Monday, April 8, 2019

Sugar: Its many disguises

Speaking for my gender, there are two qualities that define most men: we seldom like to ask for help, and we do not like to talk about our feelings. Combining the two — asking for help about our feelings — is the ultimate affront to many men’s masculinity.

We like to think of ourselves as strong, problem-solver types. But when it comes to emotional and mental issues, men need to quit trying to bottle up their feelings and tough it out, says Dr. Darshan Mehta, medical director of the Benson-Henry Institute for Mind Body Medicine at Harvard-affiliated Massachusetts General Hospital. “Your mental health is equally as important as your physical health. Not addressing negative feelings can carry over to all aspects of your life and have a profound impact.”
When to see a therapist

Depression is the most common reason men should seek professional help. Many life situations — jobs, relationships — can trigger its trademark symptoms, such as prolonged sadness, lack of energy, and a constant feeling of stress. For older men, it can also be brought on by financial anxiety about retirement, the death of a spouse or friend, or even the loss of independence, like losing the ability to drive. Left unchecked, these feelings could cause other health problems, such as rapid weight loss, insomnia, declining libido, and changes in memory. They may even lead to destructive behavior like alcohol or opioid dependence.

“While men may recognize these changes when they occur, they may not know the root cause, or if they do, what they can do about it,” says Dr. Mehta. This is when a therapist can lend a hand — or ear. “A therapist can help identify the source of your problems and then help resolve them,” he adds.
How to find a therapist

First, talk with your doctor about your situation, how you feel, and your symptoms. He or she will no doubt know therapists who can help with your specific issues. There are other places to start besides your primary care doctor, too. For example, many employee health care plans offer confidential help lines where you can ask questions and find therapists in your network. Another source is the National Alliance on Mental Illness Helpline (1-800-950-6264).

There are many kinds of professionals who offer many different types of therapy. Their individual approaches are based on their particular training and experience. The main ones include:

    Psychiatrist. A doctor with a medical degree who can prescribe medication. He or she often helps with more severe issues, such as major depression, bipolar disorder, and schizophrenia.
    Psychologist. A professional who has a PhD or a PsyD in clinical psychology. He or she can treat a full range of emotional and psychological issues, such as depression, anxiety, and substance abuse, but in most states cannot prescribe medication.
    Licensed Professional Counselor (LPC). He or she has a master’s degree plus 2,000 hours of supervised psychotherapy experience. This type of mental health professional focuses on the problems of everyday living, like stress and anxiety, relationship conflicts, and mild depression.
    Clinician Nurse Specialist. Like psychiatrists, he or she can prescribe medication. This type of professional works either independently or in collaboration with a supervising physician.
    Licensed Social Worker/Licensed Clinical Social Worker/Licensed Independent Clinical Social Worker. These mental health professionals assess and treat people living with mental illness and substance abuse issues. By providing group therapy, outreach, crisis intervention programs, and social rehabilitation, social workers help to ease clients back into their communities and daily lives. Clinical social workers provide care through numerous avenues, including hospitals, family service agencies and organizations like the U.S. Veteran’s Administration.

What to expect

Your therapist should help you establish goals of care and then outline a strategy to meet them. This may include a combination of therapy during regular sessions as well as “homework” to follow in between visits. Weekly visits are typical. Yours may be more or less frequent than that depending on how you respond to the therapy. After your initial treatment sessions, you might return periodically for “booster” visits to prevent a future relapse.

Do not give up if you do not feel a strong connection with the first therapist you try, says Dr. Mehta. “Try someone else and do not get discouraged. The goal is to find the right person who can guide you.” While therapy may feel awkward at first, most men soon recognize its value, he adds. “Once they make that connection with a therapist, they are quite receptive to therapy and welcome what it can offer.” The other day, a fit 50-year-old man came to me for a visit to review his health. As we discussed his (generally good) efforts to take care of himself, he said, “I’ve been wondering if I should take an aspirin every day. I read somewhere that it can prevent cancer.”

