BREASTFEEDING: IT’S NOT JUST BABIES WHO BENEFIT
Our expert is Eleanor Bimla Schwarz, MD, Professor of Medicine, University of California, Davis. Dr. Schwarz has led multiple studies examining the impact of breastfeeding on the health of women.
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BREASTFEEDING BENEFITS FOR MOTHERS MAY EXCEED THE BENEFITS FOR THEIR BABIES
Doctors have long understood the benefits of breastfeeding for infants. Today, more and more people are recognizing the immense benefits of breastfeeding for mothers. To start with, breastfeeding significantly reduces a mother’s risks for both breast cancer and ovarian cancer. Lactogenesis suppresses estrogen and ovulation, an important factor in the growth of these cancers. A mother’s risk of breast cancer is reduced by 4% for every year she breastfeeds. Mothers who have ever breastfed reduce their risk of ovarian cancer by 25%. The beauty is that breastfeeding is something women can do to change their future risk of cancer. As opposed to mammograms, which allow early identification of cancer, breastfeeding offers women the option of actual prevention.
Mothers who breastfeed for as little as one month also reduce their risks of high blood pressure, diabetes, high cholesterol, and heart disease. These reductions in disease risk hold true regardless of the woman’s race, income, education, and other socioeconomic factors.
THINK OF PREGNANCY AS AN 18-MONTH EXPERIENCE
Milk requires a woman’s energy resources to produce it. As mammals, our bodies get ready to produce milk as soon as a baby starts to grow. Pregnancy, it turns out, is not just a 9-month experience, it’s more like an 18-month effort. When the body has prepared to lactate and doesn’t, the ingredients for milk-making, meant to be consumed by the infant, stick on the mother as belly fat. This visceral fat puts the mother at risk for diabetes, heart disease, and a host of other health problems. Mothers who never lactated typically end up with belly fat close to the size of a stick of butter. In contrast, mothers who breastfed have, on average, a 6-centimeter smaller waist circumference, and if they do accumulate fat, it’s less likely to end up as visceral fat. Mothers who breastfed are more likely to end up “pear shaped,” where fat accumulates below their waistlines, as opposed to the more dangerous “apple shaped,” with belly fat that is linked to diabetes and heart disease.
BREASTFEEDING INCREASES IQs OF CHILDREN
We know from MRI comparisons that the brains of children fed with human milk develop differently from children fed with cow’s milk. Children’s brain development requires special fats that are not found in cow’s milk. The long-term consequences of a lack of these fats for babies fed nonhuman milk include an average loss of seven points in IQ. This difference has been known for years, but many in the U.S. have assumed that this difference came about because mothers who were rich and well-educated were more likely to breastfeed. However, a recent Brazilian study that followed children to 30 years of age counters these thoughts. In Brazil, rich and educated women were not more likely to breastfeed; even so, breastfed babies had higher IQ, more educational achievement, and higher incomes at 30 years of age.
THE COSTS TO SOCIETY OF NOT BREASTFEEDING ARE ENORMOUS
The health data are staggeringly clear; when breastfeeding is interrupted, both mothers and babies suffer, and our communities are unnecessarily burdened with costly health problems. The tragedy is that despite this, only 8% of our nation’s hospitals are following evidence-based practices in supporting breastfeeding, allowing their recognition as a “baby-friendly” hospital. We need a national conversation about making it easier for mothers to breastfeed, including paid maternity leave, on-site day care, and access to evidence-based maternity care for all.
OVERACTIVE BLADDER AND URINARY INCONTINENCE
Our expert is Diane K. Newman, DNP, ANP-BC, FAAN, Adjunct Professor of Urology in Surgery, Co-Director, Penn Center for Continence and Pelvic Health, University of Pennsylvania Perelman School of Medicine.
Diane Newman discussed these issues and more at Women’s Health 2015: The 23rd Annual Congress in Washington, DC in April of this year. Astellas US, LLC. Sponsored her talk and also the breakfast that went with.
