Sunday, 28 April 2019

Drug-resistant bacteria a growing health problem

Antibiotic-resistant bacteria sicken more than two million Americans each year and account for at least 23,000 deaths. The main cause? Overuse of antibiotics.

A new report from the Centers for Disease Control and Prevention, Antibiotic Resistance Threats in the United States, 2013, details the health and financial costs of antibiotic resistance in the United States. In terms of health, antibiotic resistance should be in the CDC’s top 15 causes of death. It also adds as much as $20 billion in direct health-care costs. And the problem could get worse before it gets better.

“Antibiotic resistance is rising for many different pathogens that are threats to health,” said CDC Director Tom Frieden, M.D., in a prepared statement. “If we don’t act now, our medicine cabinet will be empty and we won’t have the antibiotics we need to save lives.”

Those are some very strong words from the director of the CDC. Like many doctors and citizens around the country, I am keenly aware of the risks of antibiotics. Still, Dr. Frieden’s words grabbed my attention.
Antibiotic resistance explained

What is antibiotic resistance? Here is a simple example. If you get a strep throat and take penicillin for it, the penicillin will kill off most of the streptococcal (strep) bacteria. But a few strep bacteria might survive. These survivors are, for many different reasons, resistant to the medicine. The next time around, your strep throat might not respond to penicillin.

You can acquire drug-resistant bacteria in many different ways. They can come from overusing antibiotics, or taking them when they aren’t necessary, as for a viral infection. You can develop resistance to antibiotics by eating meat treated with antibiotics. It’s also possible to get an antibiotic-resistant infection from other people—even, unfortunately, from health care professionals.

Why is antibiotic resistance a problem? The major issue is that commonly used antibiotics will become less able to treat common infections. That means doctors must turn to more powerful and sometimes less friendly antibiotics, or may not have anything in their arsenal.

In its report, the CDC identified three types of bacteria as urgent hazards:

    Clostridium difficile. These bacteria can cause severe diarrhea, especially in older people and those who have serious illnesses.
    Enterobacteriaceae. These bacteria, which normally live in the digestive tract, can invade other parts of the body, like the urinary tract, and cause infections.
    Neisseria gonorrhoeae. These bacteria cause gonorrhea, a sexually transmitted infection.

Many other bacteria were listed as “serious” or “concerning” threats. They included some very common bacteria that cause pneumonia and strep throat. Fungi that cause some common yeast infections also made the “serious” list.

The CDC took the opportunity to unveil a four-pronged approach to monitor and address the problem. It aims to:

    prevent infections and the spread of antibiotic resistance
    track antibiotic-resistant infections around the country
    improve how doctors, patients, farmers, and others use antibiotics, and avoid their overuse
    develop new antibiotics and tests to detect antibiotic resistance

Taking action

Everyone can help decrease the impact of antibiotic resistance and slow its growth—or even turn it around altogether. Preventing infection in the first place is important. Here are some steps:

    Decrease excess use of antibiotics. Know when antibiotics do and don’t work. Don’t demand antibiotics from your doctor. Ask whether they will make a difference for your symptoms. The CDC’s Get Smart campaign offers tips and tools.
    Prevent infections. Hand washing (with regular, not antibacterial, soap) is a great way to prevent all infections. Other hygiene measures also are important. For example, sneeze into your elbow, not your hand. Hospitals can reduce risk with thoughtful infection control measures and programs.
    Stay up to date with your vaccinations. Getting vaccinated against pneumonia can help decrease resistance to the very common pneumococcus bacteria.
    Practice safe sex. Use condoms to help prevent the spread of sexually transmitted diseases.
    Learn more about antibiotic use in our food chain. These drugs also can increase antibiotic resistance. Make informed decisions about the food you are buying.

I hope this important report is the beginning of a serious campaign against antibiotic resistance. If these ideas work, then we may see decreased resistance and infections. If they don’t, then we’re heading down a worrisome path in our ability to confront serious, life-threatening infections. As evening turns to night, I often find myself looking for a snack. Sometimes the impulse comes from a bit of hunger, but I’m just as likely to make my way to the kitchen without thinking. I know that I’m not alone in this satisfying but potentially problematic habit.

The occasional late-night snack is nothing to worry about. But nightly bingeing merits a closer look. Experts may debate whether nocturnal overeating needs its own diagnostic category, but they don’t debate the significance of the problem.

