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Saturday, January 26, 2019

Pathways into and out of addiction

Summer holidays are here and the sunny, warm weather is in full swing. Now is not the time to get lazy about sun protection!
Sun: The good and the not-so-good

Sunlight is essential for many important bodily functions, including producing vitamin D and maintaining your circadian rhythm and mood. Yet too much sun exposure can also be harmful. Ultraviolet (UV) radiation may result in short-term and long-term skin damage, including sunburn, signs of aging, and even skin cancer. Approximately one out of five people in the United States may develop skin cancer in their lifetimes.

Approximately 95% of the UV radiation reaching our skin is ultraviolet A (UVA) light, which is primarily responsible for chronic effects such as photoaging, wrinkling, and age spots. Ultraviolet B (UVB) rays make up a smaller percentage but may be potentially even more harmful, as they are the primary cause of sunburns. Both UVA and UVB may cause skin cancer.

Even with all of these risks, many people still head to the beach with nothing more than their bathing suits, hoping to get tan. For some, a lobster-red burn is considered a badge of a successful beach day. This is absolutely not recommended. Any prolonged UV light exposure can put you at risk even if it isn’t summer, such as if you are out skiing in the winter with the sun reflected from the snow, or if you are indoors but using a tanning bed. So what can you do to protect yourself from these harmful rays?

There are many types of sunscreens available. Sunscreens work because they contain filters that reflect, scatter, or absorb UV radiation that otherwise would reach your skin. There are two main types of sunscreens available, separated into “organic filters” (aka chemical sunscreens) and “inorganic filters” (aka physical sunscreens).
Sun protection with chemical sunscreens (organic filters)

Organic filters absorb UV radiation and convert it into a small amount of heat. In the ingredients listed on the bottle, you may notice compounds such as oxybenzone, avobenzone, and octocrylene. Oxybenzone and avobenzone are relatively good filters for UVA radiation; however, they may be paired with other agents such as octocrylene, homosalate, and octisalate to stabilize them and provide UVB protection. In other countries, newer compounds including Tinosorb M/S, Mexoryl SX, and Mexoryl XL have been developed that are now being used as broad-spectrum sunscreens.
Sun protection with physical sunscreens (inorganic filters)

Inorganic filters are mineral compounds such as zinc oxide and titanium dioxide that theoretically work by reflecting and scattering UV light to protect your skin. However, some studies have shown that these compounds actually work by absorbing UV radiation and converting it into heat. These sunscreens tend to offer more broad-spectrum protection against both UVA and UVB light. They also tend to be the formulations used in children’s sunscreens, as they are easier on sensitive skin. These sunscreens tend to go on thicker and may appear whiter.
Use it correctly for effective sun protection

We recommend that everyone use sunscreen with sun protection factor (SPF) of 30 or higher when you spend time outdoors. SPF 30 will protect against approximately 97% of UVB rays. Sunscreens with SPF greater than 50 provide only a very small increase in protection against UV radiation.

Everyone, regardless of skin color, should wear sunscreen, because we are all at risk of the adverse effects of UV radiation and can benefit from protection. However, it is even more important for those with lighter skin shades who are more susceptible to these effects to wear sunscreen. The American Academy of Pediatrics recommends avoiding the use of sunscreen in children younger than six months, and instead emphasizes minimal sun exposure and to ensure adequate clothing and shade.

We recommend applying sunscreen using the “teaspoon and shot glass rule”: 1 teaspoon of sunscreen to the face and neck, and enough to fit a shot glass (approximately 1 ounce) for exposed areas of your body. You should apply sunscreen 15 to 30 minutes before sun exposure, then wait for 10 to 20 minutes before getting dressed. We recommend re-application of sunscreen at least every two hours, or after every water exposure or sweating even if they are labeled water-resistant.

In addition to wearing sunscreen, always wear appropriate protective clothing such as wide-brimmed hats, long-sleeved clothing, and pants when possible. Seek shade, wear sunglasses to protect your eyes, and avoid tanning beds. Remember to stay hydrated, and sunscreen up!
And what if you do get a sunburn?

