Is there a place for coconut oil in a healthy diet?

Coconut oil has seen a surge in popularity in recent years due to many touted health benefits, ranging from reducing belly fat to strengthening the immune system, preventing heart disease, and staving off dementia. These claims are often backed by celebrity endorsements and bolstered by proponents of popular diets such as ketogenic and Paleo, with little support from scientific evidence. On the flip side, and further adding to the confusion, you also may have seen headlines calling out coconut oil as “pure poison,” implying that it shouldn’t be consumed at all. Given these contradictory claims, a question of much public and scientific interest is whether there is room for coconut oil in a healthy diet.

Bad fats, good fats

Coconut oil largely consists of saturated fat (80% to 90% of fat in coconut oil is saturated), making it solid at room temperature. Other sources of saturated fat include animal products such as meat and dairy, and other plant-based tropical oils such as palm oil. Consumption of saturated fat has long been associated with increased risk of cardiovascular disease due to its ability to raise harmful LDL cholesterol levels.

Unlike saturated fats, unsaturated fats are liquid at room temperature. They can improve blood cholesterol levels and reduce inflammation, among other cardiovascular benefits. Unsaturated fats are predominantly found in vegetable oils, nuts, seeds, and fish.

Guidelines advise limiting the type of fat found in coconut oil

The current Dietary Guidelines for Americans recommend consuming no more than 10% of total calories from saturated fat. And last year the American Heart Association (AHA) released a scientific advisory statement recommending the replacement of saturated fats in the diet, including coconut oil, with unsaturated fats. In their statement, the AHA cited and discussed a review of seven randomized controlled trials, in which coconut oil was found to raise LDL cholesterol levels.

The rationale behind the AHA recommendation is that consuming unsaturated fats in place of saturated fat will lower “bad” LDL cholesterol, and improve the ratio of total cholesterol to “good” HDL cholesterol, lowering the risk of heart disease. For those at risk of or who already have heart disease, the AHA advises no more than 6% of total calories from saturated fat, or about 13 grams based on a 2,000-calorie diet. One tablespoon of coconut oil comes close to that limit, with about 12 grams of saturated fat.

Health benefits of coconut oil may be exaggerated

With such salient evidence supporting the replacement of saturated fat, including coconut oil, with unsaturated fat for optimal cardiovascular health, where do the myriad health claims for coconut oil come from?

Many of the health claims for coconut oil are based on studies that used a special formulation of coconut oil made of 100% medium-chain triglycerides (MCTs). This is not the coconut oil available on supermarket shelves. MCTs have a shorter chemical structure than other fats, and are quickly absorbed and metabolized by the body, which is thought to promote a feeling of fullness and prevent fat storage.

However, the coconut oil found on most supermarket shelves contains mostly lauric acid, which is absorbed and metabolized more slowly than MCT. As a result, the health benefits reported from specially constructed MCT coconut oil cannot be applied to regular coconut oil.

Interestingly, lauric acid itself has also been purported to have health benefits. While lauric acid has been shown to increase LDL cholesterol levels, it also raises HDL cholesterol levels, suggesting a potential heart-protective role of coconut oil. However, large epidemiological studies have failed to report protective associations between lauric acid and cardiovascular disease.

Findings from epidemiological studies that report low rates of cardiovascular disease among populations who consume coconut oil as part of their traditional diets (in India, the Philippines, and Polynesia, for example) have also been cited as support for the health benefits of coconut oil. However, in these studies many other characteristics of the participants, including background, dietary habits, and lifestyle, could explain the findings.

Coconut oil: neither superfood nor poison

Based on the current evidence, coconut oil is neither a superfood nor a poison. Rather, its role in the diet falls somewhere in between. Coconut oil has a unique flavor and is best consumed in small amounts, as a periodic alternative to other vegetable oils like olive or canola that are rich in unsaturated fat. This dietary choice should be made in the context of an overall healthy dietary pattern, and within the recommended limits for saturated fat intake.

