Category: SPORT

Inflammatory bowel disease (IBD) is commonly diagnosed when people are in their 20s and 30s, which is also when many people are planning families. Many people who have been diagnosed with IBD (which includes Crohn’s disease and ulcerative colitis) have questions and concerns regarding their fertility, conception, pregnancy, delivery, and breastfeeding.

Thinking about conceiving a child or becoming pregnant?

It is important to make sure that your IBD is well controlled, ideally before you begin trying to have a biological child. This is equally important for patients with male and female reproductive anatomy.

Patients with female reproductive anatomy who conceive in remission tend to remain in remission throughout their pregnancy. Research shows that poorly controlled IBD can lead to decreased fertility, and pregnancy can be complicated by premature loss, preterm labor, low birthweight, and small for gestational age babies.

You may require blood work, imaging, or endoscopy prior to conception to get an idea of whether you have an actively inflamed bowel before pregnancy. Your doctor may also modify your medications to ensure that your disease is as well controlled as possible.

You will require care from different types of health care providers during pregnancy, in addition to a gastroenterologist with expertise in IBD. Depending on the history and severity of your IBD, you may benefit from having a high-risk maternal fetal OB/GYN, colorectal surgeon, pharmacist, IBD nurse, psychologist, or nutritionist as part of your care team.

What should I do before I start trying to conceive or become pregnant?

It is recommended to take a prenatal vitamin and/or folic acid supplement. Vitamin D deficiency is common in IBD, and if your levels are low your doctor may recommend supplementation. It is also important to be up to date on your vaccines and review your medication list with your doctor.

Will I need to change my treatment before conception or pregnancy?

Many IBD medications have favorable safety profiles during conception and pregnancy. However, there are some medications that may impact fertility (such as by decreasing sperm count) or that may be unsafe to continue during pregnancy. For example, it is generally recommended to stop taking the drug methotrexate three months before conception.

As newer drugs are developed, research about the safety of IBD treatments continues. It is important to discuss your medications and any concerns you may have during the pregnancy planning period.

How will I be monitored during pregnancy?

Your gastroenterologist will carefully monitor your symptoms during preconception, pregnancy, and postpartum. You may be asked to provide stool samples to assess fecal calprotectin levels (a marker of inflammation measured in the stool), which can help your doctor monitor IBD activity prior to conception and during each trimester of your pregnancy.

Drug levels of certain IBD medications may be monitored via blood work as well, to ensure proper medication dosing. Monitoring and managing IBD throughout pregnancy is individualized for each patient, and the goal is to increase the chances of a healthy outcome for both you and your baby.

What if I have an IBD flare while pregnant?

During an IBD flare in pregnancy, the goal is to rapidly decrease inflammation and optimize an IBD treatment regimen in order to avoid complications for you and your and baby. This may involve drug level monitoring, adjusting medication dosage, or switching medication types. A short course of steroid medications may be needed in certain cases.

If your blood work indicates iron deficiency anemia (which can be caused by inflammation in the GI tract, but can also occur in pregnancy due to increased iron requirement for the baby), iron supplements, either oral or intravenous, can be used to improve blood counts.

What are my options for delivery?

Most people with IBD can deliver via their preferred method. The decision to have a vaginal or cesarean section delivery sometimes depends on a patient’s medical history. If a patient has Crohn’s disease and active perianal disease, a cesarean section may be recommended. This is because active perianal disease increases the risk of severe tears and trauma to the perineal area (area around the anus and vagina).

Patients with a history of steroid exposure and bone complications (like osteoporosis) may want to avoiding pushing during a vaginal delivery. A cesarean section may also be recommended if there are significant risk factors for injury to the perineal area, or an obstetric complication unrelated to Crohn’s or ulcerative colitis.

What happens after I give birth?

After delivery, it’s important to continue IBD medications. Approximately one-third patients will have an IBD flare within a year following delivery. Patients with poorly controlled IBD during the third trimester or while in de-escalation of therapy (reduction in medications) during or after pregnancy are at the highest risk for a postpartum flare. For this reason, it is important to maintain close follow-up with your IBD doctor during this time.

Can I breastfeed/chestfeed?

Breastfeeding/chestfeeding has many benefits for both the postpartum person and infant. Many IBD treatments have favorable safety profiles for breastfeeding/chestfeeding. Some newer biologic medications have not yet been studied well. Your doctor will discuss the risks and benefits of your individualized IBD treatment to ensure your regimen and breastfeeding goals are both optimized.

Will my baby have IBD?

While there is a genetic component to IBD, there is usually a low risk of IBD for biologic children of IBD patients. First-degree relatives (and in particular, siblings) of people with IBD do have an increased risk of Crohn’s disease and ulcerative colitis.

The bottom line

It is important to discuss family planning goals with your doctors early, so they can help you optimize your health and focus on achieving remission prior to conception. Fortunately, many IBD medications are considered safe and effective during conception, pregnancy, and postpartum. During pregnancy, proactive monitoring and early treatment of flares is essential. Every pregnancy is different, and close communication with your medical team is important to keep you and your developing baby healthy.

About the Authors

Loren Rabinowitz, MD, Contributor

Dr. Loren Rabinowitz is an instructor in medicine Beth Israel Deaconess Medical Center and Harvard Medical School, and an attending physician in the Inflammatory Bowel Disease Center at BIDMC. Her clinical research is focused on the … See Full Bio View all posts by Loren Rabinowitz, MD

Nisa Desai, MD, Contributor

Dr. Nisa Desai is a practicing hospitalist physician at Beth Israel Deaconess Medical Center, and an instructor in medicine at Harvard Medical School. She completed undergraduate education at Northwestern University, followed by medical school at the … See Full Bio View all posts by Nisa Desai, MD

Research shows a promising new option for men who experience rising PSA after a radical prostatectomy.

