2 Gazette Health | Fall 2012
A GAZETTE PUBLICATION
A publication of The Gazette | Fall 2012 Editors Designer Contributing Writers
Kim Bamber, Anna Joyce Anna Joyce Karen Finucan Clarkson Mary Wade Burnside Archana Pyati
Doug S. Hayes
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Fall 2012 | Gazette Health 3
Taking vitamin D supplements may lower childrenâ€™s risk of respiratory infections. Because the body naturally produces the vitamin in response to sunlight, this may be especially true in winter when that light is limited.
Beating egg allergy in kids
Is it safe to
Rinse Your Sinuses?
ittle teapots with long spouts have become a fixture in many homes for reasons that have nothing to do with tea. Called neti pots, they are used to rinse the nasal passages with a saline solution, and have become popular as a treatment for congested sinuses, colds and allergies, and for moistening nasal passages exposed to dry indoor air. However, the U.S. Food and Drug Administration (FDA) warned about the risk of infection tied to improper use, issuing a statement in August about safe practices for neti pots and other nasal rinsing devices. The source of water used with neti pots is the largest concern, the FDA said. Unfiltered tap water that is not treated in specific ways is unsafe to use for nasal rinsing. Tap water can contain low levels of organisms, like bacteria
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and protozoa, including amoebas that, while safe to swallow because stomach acid kills them, can live in nasal passages and cause potentially serious infections, according to the Centers for Disease Control and Prevention. These devices are generally safe and helpful when used and cleaned properly, said Steven Osborne, M.D., a medical officer with the FDA. Improper use of neti pots may have caused two deaths in 2011 in Louisiana from a very rare brain infection that the state health department linked to tap water contaminated with an amoeba called Naegleria fowleri. Talk to your doctor to determine if nasal rinsing will be safe and effective for your condition. If symptoms are not relieved or worsen after the rinse, then return to your health care provider, especially if you have a fever, nosebleed or headaches while using the rinse.
Giving small daily doses of egg powder to children with an egg allergy could pave the way to letting them eat the food safely. After 10 months, more than half of the allergic children in a new study who had been eating egg powder daily showed no allergic reaction, or only minor symptoms. A year later, 30 of the 55 kids in the study passed a challenge with even higher doses of egg powder. The 30 then avoided all egg products for four to six weeks, after which they were given egg powder, plus a whole cooked egg. Over a third of those children did not react and were cleared to eat eggs as part of their diet. A year later, they were still showing no signs of allergic reaction. Researchers said the therapy is still in the early experimental stages. And they strongly caution that this type of oral immunotherapy should never be tried at home due to the risk of severe allergic reaction. -NIH
A silent killer Silent heart attacksâ€”in which there are no typical symptoms like chest pain and shortness of breathâ€”are not only more common than previously thought, but more common than heart attacks with recognized symptoms, according to a recent study of older adults. Researchers from the National Institutes of Health found the prevalence of these heart attacks was especially high in seniors with diabetes, and that magnetic resonance imaging (MRI) was more effective than an electrocardiogram (EKG) in identifying them. Those who suffer a silent heart attack may mistake it for something else, such as muscle pain, indigestion or the flu, according to the Mayo Clinic.
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Brain abnormalities seen in hoarders Until recently, hoarding disorder has been considered a type of obsessive-compulsive disorder (OCD). Now, many experts consider it a unique diagnosis. People with hoarding disorder have trouble making decisions about when to throw things away. Possessions pile up, resulting in debilitating clutter. Results from a new study funded by the National Institute of Mental Health suggest that hoardersâ€™ decisions about possessions are hampered by abnormal activity in brain regions used to identify the emotional significance of things. Scientists believe that these abnormalities are specific to hoarding and separate the disorder from OCD. In addition to further exploring the unique traits of hoarders, researchers are now using this information to help assess potential treatments. Previous studies of brain function in hoarders implicated regions
associated with decision-making, attachment, reward processing, impulse control and emotional regulation. But the patient populations and research methods varied among the studies, making clear conclusions difficult. In the new study, researchers analyzed brain images of 43 hoarders, 31 people with OCD and 33 healthy controls. Participants were given six seconds to make a decision about whether to keep or discard junk mail that either belonged to them or to someone else. Participants later watched as the items they chose to discard were placed in a paper shredder. The hoarders chose to keep more mail that belonged to them than those in the OCD or healthy control groups. Hoarders also took longer to make decisions and reported greater anxiety, indecisiveness and sadness than the other groups. -NIH
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Fall 2012 | Gazette Health 5
REASONS to stop avoiding your dentist BY ARCHANA PYATI
Fear of the dentist is serious and has farreaching consequences for a person’s overall health. According to the Centers for Disease Control and Prevention, only 61 percent of U.S. adults in 2010 had visited the dentist within the previous year. However, 81.6 percent of adults in the “Bethesda, Gaithersburg and Frederick” region seen had a dentist at least once that year. Many patients still avoid the dentist for a variety of reasons, including a lack of insurance and basic paranoia. “If you have fear, go and have a consult first,” said Michele Dozier, D.D.S., a pediatric dentist at nusmiles in Takoma Park. “A conversation—that’s where we start.”
Prevention of gum 1 disease
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Spotting cavities before they lead to 2 infection or tooth loss
Like plaque, cavities are also caused by bacteria, which eat away the tooth’s enamel, creating holes. If caught when they’re small enough, they can be filled, said Danny Dinh, D.D.S., a dentist with the Family Smile Center in Frederick. If left to grow, cavities cause tooth decay, which may lead to an extraction or an infection of the nerves and tissues around the tooth. “By the time [the patient is] in pain, the cavity is huge. That’s when they need a root canal,” where damaged nerves and tissue are removed and what remains of the tooth is sealed and protected with a crown, said Dinh.
