Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Zika again dominates the news in Ob/Gyn. As of Friday, a storm system was approaching the subtropical state of Florida, where 43 are confirmed infected with the Zika Virus. Authorities think the storm may help spread the virus which is transmitted by mosquitos and sex. Meanwhile, the CDC (Centers for Disease Control) does not have enough Zika testing resources. I myself experienced this last week when I was told a specimen we sent to the CDC would take “weeks” to result. We Ob/Gyns are not able to effectively work in time frames like this, and so this week we will have being having some words with the powers that be. 

A new study published in Radiology has shown that Zika can cause many other brain defects besides microcephaly. They have thus far identified 8 major defects. One of the most common was ventriculomegaly, or enlarged ventricles and thinning cortex. 

Thus far the Florida outbreak has been clustered around Miami. However Thursday, an isolated case showed up some 250 miles to the north in Tampa Bay, Pinellas county. It is still unclear how this occurred. On the bright side, modeling done by researchers at the University of Florida has indicated that the total outbreak should limited to under 400 individuals or less, considering all the southern states. They also believe winter will stop the outbreak, which would then recur next summer the same way. It is estimated that 20,000 pregnant women in the Miami area are taking extreme measures such as confinement indoors or moving to avoid Zika infection. 

NewYork officials are noting that travel restrictions to Zika affected area not being properly observed by pregnant or pre conceptual women. How do they expect people to take these restrictions seriously when they gave full sanction to people traveling to the Olympics in Rio? 

Dr. Kristyn Brandi writes that Zika is spreading more rapidly than anticipated in Puerto Rico, and that resources of information and contraception are not adequately available. 

The chair of ACOG (American College of Obstetricians and Gynecologists) has written a strongly worded piece which has criticized how politics has prevented the funding of an adequate Zika response. He and co author, Dr. Didi Saint Louis of Morehouse School of Medicine have called for the full funding of comprehensive reproductive health care to allow women to avoid or delay pregnancy. They have called on Congress to reconvene to deal with this. 

In the non-Zika news, HPV virus is in the spotlight. This virus is responsible for abnormal paps, and cervical cancer, among other things. It has an effective vaccine which is meant for young people between the ages of 9 and 26. However parents remain wary to give it to their children. Research is being done regarding the prospect of putting it on the list of already mandatory vaccines which must be done before school entry. Surveys show that parents would accept this as long as there was an opt out provision. As of 2014, only 40% of girls and 20% of boys were vaccinated. It will be interesting to see if there will be those who decline the Zika vaccine once it gets developed. 

Breastfeeding is practiced by about 80% of all American women when they leave the hospital. However less than a third keep it up for the recommended time. The American Academy of Pediatrics has recommended that infants should get nothing but breast milk for six months, and that breastfeeding should continue one year. 

Co-sleeping beyond six  months has been shown to produce significant stress on women. Researchers at Penn State note this may be related to fragmented sleep and less time with partner. Perhaps this is related to the falloff in breastfeeding. 

In the everyone-already-knows-this department, researchers at UCLA have discovered that menopause accelerates aging. In all fairness, what they have determined is that methylation increases in menopause, accelerating cellular aging about 6 %.

And in the we-should-have-known department, the “ baby simulator” program in high schools designed to deter teen pregnancy may actually be encouraging it. Graduates of the program with over third more like to have a teen pregnancy. 

Stay tuned next week for more news from the amazing world of Obstetrics and Gynecology.  

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

We continue to learn more about the way Zika virus affects babies.  It turns out Zika can affect babies late in pregnancy. In fact, Zika related brain changes may not become apparent until months after they are born. The reason for this is that the baby continues to grow all except the brain, which does not. 

Zika also appears to produce joint deformities. This may take the form of curved or crooked legs or arms. 

We are also learning more about the sexual spread of Zika. Men may be able to spread Zika for longer than six months, longer than previously reported. The Obama administration has shifted another $81 million dollars from the Department of Health and Human Services to continue development of a Zika vaccine.

Florida officials continue to deal with more local spread of Zika in the Miami area. Aggressive spraying programs are underway to reduce mosquito populations. Additionally there are plans to release genetically modified mosquitos which will mate with the natural Aedes Aegypti and render their offspring sterile. This has reportedly reduced the Aedes populations in Brazil, Panama and the Cayman islands by 90%. 

Various commentators are now starting to focus on how abortion politics played a role in the Congressional failure to develop a funding plan for Zika. It continues to play a role. Since Zika produces grave birth defects in babies which usually live, it is a condition for which some women might chose abortion. Marc Rubio (Republican from Florida)  has come out this week saying that he “doesn’t believe a pregnant woman infected with the Zika virus should have the right to an abortion-even if she had reason to believe the child would be born with severe microcephaly. “ A recent STAT Harvard poll indicates that 59% of Americans believe that a women should have a right to end a pregnancy after 24 weeks of testing showed a serious possibility that the fetus had microcephaly caused by the mother’s Zika infection. The same poll also showed most Americans are unaware that Congress left for vacation without securing Zika funding. Meanwhile women and health care workers in Puerto Rico are trying to overcome historical cultural barriers to contraception in a territory at very high risk for Zika. 

The Obama administration has shifted another $81 million dollars from the Department of Health and Human Services to continue development of a Zika vaccine in Phase 2 trials. Stage 1 is preclinical development, in labs and on animals. Stage 2 is when the vaccine is first tested on humans. This second stage proceeds first to study safety and then, if it passes, to effectiveness. 

In other news, ACOG (The American College of Obstetricians and Gynecologists) has updated its opinion on home births. New data has prompted the revision. The new Committee Opinion Document states that babies are twice as likely to die and more than three times as likely to have seizures soon after birth, compared to hospitals. I would point out that this is case even when most home birth attendants chose low risk patients to deliver at home. I would also point out that the literature on which this is based only reported on two of the worst outcomes, death and seizures. The many lesser but still significant complications like subsequent learning disability remain unquantified. 

In other sobering news, the US maternal death rate has increased. Between 2000 and 2014, the death rate increased from 19 per 100,000 to 24 per 100,000. It is unclear as to why though more thorough reporting methods are believed to account for much of the increase. However some of the increase is real, and authorities speculate that it is because women having babies are older and more likely to be obese than in the past. This gives rise to more complications such as maternal hypertension and diabetes. 

Many including me are cheering the relaxation of rules surrounding marijuana research. It is currently being used legally in several states without evidence of its effectiveness. New studies should be able to “ weed” out the legitimate from the bogus uses of which I suspect there are many. 

