Sonoma Magazine Sonoma Health 2023 by SMIDigital Operations

2024

Get the Sleep You Need A good night’s sleep can improve both mental and physical health

2024 / ISSUE 3

IN THIS ISSUE

ALTERNATIVE WAYS TO TREAT PAIN

THE HEALING PROPERTIES OF FOOD

DO PROBIOTICS AND PREBIOTICS WORK?

RESET YOUR BODY WITH A DRY JANUARY

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For all that is Sonoma County. For all that is you.

EDITOR’S LETTER

A SONOM A CUSTOM PUBLISHING TITLE IN COLL ABOR ATION WITH SONOM A MENDOCINO L AKE MEDIC AL A SSOCIATION PRESIDENT AND PUBLISHER STEVE CHILDS EDITOR-IN-CHIEF ALEXANDRA RUSSELL CONTRIBUTING WRITERS

A PAINFUL TRUTH WELCOME TO THE THIRD EDITION OF SONOMA HEALTH MAGAZINE. By now, I’m hoping you’re familiar with our mission and vision to (quoting myself) “educate, illuminate and entertain with evidence-based and actionable information that connects cause and effect in a direct way, encourages you to learn more and raises pertinent questions to discuss with your doctors.” I feel like we laid some pretty solid groundwork with our first two issues, and we’ve really knocked it out of the park with this one. This time, we’re including more doctors’ voices and addressing more diverse topics, from Lyme disease and cosmetic lasers to common conditions such as tinnitus and balance issues to wellness choices involving online activity and alcohol intake. Our cover story, on the importance of sound sleep, again brings a vital wellness ingredient to the fore. Insomnia, apnea and sleep deprivation are among the conditions discussed — as well as standard treatments, including medication, exercise, devices and mental health counseling. Another topic we hope will pique your interest is a deep dive into the microscopic world of pre- and probiotics. It’s amazing what a big difference these tiny organisms can make in our health. A related story, which explores the ancient notion of food as medicine, provides further evidence that making healthy choices can lead to a lifetime of good days. Our feature articles are again a mix of personal care and medical advances, meant to delineate choices and introduce new options. Many of them address the world of pain. We all feel it. We all have it. For those living with chronic pain, it feels all encompassing. Articles on joint replacement, massage therapy and pain management (including less traditional treatment modalities) all seek to ease this debilitating symptom. I, for one, appreciate this broader-scope approach. As someone who has lived with varying levels of chronic pain for most of my adult life, I’m always looking for relief. Over the years, I’ve turned to both prescription and OTC painkillers and muscle relaxants, physical therapy (including TENS), massage, chiropractic, acupuncture, Feldenkrais (a type of exercise therapy meant to improve movement by reorganizing connections between the brain and body), foam rollers, yoga and other interventions for relief. Some worked better than others, some were beneficial for a time. Bottom line, I’m always looking for ways to ease movement and feel stronger. The information we’ve gathered in these stories has given me a few new avenues to investigate. I hope they help you as well. Ultimately, though, pain is more than physical discomfort. Multiple expert voices in these articles stress the psychological aspect of pain and healing. So maybe it’s time to take stock of my own behaviors and choices to see where I can make changes. Maybe 2024 is the year I heal myself.

ALEXANDRA RUSSELL EDITOR-IN-CHIEF

Allan Bernstein, MD; Indra Chaliha, MD, MPH, FAAP; Jean Saylor Doppenberg; Rachel Friedman, MD; Gary Green, MD, FIDSA; Stephen Halpern, MD; Karen Hart; Jet Howell; Tatiana Longoria, RN; Peter Marincovich, Ph.D., CCC-A; Brien Seeley, MD; Ellen Seeley; Ashish Shah, MD; Siya Shah; Navyaa Sharma; Gary Stein, MD; Jeffrey Sugarman, MD, Ph.D; Judith M. Wilson; Ruby Wilson MEDICAL ADVISORY BOARD

Allan Bernstein, MD (Chair); Dierdre Bernard-Pearl, MD; James DeVore, MD; Rachel Friedman, MD; Gary Green, MD, FIDSA; Brien A. Seeley, MD; Jeffrey Sugarman, MD, Ph.D; Maria Petrick, MD, FACAAI-FAAAI; Victor Wong, MD PROOFREADING

Jean Saylor Doppenberg, Katie Watts ADVERTISING / MARKETING CHIEF REVENUE OFFICER Karleen Arnink-Pate CHIEF REVENUE STRATEGIST Adam Bush DIRECTOR OF ADVERTISING OPERATIONS Dennis Sheely DIGITAL OPERATIONS DIRECTOR Tomas Chadsey DIRECTOR OF CUSTOMER SUCCESS Jason Fordley SPONSORSHIP & EVENTS DIRECTOR Brandelle McIntosh MARKETING & BRAND DIRECTOR Matt Kehoe SPECIALTY CONTENT MANAGER Ken Jaggie LOCAL ADVERTISING MANAGER Robert Manley

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PUBLISHERS OF THE PRESS DEMOCRAT, SONOMA INDEX TRIBUNE, PETALUMA ARGUS COURIER, NORTH BAY BUSINESS JOURNAL, SONOMA MAGAZINE, SONOMA HEALTH, SONOMA COUNTY GAZETTE, LA PRENSA SONOMA MANAGING MEMBER CHIEF EXECUTIVE OFFICER CHIEF CONTENT OFFICER CHIEF FINANCIAL OFFICER CHIEF REVENUE OFFICER CHIEF OPERATIONS OFFICER CHIEF DIGITAL OFFICER PRESIDENT, MAGAZINE DIVISION EXECUTIVE ASSISTANT

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BOARD OF ADVISORS

Darius Anderson, Chairman Bill Jasper Norma Person Jean Schulz Les Vadasz Sandy Weill

Volume 3, Issue 1, December 2023. Sonoma Health is published by Sonoma Media Investments LLC ©Copyright 2024 Sonoma Media Investments LLC. All rights reserved. DISCLAIMER: Editorial content in this publication is for informational purposes only and should not be construed as medical advice. If you want to learn more about any of the topics covered, seek the advice of a trained medical professional. Main/mailing Address: 416 B Street, Suite A, Santa Rosa, CA 95401 Sonoma Address: 117 W. Napa Street, Sonoma, CA 95476 Main phone 707-546-2020 Publishers of The Press Democrat, Sonoma Index Tribune, Petaluma Argus Courier, North Bay Business Journal, Sonoma Magazine, Sonoma County Gazette, La Prensa Sonoma AUDIT PENDING

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SONOMA HEALTH

Did You Know? Hearing loss relates to these common medical conditions:

Cognitive Decline

Ototoxicity

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P MET

Contents SONOM A HE ALTH 2024

UP FRONT

ARTICLES

EDITOR’S LET TER

ALEXAN D R A R US S E L L

A Painful Truth

SMLMA LET TER

WENDY DAV IES

TAT I ANA LO N GO R IA, RN; A N D J E F F RE Y S UGA RM A N, MD, P H D

Refresh your look with laser skin treatments.

Tick Talking

G AR Y GRE E N, MD, FIDS A

Challenges Accessing Health Care in Sonoma County

R AC H E L FR IE DM A N, MD

Sonoma County Numbers, Vaccine Season, Pets & Health, ACA Updates 4

SONOMA HEALTH

P. 24

A Healthy Glow

Insights about ticks and Lyme disease in the North Bay

STATS, STORIES AND SHORTS

Digital Detox

A resolution for the whole family

A Modern Threat

AN I SH S H A H, MD; N AV YA A S H A RM A AN D S IYA S H A H

The impact of cyberbullying on the mental health of children

The Dry January Challenge RUBY WILLIA MS

Embrace a healthier you

A Candle in A Dark Room

P E TE R MA R IN COVIC H, PHD, CCC-A

Tinnitus treatments aren’t perfect, but they can offer relief.

A Hard Choice JE T H OWE LL

Moving a loved one to assisted living is a difficult decision. But guilt shouldn’t be a factor in your choice.

FEATURES

IND R A CH A L IHA, M D, MP H, FA A P

Getting a good night’s sleep can be a challenge, but local sleep specialists help patients get great zzzs.

Healing From Within The beauty of “food as medicine” is that the choice to restore health and promote wellness is as close as your next meal.

Seeding Your Gut Garden ELLE N S EELEY

Probiotics and prebiotics can bolster your health in many ways.

Highs and Lows STEP H EN H A L PER N, M D

Exploring the blood pressure and cholesterol connection

Steady On

ALL A N B ER N S T EIN, M D

Multiple body systems work together to maintain balance and prevent dizziness and falls.

A Hard Choice

P. 56

A Good Night J U D I T H M. WI L S O N

A Good Night

A Healing Touch

P. 58

J E AN SAY LO R DOPPENBERG

The healthful benefits of massage therapy

Good As New G AR Y ST E I N, MD

The ins and outs of knee and hip replacement surgery

Ease Your Pain KAR E N H AR T

What health care professionals know about getting to the source of pain and a few less common, drugfree alternatives for pain management

EXTRAS

Wine Country bars and restaurants make Dry January fun.

JE A N SAY LOR DO PPENBERG

Cheers to the Challenge!

Listen and Lead Meet Dr. Tanya Phares, Sonoma County’s new Health Officer

Hear Me Now Or Pay Me Later BRIE N S E E LE Y, M D

A review of Greta Thunberg’s The Climate Book

Meet the Writers

Thanks to our many physician authors

Mocktails

P. 30

SONOMA HEALTH

CHALLENGES ACCESSING HEALTH CARE IN SONOMA COUNTY THE SONOMA-MENDOCINO-LAKE MEDICAL ASSOCIATION (SMLMA) is the membership organization that supports physicians and the practice of medicine in our area. SMLMA provides a multitude of advocacy, wellness and practice management programs for physicians, as well as opportunities for community service and involvement. One of the most frequent calls we receive at the SMLMA office is from people seeking a local doctor who is accepting new patients and will accept their medical insurance. While SMLMA aims to be a community resource, the answers to these questions aren’t always easy. A call to the SMLMA team is a good start, as we can provide you with an individually curated list of names and contact information for local physicians and specialists. However, we have no way of monitoring physician availability or insurance participation. You will need to make calls to inquire if providers are accepting new patients and your insurance — information that can sometimes change daily. SMLMA represents more than 1,000 physicians in Sonoma, Mendocino and Lake counties. To locate local physicians, call SMLMA at (707) 525-4375 or check our online Physician Finder service at smlma.org (under the Resources tab). ATTRACTING DOCTORS

Shortage of physicians (especially primary care) is one obstacle to accessing health care in Sonoma County. This is why the Family Medicine Residency programs of Kaiser Permanente, Sutter Health and Ukiah’s Adventist Health are so vital to our area. These programs bring physician graduates from around the globe to Sonoma County for hands-on-training. The goal is to connect young residents to our community with the hope they will want to stay and practice here. The biggest challenge to retaining these new physicians is our cost of living. Aside from purchasing or even renting a home, the cost of day-to-day necessities is much higher here when compared to other places residents are being offered placement. Add these costs to the responsibility of paying off medical school loans and Sonoma County, while wonderful if you can afford it, doesn’t look so appealing to new graduates. SMLMA works to support the local Residency Programs by creating an additional layer of commitment and connection to the community. Our business partnership program offers homebuying assistance, financial health advice, banking services and more. We provide opportunities for connection with colleagues from across the region and serve as a training ground for physician leadership. We always hope many of the medical residents will want to stay in Sonoma County.

AFFORDING HEALTH CARE

Another community challenge is the often prohibitive cost of insurance and care, as many “affordable” insurance plans come with high annual deductibles that must be met before significant coverage kicks in. However, many of these plans will, generally, cover basic annual health maintenance

SONOMA HEALTH

without deductibles. Check with an independent insurance broker or directly with the various plans to find coverage that works best for your budget and medical needs. Covered California (coveredca. com) is a free service that connects Californians with brand-name health insurance under the Patient Protection and Affordable Care Act. It’s the only place where you can get financial help when you buy health insurance from well-known companies. That means when you apply, you may qualify for a discount on a health plan through Covered California or get health insurance through the state’s MediCal program. Either way, you’ll have great health coverage. (See “ACA Changes for 2024,” page 17, for more information.) You can also investigate lowcost or sliding scale clinics that offer services on a reduced fee schedule based on your income. We have many community clinics throughout Sonoma County that do this, all of which are staffed by excellent physicians and provide thoughtfully planned access to care. Visit the Sonoma County Department of Health Services website for a list and links to community clinics in Sonoma County. You can learn more about Federally Qualified Health Centers (FQHCs) by viewing the Federally Qualified Health Care section at Medicare.gov. Most FQHC clinics accept Medicare, Medi-Cal, under-insured patients and uninsured patients. It is my privilege as SMLMA executive director to work with the dedicated organizations and physicians who are striving to care for our diverse communities. May we all be connected in service for the common good. Wendy Davies is executive director of the Sonoma-Mendocino-Lake Medical Association (www.smlma.org).

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SONOMA COUNTY STATS

Since 2016, the County of Sonoma has hosted an online Community Health Dashboard, sharing information and statistics relevant to the physical and mental health of its residents. Topics range from school age vaccination rates and chronic diseases to EMS transport trends and preventable hospitalizations. See how your neighbors are doing at /gis-community-health.sonomacounty.ca.gov. Here are a few pertinent check-ins. 10.5% PERCENT NOT INSURED

10% 8%

WHO HAS HEALTH COVERAGE?

8.4% 7.2%

5.9%

CALIFORNIA SONOMA COUNTY

2% 0$

2013-2017

2014-2018

2015-2019

2016-2020

Sonoma County residents obtain health insurance through a variety of public and private plans. Of those who have some type of health insurance, approximately 68% are covered through private insurance plans while another 32% are covered through publicly funded programs such as MediCal and Medicare. The majority of private plan enrollees obtain coverage through employer-sponsored programs. As has occurred nationally, the recession has forced many local employers to reduce workforce size and/ or to scale back or discontinue the provision of health insurance benefits to employees. Source: sonomacounty.ca.gov

2017-2021

LOCAL LIFE EXPECTANCY

Average life expectancy in Sonoma County is currently 80.6 years with considerable variation by population sub-groups. Females average 82.1 years while males average 78.4 years. Hispanic life expectancy (91.0 years) significantly exceeds that of Whites (79.9 years). Life expectancy also varies significantly by neighborhood poverty level. Neighborhoods with less than 5% of residents living in poverty experience lower mortality than neighborhoods with a population (in poverty) greater than 15%. Source: sonomacounty.ca.gov

CURRENT SMOKER

20.1%

19.8%

16.7%

15.6%

SONOMA COUNTY / CALIFORNIA 5

2018

2019

2020

2021

USE AND ABUSE OF ALCOHOL, TOBACCO

PERCENT OF ADULTS 18+ YEARS

BINGE DRANK IN LAST MONTH 20

12.9% 11.0%

9.0%

8.8% SONOMA COUNTY / CALIFORNIA

2018

2019

2020

The misuse of alcohol and tobacco affects the health of many people in our community. Binge drinking (defined as consuming five or more drinks on an occasion for men or four or more drinks on an occasion for women) is the most common and costly pattern of excessive alcohol use in the United States, associated with serious injuries and diseases, as well as with a higher risk of alcohol use disorder. Tobacco use is the leading cause of preventable death, often leading to lung cancer, respiratory disorders, heart disease, stroke and other serious illnesses. Source: sonomacounty.ca.gov 10

SONOMA HEALTH

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SONOM A C OUN T Y STAT S A N D ST OR IE S

VACCINE SEASON

BY GARY GREEN, MD

Remaining up-to-date on your COVID-19 VACCINE , including boosters, is the best way to reduce the likelihood of becoming sick and reduce the likelihood of severe outcomes from COVID-19. To find COVID-19 vaccine locations near you: Search vaccines.gov, text your ZIP code to 438829, or call 1-800-232-0233.

