Childbirth and the newborn period is supposed to be a joyful time. It’s stressful and overwhelming and sleep is hard to come by, but new moms are increasingly struggling with one more hurdle to enjoying time with their newborn. Depression.

About 25% of women in the United States will have depression bad enough to require treatment at some time in their life. Sadness, feeling that life isn’t worth living, not enjoying things that used to bring you joy, lack of motivation, trouble sleeping, and unusual fatigue are all symptoms of depression. What happens when a woman suffers depression in pregnancy?

An article published recently in Obstetrics & Gynecology looked at rates of depression diagnoses in women hospitalized for childbirth. The authors found that rates of depression increased from 0.41% in 2000 to 2.87% in 2015. That’s a seven-fold increase.

This study wasn’t designed to discover why diagnosis rates went up. It’s possible awareness is increasing so more patients are getting diagnosed, when the rates of illness aren’t actually rising. We do know that depression in pregnancy has serious consequences for both mom and baby, so more accurate diagnosis is important.

There are many possible triggers for depression, in pregnancy and at other times. Family history, stress, complications with the pregnancy or previous pregnancy loss, history of abuse or trauma, and relationship problems can all lead to depression.

Depression in pregnancy can have health consequences for both mom and baby. Poor nutrition, lack of exercise, alcohol and other drug abuse, smoking, poor sleep and social isolation can all stem from depression. Not taking good care of oneself during pregnancy (which includes withdrawing from loved ones who can help provide support) can lead to less robust health once the baby arrives.

Poor nutrition, substance abuse (including smoking) and social isolation can increase the risk of premature birth, low birth weight, bonding problems, and abuse/neglect of the baby once born.

If a pregnant women is feeling sad from time to time, usually all that is needed is to talk about her feelings honestly with her mate or a close friend or other family member. Symptoms that are severe enough to keep her from enjoying life, that last longer than 2 weeks or so, should be discussed with her obstetrician or family doctor.

Treatment can start with some dietary and nutrition changes and talk therapy with a trained counselor. If symptoms are bad enough, medication can definitely be prescribed to help with the mood. Remember, although no medication is perfectly safe in pregnancy (or at any other time, really), the risks of depression in pregnancy can be significant.

Pregnancy, while confusing, overwhelming and sometimes uncomfortable, doesn’t have to be as big a struggle as it is with depression. If you or a woman you know is struggling with depression in pregnancy, please make sure to discuss your symptoms with your doctor.

QUESTION: Have you or someone you know suffered with depression while pregnant? What helped?

I have a LOT of patients who have fatty liver disease. It is a huge epidemic in the USA and is the number-one cause of liver transplant now that hepatitis C has such successful treatments available.

New research is shedding more light on the causes of fatty liver disease, and giving clues to dietary factors that may be protective. I found a recent article with some very exciting findings that will help me guide my patients who are dealing with fatty liver disease.

It is becoming increasingly clear that fatty liver disease is a consequence of diets high in saturated fat and sucrose, fructose and other simple sugars. (Fruit doesn’t seem to carry the same risk; it is thought that the fiber in fruit is protective. Also most fruits don’t impact the blood sugar and raise insulin the way processed sweets and simple sugars do.)

When people eat diets high in saturated fat (like that found in meat, dairy, coconut oil and palm oil) and sugar, it causes hormonal changes that damage the liver and cause droplets of fat to accumulate in the liver cells. It can progress to permanent liver damage and even to cirrhosis and liver failure, requiring transplant.

Turns out two different foods have been found to be protective against the development of fatty liver disease. They are even powerful enough to reverse it once it has set in. I have NO medication to do this. Food is medicine!

Soy

β-Conglycinin, a protein that makes up about 30% of the protein in soybeans, has been shown to reduce intra-abdominal obesity and serum triglycerides and lower insulin levels. It took a LOT of this protein, 5 grams daily, to produce this effect, which corresponds to 15-20 grams of soy protein daily.

In both mice and humans, β-Conglycinin was shown to prevent the development of fatty liver disease and to improve the condition once it is present.

