Couch potatoes start early: How to get kids moving

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We know that American adults are couch potatoes. According to the Department of Health and Human Services, only 5% of US adults are physically active for 30 minutes every day, and only one in three gets the recommended 150 minutes of physical activity every week. It’s understood that people get less active as they get older, but we generally think of children as being physically active. However, according to a study in the journal Pediatrics, these days being a couch potato starts in childhood.

As part of the Childhood Obesity Project in Europe, researchers followed 600 children between the ages of 6 and 11, and measured how physically active they were using a wristband designed for that purpose. They found that physical activity was lower than expected even starting at age 6, with only 80% being active for the recommended 60 minutes a day. It wasn’t just a matter of starting school, either. Researchers found that they weren’t particularly active on weekends, school holidays — or even at lunchtime, when they generally have recess.

Activity declined steeply after age 8. By age 11 only 20% were active for an hour a day. Boys were more likely to engage in more vigorous activity than girls. Interestingly, they also found that overweight children were less likely to be active than children who were at a healthy weight, which raises an interesting question: is obesity not just a result of a lack of physical activity, but also a cause of it?

For anyone who has or interacts with children, this information is probably not a surprise. As the study notes, there has been a massive increase in sitting activities in children over the last decades. Much of this is screen-related — initially with video games, and now including social media and other activities that children do on their phones. Just going outside and playing has become less common. There is less free time for children, who are far more scheduled than they used to be. Physical activity tends to take place in the setting of organized sports — which, unless a child is at or working toward an elite level, rarely take place every day. For many low-income children, there are few safe spaces to play outside, and not only can their families not afford the cost of organized activity, but because of work and other life realities they are not able to supervise them in safe play or exercise with them.

All of this matters — because physical activity habits start early. Children who are sedentary turn into sedentary adolescents who turn into sedentary adults. And being sedentary not only puts people at risk of obesity, but is a risk factor in and of itself for a whole host of health problems. If we want our children to live healthy lives, we need to get them moving.

How to get children moving more

Here are some ideas:

Look for sports teams and other physical activity opportunities in your community. Many communities offer low-cost activities, and scholarships are often available if you ask. Look for and support school-based exercise opportunities. (This is yet another reason why children need recess!) For elementary school children, instead of scooping your child up at school pickup and heading home right away, stay and let your child play on the playground for a while if you can. Limit screen time (of all kinds). Children should be engaged in entertainment media for no more than two hours a day. If your child is spending a lot of time on his or her phone, consider taking it away as soon as they come home. If it’s hard to get out to exercise for whatever reason, get creative about exercising at home. Use exercise equipment like a stationary bike. Exercise videos are widely available on cable and the Internet; move the furniture back, make some space, and have your own Zumba class. Or just turn on some music and dance. Go for walks and do other exercise together. Not only will your child get moving, but you will too — which sets a good example and helps you get healthier.

This study also points out that it’s important to start early. As a pediatrician, I see sedentary habits start very early, with families that put their children in seats and playpens rather than putting them on the floor to learn to crawl and stand. As soon as a child can move, we need to give them lots of opportunities to do so — and we need to keep it up throughout childhood. Their future health depends on it.

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Post-hospital syndrome: Tips to keep yourself or a loved one healthy after hospitalization

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If you or a loved one have ever been hospitalized, you know that the primary focus of the hospital team is on diagnosing and treating the condition that put you in the hospital in the first place. The medical team works to treat a patient’s condition until the patient has improved enough to continue treatment and recovery out of the hospital.

But recent findings have brought attention to an important issue that doesn’t strike until after you’ve left the hospital — post-hospital syndrome.

What is post-hospital syndrome?

Post-hospital syndrome can be defined as a period of vulnerability lasting up to seven weeks after a patient is discharged from the hospital. This period of vulnerability leaves people at increased risk for rehospitalization from a diverse range of conditions, which are often separate from the original cause of hospital admission. Some patients even face an increased risk of death during this period.

Post-hospital syndrome is caused, in part, by ongoing effects of the original illness. For example, someone who has been hospitalized for pneumonia may experience lingering fatigue, reduced strength, foggy thinking, or constipation after leaving the hospital.

