervous,” explains University of Edinburgh psychologist Marieke Gartner.

But results on both dogs and cats come from a California lab focused on the study of oxytocin. Dubbed the “moral molecule” by Claremont University economist Paul Zak, oxytocin “motivates us to treat others with care and compassion.” Dozens of studies in his lab show that “the brain produces [oxytocin] when someone treats us with kindness,” Zak wrote in The Atlantic.

Oxytocin levels can shoot up to 100% when your child runs to hug you, or to 5 or 10% when a stranger shakes your hand, unless the stranger is very attractive, Zak explained. But when 100 participants in his lab played with a dog or cat for 15 minutes, “neither species consistently increased oxytocin in humans,” Zak wrote. And oxytocin increased for only 30% of participants.

What best predicted an oxytocin rise after interacting with a dog was the lifetime number of pets the participant had owned. With a cat, the opposite effect was true: “greater lifetime pet ownership caused oxytocin to fall,” wrote Zak. With dogs, previously owning pets “seems to have trained our brains to bond with them.” Dogs also reduced stress hormones better than cats, which “may tell us why people who own dogs are judged as more trustworthy than those who don’t,” Zak said.

Rebecca Johnson, a nurse and human/animal interaction researcher at the University of Missouri, suggests that oxytocin “helps us feel happy and trusting [and thus] may be one of the ways that humans bond with their animals over time.” Johnson told NPR that she believes that oxytocin may also improve the body’s “readiness to heal and to grow new cells.”

Dogs help improve cardiovascular health, according to one NIH-funded study of 421 adult who had suffered heart attacks. And among 240 married couples, pet owners had lower heart rates and blood pressure, and appeared to have “milder responses and quicker recovery from stress when they were with their pets than with a spouse or friend,” according to NIH News in Health.

Pets can also reduce blood pressure and boost productivity, according to two related experiments published in 2012. Among participants asked to come up with a list of goals and assess their confidence in attaining them, those who had their pet either in the room or on their mind identified more goals and felt more self-confident about them than did the control group with no pets, Tori Rodriguez writes in Scientific American Mind. The pet groups also had lower blood pressure while performing a distressing cognitive task.

A study of 16 women at Mass General Hospital compared brain functioning while participants viewed photos of their own child to those while viewing their own dog. Brain areas deemed important for functions such as emotion, reward and social interaction all showed increased activity for both photos. But while one region was activated only in response to the child photos, the fusiform gyrus — involved in facial recognition and other visual processing — showed greater response to own-dog images than to those of the child.

More formalized “animal-assisted therapy” (AAT) is offered increasingly in hospitals and nursing homes. DC’s Children’s National Medical Center has had a “Therapeutic Pups” program since 2010 when the director of the outpatient Eating Disorders Clinic began using a dog in therapy with adolescents. At the Mayo Clinic, which uses AAT for a range of issues from children having dental procedures to vets with PTSD, the therapy has “significantly reduced pain, anxiety, depression and fatigue,” according to the clinic’s Consumer Health report.

Several meta-analyses, which pull together existing studies, however, have found flaws in much of the AAT research, mostly due to an inability to “separate the feel-good temporary recreational benefits… from long-term clinical effects”, according to Alan Beck, director of Purdue University’s Center for the Human-Animal Bond. But more recent, stricter research has established positive effects on children with autism spectrum disorder (ASD) when interacting with other people in the presence of animals, two guinea pigs.

“Psychiatric service” animals, usually dogs, are also used for children with ASD. For people with an emotional or psychiatric disability severe enough to substantially limit their ability to perform at least one major life task, the dogs are individually trained to provide a surprising list of services, including “deep pressure therapy to minimize the severity and duration of anxiety or panic attacks” and assisting with “night terrors” by waking the handler or a family member, according to the PleaseDontPetMe site. (Service animals are legally permitted to go anywhere a person normally goes, including airplanes and no-pet housing. At a lower level of disability, “emotional support” animals are also prescribed but not entitled to all the same rights as a service animal.)

For anyone else who owns a dog and wishes to increase the social benefits of their pet, there’s Twindog, an app launched in early 2015 for iOs and Android. Twindog works like Tinder: you sign up with a profile and a photo — of your dog — and then swipe right to “like” other profiles or left to ignore. When you find a match — a dog match — you can move forward by sharing more photos and scheduling to meet: owners included.

— Mary Carpenter
Mary Carpenter is the Well-Being Editor of MyLittleBird.
Read more about Mary. 