3 Learning the proper way to brush
“I didn’t know how to brush my teeth until I went to dental school,” said Pantano. Proper brushing, she added, is not exactly an instinctual skill, but something that must be learned. She recommends brushing in a circular motion with the brush held at a 30- to 35degree angle. “Many patients don’t know what the proper technique is, and they never remove the plaque effectively,” said Rimple SinghCrawford, D.D.S., of Fenton Family Dental’s Clinton office. Patients target the front teeth, she said, but aren’t always diligent about cleaning molars in the back of the mouth. The insides of the bottom front teeth are another tricky area where plaque can become a problem, according to Pantano. The Philips Sonicare, she said, creates the circular motion needed for proper cleaning. Many electric toothbrushes also have timers to make sure brushing lasts long enough.
Gum disease is the No. 1 cause of tooth loss in the United States, according to Tami Pantano, D.M.D., who recently opened Audubon Dental Center of Clinton. It begins with gingivitis, where bacteria in the mouth cause plaque and tartar—a hardened form of plaque—to build up along the bottoms of the teeth. If left untreated, gingivitis can progress to periodontal disease, when plaque seeps below the gumline, causing the gums to recede and bone to deteriorate. “When that happens, that’s irreversible,” she said, adding that it takes six months for plaque to slip down beyond a toothbrush’s
reach. Those scraping instruments a dentist uses, called scalers, are sharp and precise enough to remove the buildup. “Even the healthiest mouths need cleaning every six months,” said Pantano.
Rule out oral cancer and Oral hygiene and health 4 other 7 diseases that start is critical when managing in the mouth
Dentists check more than your gums and teeth. They consider overall oral health and perform an oral cancer screening on new patients. “We examine the gums, the tooth structure…underneath the tongue where they can’t see,” said Singh-Crawford. “A lot of systemic diseases have oral dimensions,” said Pantano, citing HIV as an example of a disease that appears in its early stages in the mouth. “Most of the time, it’s a fungal infection, and if we see a fungal infection, that shows the patient is immunocompromised.”
Fix functional or 5 cosmetic problems
Even if you diligently brush and floss every day, you can’t fix structural problems without the help of a dentist and, probably, an orthodontist. “Sometimes teeth need to be straightened out for functional reasons,” said Dinh, such as the inability to clean in between the teeth due to overcrowding. Braces or retainers may be needed for adults if structural problems were not corrected when they were younger. Under bites and overbites could indicate a problem with the jaw and other temporomandibular disorders, said Pantano.
halitosis, known 6 Control as bad breath
One telltale sign of periodontal disease, said Dozier, is a distinctive, foul odor. Halitosis is caused by bacterial buildup in the mouth. Infrequent and ineffective brushing and flossing can be the culprit, as can a failure to clean the tongue, said Dinh, who recommends a tongue scraper for this purpose. Getting timely cleanings helps keep the buildup of plaque at bay, which will mean fresher breath.
Pantano recently attended a diabetes fair in Washington, D.C., where she reminded attendees how important it is to care for their mouths and get regular checkups. “Gum disease is more severe in diabetic patients…and one of the biggest reasons is that the elevated blood sugar provides extra nutrition for the bacteria,” she said. Due to weaker immunity, diabetic patients tend to be prone to infections in all areas of their body, including the mouth. Diabetes also manifests itself with oral symptoms like dry mouth, said Pantano, which a dentist can help treat. “Health starts with your mouth,” said Singh-Crawford. “If you lose your teeth, you can’t eat healthy foods like fruits and vegetables,” which are essential for diabetic patients. “It’s very important for these patients to have healthy mouths so they can chew and digest properly.”
It’s better to take a 8 preventative, rather than reactive, approach to oral health.
In the old days, dentistry tended to be more reactive than proactive, said Pantano. The thought “used to be if ‘it’s broken, fix it,’” said Pantano. “Now, we’ve figured out ways to prevent it from being broken in the first place.” Not all of her patients, though, have changed their mindset about the importance of catching problems early. She still gets calls from emergency room doctors when one of her patients shows up at the hospital in excruciating pain with an abscessed tooth. “I really push prevention,” she said. “I have happier patients and a happier me when they don’t have problems.” 1867929
Fall 2012 | Gazette Health 7
WHOOPING COUGH cases on the rise in Maryland
BY KAREN FINUCAN CLARKSON
f you think you’re immune to whooping cough, think again. “Sometimes people think, ‘I got vaccinated as a kid so I’m protected,’” said Cynthia Roldan, M.D., a pediatric hospitalist at Carroll Hospital Center in Westminster. With whooping cough— known as pertussis—staging a comeback nationwide, Maryland public health officials and physicians are encouraging vaccination of adults as well as children. Whooping cough can be fatal, especially in infants. “Pertussis can bring on seizures or make it difficult to breathe properly, resulting in brain damage or death,” said Avni Jain, M.D., a primary care physician with Adventist Medical Group in Germantown and privileges at Shady Grove Adventist Hospital in Rockville. “Two-thirds of children less than 1 year of age with pertussis are hospitalized.” Of the 111 pertussis deaths in the U.S. from 2004 to 2008, 83 percent were in infants under 3 months old, according to the Centers for Disease Control and Prevention (CDC).