RSV (respiratory syncytial

virus) is a potentially dangerous, highly contagious virus that can cause respiratory disease. Symptoms can appear like the common cold before worsening. Anyone can get RSV, but it can be more serious for adults 60 and older, including those with underlying medical conditions, as well as babies less than 6 months old. Vaccines are available to those over age 60 and to women in late stages of pregnancy (32 to 36 weeks).

AS OUR WEATHER TURNS WET AND C OLD, people naturally start to gather indoors for shopping, dining, exercising and other activities. In addition, holiday events and travel bring diverse populations together. All of these actions promote the spread of viruses. From 2022, we know that all the many respiratory viruses of that year — influenza, respiratory syncytial virus (aka RSV), and SARS-CoV-2 (COVID-19) — caused the majority of hospitalizations and fatalities. In California, COVID has been ongoing for months already this year, and RSV infections are also on the rise. The 1918 influenza pandemic went on for four to five years before becoming a winter seasonal virus. Similarly, COVID-19 has not yet become a seasonal illness. In better news, we have not seen a new variant since the Omicron variant was detected in November 2021. The evolution of random virus mutations has produced subvariants of Omicron, but not a new strain altogether. This has resulted in more contagious COVID-19 illnesses, but not in more severe disease. In September 2023, the Food and Drug Administration approved two updated single-variant COVID vaccines, made by Pfizer and Moderna. Both are based on the Omicron subvariant called XBB.1.5, which is a second-generation virus from the original Omicron strain. The new vaccine is approved and available for anyone 6 months and older — just like influenza vaccines, and we now know it’s safe and effective to mix different manufacturers of this single-dose variant. For anyone older than 11 years of age, you only need one dose, even if you have never received a COVID vaccine before.

This season, everyone over 6 months of age should receive an influenza vaccine and an updated COVID vaccine. If you are over 60 years of age with serious medical problems, you may also be a candidate for the new RSV vaccine. In the hospital now, the most severe and fatal COVID-19 illnesses are in unvaccinated adults and in frail elderly patients whose vaccine immunity has weakened due to aging immune systems. Currently in California, about 15% of residents have never received a COVID vaccine, and 10 to 15 people are still dying from the virus each day. Not surviving from a vaccine-preventable disease is certainly a tragedy.

84,905

Up-to-Date Recipients (including boosters)

Source: experience.arcgis.com

17.0%

of Sonoma County Population Source: experience.arcgis.com

1,400,393 Total Doses Administered

Source: experience.arcgis.com

SONOMA HEALTH

SONOM A C OUN T Y STAT S A N D ST OR IE S

Questions to Consider When Purchasing Pet Insurance It’s no great revelation that people with pets often experience greater health benefits than those without. But what happens when that furry, feathered or scaly friend gets sick? In recent years, many people have turned to pet insurance to prepare for and help cover prohibitive veterinary costs. When deciding whether to purchase coverage, there are several considerations that should go into your decision besides the cost of the policy. You should ask any insurer that provides you with a quote for coverage to also provide you with the information you need to make an informed decision. Questions to consider may include: • Does the coverage offered have exclusion for pre-existing conditions? If so, the insurer will likely not pay for treatment for any condition for which the pet owner has received medical advice or the pet has received treatment prior to enrollment in a new pet insurance policy. • Is there a waiting or affiliation period, which means the period of time specified in a pet insurance policy which must pass before some or all of the coverage in the policy can begin? If so, any costs for treatment provided before the end of the waiting period will not be covered by the policy. • Does the coverage exclude costs for treatment of a hereditary disorder, which means an abnormality that is genetically transmitted from parent to offspring and may cause illness or disease? If your pet has a hereditary disorder, such as hip dysplasia, many insurers will not pay for treatment related to that condition. • Does the coverage exclude costs for a congenital anomaly or disorder, which means a condition that is present from birth, whether inherited or caused by the environment, and which may cause or otherwise contribute to illness or disease? If your pet has a health issue identified as a congenital anomaly or disorder, the insurer will not pay for treatment related to it. 14

SONOMA HEALTH

• Is there a deductible or coinsurance clause that causes any claim reimbursement to be reduced by a set amount? Your veterinarian will expect you to pay the amount of any deductible or co-insurance percentage. • Is there an annual or lifetime policy limit that will cap the amount that will be paid for veterinary services? If so, you need to consider whether the coverage is a reasonable investment in terms of premium paid versus total benefit available. • Will the renewal premium be increased if a claim is made? If so, you might want to know the amount of increase that takes place. • Is there a basis for reimbursement or formula for payment for veterinary services other than the actual amount of the billed services? Examples include claims payments based upon a standardized schedule of costs or a schedule of “usual and customary” charges in the industry for the services provided. Your veterinarian will expect you to pay the balance of any billed amount not paid by the insurer. Source: hwww.insurance.ca.gov/01-consumers/105-type/8-pet/pet-qa.cfm

REIGNING CATS AND DOGS

Dog owners make up 40.1% of pet-owning households in California. Cat owners are 22.9% of the pet-owning population in California. Source: World Population Review

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SONOM A C OUN T Y STAT S A N D ST OR IE S

ACA Changes for 2024 Beginning January 1, 2024, a new law in California will let adults ages 26 through 49 qualify for full-scope Medi-Cal, regardless of immigration status. All other Medi-Cal eligibility rules, including income limits, will still apply. This initiative, called the Ages 26 through 49 Adult Expansion, is modeled after the Young Adult Expansion, which provided full scope Medi-Cal to young adults 19 through 25, and the Older Adult Expansion, which provided full scope Medi-Cal to adults 50 years of age or older. In addition to the Medi-Cal expansion, Affordable Care Act (ACA) marketplaces (the state-run clearinghouses that bring together multiple insurance options in one place) are currently in the midst of open enrollment, which runs through January 15, 2024. Here’s what’s new going into next year: Unsubsidized premiums are rising. Outof-pocket premiums will rise an average of 5%-6%, due in large part to rising prices paid to health care providers; the increase is also partially driven by inflation in the rest of the economy and a rebound in use of health care services coming out of the pandemic. Although unsubsidized premiums are rising, the Inflation Reduction Act’s temporary enhancement of subsidies continues to make the vast majority of marketplace shoppers eligible for financial help with the cost of coverage. 2024 could be another record-setting year. The number of people who enrolled in ACA health coverage in 2023 reached 15.7 million nationally, surpassing prior record-setting years in 2021 and 2022.

Insurer participation will be more robust. There are more insurers entering new markets than there are plans exiting from the marketplace. This means more choices for consumers. State-level policy changes will affect coverage. California will begin offering additional cost-sharing reduction subsidies that eliminate deductibles and lower other out-of-pocket expenses for about four in 10 Covered California enrollees. A new auto-reenrollment policy will save some consumers money on their deductibles. People who are enrolled in ACA plans now and who do not act during Open Enrollment to renew or change their coverage will, in many cases, be automatically re-enrolled by the marketplace on December 16, so coverage will continue in 2024. Those who are automatically re-enrolled in this way but want to select a different plan will still have until the end of Open Enrollment (January 15, 2024) to make a change.

Marketplace shoppers will have extra time to submit proof of income. Marketplaces automatically check trusted data sources (such as the IRS and Social Security) to verify the income of enrollees. If the marketplace cannot verify the income on a given application, the applicant may be asked to submit more documentation. Coverage will continue during this period, but financial assistance may be reduced or terminated if the requested documentation is not received by the deadline. Young adults will have more time to move off of their parents’ marketplace plans. Private health plans must permit young adults the option of remaining covered as a dependent under their parent’s policy until they turn age 26. Starting in 2024, federal marketplace health plans will not be allowed to terminate coverage for young adult dependents mid-year on their 26th birthday. The federal government is making changes to some special enrollment periods (SEP). SEPs let certain people sign up for coverage outside of the Open Enrollment period. Qualifying reasons may include: Medicaid disenrollment, natural disasters, loss of SEP coverage and pandemic-related situations. Tax credit recipients must again file tax returns to maintain eligibility for subsidies. People who receive advanced premium tax credits (APTC) must file their federal tax return the following spring to continue receiving an APTC. This “file and reconcile” requirement was waived during the pandemic, but now people who fail to file and reconcile for two consecutive years will be ineligible for APTC the following year. Source: www.kff.org

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A HEALTHY GLOW

Refresh your look with laser skin treatments

Tatiana Longoria, RN; and Jeffrey Sugarman, MD, PhD

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Laser skin treatments have become increasingly popular in recent years as people seek to maintain a youthful and refreshed appearance. After a summer of sun exposure, skin can suffer from UVinduced damage, including dark spots, fine lines and wrinkles. Laser treatments, such as intense pulsed light (IPL) and resurfacing lasers, specifically target the effects of sun damage, rejuvenating the skin and improving its texture.

HOW LASER SKIN TREATMENTS WORK

Laser skin treatments use the power of light energy to resurface the skin and/or target unwanted discolorations in the skin. This precise light energy can target damaged skin cells while preserving the healthy ones, promoting collagen growth and rejuvenation. Collagen production naturally decreases starting in our 30s, which then leads to the appearance of fine lines and wrinkles. Laser skin resurfacing treatments have been proven effective in reducing these signs of aging and promoting collagen synthesis. By stimulating collagen production and improving skin tone, laser treatments can help address a wide range of skin concerns, improving overall skin health, which, in turn, creates beautiful, natural looking results.

Skin resurfacing can also improve the look of scars including those from acne, trauma and surgical procedures. Devices such as microneedling also stimulate collagen production and are often used in conjunction with lasers. Additionally, lasers can target different pigments, such as brown and red spots, improving conditions such as melasma and rosacea. Laser treatments are generally not onetime procedures. To achieve the best results, multiple sessions are often required. By starting laser treatments during winter months, you give yourself plenty of time to complete the recommended series of treatments before the UV index rises again, ensuring a more comfortable and safe recovery process.

LASER SKIN RESURFACING TREATMENTS HAVE BEEN PROVEN EFFECTIVE IN REDUCING SIGNS OF AGING AND PROMOTING COLLAGEN SYNTHESIS. POTENTIAL SIDE EFFECTS/COMPLICATIONS

Like any medical procedure, there are potential side effects that patients should be aware of before undergoing treatment. One common side effect of aesthetic laser procedures is temporary redness and swelling at the treatment site. This is a normal response to the laser energy and typically resolves within a few hours or days. Some individuals may also experience mild to moderate discomfort or a sensation of heat during the procedure, but this is usually welltolerated and can be managed with topical numbing creams or cooling techniques. Another possible side effect is temporary

hyperpigmentation or darkening of the skin. This occurs more commonly in individuals with darker skin tones and typically fades over time. In rare cases, blistering or scarring may occur, but this is usually associated with aggressive or improper use of the laser. It is important to choose a qualified and experienced provider who can minimize the risk of these complications. Overall, while aesthetic laser treatments are generally safe and effective, it is important for patients to understand and discuss the potential side effects with their health care provider before proceeding with treatment.

Can you hear and understand as well as you used to? Check your hearing in less than 5 minutes with our FREE hearing screener: visit goodhearing.com/test or scan this QR code with your phone

Laser skin treatments have revolutionized the field of dermatology and aesthetic medicine, offering effective solutions for various skin concerns. From improving skin tone and texture to treating acne scars and pigmentation issues, lasers provide targeted and precise treatments. With the ongoing advancements in laser technology, trained medical professionals can deliver optimal results, ensuring patient safety, satisfaction and confidence. If you’re looking to rejuvenate your skin and address specific skin concerns, consult with a dermatologist to explore laser treatment options.

Expert care. Every patient, every time. Our Services Include: • Hearing Evaluations • Hearing Aids (sales, service, repair) • Hearing Protection • Assistive Listening Devices • and more

Home of the Hearing Aid Test Drive™ To schedule your personalized consultation, please call 707-509-8267 or visit goodhearing.com 5 Sonoma County locations to serve you Santa Rosa | West • Petaluma • Santa Rosa | East | Oakmont • Sonoma

TICK TALKING Insights about ticks and Lyme disease in the North Bay BY GARY GREEN, MD, FIDSA

I OFTEN HEAR PATIENTS ANXIOUSLY SAY, “There are so

many deer in my yard, I’m afraid I'll get Lyme disease from the deer ticks.” My response, without exception, is, “West Coast Lyme vector ticks are not the Midwest/East Coast deer ticks.” This is often followed by a long pause. I explain that the “deer tick” (Ixodes scapularis) of New England and the Midwest is a different tick species than the Western black-legged ticks (Ixodes pacificus), which have a coastal range from British Columbia to California. After a prolonged infected tick bite, the Midwest/East Coast deer tick more efficiently

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transmits Lyme disease than does the Western blacklegged tick due to important differences in life cycles, host preferences and transmission risks. “The lower risk of [Lyme transmission from] a Western black-legged tick is due to its preference to feed on lizards during its nymph stage,” I explain. This is typically followed by another long pause. The truth is, Lyme disease is not an epidemic in California and, with early diagnosis, it’s curable with a short course of antibiotics. (It’s also been misnamed as “the great masquerader”; historically a term more accurately reserved for a different spirochete, syphilis.)

NORTHERN CALIFORNIA TICKS AND ASSOCIATED HUMAN INFECTIONS (female/male)

WESTERN BLACKLEGGED TICK Ixodes pacificus

Lyme disease & Anaplasmosis

AMERICAN DOG TICK Dermacentor variabilis

Tularemia & Rocky Mountain spotted fever

LIFE CYCLE OF A TICK

Ticks can be found everywhere in the world, even in Antarctica. There are two major tick families: hard ticks, such as the Ixodes genus, and soft ticks, including the Ornithodoros genus. Ticks are blood-sucking arachnids, the adults are eight-legged, and they need to bite and take a blood meal in order to survive, lay eggs and molt into the next phase of their life cycle. Without a blood meal, ticks will not survive. Hard ticks can carry a variety of different organisms, including viruses, bacteria and parasites. Ixodes hard ticks can also carry and transmit multiple pathogens simultaneously. When hard ticks attach to a host, their mouthparts excrete enzymes and anticoagulants. This is when transmission of an infectious organism may occur. The Western black-legged tick only carries three bacteria that are pathogenic to humans: Borrelia burgdorferi, Borrelia miyamotoi and Anaplasma. These infections may cause a febrile illness (one that causes a fever).

THE REAL CULPRIT

Borrelia burgdorferi is a corkscrew-shaped spirochete bacteria that causes Lyme disease. It is the most common vector-borne disease in the United States, Canada and Europe. Lyme can be carried by three species of Ixodes ticks in different regions of the world: Ix scapularis

B E P R E PA R E D After

washing outdoor clothing, drying clothing on high heat kills both hard and soft ticks. The Centers for Disease Control and Prevention and California Department of Public Health also recommend:

PACIFIC COAST TICK Dermacentor occidentalis

Tularemia, Rocky Mountain spotted fever & Pacific Coast tick fever

BROWN DOG TICK Rhipicephalus sanguineus

(East Coast and Midwest), Ix pacificus (West Coast) and Ix ricinus (Europe). In the Midwest and East Coast, Borrelia burgdorferi has a high prevalence within the deer tick populations. In the spring and summer, almost 50% of these nymph and adult ticks can be infected. The higher the concentration of this bacteria inside a deer tick, the higher chance of a host becoming infected with Borrelia burgdorferi during a prolonged tick bite. We have a lower Lyme disease risk in California because the Lyme disease bacteria has much lower concentrations in Western black-legged tick populations. Rates of tick infection can vary widely depending on the habitat, but usually only 1% to 7% of adults and only 1% to 10% of nymph Ix pacificus carry the spirochete. This is because a protein in the bloodstream of the Western fence lizard (the tick’s preferred host) will remove the spirochete from the tick. The lower prevalence of Borrelia burgdorferi in Western black-legged ticks lowers the risk of Lyme disease from a tick bite in California. I estimate the risk of Lyme disease from a tick bite in California to be one-fifth to onetenth the risk of that from a tick bite in the Midwest or East Coast. Yes, we have Lyme disease in California, but not to the degree in the Midwest or East Coast.