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ANY SUFFERING from pain (see Pain-Brain Connection)—acute or chronic—can be compounded by an inability to convince medical personnel how much it really hurts. Now research has found that an individual’s genes help determine how intensely they respond to pain—as well as how their body metabolizes different pain relief medications. Eventually genetic testing could provide information about an individual’s pain tolerance level as a supplement to their subjective descriptions of pain.

Individual responses to pain depend on an interaction of environmental and innate factors. Race and ethnicity make a difference (African Americans and non-Caucasian Hispanics report more pain than Caucasians) as does gender, with women typically reporting more pain than men. But mice studies have suggested that up to 76 percent of the variance in pain response could be due to genetic differences, according to the Journal of Medical Genetics.

A recent study of more than 2,700 people, who were all experiencing chronic pain serious enough to be prescribed opioid drugs, found different genes more prevalent in each of three groups. Compared to people with high pain perception (who rated their pain seven to 10 on a 10-point scale), one gene was 33 percent more prevalent among those who rated their pain as low (one to three on the scale). Two other genes were more prevalent among those who rated their pain as moderate (four to six). And among those “high-perceivers,” a fourth gene was 25 percent more common compared to those with moderate pain. The research was presented by Tobore Onojjighofia at Proove Biosciences at the 2014 American Academy of Neurology meeting.

Approximately one-third of the U.S. population—about 100 million people—suffers from chronic pain, defined as the perception of pain persisting for longer than three to six months. But a clinically acceptable response to treatment is currently only 30 percent pain reduction, which many physicians agree is unacceptable. Also, some 70 percent of those with chronic pain, despite taking pain medication, continue to experience “breakthrough” pain flares.

Currently the process of finding the best opioid for an individual patient is based on trial and error because of the fine line between pain relief and toxicity. More than 2.2 billion “adverse drug effects” occur annually, with 100,000 cases resulting in death. (Genetic testing could also provide information to help with the selection of antidepressants.)

Although still not widespread, “pharmacogenetics testing” is already being used by physicians to get patients onto safer and more effective medications, Lynn Webster, Salt Lake City pain specialist and past president of the American Academy of Pain Medicine, told a panel of pain experts assembled last January by Pain Medicine News.

Several existing genetic tests include “Pain Medication DNA Insight,” offered by Pathway Genomics Corporation in San Diego, Calif.; and “Genetic Testing for Personalized Pain Management” by AI Biotech in Richmond, Va. The AI Biotech site states “prescribers can now personalize drug therapy by identifying patients’ drug metabolizing phenotypes for improved efficacy and reduced adverse drug effects.”

Genetic testing will have two major clinical impacts, Luda Diatchenko of McGill University told the panel. First, to help patients who are deciding whether to have elective surgery— because those undergoing even minimally invasive surgery have up to a 50 percent chance of developing chronic pain that lasts more than six months. Second is the “strong potential for clinical classification of chronic pain patients” that can help with drug treatment choice.

As for predicting the risk of addiction, Dr. Webster believes that more data and large trials are needed. But another panel member, Anita Gupta, associate anesthesiology professor at Drexel University, cited “emerging clinical research” that suggests this will be possible “in the near future.”

Dr. Webster ended the panel with the hope “that clinicians will routinely have … evidence-based genetic information to guide individualized care…. Pharmacogenetic testing should inform clinicians about the best treatment options with the least adverse-effect probability.”

Until genetic testing is more widely available, however, people can improve the way they report pain. “I ask people to remember the worst pain they’ve ever experienced in their lives,” says Seddon Savage, incoming president of the American Pain Society. “That level of pain becomes the benchmark to which we compare the current pain.”

Savage also suggests evaluating pain over a period of a week, and then assigning a number to the pain at its most severe, least severe and most typical level. In addition, she says, “Your doctor needs to know not just how much the pain hurts, but how the pain hurts.” Tissue injury, like a back injured while shoveling snow, is usually a dull ache; nerve pain, which has many causes, is often described as shooting, buzzing or burning.

Descriptive “pain scales” can be taken to the doctor to help pinpoint where your pain falls. One, created by Karen Lee Richards for ChronicPainConnection, divides the 10 pain levels into three sections with specific criteria described for each: “mild” ranges from barely noticeable (one) to distracting but you can adapt (three); “moderate” ranges from distracting (four) to interfering with daily activities (six); and “severe” ranges from limiting daily activities (seven) to “crying out and/or moaning uncontrollably” (nine). Ten is “unspeakable,” but “very few people will ever experience this level,” Richards says.

I try to imagine how these possibilities might have affected my only visit to the ER for pain at the crying-out-and-moaning level: Would things have gone better with Richards’s scale on hand or a genetic test defining me as a low-perceiver? I suspect that depends on the medical personnel. By the time I saw a doctor, her only question to me was: Could you be depressed? No, but I was furious. Fortunately, I’d already begun treatment for Lyme Disease and, over the following weeks, the pain slowly subsided.