Many men who undergo surgical treatment for prostate cancer (a radical prostatectomy) live out their lives without a recurrence of their disease. But 20% to 40% of them will experience a rise in prostate-specific antigen (PSA) levels within 10 years of the operation. PSA should be undetectable in blood if the prostate has been removed, so elevated levels signify that the cancer may have returned. Doctors call this a biochemical relapse, and ordinarily they treat it by giving radiation to the prostate bed, which is where the prostate resided before it was taken out. Referred to as pelvic bed radiation therapy, or PBRT, this sort of treatment often succeeds in bringing PSA back down to zero for years.

Now, a large study shows that PBRT is even more effective when combined with other treatments. The findings are a potential game-changer for men experiencing a biochemical relapse after radical prostatectomy.

Funded by the National Cancer Institute, the SPPORT phase 3 clinical trial was conducted at nearly 300 medical centers across the United States, Canada, and Israel. A total of 1,797 men were enrolled between 2008 and 2015, all with post-surgical PSA levels ranging between 1 and 2 nanograms per milliliter (ng/mL).

The subjects were randomly assigned in roughly equal numbers to one of three groups. The men in group 1 got PBRT by itself, while men in group 2 got PBRT combined with four to six months of androgen deprivation therapy, or ADT. (Also known as hormonal therapy, ADT blocks testosterone, a hormone, or androgen, that fuels growing prostate tumors.) The men in group 3 got PBRT, ADT, and also radiation to the pelvic lymph nodes, where prostate cancer typically goes first if it begins to spread. The investigators wanted to know which of these three strategies is most effective at keeping disease progression at bay.

Results, side effects, and what’s next

According to their results, the more intensive treatments led to better outcomes. Just over 70% of men in group 1 were still avoiding disease progression after five years, compared with 80.3% of men in group 2 and 87.4% of men in group 3. More specifically, 145 of the men in group 1 developed further PSA elevations during the follow-up period, compared with 104 men in group 2 and 83 men in group 3. Similar trends were observed with respect to how many men developed metastases, or cancer that becomes resistant to hormonal therapy after it begins to spread.

The more intensive treatments also had more short-term side effects, especially diarrhea. But differences in side effects between the three groups disappeared after three months.

The authors emphasized that longer follow-up is still needed to confirm whether adding ADT and pelvic node radiation to PBRT actually lengthens survival. Moreover, the study did not evaluate a newer therapeutic strategy for biochemical relapse, where doctors use novel imaging methods to find exceedingly small metastases throughout the body that they treat directly with radiation.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor of the Harvard Health Publishing Annual Report on Prostate Diseases, says it’s important for men to understand that any measurable amount of PSA after a radical prostatectomy is abnormal and requires further evaluation. “The time-honored normal PSA range of 0 to 4 ng/mL no longer applies when men have had their prostates surgically removed,” he says. “Evidence of further benefits from adding ADT and pelvic radiation during this study is significant. Whether this represents a new standard of care in biochemical relapse requires additional follow-up.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

Growing evidence suggests that poor sleep is linked to a host of health problems, including a higher risk of high blood pressure, diabetes, obesity, and heart disease. Now, a recent study on people in midlife finds that having a combination of sleep problems — such as trouble falling asleep, waking up in the wee hours, or sleeping less than six hours a night — may nearly triple a person’s risk of heart disease.

"These new findings highlight the importance of getting sufficient sleep," says sleep specialist Dr. Lawrence Epstein, assistant professor of medicine at Harvard Medical School. Many things can contribute to a sleep shortfall, he adds. Some people simply don’t set aside enough time to sleep. Others have habits that disrupt or interfere with sleep. And some people have a medical condition or a sleep disorder that disrupts the quality or quantity of their sleep.

Who was in the study?

The researchers drew data from 7,483 adults in the Midlife in the United States Study who reported information about their sleep habits and heart disease history. A subset of the participants (663 people) also used a wrist-worn device that recorded their sleep activity (actigraphy). Slightly more than half of participants were women. Three-quarters reported their race as white and 16% as Black. The average age was 53.

Researchers chose to focus on people during midlife, because that’s when adults usually experience diverse and stressful life experiences in both their work and family life. It’s also when clogged heart arteries or atherosclerosis (an early sign of heart disease) and age-related sleep issues start to show up.

How did researchers assess sleep issues?

Sleep health was measured using a composite of multiple aspects of sleep, including

• regularity (whether participants slept longer on work days versus nonwork days)
• satisfaction (whether they had trouble falling asleep; woke up in the night or early morning and couldn’t get back to sleep; or felt sleepy during the day)
• alertness (how often they napped for more than five minutes)
• efficiency (how long it took them to fall asleep at bedtime)
• duration (how many hours they typically slept each night).

To assess heart-related problems, researchers asked participants "Have you ever had heart trouble suspected or confirmed by a doctor?" and "Have you ever had a severe pain across the front of your chest lasting half an hour or more?"

A "yes" answer to either question prompted follow-up questions about the diagnosis, which included problems such as angina (chest pain due to lack of blood flow to the heart muscle), heart attack, heart valve disease, an irregular or fast heartbeat, and heart failure.

Poor sleep linked to higher heart risk

The researchers controlled for factors that might affect the results, including a family history of heart disease, smoking, physical activity, as well as sex and race. They found that each additional increase in self-reported sleep problems was linked to a 54% increased risk of heart disease compared to people with normal sleep patterns. However, the increase in risk was much higher — 141% — among people providing both self-reported and wrist-worn device actigraphy data, which together are considered more accurate.

Although women reported more sleep problems, men were more likely to suffer from heart disease. But overall, sex did not affect the correlations between sleep and heart health.

Black participants had more sleep and heart-related problems than white participants, but in general, the relationship between the two issues did not differ by race.

What does this mean for you?

If you have trouble falling or staying asleep, there are many ways to treat these common problems, from simple tweaks to your daily routine to specialized cognitive behavioral therapy that targets sleep issues. These are well worth trying, because getting a good night’s sleep helps in many ways.

"Treating sleep disorders that interfere with sleep can make you feel more alert during the day, improve your quality of life, and reduce the health risks related to poor sleep," says Dr. Epstein.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

More than five million Americans use wheelchairs. Getting one repaired is hard.