I have known soy to be a healthy food for a long time. Soy protein supplementation helps me maintain my weight and provides a lot of my protein needs, since I don’t eat meat, dairy or eggs. Want a safe, non-GMO, delicious soy protein shake to use for breakfast or lunch? Check out Shaklee’s Life Shake – you’ll love it, I guarantee it 🙂

Fish Oil

Fish oil has been a bit controversial in the treatment of fatty liver disease. It has been shown, in doses equivalent to 1000-4000 mg daily in humans, to prevent the development of fatty liver disease in mice and to improve fatty liver disease in humans.

I advise people who choose to take fish oil to take one that provides at least 300 mg EPA per gram of fish oil. This ensures you are getting the “good stuff” as EPA and DHA are the omega-3 fats responsible for fish oil’s good effects. Shaklee’s OmegaGuard is highly concentrated and free of contaminants. It’s the one I trust for my and my family’s use.

If you have been told you have fatty liver disease, please take steps to reduce your intake of added sugar and saturated fat. Consider adding soy to your diet, preferably as a protein shake or smoothie as it takes a LOT of soy protein to affect this disease. Also consider adding a high quality fish oil supplement.

QUESTION: Do you know anyone with fatty liver disease?

One of the most common problems we see in primary care is complaints about not getting quality sleep. People can’t fall asleep. Once they’re asleep they keep waking up. They wake up unrested. They’re tired and sleepy during the day.

Sleep disturbances have huge impact on our quality of life. Fatigue and sleepiness decrease our enjoyment of our hobbies and activities with family. In extreme cases, severe fatigue can be fatal in the case of people who fall asleep behind the wheel.

The good news is that sleep problems are very responsive to treatment even without medications. Changes in behavior related to sleep make a huge difference in quality of sleep. Continuing bad sleep habits (called poor sleep hygiene) make it very difficult for even sleeping pills to produce good results.

The absolute first thing to do is to have a consistent wake-up time every morning, 7 days per week. This sets your “biological clock” and helps improve sleep onset. And don’t nap. If you absolutely must nap every once in a while, set an alarm so you only sleep 20-30 minutes, and nap early in the day.

Can’t Fall Asleep

This actually is one of the easier problems to correct. Why can’t you fall asleep? Usually it’s because you’re worrying about something, or because you have trained yourself to be awake in bed.

The first thing to do is to make a commitment that the ONLY things you’re going to do in bed are sleep and have sex. Everything else happens somewhere else. No watching TV, no reading, no eating, no nothing. Often just taking this one step is enough to help gradually improve your ability to fall asleep.

If you are a light sleeper and use the TV to block out outside noise, change to a white-noise machine. TV noise (and light) actually makes it hard to sleep because of the change in pitch and volume from show to show and with commercial breaks.

If you have trouble getting to sleep because you’re worrying about something, take a week and try scheduling time earlier in each day to make a plan for dealing with whatever is worrying you. If you lie down and then remember something, get up and take care of it right away or make yourself a note so you don’t forget to deal with it in the morning. Oh, and don’t check work emails right before bed!

Can’t Stay Asleep

Many people fall asleep just fine but wake up before they need to get up, and then have trouble going back to sleep. This is often stress related and responds to stress reduction, meditation, and exercise.

This may sound weird, but it is important to only sleep as much as you need to feel refreshed the next day. Not everyone needs 8 hours, and spending excess time in bed can increase broken sleep and make it hard to get deep, restful sleep.

One important thing to do is STOP watching the clock. This makes it even harder to go to sleep. Set your alarm for your wake-up time and turn the clock towards the wall. Turn your phone over or plug it in in a place where you can’t reach it without getting out of bed.

Also, make sure you have a comfortable bed and bedroom. Cooler temperatures usually make it easier to sleep. It should be quiet and dark. As I said earlier, a white noise machine and blackout curtains can help if you are a light sleeper.

Substance use can interfere with quality sleep too. Caffeine, alcohol and nicotine all interfere with quality sleep. Caffeine should be avoided after noon, alcohol should be avoided after dinner and nicotine should be avoided altogether 😉

What Next?

If you have tried these measures and still find yourself unable to fall asleep, unable to stay asleep, and feeling sleepy during the day, it’s time to see the doctor. Sleep trouble is potentially dangerous and treatment can significantly improve your quality of life.

Do you eat plant-based? Vegetarian? Paleo? Keto? The Standard American Diet (appropriately abbreviated as SAD)? If you are interested in avoiding heart disease, stroke, cancer and diabetes, new research suggests you need to take a good look at your dietary fiber intake.