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WHOOPING COUGH CASES ARE ON THE RISE. The CDC reported 21,401 cases of pertussis this year, through Aug. 4. That is more than double what was reported for each of the last three years at the end of the 31st week and is on track to become the highest number recorded in more than 50 years. Maryland has seen an increase in pertussis, though it is not on par with Washington state, where 3,202 cases have triggered an epidemic. As of August, there had been 141 cases of whooping cough in Maryland this year, compared with 56 in 2011 and 64 in 2010. In Montgomery County, Registered Nurse Cindy Edwards has noticed “a significant upswing of pertussis.” Last July there was one case, whereas
THERE ARE MULTIPLE REASONS FOR THE INCREASE, according to Vivek Sinha, M.D., a family medicine physician with Southern Maryland Hospital Center’s Fort Washington Family Medical Center. “Some people, worried about side effects, are not vaccinating anymore. We’re testing more, so we’re finding it more. And, after a while, the immunity of those who were vaccinated wanes,” he said. As a result, “we don’t have as high of a herd immunity,” said Edwards. Couple that with the cyclical nature of pertussis—“every three to four years there’s a resurgence in cases,” she said— and there’s the potential for a perfect storm. The clouds of that storm began to form in the 1990s when a new whooping cough vaccine was developed. In response to concerns about potential side effects— fever, swelling at the injection site and, rarely, seizures—associated with the original 1940 vaccine, which used small amounts of inactivated whole bacteria, an acellular version, containing only fragments of bacterial cells, was substituted. “There is concern that the acellular pertussis vaccine doesn’t provide immunity as long as the older pertussis vaccine,” Edwards said. Vaccination, which is about 85 percent effective, remains the best way to prevent pertussis or minimize the severity of the disease, most medical professionals agree. Two vacVaccination is still the best way to cines—DTaP and Tdap—help prevent whooping cough. protect against diphtheria, tetanus and pertussis. DTaP is a this July there were 14. In April through June of pediatric formulation, while Tdap, considered a last year, two cases were reported, compared booster, is primarily for adolescents and adults. with 36 in the same quarter this year. “That’s not Current “guidelines recommend that DTaP be an epidemic, but still significant,” said Edwards, given five times—at 2, 4 and 6 months, then at the manager of the Disease Control Program 15 to 18 months and 4 to 6 years of age,” said with the county’s Department of Health and Sinha. “In adolescence, about the time they’re Human Services. going into seventh grade, they [continued on 20]
Fall 2012 | Gazette Health 9
CHILDREN’S HEALTH CHILDRENS’ HEALTH
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ver a nine-year period, prediabetes or diabetes in American teenagers nearly tripled. This troubling news comes as pediatricians are treating a specific group of patients with greater frequency: young people who have developed symptoms of a chronic disease more commonly found in adults.
According to study published in May in PEDIATRICS, the official journal of the American Academy of Pediatrics, researchers from the Centers for Disease Control and Prevention noted the prevalence of prediabetes or diabetes jumped from 9 percent in 1999 through 2000 to 23 percent in 2007 through 2008. Prediabetes is a precursor to type 2 diabetes, where the body gradually develops resistance to insulin. Insulin is the hormone needed to regulate blood sugar, moving it from the bloodstream to cells to be stored and later used for energy. Historically, children were more likely to be diagnosed with type 1 diabetes. Also known as juvenile diabetes, type 1 occurs when the body produces little or no insulin, and researchers say its origin is a faulty immune system. Type 2 diabetes, on the other hand, had been found mostly in adults, whose bodies stopped responding to insulin due to weight gain and other factors. Now, that generational divide seems a little less clear as more overweight and obese teenagers qualify as prediabetic. As more patients fit this profile, doctors urge parents to take a more aggressive role in ensuring their children stay physically active and maintain a low-carb, highprotein diet to facilitate weight loss and maintain healthy blood sugar levels. While not fully understood, the link between obesity and insulin resistance, a hallmark of prediabetes, has been made by scientists in recent years, which doctors see on the front lines of their practices.
BY ARCHANA PYATI
“Definitely, we’re seeing more kids with overweight and obesity, and soon, I will see more patients with prediabetes and type 2 diabetes,” said Cong Ning, M.D., a pediatric endocrinologist at Shady Grove Adventist Hospital in Rockville.
Prediabetes: Why Diagnose?
Prediabetes occurs when a person’s fasting blood sugar is in an abnormal range—between 100 and 125 mg/dL—and they have one or more of the following: a high body mass index; dark, velvety patches of skin behind the neck and underarms, known as acanthosis nigricans; a family history of diabetes; or high blood pressure. Once a person’s fasting blood sugar reaches 126 mg/dL or higher, she’s considered diabetic. While it’s not a new term, prediabetes among both adults and teens is being discussed with greater frequency now because we’re learning more about how diabetes and other chronic disease work, and the definition of what’s “normal” keeps changing, said Vivek Sinha, M.D., a family physician at Fort Washington Family Medical Center, affiliated with Southern Maryland Hospital Center. “Research has shown that even patients that are at 118 [mg/dL] show signs of insulin resistance…,” he said. Identifying teens who are prediabetic opens up the possibility of reversing course on a diagnosis that once seemed inevitable. “I’ve had patients who are prediabetic and not become diabetic
exclusively through losing weight,” said Sinha. “The name of the game is prevention rather than treatment in pediatrics.”
Disparities in Diagnoses
Belonging to certain ethnic groups amplifies the risk of prediabetes. African-Americans, Alaska Natives, American Indians, Hispanics, Asian Americans and Pacific Islanders are at a greater risk for developing prediabetes and type 2 diabetes, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Researchers in a study published in BioMed Central Research Notes in January wrote that “nearly one out of every six overweight youth has prediabetes,” and that “the burden of diabetes falls disproportionately on ethnic minority youth, particularly Native Americans, Hispanic/Latino Americans, and AfricanAmericans.” In its most recent National Diabetes Fact Sheet, the CDC noted that from 2002 to 2005, new cases of type 2 diabetes were either similar to or greater than new cases of type 1 diabetes diagnosed among black, Hispanic, Asian/Pacific Islander and American Indian 10- to 19-yearolds. Only non-Hispanic whites of this same age group had a larger percentage diagnosed with type 1 diabetes. While scientists are still mapping out the genetic underpinnings of why certain ethnicities are at greater risk for developing type 2 diabetes, other factors such as household [continued on 21]
Fall 2012 | Gazette Health 11
BY KAREN FINUCAN CLARKSON
Noise may be the No. 1 culprit of hearing loss
“IT USED TO BE THAT AGING ALONE was the No. 1 cause of hearing loss—and noise second. Now it’s [the] reverse,” said Scully. “Noise has a compound effect and, over time, takes a toll.” Many baby boomers who frequented rock concerts, cranked up the stereos and blasted
12 Gazette Health | Fall 2012
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e’re all destined to go deaf if we live long enough. If you make it to 100, you will be hard of hearing, guaranteed. Everyone loses hearing to one degree or another as they age,” said Bryan C. EgoOsuala, M.D., an otolaryngologist with The Center for Ear, Nose & Throat at Doctors Community Hospital in Lanham. The first signs of age-related hearing loss, known as presbycusis, begin to appear in one’s late 50s or early 60s, according to EgoOsuala. High-frequency sounds—such as the chirping of a bird, the ringing of a phone, or consonants and blends such as “s” and “th”—generally are the first to go. “I was stunned when my husband and children said I had a hearing problem. I thought people weren’t speaking loudly enough or were mumbling,” said Leanore Calem, 79. “I kept turning the TV up louder and louder to the point when my kids would visit they’d tell me to turn it down.” The Kensington resident is in good company. As many as half of all people 75 and older have hearing loss, as do about a third of adults from 65 to 75, according to the National Institute on Deafness and Other Communication Disorders (NIDCD). Presbycusis is progressive. “We’re all born with a finite number of hair cells in our ears—in the cochlea or inner ear—that help transmit sound to the hearing nerve, which then takes the sound to the brain,” said Ego-Osuala. “During our lives, as the hairs grow and are exposed to sound, they die. They do not regenerate. So, most hearing loss is permanent.” “What we’re finding is that, for the vast majority of people, hearing loss doesn’t happen in isolation,” said Kate Scully, a clinical audiologist with Hearing Center Silver Spring. There are a number of physiological changes and age-related ailments that cause it.
