27. December 2011 by stationmanager.

Clinical Context

The US Preventive Services Task Force recommends screening adults for alcohol misuse in primary care settings, but many clinicians struggle with the very definition of alcohol misuse. The National Institute on Alcohol Abuse and Alcoholism defines at-risk alcohol use among women as more than 3 drinks per occasion or more than 7 drinks per week. In addition, any amount of drinking during pregnancy is considered at-risk alcohol use. Binge drinking is defined as more than 3 drinks per occasion, whereas moderate drinking is defined as 1 alcoholic beverage per day.Women are at particularly high risk for negative consequences from alcohol misuse. The current Committee Opinion from the American College of Obstetrics and Gynecology (ACOG) examines means to detect alcohol misuse among women and how to provide the best care for women with at-risk alcohol use.

Study Synopsis and Perspective

Women should be screened for alcohol use at least annually and during the first trimester of pregnancy, according to new recommendations from ACOG. The ACOG Committee Opinion, entitled “At-Risk Drinking and Alcohol Dependence: Obstetric and Gynecologic Implications” is published in the August 2011 issue of Obstetrics & Gynecology.“Alcohol is so ubiquitous in our society, many women may be surprised to learn that their drinking exceeds a safe level. They may consider their alcohol use normal because it’s similar to the drinking patterns of their family, friends, and social circles,” said Maureen G. Phipps, MD, chair of The College’s Committee on Health Care for Underserved Women. “But because of our physiology, we don’t process alcohol the same way men do, and too much can wreak havoc on our bodies. The risks are amplified in women who are or may become pregnant, because the effects of alcohol exposure on a fetus can be harmful.”The Committee Opinion defines at-risk alcohol use as more than 7 drinks per week, binge drinking (> 3 drinks per occasion), or any amount of alcohol intake among women who are pregnant or at risk for pregnancy. These ACOG guidelines offer suggestions for how healthcare providers can discuss alcohol use with their patients, screening tests to detect at-risk drinking patterns, information on when and how to refer alcohol-dependent women for professional treatment, a chart of standard drink measurements, and other useful resources.“Ob-gyns have an opportunity to educate women on making safe and healthy choices about alcohol intake,” Dr. Phipps said.Obstetrician-gynecologists play a key role in screening women for at-risk alcohol use and in offering brief intervention, patient education, and treatment referral when needed. Women who are not physically addicted to alcohol may benefit from brief intervention and motivational interviewing incorporated into an office visit. Pregnant women and those at risk for pregnancy should receive clear, compelling advice to avoid alcohol use, and assistance in becoming abstinent or effective contraception. Healthcare providers should advise women that low-level alcohol drinking in early pregnancy is not an indication for pregnancy termination.Among women in the United States, alcohol-related mortality is the third leading cause of preventable death. The adverse effects of high levels of alcohol use include reduced fertility, menstrual disorders, injuries, increased risk for some cancers, seizures, and malnutrition. Psychosocial problems may include loss of income, child neglect or abuse, impaired judgment, driving under the influence, and depression. Alcohol is teratogenic, and prenatal exposure may result in growth impairment, facial abnormalities, central nervous system and/or intellectual impairment, and behavioral disorders.“Women who develop alcohol or substance use dependence are often more likely than men to deny that they have a problem and to minimize the problems associated with their use,” the Committee Opinion states. “However, when they do seek help for the problem, it often is from their primary care providers. Importantly, most women who use alcohol at risk levels have no signs on physical examination. A detailed medical history obtained by a trusted clinician remains the most sensitive means of detecting alcohol abuse.”

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19. December 2011 by stationmanager.

 Clinical Context

Alcohol intake in youth has been associated with aggressive behavior and violence, but the influence of sugary and carbonated soft drinks on behavior in youth has not been well studied. There may be a connection between high sugar intake and violent behavior reflecting abnormally low sugar levels as a precipitant of high sugar intake.This cross-sectional survey by Hemenway and colleagues of Boston youth conducted at public high schools determines the association between self-reported intake of nondiet carbonated soft drinks and aggressive behaviors.