A huge meta-analysis of over 200 studies examining almost 135 million person-years of data was done. That’s an enormous amount of data! Both observational studies and clinical trials showed that eating higher amounts of dietary fiber resulted in lower body weight, blood pressure and cholesterol. Also, eating more fiber was associated with lower risk of heart attacks, stroke, diabetes and colon cancer.

How much lower was the risk? 15-30% decreased risk, which is huge! Statistical analysis suggests that the risk reduction really is from the fiber intake. First of all, there is a dose response curve, meaning that small increases in fiber result in smaller benefit, and larger intakes of fiber result in larger benefit.

How much fiber do you need to eat to get the benefits? This research suggests the most benefit is seen at intakes of 25-29 grams per day. The average American eats less than 15 grams of fiber per day. There is evidence that even more daily dietary fiber may give even more benefits!

What is the best way to figure out how much fiber you’re getting? I always recommend folks use MyFitnessPal, a free nutrition tracking program. Track for a week and see what your average fiber intake is. The best way to gradually add fiber is with FOOD, not supplements (although fiber supplements like Metamucil are better than nothing).

Fresh and dried fruits, veggies, beans, nuts, seeds and whole grains are your best sources of dietary fiber. WebMD has a nice article listing some high fiber foods to choose.

The higher fiber content of plant foods is likely the main reason plant-based diets are so healthy and result in such positive health benefits. Not able to give up meat, eggs and dairy altogether? Take positive steps for your health and start adding more plant foods (and therefore more fiber) to your diet today!

Does your doctor offer an online patient portal for you to communicate with her? Have you decided not to take advantage of this important opportunity? You might be making a mistake.

More and more patients have the opportunity to access a growing portion of their electronic medical record directly through a patient portal. They can request medication refills and appointments, send emails to their care team, and even read the office visit notes generated by their doctors.

My employer does offer a patient portal but a number of my patients won’t take advantage of it. Sometimes they say that they don’t want to provide their email address. Elderly patients sometimes don’t have a computer at all. Sometimes they won’t say why they don’t want to enroll.

I do know that I like when that little box on my EMR dashboard is green, showing my patient uses the portal. I can email her directly about her test results and make sure all her questions are answered. She can see what medications and supplements WE think she’s taking and let us know if our records aren’t correct.

There was a report published recently that looked at online patient portal use. They found that over 60% of respondents said they did NOT use a patient portal. Most of those people also said they had never been offered one.

What I found interesting in this study was WHY people said they didn’t want to use an online patient portal. Patients wanted to talk to someone in person. Well, yeah! If I have something concerning or confusing going on I want to talk to a real person. But if all my labs are normal, shoot me an email. Oh, and also let me SEE my results (and download and print them too). That’s the bonus!

Clear and easy two-way communication between patients and their care team is very important. An online patient portal is one of many tools patients and physicians can use to facilitate communication. If you have the opportunity to sign up for an online patient portal please consider doing so!

QUESTION: Do you use an online patient portal? What has been your experience? If not, why not?

My husband and I got a notification from the county health department this week. A student at my son’s high school was diagnosed with pertussis.

My first thought was that s/he must have not been vaccinated. But then I looked into the data and found that isn’t necessarily so.

What is Pertussis?

Pertussis, or whooping cough, is a childhood illness that starts with typical cold symptoms and progresses to a horrible spastic cough. It is very dangerous for small children and can be fatal. 13 children in the US died from pertussis in 2017.

As a bacterial infection, pertussis does respond to antibiotics but only if they are started BEFORE the typical whooping cough begins. Unfortunately, before the typical cough starts it looks just like a cold. This is one of the reasons we vaccinate against it – there is no other way to prevent the awful, potentially fatal cough.

In case you are thinking “Oh, it’s just a cough,” here’s a video of a baby girl in the ICU with pertussis. And here’s a video of a 64-year-old man hospitalized with pertussis.

What about the vaccine?

I know you’re going to say “But Dr. Jen, if there’s a good vaccine available how does this happen?” The problem with the vaccine is that the immunity decreases over time. (The immunity you get from having whooping cough itself also appears to decrease over time, which is a scary thought.)

