HEALTH CARE October 2021
3 BREAST CANCER QUESTIONS Answered by the Mayo Clinic
ILLNESS-RELATED FATIGUE: MORE THAN JUST FEELING TIRED
TYPE 2 DIABETES: WHICH MEDICATION IS BEST FOR ME?
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HEALTH CARE | October 2021
JENNIFER CRYSTAL, MFA, HARVARD HEALTH BLOG
When we get an acute illness like the flu or a cold, we talk about was getting back on track. I even threw a big feel sick for a week or two and then get back to our “back to life” party when I finally achieved remission. usual lives. This is how illness is “supposed” to go. But Then I went right back to the high-functioning lifestyle I’d what happens when illness doesn’t fit this bill? What do always known. patients with chronic conditions like diabetes or multiple Three months later, I relapsed sclerosis, or with persistent ONCE YOU FIGURE OUT HOW TO completely. It took another symptoms of Lyme disease BEST MEET YOUR NEEDS, YOU CAN couple of years of treatment or long-haul COVID-19, do PLAN OTHER PARTS OF YOUR LIFE to get well enough to attend when they can’t go back to their ACCORDINGLY. YOUR HEALTH MUST graduate school, socialize, normal lives? Having suffered COME FIRST, BUT IT ISN’T THE ONLY from the latter two — tick-borne exercise and work. The journey illnesses that have plagued me wasn’t linear. I had to pace IMPORTANT ASPECT OF YOUR LIFE, for two decades, and a case myself to have more good EVEN WHEN YOU HAVE A PERSISTENT, of COVID-19 that took four days than bad. I realized I DEBILITATING ILLNESS. months to shake — I’ve learned couldn’t just wipe my hands of a few lessons about living with my illnesses. These persistent persistent illness. infections were coming with me, and not only did I have to accept them, I had to learn to move forward with them in a way that honored my REFRAME YOUR MINDSET needs but didn’t let them run my life. The most important — and hardest — lesson I’ve learned is that with debilitating, persistent conditions, there is RECOGNIZE YOUR NEEDS no going back. I got sick at age 25. I had been working full-time, living an incredibly active lifestyle, burning the Our bodies are good at telling us what they need: food, candle at both ends. Suddenly, the candle was gone. sleep, down time. We’re not always good at listening to Bedridden through years of intense treatment, all I could these messages, however, because we live busy lives and
October 2021 | HEALTH CARE
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sometimes can’t or don’t want to make time to take care of ourselves. When you have a persistent illness, ignoring your body’s needs becomes harder, if not impossible, and the consequences are more severe. I’ve learned that I have to pace myself physically and neurologically, stopping activity before I get tired so my symptoms don’t flare. I have to rest in the early afternoon. I must stick to a particular diet, stay on low-dose medications and do regular adjunct therapies in order to maintain my health. Now, after recovering from COVID-19, I also need to be conscious of residual lung inflammation. At first, I saw these needs as limitations. They take up time and energy and prevent me from living a normal life. But when I reframed my thinking, I realized that I’ve simply created a new normal that works in the context of my illnesses. Everyone, sick or healthy, has needs. Acknowledging and respecting them can be frustrating in the short term, but allows us to live better in the long term.
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THINK OUTSIDE THE BOX Once you figure out how to best meet your needs, you can plan other parts of your life accordingly. Your health must come first, but it isn’t the only important aspect of your life, even when you have a persistent, debilitating illness. I had to shift my thinking from feeling anxious and embarrassed by what I couldn’t do, to optimizing what I can. I can’t work a traditional 9-to-5 job anymore, but I can write and teach on a more flexible schedule. I can’t go for an all-day hike — and might not want to anyway, due to ticks! — but I can enjoy a morning of kayaking. What skills do you have to offer, and what innovative opportunities might put them to good use? What activities do you miss, and how can you do them in an adaptive way? If that’s not possible, what’s a new activity you could explore?
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HOPE FOR THE FUTURE, BUT LIVE IN THE PRESENT Learning to live well with a persistent illness does not mean resigning yourself to it. I’m able to do more each year, even though I sometimes have short setbacks. I change medications. I try new therapies. I manage my illnesses as they are now, but I haven’t given up hope for a cure, and am always striving to find ways to make my life even better. I can’t control what my illnesses do, but I can control how I handle them. And that makes life a little brighter.
JENNIFER CRYSTAL, MFA, IS A CONTRIBUTOR TO HARVARD HEALTH PUBLICATIONS. 6
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ILLNESS-RELATED FATIGUE When I was acutely ill with persistent Lyme, babesiosis and ehrlichiosis — all tick-borne illnesses — as well as chronic Epstein-Barr virus, a good night’s sleep did nothing. Naps were staples of my day that helped me survive but didn’t improve my energy. Drinking a cup of coffee was akin to treating an ear infection with candy. No matter how much I rested, my exhaustion persisted. I felt like I had the flu, except it lasted for years. My whole body ached. I suffered migraine headaches. I had hallucinogenic nightmares. Exercise was out of the question; at times, I was literally too tired to walk up a flight of stairs or sit at the dinner table. I couldn’t concentrate, unable to read or watch TV. Sometimes I was too tired to talk. There was no pushing through this level of fatigue, because it was caused by internal factors: illnesses that were ravaging my body. Only when they were adequately treated did I start to get my energy back. For me, the root causes were bacterial infections (Lyme, ehrlichiosis), a parasite (babesiosis) and a virus (EpsteinBarr). Profound fatigue may also result from a host of other diseases and conditions, including chronic fatigue syndrome, fibromyalgia and multiple sclerosis. IS IT EVERYDAY FATIGUE OR ILLNESS-RELATED FATIGUE? JENNIFER CRYSTAL, MFA, HARVARD HEALTH BLOG
“Tired” is a nebulous word that covers a broad spectrum of levels of fatigue. A crucial distinction, however, is between regular fatigue and illness-related fatigue. REGULAR FATIGUE Everyday fatigue that is not illness-related starts with a baseline of health. You may feel sleepy, you may in fact be sleepdeprived, or your body and mind may be worn out from long hours, exertion or unrelenting stress — but you don’t feel sick. Your muscles and joints don’t ache like when you have the flu. You are capable of getting out of bed and powering through the day, even if you don’t want to. A cup of coffee or a nap might perk you up. This type of fatigue is usually related to external factors: lack of sleep, stress, an extra-hard workout. But internally, your body is working well: your glands and organs are operating properly; infection is not depleting your body of energy; 0your nervous system may be overtaxed, but it’s not frayed from actual impairment.