If you get a sunburn, it is important to treat it right away. Seek shade and avoid being in the sun for any prolonged time.

One of the most important things in sunburn care is to drink extra water. When you have a sunburn, you actually lose more water from your body because the sunburn draws fluid to the skin surface, and the extra heat leads to increased evaporation. Topical therapies that may help with your symptoms include cool baths, gentle moisturizers, and even over-the-counter hydrocortisone cream, which may help ease the discomfort. If you have significant discomfort, you can also take aspirin or ibuprofen as directed. As always, if you ever have concerns, talk to your doctor. Why is it that despite so many interesting foods in the world, we sometimes fall into a dietary rut? For busy working families, lapsing into a boring menu routine may be due to a lack of time, planning, or know-how. Years ago, when I anchored the local TV news at dinnertime, my husband Jay made noodles with takeout meatballs so often that our three kids (even the baby) would tease him about it. “I didn’t know how to cook and I didn’t give much thought to dinner until everybody was hungry,” remembers Jay, my prince who would work all day, pick up the kids, and feed them before I got home. “We’d have leftovers of whatever you’d made or I’d go with the old standby.” (It could have been worse; Jay’s specialty in college was chili from a can.)

Unfortunately, a lack of variety and a reliance on convenience foods come with unappetizing pitfalls.
The risks of a dietary rut

Eating the same foods frequently deprives you and your kids of the flavors and textures that make meals adventures and turn your kids into healthy eaters. It also limits nutrient intake. “You need a wide variety of vitamins and minerals. In order to get them, you need to eat different types of fresh foods every day,” says Teresa Fung, adjunct professor in the nutrition department at the Harvard T.H. Chan School of Public Health.

Those nutrients should come from fresh vegetables and fruits, lean proteins, legumes (beans and lentils), nuts and seeds, healthy fats (avocados, olive oil), and low-fat dairy products.

Relying on prepackaged food or takeout meals can subject you to unhealthy ingredients like refined carbohydrates; saturated or trans fats; high amounts of salt; and lots of calories, preservatives, and additives. An unhealthy diet is associated with an increased risk for many chronic conditions, such as high blood pressure, heart disease, obesity, and cancer.
Easy ways to bust the dietary rut

Fortunately, breaking out of a dietary rut isn’t hard. Fung offers these suggestions:

1.   Get variety elsewhere. “A lot of grocery stores have a good number of healthy, prepared foods, and you can pay by the ounce,” Fung says. She recommends preparing the protein at home (like fish or chicken) and buying the side dishes — vegetables, whole grains, or salads — to bring home. “Make it something you wouldn’t normally eat,” she says.

2.  Be adventurous. “Try something unusual at least every other week. Make it yourself or get it from a restaurant,” Fung suggests. Caution: focus on vegetables or protein, and avoid anything with a lot of butter or cream. Need ideas? Pick a country and look up traditional dishes and recipes on the Internet.

3.  Try a subscription meal kit. You choose the menu on a website, and the premeasured, fresh ingredients arrive at your door. “Go for something with lots of vegetables and whole grains, and a chunk of protein,” Fung says. There are many meal kit services. Two of the biggest are Hello Fresh and Blue Apron. Prices per person, per meal, range from $10 to $12.

4.  Cook in batches. Cook once or twice a week and eat leftovers in between. Make a large entree (like white bean soup), broil several chicken breasts, or cook a few side dishes (like brown rice, quinoa, or cooked spinach) that can be eaten throughout the week. “It’s easier to cook 14 carrots in one day than two carrots per day for seven days in a row,” Fung points out.

5.  Get your kids in on it. They’ll be more inclined to eat it if they helped prepare it.
A few more tips

Jay and I finally realized that the key to variety in our family meals was planning. Now, in about half an hour on the weekend, we come up with healthy, interesting menus and shopping lists for the week.

