Saturday, January 26, 2019

Fertility and diet: Is there a connection

For years, we’ve talked about the danger to children of secondhand tobacco smoke. It makes asthma worse, increases the risk of respiratory and ear infections — and even increases the risk of sudden death in infants. We’ve had all sorts of educational campaigns for parents and caregivers, and have made some progress: between 2002 and 2015, smoking among parents of children less than 18 years old dropped from 27.6% to 20.2%. But now there is a new problem: secondhand marijuana smoke.

Studies show that when you are around someone who is smoking marijuana, the smoke gets into your system too. How much of it gets in depends on how close the person is, how many people are smoking and how much, how long you spend near them, and how much ventilation there is in the space. But research is clear that cannabinoids, the chemicals that cause the “high,” get into the bodies of people nearby — including children.

During the same time period that cigarette smoking around children came down more than 7%, marijuana smoking around children went up nearly 5%. With more and more states legalizing marijuana for recreational use, that number is likely to continue going up.

This is not good. Besides the fact that we don’t want children getting high, or exposed to the dangers of inhaled secondhand marijuana smoke, there is the additional concern about long-term effects on the brain. While research is still ongoing, there is evidence to suggest that when youth and young adults (whose brains are still developing) are exposed to marijuana, it may have permanent effects on executive function, memory, and even IQ.
I recently wrote about a walk I took with my sons, where I slipped, falling onto my youngest who fell onto a rock, which cut his forehead and meant a trip to the emergency room for four stitches.

It wasn’t our first visit, but thankfully, it’s never been for anything dire. My kids have just run into and jumped off a variety of things, so there’s been broken bones, forehead cuts (they have matching pairs), along with spiked temperatures that invariably happen when the pediatrician’s office isn’t open.

I’m pretty good at keeping my head, but I’m not at my best in an ED. I end up being too polite and deferential. In essence, I say, “Stop this bleeding now, and in exchange, I won’t bug you with more than two questions. Promise.”
How to advocate for your child in the emergency room

It’s not a winning formula. Doctors have skill, but they’re just people. They’re often rushed and can’t know everything about my child. They will fail to cover everything that worries me and my wife. Bottom line: they need help, and that means, because I’m the biggest expert on my child — side note: remember that I’m the biggest expert on my child — I need to ask questions, share relevant information, and, occasionally, be a pain.

But before I resort to that last part, I want to work with you, doc, and to do that, I’ll try to be clearheaded and give you useful information up top.
Help the emergency room doctor help your child

It’s not close to an exhaustive list, but Dr. Vincent Chiang, Harvard Medical School associate professor of pediatrics and emergency medicine and emergency room physician at Boston Children’s Hospital, has some suggestions of what to share:

    Your child’s ability to cope with any part of a medical visit. Do not equivocate. “He does not like … shots, blood, being sick, pain, lying still, anything doctors” is all helpful. Some hospitals have child life specialists that can help reduce the stress. It would be stellar if the doctor mentions it and calls for one. If not, ask if someone’s available.
    “This is our first time dealing with this.” For the doctor, most stuff registers as routine, but it’s not for parents, and saying this should be enough of a reminder to explain everything slowly, fully, and clearly. If it’s not, repeat it.
    “She never complains” or “He complains about everything.” It tells the doctor two things: something is different, and that worried you enough to come in. It can be hard to pinpoint, but try to verbalize your big concern (“My uncle had a headache and it turned out to be a tumor”). The doctor can possibly address it, so you’re not unnecessarily sitting with it.