Wheelchairs restore mobility to people who are unable to walk or have limited ability to do so. Over a lifetime, this may describe many of us due to changes in health, injuries, neurological conditions, or disabling conditions like arthritis. So, when wheelchair technology or parts quit working, a quick fix would seem essential, right?

I know this firsthand. Unable to walk from decades with multiple sclerosis, I keep small scooters on every floor of my 1911 home, which is further adapted for accessibility with stair lifts and ramps. One day when I turned on my second-floor scooter-type wheelchair, sparks arced from the tiller opening atop the steering column, followed by smoke and the acrid smell of burning electrical wires. It was late on a Friday afternoon. No emergency repair service exists for wheelchairs or scooters. Now what?

Wheelchair repair delays are far more than an annoyance

Wheelchairs allow millions of Americans with mobility disability to participate in daily activities and community life (note: automatic download). We know this improves physical and mental well-being and overall quality of life.

On that Friday, my only option was to have my husband bring my first-floor scooter to the second floor. There I stayed, awaiting repairs on the now-inoperable scooter while my husband brought my meals upstairs. Because I have used the same small assistive technology company for more than 20 years — and have the owner’s cell phone number — by midafternoon on Tuesday, I once again had functional scooters on both floors. My confinement had lasted only four days. I know I was lucky on many levels.

But what if I lived alone, didn’t have another operational scooter, or hadn’t been able to wait four days? And what about people experiencing far longer waits for help with an essential device? While the 1990 Americans with Disabilities Act (ADA) prohibits discriminatory policies and requires physical accessibility in public services and spaces, it says nothing about this issue.

How often do wheelchairs break down?

Ideally, a wheelchair should be safe, reliable, and match your activity goals and functional needs. It should provide strong postural support and seating that protects against pressure injuries. Depending on strength and endurance, you might wish to self-propel a manual wheelchair. Or you might need a mobility scooter or power wheelchair propelled by a battery-powered motor, one that might even have sip-and-puff operational assistance or a chin-operated trackball.

Regardless of complexity, however — from basic manual wheelchairs to sophisticated rehab power chairs — all wheelchairs can break down, leaving their users stranded. Factors like broken pavement, inadequate curb cuts or soft terrain, steep inclines and inclement weather, and poor wheelchair design pretty much guarantee this.

In one study of 591 wheelchair users with spinal cord injury, 64% reported needing at least one wheelchair repair in the past six months. Among users requiring just one repair, wheels and casters posed the most difficulties for manual wheelchairs (46%). Electrical systems (29%) and power/control systems (27%) caused most problems for power wheelchair users. Rates of wheelchair breakdowns have increased in recent years, and vary across wheelchair manufacturers.

Repairs are costly, in more than one way. A survey of 533 wheelchair users with spinal cord injury found:

• Out-of-pocket repair costs ranged from $50 to $620 (the median, or midpoint, cost was $150).
• Time spent experiencing adverse consequences from wheelchair breakdown before repair ranged from two to 17 days (five days was the median).
• Among those reporting adverse consequences, 27% were stranded inside their home, 12% were stuck in bed, and 9% were stranded outside their home.

Wheelchair repair delays are lengthening: Could right to repair laws help?

Lengthening repair delays (automatic download) that heighten risks to consumers’ physical and mental health have caused many wheelchair users across the US to voice their outrage. However, reducing repair wait times isn’t simple. Medicare moved to competitive bidding in 2011, causing most small vendors — like my assistive technology company — to leave the business.

The two behemoths owned by private equity firms that now dominate the marketplace focus on boosting profits and cutting costs. By reducing technician hours and parts inventories, restricting consumers’ access to parts and software passcodes, requiring pre-approvals from insurers for repairs, and other practices, these companies virtually ensure delayed repairs.

Furthermore, Medicare and other insurers do not pay for preventive maintenance such as tightening loose bolts and cleaning casters, allowing problems to go undetected until breakdowns occur. Training can allow some wheelchair users to perform preventive maintenance tasks, but such training programs are not widely available.

Trying to reduce repair delays, Colorado’s governor recently signed the first “right to repair” law in the US for power wheelchair users. Complex software programs control many functions of power wheelchairs, and by holding this software as trade secrets, the manufacturers and large vendors have forced consumers needing repairs to use their services.

Much like recent right to repair laws for cars, the Colorado law mandates that power wheelchair owners and independent repair shops have access to the embedded software tools, parts, and other resources required to diagnose, maintain, or repair power wheelchairs. Other states, such as Massachusetts, may follow. Power wheelchair users in Massachusetts are testifying at public hearings about their repair horror stories to motivate the legislature to act.

Given the complexities of the wheelchair industry, it’s not clear whether right to repair laws will shorten repair times for power wheelchairs. Additionally, this law does not address manual wheelchairs or scooters like mine. Clearly, much more remains to be done to ensure timely wheelchair repairs. As wheelchair use surges, with growing numbers of baby boomers with mobility disability wanting to remain active in their communities, solving the wheelchair repair crisis is increasingly urgent.

About the Author

Lisa I. Iezzoni, MD, MSc, Contributor

Lisa I. Iezzoni, MD, MSc, is a professor of medicine at Harvard Medical School, and is based at Massachusetts General Hospital in Boston. Dr. Iezzoni studies health care experiences of persons with disability. She is a … See Full Bio View all posts by Lisa I. Iezzoni, MD, MSc

No one is truly allergic to the sun, but some people are quite sensitive to different types of sun rays and may develop mild to serious reactions after spending time in the sun.

There are several types of “sun allergies,” but polymorphous light eruption (PMLE), an autoimmune condition in the skin that occurs after sun exposure, is one of the most common. Other conditions considered as sun allergies are solar urticaria (hives and reddish patches that usually start 30 minutes to two hours after the sun exposure), actinic prurigo (papules and nodules that are intensely itchy on sun-exposed skin areas), and photoallergic reaction (when the UV rays from the sun modify the chemical structure of medications or products applied to the skin, and a person develops an allergy to the newly modified substance).

