|Vol 4, Issue 2||www.ElCaminoWomen.com||April 1, 2019|
So happy to have entered Spring!
April is Autism Awareness Month. I think everyone reading this newsletter probably knows someone or the child of someone who’s somewhere on the Spectrum. There are so many amazing resources in the Bay Area, like Parents Helping Parents, which educates and supports families with special needs children navigate and succeed in making the system work for their children. Friends of Children with Special Needs is another great program that focuses on community integration to support and provide services to family with special needs children and adults. As we reflect on the new CDC numbers that 1/37 boys and 1/151 girls are diagnosed with an autism spectrum disorder, consider making a donation to one of these great organizations. We’ve included an article on the latest data on pregnancy-related risk factors for ASD diagnoses in this newsletter.
With the bright and warming weather, we hope everyone can find time get some sun and some exercise. Remember the value of Vitamin D and exercise to living a long and healthy life.
As always, feedback is always welcome on our practice, customer service, and even this newsletter!
In this issue:
We have finally figured out Instagram. Yes, that is our only new announcement for now. If that’s your preferred social media platform, now you can follow us there. We are still on Facebook, Twitter and LinkedIn for those who still haven’t warmed up to Instagram.
Our new therapist,Zainab Hosseini, Ed.M. ASWjoined us late in 2018. She’s seeing patients under the supervision of Dr. Awaad. As a Licensed Associate Social Worker, she provides therapy to our patients with mental health needs. She brings several years of experience in providing mental health counseling and therapy to our. Her services are in network for the insurances we currently accept under Dr. Awaad’s contract as her supervising physician. If you are thinking of establishing care with her, her panel is already about half full, to request an appointment, please call the office or email email@example.com.
Our future home in the IMOB continues to make progress. The outside is essentially complete the inside suites are being worked on. If you’re interested in seeing the progress, you can see pictures here. Unfortunately, not only was the original February 2019, move date moved to July, but that is looking more like October now.
We’re currently in our third home since we opened in July of 2009 and looking forward to settling down in our fourth (and hopefully final) home this fall.
THE SINUS SITUATION
If you have ever suffered from sinus issues, you are certainly not alone. Sinus problems affect about 1 in 8 adults in the United States. The cost of management of sinus disease exceeds $11 billion dollars a year! There is also the cost of missed work or school days and decreased quality of life.
The sinuses are “air pockets” in our skull. There are sinuses located in the forehead, between the eyes, behind the cheeks and even deeper in the head. The sinuses are connected to the nasal cavity via narrow channels through which mucus and air can drain and flow. When the mucus and air flow become blocked, sinus problems can develop.
By OpenStax College – Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.,
CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30131493
What is a sinus infection (or acute sinusitis)?
Virus or bacteria can multiply in the sinuses, often during a cold. The sinus lining swells, which blocks the channels that drain the sinuses into the nasal cavity. Mucus and pus then fill up the sinus cavities. Common symptoms of a sinus infection can include nasal congestion, facial pain and pressure, headache, thick nasal drainage, fevers, and upper teeth pain. A sinus infection, or acute sinusitis, can last for up to 4 weeks.
Most acute sinus infections are caused from viruses and do not require antibiotics. When symptoms last longer than about a week or get worse after improving, this might be a sign of bacterial infection and antibiotics may be appropriate. Decongestants (if compatible with your other medical issues), nasal sprays and rinses may also be recommended (more on these below).
What is chronic sinusitis?
If symptoms of a sinus infection last longer than 12 weeks, then you may have chronic sinusitis. The underlying issue may be prolonged inflammation rather than prolonged infection.
There are many reasons why some people have this problem but others who may live in the same environment or come from the same family do not. Some reasons include anatomy (sinuses that are physically blocked), allergies, and immune factors. There are also many other factors that are currently being researched.
For patients who suffer from chronic sinus issues, conservative medical therapy or surgery can be options.
Medical therapy for chronic sinus disease may include sprays, rinses, and medications. Topical nasal steroid sprays, some of which are even available over the counter such as Flonase and Nasacort, may be recommended in addition to oral antihistamines such as Claritin or Zyrtec. Depending on some factors, oral steroids may also be used. Longer courses of antibiotics (21 days) can also be included in the regimen.