But while providing needed treatment, hospitalization also wreaks havoc on a patient’s physical and emotional stability, and these disruptions also contribute to post-hospital syndrome. During hospitalization, for example, a patient is likely to encounter changes to their diet, routine, sleep patterns, and activity level, and experience stress and medication-induced side effects.

Minimizing the effects of post-hospital syndrome

Fortunately, there are things that patients and their loved ones can do, both during hospitalization and after discharge, to prevent or at least minimize the effects of post-hospital syndrome:

All hands on deck. Think of hospitalization as an emergency. Whenever possible, enlist a family member, friend, or colleague as an advocate to help with care and support while you are hospitalized. Get names. After admission, request a list of doctors, nurses, therapists, and social workers caring for you. This will allow you and your advocate to communicate more effectively with those in charge of your care. Plan meeting times. Ask when your doctors, physical therapists, and social workers will be discussing your case and working with you so that your advocate can be included in discussions about care. If it is important that certain family members or friends are present for such meetings, communicate this to your team ahead of time. Keep a medication list. Have a current list of your medications available and bring it to the hospital when admitted. After admission, regularly review your current and hospital medication lists with your doctors. This will help to eliminate medication errors and prevent potentially harmful side effects. Bring your equipment. If you regularly use hearing aids, dentures, eyeglasses, or mobility aids, such as a cane or walker, take them with you to the hospital, or have them delivered once hospitalized. Make certain they are labeled and kept in a safe, accessible location during your hospital stay. Stick to your routine. Whenever possible, maintain a daily routine that closely mirrors your life outside the hospital. For example, if you always have a caffeinated beverage every morning, followed by a bowel movement, make sure you order caffeine for breakfast and make time to move your bowels. Informing the clinical staff of your daily routine is important. Keep moving. After being cleared by your medical team, spend as little time in your hospital bed as possible. Lying in bed all day leads to reduced blood flow, muscle loss and weakness. Walk around the unit with a nurse, friend, or aide, as much as you are able, multiple times during the day. Spend time out of bed, sitting upright in a chair while eating meals, watching TV, and reading. Rest at the right time. Avoid extended sleep during the day when possible. Try to stay awake until close to your normal bedtime, in order to promote and maintain your body’s natural circadian rhythm. Request quiet nights. Request that all medications be given before bed, and ask your nurse or doctor not to wake you for nighttime vitals checks or blood draws. If there is a disruption, do not hesitate to ask nurses to reduce noise, or request earplugs. Seek out natural light. Request a room with a bed next to the window when available. Exposure to natural light helps maintain a normal sleep/wake cycle. Maintain your normal diet. If you require special dietary accommodations, such as low salt, lactose free, gluten free, or vegetarian, inform your doctors and nurses, and reconfirm these requirements when you order meals. Plan ahead for hospitalization. If you have a chronic health condition (heart failure, cancer, dementia, Parkinson’s disease, or difficulty walking, for example), create an “in case of hospitalization plan” with your doctor. This will essentially be a personalized version of the issues discussed here. It is important to think ahead to optimize ways for your hospitalization to go smoothly and reduce the risk and severity of post-hospital syndrome. Health care proxy. Assign a trusted advocate (relative or friend) as your health care proxy. This person has the legal standing to communicate your health care preferences to your medical team, in the event that you are unable to do so yourself. Discuss your medical care preferences with your health care proxy in advance. Ensure continuity. Before leaving the hospital, confirm you have timely follow-up appointments scheduled with your primary care doctor and appropriate specialists.

It may not be possible to eliminate all of the causes of post-hospital syndrome. But attention to the risk factors during hospitalization may significantly reduce the likelihood of difficulties after hospitalization.

Follow me on Twitter  @jwhymanMD

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Immunotherapy: What you need to know

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Not all that long ago, chemotherapy was the only option to treat most advanced (metastatic) cancers. Because these drugs work by destroying rapidly dividing cells, they harm some healthy cells — such as hair follicles — as well as cancer cells. In the past two decades, cancer treatment has been transformed by targeted drugs and the emergence of chemotherapy. Targeted drugs are designed to home in on specific genes or proteins that are altered or overexpressed on cancer cells. Immunotherapy has been very successful for certain types of advanced cancers, such as lung, bladder, and skin cancers.

