Thursday, 25 April 2019

Let National Hepatitis Testing Day nudge you to getting a hepatitis check

Years ago, troubled by intermittent bouts of intense nausea that befuddled my doctor, I turned to a naturopath for help. In addition to suggesting some changes in diet, she recommended an herbal supplement called slippery elm bark. I dutifully took it for several weeks. My nausea faded away and hasn’t returned. I’ll never know what did the trick—the slippery elm bark, the diet changes, or the tincture of time.

As someone who’s dabbled with herbal and other dietary supplements, I’m in good company. About half of Americans say they take least one dietary supplement. That term covers vitamins, minerals, herbs, and related products. As a nation, we spend more than $32 billion each year on some 85,000 different supplements. Some people, like me, use them to treat a specific ailment. But many others just want to improve or maintain their health.

Unfortunately, some people fall prey to unscrupulous supplement peddlers. Take the octogenarian profiled in an article published online this week in JAMA Internal Medicine. Three clinicians from the University of California, San Francisco describe how the man, worried about memory loss, was spending nearly $3,000 a month on more than 50 supplements recommended by his “anti-aging” physician, plus hundreds of dollars more on other products he chose himself. Most of the products had no proven benefit on memory, and some may have contributed to the memory loss he was so worried about.

“This is an extreme example of a person who was essentially ripped off by someone he trusted to care for him,” says Dr. Pieter Cohen, a dietary supplement safety researcher and assistant professor of medicine at Harvard Medical School. But there are many other examples of people who either waste their money or are harmed—sometimes fatally—by dietary supplements.

People often assume that dietary supplements are harmless because they are “natural.” Lax marketing standards make the problem worse. Supplement makers can claim their products enhance health, despite a dearth of evidence in most cases. Unlike pharmaceuticals, which undergo extensive testing to prove they’re effective and safe before they can be sold, dietary supplements can be sold with without proof of effectiveness, safety, or purity.

As Dr. Cohen noted in a perspective in the New England Journal of Medicine, the FDA has found more than 500 supplements adulterated with pharmaceuticals or closely related compounds. (You can hear an interview with Dr. Cohen about the safety of nutritional supplements here.) The offenders include stimulants, bodybuilding steroids, antidepressants, weight-loss medications, and supplements aimed at treating erectile dysfunction. All can cause unwanted side effects and may be especially risky when taken with other prescription medications.

For example, a man prescribed nitrates to treat his chest pain should not take an erectile dysfunction drug such as Viagra. Doing so can cause dangerously low blood pressure. “So he takes an ‘all-natural’ herbal supplement instead. But he’s actually getting the Viagra his doctor told him not to take,” says Dr. Cohen, noting that many products contain compounds similar to or identical to Viagra, sometimes in doses higher than prescribed versions of the drug.

Many experts agree that the laws to regulate supplements need to be reformed. But Congress has shown no appetite for that, and any changes will probably be years in the making. In the meantime, if you’re interested in taking a dietary supplement, what steps can you take to minimize the risk? Dr. Cohen offers these tips:

    Consider only single-ingredient supplements. In a multi-ingredient supplement, knowing which substance is having an effect—either good or bad—is impossible to tease out. Also, these products are more likely to be adulterated with banned drugs. So stick to single-ingredient supplements.
    Do your research. At MedlinePlus, a health information website for consumers from the National Institutes of Health, you can find information about the effectiveness, usual dosage, and drug interactions of dietary supplements (see Some of the listings feature data from the independent Natural Medicines Comprehensive Database, which provides unbiased, up-to-date facts and ratings on the safety and effectiveness of more than 1,100 natural medicines.
    Talk to your doctor. Few health care providers have the time to stay current on the staggering number of supplements on the market. But they can check if a particular ingredient interacts with any of the medicines you’re currently taking.
    Look for the USP or NSF stamp. The United States Pharmacopeia (USP) and NSF International are independent, nongovernmental organizations that test dietary supplements. USP verifies the identity, quality, strength, and purity of supplements; NSF confirms that the supplement contains the listed ingredients and nothing else. Look for one of these stamps on the label, but keep in mind that neither indicates anything about the effectiveness of the product.
If you want to stay healthy and mobile well into old age, start walking today—even if you’ve already edged into “old age.”