One very useful tool is sinonasal irrigations. Many people have heard of the Neti Pot, which refers to a teapot-shaped vessel that is used to rinse the nose and sinuses with clean saline. This helps to rinse out “snot and boogers” and particulate matter as well as help with the flow of mucus in the nose and sinuses. We prefer the Neilmed design (instead of the Neti-pot) which is essentially a “squeeze bottle” to accomplish the same goal. We feel this is more user-friendly and even more effective. In some cases, medicated rinses may be used.
For patients who continue to suffer from sinus symptoms despite medical therapy, sinus surgery may be an option. The goal of surgery is to identify and widen the natural drainage pathways between the sinuses and the nose. This allows for mucus to flow out and air to flow in. Inflamed tissue is also removed. Surgery also helps the delivery of sprays and rinses so that theycan actually get into the sinus cavities.
Sinus surgery has undergone an evolution in recent decades thanks to improved technology. In the past, surgery required incisions through the face and extensive nasal packing which led to significant pain and recovery periods. With the development of specialized endoscopes and tools, sinus surgery can now be accomplished entirely through the nostrils with much less recovery time and discomfort (and oftentimes no packing!).
With further advancements such as balloon sinuplasty, some sinus procedures in select patients can even be performed in the office under only local anesthesia. This allows patients to avoid invasive general anesthesia and costly operating room and hospital bills and offers even shorter recovery times and less discomfort!
If you are having symptoms of sinus issues, you may benefit from an Ear, Nose & Throat evaluation.
Katrina Chaung, M.D.
Board certified, Otolaryngology-Head and Neck Surgery (Ear, Nose, & Throat)
2204 Grant Road, Suite 102
Mountain View, CA 94040
WHAT WE KNOW ABOUT THE RISK OF AUTISM AND PREGNANCY
Austim Spectrum Disorder (ASD) is used to describe a group of disorders affecting communication and behavior. Symptoms generally appear in the first two years of life. The DSM-5 specifically defines it as “Persistent deficits in social communication and restricted, repetitive patterns of behavior, interests, or activities”.
In the spring of 2018, the CDC published updated numbers on the prevalence of Autism. The prevalence of ASD is estimated to be between 13.1 to 29.3 per 1,000 children. Another way to look at that those numbers is that 1/36 to 1/79 children are affected by ASD. We also know males are affected by ASD 4 times as often as females.
With the increasing prevalence there’s always the question: what is going on? We know with more awareness of any disorder, there is an increase in diagnosis of cases. But are there other factors at play? At this point, we know that the development of ASD is not completely understood. Given the complexity and diversity of the disorder, there is a general consensus that there is a genetic component that affects brain development but also that environmental factors during fetal development and early childhood affect which genes and how many genes are “turned on” during development resulting in ASD.
There are likely many genes or gene combination associated with an ASD diagnosis. There is an increased risk of an ASD diagnosis when someone has a relative with ASD. Identical twins have a 60% of both having an ASD diagnosis vs 13% for full siblings and fraternal twins.
There is a slight increase in risk with increasing paternal and maternal age. For every additional 10 years of age for both the mother and the father there is a 20-30% increased chance of having a child with ASD.
Though not a major contributing factor to the overall prevalence of ASD, toxic exposures and prenatal infections (infections of the mother while pregnant) are thought to cause a “second-hit”, or make it more likely that genes related to ASD are “turned on” during development. The risk is related to many variables: the type and concentration of the toxin and the timing and duration of exposure.
Last month the British Medical Journal published a large population based study that found a 10% increased risk of an ASD diagnosis if the mother was living within 2000 meters of specific pesticides. The risk was higher (20-40%) for a diagnosis of ASD with intellectual disability. Exposure in the first year of life also showed an increased risk of an ASD diagnosis.
The difficulty of pesticide exposure is the lack of control most people have over this. Most of us aren’t even aware of what pesticides are being used on agricultural areas and aren’t aware of where the nearest farm is. Moving away from agricultural areas is one solution (though not practical for many people). Avoiding pesticide heavy produce and vegetables is something most of us can do. The Environmental Working Group has a list of the most pesticide heavy produce as well as the least pesticide heavy.
