Tuesday, February 26, 2019

Don’t take fatigue lying down

Sure, everyone gets tired sometimes, and often bounces back after a quick rest or a good night’s sleep. However, if bouts of fatigue occur more often and last longer, you shouldn’t ignore them.

“Older adults may chalk up fatigue to aging, but there is no reason you should battle ongoing tiredness,” says Dr. Suzanne Salamon, a geriatric physician with Harvard-affiliated Beth Israel Deaconess Medical Center.

Here are signs that you should take your tiredness seriously:

    inability to do activities you enjoy
    waking up exhausted, even after a good night’s sleep
    not feeling motivated to begin the day
    sudden bouts of exhaustion that go away and then return
    shortness of breath.

This type of fatigue can affect your health in many ways. You may have less energy to exercise. You may have trouble concentrating, staying alert, and remembering things. You may anger easily and become more socially isolated.
It’s worth checking in with your doctor

Fatigue also could signal a medical condition, according to Dr. Salamon, and you should consult your doctor to see if you have any of the following issues.

    Anemia. This occurs when your blood has too few red blood cells or those cells have too little hemoglobin, a protein that transports oxygen through the bloodstream. The result is a drop in energy levels.
    Heart disease. Heart disease can cause the heart to pump blood less efficiently and lead to fluid in the lungs. This can cause shortness of breath and reduce the oxygen supply to the heart and lungs, making you tired.
    Sleep problems. Sleep apnea is characterized by pauses in your breathing, often lasting several seconds, or shallow breathing while you sleep. It is common among older adults and those who are overweight. Another sleep-related issue is an overactive bladder, which forces repeated nighttime bathroom trips. Either of these can disturb your sleep enough to leave you feeling tired during the day.
    Medication. Certain medications can make you feel tired, such as blood pressure drugs, statins, antidepressants, antihistamines, nonsteroidal anti-inflammatory drugs, and cold medications. “People react to medications differently and they often end up taking more as they get older,” says Dr. Salamon. Check with your doctor, especially if you have added a new medication or recently increased your dosage. “Sometimes it helps to take certain medicines, which may cause fatigue, at night rather than in the daytime,” she says.
    Low-grade depression or anxiety. Mental health issues often drain energy levels. “You may suffer from depression or anxiety and not even know it,” says Dr. Salamon.
    Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). This is a complex disorder that causes unexplained extreme fatigue, which can worsen after physical or mental activity and does not improve with rest. Its cause is unknown, but may be linked to one or more underlying issue.

Some simple ways to boost energy levels

For regular, everyday fatigue, try these tips:

    Drink a cup of coffee or tea. A little caffeine can jump-start your day, she says. “You don’t need more than that, but it can offer a mental and physical lift, especially if you have trouble with morning fatigue.”
    Go for a 30-minute walk. “If you can’t get outside, walk around your house in bouts of 10 to 15 minutes, two to three times a day,” says Dr. Salamon.
    Take a nap. A midday nap can help overcome tiredness later in the day. Keep naps to about 20 to 30 minutes, as studies have suggested that napping for 40 minutes or longer can have the opposite effect and leave you feeling groggy rather than refreshed. “Also, don’t nap too late in the day or in the early evening, when it could interfere with your normal sleep schedule,” says Dr. Salamon.
If you Google “coconut oil,” you’ll see a slew of stories touting the alleged health benefits of this solid white fat, which is easy to find in supermarkets these days. But how can something that’s chock-full of saturated fat — a known culprit in raising heart disease risk — be good for you?

Coconut does have some unique qualities that enthusiasts cite to explain its alleged health benefits. But the evidence to support those claims is very thin, says Dr. Qi Sun, assistant professor in the Department of Nutrition at the Harvard T.H. Chan School of Public Health.