personal CD players are discovering that for themselves. Among Americans 46 to 64, about 15 percent already have hearing problems, according to a survey by the Better Hearing Institute (BHI). While there are conflicting studies as to whether the baby boomer generation’s hearing loss is any more significant than that of previous generations, the large number of aging boomers means that by 2030 there may be 44 million Americans with some degree of hearing loss, according to BHI. That would be an approximately 19 percent increase over today’s number. CARDIOVASCULAR DISEASE CAN bring about hearing loss. “The inner ear is highly dependent on a rich blood supply, so vessel health can affect hearing,” said Scully. “Smoking also can result in vascular issues and limit blood flow to the cochlea.” More than 70 percent of those 60 to 79 live with cardiovascular disease and, as a result, are at increased risk for hearing loss. Cardiovascular disease, which includes high blood pressure, “is associated more with low-frequency hearing loss,” said Scully. That might mean someone is less likely to hear the rumbling of a truck or of thunder. Both heart and cancer patients may suffer hearing loss as certain medications can damage the ear, according to the American Speech-LanguageHearing Association. More than 200 drugs—some prescription, others over the counter—are considered ototoxic. Diabetics are twice as likely as the general population to suffer hearing loss, according to Scully, and risk of the disease increases with age. “It’s one of the first questions I ask on the intake form, as there are about 20 million diabetics in this country and 54 million with prediabetes, and the number is rising,” she said. Kidney issues have a direct correlation with hearing loss. “Over 50 percent of people with chronic kidney disease have some degree of hearing loss,” said Scully.
Age-related hearing loss tends to run in families, according to EgoOsuala. “If your mother became hard of hearing at age 38, there’s a high chance you will too. If hearing loss began at 65, we don’t consider that unusual,” he said. Because age-related hearing loss is incremental, many people don’t notice it at first or don’t think the problem is significant enough to warrant treatment, said Ego-Osuala. Such was the case with Calem, who recently began wearing a hearing aid. “I must have had serious problems a decade before, which I either wasn’t aware of or didn’t acknowledge. I think I was probably in denial.” AFTER AN APPOINTMENT WITH AN otolaryngologist, Calem learned that her ears were structurally sound. The next stop was the audiologist’s office, where Scully “explained that I had some rather drastic losses in certain registers. I knew she was right, but it was an uncomfortable admission that I didn’t like to make,” said Calem. Putting her vanity aside, Calem opted to purchase hearing aids. “Most people, if I didn’t say anything, wouldn’t notice. The only thing not covered by my hair is a tiny wire that goes from what’s in my ear to the battery, which is hooked behind my ear.” Her hearing improved dramatically. “The first moment was a stunner. It almost sounded artificial because for years I hadn’t been hearing these sounds—paper rustling, birds singing,” she said. While nearly three-quarters of those who use hearing aids report much better or somewhat better hearing, according to a 2011 AARP study, only about a fifth of those who would benefit from a hearing aid actually use one, noted NIDCD. Hearing aids are not 100 percent effective and in some cases may not be effective at all. It’s not unusual, according to Ego-Osuala, for people who wear hearing aids to continue to have trouble hearing in places, like restaurants, where there is a lot of background noise.
Only about a fifth of those who would benefit from a hearing aid actually use one. And, if hearing loss has more to do with the way a person’s brain processes the information, a hearing aid isn’t the answer. “Making something louder won’t help if the sounds are jumbled in the brain,” said Ego-Osuala. “Hearing aids have come a long way since the first digital ones were introduced in 1996,” said Scully. “Today, there are devices other than hearing aids that can help in more challenging environments.” She points
to mini microphones that the wearer can use to transmit sounds wirelessly to a hearing aid and to hearing aids that use Bluetooth technology so that phone calls and television shows can be run through them. Getting medical help as soon as a loss of hearing “is noticed by you or someone else is essential,” said Scully. “On average, people wait seven years to do something about it. Some wait decades. By the time they come in, it’s harder to deal with because they may be trying to cope with other issues.”
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Fall 2012 | Gazette Health 13
Sometimes a woman can experience both hyper- and hypothyroidism, as was the case with media queen Oprah Winfrey, who went public with her struggles with thyroid disease in 2009. After putting back on the pounds she had lost in the mid-2000s, she was diagnosed with hyperthyroidism, which then morphed into hypothyroidism, a culprit behind her weight gain. “Who knew this tiny butterfly gland at the base of the throat had so much power? When it’s off, the whole body feels the effects,” she wrote in her essay “How Did I Let This Happen Again?” published in O, The Oprah Magazine.
