Monthly Archives: April 2017

Why the Risk for Amputations Jumps If You’re Poor and Have Diabetes

When you have diabetes, you’re at a higher risk for an amputation, particularly an amputation of a lower limb or a toe.

In fact, the American Diabetes Association reports that about 60 percent of lower-limb amputations in adults that are not caused by trauma occur in people with diabetes. The risk is present for both Type 1 and Type 2 diabetes.

And the five-year death rate for those who have had an amputation caused by a diabetic foot ulcer ranges from 35 percent to 80 percent. That percentage is even worse than some cancers, says Dr. Katherine A. Gallagher, associate professor of surgery at the University of Michigan in Ann Arbor.

This higher risk comes from a cycle of uncontrolled blood sugar over time and unnoticed and untreated infections. Someone with poorly controlled diabetes may not even know they have an infection because they’ve also developed a complication called peripheral neuropathy, which can take away feeling in the feet. These infections, if not detected or treated, can lead to the need for an amputation.

People who are economically disadvantaged and who have diabetes are at a higher risk for amputations. In fact, there’s an area of the country identified as the “diabetes belt” by the Centers for Disease Control and Prevention because of the high rates of diabetesthere. The diabetes belt includes parts of 15 states in the Southeast such as Alabama, Kentucky, Tennessee and West Virginia. “The diabetes belt counties also have high rates of poverty, low levels of college educational attainment, and the residents were predominantly African-American,” says Judith Wylie-Rosett, a registered dietitian and professor and division head of health promotion and nutrition research in the Department of Epidemiology & Population Health at Albert Einstein College of Medicine in New York City. The areas in the diabetes belt also have higher incidences of stroke and cardiovascular disease compared with other parts of the U.S., Wylie-Rosett adds.

 Other research has pinpointed that in areas with less available medical care – which often means poorer areas – the risk for amputations is higher among people with diabetes.

So why is the risk for amputation higher in those with lower incomes?

First, access to care can be more difficult, Gallagher says. Someone with a lower income may not have health insurance – or they may have it but still have trouble with related health costs. They may have a harder time getting off work or away from child care or other obligations. If you live in a rural area, it could be hard to make it to a doctor’s faraway location. All of that makes it harder to get to the doctor for regular checkups or when a problem occurs. By the time a problem gets particularly bad, there may be an infection that’s too severe to treat – and an amputation may be required.

“There may not be the money or resources except for emergency care,” says Dr. Rob Pedowitz, medical director of the Family Practice of CentraState in Freehold, New Jersey.

“Often, secondary complications, such as nonhealing wounds and peripheral neuropathy, are not detected early, making the complications much more devastating,” Gallagher says.

There’s also less knowledge about taking control of your own care, says Dr. Misty D. Humphries, assistant professor, Division of Vascular and Endovascular Surgery at the University of California–Davis Medical Center. “Patients do not realize they have control over their care. They frequently become ‘passive observers’ of their own care,” she says. However, diabetes care is largely self-managed, so when you have it, you need to take an active role.

Another issue is the high cost of healthier food, says anesthesiologist and pain physician Dr. Sheetal DeCaria of the University of Chicago. Meals with less-healthy simple carbohydrates are cheaper and often easier to obtain than fresh meals with fruits and vegetables. “For example, fish is more expensive than beef, and an avocado is more costly than a candy bar,” DeCaria says.

Despite these hurdles, if you’re living with diabetes and want to take better care of your health, keep these guidelines in mind:

  • Take your diabetes diagnosis seriously – and plan changes right away to help yourhealth. Although medications are important, they’re not the only resource to treat diabetes. “The truth is the only way to fix these conditions is a lifestyle adjustment, not simply medications,” Gallagher says.
  • See a doctor regularly. This may seem hard to do at first. However, preventing future health problems and treating any current ones while they are still minor will save you money and time (not to mention pain) in the long run, Pedowitz says. Aim to visit a doctor who can check your diabetes every three months.
  • Take better care of your feet. When you visit your doctor every three months, ask him or her to check your feet for any infections or health concerns, Pedowitz recommends. Inspect your feet daily for nicks, cuts or scrapes. Always wear protective footwear, even in the house. And see a foot doctor once a year.
  • Educate yourself about diabetes. Ask your doctor about a local certified diabetes educator or registered dietitian who you can see. A diabetes educator or dietitian can fill you in on more details about diabetes care. And look out for community healthworkshops or support groups that provide screening and education related to diabetes. “Education about the condition and how to change your life can put you in the driver’s seat of your health care and ensure that amputation is not an issue you have to deal with,” Humphries says.
  • Follow common-sense good health practices. This includes moving more, eating less sugar and simple carbohydrates (like white bread or pastas) and not smoking.

