Tuesday, December 28, 2010

Real Food-What to Eat and Why

I have my new son-in-law to thank for a holiday gift that begs sharing with everyone.  Real Food-what to eat and why by Nina Planck, published in 2006, is a gem of a resource for anyone who feels confused or wants to have much clearer guidelines about what to buy and eat and what to leave on the shelf.  Endorsed by Michael Pollan for its persuasive and "eye-opening" qualities, Planck takes us back to the days of "real" food.   By this she means foods that are old, that we humans have been eating for a long time. And she also means foods that are traditionally prepared "the way we used to eat them."  One of Pollan's food rules was to avoid foods your grandmother would not recognize.  Planck goes further to endorse local and seasonal fruits and vegetables(goodbye to the perfectly unblemished and insipid winter raspberries from god knows where); whole grains (goodbye to white flour and many of those holiday treats we just downed aplenty);and fats and oils should be unrefined (goodbye to margarine, "I cant' believe it's not butter", trans, hydrogenated etc--welcome home EVOO!).  The book is chock full of information, resources, and convincing documentation. We can all challenge ourselves to Planck's lessons that will help us ring in the new year with real, delicious foods to keep us healthy in 2011.

In this same vein, schools can participate in new awareness about healthy eating through  Real Food Challenge which carries the same name and adheres to much the same principles.
Bon Appetit!

image from WebMD.com

Wednesday, December 22, 2010

Why I Love Minnesota

image from Edmonton.ca

Wanting to read about the UConn women's  marvelous basketball victory I leafed through this morning's New York Times sports section only to be drawn to photos of kids playing hockey.  Since I have brain injury and sports related concussion on my mind these days I read on.  It turns out that some of the Minnesota Youth Leagues--including those in the town where I grew up--have instituted a simple and effective way to minimize injuries and to increase enrollment at the same time.

We have been listening to the NFL grapple with ways to make football safe and school athletic departments are working to lessen the impact of head injury.  Now the Hockey Education Program (HEP) from Minnesota shows us how.  By simply instituting a system of the "fair play point" which is "an extra point in the standings awarded teams, win or lose, for each game in which they take fewer than a designated number of penalty minutes," they have managed to reduce penalties for hits to the head from 12.4 per 100 games in 2004-05 to only 2 per 100 the following season.  In addition, checks from behind which can lead to concussions as well as spinal cord injuries declined by two thirds.

In Quebec where a similar program was implemented in the 1990's they have not only succeeded in documenting reduced injuries but have increased youth registration. I am not surprised since on more than one occasion I have had a despondent boy in my office looking for a way to get out of hockey as he advanced to the older teams where checking and real injury became too threatening.

Coaches to champion teams in Minnesota say they can see that players who have been raised on this new approach to the game play in a more "effective" and elegant as well as safer way.  Minnesota players are being recognized as being better players where "lazy penalties and the dumb penalties and the stuff after the whistle" is no longer a distraction from the real sport.

It seems to me that all sports might take a lesson from the Minnesota playbook and realize that we can teach our athletes to do well in their sports without jeopardizing their futures.

Tuesday, December 21, 2010

College Students and Mental Health

A story in the New York Times this week highlighted the fact that many students on campus are seeking mental health services and sometimes overwhelming the system.  This article touched on some of the reasons that colleges seem to dealing with a great deal of psychological and psychiatric issues in addition to the usual mono, strep throat and exhaustion that are the more mundane problems they see.

Just a year ago the Journal of Adolescent Health published a review article of the research to date about this very subject.  Some interesting findings include:

  • 17% of students in a national survey of 26 colleges and universities (the Healthy Minds Study) met the screening criteria for depression.
  • increases in help-seeking behavior (rather than increases in mental illness) contribute to the perceived rise in mental health problems among college students 
  • there is an increase in severity of problems presenting to student health services.  The researchers attribute this to the fact that more students with more severe (and often previously diagnosed and treated) mental health problems are applying to, being accepted at and matriculating in colleges.  Increased access during adolescence and improved outcomes with current medications make it more likely that students will be able to function.
  • In spite of this studies show a high prevalence of untreated mental illness.  Only 24% of those diagnosed with depression were receiving treatment. 
  • financial constraints are rarely a barrier to care for college students since at least the first encounters are covered by student health insurance.
  • Improved faculty, staff and student training will be necessary to steer suffering students toward help and prevent tragedies.
Sometimes, student health and the resources they bring to bear at college are not enough. Many young adult patients come home each year and need to re-group, find treatment, start medication, gain weight or simply make a new start.   In New York City, Columbia Presbyterian has an excellent program for college students who have been asked to take or have decided to take a medical/psychiatric leave.  Called the Columbia College Student program it is group based and problem oriented, allowing like minded students to have a place where they can learn new skills and support each other during their transition back to health.

