Thursday, May 9, 2019

The latest deadly superbug — and why it’s not time to panic

I’ve been thinking about beans this week for a few reasons. One is an upcoming trip with my family to Nicaragua, where we will probably eat beans three times a day. Another is a paper in this week’s Archives of Internal Medicine showing that adding more beans to the diet can help people with diabetes better control their blood sugar.

Beans, the butt of countless flatulence jokes, are often written off as food for poor people, or cheap substitutes for meat. Given what beans can do for health, they should be seen as food fit for royalty—or at least for anyone wanting to get healthy or stay that way.
Legumes at any meal

The beans I’m talking about here are what botanists call legumes. Some people call them “pulses.” There are many types: adzuki beans, black beans, black-eyed peas, broad beans (fava beans), calico beans, cannellini beans, garbanzo beans (also called chickpeas), kidney beans, lentils, lima beans, mung beans, navy beans, peanuts, pinto beans, soybeans (also called edamame), and others.

Legumes are a terrific food. They are an excellent source of protein. They are low in fat. They are nutrient dense, meaning they deliver plenty of vitamins, minerals, and other healthful nutrients relative to calories. They provide plenty of soluble and insoluble fiber.

You can eat beans at any meal. Gallopinto (based on black beans and white rice) is a traditional breakfast dish in Nicaragua and Costa Rica. Bean burgers or falafel (deep-fried patties made from ground chickpeas, fava beans, or both) make a decent lunch. You can use beans in salads and stews, or build main dishes around them. A few recipes from a new cookbook, Bean by Bean, are available here. Many others are available courtesy of the California Dry Bean Advisory Board.
Beans and health

The article that caught my eye in Archives of Internal Medicine reported the results of a 12-week bean trial. It compared the effects of a diet enriched with legumes (one cup a day) to one enriched with whole wheat foods among people with type 2 diabetes. Both diets lowered blood sugar, though the bean-rich diet did it a little better. Both diets also lowered levels of harmful LDL (“bad” cholesterol) and triglycerides, the most abundant fat-carrying particle in the bloodstream. They also slightly lowered blood pressure.

These findings are in line with a growing body of evidence on the health benefits of eating beans. They’ve been linked to reduced risk for heart disease, type 2 diabetes, and colon and other cancers, as well as improved weight control. Last summer, a special issue of the British Journal of Nutrition was devoted to the various health benefits of legumes.

With all of this going for beans, I was surprised that they were omitted from the cover of this week’s Time magazine illustrating what we “should” be eating. Beans are every bit as colorful as the fruits and vegetables pictured, and definitely deserve a place at the table.
The gas tax?

Many people shun beans because of their gaseous aftereffects. Human digestive enzymes can’t break down the fiber and short chains of sugar molecules known as oligosaccharides in beans. But the billions of bacteria living in the gut can digest them, often creating gas in the process.

Here are some tips from the Harvard Heart Letter to help you turn off the gas:

Soak your beans. Soaking beans can get rid of a good portion of the indigestible oligosaccharides. Soak beans for 12 to 24 hours in a few quarts of water, pour off the soaking water, rinse, add clean water, and cook.

Choose wisely. Some beans seem to create less gas than others. These include adzuki and mung beans, lentils, and black-eyed, pigeon, and split peas. Heavy-duty gas formers include lima, pinto, navy, and whole soy beans.

Start slow. Let your body get used to fiber and oligosaccharides by having a small serving once or twice a week. Then gradually increase your intake, either by taking larger servings or eating beans more frequently.

Put your teeth to work. The more thoroughly you chew beans, the more you expose them to natural oligosaccharide-digesting enzymes in your saliva.

Gas-busters to the rescue. An enzyme called alpha-galactosidase breaks down some gas-producing oligosaccharides. The original product, Beano, has since been joined by others with names like Bean Relief, Bean-zyme, and plain old alpha-galactosidase. Taking a tablet before eating beans can reduce gas production. On Monday, Dr. Joseph E. Murray passed away at age 93. A long-time member of the Harvard Medical School faculty, Murray pioneered the field of organ transplantation. This great achievement, for which he was honored with the Nobel Prize in Medicine in 1990, has given the gift of life to hundreds of thousands of people destined to die young. But his success did not come easily.

How many people do you know who try to achieve something that no one has ever before even attempted, because it was judged to be impossible? And keep trying, and keep failing, but still keep trying—for a decade? And do so despite having each failure seriously criticized by many peers? I’ve only known one such person: Murray. He would not quit.