As described in “Out of Sync,” an article in the current issue of The Scientist, eating at the wrong time can throw off the body’s metabolic cycles, leading to weight gain and other problems. According to the article, new research continues to “add to the growing recognition that our metabolisms are primed by the circadian machinery written in our genes, and that discord between the two can wreak havoc on our systems.”
Two types of nighttime eating disorders

Sleep-related eating disorder is a highly-publicized malady, though it’s not clear how common it is. People with this problem eat while sleepwalking, or while in a twilight state between sleep and wakefulness. They generally aren’t conscious of what they’re doing, so they may wake up to find the bed littered with candy wrappers — with no memory of consuming the candy. Dr. Brandon R. Peters, a sleep medicine expert affiliated with the Stanford Center for Sleep Sciences and Medicine, described a case of sleep-related eating disorder last month on The Huffington Post.

A better-documented problem is night eating syndrome, in which people do the majority of their eating late at night. A study published in the Journal of the American Medical Association found that by 6 p.m., people with night eating syndrome consumed a little more than a third of their daily calories, while a control group had consumed almost three-quarters. Between 8 p.m. and 6 a.m., however, the night eaters consumed 56% of daily calories, while controls consumed only 15%.

Night eating syndrome may affect 1 or 2 out of 100 people in the general population. Dr. Albert J. Stunkard, a psychiatrist at the University of Pennsylvania, first described the disorder in the 1950s. Researchers have recently explored its link to weight gain. The problem affects anywhere from 9% to 14% of people seeking treatment at obesity clinics, and as many as 27% of severely obese people.

Night eating syndrome also occurs in people who are treated in mental health clinics. In one study of psychiatric outpatients in Pennsylvania and Minnesota, 12% had night eating syndrome. Night eaters in this study were also much more likely than other individuals to have an addiction problem. Other research indicates that people with night eating syndrome tend to suffer from a distinct form of depression. In contrast to the usual pattern where depression is more pronounced in the early part of the day, night eaters tend to become more depressed during the evening.

It’s not clear what causes night eating syndrome and why it is associated with depression or addiction. One theory is that night eating syndrome involves a disruption in the hormones that regulate sleep, appetite, or mood. Because late-night snacking usually involves carbohydrate-rich “comfort” foods, this theory holds that night eating syndrome is a form of self-medication.
Breaking the cycle

Sleeping and eating are almost certainly connected, given the link between lack of sleep and weight gain. So getting plenty of sleep may be a helpful substitute for nighttime trips to the refrigerator. Until more is known about night eating syndrome, it’s probably best to take a broad approach to stopping it.

    See your doctor for a complete health evaluation.
    An evaluation by a mental health professional is a good idea to determine whether or not another mental disorder could be contributing to the eating problem. If so, treating that underlying mental health problem, such as depression or anxiety, may improve eating patterns and the chances of getting to sleep earlier.
    See a dietitian about how to better pace meals throughout the day, which may help break the cycle of late-night eating.
    Case reports indicate that some people can improve their eating patterns by being mindful of the problem and by trying to identify its triggers.
    The type of talk therapy known as cognitive behavioral therapy may help. Stress-reduction techniques may help avert trips to the refrigerator.
    Preliminary studies indicate that the anticonvulsant topiramate (Topamax) or a selective serotonin re-uptake inhibitors (SSRI) antidepressant such as sertraline (Zoloft) may also work.
The usual message to pregnant women: Don’t drink any alcohol. Clearly alcohol use can cause major problems for the pregnant woman and her baby.

While not drinking any alcohol during pregnancy is the safest choice, small amounts of alcohol early in pregnancy may be less risky to the mother’s health and the health of their babies than previously believed. Minimal alcohol use during the first trimester doesn’t appear to increase the risk for high blood pressure complications, or premature birth or low birth weights. That’s the findings of a study previously published in the journal Obstetrics and Gynecology.

Dr. Fergus McCarthy and colleagues from Ireland, England, New Zealand, and Australia compared birth outcomes among 5,628 women who were pregnant for the first time between 2004 and 2011. More than half of them reported drinking alcohol during the first three months of pregnancy. Some (19%) reported occasionally drinking alcohol. Twenty-five percent reported low alcohol consumption, or three to seven drinks per week (“a drink” defined as a glass of wine or a little less than a 12-ounce bottle of beer). Another 15% reported having more than seven drinks per week.

