Alcohol Consumption Guidelines

People drink alcohol to celebrate occasions, socialize, and for many other reasons.  In this time of quarantine and stay-at-home orders, many people have been drinking more alcohol than they usually do, and maybe more than they should.  While drinking alcohol is itself not necessarily a problem, too much alcohol consumption has many potentially serious health consequences.  I thought this might be a good time to revisit the recommendations for alcohol consumption.

All alcohol is NOT equal.

Alcohol (ethanol) is found in beer, wine, and liquor.  The percentage of alcohol in those drinks varies, not only between each category but also within each category.  Some beers have a higher percentage of alcohol than others.  The same applies to wine and liquor as well.  You should be familiar with the percentage of alcohol present in the alcohol that you drink.

What is a standard alcoholic drink in the United States?

The recommended guidelines for alcohol intake include a specific number of "drinks" of alcohol, which we will discuss below.  A standard drink is equal to 14.0 grams (or 0.6 ounces) of pure alcohol.  

Here are some examples of what constitutes a standard drink:

• 12 ounces of beer - with a 5% Alcohol by Volume (ABV)
• 8 ounces of malt liquor - with a 7% ABV
• 5 ounces of wine - with a 12% ABV
• 1.5 ounces (one shot) of 80 proof (40% ABV) distilled spirits or liquor, such as gin, rum, vodka, or whiskey

Remember that some beer may have a higher ABV than others.  If your beer has a 9% ABV, a 12 ounce serving would be equivalent to 1.8 drinks.
 
If you order a mixed drink cocktail, it may contain 2 or even 3 different spirits, and may be equivalent to 2 standard drinks or more!  You should know what is in the cocktail that you order.

What are the recommended amounts of alcohol consumption?

According to the Dietary Guidelines for Americans, if alcohol is consumed, it should be in moderation.  Moderation is defined as up to one drink per day for women, and up to two drinks per day for men, and only by adults of legal drinking age.  The Dietary Guidelines do not recommend that anyone start drinking who does not already drink alcohol.  These guidelines also recommend that if alcohol is consumed, the calories from alcohol should be accounted for in your planning a healthy eating pattern.
   
Is one type of alcohol safer than another?

The short answer is no.  As long as you are aware of the alcohol content, and base your measurement of alcohol consumption accurately, one type of alcohol is not safer than another.  It is the amount of pure alcohol consumed that affects your health, not the type of alcohol.

Can you average your alcohol consumption by the week?

Some people like to think of the guidelines as a recommendation for the week, for instance, a woman should have no more than 7 drinks per week, and a man no more than 14 drinks per week.  This is often the way the guidelines are represented.  If a woman drinks 2 drinks every other day, and does not drink any alcohol on the alternate days, that would average out to one drink a day.  This seems like a harmless idea.  However, there is a limit to this ability to average.  It is not healthy to drink all of your weekly alcohol "allowance" in one or even two days.  This could be considered binge drinking.

What is considered excessive alcohol use?

Excessive alcohol use includes:

• Binge drinking 
• Heavy drinking (8 or more drinks a week for women, 15 or more drinks a week for men)
• Any alcohol use by people under the age 21 minimum legal drinking age 
• Any alcohol use by pregnant women

Who should not drink alcoholic beverages at all?

• Anyone younger than 21 years old
• Women who are or may be pregnant
• People who are planning to drive or operate machinery, or are participating in other activities requiring skill, coordination, or alertness
• People taking certain prescription and OTC medications that can interact with alcohol
• People with certain medical conditions
• People who are recovering from alcoholism or who are unable to control the amount they drink

What can you do to lower your alcohol intake?

This sounds obvious, but you can drink less often or drink less alcohol on the days that you drink.  Here are some ideas for doing this.

• Make sure you have 2 days a week that you do not drink at all.
• Plan ahead regarding how much alcohol you will drink, and stick to the plan.
• Sip your drink slowly, so that one drink lasts longer.
• When making cocktails at home, use half the alcohol that is called for in the recipe.  At a bar, ask the bartender for half the alcohol in your cocktail.  Substitute a soft drink or fruit juice to make up the difference.
• Choose beer with lower ABV.

Next week we will talk more about the adverse health effects of alcohol.  In the meantime, If you have any questions about alcohol consumption, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor

Kawasaki Disease and Multi-System Inflammatory Syndrome in Children

Have you recently heard about Kawasaki Disease? Have you heard about certain children getting very sick with COVID 19? Let me explain a little about these illnesses: Kawasaki disease (KD) known for > 50 years and the new Multi-System Inflammatory Syndrome in Children (MIS-C) related to COVID19.