None of this guarantees quick answers, Chiang says. Some conditions only fully reveal themselves over time. Sometimes tests are needed. If so, ask if they’re being done to rule out things or to look for something specific. More pointedly, ask the doctor if there’s anything that’s worrisome. And then ask when you two will have the next discussion, since all of this entails waiting, and that’s often the most stressful part.
Four things to know when you leave the emergency room

It’s understandable to forget questions and not mention every relevant detail. But before you leave the hospital, Chiang says to know these four things:

    The diagnosis. It’s simple, but you want to be clear on what the doctor decided your child was being treated for.
    The treatment plan. It needs to address the medical problem and the comfort measures. Example: Sprained ankle. Rest, ice, compression, elevation. If there’s pain or nausea or other discomfort, know your options for relief.
    The follow-up plan. It could be meeting with your pediatrician or a specialist, but it’s rare that there would be nothing to do. At the least, let your pediatrician know what happened as soon as possible and make sure that the follow-up plan makes sense. You cannot assume that the hospital will provide the information.
    The reasons to return. Most often, when you leave the emergency room, follow-up happens outside of the hospital, but you want to know what signs and symptoms suggest urgent care is needed again. You also want to know when things should start to go back to normal.

Make sure you’re clear on the treatment plan

Of the above four, Chiang says that the treatment plan causes the most confusion, because when you’re hearing it, you’re also hearing that your child is going home. You naturally become relaxed and the doctor might start moving on to a different patient. But there are still things to know, like if your kid can play sports or go to school/daycare, and, if not, when. There’s also the medication. Be sure of the dosing and timing, and why your child is taking it. Ask if there are interactions with other medications or additional precautions (for example, avoiding the sun, a side effect we recently experienced with an antibiotic), and how soon the first dose has to be taken, double-checking if it was already given in the hospital.

One good move is to take the time read the discharge instructions before you leave, and if the doctor hasn’t asked you to repeat back what you’ve heard about the treatment plan, then say, “This is what I understand. Am I correct?” It comes down to getting your questions answered, and that sometimes means pulling out the option of being a pain. It might feel unnatural or uncomfortable, but there’s no benefit in keeping anything to yourself. As Chiang says, “I don’t know about the question you don’t ask me.”
While anxiety symptoms vary widely, odds are good that at some point you’ve experienced occasional physical and emotional distress signals such as panicky breathing, your heart pounding in your chest, trouble sleeping, feelings of dread, or even loops of worry. That’s normal.

By itself, anxiety isn’t a problem. It anchors the protective biological response to danger that boosts heartbeat and breathing, pumping oxygenated blood to your muscles as your body prepares to fight or flee. A dollop of healthy anxiety can persuade you to get to work on time, push you to study hard for an exam, or discourage you from wandering dark streets alone.

“Experiencing anxiety is normal,” says Dr. Gene Beresin, executive director of the Clay Center for Healthy Young Minds at Massachusetts General Hospital. “A certain amount of anxiety can even be helpful. The problem is that sometimes the systems underlying our anxiety responses get dysregulated, so that we overreact or react to the wrong situations.”
What is an anxiety disorder?

Severity of symptoms and a person’s ability to cope separate everyday worries or anxious moments from anxiety disorders. National surveys estimate nearly one in five Americans over 18, and one in three teens ages 13 to 18, had an anxiety disorder during the past year.

If anxiety is persistent, excessive, or routinely triggered by situations that aren’t an actual threat, tell your doctor, who can discuss treatment options or refer you to an experienced mental health professional.
What kind of anxiety disorder do you have?

As with every health issue, an accurate diagnosis is essential. A few common anxiety disorders include:

    Generalized anxiety disorder: A pattern of excessive worry about a variety of issues on most days for at least six months, often accompanied by physical symptoms, such as muscle tension, a hammering heart, or dizziness.
    Social anxiety disorder: Feeling significant anxiety in social situations or when called on to perform in front of others, such as in public speaking.
    Phobias: A particular animal, insect, object, or situation causes substantial anxiety.
    Panic disorder: Panic attacks are sudden, intense episodes of heart-banging fear, breathlessness, and dread. “It’s the feeling you’d have if you just missed being hit by a Mack truck — but for people with panic disorder there is no Mack truck,” says Dr. Beresin.

The costs of anxiety

Constant anxiety levies a toll on health. For example, anxiety increases levels of the stress hormone cortisol, raising blood pressure, which contributes over time to heart problems, stroke, kidney disease, and sexual dysfunction. And a 2017 Lancet study using brain scans measured activity in an area called the amygdala, which mounts split-second responses to danger and encodes memories of frightening events. Greater activity in the amygdala correlated with higher risk for heart disease and stroke, possibly, the researchers speculated, by triggering immune system production of extra white cells to fight perceived threats. In people struggling with emotional stress, this might drive inflammation and plaque formation that leads to heart attacks and strokes.

