2023 FALL HEALTH CARE MAGAZINE

FALL 2023

Myths About Catching a Cold The 5 Best Foods for Boosting Your Vitamin D Levels

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Where Brian’s heart was healed TakeMeToAlaskaRegional.com

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Fall 2023 | Health care

The Good News About Varicose Vein Treatment Over the past two decades, treatment of venous insufficiency and varicose veins has evolved from painful, vein-stripping procedures to safe, minimally invasive procedures done in the office with no downtime and minimal post-op discomfort.

“Iremembervisitingmymotherinthehospitalfor four days when she had her veins stripped,” recalls Dr. Artwohl. “Today, we treat nurses that work a 12-hour shift the day after their procedure. We recently treated an airline pilot who conducted a flight less than 24 hours after his procedure.”

Are your leg problems vein related?

Robert Artwohl, M.D., of the Alaska Vein Clinic can let you know.

“V

eins are the blood vessels that return blood to the heart.

For the legs, this is a bit of a problem because most of the time our legs are below the heart and the venous blood flow must flow upward against gravity,” says Robert Artwohl, M.D. “Our veins are equipped with one-way check valves. This ensures the venous blood in our legs flows up toward the heart and not down towards the feet.

If the valves fail, blood flows downward for longer than normal, and we call this venous reflux disease. This is associated with elevated venous pressure that causes symptoms such as leg achiness, swelling, pigmentation changes, and can even lead to open sores of the skin.

A characteristic of venous disease is that

the symptoms tend to get worse as the day goes on.”

Venous reflux disease is also referred to as venous insufficiency or venous hypertension. It is the most common vascular problem treated today.

Venous symptoms can be associated with anything from tiny “spider” veins to large, bulging varicose veins, but they can also be present without any apparent abnormal veins at all. “We focus on symptoms, not just the veins themselves,” says Dr. Artwohl. “And, of course, some patients are more concerned about cosmetic issues. We deal with that as well.”

Not all leg discomfort or swelling is due to venous reflux disease. Dr. Artwohl often rules out venous issues and gets the patient to the right specialist.

Dr. Artwohl and ultrasonographer Devon Berthiaume, RVT, starting an in-office radiofrequency ablation procedure for venous insufficiency. The patient is awake and will drive herself home after the procedure.

About Dr. Artwohl Dr. Artwohl grew up as an Air Force brat and spent his formative years in Washington, D.C., Madrid, and Rio de Janeiro. He graduated from the University of Maryland School of Medicine, and also did his surgical residency there. A successful general and vascular surgeon in Alaska since 1997, Dr. Artwohl now dedicates his practice exclusively to the treatment of venous disease. He is certified by The American Board of Surgery.

“Dr. Artwohl and his staff made me feel a lot better. The pain is gone, and my legs look better too.”

—R.W., Attorney, Alaska Vein Clinic Patient

3300 Providence Drive, Suite 309 Anchorage, AK 99508 907-222-6240 alaskaveinclinic.com

Health care | Fall 2023

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Cold and Flu Season Myths About Catching a Cold 4 Reasons it’s Harder to Lose Weight in Winter

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Mayo Clinic Q&A: Relief for Dry Eyes

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Winter Safety Top Tips to Avoid Back Injuries This Winter

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Women’s Health Adult Female Acne: Why it Happens and the Emotional Toll

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Can Some Postmenopausal Women with Breast Cancer Skip Chemotherapy?

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Nutrition The 5 Best Foods for Boosting Your Vitamin D Levels

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Want to Try Veganism? Here's How to Get Started

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Fall 2023 | Health care

Publisher: Andy Pennington Section Editor: Nina Wladkowski Ad Director: Eric Groves Sales: Ryan Estrada, Adam Garrigus, Victoria Hansen, Joleesa Stepetin, Erika Watsjold Advertising Operations: Lisa McGuire Graphic Designer: Jian Bautista Graphics Manager: Michael Oldroyd This special publication was produced by the advertising department of Anchorage Daily News. The ADN newsroom was not involved in its production.

Myths About Catching a Cold Carmen Dargel, M.D., Mayo Foundation for Medical Education and Research, Premium Health News Service

DEAR MAYO CLINIC: My mom always scolded me for not drying my hair after washing it, telling me I’d “catch cold.” She also talked about dressing right for the weather, starving a fever and lots of other things. I’m wondering if there is any truth in any of these sayings. With COVID-19 still lingering, I’m trying to convince my children, ages 8 and 12, to be more mindful about germs.