On April 26th 2020, it was first reported in the UK an increase of children having severe inflammatory illness (Kawasaki-like) and testing positive for SARS-CoV-2, the novel coronavirus that causes COVID19. As of May 12, 2020, the New York State Department of Health identified 102 patients with similar presentations, many of whom tested positive for SARS-CoV-2. This has also been seen in other countries.

Kawasaki Disease (KD)

KD is a condition that causes the inflammation of the blood vessels. It is the leading cause of acquired heart disease in children in the United States. More than 4200 children are diagnosed with KD every year in the US.

What are the symptoms?

Fever above 102 F that lasts for at least five days AND other signs and symptoms that may include:

• Rash anywhere on the body but more severe in the diaper area.
• Red, bloodshot eyes without pus, drainage, or crusting.
• Red, swollen, and cracked lips; strawberry-like tongue.
• Peeling fingers and toes (typically 2 to 3 weeks after the beginning of the fever).
• Swelling and tenderness of a gland (lymph node) on one side of the neck.
• Swollen hands and feet with redness on the palms of the hands and the soles of the feet.

It is diagnosed after the doctor suspects it due to the symptoms and confirms it with some lab tests. A heart exam (echocardiogram) is always done to see if the heart vessels called coronaries have been involved.

What causes it?

The cause of Kawasaki disease is not known, but it is thought to be a reaction by the body's immune system. There are two theories:

1. The host (patient) is the problem and they can get many different infections that can trigger the disease. If this is the correct theory, SARS COVID 2 could be an agent triggering it. It can be recurrent because you can get it from different agents.
2. One agent causing KD. There has never been evidence of a specific infectious agent, despite epidemics and outbreaks of KD seen through the years. Data that supports this theory is that it occurs in a young age group, it is self-limited in nature, and the lack of response to antibiotics.

Facts about KD

• Up to 90% of cases occur in children from 6 months to 5 years old
• It occurs more frequently in children of Asian ancestry. 1 in 65 Japanese children have KD by age 5. The Caucasians' incidence is tenfold lower.
• There is a genetic susceptibility.

Is there a treatment?

 Yes! It is important to diagnose it early and start treating it immediately after the diagnosis with an infusion of Intravenous gamma globulin (IVIG) and Aspirin. The coronary arteries need to be monitored closely by the Cardiologist. Patients do stay in the hospital for this treatment. Children treated for KD are sent home from the hospital on a low dose of Aspirin to take by mouth every day for 6 to 8 weeks.

Why is it dangerous?

Children with KD have a high risk of coronary artery aneurysms thrombosis with myocardial infarction, coronary aneurysm rupture (if it gets large enough) and coronary artery stenosis (obstructed vessels). These are all complications in the vessels that feed the heart with blood and can cause heart attacks and death.

Multi-System Inflammatory Syndrome in Children (MIS-C)

MIS-C is a new health condition seen in children who have been previously infected with SARS-CoV-2, recovered from it and then develop an immune response that leads to severe inflammation in different organ systems and symptoms.

Children with MIS-C present to the hospital severely ill, like in shock, and show severe myocarditis (inflammation of the heart) or cardiac dysfunction. These patients have shown extremely high cardiac damage markers, with evidence of antibodies indicating that they have previously been infected with the new coronavirus that causes COVID-19.

The CDC has released the criteria to diagnose MIS-C:

• Fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization, with multisystem (2 or more) organ involvement AND
• No alternative diagnoses;
  AND
• Positive SARS-CoV-2 test or COVID-19 exposure within the 4 weeks prior to the onset of symptoms

Some symptoms of MIS-C can be similar to KD but they are different in the following ways:

MIS-C COVID-19 Shock	Kawasaki Disease Shock
Low levels of specific white blood cells called lymphocytes	Normal lymphocyte levels
Majority of patients are older than 5 years	80% of patients are less than 5 years old
SEVERE abdominal pain	Some GI complaints
Labs: high ferritin and CRP, low platelets and albumin.	Same but less severe
African American at highest risk	Asians at highest risk
Myocarditis/myocardial infarction	Coronary aneurysms (25-60%)

Japan and China have not had reports of increased shock in children and these are the areas where they are more genetically predisposed to KD, thus making it less likely that this new MIS-C disease is related to KD.

There are still a lot of unanswered questions about Kawasaki Disease and MIS-C with COVID19, but investigations so far have shown these are different conditions.