There are programs funded by the Centers for Disease Control and Prevention to help meet the challenges of addressing patients who are lower-income, living in rural areas and have other factors that are associated with diabetes and diabetes complications, Wylie-Rosett says.

The Real Facts About Eating Disorders

I am a psychologist specializing in children and teens who have an eating disorder such as anorexia nervosa, bulimia nervosa and avoidant restrictive food intake disorder, or ARFID. When I tell people what I do for a living, I’m often bombarded by harsh, judgmental comments such as “they could stop if they wanted to” or “there must be something wrong with that mother.” When I tell them I work in the Bronx, the comments are often along the lines of: “You must not be that busy – only rich, white kids have eating disorders!” In discussing this with other psychologists and mental health professionals, I am frequently met with “I could never treat them – they are so difficult.” The most difficult part of hearing these statements, especially by fellow mental health practitioners, is that they perpetuate the stigma associated with eating disorders that lead many to self-blame and delay or avoid treatment. My mission is to promote the actual facts about eating disorders to mental health professionals, parents, teachers, kids, pediatricians and the public. So here some of the things everyone should know:

Eating disorders can be fatal.

Anorexia nervosa is the most fatal of all mental health disorders, with approximately 50 percent of those deaths attributed to suicide. Anorexia nervosa and bulimia nervosa have high rates of suicide, self-injury, cardiac-arrest, early-onset osteoporosis, kidney failure and pancreatitis, just to name a few. Binge eating disorder often leads to morbid obesity and other health problems resulting from obesity, including diabetes, heart disease and high blood pressure. If these facts surprise you, you are not alone. Most mental health specialists are not aware of the high fatality rates and suicidality among patients with an eating disorder.

Eating disorders come in all shapes, sizes and genders.

When you think about a person with an eating disorder, whom do you picture? At least 10 percent of people diagnosed with an eating disorder are men and boys, and this number is probably an underestimate, as often boys and men are not screened for eating disorders and tend to under-report symptoms. Also, often surprising to many people is the fact that the highest prevalence of bulimia nervosa is among Hispanics, regardless of their level of income. Finally, eating disorders occur among people of all weights and sizes. There is no way to tell from looking at someone whether or not they have an eating disorder.

Eating disorders start for many reasons.

Emerging research supports a genetic predisposition to an eating disorder. That being said, genetics alone do not cause an eating disorder. The most common way an eating disorder starts is with a diet. For most people, the diet works or it doesn’t work, and they do not develop an eating disorder. For others, rapid weight loss can trigger an eating disorder. Once the eating disorder takes over, it’s very hard for someone to escape the grip on their own. Some find comfort, even companionship, with their eating disorder and have difficulty breaking up with their friend. Many of my patients tell me that restricting, binge eating and purging give them relief from other stressors in their life. Although this relief is short term, it’s difficult for many to break this cycle. Still another way an eating disorder, such as ARFID, might start is with a choking episode or a severe allergic reaction. Following this, some children are afraid to eat some or all foods. Even though they may not have a concern about how their body looks, they lose a lot of weight, and medically their body doesn’t know (or care) how the weight loss started or what’s maintaining it – our bodies just know they’re malnourished.

Eating disorders rarely occur in isolation.

Weight, shape and eating are only part of the story when it comes to eating disorders. It’s rare for someone to have a diagnosis of only an eating disorder. Eating disorders are associated with anxiety, depression, post-traumatic stress disorder, history of sexual abuse, substance abuse and personality disorders. Treatment must look at the big picture. Without this, as one problem gets fixed, other problems tend to pop up quickly.

Eating disorders can be treated.

One of the most dangerous myths about eating disorders is that they can’t be treated and that once you have an eating disorder, you can never be fully better. You can be free from your eating disorder. Yes, eating disorders are serious and some are difficult to treat at times; however, we have effective treatments for patients suffering with an eating disorder, and the treatments really work.

So What Can I Do If I Think My Child Has an Eating Disorder?

  • Seek help: Early intervention is the best way to treat an eating disorder. Even if you think it’s “not quite” an eating disorder, have your child evaluated as soon as possible.
  • Seek help from someone who knows how to recognize and treat eating disorders. Not all mental health practitioners and pediatricians have specific training in eating disorders. Ask the person evaluating your child how many patients with eating disorders they treat, and ask if they have specialized training in this area. See if the treatment they are using is evidence-based. This means that there’s scientific research supporting the effectiveness of the treatment.

The most important advice I give to parents who are worried their child might have an eating disorder is to listen to your instincts. Most parents know their children better than the doctors. If you’re worried that your child might have an eating disorder and your doctor minimizes your concerns, get another opinion. It’s critical that you feel heard by your team and that they make you and your child feel hopeful that things will get better.

You can find a list of therapists who specialize in eating disorders through the National Eating Disorders Association or through the Academy of Eating Disorders. Don’t wait until it’s too late; get help today.