WINTER TICK Dermacentor albipictus

West Coast Babesiosis

Rocky Mountain spotted fever

AND DON’T FORGET

It’s important to not be Lyme-centric; there are other tick-borne infections in California. The Western black-legged tick can also, though rarely, transmit Anaplasma phagocytophilum (known as anaplasmosis) and Borrelia myamotoi (tickborne relapsing fever). Different hard tick species in Northern California can transmit bacterial infection including the pathogens Francisella tularensis (Tularemia), Rickettsia rickettsia (Rocky Mountain Spotted Fever), Rickettisia philipii (Pacific Coast Tick Fever) and the parasite Babesia duncani (Babesiosis). They can be dangerous, but these infections are uncommon-to-rare in California. We should also dispel a number of myths about hard ticks and Lyme disease. Ticks wait for us to pass by perching on tall grass, brush, logs, benches or in leaf litter with a behavior called “questing.” Ticks do not jump, fly or fall from trees. Ticks do not burrow under the skin. Most tick bites do not result in infection. After you return home from your adventures in the outdoors, it is important to perform a tick check of yourself and your family members, but with a little preparation and precaution, we can safely enjoy our time outdoors without worry.

• Wearing light colored clothing so you can spot dark ticks more easily on your clothing

• Pre-soaking hiking clothing in permethrin (and letting this dry) to repel ticks

• Tucking your pants legs into your socks so ticks don’t have access under pants to bare skin

• Applying DEET onto skin to help with tick avoidance

• Showering after outdoor activity to more easily detect ticks and wash off unattached ticks.

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World-class cancer care, WITHOUT THE HASSLES

The UC Davis Comprehensive Cancer Center is recognized as one of the nation’s most elite. And we’re ready to serve you when you need us. UC Davis Health is home to the UC Davis Comprehensive Cancer Center, the only center in inland Northern California to hold “comprehensive” designation from the National Cancer Institute. Treatment at NCI-designated cancer centers is associated with improved outcomes for many people with cancer. And “comprehensive” designation means patients get access to leading-edge treatments, early access to clinical trials, and the benefit of collaboration between cancer physicians and researchers. We’re honored to offer Northern California access to life-changing care that’s among the best in the world — without the traffic, expense and stressors of congested urban areas.

Excellence ■

A complete range of adult and pediatric specialties, including a unique program for adolescent and young adult patients

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Extensive expertise with uncommon cancers

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Access to leading-edge care, such as robotic surgery, targeted treatments and theranostics

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Experts from a variety of disciplines often convene tumor boards to analyze options

Innovation ■

More than 200 active clinical trials at any one time, including Phase 1 trials

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Hundreds of scientists and staff engaged in research

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A member of the National Comprehensive Cancer Network (NCCN®)

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Advanced testing capabilities such as the UC Davis-developed EXPLORER — the world’s first total-body PET scanner Part of the UC Cancer Consortium, drawing on the collective expertise of the entire UC Health system to advance care

Convenience ■

Telehealth and video visits available

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Easy hotel access (including one on the UC Davis Health Sacramento campus)

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Convenient online tools to communicate with your care team, view your medical record, and more A wide range of support services to promote healing and help our patients and families

For more information, visit cancer.ucdavis.edu.

D IG ITA L D E TOX A Resolution for the Whole Family By Rachel Friedman, MD

SONOMA HEALTH

IN TODAY’S WORLD, screens have woven their way into nearly every aspect of our lives. They

connect us to each other, entertain us and feed us an increasing proportion of the information and news we consume. Many adults must use a screen — computer, tablet or phone — to perform their jobs; many schools now require screens for curricular content and homework. While there are certainly numerous benefits to our digital, hyperconnected world, excessive screen time has its drawbacks. A digital detox (in some form) may be the best thing you can do for your own — or your family’s — mental and emotional health.

THE PANDEMIC’S DIGITAL TSUNAMI

When COVID-19 swept across the globe in 2020, the digital world became our primary social outlet, and nearly every industry pivoted to a virtual or digital version. As a family physician, I switched almost entirely to telehealth encounters by day, and plunged into social media platforms every evening to communicate with colleagues worldwide, keep up with the latest research, share public health advisories and try to provide objective, thoughtful answers amid a sea of misinformation. Screens made it possible for our communities to continue to access health care safely and for physicians to collaborate across the globe. Children also benefited. When schools closed and even playdates felt dangerous, virtual classes let learning continue as digital spaces turned into a new academic reality for our students. Grandparents read books to their grandchildren via video chat, and screen time activities let both children and teens stay socially connected. It shouldn’t be surprising, then, that children’s average daily screen time increased to almost six hours per day during the pandemic, and teens’ use doubled to more than eight hours per day.

Our experiences mirrored what research suggests: excessive screen time can lead to sleep disturbances, increased stress and mental health challenges for both children and adults. It’s been linked to increased risk of obesity and reduced cognitive development among children. In adults, too much screen time can independently create symptoms of anxiety and depression.

A PHYSICIAN’S PERSONAL DETOX JOURNEY

Amid escalating arguments over screen time and its conspicuous effects on my children’s behavior, my family embarked on a journey to break the habit. We started a few weeks before the end of summer vacation with the announcement that once school started, we would be undergoing a “digital detox.”

EXCESSIVE SCREEN TIME CAN LEAD TO SLEEP DISTURBANCES, THE DIGITAL BURNOUT INCREASED STRESS As the initial shock of the pandemic waned, the toll of this digital immersion became glaringly AND MENTAL HEALTH apparent to me. Emotional burnout set in, and CHALLENGES FOR everyone in our house seemed more irritable. My sleep cycles felt off, even though I was less BOTH CHILDREN AND stressed than I had been in previous years. The constant barrage of notifications, messages ADULTS. and updates left me mentally exhausted. I felt I had less bandwidth to be patient with my kids after a long workday, and they also seemed to be increasingly whiny, moody and intolerant of frustration or boredom. The lines between work, leisure and personal space had blurred, leaving us overwhelmed and hoping for an escape from the fray. Life was starting to return to normal, so why were we all so unhappy?

The “weaning” period involved a gradual increase in time and media type restrictions. First, we created a limited list of shows/ apps the children could engage with, then gradually restricted even that screen time to weekends only. Finally, we put away all

RECOMMENDED READING

• Digital Minimalism: Choosing a Focused Life in a Noisy World by Cal Newport • Digital Detox: The Two-Week Reset for Kids by Molly Frank RECOMMENDED WATCHING

• Screened Out • Screenagers

handheld devices and TV remotes so that their only screen time was through the shared experience of family shows or movies. By the time the first day of school arrived, they had gotten used to these changes, and we were able to start the school year with a complete digital detox for the kids. Fortunately, at that time they were both at schools that did not require any media use at school or for homework. As a physician who must have phone and laptop connectivity for work, my adult version of detox involved a complete break from all social media and online news. Even with the gradual transition, the first few weeks of our digital detox were challenging, highlighting the depth of our screen attachment. However, once we got through the initial induction period, I was pleasantly surprised to notice my children becoming more engaged, creative and curious. Without the default turn to social media and doomscrolling before bed, I found myself reaching out to more friends and family individually, started an artistic hobby and was able to truly experience birthday parties and hikes without the mental strategizing of what and when to post. Our family bond strengthened as we rediscovered joys in simple, screen-free activities and leisure Continued on page 27 without entertainment.

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A MODERN

THREAT

The impact of cyberbullying on the mental health of children By Dr. Anish Shah, MD; Navyaa Sharma and Siya Shah

THE RISE OF SOCIAL MEDIA over the past two decades has made it easier than ever to keep in contact with friends, loved ones and acquaintances. However, the past few years have made it increasingly obvious that there are darker sides to the ubiquity of social media platforms. Unfortunately, children and teenagers have faced the brunt of cyber abuse, with disastrous consequences for their mental health. Cyberbullying is a form of repeated, intentional, aggressive behavior, including hateful text messages and harassment in public or via YouTube or TikTok videos. It often comes in the form of private tormenting or escalates to near-inescapable public humiliation. Worse yet, cyberbullying is experienced at all hours of the day and often at the hands of someone the victim knows. Up to 58% of teens and children report being victims of some form of cyberbullying, and the situation is even more dire for children from marginalized communities — up to 71% of LGBTQ youth have been victims. In addition, those with preexisting mental health issues are more likely to be targeted.

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Victims experience symptoms of depression and anxiety and tend to have lower grades than their peers, low self-esteem, poor quality of life, often turn to substance abuse and experience social ostracization. Its impact is associated with higher rates of suicidal thoughts or actions. The situation worsened during the pandemic, with increased time spent online and increased social isolation. Teens who engage in cyberbullying are also worse off for it. Many people who engage in cyberbullying are also victims of it. Consider the very public case of Conrad Roy III, who, in 2014, tragically took his own life after being bullied by his thengirlfriend, Michelle Carter. After weeks of constant text messages telling him he should kill himself and that he didn’t deserve to live, Roy committed suicide. Carter was found guilty of involuntary manslaughter and sent to prison.

TAKE ACTION

Research indicates that social support is linked to reduced symptoms of depression

and anxiety for victims of cyberbullying and bully-victims alike. Family support is also tied to improved overall wellbeing. By identifying likely victims of cyberbullying, family, friends and school officials can work together to provide needed support. Signs of cyberbullying vary, but if parents observe that their child is emotionally upset after using the internet, spending more time than usual in isolation or appears withdrawn, they should pay close attention. Additionally, if a child suddenly stops using the computer or device and seems startled when getting incoming messages, text or emails, there could be a problem. When parents observe that their children avoid discussions about social media and phone activities, this behavior can also be a sign. Similarly, families must be aware of their children’s online activities to stop them from perpetrating cyberbullying and help address their underlying issues. With this twopronged approach, we can fight back against cyberbullying and protect the mental health of children and teens — and the adults they grow into.

DIGITA L DE T OX

Continued from page 25

THE WAY FORWARD

In an ideal world, we might have continued the digital detox forever, but a return to screens at home eventually occurred. We have reintegrated some weekend screen time and family movie nights back in for the kids, but we now have a tool for rejuvenation and reconnection when screen time saturation creeps back in. Our version of a mini detox usually involves a return to either weekendonly screen time or weekends plus family shows/movies. One to two weeks of this helps our brains and bodies reset, while reminding us that there are so many things to do in the world that don’t involve an app or a screen. Research affirms that embracing digital minimalism doesn’t necessitate a complete severance from screens, but rather a more intentional and balanced approach. Just reducing screen time, or taking periodic digital detoxes, can refresh the mind, improve sleep, enhance interpersonal relationships and even foster creativity. When screens are removed, our brains find much-needed respite, leading to improved concentration and better mental health.

Improvement has been seen when antibullying messages are taught in school; there are clear benefits to encouraging responsible online behavior to children at younger ages. Established prevention programs have been helpful thus far. To protect future generations, it is critical to maintain antibullying programs and to continue to spread awareness about the disastrous effects of online abuse.

BE PROACTIVE

Ideally, don’t introduce phones into your child’s life until somewhere between the middle to end of middle school. If that is just not possible, it’s important — at any age — to stay alert when interacting online. Teach your children to not accept random friend requests, post personal information online or click random links sent from strangers. Use strong passwords on social media sites, and don’t share passwords with people they don’t trust. When these precautions don’t stop a cyberbully: act.

YOUR FAMILY DIGITAL DETOX GUIDE PLANNING FOR A DIGITAL DETOX

IMPLEMENTING THE DETOX

• Set Clear Goals: Define the Aim – whether reducing daily screen time or going completely screen-free for a week or two.

• Gradual Reduction: If going cold turkey seems daunting, start by reducing daily screen time and progressively increase the off-screen intervals.

• Inform and Involve Everyone: This is a family journey. Discuss the reasons and benefits with everyone to ensure cooperation. • Prepare Screen-Free Activities: Stock up on books, board games and outdoor activity equipment.

Among approximately 5,700 middle and high school students, nearly one-third stated that blocking the perpetrator works best. It’s also highly effective to ignore cyberbullies and online trolls, since the majority of them thrive on reaction. In general, taking a “tech break” is also advised to calm one’s mind and forget about cyberbullying. For most teenagers, however, this is easier said than done. If the bullying continues, contacting law enforcement is highly recommended. An incident can be addressed by federal law, such as the Americans with Disabilities Act of 1990 or Education Amendments of 1972. Criminal law can be applied to most issues concerning stalking, coercion, sexually explicit images, etc. With cyberbullying on the rise, it’s important for social media companies to take responsibility and implement stronger age verification measures. In an ideal world, this tool would most effectively protect teenagers from becoming future victims or perpetrators of cyberbullying.

• Set Designated Screen Times: If complete elimination isn’t possible, allocate specific times for necessary screen usage. • Stay Accountable: Check in with family members about their experiences and feelings. Celebrate milestones together!

Safe School Ambassadors The Safe School Ambassadors Program (SSA) is an evidence-based program that harnesses the power of students to prevent and stop bullying and mistreatment. SSA is a student-centered model that educates diverse social leaders with the skills to prevent and reduce bullying. It is the nation’s most effective student-led bullying prevention program. The SSA Program is currently active in at least 28 Sonoma County schools, across 11 districts. Since 2010, 64 schools in 21 districts in the county have implemented the program.

To learn more, visit Safe School Ambassadors® Community Matters.

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IN A WORLD where happy hours, celebrations and unwinding after work with a glass of wine

or beer have become the societal norm, the concept of going alcohol-free for a whole month can seem like an unconventional idea. But Dry January, the growing trend of abstaining from alcohol for the first month of the year, is challenging the status quo and offering a path to improved health and well-being. It may sound daunting, especially if alcohol has been a constant presence in your life. However, the decision to take a 30-day break from alcohol can be a game-changer for your health. It’s about more than just abstaining; it’s about reevaluating your relationship with alcohol. Before you begin, be aware that it’s strongly recommended that you seek professional advice regarding your health before attempting to take a break from alcohol, especially if you have reached a point of physical dependence.

TAKING THE FIRST STEP

To get started, set clear goals for your Dry January journey. Write down your reasons for taking this break. Whether it’s to improve your health, gain mental clarity, calm your intake after a season of indulgence or break a habit, having a compelling “Why” can help keep you motivated throughout the month. As you embark on your Dry January adventure, you might encounter some withdrawal symptoms. These can vary from person to person, but common ones include irritability, anxiety, difficulty sleeping, headaches, tiredness and cravings. It’s essential to be aware of these potential hurdles and have strategies in place to overcome them. Here are some strategies to help you navigate those inevitable cravings: • When cravings strike, the first step is selfreflection. Ask yourself, “What do I really need right now?” Sometimes, what you perceive as a craving for alcohol may be your body’s way of signaling other needs. Are you hungry, thirsty, tired, lonely or simply bored? Create a list of self-care activities that you can turn to, such as taking a relaxing bath or going for a refreshing walk outside. • Cravings typically last only about 15 to 20 minutes. Set a timer when you experience a craving and distract yourself during that time. You’ll be surprised at how quickly the craving can pass when you shift your focus. • Explore non-alcoholic (NA) beverages and plan ahead: Explore the world of nonalcoholic beverages and mocktails. If you plan to go out to social events or gatherings, decide in advance what you will order. Or bring your own non-alcoholic beverage of choice to ensure you have an alcohol-free option readily available.

Andrew Huberman, a neuroscientist and host of the Huberman Lab Podcast, sheds light on the science behind withdrawal symptoms. He explains that alcohol affects the brain’s reward system and, when you stop drinking, your brain initially craves the pleasurable sensations alcohol provides. However, over time, your brain recalibrates, and the cravings diminish.