What causes PMLE?

People who have PMLE have immune cells that are triggered by sun rays, which attack their skin, and they develop a skin reaction to the sun’s the ultraviolet (UV) rays.

PMLE represents 70% of all sun-induced skin eruptions. It can affect both sexes and all skin types, and it usually starts when someone is a teen or young adult. PMLE may be an inherited condition. Being a female, having fair skin, and living in the north are other risk factors.

PMLE is more common in young women who live in temperate climates. People who live in temperate climates spend all winter out of the sun, so when it becomes warmer the sun exposure is intense. People who live in warmer climates are desensitized because they have a higher sun exposure all year.

What does PMLE look like?

PMLE can appear several hours or days after the first major sunlight exposure of the season, usually during spring or at the beginning of summer. The areas of the body generally affected the most are the ones that are covered during wintertime, but not in the summer: the neck, the chest, and the outer parts of the arms.

After exposure to the sun, people with PMLE usually notice reddish patches on their skin. These spots may itch, burn, or sting, but they typically don’t leave a scar. In more severe cases, the patches cover most of the body and may also be associated with headaches, fevers, tiredness, and low blood pressure. (If you experience these symptoms, see an urgent care provider for evaluation.) If you think you have PMLE or another sun allergy, a dermatologist is the best doctor to evaluate and treat your skin condition.

Does PMLE get better?

PMLE lesions often get better in approximately 10 days, and it’s important to avoid sun exposure until you are healed. People who develop PMLE can experience significant discomfort and have their life negatively impacted during the spring and summer months. However, repetitive sun exposure can make PMLE less likely to occur. The hardening effect, as it is called, means that the skin lesions that appear after the first episode are less severe, and they can be better tolerated during subsequent episodes.

What are current treatments for any sun allergy, including PMLE?

The best treatment is to prevent sun exposure. Avoid sunlight when it is most intense (from 10 a.m. to 4 p.m.), and use UV-protecting clothing or clothes made of darker and thicker fabrics, as they will prevent the UV rays coming from the sun from reaching your skin. Hats with a wide brim protect your scalp, face, and (partially) the neck.

Broad-spectrum sunscreens that protect your skin from both UVA and UVB rays should be used daily, even if it’s cloudy. Apply sunscreen on your face and any part of your skin that is not covered by a hat or clothing. Reapply sunscreen every two hours, and if you go swimming or get sweaty reapply more frequently (water-resistant sunscreen should also be reapplied).

If you develop PMLE, the areas of skin impacted can be treated with steroid creams. In severe cases, your doctor may recommend a short course of steroid pills. Medications that reduce the immune response, such as azathioprine, are options for treating PMLE, since it is an autoimmune condition (the body is attacking it is own healthy cells).

Antihistamines are medications typically used for allergies that may help shorten the duration of reddish patches that itch or burn, and they also reduce inflammation.

Hydroxychloroquine (a medication also used to treat malaria) can be used in case of flare-ups, or as a prevention method when people travel to sunny locations during winter vacations.

Oral Polypodium leucotomos extract, a natural substance derived from tropical fern leaves, may work as a potent antioxidant, and has anti-inflammatory properties that are beneficial in the prevention of PMLE. Other nutritional supplements containing lycopene and beta-carotene (vitamin A derivatives) have a similar effect. A dermatologist will guide you on the best way to use these medications.

The bottom line

Sun allergies are common in temperate climates, but with a dermatologist’s guidance, vigilant sun prevention, and medications they can be managed throughout the sunny months of the year.

About the Authors

Neera Nathan, MD, MSHS, Contributor

Dr. Neera Nathan is a dermatologist and researcher at Massachusetts General Hospital and Lahey Hospital and Medical Center. Her clinical and research interests include dermatologic surgery, cosmetic dermatology, and laser medicine. She is part of the … See Full Bio View all posts by Neera Nathan, MD, MSHS

Lais Lopes Almeida Gomes, Contributor

Dr. Lais Lopes Almeida Gomes is a dermatology research fellow at Massachusetts General Hospital, and a pediatric dermatologist in Brazil. Her clinical and research interests include atopic dermatitis and global health. She is part of the … See Full Bio View all posts by Lais Lopes Almeida Gomes

You may have noticed nipped-in, hourglass waists among women wearing the celebrity trend du jour: so-called waist trainers. This tummy-tucking shapewear evokes images of buttoned-up corsets and too-tight girdles from a dim past. But does it live up to the hype?

Splashy advertisements suggest these compression devices can help you selectively sculpt inches off your waistline by wearing them during workouts or as part of everyday routines. But the claims largely don’t live up to the evidence, says Michael Clem, a physical therapist with Spaulding Rehabilitation Network.

“People want the quick fix,” Clem says. “Putting something around our waist seems easy — we do it every day with pants and belts. What’s one more thing? Diet and exercise take longer and require more dramatic habit changes. We all know what we need to do, we just don’t want to do it.”

Debunking the hourglass hype

Clem debunks four common claims made about waist trainers — and points out one case where they may prove useful.

• Spot-reduce fat: Compressing fat with a waist trainer and expecting it to stay put once you uncinch the shapewear is a faulty concept. “Fat is a systemic deposit,” Clem says. “Putting something around your waist can’t help you burn the fat in just that place.”
• Sweat away the inches: Similarly, perspiring more profusely in one body area — in this case, under your waist trainer — will not melt fat there. “Sweat is a mechanism for cooling the body. We expend calories when we sweat but we can’t say those calories are going to come from the area we sweat from,” Clem notes.
• Eat less due to belly compression: While orthopedic braces or compression sleeves can heighten awareness of a body part, leading wearers to act differently, the same probably can’t be said of a thick band around the belly. Our awareness of internal organs isn’t as strong, Clem says. And while waist trainers apply pressure to the abdomen, they probably wouldn’t alter the body’s feeling of being full.
• Build a stronger core: Wearing a waist trainer might help if a doctor recommends temporary use after certain surgeries — such as while someone is rebuilding core muscles after a cesarean section, hernia surgery, or appendectomy — by offering tangible “feedback” on abdominal muscle use as a person recovers. “But there are much better ways to teach someone to feel their core,” says Clem, including working with a physical therapist on posture and breathing.