One form of immunotherapy is called an immune checkpoint inhibitor. It takes the brakes off immune cells, unlocking their ability to detect altered proteins on cancer cells in order to attack and kill these cells. These drugs include programmed death (PD-1)-inhibitors and PD-L1-inhibitors (such as pembrolizumab, atezolizumab, nivolumab), and cytotoxic T-lymphocyte antigen (CTLA)-4 inhibitors (ipilimumab).

The speed of FDA approvals for these drugs has outstripped the general understanding of their effects, and side effects, raising many questions for people who have cancer — and even for many physicians. If you’re receiving immune checkpoint inhibitors, or wondering about them as part of cancer therapy, here are some facts you should know.

Does immunotherapy benefit all patients?

Immunotherapy benefits some, but not all, cancer patients. It seems to work better for certain cancers — for example, cancers with higher levels of PD-L1 protein or a massive number of gene mutations due to DNA repair defects. However, there are many exceptions, and we do not fully understand how best to select patients who will benefit.

How long does immunotherapy last?

Cancer cells adapt, building resistance to targeted therapies. When a tumor responds to immunotherapy, the remission tends to last a long time (a year or more), unlike a response to chemotherapy (weeks or months). Also, with immunotherapy, tumors initially may swell as immune cells engage with the cancer cells, then later shrink as cancer cells die. The early swelling is called psuedoprogression.

What about side effects?

All drugs have side effects, including the immunotherapy drugs discussed here. Understanding the information below can help if you or a loved one does experience side effects.

Does immunotherapy have serious side effects?

Immunotherapy with PD1/PD-L1 inhibitors is generally well tolerated, but serious side effects may occur. This happens in about 20% of people given PD1/PD-L1-inhibitors. It occurs in 40% to 60% of people given a combination of PD1-inhibitor and CTLA4-inhibitor immunotherapies.

Most side effects appear around two to three months after therapy starts. However, close monitoring, early recognition, and prompt therapy can help control side effects. Because immunotherapy drugs unleash immune cells, inflammation may occur in organs such as the colon (causing diarrhea), lungs (causing coughing or shortness of breath), skin (causing rash), liver (causing an elevation of liver enzymes in blood), thyroid gland (causing generally low, but sometimes high, thyroid hormone levels), and other areas of the body.

How are side effects of immunotherapy managed?

Severe side effects are controlled by stopping the immunotherapy and starting corticosteroids (such as prednisone), which are tapered slowly over a period of weeks. If you’ve had immunotherapy at any time in the past, report any new symptom to your treating oncologist before self-medicating with drugs purchased over the counter. For example, if you have diarrhea, taking loperamide (Imodium) may arrest the symptom. But it won’t address the root cause, which is inflammation of the large intestine. Uncontrolled inflammation of the intestine may lead to rupture of the intestinal wall, which can be life-threatening. Similarly, if you have a cough, consuming cough suppressants allows lung inflammation to continue and become potentially life-threatening.

Do antibiotics affect how well immunotherapy works?

As we are beginning to better understand the immune system, an important nugget of emerging information is that antibiotics may reduce the ability of immunotherapy to kill cancer by killing harmless bacteria that live in the gut. People taking immune checkpoint inhibitors who receive antibiotics are less likely to benefit from immunotherapy than those who do not. Hence, it appears important to avoid unnecessary antibiotics for minor infections, which may be prescribed for patients visiting the ER for fever, cough, or other symptoms suggestive of infections. Check with your cancer team about this.

What do healthcare professionals need to know when I’m sick?

If you go to urgent care or the emergency room, tell health professionals about your cancer treatment. What type of cancer was diagnosed? When and where were you treated? What type of immunotherapy and other therapies did you receive? Also, ask your primary care doctor to include important information like this in your medical records. Remind health care providers about it if you’re sick. You can use health apps to log the information, so you’ll always have it handy if you need it.

To learn more about immunotherapy or join a clinical trial, talk to your cancer care team. You can also search for clinical trials on the National Cancer Institute website, or call 1-800-422-6237.

Follow me on Twitter @sonpavde

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