Quality of life suffers, too. Intrusive thoughts, dread of panic attacks, intense self-consciousness and fear of rejection, and other hallmarks of anxiety disorders compel people to avoid anxiety-provoking situations. This interferes with relationships, work, school, and activities as people isolate themselves, turn down opportunities, and forgo possible joys in life.
On the other hand, antioxidants, vitamin D, dairy products, soy, caffeine, and alcohol appeared to have little or no effect on fertility in this review. Trans fat and “unhealthy diets” (those “rich in red and processed meats, potatoes, sweets, and sweetened beverages”) were found to have negative effects.

Studies of men have found that semen quality improves with healthy diets (as described above), while the opposite has been linked with diets high in saturated or trans fat. Alcohol and caffeine appeared to have little effect, good or bad. Importantly, semen quality is not a perfect predictor of fertility, and most studies did not actually examine the impact of paternal diet on the rate of successful pregnancies.

For couples receiving assisted reproductive technologies, women may be more likely to conceive with folic acid supplements or a diet high in isoflavones (plant-based estrogens with antioxidant activity), while male fertility may be aided by antioxidants.
So what does this mean if you’re trying to get pregnant?

Considering the average couple trying to become pregnant naturally, this review seems less of a bombshell than the headlines might suggest. Yes, eating a healthy diet is a good idea for men and women. Extra folic acid, B12, and omega-3 fatty acids might be helpful for women, but healthy diets are already recommended to everyone, and a prenatal vitamin (which includes folic acid and vitamin B12) is already recommended for women trying to get pregnant. Folic acid supplementation has long been known to reduce the risk of developmental neurologic problems in the developing fetus.
Unanswered questions about diet and fertility

Even if we accept these findings as important enough to direct our dietary choices, we still need to answer some basic questions:

    How much folic acid or B12 is best? Is there an advantage to taking a supplement rather than relying on dietary sources?
    Which sources of and how many servings of dietary omega-3 fatty acids are best? How should a woman balance the risk of fish contamination with toxins such as mercury?
    Are there some people who need to pay more attention to these dietary recommendations than others?
    What about other components of the diet? Fear not, researchers are hard at work looking at this question. For example, consider the results of three other recently published studies:
        Consumption of sugar-sweetened beverages (especially sodas or energy drinks) was linked to lower fertility for men and women, while drinking diet soda and fruit juice had no effect.
        Women who consumed high amounts of fast food and little fruit took longer to become pregnant than those with healthier diets.
        Couples eating more seafood were pregnant sooner than those rarely eating seafood. Most pregnant women consume far less than the recommended 2 to 3 servings of lower-mercury fish (such as salmon, scallops, and shrimp) per week.

You can probably come up with more questions. Hopefully, researchers are already busy trying to answer them.
In the meantime…

Until we know more, the take-home message of this new research is not so different than before it was published. If you’re a man or a woman trying to become a parent, eat a healthy diet.

Many doctors recommend that women of childbearing age who are not using contraception take a prenatal vitamin daily. At the very least, women who are planning a pregnancy should take a prenatal vitamin at least a month before trying to conceive. A higher than usual dose of folic acid may be recommended for certain women, depending on the medications they take and other medical conditions they have. Doctors also recommend the following to maximize the chances of a healthy pregnancy:

    Try to maintain a healthy weight prior to conception. Obese women have a higher risk of complications.
    Avoid excessive vitamins before conception. Too much vitamin A, for example, can be bad for a developing fetus.
    Consider seeing your doctor for a “preconception” visit to review what you can do to optimize your chances of a successful pregnancy. For example, certain medications are harmful to the developing fetus and should be stopped well before planning a pregnancy.

And just in case it’s not obvious, don’t rely on research regarding diet and fertility to prevent pregnancy. An unhealthy diet and avoiding supplemental vitamins or omega-3 fatty acids is not a form of birth control.

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