October 2021 | HEALTH CARE
When determining whether your tiredness is everyday fatigue or illness-related, consider the following questions: • • • • • • •
Do you feel worn out, or do you feel sick? Have you experienced this before, or does it feel more extreme or unrelenting? When you lessen the load of external factors — work, stress, long days — does the fatigue improve, or does it persist? Do you feel refreshed after a good night’s sleep or a nap? Can you go about your day, or is it impossible to get out of bed? Has the fatigue persisted longer than you would expect? Are you experiencing other symptoms that might point to illness? THE BOTTOM LINE
No one knows your body better than you do. You know what feels normal, and you know what you feel like when you’re sick. If you are not responding to regular fatigue remedies, your fatigue has persisted over time, you have other symptoms or you just don’t feel right, it’s probably time to call your doctor.
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DEAR MAYO CLINIC: I’m confused about breast selfexams. I’m 45 years old, and I remember being told to do self-exams monthly. At one point, my health care provider even gave me a laminated card to put in the shower that showed the correct technique. Now it seems self-exams aren’t talked about much anymore. Are we still supposed to do them? ANSWER: You are correct that the role of breast selfexams have changed. While detailed breast self-exams no longer are recommended as part of formal screening for breast cancer, it is still important for you to know how your breasts usually look and feel. That way, if anything changes, you will be more likely to notice the difference. Breast self-awareness can help you become more familiar with your own breasts, so you understand what’s normal for you. In the past, health care providers often recommended that women do breast self-exams regularly using a step-bystep approach to detect signs of breast cancer. Although breast self-exams seemed like a good way for women to find breast cancer in its early stages, research showed that those self-exams triggered more breast tests and biopsies being done that came back with normal findings — sometimes called false positives — in women who did breast self-exams, compared to women who did not do the exams.
2021 | HEALTH CARE
Now, instead of using detailed self-exams as part of a formal breast cancer screening process, health care providers recommend breast self-awareness, so that women become familiar with the normal look and feel of their breasts. That way, if you notice a change in your breast, such as a lump or bump that seems out of the ordinary to you, you can tell your health care provider about it. From there, the two of you can decide if any further investigation is needed. Although it is a good idea for you to be aware of the typical look and feel of your breasts, keep in mind that breast self-awareness can’t replace a clinical breast exam conducted by your health care provider. And breast selfawareness should not replace screening mammograms or other breast cancer screening tests that your health care provider recommends. Screening mammograms often can detect breast changes in women who have no new noticeable breast abnormalities or any other signs or symptoms of cancer. The goal of these screening mammograms is to detect cancer in its earliest stage, before you’d be able to notice any changes. Mammograms continue to play a key role in early breast cancer detection and have been shown to help decrease breast cancer deaths. Take time to talk to your health care provider about the approach to breast cancer screening that’s right for you. Factors that can make a difference in that approach
include your age, medical background and family history, among others. Discuss the benefits, risks and limitations of screening tools, such mammograms, and decide together what is best for your situation. — Karthik Ghosh, M.D., Breast Diagnostic Clinic, Mayo Clinic, Rochester, Minn. DEAR MAYO CLINIC: After a recent mammogram, I was told that I have dense breast tissue. What does that mean? Should I be concerned? What does that mean for my future screenings? ANSWER: When health care providers say “breast density” or “dense breasts,” they are referring to how the breasts look on a mammogram. Women have different amounts of tissue and different types of tissue in their breasts. Breasts are composed of fat, connective tissue that holds the breasts together and the part of the breast that makes milk when breastfeeding. Those tissues look different on a mammogram. We can see through the fat, which appears black on a mammogram. However, the other types of tissue are white and can be difficult to see through. Dense breast tissue can make it more challenging to see cancer on a mammogram because the dense tissue and the cancer are both white. Dense breasts are common, with about half of women having dense breasts. In addition to cancers being more difficult to see in dense breast tissue, having dense breast tissue confers a slightly higher risk of developing breast cancer.
THE RADIOTRACER USED IN MBI HAS BEEN USED FOR A LONG TIME, AND IT IS SAFE. activity, like cancer. That activity is detected with a special camera. The radiotracer used in MBI has been used for a long time, and it is safe. The radiation doses for mammography and molecular breast imaging are very low — below the amount of background radiation we get just by walking around outside. Any risk from radiation at these extraordinarily low doses is purely theoretical. In contrast, it is known that the risk of breast cancer is real for women. One in 8 women is going to get breast cancer in her lifetime, and the goal is to find those cancers while they are small and most treatable. MBI is one tool that helps do that. In a molecular breast imaging exam, a woman receives an injection of the radiotracer. The breasts are placed in mild compression to stabilize them while pictures are taken, but it’s less compression than a mammogram and most women report that it is not uncomfortable. Imaging takes about 40 minutes, and patients can watch a show or play a game on their phone while the pictures are taken. Women should get their yearly screening mammograms, and those women with dense breast tissue should consider supplemental screening. Molecular breast imaging is an important complementary tool that helps
Because of these issues, Mayo Clinic developed a test called molecular breast imaging, or MBI, which looks at the function of the breast tissue rather than the anatomy. We have performed several large screening trials and incorporated MBI into Mayo’s clinical practice. Molecular breast imaging consistently finds about three to four times more breast cancers in women who have dense breast tissue than screening mammography alone. Molecular breast imaging and mammography have only been studied where MBI is performed in addition to mammography. There are a couple of reasons for this. Mammography is really good at detecting calcifications, which you can think of as tiny stones or grains of sand in the breast. Calcifications sometimes can be the earliest sign of breast cancer. Molecular breast imaging does not perform as well with abnormalities that present as calcifications only. However, MBI is very good at finding those lesions that might be hiding in the dense breast tissue, so they really work in concert together. Molecular breast imaging uses a radiotracer, which is a radioactive agent that goes to active parts of the breast and lights up in areas that have more metabolic HEALTH CARE | October 2021
find cancers that might otherwise go undetected for a long period of time because they can’t be seen on a mammogram. — Katie Hunt, M.D., Division of Breast Imaging, Mayo Clinic, Rochester, Minn.
supplements or when it is taken as a pill. There is little research to ensure turmeric supplements are safe when used in combination with cancer treatments, including surgery, radiation and chemotherapy.