Stay tuned next week for more breaking news from the world of Obstetrics and Gynecology.

Food Friday: Pre and Post Work Out Food and Drink

This is actually called nutrient timing in the hallowed halls of medicine. When I initially started looking into this, I found a number of sources calling it bunk, and just as many others touting it earnestly. I wanted to get to the truth of the matter. 

To understand the rationale for pre and post workout food and drinks, one must understand the concepts of catabolism and anabolism. These are the two basic metabolic modes that the body can be in. 

Catabolism is the state of breaking down.

Make no mistake, all exercise is, by design, a teardown or at least a strain, on body parts. What makes exercise more than just trauma is that it is done in such a way to be just enough strain to stimulate new growth, or anabolism. Moreover, it is balanced between upper and lower body, as well as between flexor and extensor muscle systems of the body. Exercise is a well designed program of strategic strains on the body so as to stimulate a growth and strengthening of the systems. 

Anabolism is a state of building up that one will hopefully achieve in the aftermath of exercise. 

Clearly this state of anabolism is resource requiring, even resource intensive. We need certain amounts of water, carbohydrates and fats for energy, and protein to build body parts. 

Review of the literature reveals a shortage of good studies on the effectiveness of pre and post exercise supplements. However a number of general insights can be gained. 

• Gains after exercise are greater when exercise is in initiated in a non fasting state. 
• A meal should not be closer than 1.5 to 2 hours before a workout. 
• The so called post exercise window when one can benefit from this supplementation is not as small nor as soon as was previously believed.
• To maximize anabolic effect, pre and post meals should be separated by no more than 4 hours. 
• Good nutrition spread throughout the day also supports continued anabolism. 
• The post exercise interval is more important than the pre-exercise interval, but supplements at both times appears to confer some benefit in optimal anabolic gain and have little risk. 
• Carbohydrate is needed as well in the post exercise interval in order to replace glycogen, but the carbohydrate need is met by meeting the normal daily requirement for carbohydrate distributed throughout the day. 
• Protein supplementation pre and post workout should be about 0.5 g/kg of Lean body mass (LBM) For example, a 50 kg person would consume 25g of protein a couple hours before a workout and a couple of hours after a workout. 
• Pre and post exercise supplements seem to confer a greater percentage gain in the untrained versus the already trained. 
• Pre and post workout supplements need not be expensive or prepackaged. Protein powder in milk will do nicely. 

Good for you if you are interested in both fitness and nutrition. Now you can leverage them both for some serious gains. Ladies, remember, muscles do not make you look big. They make you look toned and sleek. And they burn more calories than fat. Best yet, they let you do fun things like carry backpacks, ride horses and play sports. 

reference: 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3577439/

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Florida has an ongoing Zika outbreak in a Miami neighborhood of Wynwood. The CDC (Centers for Disease Control) has confirmed local transmission there for several days. In response, Florida Governor Scott has pledged that Zika tests will be free for all pregnant women. Apparently there is a Zika test kit shortage and physicians' offices have waiting lists for their use. Pregnant residents in Florida are beginning to curtain their activities and travel in their home towns. Other women are delaying pregnancies, freezing eggs for later, or leaving the area when pregnant.

California has the seen the first births of Zika infected babies. These cases have been from mothers who travelled to Zika affected areas. 

Texas Medicaid has decided to cover the cost of mosquito repellant to women of reproductive age. 

President Obama has asked Congress to reconvene early to work on Zika. Meanwhile the CDC has itself provided an additional  $16,000,000 to 40 states to combat Zika. They had already given $25,000,000 in July. This comes out to and additional $400,000 per state on average and does not sound like much in the scheme of things. The money is meant for developing programs to collect and track data on both the mothers and the babies affected by Zika. I have to say that when money is short, as it is, that making the choice to fight the virus with information seems like the wisest first step. When more money comes in, which hopefully it will, it can go to bigger ticket items like better mosquito control and vaccines. Current mosquito control techniques are poor against the mosquito since it can live indoors or outdoors, can hatch in a tiny amount of water, can bite multiple people, and has eggs which can last for months. 

The CDC has clarified that all pregnant women need to be assessed for risk of Zika. They do not necessarily need to be tested, but their travel history and the travel history of their partner or partners should be assessed. 

The CDC has reviewed data which show that the use of Long Acting Reversible Contraceptives (LARCS) is low in Zika affected States. LARCS are among the most effective means of contraception and considered safe for most all women. 

Finally in encouraging Zika news, The Journal Science has reported that three different Zika vaccines have worked “to perfection” in rhesus monkeys. Each of these vaccines works by a different mechanism to stimulate the immune system to combat the virus. One vaccine uses dead virus, but the other two use two different viral DNA subunits to stimulate an effective immune response. 

In other news, the CDC has reported that adults across the board are about 15 pounds heavier than they were 20 years ago. Boys and girls weigh more as well, though boys' heights have gone up. Girls' hights have stayed the same. The average 5’4 woman weighs 168.5 pounds, which qualifies as a BMI (Body Mass Index)  of 29, nearly going from overweight to obese at a BMI of 30. Normal BMI is somewhere between 19 and 25. See the NIH (National Institute of Health) BMI calculator HERE: 

http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Vitamin D is in the news again. Apparently Vitamin D levels decrease by 20 % after cessation of oral contraceptives (OCs). This has potential consequences not only for women but for any pregnancies that ensue. Because of his new finding, it might be appropriate to check Vitamin D levels after OCs are stopped or before pregnancy is considered. 

In the close-to-science-fiction department, we turn our attention to telomeres. What is a telomere ? Tasciences.com quotes Blackburn and Epel from the Journal Nature, saying that

“ Telomeres are the end caps at the end of each DNA strand that protect our chromosomes, like the plastic tips at the end of shoelaces. Without the coating, shoelaces become frayed until they can no longer do their job, just as without telomeres, DNA strands become damages, and our cells can’t do their job.”.

Telomere length is therefore a marker of cell aging. Cell lifespan shortens as telomeres shorten. We are born with a certain telomere length. The majority of telomere shortening occurs in the first 4 years of life. Little is known about why telomeres shorten. It turns out that early exclusive breastfeeding for just 4-6 weeks is associated with longer telomere length at age 4-5 years. This may have consequences for long term health and overall longevity. The CDC has reported that just about half of all postpartum women are breastfeeding at 6 months. Less than a third were still breastfeeding at a year. The American Academy of Pediatrics has recommended that women breastfeed for at least 6-12 months. 