What can you do from home?

Call your pediatrician if your child has:

• a fever lasting more than 24-48 hours
• trouble breathing
• your child seems confused, looks ill or very sleepy
• abdominal pain, diarrhea or vomiting
• rash or changes in skin color

If you have any questions about Kawasaki Disease or Multi-System Inflammatory Syndrome in Children, please log into your account and send us your question. We are here to help.


Dr. Valerie Hines, MD FAAP

The Anti-Inflammatory Diet

Do you struggle with chronic pain, GI complications, depression, fatigue or other symptoms? These things could be related to chronic inflammation. The foods you eat in your diet can help lower inflammation. Let's talk about how this works and why it is important. 

What is Inflammation?

Inflammation is one of the body's defense mechanisms used to fight infections and promote healing. An increase in inflammation often occurs in response to certain diseases; however, in these situations there is no infection or foreign body to fight. Inflammation can remain elevated due to these disease states causing chronic inflammation which can increase disease states and issues like pain.

What are some of the diseases that are related to chronic inflammation? 

• Alzheimer's disease
• Asthma
• Autoimmune disease – rheumatoid arthritis, lupus
• Cancer
• Chronic obstructive lung disease
• Chronic pain (back, neck, headaches, arthritis)
• Depression
• Heart disease
• Inflammatory bowel disease
• Type 2 diabetes
• Obesity

How can what I eat affect my inflammation?

The Standard American Diet tends to be high in simple sugars, unhealthy fats, and processed foods while low in fruits, vegetables and fiber. This diet tends to promote chronic inflammation in the body. Changing what and how you eat has been shown to decrease the inflammation in your body. It does not take the place of medications and treatment, but can decrease flare-ups, pain and other symptoms. The anti-inflammatory diet does not focus on weight loss, but healthy choices to improve your overall health.

What is the anti-inflammatory diet?

• Protein 
• Choose plant-based proteins like nuts, beans, peas, legumes and whole grains
• Choose lean meats – white meat poultry without skin, wild caught fish (tuna, salmon, mackerel, sardines), eggs, wild game
• Choose low fat/fat free milk and yogurt and no added sugar plant milks 
• Avoid high fat red meats, processed meats (hot dogs, sausage, spam, bologna), and high fat dairy products (cheese, whole milk, cream, butter)
• Fruits and Vegetables
• Choose a variety of colors of fruits and vegetables. 
• Increase non-starchy vegetables especially dark green leafy vegetables
• Increase fruits especially berries, cherries and oranges
• Olive oil has been shown to reduce inflammation and have other health benefits 
• Avocados are a healthy fat that can help reduce inflammation 
• Increase Fiber Intake
  
  • Fiber helps reduce inflammation 
  • Whole grains, beans, oatmeal, fruits, vegetables, popcorn, brown rice, nuts (especially walnuts and almonds) are all good sources of fiber
• Limit Simple Sugars and Unhealthy Fats
• Sugar and fats like saturated fats and Omega-6 fatty acids cause the body to increase inflammation 
• Limit sugary drinks including fruit juice
• Limit cakes, cookies, pies, donuts, and other high fat/high sugar baked goods
• Limit high fat snacks like chips, crackers, and snack mixes
• Limit fried foods like French fries, fried meat, and fried vegetables
• Avoid all trans fats (check the label for 0 trans fats)
• Omega-3 and Omega-6 fatty acids are essential fatty acids you get from your diet. You need a good balance of these. Our diet tends to have significantly more Omeg-6 fatty acids than Omega-3 fatty acids which increases inflammation.  
• Sources of Omega-6 fatty acids – plant oils like corn, soybean, and sunflower, nuts, and seeds. 
• Sources of Omega-3 fatty acids – fatty fish, whole grains, walnuts, flax seed, and green leafy vegetables
• Herbs and Spices 
• Turmeric, garlic, ginger, and many other spices can lower inflammation and help flavor food without adding sodium.

A bonus – the anti-inflammatory diet is a good option for all types of people of all ages so it can benefit the whole family!

Do I have to make all these changes at one time?

No, you do not have to make all these changes at one time to see the results of lowered inflammation. Pick 1-3 changes to make at a time. Once you have mastered those changes, pick 1-3 more things to work on.  Over time, you will get into a new lifestyle that promotes choosing a variety of whole foods while reducing inflammation and improving your overall health.

If you have any questions about The Anti-Inflammatory Diet, please log into your account and send us your question. We are here to help.