14 Gazette Health | Fall 2012
THYROID DISEASE Why It May Go Undetected
BY ARCHANA PYATI
magine eating a healthy diet and exercising regularly, yet gaining weight and feeling a debilitating fatigue for no explicable reason. Now imagine going to your doctor, taking a blood test and being told you are absolutely fine. This is precisely what happened to Abbey Black, 32, a medical assistant who lives on the outskirts of Hagerstown in Falling Waters, W. Va. Seeking a specialist’s opinion can be important for women who suffer from hypothyroidism, a type of thyroid disease. It took Black a year from the “everything’s fine” conversation
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with her general practitioner to receiving a diagnosis from an endocrinologist that made sense to her: Hashimoto’s thyroiditis. The autoimmune disease occurs when antibodies attack the thyroid gland, impairing its ability to secrete hormones that control every major bodily function—from metabolism to heartbeat to hair growth to bowel movements. “It’s a frustrating disease,” said Black, whose mother and sisters also have Hashimoto’s. “You have to work a lot harder at things when you have thyroid disease.” The American Thyroid Association (ATA) estimates that 20 million Americans have some form of thyroid disease, and it disproportionate-
ly affects women. Women are five to eight times more likely to develop thyroid problems, and up to 60 percent of those with a thyroid disease are not aware they have a disorder. “There’s a lot of misdiagnoses,” said Majd Hakim, M.D., the Frederick-based endocrinologist who treated Black. “Many patients have symptoms for many years before they get diagnosed.” Hakim said the underdiagnoses stem, in part, from a less-than-precise blood test doctors administer to find out if a patient’s thyroid is working properly. The test measures the amount of thyroid-stimulating hormone—or TSH—in the blood. Secreted by the pituitary gland, TSH triggers the thyroid to produce
ISTOCKPHOTO: OPRAH WINFREY BY JASON MERRITT /XX, EDSTOCK CONTRIBUTOR; WOMAN AND DOCTOR, SKYNESHER
Up to 60 percent of those with a thyroid disease are not aware they have it. essential hormones T3 (triiodothyronine) and T4 (thyroxine). The test range for what’s normal is fairly broad, which causes many patients’ thyroid disorder to remain undetected. Symptoms, like fatigue, weight gain, insomnia and depression, persist and may even be attributed to a mood disorder. “We need to look at patient family history, symptoms…a lot of times [patients] get misdiagnosed because their hormone level falls within the normal range,” said Hakim. In Black’s case, her condition resulted in hypothyroidism, where the thyroid doesn’t secrete enough T3 and T4; the sluggishness and weight gain without an increased appetite are a result of the metabolism slowing down. Hyperthyroidism, a condition caused by the thyroid producing too much T3 and T4, usually creates the opposite effect—loss of weight while feeling hungrier and eating more, anxiety and a rapid heartbeat. Not only can the TSH test sometimes fail to identify an overactive or underactive thyroid, but in those who have been diagnosed with hypothyroidism, it may not be precise enough to ensure a patient receives the correct amounts of hormone replacement therapy, said Hakim. Getting the level of the T4 hormone, known commercially as Synthroid, just right is especially critical since T4 eventually converts into T3. “The bottom line is the problems occur when they’re not taking the right amount of T4 to begin with,” Hakim said. “It’s a very, very common scenario.” Hyperthyroidism can be the result of another underlying
autoimmune disorder like Graves’ disease when antibodies are unleashed on the thyroid, causing it to go into overdrive. Studies have shown that stress, pregnancy or a viral infection can lead to an overactive thyroid, said Madhuri Devdhar, M.D., an endocrinologist with Adventist Medical Group in Montgomery Village. While antithyroid medications are prescribed for Graves’, they’re not meant for long-term use due to damaging side effects, including the loss of white blood cells, said Hakim. An iodine pill that has been radiated is frequently used as a one-time treatment for Graves’, and is generally considered safe, while surgery is the less common and riskier solution. Both often lead to hypothyroidism since the thyroid becomes disabled due to the powerful radioactive iodine dosage or surgical removal. Hormone replacement therapy, which is usually prescribed for the remainder of the patient’s life, “is very benign,” and causes “very little problem as far as side effects,” said Hakim. Black, the medical assistant, whose second child was due last month, has successfully navigated her thyroid disease along with her pregnancy. A woman’s thyroid requirements increase by 30 to 50 percent during pregnancy since a fetus can’t produce its own thyroid hormone in the first trimester, according to Hakim. Black has had to increase her dosage of Synthroid a few times. After her delivery, she imagines life will go back to the way it was, where weight management is the perennial issue.
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Fall 2012 | Gazette Health 15
Misnomer alert: It’s usually not caused by beer.
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BY KAREN FINUCAN CLARKSON
16 Gazette Health | Fall 2012
f a keg now sits where your six-pack used to be, you could end up paying a hefty price—your health or your life. “Excess weight in the midsection can lead to problems with cardiovascular disease, hypertension, metabolic syndrome—which can lead to diabetes—and some cancers, the most common for men being prostate cancer,” said Patricia Guay-Berry, clinical nutrition manager at Suburban Hospital in Bethesda. With nearly 75 percent of the men in Maryland considered overweight or obese, according to The Henry J. Kaiser Family Foundation, there are more than 1.5 million men whose spare tires could use some deflating. And the sooner the better, as belly fat is potentially lethal, according to the Mayo Clinic. What makes abdominal fat so dangerous is that it includes visceral fat, which lies deep inside the abdomen and surrounds the internal
organs, said Heather Boyd, lead dietitian at the FMH Wellness Center in Frederick. “Visceral fat is more likely to get broken down and go into the bloodstream, increasing lipid and triglyceride levels,” she said. Unhealthy blood fat levels cause plaque to form on artery walls, eventually restricting blood flow and leading to heart attack and stroke. Despite the label, beer does not make a belly. “The beer belly got its name because people who drink a lot of beer take in extra calories,” said Reed M. Shnider, a cardiologist with Cardiology Associates LLC and privileges at MedStar Montgomery Medical Center in Olney, “and when you take in more calories than you burn, you get fat.” In men, that fat ends up in the gut; in women, it most often plants itself in the hips and thighs. “Men are apples and women are pears,” said Shnider. Gender plays a major role in how fat is distributed.