DEAR MAYO CLINIC: I recently was diagnosed with breast cancer, and I will have surgery followed by chemotherapy. A friend told me that turmeric has anticancer properties. I have taken turmeric supplements in the past for osteoarthritis. Can you tell me more about turmeric and if I can safely take it as a supplement along with conventional breast cancer treatment.
The use of supplements, like turmeric, among cancer patients undergoing cancer treatment can be a concern. Supplements are not standardized like prescription medications, meaning the dose is not regulated and purity cannot be guaranteed. What you get may differ from bottle to bottle and among brands, and there can be variables depending on what specific part of the plant is used. Many supplements that have powerful anti-inflammatory effects, like turmeric, have bloodthinning properties, which can increase the risk of bleeding and cause complications around the time of surgery.
ANSWER: Turmeric, a bright yellow spice powder made from the root of a plant in the ginger family, is grown in many Asian countries and other tropical areas. It’s a major ingredient in curry powders common in many Indian THERE IS NO MAGIC BULLET. THE BEST and Asian dishes, and it is OPTION — ONE PROVEN IN STUDIES TIME used as a coloring for foods, fabrics and cosmetics. AND TIME AGAIN — IS TO GET ALL THE The root can be dried and ANTIOXIDANTS, PHYTONUTRIENTS, VITAMINS made into capsules, tablets, AND MINERALS YOUR BODY NEEDS BY EATING extracts, powders or teas. Or A WHOLE FOOD PLANT-BASED DIET RICH IN it can be made into a paste COLORFUL VEGETABLES AND FRUITS, WHOLE to apply to the skin.
In combination with chemotherapy, using supplements is worrisome because of potential drugherb interactions. Laboratory studies have shown that two common chemotherapy drugs used to treat breast cancer — doxorubicin and GRAINS, BEANS, NUTS AND SEEDS. Turmeric’s main active cyclophosphamide — may component — curcumin — have reduced effectiveness is what gives the spice its when used alongside yellow color. Curcumin has anti-inflammatory properties, turmeric, but the clinical significance is not yet known. making it a potential treatment for a number of health Another commonly used chemotherapy drug for breast conditions, including reduced pain and increased ease cancer, paclitaxel, when combined with turmeric may of movement in people with osteoarthritis. One study result in liver toxicity. The bottom line is that it’s not known found that taking turmeric extract three times daily was how turmeric affects chemotherapy and further research comparable to taking a 1,200-milligram dose of ibuprofen should be a guide. To reduce the risk of harm, cliniciandaily for arthritis guided supplement use is recommended. pain. However, more research is necessary to confirm these effects. It is best to talk with your cancer care team about the supplements you take to ensure they are safe, especially In addition to its anti-inflammatory properties, research in combination with your cancer treatment. Oftentimes, suggests that curcumin has many other health benefits. marketing of supplements appears promising. However, Among them are antioxidant, metabolic-regulating, high-quality research supporting these claims may be antimicrobial, immune-modulating, mood-enhancing, lacking and could pose harm. neuroprotective and anti-cancer effects. As a rule of thumb, there is no magic bullet. The best Preclinical studies demonstrate curcumin stops the option — one proven in studies time and time again — is growth of breast cancer cells in the laboratory, but it’s to get all the antioxidants, phytonutrients, vitamins and not known if this happens in humans since the body minerals your body needs by eating a whole food plantquickly breaks down curcumin, making it difficult to study. based diet rich in colorful vegetables and fruits, whole High-quality human studies are needed to confirm these grains, beans, nuts and seeds. — Dawn Mussallem, D.O., findings and guide effective and safe use of turmeric Hematology/Oncology, Mayo Clinic, Jacksonville, Fla. as a supplement. Mayo Clinic Q & A is an educational resource and When ingested as a superfood or when turmeric is used doesn’t replace regular medical care. E-mail a as a spice in culinary cuisine, the curcumin it contains question to MayoClinicQ&A@mayo.edu. For more appears to be generally safe among cancer patients. information, visit www.mayoclinic.org. But dietary food sources are different than turmeric
2021 | HEALTH CARE
SARA FILMALTER, M.D., PREMIUM HEALTH NEWS SERVICE DEAR MAYO CLINIC: A few neighbors formed a running group to train for a marathon in 2022. I’m thinking about joining them as I know that running can be good exercise, but I’ve never run before. Is running a marathon actually good for my health? Should I do certain things to avoid injuries?
Kingdom showed first-time marathon runners significantly improved their cardiovascular health during training for a 26.2-mile race.
ANSWER: Being active and engaging in regular aerobic exercise is important for overall heart health and wellness. Typically, 30 minutes of moderate intensity activity five days a week is recommended for most healthy adults. Running is a simple, low-cost exercise, and you should be commended for starting a new exercise regimen. As a first-time runner, I’d recommend that you talk with your health care provider about any concerns, especially if you have any health conditions, such as high blood pressure, heart issues or a history of prior musculoskeletal injuries. Ask your health care provider about any symptoms that you might want to watch for when you run. Before starting out, I would suggest you invest in a good pair of running shoes and make sure that you warm up and stretch prior to any run. Focus on cross training with exercises that strengthen your hips and core. If your neighbors are seasoned runners, you may want to consider joining a training program to help you build stamina and increase your mileage over time. A marathon may sound overwhelming to a novice runner, but recent research shows that it really could be the key to better health. A study out of the United HEALTH CARE | October 2021
Specifically, this study showed participants had improvements in overall cardiovascular health but particularly related to the stiffness of the aortic vessel. This is important because as people age, the body’s vessels become stiffer. This can be detrimental to your health since with stiff vessels your body has to work harder to pump blood. In addition to runners having a substantial decrease in the stiffness of the aortic vessel, which moves blood throughout our body, the study found marathon training improved blood pressure. The study looked at marathon runners six months prior to training and three week after they completed the London Marathon. On average, the subjects ran about 6 to 13 miles in training per week. If running a marathon seems too daunting, consider a half marathon or a 5K. The cardiovascular benefits of running remain, no matter the distance. One of the most interesting findings of the U.K. study was that the slowest runners had the greatest improvements in cardiovascular health. If running is not enjoyable or you have other issues — let’s say
2021 | HEALTH CARE
your knees or back make it challenging to run — you can still benefit from lacing up your sneakers. Walking regularly at a brisk pace can result in improvements in overall cardiovascular health and vessel stiffness. Whatever activity you chose, the key is that you want to aim for at least 30 minutes of moderate intensity activity five days a week. Walking or running with the neighbors is a great way to combine exercise and socialization. And if you’re wondering about the definition of moderate intensity, you should be able to carry on a conversation, but you should not be able to carry a tune. — Sara Filmalter, M.D., Family and Sports Medicine, Mayo Clinic, Jacksonville, Fla.