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Younger kindergarteners more likely to be diagnosed with ADHD

In a class of kindergarteners, a child born in August is about 30% more likely to be diagnosed with attention deficit hyperactivity disorder (ADHD), and 25% more likely to be treated for it, than a child born in September — if you have to be 5 years old by September 1st to start kindergarten.

These were the findings of a study published in the New England Journal of Medicine. They didn’t find such a difference between any two other months — and in schools that didn’t have a September 1 cutoff for entry, the difference between August and September disappeared.

It’s not a Leo versus Virgo thing: it’s age. In schools with a September 1 cutoff, children born in August are a full year younger than children born in September. For children who are only 5, a year is a lot, especially when it comes to maturity, and the ability to stay focused and engaged on academic subjects. While some children might be naturally more mature than others, a child who is turning 6 is likely going to be able to sit still and focus more than a child who just turned 5.

But that doesn’t mean that the 5-year-old has ADHD; it means that the 5-year-old is acting normally for his or her age. And that’s what is worrisome about the study: it suggests that at least in some cases, teachers and doctors are mistaking normal behavior for a problem. Even worse, some children are getting medications that they really don’t need — or they wouldn’t need, if they were just a little bit older or the classroom demands were a little bit different.

Some families may see this study as proof that they should “red-shirt” their child. (The term is borrowed from school sports when a high school or college student is kept out of varsity sports for a year to gain skills while still keeping their eligibility to play; apparently they wear red shirts to set them apart from other new players.) When parents red-shirt their child, they wait an extra year before starting kindergarten. Parents are more likely to do this when their child has a spring or summer birthday, especially if their child is a boy. It’s thought that the extra year gives them more time to mature and be ready for school.

There are certainly some children who benefit from a bit more time before starting kindergarten, which has become increasingly focused more on academics than on socialization and play. But I would argue that parents shouldn’t have to do it — and many families simply can’t afford to pay for another year of preschool or childcare.

As a pediatrician, I see two big take-homes from this study. First, teachers and doctors need to do a better job of factoring in a child’s age and maturity level when assessing their behavior; just because they are different from their classroom peers doesn’t always mean that they have a psychiatric diagnosis, let alone need medication. Some do, of course, but many just need time.

Second, we need to do a better job of accommodating the relative differences in ages and maturity levels that exist in a perfectly normal kindergarten classroom. We need to be able to meet children where they are, and help each child get where they need to be — with patience and support, not labels or medications. That definitely means more support for teachers, but it also may mean that we need to rethink kindergarten curricula. Maybe we had it more right when we focused more on socialization and play. If a child needs to be 6 to do what we are asking a 5-year-old to do, maybe the problem isn’t with the child. Maybe it’s with us.

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Can watching sports be bad for your health?

As the new year begins, sports fans rejoice! You’ve had the excitement of the college football bowl games and the national championship, the NFL playoff games are winnowing teams down to the Super Bowl contestants, and basketball and hockey seasons are in full swing. There’s even some early talk of spring training for the upcoming Major League Baseball season.

While I hate to rain on anyone’s parade, the truth is that there can be health risks associated with watching sports. I’ve seen it firsthand while working in a walk-in clinic near Fenway Park, where people would show up bleeding from cuts that needed stitches (from trips and falls at the stadium), broken bones (from trying to catch a foul ball or after an altercation with another fan), dehydration, or other minor problems.

The problems can be more serious. In fact, studies have shown that watching sports — whether live at the stadium or on television — can have dire health consequences.

The big game may come with a big cost

Doctors and nurses often describe how quiet things get in the emergency room during a World Series game or the Super Bowl. But once the game ends, things get busy. It seems that many people with chest pain, trouble breathing, or other symptoms of a potentially serious problem delay seeking care until after the game.

Of course, there’s another possibility: the game itself — especially if a game is close and particularly exciting — might cause enough stress on the body that heart attacks, strokes, or other dangerous conditions develop.