The Journal Pediatrics reports that “ Breast milk give a boost to premature babies mental and physical development.” Those who received breast milk during the first 28 days of life had measurably better IQ, math, memory and motor skills at age 7 compared to those who received less breast milk. I will comment that to pump breast milk for 28 days while your premature baby is in the NICU (newborn ICU) requires a high level of dedication. Perhaps it is difficult to factor out this maternal dedication as a factor in the better outcomes of the breastfed babies in their study.  These breastfeeding mom’s of preemies either are or become some of the most dedicated and resourceful moms out there, due, at least in part, to what they have to deal with. Maybe the better outcomes are born of the mother’s overall dedication. Hat’s off to you…. dedicated NICU moms. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology next week on Medical Mondays.  

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

About 1.6 million pregnant women are at risk for Zika virus infection in South and Central  America. Now, health officials are concerned that local transmission of Zika virus has begun in southern Florida. This means the virus was acquired in Florida, instead of being acquired elsewhere while a person was traveling. This means that some of the mosquitos in Florida carry the virus.

In related news, the blood supply in South Florida is now considered to be potentially contaminated with Zika virus. The FDA ( Food and Drug Administration) has asked that all blood donations from South Florida halt until all donations can be screened for Zika virus.

In even more striking news, the CDC ( Centers for Disease Control)  is recommending that all pregnant women be screening for the Zika virus. 

As most of you know, Congress left for its seven week vacation without coming to an agreement on Zika funding. The President of the American College of Obstetricians and Gynecologists has written a strongly worded letter to Congress on this matter. 

http://www.acog.org/About-ACOG/News-Room/Statements/2016/ACOG-Statement-on-Congress-Failure-to-Take-Action-on-Zika

Proceedings from the National Academy of Sciences include research that indicates that women who enter menopause early age faster than other women. They were able to quantify this, saying that menopause speeds up cellular again about 6 %. They also indicated that poor sleep can trigger similar aging type changes. 

In related news, women who start menstruation late and who have menopause late compared to average are more likely to achieve 90 years of age. Information like this is useful in that it helps identify factors tied to longevity. 

Research from the Journal Circulation has indicate that only 2.5 hours of moderate exercise per week has measurable effects on heart disease risk in women. Let’s see, taking one day off per week leave six days for exercise. Divide that into 2.5 hours to get the time per day needed for exercise. Only 25 minutes per day needed to reduce cardiac risk ! 

Stay tuned next week for more breaking news from the world of Ob/Gyn and women’s health.

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

The news this week is dominated by virus science.

The first United States baby with Zika related microcephaly has been born in New York City. While this is not surprising, the fact that many women are ignoring Zika related travel warnings is. This summer, over 2000 pregnant women traveled to Zika affected areas and have com back requesting testing. In many cases, they are traveling to the Dominican Republic. AS f the present, cases from the Dominican Republic account for more than a fifth of all US cases. The CDC(Centers fro Disesase Control) and the American Academy of Pediatrics are grappling with how to develop protocols to care for infants who will be born with microcephaly. These infants have serious mental and physical disabilities since the higher portions of the brain are underdeveloped. 

Florida is one of the most vulnerable states in the Union to the Zika virus. Authorities estimates over a quarter of a million women are at risk in Florida. Various research indicates that a Medicaid expansion there would help reduce the risk of pregnancy women to Zika. There is also a push to require employers to take measures to limit their pregnant employees exposure to mosquitos. 

As of mid July the CDC is tracking around 1300 cases of pregnant women with Zika. Fourteen were sexually transmitted, and the rest acquired through travel. 

There is also a Utah case on record this week of a man who acquired Zika through close family contact. He was taking care of an elderly man who had acquired Zika due to travel. 

Hepatitis C is on the rise, both in women of reproductive age, and not surprisingly, in their children under 2. There is no vaccine yet for Hepatitis C, but very recently, a very good treatment has been released. 

In other viral news, work has been done showing that certain vaginal flora (Prevotella BIVIA) make it easier to transmit HIV. However, a silicone ring imbued with antiviral drug may help reduce the risk of transmission. Pregnant women with HIV have now been shown to do better if their therapy is continued postpartum. 

Finally, in some other good news pertaining to viruses, the American Cancer Society has endorse the vaccination of all preteens, boys and girls against HPV (Human papilloma virus.). 

Say tuned for more riveting news from the word of Ob/Gyn next week on Medical Monday. 

Food Fridays: Summer Eating Digest

Summer cooking and eating is a special case. Here is a handy review post for you to access all of your summer tips I have written so far in one convenient place. Some are for safety, and some are for taste. You’ll be glad you looked at this quick review. Click on the links to see more. 

The Picnic Post:

http://drginanelson.com/drginablogs/2015/6/26/food-friday-picnics?rq=food%20safety

This has the most explicit information on food safety in the site, plus some helpful links. 

The Healthy Barbecue Post:

This is right on time for your next outing. There’s a fair amount here about how not to burn the house down or end up in the emergency room. 

http://drginanelson.com/drginablogs/2015/6/11/food-friday-healthy-barbecue-grilling-and-picnics?rq=barbecue

The Summer Drinks Post:

 You not find beer or sugary soda in this eclectic list. 

http://drginanelson.com/drginablogs/2015/7/10/food-friday-drink-?rq=cold%20drinks

The Cold Food Post:

This is a recent post here in case you missed it: 

http://drginanelson.com/drginablogs/2016/7/1/food-friday-hot-weather-cold-food?rq=cold%20food

The Salsa Post:

This is one of my favorite older posts I really enjoyed making: 

http://drginanelson.com/drginablogs/2015/9/10/food-friday-the-healthy-junk-food?rq=salsa

The Cold Dessert Post:

http://drginanelson.com/drginablogs/2015/8/28/food-friday-cold-desserts?rq=cold%20desserts

Anybody hungry yet ?

( My apologies to those in the Southern hemisphere who are in the middle of their winter.) 

Wellness Wednesday: Healthy Habit Formation

Healthy habits are the basis of peak wellness. Heathy habits are something we can develop. Whether the healthy habit is taking vitamins, being grateful, exercising, or eating fiber, the practice only works if it is done over and over for extended periods of time. This repetition is achieved through habit formation. 

What does science say about how habits are developed ? 

The brain is designed to form habits.  New behaviors or tasks can be challenging. Over time, the brain “chunks” small possibly difficult behaviors into automatic routines which becomes easy or even effortless. This is a habit. Habits are adaptive and have helped us survive. Habit formation is our brain’s way of automating certain key behaviors, so more conscious attention can be paid to novel situations.  If we understand how this works we can form new habits at will. 