High or abnormal cholesterol levels, inflammation and endothelial dysfunction play a key role in atherosclerosis and plaque buildup, the most common cause of heart attacks and strokes. Endothelial dysfunction refers to impaired functioning of the inner lining of blood vessels on the heart’s surface. It results in these vessels inappropriately narrowing instead of widening, which limits blood flow. There are many different types of cholesterol, including high density lipoprotein, HDL or good cholesterol; triglycerides, a byproduct of excess calories consumed, which are stored as fat; and low-density lipoprotein, LDL, or bad cholesterol.
plaque stabilization — when plaque breaks apart, it can cause a heart attack or stroke. Statins have been around for about 40 years, so we have quite a bit of information on their short- and long-term safety and effectiveness.
It’s well established that lowering LDL cholesterol, sometimes regardless of whether or not you have high cholesterol, improves cardiovascular outcomes. But do older adults reap the same benefits from lowering cholesterol, and do they face additional risks?
PCSK9 inhibitors are a newer class of cholesterol-lowering drugs. They work by allowing more LDL receptors to remain in the liver, thus allowing the liver to sweep more LDL cholesterol out of the bloodstream. PCSK9 inhibitors have been shown to decrease LDL cholesterol by about 60%. There are two PCSK9 inhibitors on the market, evolocumab (Repatha) and alirocumab (Praluent), and both must be taken by injection every few weeks.
LOWERING LDL REDUCES CARDIOVASCULAR RISK Studies have consistently shown that lowering LDL cholesterol reduces the risk of cardiovascular death, heart attacks, strokes and the need for cardiac catheterizations or bypass surgeries. This has been shown in those with established coronary artery disease, as well as in high-risk patients without coronary artery disease. Lifestyle changes can decrease cholesterol numbers by about 5% to 10%, while cholesterol-lowering medication can decrease LDL cholesterol by 50% or more. Therefore, while lifestyle modifications like a heart-healthy diet — the Mediterranean diet, for example — quitting smoking, regular exercise and weight loss are critical to reducing cardiovascular risk, medications are often needed to provide additional cardiovascular protection. Statins, including atorvastatin (Lipitor), simvastatin (Zocor), rosuvastatin (Crestor) and pravastatin (Pravachol), are the mainstay therapy for lowering LDL. Statins work by reducing your own body’s production of cholesterol, which promotes uptake of LDL circulating in the blood by the liver. But not all of the benefit of statins can be explained by decreasing LDL alone. Studies show that statins have favorable effects on inflammation, endothelial dysfunction and
Ezetimibe (Zetia) is a different type of LDL-lowering drug. Taken as a pill, it lowers cholesterol by inhibiting its absorption in the small intestines. Ezetimibe is mainly used as an add-on medication to statins to achieve further LDL lowering, or on its own in people who cannot tolerate statins. In older adults, ezetimibe alone was found to reduce cardiovascular events but not stroke.
LDL LOWERING THERAPIES: ARE THEY SAFE FOR OLDER ADULTS? The clinical benefit of lowering LDL cholesterol in older adults has been a point of contention, because people ages 75 and older are not usually included in large numbers in clinical trials. Some have even argued that the risks of LDL-lowering treatment may outweigh benefits for older adults compared to younger adults. But the evidence debunks this myth. Meta-analyses and clinical trials indicate that statin use is not associated with increased risk of muscle injury, cognitive impairment, cancer or hemorrhagic stroke compared with those not using statins, regardless of age. Likewise, in clinical trials, risk of liver or kidney injury is similar in people taking statins or a placebo, regardless of age. A prospective study evaluating liver safety in very elderly patients found statins to be safe overall in patients age 80 and older. The most common side effect of statins is muscle aches, which occur HEALTH CARE | October 2021
less than 1% of patients. Even if one type of statin causes side effects in a person, another statin may not. Statins can raise blood sugars, but this is unlikely to lead to Type 2 diabetes in anyone not already at high risk for the condition. Similarly, ezetimibe use is largely safe, with diarrhea and upper respiratory infections being the most common side effects. Notably, the safety profile for ezetimibe plus statins is the same as for statins alone, even in older adults. And finally, PCSK9 inhibitors have not been found to increase risk of diabetes, neurocognitive disorders, liver injury, or muscle injury.
THE EVIDENCE FOR LDL-LOWERING THERAPIES IN OLDER ADULTS The question remains: do the benefits of cholesterol-lowering treatments outweigh the risks for older adults? In a systematic review and meta-analysis published in The Lancet, researchers evaluated the clinical benefit of statin and non-statin cholesterol-lowering therapy for older adults. They did this by extracting and re-analyzing data from previous studies that had evaluated statin and non-statin cholesterol-lowering treatments. The analysis included 21,492 patients age 75 and older. Of these, 54.1% of patients had been enrolled in statin trials; 28.9% in ezetimibe trials; and 16.4% in PCSK9 inhibitor trials.
major cardiovascular events. LDL lowering prevented cardiovascular events to a similar degree in older and younger adults. In older adults, statin and non-statin LDL-lowering therapies were similarly effective for preventing most major cardiovascular events. The exception was stroke, for which non-statin therapy was slightly more effective; this is likely driven by the use of PCSK9 inhibitors.
The analysis above largely represented older patients with existing cardiovascular disease.There are ongoing trials that will help evaluate the utility of statins in older patients as a primary prevention for major cardiovascular events. DAVIS KIMAIYO, M.D., IS A CONTRIBUTOR TO HARVARD HEALTH PUBLICATIONS.