A number of studies support the idea that watching sports can lead to health problems. For example, a 2017 study found that spectators of Montreal Canadiens hockey games experienced a doubling of their heart rate during games. The effect was more pronounced for live games than televised games, but even the latter experience led to faster heart rates similar to that during moderate exercise.

A similar observation had been made in the 1990s by researchers studying spectators of live Scottish football matches: blood pressure and heart rate rose dramatically compared to baseline measures while at home. The maximal heart rates were recorded just after a goal had been scored by the favored team.

Perhaps these observations explain why other studies have linked hospital admission for heart failure and even cardiac arrest with watching sporting events. The former study (in New Zealand) only found higher rates of heart failure admissions among women, and the latter study (in Japan) only found higher rates of cardiac arrest among older men. The gender differences remain unexplained.

Keeping it in perspective

It’s worth emphasizing that most people who choose to watch sports enjoy it and do not experience any health problems during or afterwards. My sense is that people with no health problems are at little risk even if they get worked up while watching sports, but there may be some small risk (similar to what might accompany moderate or vigorous exercise) for people who have cardiovascular disease.

What’s a sports fan to do?

The obvious recommendation is to remember, it’s only a game. But, ask anyone who cares about sports, sporting events, or a particular team — it’s much more than that.

It’s also easy to suggest being careful about how much you drink, to avoid overeating (especially salty junk food), and to be aware of your surroundings. For example, if you’re at a baseball game, pay attention to the game so you’ll at least have a chance of getting out of the way of a line-drive foul ball. Notice where the railings are and avoid leaning over dangerous ledges. And, of course, avoid altercations with hostile fans. Stay well-hydrated if you’re out in the heat for hours — remember that although beer is a liquid, it can actually make you more dehydrated.

For people who have cardiovascular disease, don’t forget to take your medications, even when there’s a big game on. Ask your doctor about how much exercise your heart can take, and whether you have any conditions that restrict your ability to exercise. If you do, improving your cardiac fitness might help improve your ability to exercise — and it might also make it safer to enjoy watching the sports you love.

Follow me on Twitter @RobShmerling

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Fatty liver disease: What it is and what to do about it

Non-alcoholic fatty liver disease (NAFLD), a condition of extra fat buildup in the liver, is on the rise — it now affects roughly 20% to 40% of the US population. It usually doesn’t cause any symptoms, and is often first detected by accident when an imaging study (such as an abdominal ultrasound, CT scan, or MRI) is requested for another reason. A fatty liver may also be identified on an imaging test as a part of investigating abnormal liver blood tests. NAFLD is intimately related to conditions like diabetes and obesity. It’s also linked to an increased risk of cardiovascular disease. Understanding NAFLD and its causes, consequences, and treatment options is still a work in progress.

The many faces of fatty liver disease

There are lots of medical terms related to fatty liver disease, and it can get confusing. The main medical umbrella term NAFLD refers to a fatty liver that is not related to alcohol use. NAFLD is further divided into two groups:

  • Non-alcoholic fatty liver (NAFL), otherwise known as simple fatty liver, or
  • Non-alcoholic steatohepatitis (NASH)

Why the type of fatty liver disease matters

Distinguishing between simple fatty liver and NASH is important. Why? Because for most people, having simple fatty liver doesn’t cause sickness related to the liver, whereas those with NASH have inflammation and injury to their liver cells. This increases the risk of progression to more serious conditions like fibrosis (scarring) of the liver, cirrhosis, and liver cancer. NASH cirrhosis is expected to be the number one reason for liver transplant within the next year. Luckily, most people with NAFLD have simple fatty liver and not NASH; it is estimated that 3% to 7% of the US population has NASH.

It takes a liver biopsy to know if a person has simple fatty liver or NASH. But the possible (though infrequent) complications and cost of a liver biopsy make this impractical to do for everyone with NAFLD.

Scientists are trying to find noninvasive ways to identify who is at the greatest risk for fibrosis, and thus who should go on to have a liver biopsy. Possible approaches include biomarkers and scoring systems based on blood tests (such as the NAFLD fibrosis score and Fibrosis-4 index), as well as elastography (a technology which uses soundwaves to estimate fibrosis based on the stiffness of the liver).

