Wednesday, April 10, 2019

Vitamin D and physical function: Is more better

My dear friend Pam and her mother Nancy sat across from me at the restaurant table. “I’m so sorry about Glenn,” I said. Glenn was a generous and funny man who adored Nancy and their four daughters, and was incredibly kind to me when I was a constant fixture at their house during my middle and high school years. He died at 81, after a difficult health battle.

What made things slightly easier, explained Nancy, was that Glenn had already decided what he wanted at the very end. Glenn had signed a Durable Do Not Resuscitate Order (DDNR), a doctor’s order that allows you to refuse CPR in case your heart stops beating or your breathing stops. It’s usually for people who are near the end of their lives or have an illness that won’t improve, and it takes the burden of decision-making off family members.

And now a relatively new initiative takes DDNRs even further.

Like the DDNR, the POLST form (Physician’s Orders for Life-Sustaining Treatment) turns your health care preferences into a medical order that must be followed by doctors, hospital staffers, and paramedics. The POLST provides instructions for treatments beyond CPR, such as pain medicine, antibiotics, and nutrition, and it’s for use both inside and outside of the hospital setting. “There used to be no such thing as a medical order that follows you home. That’s where the POLST comes into play. It specifically tells medical providers what to do or not do,” says Dr. Justin Sanders, an attending physician in palliative care at Harvard-affiliated Dana-Farber Cancer Institute.

The POLST is not a legal document; it’s a medical order signed by you, your physician, and a witness.

Many states are just developing their POLST forms, and may call them by another name, such as a MOLST (Medical Orders for Life-Sustaining Treatment), POST (Physician Orders for Scope of Treatment), or a MOST (Medical Orders for Scope of Treatment).

But the POLST isn’t perfect. An editorial published in JAMA on January 19 raises the question of whether POLSTs are effective, citing studies that suggest POLSTs may not always be interpreted accurately by medical personnel.

Another issue: POLSTs can dictate very specific treatment that’s based on a person’s needs when he or she signs the form with the doctor. But there’s nothing in place to revisit the POLST when a person’s physical status changes. Foreseeing future medical treatment needs may be difficult, and having a medical order that must be followed, even if it’s become irrelevant, may be a problem.
Advance directives

It may help to have other documents in place that spell out your wishes — not just medical orders, but legal documents that also fall under the umbrella term of an advance directive. These include:

    A living will, a legal document that formalizes your treatment preferences if you’re unable to make your own health care decisions. There’s no standard form; each living will is drafted by an attorney, and legal language for these wills varies from state to state. A living will may be simple, stating that you don’t wish to be on life support; or it may be very detailed, mentioning your wishes in different situations, such as if you need dialysis, antibiotics, or any life-sustaining treatments. The document must be signed by you, two witnesses, and a notary public. A living will is not a medical order that paramedics will likely follow in an emergency; there may not be time to read or interpret it.
    A health care proxy or surrogate, a legal document that names the person who’ll make your health care decisions if you lack the capacity to make them. This document is sometimes called a durable power of attorney for health care. It must be signed by you, two witnesses, and a notary public. Depending on the state, the proxy may be named in a living will. Whom should you appoint? “Make it someone who’ll have the strength to carry out your wishes. That can be a friend as well as a family member,” says Dr. Sanders.

Dr. Sanders feels that completing a health care proxy and speaking openly with that person about the care you want is the most important thing you can do to receive treatment consistent with your wishes.

Ultimately, this can make things easier on your loved ones when the time comes. I’ll bet Glenn and his family would agree. Healthy behaviors clearly make sense from a rational standpoint, but they can be a drag — and difficult to maintain. For example, there are few people who doubt the beneficial effects of exercise, yet one study found that close to 75% of people either do not exercise at all or exercise only seldomly. Eating healthily is also important, yet more than a third of all adults are obese. It’s not because we’re ignorant or because we aren’t motivated to adopt healthy behaviors. It’s just very difficult to stay the course.