ANSWER:

While your mom may have warned you that going outside with wet hair will make you sick, the question remains: Does wet hair cause the common cold? The short answer is no.

Colds are caused by viruses, so you can’t catch a cold from going outside with wet hair. And wet hair won’t make you more attractive to germs.

The same is true with respect to dressing for cold temperatures. While it might be optimal to dress in warmer clothes when it’s cold outside, research indicates that cold weather — just like going outside with wet hair — doesn’t make you sick.

People often associate going outside with wet hair or being underdressed with getting sick because exposure to germs is often more likely when you go outside. The common cold is transmitted through bodily fluids, such as when people who are sick sneeze, cough or blow their nose. So, you have just as much of an opportunity to be exposed to germs indoors, especially when you are in close contact with others.

Other myths I’m often asked about include: Myth: Vitamin C will help stave off illness.

Fact: Though it has been subject to much research, no definitive body of work says high doses of vitamin C prevent or treat colds.

Myth: Starve a fever; feed a cold.

Fact: While it might be hard to remember the adage, the bottom line is that when you don’t feel well, eating may not be on the top of your list. And that is OK. Hydration is more important when you are ill. The best advice is to drink plenty of water or other fluid to stay hydrated, and rest and relax.

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Myth: Avoid dairy products if you have a cold because they can produce more mucus.

Fact: Ingesting dairy products will not cause more mucus. Most likely, the texture of certain foods or drinks may coat your throat, which would give the feeling that you have more phlegm. Certain dairy products can be good when you are under the weather, though. Cold ice cream can soothe a sore throat, and probiotics in yogurt can help alleviate stomach upset if you are taking antibiotics for an infection. Check with your primary health care provider or pharmacist to get a list of foods you should avoid with medications.

The best advice I have is to rely on the most common safe behaviors to avoid falling ill: •

Wash your hands. Clean your hands thoroughly and often with soap and water. If soap and water aren’t available, use an alcohol-based hand sanitizer.

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Disinfect your space. Clean kitchen and bathroom countertops with disinfectant, especially when someone in your family has a cold. Be diligent about wiping down doorknobs and frequently touched surfaces.

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Use tissues — and masks. Sneeze and cough into tissues. Discard used tissues right away. Then thoroughly wash your hands. If you are wearing a mask, discard the mask and replace it with a clean one.

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Don’t share. Don’t share drinking glasses or utensils with other family members. Use your own glass or disposable cups when you or someone else is sick.

Label the cup or glass with the name of the person with the cold.

Practice social distancing and safe behaviors, especially if others are ill. Avoid close contact with anyone who is ill. Consider wearing a mask if you are going to be out in public or around a lot of people in an intimate setting. Since COVID-19 is still a threat, it’s important to practice safe behaviors regardless of whether you have been vaccinated for COVID-19. And cold and flu germs are still prevalent.

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Take care of yourself. Eating well, getting exercise and enough sleep, and managing stress might help you avoid getting sick.

You can rest assured that if you go outside with wet hair, or without a jacket, you won’t increase your chances of getting sick, but it may cause temporary discomfort. — Carmen Dargel, M.D., Family Medicine, Mayo Clinic Health System, Onalaska, Wis. Mayo Clinic Q & A is an educational resource and doesn’t replace regular medical care. E-mail a question to MayoClinicQ&A@mayo.edu. For more information, visit www.mayoclinic.org.

Women, Infants, and Children (WIC) Program WHO QUALIFIES FOR WIC

HOW DO I APPLY?

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Pregnant women Postpartum women for up to six months Breastfeeding women for up to one year Infants and children up to 5 years of age

• • •

AND • You must live in Alaska • Meet WIC income eligibility

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Call (907) 729-7277 Visit a WIC clinic Fill out the application beforehand: southcentralfoundation.com

BRING WITH YOU

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Identification for each participant Proof of Alaska residence Proof of income for everyone in the household

Scan the QR code to view Southcentral Foundation’s WIC office information.

The Alaska Native Tribal Health Consortium and Southcentral Foundation jointly own and manage the Alaska Native Medical Center under the terms of Public Law 105-83. These parent organizations have established a Joint Operating Board to ensure unified operation of health services provided by the Medical Center.

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Fall 2023 | Health care

Reasons it’s Harder to Lose Weight in Winter Jenna Birch, Health.com, Premium Health News Service

There’s no question it’s easier to make healthy choices in spring and summer with an abundance of produce in season and ideal weather to be active. But come the cold, harsh months of winter, eating clean and slimming down can seem a whole lot more challenging. Here are a few common winter weight-loss hurdles and how to dodge them.