That’s the conclusion of a report from the Lifestyle Interventions and Independence for Elders (LIFE) trial, published online yesterday in the Journal of the American Medical Association. The trial included more than 1,600 men and women between the ages of 70 and 89. None exercised regularly, and all were relatively frail. Half were randomly assigned to an exercise program that included daily walking plus strength and balance exercises. The other half took part in education workshops on healthy aging that included some gentle stretching routines.

After 2½ years, the volunteers in the exercise group were 28% less likely to have become disabled (defined by the inability to walk about 400 yards without help) compared to those in the education group. They were also 18% less likely to have had any episode of physical disability.

The improvements, while promising, probably don’t capture the real benefit of exercise. That’s because some of the people in the workshops, who learned how exercise can lead to healthier aging, became more physically active on their own. If none of the workshop and stretch people exercised, the results of the structured program would have been more impressive.
Longer life with less disability

In 1914, the average child born in the United States had a life expectancy of about 55 years. Today’s children can expect to live closer to 80 years. For some, those “extra” years will be healthy, active, independent years. For others, old age will mean frailty and dependence on others.

Independence can be defined as the ability to perform basic activities of daily living without help. These activities include:

•   walking

•   eating

•   bathing or showering

•   dressing

•   getting in and out of bed or a chair

•   using a toilet

Walking without assistance is probably the one that most determines if a person can live independently.

Older people who are physically more active and who exercise regularly are more likely to walk independently and do other activities of daily living on their own compared to sedentary elders. Is it possible for inactive folks to change this scenario?

According to today’s report from the LIFE trial, the answer is yes. A structured exercise program can make a difference even among older individuals who do not currently exercise.
Get started now

Some older people may have the impression that they have passed the age at which starting an exercise program will do them any good. According to the LIFE results, taking up exercise at any age offers benefits down the road.

Starting an exercise program can be a challenge no matter what stage of life you are in. It’s best to start slow. Exercising for just 10 minutes to begin with is great. Then gradually work your way up.

The goals for the volunteers in the LIFE trial are good ones for all of us. They include:

•   Get at least 150 minutes per week of walking or other moderate intensity exercise

•   Do resistance training with weights or machines two or three times a week, but not two days in a row.

•   Stretch and do other activities that improve flexibility and balance every day.
Exercise is a good investment

The lead author of the study, Dr. Marco Pahor of the University of Florida, estimated that the exercise program cost about $1,800 per participant per year. That may sound like a lot, but keep in mind that it included instructors and monitors and physical activity checkups. Also keep in mind that $1,800 a year is a lot less than the cost of caring for someone who can’t perform basic activities of daily living.

For me, there’s another key message to this report, one that we are seeing over and over again from research: You’re never too old to exercise. Many of us have trouble parting with our possessions—even when we no longer need them. I have a collection of greeting cards I’ve been storing since childhood and will probably never look at again. My husband owns a few pieces of clothing older than our 17-year marriage.

Yet some people take their keepsakes to the extreme, holding onto decades’ worth of receipts, newspapers, and other seemingly useless items. They have hoarding disorder—a mental health condition characterized by a compulsive need to acquire and keep possessions, even when they’re not needed. It’s the subject of a review article in today’s New England Journal of Medicine.

Exactly when a “pack rat” crosses the line into true hoarding has to do with “the intensity with which they’re saving, and the difficulty getting rid of things,” says Dr. Jessica Rasmussen, an instructor in psychology at Harvard Medical School and Assistant in Psychology at Harvard-affiliated Massachusetts General Hospital.

A wave of recent TV shows like Hoarders and Hoarding: Buried Alive has publicized the rarest and most extreme form of hoarding—homes filled floor-to-ceiling with piles of boxes, books, knick-knacks, and rat- and bug-infested garbage. Severe hoarders can accumulate so much that they render their living spaces unusable—and dangerous.
Why do people hoard?

