Monday, 4 February 2019

Real-life healthy dinners (for real people with real busy lives)

Some called it the Katie Couric effect. Soon after her husband died of colon cancer in 1998, the journalist and television personality had a televised colonoscopy to promote the test. Rates of screening colonoscopies soared for at least a year. Or, call it the Angelina Jolie effect. In 2013, the actress wrote an editorial in the New York Times about the tests she had for genes (called BRCA) linked with breast and ovarian cancer, and how the positive result led her to have a double mastectomy. Soon after, rates of BRCA testing jumped.

Whatever you call it, the effect is real. When it comes to matters of health, celebrities can have an enormous impact.
It’s good when celebrities do good

The impulse to take a challenging or tragic medical experience and turn it into something that helps others is commendable. It may be easier to keep such matters private or avoid talking about them in public. But time and again, we see celebrities joining forces with health-promoting organizations, speaking out, and sharing their stories to help others avoid what they’ve experienced. Many have credited Katie Couric with removing the embarrassment associated with colonoscopy and showing how easy it is.
Is there a downside?

There are a number of ways celebrity pronouncements on matters of health can go wrong. For example, the information can be faulty or confusing. The forays of Jenny McCarthy (who claimed vaccines cause autism) and Gwyneth Paltrow (who recommended vaginal steams to “cleanse the uterus”) into matters of health and illness are examples of influence most doctors would consider unhelpful or even dangerous.

When I heard about Katie Couric’s colonoscopy, I thought it was brave and certainly a unique way to get her message across. But as well-intended as it may have been, she was 43 years old at the time. Since guidelines suggest people begin routine screening at age 50, I wondered if she was a good candidate for the test. Unless she had symptoms (such as intestinal bleeding), a strong family history of early colon cancer, or some other special circumstance that put her at higher than average risk for colon cancer, her colonoscopy could be considered unnecessary testing. And that could have led others to have unnecessary testing as well.

A recent study raises a similar concern about Angelina Jolie’s BRCA testing. It found that in the weeks after her editorial was published, testing increased by more than 60% (at an estimated cost of $13.5 million). However, mastectomy rates actually fell over the next two to six months, leading the authors to suggest that most of the additional women who had testing had negative results and therefore may have been poor candidates for testing in the first place. Of note, the study did not confirm whether those having the BRCA test had risk factors (especially a family history of early breast or ovarian cancer) that would make the test appropriate. Critics of the study have suggested that mastectomy rates within six months of testing is not an adequate measure of whether the tests were appropriate. Still, the point is worth considering. When a celebrity recommends a medical test or treatment, the audience is not limited to those who are most likely to benefit.
The bottom line

For any medical test or treatment, ask whether it’s likely to be helpful. The answer may be straightforward. For example, a well-studied and well-accepted screening test may be recommended based only on your age and gender. But in many cases, the answer may rely on a considerable amount of judgement based on how likely it is that you have a particular condition, the ability of the test to detect it, and the impact of the test result on treatment decisions. For example, if a person has knee pain that’s mild and well-controlled with exercises, it may make little sense to have an MRI, as the results are highly unlikely to affect treatment.

Every once in a while, I’ll have a terrible shift in the emergency department (ED) in which I have to pronounce yet another young person dead from an opioid overdose. I typically have to call their parents, who usually express sorrow but not surprise at the horrific news, as we all know how deadly opioid use disorder can be. But more frequently, the overdose patients I care for survive. Typically, they were found unresponsive by a friend or family member — 911 is called, the person is given the reversal agent naloxone, and is brought to the ED where my colleagues and I take over.
How naloxone works

Here’s the problem: Naloxone is, in many respects, a wonder drug. It inhibits the opioid receptor in the brain (so it blocks the effect of an opioid) and, if there is an opioid already present, naloxone can knock it off a receptor. So, if a person overdoses on an opioid such as heroin, the naloxone pushes the heroin away and blocks the receptor but does not activate it, so the person can recover from their overdose. However, since its time of action is fairly short — shorter than the effect of many of the opioids people use — we watch patients for a few hours in the ED until we’re sure the opioids have completely cleared their system. Basically, we want to make sure that they don’t overdose again. After they sober, we offer to have them speak to a social worker (most refuse), or provide a list of detox facilities, and then they quietly leave the ED.

This status quo bothers me. In particular, I’m concerned that although naloxone is now readily available — carried by police, firefighters, basic life support ambulances, and even bystanders —overdose deaths continue to climb. I want to talk frankly with the patient who overdoses and survives, and specifically let them know their risk of dying should they not get treatment. I also want to make the case that better treatment options after an overdose are needed.