As a clinician, I really love it when people come in with questions that stretch my thinking. I have a stock set of answers to the “does aspirin prevent heart disease” question, but I didn’t have an easy answer to the cancer prevention question. What were the data? What should I be recommending? Is it true for everyone? Or maybe just for some people?

I turned to a respected source of information: the United States Preventive Services Task Force. This group of volunteer medical experts can be convened by the Agency for Healthcare Research and Quality to review the evidence about many topics in preventive care and give recommendations about various practices, depending on their interpretation of the research. For example, counselling someone to stop using tobacco is a Grade A recommendation — that is, the task force feels there is good evidence that the benefit of such an action is substantial.

I reviewed the recent clinical guidelines on this topic and found out that, well, the cancer/aspirin question is a complicated one. Here is what I learned:

    There are no good data that aspirin will prevent cancers other than colon cancer. While that evidence may be forthcoming, we don’t have it yet.
    Aspirin can help decrease the risk of colon cancer, but the benefits might be quite delayed. People have to be willing to take it for at least 10 years before the benefits begin, and they might not see the benefit in cancer prevention, specifically, for another five to 10 years after that. That means two things: they have to be able to tolerate aspirin for a long time, and, perhaps more importantly, the benefit of taking the aspirin up front has to outweigh the risk.

Therefore, the group of people who might benefit from taking a daily aspirin to prevent colon cancer is “adults aged 50 to 59 years who have a 10% or greater 10-year risk of developing cardiovascular disease, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.” If you are over 60, then the decision is more individual, according to the task force.

Whoa. That’s a mouthful. So what do I tell this guy sitting in front of me asking this great question?

Well, for him, the answer was, “I don’t think so.” Why? For starters, his risk of having a heart attack in the next 10 years is less than 10%. That means that the short-term risk of taking a daily aspirin is higher than the near-term benefit of preventing cardiac disease. And aspirin’s role in preventing colon cancer is so very long-term that it almost doesn’t play into the equation at all!

In truth, while the nuances of recommending aspirin for its potential health benefits are intellectually quite interesting, I think they are ultimately frustrating for both patients and doctors from a practical standpoint. Aspirin is not a free lunch. Maybe it will help prevent colon cancer in the long term, but, as a physician, I am always aware of its short-term risks, which can include stomach trouble, including bleeding, as well as an increased risk of stroke for some.

For this patient — and probably for many of you — I would go on to say that aspirin may not be the answer for cancer prevention. Then we would discuss other ways to prevent and detect colon cancer. I would remind you to make sure you were doing appropriate colon cancer screening with colonoscopy, sigmoidoscopy, or fecal occult blood testing. We would talk about diet and exercise. And we would agree to keep an eye on the data going forward, hoping, as always, to find a great option that keeps us as healthy as possible for as long as possible. For many women, pregnancy and the arrival of a new baby is a joyous time — but not for every woman. Recently, postpartum depression — extreme feelings of sadness and anxiety following the birth of a child — has come out from the shadows. But what about depression during pregnancy?

It’s more common than you think: as many as 14% to 23% of pregnant women will experience symptoms of depression. It’s of sufficient public health concern that the U.S. Preventive Services Task Force recommends screening all pregnant women and new moms for depression. However, treating depression during pregnancy raises a number of questions, particularly about the use of antidepressants.

Each year, an estimated one million pregnant women in the U.S. take these medications, according to a report from the CDC. The study looked at the records of 5.8 million privately insured women of reproductive age and found that 15.4% of them were taking antidepressants. Given that there are roughly 7.5 million pregnancies per year in the United States (and about half of these are unintended), there could be as many as a million developing fetuses exposed to antidepressants early in pregnancy. The actual number may be higher, as previous studies have suggested that antidepressant use is more common among women on public health insurance (and data on these women were not included in the report).
SSRIs and birth defects?

The CDC report found that four of the five most commonly prescribed antidepressants were selective serotonin reuptake inhibitors (SSRIs): sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac). The authors also cited several recent studies that suggest a possible association between SSRIs and birth defects, such as brain and heart malformations.