No vaccine is 100% effective, but the current vaccine is pretty good. Immunity is estimated at 80-90% over the first year and starting to wane about 4 years after vaccination. The pertussis vaccine was changed from whole-cell to acellular (no cells) in the 1990s because the whole cell vaccine had a lot of side effects. However, the new acellular vaccine is not as effective.

It is recommended that TDaP (tetanus, diphtheria and acellular pertussis) vaccine booster doses be given every 5-10 years. Unfortunately it is not indicated for adults over 65. Pregnant women and those who spend time with babies and small children should be particularly careful to get booster doses regularly.

Bottom Line

Even though the pertussis vaccine isn’t perfect it still does a nice job of reducing the risk of whooping cough in the US. According to the CDC, in 2015 there were about 20,000 cases of pertussis in the US and 6 deaths between 2014 and 2015. Worldwide it is estimated that there were 24 million cases of whooping cough and over 160,000 deaths in 2015. Most of these cases occurred in developing countries where vaccination coverage is low.

Community vaccination decreases the risk that someone will be exposed to pertussis. Personal vaccination decreases the risk that, if exposed, an individual will get sick. Because the most vulnerable individuals are babies under the age of 1 year (too young to be fully vaccinated) it is important that all of us get regular boosters.

We live in a country that vaccinates, and we all benefit from that. We all should roll up our sleeves and get vaccinated to protect our precious, vulnerable babies from pertussis.

My family and I are traveling this Christmas, but I wanted to take a moment to write to you. I’m hoping you have a wonderful, peaceful holiday with your loved ones!

I’ve been reminded of a few things today:

• Traveling makes you crabby sometimes
• People do crazy things when driving in construction traffic
• North Carolina has even more orange barrels than Ohio
• When you’re 6’4″ you don’t fit on a pull-out couch anymore
• Eating sushi while driving is not recommended

However, I also was reminded that traveling with my favorite people in the world to see my OTHER favorite people in the world is really a lot of fun 🙂

God bless you and bring you a bring you plenty of joy this holiday season <3

Ow.  My leg hurts.  I had surgery yesterday to fix my varicose veins.

I’ve had varicose veins for over 20 years.  Every fall I keep thinking “This winter I’ll get my varicose veins fixed.”  And then every spring I think “I guess next winter I’ll get my varicose veins fixed.”

Well this year is THE year.

So therefore, my leg hurts.  Yesterday I had the first part of a two-part procedure to fix my varicose veins.  The plan is to have Part Two in 2 weeks and have my leg all healed up by summertime.

Why do we care about varicose veins?  What’s the big deal?  So my legs are lumpy-looking.  So what?

Turns out varicose veins can actually be a medical problem and not just cosmetic.  In my case, they make my leg swell and get sore and tired very easily.  If left alone for long enough, they can cause a skin condition called venous stasis dermatitis.

Stasis dermatitis happens when the veins are not functioning properly.

Credit: https://www.health-first.org

Many things cause the valves inside the veins to not work properly.  Gravity.  High estrogen levels from pregnancy.  Obesity.  Blood clots.  Connective tissue problems.  Heredity.  Whatever the reason, varicose veins have abnormal valves that allow blood to flow backwards.

The blood going in the wrong way makes the leg swell.  The blood cells are forced out by the pressure into the tissues and stain the skin with rust from the iron in the hemoglobin.  The skin can break down and any wounds are very difficult to heal.

As you can imagine, these problems are much more serious than the unattractive appearance of ropy, bulging veins.  And varicose veins tend to get worse as we age.

So what should you do if you want to avoid the problems of varicose veins and venous insufficiency?

Prevention is very helpful.  If you tend to be on your feet a lot for work, wear support stockings.  The moderate-compression stockings sold over the counter are helpful but keep in mind they need to be replaced regularly.  One key is, if you don’t have to work hard to get them on, they’re probably not tight enough.  And once they become easier to get into, they need replaced.

If you start to see ropy veins or spider veins, consider seeing your doctor for prescription stockings.  Any doctor can order them, but they need to be ordered from a pharmacy that carries home-health supplies.  You will need to be measured at the pharmacy to make sure your stockings fit you properly.

Follow the manufacturer’s directions for taking care of your stockings.  For instance, do NOT wash them in fabric softener.  This will soften and stretch the fibers and make your stockings stretch out more quickly.