1. Temptation is everywhere.

Hot chocolate, creamy soups, mashed potatoes, macaroni and cheese — ’tis the season for comfort foods. If you’re not careful, you may slip into the mindset that all indulgences are “bad,” says health and lifestyle coach Sheila Viers — and once you start labeling your food choices as “good” and “bad,” every decision becomes a loaded one.

Instead of sweating over all the dietary “shoulds,” try making food choices that are right for you. “Maybe you plan ahead,” Viers suggests, so you are deciding in advance when you want to indulge — like at the Friday night potluck, for example. Or maybe you choose one small indulgence per day — say, a few squares of highquality dark chocolate — to satisfy your sweet tooth. “The important thing is that the decision feels good to you.”

2. You’re fighting the urge to hibernate.

Between the snow and ice, and shorter, darker days, winter is enough to tank your motivation to exercise. Who wants to venture out into the freezing weather to go for a run, or to the gym when it’s so cozy at home? Luckily, you don’t have to leave your living room to get in a killer sweat sesh (promise). There are tons of great workout videos online. “You can put a couple together,” says Viers. “Or split them up, with 10 minutes before work and 10 minutes in the evening.”

3. You’re loading up on salt.

If you’re eating less fresh food in the winter months, you’re probably eating more packaged and processed foods — think canned veggies and soups, pasta, bread, chips and crackers — which can be sneaky sources of sodium.

Even if you’re keeping your calorie intake in check, water weight can make you feel bloated and sluggish. Viers’ advice: Hydrate as much as you can. Adding potassiumrich foods, like avocados, bananas, tomatoes, sweet potatoes and coconut water, to your diet may help, too, because they help regulate sodium levels in your body.

Health care | Fall 2023

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4. Raw veggies seem so unappealing.

Let’s face it: When you’re feeling cold, your belly isn’t exactly rumbling for kale. Soups and stews are a great way to get vegetables; you just have to choose wisely, says Viers: “A soup with a cream base is more likely to contain more calories, for example, so you can opt for broth-based soups.” And if you’re turned off by cold salad, try roasting sweet potatoes, peppers, parsnips, carrots, asparagus and Brussels sprouts.

Don’t forget about warm fruits either. They can be a delicious and healthy winter treat. You can bake or roast peaches, pears, plums or even cherries, and eat them with a little drizzle of honey or cinnamon, or a dollop of whipped cream.

Health delivers relevant information in clear, jargon-free language that puts health into context in peoples’ lives.

Online at www.health.com.

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Fall 2023 | Health care

Relief for Dry Eyes

Robert Friese, O.D., Mayo Foundation for Medical Education and Research, Premium Health News Service

DEAR MAYO CLINIC: Since the start of winter, my eyes feel dry and scratchy. I can no longer wear contacts because my eyes burn and sting, and are watery. How can my eyes be dry and watery at the same time, and what can be done to fix this?

ANSWER: It is common to have dry and watery eyes at the same time. Watery eyes are the number one complaint of those with dry eyes. That’s because when your eyes get dry enough, they act as if there is something in them and try to flush it out. And this leads to watery eyes.

People with dry eyes produce poor-quality tears, not enough tears or both. This leads to chronic inflammation of the eye surface and a stinging or burning sensation. You also could have eye redness, difficulty wearing contact lenses, blurred vision, sensitivity to light or eye fatigue. Winter can be especially challenging with dry air and forced-air heaters in vehicles or other enclosed environments.

There are many causes of dry eyes, and some people have a greater risk of developing dry eyes. People who have acne rosacea; diabetes; thyroid disease; autoimmune diseases; and inflammatory diseases that include rheumatoid arthritis, lupus and Sjogren’s syndrome are more likely to develop dry eyes.

The development of dry eyes can be affected by the overall health of your eyes. Irregular eyelid margins, eyelash mites and some eye diseases can contribute to dry eye disease. Wearing contacts for a long time, or a poor blinking rate or incomplete blinking, which often occurs when using digital devices, also can lead to dry eyes.

Environmental factors, like secondhand smoke, low seasonal air quality or polluted air, can cause eye irritation and be problematic. Your diet also can affect your eyes. Diets high in omega-6 fatty acids and low in omega-3 fatty acids can cause inflammation, a key component to dry eye disease.

Health care | Fall 2023

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A heart-smart diet high in vitamin D, such as the Mediterranean diet, is an eye-smart diet.

Taking some medications, like antihistamines, antidepressants and birth control pills, can increase the likelihood of dry eyes. Preservatives in medicated eyedrops used chronically, including glaucoma drops and over-the-counter artificial tears, also can worsen dry eye symptoms. Avoid drops that claim to get the red out.

