Month: January 2021

Preeclampsia is a common and dangerous complication of pregnancy that causes high blood pressure and excess protein in urine. Typically, it occurs during the third trimester or very soon after birth, but there may be a simple way to help prevent it.

If you’re pregnant, preeclampsia can cause kidney and liver abnormalities, blood clotting problems, headache, stroke, and even death. It makes it harder to deliver nutrients and oxygen to a growing fetus. And it’s linked to premature birth and low birthweight in babies. Yet a daily low-dose aspirin may help prevent many of these problems, according to a recent statement from the US Preventive Services Task Force (USPSTF).

Who is most likely to develop preeclampsia?

While preeclampsia can happen without any warning, certain risk factors make it more likely to occur:

• carrying multiples, such as twins or triplets
• having diabetes
• being 35 or older
• having obesity, described as a body mass index (BMI) greater than 30
• having high blood pressure before pregnancy
• having kidney disease or an autoimmune disorder.

Preeclampsia also occurs more often in Black people as a result of structural racism, which restricts access to care, and can also be a source of chronic stress from factors like food and housing insecurity that lead to poorer health and well-being.

Overall, preeclampsia affects about one in 25 pregnancies in the United States. It accounts for almost one out of every five medically-induced premature births. Preventing it will save lives.

What does the task force recommend to help prevent preeclampsia?

In the 2021 statement, the USPSTF recommends that doctors prescribe a daily low-dose (81 mg) aspirin for those at high risk for preeclampsia. The aspirin should be started at the end of the first trimester (12 weeks of pregnancy) and continued until the birth.

This supports a previous recommendation from the task force in 2014. And importantly, the statement reflects findings from a recent systematic review of research. The review looked at the role of aspirin in preventing preeclampsia, and whether aspirin can reduce complications among pregnant people, fetuses, and newborns. It also examined the safety of low-dose aspirin in pregnancy.

What did the review tell us?

Thirty-four randomized clinical trials comparing low-dose aspirin and placebo (a sugar pill) were included in the analysis. Most participants in the trials were young and white. Providing low-dose aspirin to those who were at high risk of preeclampsia successfully reduced risk for

• developing preeclampsia
• preterm birth (births before 37 weeks of pregnancy)
• growth restriction (small babies)
• fetal and newborn death due to preeclampsia.

The review considered whether using aspirin led to more bleeding problems. When comparing the aspirin group and the placebo group, no differences occurred in bleeding problems, such as maternal hemorrhage following a birth, fetal brain bleeding, and the placenta separating from the wall of the uterus too early.

Who should take low-dose aspirin during pregnancy?

Overall, the benefits of taking low-dose aspirin outweigh risks for some pregnant people. Your doctor may recommend it if you

• have had preeclampsia before
• already have high blood pressure or diabete
• are carrying multiples, such as twins or triplets
• have kidney or autoimmune disease.

It’s important to know that there are moderate risk factors to consider, too. When combined, they can increase the chance of preeclampsia and its complications. Your doctor may recommend low-dose aspirin if you have two or more of these factors:

• having your first baby
• having obesity
• having a mother or sister who had preeclampsia
• being 35 years old or older
• having conceived with in-vitro fertilization (IVF)
• having had a baby before who was small for gestational age
• having a difficult pregnancy outcome in the past.

Unequal distribution of healthcare, and social and environmental stress, make preeclampsia and its complications more likely to occur in pregnant people who are Black and those who have lower income. Therefore, the task force recommends low-dose aspirin for these pregnant individuals even if they have only one moderate risk factor.

The bottom line

New evidence supports using low-dose aspirin to help prevent preeclampsia, a dangerous and common complication of pregnancy. If you’re pregnant or considering pregnancy, talk with your doctor or midwife about preeclampsia. It’s important to learn the warning signs of possible problems even if you’re not at high risk. Together, you can decide whether low-dose aspirin is a good choice for you.

As a doctor, I am constantly advising my patients to prioritize their own mental and physical health. Get adequate sleep. Eat healthy. Learn how to say no so you don’t collapse from exhaustion. Love and care for yourself like you do others.

I talk the talk but don’t always walk the walk — even though I know, both intellectually and physically, that self-care is critical to my well-being. When I am run down, my MS symptoms cry out for attention: left leg weakness and numbness, subtle vertigo, a distinct buzzing in my brain like a relentless mosquito that won’t go away no matter how many times I twitch and shake my head. I have become frighteningly good at ignoring these symptoms, boxing them up and pushing them away. Often, I can muscle through; other times it just hurts.