The investigators made these important observations: • •
Older patients have a 40% higher risk of major cardiovascular events than younger patients — 5.7% versus 4.1%. For every 38-mg/dL reduction in LDL cholesterol, older patients taking LDL-lowering therapies enjoyed a 26% reduction in risk of
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CARRIE DENNETT, ENVIRONMENTAL NUTRITION
Whether you’re looking for a little more calm or a peaceful night’s sleep, you might reach for plant-based therapies to help you relax. Many plants have traditional uses as tinctures and teas for promoting calm and sleep, and now modern science is uncovering why. Many sedative drugs activate GABA receptors, which inhibits excessive brain activity, helping keep us calm during the day and promote restful sleep at night. As it turns out, many calming plants do, too.
Chamomile is an ancient medicinal herb with many uses, including as a mild sedative to calm nerves, reduce anxiety and treat insomnia. Research using prescribed doses of chamomile extract to reduce symptoms of generalized anxiety disorder looks promising.
Kava is a beverage or extract made from the plant Piper methysticum, a perennial shrub in the pepper family that is native to islands in the South Pacific, where it’s a popular social drink, regularly consumed to promote relaxation. Kava is often used to reduce stress, restlessness and promote better sleep. Compounds in kava called kavalactones are thought to be responsible for its calming effects, and in appropriate doses may relieve symptoms of mild-to-moderate anxiety.
Lemon balm, or Melissa officinalis, is an herb included in many calming tea blends. Various research studies have found that lemon balm may help reduce stress, insomnia and mild-to-moderate anxiety symptoms. Plus, it tastes delicious.
L-theanine is an amino acid found in green tea associated with improvements in mood and reduction of stress and symptoms of anxiety. One 2020 systematic review found that L-theanine may help reduce stress and anxiety in people exposed to stressful conditions, but cautioned that larger and longer-term clinical studies are needed.
BOTTOM LINE As with other dietary supplements, herbal preparations are not regulated by the Food and Drug Administration and manufacturers don’t have to prove that their products produce results. To make sure what you’re buying contains what it says it does, purchase products from reputable manufacturers, preferably those that have undergone third-party testing and certification from groups such as ConsumerLab, U.S. Pharmacopeia or NSF International.
HEALTH CARE | October 2021
James Naples, M.D., and Valeria Duque, Au.D., CCC-A, Harvard Health Blog
As our society and culture become more connected through technology, the use of headphones has increased. Headphones allow people to enjoy music and have conversations from anywhere at any time. The ease of headphone use and the mobility that they afford cannot be overstated. This is particularly true as our society spends more time with virtual meetings and headphones, as usage increased during the COVID-19 pandemic. Despite the convenience of headphones and the increased utility, questions about safety of use have been raised. There is such a thing as healthy headphone use; you just need to know about safe sound levels and when to take a break from headphones.
HOW DOES SOUND CAUSE HEARING LOSS? Isn’t sound supposed to provide a tool for communication and awareness of our environment? Yes, sound is an essential mode of communication that also orients us to our environment; however, the inner ear is very sensitive to the balance of sound that it perceives. There are thousands of cells in the ears, some of which have little hairlike structures called hair CONTINUED ON PG 20
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2741 Debarr Road C308, Anchorage, AK 99508 Phone: (907) 331-3640 peakneurology.com Dr. Ross Dodge Adult & Pediatric Sleep Medicine
PEAK Neurology & Sleep Medicine is Alaska’s most advanced clinical program for providing sleep medicine services. Sleep disorders are widely prevalent and often under-diagnosed. Clinical syndromes such as Obstructive Sleep Apnea and Insomnia can impede treatment for many common conditions, which is why a comprehensive approach to diagnosis and treatment is fundamental. It is also why we share many of our patient’s frustration with a ‘used-car sales’ approach to care: simply performing a sleep study and generating an automatic prescription for CPAP does not constitute clinical care. At PEAK Neurology & Sleep Medicine our clinical staff is available for in-person and telemedicine consultations to help patients understand the causes of sleep disorders and develop practical treatment plans that are consistent with patient goals. Put simply, our sleep medicine program is about quantity of health and quality of life. HEALTH CARE | October 2021
cells that are responsible for transmitting sound from the ears back to the brain, where it is further processed. Excess sound can cause permanent damage to these cells, which interrupts the mechanism of sound transmission. Damage may also happen via the connection between the hair cells and nerve cells, which can be interrupted by excess sound, even if the hair cells remain normal. In short, one thing is clear: sound that is too loud is harmful.
HOW LOUD IS TOO LOUD? The CDC has detailed information on various daily experiences and the volume, or decibel (dB) level, associated with them. One of the important things to note when considering headphone use is that personal listening devices are tuned to a maximum volume of around 105 to 110 dB. For reference, exposure to sound levels above 85 dB, equal to a lawnmower or leaf blower, can cause possible ear damage with exposure of more than two hours, while exposure to sound of 105 to 110 dB can cause damage in five minutes. Sound less than 70 dB is unlikely to cause any significant damage to the ears. This is important to know, because the maximum volume of personal listening devices is above the threshold at which damage occurs, in both children and adults! It is important that as a listener, you are aware that most devices can, in fact, be used in a way that is harmful. Ultimately, personal listening devices should be comfortable to the listener.
HOW LONG IS TOO LONG? In addition to volume, the duration of sound exposure is an important factor that contributes to possible ear damage. Simply stated, louder sounds have potential for more damage with less exposure. The Occupational Safety and Health Administration mandates that employers offer hearing protection for employees with averaged exposure of 85 dB for greater than eight hours. While this sounds like a long time, headphone use at only slightly higher sound levels can cause damage in less than one hour, and it is easy to imagine listening to music with headphones for an hour or longer. Importantly, listening at a comfortable level should be safe for an unlimited amount of time, though it is essential to balance duration of use with loudness of exposure.
