Commentary

Questions about sleep – from newborns to teenagers – are among the most common in pediatric practice. A good night’s sleep is in everyone’s best interest for daily functioning and healthy development. Asking about sleep also provides a window into the family’s perspectives on discipline, parental cooperation, family stresses, and views on a child’s developing autonomy.

During their first year, infants may need as many as 18 hours of sleep daily, and the duration of sleep gradually declines thereafter to 8-10 hours nightly in adolescence. Sleep plays an essential role in consolidating memories, attention, and other cognitive functions; the immune system; and metabolism. Additionally, developing healthy sleep habits is one of the first and most profound ways that children learn to expect consistency from their parents, to soothe themselves, and to manage limits. As a child grows, her ability to plan, manage anxiety, and exercise discipline is cultivated through managing her sleep with increasing independence.

Preschoolers who are not getting adequate sleep may have behavioral problems, particularly in new settings (like school) or at transitional times (like bedtime). When a preschooler presents with hyperactivity, irritability, and tantrums, or failure to keep up with developmental expectations, asking about sleep patterns is a good early step. Although sleep disruption may be symptomatic of psychiatric disorders related to mood, anxiety, or attention, before you consider a disorder and treatment make sure that tensions at bedtime and poor sleeping habits are not a major factor.

How do you help tired, stressed parents encourage or enforce healthy sleep habits? Does the family have a routine after dinner that allows a child to settle down (such as taking a bath and then a quiet activity like reading a book with a parent)? Are the parents able to enforce this routine consistently, or does bedtime get dragged out for hours? And if so, why? In addition to ensuring that a child gets enough exercise during the day (but not in the hour before bed), parents will need to turn off the lights at a reasonably early hour so that a child may get adequate sleep before they will awaken with daylight.

Many parents will delay sleep until later as children push to stay awake and play. Sometimes, if both parents work and feel their only time with their children is after they return from work well into the evening, they may want more time with their children or feel guilty about having a strict, early bedtime routine. Reassure parents that even a short stretch of quality time with their children (reading to them, snuggling, asking about their day) is enough to nurture a profound connection.

"Screen time" merits special mention, especially in younger children. Letting children watch television or play on computers in order to "unwind" at the end of a long day is common, but in the time before bed, screen content can be very disruptive to restful sleep. Parents should assess if "screen time" is helping or hurting their child’s ability to fall asleep. Some families have found it helpful to have no screen time (any screen: television, computer, tablet, or cell phone) within 1 hour of lights going out: back-lit screens suppress endogenous melatonin release and can delay sleep. With school-age children, reading at bedtime is certainly preferable to an additional hour of computer time.

It is also worth asking where a child is sleeping. Do they have their own bed? Are they alone in their room? Is their room on the same level of the house as their parents’ room? Children who are anxious may sleep better if they share a room with a sibling or are close to their parents’ room. On the other hand, if they sleep with a sibling who is waking often during the night, they may have disrupted sleep.

It is worth finding out if a child is able to sleep through the night in their own bed. Many children have their own bed and room, but have a routine of sleeping in their parents’ bed. This usually results in inadequate sleep for both child and parents, and a child who does not learn how to appropriately soothe himself. Is it permissible for a child to climb into their parents’ bed in the middle of the night once in a while, if they have a bad dream, do not feel well, or have faced a stressful day? Yes. Is a child arguing to go to sleep in their parents’ bed, refusing to sleep in their own bed, with their parents "giving in"? Then it is a habit worth undoing.

School-age children who are not getting adequate sleep also may appear more irritable, forgetful, and inattentive, and they may have problems with academic, athletic, and social performance. These are years in which children start to have more independence and responsibility for their bedtime routines. They may have greater access to screens in the evening, and may be in charge of setting an alarm or turning their light out. These are also years in which children are more likely to experience anxiety, as they face and manage a host of new challenges. Anxiety can be very disruptive of restful sleep, and will in turn cause more problems about which these children get anxious. Alongside their greater responsibility, school-age children still need basic and consistently enforced ground rules about sleep in order to build independence. Clearly at this age, reading before bedtime is a good option.

Parents should help their school-age children to start their homework early, and to enjoy screen time, but not within an hour of bedtime, and to follow a consistent (and more independent) routine before bed. Do they have a consistent bedtime? Do they take a shower or bath each night? (A hot shower or bath naturally cues the body that it is time for sleep as the body’s core temperature rises and then drops.) Do they read before lights out? Is the house quiet at their bedtime? Parents should also find out if their children have worries that are making it difficult to go to sleep. Are they worried about a test or big game? Or about bigger issues of safety? Parents can help a child to discuss their worries and address those that are addressable; usually, this is enough to help children learn to master their worries. When a school-age child’s anxiety does not improve with open discussion, then it may be helpful to have a more formal evaluation for anxiety with a mental health clinician.

Adolescence is a time in which sleep patterns naturally shift, while the need for sleep remains robust. Teenagers become tired later and need to sleep in until later in the morning, just at the same time that school demands impinge on sleep with an earlier start to the day and more extensive homework at night. Older adolescents may go out with friends on weekends and shift their bedtime routine by 4 or more hours for two nights out of every seven, which is as profoundly disruptive to restful sleep as traveling across four time zones and back every week. These are years in which more independence can again lead to more screen use in the evening, whether for writing a paper on a computer or texting a friend late into the night.

An adolescent who is sleep deprived may have low energy, be forgetful and distractible, and see their academic and athletic performance suffer. They may appear more withdrawn or moody. This is an age in which serious mood problems, such as depression, are more likely to emerge, and are associated with sleep problems. But these problems will not improve with simple sleep hygiene interventions; thus, the teens who do not get better after these interventions may need a psychiatric evaluation.

The strategies that might help adolescents are not much different from those for younger children. It is important with adolescents, however, to explain why they should exercise regularly, have a consistent bedtime routine, and not bring their cell phone to bed. While parents should still be able to set and enforce ground rules, they also need to be equipping their adolescents to understand and manage their sleep independently, which they will need to do soon enough. Encouraging self-regulation between ages 13 and 17 is essential as college or independence approaches, and efforts at control are hard to enforce and send the wrong message.

Inconsistent, inadequate sleep often reflects what has been a frustrating struggle for parents. Asking questions about sleep gives parents the supportive message that sleep is challenging and important, and may empower them to approach it with renewed firmness and clarity. When you help parents to set routines and limits that support consistent, adequate sleep, their children will be on a path to healthy development.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

Questions about sleep – from newborns to teenagers – are among the most common in pediatric practice. A good night’s sleep is in everyone’s best interest for daily functioning and healthy development. Asking about sleep also provides a window into the family’s perspectives on discipline, parental cooperation, family stresses, and views on a child’s developing autonomy.

During their first year, infants may need as many as 18 hours of sleep daily, and the duration of sleep gradually declines thereafter to 8-10 hours nightly in adolescence. Sleep plays an essential role in consolidating memories, attention, and other cognitive functions; the immune system; and metabolism. Additionally, developing healthy sleep habits is one of the first and most profound ways that children learn to expect consistency from their parents, to soothe themselves, and to manage limits. As a child grows, her ability to plan, manage anxiety, and exercise discipline is cultivated through managing her sleep with increasing independence.

Preschoolers who are not getting adequate sleep may have behavioral problems, particularly in new settings (like school) or at transitional times (like bedtime). When a preschooler presents with hyperactivity, irritability, and tantrums, or failure to keep up with developmental expectations, asking about sleep patterns is a good early step. Although sleep disruption may be symptomatic of psychiatric disorders related to mood, anxiety, or attention, before you consider a disorder and treatment make sure that tensions at bedtime and poor sleeping habits are not a major factor.

How do you help tired, stressed parents encourage or enforce healthy sleep habits? Does the family have a routine after dinner that allows a child to settle down (such as taking a bath and then a quiet activity like reading a book with a parent)? Are the parents able to enforce this routine consistently, or does bedtime get dragged out for hours? And if so, why? In addition to ensuring that a child gets enough exercise during the day (but not in the hour before bed), parents will need to turn off the lights at a reasonably early hour so that a child may get adequate sleep before they will awaken with daylight.

Many parents will delay sleep until later as children push to stay awake and play. Sometimes, if both parents work and feel their only time with their children is after they return from work well into the evening, they may want more time with their children or feel guilty about having a strict, early bedtime routine. Reassure parents that even a short stretch of quality time with their children (reading to them, snuggling, asking about their day) is enough to nurture a profound connection.

"Screen time" merits special mention, especially in younger children. Letting children watch television or play on computers in order to "unwind" at the end of a long day is common, but in the time before bed, screen content can be very disruptive to restful sleep. Parents should assess if "screen time" is helping or hurting their child’s ability to fall asleep. Some families have found it helpful to have no screen time (any screen: television, computer, tablet, or cell phone) within 1 hour of lights going out: back-lit screens suppress endogenous melatonin release and can delay sleep. With school-age children, reading at bedtime is certainly preferable to an additional hour of computer time.

It is also worth asking where a child is sleeping. Do they have their own bed? Are they alone in their room? Is their room on the same level of the house as their parents’ room? Children who are anxious may sleep better if they share a room with a sibling or are close to their parents’ room. On the other hand, if they sleep with a sibling who is waking often during the night, they may have disrupted sleep.

It is worth finding out if a child is able to sleep through the night in their own bed. Many children have their own bed and room, but have a routine of sleeping in their parents’ bed. This usually results in inadequate sleep for both child and parents, and a child who does not learn how to appropriately soothe himself. Is it permissible for a child to climb into their parents’ bed in the middle of the night once in a while, if they have a bad dream, do not feel well, or have faced a stressful day? Yes. Is a child arguing to go to sleep in their parents’ bed, refusing to sleep in their own bed, with their parents "giving in"? Then it is a habit worth undoing.

School-age children who are not getting adequate sleep also may appear more irritable, forgetful, and inattentive, and they may have problems with academic, athletic, and social performance. These are years in which children start to have more independence and responsibility for their bedtime routines. They may have greater access to screens in the evening, and may be in charge of setting an alarm or turning their light out. These are also years in which children are more likely to experience anxiety, as they face and manage a host of new challenges. Anxiety can be very disruptive of restful sleep, and will in turn cause more problems about which these children get anxious. Alongside their greater responsibility, school-age children still need basic and consistently enforced ground rules about sleep in order to build independence. Clearly at this age, reading before bedtime is a good option.

Parents should help their school-age children to start their homework early, and to enjoy screen time, but not within an hour of bedtime, and to follow a consistent (and more independent) routine before bed. Do they have a consistent bedtime? Do they take a shower or bath each night? (A hot shower or bath naturally cues the body that it is time for sleep as the body’s core temperature rises and then drops.) Do they read before lights out? Is the house quiet at their bedtime? Parents should also find out if their children have worries that are making it difficult to go to sleep. Are they worried about a test or big game? Or about bigger issues of safety? Parents can help a child to discuss their worries and address those that are addressable; usually, this is enough to help children learn to master their worries. When a school-age child’s anxiety does not improve with open discussion, then it may be helpful to have a more formal evaluation for anxiety with a mental health clinician.

Adolescence is a time in which sleep patterns naturally shift, while the need for sleep remains robust. Teenagers become tired later and need to sleep in until later in the morning, just at the same time that school demands impinge on sleep with an earlier start to the day and more extensive homework at night. Older adolescents may go out with friends on weekends and shift their bedtime routine by 4 or more hours for two nights out of every seven, which is as profoundly disruptive to restful sleep as traveling across four time zones and back every week. These are years in which more independence can again lead to more screen use in the evening, whether for writing a paper on a computer or texting a friend late into the night.

An adolescent who is sleep deprived may have low energy, be forgetful and distractible, and see their academic and athletic performance suffer. They may appear more withdrawn or moody. This is an age in which serious mood problems, such as depression, are more likely to emerge, and are associated with sleep problems. But these problems will not improve with simple sleep hygiene interventions; thus, the teens who do not get better after these interventions may need a psychiatric evaluation.

The strategies that might help adolescents are not much different from those for younger children. It is important with adolescents, however, to explain why they should exercise regularly, have a consistent bedtime routine, and not bring their cell phone to bed. While parents should still be able to set and enforce ground rules, they also need to be equipping their adolescents to understand and manage their sleep independently, which they will need to do soon enough. Encouraging self-regulation between ages 13 and 17 is essential as college or independence approaches, and efforts at control are hard to enforce and send the wrong message.

Inconsistent, inadequate sleep often reflects what has been a frustrating struggle for parents. Asking questions about sleep gives parents the supportive message that sleep is challenging and important, and may empower them to approach it with renewed firmness and clarity. When you help parents to set routines and limits that support consistent, adequate sleep, their children will be on a path to healthy development.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

Questions about sleep – from newborns to teenagers – are among the most common in pediatric practice. A good night’s sleep is in everyone’s best interest for daily functioning and healthy development. Asking about sleep also provides a window into the family’s perspectives on discipline, parental cooperation, family stresses, and views on a child’s developing autonomy.

During their first year, infants may need as many as 18 hours of sleep daily, and the duration of sleep gradually declines thereafter to 8-10 hours nightly in adolescence. Sleep plays an essential role in consolidating memories, attention, and other cognitive functions; the immune system; and metabolism. Additionally, developing healthy sleep habits is one of the first and most profound ways that children learn to expect consistency from their parents, to soothe themselves, and to manage limits. As a child grows, her ability to plan, manage anxiety, and exercise discipline is cultivated through managing her sleep with increasing independence.

Preschoolers who are not getting adequate sleep may have behavioral problems, particularly in new settings (like school) or at transitional times (like bedtime). When a preschooler presents with hyperactivity, irritability, and tantrums, or failure to keep up with developmental expectations, asking about sleep patterns is a good early step. Although sleep disruption may be symptomatic of psychiatric disorders related to mood, anxiety, or attention, before you consider a disorder and treatment make sure that tensions at bedtime and poor sleeping habits are not a major factor.

How do you help tired, stressed parents encourage or enforce healthy sleep habits? Does the family have a routine after dinner that allows a child to settle down (such as taking a bath and then a quiet activity like reading a book with a parent)? Are the parents able to enforce this routine consistently, or does bedtime get dragged out for hours? And if so, why? In addition to ensuring that a child gets enough exercise during the day (but not in the hour before bed), parents will need to turn off the lights at a reasonably early hour so that a child may get adequate sleep before they will awaken with daylight.