Complications in pregnancy have been associated with an increased risk of ASD but no specific complication seems to be more significant than others. From abnormal placentas to low birth weight and even meconium fluid aspiration are all factors that can increase the risk of ASD. Some studies have also shown that diabetes, obesity and hypertension in pregnancy are associated with an increased risk as well.
What can we control?
So much of this: genetics, our age when we’re ready to have children, and where we live (or what our neighbors are spraying on their crops) are out of our control. But what we can do is try to buy produce that is less pesticide heavy, preferably organic fruits and vegetables, and work to have healthier pregnancies by working towards a more normal weight and lower carb diet to avoid related complications of pregnancy.
Most importantly, ASD is common and it’s important we all have a good understanding of the disorder as it’s very likely one of our loved ones or neighbors is or will be diagnosed with ASD. You can learn more here.
SKIN HACKS FOR HEALTHY SKIN BY A PEDIATRIC DERMATOLOGIST
By Dr. Lillian Soohoo
Board-certified Pediatric Dermatologist and mother of three
The Menkes Clinic, Mountain View
Can you walk through a specific scenario when you needed to use a home or natural symptom-soother to help your child’s water-related issue?
We know that our kids love to frequent the swimming pool, especially during the carefree summer months. They enjoy hanging out in their sandals and flip flops, shedding their footwear to run around in bare feet around the pool, in the locker room, and shower areas. Did you know that walking barefoot in these and other public surfaces is a common cause of skin-loving infections? Yes, dermatologic conditions such as athletes’ foot and warts may show up on the bottoms of their feet and in between their toes. Both skin infections can last months and even years if not treated and are a source of itching, burning, and even pain. Simple precautions can help to prevent your kids from encountering these common fungal and viral organisms on their feet!
What was the symptom-soother you used?
Always instruct kids (and adults) to wear their flip flops or other protective sandals/shoes in public areas. This includes around the pool deck, public showers, inside the locker room, and on all paved outdoor pathways—wherever people walk barefoot in public.
How/why does that work? (What’s the mechanism / science behind it?)
Children’s’ skin is softer, moist and easier for common infectious organisms, such as athletes’ foot fungus and wart virus (HPV), to penetrate the skin and find a comfortable home. In the case of athletes’ foot, the causative fungus lives and thrives on the outermost, dead layer of the skin, called the stratum corneum which is made primarily of keratin. When infection ensues, it is usually seen as a scaly, often itchy rash occasionally with cracking of skin in between the 4th and 5th toes. Athletes’ foot fungus can also move on to infect the toenails too, since nails are another plentiful source of keratin. This results in thickened, discolored, and unattractive toenails. Treatment with topical antifungal creams is usually effective for skin infections on the feet, however toenail infections often require prescribed oral medications for best results and complete cure. Human papilloma virus (HPV) also takes advantage of exposure to moist, bare skin to be the most common cause of warts on the feet (also known as plantar warts). Treatment is often prolonged, difficult and painful so wearing protective footwear again, is the key to preventing these stubborn infections.
Remember all public flooring surfaces including pool decks and showers, as well as martial arts, dance and gymnastics studios where many individuals typically walk in bare feet are high risk areas for contracting these common fungal and viral skin infections of the feet in children.
Other quick remedies for water and swim related skin rashes
Using a moisturizer such as Cetaphil or Cerave cream over the entire skin after prolonged time in swimming pools is effective in relieving dry skin. Simply have your kids shower off without soap to rinse off their skin, pat dry and then slather cream over their body to restore soft, smooth skin.
If your child has an itchy rash after spending the day in the sun at the pool or the beach, be aware that this may be due to an allergy to his/her sunscreen. Many sunscreens contain chemicals that cause irritation, flaring of eczema and allergic rashes. Stick to those sunscreens which contain zinc oxide as their primary active ingredient. If you suspect your child is having an allergy to their sunscreen, stop using it immediately. If the rash persists or is uncomfortable see your dermatologist who may need to prescribe topical medications.