—Mary Carpenter

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PEOPLE SUFFERING FROM depression often struggle more over the holidays. If you’ve ever known someone with intractable depression or who has considered trying to commit suicide, you will understand the enthusiasm for a drug that can reduce this suffering and risk almost instantaneously –-compared to traditional anti-depressants, which can take up to eight weeks to work.

Ketamine is most commonly known as a horse tranquilizer or club drug, but few are aware of its near-miraculous potential for combating depression. Dr. Thomas Insel, past director of the National Institute of Mental Health (NIMH), called ketamine “the most important breakthrough in antidepressant treatment in decades.”

“We need suicide treatments so greatly in psychiatry,” NIMH researcher Elizabeth Ballard told WebMD. That ketamine reduces suicidal thoughts, independent of its effect on depression or anxiety, is important, said Ballard, because not all suicides can be traced to depression: some are related to post-traumatic stress disorder, borderline personality disorder or substance dependence. Ketamine offers the possibility of preventing suicide long enough for a person to get more in-depth treatment by providing a critical “window of relief,” according to the WebMD article.

The same “window of relief” can be important for depressive patients, even when long-term use isn’t possible because of ketamine’s side effects. Every year, some 14 million Americans have major depression; of those who seek treatment, up to 40 percent will not fully recover with standard antidepressants. Living with severe depression over time can cause irreversible damage to the cardiovascular system when fluctuating serotonin levels cause high levels of adrenaline to surge through the blood vessels.

In addition, depression appears to shrink the size of the hippocampus – involved in forming and storing long-term memories — based on worldwide studies of more than 1,700 people with major depression. In 65 percent of these, the hippocampus size was reduced, with more depressive episodes causing greater reduction in size.

Months or even mere days on the drug can offer such relief that patients break through “negative behaviors and thought loops that were previously inescapable,” according to the NIH-affiliated Ketamine Advocacy Network, which provides information on the drug along with a list of physicians and clinics offering ketamine treatment. (There appear to be none in the DMV, but a clinic is rumored to be opening in Towson in 2016.) Physicians most likely to provide ketamine treatments are anesthesiologists and pain management specialists or “pdocs.”

Ketamine belongs to a class of drugs known as dissociative anesthetics that includes phencyclidine (PCP) and nitrous oxide (laughing gas). These drugs can make a person feel detached from their surroundings and even immobilized, similar to the effect of heroin, and can cause hallucinations. Ketamine wears off in around an hour, but its use can lead to increased tolerance and addiction. Recreationally known as “special K,” ketamine has many risks, especially if mixed with alcohol, that include over-sedation and death; and it has been used as a date rape drug. Its rate of use is around .2 percent among ages 18 to 25.

For medical use, ketamine is usually given by injection in doses close to .1 gram — compared to quantities as high as one gram or more, usually snorted, for recreational use. Effects peak around one minute after injection. In a University of Oxford study, 28 treatment-resistant depressive patients received either three or six infusions of 80 milligrams (.12 grams) each over a three-week period. For one third of these, depression scores decreased by half by the third day after the last infusion, with benefits lasting between 25 days and eight months.

“Patients talked about how ‘the flow of their thinking seems suddenly freer,’” said Dr. Rupert McShane, lead investigator of the Oxford study. “For some, even a brief experience…helps them to realize that they can get better and this gives hope.”

Ketamine’s mechanism of action – blocking the pathway of the neurotransmitter glutamate, which is involved in memory and cognition – can allow it to work for people not helped by commonly used antidepressants, which affect the serotonin and noradrenaline pathways. Ketamine appears to combat depression by strengthening synaptic connections between brain cells that have been impaired by depression and stress.

Ketamine’s medical safety has been documented in its use for more than 20 years to treat both acute and chronic pain, particularly pain related to nerve damage. In clinical settings, other drugs such as benzodiazepines are often given to reduce the psychotropic effects.

Ketamine doesn’t work well for everyone and, because it can have unpleasant if short-lived side effects, many in the scientific community caution that more long-term research is needed before making it widely available. In addition, because ketamine has been in use for so long, pharmaceutical companies are unable to hope for big dividends from developing the drug and have so far been unwilling to fund studies on long-term ketamine use for depression. Instead, the hunt is underway for drugs similar to ketamine but different enough to be patented.

The Ketamine Advocacy Network aims to “overcome these obstacles [by spreading] awareness and acceptance of this powerful new weapon against depression, bipolar and PTSD.”

–Mary Carpenter