If you start to see the big, ropy veins, your legs swell or your legs feel tired and sore after being on your feet for extended periods, see your doctor.  It may be that surgical treatment to close off and remove the veins that aren’t working properly will help the circulation in your legs.

Varicose veins aren’t serious like a heart attack or cancer, but they can certainly impact your health and affect your quality of life.  Take steps to prevent them, and if they develop, get them checked by your doctor.

QUESTION: Do you have varicose veins?  What are you doing to take care of them?

There has been a lot of talk lately about how “acidic” the Western diet is.  Meat is acidic, dairy is acidic, soda is acidic, it goes on and on!

I’ve been doing some research lately about foods that increase acid production in the body.  This doesn’t mean the foods themselves are acidic, but the processing of the nutrients in the food causes more acid to build up in the body.

Why do we care about acid in the body?  There are a lot of reasons today I’m focused on the fact that having to get rid of too much acid puts a strain on the kidneys and promotes the loss of bone matrix (leading to osteoporosis) and the formation of kidney stones.

If you have kidney problems, osteoporosis (or a family history of osteoporosis) or kidney stones, you should definitely pay close attention to how many acid-forming foods you’re eating per day.

In this post I’m going to focus on osteoporosis.  I expect I will write in the future about kidney stones as well.

It is estimated that the Western diet we eat today produces a LOT of acid, the equivalent of 4.9 grams of hydrochloric acid every day.  Our lungs and kidneys get rid of most of it, but not all of it.  Our bodies use calcium from bone to neutralize anything that is left.  Over years, this leaches the minerals from our bones and leads to osteoporosis and fractures.

Where does the acid come from?  The most acid-forming foods in the Western diet are sulfur-containing amino acids (found in large amounts in animal protein), cereal grains like wheat, phosphoric acid in soda, and salt.  Yes, I know, salt is salt and doesn’t contain acid, but it interferes with the kidneys’ ability to process acid.  Eating too much salt will cause acid to build up in the body.

Are there foods that will decrease acid production in the body?  Yep.  Diets high in magnesium, potassium, and fruits and vegetables increase bone mineral density and decrease fracture risk. You can replace animal protein with plant protein like beans, soy and quinoa.  You can also replace cereal grains with non-grain plant foods like roots, tubers, leafy green vegetables, vegetable fruit (veggies with seeds like tomatoes and cucumbers) and fruits.  These foods decrease acid production in the body.

What about supplements?  Turns out that potassium citrate and magnesium supplementation decreases bone turnover, increases bone density and decreases the amount of acid excreted in the urine.  Magnesium and potassium citrate also decreased the formation of kidney stones and even dissolved calcium oxalate stones (the most common type).  A beneficial side effect was that potassium supplementation also decreased blood pressure significantly in those with hypertension.

One BIG word of caution about potassium supplements.  PLEASE check with your doctor to see if potassium supplements would be safe for you before you start taking them.  There are medications that increase potassium levels, and as we age our kidneys get less able to manage potassium properly.  High potassium levels in the blood are VERY dangerous.  Blood test monitoring is prudent in anyone at risk for elevated potassium.

How can you see whether you’re getting too much sodium or not enough potassium?  There is a free calorie tracker at myfitnesspal.com that will give you nutrient information such as vitamin and mineral intake, calories, fat and protein grams in addition to calories.

I checked consumerlab.com for recommendations about magnesium and potassium citrate.  I found that they gave good ratings to the potassium citrate supplement from Natural Factors, the potassium-magnesium citrate supplement from Thorne Research, and the magnesium citrate supplements from Solgar, Kirkland and Spring Valley.

If you have osteoporosis or a family history of osteoporosis, you should strongly consider changing your diet to include more fruits and vegetables, roots, tubers and green leafy vegetables.  Don’t drink soda, period.  You should limit your animal protein intake (meat, dairy, egg and fish) and substitute plant sources of protein.  You should carefully monitor your sodium intake.  You should also make sure you’re getting enough potassium, and if not (most of us don’t, including me) you should consider taking a potassium citrate supplement, with magnesium citrate if you have a personal or family history of kidney stones.

QUESTION: Do you have osteoporosis?  Did anything in this post surprise you?

Last week we talked about ways to teach your kids to eat healthy and be fit.  That’s not all it takes to create a healthy family, though!

A healthy diet and physical fitness will help your kids grow up healthy in their bodies.  What else do your kids need to learn to live healthy all their lives?