OVERACTIVE BLADDER AND INCONTINENCE ARE MAJOR PROBLEMS FOR WOMEN
Almost 31% of women between the ages of 42 and 50 and 38% of women over age 60 suffer from overactive bladder (OAB) and/or urinary incontinence (UI). These conditions, which often go together, are estimated to afflict as many as 33 million Americans and 200 million worldwide. More than two-thirds of the persons with these conditions are women. The total annual cost of providing care for persons with urinary incontinence in the US is estimated to be $28 billion. The inability to control urine is one of the most unpleasant and distressing problems from which a person can suffer, often causing isolation, depression, and physiological problems including skin breakdown and UTIs. Incontinence is a major reason for putting aging parents in nursing homes.
THESE CONDITIONS ARE UNDERREPORTED AND UNDERTREATED
One of the biggest obstacles to effective management of UI and OAB is the misperception that these conditions are inevitable and irreversible, a view almost as common among healthcare providers as patients. Therefore, most women do not report their UI problem to their health care providers. Embarrassment is another reason for not reporting the problem. Surveys on care-seeking behavior note that less than half of people with UI or OAB symptoms report them to primary care providers. Instead of seeking treatment, many individuals start self-care practices such as limiting trips outside the home, discontinuing exercise that triggers urine leakage, restricting fluids or they use menstrual pads to collect leaks. Underreported and undertreated OAB and UI leads to decreased quality of life in sufferers and financial burdens for both the patient and the healthcare industry
ASK YOUR PATIENT IF SHE HAS PROBLEMS WITH FREQUENCY OR URGENCY
It’s important to ask even before she brings it up because we know that a woman will typically wait years before asking for help. (Men, in contrast, typically ask for help after a couple of months with OAB.) The goal is to do something about the condition earlier, given that most patients with OAB or UI can be managed and effectively treated, especially if treatment starts in the initial stages. By the time a woman is 80, you probably can’t do much to cure her, although you can help with symptoms.
THINGS THAT MAY HELP
If a woman is overweight, losing weight is highly likely to improve her urinary symptoms.
Keeping a “voiding diary,” can also help her discover her triggers, such as caffeine, alcohol, or chocolate that might be causing symptoms, and it can help both you and her track the progress of her treatments. There are a number of .pdf voiding diaries available on the Internet, or she can download a voiding diary app at the iTunes store.
Encourage her to do Kegel exercises. Many studies show that these are particularly helpful with stress urinary incontinence, (SUI) the kind that happens when, for example, she coughs or during exercise. Her muscles may be weak, and it may take 4 to 6 weeks for her to notice greater bladder control and less leakage. Further, it may take 3 to 4 months to get the full benefit.
TIMED VOIDING CAN MAKE A MAJOR DIFFERENCE FOR A WOMAN WITH MIXED SYMPTOMS
If a patient complains of voiding every 30 minutes, ask her to wait 45 minutes before voiding. When she’s gotten used to 45 minutes, ask her to increase it to an hour. Ideally, by the end of treatment, she’ll be able to wait two to four hours to void.
While she’s waiting to void, instruct her to find something distracting, such as doing a couple of quick pelvic floor muscle contractions, or focusing on deep breathing. She’s likely to find that she can override the nerve message telling her that she has to void right now. It’s the same principle as when a nurse wants to pee but suddenly learns that a patient has fallen out of bed. The nurse will delay voiding in order to take care of her patient, even if it takes an hour or two. The messages from her bladder are overridden by the emergency situation.
Although timed voiding can be very effective, let her know that this is a process that takes months, not days. If someone is used to voiding every hour, an additional problem is that her bladder has adjusted to the size that holds an hour’s urine. It can gradually enlarge over time when forced to, but it’s a gradual process.