Study Synopsis and Perspective

Public health researchers and nutrition advocates have criticized consumption of carbonated soft drinks because they may fill people up with empty calories, sugar, and caffeine, but new research published online October 24 in Injury Prevention suggests that the drinks also may be linked with, or may be a strong marker for, violent behavior in teenagers.“This is the first study to suggest such an association,” said David Hemenway, MD, professor of public health and director of the Injury Control Center at the Harvard School of Public Health, Boston, Massachusetts, and the study’s lead author, in an interview with Medscape Medical News.After controlling for sex, age, race, body mass index, typical sleep patterns, tobacco use, alcohol use, and having family dinners, the investigators found that high consumption of carbonated, nondiet soft drinks was associated with a statistically significant 9% to 15% greater likelihood of engaging in aggressive behaviors. Heavy soft drink use had about the same effect as tobacco and alcohol on violence.“This is just one study, and it needs to be looked at in more detail.” Dr. Hemenway said. He was reluctant to call it a cause-and-effect relationship, stressing that the exact sugar or caffeine content in the soft drinks was “unknown,” and that “possibly other factors not accounted for in our analysis are related to high soft drink consumption and aggression.”Dr. Hemenway and coauthors found that teenagers who drank more than five 12-ounce cans of carbonated soft drinks each week were more likely to carry a weapon and commit violence against friends, dates, and siblings. The study also found that the relationship appears to be a dose-response relationship, with the strongest relationships shown for teenagers drinking 14 or more cans per week. Of those adolescents, 42.7% carried a gun or knife, 58.6% were violent toward their peers, 26.9% were violent toward dates, and 45.3% perpetrated violence toward other children in their family. These percentages were significantly higher than in each of the 3 other consumption categories (≤1 can, 2 - 4 cans, and 5 - 7 cans in the last 7 days), and there was a statistically significant, linear increase in consumption linked to each of the 4 violence behaviors (P ≤ .001). Nearly 1 in 3 students were drinking at least 5 cans of carbonated soft drinks. The study used self-report data from the Boston Youth Survey, a biennial, paper-and-pencil survey of ninth- to twelfth-grade students in Boston public schools to evaluate the effect of soft drink use on aggressive and violent behavior.The 2725 high school students selected for the study were not representative of adolescents across the United States: 50% were black or multiracial, 33% were Hispanic, 9% were white, and 8% were Asian. Of these groups, only Asians were found to drink much less than the others.The study was not able to show a relationship between soft drink consumption and obesity, which has been shown in other studies. Heavy soft drink use was also associated with other dimensions; for example, getting insufficient sleep and using alcohol and tobacco within the past 30 days.Dr. Hemenway acknowledged several study limitations, including the self-report of the data, the generalizability to other adolescents, and the lack of information on the sodas themselves. In the discussion section, the authors write that a “direct-cause-and effect relationship between soft drink consumption and aggression is one possibility,” adding that “various ingredients, including carbonated water, high fructose corn syrup, aspartame, sodium benzoate, phosphoric or citric acid, and often caffeine…might affect behaviour.”The author introduces his study by reminding readers of the “Twinkie defense,” which was used successfully to reduce Dan White’s conviction from homicide to manslaughter for the 1978 killing of San Francisco City District Supervisor Harvey Milk and Mayor George Moscone.“I am totally not convinced,” noted Marion Nestle, PhD, MPH, Pauline Goddard professor of nutrition, food policies, and public health at New York University School of Medicine, New York City, in an email to Medscape Medical News.” As I said, I’m no fan of sodas, but [it] defies common sense.”Dr. Nestle also was not impressed with the study design. She noted: “This looks like a ‘tracking’ study to me. I don’t see how the study can conclude anything specific about soft drinks except guilt by association.” She added that “poor kids drink more soft drinks than rich kids, and they are marketed to more aggressively.“If it turns out that alcohol and junk food diets can be linked to negative behaviours,” she said, “[s]oda companies will reap what they sowed when they focused so much marketing on low-income, minority communities.”The study was supported by the US Centers for Disease Control and Prevention. It was externally peer reviewed. The authors and Dr. Nestle have disclosed no relevant financial relationships.

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14. December 2011 by stationmanager.

Teenagers living in rural areas who regularly volunteer and help others are less likely than their peers, who don’t often engage in these activities, to drink or use drugs as young adults, a new study suggests.Previous studies have suggested teenagers in rural areas may be more likely to use illicit substances earlier, which puts them at risk for developing addiction problems, Health Canal reports. Rural communities often have fewer recreation centers and organized activities, the article notes.The study included 531 rural teens who were surveyed in grades 10-12, and again in early adulthood. They were asked about their time spent volunteering and helping others, as well as substance use. The researchers found rural teens who frequently volunteer and help others are less likely to engage in substance use in young adulthood than those who infrequently participate in these activities.“There is a tendency for youths to take part in risky behaviors if they are not engaged in positive, structured activities,” lead researcher Gustavo Carlo of the University of Missouri said in a news release. “Many rural communities have suffered from the economic downturn and are unable to offer opportunities for youth activities. Financial stress can also affect the psychological health of parents making them less cognizant of how children spend their time.”Carlo says his research indicates more programs that promote volunteering and helping others can decrease the chance that rural teenagers will use illicit substances in adulthood.