What do we need to form new habits ? 

In simple terms there are three steps: 

1. Cue
2. Routine
3. Reward

This is called a habit loop. These are well explained in Charle’s Duhigg’s book "The Power of Habit”.  The cue triggers the routine, and the routine triggers anticipation of the reward. For example, my exercise routine is cued by changing into exercise clothes. From there, I go downstairs to workout, and the reward is the endorphins and the satisfaction. There is no doubt that at first, it is hard to link the steps. But it becomes easier with each cycle. To be realistic, it takes somewhere between 6 weeks and 3 months to form a new habit. 

What about bad habits ? They too have cues, routines and rewards. Basically, they have to be understood in terms of their rewards, namely, what you get out of it. In many cases, smokers smoke to get a moment of peace in a busy day. This is obviously legitimate. However, the cigarette is unhealthy and chemically addictive in addition to being behaviorally addictive. It turns out we should not exactly delete bad habits since this leaves a void. Instead we are better off to overwrite them with good ones. To illustrate, a smoker could use patches to wean down on the addictive nicotine, while overwriting her smoking habit with a healthful tea drinking habit. Perhaps to make it more engaging, she would brew the tea from loose leaves. Her reward would be the moment of peace, the taste, smell, and mental clarity that followed. 

My subject in this post are the cues. In simple terms, they are reminders of health habits. I decided to expand my set of reminder cards to include not only the subject of nutrition, but also the subjects of sleep, exercise, communication, and creativity. I believe these are some of the elements in total peak wellness. Here are my cue phrases so far. 

Sleep 

The Power of Habit: Why We Do What We Do in Life and Business

$9.18

By Charles Duhigg

Buy on Amazon

•      Adequate restorative sleep 
•      Consistent wake time 
•      Consistent sleep time 
•      Correct sleep environment 
•      Medical evaluation if necessary 

     Exercise 

•      Start easy and short 
•      Warm up
•      Cool down 
•      Value initiation over endurance 
•      Good gear 
•      Eat for exercise 
•      Hydrate for exercise 
•      Tunes for exercise 
•      Podcasts for exercise 
•      Exercise daily 
•      One break day per week 
•      Stretch after exercise 
•      Buddy exercise 
•      Track your exercise 
•      Explore HIT 
•      Include yoga 
•      Mix it up 
•      Use good form 
•      Consult professionals 

Creativity 

•      Get inspired through people travel and media 
•      Find your styles 
•      Express creativity in your personal space 
•      Make a space for your creativity
•      Take time for hobbies 
•      Take time for Travel
•      Take time for recreational reading 
•      Pick a hobby and learn it well
•      Share your creative work

Work 

•      Always work
•      Honor work in and out of the home 
•      Chose meaningful work 
•      Become expert at your work
•      Give work boundaries in time, space, and thought
•      Do you best at work 
•      Communicate effectively at work
•      Reach out often at work
•      Play as a team 
•      Ask for appropriate compensation

Communication 

•      Breathe and think before speaking 
•      Use Honesty 
•      Use courtesy
•      I statements
•      Precision of speech
•      Closed loop communication
•      Listen more than speak 
•      Listen actively
•      Repeat back clarification 
•      Acknowledge others’ point of view
•      Build common ground

You can find nutrition reminders HERE discussed in a prior post. I plan to devote a few wellness Wednesday’s to the development of these reminders or cues. 

For more reading : 

http://jamesclear.com/three-steps-habit-change

https://www.psychologytoday.com/basics/habit-formation

https://www.sciencedaily.com/releases/2014/08/140808111931.htm

http://www.scientificamerican.com/article/power-of-habit-excerpt/

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Women in Latin American are more likely to get Zika than men. We presume they are exposed equally to Zika carrying mosquitos. This difference appears once girls become sexually active. How do you put it together ? Here is what doctors and researchers think. They believe sex may spread Zika more than was previously believed. Furthermore, getting Zika though sex is easier for a woman than for a man. Other sexually transmitted infections follow this pattern and in their case, it is because sex in women causes undetected micro abrasions which allow greater access to the bloodstream. 

President Obama has come out and said that Congress should not recess for summer until Zika funding is secured. With this funding, a vaccine will be produced sooner. Some speculate that the issue of Zika calls to mind issues of contraception and abortion, and that is why Congress is unable to deal effectively with it. Zika is bringing reproductive rights into focus. ACOG ( American College of Obstetricians and Gynecologists) representatives have noted that the southern states likely to have the most Zika are the same ones which have high unintended pregnancy rates and poor access to family planning resources. But Texas is taking a different angle anyway. They are trying to scratch up enough funds on its own to provide mosquito repellant to it’s poor women, budgeting 2 bottles per month per women.  

In other news, US maternal mortality rates have doubled in the last 25 years. Black women fare the worst, with mortality rates quadruple that of white women. 

The president of ACOG has come out stating that we should have a much more critical attitude toward chemicals in the environment which may cause birth defects. Project TENDR has been created from a variety of expert disciplines to advocate for greater government oversight on the chemicals. TENDR stands for Targeting Environmental Neurodevelopmental Risks. 

Newborns get about two months of flu protections from a shot given to mom during pregnancy. 

Despite the demonstrates efficacy of the HPV vaccine, it is still woefully underutilized. Moreover, HPV related cancers are on the rise. Between 2008 and 2012, they have increased about  17 %. HPV cancers are not just cervical cancer in women. They also include head and neck cancers in both men and women. 

Finally, in the good news department, an eight study meta-analysis out of Europe has shown that obese infertile women who have trouble ovulating do better with lifestyle intervention than fertility drugs. Six months of interventions resulting in weight loss were four times more likely to conceive than their counterparts who used fertility drugs alone.  

Wellness Wednesday: Summer Safety Kit

Here is a convenient comprehensive kit to keep you safe this summer. It recaps some posts from the recent and more distant past, all in one convenient place and on the theme of having a safe and happy summer. 

Reclaim your Summer

This deals with the importance of time off and the concept of summer vacation for adults. 

Weathering the Heat

Contains some amazing facts and figures about heat stroke.

Five Steps to Mosquito Protection

This is especially important to review in this season of the Zika Virus.

Wellness While Gardening

Tells of the little known perils of playing in the dirt. 

Hydration 101

This critical post has concrete information to help you stay out of trouble this summer. 

Stay tuned for next week on Wellness Wednesday, when we will talk about the Summer of the Mind.  