When he returned to the Peter Bent Brigham Hospital in Boston after serving as a plastic surgeon in World War II, Murray became the surgical leader of a team whose goal was to achieve human organ transplantation, starting with the kidney. Almost all of us are born with two kidneys, and appear to need only one. The other is like an insurance policy. If you take a kidney from a healthy person (the donor), it can be given to someone with two diseased kidneys (the recipient).

The idea behind kidney transplantation was simple. Actually doing it required solving immense problems. How do you hook up the recipient’s blood vessels to the new kidney? What about the nerves and lymph vessels? Where do you put the new kidney? Do you leave the two ailing kidneys in place or remove them? Murray solved those problems and others through studies in animals.

But the seemingly insurmountable problem for organ transplantation was rejection of the transplanted organ. To the recipient’s immune system, the new kidney “looks” foreign. It is treated as an invader, attacked, and ultimately killed. The only exception would be if the donor was genetically identical to the recipient.

That’s when fate intervened. In the fall of 1953, 22-year-old Richard Herrick fell ill while serving a tour of duty on a Coast Guard vessel in the Great Lakes. As his kidneys began to fail, toxins they were supposed to eliminate began building up in his blood and poisoning the rest of his body. He was given two years to live.

But unlike almost all other people with kidney failure, Richard Herrick had one potential advantage—his identical twin, Ronald. Because Richard and Ronald were genetically identical, in theory Richard’s immune system would not reject a kidney from Ronald.

A surgical team at the Peter Bent Brigham Hospital in Boston, led by Dr. Joseph Murray, performs the first kidney transplant in 1954. Photo courtesy Brigham and Women’s Hospital Archives.

In 1954, on the day before Christmas, Murray and his team helped Ronald give Richard a very special gift: a kidney. Before the operation, Richard was gaunt and white from severe anemia. His brain, affected by the toxins in his blood, made him disoriented and combative. He cursed the medical staff and accused them of sexually assaulting him. He bit a nurse who was trying to change his sheets.

After the operation, Richard’s mind cleared, his color improved, and he started to regain the weight he had lost. He returned to health, he courted and married one of his nurses, and they had two children. His brother, Ronald, suffered no ill effects from having just one kidney, and lived another 56 years.

Of course, most people with kidney failure were not lucky enough to have a healthy identical twin. There were some treatments—some medicines and radiation treatments—that had some effect in quieting the immune system. Murray tried them all, and for nearly a decade, had one failure after another. People destined to die young of kidney failure continued to die young.

With each failure, some colleagues were very critical of Murray. They told him he was subjecting the recipients and the healthy donors to the risks of surgery for no good reason: transplantation would never work. Murray held his ground. He said that every recipient and donor understood completely the risks, and that the transplant might well fail. But the recipients had no other alternative. They were going to die, and even if the chance was small, they wanted a chance at life.

Through the remarkable work of four other scientists—William Damashek, Robert Schwartz, George Hitchings and Gertrude Elion—drugs that effectively quieted immune rejection were invented. Using these drugs, transplantation could be successfully achieved between unrelated donors and recipients. For his pioneering efforts in organ transplantation, Murray shared the Nobel Prize in Medicine in 1990.

Dr. Joseph Murray stands with Ronald Herrick, the donor for the first-ever kidney transplant, at the opening of the U.S. Transplant Games in 2004.

In 2004, Murray and Ronald Herrick were honored at the U.S. Transplant Games, held at the Metrodome in Minneapolis, Minnesota. They stood on a platform high above the playing field, and lit the torch. On the field below were more than 2,000 participants—adults and kids, each with a transplanted organ inside them—warming up for their events. Here is how Murray described it in an article he wrote for Harvard Medicine in 2011:

    “Below us were throngs of competitors—jumping, stretching, loosening up. The new organs within them had allowed them not only to remain alive, but also to compete.

    I thought back to the day when it all began [50 years before]. Ronald Herrick and I were still here, but Richard Herrick and the rest of our team were gone. So too were many of the recipients—including all those who died young despite our best efforts. They all understood, perhaps better than we, that life is precious and fragile, and often must be fought for. They went to their graves believing that if they were not going to make it, they might at least help us learn how to save someone else…. Done just right, Thanksgiving dinner can be good for the heart. The bird at the center of the feast was once in line to be our country’s mascot. Benjamin Franklin and other turkey aficionados thought of this fowl as wild, wary to the point of genius, and courageous. When cooked, it has another excellent quality—turkey meat is easy on the heart. Actually, so are other mainstays of traditional Thanksgiving feasts.
Talking turkey

If you are looking for a lean cut of meat, turkey is hard to beat. A 3-ounce serving of skinless white meat contains 26 grams of protein, barely 2 grams of fat, and under 1 gram of saturated fat. A 3-ounce serving of prime rib has less protein and a lot more fat—28 grams of total fat and more than 11 grams of saturated fat, or half the recommended daily amount for someone needing about 2,200 calories a day. (See how other meats stack up in Comparing holiday entrées below). Turkey has fewer calories, too.