Anywhere from 2% to 6% of adults have hoarding disorder. The condition tends to run in families, although a specific “hoarding gene” hasn’t yet been found. Women seem to hoard more than men, but that gender distinction still needs to be proven.

People hoard for many reasons, says Dr. Gail Steketee, a leading hoarding researcher who is dean and professor at the Boston University School of Social Work. One reason is sentimental attachment. “There is some specific association to an object, or an object is seen to represent a person’s identity in some important way.” For example, a woman who views herself as a cook might hold on to every conceivable kitchen implement, to the point where her kitchen becomes too cluttered to use.

In other cases, people feel a sentimental attachment to certain possessions—like a shell they found on their first trip to the beach. They fear that if they throw away the object, they’ll lose the memory or experience. And there are people who see the usefulness in everything, even in items many of us would regard as junk, like an old nail or a ripped shoelace.
The dangers of hoarding

As piles of hoarded items grow, dust can collect on them, leading to COPD and other respiratory issues. Those piles can also block hallways and stairways, hampering mobility—especially in older adults who already struggle to get around. “If the person has arthritis and is having trouble navigating the house, they can be at greater risk for falling,” Dr. Rasmussen says. Clutter can contribute to other health hazards as well, including bug and rodent infestations and fire hazards.

Hoarding also takes an emotional toll on families and friends. “Sometimes people are frustrated by the notion of, ‘Why can’t my loved one just throw this away?'” Dr. Rasmussen says.

Often it’s a family member who finally makes the call for help, either because the person who is hoarding doesn’t recognize the problem or isn’t comfortable talking about it. “There is a lot of shame people have, a lot of embarrassment,” says Dr. Rasmussen. “There’s still a lot of stigma around it.”
Help for Hoarders

Though families fed up with hoarding might be tempted to get a dumpster and start cleaning house like they do in the hoarding TV shows, a full-scale cleanup can be emotionally distressing for the hoarder. Instead, experts recommend cognitive behavioral therapy (CBT) to help the person better understand why he or she is hoarding, and to improve decision making, organizational, and problem-solving skills. CBT can be done one-on-one with a therapist, or in a group or workshop setting.

It’s helpful to find a therapist who is trained in hoarding, Dr. Steketee suggests. You can find a database of providers in your area by visiting the International OCD Foundation’s website. Dr. Steketee has co-authored a book, Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding, which also can help hoarders dig out from the clutter.
Help for Pack Rats

Even many of us who aren’t true hoarders could do with a little downsizing, says Dr. Rasmussen. She suggests setting aside time on a regular basis—20 or 30 minutes—to go through and clean out your stuff.

To simplify the process, sort items into one of three categories:

    I’m definitely going to keep this item
    I’m definitely going to throw away or give away this item
    I’m not sure

Then follow through. “If you have a keep pile, everything should have a home or a place,” Dr. Rasmussen says. Get rid of the discard pile as soon as possible. With the unsure pile, ask yourself some simple questions like:

    Do I really need this?
    Am I going to use this?
    How often have I used this?
    Could I get something like this again if I need it?

Once you have an organizational system in place and can distinguish between what you need and what you want, you’ll have an easier time cleaning house and won’t feel as overwhelmed, Dr. Rasmussen says. The point of this day is to raise awareness of viral hepatitis, a condition that can lead to liver failure, liver cancer, and death. Early detection of hepatitis in the millions of people who have it but don’t know it can protect them from its harms and keep them from spreading it to others.

Hepatitis means that the liver is inflamed. Many things can cause this to happen. Some medications, for example, inflame the liver. But the most common cause is liver-attacking viruses. Sometimes the initial infection causes immediate symptoms (acute infection). Sometimes it causes few or no symptoms, but the virus stays active in the liver for years, with the potential of causing long-term damage.

There are five main types of viral hepatitis:

Hepatitis A can make you sick when you are first infected but does not cause long-term infection.