THE HEALING PROCESS: WEEK BY WEEK

Incredible health benefits await you during your Dry January journey. W E E K 1: Mental Clarity and Improved Sleep In the first week of Dry January, you’ll begin to experience a surge in mental clarity. Alcohol can cloud our judgment and affect decision-making, so it’s no surprise that abstaining from it will lead to improved cognitive function. Moreover, you’ll likely notice a significant improvement in your sleep patterns. Alcohol disrupts sleep by interfering with your sleep cycle and preventing deep, restorative rest. By the end of the first week, you’ll be enjoying more restful and rejuvenating nights. W E E K 2: Physical Rejuvenation and Increased Energy In the second week, your body will continue its healing process. You’ll notice improved skin complexion (alcohol often dehydrates the skin and can lead to inflammation). Your energy levels will also soar, as your liver and body functions no longer need to process alcohol, letting them focus on revitalizing your overall health. W E E K 3: Weight Management and Emotional Well-being By the third week, many Dry January participants experience weight loss as a result of consuming fewer empty calories from alcoholic beverages. This can boost confidence and self-esteem.

Furthermore, emotional well-being improves. Alcohol is often used as a coping mechanism for stress and anxiety, but it can exacerbate these issues in the long run. During this week, spend time learning healthier ways to manage your emotions and handle life’s challenges. W E E K 4: Enhanced Focus and Reduced Risk In the final week of your Dry January journey, the fog that alcohol can create in your mind will have lifted, letting you concentrate better on your daily tasks and goals. Additionally, research suggests that taking a break from alcohol — even for a short period — can reduce your long-term health risks. This includes a lower risk of heart disease, liver disease and certain types of cancer.

PUT YOURSELF FIRST

Embarking on a Dry January challenge can be a transformative experience, offering numerous health benefits at every stage of the journey. While the initial withdrawal symptoms may be challenging, take them as a sign that your body is healing and recalibrating. With commitment, support and a clear goal in mind, you can successfully complete your 30-day break from alcohol and enjoy improved energy, sleep, mental clarity and overall well-being. In This Naked Mind: Control Alcohol, Find Freedom, Discover Happiness & Change Your Life, author Annie Grace emphasizes the transformative power of taking a break from alcohol: “When you give yourself the gift of an alcohol-free month, you’re not just abstaining; you’re allowing your body and mind to heal, to flourish and to rediscover the beauty of living fully.” Taking control of your relationship with alcohol can lead to a happier, healthier you. So, why not give Dry January a try? Be sure to take a before and after picture, because you’ll be surprised by the transformation in only one month. Your body and mind will thank you. And who knows, you might just discover a new and vibrant way of living that extends well beyond the month of January. Ruby Williams is a Sonoma County alcohol freedom coach and owner of Freedom Renegade Coaching. Ruby.Williams@ FreedomRenegadeCoaching.com www.freedomrenegadecoaching. com.

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6 SONOMA HEALTH

DRY JA N UA RY

CHEERS TO THE CHALLENGE!

It’s tough to live in Wine Country — and to partake of its many culinary wonders — if you’re also in the midst of a Dry January challenge. Luckily, many local establishments have created bar menus that cater to the abstainer. So join your friends and cheer in the New Year. Just do it dry-style! 1 S TA RK’S STEAK & S EAFOOD, S A N TA ROSA: At Stark’s, there’s more than sodas and sparkling waters for nondrinkers. “We put the same care into crafting our non-alcoholic mixed drinks as we do into those with alcohol,” says co-owner Terri Stark. “We put all of our cocktails together so that they can easily stand on their own without alcohol.” ••• Making the Honey Rosemary Spritzer mocktail at Stark’s Steak and Seafood in Santa Rosa. (Photo Loren Hansen)

2 DU KE’S SPI RIT ED COC KTAILS, HE AL D SBURG: In addition to its more talked-about offerings, this popular spot serves up non-alcoholic drinks and a list of mocktails. “It’s important to us to make everyone feel like they are included and that, even if you don’t drink, you won’t miss out on enjoying a fun, creative and satisfying drinking experience,” says Laura Sanfilippo, co-owner of the bar. ••• In this photo, non-alcoholic cocktails Delicate Flower, Green Business, (Photo courtesy of Duke’s Spirited Cocktails)

3 FE RN BA R, SEBASTOP OL: The Barlow, a mecca for lovers of hyperlocal food, wine and beer, finally has a destinationworthy cocktail bar. At Fern Bar, “spirit-free” beverages are given spotlight treatment on the cocktail list rather than being pushed down to the bottom of the menu. ••• Euphoria, a non-alcoholic cocktail with Seedlip Grove, goji and schisandra berry, Euoporia Elixir, lime, prickly pear-hibiscus puree, and jasmine water. (Photo Heather Irwin)

4 PER CH + PLOW, SA N TA R O SA: Since opening in early 2018, Perch + Plow has quickly become a go-to spot. The restaurant’s cocktail program also includes four standard mocktails and non-alcoholic creations made on request, which emphasizes the importance of providing interesting drink options to those who are not drinking alcohol. ••• Red Ridinghood mocktail at Perch + Plow in Santa Rosa

5 LU MA, PETA LU MA: Offering fresh Mediterranean cuisine while being mindful of our planet, Luma features locally sourced meats, produce and a sustainable bar program that includes a full menu of NA and low-alcohol choices. Sister restaurant The Shuckery also creates an accessible bar program where no one’s beverage choice is an afterthought. ••• No-Groni Italian Orange, Aperitif Rosso, Pink London N/A Spirit

6 BR AVA S B A R D E TA PA S, HEA L D SB U R G: Bravas serves up traditional Spanish and modern tapas-style dining including small and large plates to share. Bravas offers a selection of local and Spanish wines, sangrias, and Spain-inspired cocktails, including a variety of signature gin and tonics. Seasonal nonalcoholic drinks take advantage of locally sourced fresh ingredients. ••• The Orange Vanilla Soda and Lime Fizzy Lifting Drink at Bravas Bar de Tapas in Healdsburg. (Photo Loren Hansen)

Why Take a Break From Alcohol? • Time to get healthy • Save money • More engergy • Better sleep • Stronger relationships

••• What happens after not drinking for 30 days? DAY 1 to DAY 30:

Blood Pressure = Lowered Sleep = Improved Anxiety = Manageable Confidence = Increased Finances = Improving

••• How to Take a Break From Drinking

• Go in with an open mindset • Don’t romanticize alcohol • Develop new tools • Find your people

SONOMA HEALTH

HEALING

FROM

WITHIN

The beauty of “food as medicine” is that the choice to restore health and promote wellness is as close as your next meal. By Indra Chaliha, MD, MPH, FAAP

“Food as medicine” may be a burgeoning concept in the Western world, but it’s existed for centuries as a cornerstone of health in many cultures around the globe. There is no single definition of the “food as medicine” concept, but it generally refers to prioritizing food and diet in an individual’s daily life, with the goal of preventing, reducing symptoms of or reversing a disease state. The “meals that heal” concept dates back to 400 BC in ancient Greece, when Hippocrates (the father of modern medicine) declared, “Let food be thy medicine, and medicine be thy food.”

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FOOD AS MEDICINE

BY EXPLORING AND UNDERSTANDING THE MEDICINAL VALUE OF FOOD, WE MAY FIND SOME SIMPLE SOLUTIONS TO OUR HEALTH ISSUES ANCIENT KNOWLEDGE

In India, where I was raised, many people practice Ayurveda, a natural system of medicine that’s more than 3,000 years old. The term Ayurveda is derived from the Sanskrit words “ayur” (life) and “veda” (science or knowledge). In Ayurveda, food is considered maha bhaisajya, the most superior medicine. This is true for both prevention of disease and disease management. Food is poorna brahma, meaning it satiates the mind, body and spirit. This approach to health care is highly relevant in today’s world, where lifestyle-based disorders abound and we are inundated with unhealthy, processed food. In ancient theories and practices of health, including Ayruveda, food and nutrition are quite different from those of biomedicine and modern nutrition. If we apply ancient knowledge, food can provide a relationship between human, the smaller unit (microcosm), and the whole world, which is the larger totality (macrocosm). The “being” interacts with the outside world through its senses of knowledge and of action as well as its cognitive functions. At the same time, the outside world is influencing the being. By exploring and understanding the medicinal value of food, we may find some simple solutions to our health issues. Good digestion is one of the keys to good health. Ayurveda recommends avoiding certain foods that can create “toxic residue” in the body (for example, frozen, canned or processed foods, soups and sauces). While it’s important to reduce consumption of these unhealthy meals, it’s just as important to increase and add foods that have medicinal value. Ayurvedic foods that the body can use for energy, healing and repairing include fresh fruit, pure fruit juices, milk, honey, sprouted whole grains, land and sea vegetables, cheese, nuts, seeds, legumes, sprouted seeds and herbal teas.

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S I X F L A V O R S O F F O O D In Ayurveda, food is divided into six flavor categories. Incorporating all six tastes into each meal — in moderation — ensures a balance of nutrients and major dietary building blocks. Each taste has its own attributes and benefits, but also its own challenges when consumed in excess. There are no “bad tastes” according to Ayurveda, just imbalances of flavors. S W E E T. The sweet taste includes nourishing foods such as carbohydrates, fats and proteins. Sweet taste generally builds muscle or fat tissue. It’s the most satisfying as a naturally appealing element of our diet and, as such, it’s tied intensely to our emotions. Consumed in excess, it will cause lethargy and obesity. Examples: Many fresh and dried fruits, whole grains, beans and legumes, some nuts and spices (cinnamon, cardamom)

P U N G E N T. The pungent taste is one of dry, intense heat that stimulates the tissues and nerve endings of the mouth with a sensation of sharp and fiery heat. Pungent herbs and foods dry excess moisture and mucus and stimulate the metabolism. They can detoxify, aid and stimulate digestion, improve appetite and enhance blood circulation. Examples: Chilis, onions, sage, thyme and spices (see “Add Some Spice” for more information).

S O U R . In Ayurveda, sour foods stimulate appetite and digestion due to an increase in the flow of saliva. It fuels the appetite, enhances the secretion of digestive enzymes and stimulates metabolism overall. Examples: Citrus fruits; sour milk products such as yogurt, cheese and sour cream; fermented food such as sourdough bread, wine, vinegar, pickles, sauerkraut and soy sauce

B I T T E R . When consumed in small portions, bitter flavors cleanse the body and improve appetite. Bitter foods can also be detoxifying and reduce inflammation. Bitter foods are widely used in Eastern countries and are becoming more popular in the West, as they help to balance the flavors in a dish by adding contrast. Examples: Spinach, kale, eggplant, spices (turmeric, fenugreek, dandelion), coffee and certain fruits (grapefruits, olives, bitter melon)

S A LT Y. Salt is anabolic (tissue building, energy-storing) and hydrophilic, meaning it can draw water towards it. This second property is why salt retains water in the body and also how it enhances flavor. Many salty foods also contain iodine which makes them beneficial for the thyroid, which needs the mineral to produce its hormones. The use of salt is a good lesson in the importance of dosage. In correct quantities, it is vital to our existence and as essential to our health as water and food. If you use more than just a bit, it will nullify the flavor and medicinal effect. Examples: Salt, seaweed, kombu, wakame, miso paste, soy sauce

A S T R I N G E N T. Astringency is better known in Wine Country as tannin. Astringent foods aid in nutrient absorption and are detoxifying. One recent review suggests elements in green tea, in particular, may protect against cancer, diabetes, heart disease, Alzheimer’s and influenza. Both green and black tea are rich in compounds that help dampen inflammation, a culprit in heart disease. Tea drinking has also been linked to lower cholesterol and improved blood vessel function. Examples: Pomegranate, green and black tea, artichokes, turnips, sprouts, beans and unripe bananas

When did Primrose open? Is there one thing families should know in Opening in 1997, Primrose was the first memory care advance? specific facility in Sonoma County. Over the years we’ve Adult children should talk with their parents, no matter been fortunate enough to retain our core staff. The how hard the conversation, about how they want to live continuity of staff and the quality of care we provide is if they develop dementia. Preparing for the journey is the an indispensable component of a safe and secure home single best thing I can tell people. The legal process, the for our residents. emotional process: these need to be talked about. When did Primrose open? Is there one thing families should know in Opening in 1997, Primrose was the first memory care advance? What sets Primrose apart from other assisted What’s important to know when dealing with specific facility in Sonoma County. Over the years we’ve Adult children should talk with their parents, no matter living facilities? dementia patients? been fortunate enough to retain our core staff. The how hard the conversation, about how they want to live Our memory loss programs incorporate the latest Remember those affected with dementia, no matter continuity of staff and the quality of care we provide is if they develop dementia. Preparing for the journey is the research findings, including aromatherapy, touch how impaired they are, are still wonderful people an indispensable component of a safe and secure home single best thing I can tell people. The legal process, the therapy, music and pets. We have 3½ acres, so our and have something to contribute. We’ve learned for our residents. emotional process: these need to be talked about. residents can experience the feeling of freedom in enormously from our clients. a safe, secure setting. We are often successful with What sets Primrose apart from other assisted What’s important to know when dealing with challenging clients, We strive for fewer medications and What is your Day Club? living facilities? dementia patients? offer a facility that’s life affirming and outdoor-oriented in We offer daytime care for people with Alzheimer’s and Our memory loss programs incorporate the latest Remember those affected with dementia, no matter as homelike a situation as possible. related dementias. This social program includes fun research findings, including aromatherapy, touch how impaired they are, are still wonderful people activities, snacks and meals. The Day Club gives people therapy, music and pets. We have 3½ acres, so our and have something to contribute. We’ve learned a chance to experience Primrose firsthand and provides residents can experience the feeling of freedom in enormously from our clients. caregivers with helpful time off during the day. a safe, secure setting. We are often successful with challenging clients, We strive for fewer medications and What is your Day Club? offer a facility that’s life affirming and outdoor-oriented in We offer daytime care for people with Alzheimer’s and as homelike a situation as possible. related dementias. This social program includes fun www.primrosealz.com | 707-578-8360 activities, snacks and meals. The Day Club gives people Day Club • Respite • Residential Group a chance•toSupport experience Primrose firsthand and provides Lic # 496803764-1 caregivers with helpful time off during the day.

Family Owned and Operated

FOOD AS MEDICINE

FUNCTIONAL FOODS

Many other cultures have similar beliefs about food’s role in healthy living. Traditional Chinese cuisine, for example, highlights foods linked to cardiovascular health, such as vegetables, soy-based foods, pungent flavorings and tea. This traditional plant-based diet has been shown to be one of the main factors in decreased rates of heart disease, diabetes and obesity among rural Chinese people. Similarly, the Mediterranean diet, inspired by the eating habits and traditional food typical of southern Spain, southern Italy and Crete, has been linked with lower risk factors for heart disease, such as high cholesterol and high blood pressure. Today, the Mediterranean diet is one of the healthy eating plans that American nutrition experts recommend. It’s also recognized by the World Health Organization as a healthy-eating pattern. Many cultures have similar healthful eating patterns, including Japan. In the 1980s, Japanese academics were among the first to promote the concept of “functional foods,” defined as foods that provide nutrition, sensory satisfaction and physiological functions. These are whole foods and fortified, enriched or

enhanced foods that improve health beyond basic nutrition. The concept of functional foods gained prominence during the recent COVID-19 pandemic. It’s been reported that nearly 63% of shoppers now regularly buy foods for specific health benefits. Consumers are particularly interested in foods that provide vitamins and minerals, products that promise to boost immunity and those that offer support for individuals at higher risk for getting more severe COVID-19, such as those with hypertension, obesity or diabetes. Parents are also investigating functional foods as a way to boost pediatric health. Many of the characteristic components of these traditional ways of eating are proven to have positive effects on health, capacity and well-being — much like the eating practices that advance Ayurvedic principles.

MODERN NEEDS

In May 2023, HealthFocus International looked at the “food as medicine” concept across 22 countries and found that 70% of people strongly believe in medicinal benefits from foods; 49% have increased their belief in food as medicine over the past two years.