These can lead to rebound red eyes, which cause eyes to be even redder and more irritated than before.

Finally, dry eyes are more common as you get older. Normal aging changes your eyes, and they don’t function as well as when you’re younger. Dry eyes also can be caused by changes in hormone levels associated with age, menopause, pregnancy or birth control pills.

So, what can you do if you have dry, yet watery eyes? The first step is to visit your eye doctor and discuss your symptoms. Many people fail to mention these issues because they don’t see them as important. Your doctor will work to evaluate your symptoms, and the quality and quantity of your tears.

Once an evaluation is complete, your doctor will design a treatment plan to improve the environment for your eyes and your dry eye disease. This could include using supplements, hot compresses or prescription drops; improving your diet; and controlling your environment with a humidifier.

Unfortunately, there’s no magic wand to make dry eye disease instantly better.

Your dry eye disease didn’t occur overnight. It took many months or years to develop, and it’s not going to go away immediately. However, if you follow a treatment plan, and you learn and use new habits, your dry eye disease can improve. — Robert Friese, O.D., Ophthalmology, Mayo Clinic Health System, Fairmont, Minn.

Mayo Clinic Q & A is an educational resource and doesn’t replace regular medical care. E-mail a question to MayoClinicQ&A@mayo.edu. For more information, visit www.mayoclinic.org.

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You bring out the best in us.

Providence has once again been recognized as a top health care provider by U.S. News & World Report. Providence Alaska Medical Center has been named 2023-2024 Best Regional Hospital in Anchorage and High Performing in seven procedures and conditions.

Our award-winning care reflects the exceptional work of our caregivers, providers and community partners, who share our commitment to ensuring Alaskans get the best care possible close to home. Learn more at Providence.org/PAMCawards.

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Top Tips to Avoid Back Injuries this Winter Arjun Sebastian, M.D., Mayo Foundation for Medical Education and Research, Premium Health News Service

DEAR MAYO CLINIC: I threw out my back doing yard work.

While I was laid up for a few weeks, I’m okay now. I’m concerned I will reinjure my back shoveling snow this winter. How can I protect my back while shoveling?

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ANSWER: Winters in certain parts of the country can be long and snowy. While seemingly an innocuous task, snow shoveling can be a rigorous aerobic activity and one that significantly stresses the back.

You should be mindful to avoid serious injuries when shoveling.

Here are a few tips and techniques to hopefully keep your driveway and sidewalk clear while avoiding serious injury: •

Assess your personal fitness and ability. If you have any preexisting conditions, such as heart disease or lower back conditions, it is critical to consult with your health care provider before the snow starts falling. Often, for those who have longstanding back issues, the best way to avoid injury may be to avoid shoveling altogether by purchasing a snowblower or hiring someone to help.

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Warm up and stretch beforehand. Treat snow shoveling like any other workout. Warm up to get the heart rate up and blood flowing beforehand. Stretches focusing on the lower back and hamstrings also will help prevent overstressing the back during shoveling.

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Dress warmly and hydrate ahead of time. Keeping the body warm during aerobic activity improves blood flow and oxygenation to muscles in the lower back, which reduces stress and overexertion. A good pair of boots or shoes with good traction will help you avoid slips and falls that could cause a back injury. Make sure to hydrate appropriately ahead of time to avoid exhaustion and lower back cramps.

Pick the right time and the right shovel. Depending on the timing of snowfall, many people tend to shovel early in the morning after waking up. This is not the most optimal for your body, as you are less likely to be warmed up and you’ll be more prone to injury. Try to avoid early morning or late-night shoveling as much as possible. If a large amount of snow is predicted to fall, consider taking multiple passes, with frequent breaks, so you are not shoveling large piles of snow. Lay down salt or sand ahead of time to improve traction and prevent ice buildup. Lastly, invest in a good shovel, ideally one that is lightweight, metal and sturdy, and has good grips and a long shaft to help with leverage.

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Keep your back straight, use your legs and take frequent breaks. When shoveling, the rule is to start slow and take frequent breaks, especially early in the season as you’re building up your stamina. While you shovel, avoid bending with your back to scoop.

Instead bend at the knees and hips. Keep your arms close to your body to avoid overstressing your back.

When dumping the snow from the shovel, turn with your entire body versus twisting with your back. Avoid scooping large, heavy loads. Ideally, break up the snow into smaller, more manageable shovel loads.