“Don’t think you can spot reduce. It doesn’t work. It’s a combination of aerobics and strength training that will help.” –Heather Boyd, dietitian
Hormones seem to influence where fat goes in the body, according to Boyd. Both estrogen and testosterone hold in check an enzyme known as lipoprotein lipase (LPL), which promotes fat storage. In a woman’s body, the highest LPL levels are usually found in the breasts, hips and thighs, and in a man’s body, LPL levels are highest in the abdomen. As hormone levels decline with age, LPL in those areas becomes more active and fat deposits grow. A waist circumference of 40 inches or more for men and 35 inches or more for women is cause for concern, according to Boyd. It indicates an unhealthy concentration of belly fat. “The good news [for men] is that abdominal weight is easier to lose than weight from the hips and thighs,” said Guay-Berry. Although visceral fat is buried in the abdomen, it tends to respond well to diet and exercise. The prevailing theory is that visceral fat is more [continued on 20]
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Fall 2012 | Gazette Health 17
Nail fungus is an unsightly but relatively benign condition, and accounts for about half of all nail disorders, according to the American Academy of Dermatology (AAD). “The fungus is everywhere,” said Farid Quraishi, D.P.M., a podiatrist at Oxon Hill Orthopaedics in Oxon Hill. “It’s in your house, in your soil, all over the place.” BY MARY WADE BURNSIDE 18 Gazette Health | Fall 2012
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NAIL FUNGUS: Easy to get. Hard to treat.
hile fingernails also can become infected, toenails are more susceptible to fungal infections because of their proximity to the floor and the soil, said Quraishi. Toes are also often confined to a warm, moist, weight-bearing environment in shoes, according to the AAD. Wearing shoes and socks—one way to help prevent nail fungus— does not always do the trick. “Even if you wear socks, some people don’t change their socks every day,” said Quraishi, who has privileges at Southern Maryland Hospital Center in Clinton and Fort Washington Medical Center in Fort Washington. Those who have athlete’s foot— an infection of the foot caused by fungus—can become reinfected from not washing their socks or not spraying their shoes with an antifungal spray. The same can hold true for those with nail fungus. In fact, Quraishi said, many of his patients who have nail fungus have previously had athlete’s foot. If left untreated, a nail fungus infection can lead to more problems, especially for those with weakened immune systems, such as patients with leukemia or AIDS, according the Mayo Clinic. Also, someone with diabetes who contracts a nail fungal infection may have more complications. “People who are immunocompromised, people who have circulation problems in the leg, people who have diabetes, they are more susceptible to getting fungus in the nail,” Quraishi said. Some people are genetically predisposed to the condition, according to Lawrence Green, M.D., a dermatologist who practices at Shady Grove Adventist Hospital in Rockville. Plus, the older we get, the more easily we seem to contract nail fungus, he noted. “There must be some sort of a decrease in your natural immune function so you can’t fight it off like when you are 25, so you get it easier,” said Green.
As many as 30 percent of seniors have had nail fungal infections, known as Onychomycosis, according to the AAD. With Onychomycosis, the nail can become thick and crumbly. “Your nail gets thicker, whiter and the debris builds up under the nail,” Green said. “That’s the most common form of toenail fungus. There are other kinds in which you don’t get the thick and crumbly nail.” Another type, white superficial Onychomycosis, is similar, but has less severe symptoms. In both cases, patients might not notice any change in their nails for some time after being infected. “It comes on slowly,” Green said. “Some people don’t look at their nails. It takes a while to develop.” Since the infection is underneath the nail plate in the nail bed, treatment is difficult, according to the AAD. The slow growth rate of nails can explain why it can take time for someone to notice the infection, as well as why it can take so long to cure. It can take a year or longer to grow a toenail, Quraishi said. “And for everybody it’s different.” While the condition is not necessarily painful, said Quraishi, it can be if one stubs a toe or tries to wear pointy shoes or other footwear that presses against the nail. Both Quraishi and Green said oral medications are more effective than topical ones in treating nail fungus. Quraishi prescribes the oral medication terbinafine, commonly known as Lamisil, which he said has been found to be 85 percent effective. He compared this to a rate of 35 percent for a topical medication, which generally must be applied twice a day for several months. Before prescribing Lamisil, Quraishi takes a culture of the nail to determine whether a patient has a nail fungus. If that comes back positive, blood work is done to test the patient’s liver function. “With Lamisil, it can have systemic results and 1 percent of the patients can get [continued on 20]
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COUGH, continued from 8
should get Tdap. Adults between the ages of 19 and 64 should get a single Tdap vaccine.”
BELLY, continued from 17
metabolically active than subcutaneous fat, which is found under the skin, said Boyd. In other words, bellies tend to shrink faster than hips or thighs. And, after just a 10-pound reduction in visceral fat, “lipid levels start dropping. Ten pounds can make a difference,” she said. In addition to diet, exercise is critical to reducing the size of one’s paunch. “But don’t think you can spot reduce. It doesn’t work,” said Boyd. While sit-ups and crunches may strengthen abdominal muscles, those muscles will be hidden under a layer of fat. “It’s a combination of aerobics and strength training that will help reduce that beer belly.”