SUGGESTIONS FOR SAFE LISTENING Our ears can be damaged by excess sound, and the combination of excess level of sound and duration of exposure contributes to potential hearing problems. Here are some suggestions for healthy listening habits. • • •
Be aware of how long you have been listening and how loud the sound is. Take breaks after prolonged listening sessions, and be sure to listen at a comfortable level. Be prepared. If you are going to attend an event where there is likely to be prolonged loud noise, such as a concert or sporting event, bring earplugs or headphones. There is a range of devices available that offer protection from a potentially damaging situation, from simple foam earbuds, to headphones with noise cancelling properties, to customizable ear molds made by an audiologist. Finally, don’t hesitate to talk with an audiologist or otolaryngologist about any questions you have around headphone use or safe sound levels. Hearing health is important and complex, and we can help you take steps to protect your ears while using headphones.
James Naples, M.D., and Valeria Duque, Au.D., CCC-A, are contributors to Harvard Health Publications.
2021 | HEALTH CARE
Mended Hearts-Anchorage (Chapter 290) has been active in Anchorage Alaska for 20+ years Mended Hearts Inc. is the largest cardiovascular peer-to-peer support network in the world. We are a nonprofit organization offering the gift of hope to cardiovascular patients, their caregivers, and families for over 70 years! Since its humble beginning in 1951 (founded by cardiac surgery pioneer Dr. Dwight Harken) Mended Hearts has served millions by providing support and education, bringing awareness to issues that those living with heart disease face, and advocating to improve quality of life across their lifespan. Mended Hearts also offers a program for children with heart defects known as Mended Little Hearts.
We invite you to join Mended Hearts-Anchorage and become part of a close-knit group that is focused on providing morale support for those with heart disease in our community.
Thousands of Alaskans are living with cardiovascular disease. Many go undiagnosed until a medical emergency occurs. They and their caregivers and loved ones face many emotional and physical challenges during recovery. Our Mended Hearts volunteers provide encouragement, educational information, and peer-to-peer emotional, social, and practical support to them from diagnosis through recovery. Because we are heart patients as well, we understand that adjusting to life after a heart event is challenging. Heart disease is complex, and few patients and their caregivers experience it the same way. There may be appointments to track, new medications to take, lifestyle changes to make, and many other issues to consider. However, you are not alone on this journey. Mended Hearts-Anchorage is. a dedicated group of volunteers whose mission is to provide support and encouragement to you, your caregiver and family. I invite you to learn more about our local chapter at www. alaskamendedhearts.org and www.mendedhearts.org.
Joining Mended Hearts connects you instantly to patients and caregivers just like you who understand the needs of cardiovascular disease patients. The Mended Hearts program provide counseling and emotional support at the hospital bedside, one-to-one support after discharge, plus a variety of helpful support group meetings, educational materials, online events, and social activities.
You can join the nation’s largest cardiovascular disease support network today and be part of our caring support network. Free memberships are available, and we welcome all. If you join at a donation level, you will get some gifts from Mended Hearts and Mended Little Hearts. Membership levels and gifts are shown here.
Presenting ARC of Anchorage (CEO) with a new AED (July 21)
HEALTH CARE | October 2021
CAROLYN WILLIAMS, PH.D., RD, EATINGWELL.COM
AS PART OF A HEALTHY DIET, FIBER IS A NUTRIENT MOST ASSOCIATED WITH KEEPING THE DIGESTIVE TRACT REGULAR AND — THANKS TO THE MARKETING ON THE OATMEAL CONTAINER — LOWERING CHOLESTEROL. But fiber’s role in the body goes way beyond regularity, and one of fiber’s most important roles stems from the influence that gut health has on heart health. To put it simply, a healthier gut means a healthier heart. According to research, a healthy gut has a protective effect on the heart by influencing factors that cause and contribute to heart disease. Check out these four ways that eating fiber protects your heart.
1. LOWERS CHOLESTEROL IN MULTIPLE WAYS Foods with soluble fiber, such as oats, have demonstrated ability to lower levels of LDL cholesterol — the type of cholesterol we want less of — when eaten consistently and regularly. Soluble fiber attaches to bile, a cholesterol-
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based compound that assists in digesting fats, and both the fiber and bile are later excreted. The body then uses circulating lipids — fats — to form new bile molecules, lowering total and LDL cholesterol. But in addition to that, research now suggests that gut bacteria also influence blood lipid levels. In fact, bacteria in healthy guts play a role in lowering LDL cholesterol and triglycerides.
2. PREVENTS INFLAMMATION Gut health plays a key role in the inflammatory process. The mechanism works like this: A healthy gut creates a protective barrier in the intestines, allowing nutrients to pass into the bloodstream but blocking out many inflammatory compounds in food. When these good bacteria are disrupted or become unbalanced, this barrier isn’t as effective and starts to “leak,” allowing those compounds into the body. Because most chronic conditions are driven by inflammation, promoting gut health with a healthy, fiber-rich diet is key for preventing heart disease as well as a host of other lifestyle-related conditions.
3. LOWERS BLOOD PRESSURE Fiber can’t be digested, but good bacteria in the gut can ferment some fibers in the colon. The fermentation process produces short-chain fatty acids (SCFA). These SCFA provide energy and nutrients for the bacteria, and research suggests that SCFA production can also lower blood pressure. In fact, eating a high-fiber diet is even considered a treatment for hypertension by some health professionals, since increasing fiber intake is the best way to increase SCFA production.
4. HELPS YOU LOSE BELLY FAT Consuming a high-fiber diet is associated with less abdominal fat, or fat in the midsection. This is important since people who carry extra weight in their abdominal area are at higher risk for developing heart disease. Increasing daily fiber can help with weight loss by slowing down the digestive process to provide a feeling of fullness and satiety. And it can also increase the number and diversity of good bacteria to reduce inflammation, which is also now considered an underlying driver of obesity.
THE TAKEAWAY The gut-heart connection is a new area of research with lots of unknowns. Until research offers more insight, we do know that eating plenty of fiber-rich foods is one of the best ways to support gut health and that most of us need to get more fiber in each day. Fruits, vegetables, legumes and whole grains are the best sources of dietary fiber, providing a mix of soluble and insoluble fiber, so look for ways to sneak more of them into meals and snacks.
ALASKA’S SLEEP THERAPY SPECIALISTS What We Offer Our Patients: Specialized Education Mask Fittings 30-Day Mask Exchange Detailed Insurance Benefit Verification Online Monitoring of Therapy Loaning of Masks to Trial at Home On-Going Therapy Support Convenient Ordering Reminders Mail-To-Home Options Automatic and Online Bill Pay Options ... and Much More! We accept most private insurances.