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Treat lower back strain appropriately. If you strain your lower back by shoveling snow, take some time to rest to give your body time to recover. Over-the-counter medications, such as Tylenol, or nonsteroidal antiinflammatory medications such as ibuprofen, can help control pain. Topical agents, as well as heat and cold compresses, also can help. Gentle lower back therapy, including stretching and core exercises, can help with the recovery process, as well.

•

Be aware of red flag symptoms and seek medical care when appropriate. If you have any severe, progressive or persistent lower back pain, seek medical care urgently. This is especially true if your back symptoms are accompanied by pain radiating down your lower extremities, weakness in your legs or feet, numbness in your genital area, or symptoms

of incontinence. Other non-spinal symptoms, such as shortness of breath, chest pain, lightheadedness or palpitations, also should warrant urgent medical evaluation.

With proper preparation and mindful attention to the actions you take while shoveling, snow clearing doesn’t have to be a tedious or difficult winter task. Should you need additional assistance for injuries, consult with your primary health provider or a spine care center. — Arjun Sebastian, M.D., Orthopedic Surgery, Mayo Clinic, Rochester, Minn.

Mayo Clinic Q & A is an educational resource and doesn’t replace regular medical care. E-mail a question to MayoClinicQ&A@mayo.edu. For more information, visit www.mayoclinic.org.

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Health care | Fall 2023 13

Neera Nathan, M.D., MSHS, and Payal Patel, M.D., Harvard Health Blog, Premium Health News Service

Acne can be frustrating, especially when it does not go away after your teenage years. Believe it or not, acne can continue to affect adults beyond adolescence, or develop for the very first time in adulthood. This may be particularly distressing for adult women, who are more likely to get acne after the age of 20 compared to men.

What is adult female acne?

Adult female acne can look very similar to teenage acne. While adult acne is commonly thought to affect the jawline and chin, it can appear on any part of the face or trunk. Adult women can have clogged pores, inflamed pus-filled bumps or deep-seated cysts. Unfortunately, treatment options that worked well in the teenage years may not work as well in adult females with acne, due to triggering factors such as hormonal imbalance, stress, and diet.

There are many reasons adult females can get acne. Hormonal disturbances caused by pregnancy, menstrual cycle, menopause and oral contraceptives can contribute to acne by modifying the production of certain hormones. These hormones stimulate oil production within the skin, promoting the growth of acne-causing bacteria. Stress can increase the production of substances that activate oil glands within the skin of acne patients. Consumption of dairy and high-glycemic foods is also linked to acne. Certain hair or skin products can

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clog pores and cause comedonal acne — blackheads and whiteheads. A board-certified dermatologist can help determine the appropriate treatment for the type of acne you have.

Consequences of adult acne and scarring The extent to which acne causes emotional distress varies, and is not related to the severity of the acne or acne scars. Some women with acne may experience disruption in their personal and professional lives as they fear stigmatization in relationships and employment. Adult females may also be more likely to seek treatment for active acne when acne bumps and scarring persist.

Acne scarring can be disfiguring. Permanent changes in skin texture in the form of pits or raised scars may not be easily concealed with makeup. Raised scars may also lead to skin picking and worsening skin texture and pigment.

Acne can also heal with red or dark spots that may not resolve for weeks to months. The dark spots may persist even longer without proper sun protection, especially on darker skin. Having both acne and dark spots may negatively impact one's quality of life and self-perception.

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The emotional toll associated with acne may include an elevated risk of developing depression compared to patients who do not have acne.

Clinical studies show that having severe acne can negatively affect quality of life on par with long-term diseases such as arthritis, diabetes, back pain and asthma. If you have acne, extensive scarring or dark spots of any severity that are affecting your mental health, you may benefit from earlier intervention with oral medications.

What are options for treatment and support?

Acne is a medical condition, but it only needs to be treated if the acne or marks left behind from it are bothersome to you. Please see a board-certified dermatologist — in-person or virtually — for the best available options if you wish to seek treatment.

Your dermatologist may prescribe a combination of topical and oral treatments. Some of these medications may not be appropriate if you are pregnant or breastfeeding or carry risks.

Ask your dermatologist about hair and skin products that may be irritating, clogging pores, or promoting oil production in the skin, making your acne worse. Also, avoid skin picking to prevent scarring, and try to minimize emotional and physical stressors.

For individuals with dark spots or scarring, consult a board-certified dermatologist to get a personalized treatment geared to your skin concerns. Use a broad-spectrum, tinted sunscreen daily and reapply it every two hours to help prevent acne marks from worsening. If your acne is causing you significant mental distress, ask your doctor about mental health resources.