20 Gazette Health | Fall 2012
pediatrician with Discovery Pediatrics in Silver Spring and secretary/treasurer of the medical staff at Holy Cross Hospital. While the adult may not be terribly ill, he is contagious. Keeping those who cough or sneeze away from an infant is sensible, though not always practical. “If you’re a mom or dad taking care of a baby, you’re probably not going to let a cough or cold keep you from doing so,” said Sinha. Even more problematic is that someone in the early stages of whooping cough may not know he has it. “The incubation period lasts up to three weeks and during that time there may not be any symptoms, or just mild ones. You may not feel your best or have a bit of a runny nose.” ONCE SYMPTOMS APPEAR, IT TAKES “about a week for the cough to turn more severe,” said Roldan. “It’s a rapid, deep cough followed, at the end of the episode, by a high-pitched whoop…Older kids may not have the whoop, but may cough so forcefully that they vomit. Like other upper respiratory infections, whooping cough
While it’s important “to become more mindful of what you are putting in your mouth,” said GuayBerry, it’s not necessary to deprive yourself of the libation that gave your gut its name. “Beer and other beverages can be continued, but make sure to have them in moderation. “For men, that means two beers or two 1-ounce servings of liquor or spirits or two 6-ounce glasses of wine maximum per day.” “People with beer bellies can benefit tremendously from lifestyle modification,” said Shnider. “Altering the collection of fat in the abdomen is one of the most sensible things you can do to improve your overall health.”
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may worsen at night.” Pertussis often presents differently in infants. Cold symptoms may be lacking. “Half of them have apnea, meaning they stop breathing,” said Madden. “About 20 percent get pneumonia, 1 percent have seizures and 1 percent die. In about 0.3 percent there is brain swelling, which could be due to a lack of oxygen or from toxins that the bacteria produce.” Whooping cough is most commonly treated with an antibiotic. “After five days on an antibiotic, [a person is] no longer considered contagious,” said Edwards. Still, it can take weeks to fully convalesce. In the meantime, Edwards works to identify anyone with whom a whooping cough patient may have
NAILS, continued from 19
hepatitis,” he said. If a patient begins to have systemic symptoms, such as nausea or vomiting, he should stop taking it. According to Green, a patient taking Lamisil has “virtually” no chance of having liver problems. The medication itraconazole, marketed under the brand name Sporanox, requires that the liver function be monitored, and in rare cases may cause congestive heart failure, according to the U.S. National Library of Medicine. Laser treatments on nail fungus are used by some doctors, but neither Quraishi nor Green use this form of treatment. “It’s not covered by insurance, so using it is out-of-pocket,” said Quraishi. “The problem with
had close contact during the incubation period and when symptoms were present. “Our investigation involves a fairly large group of contacts,” she said, “and we recommend to every single one that they receive a prophylactic antibiotic. We coordinate with physicians and, if a minor is involved, the parents.” While natural infection may subsequently boost immunity to pertussis for a period—between four and 20 years, according to CDC estimates—routine vaccinations should be continued. “We need to be vigilant about vaccinations,” said Roldan. “No delays or withholding. That’s how to protect the unprotected.”
that is that the anecdotal evidence is good, but there are no long-term studies because it’s a new treatment. It does treat the fungal nail, but nobody knows what the reinfection rate is. ” Prevention is the best way to battle nail fungus. However, “By the time most people come to see me, they have fungal nails, so there is very little I can tell them in terms of avoiding it,” Quraishi said. Some tips to protect your nails include: wear clean socks and shoes, and spray them with an antibacterial spray once or twice a month; keep your feet clean and dry, as well as dry between the toes; and if you shower at a gym, wear flip-flops, Quraishi said. “Once you get it, it’s hard to get rid of it.”
ISTOCKPHOTO/DEREJEB. MODELS MAY NOT ACTUALLY HAVE HAD WHOPPING COUGH
IN FEBRUARY, THE CDC’S ADVISORY Committee on Immunization Practices recommended Tdap for all adults 65 and older. Given whooping cough’s resurgence, the committee is reviewing the need for additional doses of Tdap and the timing of revaccination of those who have received Tdap. Because more than 30 percent of whooping cough cases in infants can be traced to the mother, it is imperative that pregnant women be vaccinated, said Roldan. A dose of Tdap may be given to underimmunized women during the late-second or third trimester, or in the immediate postpartum period before discharge from hospital. Pertussis is highly contagious and, once brought into a home, infects 80 percent of susceptible members of the household. “The only way to protect your infant is to protect everyone around the infant,” Roldan said. Jain concurred: “If you have a small infant in the house, get everyone immunized who may come in contact—parents, grandparents, siblings, nanny.” Because pertussis initially mimics a common cold, many cases, particularly mild ones in adults, go undiagnosed, according to Robin Madden, M.D., a
More than 30 percent of whooping cough cases in infants can be traced to the mother.
PREDIABETES, continued from 11
income, low levels of physical fitness and poor dietary choices play a role, said Sinha and Ning. Less than 10 percent of childhood obesity is caused by genetics or an endocrine disorder, while diet and exercise are the main determinants, according to Ning.
Role of Parents
Doctors say parental involvement is the game changer when it comes to lowering risk. “If a child is prediabetic, then parents have to become diabetes experts,” said Sinha. “I have seen patients who have come out of the prediabetes zone, but that doesn’t mean they won’t go back in.” For parents who may not know where to start, Sinha arranges appointments with a nutritionist to help them devise a sensible diet for their child. Food diaries, in which patients write down everything they consume, sometimes work, although compliance is minimal, he said. To avoid setting a bad example, parents must also confront their own
“If a child is prediabetic, then parents have to become diabetes experts. I have seen patients who have come out of the prediabetes zone, but that doesn’t
mean they won’t go back in.” -Vivek Sinha, M.D.
weight problem if they have one. “A lot of kids who are overweight, their parents are overweight as well,” said Sinha. Parental perceptions about their child’s weight and health status are sometimes at odds with reality. “Parents perceive that a child’s diet is healthy,” said Ning. “They don’t have any idea what a normal diet is.” For adolescent patients who are trying to
lose weight, Ning prescribes a 1,500calorie-a day diet. Cultural norms and attitudes about weight and body image can also influence behavior. The BioMed Central Research Notes study found that compared with parents of other races, African-American parents “were more likely to report their overweight child’s weight as underweight or normal and less likely to report they felt their child’s weight was unhealthy.” The study also found that AfricanAmerican girls “tolerated heavier body weight and perceived less social pressure to lose weight, resulting in infrequent pursuit of lifestyle changes.”