(907) 331-3612 1102 E.. NORTHERN LIGHTS BLVD. NCHORAGE, AK 99508 ANCHOR
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TO SCHEDULE AN APPOINTMENT: 24 hour notification of cancellation required; $75 no show fee
P: (907) 538-3655 F: (907) 929-7327 firstname.lastname@example.org
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STEPHANIE GOULD, BS, RRT Director of Operations Direct: (907) 205-4556
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You know that grumpy feeling when you haven’t had quality sleep in a few days? Or if you’re in an exercise rut and lacking extra energy? It happens to everyone. But new research has revealed it may have consequences on your mental health.
A recent study published in Frontiers in Psychology looked at the connection between mental health and lifestyle habits. They found that sleep quality was the strongest predictor of mental health. This was closely followed by sleep quantity, physical activity and consumption of fruits and vegetables.
After the year and a half we have all had, this may not be the most encouraging news if you’re struggling to sleep, find time to move your body and get your veggies in. However, here are simple ways to improve your mental health by focusing on these three basic habits.
How can you improve the quality and quantity of your sleep? It all starts with building a healthy nighttime routine. Here are a few simple tips:
• • •
Have a consistent sleep schedule by going to bed and waking up at the same time. Turn off screens at least 30 minutes before bed. Avoid caffeine and alcohol before bed. Have a healthy bedtime routine.
WHEN YOU EXERCISE, IT RELEASES ENDORPHINS IN YOUR BODY, WHICH CAN LEAD TO SHORT- AND LONG-TERM FEELINGS OF WELL-BEING. For this study, they asked participants how many days they were physically active for 30 minutes or more. The HEALTH CARE | October 2021
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average response was three days per week. Though a lack of physical activity did not have profound effects on depressive symptoms and well-being, increased levels of physical activity significantly improved depression and overall wellness. If you are looking for a way to boost your mood, move your body. Here are a few ways to get started:
That said, increased fruit and vegetable intake had significant impacts on overall well-being. There are so many ways that what you eat can impact your stress levels, anxiety, depression and much more. Here are some easy ways to boost your intake:
• • •
Pick an activity that you actually like. Get the family involved. Go for a walk, hike or bike ride together. Block off your schedule with times devoted to exercise. Try a fitness tracking app or virtual workout class. Think outside the box. Shoveling, cleaning and playing with kids all count as movement!
3. FRUIT AND VEGETABLE INTAKE SIMILAR TO PHYSICAL ACTIVITY, THE RESEARCHERS NOTED THAT FRUIT AND VEGETABLE INTAKE WAS A SECONDARY FACTOR TO MENTAL HEALTH COMPARED TO SLEEP.
Add vegetables to foods you already eat, like pasta, omelets or stews. Snack on fruits. Pair them with yogurt, peanut butter or nuts for a protein boost to keep you full for longer. Choose frozen veggies. They are a fraction of the price, last forever in the freezer and cook quickly. Plus, most require no time to prep, saving you precious time. Blend fruits and vegetables in smoothies.
BOTTOM LINE Mental health is complicated and individual, but research continues to illuminate factors that may help boost our health, happiness and well-being. Focusing on these basic healthy habits — sleep, physical activity and fruit and vegetable intake — is a science-approved way to boost your mood and improve your overall health. And you don’t need a complete lifestyle overhaul. These small tips can help nudge you in the right direction.
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SAMAR HAFIDA, M.D., HARVARD HEALTH BLOG IF YOU ARE LIVING WITH TYPE 2 DIABETES, YOU CERTAINLY ARE NOT ALONE. ONE IN 10 PEOPLE IN THE U.S. HAS DIABETES, ACCORDING TO THE CDC. HOWEVER, DESPITE CONSIDERABLE PROGRESS IN DIABETES TREATMENT OVER THE PAST 20 YEARS, FEWER THAN HALF OF THOSE WITH DIABETES ACTUALLY REACH THEIR TARGET BLOOD SUGAR GOAL. In part, this may be because doctors can be slow to make changes to a patient’s treatment plan, even when a patient’s treatment goals are not being met. One reason for this may be the overwhelming number of medications currently available. And yet, waiting too long to adjust treatment for Type 2 diabetes can have long-lasting negative effects on the body that may raise the risk of heart and kidney disease and other complications.
Type 2 diabetes is a chronic disease where the body’s ability to use glucose or sugar as fuel is impaired. Our bodies produce a hormone called insulin which enables sugar from carbohydrates in food we eat to reach the cells and be used as energy. In Type 2 diabetes, insulin’s ability to do its job is compromised, and over time the body actually produces less of it. This means less sugar in the cells for fuel, and more sugar in the blood where it can’t be used. Having high levels of blood sugar over time can cause damage to vital organs like the heart, kidneys, nerves and eyes. Some risk factors that predispose people to developing Type 2 diabetes, such as genetics and age, are not modifiable. Other risk factors, such as being overweight or having obesity, can be altered. This is why losing 5% to 10% of one’s baseline weight by healthful eating and physical activity remains the backbone of Type 2 diabetes management.