Many parents will delay sleep until later as children push to stay awake and play. Sometimes, if both parents work and feel their only time with their children is after they return from work well into the evening, they may want more time with their children or feel guilty about having a strict, early bedtime routine. Reassure parents that even a short stretch of quality time with their children (reading to them, snuggling, asking about their day) is enough to nurture a profound connection.

"Screen time" merits special mention, especially in younger children. Letting children watch television or play on computers in order to "unwind" at the end of a long day is common, but in the time before bed, screen content can be very disruptive to restful sleep. Parents should assess if "screen time" is helping or hurting their child’s ability to fall asleep. Some families have found it helpful to have no screen time (any screen: television, computer, tablet, or cell phone) within 1 hour of lights going out: back-lit screens suppress endogenous melatonin release and can delay sleep. With school-age children, reading at bedtime is certainly preferable to an additional hour of computer time.

It is also worth asking where a child is sleeping. Do they have their own bed? Are they alone in their room? Is their room on the same level of the house as their parents’ room? Children who are anxious may sleep better if they share a room with a sibling or are close to their parents’ room. On the other hand, if they sleep with a sibling who is waking often during the night, they may have disrupted sleep.

It is worth finding out if a child is able to sleep through the night in their own bed. Many children have their own bed and room, but have a routine of sleeping in their parents’ bed. This usually results in inadequate sleep for both child and parents, and a child who does not learn how to appropriately soothe himself. Is it permissible for a child to climb into their parents’ bed in the middle of the night once in a while, if they have a bad dream, do not feel well, or have faced a stressful day? Yes. Is a child arguing to go to sleep in their parents’ bed, refusing to sleep in their own bed, with their parents "giving in"? Then it is a habit worth undoing.

School-age children who are not getting adequate sleep also may appear more irritable, forgetful, and inattentive, and they may have problems with academic, athletic, and social performance. These are years in which children start to have more independence and responsibility for their bedtime routines. They may have greater access to screens in the evening, and may be in charge of setting an alarm or turning their light out. These are also years in which children are more likely to experience anxiety, as they face and manage a host of new challenges. Anxiety can be very disruptive of restful sleep, and will in turn cause more problems about which these children get anxious. Alongside their greater responsibility, school-age children still need basic and consistently enforced ground rules about sleep in order to build independence. Clearly at this age, reading before bedtime is a good option.

Parents should help their school-age children to start their homework early, and to enjoy screen time, but not within an hour of bedtime, and to follow a consistent (and more independent) routine before bed. Do they have a consistent bedtime? Do they take a shower or bath each night? (A hot shower or bath naturally cues the body that it is time for sleep as the body’s core temperature rises and then drops.) Do they read before lights out? Is the house quiet at their bedtime? Parents should also find out if their children have worries that are making it difficult to go to sleep. Are they worried about a test or big game? Or about bigger issues of safety? Parents can help a child to discuss their worries and address those that are addressable; usually, this is enough to help children learn to master their worries. When a school-age child’s anxiety does not improve with open discussion, then it may be helpful to have a more formal evaluation for anxiety with a mental health clinician.

Adolescence is a time in which sleep patterns naturally shift, while the need for sleep remains robust. Teenagers become tired later and need to sleep in until later in the morning, just at the same time that school demands impinge on sleep with an earlier start to the day and more extensive homework at night. Older adolescents may go out with friends on weekends and shift their bedtime routine by 4 or more hours for two nights out of every seven, which is as profoundly disruptive to restful sleep as traveling across four time zones and back every week. These are years in which more independence can again lead to more screen use in the evening, whether for writing a paper on a computer or texting a friend late into the night.

An adolescent who is sleep deprived may have low energy, be forgetful and distractible, and see their academic and athletic performance suffer. They may appear more withdrawn or moody. This is an age in which serious mood problems, such as depression, are more likely to emerge, and are associated with sleep problems. But these problems will not improve with simple sleep hygiene interventions; thus, the teens who do not get better after these interventions may need a psychiatric evaluation.

The strategies that might help adolescents are not much different from those for younger children. It is important with adolescents, however, to explain why they should exercise regularly, have a consistent bedtime routine, and not bring their cell phone to bed. While parents should still be able to set and enforce ground rules, they also need to be equipping their adolescents to understand and manage their sleep independently, which they will need to do soon enough. Encouraging self-regulation between ages 13 and 17 is essential as college or independence approaches, and efforts at control are hard to enforce and send the wrong message.

Inconsistent, inadequate sleep often reflects what has been a frustrating struggle for parents. Asking questions about sleep gives parents the supportive message that sleep is challenging and important, and may empower them to approach it with renewed firmness and clarity. When you help parents to set routines and limits that support consistent, adequate sleep, their children will be on a path to healthy development.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

The world is not only getting older and warmer, but it’s getting heavier and more unfit each year. According to the World Health Organization’s most recent data, more than 1.4 billion adults were overweight in 2008, and 500 million of these adults were obese. In 2012, more than 40 million young children were overweight or obese. Diabetes, a disorder closely linked with obesity, affects about 347 million people worldwide – approximately ten times more people than those with HIV/AIDS. Although the number of AIDS-related deaths has steadily decreased over the last decade, even in developing countries, the number of diabetes-related deaths has steadily increased. The WHO projects that diabetes-related deaths will double by 2030, making it the seventh leading cause of death worldwide. In the United States, diabetes already is the seventh leading cause of death.

According to the Centers for Disease Control and Prevention, obesity-related diseases cost $147 billion annually, a number which dwarfs the health care costs associated with smoking ($96 billion). In addition to the link with type 2 diabetes, there are strong links between obesity and heart disease, kidney disease, depression, and hypertension. From 1987 to 2007, obesity was estimated to have caused more than a 20% increase in total health care spending.

The American Diabetes Association estimates that people diagnosed with diabetes have average yearly medical expenditures of over $13,000, which is over two times higher than the expenditures of a person without diagnosed diabetes. The 2012 estimated annual cost of care for diagnosed diabetes was $245 billion, which includes $176 billion in direct medical costs and $69 billion in reduced productivity (Diabetes Care 2013 [doi:10.2337/dc12-2625]). These figures, while staggering, do not include projected expenditures for people who have yet to receive a diabetes diagnosis.

The federal government has chosen to take dramatic steps to help Americans lose weight. Since 2011, the Centers for Medicare & Medicaid Services has covered screening and intensive behavioral therapy for obesity by primary care physicians during office visits or outpatient hospital care. Additionally, the Affordable Care Act (ACA) now requires insurance companies to help overweight and obese patients try to lose weight and be healthier. The 2012 Institute of Medicine (IOM) report, Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation also has made major recommendations for health care practitioners, schools, and the food and beverage industry to take a more active part in improving our overall health.

Simple steps make a big impact on health

Despite the daunting – and perhaps somewhat disheartening – statistics on obesity and diabetes in the United States and around the world, research has shown that small steps to achieving a healthy weight and maintaining an active lifestyle can make a dramatic difference on the course of a person’s life. According to the Department of Agriculture, healthier diets could prevent about $71 billion in yearly health care costs, lost productivity, and premature deaths. This number is staggering, when you consider that the change could be as small as choosing a salad instead of fries for a side dish.

Medical research backs up the well-worn adage that "an apple a day keeps the doctor away." The Diabetes Prevention Program study, conducted in the early 2000s, found that lifestyle changes, such as getting more exercise and eating a balanced diet, had a major impact on whether a patient who is overweight with prediabetes developed type 2 diabetes (N. Engl. J. Med. 2002;346:393-403).

Lifestyle changes can also reduce the onset of diabetes in high-risk groups such as Asian Indians, where the incidence of diabetes is the highest in the world. The Indian Diabetes Prevention Programme showed that weight loss and healthy eating reduced the incidence of type 2 diabetes in this population at a rate similar to the use of metformin, one of the most common oral antidiabetic drugs (Diabetologia 2006;49:289-97).

The 16th U.S. Surgeon General, David Satcher, M.D., Ph.D., is famous for giving his "Prescription for Great Health" when he addresses colleges and universities, which includes not smoking, staying away from illicit drug use, and abstaining from unsafe sex. Importantly, the first two key points of his "prescription" are exercising at least five times a week for 30 minutes and eating at least five servings of fruits and vegetables daily. Again, very simple recommendations, but his advice has lasting and profound ramifications.

Do obstetrician/gynecologists have a role?

As ob.gyns., we always have played an incredibly critical role in maintaining the health and well-being of our patients. Now, more than ever, we have a significant opportunity to set our patients on a path to better eating, incorporating exercise into their daily routines and passing down these good habits to their children.

In the "old days," the ob.gyn. focused on a limited period in a patient’s life. Perhaps we only saw a patient for annual exams and then for a more intense time prior to and during pregnancy, and then for a checkup post partum where we may have examined our patients only for complications of the pregnancy and delivery and not much more. Although we may have included some counseling on maintaining a healthy pregnancy, many of us relied on a patient’s primary care physician to provide ongoing support.

Today, however, we must take a more active role in helping our patients establish and maintain a healthy lifestyle. Despite the increased insurance coverage under the ACA and the expansion of Medicaid, a woman’s ob.gyn. may be the only health care practitioner she will see on a routine basis. Many women do not visit a general practitioner for routine physical examinations, but women will see their ob.gyn. for regular exams. We can use these annual or biannual office visits to help women set goals to live a healthy life, approaching each patient as a whole person who needs comprehensive care throughout her reproductive life and beyond.

For patients who are overweight or obese, we may focus on helping them reduce their body mass index and blood pressure and encourage them to stay fit. We also should do everything we can to ensure that if a woman has had gestational diabetes, she’s doing what she can to reduce her risk of developing type 2 diabetes after pregnancy. For these patients, we should consider testing their blood glucose every 1-2 years during the annual checkup.

Healthy weight in pregnancy: to gain or to lose?

Whether or not an ob.gyn. practice implements a screening program and more intensive obesity and diabetes counseling, we all will face the same question: How much weight should my patient gain to have a healthy baby? Interestingly, in the first half of the 20th century, ob.gyns. were discouraged from recommending that their pregnant patients gain very much weight. Indeed, the 13th edition of "Williams Obstetrics" (New York: Appleton-Century-Crofts, 1966, p. 326) stated that obstetricians should limit their patients from gaining more than 25 pounds during gestation, and that the ideal weight gain was 15 pounds.

This guidance was called into question by a 1970 National Academy of Sciences report, "Maternal Nutrition and the Course of Pregnancy," which indicated a strong link between infant mortality and low maternal pregnancy weight. Further evidence suggested a need for new standards and, in 1990, the IOM issued recommendations on women’s nutrition during pregnancy (Nutrition During Pregnancy, Weight Gain and Nutrient Supplements. Washington, D.C.: National Academy Press, 1990). (See table.)

Americans consume 31% more calories today than they did 40 years ago. Because of this, a woman’s need to gain weight to improve the outcome of her pregnancy is significantly reduced. The calories that many people include in their diets often come from high-fat, sodium-loaded, processed foods. We also have become a more sedentary society, spending our days at a computer, browsing the internet, watching TV, and opting to drive rather than to walk. Taking these factors into account, revising the recommendations for weight gain seemed crucial. In 2009, the IOM revised its guidance on healthy weight gain in pregnancy, and these ranges are currently widely accepted by obstetricians today (iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx). (See table.)

With the obesity and diabetes epidemics on the rise, we may need to update the 2009 IOM guidelines again – and very soon. Isolated studies have indicated that, for women who are severely obese, moderate weight loss during pregnancy may improve pregnancy outcomes. These findings remain controversial, but the "heavy" burden of diabetes and obesity on the U.S. health care system in general, and the need to reduce obstetrical complications that accompany deliveries in patients who are overweight or obese and diabetic, means that we as a community may need to reexamine our practices and approaches much more closely.

"Food" for thought

We all know of patients who, once they become pregnant, begin justifying a greater intake of food as "eating for two." Many women may use their pregnancy as an excuse to overindulge in unhealthy foods or to forgo the gym and other regular exercise regimens. Recommending basic steps to change a patient’s lifestyle can make an incredible difference in improving maternal and fetal health outcomes.

Summary recommendations for healthy pregnancy

• A low-glycemic diet, combined with moderate exercise, can reduce or eliminate many of the negative consequences of obesity on pregnant women and their babies.

• Proper weight management during pregnancy can improve birth outcomes.

• Weight loss during pregnancy is not recommended, except, potentially, for morbidly obese women (BMI greater than 40).

• For women who are normal weight, overweight or obese, leading healthy lifestyles can greatly improve maternal and fetal health outcomes. These include physical exercise, balanced diet, and weight loss, in combination with medication in some cases.

• It is never too late to begin healthy habits!

If we microfocus only on a woman’s predelivery and postdelivery health, then we’re losing a big opportunity to improve her whole self and prevent future health complications during and outside of pregnancy. The good news for ob.gyns. is that this complex problem has a simple, well-documented, and proven solution.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

The world is not only getting older and warmer, but it’s getting heavier and more unfit each year. According to the World Health Organization’s most recent data, more than 1.4 billion adults were overweight in 2008, and 500 million of these adults were obese. In 2012, more than 40 million young children were overweight or obese. Diabetes, a disorder closely linked with obesity, affects about 347 million people worldwide – approximately ten times more people than those with HIV/AIDS. Although the number of AIDS-related deaths has steadily decreased over the last decade, even in developing countries, the number of diabetes-related deaths has steadily increased. The WHO projects that diabetes-related deaths will double by 2030, making it the seventh leading cause of death worldwide. In the United States, diabetes already is the seventh leading cause of death.

According to the Centers for Disease Control and Prevention, obesity-related diseases cost $147 billion annually, a number which dwarfs the health care costs associated with smoking ($96 billion). In addition to the link with type 2 diabetes, there are strong links between obesity and heart disease, kidney disease, depression, and hypertension. From 1987 to 2007, obesity was estimated to have caused more than a 20% increase in total health care spending.

The American Diabetes Association estimates that people diagnosed with diabetes have average yearly medical expenditures of over $13,000, which is over two times higher than the expenditures of a person without diagnosed diabetes. The 2012 estimated annual cost of care for diagnosed diabetes was $245 billion, which includes $176 billion in direct medical costs and $69 billion in reduced productivity (Diabetes Care 2013 [doi:10.2337/dc12-2625]). These figures, while staggering, do not include projected expenditures for people who have yet to receive a diabetes diagnosis.