At The Menkes Clinic, together with my colleagues Dr. Andrew Menkes and Dr. Krystle Wang, we strive to answer questions clearly and to provide the latest, scientifically proven treatments for our patients.
UNDERSTANDING THE HORMONAL EXPLANATION OF OBESITY–#3 IN OUR LASTING WEIGHT LOSS SERIES
For a really long time, we’ve been teaching (and have been taught) that weight gain and weight loss are all based on the simple idea of how many calories we take in and how many calories we burn. If we eat 2000 calories in a day and burn 2000 calories that same day with our activities, we should not be gaining weight.
If it’s so simple, then why are so many physicians—who have committed their lives to keep others in good health—overweight? And more so, why are so many intelligent, ambitious and accomplished people struggling for years with being overweight or obese?
Unfortunately, this model doesn’t include a lot of variables, what determines calories out? What about the storing of fat? We all know people who eat way more than we think they’re burning, and they are not gaining weight. We have many of us cut significant calories for some period of time without being able to maintain that new, starvation earned weight. It is not all just personal failing, there’s something wrong with this model. You can go here or here to read more about why it’s not just this simple.
So, what’s going on?
It’s very important to understand the hormonal obesity theory. The idea that there are hormonal signals in the body that regulate fat storage in the body, like how thyroid hormone regulates the thyroid gland. Currently, the primary hormone we understand to cause increased fat storage is insulin. Cortisol (stress hormone) also has a role to a lesser degree. There are likely other hormones that partake in the regulation of fat storage, but insulin is the main player. There are studies and studies that show weight gain correlates with insulin doses in diabetics. We know the opposite to also be true. If you know anything about type 1 diabetes (when the body makes too little insulin), not only does a person’s sugars reach very high levels, but they can’t store any fat and start wasting away (until they get treated with insulin). So, for most people, think of insulin as the gate keeper of fat storage.
This also explains why it does matter if you get your calories from cake or salmon. Cake, mostly refined carbs, causes a spike in your insulin levels. Salmon, which has no carbs, has minimal effect on insulin. Since insulin is the main determinate of whether or note fat is stored, the different type of calorie determines whether or not fat can be stored, not the number of calories.
There are also other issues at play that exacerbate fat storage:
- Increased intake of carbs–the subsequent higher levels of insulin over time—causes the body to be insulin resistance
- Insulin resistance requires the body to produce higher levels of insulin to manage the same of amount of carb intake to keep your blood sugars normal. These higher levels of insulin make the body store even more fat
- More fat stores, in turn, increase your insulin resistance too
- We know that Cortisol (stress hormone) also increases insulin, which adds to weight gain
- This is why long term stress causes weight gain
- This is why sleep deprivation causes weight gain
What about leptin?
Leptin is a hormone that is produced by fat cells. The way it’s supposed to work, a person eats, as food is stored as fat, the fat cells release leptin, making the person feel full and stop eating. This has kept people for centuries and millennia from becoming obese.
What’s changed is refined carbs. As the amount of carbs in the diet has increased through refined carbs and processed foods, people have developed increased insulin levels. Increased insulin levels blocks the leptin signal to the brain, allowing people to keep eating
- Weight gain and weight loss are not as simple as calories in and calories out
- Eating less doesn’t cause weight loss: it increases hunger and the body will decrease it’s metabolic rate to maintain your body’s weight
- Eating more doesn’t cause weight gain: it suppresses hunger and body will increase it’s metabolic rate to maintain your body’s weight
- Increased appetite and decreased energy are not the cause of being overweight and obese. Becoming overweight is the cause of increased appetite and decreased energy.
- The solution for most people who are overweight and obese is to decrease their insulin levels and reverse their insulin resistance
- Due to leptin resistance in overweight and obese people, hunger doesn’t always mean the body needs fuel, since normal leptin pathways aren’t working properly
We will talk about ways to decrease your insulin levels and your insulin resistance in future articles as part of our Lasting Weight Loss Series. But if you to read more about the hormonal obesity theory, it’s worth reviewing this series of articles and this one. If you prefer to watch a lecture series, try this one.