Recently, a friend challenged me to think about my relationship with my illness, to describe MS as a character in my story. This was a useful exercise. I conjured up an image of a stern teacher. She is frighteningly blunt and lets me know, loud and clear, when I disappoint her. She can be mean and scary, and I don’t really like her. But I must admit she is usually right. Still, I often defiantly dismiss her, even when part of me knows this is not in my best interest.

This holiday season, I wanted to do better. I needed to do better. So, as Thanksgiving approached, as I prepared to host 16 family members, many for multiple days, I paused to ask myself, What does MS have to teach me about self-care? I don’t like having this disease, but I do. I can’t change my reality, so I might as well benefit from the lessons MS is forcing on me. I believe they are relevant to all of us, whether we live with chronic illness or not, so I’ll share them here.

The first steps: Listen and observe

When my MS symptoms flare, it’s a message that I am tired, overextended, and stressed. I need to rest. I don’t always listen right away, but eventually I am forced to, and when I listen, I feel better. All of us can benefit from slowing down and tuning in to our physical selves. What sensations are you experiencing in your body, and what does this tell you about your underlying feelings and state of mind? Yes, we should heed our thoughts, but tuning in to our bodies takes us deeper, to feelings that might be hidden, secrets we might not want to acknowledge, a physical truth. If you don’t have a chronic illness, the messages might be more subtle — a vague tightness in your chest, a quick catch in your breath, a barely noticeable tremor in your hands — but they exist, and they signal stress.

The science is clear: the body’s stress response — though potentially lifesaving in a true emergency, when “fight or flight” is essential to survival — can be toxic in our everyday lives. Stress triggers our sympathetic nervous system to kick into overdrive in response to a perceived threat, releasing hormones such as cortisol and inflammatory molecules that, when produced in excess, fuel disease. Conversely, we know that pausing to take notice and interrupting this negative cycle of stress is beneficial. It can be as simple as breathing deeply and counting to 10. Our bodies know what’s up and let us know when we need to take care of ourselves. We must pay attention.

You are not responsible for everyone and everything

The holidays, essentially from mid-November through the end of the year, are a stress test we create for ourselves. The land mines are everywhere: more food, more drinking, more family dynamics, more unfamiliar (or overly familiar) surroundings. Personally, with my overinflated sense of responsibility, I experience a kind of dizzying performance anxiety every holiday season. I believe it is my job to make sure everyone present has a positive experience. For better or worse, I am someone who notices and feels the personal and interpersonal dynamics in a room. I sense and absorb even the most subtle discomfort, frustration, anger, shame, and insecurity, alongside the more upbeat emotions. Importantly, I also I feel the need to step in and make things better, to prop everyone up. It’s exhausting. But MS reminds me of how absurd, and even egotistical, this is. In truth, I can’t possibly care for everyone. Neither can you.

It helps to check our automatic thoughts. More than once on Thanksgiving Day, as the busy kitchen buzzed with activity and conversation, I intentionally stepped back and watched, reminding myself that I didn’t have to hold the whole thing up. Even though I inevitably slipped back into hyper-responsibility mode, these moments of self-awareness impacted my behavior and the dynamic in the room.

It’s okay to say what you need

To take full responsibility for my own well-being, I need to speak honestly and act with integrity. This means asking for what I need, clearly and without apology. Historically, I have been terrible at this in my personal life, burying my own needs in the name of taking care of everyone else’s, even rejecting clear offers of help. “I’m good, I’ve got it,” I might say, while simultaneously feeling bitter and resentful for having to do it all myself. This lack of clarity isn’t fair to anyone. MS reminds me that I need to do better.

This year, when my guests asked me what they could bring, I took them at their word and made specific requests instead of assuring everyone that I had it covered. When my mother started banging around in the kitchen at 7 a.m. with her endearing but chaotic energy, asking for this and that pot and kitchen utensil so she could start cooking, I told her I needed to sit down and have a cup of coffee first. She would need to wait or find things herself. She was okay with that. Family dynamics can be entrenched and hard to change, but clear communication can set new ways of being into motion, one baby step at a time.