In most cases, there’s probably no harm in trying one of the shape-shifting devices, although anyone who is pregnant should not use them. And if you have any health issues, it’s best to talk to your doctor about whether compressing your core could have any negative effects, including not being able to breathe deeply and comfortably.

Want to shape your waist? Try core strengthening exercises

Listed from least to most challenging, here are three great exercises to strengthen core muscles that help define the waist. Start with one set and work up, paying attention to your form.

Bridge

Reps: 10
Sets: 1–3
Tempo: 3–1–3
Rest: 30–90 seconds between sets

Starting position: Lie on your back with your knees bent and feet flat on the floor, hip-width apart. Place your arms at your sides. Relax your shoulders against the floor.

Movement: Tighten your buttocks, then lift your hips up off the floor until they form a straight line with your knees and shoulders. Hold. Return to the starting position.

Tips and techniques:

• Tighten your buttocks before lifting.
• Keep your shoulders, hips, knees, and feet evenly aligned.
• Keep your shoulders down and relaxed into the floor.

Opposite arm and leg raise

Reps: 10
Sets: 1–3
Tempo: 3–1–3
Rest: 30–90 seconds between sets

Starting position: Kneel on all fours with your hands and knees directly aligned under your shoulders and hips. Keep your head and spine neutral.

Movement: Extend your left leg off the floor behind you while reaching out in front of you with your right arm. Keeping your hips and shoulders squared, try to bring that leg and arm parallel to the floor. Hold. Return to the starting position, then repeat with your right leg and left arm. This is one rep.

Tips and techniques:

• Keep your shoulders and hips squared to maintain alignment throughout.
• Keep your head and spine neutral.
• Think of pulling your hand and leg in opposite directions, lengthening your torso.

Stationary Lunge

 

Reps: 8-12 on each side
Sets: 1-3
Tempo: 3-1-3
Rest: 30-90 seconds between sets

Starting position: Stand up straight with your right foot one to two feet in front of your left foot, hands on your hips. Shift your weight forward and lift your left heel off the floor.

Movement: Bend your knees and lower your torso straight down until your right thigh is about parallel to the floor. Hold, then return to starting position. Finish all reps, then repeat with your left foot forward. This completes one set.

Tips and techniques:

• Keep your front knee directly over your ankle.
• In the lunge position, shoulder, hip, and rear knee should be aligned. Don’t lean forward or back.
• Keep your spine neutral and your shoulders down and back.

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

When trying intermittent fasting, both the quantity and quality of what you eat during your eating window matter.

Intermittent fasting is a trendy topic that arises repeatedly in my clinic these days. I get it: restrict the time period when you eat, but within that time window eat as you normally would. No calorie counting. No food restrictions. Simple and flexible. In an on-the-go world, intermittent fasting has come into vogue as a potential pathway toward sustainable weight loss.

What is Intermittent fasting?

Intermittent fasting (IF) has become a catch-all term for one of the key levers in our dietary pattern: timing. More accurately, intermittent fasting refers to an eating schedule that is designed to expand the amount of time your body experiences a fasted state. You achieve this by reducing the so-called eating window. The most popular time-restricted eating protocols (typically based on study designs) are explained in these previously published articles:

• Time to try intermittent fasting?
• Intermittent fasting: The positive news continues
• Not so fast: Pros and cons of the newest diet trend

How might time-restricted eating help with weight loss?

To start, consider a fed state that promotes cellular growth versus a fasted state that stimulates cellular breakdown and repair. Both can be beneficial or harmful, depending on the context (consider how cellular growth builds lean muscle mass and also spawns cancer). Many of our genes, particularly those that regulate our metabolism (how we digest and utilize the energy from food), are turned on and off each day in accordance with our innate circadian rhythms (our sleep/wake cycle).

We transition from a fed to an early fasted state several hours — five to six, on average — after our last meal. This often aligns with the time when the sun has set, our metabolism slows, and we sleep. However, in our modern environment with artificial lights, 24-hour convenience stores, and DoorDash, we are persistently primed to eat. Rather than obeying our circadian cues, we are eating at all times of day.

Plenty of research, mainly in animal models but also some human trials, indicates that your body experiences numerous benefits from being in a fasted state, given its impact on cellular processes and function. In a fully fasted state, your metabolism switches its primary source of fuel from glucose to ketones, which triggers a host of cellular signaling to dampen cellular growth pathways and increase cellular repair and recycling mechanisms. Repeated exposure to a fasted state induces cellular adaptations that include increased insulin sensitivity, antioxidant defenses, and mitochondrial function.

Given how much of chronic disease is driven by underlying insulin resistance and inflammation, it’s plausible that fasting may help reduce diabetes, high cholesterol, hypertension, and obesity. And multiple short-term clinical studies provide evidence that intermittent fasting — specifically, time-restricted feeding — can improve markers of cardiometabolic health.

Is intermittent fasting a reliable strategy to achieve weight loss?

To date, the answer has remained murky due to the quality of the evidence, which often involves very small sample sizes, short intervention periods, varied study designs (often lacking control groups), different fasting protocols, and participants of varying shapes and sizes. The data on intermittent fasting and its impact on weight loss largely involves studies that employ the time-restricted eating methodology of intermittent fasting. A recent compilation of the evidence suggests that limiting your eating window might indeed help you shed a few pounds.

New research on IF as a tool for weight loss

To tease out the independent impact of time restriction on weight loss, we need to evaluate a calorie-restricted diet combined with time-restricted eating, compared to time-restricted eating alone. The recent results of a yearlong study assessed this exact question: does time-restricted eating with calorie restriction produce greater effects on weight loss and metabolic risk factors in obese patients, as compared with daily calorie restriction alone?