Dark meat has more saturated fat than white meat, and eating the skin adds a hefty wallop of these bad fats.

Turkey is also a good source of arginine. As with other amino acids, the body uses this one to make new protein. Arginine is also the raw material for making nitric oxide, a substance that relaxes and opens arteries. Whether foods rich in arginine help keep arteries open has prompted both research and debate.
The rest of the feast

We tend to think of Thanksgiving dinner with a guilty smile. Yet several traditional foods are essentially healthy.

Cranberries. The fruit that provides the base of this traditional side dish deserves to move from holidays to everydays. Cranberries are packed with dozens of different antioxidants. On a standard test that measures the ability of food to neutralize unstable molecules that can damage DNA, proteins, cell membranes, and cellular machinery, the cranberry is near the top of the list (along with its cousin, the blueberry, as well as blackberries, artichokes, beans, and prunes). The natural mix of antioxidants found in cranberries and other foods is what matters, not the high doses of single ones found in supplements. If you make your own cranberry sauce from whole berries, you’ll get a tastier and less sugary sauce than you can get out of a can.

Sweet potatoes. These un-potatoes—they’re related to the morning glory, not the white potato—are an excellent source of vitamin A, beta carotene, vitamin C, potassium, and fiber.

Pumpkin. Before this orange squash is made into pie, it’s just plain good for you. Pumpkin is low in fat, low in calories, and loaded with potassium, vitamin A, beta carotene, and vitamin C.

Pecans. Most nuts are great sources of heart-healthy fats. Pecans are no exception. Twenty pecan halves contain about 20 grams of unsaturated fat. Studies from around the globe show that people who routinely eat nuts are less likely to die of heart disease than those who don’t.
Keeping better company

Although many of the foods that grace a Thanksgiving table are healthy on their own, they tend to lose their virtue by the company they keep. Brown sugar, butter, and marshmallows overshadow the goodness of sweet potatoes. The benefits of pumpkin and pecans are overwhelmed when baked into pies with cream, eggs, butter, and sugar.

It doesn’t have to be that way. If you’re set on a traditional dinner, alternative recipes abound for healthier stuffing, vegetables, and desserts. You can also start your own traditions. After all, today’s Thanksgiving dinner bears little resemblance to the original feast.

Don’t get carried away focusing on fat. Calories count just as much as fat. Controlling your portions so you don’t end the meal feeling as stuffed as your Thanksgiving turkey will go a long way toward protecting your heart, and your waistline. The Thanksgiving holiday began, as its name implies, when the colonists gave thanks for surviving their first year in the New World and for a good harvest. Nearly 400 years later, we’re learning that the simple act of giving thanks is not just good for the community but may also be good for the brain and body.

The word gratitude comes from the Latin word gratia. Depending on the context it means grace, graciousness, or gratefulness. In some ways, gratitude encompasses all of these meanings. It is an appreciation for all that one receives. Gratitude helps people refocus on what they have instead of what they lack. By acknowledging the goodness in their lives, expressing gratitude often helps people recognize that the source of that goodness lies at least partially outside themselves. This can connect them to something larger—other people, nature, or a higher power.

In the relatively new field of positive psychology research, gratitude is strongly and consistently linked to greater happiness. Expressing gratitude helps people feel positive emotions, relish good experiences, improve their health, deal with adversity, and build strong relationships.

We feel and express gratitude in multiple ways. We can apply it to the past (retrieving positive memories and being thankful for elements of childhood or past blessings), the present (not taking good fortune for granted as it comes), and the future (maintaining a hopeful and optimistic attitude). Fortunately, it’s a quality that anyone can cultivate.
Research on gratitude

Several small but intriguing studies offer glimpses of what gratitude can do for us.