Medical MondayL Breaking News from the World of Obstetrics and Gynecology

In Zika news, it has become clear that we do not yet know the length of time that Zika stays in the reproductive tract of a man. Thus, we do not now how long he may be able to transmit it sexually. 

In a recent poll, 73% of Americans feel Congress should pass the funding to fight the Zika virus as recommended by the Obama administration. However, reflecting a poor grasp of the situation, only 46% feel they need to pass it immediately. 

In the we already knew this department, ACOG ( American College of Obstetricians and Gynecologists) has issued new evidence based guidelines to help prevent perineal lacerations. These include using episiotomy selectively, and well as using warm compresses before birth. 

SCOTUS ( Supreme Court of the United States) has struck down a restrictive Texas abortion law. This law would have required that abortions be provided at an ambulatory surgical center by a physician with hospital privileges. There is no scientific data saying that either of these elements is necessary for safety of the procedure, which is normally done in an office by a midlevel provider such as a nurse practitioner. Many abortion clinics would have had to close had this law stayed o the books. The Court ruled by a 5-3 vote largely along gender lines that these laws placed an undue burden to women seeking legal forms of health care. 

In other SCOTUS news, the Court has refused to hear a legal challenge to the Washington State rule that pharmacies must deliver all prescribed medications, even emergency contraception. This ends a nine year legal battle in which some pharmacists and a pharmacy refused to stock or fill the morning after pills. The Court voted 5 to 3 not to accept the case. Four Justices must agree to accept a case if it is to be heard. 

In the pendulum swings department, there are two items. First, Obs are giving serious consideration to the optimal time for delivery. In the past, 42 weeks was considered a reasonable time for induction. In my tenure, this has become 41 weeks. Now 39 weeks is under consideration. 

Secondly, women with a statistical risk of ovary cancer of 4% or more who is over 40 may be better off with her ovaries and tubes removed. When I finished residency in 1994, we encouraged women facing a hysterectomy to have the ovaries out as well if they were over 45. In recent years, this has become more of a patient choice. Now, we are refining this judgment to include family history and other risk factors in a statistical model to determine the best course, and it may favor removal of the ovaries earlier than previously recommended. 

Once again the USPTF (US Preventive Services Task Force) has cited the lack of evidence supporting the annual pelvic exam, and how it should be done only when symptoms are present. And yet, when examining their published statements, one sees that they do not highlight the fact that there has been nothing done to prove or disprove the utility of the exam either way. This is because doctors the world over have taken it as common sense to do the exam, thus no study has been done. The public should know that saying that there is no proof that something is not useful is NOT the same as saying that something has been proven TO BE not useful. Personally I find important things every week if not every day I do a pelvic exam, and that includes both speculum and bimanual exams. Furthermore, nobody is traumatized by their exam. Children and those with disabilities who need exams and who might be traumatized are examined with the aid of anesthesia supervision. 

Stay tuned next week for more breaking news from the world of Obstetrics and Gynecology.  

Wellness Wednesday: Hydration 101

Summer has finally arrived in the northern hemisphere.

Our part of the planet is pointed much more directly at the sun and you can feel it. Sun protection and hydration become critical. Last Wednesday we covered mosquito protection and this week we will recap hydration. 

A July post from last year has some facts that bear repeating: 

• 2 Liters = the amount of fluid a non pregnant woman needs per day
• 3 Liters= the amount of fluid a pregnant woman needs per day
• Add 1 Liter for temps over 85 degrees
• Add 1 more Liter for activity like hiking. 

So… the fluid requirement for a pregnant woman hiking on a hot day is 5 Liters !!! 

And to recap…

Consider a woman weighing 154#=70kg

• 60% of the body=water =42 kg or 4.2 Liters for our 70 kg woman
• 1% loss of fluid = 42 ml impairs thermoregulation and causes thirst. 
• 2% loss of fluid - discomfort and loss of appetite 
• 3% loss of fluid - dry mouth appear
• 4% loss of fluid- work capacity decreased 
• 5% loss of fluid- reduced concentration, headache, and sleeping 
• 6% loss of fluid-tingling and numbness of extremities 
• 7% loss of fluid-collapse 

Taken from the World Health Association (WHO) website 

Hydration does a number of great things

Firstly, it protects you from harms: 

• Urinary tract infection
• Kidney Stones 
• Preterm labor 
• Headache 
• Helps prevent heat stroke 

see Weathering the Heat 

Finally, hydration makes you feel good and look good. 

It’s fun to get creative with your healthy drinks.

Break out of the old routine of sodas and beer which do nothing but dehydrate and put fat on the belly. 

Try these instead : 

• Plain Club Soda with a little splash of 100% fruit juice and twists of citrus 
• Mocktails like a Virgin Mary or a not so sweet Virgin Daquiri
• Herbal iced tea or Sun tea, sweetened with a little fruit juice 
• Healthier frappes made with ice, one pump of chocolate, and your milk of choice 
• Green smoothies 

Drinking a tall cold glass of something healthy and fun is good for you both physically and mentally. It gives you a little creative outlet, and a chance to sit down and take a micro break. 

Be sure to catch all of our blog posts at 

www.drginanelson.com/drginablogs  

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Good Monday. This week the news is again dominated by the specter of Zika. I reported earlier that the Puerto Rican chapter of ACOG (American College of Obstetricians and Gynecologists)  is working hard to deliver donated contraceptives to women in this vulnerable population. However, IUDS are not common there due to cost, and as a result, few doctors know how to insert them. Approximately 60,000 IUDS and 80,000 packs of birth control pill packs have been donated by Bayer, Allergen and Medicines 360. The donor companies have also started training physicians to use and presumably teach the use of IUDS. However, their dispensation is held up since the CDC has yet to line up a licensed distributor in Puerto Rico.

This sounds like a problem that can be solved. IUDs are not that hard to put in. I cannot help but think that telemedicine, i.e. videoconferencing, could not help train doctors to put in IUDs. By some accounts there are about 150 Ob/Gyns in Puerto Rico, and about 138,000 women there who are vulnerable to pregnancy.

A little more Googling on my part indicated that the Puerto Rico Obstetrics and Gynecology is holding a “ Sunshine Seminar”  August 4-7 this year at the Wyndham Grande Rio Mar Beach Resort and Spa. Really ? Instead of studying morcellators and bioidentical hormones, maybe conference attendees should put some gloves on and start seeing as many patients as they can. 

I am going to contact the chair of the Department of Obstetrics and Gynecology Dr. Sharee Umpierre at the University of Puerto Rico and see what she has to say about the situation. 