“If you want to lower your risk of heart disease, coconut oil is not a good choice,” he says. It’s true that coconut oil tends to raise beneficial HDL cholesterol more than other fats do, possibly because coconut oil is rich in lauric acid, a fatty acid that the body processes slightly differently than it does other saturated fats.
Coconut oil’s effect on cholesterol

But there’s no evidence that consuming coconut oil can lower the risk of heart disease, according to an article in the April 2016 Nutrition Reviews. The study, titled “Coconut Oil Consumption and Cardiovascular Risk Factors in Humans,” reviewed findings from 21 studies, most of which examined the effects of coconut oil or coconut products on cholesterol levels. Eight were clinical trials, in which volunteers consumed different types of fats, including coconut oil, butter, and unsaturated vegetable oils (such as olive, sunflower, safflower, and corn oil) for short periods of time. Compared with the unsaturated oils, coconut oil raised total, HDL, and LDL cholesterol levels, although not as much as butter did.

These findings jibe with results from a study by Dr. Sun and colleagues in the Nov. 23, 2016, issue of The BMJ, which examined the links between different types of saturated fatty acids and heart disease. Compared with other saturated fats (like palmitic acid, which is abundant in butter), lauric acid didn’t appear to raise heart risk quite as much. But that’s likely because American diets typically don’t include very much lauric acid, so it’s harder to detect any effect, Dr. Sun notes.
Tropical diets are different

Coconut oil proponents point to studies of indigenous populations in parts of India, Sri Lanka, the Philippines, and Polynesia, whose diets include copious amounts of coconut. But their traditional diets also include more fish, fruits, and vegetables than typical American diets, so this comparison isn’t valid, says Harvard Medical School professor Dr. Bruce Bistrian, who is chief of clinical nutrition at Beth Israel Deaconess Medical Center.

Some of the coconut oil available in stores is labeled “virgin,” meaning that it’s made by pressing the liquid from coconut meat and then separating out the oil. It tastes and smells of coconut, unlike the refined, bleached, and deodorized coconut oil made from the dried coconut meat used in some processed foods and cosmetics. Virgin coconut oil contains small amounts of antioxidant compounds that may help curb inflammation, a harmful process thought to worsen heart disease. But to date, proof of any possible benefit is limited to small studies in rats and mice, says Dr. Bistrian.
Unsaturated fats

In contrast, there’s a wealth of data showing that diets rich in unsaturated fat, especially olive oil, may lower the risk of cardiovascular disease, Dr. Sun points out. The evidence comes not only from many observational studies (like those in the aforementioned BMJ report) but also a landmark clinical trial from Spain, which found that people who ate a Mediterranean-style diet enhanced with extra-virgin olive oil or nuts had a lower risk of heart attack, stroke, and death from heart disease than people who followed a low-fat diet.

Of course, there’s no need to completely avoid coconut oil if you like the flavor. Some bakers use coconut oil instead of butter in baked goods, and coconut milk is a key ingredient in Thai cooking and some Indian curry dishes. Just be sure to consider these foods occasional treats, not everyday fare. High-grade cancer that’s still confined to the prostate is generally treated surgically. But a third of the men who have their cancerous prostates removed will experience a rise in blood levels of prostate-specific antigen (PSA). This is called PSA recurrence. And since detectable PSA could signal the cancer’s return, doctors will often treat it by irradiating the prostate bed, or the area where the gland used to be.

In February, researchers reported that radiation is a more effective treatment for PSA recurrence when given in combination with androgen-deprivation therapy (ADT). ADT interferes with the body’s ability to make or use testosterone, which is the hormone (or androgen) that makes prostate tumors grow more aggressively. It targets rogue cancer cells in the body that escape radiation.
Here’s what the study found

The newly published study randomly assigned 760 men with detectable PSA after surgery to one of two groups. One group got radiation plus ADT and the other group got radiation plus a daily placebo tablet. The study recruited patients between 1998 and 2003, and after an average follow-up of 12 years, 5.8% of men in the combined treatment group had died of prostate cancer, compared to 13.4% in the radiation-only group. Rates of metastatic prostate cancer were also lower among men treated with ADT: 14.5% compared to 23% among the placebo-treated controls.

“The take-home message is that ADT has a major and beneficial impact on the risk of death from prostate cancer when added to radiation for PSA recurrence,” said Ian Thompson, M.D., a professor of oncology at the UT School of Medicine, in San Antonio, Texas, and the author of an editorial accompanying the newly published findings.