How Big the Risk of Alcoholic Drinkers to Be Exposed to Breast Cancer

For years, a seemingly endless march of studies has pronounced that moderate consumption of alcohol could be beneficial for heart health. If you like a glass of wine with dinner, you’ve probably welcomed this news. But if you have other risk factors for breast cancer, you might want to scale back on your alcohol consumption.

Alcohol and the Heart

According to the Mayo Clinic, some of the studies suggesting that alcohol has heart-protective properties have focused on the potential health benefits of compounds in red wine called flavonoids, which are antioxidants that have been linked with reduced inflammation in the body and other health benefits that can reduce your chances of developing heart disease. Other studies have noted that a substance called resveratrol could be at work, and that moderate intake of alcohol can lead to a small increase in HDL cholesterol – that’s the good kind – and anti-clotting properties that can also be beneficial to heart health.

Therefore, some researchers and doctors have offered that drinking in moderation could be good for you. The American Heart Association defines drinking in moderation as one to two drinks per day for men and one drink per day for women. A drink is measured as about 10 grams of alcohol, which translates to one 12-ounce beer, four ounces of wine, 1.5 ounces of 80-proof spirits or 1 ounce of 100-proof spirits.

However, despite the fanfare surrounding some studies, the data on potential health benefits of alcohol is still mixed. The American Heart Association “does not recommend drinking wine or any other form of alcohol to gain these potential benefits, ” but it does recommend lowering your cholesterol and high blood pressure, getting plenty of physical activity, eating a healthy diet and controlling your weight.

Alcohol and Breast Cancer Risk

These health guidelines are similar to those offered by the American Cancer Society for helping to reduce your risk of cancer, which says limiting alcohol intake lowers the risk of developing breast cancer. “Even a few drinks a week is linked with an increased risk of breast cancer in women,” the ACS reports. “This risk may be especially high in women who do not get enough folate (a B vitamin) in their diet or through supplements. Alcohol can also raise estrogen levels in the body, which may explain some of the increased risk. Cutting back on alcohol may be an important way for many women to lower their risk of breast cancer.”

Dr. Melissa Pilewskie, a breast surgeon oncologist at Memorial Sloan Kettering Cancer Center in New York City, says “what we know from the data is that there is a low to moderate risk association with alcohol consumption and breast cancer risk.” She says women who drink one or more alcoholic drinks per day have a greater risk of developing breast cancer than women who don’t drink or drink just one drink per day. “Basically,” Pilewskie says, “women who don’t drink or have an occasional drink, there doesn’t seem to be an increased risk. But for those who drink more than, on average, one drink per day, we do see an increase in breast cancer risk.”

The size of this risk is similar to other “small risk factors, such as having a family member with breast cancer, obesity and things like that,” Pilewskie says. A 2017 reportproduced by the World Cancer Research Fund and the American Institute for Cancer Research pooled data from 16 studies looking at the connection between alcohol and premenopausal breast cancer and another 15 studies that examined the connection between alcohol and postmenopausal breast cancer. The report states that women who drank one alcoholic drink per day had a 5 percent increased risk of developing premenopausal breast cancer while postmenopausal women who drank one alcoholic drink per day had a 9 percent increased risk of developing breast cancer.

It seems clear that there’s a link between alcohol consumption and breast cancer. But what’s different about the risk associated with alcohol intake versus other risk factors, Pilewskie says, is that “this is something that we have control over. We don’t have control over our sex or our family history,” but we can decide to not drink. “I counsel women that if they’re concerned or have other risk factors for breast cancer that they should limit their alcohol consumption to one drink per day or less,” she says.

Unlike with some of the heart health findings, there does not seem to be any variation in risk associated with different types of alcoholic drinks. And as Hollie Zammit, an outpatient oncology dietitian at UF Health Cancer Center, Orlando Health, notes, ethanol – the alcohol that’s in all our drinks regardless of whether it’s beer, wine or liquor – “is a group 1 carcinogen, and it can increase our risk for several cancers.” The International Agency for Research on Cancer maintains the list of carcinogens and defines group 1 carcinogens as substances that are known to cause cancer in humans. This group also includes asbestos, plutonium, radon and talc, among more than 100 other substances and compounds.

 Although we know there’s a connection between alcoholic beverages and breast cancer, the causal mechanism is still being studied. “We don’t really understand where the association comes from. Is it alcohol itself or other changes in the body that occur in women who drink?” Pilewskie says. “We also don’t really know if having one drink per day is the same as not drinking every day and then having seven drinks in a day. That is another gray zone. Whether it’s consumption at one time or cumulative consumption is also an unknown,” she says.