ACCESS TO NUTRITIOUS FOOD IS CRITICAL TO HEALTH AND RESILIENCE 36

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Access to nutritious food is critical to health and resilience. Food as medicine is a concept that reaffirms this connection, recognizing that access to high-quality nourishment is essential for well-being. A review published in The Journal of Nutrition, noted significant interest among health care organizations to offer programs such as food prescription initiatives to increase consumption of fruits and vegetables for their patient populations. Prescribing food is more complicated than prescribing medication, however. Widespread uptake of food-as-medicine approaches will require training clinicians on the appropriateness and use of these interventions. The good news is that most patients consider their physicians to be among their most credible sources of nutrition information. Food has the ability to help control disease pathology and promote health. Here are some simple Ayurvedic principles that can help with day-to-day food choices. Note: This article is intended for entertainment and informational purposes only. It is not to be construed as medical advice. Make all dietary changes under the supervision of a licensed medical professional.

ADD SOME SPICE SPICES ARE AN IMPORTANT PART OF INDIAN CUISINE and have been used

medicinally since ancient times. Herbs are the leafy part of plants, whereas spices include any part of dried plants aside from the leaves — seeds, roots, bark or stems. Many of these plantbased ingredients are packed with health-promoting properties. According to the National Institutes for Health, numerous studies over the past several decades have affirmed the beneficial role of spices and their active components in preventing and combating various diseases including arthritis, asthma, cancer, cardiovascular diseases, diabetes and neurodegenerative diseases. Though their benefits are far from being settled science (and they should never replace prescribed medical treatments), adding a modicum of spice is one of the easiest ways to incorporate all six Ayurvedic tastes into your diet. Here are some beneficial spices to enhance your regular meal preparation. CARDAMOM A powerful antioxidant,

cardamom may help lower blood pressure and is being studied as a possible digestive aid, oral health promoter and anti-inflammatory. Essential oils and extracts of cardamom may be effective against a variety of bacterial strains that contribute to fungal infections, food poisoning and stomach issues. CINNAMON Rich in antioxidants and other beneficial compounds, some research suggests cinnamon may help manage blood sugars, protect against heart disease and reduce inflammation. Cinnamon has been shown to significantly increase sensitivity to the hormone insulin, which may improve blood sugar control. CLOVE Clove is used in Ayurveda, Chinese medicine and Western herbalism. One study clearly demonstrated the anti-inflammatory effect of clove essential oil. Another study showed that conditioning hair with a clove oil formulation was demonstrated to enhance hair growth. It has also shown anticancer activity. CORIANDER Coriander (also known as cilantro) is sometimes used as an antiinflammatory and as an antimicrobial. It also contains antioxidants. A concentrate of the seeds joined with castor oil can be used as a

topical solution for stiffness and joint pain. Coriander is a significant herb for treating gastrointestinal issues such as indigestion and flatulence. Coriander leaves show stronger antioxidant activity than the seeds. CUMIN Cumin can boost your regular meals with an extra dose of micronutrients. Evidence shows that compounds found in cumin can slow down the aging process, lower chronic inflammation, support immune function and reduce the risk of chronic disease. Cumin is very dense in iron, providing almost 20% of your daily iron in one teaspoon. Research further shows that compounds found in cumin can enhance the activity of all three pancreatic enzymes — amylase, protease and lipase. FENUGREEK Though lesser known in Western cuisines, fenugreek has many traditional uses in Ayurveda. It is used to enhance digestion, support elimination and soothe the stomach. Its warming properties help balance moisture in the lungs. Clinical studies support its use as natural lactation aid. It has shown anti-inflammatory and antiarthritic activities in all the models tested. Fenugreek paste can even help soothe sore, stiff or swollen joints when warmed and applied to the affected area.

GARLIC One recent study attributed the antibacterial activity of garlic to allicin, the compound responsible for the aroma of fresh garlic. Allicin was found to be 100 times more effective than two popular antibiotics in fighting Campylobacter bacterium, one of the most common causes of intestinal infections. A study published in the Asian Pacific Journal of Cancer Prevention concluded, “Allium vegetables, especially garlic, are related to a decreased risk of prostate cancer.” Garlic may also help prevent certain other forms of cancer. GINGER In Asia, ginger has been used as a cooking spice for at least 4,400 years. What’s more, traditional medicine has used ginger for centuries to reduce inflammation. Ginger has been used to help treat arthritis (including osteoarthritis), colic, diarrhea, nausea and heart conditions — not to mention the common cold, flu-like symptoms, headaches and painful menstrual periods. (Pregnant women should ask their doctors before taking ginger and not take more than 1g per day.) TURMERIC Turmeric has been used as a traditional medicine since ancient times in China and India. Studies show it’s an antifungal and may be an effective protector against several neurodegenerative diseases. For example, in a recent clinical trial at UCLA’s Longevity Center, patients with mild cognitive impairment — a possible precursor to or risk indicator for Alzheimer’s — who were treated with curcumin (the active chemical in turmeric) had significant improvements in memory and attention and experienced better mood. Turmeric’s most impressive health benefit, though, might be its cancer-fighting potential. Researchers at the University of Texas MD Anderson Cancer Center have shown it acts via multiple mechanisms to kill cancer cells.

SONOMA HEALTH

SEEDING YOUR

GUT GARDEN

Probiotics and prebiotics can bolster your health in many ways. By Ellen Seeley MANY OF US HAVE CULTIVATED home gardens, and we take pride in keeping them beautiful, diverse, productive and healthy. How many of us, though, have thought about how our “gut gardens” also need TLC? That’s right, our gut gardens (or “gut microbiome”): the teeming communities of bacteria, archaea, viruses, fungi and protozoa we host in our digestive tracts. They are foundational to our ability to digest and absorb food, maintain resilient immune and nervous systems (including making vital neurotransmitters such as serotonin), run a robust metabolism and so much more. You might say that we’re merely walking communities of bacteria and fungi, given that our microbes outnumber us (39 trillion microbial cells vs. 30 trillion human cells). All of these bacteria and fungi play a role in our well-being.

MICROBIAL DISRUPTIONS

Ideally, we start life with a rich infusion of our mother’s bacteria by passing through the birth canal (which C-section babies will miss) and then breastfeeding. Unfortunately, as we grow, there are many environmental and lifestyle factors that can disrupt our microbial balance: synthetic chemical exposure, an unhealthy or limited diet, stress, poor sleep and even staying “too clean.” When our microbiome is disrupted, either with dysbiosis (too many of the wrong bacteria), low diversity (diversity equals resilience) or too much bacteria in the wrong place (for example, the small intestine), we can experience a multitude of health woes. According to various expert sources (including Dr. Michael Ruscio, author of Healthy Gut, Healthy You and research microbiologist Dr. Kiran Krishnan), digestive problems, immune and autoimmune conditions, poor mental health, dental health conditions, urinary tract infections, yeast infections, neurological dysfunction and poor sleep are key examples of the downstream effects of these imbalances. So how do we restore the balance? First, consider whether there are lifestyle and environmental inputs within your control that could be made more microbiome-friendly: eating a varied and well-balanced diet including ample produce, spending time in sunlight and nature, sleeping well, getting daily activity, managing stress and reducing chemical exposure.

SUCCESSFUL SUPPLEMENTS

Afterward, if you’re still experiencing symptoms, it may be time to try probiotics (and their trusty sidekick, prebiotics). Probiotics are “live microorganisms that confer health benefits when consumed or applied to the body.” Prebiotics are plant fibers that we cannot digest, but our microbiota can; they “eat” the prebiotics by fermenting them, which produces vitamins, antioxidants, neurotransmitters and other beneficial substances for us. Probiotic supplements (mainly in capsule form but also sometimes sold as liquids, powders or gummies) are identified in Latin, ideally by their specific strain. This looks like the genus (e.g. Lactobacillus), then species (e.g. plantarum), subspecies (if applicable), and finally the strain code (e.g. 299v). The scientific community has been studying probiotics for years to assess their propensity to improve gut health, immunity, reproductive and oral health. More recently, it’s added a focus on such functions as sleep and mental health. The following are some of the many potential applications being studied for probiotics (though more research is needed in this relatively young scientific realm): Cancer: Probiotics have shown that they can inhibit cancer cell proliferation and may be useful in combination therapy for cancer treatment. They may also lower the risk of side effects from radiation therapy.

SONOMA HEALTH

PROBIOTICS

Diabetes: Probiotics help improve metabolic factors such as total cholesterol, triglycerides, C-reactive protein, HbA1c, blood glucose and insulin, as well as blood pressure; therefore, they may serve as an adjunct therapy for diabetes. Allergies/Histamine Intolerance: Because probiotics help mitigate inflammation, balance immune response and fortify the gut lining, they may be useful for combating allergies. Yeast Infections: Numerous strains of Lactobacillus, and one Streptococcus species, have shown effectiveness in reducing the recurrence of bacterial vaginosis. Lactobacillus strains may also form a useful adjunct therapy to antibiotics in combating yeast infections. Oral Health: Evidence suggests that probiotics may assist in fighting oral illnesses, cavities, halitosis and periodontal infection (when used alongside healthy oral habits). Skin Conditions: Evidence is mixed on the ability of probiotics to treat skin upsets such as eczema, but it’s suggested that infants with more diverse microbiomes are less likely to develop inflammatory skin conditions. Mental Health: Because probiotics and prebiotics affect the gut environment so significantly — and because the gut (connected to the brain via the vagus nerve) acts as a “second brain” — these supplements show promise for supporting mental health (in conjunction with medication and therapy). For example, their fermentation is responsible for 90% of our serotonin supply (our chief mood booster), so they may serve to bolster the effects of serotonin-modulating drugs.

BUGS BEARING GIFTS

Key metabolites are created when our bacteria ferment the fibers we give them. They include such valuable substances as vitamins (including many B vitamins and vitamins D3 and K2), antioxidants such as Coenzyme Q10, hormones and neurotransmitters such as serotonin, and short-chain fatty acids (SCFAs). The latter don’t get much recognition, but they are incredibly valuable compounds. SCFAs (acetate, propionate and butyrate) serve as the main energy source for our enterocytes (the cells lining the colon). They also

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help regulate appetite and metabolism (by, for instance, decreasing the size of fat cells and increasing fat oxidation), enhance mineral absorption and balance immune function, and possibly even help manage insulin and blood glucose. Because they affect the gutbrain axis, SCFAs can even affect mood and neurological health. Another important set of metabolites that our gut bugs make are neurotransmitters. Contrary to popular belief, most of our serotonin, dopamine, norepinephrine and GABA (gamma-amniobutyric acid, which supports neurotransmitters) are produced in the gut, not in the brain. This explains the flurry of scientific research devoted to probiotics and psychological health (as well as neurological conditions such as Alzheimer’s and Parkinson’s disease) in recent years. Though the level of their promise has still not been fully determined, probiotics may prove useful partners for psychotropic medications in the future. Postbiotics, sometimes included in probiotic products, are inactivated or dead microbial cells, with or without metabolites or cell components, that confer health benefits. They may also strengthen our gut barrier, keep our live microbes in line, modulate our immune responses and communicate valuable messages to our nervous system. Postbiotics may provide benefits that live probiotics cannot, such as shelf life and safety for immunocompromised people. Some gut microbes that are unsafe to consume as live probiotics can, when inactivated, still exert positive effects by providing SCFAs and other beneficial metabolites. Newer probiotic products with live microbes have begun to include postbiotics in their formulas. This is to provide complementary benefits without the complexities of additional live bacteria.

GETTING WHAT YOU NEED

Some academics and clinicians doubt the utility of probiotics for healthy people, deeming them helpful only for individuals with gastrointestinal problems or those recovering from a course of antibiotics. But what defines the imagined “healthy” person? It is difficult to find individuals who have never experienced any health challenges: no cavities, no allergies, no yeast infections, sleep difficulties, stress-induced tummy aches or mental health woes.

To the gut garden add the skin, oral, lung, urinary and genital microbiomes. These are all mini ecosystems whose balance is critical to our good health. Second, many probiotics have been studied and found ineffective, both for alleviating specific conditions and for generating healthier gut microbiomes. But much of this may be attributable to poor manufacturing. These products may only contain strains with poor survivability; strains that are transient and don’t colonize the gut; or even (through faulty labeling and lack of DNA verification) different strains than are listed on the label. Plus, many products neglect the mycobiome (fungi), when inclusion of beneficial yeast can be key to microbial balance. Inappropriate timing/context of use can also worsen people’s health. If employed at the wrong time (in cases of slow motility or small intestinal bacterial overgrowth/IBS, for example, or a weak immune system), probiotics may not show benefit and may even worsen symptoms. Success with probiotics involves assessing an individual’s health needs, selecting a trustworthy, high-quality probiotic (see “New Players,” page 42) and then timing its use appropriately (it may be the last step, not the first). When these factors are all addressed, probiotics can become powerful tools in our health arsenal. The unseen world of bacteria and fungi is full of our allies, as long as we treat them right. Born and raised in Sonoma County, Ellen Seeley earned a master’s degree in community development from UC Davis. Today, she is a freelance writer and copy editor for health and lifestyle publications, as well as working in the wellness department at Oliver’s Market.

Let us be your anchor.

Why Anchor Health Anchor Health was founded on the belief that all people need strength and support to carry them through the challenging times in life. Knowing what to do for someone with a terminal illness is difficult and overwhelming. At Anchor Health, you are not alone. We will guide you through the storms of life and navigate you to calm and peaceful waters. Virtual Reality Anchor utilizes virtual reality technology to take patients and a plus one anywhere in the world. This may be a bucket list trip, childhood home and neighborhood, or any location special to our patients/ families. Pediatric Hospice Care Anchor Health offers pediatric hospice care specializing in care for children with serious illnesses and their families. We understand how difficult this time can be and have an entire team focused on the needs of these children.

anchorhpc.com SONOMA, NAPA & SOLANO (707) 309-7300 MARIN & SAN FRANCISCO (415) 598-0944 EMAIL intake@anchorhpc.com

Music Therapy We believe that music has an added benefit to any patient facing life limiting illnesses. Any patient enrolled in our care has access to music therapy as part of their care team. Our Music Therapist can create life review, heartbeat recordings and engage with patients to encourage their participation in playing a variety of different musical instruments. Music therapy addresses the physical, emotional, and social needs of hospice patients.

Care and support at the end of one's lfe

NEW

PLAYERS

THE REIGNING ALL-STARS of the probiotics industry have long been Lactobacillus and Bifidobacterium, but a much more ancient “gut gardener” has recently begun to regain deserved recognition. In the last few years, Bacillus has received a great deal of attention as an overlooked player that, as a Paleolithic-era genus, provides unique benefits not offered by Lacto- and Bifido- strains. Bacillus is a spore-based bacterium, or “homeostatic soil-based organism.” Hunter-gatherers regularly ingested it when they consumed dirt-covered roots, tubers, fruits and leaves. Enclosed in a spore, it is virtually indestructible and thus protected until the spore reaches the colon and bursts open. Then, it becomes a vitamin-, enzyme- and neurotransmitter-producing factory worker, as well as making the intestines more hospitable for its Lacto- and Bifido- neighbors. Unlike the latter two, it does appear to colonize the digestive tract (meaning it will remain even after one stops taking it as a supplement). It, too, supports gut barrier integrity, reduces inflammation in the gut lining and prevents unwanted pathogens from colonizing the intestines. Saccharomyces, a genus of the fungi kingdom, also appears primarily in the form of Saccharomyces boulardii, a beneficial yeast that targets pathogenic yeasts (such as those causing yeast infections). This is a yeast probiotic that also reduces gut inflammation, prevents pathogenic bacteria overgrowth and upholds gut barrier integrity. It has been studied for chronic diseases associated with leaky gut, such as Crohn’s disease and ulcerative colitis. Plus, it increases mineral absorption by breaking down phytic acid and is one of the most effective probiotic helpers (even more than the renowned Lactobacillus rhamnosus GG) for combating antibiotic-associated dysbiosis (and thus also antibiotic-associated diarrhea). Finally, it helps produce DAO, the enzyme that degrades histamine (an important consideration for allergy sufferers).