Here are some strategies to help you develop and maintain healthy behaviors.
Combat stress

In an ideal world, it would be great to be able to reflect on each choice prior to making it. Yet, under stress, our brains tend to be reflexive rather than reflective. When we are reflexive, we tend to go back to old habits that are the established “default” pathways in our brains. For example, excessive sugar consumption is a risk factor for obesity, yet sugar also decreases the stress hormone cortisol, which is why people may get hooked on it. In general, stress prompts habit behavior in humans, so dealing first and foremost with stress is probably advisable when you’re looking to make lasting changes. Luckily, your brain can change throughout life. This means that decreasing stress could ultimately help your brain become less vulnerable to habit.

People tend to focus on themselves when stressed, but a recent study showed that helping others may significantly decrease the negative effect of stress on your body. This may be due to the protective anti-stress effects of the hormone oxytocin. Another study affirmed these findings by showing that helping others may help you live longer.

Also, people who find meaning in their adversity and focus on the benefits of their hard times deal much more effectively with stress. To that end, what could you learn from the stressors in your life now? How could they make things better? For example, people who lose a dear friend may learn to appreciate others more. Those who’ve had financial difficulties may learn to save more effectively. Looking for the silver lining in a cloud can be more than just a “fake” refocusing of your mind. If you do it authentically, it can reduce the negative impact of stress.
Set meaningful goals

Setting goals can help you think more clearly and stay motivated, yet for many people, this approach does not work. A recent study provided an explanation for why this may be. Beyond your conscious goals, there are many unconscious goals also competing for attention. For example, while weight loss may be your conscious goal, stress relief may be your unconscious goal. While healthy eating may be your conscious goal, this may take a back seat to resolving relationship difficulties. All around, goals are selfish. It’s every goal for itself in the human brain. If your health-related goal doesn’t have special preference, it may fail you. It helps to attach a “priority tag” to the goals that are most important to you.

To do this, you need to delve a little more deeply — that is, ask yourself why your goal matters to you. Things like looking good, living longer, enjoying life, avoiding dementia, and understanding that being unhealthy-but-wealthy is suboptimal for you may all help your goal gain priority. To make changes for the better, your health-related goals should be the goals above all other goals. When you elevate their importance by thinking of them in ways like these, they will beat out other goals in your brain.
Design intentions that your brain will respond to

Finally, your brain responds to two types of intentions — goal and implementation intentions. Goal intentions are broad and non-specific. Implementation intentions are quite specific. Studies show that breaking all goal intentions into more specific intentions can go a long way. For instance, rather than just planning to work out, specify the time and place, or even the change you are seeking in pounds. When you spell things out for your brain, it can access that goal more readily than when you are vague and non-specific.

Habits are a powerful force that make change difficult. Yet, decreasing stress, attaching a priority tag to your goal, and being more specific will prepare your brain more adequately for the changes that will support your life. You probably know that regular exercise offers a wealth of benefits for your body, like staving off excess weight and chronic illnesses like heart disease and diabetes. But mounting evidence suggests that exercise is also good for your brain. A study published in the journal Neurology links better cardiovascular fitness to improved thinking skills in older adults.

The findings add to our understanding of how exercise benefits the brain, which seems to stem from several possible mechanisms, says Dr. John Ratey, associate clinical professor of psychiatry at Harvard Medical School and author of Spark: The Revolutionary New Science of Exercise and the Brain. “It’s not just about delivering more oxygen to the brain, although that’s part of it,” he says. Having a fit, healthy cardiovascular system also protects against vascular dementia, which happens when blood vessels feeding the brain become blocked or narrowed, leading to memory and other cognitive problems.

But exercise also stimulates the growth of new blood vessels in the brain, as well as the growth and survival of new brain cells, says Dr. Ratey. Brain imaging studies suggest that key brain areas responsible for thinking and memory are larger in people who exercise than in those who don’t.
Fit body, younger brain?

The new study included 877 adults with an average age of 65. To assess their cardiovascular fitness, researchers used a standard measure known as VO2 max, which is defined as the maximum amount of oxygen your body can use while you’re exercising as hard as you can. (The V stands for volume, usually measured in milliliters of oxygen per kilogram of body weight per minute. O2 is for oxygen, and max is for maximum.) The participants also took a variety of tests to gauge their thinking skills, memory, and executive function (a category of mental skills used to manage time, plan and organize, and remember details).