PREVENTING TYPE 2 DIABETES
What is type 2 diabetes?
Type 2 diabetes is a disorder that is known for disrupting the way your body uses or stores or process glucose (sugar). All the cells in your body need sugar to work normally. Sugar gets into the cells with the help of a hormone called insulin. If there is not enough insulin or if your body stops responding to insulin, sugar builds up in the blood.
There are two different types of diabetes, type 1 and type 2:
- In type 1 diabetes, the problem is that the pancreas stops making insulin.
- In type 2 diabetes, the body stops responding to normal or high levels of insulin, and over time, the pancreas does not make enough insulin.
- Pre-diabetes is the stage where is a person at high risk for developing diabetes.
In the United States, approximately 90% of all people with diabetes have type 2 diabetes. This is a chronic medical condition that requires regular monitoring and treatment throughout your life in order to keep your blood sugar levels as close to normal as possible. Symptoms of diabetes can be varied. The most common we see is the need to urinate frequently, feeling thirsty and blurred vision.
People with pre-diabetes/diabetes have a higher-than-average risk of heart attacks, strokes, and other problems.
What increases the risk for type 2 diabetes?
- Being overweight or obese, especially if someone carries extra weight in their belly as opposed to in your hips, thighs, and butt (Individuals >45 years of age with body mass index (BMI) > 25)
- Not doing enough physical activity (sedentary lifestyle).
- Having a family history of diabetes (genetic causes).
- Having diabetes during pregnancy, called “gestational diabetes”. Women who develop gestational diabetes during pregnancy are at increased risk for developing type 2 diabetes later in life.
- Plus, Asian, Latino, or black people are more likely to get diabetes than white people.
What are the tests that can find people who are at risk?
- Fasting glucose test – This test measures blood sugar when a person has not had anything to eat or drink (except water) for 8 hours. People with pre-diabetes have a fasting glucose between 100 and 125.
- Glucose tolerance test – For this test, a person does not eat or drink anything for 8 to 12 hours. But then, as part of the test, a person will have a sugary drink. Two hours later, a doctor takes a blood sample to see how high your blood sugar got. People with prediabetes have glucose tolerance results between 140 and 199.
- Hemoglobin A1C test (also called HbA1C or A1C) – For this test it does not matter whether a person eat beforehand. It is a blood test that shows what the average blood sugar level has been for the past 2 to 3 months. People with pre-diabetes have A1C levels between 5.7 and 6.4
What should you do to prevent developing prediabetes/diabetes?
If a person has pre-diabetes, he/ she needs to make lifestyle changes to reduce the chance that they will get full-blown diabetes. Here’s what is recommended:
- Lose weight – Losing 5 to 10 percent of your body weight can lower the risk a lot. For example if you weigh 200 pounds that means you should lose 10 to 20 pounds. If you weigh 150 pounds that means you should lose 7 to 15 pounds.
- Eat right – Choose a diet rich in fruits, vegetables, and low-fat dairy products, but low in meats, sweets, and refined grains. Stay away from sweet drinks, like soda and juice (Mediterranean-style diet is recommended)
- Be active for 30 minutes a day – You don’t have to go to the gym or break a sweat to get a benefit. Walking, gardening, and dancing are all activities that can help (at least 150 minutes of moderate-intensity, aerobic exercise per week)
- Quit smoking – If you smoke, your doctor will help to advice on how to quit. People are much more likely to succeed if they have help and get medicines to help them quit.
If your doctor prescribed any medicines, take them every day, as directed. That goes for medicines to prevent diabetes, and for ones to lower blood pressure or cholesterol.
From my experience with my patients I know that being diagnosed with type 2 diabetes can be a frightening and overwhelming experience, and you likely have too many questions about it. The first few months after being diagnosed are filled with emotional highs and lows. I will be more than happy to answer your questions and talk to you about what to expect.
CHANGES IN CDC RECOMMENDATIONS AROUND THE ZIKA VIRUS AND PREGNANCY
In the first 3 months of this year, the CDC has made major changes to the recommendations and restrictions around Zika exposure during pregnancy. It’s website resources on the Zika virus has also gone through multiples changes during these months.