WHAT IS TYPE 2 DIABETES? MOST DIABETES MEDICATIONS EFFECTIVELY HEALTH CARE | October 2021
LOWER BLOOD SUGAR The blood sugar goal for most adults with diabetes is an A1C of below 7%. A1C is a measure of a person’s average blood sugar over a period of about three months. In many people, diet and exercise are not enough to reach this goal, and one or more medications may be needed. Metformin is a tried and tested medicine that has been used for many decades to treat Type 2 diabetes, and is recommended by most experts as first-line therapy. It is affordable, safe, effective and well-tolerated by most people. When metformin does not adequately control blood sugar, another medication must be added. It is at this point that doctors and patients must choose among the many drugs and drugs classes available to treat Type 2 diabetes. In general, for people who are at low risk of heart disease or have no history of diabetic kidney disease, most diabetes medications that are added to metformin effectively reduce blood sugars and can lower A1C to under 7%. So, how to choose a medication? Each person with diabetes has their own goals, needs and preferences. Before choosing a medicine, it is important to ask some relevant questions: Is my blood sugar at goal? Is this medicine affordable? Do I have heart or kidney disease? What are the side effects? Is it a pill or injection, and how often is it taken? Regardless of which treatment is selected, the American Diabetes Association Standards of Care recommends reassessment of diabetes control every three to six months, followed by modifications to treatment if needed. NEWER DIABETES MEDICATIONS: WEIGHING BENEFITS AND RISKS Lately, newer treatment options for Type 2 diabetes — glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter-2 (SGLT2) inhibitors — have been heavily advertised.These newer drug classes lower blood sugar and also have cardiovascular and kidney benefits. GLP-1 receptor agonists are drugs that lower blood sugar after eating by helping your body’s insulin work more efficiently. All drugs in this group except one are self-injected under the skin, either daily or weekly. Several of them, such as liraglutide (Victoza), semaglutide (Ozempic) and dulaglutide (Trulicity), have been shown to lower the risk of cardiovascular disease
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in people who are at high risk for it, or who have pre-existing heart disease. They also promote weight loss. Some people who take GLP-1 receptor agonists may have side effects such as nausea and vomiting, and in very rare cases pancreatitis. SGLT2 inhibitors like empagliflozin (Jardiance), canagliflozin (Invokana), dapagliflozin (Farxiga) and ertugliflozin (Steglatro) are also a newer class of medications that work by blocking your kidneys from reabsorbing sugar back into your body. They also have cardiovascular benefits, especially in those who have heart failure, and have been shown to slow the progression of diabetic kidney disease. Other benefits include lowering blood pressure and promoting weight loss. Use of these medications may increase the risk of genital yeast infections, especially in women. A rare but serious consequence of SGLT2 inhibitors is diabetic ketoacidosis, which is a medical emergency that can be avoided by stopping these medications in consultation with your doctor before major surgeries, or if you are ill or fasting. While these diabetes medications certainly have more to offer than just improvements in blood sugar, they remain costly and inaccessible to many individuals. This is why it is essential to have an open and honest conversation with your doctor about what is most important to you and what aligns with your goals and preferences. Management of a complex disease like diabetes takes an entire team, with you being the key team member.
SAMAR HAFIDA, M.D., IS A CONTRIBUTOR TO HARVARD HEALTH PUBLICATIONS.
ALASKA SPINE & PAIN IS NOW ANODYNE OF ANCHORAGE
Helping you move from pain to wellness.
OUR GOAL IS TO IMPROVE YOUR QUALITY OF LIFE by effectively treating your chronic pain without the use of opioids, while improving your function and mobility to get back to the activities that you enjoy most. We treat the problem rather than masking it. We do not believe in providing temporary relief while the underlying problem can actually get worse over time, eventually leading to surgical procedures which could have been avoided. We offer a wide variety of services to help you get out of pain and back on track to health and wellness. Making better choices impacts your everyday life. There are many roads down the path to wellness;
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2021 | HEALTH CARE
Snacking before bed can be a tricky business. Eat too much, and get ready for a night of tossing and turning. Eat too little, and you might find yourself devouring your entire kitchen at 3 in the morning. It’s no secret that steering clear of refined carbs and junky foods before bed is one of the best ways to avoid a sleepless night. But even noshing on healthy evening snacks can still mess with your sleep quality if you’re not careful. The key to successful bedtime snacking? Balance. “Being overly full or starving is more likely to lead to sleep issues than any one particular food,” says registered dietitian Alex Caspero, R.D.
If you’ve yet to find your snacking sweet spot, one of these five mistakes could be why — here’s the intel you need to turn things around:
1. GETTING CARRIED AWAY WITH PORTIONS. Even when you eat healthy snacks before bed, such as pretzels and hummus or cheese and crackers, it’s easy to overdo it in the portion department. This sends the body into digestion mode, which can make it difficult to fall asleep, and stay asleep. “We need just enough to offer satisfaction, so we don’t wake during the night hungry,” says Caspero. The trick is to be strategic with your snack choices. THE FIX: CHOOSE SNACKS THAT ARE HARDER TO OVEREAT, SUCH AS PISTACHIOS. IF YOU’VE GOT A SWEET TOOTH, TRY FRUITS LIKE GRAPES OR BERRIES.
2. IGNORING YOUR CRAVINGS. When you’re craving dessert and attempt to resist it by snacking on healthier alternatives, you might find yourself consuming more calories in the long run, says Connecticut-based registered dietitian Alyssa Lavy, R.D. Because the healthy snack isn’t satisfying your craving, you might keep snacking to fill the void. This might lead to feelings of disappointment, which can cause stress, ultimately, disrupting sleep quality. THE FIX: INDULGE YOUR DESSERT CRAVING, STICK TO A REASONABLE PORTION — SUCH AS ONE OR TWO COOKIES OR 1/2 CUP OF ICE CREAM.
3. CHOOSING A PROTEIN-HEAVY SNACK. Most people can forgo protein before bed and stick with a small amount of carbs and healthy fats to satisfy their hunger. “Protein revs up our metabolism, which is great during the day, but not so great when you’re trying to wind down,” says Minnesota-based registered dietitian Leah Kleinschrodt, R.D. However, she adds, some people do need some protein at night to help stabilize their blood sugar. THE FIX: AIM FOR ABOUT 2 OUNCES OF PROTEIN (15 GRAMS) BEFORE BED.
HEALTH CARE | October 2021
4. SNACKING RIGHT BEFORE BED. Getting your snack on just before bed can delay your ability to fall asleep, since your body will be busy digesting the grub. And if you’re lying down as your stomach’s doing its thing, gravity can’t help mosey the digested food through the digestive tract, which can cause an upset stomach during the night, says Kleinschrodt. THE FIX: MAKE SURE YOU HAVE YOUR BEDTIME SNACK NO LATER THAN 30 MINUTES BEFORE YOU TURN IN.
5. GOING TO BED HUNGRY. Much like being too full can mess with your ability to fall asleep, so can being too, well, empty. Hunger is a sign that your blood sugar is trending downward or already low. Not exactly an ideal state when you’re trying to score some shut-eye. THE FIX: MUNCH ON 1/2 CUP OF BERRIES WITH 2-3 TABLESPOONS OF HEAVY WHIPPING CREAM.
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United Way of Anchorage The project described was supported by Funding Opportunity Number CMS-CA-NAV-20--001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily HEALTH CARE | October 2021 represent the official views of HHS or any of its agencies.
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