The federal government has chosen to take dramatic steps to help Americans lose weight. Since 2011, the Centers for Medicare & Medicaid Services has covered screening and intensive behavioral therapy for obesity by primary care physicians during office visits or outpatient hospital care. Additionally, the Affordable Care Act (ACA) now requires insurance companies to help overweight and obese patients try to lose weight and be healthier. The 2012 Institute of Medicine (IOM) report, Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation also has made major recommendations for health care practitioners, schools, and the food and beverage industry to take a more active part in improving our overall health.

Simple steps make a big impact on health

Despite the daunting – and perhaps somewhat disheartening – statistics on obesity and diabetes in the United States and around the world, research has shown that small steps to achieving a healthy weight and maintaining an active lifestyle can make a dramatic difference on the course of a person’s life. According to the Department of Agriculture, healthier diets could prevent about $71 billion in yearly health care costs, lost productivity, and premature deaths. This number is staggering, when you consider that the change could be as small as choosing a salad instead of fries for a side dish.

Medical research backs up the well-worn adage that "an apple a day keeps the doctor away." The Diabetes Prevention Program study, conducted in the early 2000s, found that lifestyle changes, such as getting more exercise and eating a balanced diet, had a major impact on whether a patient who is overweight with prediabetes developed type 2 diabetes (N. Engl. J. Med. 2002;346:393-403).

Lifestyle changes can also reduce the onset of diabetes in high-risk groups such as Asian Indians, where the incidence of diabetes is the highest in the world. The Indian Diabetes Prevention Programme showed that weight loss and healthy eating reduced the incidence of type 2 diabetes in this population at a rate similar to the use of metformin, one of the most common oral antidiabetic drugs (Diabetologia 2006;49:289-97).

The 16th U.S. Surgeon General, David Satcher, M.D., Ph.D., is famous for giving his "Prescription for Great Health" when he addresses colleges and universities, which includes not smoking, staying away from illicit drug use, and abstaining from unsafe sex. Importantly, the first two key points of his "prescription" are exercising at least five times a week for 30 minutes and eating at least five servings of fruits and vegetables daily. Again, very simple recommendations, but his advice has lasting and profound ramifications.

Do obstetrician/gynecologists have a role?

As ob.gyns., we always have played an incredibly critical role in maintaining the health and well-being of our patients. Now, more than ever, we have a significant opportunity to set our patients on a path to better eating, incorporating exercise into their daily routines and passing down these good habits to their children.

In the "old days," the ob.gyn. focused on a limited period in a patient’s life. Perhaps we only saw a patient for annual exams and then for a more intense time prior to and during pregnancy, and then for a checkup post partum where we may have examined our patients only for complications of the pregnancy and delivery and not much more. Although we may have included some counseling on maintaining a healthy pregnancy, many of us relied on a patient’s primary care physician to provide ongoing support.

Today, however, we must take a more active role in helping our patients establish and maintain a healthy lifestyle. Despite the increased insurance coverage under the ACA and the expansion of Medicaid, a woman’s ob.gyn. may be the only health care practitioner she will see on a routine basis. Many women do not visit a general practitioner for routine physical examinations, but women will see their ob.gyn. for regular exams. We can use these annual or biannual office visits to help women set goals to live a healthy life, approaching each patient as a whole person who needs comprehensive care throughout her reproductive life and beyond.

For patients who are overweight or obese, we may focus on helping them reduce their body mass index and blood pressure and encourage them to stay fit. We also should do everything we can to ensure that if a woman has had gestational diabetes, she’s doing what she can to reduce her risk of developing type 2 diabetes after pregnancy. For these patients, we should consider testing their blood glucose every 1-2 years during the annual checkup.

Healthy weight in pregnancy: to gain or to lose?

Whether or not an ob.gyn. practice implements a screening program and more intensive obesity and diabetes counseling, we all will face the same question: How much weight should my patient gain to have a healthy baby? Interestingly, in the first half of the 20th century, ob.gyns. were discouraged from recommending that their pregnant patients gain very much weight. Indeed, the 13th edition of "Williams Obstetrics" (New York: Appleton-Century-Crofts, 1966, p. 326) stated that obstetricians should limit their patients from gaining more than 25 pounds during gestation, and that the ideal weight gain was 15 pounds.

This guidance was called into question by a 1970 National Academy of Sciences report, "Maternal Nutrition and the Course of Pregnancy," which indicated a strong link between infant mortality and low maternal pregnancy weight. Further evidence suggested a need for new standards and, in 1990, the IOM issued recommendations on women’s nutrition during pregnancy (Nutrition During Pregnancy, Weight Gain and Nutrient Supplements. Washington, D.C.: National Academy Press, 1990). (See table.)

Americans consume 31% more calories today than they did 40 years ago. Because of this, a woman’s need to gain weight to improve the outcome of her pregnancy is significantly reduced. The calories that many people include in their diets often come from high-fat, sodium-loaded, processed foods. We also have become a more sedentary society, spending our days at a computer, browsing the internet, watching TV, and opting to drive rather than to walk. Taking these factors into account, revising the recommendations for weight gain seemed crucial. In 2009, the IOM revised its guidance on healthy weight gain in pregnancy, and these ranges are currently widely accepted by obstetricians today (iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx). (See table.)

With the obesity and diabetes epidemics on the rise, we may need to update the 2009 IOM guidelines again – and very soon. Isolated studies have indicated that, for women who are severely obese, moderate weight loss during pregnancy may improve pregnancy outcomes. These findings remain controversial, but the "heavy" burden of diabetes and obesity on the U.S. health care system in general, and the need to reduce obstetrical complications that accompany deliveries in patients who are overweight or obese and diabetic, means that we as a community may need to reexamine our practices and approaches much more closely.

"Food" for thought

We all know of patients who, once they become pregnant, begin justifying a greater intake of food as "eating for two." Many women may use their pregnancy as an excuse to overindulge in unhealthy foods or to forgo the gym and other regular exercise regimens. Recommending basic steps to change a patient’s lifestyle can make an incredible difference in improving maternal and fetal health outcomes.

Summary recommendations for healthy pregnancy

• A low-glycemic diet, combined with moderate exercise, can reduce or eliminate many of the negative consequences of obesity on pregnant women and their babies.

• Proper weight management during pregnancy can improve birth outcomes.

• Weight loss during pregnancy is not recommended, except, potentially, for morbidly obese women (BMI greater than 40).

• For women who are normal weight, overweight or obese, leading healthy lifestyles can greatly improve maternal and fetal health outcomes. These include physical exercise, balanced diet, and weight loss, in combination with medication in some cases.

• It is never too late to begin healthy habits!

If we microfocus only on a woman’s predelivery and postdelivery health, then we’re losing a big opportunity to improve her whole self and prevent future health complications during and outside of pregnancy. The good news for ob.gyns. is that this complex problem has a simple, well-documented, and proven solution.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

The world is not only getting older and warmer, but it’s getting heavier and more unfit each year. According to the World Health Organization’s most recent data, more than 1.4 billion adults were overweight in 2008, and 500 million of these adults were obese. In 2012, more than 40 million young children were overweight or obese. Diabetes, a disorder closely linked with obesity, affects about 347 million people worldwide – approximately ten times more people than those with HIV/AIDS. Although the number of AIDS-related deaths has steadily decreased over the last decade, even in developing countries, the number of diabetes-related deaths has steadily increased. The WHO projects that diabetes-related deaths will double by 2030, making it the seventh leading cause of death worldwide. In the United States, diabetes already is the seventh leading cause of death.

According to the Centers for Disease Control and Prevention, obesity-related diseases cost $147 billion annually, a number which dwarfs the health care costs associated with smoking ($96 billion). In addition to the link with type 2 diabetes, there are strong links between obesity and heart disease, kidney disease, depression, and hypertension. From 1987 to 2007, obesity was estimated to have caused more than a 20% increase in total health care spending.

The American Diabetes Association estimates that people diagnosed with diabetes have average yearly medical expenditures of over $13,000, which is over two times higher than the expenditures of a person without diagnosed diabetes. The 2012 estimated annual cost of care for diagnosed diabetes was $245 billion, which includes $176 billion in direct medical costs and $69 billion in reduced productivity (Diabetes Care 2013 [doi:10.2337/dc12-2625]). These figures, while staggering, do not include projected expenditures for people who have yet to receive a diabetes diagnosis.

The federal government has chosen to take dramatic steps to help Americans lose weight. Since 2011, the Centers for Medicare & Medicaid Services has covered screening and intensive behavioral therapy for obesity by primary care physicians during office visits or outpatient hospital care. Additionally, the Affordable Care Act (ACA) now requires insurance companies to help overweight and obese patients try to lose weight and be healthier. The 2012 Institute of Medicine (IOM) report, Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation also has made major recommendations for health care practitioners, schools, and the food and beverage industry to take a more active part in improving our overall health.

Simple steps make a big impact on health

Despite the daunting – and perhaps somewhat disheartening – statistics on obesity and diabetes in the United States and around the world, research has shown that small steps to achieving a healthy weight and maintaining an active lifestyle can make a dramatic difference on the course of a person’s life. According to the Department of Agriculture, healthier diets could prevent about $71 billion in yearly health care costs, lost productivity, and premature deaths. This number is staggering, when you consider that the change could be as small as choosing a salad instead of fries for a side dish.

Medical research backs up the well-worn adage that "an apple a day keeps the doctor away." The Diabetes Prevention Program study, conducted in the early 2000s, found that lifestyle changes, such as getting more exercise and eating a balanced diet, had a major impact on whether a patient who is overweight with prediabetes developed type 2 diabetes (N. Engl. J. Med. 2002;346:393-403).

Lifestyle changes can also reduce the onset of diabetes in high-risk groups such as Asian Indians, where the incidence of diabetes is the highest in the world. The Indian Diabetes Prevention Programme showed that weight loss and healthy eating reduced the incidence of type 2 diabetes in this population at a rate similar to the use of metformin, one of the most common oral antidiabetic drugs (Diabetologia 2006;49:289-97).

The 16th U.S. Surgeon General, David Satcher, M.D., Ph.D., is famous for giving his "Prescription for Great Health" when he addresses colleges and universities, which includes not smoking, staying away from illicit drug use, and abstaining from unsafe sex. Importantly, the first two key points of his "prescription" are exercising at least five times a week for 30 minutes and eating at least five servings of fruits and vegetables daily. Again, very simple recommendations, but his advice has lasting and profound ramifications.

Do obstetrician/gynecologists have a role?

As ob.gyns., we always have played an incredibly critical role in maintaining the health and well-being of our patients. Now, more than ever, we have a significant opportunity to set our patients on a path to better eating, incorporating exercise into their daily routines and passing down these good habits to their children.

In the "old days," the ob.gyn. focused on a limited period in a patient’s life. Perhaps we only saw a patient for annual exams and then for a more intense time prior to and during pregnancy, and then for a checkup post partum where we may have examined our patients only for complications of the pregnancy and delivery and not much more. Although we may have included some counseling on maintaining a healthy pregnancy, many of us relied on a patient’s primary care physician to provide ongoing support.

Today, however, we must take a more active role in helping our patients establish and maintain a healthy lifestyle. Despite the increased insurance coverage under the ACA and the expansion of Medicaid, a woman’s ob.gyn. may be the only health care practitioner she will see on a routine basis. Many women do not visit a general practitioner for routine physical examinations, but women will see their ob.gyn. for regular exams. We can use these annual or biannual office visits to help women set goals to live a healthy life, approaching each patient as a whole person who needs comprehensive care throughout her reproductive life and beyond.

For patients who are overweight or obese, we may focus on helping them reduce their body mass index and blood pressure and encourage them to stay fit. We also should do everything we can to ensure that if a woman has had gestational diabetes, she’s doing what she can to reduce her risk of developing type 2 diabetes after pregnancy. For these patients, we should consider testing their blood glucose every 1-2 years during the annual checkup.

Healthy weight in pregnancy: to gain or to lose?

Whether or not an ob.gyn. practice implements a screening program and more intensive obesity and diabetes counseling, we all will face the same question: How much weight should my patient gain to have a healthy baby? Interestingly, in the first half of the 20th century, ob.gyns. were discouraged from recommending that their pregnant patients gain very much weight. Indeed, the 13th edition of "Williams Obstetrics" (New York: Appleton-Century-Crofts, 1966, p. 326) stated that obstetricians should limit their patients from gaining more than 25 pounds during gestation, and that the ideal weight gain was 15 pounds.

This guidance was called into question by a 1970 National Academy of Sciences report, "Maternal Nutrition and the Course of Pregnancy," which indicated a strong link between infant mortality and low maternal pregnancy weight. Further evidence suggested a need for new standards and, in 1990, the IOM issued recommendations on women’s nutrition during pregnancy (Nutrition During Pregnancy, Weight Gain and Nutrient Supplements. Washington, D.C.: National Academy Press, 1990). (See table.)

Americans consume 31% more calories today than they did 40 years ago. Because of this, a woman’s need to gain weight to improve the outcome of her pregnancy is significantly reduced. The calories that many people include in their diets often come from high-fat, sodium-loaded, processed foods. We also have become a more sedentary society, spending our days at a computer, browsing the internet, watching TV, and opting to drive rather than to walk. Taking these factors into account, revising the recommendations for weight gain seemed crucial. In 2009, the IOM revised its guidance on healthy weight gain in pregnancy, and these ranges are currently widely accepted by obstetricians today (iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx). (See table.)

With the obesity and diabetes epidemics on the rise, we may need to update the 2009 IOM guidelines again – and very soon. Isolated studies have indicated that, for women who are severely obese, moderate weight loss during pregnancy may improve pregnancy outcomes. These findings remain controversial, but the "heavy" burden of diabetes and obesity on the U.S. health care system in general, and the need to reduce obstetrical complications that accompany deliveries in patients who are overweight or obese and diabetic, means that we as a community may need to reexamine our practices and approaches much more closely.

"Food" for thought

We all know of patients who, once they become pregnant, begin justifying a greater intake of food as "eating for two." Many women may use their pregnancy as an excuse to overindulge in unhealthy foods or to forgo the gym and other regular exercise regimens. Recommending basic steps to change a patient’s lifestyle can make an incredible difference in improving maternal and fetal health outcomes.

Summary recommendations for healthy pregnancy

• A low-glycemic diet, combined with moderate exercise, can reduce or eliminate many of the negative consequences of obesity on pregnant women and their babies.