VULVODYNIA: WE DON’T HAVE A CURE, BUT WE CAN MANAGE IT
Our expert is Susan E. Hoffstetter, PhD, WHNP-BC, FAANP, Associate Professor, Division of Gynecologic Sub-Specialties, Section of Urogynecology, St. Louis University School of Medicine. Her sub-specialty is vulvar and vaginal disorders. She is Chair of the Board of Directors, Nurse Practitioners in Women’s Health and a Fellow in the International Group for Vulvovaginal Diseases.
If there is a medical topic you would like to see explored here, please let me know!
VULVODYNIA IS OFTEN UNDIAGNOSED OR MISDIAGNOSED
Vulvodynia is chronic vulvar nerve pain affecting the external female genital organs including the labia, clitoris, and vaginal opening. Women describe it as a burning or stinging sensation, or a feeling of rawness, or it can be a stabbing pain. Because it doesn’t have externally visible symptoms, and the physical exam can appear completely normal, vulvodynia is frequently either undiagnosed or misdiagnosed. In fact it’s only recently that we recognize it as a real pain syndrome. Too often women who experience this kind of pain in the vulvar area have been told that it was all in their heads, or they were instructed to take medications that didn’t help, such as medications for a yeast infection that they didn’t have.
WE DON’T UNDERSTAND THE ETIOLOGY OF VULVODYNIA YET
The risk factors for this condition are broad. They can include: allergens; early age of menarche; frequent use of vaginal medications (more than four treatments per year); coitus; physical, emotional, or sexual abuse; and adverse life effects such as divorce. Stress also plays an important role in vulvodynia, similar to the way headaches or GI tract problems can be made worse then there’s financial, work, or relationship stress.
WE CAN MANAGE IT, AND WE CAN IMPROVE FUNCTION
Because the causes of vulvodynia are multifactorial, there are a variety of approaches to managing it. Often we can reduce discomfort by as much as 50% by providing a nurturing environment for the skin. This means avoiding contact in the area with any product that isn’t hypoallergenic, including all products with fragrance. It also means avoiding washes and wipes. Hypoallergenic lotions or moisturizers, particularly vegetable oil-based ones, can help. Additional steps include oral neuropathic pain medications, which alter the perception of pain. Yoga or meditation may help with stress reduction. A woman with vulvodynia may have pelvic floor muscle problems because the muscles have inappropriately tightened in response to pain. A physical therapist with expertise in pelvic floor problems can help.
QUICK FIXES USUALLY DON’T WORK LONG TERM
Some practitioners recommend topical medicines, but I stay away from them. We clinicians want to be helpful and we want to recommend something for right now, but multiple studies have shown that while some quick fix medications work for the short term, over time the medication itself can become a contact irritant and offers little symptom resolution. The right treatment strategy is apt to be very individualized, and when treating patients, I rarely do the same thing in the same order. I tell my patients, “We’re going on a journey together, and we’ll work on the most bothersome symptoms and then when these improve, we’ll move on to the secondary symptoms.”
IF THERE’S A BLADDER COMPONENT TO HER VULVODYNIA, DIET CHANGES CAN HELP
Foods have an impact and can aggravate vulvodynia when there are bladder problems involved. Have her avoid foods with a high acid content such as tomatoes, strawberries, or citrus. She might also try avoiding alcohol and the water-soluble vitamins such as the Bs and Cs. All of these can make the urine more acidic which can aggravate the vulva. In addition, some women have a bladder condition called interstitial cystitis (IC). Both the IC and the vulvodynia need to be treated for best outcomes.
INCLUDE THEIR PARTNERS
A woman may experience tremendous relationship problems when her vulvodynia causes her to avoid intercourse. I encourage my women to bring their partner in with them so everyone can understand what’s going on. It can be devastating when a woman not only has to deal with chronic pain, but she also has to deal with a situation that harms her intimate relationship.