Our group at Brigham and Women’s Hospital therefore conducted a study, recently presented at the American College of Emergency Physicians national meeting in Washington, DC. In this study, we aimed to define how many patients who were treated with naloxone by an ambulance crew and initially survived were still alive after one year. Even though these patients are typically just observed in the ED hallway, allowed to sober while the ED staff is busy taking care of other patients with life-threatening emergencies like heart attacks, trauma, and strokes, our team hypothesized that the individual sobering in the hallway bed has perhaps one of the highest one-year mortality rates of anyone seen in the department.
Here’s how the study worked — and what we found

To perform the study, we took advantage of a special project in Massachusetts called the “Chapter 55” legislation which, for the first time, linked many previously separate state databases. We connected the Emergency Medical Services (EMS) database with the all-payer claims database and death records database for our study. In brief, we evaluated patients who received naloxone by EMS over a 30-month period. We then looked at death records one year beyond the first time they received naloxone.

During the study period, there were 12,192 naloxone administrations by EMS, which equals over 400 per month. Of these, 6.5% of patients died that same day and 9.3% died within one year. Excluding those who died the same day, about 10% of the patients who initially survived were dead at one year. Even more significant was that 51.4% of those patients died within one month. Also, apart from those who died the same day, about 40% of those who died within one year died outside of the hospital, highlighting the danger of overdosing before medical personnel can reach the victim and the need for bystander naloxone.
What does this mean about preventing deaths from opioid use disorder?

These results are disheartening: an opioid overdose patient who sobers in the hallway, is offered a detox list, and then is discharged has a one-in-10 chance of being dead within a year. And the highest risk is within one month. Naloxone is an important tool in fighting the opioid crisis, but is no solution. Patients who survive opioid overdose should be considered extremely high-risk. I believe that as a society, we should talk seriously about the resources that are available for people who overdose. We should counsel these patients and offer them buprenorphine (a medication used to help treat opioid use disorder) directly from the ED, provide recovery coaches, and create easily accessible treatment sites where they can go for ongoing care.
At the end of a long workday, my husband and I will often trade texts figuring out who will pick up the kids at my mother’s, and who will deal with dinner. Thankfully, we’re equal partners in all responsibilities (except spider-killing, which is strictly Hubby’s job) and dietary preferences. We’re both health-conscious foodie types. We want good food that’s good for us.
An unvarnished look at family dinner

The kids, on the other hand… I’m not sure how this happened, but we somehow raised creatures with tastes vastly different from ours, and each other. We’ve never tried to cook an evening family meal that everyone would eat, because such a meal does not exist. Instead, we stock up on parent-approved kids’ faves that they can essentially get for themselves, or that can be prepared with minimal time and fuss, on a moment’s notice. And we try to all eat in the same room, at sort of the same time.

Do our kids eat as healthfully as we do, or we would like them to? No, but they eat healthfully enough, they’re developing well, and that’s fine. On a “good” night, their dinners may consist of: an apple with cinnamon/a yogurt/a bag of pea puffs for my five-year-old daughter, and scrambled eggs with cheddar/pita bread/a fresh peach for my seven-year-old son. On a “bad” night, it may be a warmed-up blueberry pancake with extra blueberries and extra butter for my daughter, and bacon (lots of bacon) for my son. This is entirely okay with us. As a matter of fact, it’s incredibly liberating to let go of the idea that we always need to eat exactly the same thing, and that it has to be perfectly healthy. After all, Hubby and I enjoy pizza and wings sometimes, too!
Here’s a practical approach to striking a balance

What matters is what we all eat most of the time, and most of the time, we’re eating a healthy combo of fruits and veggies (we eat mostly fruits and veggies, all week), lean protein, and healthy fats.

So, dinner.

Hubby and I rely heavily on frozen foods. Not pre-prepared, store-bought frozen meals, but rather frozen veggies galore, veggie burgers, and tofu “chik’n.” The pantry is stocked with quick-cooking quinoa and brown rice, canned and bottled accompaniments for different-themed meals (like Kalamata olives, sundried tomatoes, and hearts of palm for a Greek salad; sliced water chestnuts and baby corn for a stir-fry; salsa for a southwestern meal). We always keep various nuts and seeds on hand (cashews, almonds, pine nuts, pepitas, sesame and sunflower seeds, for example), as these can be added to a salad or stir-fry for extra healthy fiber/protein/fat. We make sure we’re always stocked up on condiments like sesame oil, soy sauce, ground ginger and cilantro, olive oil, various vinegars, broths, and wines for cooking. In the fridge, there’s almost always romaine lettuce, onions, peppers, lemons, limes, and cherry tomatoes (all of which last awhile and can be used in many types of recipes). And of course, tons and tons of fruit, yogurts, and cheeses of all kinds.

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