To answer this question, the trial involved people ages 18 to 75 with BMIs between 28 and 45, notably excluding those who were actively participating in a weight-loss program or using medications that affect weight or calorie intake. Participants were instructed to follow a 25% calorie-reduced diet (1,500 to 1,800 calories per day for men and 1,200 to 1,500 calories per day for women) with a set ratio of calories from protein, carbs, and fats. In order to confirm adherence to the diet (a notorious challenge in diet studies), participants were encouraged to weigh foods and were required to keep a daily dietary log, photograph the food they ate, and note the times at which they ate with the use of a custom mobile app.

Half of the participants (those in the time-restricted eating group) were instructed to consume the prescribed calories within an eight-hour period, whereas the other half in the daily-calorie-restriction group consumed the prescribed calories without time restriction. All participants were also instructed to maintain their usual daily physical activity throughout the trial, to remove this variable and to isolate the timing of food intake as the only difference between the two groups.

After a full year, 118 patients successfully completed the study, with similar rates of adherence to the diet and composition of the diet between the two groups. Both groups lost a significant amount of weight: an average of about 18 pounds for the time-restricted eating group and 14 pounds for the daily-calorie-restriction group. The difference in weight loss between the two groups was not statistically significant, nor was there a significant difference in weight loss among subgroups when sorted by sex, BMI at baseline, or insulin sensitivity. The resulting improvements in blood pressure, lipids, glucose, and cardiometabolic risk factors were also similar between the two groups. This trial provides strong evidence that, all else being equal, restricting the eating window alone does not have a substantive impact on weight loss.

What does the new research on IF mean for you?

For most people (with notable exclusions of those who have diabetes, eating disorders, are pregnant or breastfeeding, or require food with their meds), a time-restricted eating approach appears to be a safe strategy that is likely to produce some weight loss, assuming you are not changing your current dietary pattern (eating more calories).

The weight loss effects of time-restricted eating derive primarily from achieving a negative energy balance. If you maintain your regular diet and then limit the time window during which you eat, it is likely that you will eat a few hundred fewer calories per day. If this is sustainable as a lifestyle, it could add up to modest weight loss (3% to 8% on average, based on current data) that can produce beneficial improvements in cardiometabolic markers such as blood pressure, LDL cholesterol and triglyceride levels, and average blood sugar.

But — and this is a big but — if you are overcompensating for the time restriction by gorging yourself during your eating window, it will not work as a weight loss strategy. And it may indeed backfire. The other two levers in your dietary pattern — the quantity and quality of what you eat during your eating window — still matter immensely!

One downside of IF: Loss of lean muscle mass

While weight loss for cardiometabolic health is a sensible goal, weight loss from any intervention (including intermittent fasting) often entails a concurrent loss of lean muscle mass. This has been a notable finding — what I might even call an adverse side effect — of intermittent fasting protocols. Given the importance of lean muscle mass for revving your metabolic rate, regulating your blood sugar, and keeping you physically able overall, pairing resistance training with an intermittent fasting protocol is strongly advised.

Finally, the weight loss achieved through time-restricted eating (which we often refer to interchangeably with intermittent fasting) is likely different than the cellular adaptations that happen with more prolonged fully fasted states. At this time, it is hard to determine the degree to which the cardiometabolic benefits of fasting derive from weight loss or from underlying cellular adaptations; it is likely an interrelated combination of both.

Nevertheless, it seems clear that in a 24/7 world of around-the-clock eating opportunities, all of us could benefit from aligning with our circadian biology, and spend a bit less time in a fed state and more time in a fasted state each day.

About the Author

Richard Joseph, MD, Contributor

Dr. Richard Joseph is the founder of VIM Medicine, cofounder of Vital CxNs, a practicing clinician in the Center for Weight Management and Wellness at Brigham and Women’s Hospital in Boston, MA, and a faculty member at Harvard … See Full Bio View all posts by Richard Joseph, MD

I recently learned about a study suggesting a vegan diet is an effective treatment for rheumatoid arthritis.

While that sounded intriguing, another claim made in an interview about the study really caught my attention: the lead author of the study said that physicians should encourage people with rheumatoid arthritis to try changing their eating patterns before turning to medication.

Before turning to medication? Now wait just a minute. That flies in the face of decades of research convincingly demonstrating the importance of early medication treatment of rheumatoid arthritis to prevent permanent joint damage. An increasing number of effective treatments can do just that.

In fact, there’s no convincing evidence that changes in diet can prevent joint damage in rheumatoid arthritis. And that includes this new study.

So, what did this research find? Let’s take a look.

A vegan diet for rheumatoid arthritis

Researchers enrolled 44 people with rheumatoid arthritis in the study. All were women, mostly white and highly educated. They were randomly assigned to one of two groups for 16 weeks:

• Vegan diet. Participants followed a vegan diet for four weeks, followed by additional food restrictions that eliminated foods the researchers considered to be common arthritis trigger foods. These foods included gluten-containing grains (wheat, barley, and rye), white potatoes, sweet potatoes, chocolate, citrus fruits, nuts, onions, tomatoes, apples, bananas, coffee, alcohol, and table sugar. After week seven, these foods were reintroduced, one at a time. Any reintroduced food that seemed to cause pain or other symptoms of rheumatoid arthritis was eliminated for the rest of the 16-week period.
• Usual diet plus placebo. These participants followed their usual diet and took a placebo capsule each day for 16 weeks. The capsule contained insignificant doses of omega-3 fatty acids and vitamin E.

After the first 16 weeks, participants took four weeks off, then the groups swapped dietary assignments for an additional 16 weeks.

What did the study find about the vegan diet?

The vegan approach seemed to help lessen arthritis symptoms. Study participants reported improvement while on the vegan diet, but no improvement during the placebo phase.

For example, the average number of swollen joints fell from 7 to 3.3 in the vegan diet group, but actually increased (from 4.7 to 5) in the placebo group. In addition, while on the vegan diet, participants lost an average of 14 pounds, while those on the placebo gained nearly 2 pounds.

What else do we need to consider?

