Lifelong exercise keeps the brain working better

Lifelong exercise can lead to improved brain function in later life, a study has shown.

People perform better in mental tests at the age of 50 if they have engaged in regular intense activity, such as playing sport, running, swimming or working out in the gym, since childhood.

More than 9,000 individuals took part in the research from the age of 11.

Interviews were conducted at regular age intervals to monitor levels of exercise. Participants also undertook tests of memory, attention and learning.

Those who had exercised two to three times per month or more from the age of 11 scored higher in the tests than those who had not.

Study leader Dr Alex Dregan, from King's College London, said: “As exercise represents a key component of lifestyle interventions to prevent cognitive decline, cardiovascular disease, diabetes and cancer, public health interventions to promote lifelong exercise have the potential to reduce the personal and social burden associated with these conditions in late adult years.”

The findings are published today in the journal Psychological Medicine.

Government guidelines say that adults aged 19 to 64 should exercise for at least 150 minutes per week.

“It's widely acknowledged that a healthy body equals a healthy mind,” said Dr Dregan. “ However, not everyone is willing or able to take part in the recommended 150 minutes of physical activity per week. For these people any level of physical activity may benefit their cognitive well-being in the long-term and this is something that needs to be explored further.

“ Setting lower exercise targets at the beginning and gradually increasing their frequency and intensity could be a more effective method for improving levels of exercise within the wider population.”

Intense exercise appeared to provide greater benefit for the brain than regular moderate activity, said Dr Dregan.

“ Clinical trials are required to further explore the benefits of exercise for cognitive well-being among older adults, whilst examining the effects of exercise with varying levels of frequency and intensity,” he added.

Take Responsibility and Gain Trust

In my last post, I talked at great length about what it means to possess and execute emotional intelligence and ways in which you can strengthen those emotional intelligence muscles to improve your leadership abilities.  As I previously pointed out, one of the ways to increase your level of emotional intelligence is by practicing accountability.

The reality is that accountability, despite being often overlooked as a key leadership skill, is critical to success. A 2016 study by the talent development and transition company, Lee Hecht Harrison, which surveyed 1,900 human resource professionals and business leaders across the globe, found that 71% of respondents believe that leadership accountability is a critical but often overlooked business issue. The data also showed that only 31% were satisfied with the degree of accountability being shown by their leaders.

But what does it mean to be accountable—to practice accountability? On the most basic level, it means that you take responsibility for your actions and the decisions you make. You own outcomes—good or bad—and you don’t blame others or external factors when things don’t go according to planned. 

Yet, there is more to practicing accountability than standing up and owning your own work, your decisions and the results they produce. Practicing accountability is really about developing a deep and mutual trust with those to whom you are accountable—your team. Here are some ways in which you can develop that trust:
  • Have honest conversations with team members—be truthful and real in all that you say and do.
  • Communicate authentically and clearly at all times—let them know what you want, need and expect.
  • Don’t accept excuses or the blame game—from yourself or fellow team members.
  • Work together to figure out the problems and road blocks that are limiting performance and develop skills within the group to maximize impact.
  • Call the group together as soon as you can to share successes and good news.
When you practice real accountability, you are saying to your team: “Trust me. I am honest and clear with you about how I operate, what I care about and my personal and professional expectations of you. I want us to succeed together.” And when you do that, you are then able to ask the same of your team members. They will step up, give their best and be personally accountable because they know that you have their back. In short, where you lead, they will follow. And you will all move forward on a path towards success.

The Psychology of Obesity: Working together to eliminate shame and stigma

This month's blog post is written by psychologist, Robyn Osborn Pashby, PhD

Our healthcare system is failing people with obesity. Yet rather than viewing the obesity epidemic as a failure of the system, failed weight loss interventions are too often attributed to failure of will. Sadly weight bias on the part of society as a whole, and health practitioners specifically, feeds into this stigma and prevents healthy psychological support for weight loss. For patients, this weight bias and stigma fuels a sense of self as a failure, and repeated perceived failures can lead to a belief that something is wrong with oneself as a person – shame. Shame isolates people from one another at a time when support could be beneficial. Depletion of energy from this sense of failure and shame creates a cycle that can interfere with healthy cognitive, emotional, and behavioral changes.