Libbi Calloway, MS, RD, LD

A User’s Guide to Face Masks

As some states start lifting restrictions and reopening businesses, it may seem like the threat from COVID-19 is past us.  Unfortunately, that is far from true.  The latest models predict significant increases in cases over the next couple of months.  We all need to continue to do what we can to help control the spread of the coronavirus.  Wearing a face mask, or covering, is one thing that we can all do.  Let's talk about how it works and why it is important.

Why is it important to wear a face covering?

The coronavirus that is responsible for the current pandemic is more contagious than influenza, and even more contagious than other coronaviruses that we have encountered in the past.  It spreads through respiratory droplets, or aerosolized particles, that we spread through a cough or sneeze.

An estimated 25% of people with this coronavirus feel perfectly fine and don't know they are infected, or that they are contagious.  It appears that these asymptomatic carriers are responsible for a significant amount of the spread of this virus.  You could very well be one of them and not know it!

How can wearing a face covering protect you and those around you?

A simple mask is very effective at trapping droplets from your coughs and sneezes.  Studies have been done on patients infected with a variety of viral respiratory infections (such as influenza, cold viruses, and milder coronaviruses), which show that wearing a mask blocks most virus-laden respiratory droplets exhaled.  In these studies, with normal un-masked exhaling, infected patients were releasing virus particles into the air 30% of the time, even without a sneeze or cough.  Other studies have shown that a cough or sneeze can send those particles at least 6 feet away.  

If you wear a mask, you are protecting those around you from being exposed to viral droplets that you might exhale even with normal breathing, and especially with a cough or sneeze.  

We all have a responsibility to do what we can to decrease the spread of this infection, and wearing a mask is a great way to protect those around you from getting exposed.  Remember, you may not even know you are spreading it!  In fact, I think you are being disrespectful to those around you if you are going into public buildings, or coming within 6 feet of others, without wearing a mask.

How well a mask protects the wearer depends on the quality of the material used, and the fit of the mask.  If you are practicing social distancing, and washing your hands often, and you wear a mask made out of 2 layers of a heavy cotton or flannel, that fits properly, you are lowering your risk of getting sick.

Dos and Don'ts of Wearing a Face Covering

       How to put on, wear, and take off a mask

• Always wash your hands firsts
• Don't touch the fabric part of the mask (that is where the germs are getting trapped and you don't want that on your hands)
• Use the ear loops or ties to secure your mask and to remove it.
• The mask should cover the area from near the bridge of your nose to down below your chin, and should reach on the sides to about halfway or more toward your ears.
• Pull the ties or loops so that it fits as snugly as possible against your face.
• If there is a metal nose piece, you can bend this to fit your nose.
• If your mask has pleats, the folded part of the pleat should be down.

How NOT to wear your mask

• Don't take one loop off your ear to talk.
• Don't tug the mask down so that your nostrils are uncovered.
• Don't wear the mask with the bottom edge above your chin.

Should you wear a mask outdoors?

If you are going to be within 6 feet of others, you should wear a mask, even outdoors.

Should you wear a mask at home?

You only need to wear a mask at home if someone is sick.  In this case, the person who is sick should be confined to a separate room with minimal to no contact with others in the household (including pets) and should use a separate bathroom if possible.  Both the person who is sick and the caregiver should wear a mask when in contact with each other.  The caregiver should wash their hands as soon as they remove their mask after leaving the room.

How can you make your own mask?

• There are a variety of mask patterns that are available online.  If you have basic sewing skills, a mask is an easy sewing project.  There are also no-sew mask patterns available as well.  I will provide links below.
• A variety of fabrics can be used to make a mask, including cotton quilting fabric, an old T shirt, a tightly woven tea towel (not terry cloth), flannel (from an old shirt or pajamas), and bandanas.  You should hold the fabric up to the light to see how much light comes through; the less light comes through, the tighter the weave and the better protection it will provide. 
• Ideally your mask should have 2 fabric layers, preferably with one edge open so that you can put a paper towel or coffee filter between the layers for added protection.  The coffee filter or paper towel can be thrown away before washing and replaced with a new one prior to the next use.

How do you take care of a mask?

• If you have a surgical mask or N95 mask, you can't really clean those.  They just need to be replaced with a new one.
• A fabric mask should be washed regularly with soap and water.  Bleach seems tempting, but bleach or hydrogen peroxide can degrade the fabric fibers, which will make the mask less effective.  Soap and water works great to kill viruses.  You can air dry it or put it in the dryer.  
• Do NOT put your face covering in the microwave.  This does not sanitize it adequately, and it is a fire hazard.  Most cloth material will catch fire if in the microwave for very long.  Surgical masks also contain a metal nose piece, which is certainly not microwave-friendly.
• It is not necessary, but if you want you can run a hot iron over the mask before wearing, if it makes you feel like you've made a full assault on any germs that might remain after washing.