Additionally, seeking treatment for your acne may help you feel better. Consider joining online or in-person support groups in your area.

For more information, visit the American Academy of Dermatology Acne Resource Center.

Neera Nathan, M.D., MSHS, and Payal Patel, M.D., are contributors to Harvard Health Publications.

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Can some Postmenopausal Women with Breast Cancer Skip Chemotherapy?

T. Salewa Oseni, M.D., Harvard Health Blog, Premium Health News Service

Breast cancer remains the most common cancer among women. In the last two decades, the treatment of breast cancers has become personalized. This has been possible due to the subtyping of breast cancers. Breast cancers have been subtyped based on the receptors on the breast cancer cell. The most clinically significant receptors — those that have targeted therapies — are the estrogen and progesterone receptors and the human epidermal growth factor receptor 2 (HER2). Cancers that have the estrogen and progesterone receptors are termed hormone receptor (HR)-positive cancers.

The development of hormone therapy for HR-positive breast cancers means that some women, for whom the risks of chemotherapy outweigh the benefits, may be able to forego chemotherapy. The development of genomic assays, tests that analyze genes expressed in cancer, have provided a way to help doctors and women decide who will obtain the most benefit from chemotherapy.

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How does genomic testing help to personalize breast cancer treatment?

Increasingly detailed knowledge about breast cancers has led to the development of personalized therapy. In addition to knowing the type and stage of your cancer, genomic testing has further refined how we assess the risk of recurrence for breast cancer. One genomic test, Oncotype Dx, is a useful tool that can help predict the likelihood of benefit from chemotherapy, as well as the risk of recurrence for invasive breast cancer.

Not all women will require chemotherapy, but for some women hormone therapy alone is not enough. Oncotype Dx analyzes the expression of 21 genes in HRpositive, HER2-negative breast cancer and assigns a recurrence score (RS) based on risk of recurrence. The Oncotype Dx test places women into three groups: low, intermediate or moderate, and high risk of recurrence. Women with a low score do not need chemotherapy and benefit the most from hormone therapy, while women who have a high recurrence score benefit the most from chemotherapy in addition to hormone therapy.

There is new research to help women make decisions about chemotherapy Until recently, it was unclear how much benefit women with an intermediate risk score obtained from chemotherapy. A randomized clinical controlled trial, the Tailor Rx trial, answered this question. The trial randomized women with nodenegative — cancer that has not yet spread to the lymph nodes — HR-positive, HER2-negative breast cancers with an intermediate risk score to hormone therapy alone, or to chemotherapy in addition to hormone therapy. The results showed that most women with an intermediate risk of invasive cancer did not get any added benefit with chemotherapy. However, the subgroup of women who did benefit from chemotherapy were premenopausal women under age 50.

While the results of the Tailor Rx trial were practice-changing, it did lead to questions about the benefit of chemotherapy in women whose cancer has spread to their lymph nodes and who had HR-positive, HER2-negative breast cancer. The RxPonder trial answered this question.

The RxPonder trial randomized 5,015 women with stage II/III HR-positive, HER2negative breast cancer, with one to three positive lymph nodes, and an intermediate RS (≤ 25). Patients were randomized to receive hormone therapy alone, or hormone therapy with chemotherapy. The main goal of the study was to determine how many women did not get a recurrence of the invasive breast cancer while they were being followed.

There were many ways to compare the women in the study, but the main characteristics chosen for comparison were: menopausal status, RS, and the kind of axillary surgery they received. At a median follow up of 5.1 years, there was no association between chemotherapy benefit and RS value between zero and 25 for the entire population. However, there was an association seen between chemotherapy benefit and menopausal status. This trial provided evidence that even women with cancer in their lymph nodes, if they had a low or intermediate RS, could avoid chemotherapy.

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Premenopausal women responded better to hormone therapy and chemotherapy Of the women enrolled in the RxPonder trial, 3,350 were postmenopausal and 1,665 were premenopausal. Further analysis by menopausal status revealed that there was no difference in five-year survival for postmenopausal women treated with hormone therapy alone versus hormone therapy with chemotherapy.

However, for premenopausal women there was a 46% reduction in the risk of invasive disease. For this subgroup of women, the five-year, invasive disease-free survival rates were 94.2% in women treated with hormone therapy and chemotherapy, compared to 89% in women treated with hormone therapy alone. The premenopausal women who received both chemotherapy and hormone therapy had an additional benefit of around 5%. It is unclear if the survival benefit seen in premenopausal women is primarily due to chemotherapy’s effect, or indirectly by ovarian suppression due to chemotherapy What does this mean for breast cancer treatment decision-making?