WHAT TO LOOK FOR

Finding a trustworthy probiotic involves a few critical steps. First, determining survivability is key. Does the product bear an “Arrive Alive” guarantee or indicate acid and bile resistance? The strains won’t be nearly as helpful if they don’t survive their journey through the upper gastrointestinal tract and are dead upon arrival to the colon. Next, it’s important to assess whether a product includes the “right” bacterial and

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fungal strains — a lofty task, given that probiotic science is still in its infancy. But certain strains have been correlated with relief of certain symptoms, so ask your provider if there are particular strains to seek. Doing your own research can be beneficial before you have this conversation. For general colon health, increasing microbial diversity is key, so individuals who aren’t addressing specific symptoms may do well just trying a product with a diverse mix of strains.

A number of researchers and clinicians recommend searching for a product with three taxonomic categories of support, including the more vulnerable, non-colonizing Lactobacillus and Bifidobacterium genera, the indestructible, spore-protected colonizer Bacillus, and a helpful yeast such as Saccharomyces boulardii. Such a product will be a “three-legged stool,” hitting multiple needs at once. Before making a purchase, it’s wise to check a company’s website to ensure it conducts third-party testing, especially for DNA/ identity verification (the strains printed on the bottle are the same as those in the product); according to consumer watchdogs, differences are far too common. Getting entirely different strains from what you think you’re taking could mean anything from a lack of symptom improvement to an actual worsening of your condition. Finally, time the implementation correctly. Do motility (gastrointestinal movement) and mucosal integrity need to be addressed first? For example, if you experience frequent heartburn or constipation, or if you’re not feeling the benefits of your well-balanced diet, one of the above could be the issue. In these cases, you may want to research other types of supplemental support to establish proper motility and repair your mucosa. In these cases, starting with a probiotic will cause more problems. Ditto with targeting certain pathogens. Probiotics may be best brought in as the last step, not the first. Speak with your medical provider if you’re unsure.

PROBIOTICS

OTHER DIRECTIONS

Other applications for probiotics include serving as an adjunct treatment for autoimmune conditions and, via a new technology, intractable infections. According to research, many autoimmune diseases have become more common in the absence of certain pathogenic bacteria; this suggests that even “bad bugs” are important microbial community members. Because a primary precipitating factor for developing an autoimmune condition is excess intestinal permeability, the ability of probiotics to help repair the gut-barrier makes them quite valuable. They also help calm inflammation, as shown by reduced levels of C-reactive protein, and therefore can slow the immune system’s over-activation. While they don’t replace the other therapeutic steps involved in treating autoimmune conditions, they may serve as key helpers. One of the most exciting applications for probiotics is challenging for some to consider. Fecal microbial transplant (FMT) is an exciting new path to probiotic delivery that involves transferring the gut bacteria from a healthy donor (often a relative) to a diseased patient, via enema or encapsulation. Resistant Clostridium difficile (aka C. diff) infections have been effectively cured through fecal bacteriotherapy (usually by total fecal replacement, whereby the patient is cleaned out before implantation). According to Johns Hopkins, “Although there is great interest in other possible applications of FMT for conditions such as inflammatory bowel disease, autism and obesity, there is no scientific evidence that fecal transplant is safe and effective for treating problems other than C. diff.” Research on additional FMT uses is ongoing.

WHAT ABOUT FERMENTED FOODS? Many people might wonder if fermented foods are a valid source of probiotic organisms, since they are heavily promoted as such. While they are generally less expensive (and more fun!) than probiotics supplements, they unfortunately can’t be relied upon for therapeutic-level probiotic support. First, your average sauerkraut, kombucha or kimchi may contain way more strains than a supplement, but none of them are identified or named. Second, while their fermentation of the food substrate (vegetables, fruit, milk sugar, etc.) unlocks a great deal more nutrition in that food, the comparatively low quantities of bacteria aren’t likely to survive your stomach acid, bile and pancreatic enzymes. That said, fermented foods can be a great source of enzymes and prebiotics. Just be cautious to avoid them if you have histamine intolerance or Mast Cell Activation Syndrome, because they are histamine-producing. Folks with allergies might need to steer clear as well.

MOST OF OUR SEROTONIN, DOPAMINE, NOREPINEPHRINE AND GABA ARE PRODUCED IN THE GUT, NOT IN THE BRAIN. SONOMA HEALTH

HIGHS AND

LOWS

Exploring the blood pressure and cholesterol connection By Stephen Halpern, MD WE HEAR IT ALL THE TIME: eat healthful foods and get more exercise to balance your cholesterol intake and control your blood pressure. But beyond the headlines, how many of us truly understand what that means? What is cholesterol — “good” and “bad” — and how does it affect our bodies’ ability to function efficiently? How does blood pressure play a role? Cholesterol is an essential fat produced by the liver and also contained in ingested foods. It’s made up of several components that, among other things, are required for the basic structure of cells in the body. Unfortunately, when cholesterol is too abundant, it can create fatty deposits that line vessel walls and, potentially, obstruct blood flow to essential organs such as the heart (coronary disease). Blood pressure is created by a simple pump — the heart — that maintains blood flow to essential organs to provide them with nutrients and remove metabolic toxins. These two systems can interact in the human body in both productive and counterproductive ways.

SONOMA HEALTH

PROPER BODY FUNCTIONING

Human bodies (and, for that matter, most living organisms) are constructed of a series of interactive surveillance systems that have sensing and actuating functions to maintain health and integrity. Many of these systems are adaptive. For example, hormonal changes redirect blood flow to maintain blood pressure when standing, we experience the sensation of thirst when dehydrated and lipids synthesized by the liver maintain cell health. When these interactive systems are functioning properly, the body is a well-tuned machine. However, when there are hereditary “faults” (such as a family history of high blood pressure or high cholesterol) or habitual missteps (a diet high in salt or fats, for example), these interactive systems can become maladaptive and interact with each other with worse potential outcomes. We can use this model to explain how various risk factors for coronary disease, such as hypertension (high blood pressure) and hypercholesterolemia (high cholesterol) can interact and worsen this risk. First, we must address how the ideal treatment targets for both blood pressure and cholesterol have evolved.

ADVANCES IN CARE

Medical treatment is a changing landscape. If you had a heart attack 50 years ago, you had a 50% chance of surviving hospitalization, where your treatment would have consisted of bed rest, sedation and nitroglycerin tablets during your several-week hospital confinement. Today, if you present to the hospital early after experiencing chest pain due to a heart attack, you’ll likely have an angiogram (heart catheterization), receive a stent to open a blocked coronary artery and be discharged in a day or two. Fifty years ago, if you became lightheaded or passed out with a very slow heart rate, a pacemaker the size of a hockey puck would be implanted in your chest through a fourinch incision beneath your neck bone, and you would spend one week in the hospital. The same presentation today would result in a pacemaker implant the size of three stacked silver dollars through a one-inch incision, or maybe a smaller device placed directly into the heart accessed through a vein, and same day discharge.

Identification of normal values and treatment options for cholesterol have evolved similarly to treatments for heart attacks. More than 60 years ago, when we only measured the amount of total cholesterol in the blood, a value of 300 or less was felt to be normal. Similarly, the recommended dietary intake of cholesterol also was 300 mg per day. As measurements of cholesterol became more precise and several subtypes of lipoproteins (water soluble proteins that carry cholesterol subtypes) were identified — HDL (high density lipoprotein), LDL (low density lipoprotein) and triglycerides LDL — treatment targets changed to emphasize the most atherogenic subtype (that is, the one most likely to cause plaques that obstruct arteries): LDL. The rationale to target and lower LDL as part of clinical practice guidelines, based on scientific evidence to improve cardiovascular health, has been in existence under the direction of the American College of Cardiology since 1980. The treatment targets for various populations (stratified by age, sex and risk factors for heart disease) have changed, in part based on data from the Framingham study. The Framingham study has followed the inhabitants of the city of Framingham, Mass., since 1948, establishing a relationship between hypertension, cholesterol, smoking history, exercise and blood sugar levels with the likelihood of developing coronary disease during the next 10 years after entering data points.

THE VITAL NUMBERS

Acceptable LDL targets have likewise evolved, from less than 160 milligrams per decilitre (mg/dL) for a young adult without coronary disease and below 100 mg/dL for

someone with coronary disease, to less than 100 mg/dL for most adults and for adults younger than 55 with coronary disease. Many of these targets were established by results of randomized clinical trials (see sidebar, page 41) based on relatively short outcome data (five years, for example) or Framingham data that establishes a 10-year risk of developing coronary disease. Although determining 10-year risk is reasonable if you are 75 years of age, lifetime risk would be a more appropriate concern if you are 45 years of age or younger. Based on known LDL values (30-70 mg/dL) for three populations — mammals, hunter gatherer societies and newborns — there are those in cardiology who feel that everyone should have an LDL below 70 to minimize lifetime risk of developing coronary artery disease. There are also subtypes of LDL (smaller dense type) that are more atherogenic (that is, more likely to cause plaques that obstruct arteries). In contrast to desired low levels of LDL, the subtype known as HDL acts as a scavenger, removing LDL from cells of the body (reverse cholesterol transport), then transporting it to the liver for elimination. The higher the HDL (and the higher the subtype large HDL) the more reverse transport occurs. Treatment targets for hypertension have undergone a similar transformation. Initial treatments, based upon a Veterans Administration cooperative study started in 1964, defined hypertension as diastolic pressure between 90 and 129 mmHG; these guidelines ignored the importance of treating elevated systolic pressures (above 160 mgHG) until 1991. Successful reduction of diastolic blood

SCIENTIFIC MEASUREMENTS

Some medical tests report results in milligrams per deciliter, or mg/dL. A milligram is onethousandth of a gram. A gram is about 1/30 of an ounce. mmHG stands for millimeters of mercury, and it’s a measurement of pressure. You’ve likely heard of it when it comes to blood pressure, but mmHg is also used to measure the pressure inside a fluid, such as the fluid inside your blood vessels. SONOMA HEALTH

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BLOOD PRESSURE + CHOLESTEROL

DECODING BLOOD PRESSURE Blood pressure is measured using two numbers: The first number, called systolic blood pressure, measures the pressure in your arteries when your heart beats.

SYSTOLIC

pressure to below 90 mgHG was shown to reduce the risk of heart failure, stroke and mortality. More recent studies clearly have demonstrated reduction in cardiovascular events and mortality in nondiabetics when systolic blood pressure less than 120 mgHG is achieved. Current data recommend blood pressure of below 120/80 unless diabetic, in which case systolic blood pressure below 140 mmHG may be acceptable.

KEY INTERACTIONS

It’s not surprising that individual risk factors for coronary disease may influence and adversely affect each other, since the various organ systems of the body that maintain hormonal balance interact. This holds true for the relationship between cholesterol and blood pressure. Blood pressure is controlled and maintained at “normal” levels by a complex set of

hormones and proteins (called the renin angiotensin system, or RAS) that are regulated and released by the kidney, liver and fat cells in response to changes in posture, activity and blood volume. These hormones and proteins exert their effects by attaching to receptors in target organs or vessel walls that constrict to maintain blood pressure. Although this system does not increase levels of cholesterol in the blood, it does have an effect on the type of cholesterol deposited in vessel walls (including coronary arteries), creating more “foam cells,” a more unstable type of cholesterol that’s more likely to rupture within the vessel wall and result in an acute event such as a heart attack. Cholesterol also has an effect on blood pressure in two ways. Accumulation of cholesterol in vessel walls stiffens them, reducing their ability to relax, thereby increasing diastolic blood pressure. Stiff vessels are not as flexible as the heart pumps blood, resulting in

The second number, called diastolic blood pressure, measures the pressure in your arteries when your heart rests between beats.

DIASTOLIC

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CLINICAL TRIALS Medical treatments evolve as new scientific information becomes available. In medical school, students learn about medical science predominantly from lectures and textbooks. Once a practicing physician, however, most knowledge is obtained from reading peer-reviewed medical journals that report the results of clinical trials identifying new treatments or diagnostic tests for various diseases. Most of these studies are result-driven (identifying better treatments of a disease, for example) or outcome-driven (resulting in longer or better quality of life), comparing commonly accepted treatments or medications (comparators) with newer, as-yet-unproven treatments. The clinical trials that carry the most weight are double blinded (neither patient nor physician is aware of administered treatment), randomized (chance allocation of treatment choice), comparator (compared with currently accepted treatment) trials, because if designed properly they’re the least likely to be affected by chance outcomes. These trials are most responsible for the changing paradigm of diagnostic and treatment improvements.

SONOMA HEALTH

A HEALTHY LIFESTYLE AND HEALTHY DIET MAY NOT ELIMINATE THE NEED FOR MEDICATIONS, BUT MAY MINIMIZE YOUR RELIANCE ON THEM increased systolic blood pressure. Cholesterol also increases blood pressure by increasing the sensitivity of receptors to RAS hormones, increasing the constrictive responsiveness of vessel walls to these hormones.

MAKE SMART CHANGES

Medications not only target each of these systems to maintain blood pressure and cholesterol within acceptable ranges, but also to minimize the negative interactions between them. Medications are constantly being developed to achieve better results (lower blood pressure and cholesterol), with more precise therapeutic targets to minimize potential side effects. A healthy lifestyle (moderate exercise with a target of 150 minutes weekly) and healthy diet (high in lean protein, vegetables, fruits and grains, low in sodium if you have high blood pressure) may not eliminate the need for these medications, but may minimize

your reliance on them. Adopting a healthful lifestyle does not mean that you can’t partake in an occasional barbecue with coleslaw and potato salad, or take a week off from exercising. It’s all about balance. High blood pressure and high cholesterol are two very important risk factors for developing coronary disease. There are others, including age and gender, obesity, inactivity and an unhealthy diet — all determined by a combination of lifestyle choices and heredity. Being willing to strive to modify risk factors over which you have control (including high cholesterol and high blood pressure) is an achievable goal best approached in moderation, since striving for perfection is not only unachievable but often counterproductive. William Shakespeare wrote, “Our bodies are our gardens to which our wills are gardeners.” Be a good gardener.

A CANDLE IN A DARK ROOM

By Peter Marincovich, Ph. D., CCC-A

Tinnitus treatments aren’t perfect, but they can offer relief. TINNITUS IS A CONDITION IN WHICH PEOPLE PERCEIVE SOUNDS, such as ringing or buzzing, in the ears or head. Causes of tinnitus are varied, but may include long-term noise exposure (or a single loud event), pressure caused by blockage in the middle ear, stress or anxiety, head and neck trauma, dental issues, ototoxic effects from prescription drugs and/or smoking. About 50 million people in the United States suffer from tinnitus, and it is the #1 service-related disability among U.S. veterans. A sensorineural reaction in the brain to damage in the ear and auditory system, tinnitus is typically accompanied by hearing loss. Sensorineural hearing loss is caused by a problem in the inner ear, often because the tiny hair cells that move sound through the ear don’t work properly because of damage or disease. In many cases, it appears the brain is trying to “correct” the auditory deficit; it is “reorganizing to help hear,” and that is where the tinnitus is coming from. Tinnitus is not a disease in and of itself, but rather a symptom of some underlying health condition. Sometimes tinnitus is a sign of high blood pressure, an allergy or anemia. In rare cases, tinnitus is a sign of a tumor or aneurysm. Other risk factors include diabetes, temporomandibular joint disorder (TMJ), thyroid problems, obesity, concussion or head injury.

SONOMA HEALTH

MANAGEMENT OPTIONS AVAILABLE

There are no consistently applied best practices in how to educate patients about what tinnitus is and options for management, according to a study by University of Miami researchers, published in the Journal of Communication and Health Care. Having evidence-based patient education is particularly important in tinnitus, where there is no cure but there are management options that can restore a patient’s quality of life, says Tricia Scaglione, Au.D, director of the Tinnitus and Sound Sensitivities Clinic and assistant professor of Otolaryngology at the University of Miami Miller School of

TINNITUS

Medicine. “Numerous health care providers, including some ear nose and throat [ENT] specialists, do not realize that there are useful options for managing [tinnitus].” Scaglione continues, “as a result, far too many patients are misled to believe that there is nothing they can do about their tinnitus and that they have to live with the chronic and disturbing symptoms.”