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6. December 2011 by stationmanager.

FOR decades, scientists have studied areas deep within the brain that seem associated with pleasure and addiction.

 Put an electrode in that part of a rat’s brain, and it will become obsessed with stimulating those areas. When rats are allowed to push a lever in exchange for a mild current that produces a “high” in the “pleasure centers,” they will press the lever up to 7,000 times per hour. These rats forget to eat or drink, and they must be unhooked to prevent self-starvation. Male rats ignore females in heat to get a fix, and nursing mothers ignore their babies. “Pressing that lever became their entire world,” David J. Linden, a neuroscientist at Johns Hopkins University medical school, writes in his fascinating new book, “The Compass of Pleasure.”     

       Professor Linden explains how drugs such as cocaine that light up these pleasure centers (there are several interconnected areas) actually rewire the brain to increase cravings. You can look at magnified photos of rat brains and tell which animal was given cocaine and which wasn’t. Yet it’s not just drugs. Brain scans suggest that everything from sugar to sex lights up the brain’s pleasure circuitry. These all can have neurological consequences that correspond to what we think of as addiction. For example: exercise. As a pathological runner since my days as a high school cross country athlete in Oregon, that struck a chord. Am I addicted to running? “Exercise addicts display all of the hallmarks of substance addicts: tolerance, craving, withdrawal and the need to exercise ‘just to feel normal,’ ” Linden writes. O.K., I confess. I might be an addict. Exercise seems to trigger the release of chemicals called endorphins and enkephalins (the brain’s version of opium) and endocannabinoids (the brain’s version of marijuana). In the lab, rats can develop an addiction to exercise on a wheel.

      Brain researchers are finding many similar patterns. Who knew that orgasms, in men and women alike, light up the pleasure centers much like cocaine? (And who knew that researchers immobilize subjects in a lab, hook them up to a brain scanner, and then instruct them to engage in sexual activity?) Linden argues that there is such a thing as a genuine biological addiction to sex. The public’s failure to recognize this, he says, means that people often don’t receive treatment. “Sex addicts are among the least likely to seek help among all sufferers of addiction,” he writes, adding that this is tragic because sex addicts may be more likely than drug addicts to take others down with them.

    Brain chemistry research also suggests that gambling and overeating can be addictive behaviors, analogous to narcotics addictions. In particular, foods with sugar or fat seem to trigger cravings that then rewire the brain’s pleasure circuitry to amplify that craving. One study found that rats fed foods like cheesecake and chocolate showed differences in brain circuitry after just 40 days. The impact was that the pleasure centers of their brains were numbed, so they apparently needed to gobble even more cheesecake to generate the same satisfaction. Whether it’s sugar or heroin, the body steadily ratchets up the quantity necessary to provide the same high. Does this mean the end of free will? Of course not. But it’s a reminder that cravings are complex phenomena with strong ties to brain chemistry and genetics. Maybe that’s why President Obama has shown astounding self-discipline in his political career while enduring a long struggle with nicotine.

     Moreover, our brains impel us not only toward vices, but also toward virtues. In recent years, researchers have found that generosity isn’t always a sacrifice; instead, it often exhilarates us. One set of experiments at the University of Oregon involved young women hooked up to brain scanners as they were presented with modest amounts of money. Sometimes the money was then “taxed,” sometimes they were given the chance to donate to charity, and sometimes they were given additional money. Their pleasure centers lit up when they received money, as one might expect — but also when they gave money away. There were considerable variations among individuals. About half of the women seemed to derive as much pleasure, based upon their brain patterns, from giving money as from receiving it. The other half enjoyed receiving money more. Not surprisingly, the latter contributed less to charity. Maybe the research will lead to new tools to fight drug addiction, alcoholism or obesity. Maybe I’ll be able to get a runner’s high without the sweat. But, to me, the most fascinating insight is that for at least half of humans it truly does seem to be as blessed to give as to receive. On the basis of the latest brain research, as well as practical experience, let’s acknowledge this profound truth: altruism and generosity can be hedonistic pleasures.

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