IF THINGS AREN’T GETTING BETTER, THERE ARE OTHER
APPROACHES TO TRY
The National Vulvodynia Association (https://www.nva.org) can suggest resources. The International Society for the Study of Vulvovaginal Disease (ISSVD.org) is also a useful resource.
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Our expert is Lucy Faulconbridge, PhD, Assistant Professor of Psychology and Director of Research at the Center for Weight and Eating Disorders at the University of Pennsylvania’s Perelman School of Medicine. Her research focus is the co-morbidity of obesity with mental illness, particularly depression.
BARIATRIC SURGERY CAN BE EXTREMELY HELPFUL AS A LAST RESORT
Bariatric surgery is generally only available for severely obese individuals who have not succeeded in controlling their weight using diet and exercise. Almost all of our patients at Penn have tried traditional diet programs and lost significant amounts of weight, but they aren’t able to keep the weight off. For them, being overweight is more than carrying extra pounds; it can mean significant psychological and medical issues, such as depression, heart disease, diabetes, severe sleep apnea, a great deal of physical pain, and a shorter life. For these individuals, bariatric surgery is a tool that by itself isn’t going to solve their problems. However, by following the post-operative recommendations, which include eating a diet high in protein and low in carbohydrates, with five or six small meals throughout the day, and with exercise, bariatric surgery can help patients to lose significant amounts of weight and to keep it off over the long-term. This means both a longer life and a higher quality of life.
GUIDELINES FOR BARIATRIC SURGERY
Per the recommendations of the American Society for Metabolic and Bariatric Surgery, patients are eligible for bariatric surgery if they have a BMI of 35 along with co-morbidities such as high blood pressure or diabetes, or if their BMI is 40 or more even without co-morbidities. However, more and more surgeons are allowing individuals with lower BMIs to get the surgery.
BARIATRIC SURGERY ISN’T ALWAYS A SUCCESS
Although it is not widely talked about, bariatric surgery failure rates are higher than you would think. A recent study published in JAMA Surgery (2012) showed that nearly 20% of Roux-en-y gastric bypass patients failed to lose at least 50% of their excess BMI by both the 1- and 2-year follow-ups. The person who doesn’t follow the lifestyle recommendations and instead drinks milkshakes all day long is going to regain the weight. It’s a misconception that “I’ll get the surgery and not have to do anything.” There’s also a 0.5% risk of death either during the surgery or within 30 days of the surgery. Many people don’t realize that this is a serious surgery that involves a massive change to their lifestyle.
WHAT WORKS FOR WEIGHT CONTROL ISN’T EASY OR SEXY
Our recommendations for a healthy lifestyle haven’t changed much in 50 years: have three balanced meals a day; eat a range of low- calorie foods while limiting high-fat and high-sugar foods; and enjoy your food without making it your primary means of enjoyment. In other words: moderation. This is not a sexy answer, and it’s not an easy answer, but it really is the best answer we have right now.
DON’T BLAME YOUR PATIENT
We know that a huge amount of stigma is associated with being overweight, and it comes not only from the public, but also from health care providers. Your patient doesn’t want to be overweight, and being judgmental only makes him or her feel guilty, depressed, less likely to want to come back, and it may lead to binging. Instead, recognize that in the current environment, it’s truly challenging to maintain a healthy body weight.
CHANGE NEEDS TO COME BOTH THROUGH EDUCATION AND AT THE POLICY LEVEL
In this country, making the choice to eat healthy is very hard, given that high-calorie, highly processed food is available everywhere all the time. This can be addressed at the policy level, for example by changing the food that’s available in schools or taxing soft drinks. But education is also tremendously important. I have clients who come in thinking that drinking a typical soft drink is like drinking water. They’ve never been taught that there are often as many as 140 calories in just one 12-ounce can. They also need to know that eating a small orange may involve something in the range of 45 calories, versus eating a candy bar, which could easily be 250 calories. Choosing an orange over a candy bar doesn’t make a difference in weight for one day, but we quickly develop habits, and 20 years of eating a candy bar instead of an orange makes an enormous difference.