Pilewskie says awareness and education about the potential risk surrounding alcohol is the key. “It’s something to be aware of and something that, from a physician standpoint, I think is often not communicated.” She says a study she was involved in found that “about 20 percent of our high-risk patients drank more than one drink per day, so that’s a population where we can have impact in providing education on this. I think it’s important for women to know, but also for physicians to talk about this as a risk factor.”

Zammit agrees, saying “for my patients who don’t drink, I tell them, ‘don’t start.’ For my patients who have a couple glasses of wine, we encourage them to cut back or cut it out if they can.”

Dr. Raquel Reinbolt, assistant professor of internal medicine at The Ohio State University Wexner Medical Center, also recommends moderation and common sense when it comes to alcohol consumption. “From a common-sense point of view, we know that for anyone, a lot of alcohol is not a good thing.” In addition to the potential for increased risk from the alcohol itself, alcoholic drinks are high in calories with no nutritive value. As such, it’s easy to pack on the pounds when you’re drinking too much. This is a problem because patients who are overweight are at a higher risk of developing breast cancer. So be mindful of how much you drink and as much as possible opt for a low-sugar soft drink or water instead of an alcoholic beverage. “In a practical sense, moderation is appropriate. If I were an internal medicine doctor, I would be telling patients the same thing – the data is interesting, and we should caution patients to be moderate and use common-sense ” in regard to deciding whether and how much to drink.

7 Things Not to Say to Someone With Diabetes

For the more than 29 million Americans who have diabetes, living with the disease is challenge enough. However, awkward, ill-informed or insensitive remarks can add to the difficulties faced.

Well-meaning friends, family members, co-workers or strangers can inadvertently make comments that can be judgmental or are based on stereotypes or myths about diabetes. To address misconceptions, it’s important to know what not to say to someone with diabetes. Based on my experiences as a certified diabetes educator and registered dietitian, here are some of the most common diabetes faux pas, paired with the facts and advice on how best to show your support:

1. “Why do you have diabetes – did you eat too much sugar?” Diabetes is not caused by eating too much sugar. Diabetes and its risk factors are complicated. Type 1 diabetes is caused by an autoimmune response in your body (the body’s immune system attacks itself), genetics and still-to-be discovered factors that trigger its onset. Right now, we have no way to stop the onset of Type 1 diabetes. The onset of Type 2 diabetes is caused by a combination of genetics, lifestyle and many unknown factors. While research has shown that, for some, we can prevent or delay Type 2 diabetes, there is no single cause for diabetes.

2. “Are you sure you should be eating that?” People living with diabetes have to think about what they eat for every meal and snack. However, there is no such thing as the “diabetes diet.” A well-balanced diet is recommended for everyone, not just for people with diabetes. It’s best to avoid giving unsolicited advice if you’re trying to help someone meet their nutrition goals. Instead, show your support by making healthy food choices yourself and by having healthy food options available when sharing a meal.

3. “You don’t look like you have diabetes.” Do not assume there is a certain look for diabetes. While being overweight can raise a person’s risk of developing Type 2 diabetes, many people with Type 2 diabetes are not overweight or obese. Anyone can have diabetes.

4. “Oh, you have to take insulin. Do you have the bad type of diabetes?” Diabetes affects each person differently. It’s a common misconception that a person who requires insulin injections has a more severe form of the disease, as compared to someone who takes pills or manages their diabetes with diet and exercise alone. People with Type 1 diabetesneed to take insulin multiple times every day because their body does not produce any insulin. People with Type 2 diabetes do produce insulin. However, Type 2 diabetes can change over time, and medication needs may change and one may require insulin to keep their blood sugar in a healthy range. There is no good or bad type of diabetes. Neither does taking insulin or any diabetes medication reflect how well a person manages their diabetes or signal any type of failure. Everyone with diabetes has different needs, and by working with their health care team, they can determine the best food, activity and medication plans for them.

5. “I didn’t know you’re diabetic.” Although this statement may be said in a caring manner, calling someone “diabetic” appears to label them by their chronic illness. Some find this stigmatizing and offensive. Rather, say, “I didn’t know you have diabetes.”

6. “Your blood sugar is high. Did you do something wrong?” Blood sugar levels are key in making diabetes management decisions. That being said, glucose levels are not an indicator of success or failure, but one of many metrics monitored to provide feedback. Keep in mind that there are many variables that affect blood sugar levels, some of which are beyond a person’s control. Instead of asking someone if they did something “wrong,” offer positive, encouraging support.

7. “I hope you don’t get diabetes complications like my aunt.” People with diabetes are well aware of the potential complications of the disease. You do not need to highlight them. Listen to the person in your life who has diabetes, and hold off on sharing stories about unfortunate complications your friends and loved ones may have experienced. Many advances in diabetes care have greatly reduced the rates of complications. Healthcare teams and diabetes education programs can help guide and support each person with diabetes and their family members to determine the best care plan for each individual.