• Proper weight management during pregnancy can improve birth outcomes.

• Weight loss during pregnancy is not recommended, except, potentially, for morbidly obese women (BMI greater than 40).

• For women who are normal weight, overweight or obese, leading healthy lifestyles can greatly improve maternal and fetal health outcomes. These include physical exercise, balanced diet, and weight loss, in combination with medication in some cases.

• It is never too late to begin healthy habits!

If we microfocus only on a woman’s predelivery and postdelivery health, then we’re losing a big opportunity to improve her whole self and prevent future health complications during and outside of pregnancy. The good news for ob.gyns. is that this complex problem has a simple, well-documented, and proven solution.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

The world is not only getting older and warmer, but it’s getting heavier and more unfit each year. According to the World Health Organization’s most recent data, more than 1.4 billion adults were overweight in 2008, and 500 million of these adults were obese. In 2012, more than 40 million young children were overweight or obese. Diabetes, a disorder closely linked with obesity, affects about 347 million people worldwide – approximately ten times more people than those with HIV/AIDS. Although the number of AIDS-related deaths has steadily decreased over the last decade, even in developing countries, the number of diabetes-related deaths has steadily increased. The WHO projects that diabetes-related deaths will double by 2030, making it the seventh leading cause of death worldwide. In the United States, diabetes already is the seventh leading cause of death.

According to the Centers for Disease Control and Prevention, obesity-related diseases cost $147 billion annually, a number which dwarfs the health care costs associated with smoking ($96 billion). In addition to the link with type 2 diabetes, there are strong links between obesity and heart disease, kidney disease, depression, and hypertension. From 1987 to 2007, obesity was estimated to have caused more than a 20% increase in total health care spending.

The American Diabetes Association estimates that people diagnosed with diabetes have average yearly medical expenditures of over $13,000, which is over two times higher than the expenditures of a person without diagnosed diabetes. The 2012 estimated annual cost of care for diagnosed diabetes was $245 billion, which includes $176 billion in direct medical costs and $69 billion in reduced productivity (Diabetes Care 2013 [doi:10.2337/dc12-2625]). These figures, while staggering, do not include projected expenditures for people who have yet to receive a diabetes diagnosis.

The federal government has chosen to take dramatic steps to help Americans lose weight. Since 2011, the Centers for Medicare & Medicaid Services has covered screening and intensive behavioral therapy for obesity by primary care physicians during office visits or outpatient hospital care. Additionally, the Affordable Care Act (ACA) now requires insurance companies to help overweight and obese patients try to lose weight and be healthier. The 2012 Institute of Medicine (IOM) report, Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation also has made major recommendations for health care practitioners, schools, and the food and beverage industry to take a more active part in improving our overall health.

Simple steps make a big impact on health

Despite the daunting – and perhaps somewhat disheartening – statistics on obesity and diabetes in the United States and around the world, research has shown that small steps to achieving a healthy weight and maintaining an active lifestyle can make a dramatic difference on the course of a person’s life. According to the Department of Agriculture, healthier diets could prevent about $71 billion in yearly health care costs, lost productivity, and premature deaths. This number is staggering, when you consider that the change could be as small as choosing a salad instead of fries for a side dish.

Medical research backs up the well-worn adage that "an apple a day keeps the doctor away." The Diabetes Prevention Program study, conducted in the early 2000s, found that lifestyle changes, such as getting more exercise and eating a balanced diet, had a major impact on whether a patient who is overweight with prediabetes developed type 2 diabetes (N. Engl. J. Med. 2002;346:393-403).

Lifestyle changes can also reduce the onset of diabetes in high-risk groups such as Asian Indians, where the incidence of diabetes is the highest in the world. The Indian Diabetes Prevention Programme showed that weight loss and healthy eating reduced the incidence of type 2 diabetes in this population at a rate similar to the use of metformin, one of the most common oral antidiabetic drugs (Diabetologia 2006;49:289-97).

The 16th U.S. Surgeon General, David Satcher, M.D., Ph.D., is famous for giving his "Prescription for Great Health" when he addresses colleges and universities, which includes not smoking, staying away from illicit drug use, and abstaining from unsafe sex. Importantly, the first two key points of his "prescription" are exercising at least five times a week for 30 minutes and eating at least five servings of fruits and vegetables daily. Again, very simple recommendations, but his advice has lasting and profound ramifications.

Do obstetrician/gynecologists have a role?

As ob.gyns., we always have played an incredibly critical role in maintaining the health and well-being of our patients. Now, more than ever, we have a significant opportunity to set our patients on a path to better eating, incorporating exercise into their daily routines and passing down these good habits to their children.

In the "old days," the ob.gyn. focused on a limited period in a patient’s life. Perhaps we only saw a patient for annual exams and then for a more intense time prior to and during pregnancy, and then for a checkup post partum where we may have examined our patients only for complications of the pregnancy and delivery and not much more. Although we may have included some counseling on maintaining a healthy pregnancy, many of us relied on a patient’s primary care physician to provide ongoing support.

Today, however, we must take a more active role in helping our patients establish and maintain a healthy lifestyle. Despite the increased insurance coverage under the ACA and the expansion of Medicaid, a woman’s ob.gyn. may be the only health care practitioner she will see on a routine basis. Many women do not visit a general practitioner for routine physical examinations, but women will see their ob.gyn. for regular exams. We can use these annual or biannual office visits to help women set goals to live a healthy life, approaching each patient as a whole person who needs comprehensive care throughout her reproductive life and beyond.

For patients who are overweight or obese, we may focus on helping them reduce their body mass index and blood pressure and encourage them to stay fit. We also should do everything we can to ensure that if a woman has had gestational diabetes, she’s doing what she can to reduce her risk of developing type 2 diabetes after pregnancy. For these patients, we should consider testing their blood glucose every 1-2 years during the annual checkup.

Healthy weight in pregnancy: to gain or to lose?

Whether or not an ob.gyn. practice implements a screening program and more intensive obesity and diabetes counseling, we all will face the same question: How much weight should my patient gain to have a healthy baby? Interestingly, in the first half of the 20th century, ob.gyns. were discouraged from recommending that their pregnant patients gain very much weight. Indeed, the 13th edition of "Williams Obstetrics" (New York: Appleton-Century-Crofts, 1966, p. 326) stated that obstetricians should limit their patients from gaining more than 25 pounds during gestation, and that the ideal weight gain was 15 pounds.

This guidance was called into question by a 1970 National Academy of Sciences report, "Maternal Nutrition and the Course of Pregnancy," which indicated a strong link between infant mortality and low maternal pregnancy weight. Further evidence suggested a need for new standards and, in 1990, the IOM issued recommendations on women’s nutrition during pregnancy (Nutrition During Pregnancy, Weight Gain and Nutrient Supplements. Washington, D.C.: National Academy Press, 1990). (See table.)

Americans consume 31% more calories today than they did 40 years ago. Because of this, a woman’s need to gain weight to improve the outcome of her pregnancy is significantly reduced. The calories that many people include in their diets often come from high-fat, sodium-loaded, processed foods. We also have become a more sedentary society, spending our days at a computer, browsing the internet, watching TV, and opting to drive rather than to walk. Taking these factors into account, revising the recommendations for weight gain seemed crucial. In 2009, the IOM revised its guidance on healthy weight gain in pregnancy, and these ranges are currently widely accepted by obstetricians today (iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx). (See table.)

With the obesity and diabetes epidemics on the rise, we may need to update the 2009 IOM guidelines again – and very soon. Isolated studies have indicated that, for women who are severely obese, moderate weight loss during pregnancy may improve pregnancy outcomes. These findings remain controversial, but the "heavy" burden of diabetes and obesity on the U.S. health care system in general, and the need to reduce obstetrical complications that accompany deliveries in patients who are overweight or obese and diabetic, means that we as a community may need to reexamine our practices and approaches much more closely.

"Food" for thought

We all know of patients who, once they become pregnant, begin justifying a greater intake of food as "eating for two." Many women may use their pregnancy as an excuse to overindulge in unhealthy foods or to forgo the gym and other regular exercise regimens. Recommending basic steps to change a patient’s lifestyle can make an incredible difference in improving maternal and fetal health outcomes.

Summary recommendations for healthy pregnancy

• A low-glycemic diet, combined with moderate exercise, can reduce or eliminate many of the negative consequences of obesity on pregnant women and their babies.

• Proper weight management during pregnancy can improve birth outcomes.

• Weight loss during pregnancy is not recommended, except, potentially, for morbidly obese women (BMI greater than 40).

• For women who are normal weight, overweight or obese, leading healthy lifestyles can greatly improve maternal and fetal health outcomes. These include physical exercise, balanced diet, and weight loss, in combination with medication in some cases.

• It is never too late to begin healthy habits!

If we microfocus only on a woman’s predelivery and postdelivery health, then we’re losing a big opportunity to improve her whole self and prevent future health complications during and outside of pregnancy. The good news for ob.gyns. is that this complex problem has a simple, well-documented, and proven solution.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

The world is not only getting older and warmer, but it’s getting heavier and more unfit each year. According to the World Health Organization’s most recent data, more than 1.4 billion adults were overweight in 2008, and 500 million of these adults were obese. In 2012, more than 40 million young children were overweight or obese. Diabetes, a disorder closely linked with obesity, affects about 347 million people worldwide – approximately ten times more people than those with HIV/AIDS. Although the number of AIDS-related deaths has steadily decreased over the last decade, even in developing countries, the number of diabetes-related deaths has steadily increased. The WHO projects that diabetes-related deaths will double by 2030, making it the seventh leading cause of death worldwide. In the United States, diabetes already is the seventh leading cause of death.

According to the Centers for Disease Control and Prevention, obesity-related diseases cost $147 billion annually, a number which dwarfs the health care costs associated with smoking ($96 billion). In addition to the link with type 2 diabetes, there are strong links between obesity and heart disease, kidney disease, depression, and hypertension. From 1987 to 2007, obesity was estimated to have caused more than a 20% increase in total health care spending.

The American Diabetes Association estimates that people diagnosed with diabetes have average yearly medical expenditures of over $13,000, which is over two times higher than the expenditures of a person without diagnosed diabetes. The 2012 estimated annual cost of care for diagnosed diabetes was $245 billion, which includes $176 billion in direct medical costs and $69 billion in reduced productivity (Diabetes Care 2013 [doi:10.2337/dc12-2625]). These figures, while staggering, do not include projected expenditures for people who have yet to receive a diabetes diagnosis.

The federal government has chosen to take dramatic steps to help Americans lose weight. Since 2011, the Centers for Medicare & Medicaid Services has covered screening and intensive behavioral therapy for obesity by primary care physicians during office visits or outpatient hospital care. Additionally, the Affordable Care Act (ACA) now requires insurance companies to help overweight and obese patients try to lose weight and be healthier. The 2012 Institute of Medicine (IOM) report, Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation also has made major recommendations for health care practitioners, schools, and the food and beverage industry to take a more active part in improving our overall health.

Simple steps make a big impact on health

Despite the daunting – and perhaps somewhat disheartening – statistics on obesity and diabetes in the United States and around the world, research has shown that small steps to achieving a healthy weight and maintaining an active lifestyle can make a dramatic difference on the course of a person’s life. According to the Department of Agriculture, healthier diets could prevent about $71 billion in yearly health care costs, lost productivity, and premature deaths. This number is staggering, when you consider that the change could be as small as choosing a salad instead of fries for a side dish.

Medical research backs up the well-worn adage that "an apple a day keeps the doctor away." The Diabetes Prevention Program study, conducted in the early 2000s, found that lifestyle changes, such as getting more exercise and eating a balanced diet, had a major impact on whether a patient who is overweight with prediabetes developed type 2 diabetes (N. Engl. J. Med. 2002;346:393-403).

Lifestyle changes can also reduce the onset of diabetes in high-risk groups such as Asian Indians, where the incidence of diabetes is the highest in the world. The Indian Diabetes Prevention Programme showed that weight loss and healthy eating reduced the incidence of type 2 diabetes in this population at a rate similar to the use of metformin, one of the most common oral antidiabetic drugs (Diabetologia 2006;49:289-97).

The 16th U.S. Surgeon General, David Satcher, M.D., Ph.D., is famous for giving his "Prescription for Great Health" when he addresses colleges and universities, which includes not smoking, staying away from illicit drug use, and abstaining from unsafe sex. Importantly, the first two key points of his "prescription" are exercising at least five times a week for 30 minutes and eating at least five servings of fruits and vegetables daily. Again, very simple recommendations, but his advice has lasting and profound ramifications.

Do obstetrician/gynecologists have a role?

As ob.gyns., we always have played an incredibly critical role in maintaining the health and well-being of our patients. Now, more than ever, we have a significant opportunity to set our patients on a path to better eating, incorporating exercise into their daily routines and passing down these good habits to their children.

In the "old days," the ob.gyn. focused on a limited period in a patient’s life. Perhaps we only saw a patient for annual exams and then for a more intense time prior to and during pregnancy, and then for a checkup post partum where we may have examined our patients only for complications of the pregnancy and delivery and not much more. Although we may have included some counseling on maintaining a healthy pregnancy, many of us relied on a patient’s primary care physician to provide ongoing support.

Today, however, we must take a more active role in helping our patients establish and maintain a healthy lifestyle. Despite the increased insurance coverage under the ACA and the expansion of Medicaid, a woman’s ob.gyn. may be the only health care practitioner she will see on a routine basis. Many women do not visit a general practitioner for routine physical examinations, but women will see their ob.gyn. for regular exams. We can use these annual or biannual office visits to help women set goals to live a healthy life, approaching each patient as a whole person who needs comprehensive care throughout her reproductive life and beyond.

For patients who are overweight or obese, we may focus on helping them reduce their body mass index and blood pressure and encourage them to stay fit. We also should do everything we can to ensure that if a woman has had gestational diabetes, she’s doing what she can to reduce her risk of developing type 2 diabetes after pregnancy. For these patients, we should consider testing their blood glucose every 1-2 years during the annual checkup.

Healthy weight in pregnancy: to gain or to lose?