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HEALTH OF AMERICAN WOMEN: IT’S PROBLEMATIC
Our expert is Steven Woolf, MD, MPH, Professor, Department of Family Medicine and Population Health, Virginia Commonwealth University. Dr. Woolf has served as Director of the VCU Center on Society and Health since he established it in 2007. He has published more than 170 articles in a career focused on evidence-based medicine and the development of evidence-based clinical guidelines, with a special focus on preventive medicine, cancer screening, quality improvement, and social justice.
Be sure to attend Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015 in Washington, DC. Steven Woolf will be one of the many outstanding presenters.
THINGS ARE NOT WHAT YOU EXPECT
IN U.S. HEALTHCARE
There’s a widespread perception that the United States has the best health care in the world. After all, we spend more on health care per person, we have cutting-edge technology, excellent researchers, and really sophisticated health centers. Yet in spite of all this, our life expectancy is shorter, and our disease rates are higher than the rest of the industrialized world. This is seen across all sectors and all age groups up to age 75. In addition, we see patterns for women that are particularly worrying. In the 1980s, when it comes to life expectancy, U.S. women were somewhat in the normal range compared to the rest of the industrialized world. Today, women in the U.S. are at the bottom. We spend $2.8 trillion per year on health care, yet women in 42% of U.S. counties are dying at higher rates than they were a generation ago.
MULTIPLE FACTORS CONTRIBUTE TO THE DECLINE IN U.S. HEALTH OUTCOMES
I chaired a panel of the National Research Council and the Institute of Medicine that was charged with looking for an explanation for this decline in health outcomes. We did a deep dive and looked at such factors as: the health care system; health behaviors; socioeconomic conditions; the physical and social environment, such as the built environment and the way cities are organized; and public policies and social values. In each of these domains we found that the U.S. lagged in comparison to other industrialized countries. The bottom line is that unless we take bold transformative action, U.S. health outcomes are likely to deteriorate further.
THE HEALTHCARE PROVIDER CAN HELP AT THE NATIONAL LEVEL
The decline in life expectancy in the U.S. is a huge public health concern, especially as it concerns women, and yet it’s hard to get research funding to study the causes. We spend research funds on such things as nanotechnology and gene mapping, but we’re not dealing adequately with social factors that have a much greater impact on our population. When it comes to women’s health, we’re dealing with a problem that threatens half the population and that will shape the health trajectory for the next generation because the health threats to women also extend to their children. We need more research to figure out what is going on. Health care providers can have an impact nationally by working with their professional groups, since professional groups can have a large impact on public policy.
HEALTHCARE PROVIDER CAN HELP AT THE COMMUNITY LEVEL
Health care providers can have a major impact on local policy. When a healthcare provider speaks up when the community is deciding about more physical activity in the schools, or healthier food in the cafeteria, or where a bus depot will be located, the community listens. When policy issues that affect health are being decided, they should attend community meetings or accept invitations from local radio, television, or newspapers for a chance to be interviewed on the subject.
HEALTHCARE PROVIDERS CAN HELP AT THE INDIVIDUAL LEVEL
Healthcare providers can help their patients by looking beyond the walls of the clinic and taking into account the environment in which their patients live. Let’s say a mother comes to a pediatrician with an obese child. The pediatrician could say, “Johnny needs to exercise more, so make sure he goes out and plays for 30 minutes a day.” A pediatrician who doesn’t realize that Johnny lives in a high crime area will also not know that the mother would be crazy to let him play outside. Imagine a scenario in which the electronic medical record alerts the pediatrician to the neighborhood conditions for this patient and identifies a community resource center that offers indoor after-school exercise options. The pediatrician’s advice would be more meaningful: “I know you’re not comfortable with Johnny playing outside. But there’s a community center at the corner of 7th and Vine, where he can exercise indoors. I’ll print this information out for you.”
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