Let's all try to do our part to stop the spread of coronavirus.  If you have any questions about masks, or other questions about coronavirus, please send a question in to one of our doctors.

Here are a couple of links to help you make your own mask:

A simple no-sew mask - https://www.youtube.com/watch?v=tPx1yqvJgf4

Another no-sew mask - https://www.youtube.com/watch?v=KQZPhj_erhg

Let's all try to do our part to stop the spread of coronavirus.  If you have any questions about masks, or other questions about coronavirus, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor

Routines for Children During COVID19 Era

How many of you are feeling that your children are having a hard time coping with all of this time inside your home? Are you struggling trying to find time for home-schooling, work, cooking, cleaning, having fun, and resting? Are your children acting up more than usual?

If you answered yes to some of these questions, starting a ROUTINE might be your next step. Children need a routine to get the sense of stability that can be missing during this COVID19 era of uncertainty. Routines give them a sense of control in their life, they need to know what comes next and what will be happening that day. Parents also benefit from routines to be calmer and control the stress in the household. Stress and anxiety can get worse when a routine is lost; it is important to find a new routine to get back on track.

Obviously, every family is different and has children of different ages and personalities, so expectations have to be according to their age.

I would suggest following routines from Monday through Friday and let the weekend be more relaxed. This can be a helpful example of a weekday routine:

1. Wake up every morning around the same time. No need for it to be too early, but sleeping in daily does not help getting things done or resting at the end of the day. Note on teenagers: Teenagers can start a little later because they might go to sleep later, but do not let them sleep in past 10 am, because they also need to get their work done. This can decrease their anxiety and depression, and help them organize themselves. Teenagers are one of the family members who will benefit most from routines.
2. Have a healthy breakfast.
3. Cleaning up. Children should help based on their age, for example getting breakfast cleaned up, fixing their room, brushing their teeth, and changing clothes every morning. NO PJs all day!
4. School work. If they are in school it is important for them to start their school activities early, ideally by 9am. If you work from home, try to get them started before you start with your work. This will vary a lot according to who is at home and how they can help.  Taking breaks from work or home chores to help them can make it less frustrating for them, BUT with some independence (age appropriate).
5. Breaks. Take breaks where they can play but try to avoid screen time during breaks. Physically active play can help them be more focused after their break. Set a time for the end of each break, maybe 20 minutes.
6. Lunch. Try to have healthy food as much as possible. Divide chores, let them help do dishes, laundry, clean their room, etc. These can even be written in a calendar on the fridge such as who does what on what days. Take a longer break after lunch.
7. Finish school early. Go back to school activities and work after lunch. Try to set a time in which all school work should be completed, for example 4-5pm. They need to look forward to a time of the day in which work ends and they are "free".
8. Social time. Many kids do feel the need to see their friends and enjoy talking to them. Try to arrange for calls or games through media after school so they can feel connected to them. If they are done with their homework, let them spend more time than usual with their friends.
9. Play. Spend time playing with your kids or let them play at what they like best. Sometimes they just need 10 minutes of a card game or board game with you and then they feel better. If videogames or screen time are allowed, let them play, but limit their time. Maximum 2 hours a day.
10. Family dinner. Try to have at least one meal a day together. During dinner, ask them about their feelings. Give them a place to express their current feelings, without judgement. It might be a nice time to give them positive feedback on what they are doing well. Sometimes we spend too much time telling them what they do wrong, or saying "No". This can be a good time to reflect on the positive things they are doing.
11. Bedtime routine. They should keep their bedtime routine to help them sleep better, so daily baths, brushing their teeth, and a book in bed can always help them go to sleep better. Avoid screen time 2 hours before bedtime to get a good night sleep!

Teenagers: try to keep them off their phone/tablets before bedtime.

This is just a weekly routine example, but it can help you make your own routine at home. Children and teenagers do best when routines are CONSISTENT and regular. Try to stick to them from Monday through Friday and let the weekend be more relaxed. You can always have a special treat or surprise that might make them feel extra happy in these days.

 If you have any questions about healthy routines for children during the pandemic, please log into your account and send us your question. We are here to help.

Dr. Valerie Hines, MD FAAP