Whether or not an ob.gyn. practice implements a screening program and more intensive obesity and diabetes counseling, we all will face the same question: How much weight should my patient gain to have a healthy baby? Interestingly, in the first half of the 20th century, ob.gyns. were discouraged from recommending that their pregnant patients gain very much weight. Indeed, the 13th edition of "Williams Obstetrics" (New York: Appleton-Century-Crofts, 1966, p. 326) stated that obstetricians should limit their patients from gaining more than 25 pounds during gestation, and that the ideal weight gain was 15 pounds.

This guidance was called into question by a 1970 National Academy of Sciences report, "Maternal Nutrition and the Course of Pregnancy," which indicated a strong link between infant mortality and low maternal pregnancy weight. Further evidence suggested a need for new standards and, in 1990, the IOM issued recommendations on women’s nutrition during pregnancy (Nutrition During Pregnancy, Weight Gain and Nutrient Supplements. Washington, D.C.: National Academy Press, 1990). (See table.)

Americans consume 31% more calories today than they did 40 years ago. Because of this, a woman’s need to gain weight to improve the outcome of her pregnancy is significantly reduced. The calories that many people include in their diets often come from high-fat, sodium-loaded, processed foods. We also have become a more sedentary society, spending our days at a computer, browsing the internet, watching TV, and opting to drive rather than to walk. Taking these factors into account, revising the recommendations for weight gain seemed crucial. In 2009, the IOM revised its guidance on healthy weight gain in pregnancy, and these ranges are currently widely accepted by obstetricians today (iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx). (See table.)

With the obesity and diabetes epidemics on the rise, we may need to update the 2009 IOM guidelines again – and very soon. Isolated studies have indicated that, for women who are severely obese, moderate weight loss during pregnancy may improve pregnancy outcomes. These findings remain controversial, but the "heavy" burden of diabetes and obesity on the U.S. health care system in general, and the need to reduce obstetrical complications that accompany deliveries in patients who are overweight or obese and diabetic, means that we as a community may need to reexamine our practices and approaches much more closely.

"Food" for thought

We all know of patients who, once they become pregnant, begin justifying a greater intake of food as "eating for two." Many women may use their pregnancy as an excuse to overindulge in unhealthy foods or to forgo the gym and other regular exercise regimens. Recommending basic steps to change a patient’s lifestyle can make an incredible difference in improving maternal and fetal health outcomes.

Summary recommendations for healthy pregnancy

• A low-glycemic diet, combined with moderate exercise, can reduce or eliminate many of the negative consequences of obesity on pregnant women and their babies.

• Proper weight management during pregnancy can improve birth outcomes.

• Weight loss during pregnancy is not recommended, except, potentially, for morbidly obese women (BMI greater than 40).

• For women who are normal weight, overweight or obese, leading healthy lifestyles can greatly improve maternal and fetal health outcomes. These include physical exercise, balanced diet, and weight loss, in combination with medication in some cases.

• It is never too late to begin healthy habits!

If we microfocus only on a woman’s predelivery and postdelivery health, then we’re losing a big opportunity to improve her whole self and prevent future health complications during and outside of pregnancy. The good news for ob.gyns. is that this complex problem has a simple, well-documented, and proven solution.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

The world is not only getting older and warmer, but it’s getting heavier and more unfit each year. According to the World Health Organization’s most recent data, more than 1.4 billion adults were overweight in 2008, and 500 million of these adults were obese. In 2012, more than 40 million young children were overweight or obese. Diabetes, a disorder closely linked with obesity, affects about 347 million people worldwide – approximately ten times more people than those with HIV/AIDS. Although the number of AIDS-related deaths has steadily decreased over the last decade, even in developing countries, the number of diabetes-related deaths has steadily increased. The WHO projects that diabetes-related deaths will double by 2030, making it the seventh leading cause of death worldwide. In the United States, diabetes already is the seventh leading cause of death.

According to the Centers for Disease Control and Prevention, obesity-related diseases cost $147 billion annually, a number which dwarfs the health care costs associated with smoking ($96 billion). In addition to the link with type 2 diabetes, there are strong links between obesity and heart disease, kidney disease, depression, and hypertension. From 1987 to 2007, obesity was estimated to have caused more than a 20% increase in total health care spending.

The American Diabetes Association estimates that people diagnosed with diabetes have average yearly medical expenditures of over $13,000, which is over two times higher than the expenditures of a person without diagnosed diabetes. The 2012 estimated annual cost of care for diagnosed diabetes was $245 billion, which includes $176 billion in direct medical costs and $69 billion in reduced productivity (Diabetes Care 2013 [doi:10.2337/dc12-2625]). These figures, while staggering, do not include projected expenditures for people who have yet to receive a diabetes diagnosis.

The federal government has chosen to take dramatic steps to help Americans lose weight. Since 2011, the Centers for Medicare & Medicaid Services has covered screening and intensive behavioral therapy for obesity by primary care physicians during office visits or outpatient hospital care. Additionally, the Affordable Care Act (ACA) now requires insurance companies to help overweight and obese patients try to lose weight and be healthier. The 2012 Institute of Medicine (IOM) report, Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation also has made major recommendations for health care practitioners, schools, and the food and beverage industry to take a more active part in improving our overall health.

Simple steps make a big impact on health

Despite the daunting – and perhaps somewhat disheartening – statistics on obesity and diabetes in the United States and around the world, research has shown that small steps to achieving a healthy weight and maintaining an active lifestyle can make a dramatic difference on the course of a person’s life. According to the Department of Agriculture, healthier diets could prevent about $71 billion in yearly health care costs, lost productivity, and premature deaths. This number is staggering, when you consider that the change could be as small as choosing a salad instead of fries for a side dish.

Medical research backs up the well-worn adage that "an apple a day keeps the doctor away." The Diabetes Prevention Program study, conducted in the early 2000s, found that lifestyle changes, such as getting more exercise and eating a balanced diet, had a major impact on whether a patient who is overweight with prediabetes developed type 2 diabetes (N. Engl. J. Med. 2002;346:393-403).

Lifestyle changes can also reduce the onset of diabetes in high-risk groups such as Asian Indians, where the incidence of diabetes is the highest in the world. The Indian Diabetes Prevention Programme showed that weight loss and healthy eating reduced the incidence of type 2 diabetes in this population at a rate similar to the use of metformin, one of the most common oral antidiabetic drugs (Diabetologia 2006;49:289-97).

The 16th U.S. Surgeon General, David Satcher, M.D., Ph.D., is famous for giving his "Prescription for Great Health" when he addresses colleges and universities, which includes not smoking, staying away from illicit drug use, and abstaining from unsafe sex. Importantly, the first two key points of his "prescription" are exercising at least five times a week for 30 minutes and eating at least five servings of fruits and vegetables daily. Again, very simple recommendations, but his advice has lasting and profound ramifications.

Do obstetrician/gynecologists have a role?

As ob.gyns., we always have played an incredibly critical role in maintaining the health and well-being of our patients. Now, more than ever, we have a significant opportunity to set our patients on a path to better eating, incorporating exercise into their daily routines and passing down these good habits to their children.

In the "old days," the ob.gyn. focused on a limited period in a patient’s life. Perhaps we only saw a patient for annual exams and then for a more intense time prior to and during pregnancy, and then for a checkup post partum where we may have examined our patients only for complications of the pregnancy and delivery and not much more. Although we may have included some counseling on maintaining a healthy pregnancy, many of us relied on a patient’s primary care physician to provide ongoing support.

Today, however, we must take a more active role in helping our patients establish and maintain a healthy lifestyle. Despite the increased insurance coverage under the ACA and the expansion of Medicaid, a woman’s ob.gyn. may be the only health care practitioner she will see on a routine basis. Many women do not visit a general practitioner for routine physical examinations, but women will see their ob.gyn. for regular exams. We can use these annual or biannual office visits to help women set goals to live a healthy life, approaching each patient as a whole person who needs comprehensive care throughout her reproductive life and beyond.

For patients who are overweight or obese, we may focus on helping them reduce their body mass index and blood pressure and encourage them to stay fit. We also should do everything we can to ensure that if a woman has had gestational diabetes, she’s doing what she can to reduce her risk of developing type 2 diabetes after pregnancy. For these patients, we should consider testing their blood glucose every 1-2 years during the annual checkup.

Healthy weight in pregnancy: to gain or to lose?

Whether or not an ob.gyn. practice implements a screening program and more intensive obesity and diabetes counseling, we all will face the same question: How much weight should my patient gain to have a healthy baby? Interestingly, in the first half of the 20th century, ob.gyns. were discouraged from recommending that their pregnant patients gain very much weight. Indeed, the 13th edition of "Williams Obstetrics" (New York: Appleton-Century-Crofts, 1966, p. 326) stated that obstetricians should limit their patients from gaining more than 25 pounds during gestation, and that the ideal weight gain was 15 pounds.

This guidance was called into question by a 1970 National Academy of Sciences report, "Maternal Nutrition and the Course of Pregnancy," which indicated a strong link between infant mortality and low maternal pregnancy weight. Further evidence suggested a need for new standards and, in 1990, the IOM issued recommendations on women’s nutrition during pregnancy (Nutrition During Pregnancy, Weight Gain and Nutrient Supplements. Washington, D.C.: National Academy Press, 1990). (See table.)

Americans consume 31% more calories today than they did 40 years ago. Because of this, a woman’s need to gain weight to improve the outcome of her pregnancy is significantly reduced. The calories that many people include in their diets often come from high-fat, sodium-loaded, processed foods. We also have become a more sedentary society, spending our days at a computer, browsing the internet, watching TV, and opting to drive rather than to walk. Taking these factors into account, revising the recommendations for weight gain seemed crucial. In 2009, the IOM revised its guidance on healthy weight gain in pregnancy, and these ranges are currently widely accepted by obstetricians today (iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx). (See table.)

With the obesity and diabetes epidemics on the rise, we may need to update the 2009 IOM guidelines again – and very soon. Isolated studies have indicated that, for women who are severely obese, moderate weight loss during pregnancy may improve pregnancy outcomes. These findings remain controversial, but the "heavy" burden of diabetes and obesity on the U.S. health care system in general, and the need to reduce obstetrical complications that accompany deliveries in patients who are overweight or obese and diabetic, means that we as a community may need to reexamine our practices and approaches much more closely.

"Food" for thought

We all know of patients who, once they become pregnant, begin justifying a greater intake of food as "eating for two." Many women may use their pregnancy as an excuse to overindulge in unhealthy foods or to forgo the gym and other regular exercise regimens. Recommending basic steps to change a patient’s lifestyle can make an incredible difference in improving maternal and fetal health outcomes.

Summary recommendations for healthy pregnancy

• A low-glycemic diet, combined with moderate exercise, can reduce or eliminate many of the negative consequences of obesity on pregnant women and their babies.

• Proper weight management during pregnancy can improve birth outcomes.

• Weight loss during pregnancy is not recommended, except, potentially, for morbidly obese women (BMI greater than 40).

• For women who are normal weight, overweight or obese, leading healthy lifestyles can greatly improve maternal and fetal health outcomes. These include physical exercise, balanced diet, and weight loss, in combination with medication in some cases.

• It is never too late to begin healthy habits!

If we microfocus only on a woman’s predelivery and postdelivery health, then we’re losing a big opportunity to improve her whole self and prevent future health complications during and outside of pregnancy. The good news for ob.gyns. is that this complex problem has a simple, well-documented, and proven solution.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

How often do you fire patients? I do it here and there, maybe a few times a year, but certainly not as often as patients fire me.

Contrary to popular belief, I don’t get some sort of perverse thrill out of it. I am maybe relieved, knowing that I’m (hopefully) done with a difficult relationship. But it’s a pain, always requiring a trip to the post office to send the registered letter. There’s also the fear that they’ll report me to the board for it, and I’ll have to defend my actions. And I certainly can’t guard against the one-sided Yelp reviews.

What tips you over the edge? I consider myself pretty tolerant. In long-standing patients, I’ll generally let the occasional no-show slide. For drug abusers, I’m actually willing to continue with many of them, but will let them know that I’m not going to give them controlled substances anymore. Most of them leave at that point anyway.

I have zero tolerance for malicious behavior. Abuse my staff, and you’re out of here. I’m more willing to put up with someone who’s nasty to me than one who treats my staff the same way.

What other things do I fire them for? Occasionally noncompliance, especially if it’s putting their own safety in danger. Only once have I fired someone for refusing to have tests done. That was after, literally, 5 years of him repeatedly showing up annually to ask me to order them for his symptoms, then never following through and showing up a year later to start over again. At some point, my patience for that type of thing runs out, and I consider myself fairly patient.

Like most doctors, I’ve had more patients fire me than I’ve fired patients. For most, you don’t realize they’re gone. They just never come back. Occasionally, you get a release from another doctor, but more often you don’t.

Rarely, someone sends a nasty letter telling me why they went elsewhere and what they think of my medical skills/fashion sense/office décor ... whatever. The first time I got one of those, it hurt. Nowadays, I just don’t care.

Part of growing up as a doctor is realizing you’ll never make everyone happy or be able to help them all. Trying to do so will only lessen your sanity, so it’s a message best learned early.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often do you fire patients? I do it here and there, maybe a few times a year, but certainly not as often as patients fire me.

Contrary to popular belief, I don’t get some sort of perverse thrill out of it. I am maybe relieved, knowing that I’m (hopefully) done with a difficult relationship. But it’s a pain, always requiring a trip to the post office to send the registered letter. There’s also the fear that they’ll report me to the board for it, and I’ll have to defend my actions. And I certainly can’t guard against the one-sided Yelp reviews.

What tips you over the edge? I consider myself pretty tolerant. In long-standing patients, I’ll generally let the occasional no-show slide. For drug abusers, I’m actually willing to continue with many of them, but will let them know that I’m not going to give them controlled substances anymore. Most of them leave at that point anyway.

I have zero tolerance for malicious behavior. Abuse my staff, and you’re out of here. I’m more willing to put up with someone who’s nasty to me than one who treats my staff the same way.

What other things do I fire them for? Occasionally noncompliance, especially if it’s putting their own safety in danger. Only once have I fired someone for refusing to have tests done. That was after, literally, 5 years of him repeatedly showing up annually to ask me to order them for his symptoms, then never following through and showing up a year later to start over again. At some point, my patience for that type of thing runs out, and I consider myself fairly patient.

Like most doctors, I’ve had more patients fire me than I’ve fired patients. For most, you don’t realize they’re gone. They just never come back. Occasionally, you get a release from another doctor, but more often you don’t.