The New England Journal of Medicine reports an increase in abortion medication in Zika affected South American countries. 

In some good news, the FDA has given the go ahead on human clinical trials on a Zika vaccine known as GLS-5700. The safety and immune response will be studied in about 40 subjects. Thank you very much you brave souls. 

In more good news, the NIH ( National Institute of Health) have started a massive study on Zika in affected countries. 

The House has approved $1.1 B to fight Zika. This would come from $750M in savings, $107M unused Ebola funds, $100M in cuts to the Department of Health and Human Services (Medicaid and Medicare) and $534M from Obamacare in the US territories. This does not add up. And, it will not pass the Senate or the President’s Desk. 

Ten cases of Zika were confirmed in Dallas County, Texas as of Friday. So it begins. 

In other breaking research news, there is quite a bit of what we already knew or suspected: Cranberry juice may help prevent UTI (urinary tract infection). Physical inactivity increases risk of ovary cancer and healthy lifestyle reduces cancer risk. Leading oncologists push for greater use of the HPV (Human Papilloma Virus) vaccine. Healthcare is more affordable since Obamacare. Age of puberty for girls is going down. Soy isoflavones reduces menopause symptoms. Women who work long hours face more chronic disease. 

Why are studies done on matters that already seem established ? One reason is that prior studies may have been done to get a rough indication of a cause or pattern. Later, better designed studies can establish something closer to proof. However, some of these things are just common sense. If we took full advantage of the knowledge we already have and actually put it into clinical use with our patients, there would be so much more health and so much less disease. Case in point: HPV vaccines usage. 

Stay tuned next week for more news from the world of Obstetrics and Gynecology. 

Food Friday: Kitchen Gadget Heaven

I have a kitchen gadget fetish. But I am not ashamed. Food…including the taste, the process, and the nutrition, is very important to me. It is worth my time and money. I have my priorities. Over time, I have learned what I really need in the way of kitchen gadgets. I would like to share my thoughts with you, so you don’t end up spending your money on stuff you don’t use. 

Good kitchen equipment is nice, but not essential to delicious healthy food. Many memorable meals were made in tiny European kitchens or over an open fire by a river with very little in the way of gadgetry.

Some basics as needed, and most can be obtained at your local goodwill store. Moreover, parents and family are usually willing to part with older serviceable items like blenders, thus making it possible for them to get the latest greatest model. Use your ingenuity, save up some money for nice things, and place food and food preparation high on your list of priorities. Food is a critical part of your health and cuisine a delightful part of your social life. 

Must have

• dishes
• flatware, i.e. knives, forks, etc.
• all purpose glasses, for hot and cold, the ideal being for both, i.e. Picardie glasses (repurposed jam jars for cups, anyone ? )
• saucepan
• frypan, nonstick
• ladle
• spatulas
• knife set
• usable cloth napkins
• pitcher
• roasting pan
• covered casserole pan, stove to oven
• potholders
• dishtowels
• cutting board
• cookbooks or internet access
• set of preparation bowls
• measuring sets: quarts, cups, teaspoons and tablespoons.

Nice to have

• serving dishes and utensils
• table wear such as table cloths
• toaster
• blender
• hand blender
• slow cooker
• sushi roller
• yogurt maker
• ice cream maker
• air popcorn popper  
• dedicated freezer
• panini press
• waffle iron

Objects of Desire

• barbeque or grill
• Cuisinart food processor
• Kitchenaid Mixer
• Vita Mix Blender
• wood burning pizza oven
• pressure cooker

My new favorite gadget is my Instant Pot Pressure Cooker. It is the opposite of a slow cooker. It is a fast cooker, but the result is the same: tender flavorful meat from inexpensive cuts, and rich well developed sauces. For a long time I had the great idea to set food cooking in the slow cooker before I went to work, and when I returned 8-9 hours later, it would be all nicely done. Well, that did not materialize for a variety of reasons. I failed to prep the night before. I worried about burning the house down when I was gone. I didn’t want to leave it overnight, or I thought I might not come home as planned.

When Michelle Tam of Nomnompaleo.com turned me onto the Instant Pot, I knew it was a match made in heaven. I could come home from work anytime and have a thoroughly cooked hearty meal ready in thirty minutes or less. Last night I spent 15 minutes of prep time on a brand new recipe,  threw raw chicken thighs in the instant pot with sauce and onions, and 15 minutes later I had steaming fragrant lemongrass coconut chicken that seemed like it had simmered all day. Everyone was intrigued and there were no leftovers. 

Cooking is one of the best hobbies, along with fitness. I have prepared a little collection for you to illustrate just how I feel about the the tools of the cooking trade. Enjoy ! 

Wellness Wednesday: Five Steps to Mosquito Protection

Mosquito season is here. This has taken on a critical importance in many states in the south and eastern parts of the United States and in all of Central and South America. This is because mosquitos can carry, among other things, the Zika virus, which has been shown to produce serious brain damage in the unborn, and potentially serious disease in adults. Mosquitos also carry other serious diseases, including some which affect dogs and horses. Examples include West Nile virus, Heartworm, Dengue fever, Malaria, and even Ebola.  It is high time to discuss mosquito bite prevention. 

First one must note that mosquitos need standing water to reproduce, and even a tiny amount will do. Natural bodies of water such as ponds, puddles, and sloughs can breed mosquitos. Manmade water collections such as buckets, tarps which have collected rainwater, birdbaths and the like will provide very suitable breeding ground as well. 

Step One:

Eliminate standing water around your home. Get rid of any debris in your yard or patio (e.g. toys, wheelbarrows, pots etc.) which could harbor mosquito larvae. Change the water in your birdbaths at least once per week. Fill in any low spots in the yard. 

For larger bodies of water such as a pond or fountain, purchase “ Mosquito Bits “ or “Mosquito Dunks”. These are pellets or pucks of biological agents which interfere with mosquito reproduction. Once example is Bacillus Thuringiensis, which does not harm the environment. 

Step two: 

Install replace or repair your screens. You will want to enjoy the summer breeze without worrying about the mosquitos. 

Step three: 

Invest in some lightweight cool summer clothes. White gauze shirts with long skirts or lightweight palazzo pants are a pretty option. Most outdoor clothing companies such as North Face or Patagonia offer mosquito resistant shirt which are also usually sun protective as well. 

Step four: 

Buy some DEET based mosquito repellant. This is the only mosquito repellant which has been proven to work. Moreover, it has been shown to be safe in pregnancy. Use your insect repellent correctly. 