Mired in self-blame, shame, and humiliation, people with obesity often recount failed interventions and list the ways in which they are not strong enough, good enough, or determined enough to lose weight. The same people who run businesses, care for families, serve community organizations, and make our country’s policies, laws, and regulations believe they are failures because of the number on the scale. The belief that obesity is a failure of will can cause or exacerbate eating and mood struggles, interfering with health behavior change. The constant barrage of negative self-talk results in emotional and intellectual exhaustion. This is problematic because energy for behavior change is a finite resource. The more of it that is allocated to negative self-talk criticizing oneself for a “lack of self-control,” or berating oneself for “failing” the latest diet plan, the less energy available for self-care and maintenance of healthy lifestyle changes.

Shame also interferes with a person’s likelihood of accessing support. Weight management requires support from numerous disciplines (often medical, psychological, nutrition, and/or movement) as well as from loved ones, friends, families, and coworkers. Thoughts like, “I should lose weight before I go back to my doctor,” is just one example of how shame can interfere with a person accessing the very support that is most helpful. Shame can lead a person with obesity to believe that support is something reserved for others…those who are worthy of the support. Thus, reducing shame, identifying and disempowering the shame-based beliefs, and building a core sense of worthiness are all critical in helping individuals embrace autonomy and maintain energy for long term health behavior change.

In our next Twitter chat we will discuss the psychology of obesity. Specifically, we will be addressing the following questions:

What types and sources of psychological support are most helpful for persons with #obesity?
How do stigma and shame affect eating, exercise, and even accessing treatments such as #bariatricsurgery?
In what ways can self-talk be used for making positive changes rather than reinforcing shame and stigma?
Can a goal of feeling good (rather than # on the scale) have a meaningful impact on weight management?
In what ways can health practitioners lessen the burden of stigma and shame for patients with #obesity?

We hope you will join the discussion 9:00p EST Sunday, October 8!

~The #obsm chat leadershipArghavan Salles, MD, PhD; Heather Logghe, MD; Neil Floch, MD; Amir Ghaferi, MD, MS; and Babak Moein, MD

How to prescribe a glucometer – or why I can’t support Medicaid-for-All

This is a guest post by Seiji Yamada, MD, MPH.
A shorter version recently appeared on the KevinMD blog, http://www.kevinmd.com/blog/2017/09/heres-glucometer-turned-doctor-medicaid.html

In a recent Vox interview, Senator Brian Schatz of Hawaii announced his plans to sponsor a bill to allow individuals without insurance to buy Medicaid coverage for themselves.  As a family doc who cares for patients on Medicaid in safety net clinics in Senator Schatz’s home state, I cannot support such a plan.

While private insurance companies offer supplemental insurance, Medicare continues to be run largely by the federal government.  In contrast, while Medicaid programs receive federal funding, they are largely run by state governments.  In a trend known as Medicaid managed care, in recent decades, states have been contracting out Medicaid to private insurance companies.