Rates of premature birth, babies with low birth weight or small size, and pre-eclampsia—a potentially life-threatening condition in which a pregnant woman develops high blood pressure—were similar across the alcohol consumption categories
The potential hazard of alcohol during pregnancy

For the past few decades, women have been urged to avoid alcohol during pregnancy. Respected medical societies like the American College of Obstetricians and Gynecologists and the United Kingdom’s Royal College of Obstetricians and Gynaecologists Women both say women shouldn’t drink any alcohol during pregnancy. The main reason for this is that heavy use of alcohol during pregnancy has been linked to a long-term and irreversible condition known as fetal alcohol syndrome (FAS).

Babies with FAS may be born early. They are often underweight and don’t grow well. Some have characteristic facial features like a thin upper lip and small eye openings, or the small vertical groove between the upper lip and the nose may be flattened. Other physical signs that go along with fetal alcohol syndrome include a small head, short nose, and problems with the way the heart or the joints are formed.

Children with FAS are slower to learn language skills than other kids. When they reach school age they often have learning disabilities and difficulty with attention, memory and hyperactivity. They are more likely to have poor coordination and a hard time with problem-solving. And some have trouble making friends and relating to other kids. All of which can make school a really difficult time.

Despite this clear advice, up to half of women drink some alcohol during pregnancy.
Putting it into practice

How clear is the medical evidence supporting strict abstinence from alcohol during pregnancy? Not very strong. Other studies suggest pregnant women who have an occasional drink don’t harm themselves or their baby. A 2012 Danish study, for example, found that low to moderate alcohol consumption during pregnancy did not affect executive functioning among 5-year-olds. Executive functioning is a catchall term that describes the ability to perform activities such as planning, organizing, strategizing, remembering details, and managing time.

However, since it’s not clear how much alcohol it takes to cause problems, the best advice remains the same: women should avoid alcohol if they are pregnant or might become pregnant.

For the many women that drank some alcohol before they realized they were pregnant, this and other studies should reassure them. They almost surely did no harm to their unborn children. Savvy shoppers know that it’s a bad idea to shop for food when they are hungry. It’s a formula for filling your cart with high calorie foods, and likely spending more money than expected. Shopping while sleep deprived may have the same effect.

That finding comes from an interesting experiment done by a team of Swedish researchers. They asked 14 men to go grocery shopping twice—once on the morning after a good night’s sleep, the other on a morning after a night of no sleep. All were given the equivalent of $50 to spend, and were asked to buy as much as they could out of a possible 40 items, including 20 high-caloric foods and 20 low-caloric foods. To make sure the men weren’t hungry, they were fed a solid breakfast before grocery shopping.

The men bought more food, and more high-calorie foods, the morning after sleep deprivation than after sleeping well. The results were published yesterday online in the journal Obesity.

We’ve known for some time that not getting enough sleep is linked to weight gain. It’s possible that shopping may contribute to this phenomenon. Lack of sleep may contribute to weight gain via other possible mechanisms. Too little sleep may

    slow metabolism
    prompt cells to store carbohydrates as fat rather than use it for energy or burn it off as heat
    cause cells to not respond as well as they should to insulin. That increases the level of sugar and insulin in the bloodstream, which can lead to weight gain.
    lower levels of leptin, a hormone that suppresses appetite, and increase levels of ghrelin (GRELL-in), an appetite-stimulating hormone.

It’s interesting that the researchers chose men rather than women for this experiment. Perhaps in Sweden, where the study was done, men do more of the grocery shopping. In the United States, we certainly need to see if the results will be the same in women.
Putting it into practice

For years, research on weight gain and obesity has focused on genes, foods, diets, and physical activity (or the lack of it). This study from Sweden, along with many others, are showing that our behaviors also play important roles in weight maintenance and weight gain. A good example of this work is the research conducted by Cornell University’s Brian Wansink and colleagues on “mindless eating.”

You can put the Swedish study into practice today. Be aware of how your body responds when you don’t get enough sleep. Whenever possible, shop for food only on days when you’ve gotten at least seven hours of sleep—and don’t go to the grocery store hungry. And when you know you are sleep deprived and tired, focus on mindful eating even more than usual.

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