While the findings sound great, the study had significant limitations:

• Size. Only 44 study subjects enrolled and only 32 completed the study. With such small numbers, it only takes a few to alter the results. Larger studies (with several hundred or more participants) tend to be more reliable.
• Lack of diversity. This trial did not include men and had mostly white, highly educated participants.
• No standard diagnosis of rheumatoid arthritis. A physician’s diagnosis was required, but there was no requirement that standard criteria be met.
• Study duration. A treatment lasting four months may seem like a long time, but for a chronic disease like rheumatoid arthritis that can wax and wane on its own, this is too short a time to make firm conclusions.
• Self-reported diet. We don’t know how well study subjects stuck to their assigned diets.
• Medication use. Study subjects took arthritis medications, though no information on specific drugs is offered. Some made dosage adjustments during the trial. While the researchers tried to account for this through a separate analysis, the small number of participants could make that analysis unreliable.
• Weight loss. Losing weight, rather than eating a vegan diet, might have contributed to symptom improvement.
• No assessment of joint damage. No x-rays, MRI results, or other assessments of joint damage were provided. That’s important, because we know that people with arthritis can feel better even when joint damage continues to worsen. Steroids and ibuprofen are good examples of treatments that reduce symptoms of rheumatoid arthritis without protecting the joints. Without information about joint damage, it’s impossible to assess the true benefit or risk of relying on a vegan diet to treat rheumatoid arthritis.

Finally, it’s unclear how a vegan diet would improve rheumatoid arthritis. This raises the possibility that the findings won’t hold up.

Should everyone with rheumatoid arthritis become vegan?

No, there isn’t enough evidence to justify recommending a vegan diet — or any restrictive diet — for everyone with rheumatoid arthritis.

That said, a plant-rich diet is healthy for nearly everyone. As long your diet is nutritionally balanced and palatable to you, I see little harm in adopting an anti-inflammatory diet. But in the case of rheumatoid arthritis, diet should be combined with medicationto prevent joint damage, not used instead of it.

The bottom line

Growing evidence suggests diet can play a role in treating rheumatoid arthritis. But it’s one thing for a person to feel better on a particular diet; it’s quite another to say diet is enough by itself.

For high cholesterol or high blood pressure, dietary changes are the first choice of treatment. But rheumatoid arthritis is different. Disabling joint damage can occur early in the disease, so it’s important to start taking effective medications as soon as possible to prevent this.

We will undoubtedly see more research exploring the impact of diet on rheumatoid arthritis, other forms of arthritis, and other autoimmune disorders. Perhaps we’ll learn that a vegan diet is highly effective and can take the place of medications in some people. But we aren’t there yet.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

My favorite summer activities officially kick in when the calendar flips to May. It’s prime time for open water swimming, running, cycling, hiking, and anything else that gets me outside and moving. Yet, my first step is to get my legs in shape.

“Legs are the foundation for most activities,” says Vijay Daryanani, a physical therapist at Harvard-affiliated Spaulding Rehabilitation Hospital. “They’re home to some of the body’s largest muscles, and building healthy legs can improve one’s performance, reduce injury, and increase endurance.”

Four leg muscle groups to build for summer activities

Four muscles do the most leg work: quadriceps, gluteus maximus (glutes), hamstrings, and calves. Here is a look at each.

Quadriceps (quads). Also known as the thigh muscles, the quads are a group of four muscles (hence the prefix “quad’). They extend your leg at the knee and power every leg action: stand, walk, run, kick, and climb.

Glutes. The body’s largest muscles, the glutes (your buttock muscles) keep you upright and help the hips and thighs propel your body forward.

Hamstrings. The hamstrings are a group of three muscles that run along the back of your thighs from the hip to just below the knee. They allow you to extend your leg straight behind your body and support hip and knee movements.

Calves. Three muscles make up the calf, which sits in the back of the lower leg, beginning below the knee and extending to the ankle. They work together to move your foot and lower leg and push you forward when you walk or run.

Spotlight muscle strength and length

Strength and length are the most important focus for building summer-ready legs, says Daryanani. “Strengthening leg muscles increases power and endurance, and lengthening them improves flexibility to protect against injury.”

If you are new to exercise or returning to it after time off, first get your legs accustomed to daily movement. “Start simply by walking around your home nonstop for several minutes each day, or climbing up and down stairs,” says Daryanani.

After that, adopt a walking routine. Every day, walk at a moderate pace for 20 to 30 minutes. You can focus on covering a specific distance (like one or two miles) or taking a certain number of steps by tracking them on your smartphone or fitness tracker. You won’t just build leg strength — you’ll reap a wide range of health benefits.

There are many different leg muscle-building exercises, some focused on specific activities or sports. Below is a three-move routine that targets the four key leg muscles. Add them to your regular workout or do them as a leg-only routine several times a week. (If you have any mobility issues, especially knee or ankle problems, check with your doctor before starting.)

To help lengthen your leg muscles and increase flexibility, try this daily stretching routine that includes several lower-body stretches.

Dumbbell squats

Muscles worked: glutes and quads

Reps: 8-12

Sets: 1-2

Rest: 30-90 seconds between sets

Starting position: Stand with your feet apart. Hold a weight in each hand with your arms at your sides and palms facing inward.

Movement: Slowly bend your hips and knees, leaning forward no more than 45 degrees and lowering your buttocks down and back about eight inches. Pause. Slowly rise to an upright position.

Tips and techniques:

• Don’t round or excessively arch your back

Make it easier: Do the move without holding weights.

Make it harder: Lower yourself at a normal pace. Hold briefly. Stand up quickly.

Reverse lunge

Muscles worked: quads, glutes, hamstrings

Reps: 8-12

Sets: 1-3

Rest: 30-90 seconds between sets

Starting position: Stand straight with your feet together and your arms at your sides, holding dumbbells.

Movement: Step back onto the ball of your left foot, bend your knees, and lower into a lunge. Your right knee should align over your right ankle, and your left knee should point toward (but not touch) the floor. Push off your left foot to stand and return to the starting position. Repeat, stepping back with your right foot to do the lunge on the opposite side. This is one rep.