We take turns making dinner, and we batch-cook a lot of meals.

Our other secret weapon: a gorgeous gas grill. It was a gift from Jay’s loving mom, and it turned my hubby into an inspired cook who can grill everything from salmon and veggies to dessert peaches. So there’s no more teasing about noodles when Jay makes dinner; you’ll only hear compliments to the chef! I am often asked, what is the best way to recover from addiction? There are as many pathways out of addiction as there are pathways into addiction. There is no single best or certain approach to recovery. For example, lapses and relapses are very common for any treatment approach. During the past four decades, this understanding has led me to develop clinical pragmatism.

As a clinician, my job has been to help people find an approach to dealing with addiction that is effective, possible, and sustainable. Early in my career, the struggle to find effective treatment approaches was played out against a backdrop of 12-step programs. This battle usually emerged as Alcoholics Anonymous versus professional treatment — a strictly abstinence approach versus something less strict and more mysterious. For example, recovering people battled with professionals who had little or no experience with the causes of addiction, total abstinence as a treatment outcome, or the use of medication during treatment.

Now, some of these battles still remain, but self-help groups and professionals have learned to work collaboratively in the best interest of recovering people — and argue less about what works best. A variety of research projects have demonstrated that there is no one best treatment. For example, new research shows that as Norman Zinberg, a seminal figure in the addiction field, often quipped, clinicians and self-help programs alike need to “meet people with addiction where they are and take them where they don’t want to go!”
There is no “best” or one-size-fits-all mutual-help approach

A new longitudinal study published in the Journal of Substance Abuse Treatment reminds us, for example, that a variety of mutual help approaches seem to work about the same. In this study, the investigators examined different types of mutual support groups for people with alcohol use disorder. These included Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups. When the researchers controlled the participants’ alcohol recovery goals at baseline, there were no significant outcome differences between groups. The authors concluded that the findings “…tentatively suggest that clinicians, the courts, and others who assist and advise those with alcohol use disorder (AUD) consider referral to a broad array of mutual help options including WFS, LifeRing, and SMART.” Nevertheless, we need to interpret these results with caution.

Researchers must be careful to avoid interpreting the absence of treatment group difference as evidence that supports treatment parity. There are many reasons that research can fail to identify treatment group distinctions; for example, many different types of people in the groups, insufficient follow-up, and a variety of other technical issues can mask genuine differences among treatment groups. Science rarely advances by resting on a foundation of “no difference” findings.

Absent one specific treatment that best helps people to escape addiction, we need to work with the whole portfolio of change agents. Self-directed, other-directed, and mutual support approaches can influence people and their attempts to change. Medication assisted treatment works and should be considered for people who might benefit from this option.

People with addiction mostly change on their own. We see only a small segment of people with addiction in treatment or self/mutual-help groups. However, some people do change with the assistance of professional treatment. Sometimes people enter treatment after they have made some changes and want to understand how to maintain these changes. They often want to know what led to their addiction in the first place. Still others change with the help of mutual support groups. Ultimately these varied pathways out of addiction represent variations of personal responsibility.
Social support and self-help can sustain change

Research shows that people who escape addiction are usually motivated by one or more of the following losses: loss of health, loss of a loved one, loss of a job. Ultimately, professional treatment and 12-step programs shift attention from a loss focus — what not to do — to a system that emphasizes what to do. Treatment and self-help provide the social support to encourage the work of changing and maintaining change.

The brass ring of addiction treatment is to identify which person, with which intervention and treatment provider, at which moment in their addiction experience, will have the most favorable change outcomes. Treatment outcomes are explained in large part by the quality of the relationship between the person with addiction and their care provider (such as a therapist or sponsor) or 12-step group.

Participants in 12-step programs and psychotherapy alike must learn to shift their attention from what they have lost to a perspective that emphasizes what people in recovery can and need to do going forward. Importantly, 12-step programs provide the ever-present social support system to encourage the doing.

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