• Read the instructions and precautions of your product. 
• Only use on exposed skin and clothing. 
• Do not use near eyes and mouth.
• Apply to face by spraying hands or cloth, the wiping on. 
• Never use on injured skin. 
• Do not breathe it. 
• Do not use near food. 
• Do not use it on animals. 
• Keep out of reach of children. 
• Do not apply to children’s hands. 
• When returning indoors, wash treated skin and clothes with soap and water. 

Step five: 

Stay indoors during the twilight hours when mosquitos are most active. 

Stay tuned next week for more summer health tips on Wellness Wednesday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

The CDC( Centers for Disease Control has revealed that there are 6 cases of Zika related birth defects in the mainland US. These  are those that have delivered so far. Overall, there are 234 cases of confirmed Zika in pregnancy women in the US. All of these Zika infections were acquired elsewhere and brought here. Accordingly, New York has the most cases of Zikaa in the US, being a port of entry. So far there have been no cases of Zika infections transmitted by mosquitos in the US, though Aedes mosquitos are due to being bitting in the Southern states this week. 

Another preliminary study has come out suggesting that contracting Zika later in pregnancy confers less risk of perinatal malformations. This study was done in Columbia where there are over 12000 pregnant women who have the virus. It is interesting to note that about 80% of Zika infections are asymptomatic. These asymptomatic cases cause microcephaly all the same. 

The WHO (World Health Organization) has come out stating that there is little risk that the Olympics will case Zika to spread around the world. I personally question this, but hope they are correct. 

In other news, California Governor Jerry Brown has signed a bill potentially allowing illegal immigrants to buy insurance coverage on the state’s exchange. This seemingly radical idea is interesting to consider, since these people do come in for care. Without this coverage this care goes unreimbursed but still costs the taxpayer money. With the coverage, these people would presumably come in for preventive care or at least for earlier treatment which would mean a savings in both money and human suffering. 

A study released this last week predicts that if the next president repeals the ACA (Affordable Care Act) the  24 million Americans will lose health insurance coverage. Most doctors feel this would cost us more than the insurance in the long run. Speaking of the ACA, premiums may rise as much as 10% next year. 

CMS(Center for Medicaid Services) has adopted a policy encouraging the use of LARCs (Long Acting Reversible Contraceptives). They have concluding that this is good way to reduce the incidence and cost of unintended pregnancy. An article this week in the Atlantic has highlighted how many communities in the south the so-called “ Bible Belt” discourage discussion of contraceptives, especially IUDs, preferring instead “ abstinence curriculums” .

New research published in Obstetrics and Gynecology has indicated that most websites and apps for fertility are inaccurate in predicting fertility window. Really ? This is not rocket science. 

In the good news department, there may finally be some help to prevent vertical ( mother to child) transmission of Hepatitis B. When Tenofevir is used before birth, infant’s viral load and 7 month infections rates are lower than those who did not get the treatment. 

Stay tuned next week for more news from the world of Obstetrics and Gynecology. And don’t forget…. DEET is safe in pregnancy !! 

Food Friday: Portion Sizes

For something so critical to nutrition and well being, I am surprised I haven’t written about this yet. We talk about what to eat, and when to eat. But this discussion is nowhere near complete unless we talk about how much to eat. And how much can be very subjective. Estimates of portion size can be critically flawed. Sometimes when I listen to patients recount dietary history, it sounds correct, and yet they are not losing weight as one might expect. I think in many cases this is because portion size may be underestimated, sabotaging their efforts. 

It’s no secret that portion sizes in restaurants and grocery stores have purposely catered to our gluttonous tendencies. Portions have grown to more than twice of those in the 1980s. Even our plates and cups are bigger. This keeps us coming back for more and allows them to charge us more. A win win right ? Not for us. Obesity is a huge public health problem, and one that has both physical and psychological consequences. 

Let’s examine various methods of portion size management, and you can see what can work for you.

1. Know your calorie requirements. Use the handy calculator in the link. 

http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/calorie-calculator/itt-20084939

2. Have a general sense of your nutrition proportions: ( These are from the US FDA, the Food and Drug Administration.)

3. Check reference or for labels to check the size and specifications of a serving size. Compare this to what you need for your meal or snack. Serving size on the container does not necessarily equal recommended size .

4. Have a set of measuring cups and spoons. Have a small kitchen scale. Until your are familiar with common units of measure, measure and weight things. Here are some common measures of volume: 

2 Tablespoons = ping pong ball

1/2 cup =tennis ball

1c = baseball 

5. Avoid eating out. If you do, order small portions and just eat part of it. 

6. Buy in bulk but repackage in smaller quantities and do not eat from the bag. 

7. Don’t skip meals 

8. Do eat in between meal snacks which pair protein with produce. 

9. Use smaller plates and make sure your plate is at least half filled with green vegetables before you take other dishes. 

10. Avoid doing other things while eating. 

11. Eat slowly. Your brain takes at least 15 minutes to register that you are full. 

12. Stop eating when you feel 80% full. 

Part of the pleasure of eating is the taste and the company you eat with. But I would like to point out that the pleasure of eating also involves knowing that what you are eating is good for your body. Finally part of the pleasure of eating is knowing you have not eaten too much. Watch portions sizes, and your meals with will be better than ever. 

Medical Monday: Breaking news From the World of Obstetrics, Gynecology, and Women’s Health

To follow recent tradition, I will give the Zika update first. The WHO (World Health Organization) has reported that the spectrum of neurological damage to babies with Zika is greater than previously appreciated. Microcephaly is certainly the most obvious problem, but others such as spasticity, seizures, and vision problems are possible. 

This week a new method of acquiring the virus was confirmed. An American lab worker working with the Zika virus has contracted it though a needle stick. 

In the US, funding is still not present to fund the fight against the virus. Nonetheless, scientists at the National Institute of Allergy and Infectious Disease (NIAID) are “aggressively pursuing" a vaccine. 

Research is also taking place regarding how to alter the genes of the Zika carrying mosquitos so that they are sterile. Wiping out an entire species through genetic engineering may have unintended consequences. Researchers are examining this important issue. 

Over thirteen hundred cases of Zika are confirmed in Puerto Rico, but there are probably many more including those who are asymptomatic. ACOG (American College of Obstetricians and Gynecologists) is leading the effort to train physicians on the island to place IUDs for contraception. The WHO this week has finally issued a recommendation to women in affected areas to delay pregnancy. 