Keeping your liver healthy

If you have been diagnosed with fatty liver disease, it is important to keep your liver as healthy as possible and avoid anything that can damage your liver. Here are some important things you should do.

  • Don’t drink too much alcohol. How much is too much remains controversial, but it’s probably best to avoid alcohol completely.
  • Make sure that none of your medications, herbs, and supplements are toxic to the liver; you can crosscheck your list with this LiverTox Even acetaminophen (the generic ingredient in Tylenol and some cold medicines) may be harmful if you take too much for too long, especially if you have liver disease or drink alcohol heavily.
  • Get vaccinated to protect against liver viruses hepatitis A and B.
  • Control other health conditions that might also affect your liver, and check with your doctor if you might have other underlying, treatable diseases contributing to your fatty liver.
  • Get regular screening tests for liver cancer if you already have cirrhosis.

What about drug therapy?

Unfortunately, there are no FDA-approved medications for fatty liver disease. So far, the two best drug options affirmed by the American Association for the Study of Liver Diseases for biopsy-proven NASH are vitamin E (an antioxidant) and pioglitazone (used to treat diabetes). However, not everyone will benefit from these treatments, and there has been some concern about safety and side effects. If you have NASH, it’s best to speak to your doctor about whether these treatments are appropriate for you, as they are not for everyone. There are more drugs in the pipeline, some with promising initial study results.

The most effective treatment: lifestyle changes

The good news is that the most effective treatment so far for fatty liver disease does not involve medications, but rather lifestyle changes. The bad news is that these are typically hard to achieve and maintain for many people. Here’s what we know helps:

  • Lose weight. Weight loss of roughly 5% of your body weight might be enough to improve abnormal liver tests and decrease the fat in the liver. Losing between 7% and 10% of body weight seems to decrease the amount of inflammation and injury to liver cells, and it may even reverse some of the damage of fibrosis. Target a gradual weight loss of 1 to 2 pounds per week, as very rapid weight loss may worsen inflammation and fibrosis. You may want to explore the option of weight loss surgery with your doctor, if you aren’t making any headway with weight loss and your health is suffering.
  • It appears that aerobic exercise also leads to decreased fat in the liver, and with vigorous intensity, possibly also decreased inflammation independent of weight loss.
  • Eat well. Some studies suggest that the Mediterranean diet may also decrease the fat in the liver. This nutrition plan emphasizes fruits, vegetables, whole grains, legumes, nuts, replacing butter with olive or canola oil, limiting red meat, and eating more fish and lean poultry.
  • Drink coffee, maybe? Some studies showed that patients with NAFLD who drank coffee (about two cups every day) had a decreased risk in fibrosis. However, take into consideration the downsides of regular caffeine intake.

Even though it can be difficult to make these lifestyle changes and lose the weight, the benefit is immense if you have fatty liver, so give it your best effort! And remember, the greatest risk for people with a fatty liver is still cardiovascular disease. Not only can some of these lifestyle changes improve or resolve your fatty liver, they will also help keep your heart healthy.

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Surgery for appendicitis? Antibiotics alone may be enough

I remember when my best friend in fifth grade couldn’t make our much-anticipated end-of-the-school-year camping trip because he had just undergone surgery for appendicitis. Now I prevent kids from participating in their school activities for four to six weeks after I remove their appendix. But what is the appendix, why do we have an organ that causes so many problems, and do you need surgery for appendicitis?

Role of the appendix is unclear

The appendix is a fingerlike tube, about three to four inches long, that comes off of the first portion of the colon. It is normally located in the lower right abdomen, just after the small intestine (needed for digestion and absorption) turns into the colon (whose purpose is to reclaim water and remove waste products).

The true function of the appendix remains unknown today, but one debated theory is that the appendix acts as a storehouse for good bacteria, to reboot the digestive system after a diarrheal illness. Other experts believe the appendix is just a useless remnant from our evolutionary past. Surgical removal of the appendix appears to cause no observable health problems.