Prior to 1994, Hawaii’s state Medicaid system was run by HMSA, Hawaii’s Blue Cross/Blue Shield.  During the Clinton presidency, the buzzword was managed competition, the idea being that insurance corporations would compete on price to provide publicly funded health insurance.  Thus in 1994, the State of Hawaii devolved to managed care Medicaid and started farming out Medicaid to other corporations besides HMSA.  In 2009 Medicaid managed care was extended to the aged, blind, and disabled.
Medicaid also generally reimburses at lower rates than Medicare or private insurance.  (Senator Schatz proposes to fix this.)  However, low reimbursement is only one reason that physicians in private or group practice take few Medicaid patients today.  Another reason is the administrative hassles to care put up by insurance companies as well as the difficulties of dealing with multiple insurance companies.  Thus, Medicaid patients have relatively restricted networks of providers from which to choose.  Many are therefore seen by safety net providers such as Federally Qualified Health Centers (FQHCs) or training clinics.
The modern practice of medicine is complicated enough, but the different requirements and different formularies of different insurance companies complicates it to Kafkaesque levels.  I believe that the powerlessness and helplessness induced by this nightmarish bureaucracy is a major cause of physician burnout.  I want to give just one example.  Let us say that one of our patients has newly diagnosed diabetes.  Let us say that he has Medicaid.  Just to prescribe him a glucometer, I have to go through the following:
Patients on Medicaid must enroll with one of the following:  HMSA, AlohaCare, Ohana (WellCare), United Healthcare, and Kaiser.  I need to go to the insurance section of the patient’s Electronic Health Record (EHR) to find out which insurance corporation is responsible for this patient.  Then I go to The Prescribing Guide (http://prescribingguide.com/), a cheat sheet developed and maintained by my family medicine faculty colleague Chien-Wen Tseng, MD.  The prescribing guide tells me which brand of glucometer to prescribe.
Each insurer contracts with a different glucometer manufacturer, so I can’t just prescribe a generic glucometer.  I have to figure out whether to prescribe Freestyle, or OneTouch, or AccuChek.  Because the contracts are continually re-negotiated, the preferred brand can change every six months.  If you enter the wrong brand, the pharmacy will reject it and tell you to get a prior authorization.
Next, I have to identify the ICD-10 code that corresponds to the highest complexity of the patient’s diabetes.  Does she have nephropathy, or neuropathy, or ophthalmopathy?  I often have to review the patient’s labs to see if the creatinine/GFR is abnormal.  Am I going to place the patient on long-term insulin?  Because if I am, I can justify asking for test strips for more than once a day testing.  The number of times per day the glucose is to be measured, the ICD-10 code, and whether or not the patient is on insulin has to be on the prescription.  If not, the pharmacy will reject it.
Now that I have prescribed a glucometer, I can now start working on prescribing a diabetes medication.
And I’ve yet to address the fatigue, the blood pressure, or the back pain for which his friend’s oxycodone worked real good, Doc.
. . .
All the world's a stage, And all the men and women merely players” -Shakespeare
Was this theater of the absurd composed by Alfred Jarry?  Samuel Beckett?  No, this play was composed by the layers of business administration types that have piled onto the health care system over the past couple of decades to bring corporate-style efficiency to medicine.  Insurance companies limit their costs by imposing roadblocks.  By making it so time-consuming and so frustrating to get anything done, we physicians throw up our hands and decide, no it’s not worth the hassle to order a different medication or sophisticated tests.  Perhaps my patient gaining weight on a sulfonylurea would benefit from a glucagon-like peptide 1 receptor agonists or a sodium glucose transporter 2 inhibitors instead.  But the prior authorization form requires me to list the dates that the patient has taken every other diabetes medication she has ever been prescribed . . .
For those physicians who are employed by hospitals or other institutions, we are finding that our employers are engaging in an arms race with the insurers by hiring their own army of coders and billers.  These coders and billers find our documentation lacking in order to maximize return.  So now we are told to write addenda to chart notes entered months ago - in order to justify higher reimbursement.  These coders and billers shake their heads sadly and say to themselves, “Dr. Yamada, you are such an idiot.”
. . .
The new interns started in July.  When they were medical students, I taught them about the pathophysiology of diabetes, about the evidence base of what treatments have been shown to improve patient outcomes, about how to discuss lifestyle measures, about the social determinants of the development of diabetes.  Now that they’re interns, though – all of that goes out the window.  Now that they’re managing real patients, I teach them how to enter billing codes into the electronic health record, and how to get a glucometer covered by insurance.
They look at me with incredulity.  They are dumfounded by how irrational and Byzantine our health system is.  They realize that I am no longer teaching them medicine.  Because there is no time for that now.  There is only throughput.  Treat ‘em and street ‘em.
 “Welcome to the desert of the real,” I say.  “Get used to it.”
. . .
The MBAs who manage us physicians say, “It’s not about throughput.  It’s about quality.  We’re not going to pay you for throughput any more.  We’re going to pay for performance.  We don’t care how many times you see the patient.  We only care about their A1cs.”
OK, then, tell me how you get better outcomes with a patient with diabetes without seeing them every once to talk with the patient about diet and exercise, to prescribe a glucometer so they can learn how diet and exercise affects their glucoses.  What is the point of telling the homeless patient to bring down their A1cs by eating more fresh vegetables?  What use is the A1c when the patient has cancer?  What does the patient dealing with domestic violence care about her A1c?  To measure the quality of care provided by a physician through A1cs is like the drunkard searching for his keys under the streetlight because that’s where the light is.  The A1c is easily measured.  Other aspects of medical care are not so easily assessed.
. . .
Insurance companies and their corporate mind-set have so thoroughly taken over American medicine that we can hardly see the forest for the trees any more.  EHRs, essentially designed for reimbursement purposes, define the patient encounter – such that physicians look only at their screens.  I can’t afford to make eye contact with my patients, or I’ll fall hopelessly behind.  Was there a time that we used to eat lunch?  Nowadays, lunchtime is for finishing with charting or dealing with phone calls.  Dealing with medication refills, or lab or x-ray results?  Planning for the patients on tomorrow’s schedule?  We do that in the evenings or weekends by remote access to the electronic health record.