Both ovary and breast cancer therapies are in the news this week, and the messages are promising. For starters, research presented a the annual meeting of the American Society of Clinical Oncology has highlighted 11 additional genetic mutations associated with increased risk of ovarian cancer. This may ultimately give us expanded opportunities for screening and treatment of this disease. 

On the treatment side, it turns out that a combination of IV and intraperitoneal chemotherapy is more life extending than either therapy alone, for the treatment of ovarian cancer. Also on the treatment side, it turns out that extending anti-cancer hormone therapy such as Tamoxifen for 10 instead of 5 years reduces risk of recurrence or second primary in older women with early stage breast cancer. 

Syphylis cases have more than tripled in the last decade. At the same time, the majority of sexually active women between 15-25 have NOT been screened EVER for any sexually transmitted infections since they do not believe themselves to be at risk.

The CDC ( Centers for Disease Control) has reported the “ the US obesity epidemic continues to worsen”. Fully 40% of US women are obese. Obese is defined as a body mass index (BMI) at or greater than 30. Do you know your BMI ? 

Wellness Wednesday: Summer reminders #1 Sun protection

More than a few ladies came in to clinic this week looking like lobsters. So I write again to give you the perspective your future self would have wanted your present day self to have. 

Sun protection will reduce your cancer risk. It will also protect from general skin deterioration. We have all seen wrinkles, crepe-y skin, blotchy discolored skin, overtanned depigmentation spots and, yes, skin cancer.  

With the advance of medical care, technology and nutrition, we can expect ever increasing lifespans. This means we have to take of our bodies so that they will last even longer than before.

You might ask why skin deteriorates since the actual matter of our skin recycles about every three months. This is a very interesting question whose answer should motivate you to have good sun protection. 

If you injure your skin with a bad sunburn, one so bad that you peel, new healthy skin grows up from beneath. Aren’t you good then ? Well, the new skin is good. However, unbeknownst to you, the DNA of the deeper cells which have generated the layer has been damaged. This DNA damage is what reduces the error correcting ability of the cells over the long term. Error correction ? Aren't cells identical when one divides to two ? Yes and no. They are mostly identical. But over time, imperfections in the cell division occur and errors are generated and build up. Damaged DNA leads to more errors. This is what eventually gives rise to the skin damage listed earlier. 

The DNA is damaged by the uv light, whether it be from the sun, or a tanning booth. Protection is a matter of timing, clothing, and sunscreen. It is also a matter of the correct use of sunscreen. 

To review this critical information, please see the following posts: 

Skin Deep 

On the Virtues of Hats and Sun Protection

Have a sunny week. 

Food Friday: Better Carbs

Authorities agree that we consume too many carbohydrates and that this has contributed to the obesity epidemic. However it’s easy to eat plenty of carbs, lose weight, and have lots of energy if you just shift the way you think about them. 

When most people think about carbs (carbohydrates) they think of starches like white potatoes, grains like rice, and of course wheat products like bread, tortillas and pasta. But carbohydrates also comprise sugar, honey, maple syrup, corn syrup, etc, and all the products which feature them prominently, like conventional soda, frappes, and lattes. These sorts of carbohydrates are unhealthy because they jet sugar into your bloodstream much faster than you can utilize it and it ends up being stored as fat. The fat ends up having a variety of toxic effects down the line. Even the white flours, pastas, rices and white potatoes do this. The white flour and white rice have been denatured of their fibrous structure and because of this breakdown very quickly into sugar. 

Whole wheat flour and brown rice are commonly thought of as better carbs, and they are, but not as much as you might think. Their glycemic index (rate at which they break down into sugar) is not that much better than their white counterparts. These should be utilized by people of normal weight and body composition with high energy requirements. This would include adolescents and athletes.

It has been shown that consumption of 2-3 servings of whole grains per day reduces risk of diabetes, high blood pressure, colon cancer and obesity, compared to rates in those that don’t eat these. The precise reason for this is unclear, though it may well be because of the fiber and additional nutrients that whole grains contain compared to refined (denatured) grains.  It is a sad commentary that the presence of 2-3 servings of whole grains per day constitutes a measurably higher caliber of diet than our general population’s diet.

Certainly whole grains are not the only readily available dietary source of fiber and nutrients. What if, in an imaginary prospective research study, conventional eaters were compared to those with 2-3 servings of whole grains per day, AND against those with an equivalent amount of fiber, BUT in the form of vegetables and fruits? I suspect that the third group that took their carbs as fruits and vegetables would do even better. I feel confident in speculating like this because, as a rule, produce (vegetables and fruits) is considerably more nutrient dense than whole grains. Depending on the particulars, they have fiber, vitamins, minerals, but also other types of nutrient such as healthy fats and antioxidants. Moreover, they have even lower glycemic indices. 

So, I propose that we learn to take most of our carbs as produce. What ? No bread at dinner ? No pancakes or cereal at breakfast ? No bread for sandwiches at lunch ? People are sure they will starve. What they will do is lose some of their belly fat. They will lower their blood sugars. Pregnant women will gain less excess weight, and be less likely to have gestational diabetes. They will also spend more money and time on food. But, they could also be spending money on treatments for obesity, diabetes, heart disease and worse. 

There are other differences that should go along with this approach. Portion sizes usually need to be larger. Additionally, there should is more emphasis on healthy fats such as coconut oil for high heat and olive oil for low heat and dressings. Also, from a culinary standpoint, there should be a greater utilization of flavors such as spices, garlic, lemon, chili and so on.  Healthy sauces and dressings figure more prominently. and Finally, there is more emphasis on lean meats, poultry and cold water fish. 

I wanted to take this post and show you how this might look. I think that while you will find it completely different, you will find it rather appealing. 

Breakfast idea: 

I would pair this with a small bowl of fresh fruit. 

Lunch: 

Stiff leaves of romaine make a crunchy manageable container for savory contents, much like a taco shell. 

Dinner:

These are cauliflower mashed “ potatoes”, also known as “faux”  potatoes, which can be served as a side dish at dinner, drizzled with olive oil or butter.

These are zucchini noodles which just need a hearty meat sauce.

Dinner is in some ways the easiest, since you still have your “main dish” and your salad. All you need is another cooked vegetable, like these vegetable fries, and perhaps some fresh fruit. 

There are an infinity of substitutions like this. When families are transitioning from conventional diets to more of a paleo style diet like this, they may find it politic to try to make their new healthier dishes resemble old conventional ones. Eventually, this pretense can be abandoned, as more exciting approaches to healthy cooking are discovered. Check out any number of the new Paleo cookbooks out there. For more information, see the last four Food Friday blog posts on food inspiration.