Colleges are in a uniquely effective position to detect, diagnose, treat, and refer students for treatment of mental health disorders, many of which emerge during exactly these years of late adolescence.  Although there is much work to be done, many innovative programs and initiatives are being studied in hopes of creating a better safety net.

Thursday, December 16, 2010

Paying Attention to Attention

At this time of year when students start streaming back from college for break, I usually have a few who come in to ask for medication for their newly (self-) diagnosed ADHD.  What has usually happened is that they have just gone through reading week  and final exams and have discovered that the ten bucks they shelled out for their roommate's Adderal did a lot to help them focus and stay up all night to write the final paper in Sociology.  Usually these are students who were never prescribed medication before,performed well enough in high school to go to college, often are risk takers or adventure seekers and  get insufficient sleep. And rarely do they have ADHD.  Frankly, this group is not the one that makes me worry about missing a diagnosis.

A recent article in the New York Times by Dr Perri Klass highlighted the over-use of the ADHD diagnosis and the current trend toward blaming difficulties in focussing on our fast-paced, internet-based culture.  She makes passing  mention in the article of the "inattentive-type" ADHD student who often passes right under the radar.  This is the group of patients and students that concerns me most.  These students are more likely to be girls than boys, more likely to have been missed for a long time because they do not cause trouble. They are the "quiet daydreamers, slow, distracted, and forgetful," as described in a recent article in Pediatric News by Dr. Barbara Howard of Johns Hopkins University.  The concern with these inattentive-type ADHD patients is that they need a careful evaluation to rule out other causes of their dysfunction.  As Dr Howard states, "far and away, the most common missed diagnosis and frequent bedfellow of inattentive-type ADHD is anxiety."

And this is the story that I most frequently uncover in practice when a student approaches me with a request for stimulant medication.  There is usually an underlying problem of anxiety, drug use, sleep deprivation, or real life concerns over family matters.  Only a careful assessment can uncover whether a student has these issues going on which need sorting through or whether indeed there is a diagnosis of ADHD that has been overlooked.  In any case they deserve our attention!

image from newyorkdailynews.com

Wednesday, December 8, 2010

ImPACT testing now available in my office

I am now doing my part to protect the heads of athletes in our community. As a Credentialed ImPACT Consultant I can now administer and interpret the test in my office.

ImPACT testing is a quick and easy tool to use in conjunction with careful evaluation and examination of athletes and others who may have sustained a head injury. It is well known from the recent flurry of coverage in the media that concussions are more common and more difficult to manage well than heretofore imagined.   I have posted many pieces on this site about the evolution of our thinking on this subject. Just yesterday, Governor Christie announced  new legislation in New Jersey that requires all school districts to create a policy to address the issue.

ImPACT is a twenty minute, online test administered and interpreted by a trained professional. In the NHL, NFL, many schools and other sports organizations, it is administered as a baseline during pre-season and then used to help determine when an athlete's visual memory, reaction time and verbal memory have returned to normal following an injury. In many cases this objective information is invaluable in helping to determine when it is safe to return to practice, competition and play.

My adolescent medicine training is particularly helpful in making these decisions. The importance of sports and team membership in building a strong sense of well-being cannot be underestimated. At the same time, it may take an objective professional to keep an eye on long term health and goals. Many complex factors go into this decision: parental concerns, family's tolerance for risk, previous injuries, school policies, objective medical information, school functioning, role on the team, success of the team and pressures from the coach to name a few. 

Anyone interested in ImPACT testing through my office can find more information on my website or can call my office. I am happy to consult with students and families even if they are not currently patients in my office.  Many insurance plans cover ImPACT testing.

Monday, December 6, 2010

No Child Left Inside: Letting Nature Nurture

After we talk about excessive online activity and obesity in our young people, let's think about getting our kids back to nature.  At the recent annual meeting of the American Academy of Pediatrics the keynote speaker was Richard Louv who makes the case for getting our kids outside.  He has coined the phrase "nature deficit disorder" and on his website, Children and Nature, he cites scientific literature and posts oodles of opportunities for kids to get outside, no matter where they live.  There is even a downloadable prescription pad for pediatricians to prescribe outdoor play. It says:
  • Go outside and play in nature.
  • Limit your “Screen Time” to no more than 60 mins each day.
  • Read stories about nature.
  • (Or have someone read them to you.)
Another speaker at the same conference enjoined listeners to help parents have permission to "bring back boredom" to allow kids to daydream and be more creative.  Planting seeds, playing in the snow, looking at the sky, listening to the birds, smelling the air: it doesn't have to be very complicated.  What seems "boring" will feed the imagination if we allow it to speak.