Rarely, someone sends a nasty letter telling me why they went elsewhere and what they think of my medical skills/fashion sense/office décor ... whatever. The first time I got one of those, it hurt. Nowadays, I just don’t care.

Part of growing up as a doctor is realizing you’ll never make everyone happy or be able to help them all. Trying to do so will only lessen your sanity, so it’s a message best learned early.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often do you fire patients? I do it here and there, maybe a few times a year, but certainly not as often as patients fire me.

Contrary to popular belief, I don’t get some sort of perverse thrill out of it. I am maybe relieved, knowing that I’m (hopefully) done with a difficult relationship. But it’s a pain, always requiring a trip to the post office to send the registered letter. There’s also the fear that they’ll report me to the board for it, and I’ll have to defend my actions. And I certainly can’t guard against the one-sided Yelp reviews.

What tips you over the edge? I consider myself pretty tolerant. In long-standing patients, I’ll generally let the occasional no-show slide. For drug abusers, I’m actually willing to continue with many of them, but will let them know that I’m not going to give them controlled substances anymore. Most of them leave at that point anyway.

I have zero tolerance for malicious behavior. Abuse my staff, and you’re out of here. I’m more willing to put up with someone who’s nasty to me than one who treats my staff the same way.

What other things do I fire them for? Occasionally noncompliance, especially if it’s putting their own safety in danger. Only once have I fired someone for refusing to have tests done. That was after, literally, 5 years of him repeatedly showing up annually to ask me to order them for his symptoms, then never following through and showing up a year later to start over again. At some point, my patience for that type of thing runs out, and I consider myself fairly patient.

Like most doctors, I’ve had more patients fire me than I’ve fired patients. For most, you don’t realize they’re gone. They just never come back. Occasionally, you get a release from another doctor, but more often you don’t.

Rarely, someone sends a nasty letter telling me why they went elsewhere and what they think of my medical skills/fashion sense/office décor ... whatever. The first time I got one of those, it hurt. Nowadays, I just don’t care.

Part of growing up as a doctor is realizing you’ll never make everyone happy or be able to help them all. Trying to do so will only lessen your sanity, so it’s a message best learned early.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Supplementation with polyunsaturated fatty acids – or omega-3 fatty acids – during pregnancy is an important topic because of unproven claims that polyunsaturated fatty acids (PUFAs) improve fetal brain and eye development if taken during pregnancy, resulting in unnecessary expense for many women who buy these products. In Canada, there are prenatal vitamins available that contain omega-3 fatty acids with a statement that the product "helps support cognitive health and/or brain function" or that omega-3 fatty acids "support "healthy fetal brain and eye development." These are misleading, inappropriate statements, considering that there is no compelling evidence to support these claims.

Claims about the benefits of PUFA supplementation during pregnancy, which have circulated for about a decade, originate from studies that show that when PUFAs are restricted during pregnancy, fetal brain development can be adversely affected, particularly in animals. Other data include several human studies that have linked high cognitive scores to a high seafood content of the maternal diet. The highest levels of PUFAs are measured in the retina, which is part of the visual acuity claim.

My colleagues and I addressed the uncertainties about the benefits of PUFA supplementation in a systematic review of nine randomized controlled trials comparing visual and neurobehavioral outcomes in infants whose mothers received PUFA supplements during gestation with control women who received placebos. Three studies evaluated retinal development and six evaluated neurodevelopment; most ended the supplement at delivery, and evaluations were conducted during the first year, or up to age 2.5, 4, and 7 years in different studies.

Overall, there was no evidence of a beneficial effect of PUFA supplementation during pregnancy on neurodevelopment (IQ, language behaviors) or on visual acuity. As we concluded, there were "very limited, if any" benefits identified, and in the studies with statistically significant differences between the two groups, "the differences were small and of little potential clinical importance" (Obstet. Gynecol. Int. 2012 [doi:10.1155/2012/591531]).

A study published in May 2014 also found no beneficial effect of prenatal supplementation with 800 mg/day of omega-3 fatty acid docosahexaenoic acid (DHA) on neurodevelopmental outcomes in children followed to age 4 years, and the authors concluded that the data "do not support prenatal DHA supplementation to enhance early childhood development." The randomized placebo-controlled study evaluated about 650 children at age 4 years, whose mothers had received the supplement or 333 who received placebo. The mean cognitive scores were not different between the two groups, and the proportion of children with delayed or advanced scores also did not differ between the two groups, nor did other objective assessments of cognition, language, and executive functioning (JAMA 2014;311:1802-4).

Based on the lack of evidence to date, there is no reason to add PUFAs to prenatal vitamins or recommend that women take a PUFA supplement during pregnancy.

The bottom line for clinicians/health care providers is that although the available evidence today has found no detrimental effects of even high doses of omega-3 fatty acid supplementation (up to 3.7 g/day), with the present state of knowledge, there is no evidence that prenatal supplementation with PUFAs improves brain development or acuity of vision in children. Instead of supplementation with PUFA during pregnancy, women should consume a diet with adequate PUFAs, with food that includes eggs and fish, with caution about the mercury content of fish.

Dr. Koren is professor of pediatrics, pharmacology, pharmacy, medicine, and medical genetics at the University of Toronto. He heads the Research Leadership for Better Pharmacotherapy During Pregnancy and Lactation at the Hospital for Sick Children, Toronto, where he is director of the Motherisk Program. He also holds the Ivey Chair in Molecular Toxicology at the department of medicine, University of Western Ontario, London. He had no disclosures relevant to this topic. E-mail him at [email protected].

Supplementation with polyunsaturated fatty acids – or omega-3 fatty acids – during pregnancy is an important topic because of unproven claims that polyunsaturated fatty acids (PUFAs) improve fetal brain and eye development if taken during pregnancy, resulting in unnecessary expense for many women who buy these products. In Canada, there are prenatal vitamins available that contain omega-3 fatty acids with a statement that the product "helps support cognitive health and/or brain function" or that omega-3 fatty acids "support "healthy fetal brain and eye development." These are misleading, inappropriate statements, considering that there is no compelling evidence to support these claims.

Claims about the benefits of PUFA supplementation during pregnancy, which have circulated for about a decade, originate from studies that show that when PUFAs are restricted during pregnancy, fetal brain development can be adversely affected, particularly in animals. Other data include several human studies that have linked high cognitive scores to a high seafood content of the maternal diet. The highest levels of PUFAs are measured in the retina, which is part of the visual acuity claim.

My colleagues and I addressed the uncertainties about the benefits of PUFA supplementation in a systematic review of nine randomized controlled trials comparing visual and neurobehavioral outcomes in infants whose mothers received PUFA supplements during gestation with control women who received placebos. Three studies evaluated retinal development and six evaluated neurodevelopment; most ended the supplement at delivery, and evaluations were conducted during the first year, or up to age 2.5, 4, and 7 years in different studies.

Overall, there was no evidence of a beneficial effect of PUFA supplementation during pregnancy on neurodevelopment (IQ, language behaviors) or on visual acuity. As we concluded, there were "very limited, if any" benefits identified, and in the studies with statistically significant differences between the two groups, "the differences were small and of little potential clinical importance" (Obstet. Gynecol. Int. 2012 [doi:10.1155/2012/591531]).

A study published in May 2014 also found no beneficial effect of prenatal supplementation with 800 mg/day of omega-3 fatty acid docosahexaenoic acid (DHA) on neurodevelopmental outcomes in children followed to age 4 years, and the authors concluded that the data "do not support prenatal DHA supplementation to enhance early childhood development." The randomized placebo-controlled study evaluated about 650 children at age 4 years, whose mothers had received the supplement or 333 who received placebo. The mean cognitive scores were not different between the two groups, and the proportion of children with delayed or advanced scores also did not differ between the two groups, nor did other objective assessments of cognition, language, and executive functioning (JAMA 2014;311:1802-4).

Based on the lack of evidence to date, there is no reason to add PUFAs to prenatal vitamins or recommend that women take a PUFA supplement during pregnancy.

The bottom line for clinicians/health care providers is that although the available evidence today has found no detrimental effects of even high doses of omega-3 fatty acid supplementation (up to 3.7 g/day), with the present state of knowledge, there is no evidence that prenatal supplementation with PUFAs improves brain development or acuity of vision in children. Instead of supplementation with PUFA during pregnancy, women should consume a diet with adequate PUFAs, with food that includes eggs and fish, with caution about the mercury content of fish.

Dr. Koren is professor of pediatrics, pharmacology, pharmacy, medicine, and medical genetics at the University of Toronto. He heads the Research Leadership for Better Pharmacotherapy During Pregnancy and Lactation at the Hospital for Sick Children, Toronto, where he is director of the Motherisk Program. He also holds the Ivey Chair in Molecular Toxicology at the department of medicine, University of Western Ontario, London. He had no disclosures relevant to this topic. E-mail him at [email protected].

Supplementation with polyunsaturated fatty acids – or omega-3 fatty acids – during pregnancy is an important topic because of unproven claims that polyunsaturated fatty acids (PUFAs) improve fetal brain and eye development if taken during pregnancy, resulting in unnecessary expense for many women who buy these products. In Canada, there are prenatal vitamins available that contain omega-3 fatty acids with a statement that the product "helps support cognitive health and/or brain function" or that omega-3 fatty acids "support "healthy fetal brain and eye development." These are misleading, inappropriate statements, considering that there is no compelling evidence to support these claims.

Claims about the benefits of PUFA supplementation during pregnancy, which have circulated for about a decade, originate from studies that show that when PUFAs are restricted during pregnancy, fetal brain development can be adversely affected, particularly in animals. Other data include several human studies that have linked high cognitive scores to a high seafood content of the maternal diet. The highest levels of PUFAs are measured in the retina, which is part of the visual acuity claim.

My colleagues and I addressed the uncertainties about the benefits of PUFA supplementation in a systematic review of nine randomized controlled trials comparing visual and neurobehavioral outcomes in infants whose mothers received PUFA supplements during gestation with control women who received placebos. Three studies evaluated retinal development and six evaluated neurodevelopment; most ended the supplement at delivery, and evaluations were conducted during the first year, or up to age 2.5, 4, and 7 years in different studies.

Overall, there was no evidence of a beneficial effect of PUFA supplementation during pregnancy on neurodevelopment (IQ, language behaviors) or on visual acuity. As we concluded, there were "very limited, if any" benefits identified, and in the studies with statistically significant differences between the two groups, "the differences were small and of little potential clinical importance" (Obstet. Gynecol. Int. 2012 [doi:10.1155/2012/591531]).

A study published in May 2014 also found no beneficial effect of prenatal supplementation with 800 mg/day of omega-3 fatty acid docosahexaenoic acid (DHA) on neurodevelopmental outcomes in children followed to age 4 years, and the authors concluded that the data "do not support prenatal DHA supplementation to enhance early childhood development." The randomized placebo-controlled study evaluated about 650 children at age 4 years, whose mothers had received the supplement or 333 who received placebo. The mean cognitive scores were not different between the two groups, and the proportion of children with delayed or advanced scores also did not differ between the two groups, nor did other objective assessments of cognition, language, and executive functioning (JAMA 2014;311:1802-4).

Based on the lack of evidence to date, there is no reason to add PUFAs to prenatal vitamins or recommend that women take a PUFA supplement during pregnancy.

The bottom line for clinicians/health care providers is that although the available evidence today has found no detrimental effects of even high doses of omega-3 fatty acid supplementation (up to 3.7 g/day), with the present state of knowledge, there is no evidence that prenatal supplementation with PUFAs improves brain development or acuity of vision in children. Instead of supplementation with PUFA during pregnancy, women should consume a diet with adequate PUFAs, with food that includes eggs and fish, with caution about the mercury content of fish.

Dr. Koren is professor of pediatrics, pharmacology, pharmacy, medicine, and medical genetics at the University of Toronto. He heads the Research Leadership for Better Pharmacotherapy During Pregnancy and Lactation at the Hospital for Sick Children, Toronto, where he is director of the Motherisk Program. He also holds the Ivey Chair in Molecular Toxicology at the department of medicine, University of Western Ontario, London. He had no disclosures relevant to this topic. E-mail him at [email protected].

Estrogen therapy is highly effective in the treatment of hot flashes among postmenopausal women. For postmenopausal women with a uterus, estrogen treatment for hot flashes is almost always combined with a progestin to reduce the risk of endometrial polyps, hyperplasia, and cancer. For instance, in the Postmenopausal Estrogen/Progestin Interventions Trial, 62% of the women with a uterus treated with conjugated equine estrogen (CEE) 0.625 mg daily without a progestin developed endometrial hyperplasia.¹

In the United States, the most commonly prescribed progestin for hormone therapy has been medroxyprogesterone acetate (MPA; Provera). However, data from the Women’s Health Initiative (WHI) trials indicate that MPA, when combined with CEE, may have adverse health effects among postmenopausal women.

Let’s examine the WHI data
Among women 50 to 59 years of age with a uterus, the combination of CEE plus MPA was associated with a trend toward an increased risk of breast cancer, coronary heart disease, and myocardial infarction.² In contrast, among women 50 to 59 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of invasive breast cancer, coronary heart disease, and myocardial infarction (TABLE 1).

Among women 50 to 79 years of age with a uterus, the combination of CEE plus MPA was associated with a significantly increased risk of breast cancer (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.01–1.53; P = .04).² In contrast, among women 50 to 79 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of breast cancer (HR, 0.79; 95% CI, 0.61–1.02, P = .07).²

Related article: In the latest report from the WHI, the data contradict the conclusions. Holly Thacker, MD (Commentary; March 2014)

When the analysis was limited to women consistently adherent to their CEE monotherapy, the estrogen treatment significantly decreased the risk of invasive breast cancer (HR, 0.67; 95% CI, 0.47–0.97; P = .03).³

The addition of MPA to CEE appears to reverse some of the health benefits of CEE monotherapy, although the biological mechanisms are unclear. This observation should prompt us to explore alternative and novel treatments of vasomotor symptoms that do not utilize MPA. Some options for MPA-free hormone therapy include:

• transdermal estradiol plus micronized progesterone
• CEE plus a levonorgestrel-releasing intrauterine system
• bazedoxifene plus CEE.

In addition, nonhormonal treatment of hot flashes is an option, with selective serotonin reuptake inhibitors (SSRIs).