In one interesting study, psychologists Robert A. Emmons of the University of California, Davis, and Michael E. McCullough of the University of Miami (who have done much of the research on gratitude) asked participants to write a few sentences each week. One group was asked to write about things they were grateful for that had occurred during the week. A second group wrote about daily irritations or things that had displeased them. The third wrote about events that had affected them (with no emphasis on being positive or negative). After 10 weeks, those who wrote about being grateful were more optimistic and felt better about their lives. Surprisingly, they had also exercised more and had fewer visits to physicians than those who focused on sources of aggravation.

Another leading researcher, psychologist Martin E. P. Seligman at the University of Pennsylvania, tested the effect of different positive psychology interventions among 411 volunteers. The biggest boost in happiness scores came when participants were asked to write and personally deliver a letter of gratitude to a person they had never properly thanked for his or her kindness. The surge in happiness was larger than that from any other intervention, with benefits lasting a month.

Gratitude can improve relationships. One study of couples found that individuals who took time to express gratitude for their partner not only felt more positive toward the other person but also felt more comfortable expressing concerns about their relationship.

Gratitude has a place at work, too. At the University of Pennsylvania’s Wharton School, researchers found that just by saying “thank you,” managers can motivate their team members to work harder.

Not all studies show such positive results. But the research suggests that some of these techniques are worth trying.
Cultivating gratitude

Although some people may be born with a gift for expressing gratitude, anyone can learn how to do it. And this mental state grows stronger with use and practice. Here are some ways to cultivate gratitude.

    Write a thank-you note. You can make yourself happier and nurture your relationship with another person by writing a thank-you letter expressing your enjoyment and appreciation of his or her effect on your life. If this seems corny, then seize opportunities to go beyond a perfunctory thank you email — after having been invited to dinner or after spending time with a friend, write a heartfelt note. Every so often, write one to yourself.
    Thank someone mentally. No time to write? It may help just to think about someone who has done something nice for you, and mentally thank him or her.
    Keep a gratitude journal. Make a habit of writing down thoughts about the gifts you’ve received each day. Sharing these thoughts with a loved one is even better.
    Count your blessings. Pick a time every week to sit down and think about your blessings. Reflect on what went right or what you are grateful for. Sometimes it helps to pick a number — say three to five things — you will identify each week. Be specific and think about the sensations you felt when something good happened to you.
    Pray. People who are religious can use prayer to cultivate gratitude. If you pray, try to do so with intention — thinking carefully about what you are communicating through prayer rather than reciting the words automatically.
    Meditate. Mindfulness meditation involves focusing on the present moment without judgment. Although people often focus on a word or phrase (such as “peace”), it is also possible to focus on what you’re grateful for (the warmth of the sun, a pleasant sound, etc.).
Last week, Americans reelected President Obama and returned a Democratic majority to the Senate. How that will affect the economy, foreign policy, and other aspects of government remain to be seen. One thing we can say for certain—it pulls the Affordable Care Act (ACA) out of limbo.

Almost from the day President Obama signed the ACA into law in 2010, it has been under threat—from legislators, legal battles in court, and presidential candidate Mitt Romney’s vow to repeal “Obamacare” if elected. The President’s re-election means we can expect to see the ACA implemented. It also suggests that many Americans are comfortable moving forward with the ACA, and support a role for federal government in improving access to and delivery of health care.

Some popular elements of the law are already in place: allowing children to stay on their parent’s health coverage until age 26, and allowing for cost-free preventive services. Other more complicated aspects of the ACA remain to be realized.
Work to be done

The ACA seeks to expand health insurance to about 30 million of the 50 million Americans who are without health insurance. The law calls for state-run exchanges through which individuals can buy health insurance. Each state must notify the Department of Health and Human Services this week (by November 16th) about whether it is planning to set up its own exchange. The next deadline comes on January 1, 2013, when states intending to run their own exchanges must show they are on track to offer insurance by October 1, 2013. Residents of states that choose not to establish an exchange will be able to buy health insurance from a federal exchange.

The ACA also extends eligibility for Medicaid to Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four). To cover the cost of this expanded health coverage, states will receive 100% federal funding for the first three years, and 90% after that. The Supreme Court’s decision last June allows states to decide whether or not to expand Medicaid coverage. My hope is that the benefits of enrolling uninsured individuals in Medicaid (which include lowering the costs of delivering uncompensated care) will prompt them to do so.

Although the ACA makes no major modifications to Medicare, there are still significant changes on the horizon. The Center for Medicare and Medicaid Innovation will continue to seek new ways to pay for and deliver care that improve care and health while lowering costs. These efforts include shared savings with accountable care organizations, bundled payments, and comprehensive primary care initiatives. The Secretary of Health and Human Services can expand promising programs without congressional approval if they are shown to be beneficial. To control the escalating costs of health care, I and others believe our health care system needs to change from the traditional fee-for-service reimbursement model to one in which clinicians are reimbursed based on the quality and/or the value of the care they provide. Successful experiments from the innovation center should move this process forward.