Tips and techniques:

• Keep your spine neutral when lowering into the lunge.
• Don’t lean forward or back.
• As you bend your knees, lower the back knee directly down toward the floor with the thigh perpendicular to the floor.

Make it easier: Do lunges without weights.

Make it harder: Step forward into the lunges, or use heavier weights.

Calf raises

Muscles worked: calves

Reps: 8-12

Sets: 1-2

Rest: 30 seconds between sets

Starting position: Stand with your feet flat on the floor. Hold on to the back of a chair for balance.

Movement: Raise yourself up on the balls of your feet as high as possible. Hold briefly, then lower yourself.

Make it easier: Lift your heels less high off the floor.

Make it harder: Do one-leg calf raises. Tuck one foot behind the other calf before rising on the ball of your foot; do sets for each leg. Or try doing calf raises without holding on to a chair.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

While psychiatric medications can be essential for improving mental health and well-being, they often come with unwanted side effects. One particular side effect of many psychiatric medications is weight gain. In this post we will explore how these medications cause weight gain, and what you can do to lessen the impact of this unwanted effect of many psychiatric medications.

What are the different types of psychiatric medications?

There are five main types of psychiatric prescription medications: antidepressants, antipsychotics, anxiolytics (also known as anti-anxiety medications, which can include medications for sleep), mood stabilizers, and stimulants. Stimulants are not likely to cause weight gain. In fact, many of them reduce appetite and can cause weight loss as a side effect. These medications will not be discussed in this post.

Antidepressants can be divided into separate classes:

• SSRIs, or selective serotonin reuptake inhibitors, increase serotonin levels in the brain.
• SNRIs, or serotonin-norepinephrine reuptake inhibitors, increase both serotonin and norepinephrine in the brain.
• TCAs, or tricyclic antidepressants, increase serotonin, norepinephrine, and dopamine in the brain.
• MAOIs, or monoamine oxidase inhibitors, increase serotonin, dopamine, and norepinephrine in the brain.

Why do antidepressants cause weight changes?

All of these medications increase serotonin levels in the brain. Serotonin regulates mood and affects appetite, yet this can have varying results depending on length of treatment. Short-term use reduces impulsivity and increases satiety, which can reduce food intake and cause weight loss. However, long-term use (longer than a year) can cause downregulation of serotonin receptors, which subsequently causes cravings for carbohydrate-rich foods such as bread, pasta, and sweets that ultimately may lead to weight gain. The antidepressants with the highest risk of causing weight gain are amitriptyline, citalopram, mirtazapine, nortriptyline, trimipramine, paroxetine, and phenelzine.

Why do antipsychotic medications worsen obesity-related diseases?

Antipsychotics can also be categorized into two classes: typical and atypical antipsychotics. Both classes can cause weight gain, but they differ in that atypical antipsychotics cause fewer movement disorder side effects. Like antidepressants, antipsychotics affect the chemical messengers in the brain associated with appetite control and energy metabolism, namely serotonin, dopamine, histamine, and muscarinic receptors. In addition to causing weight gain, antipsychotics can also impair glucose metabolism, increase cholesterol and triglyceride levels, and cause hypertension, all of which can lead to metabolic syndrome and worsen obesity-related diseases. The antipsychotics most likely to cause weight gain are olanzapine, risperidone, and quetiapine.

What about anti-anxiety medications and weight changes?

There is no clear link between traditional anti-anxiety medications such as benzodiazepines and weight gain. However, many antidepressants are also used for the treatment of anxiety, and may cause weight gain as discussed above.

Similarly, not all medications for sleep cause weight gain; one that has been associated with weight gain is diphenhydramine (the active ingredient in Benadryl that is also used in many over-the-counter sleep aids). Diphenhydramine can contribute to weight gain by causing increased hunger and tiredness, which can make a person less active. Other sleep aids such as zolpidem (Ambien) or eszopiclone (Lunesta) have not been linked to weight gain.

Trazodone, a medication used for depression as well as insomnia, reduces excess serotonin at some sites, while increasing serotonin levels at other sites, thus affecting appetite as previously discussed.

Mood stabilizers are often used to treat bipolar disease, and can increase appetite or cause changes in metabolism. Although some antidepressants and antipsychotics are also used to treat bipolar disease, mood stabilizers such as lithium, valproic acid, divalproex sodium, carbamazepine, and lamotrigine are the mood stabilizers often used for treatment of bipolar disorder, and with the exception of lamotrigine, they are all known to increase the risk of weight gain.

There are effective strategies to minimize weight gain

For people taking psychiatric medications for mental health, there are strategies to minimize weight gain. Optimizing lifestyle and daily habits is important. This includes eating a healthy diet with whole foods and limiting processed foods and added sugars; staying physically active; minimizing stress; and ensuring adequate restful sleep. Physical activity, in particular, can have a double effect of both improving mental health and minimizing weight gain that might otherwise occur. Cognitive and behavioral strategies under the guidance of a psychologist may be useful for avoiding giving in to any increased cravings for sweets and carbohydrates.

Another strategy to minimize weight gain is to work with your healthcare provider to determine if there might be an appropriate alternate medication option with a lower risk of weight gain. In addition, the anti-diabetes medication metformin has been shown to be effective in treating and preventing psychotropic-induced weight gain. Other medications prescribed for weight loss may also be appropriate to help counteract the weight gain experienced by psychotropic medications.

Be aware that almost all medications have a risk of causing side effects, and it is important to ensure that the benefits of taking any medications will outweigh the risks. Speaking to your primary care provider, psychiatrist, or obesity medicine specialist can be useful in determining which options may work best for you.

About the Author

Chika Anekwe, MD, MPH, Contributor

Chika V. Anekwe, MD, MPH is an obesity medicine physician at Massachusetts General Hospital (MGH) Weight Center and Instructor in Medicine at Harvard Medical School (HMS). Her professional interests are in the areas of clinical nutrition, … See Full Bio View all posts by Chika Anekwe, MD, MPH