Today, appendicitis is usually treated with surgery

In the medical community, the suffix “-itis” refers to inflammation (think arthritis, which is inflammation of a joint). Many times, “-itis” is due to an infection — pharyngitis, or strep throat, for example. After much research and debate, the cause of “-itis” of the appendix is still unclear. However, it appears that most causes of appendicitis are infectious agents, such as bacteria, viruses, parasites, or fungi.

Whatever the cause, whenever there is an obstruction of the entrance to the appendix — either from swelling or inflammation, or from mechanical blockage, like a hard piece of stool or a tumor — appendicitis may ensue. The real danger from appendicitis comes from the potential of the appendix to perforate, or burst, which can spread infection throughout the abdomen.

Even before 1886, when Dr. Reginald Fitz, a Harvard pathologist, first described appendicitis as a surgical disease, physicians had dealt with the pain and complications stemming from this tiny, menacing organ. Today, the standard of care for the treatment of appendicitis remains surgical removal of the appendix (appendectomy), along with intravenous fluids and antibiotics. In fact, appendectomy is one of the most common abdominal operations in the world. It is also the most common emergency general surgical operation performed in the United States. Most appendectomies are performed by the laparoscopic technique, also known as “keyhole” or minimally invasive surgery. Patients usually remain at the hospital for less than 24 hours post-operatively.

Emerging evidence suggests antibiotics alone may be enough to treat appendicitis

Many studies have demonstrated that surgery may not be necessary for all cases of appendicitis. A paper published in June 2015 received international visibility and challenged the status quo when antibiotic therapy was compared with surgery for the treatment of appendicitis. The conclusion of the APPAC trial (APPendicitis ACuta), which ran in Finland from November 2009 to June 2012, was that most patients who were treated with antibiotics for uncomplicated acute appendicitis did not require surgery during the one-year follow-up period. (Uncomplicated appendicitis refers to those cases in which there is no evidence of perforation or abscess formation, and in which the inflammation is mostly confined to the appendix.) Those who eventually did require appendectomy after failure of the antibiotic regimen did not experience significant complications.

In 2018, the APPAC authors published a follow-up in which they concluded that six out every 10 patients who were initially treated with antibiotics for uncomplicated acute appendicitis remained disease-free at five years. They again concluded that antibiotic treatment alone appears feasible as an alternative to surgery for uncomplicated acute appendicitis. Many additional studies also support a nonoperative approach to appendicitis. (And having spent almost 15 years in the navy, I know that for sailors suffering from appendicitis at sea, the use of powerful antibiotics has been the standard of care for decades when access to a surgeon is not readily available.)

As is always the case in scientific research, these studies have many limitations, including basic study design, multiple confounding variables, misinterpretation of results, and intrinsic flaws known to anyone using statistics. You can also find many articles and rebuttals describing the problems with using medication for a “surgical disease.” So as of now, while we eagerly await more data on the integrity of antibiotics for the safe use and definitive treatment of uncomplicated appendicitis, surgery remains the gold standard.

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Heart disease and breast cancer: Can women cut risk for both?

Very often I encounter women who are far more worried about breast cancer than they are about heart disease. But women have a greater risk of dying from heart disease than from all cancers combined. This is true for women of all races and ethnicities. Yet only about 50% of women realize that they are at greater risk from heart disease than from anything else.

Currently in the US, three million women are living with breast cancer, which causes one in 31 deaths. Almost 50 million women have cardiovascular disease, which encompasses heart disease and strokes and causes one in three deaths.

Here’s what’s really interesting, though: heart disease and breast cancer share many of the same risk factors. What’s more, there are two big risk categories that we can do something about: exercise and diet.

Heart disease and breast cancer: How much exercise is needed?

Many studies have shown that the less physically active a woman is, the higher her risks are for cardiovascular disease and breast cancer. Of course, the flip side is that the more physically active she is, the lower her risks.