The CDC first issues restrictive travel rules for pregnant (or soon to be pregnant) women and their partners in 2016, after the WHO labeled the Zika Virus a global health emergency. The WHO’s work was in response to the discovery of a link between the Zika virus and severe birth defects in babies.
The CDC has finally downgraded it’s warning. Though the link between Zika virus in pregnancy and birth defects persists, the overall prevalence of the Zika virus globally is decreasing. The new guidelines encourage a discussion between women who are pregnant or trying to get pregnant and their physicians. The only location currently identified as having an active outbreak is in Rajasthan, India. The CDC urges people to avoid travel to this area.
The new recommendations include:
- Women who are pregnant should not travel to areas with an active outbreak or have unprotected sex with someone who has recently traveled to a high risk area
- Pregnant women considering traveling to an area with known transmission should talk to their physician first to understand the risks of the virus, ways to protect herself and what testing is needed upon return.
- For women planning on pregnancy who have recently travelled to Zika endemic areas or areas with an active outbreak, they should wait 2 months after they’ve returned before trying to get pregnant.
- If only a partner has traveled to a Zika area, the couple should wait 3 months before having unprotected sex or trying to conceive.
- There has been no local spread of Zika Virus in the US in 2018 or 2019.
- There is no vaccine to prevent or medicine to treat the Zika virus
THE BRAIN FOG OF MENOPAUSE
Hot flashes, vaginal dryness, sleep problems, mood changes – just a few signs and symptoms of menopause. Recent studies show that there is yet another symptom – cognitive decline. As we age, a decrease in estrogen levels lead to a plethora of issues. This decline in estrogen can also affect the brain. Termed “brain-fog,” this condition can lead to difficulty with:
- short-term memory
- word recall
- clarity of thought
The timing of menopause is about 15 years earlier than when the average woman will show signs of dementia. Unfortunately, some women are given a diagnosis of dementia-related cognitive declines as they transition through menopause. In December 2018, researchers published an article on cognitive changes due to menopause. In the case study, two women had impairment that was misattributed to Alzheimer’s and dementia. However, after imaging and testing, these women were found to not have either of these conditions. Rather, their symptoms were caused due to menopause.
In a 6-year long study, 1,900 women in their 50s were asked if they have had menopausal symptoms that negatively affected their cognitive abilities. The survey results showed that while menopause was linked to depression, anxiety, sleep disturbance, and vasomotor symptoms, these symptoms were not correlated to cognitive defects. In another study, perimenopause was associated with a decrease in cognitive performance, but rebounded in post menopause. These results suggest that cognitive decline is time-sensitive and that it peaks during menopause but recovers.
Exercise is one of the first recommendations made for this issue. Though there’s no data linking improvement in the Menopause Brain Fog and exercise, we know so many issues with cognition improve with exercise, it’s an easy first step.
Adequate sleep and stress reduction techniques like meditation have also been shown to improve cognitive function related to other health issues and are also important things to consider if you’re having trouble with mental clarity during menopause.
Hormone-replacement therapy can help ease those symptoms. Women who were treated with estrogen therapy had lower rates of impairment. Please make an appointment with us if you are of menopausal age and are experiencing any of the following symptoms:
- Increased irritability
- Difficulty organizing
- Keeping track of belongings
- Making goals and plans
An assessment is important to make sure there’s nothing more serious going on and then based on your personal goals, we can work on a treatment plan that works best for you.
HIGHLIGHTS FROM OUR WOMEN’S HEALTH BLOG
Our Women’s Health Blog is a way for us to put out up to date information on various topics we find important for all of you. Our top article last quarter was How can I have a girl? Or maybe, how can I have a boy? It was an updated review of the science of gender selection from our previously most popular blog post 3 years ago. The next three most read articles were both around vaginal changes after menopause: a brief one on seeking help for the problem, the second an abstract about using the MonaLisa Touch laser for Lichen’s Sclerosis and the third on a lower dose estrogen treatment. Follow us on Facebook, Twitter, LinkedIn, or Instagram to be informed when we post new articles.
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