When researchers divided the participants into four groups based on their VO2 max values, they found striking differences in executive function between those with the highest and lowest levels. In fact, the test score differences corresponded to an age difference of seven years, they estimated. They saw similar trends for both memory and overall thinking ability, corresponding to age differences of six and four years, respectively.
Better brain connectivity and activation

In a study published last year in Neuroimage, participants underwent functional MRI testing, which tracks the changes that take place when a region of the brain responds during various tasks. The researchers found stronger connections between different regions of the brain in people with higher levels of cardiorespiratory fitness. Earlier research also correlated fitness levels with activation in the brain’s frontal lobe — the part of the brain responsible for executive function.

Together, these findings suggest that exercise may help keep your brain young, or at least slow down the normal decline in age-related thinking skills. The government’s Physical Activity Guidelines for Americans are more than adequate for that purpose, says Dr. Ratey. For all adults, the weekly goals are:

    Two hours and 30 minutes of moderate-intensity aerobic activity, like brisk walking OR one hour and 15 minutes of vigorous-intensity activity, like jogging.
    Muscle-strengthening activities on two or more days per week.
As a pediatrician, I talk about healthy eating a lot — and I talk to a lot of families whose children do not have the best eating habits. It’s not that the parents are bad parents. Many, many good parents have children who like potato chips more than Brussel sprouts — and it’s a natural instinct to want to give children food they like, and to feel worried when they don’t eat the food in front of them.

Eating habits are just that: habits. And habits can be not only taught, but changed.

Here are 10 ways to set your child up for a lifetime of healthy eating and all the health benefits that brings:

    Start early. It is amazing how much the eating habits of babies and toddlers can end up lasting a lifetime — in both good and bad ways. A baby whose parents make him finish a bottle, for example, can lose his ability to listen to his own hunger cues (which is one of the reasons breastfeeding can help prevent obesity). A toddler who gets lots of fruits and vegetables on her plate comes to think of them as normal, yummy foods — as opposed to foods she is being forced to eat.
    Serve healthy foods. This sounds obvious, but I talk to a whole lot of families who do not routinely serve fruits, vegetables, and other healthy foods — or if they do, they leave them off their child’s plate (because the child “doesn’t like them”). It’s so important to serve them and keep them on the plate — and, I think, insist on at least a bite or two. It can take a bunch of tries before kids realize that broccoli isn’t so bad after all!
    Don’t be a short-order cook. I talk to a lot of parents who serve one meal — and then make another one for their child (some make separate ones for separate children, or additional meals if the first one gets rejected). If you do that, there is simply no incentive to try anything new.
    Set a schedule and stick to it. Once your child is eating meals (by the end of the first year), make a schedule of three healthy meals and two healthy snacks per day (one between breakfast and lunch, the other between lunch and dinner). If your child doesn’t eat what is served after about 20 minutes, take it away, and don’t feed them again until the next scheduled meal or snack. After a while, your child will figure out that if they don’t eat, they will be hungry. The important corollary to this is…
    Limit snacking. Outside of the established “okay” snacks, your child should not be hunting through the cabinet or refrigerator. If they are, they won’t have any appetite for meals.
    Watch the drinks. Even a single cup of juice can cut a child’s appetite. If they are thirsty, give them water to drink.
    Think about what you buy. If there isn’t junk food in the house, it’s a lot harder to eat it. Same goes for soda and sweets. Stock the house with healthy stuff instead.
    Set an example. Kids always pay way more attention to what we do than what we say. If you don’t eat healthy foods, why should they?
    Have family dinners. Not only is it the best way to set an example and help be sure that what they eat is good for them, family dinners are good for family relationships and for child development, and can help keep teens out of trouble.
    Shop and cook together. If you can, grow food together too! Make healthy eating a fun, shared experience.

Every child and every family is different. Be sure to talk to your doctor if your child has any health problems — or, if despite your best efforts, your child’s diet is mostly chicken nuggets and French fries. Sometimes more creative approaches are needed, and we are here to help.

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