Men in this study received a high dose of the ADT drug bicalutamide, which doctors use less frequently for PSA recurrence today, instead favoring other testosterone-suppressing medications that have since been shown to be more effective. Therefore this is an instance of a long-term study reporting results after treatment standards — in this case the selection of a specific ADT regime — have changed.
A new treatment standard

Still, some men have difficulty tolerating ADT, and not all of them should get it, particularly if they’re older and more likely to die of something other than prostate cancer. “I’d reserve ADT for younger men with a long life expectancy ahead of them who were diagnosed initially with high-grade or late-stage disease,” Thompson said. As a primary care physician at Massachusetts General Hospital (MGH), I am profoundly grateful for my 10 years in recovery from opiate addiction. As detailed in my memoir Free Refills, I fell into an all too common trap for physicians, succumbing to stress and ready access to medications, and became utterly and completely addicted to the painkillers Percocet and Vicodin. After an unspeakably stressful visit in my office by the State Police and the DEA, three felony charges, being fingerprinted, two years of probation, 90 days in rehab, and losing my medical license for three years, I finally clawed my way back into the land of the living. I was also able to return, humbled, to a life of caring for patients.

There is one question that I invariably get asked, by my doctors, colleagues, friends, family members, and at lectures and book talks: now that you are in recovery from opiates, what are you going to do when you are in a situation such as an accident or surgery, when you might need to take opiates again? I have blithely answered this question with platitudes about how strong my recovery is these days, and how I will thoughtfully cross that bridge when I come to it. In other words, I punted consideration of this difficult issue into some unknown future time.

Unfortunately, that future is now, and that bridge is awaiting my passage.

Last week I slipped on my top outside step, which was covered in ice, went into free fall, and managed to completely tear my left quadriceps tendon. This required a surgical repair in which doctors drilled three holes into my kneecap and then tethered what was left of my quadriceps muscle to the kneecap. Taking Tylenol or Motrin for this kind of pain is kind of like going after Godzilla with a Nerf gun. I was sent home with a prescription for one of my previous drugs of choice: oxycodone.

My leg was hurting beyond belief. I literally felt as if it were burning off. But, I had spent the last 13 years of my life conditioning myself, almost in a Clockwork Orange kind of way, to be aversive to taking any and all opiates.

What is a person who used to suffer from a substance use disorder (SUD) to do? There are millions of us in this country who may eventually face this choice.

Fortunately, I am not the first person who has confronted this issue. There exist safeguards one can put in place. It is important that all of your doctors know about your history of SUD. It is also helpful if you have a significant other or partner at home who can manage the pills for you, and dole out two of them every four to six hours as directed, to avoid the temptation to take more than prescribed in order to get high. (Old habits die hard.) Finally, the key to all addiction treatment is being open and honest. It is critical to check in with one’s support network about medications, cravings, and fears, and to use all of the recovery tools that are available to you, such as asking for help if you need to, and not trying to control things that can’t be controlled.

In the end, my level of pain was so great that there really wasn’t any choice but to take the oxy. My nerve receptors made the decision for me. I’m sure there are Shaolin monks somewhere who can block out high levels of pain, but that just isn’t me.

I am reassured, and even pleasantly surprised, by several aspects of having taken the oxycodone. First, it worked well for the pain. Second, I did not get high from the pills. I guess that taking two pills is different from taking (or snorting) 10 or 20, as we tend to do when we are addicted. Finally, it was very easy to stop taking them, and I have had absolutely no cravings or dreams about using since stopping.

This is a critical issue. It would be cruel and inhumane to not sufficiently treat any patient’s pain, especially after surgery, and it is important not to discriminate against people with SUDs. There are millions of people in recovery from opiates in the United States alone, and they are as deserving of pain control as anyone else.

Finally, I am grateful beyond belief to have survived my opiate addiction, and to not have become one of those all too common overdose stories we all read about in the newspapers. I am also grateful to my excellent doctors at MGH for fixing my wounded knee, and for providing me adequate pain control. Fortunately, my recovery and my pain control do not seem to have been mutually exclusive.

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