BEST PRACTICES

Any time a patient reports tinnitus, a complete medical evaluation is recommended; since the condition is typically accompanied by hearing loss, a comprehensive diagnostic audiologic evaluation as well as functional hearing assessment is also recommended. After having ruled out medical concerns, the next best step is to identify the perceived pitch and loudness of the tinnitus. We now have tools to retrain the brain at that pitch and loudness to help patients manage their tinnitus. This process, called “sound therapy,” does not eliminate the tinnitus, but by giving the patient some control, it’s a significant benefit to their quality of life.

The two most common types of sound therapy are masking and habituation. Masking exposes a person to background noise, such as white noise, nature sounds or ambient sounds, to mask tinnitus noise or distract attention away from it. Habituation retrains the way the brain interprets tinnitus; essentially, the brain learns to reclassify the unwanted sound as something neutral or unimportant. Hearing aids may also reduce tinnitus symptoms by ensuring external sound sources provide alternate auditory stimulus. When the brain’s attention is distracted and internal “head noise” is not alone, blended perceptions may be less noticeable and troublesome. I counsel patients to think of their tinnitus as a candle in a dark room. Due to the contrast, the candle/tinnitus is very apparent. Using sound therapy, we do not try to eliminate the brightness of the candle/tinnitus per se, but rather increase the brightness of the room, thereby reducing the contrast and making the tinnitus less apparent. With appropriate adaptation, the patient learns

compensating strategies. Sound therapies, sound machines, phone apps, behavioral therapies and relaxation strategies are often recommended in combination.

Pronounced

TIN-it-us or

Tin-I-tus The pronunciations are used interchangeably, however “tin-I-tus” refers to inflammation and “TIN-it-us” is more accurate.

New hope for healing

STEADY ON Multiple body systems work together to maintain balance and prevent dizziness and falls. By Allan Bernstein, MD

SONOMA HEALTH

THE EARLIEST HUMANS climbed trees and walked on the ground. This flexibility helped them get around in diverse habitats and cope with changing climates. As natural selection increasingly favored bipedal locomotion, humans developed a stanchion posture and have been successful in reaping its advantages in the millions of years since. But it can be challenging, especially if the systems we have in place to keep us upright start to break down. There are three major anatomical components that support balance: the vestibular system in the inner ear, the visual system and the nerves in our legs and feet. When these systems are “in tune,” we can dance, ice skate, traverse narrow pathways, stand up rapidly, go up and down stairs and even walk in the dark. Ideally, these systems are kept finely tuned at all times.

THE MECHANICS OF BALANCE

The vestibular system is a series of fluid-filled semicircular canals, three in each ear, that continuously adjust to our position in space. Each time we move, fluid motion in these canals is detected by neurons (“hair cells”) that signal the brain as to what motion is taking place. If that didn’t happen, each time you turned, you’d keep turning without the ability to stop. One set of canals regulates our horizontal movements while the other regulates vertical and diagonal movements. Imagine being on a carousel that can’t stop or a Ferris wheel that’s continuously spinning in a tumbling motion. That’s the sensation that occurs if any one of these canals is injured in any way. The term “vertigo” refers to a sense of motion when we are physically not moving. The room will seem to spin when the vestibular system isn’t functioning properly. “Benign positional vertigo” is the medical term for an abnormal sensation of spinning in response to minor movements. It is usually associated with a loose otolith (a small calcified particle that’s normally attached to each hair cell, much like the bob weight attached to the rod of the pendulum in a metronome). An otolith that has detached from its hair cell inside one of the vestibular canals can tumble about, causing aberrant neural signals regarding balance. It’s common and benign, as the term implies, but can be disabling when it occurs. (See sidebar, page 54, for other common causes of imbalance.) Our visual system is another major component of balance, as it helps orient us in the upright position and keeps us aware of our position in space. Using both eyes allows us depth perception to judge distances. An intact visual system lets us calculate the speed of our movements as well as the speed of objects around us. If we have visual difficulties, our balance may suffer. If we don’t see objects clearly, we risk running into or tripping

over them. Medical conditions (including some medications) resulting in double vision will impair our sense of balance. Traversing an unfamiliar dark environment is an invitation to sustaining a fall, since we are unable to anticipate what we might walk into. The body’s nervous system includes a function known as proprioception. It lets our brain know where all our body parts are in a spatial environment. For example, with your eyes closed, you are able to bring your hand to your mouth. If this system is damaged in any way, this might be an impossible task. Proprioception is how we know where our feet are without having to look down all the time. Damage to the nerves in our feet will reduce our ability to know where our feet are, increasing the risk of tripping and falling. The neural pathway from the feet to the brain goes along the spinal cord and is prone to injury. Narrowing of the spinal canal in the neck region, such as from a herniated disc, may block communication from the feet to the brain resulting in loss of balance. Certain medical conditions, including vitamin B12 deficiency, may also interfere with the ability for the nerves in the feet to “talk to” the brain. Most of us can function with two out of three of these major components (vision, inner ear, proprioception), allowing us to walk in unfamiliar terrain or keep our balance. However, if two or more systems are faulty, we increase the risk of falling.

OTHER PLAYERS

There are also secondary systems that aid with balance, such as the state of the muscles that keep us upright — the joints in our hips, legs and ankles — as well as parts of the brain specifically concerned with coordination. The mechanics of balance require functioning muscles and joints. Being able to lift

our foot for each step (rather than a shuffling gait) will prevent tripping over curbs and allow us to climb a staircase. Being able to shift our weight from left to right is essential for mobility and requires input from the brain, the muscles of the torso and leg, and the support of each hip, knee and ankle structure. Damage in any of these areas raises the risk of falling — with any movement. Strengthening core muscle, as well as individual muscles in the hips and legs, should be part of any fall prevention program. Numerous medical conditions can affect balance, including Parkinson’s disease, peripheral neuropathy (nerve damage), strokes and spinal cord injuries. Both high and low blood pressure may affect balance by interfering with effective blood flow to the brain. Cardiac rhythm disturbances that drop blood pressure may cause loss of balance as the first symptom. Both very low and very high blood sugars interfere with brain function and can cause loss of balance. The effects of many medications may interfere with balance, including most sleeping medications, many anti-anxiety medications, antihistamines, anti-epilepsy medications and blood pressure medications that may be “too effective.”

BOTH HIGH AND LOW BLOOD PRESSURE MAY AFFECT BALANCE BY INTERFERING WITH EFFECTIVE BLOOD FLOW TO THE BRAIN.

SONOMA HEALTH

VERTIGO

COMMON CAUSES OF IMBALANCE

Balance problems can be caused by several different conditions, the causes of which are usually related to the specific sign or symptom. In addition to conditions mentioned in the main article, these are some other common causes. Losing your balance while walking, or feeling imbalanced, can result from: • Vestibular problems. Abnormalities in your inner ear can cause a sensation of a floating or heavy head and unsteadiness in the dark. • Nerve damage to your legs (peripheral neuropathy) can lead to difficulties with walking. • Joint, muscle or vision problems. Muscle weakness and unstable joints can contribute to your loss of balance. Difficulties with eyesight also can lead to unsteadiness. • Certain neurological conditions. These include cervical spondylosis and Parkinson’s disease. A sense of dizziness or lightheadedness can result from: • Inner ear problems. Abnormalities of the vestibular system can lead to a sensation of floating or other false sensation of motion. • Psychiatric disorders. Depression (major depressive disorder), anxiety and other psychiatric disorders can cause dizziness. • Abnormally rapid breathing (hyperventilation). This condition often accompanies anxiety disorders and may cause lightheadedness. Source: Mayoclinic.org

SONOMA HEALTH

Dehydration is often an under-recognized cause of loss of balance, as is alcohol. Adequate hydration can prevent unexpected falls, especially when rising quickly. Drinking liquids throughout the day reduces this risk. On the other hand, drinking alcohol to excess has an acute effect but also long-term effects on the brain, spinal cord and peripheral nerves. Some of it stems from the direct toxic effect of the alcohol and some is related to its creating vitamin deficiencies that may be unrecognized.

BETTER SAFE THAN SORRY

How do we improve our balance, especially as we get older? The key is to assess all the areas of risk and always pay attention to your surroundings. Physical activity to improve all muscles involved in motion should be part of a daily routine. Other preventive measures include: • Eye exams. Use appropriate corrective lenses and be aware that cataracts gradually impair our vision as we get older, including depth perception. Living in a sunny climate and spending time outdoors increases the risk of developing cataracts. Monitor them on a regular basis.

• Review your medication list on a regular basis. Many medications are associated with dizziness, unsteadiness, changes in blood pressure and may cause inattention, an additional risk factor for loss of balance and falling. • Wear appropriate footwear for the situation you are in. For example, touring a vineyard in heels or sandals is going to put you at risk of loss of balance with associated falls, ankle injuries — or worse. Walking sticks are a great way to conduct extensive exercise outdoors and reduce the risk of falls, even if you have impaired balance. Maintaining balance and mobility is key to a healthy and active lifestyle. If you’re experiencing vertigo or balance issues, speak with your primary care provider immediately, as referral to a neurologist or other medical specialist may be in order.

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A Hard Choice Moving a loved one to assisted living is a difficult decision. But guilt shouldn’t be a factor in your choice. By Jet Howell

SONOMA HEALTH

ONE OF THE HARDEST DECISIONS a home caregiver can make is that of moving a loved one to an assisted living, memory care or skilled nursing facility. Sadly, as our population ages, more of us will be faced with making these critical care choices. Every day in the United States, 10,000 baby boomers turn 65; according to AARP, the number of older adults will more than double over the next several decades. In Sonoma County, 28% of residents are age 60+, making Sonoma County’s population the second oldest in the Bay Area. The hard decision about housing typically comes when a loved one is no longer safe to live on their own and we cannot provide the roundthe-clock care they need. We all have limits to our caregiving ability, and guilty feelings are a normal reaction to our changing roles and loss of control. It’s important to remember that you cannot control your loved one’s health or diseases; you can only do what is best for them and your situation. Guilt is a hardwired emotion between a parent and child — especially in the face of sometimes tricky family dynamics. Moving a loved one is a serious decision and guilty feelings are a normal part of the process, but feeling guilty does not mean you’ve failed or broken a promise to your loved one.

OVERCOME YOUR GUILT

Allow your feelings and know that you’re not alone. Giving care 24/7 is emotionally and physically draining. Acknowledge that your loved one would not want you to jeopardize your own health or wellbeing by taking care of them. There are times when professional assistance is best for everyone. Instead of dwelling on negative emotions, try focusing on how this decision will benefit both you and your charge. Seek others who will understand and can help you cope. Reach out for support from care groups, doctors and others who have gone through this process. Look for a residents’ family support group within the community you’ve chosen or contact local organizations such as the Redwood Caregiver Resource Center or local chapters of the Council on Aging or the Alzheimer’s Association. Know that guilt will lessen over time. Sometimes after your loved one has relocated, you may feel guilty for feeling some relief. But consider the positives of placing your loved one in a senior community. They will likely benefit from the structure and stimulation of nursing home activities and a daily routine in an accepting and understanding environment. This placement gives your loved one the opportunity to socialize with other people who are in similar stages of aging. Many seniors gain weight, and their physical and mental health improve when they have fresh cooked meals, medications on time, attentive physical care and opportunities to engage in activities such as music, art, exercise and games. In many cases, fellow residents are eager to include new people in the social aspect of group living. Group

activities evoke feelings of camaraderie and human connection, which are necessary for well-being. It may also help to learn more about your loved one’s condition and how it will progress. Talk with their doctor about how to manage their decline and what you can do to facilitate their well-being in their new surroundings. Finally, it’s vital to establish boundaries with those who may want to judge your decision. They have not walked in your shoes and should not be allowed to second-guess the choices you have made to keep your loved one safe and cared for. Don’t let others assign guilt to you.

FACILITATING THE TRANSITION

If possible, set up your loved one’s room to mimic the layout and furniture of their former home. Hang photos and bring photo albums. To the best of your ability, ensure their care plan keeps their routines the same as before moving. This could mean the newspaper is delivered each morning or retaining a certain shower time. Make a framed document with “The Five Most Important Things to Know” about your loved one to help the staff have meaningful conversations with them. To this same end, create a magnetic legacy photo board so your loved ones can take each one down to hold them up close or show others (if necessary, seal the photos in plastic to help preserve them). When you visit, ask meaningful questions and record a little of their history for the staff and next generation to learn. Take the time to acknowledge and appreciate that you are doing the best you can and deserve to have a life and relationships outside of caregiving. In many

cases, relationships improve when you return to being a family member first and caregiver second. You will still oversee your loved one’s care, but the day-to-day stresses and responsibilities will be shared with a full support team.

Jet Howell (seen here with a client) is founder of Jet’s Senior Living Placement Solutions, which offers free placement services to families in Sonoma County and Northern California who need assisted living or memory care for a loved one. Since 2015, she has been helping seniors and their families choose appropriate living solutions – saving time money and heartache. www.jetsseniorliving.com (707) 495-9385.

TOP WARNING SIGNS TOP WARNING SIGNS IT'S IT'S TIME FOR MORE SUPP TIME FOR MORE SUPPORT

Jet

NOT EATING PROPERLY

FALLING FREQUENTLY

NOT TAKING MEDICINE ON TIME

NOT SAFE TO DRIVE ANYMORE

NEED EMERGENCY RESPONSE SYSTEM

CAN'T BATH OR GROOM ALONE

CONFUSION WITH TIME & PLACE

WANDERING & GETTING LOST

FORGET TO TURN OFF STOVE

DIFFICULTY PAYING BILLS

WITHDRAWN FROM SOCIAL ACTIVITES MEMORY LOSS THAT DISRUPTS DAILY LIFE

CHANGES IN MOOD & PERSONALITY PROBLEMS WITH WORDS, SPEAKING & WRITING

SONOMA HEALTH

Jet thr of

GOOD 58

SONOMA HEALTH

NI G

Getting a good night’s sleep can be a challenge, but local sleep specialists help patients get great zzzs.

By Judith M. Wilson

EVERYONE NEEDS A GOOD NIGHT’S SLEEP. Peaceful slumber gives the body time to rest and is essential for good physical and mental health. But not everyone is fortunate enough to enjoy the bliss of waking up well rested and reinvigorated. The National Sleep Foundation reports that between 50 and 70 million Americans suffer from sleep or wakefulness disorders and, in the past, relief was often elusive. Now, though, sleep medicine, a board-certified specialty since the early 2000s, is a rapidly growing specialty offering effective methods of diagnosis and treatment to make sleep the pleasing, productive experience it should be. “Sleep medicine is a relatively new health science,” says Abhijit G. Deshpande, MD, a board-certified specialist in sleep medicine with Sutter Health in Santa Rosa. He explains that somnology, the scientific study of sleep, has been around for the past 40 or 50 years. Nonetheless, sleep didn’t get much attention from the medical community until more recently.