I still have a lot to learn, but I am making stuttering progress, learning to listen to my body and honor my needs while also caring for those I love, or at least trying. Undeniably, I experienced some post-Thanksgiving fatigue, exacerbated by my daughter’s early-morning hockey game the next day, requiring a 4:30 a.m. departure. I felt it in my body — the familiar leg weakness, vertigo, and brain cobwebs — and, completely uncharacteristically, I took a nap.

So many physical abilities decline with normal aging, including strength, swiftness, and stamina. In addition to these muscle-related declines, there are also changes that occur in coordinating the movements of the body. Together, these changes mean that as you age, you may not be able to perform activities such as running to catch a bus, walking around the garden, carrying groceries into the house, keeping your balance on a slippery surface, or playing catch with your grandchildren as well as you used to. But do these activities have to deteriorate? Let’s look at why these declines happen — and what you can do to actually improve your strength and coordination.

Changes in strength

Changes in strength, swiftness, and stamina with age are all associated with decreasing muscle mass. Although there is not much decline in your muscles between ages 20 and 40, after age 40 there can be a decline of 1% to 2% per year in lean body mass and 1.5% to 5% per year in strength.

The loss of muscle mass is related to both a reduced number of muscle fibers and a reduction in fiber size. If the fibers become too small, they die. Fast-twitch muscle fibers shrink and die more rapidly than others, leading to a loss of muscle speed. In addition, the capacity for muscles to undergo repair also diminishes with age. One cause of these changes is decline in muscle-building hormones and growth factors including testosterone, estrogen, dehydroepiandrosterone (better known as DHEA), growth hormone, and insulin-like growth factor.

Changes in coordination

Changes in coordination are less related to muscles and more related to the brain and nervous system. Multiple brain centers need to be, well, coordinated to allow you to do everything from hitting a golf ball to keeping a coffee cup steady as you walk across a room. This means that the wiring of the brain, the so-called white matter that connects the different brain regions, is crucial.

Unfortunately, most people in our society over age 60 who eat a western diet and don’t get enough exercise have some tiny "ministrokes" (also called microvascular or small vessel disease) in their white matter. Although the strokes are so small that they are not noticeable when they occur, they can disrupt the connections between important brain coordination centers such as the frontal lobe (which directs movements) and the cerebellum (which provides on-the-fly corrections to those movements as needed).

In addition, losing dopamine-producing cells is common as you get older, which can slow down your movements and reduce your coordination, so even if you don’t develop Parkinson’s disease, many people develop some of the abnormalities in movement seen in Parkinson's.

Lastly, changes in vision — the "eye" side of hand-eye coordination — are also important. Eye diseases are much more common in older adults, including cataracts, glaucoma, and macular degeneration. In addition, mild difficulty seeing can be the first sign of cognitive disorders of aging, including Lewy body disease and Alzheimer’s.

How to improve your strength and coordination

It turns out that one of the most important causes of reduced strength and coordination with aging is simply reduced levels of physical activity. There is a myth in our society that it is fine to do progressively less exercise the older you get. The truth is just the opposite! As you age, it becomes more important to exercise regularly — perhaps even increasing the amount of time you spend exercising to compensate for bodily changes in hormones and other factors that you cannot control. The good news is that participating in exercises to improve strength and coordination can help people of any age. (Note, however, that you may need to be more careful with your exercise activities as you age to prevent injuries. If you’re not sure what the best types of exercises are for you, ask your doctor or a physical therapist.)

Here are some things you can do to improve your strength and coordination, whether you are 18 or 88 years old:

• Participate in aerobic exercise such as brisk walking, jogging, biking, swimming, or aerobic classes at least 30 minutes per day, five days per week.
• Participate in exercise that helps with strength, balance, and flexibility at least two hours per week, such as yoga, tai chi, Pilates, and isometric weightlifting.
• Practice sports that you want to improve at, such as golf, tennis, and basketball.
• Take advantage of lessons from teachers and advice from coaches and trainers to improve your exercise skills.
• Work with your doctor to treat diseases that can interfere with your ability to exercise, including orthopedic injuries, cataracts and other eye problems, and Parkinson’s and other movement disorders.
• Fuel your brain and muscles with a Mediterranean menu of foods including fish, olive oil, avocados, fruits, vegetables, nuts, beans, whole grains, and poultry. Eat other foods sparingly.
• Sleep well — you can actually improve your skills overnight while you are sleeping.