The authors feel that there is a serious public health concern about the use of SSRIs in pregnancy “Given the high proportion of unplanned pregnancies, the lack of adequate information on the safety or risk of antidepressant use during pregnancy, and the reported possible association between the use of some antidepressants during early pregnancy and the occurrence of major birth defects.” This concern is driving the CDC’s new initiative to push for more and better research on the safety of antidepressant use in pregnancy.
But it’s not that simple — and some experts take a broader view

But not all psychiatrists who treat pregnant women (perinatal psychiatrists), are in complete agreement with these conclusions. Dr. Marlene P. Freeman, associate director of the Center for Women’s Mental Health at Harvard-affiliated Massachusetts General Hospital, reassures us that there are plenty of studies on this topic, and that most of these do not suggest that SSRIs taken during pregnancy cause birth defects. “SSRIs are extremely well studied, and the preponderance of data does not suggest that they are teratogens,” (teratogens are agents that cause birth defects), she explains. “In the large body of literature published, there are certainly concerns with antidepressant exposure, but the more worrisome findings are inconsistently observed, with low absolute risk.” She and other perinatal psychiatrists emphasize the very important distinction between “possible association” and “cause and effect,” and advocate a more thoughtful approach to interpretation of the research.

Dr. Freeman is most concerned about a medication that is not mentioned in the article at all: valproic acid (Depakote), which is commonly prescribed for bipolar disorder, seizure disorders, and migraines. “It has a known and substantial risk of neural tube defects and poor neurocognitive outcomes for children,” she says. (Damage to the neural tube can result in developmental and learning problems for children.) She also points out that because about half of all pregnancies are unintended, and because “the neural tube is formed very early in pregnancy, damage can be done prior to women even knowing they are pregnant.”
Weighing the risks and benefits of antidepressants during pregnancy

The authors of the report acknowledge that “depressed women have higher rates of smoking, binge or heavy drinking, obesity, and physical inactivity, which might also pose risks to a developing fetus during pregnancy.” Dr. Freeman agrees with this, and adds, “we need to balance putative risks with that of the untreated disorder.” In other words, whenever a clinician prescribes a drug, he or she has to weigh any potential harmful effects against the harm in not treating at all. And for pregnant women with severe depression, not taking medication may pose an unacceptable risk of harm.

If you are pregnant and think you may be experiencing an episode of depression, talk with your doctor, especially if you have already been diagnosed with depression or other mental health issues (for example, anxiety). It’s also a good idea to have a conversation with your doctor if you take antidepressants and are thinking about conceiving. Untreated depression can be harmful to both a mother and her developing child, so it’s important to explore the full range of treatment options. For some women, the benefits of antidepressants may outweigh potential risks, and certain medications are likely safer than others.

The MGH Center for Women’s Mental Health website and blog are excellent resources for more information about psychiatric medications and pregnancy, including helpful reviews of recent research studies. Increasingly, people are aware of the dangers of “too much sugar” in the diet. Consuming excess sugar can lead to a condition called metabolic syndrome, which is characterized by high blood pressure, high blood sugar, unhealthy cholesterol levels, and abdominal fat. Excess sugar also contributes to widespread inflammation and even leads to a higher risk of cardiovascular disease and type 2 diabetes.

Excess sugar intake can be bad for your brain, too. Studies have found that high sugar intake has a negative effect on cognition, and it has also been implicated in hyperactivity and inattention in children and adolescents.

But what does “too much sugar” look like? On the one hand, we have the well-known “problem foods” like sugar-sweetened sodas, candy, and baked treats. On the other hand, we have the naturally occurring sugars in some whole foods (like plain yogurt, milk, or fruit) that are part of a healthy diet.