How much physical activity is recommended? Well, the latest government physical activity guidelines for Americans and the American Heart Association guidelines on activity both call for at least 150 minutes of moderate physical activity weekly. That’s only 21 minutes daily. More is better. But by current statistics, less than 18% of women are meeting that minimum of 21 minutes a day. Everything counts! Walking, gardening, taking the stairs, dancing around, cleaning house. Exercise does not have to be at the gym. Avoiding long periods of time sitting is key. So, sit less, move more.

Heart disease and breast cancer: How can diet help?

Research also shows that a diet high in fruits and vegetables, whole grains, and healthy protein (like seafood, tofu, or beans) and low in refined grains, added sugars, and red and processed meats is associated with a lower risk of both heart disease and breast cancer. The American Cancer Society nutrition guidelines for cancer prevention and the American Heart Association nutrition guidelines for heart disease prevention are essentially the same:

  • DO Eat mostly plants, meaning fruits and vegetables; aim for plant proteins like beans, lentils, nuts, and seeds; eat whole grains like brown rice, quinoa, and corn instead of refined grains; if you’re going to eat meat, eat fish or poultry.
  • DON’T eat refined grains (things made with white flour; white rice); avoid added sugars and sugary beverages; try not to eat red or processed meats or other processed foods with chemicals (like fast foods or frozen dinners).

What else is important to know?

It’s critical to understand your risk factors for heart disease — and what you can do to lower those risks. Sixty-four percent of women who die of heart disease never have any symptoms beforehand. Beyond an unhealthy diet and physical inactivity, other major risk factors include smoking, obesity, diabetes, high cholesterol, high blood pressure, growing older (particularly post-menopause), and a family history of heart disease. It may be important to check your “numbers” (blood sugars, cholesterol, blood pressure) in order to know if any of these are a problem. For women who have risk factors, we can screen for any heart disease with a coronary artery CT scan.

It’s also important to know that women can have different symptoms of heart disease than men. In my own practice, most of my female patients who have had heart attacks thought they had acid reflux. They experienced a burning feeling in their chest, accompanied by nausea and even burping. One was even seen in urgent care and told that she had acid reflux. The clue in all cases was that the sensation was brought on by activity, not eating.

Mammograms are very important for breast cancer screening. What age to start them and how often to have them is somewhat controversial. It should be individualized to the patient.

I encourage everyone to meet with their doctor and discuss their risks for heart disease and breast cancer, as further testing may be required.

What’s the bottom line?

Physical activity and a healthy, plant-based diet are key for heart disease and breast cancer prevention. Also, cardiovascular disease and cancer treatment outcomes are better in patients who adopt healthy lifestyle habits, especially regular exercise. Basically, a plant-based Mediterranean diet and plenty of physical activity are sensible measures that are important for prevention and even treatment of cardiovascular disease and breast cancer — both major health issues for women.

Follow me on Twitter @drmoniquetello

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Long-term statin use protects against prostate cancer death

Statins and other drugs that lessen cardiovascular disease risk by lowering blood lipids rank among the world’s most prescribed medications. And for the men who take them, accumulating evidence has for years pointed to another added benefit: a lower risk of developing prostate cancer.

Now researchers are reporting that long-term statin use (more than 10 years) can also reduce the odds of a prostate cancer death. The new findings come from a study led by Alison Mondul, a cancer epidemiologist at the University of Michigan School of Public Health.

Mondul says that most men develop slow-growing, indolent prostate cancers that will never become clinically relevant. Her goal with this new study, she says, was to look more specifically at whether statins protect against fatal prostate cancers.

Here’s what the researchers did

Since death from prostate cancer can take many years to occur, Mondul and her team needed a dataset with an adequate duration of follow-up. And the study they went to for data — the Atherosclerosis Risk in Communities Study (ARIC) — fit the bill with a launch date of 1985. The ARIC study enrolled nearly 16,000 men and women between the ages of 45 and 64, and monitored their heart disease outcomes until 2016. Mondul’s team zeroed in on 6,518 men from the ARIC cohort who had enrolled between 1990 and 1992 — the beginning of the statin era. Approximately 25% of those men were African Americans, and none of them had prostate cancer when they entered the study.