The treatment of breast cancer has truly become personalized. It has always been important to know the stage of your cancer, but now it is also important to know the type of your cancer. With this information, women can make an informed discussion with their oncologist about the risks and benefits of chemotherapy.

If you are a premenopausal woman with a HR-positive, node-positive breast cancer, chemotherapy and hormone therapy may give you the greatest chance of decreasing your risk of the cancer coming back. However, for a postmenopausal woman with HR-positive breast cancer, chemotherapy may not add many treatment benefits to hormone therapy, and it carries risks that may affect your quality of life. Studies like the TailorRx and RxPonder trials have provided more information to help you make an informed decision.

T. Salewa Oseni, M.D., is a contributor to Harvard Health Publications.

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Health care | Fall 2023 23 plans provided by Moda Health Plan, Inc.

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5 Best Foods for Boosting Your Vitamin D Levels Betty Gold, RealSimple.com, Premium Health News Service

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As temperatures creep lower and we continue to lean fully into cozy season — stocking up on scarves and sweaters, sipping hot apple cider, baking every pumpkin spice recipe we can get our hands on — there’s a strong likelihood that we’re all about to be spending a significant amount of extra time indoors compared to summertime. We’re all in favor of embracing the Nordic lifestyle trend known as friluftsliv, which means spending as much time outside in the fresh air as possible despite the weather conditions, but let’s be honest: winter is long, cold and very much lacking the amount of sunshine we soaked up all summer long.

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Case in point? You’re right to wonder whether your body is getting a sufficient amount of vitamin D. “Limited exposure to sunlight may lead to lower levels of active vitamin D,” explains Mike Roizen, M.D., chief wellness officer at Cleveland Clinic and author of “What to Eat When.”

Vitamin D contributes to a healthy immune system, and it’s important to find ways to support your immunity during this time.

What else does vitamin D do in the body? “Vitamin D is a fat-soluble vitamin that’s needed to maintain healthy bones,” says nutrition expert Rachel Berman, RD, general manager of Verywell. “Its primary function is to absorb calcium and phosphorus during digestion. Calcium is the mineral needed to support bone health and proper nerve and muscle function.”

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While sunlight is the most commonly thought-of source of active vitamin D, your diet is also an excellent way to up your vitamin D levels, especially when indoor time is at an all-time high. “Vitamin D is called the ‘sunshine vitamin’ since it’s formed in the body when your skin is exposed to UV rays — it is also found in supplements and naturally in certain foods,” Berman says. “Experts recommend getting about 600 IUs of vitamin D in our diet.” Here, the five best vitamin D-rich foods you should be eating in every season, according to Berman.

1. Fatty fish Fatty fish — including salmon, tuna and sardines—are strong sources of vitamin D. “I like adding herbs and spices to salmon and baking to eat as a main dish or flaked with some breadcrumbs, egg and chopped veggies to form a salmon burger patty,” says Berman.

2. Mushrooms Maitake mushrooms — aka hen-of-the-wood mushrooms — are another good source of vitamin D. They are great chopped up in a salad or sautéed in olive oil as a side dish.

3. Eggs According to Berman, egg yolks provide smaller amounts of vitamin D; incorporate them into breakfast more often.

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4. Cheese Like eggs, cheese offers a smaller supply of vitamin D; combine the two in an omelet or frittata.

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Some common foods are also fortified with vitamin D to help us get enough in our diet — think cereals, plant-based milk and yogurt.

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Steve Calechman, Harvard Health Blog, Premium Health News Service

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Being a vegan is nothing new, but even 10 years ago it would have gotten eye rolls, and it was a lot of work for a vegan to find acceptable meat-free and dairy-free meals. Now the dynamic has shifted: grocery stores have shelves of frozen vegan burgers, and restaurants denote meat- and dairy-free items with the green V. Veganism has become hip, in addition to having potential health benefits, like improved heart health and weight loss, from cutting out animal products and increasing vegetables. Each January, more and more people are trying the “Veganuary” month-long challenge brought out of a UK-based nonprofit, choosing to start the year out with a vegan diet. But it’s a big dietary change, and merely announcing, “I’m vegan” doesn’t take away the lifestyle challenges that can entail.

“It’s not magic. It’s a hard thing to do,” says Eric Rimm, professor of epidemiology and nutrition at the Harvard T.H. Chan School of Public Health.