Related article: Is one oral estrogen formulation safer than another for menopausal women? Andrew M. Kaunitz, MD (Examining the Evidence; January 2014)

MPA-free hormone therapy for hot flashes
Estrogen plus micronized progesterone
When using an estrogen plus progestin regimen to treat hot flashes, many experts favor a combination of low-dose transdermal estradiol and oral micronized progesterone (Prometrium). This combination is believed by some experts to result in a lower risk of venous thromboembolism, stroke, cardiovascular disease, and breast cancer than an estrogen-MPA combination.^4–7

When prescribing transdermal estradiol plus oral micronized progesterone for a woman within 1 to 2 years of her last menses, a cyclic regimen can help reduce episodes of irregular, unscheduled uterine bleeding. I often use this cyclic regimen: transdermal estradiol 0.0375 mg plus cyclic oral micronized progesterone 200 mg prior to bedtime for calendar days 1 to 12.

When using transdermal estradiol plus oral micronized progesterone in a woman more than 2 years from her last menses, a continuous regimen is often prescribed. I often use this continuous regimen: transdermal estradiol 0.0375 mg plus continuous oral micronized progesterone 100 mg daily prior to bedtime.

Related article: When should a menopausal woman discontinue hormone therapy? Andrew M. Kaunitz, MD (Cases in Menopause; February 2014)

Estrogen plus a levonorgestrel-releasing intrauterine systemThe levonorgestrel intrauterine system (LNG-IUS; 20 µg daily; Mirena) is frequently used in Europe to protect the endometrium against the adverse effects of estrogen therapy in postmenopausal women. In a meta-analysis of five clinical trials involving postmenopausal women, the LNG-IUS provided excellent protection against endometrial hyperplasia, compared with MPA.8

One caution about using the LNG-IUS system with estrogen in postmenopausal women is that an observational study of all women with breast cancer in Finland from 1995 through 2007 reported a significantly increased risk of breast cancer among postmenopausal women using an LNG-IUS compared with women who did not use hormones or used only estrogen because they had a hysterectomy (TABLE 2).⁹ This study was not a randomized clinical trial and patients at higher baseline risk for breast cancer, including women with a high body mass index, may have been preferentially treated with an LNG-IUS. More information is needed to better understand the relationship between the LNG-IUS and breast cancer in postmenopausal women.

Paroxetine can block the metabolism of tamoxifen to its highly potent metabolite, endoxifen. Consequently, paroxetine may reduce the effectiveness of tamoxifen treatment for breast cancer and should be used with caution in postmenopausal women with breast cancer being treated with tamoxifen.

Related article: Paroxetine mesylate 7.5 mg found to be a safe alternative to hormone therapy for menopausal women with hot flashes. (News for your Practice; June 2014)

Escitalopram
Gynecologists are familiar with the use of venlafaxine, desvenlafaxine, clonidine, citalopram, sertraline, and fluoxetine for the treatment of postmenopausal hot flashes. Recently, escitalopram (Lexapro) at doses of 10 to 20 mg daily has been shown to be more effective than placebo in the treatment of hot flashes and sleep disturbances in postmenopausal women.^23,24 In one trial of escitalopram 10 to 20 mg daily versus placebo in 205 postmenopausal women averaging 9.8 hot flashes daily at baseline, escitalopram and placebo reduced mean daily hot flashes by 4.6 and 3.2, respectively (P<.001), after 8 weeks of treatment.

In a meta-analysis of SSRIs for the treatment of hot flashes, data from a mixed-treatment comparison analysis indicated that the rank order from most to least effective therapy for hot flashes was: escitalopram > paroxetine > sertraline > citalopram > fluoxetine.²⁵ Venlafaxine and desvenlafaxine, two serotonin and  norepinephrine reuptake inhibitors that are effective in the treatment of hot flashes, were not included in the mixed-treatment comparison.

Use of alternatives to MPA could mean fewer health risks for women on a wide scale
Substantial data indicate that MPA is not an optimal progestin to combine with estrogen for hormone therapy. Currently, many health insurance plans and Medicare use pharmacy management formularies that prioritize dispensing MPA for postmenopausal hormone therapy. Dispensing an alternative to MPA, such as micronized progesterone, often requires the patient to make a significant copayment.

Hopefully, health insurance companies, Medicare, and their affiliated pharmacy management administrators will soon stop their current policy of using financial incentives to favor dispensing MPA when hormone therapy is prescribed because alternatives to MPA appear to be associated with fewer health risks for postmenopausal women.

WE WANT TO HEAR FROM YOU! Share your thoughts on this article. Send your Letter to the Editor to: [email protected] 

Estrogen therapy is highly effective in the treatment of hot flashes among postmenopausal women. For postmenopausal women with a uterus, estrogen treatment for hot flashes is almost always combined with a progestin to reduce the risk of endometrial polyps, hyperplasia, and cancer. For instance, in the Postmenopausal Estrogen/Progestin Interventions Trial, 62% of the women with a uterus treated with conjugated equine estrogen (CEE) 0.625 mg daily without a progestin developed endometrial hyperplasia.¹

In the United States, the most commonly prescribed progestin for hormone therapy has been medroxyprogesterone acetate (MPA; Provera). However, data from the Women’s Health Initiative (WHI) trials indicate that MPA, when combined with CEE, may have adverse health effects among postmenopausal women.

Let’s examine the WHI data
Among women 50 to 59 years of age with a uterus, the combination of CEE plus MPA was associated with a trend toward an increased risk of breast cancer, coronary heart disease, and myocardial infarction.² In contrast, among women 50 to 59 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of invasive breast cancer, coronary heart disease, and myocardial infarction (TABLE 1).

Among women 50 to 79 years of age with a uterus, the combination of CEE plus MPA was associated with a significantly increased risk of breast cancer (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.01–1.53; P = .04).² In contrast, among women 50 to 79 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of breast cancer (HR, 0.79; 95% CI, 0.61–1.02, P = .07).²

Related article: In the latest report from the WHI, the data contradict the conclusions. Holly Thacker, MD (Commentary; March 2014)

When the analysis was limited to women consistently adherent to their CEE monotherapy, the estrogen treatment significantly decreased the risk of invasive breast cancer (HR, 0.67; 95% CI, 0.47–0.97; P = .03).³

The addition of MPA to CEE appears to reverse some of the health benefits of CEE monotherapy, although the biological mechanisms are unclear. This observation should prompt us to explore alternative and novel treatments of vasomotor symptoms that do not utilize MPA. Some options for MPA-free hormone therapy include:

• transdermal estradiol plus micronized progesterone
• CEE plus a levonorgestrel-releasing intrauterine system
• bazedoxifene plus CEE.

In addition, nonhormonal treatment of hot flashes is an option, with selective serotonin reuptake inhibitors (SSRIs).

Related article: Is one oral estrogen formulation safer than another for menopausal women? Andrew M. Kaunitz, MD (Examining the Evidence; January 2014)

MPA-free hormone therapy for hot flashes
Estrogen plus micronized progesterone
When using an estrogen plus progestin regimen to treat hot flashes, many experts favor a combination of low-dose transdermal estradiol and oral micronized progesterone (Prometrium). This combination is believed by some experts to result in a lower risk of venous thromboembolism, stroke, cardiovascular disease, and breast cancer than an estrogen-MPA combination.^4–7

When prescribing transdermal estradiol plus oral micronized progesterone for a woman within 1 to 2 years of her last menses, a cyclic regimen can help reduce episodes of irregular, unscheduled uterine bleeding. I often use this cyclic regimen: transdermal estradiol 0.0375 mg plus cyclic oral micronized progesterone 200 mg prior to bedtime for calendar days 1 to 12.

When using transdermal estradiol plus oral micronized progesterone in a woman more than 2 years from her last menses, a continuous regimen is often prescribed. I often use this continuous regimen: transdermal estradiol 0.0375 mg plus continuous oral micronized progesterone 100 mg daily prior to bedtime.

Related article: When should a menopausal woman discontinue hormone therapy? Andrew M. Kaunitz, MD (Cases in Menopause; February 2014)

Estrogen plus a levonorgestrel-releasing intrauterine systemThe levonorgestrel intrauterine system (LNG-IUS; 20 µg daily; Mirena) is frequently used in Europe to protect the endometrium against the adverse effects of estrogen therapy in postmenopausal women. In a meta-analysis of five clinical trials involving postmenopausal women, the LNG-IUS provided excellent protection against endometrial hyperplasia, compared with MPA.8

One caution about using the LNG-IUS system with estrogen in postmenopausal women is that an observational study of all women with breast cancer in Finland from 1995 through 2007 reported a significantly increased risk of breast cancer among postmenopausal women using an LNG-IUS compared with women who did not use hormones or used only estrogen because they had a hysterectomy (TABLE 2).⁹ This study was not a randomized clinical trial and patients at higher baseline risk for breast cancer, including women with a high body mass index, may have been preferentially treated with an LNG-IUS. More information is needed to better understand the relationship between the LNG-IUS and breast cancer in postmenopausal women.

Paroxetine can block the metabolism of tamoxifen to its highly potent metabolite, endoxifen. Consequently, paroxetine may reduce the effectiveness of tamoxifen treatment for breast cancer and should be used with caution in postmenopausal women with breast cancer being treated with tamoxifen.

Related article: Paroxetine mesylate 7.5 mg found to be a safe alternative to hormone therapy for menopausal women with hot flashes. (News for your Practice; June 2014)

Escitalopram
Gynecologists are familiar with the use of venlafaxine, desvenlafaxine, clonidine, citalopram, sertraline, and fluoxetine for the treatment of postmenopausal hot flashes. Recently, escitalopram (Lexapro) at doses of 10 to 20 mg daily has been shown to be more effective than placebo in the treatment of hot flashes and sleep disturbances in postmenopausal women.^23,24 In one trial of escitalopram 10 to 20 mg daily versus placebo in 205 postmenopausal women averaging 9.8 hot flashes daily at baseline, escitalopram and placebo reduced mean daily hot flashes by 4.6 and 3.2, respectively (P<.001), after 8 weeks of treatment.

In a meta-analysis of SSRIs for the treatment of hot flashes, data from a mixed-treatment comparison analysis indicated that the rank order from most to least effective therapy for hot flashes was: escitalopram > paroxetine > sertraline > citalopram > fluoxetine.²⁵ Venlafaxine and desvenlafaxine, two serotonin and  norepinephrine reuptake inhibitors that are effective in the treatment of hot flashes, were not included in the mixed-treatment comparison.

Use of alternatives to MPA could mean fewer health risks for women on a wide scale
Substantial data indicate that MPA is not an optimal progestin to combine with estrogen for hormone therapy. Currently, many health insurance plans and Medicare use pharmacy management formularies that prioritize dispensing MPA for postmenopausal hormone therapy. Dispensing an alternative to MPA, such as micronized progesterone, often requires the patient to make a significant copayment.

Hopefully, health insurance companies, Medicare, and their affiliated pharmacy management administrators will soon stop their current policy of using financial incentives to favor dispensing MPA when hormone therapy is prescribed because alternatives to MPA appear to be associated with fewer health risks for postmenopausal women.

WE WANT TO HEAR FROM YOU! Share your thoughts on this article. Send your Letter to the Editor to: [email protected] 

Estrogen therapy is highly effective in the treatment of hot flashes among postmenopausal women. For postmenopausal women with a uterus, estrogen treatment for hot flashes is almost always combined with a progestin to reduce the risk of endometrial polyps, hyperplasia, and cancer. For instance, in the Postmenopausal Estrogen/Progestin Interventions Trial, 62% of the women with a uterus treated with conjugated equine estrogen (CEE) 0.625 mg daily without a progestin developed endometrial hyperplasia.¹

In the United States, the most commonly prescribed progestin for hormone therapy has been medroxyprogesterone acetate (MPA; Provera). However, data from the Women’s Health Initiative (WHI) trials indicate that MPA, when combined with CEE, may have adverse health effects among postmenopausal women.

Let’s examine the WHI data
Among women 50 to 59 years of age with a uterus, the combination of CEE plus MPA was associated with a trend toward an increased risk of breast cancer, coronary heart disease, and myocardial infarction.² In contrast, among women 50 to 59 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of invasive breast cancer, coronary heart disease, and myocardial infarction (TABLE 1).

Among women 50 to 79 years of age with a uterus, the combination of CEE plus MPA was associated with a significantly increased risk of breast cancer (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.01–1.53; P = .04).² In contrast, among women 50 to 79 years of age without a uterus, CEE monotherapy was associated with a trend toward a decreased risk of breast cancer (HR, 0.79; 95% CI, 0.61–1.02, P = .07).²

Related article: In the latest report from the WHI, the data contradict the conclusions. Holly Thacker, MD (Commentary; March 2014)

When the analysis was limited to women consistently adherent to their CEE monotherapy, the estrogen treatment significantly decreased the risk of invasive breast cancer (HR, 0.67; 95% CI, 0.47–0.97; P = .03).³

The addition of MPA to CEE appears to reverse some of the health benefits of CEE monotherapy, although the biological mechanisms are unclear. This observation should prompt us to explore alternative and novel treatments of vasomotor symptoms that do not utilize MPA. Some options for MPA-free hormone therapy include:

• transdermal estradiol plus micronized progesterone
• CEE plus a levonorgestrel-releasing intrauterine system
• bazedoxifene plus CEE.

In addition, nonhormonal treatment of hot flashes is an option, with selective serotonin reuptake inhibitors (SSRIs).

Related article: Is one oral estrogen formulation safer than another for menopausal women? Andrew M. Kaunitz, MD (Examining the Evidence; January 2014)

MPA-free hormone therapy for hot flashes
Estrogen plus micronized progesterone
When using an estrogen plus progestin regimen to treat hot flashes, many experts favor a combination of low-dose transdermal estradiol and oral micronized progesterone (Prometrium). This combination is believed by some experts to result in a lower risk of venous thromboembolism, stroke, cardiovascular disease, and breast cancer than an estrogen-MPA combination.^4–7

When prescribing transdermal estradiol plus oral micronized progesterone for a woman within 1 to 2 years of her last menses, a cyclic regimen can help reduce episodes of irregular, unscheduled uterine bleeding. I often use this cyclic regimen: transdermal estradiol 0.0375 mg plus cyclic oral micronized progesterone 200 mg prior to bedtime for calendar days 1 to 12.

When using transdermal estradiol plus oral micronized progesterone in a woman more than 2 years from her last menses, a continuous regimen is often prescribed. I often use this continuous regimen: transdermal estradiol 0.0375 mg plus continuous oral micronized progesterone 100 mg daily prior to bedtime.