Some other changes to Medicare may influence Medicare beneficiaries more directly. The ACA gradually closes the Medicare prescription drug “doughnut hole.” This should lead to smaller out-of-pocket drug costs. At the same time, some Medicare beneficiaries may see their costs go up, with the increase in the Medicare payroll tax and an increase in premium costs for beneficiaries with higher incomes.

The ACA established the Patient Centered Outcomes and Research Institute. Its mission is to conduct and support research that will help patients and their health care providers make more informed decisions. The institute has funded 50 pilot projects and will soon announce the recipients of awards for nearly $100 million for research on comparative clinical effectiveness in several priority areas.

Keep in mind that the ACA does nothing to address the looming cuts associated with the sustainable growth rate (SGR). This formula, enacted in 1997, caps what Medicare pays physicians by linking payments to the gross domestic product. This January, Medicare fees to physicians are scheduled to be reduced by 27%, unless Congress intervenes. A permanent fix will cost $270 billion over the next 10 years. Paying for it would require finding $270 billion worth of savings or adding $270 billion to the deficit.
What the ACA represents

I see the ACA as an important step down the path to assuring all that Americans have access to affordable health insurance. It does not have all of the answers. Although it starts to address health care costs, more work must be done to control health care spending. It will almost certainly take additional legislation to make substantial gains in this arena—as was necessary in Massachusetts. Massachusetts implemented a health care expansion in 2006 that is similar to the ACA, but found that additional cost-control legislation was needed to sustain the state’s near universal insurance coverage. It is my hope that legislators will work together to identify strategies to control costs and create a health care system that delivers high-quality and high-value care in a way that our nation can afford.

Dr. Nancy L. Keating is an associate professor of medicine and health care policy at Harvard Medical School and an associate physician at Brigham and Women’s Hospital. After years of hoping and searching, and a couple more of training, I finally have the perfect partner in my practice as a speech and play therapist: a Portuguese water dog named Map. Like any good therapy dog, Map can reach children in a way that no one else can.

Therapy dogs provide comfort and support. They must be social, gentle, and enjoy getting and giving physical affection—Maps has those qualities in spades. They also must be well behaved and respond to their handlers, neither of which applied to Map when I got him as a puppy. He chewed everything in sight. On walks, he sniffed every blade of grass, picked up every acorn and nosed into every clump of mud, no matter what I said or wanted.

After many therapy dog classes and a lot of practice, we learned. I say “we” because I had to be trained as well. I’ll admit, there were many bumps on the road, but after two years of training, Map became a certified therapy dog. He shines when he is in his blue training coat visiting a preschool. He loves to see the kids and to work with me.

How does Map help kids? His presence somehow lets children open up to learning. He offers kids a way to feel more whole in the face of physical illness or disability. He can also help children heal from emotional pain. One child I worked with, a four year old, lost his parents on 9/11. He stopped talking and refused to answer anyone. Over several visits, Map helped this child find his voice again.

Children with language delays or developmental disabilities are a big part of my practice. For those who are comfortable with dogs, Map is a great co-therapist. Children practice social skills and talk to Map as if he is a peer. I worked with one perky four year old who would not talk or make any sounds. He had what’s called childhood developmental dyspraxia. This is the inability to produce sound combinations with vowels and consonants. Out of frustration he threw tantrums instead of requesting things from his parents and he substituted a gesture system for language. I knew that children in a crisis state can relate to animals, so I brought Map to his school to see him. The child smiled, leaned over Map and buried his face into his coat. He looked up and said, “Puppeeeeee!” This was his first word. It was a long process to recovery, but the child got better—and Map was there to help. By the age of six, this boy could converse just like his peers. His parents happily had a new problem, “Can you get this child to stop talking? We can’t get in a word!” they told me.

Sharing and negation skills are something else that Map can help me help children improve. Sometimes Map sets the example. He is good at sharing his beloved rubber bone. A child can take away his bone and Map won’t budge or move. The child then shares a toy with Map.

Map is also trained to follow a child in play and focus on him or her, giving the child his undivided attention. Even though many children get this kind of attention from their family, they still love this special attention from a trained therapy dog. As you can see in the video below, Map can stay with a child during an obstacle course and, just as important, is a good listener.

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