Plus, vegan doesn’t automatically equal health. French fries — cooked in vegetable oil — and soda fit the definition. "Being vegan does not relieve you of the responsibility of making good nutrition choices," says Meir Stampfer, professor of epidemiology and nutrition at the Harvard T.H. Chan School of Public Health.

The first big question when going vegan is how you will make those wise nutrition choices.

Understanding your why and motivations With any kind of change, the stronger and more personal your reason, the more likely you’ll stick with it.

When deciding to be a vegan, there can be an ethical and even an emotional component of concern for animal welfare and the environment. Those things mean something to you, and you’re not going to eat, wear or use any animal products because you consider that inhumane. It will probably make you go all-in from the start, and your deeply held belief and devotion to a bigger cause won’t make giving up certain foods feel like a loss.

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But what if better health is your primary reason for going vegan? The elimination of animal products and dairy means a reduction in saturated fats and sodium, which can help with losing weight and/ or preventing weight gain, and can reduce the risks of cardiovascular disease, blood cholesterol and diabetes, Stampfer says.

With a lifestyle and health-oriented goal, you’re in control of how and when you go about your transformation. There are no deadlines to meet to be vegan. It’s about a way to eat — your way to eat — and it’s fine to do at your own pace, since an immediate overhaul can feel too sudden and restrictive and might make you quit after a few weeks. To some people, “It feels like you’re being punished,” Rimm says.

It can also feel overwhelming to think about giving up long-loved foods forever. Instead, start by being vegan with just breakfast only two days out of the week. Or you could give up chicken and see how that feels, then eventually give up red meat or ice cream and keep slowing or eliminating old foods over several months. And at some point, maybe even a couple of years later, you realize, “Hey, I’m a vegan.”

And still, you can decide that once a week, you'll have feta cheese on your salad because it makes everything taste good. Is it being a “classic” vegan? No, but you can define it — and just call your approach plant-based, plant-forward or whatever you want to align with your ultimate goals. “There’s no police,” Stampfer says.

Planning for pitfalls Preparation is key when trying a new way of eating. Find appealing vegan recipes in cookbooks or on websites, or set up a food subscription service, and at the beginning line up two weeks of meals so what you’re going to eat isn’t a constant scramble and daily stress, Rimm says.

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And then ask some questions of your life:

• How often do you eat out?

• Do you like to cook?

• Do you like to socialize?

• Do you know anyone else who’s vegan who can give you tips, recipes, vegan-friendly restaurants?

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None of the answers are disqualifying, but you can identify potential pitfalls and get a handle on how you approach food. And the last question is key, since having support when making a change can help smooth the transition and make you feel less alone in the attempt. “It prepares people for what they’re up against,” Rimm says.

Health caveats and choices when trying a vegan diet It’s one thing to give up animal products, and that move can lead to health improvements, but it’s just as important to know what you’re replacing those items with. And the prescription for being vegan isn’t much different from any healthy diet. You want to choose whole grains and avoid refined foods and sugar, so your blood sugar doesn’t spike and you’re not feeling hungry again soon, leading you to eat more, gain weight, and potentially develop diabetes, Stampfer says.

You also want to eat good fats. Fats took a beating in the 1980s and ‘90s, and they still carry an unfair stigma of being unhealthy. But only certain ones are, such as the already-mentioned saturated fats. The goal is to minimize — not eliminate — them, since that isn’t possible, Stampfer says. Instead, use monoand polyunsaturated ones, like olive oil, nuts and avocados, which are calorically dense and provide a measure of satiety.

One concern with eating vegan is getting ample B12. The vitamin mostly comes from animal sources, and is essential in forming red blood cells and DNA and in the development and function of brain and nerve cells. Rimm says to inform your doctor about your new diet and have your B12 levels checked to get a baseline, and then supplement with a daily amount — around 2.4 micrograms. This is not an issue to treat casually. “You’d die without adequate B12,” Stampfer says.

But here’s one thing that’s not such a worry: protein. It might seem to be, because animal products and meats are gone, but tofu and beans are well-known substitutes, and vegetables and grains also are sources, along with nuts and avocados. As Stampfer says, “We don’t need as much as we think. It’s rare to see people who don’t get enough protein.”

It might be something to be mindful of, and it’s something that might be foremost on your mind at the beginning when you’re adjusting. But is it a reason not to make the switch? That again goes back to your motivation, and whether it’s a desire to protect animals or a way to live with more energy, then you probably can find alternatives, and rather than feel dread, enjoy the experimentation that comes from choosing to do anything new.

Steve Calechman is a contributor to Harvard Health Publications.

Health care | Fall 2023 33

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