Related article: When should a menopausal woman discontinue hormone therapy? Andrew M. Kaunitz, MD (Cases in Menopause; February 2014)

Estrogen plus a levonorgestrel-releasing intrauterine systemThe levonorgestrel intrauterine system (LNG-IUS; 20 µg daily; Mirena) is frequently used in Europe to protect the endometrium against the adverse effects of estrogen therapy in postmenopausal women. In a meta-analysis of five clinical trials involving postmenopausal women, the LNG-IUS provided excellent protection against endometrial hyperplasia, compared with MPA.8

One caution about using the LNG-IUS system with estrogen in postmenopausal women is that an observational study of all women with breast cancer in Finland from 1995 through 2007 reported a significantly increased risk of breast cancer among postmenopausal women using an LNG-IUS compared with women who did not use hormones or used only estrogen because they had a hysterectomy (TABLE 2).⁹ This study was not a randomized clinical trial and patients at higher baseline risk for breast cancer, including women with a high body mass index, may have been preferentially treated with an LNG-IUS. More information is needed to better understand the relationship between the LNG-IUS and breast cancer in postmenopausal women.

Paroxetine can block the metabolism of tamoxifen to its highly potent metabolite, endoxifen. Consequently, paroxetine may reduce the effectiveness of tamoxifen treatment for breast cancer and should be used with caution in postmenopausal women with breast cancer being treated with tamoxifen.

Related article: Paroxetine mesylate 7.5 mg found to be a safe alternative to hormone therapy for menopausal women with hot flashes. (News for your Practice; June 2014)

Escitalopram
Gynecologists are familiar with the use of venlafaxine, desvenlafaxine, clonidine, citalopram, sertraline, and fluoxetine for the treatment of postmenopausal hot flashes. Recently, escitalopram (Lexapro) at doses of 10 to 20 mg daily has been shown to be more effective than placebo in the treatment of hot flashes and sleep disturbances in postmenopausal women.^23,24 In one trial of escitalopram 10 to 20 mg daily versus placebo in 205 postmenopausal women averaging 9.8 hot flashes daily at baseline, escitalopram and placebo reduced mean daily hot flashes by 4.6 and 3.2, respectively (P<.001), after 8 weeks of treatment.

In a meta-analysis of SSRIs for the treatment of hot flashes, data from a mixed-treatment comparison analysis indicated that the rank order from most to least effective therapy for hot flashes was: escitalopram > paroxetine > sertraline > citalopram > fluoxetine.²⁵ Venlafaxine and desvenlafaxine, two serotonin and  norepinephrine reuptake inhibitors that are effective in the treatment of hot flashes, were not included in the mixed-treatment comparison.

Use of alternatives to MPA could mean fewer health risks for women on a wide scale
Substantial data indicate that MPA is not an optimal progestin to combine with estrogen for hormone therapy. Currently, many health insurance plans and Medicare use pharmacy management formularies that prioritize dispensing MPA for postmenopausal hormone therapy. Dispensing an alternative to MPA, such as micronized progesterone, often requires the patient to make a significant copayment.

Hopefully, health insurance companies, Medicare, and their affiliated pharmacy management administrators will soon stop their current policy of using financial incentives to favor dispensing MPA when hormone therapy is prescribed because alternatives to MPA appear to be associated with fewer health risks for postmenopausal women.

WE WANT TO HEAR FROM YOU! Share your thoughts on this article. Send your Letter to the Editor to: [email protected] 

Rosacea is a common chronic disorder that predominantly manifests as facial erythema, telangiectasia, and flushing.¹ Other primary clinical features include inflammatory lesions (eg, papules, pustules) and occasionally edema and rhinophyma. Ocular involvement also may occur. Rosacea patients routinely report sensitive skin with symptoms such as stinging, burning, and intolerance to topical agents (eg, medications, moisturizers, cosmetics).^2,3

Rosacea affects facial appearance and can impair a patient’s emotional well-being. It may limit social and professional activities. Many patients and nonpatients alike presume the appearance of facial redness suggests alcohol overuse or emotional distress.^4-6 A reduction in facial erythema as well as improvements in other clinical signs of rosacea have been shown to reduce patient self-consciousness and lead to increased socialization.⁷ Facial erythema is a major factor that adversely affects quality of life in rosacea patients.⁸

Although a number of options are available to successfully treat inflammatory lesions of rosacea, facial erythema has been the most difficult manifestation of the disease to medically treat.^2,9 Chronic erythema and episodic flushing may be at least partially related to cutaneous vasomotor responses causing both transient and persistent dilation of facial blood vessels.^10-12 The agents used for treating the inflammatory components of rosacea reduce erythema associated with papules and pustules but have little effect on the background erythema that is so noticeable. Oxymetazoline and brimonidine tartrate have been evaluated as potential rapid treatments of facial erythema. Daily application of oxymetazoline solution 0.05% has been shown to reduce facial erythema in rosacea patients.¹³

Brimonidine tartrate is a highly selective α₂-adrenergic receptor agonist with potent vasoconstrictor activity.¹⁴ It has been used to treat open-angle glaucoma for more than 15 years with well-documented safety and efficacy.¹⁵ Phase 2 and 3 studies for once-daily application of brimonidine tartrate gel 0.5% have confirmed its efficacy and safety for the treatment of facial erythema in rosacea patients,^9,12 and it was approved by the US Food and Drug Administration (brimonidine gel 0.33%) for persistent (nontransient) facial erythema of rosacea in late 2013. The effect was shown to occur in some patients as soon as 30 minutes following product application and usually persisted for approximately 9 to 12 hours. Erythema gradually returned as the effect waned, returning to baseline by 24 hours after application.¹²

Clinical efficacy of brimonidine gel was evaluated by a 2-grade improvement (primary end point) or 1-grade improvement (secondary end point) based on patient and clinician assessments using the patient self-assessment (PSA) and clinical erythema assessment (CEA), respectively, over the course of the 4-week studies. Patients also evaluated their satisfaction with the overall appearance of their facial skin.¹² A 2-grade improvement on both PSA and CEA has been noted as a stringent criterion in evaluating the effectiveness of treatment of facial erythema.¹⁴ A 1-grade improvement on both PSA and CEA has been recognized as clinically relevant as a measure of effect that is noticeable to both patients and clinicians.¹² Patients who achieved either a 1- or 2-grade improvement in both PSA and CEA were substantially more likely to report overall satisfaction with their appearance. A 2-grade improvement in both PSA and CEA scales was accompanied with 80% of patients rating their skin appearance as satisfactory or better. Conversely, few patients (ie, <10%) who did not achieve at least 1-grade composite success were satisfied with their appearance. Adverse effects were uncommon, with no evidence of tachyphylaxis and rare occurrence of rebound erythema.¹²

In summary, although there are a number of options available to reduce or eliminate inflammatory lesions of rosacea, effective medical treatment of the erythematous component of rosacea, which can be the most distressing aspect of the disease for patients, has been unsatisfactory. With the availability of topical brimonidine tartrate, dermatologists have a proven medication to improve facial redness in rosacea patients. Other options such as oxymetazoline may become available in the future.

Rosacea is a common chronic disorder that predominantly manifests as facial erythema, telangiectasia, and flushing.¹ Other primary clinical features include inflammatory lesions (eg, papules, pustules) and occasionally edema and rhinophyma. Ocular involvement also may occur. Rosacea patients routinely report sensitive skin with symptoms such as stinging, burning, and intolerance to topical agents (eg, medications, moisturizers, cosmetics).^2,3

Rosacea affects facial appearance and can impair a patient’s emotional well-being. It may limit social and professional activities. Many patients and nonpatients alike presume the appearance of facial redness suggests alcohol overuse or emotional distress.^4-6 A reduction in facial erythema as well as improvements in other clinical signs of rosacea have been shown to reduce patient self-consciousness and lead to increased socialization.⁷ Facial erythema is a major factor that adversely affects quality of life in rosacea patients.⁸

Although a number of options are available to successfully treat inflammatory lesions of rosacea, facial erythema has been the most difficult manifestation of the disease to medically treat.^2,9 Chronic erythema and episodic flushing may be at least partially related to cutaneous vasomotor responses causing both transient and persistent dilation of facial blood vessels.^10-12 The agents used for treating the inflammatory components of rosacea reduce erythema associated with papules and pustules but have little effect on the background erythema that is so noticeable. Oxymetazoline and brimonidine tartrate have been evaluated as potential rapid treatments of facial erythema. Daily application of oxymetazoline solution 0.05% has been shown to reduce facial erythema in rosacea patients.¹³

Brimonidine tartrate is a highly selective α₂-adrenergic receptor agonist with potent vasoconstrictor activity.¹⁴ It has been used to treat open-angle glaucoma for more than 15 years with well-documented safety and efficacy.¹⁵ Phase 2 and 3 studies for once-daily application of brimonidine tartrate gel 0.5% have confirmed its efficacy and safety for the treatment of facial erythema in rosacea patients,^9,12 and it was approved by the US Food and Drug Administration (brimonidine gel 0.33%) for persistent (nontransient) facial erythema of rosacea in late 2013. The effect was shown to occur in some patients as soon as 30 minutes following product application and usually persisted for approximately 9 to 12 hours. Erythema gradually returned as the effect waned, returning to baseline by 24 hours after application.¹²

Clinical efficacy of brimonidine gel was evaluated by a 2-grade improvement (primary end point) or 1-grade improvement (secondary end point) based on patient and clinician assessments using the patient self-assessment (PSA) and clinical erythema assessment (CEA), respectively, over the course of the 4-week studies. Patients also evaluated their satisfaction with the overall appearance of their facial skin.¹² A 2-grade improvement on both PSA and CEA has been noted as a stringent criterion in evaluating the effectiveness of treatment of facial erythema.¹⁴ A 1-grade improvement on both PSA and CEA has been recognized as clinically relevant as a measure of effect that is noticeable to both patients and clinicians.¹² Patients who achieved either a 1- or 2-grade improvement in both PSA and CEA were substantially more likely to report overall satisfaction with their appearance. A 2-grade improvement in both PSA and CEA scales was accompanied with 80% of patients rating their skin appearance as satisfactory or better. Conversely, few patients (ie, <10%) who did not achieve at least 1-grade composite success were satisfied with their appearance. Adverse effects were uncommon, with no evidence of tachyphylaxis and rare occurrence of rebound erythema.¹²

In summary, although there are a number of options available to reduce or eliminate inflammatory lesions of rosacea, effective medical treatment of the erythematous component of rosacea, which can be the most distressing aspect of the disease for patients, has been unsatisfactory. With the availability of topical brimonidine tartrate, dermatologists have a proven medication to improve facial redness in rosacea patients. Other options such as oxymetazoline may become available in the future.

Rosacea is a common chronic disorder that predominantly manifests as facial erythema, telangiectasia, and flushing.¹ Other primary clinical features include inflammatory lesions (eg, papules, pustules) and occasionally edema and rhinophyma. Ocular involvement also may occur. Rosacea patients routinely report sensitive skin with symptoms such as stinging, burning, and intolerance to topical agents (eg, medications, moisturizers, cosmetics).^2,3

Rosacea affects facial appearance and can impair a patient’s emotional well-being. It may limit social and professional activities. Many patients and nonpatients alike presume the appearance of facial redness suggests alcohol overuse or emotional distress.^4-6 A reduction in facial erythema as well as improvements in other clinical signs of rosacea have been shown to reduce patient self-consciousness and lead to increased socialization.⁷ Facial erythema is a major factor that adversely affects quality of life in rosacea patients.⁸

Although a number of options are available to successfully treat inflammatory lesions of rosacea, facial erythema has been the most difficult manifestation of the disease to medically treat.^2,9 Chronic erythema and episodic flushing may be at least partially related to cutaneous vasomotor responses causing both transient and persistent dilation of facial blood vessels.^10-12 The agents used for treating the inflammatory components of rosacea reduce erythema associated with papules and pustules but have little effect on the background erythema that is so noticeable. Oxymetazoline and brimonidine tartrate have been evaluated as potential rapid treatments of facial erythema. Daily application of oxymetazoline solution 0.05% has been shown to reduce facial erythema in rosacea patients.¹³

Brimonidine tartrate is a highly selective α₂-adrenergic receptor agonist with potent vasoconstrictor activity.¹⁴ It has been used to treat open-angle glaucoma for more than 15 years with well-documented safety and efficacy.¹⁵ Phase 2 and 3 studies for once-daily application of brimonidine tartrate gel 0.5% have confirmed its efficacy and safety for the treatment of facial erythema in rosacea patients,^9,12 and it was approved by the US Food and Drug Administration (brimonidine gel 0.33%) for persistent (nontransient) facial erythema of rosacea in late 2013. The effect was shown to occur in some patients as soon as 30 minutes following product application and usually persisted for approximately 9 to 12 hours. Erythema gradually returned as the effect waned, returning to baseline by 24 hours after application.¹²

Clinical efficacy of brimonidine gel was evaluated by a 2-grade improvement (primary end point) or 1-grade improvement (secondary end point) based on patient and clinician assessments using the patient self-assessment (PSA) and clinical erythema assessment (CEA), respectively, over the course of the 4-week studies. Patients also evaluated their satisfaction with the overall appearance of their facial skin.¹² A 2-grade improvement on both PSA and CEA has been noted as a stringent criterion in evaluating the effectiveness of treatment of facial erythema.¹⁴ A 1-grade improvement on both PSA and CEA has been recognized as clinically relevant as a measure of effect that is noticeable to both patients and clinicians.¹² Patients who achieved either a 1- or 2-grade improvement in both PSA and CEA were substantially more likely to report overall satisfaction with their appearance. A 2-grade improvement in both PSA and CEA scales was accompanied with 80% of patients rating their skin appearance as satisfactory or better. Conversely, few patients (ie, <10%) who did not achieve at least 1-grade composite success were satisfied with their appearance. Adverse effects were uncommon, with no evidence of tachyphylaxis and rare occurrence of rebound erythema.¹²

In summary, although there are a number of options available to reduce or eliminate inflammatory lesions of rosacea, effective medical treatment of the erythematous component of rosacea, which can be the most distressing aspect of the disease for patients, has been unsatisfactory. With the availability of topical brimonidine tartrate, dermatologists have a proven medication to improve facial redness in rosacea patients. Other options such as oxymetazoline may become available in the future.