Hepatitis B can make you sick when you are first infected and can cause long-term infection. Of the approximately 1.1 million Americans who have been infected with the hepatitis B virus, more than half of them don’t know that they carry it.

Hepatitis C is a long-term infection, usually diagnosed many years after the initial infection. An estimated 3 million Americans are infected with the hepatitis C virus. Two-thirds of them do not know they are infected.

Hepatitis D is rare infection that happens only in people already infected with hepatitis B.

Hepatitis E can make you sick when you are first infected (acute infection) but rarely causes long-term infection. It is not common in the United States, but is common in developing countries with inadequate water supplies and poor sanitation.

There are two good reasons why it’s important to know if you are infected with a hepatitis virus:

    hepatitis B and C can be treated. Treatment greatly reduces the risk of cirrhosis, liver cancer, the need for liver transplant and death from liver failure. There are no specific treatments for hepatitis A, D, and E.
    knowing that you have viral hepatitis helps you take actions to avoid passing the virus to others.

In last week’s New England Journal of Medicine, two reports of treatment for the most common type of hepatitis C showed incredible success with antiviral drugs. The drugs cleared the hepatitis C virus from blood in 96% to 99% of infected people. I have to point out that clearing the virus from blood does not always mean cure. But it does greatly reduce the chance of ongoing liver damage and risk of liver cancer.
Who needs a hepatitis test?

If you are a baby boomer (born between 1945 and 1965) and have not been tested for hepatitis C, do it soon. It’s also a good idea to get the test if you are a post-boomer who:

    has injected or snorted drugs in the past
    currently injects or snorts drugs
    had a blood transfusion before 1992
    had surgery before the mid-1980s
    receives dialysis for kidney failure
    was born to a mother with hepatitis
    has served time in jail
    has gotten a tattoo in a shop that is not regulated by its state and lacks a high safety rating

Whether you should be tested for hepatitis B depends on your risk. Some groups for which this test is useful include men and women born in Asia, Africa, and other regions with moderate or high rates of hepatitis B, those who have sex or live with someone infected with hepatitis B, those with a condition that may suppress the immune system or taking a medication that does that, and women who are pregnant.

Testing for hidden hepatitis A, D, or E is not routinely done.
Get vaccinated

Vaccines that can guard against hepatitis A and B are available. It’s a good idea to talk with your doctor to see if these are for you.

All children should be vaccinated against hepatitis A around the time of their first birthday. For adults, the hepatitis A vaccine is recommended for those who live in an area with a high rate of hepatitis A, who work in or travel to countries with high rates of hepatitis A, who use so-called recreational drugs, who receive blood products to help their blood clot, or who have long-term liver disease.

All children and teens should be vaccinated against hepatitis B. For adults, the hepatitis B vaccine is recommended for those who:

    have sex with or live in the same house as a person with hepatitis B virus infection.
    have sex with more than one partner.
    have long-term liver disease.
    have diabetes and are under age 60.
    live or travel for more than 6 months a year in a region where hepatitis B is common.
    inject drugs.
    are on dialysis or have advanced renal disease.
    have HIV infection.

Vaccines aren’t yet available for hepatitis C, D, and E, but work is underway to develop them.
Looking ahead

The outlook for infection with hepatitis B and C will continue to improve with the availability of the new, very effective drugs described in the New England Journal of Medicine. But treatment is extremely expensive. It’s estimated that a 12-week course of sofosbuvir (Sovaldi), a new hepatitis drug, will cost $84,000.

That’s why vaccination and other prevention efforts are so important. Here are a few tips from the National Institutes of Health:

    Wash your hands after going to the bathroom and before fixing food or eating.
    Use latex condoms, which may lower the risk of transmission.
    Avoid tap water when traveling to certain countries or regions. Ask your doctor about risks before you travel or call the Centers for Disease Control and Prevention at 877-FYI-TRIP.
    Don’t share drug needles.
    Don’t share personal items—such as toothbrushes, razors, and nail clippers—with an infected person.

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