Between those lurk the less well known hidden sugars that are so common in the average person’s diet.
Sugar’s hiding places

You might be surprised where added and hidden sugars can be found in the foods we eat every day. For example, a tablespoon of one popular brand of tomato ketchup has 4 grams of sugar, and most people add about 3 tablespoons of ketchup to their burgers. That 12 grams of sugar from the ketchup alone is more sugar than you’d find in a serving of two store-bought chocolate chip cookies, which contains only 9 grams of sugar! And a store-bought vegetable juice would seem like a healthy choice at only 60 calories in a single 1-cup (8 ounce) serving — but that single serving size still contains 11 grams of natural sugar, even though the label doesn’t list any added sugar.

A data review completed by the Department of Health and Human Services (HHS) noted that American adults consume 13.4% of their calories from hidden sugars, and in children, this figure is a whopping 17%. The main sources of the hidden sugars in the typical U.S. diet were snacks and sweets (31%), added sugars in beverages (47%), and soda (25%). Of course, few people would be surprised that soda is high in sugar.
What the experts say about hidden sugar

Until now, we clinicians have given dietary advice based on the recently revised MyPlate, which simply reminds us to select foods and beverages with less saturated fat, sodium, and added sugars, without going into much detail. However, a recent article in JAMA has summarized all the current guidelines for sugar intake (I’ve listed them in the table below). These recommendations offer specific advice on sugar consumption and, unlike prior guidelines, they address added and hidden sugars in food — a welcome and important change.
US Department of Agriculture and
US Department of Health and Human Services (2015-2020)     Limit consumption of added sugars to <10% of calories per day
World Health Organization (March 2015)     Restrict added sugar consumption to <10% of daily calories
American Heart Association (2009)     Limit added sugars to 5% of daily calories (for women, 100 calories/day; for men, 150 calories/day)
Pay attention to these hidden sources of sugar

Consider these common “sugar traps.”

    Specialty coffees. Take, for example, a new Starbucks coffee drink, the caramelized honey latte. At 340 calories, a “grande” (16-ounce) serving might seem like a relatively harmless once-in-a-while dessert-like treat. In fact, you might even guess that it’s on the healthier side because it contains honey, one of the “less demonized” sugars. Look a little more closely, though, and you’ll see it contains 45 grams of sugar! That’s 180 calories of sugar. This single not-very-nutritious beverage takes you over your daily sugar limit.
    Honey. Let’s look a little more closely at honey as well. One study in the Journal of the American College of Nutrition found that honey contains oligosaccharides (a prebiotic that feeds gut flora) as well as small amounts of proteins, enzymes, amino acids, minerals, trace elements, vitamins, aroma compounds, and polyphenols. So one may argue, therefore, that honey is a healthy ingredient. However, your body breaks down honey — even raw, organic honey — as glucose and fructose. Just like plain old table sugar.
    Fruit juices. Basically, fruit juice is devoid of the healthy fiber you’d get from eating the fruit itself and instead concentrates the sugars. A single 8-ounce (1 cup) serving of Tropicana orange juice contains only 110 calories and 0 grams of fat, but 22 grams of sugar! Those 22 grams of sugar are 88 calories — that is, more than half the calories in your morning glass of juice. And if you’re a woman, that’s nearly your entire sugar-calorie “allowance” for the day using the guidelines from the American Heart Association above. To think of it another way, that’s the equivalent of 5 ½ teaspoons of sugar. You probably wouldn’t add that much sugar to your morning coffee or tea.
    “AKA” sugars. To be an astute label reader, you need to know that sugar can go by many names. For example, sugar can be also known as: agave nectar, barley malt, dextrose, rice syrup, isomalt, or high fructose corn sugar.

Know the sugar content of your food

A healthy diet is rich in fresh fruits and vegetables, healthy proteins (grass-fed meats, fish, poultry, and beans), a variety of whole grains, and healthy oils. Many of these foods include naturally occurring sugars and therefore are part of a healthy diet. But to truly eat well, you need to be on the lookout for hidden and added sugars. We also use guidelines for a healthy diet, for example, such as whole grains with an understanding that certain individuals may have food sensitivities, while others prefer to omit certain foods from their diet for various personal and or scientific reasons.

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