Like all the ARIC participants, each of these men returned every three years for an extensive physical exam, during which they also supplied answers to questions about their medical history, demographic and lifestyle factors, and medication use. By 1996, 21% of the white men and 11% of the African Americans were using lipid-lowering drugs, mostly statins. And by 2012, 750 of the men had developed prostate cancer, and 90 of them had died of the disease.

This is what they found out

Mondul’s investigation showed men who used lipid-lowering drugs for more than 10 years were 33% less likely to develop a fatal prostate cancer and 32% less likely to be diagnosed with prostate cancer in the first place. Moreover, the protective benefits were similarly evident among both white and African American men.

Just why statins and other lipid-lowering drugs might protect against prostate cancer isn’t clear. Mondul says some evidence suggests accumulating lipids in cancer cells trigger altered, pro-tumor signaling. “Statins are also anti-inflammatory, and inflammation is a cancer hallmark,” she says.

More research is needed. Meanwhile, Mondul emphasizes that men shouldn’t take statins (which can induce side effects including headache, drowsiness, insomnia, and muscle aches) solely to guard against prostate cancer. “But if men choose to take a statin for cardiovascular benefits, then they should feel good about influencing their prostate cancer risk in a positive way,” she says.

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NSAIDs: How dangerous are they for your heart?

Nonsteroidal anti-inflammatory drugs, commonly referred to as NSAIDs, are one of the most common medications used to treat pain and inflammation. Ibuprofen, naproxen, indomethacin, and other NSAIDs are effective across a variety of common conditions, from acute musculoskeletal pain to chronic arthritis. They work by blocking specific proteins, called COX enzymes. This results in the reduction of prostaglandins, which play a key role in pain and inflammation. There are two types of NSAIDs: nonselective NSAIDs and COX-2 selective NSAIDs (these are sometimes referred to as “coxibs”).

There has been a growing body of evidence that NSAIDs may increase the risk of harmful cardiovascular events including heart attack, stroke, heart failure, and atrial fibrillation. Given the widespread use of NSAIDs, these findings have generated significant concern among patients and healthcare providers. I am frequently asked by patients: is it safe to continue to take NSAIDs?

NSAIDs and cardiovascular disease: Minimizing the risks

There are several factors to consider when evaluating the potential risk of NSAID therapy. The first is the duration of treatment. The risk of having a heart attack or stroke is extremely small over a short course of therapy (less than one month), such as would be the case in treating acute pain from a musculoskeletal injury like tendonitis. Another important consideration is dose and frequency. The risk tends to increase with higher doses and increased frequency. The third factor is whether the person has existing cardiovascular disease. In people without known cardiovascular disease, the absolute increase in risk is incredibly small (one to two excess cardiovascular events for every 1,000 people who take NSAIDs).

My general principles for NSAID use are:

  1. In all patients, I recommend the lowest effective NSAID dose for the shortest duration of time to limit potential side effects.
  2. In people without known cardiovascular disease, the increase in risk is so minimal that it rarely influences my decision about whether to use NSAIDs.
  3. In patients with known cardiovascular disease, I might advise an alternative treatment. Many patients with pre-existing heart disease can be safely treated with short courses of NSAIDs. However, the choice of specific NSAID and dose is more important in these patients. I generally recommend the nonselective NSAID naproxen or the COX-2 selective NSAID celecoxib, as studies have demonstrated that these two drugs may have the best safety profile in higher-risk patients.

In summary, although all NSAIDs are associated with an increased cardiovascular risk, the magnitude of the increased risk is minimal for most people without cardiovascular disease taking them for short periods of time. For patients who have heart disease or who require long-term treatment with high doses of NSAIDs, the increased risk is more of a concern. If you fall into this category, discuss your options with your healthcare provider to determine whether an alternative therapy is possible, or to help select the safest NSAID option for you.