When talking to a prediabetic patient, Ning prefers not to use the word “obese,” especially when the parents are overweight themselves. She places a teenager’s weight in context, saying instead, “You seem to be overweight for your height.” Among the teenagers she treats for prediabetes, Ning said, “girls tend to
have a problem with depression” and, at times, eating disorders. Infrequent menstrual periods are also a hallmark of prediabetic girls, suggesting they might have polycystic ovary syndrome, an endocrine disorder that may lead to infertility. Sinha advises boys at risk for developing prediabetes to “treat their bodies like a temple.” Yet these pep talks can’t always lift a teenager’s self-esteem and create motivation to change. “They’re tired,” said Sinha. “They’re exhausted by being different. They’re exhausted by…being told what to do....I see many patients who are very frustrated and who have given up.” Patients who are already motivated academically tend to do better with treatment plans, he said. They tend to approach their own weight loss like a challenging assignment and get excited about setting goals and completing tasks. Strong parenting and lots of positive reinforcement aid the process: “You want to empower the child, and get them to take responsibility for their own health.”
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experts’ opinion National Institutes of Health
Is a Vegetarian Diet Healthy? Adventists in all 50 states and in Canada. Members of this religious group miss out on a lot of major health problems that plague many have unique dietary habits and a generally healthy lifestyle. Adventists are Americans. They generally live longer than the rest of us, and they’re encouraged to follow a vegetarian diet, but about half the population sometimes eats meat. These variable eating patterns allow scientists to more likely to bypass heart-related and other ailments. Most people think of vegetarian diets as simply eating plant foods and compare a wide range of dietary habits and look for links between diet and disease. not eating meat, poultry and fish, but there are many variations. To date, the researchers have found that the closer people are to Strict vegetarians, or vegans, eat plant foods and reject all animal products—meat, poultry, fish, eggs, dairy and sometimes honey. Those who being vegetarian, the lower their risk of diabetes, high blood pressure also eat dairy products are called lacto-vegetarians. Vegetarians who eat and metabolic syndrome—a condition that raises the risk of heart disboth dairy and eggs are called lacto-ovo vegetarians. Some vegetarians eat ease and stroke. “The trend is almost like a stepladder, with the lowest fish but not meat or poultry. They’re called pescatarians (pesce is Italian risks for the strict vegetarians, then moving up for the lacto-vegetarians and then the pescatarians and then the for fish). nonvegetarians,” Fraser explained. “Then there are the so-called flexitariEarlier studies found that vegetarian ans, or semivegetarians. These are people Adventists also tend to live longer than who eat a mostly vegetarian diet, but they both meat-eating Adventists and nonoccasionally eat meat,” said Jody Engel, a Adventists. The vegetarians also have nutritionist and registered dietitian at the fewer instances of coronary heart disease National Institutes of Health (NIH). “They and lower rates of some cancers. might say ‘I’m a vegetarian, but I need to eat my burgers every Sunday.’ People tend BECAUSE VEGETARIANS BY DEFINITION to follow their own rules, which is one readon’t eat meat, some people jump to the son why it’s hard for researchers to study conclusion that simply cutting meat from vegetarians. There’s so much variance.” their diet will lead to health benefits. Despite the different definitions, “there’s “But it’s actually more complicated than tremendous agreement among nutrition that,” said Fraser. “Differences in life experts and health organizations that a expectancy and other health matters more plant-based diet is beneficial, whether Vegetarians have fewer instances might be related to the extra fruits, vegyou’re a true vegetarian or not,” said NIH of coronary heart disease and etables, nuts and legumes—including nutritionist Dr. Susan Krebs-Smith, who soy—that vegetarians tend to eat. You monitors trends in cancer risk factors. lower rates of some cancers. can’t necessarily conclude it’s based on Vegetarian diets tend to ingest fewer the absence of meat.” calories, and have lower levels of saturated Experts generally agree that vegetarians who eat a wide variety of fat and cholesterol, and more fiber, potassium and vitamin C than those with other eating patterns. They tend to weigh less than meat eaters, and foods can readily meet all their body’s needs for nutrients. However, they to have lower cancer rates. “Evidence also suggests that a vegetarian diet need to be sure they take in enough iron, calcium and zinc. Studies show is associated with a lower risk of death from certain heart diseases, and that most vegetarians do get enough, in part because so many cereals, that those who follow a vegetarian diet tend to have lower LDL [‘bad’] breads and other foods are fortified with these nutrients. “Vegans in particular need to be certain to get enough vitamin B12 and omega-3 fatty cholesterol levels,” said Engel. acids,” said Rachel Fisher, a registered dietitian involved in nutrition IN SOME CASES, THOUGH, IT’S UNCLEAR IF CERTAIN HEALTH BENEFITS research at NIH. Omega-3—found in fish, flaxseed, walnuts and canola come from plant-based eating or from the healthy lifestyle of most veg- oil—is important for heart health and vision. Some vegetarians take dietary supplements to ensure they’re getting etarians. “Vegetarians are generally more physically active and have everything they need. Talk to a registered dietitian or other health profeshealthier habits than nonvegetarians…,” said Krebs-Smith. To tease out the effects of diet, scientists have to conduct large, careful- sional if you’re a vegetarian or thinking of becoming one. Whether you’re a vegetarian or not, Fisher said, you can benefit from ly controlled studies that account for other factors. One of the world’s largest studies of plant-based diets is now under way at Loma Linda the high fiber, low fat and rich nutrients of a vegetarian diet. University in California. Cardiologist Gary Fraser is leading an NIH-Excerpted from NIH News in Health funded team of scientists to analyze data on 96,000 Seventh-day VEGETARIANS MISS OUT ON A LOT OF FOODS, BUT THEY ALSO TEND TO
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22 Gazette Health | Fall 2012
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24 Gazette Health | Fall 2012
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