I can think of two other very important things children need in order to live healthy.  First, they need to be deeply connected to others who love them.  Second, they need to know how to make (and be very good at making) healthy choices.

How do we keep our kids connected to people who love them?  We make sure they spend time with them.  The first people children connect with is their immediate family (parents and siblings).  Grandparents, aunts and uncles, cousins are all important role models, caretakers and playmates.

As our kids grow, neighborhood and school friends and their families become important parts of their extended families.  If your family attends church or temple, your religious community becomes an increasingly important source of support.

Why are social connections with people who love us so important?  For many reasons.  It’s exhausting raising kids!  Having more adults and older kids around to provided guidance and positive role models takes some of the pressure off of parents.  After all, a wise person said once that it takes a village to raise a child.

Hanging out with others who have the same values as your family helps to reinforce the values you are teaching your child.  While everyone has a little different approach, it’s good that your kids see other parents and adults insist on the same rules of behavior that you have taught them.  Mom and Dad aren’t so weird if Grandma, Aunt Stacy and Mrs. Cooper at Sunday School all insist on washing hands before snack and saying “please” and “thank you.”

One of the most important reasons for staying socially connected to other people as they grow up is that social connection is the anti-drug.  Studies have shown that people (teenagers and adults both) are unlikely to use drugs or engage in other dangerous and potentially self-destructive behaviors if they have deep social connections to people whose opinion of them matters to them.

This brings us to the second lesson kids need to learn well:  How to make good choices.  How do kids learn to make choices?  It sounds very strange, but THIS skill is one that really can’t be taught.  It’s one that kids have to learn on their own.

Credit: wayanadnoticeboard.com

How do you teach your child to whistle?  You can’t, right?  You can show them how to purse their lips or position their fingers just right, but it’s a skill they have to learn by trial and error.  And you can’t convince them they can do it, you have to just encourage them to keep trying.

Learning to make good choices is the same way.  You can tell them the theory, help them see risks and benefits, weigh consequences, etc.  But the best way for kids to learn to make choices is simply to make them.  And start making them EARLY.

Do you know any kids in your life whose parents make ALL the choices?  Yep, I do too.  How do you suppose those kids are going to learn to say no to drugs, alcohol and sex?  If all the decisions have been made for them their whole life, they may be content to continue to let others tell them what to do.

Credit: galleryhip.com

Start early.  Even one-year-old babies can help choose their clothes.  Offer two outfits and see if they will pick.  Toddlers can choose their breakfasts.  Schoolkids with birthday money to spend can choose the toy or game they want to buy.  Teenagers should be actively involved in important decisions that affect them, like choosing their high school and what car they will drive.

As your child grows, the importance and freedom they have with their choices should increase in a way that matches their problem-solving skills.  For instance, toddlers don’t get to choose chocolate cake for breakfast (even if it does contain eggs and milk, LOL!).  As they get older let them deal with consequences if they regret their decision later.  That schoolkid who decides later they don’t like the toy they bought will learn a valuable lesson when they have to save up to buy something else.

There is a great parenting book series by Foster Cline and Jim Fay called Love and Logic.  Anyone struggling with the “terrible threes” should check out the early childhood book.  (I need to get the book that deals with teenagers, LOL!)

Now we come to a sticky point.  How do you teach someone something that you don’t know?  You can’t right?  So if you want your kids to learn to be healthy and adventurous eaters, YOU have to be willing to eat healthy foods and try new things, right?  If you want your kids to learn the value of physical fitness, YOU have to model a willingness to participate and get sweaty.

You are the most important teacher your child will ever have.  They listen carefully to what you say (even when it seems they won’t).  But they watch what you do as well, and what you DO speaks much more loudly than what you SAY.

Seek out opportunities to connect your family to your community.  Choose a church or temple to attend. Join groups that have the same interests as you. Volunteer.  Spend time with your extended family and with your neighbors and your kids’ friends’ families.

Show your kids how you make decisions.  Think out loud with them and talk through alternatives and possible consequences.  Be up-front with them when things don’t go as planned.  They will learn that making a bad decision doesn’t make you a bad person.

Everyone wants their kids to be happy.  In my opinion, giving your kids the skills to be healthy and fit, make solid decisions and be secure in the love of their family and community will go a long way towards making that happen.