We are all searching for ways to treat the anxieties that we see in our patients, students and children.  Many agree, at least anecdotally, that too much time is spent in sedentary activities.  A recent survey by the American Psychological Association on stress noted that "tweens and teens report that they turn to sedentary behaviors to make themselves feel better when they are really worried or stressed, such as listening to music (36 percent of tweens and 66 percent of teens), playing video games (56 percent of tweens and 41 percent of teens) or watching TV (34 percent of tweens and 30 percent of teens)." 

Perhaps the panacea lies in the notion of getting kids off the couch and into the outdoors.   This may afford them the best chance of avoiding the metaphorical "couch" treatment for their mental health. 

image from www.greenloudon.wordpress.com

Sunday, December 5, 2010

Staying Connected in a Fast Paced World

 The iConnected Parent by Barbara Hofer and Abigail Sullivan Moore is a new  must read for any parent of high school seniors or college age students.  And  parents with children of any age who want to learn more about contemporary commnication habits may want to take a look as well.  The book reveals the blessings and pitfalls of our current electronic connectivity and its impact on young adult development. "iConnected Parents...represent a new era in parenting:a potent new mix of devoted parent, guide, and friend, fluent in speed-dial, Facebook, and the flick of a mouse."  They explore the continuous tether that links our kids to us in ways that were not possible when most of us were their age.

Hofer is a professor of psychology at Middlebury who has researched the link between parent-child communication and the development of independence in adolescents and young adults.  Moore is a journalist and frequent contributor to the New York Times.  In this book they present a compilation of some research and some investigative reporting with many interviews of students, parents, and administrators who have a range of opinions on the issue.

A few highlights:
  • Families of the college students interviewed communicate one way or another an average of more than 13 times per week.
  • Parents are intervening in course selection, paper editing, negotiations over grades, and roommate concerns in ways that college administrators find distressing if not illegal and unethical.
  • The new connectivity between generations can stir some complicated involvement that not all parties find helpful or healthy.
  • Parents need to be better listeners and not problem solvers.  Having easy access to advice with one click may serve to increase anxiety in parents as well as kids.
  • Dependence on and easy access to Mom and Dad does not foster resilience, patience or self-reliance.
  • These new relationships are so pervasive now that it may be the start of a new inter-generational norm, heretofore not experienced in American life.
My criticisms of the book include the fact that the research is presented in a thoroughly unscientific and unquantitative way.  Not nearly enough thought is given to Facebook and how parents should manage their accounts or interFace with their offspring.  Finally, although the subtitle of this book involves the word "college" I wonder about the conncectivity between non-college bound students and their parents. It would also be interesting to know more about the effect of socio-economic and ethnic backgrounds on the issue.

To its credit, this book has one of the best chapters I have read on mental health issues at college.  Not surprisingly, the bottom line when a child is struggling in this way is that communication and connection need to go way beyond the one on one parent-child and include key professionals.

Finally, this is a wonderful book for grandparents to read who often feel left out of modern communication but at the same time marvel at their family's connectivity.   Having a generational perspective on this can help all of us carefully define what the "new normal" should look like so that everyone benefits in the long run.

image from bbc.co.uk

Wednesday, December 1, 2010

Vitamin D Craze Bites the Dust

Nutrition label.

A word of caution.  Whenever a new test, treatment or diagnosis seems to be making the cover stories on the magazines at the grocery store, be wary.   With titles like, "the diagnosis your doctor probably doesn't know about", we are led to believe that we need to jump on the bandwagon.  Frequently these recommendations have something to do with nutrition.

Yesterday the Institute of Medicine announced that the validity of the recent fad to test and treat for vitamin D deficiency is questionable.  It never made sense to me that over 80% of people were allegedly deficient in this vitamin that is nearly ubiquitous in dairy products and can be made in our bodies naturally if we are exposed to sunlight.   (Interestingly there is an article in the same New York Times 11/30/10 issue that discusses the deficiency of active outdoor time in our population.)

Several months ago my own physician sent my blood for a Vitamin D level inspite of the fact that I told him I would not take supplements since I spend at least an hour outside five to six times per week.   Of course I fell in the 80% of Americans who test low for this particular value.  And the test cost over $200.  My theory is that we really do not know yet what exactly we are measuring and what its relevance is to actual Vitamin metabolism in our bodies.

This is just one more lesson to all of us, including physicians who order blood work, to be circumspect about recommendations and to wonder whose idea they are, who is benefiting and above all to ask the question: "Where is the data?"

image from jmarbach.com