Though Senator Schatz’s proposal would make Medicaid something like the public option that didn’t make it into the Affordable Care Act, it would likely leave intact insurance company-run Medicaid managed care – with its restricted networks and administrative hassles.  As a practicing physician, I would like to get corporate profits and the layers upon layers of bureaucrats out of medicine.  The American physician is in a predicament like that of Josef K in Kafka’s The Trial.  The rules are obscure and seem to be constantly changing.  We are never told what crime we committed to justify our being treated the way we are.  The sense of a lack of agency and helplessness induced is one major cause of physician burnout.  The practice of American medicine needs to be rationalized, so that we health workers can go back to focusing on the medicine.  Medicare for All is what we need.  Not all the inefficiencies and irrationalities of the modern practice of medicine will be fixed by Medicare for All – but patients and doctors need a way out of this Kafka novel.

I Second That Emotion(al) Intelligence

I recently posted a blog advocating putting what is best for your business ahead of your personal feelings. Expanding on that post, I would argue that effective leadership is not only about keeping your emotions in check, but leading your team with emotional intelligence.

Emotional intelligence is the ability to understand and calibrate your own emotions as well as the ability to respond effectively to those of others. It is also being aware of how your words and actions affect your colleagues and team members. Being in tune with your emotions and the emotions of others, as well as having the ability to understand the dynamics of your environment, are key skills to possess when leading a team.

According to Daniel Coleman, an American psychologist who has written extensively on emotional intelligence, there are five attributes that leaders with high levels of emotional intelligence possess:

  • Self-awareness:Leaders who are self-aware possess the ability to understand their feelings and how their feelings affect other people.
  • Self-management:The best managers are those who are able to keep their feelings in check and remain in control even during trying times.
  • Empathy: If you are able to walk in others’ shoes and be compassionate, you will have stronger and more positive relationships with fellow team members. 
  • Motivation: Working towards the high standards and goals you set for yourself is critical to managerial success.
  • Social skills: Managers who can effectively communicate, speak passionately and encourage team members are more likely to motivate performance and drive positive results.

Understanding emotional intelligence is only part of the equation. Let’s face it. Very few of us are born with the behaviors that comprise strong emotional intelligence and like most things, we have to work to develop these soft skills. With that in mind, here are some things we can all do to improve upon our ability to lead with emotional intelligence:

  • Keep a journal to help you become more self-aware
  • Slow down and reflect on how you are feeling and behaving
  • Practice being calm and centered
  • Hold yourself accountable by making a commitment to admit mistakes and take responsibility
  • Be positive, optimistic and hopeful and encourage that in others
  • Take stock of your own performance on a regular basis
  • Pay attention to other people’s feelings and body language as a way to gauge how you are coming across and affecting others
  • Learn conflict resolution
  • Focus on encouraging and praising team members

At the end of the day, the better we can relate to and work with others, the more successful we will be. Working on your own emotional intelligence can turn you from a strong leader into an exceptional one.