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Working with a disability

A decade ago, I was completing my master’s degree in environmental science and policy, and preparing to embark on a multi-decade career in advocacy and public policy that would have required not only long hours during the workweek, but frequent travel and overtime. Unfortunately, my body had other plans. Slowly my experiences began to erode my fantasies, until finally my vision of a flourishing full-time career evaporated entirely.

The slow toll of disability on work life and goals

This didn’t happen suddenly or all at once. Instead, I gradually and incrementally began to pull back from applying for high-energy full-time jobs. As an alternative, I started opting for part-time jobs while completing freelance work on the side to supplement my modest income. I was lucky: I did eventually find a decent-paying, part-time position in the environmental field, in a municipal government that allowed me a flexible schedule and some telecommuting opportunities. If I was too sick to work one day, I could come in the next day or make it up another week. Since I only had to be in the office two days a week, I didn’t have to struggle to schedule and make my necessary medical appointments, either. I held this part-time position for several years before budget cuts contributed to my layoff. Since then it’s been more of a struggle for me, as well-paid, part-time positions are something of a unicorn in the working world in the United States.

As I’ve mentioned in past posts, having a chronic illness is like its own job. It eats up hours and effort to attend medical appointments, fill prescriptions, follow up on referrals, and be your own advocate. This, coupled with the time and energy of dealing with symptoms and attending to our bodies, can compromise one’s ability to work. For some, it can limit the hours we can work or what conditions we can work under — if we can work at all.

Options and legal protections available

In the United States, the American Disabilities Act (ADA) makes it illegal to discriminate against potential or current workers due to disability. In order to be protected under the ADA, one must have a medical condition — either physical, mental, or intellectual — that limits a major life activity such as performing manual tasks, learning, or working. In particular, employers with 15 or more employees are required to provide “reasonable accommodations” to those employers that have a documented disability to enable them to carry out the essential functions of their position. As long as those accommodations don’t cause the employer a significant hardship or expense to meet, they must attempt to meet their employee’s requests under the ADA.

In the past, accommodations I requested under the ADA and was granted were the ability to sometimes from work from home or switch working days as needed, turning off overhead fluorescent lights above my desk, and taking frequent stretching breaks and snacking on salty foods (I have very low blood pressure) throughout the work day. I had a fellow employee request and receive an ergonomic seat and keyboard setup for her work desk, while I recently had a friend request a stand-up desk at her office due to disc issues in her lumbar spine.

Here’s what you can do

If you have an amicable relationship with your supervisor, you can approach them first with such reasonable accommodation requests. However, at other times it may be more appropriate to submit your requests directly through the human resources office. Some employers may have onsite employee assistance programs (EAPs). An EAP is a program designed to assist businesses and organizations in addressing productivity issues by helping employees identify and resolve personal concerns that affect their job performance — including working with a disability.

For those employers that don’t have their own EAP, they can contact the U.S. Department of Labor’s Office of Disability Employment Policy, which offers resources — including best practices and innovative strategies — that support hiring and retaining employees with disabilities. Every state also has their own version of a rehabilitation commission that offers vocational rehabilitation (VR) services free of charge to those who apply and are eligible. Specifically, state VR agencies assist people with disabilities in locating and maintaining employment, including negotiating reasonable accommodations with a prospective employer.

Finally, for those who are concerned about working jobs that may not offer health insurance, many states enable Medicaid buy-in programs or opt-in programs for those who are disabled. For instance, in Massachusetts there is there is a program through MassHealth (the state’s Medicaid) called CommonHealth that people with disabilities can qualify for as long as they are working, as eligibility is not income-based (though income is used to determine the monthly premium).

The bottom line

If you are having an issue finding or keeping work — whether full-time or part-time — due to your disability, please contact your state government’s rehabilitation commission, or search online for disability advocacy groups near you for help. Because those of us with chronic illness should be able to apply our skills, experience, and training in the workplace and earn a decent living.

The post Working with a disability appeared first on Harvard Health Blog.

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