Deshpande’s interest was piqued in 1996, when he was practicing as a doctor of internal medicine at a migrant health clinic in Washington state. He advised patients to take 10,000 steps per day and gave them pedometers to keep count. One, a middle-aged Hispanic woman, didn’t do it; when he asked why, he discovered that she was too tired during the day to make the effort. He began to suspect that some health problems might be the result of poor sleep and started to recognize how the lack of good sleep can affect the quality and quantity of life. “That’s how my journey started,” he says. “Since 2004, I’ve been practicing sleep medicine exclusively.” SONOMA HEALTH

SLEEP

THE IMPORTANCE OF SLEEP

“One-third of our life span is spent sleeping,” Deshpande continues, and anything that negatively affects sleep has an impact on daytime functioning and health. Premature aging, dementia, diabetes, heart attacks and strokes are just a few of the potential consequences of going without treatment. Inadequate sleep also affects the mind and the intellect. Lack of interest in activities one previously enjoyed, procrastination and a decrease in empathy and semantic memory are all symptoms of insufficient rest. “The tired brain can’t enjoy new things,” he says, and, “We become a little bit sharp-tempered.” Christian Castillo, MD, a specialist in pulmonary, critical care and sleep medicine at Kaiser Permanente’s Santa Rosa Medical Center, explains that we all typically experience several cycles of sleep during the night, but sleep disorders interrupt these normal cycles and prevent individuals from achieving the stages of deep, refreshing sleep they need. Most adults need 7 to 8.5 hours of good-quality sleep per session, with outliers who need a little more or less. While some people claim they only need 5 hours of sleep, Castillo suspects they’re not good judges of the effect too little sleep is having on them. (See “Phases and Stages of Sleep,” page 61) Castillo finds insomnia – difficulty falling and staying asleep – challenging to treat, because it’s a subjective complaint with little objective data to support it. In addition, it must occur in an individual who has the opportunity to sleep rather than one suffering from sleep deprivation, in which a person is forced to stay awake. In that case, the lack of sleep affects organ-system function and immunity. He cites studies on sleep-deprived rats, who developed sepsis (a serious condition in which infection-fighting processes turn on the body) because of the impact on their immune system. “Within a couple of weeks, it was fairly devastating for the rats. It ended with death,” he says. “For ethical reasons, we haven’t done studies to look at the longterm effects on humans,” he adds, but observes that the importance of sleep is clear in studies on sleep deprivation as a means of torture. Castillo explains there’s a clear distinction between sleep disorders and sleep deprivation. Insomnia, for example, is a sleep disorder that affects the brain and causes psy-

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chological effects such as mood changes and short temper. Sleep deprivation causes disorientation and can lead to a psychological breakdown fairly quickly. And, assuming that the rat studies can be applied to humans, it also has the potential to affect the organs and immune system.

FINDING A CAUSE

Diagnosing any type of sleep disorder begins with a doctor taking a complete medical history. A variety of tests to chronicle sleep patterns and daytime functions, and evaluate sleep, brain and respiratory patterns provides additional information. Depending on the history and examination, Deshpande orders tests using actigraphy, a noninvasive, medically standardized test (it’s worn like a watch) that uses technology to assess cycles of activity and rest over several days to several weeks. Sometimes, he also refers a patient to a sleep center for tests to collect information that will assist him in making a diagnosis and developing a treatment plan. To date, physicians have identified 84 distinct sleep disorders (most are classified under larger categories, including insomnia, apnea and movement disorders), and it is possible for a single individual to suffer from multiple [of them] at once. “Having more than two is like having three flat tires. Unless you treat all three flat tires, your car won’t run properly,” says Deshpande. It’s important to address all issues together.

in the brain that’s part of the limbic system, to create a “flight, fight or freeze” response, which is physiological and can have a negative effect on the body. To prevent the response, “You have to stop the amygdala from firing,” he says. In addition, brain-wave patterns differ when an individual is experiencing a lot of stress. Thus, most sleep disorders are physiological with a psychological component.

DANGER ZONE

According to National Institutes of Health (NIH), sleep apnea is a common condition in which your breathing stops and restarts many times while you sleep. This can prevent your body from getting enough oxygen. There are two types of sleep apnea. The most common type is obstructive sleep apnea, which happens when your upper airway becomes blocked many times while you sleep, reducing or completely stopping airflow. Central sleep apnea happens when your brain does not send the signals needed to breathe. Health conditions that affect how your brain controls your airway and chest muscles can cause central sleep apnea. If your sleep apnea is not diagnosed or treated, you may not get enough good quality sleep. This can lead to trouble concentrating, making decisions, remembering things or controlling your behavior. Sleep apnea is also linked to serious health problems. “Sleep apnea is by far the worst [sleep disorder], because it affects the whole body,” says Deshpande. He explains that in undiagnosed/untreated sleep apnea, the throat starts to close, and people wake up, but only briefly. “If you wake up for five seconds, it’s not enough time for your brain to create a memory of that event,” he says, so a person has no recollection of the waking and therefore might not seek treatment. This disconnect means sleep apnea has the potential to be a silent killer.

BENEATH THE SURFACE

Abhijit G. Deshpande, MD

Most sleep disorders are physiological, but the brain plays a role, too. As an example, Deshpande explains that anxiety is considered psychological, but chronic stress triggers the amygdala, an almond-shaped structure

Castillo explains that sleep and pulmonary medicine have an historic connection, which dates back to the 1950s, when pulmonologists treating chronic respiratory failure thought that hypoventilation (breathing that is too shallow or too slow to meet the needs of the body) during waking hours was causing excessive daytime sleepiness. Called Obesity Hypoventilation Syndrome, this chronic

SLEEP PHASES AND STAGES

When you sleep, you cycle through two phases of sleep: rapid eye movement (REM) and non-REM sleep. The cycle starts over every 80 to 100 minutes. Usually there are four to six cycles per night. You may wake up briefly between cycles. NON-REM SLEEP

Non-REM sleep has three stages, defined by measurements of brain activity taken in sleep studies. Stage 1. This stage is the transition between wakefulness and sleep. Stage 2. When you reach stage 2, you are asleep. Stage 3. This stage is called deep sleep or slow-wave sleep, after a particular pattern that appears in measurements of brain activity. You usually spend more time in this stage early in the night. RAPID EYE MOVEMENT (REM) SLEEP

During REM sleep, your eyes twitch and your brain is active. Brain activity measured during REM sleep is similar to your brain’s activity during waking hours. Dreaming usually happens during REM sleep. Your muscles normally become limp to prevent you from acting out your dreams. You usually have more REM sleep later in the night, but you do not have as much REM sleep in colder temperatures. This is because, during REM sleep, your body does not regulate its temperature properly. Source: www.nhlbi.nih.gov

type of respiratory failure was found in obese patients, who presented with elevated carbon dioxide levels on arterial blood samples as a result of chronic hypoventilation. However, it was later discovered that patients were having episodes of chronic and recurrent upper airway obstruction during sleep that interfered with their slumber and resulted in the daytime excessive fatigue and sleepiness. This is what we now identify as obstructive sleep apnea. “Every year in our sleep lab, we do more and more tests. We seem to get more diagnoses of sleep apnea every year,” he says. Polysomnography is a diagnostic test used to evaluate a variety of possible sleep disorders. It’s used in conjunction with a good

clinical history to diagnose or corroborate sleep disorders such as sleep apnea, sleep-related movement disorders and certain parasomnias (disruptive sleep-related disorders). A polysomnogram, which is performed while a patient sleeps connected to monitoring devices, records physiologic variables during sleep. Physicians evaluate these data points, looking for patterns that can be diagnostic of sleep-disordered breathing as well as other possible sleep disorders. Patients arrive at a sleep clinic at the end of their waking day, and a technician helps assist in the set-up of the equipment, including attaching the monitoring devices (and showing the patient how to take the leads off and reattach them if they need to get up to use the bathroom). Sleeping rooms are equipped with an infrared camera and audio system that lets the technologist see, hear and communicate with the patient without entering the room. While a patient is asleep, an EEG measures brain waves, pulse oximetry measures the blood oxygen level, and probes on the chest and in the nostrils measure breathing. The doctors say that most sleep disorders are forms of insomnia and sleep apnea, and that’s what they focused on. “To diagnose sleep disorders, I look at oxygen levels, heart rate, breathing, movements in the legs and eye movements,” says Castillo. “All these factors really help us characterize your overall sleep. “Most sleep disorders are forms of insomnia, sleep apnea and restless leg syndrome,” he continues. “A polysomnogram can help with diagnosis and can be useful in determining the best treatment plan or adjusting treatment to make it more effective.” In the morning, the technician removes the monitoring equipment, accumulates the data and sends it to the physician to analyze. Then the physician confers with the patient and develops a treatment plan. “With sleep apnea, the gold standard that is almost universally recommended is positive airway pressure therapy,” says Castillo.

effective but cumbersome solution. “It takes some commitment and discipline from the patient to be able to use this treatment,” he says. Ayckroyd adds that CPAP devices and mask selection have improved over the years, with better climate control and sound abatement, lighter weight and the availability of portable devices, battery back-up systems and other accessories. BIPAP (bilevel positive airway pressure), which delivers two pressure settings, one for inhalation and one for exhalation, can also be effective. When it comes to CPAP and BIPAP, some patients respond better to one or the other, so discuss your options with your medical provider. A new treatment, hypoglossal nerve stimulation (HGNS), is an implanted device that, when activated (before and during sleep), stimulates the hypoglossal nerve; this stimulates the tongue, preventing it from collapsing during sleep — which, for some people, can play a major role in contributing to their obstructive apnea events. Other options include dental devices, upper-airway surgery, weight-loss surgery and dedicated positioning devices.

SEEKING SOLUTIONS

For insomnia, Cognitive Behavioral Therapy for Insomnia (CBTI) is an effective treatment involving behavioral change. “You need to find out the real cause [of your bad sleep habits],” says Deshpande. “It’s as if you’ve learned to do something wrong, and now you need to learn to do it right.”

Gregory Ayckroyd, MD, medical director of Providence Sleep Medicine in Santa Rosa, explains that CPAP (continuous positive airway pressure) is a machine that uses steady mild positive air pressure to keep breathing airways open while a person sleeps. It’s an

Christian Castillo, MD

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SLEEP

People who experienced the trauma of losing their homes to wildfires, for instance, might have developed insomnia and, now that the immediate threat has passed, they need to learn how to turn off the disturbing thoughts that keep them awake. All the doctors interviewed for this story recommended exercise to help with sleep, but timing can be an important consideration, they caution. Working out in the morning is beneficial, but exercise late in the day can be a deterrent to sleep. Deshpande adds that being physically active throughout the day can help you fall asleep more easily at night. There are also medications that can help. Some prescription meds, such as zolpidem (Ambien) and traizolam (Halcion), work to relax the nervous system, resulting in longer, deeper sleep. Other approved medications for treatment of insomnia include suvorexant (Belsomra) or daridorexant (Quviviq), which block the action of orexin, a substance produced by the brain that promotes wakefulness. (A lack of orexin in the brain causes narcolepsy.) Castillo adds that over-thecounter melatonin can help some patients fall asleep. Some cannabinoid products may also have possible benefits, but more research is needed to determine how effective they are, and to find appropriate doses and identify negative effects. Of course, all medications can have adverse side effects and should be discussed with your provider before starting.

LOOKING TO NATURE

Anthroposophic medicine is an integrative, holistic, multimodal treatment system. In Europe, it’s integrated with conventional medicine in large hospitals and medical practices; the World Health Organization recently published benchmarks for training in anthroposophic medicine. Daciana Iancu, MD, is board-certified in internal and integrative medicine and has worked in primary care and hospitals. Founder of AnthroSonoma Integrative Medicine in Sebastopol, Iancu observes that western countries don’t value sleep the way some other cultures do. “If you go to other countries, and people are in a waiting room, they close their eyes and rest,” she says, explaining that sleep and rest are valued more in other cultures, while many people here take pride in working constantly and not needing much sleep. She looks for the underlying cause of in-

cause they help reduce spasms. She does not treat sleep apnea. Rather, she refers patients for testing and treatment.

REACHING OUT

Daciana Iancu, MD

somnia and finds that “Often, it has to do with stress and people being too revved up.” She recommends that people start preparing for a good night’s sleep in the morning, taking into consideration what they eat, their daily caffeine intake and when they exercise. She suggests taking calming herbs after an early dinner, so by bedtime, they’ll be in a restful state. Relaxing activities such as gentle yoga, a warm bath or a cup of calming herb tea can also help. In addition, she prescribes herbs and homeopathic remedies for insomnia and conditions such as nocturnal foot cramps and restless leg syndrome, be-

Everyone, regardless of age, needs to sleep well. Regular periods of rest refresh the body and are essential for healthy, happy lives. If you’re wide awake or tossing and turning for much of the night, finding a way to sleep might seem daunting, but it could be life-changing. If sleep is elusive, ask for help. “It’s the ultimate preventive medicine. By getting ahead, you avoid problems,” says Deshpande, who finds treating sleep disorders satisfying, because patients almost always have successful outcomes. “Do exactly what I ask you to do, and your life is about to change,” he says. In the future, he’d like to see more practitioners of sleep medicine locally, creating the potential to reach more people and give everyone in Sonoma County the chance to enjoy fulfilling, restful sleep. As the practice of sleep medicine continues to grow, it’s far from being an impossible dream. It’s an attainable goal.

SLEEP HYGIENE Good sleep habits help ensure a good night’s sleep.

The following tips are from the American Academy of Sleep Medicine: • Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations; • Set a bedtime that is early enough for you to get at least 7 to 8 hours of sleep; • Don’t go to bed unless you’re sleepy; • If you don’t fall asleep after 20 minutes, get out of bed. Go do a quiet activity without a lot of light exposure. Avoid electronics; • Establish a relaxing bedtime routine; • Use your bed only for sleep and sex;

• Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature; • Limit exposure to bright light in the evenings; • Turn off electronic devices at least 30 minutes before bedtime; • Don’t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack; • Exercise regularly and maintain a healthy diet; • Avoid consuming caffeine in the afternoon or evening; • Avoid consuming alcohol before bedtime; • Reduce your fluid intake before bedtime.

Source: sleepeducation.org

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Stacy Desjardins of Santa Rosa Medical Massage treats a client.

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A Healing Touch The healthful benefits of massage therapy By Jean Saylor Doppenberg

EVERYONE PUSHES THEIR BODY to the limit on occasion. It might be from trying to do too much gardening in a single weekend, or carrying a child on your hip too often for too long. Perhaps you have a job where you sit for hours without taking enough breaks, or you overdo your enthusiasm for weekend sports. If so, there’s likely a therapeutic massage modality that can help ease what ails you. Most of us are familiar with the common massage techniques that provide full-body relaxation, such as Swedish and deep tissue (Western modalities) and Shiatsu and acupressure (Eastern modalities). But the health benefits of massage therapy encompass many other types of touch that focus on helping bring symptom relief to specific areas of the body that may be experiencing pain or discomfort. Massage is increasingly being offered, along with standard treatment, for a wide range of medical conditions and situations. According to the Mayo Clinic, some specific conditions that massage can help include anxiety and depression; digestive disorders; insomnia; fibromyalgia, chronic pain and postoperative discomfort; as well as strains, tears and sports injuries.

TYPES OF MASSAGE

“Massage” is a French word meaning “friction of healing” –– an apt way to describe the popular body-manipulation experience enjoyed by millions. Cultures around the world, from the Far East to the European continent, have practiced massage for millennia, many using methods that have stood the test of time. Today, there are practitioners who draw from numerous modalities of massage therapy that offer specific health benefits. Just as some types primarily provide overall fullbody relaxation, others target a particular health issue, such as recovery from an injury or surgery. Some types of massage fall under the umbrella of a common foundational massage, such as the Swedish method, according to Ivy Adams, massage therapy program chair at Northwest Career College in Las Vegas. For example, head and scalp massage, foot massage, and compression and percussion massages are all taught as part of a practitioner’s training in Swedish massage.

In addition to the Swedish massage method, other common types of massage include: • Sports massage (for athletes who wish to reduce the risk of injury); • Shiatsu (massage using the fingers, thumbs, palms and feet); • Reflexology (targeting the feet, ears and hands); • Aromatherapy (using essential oils); • Hot stone (the placing of hot or cool stones on the body to facilitate relaxation); • Deep tissue (a forceful technique that releases tension deep in the muscles and connective tissue); • Trigger point (designed to trigger point pain in specific areas of the body) ; • Myofascial (using gentle strokes to release tightness and pain throughout myofascial tissues); and • Pregnancy massage (for women in various stages of pregnancy).

THE GOOD STUFF

According to Psychology Today, it has been found that touch calms our nervous center and slows down our heartbeat. Human touch also lowers blood pressure as well as cortisol, our stress hormone, and triggers the release of oxytocin, a hormone known for promoting emotional bonding to others. For many patients, massage therapy is an additional component of specific medical treatment plans to help them return to daily activities. For example, massage therapy can be helpful after joint replacement surgery or injury. Mayo Clinic has found that physical benefits of massage include improved circulation and flexibility, decreased muscle stiffness and joint inflammation, and quicker recovery between workouts. One recent Australian study found that a 10-minute muscle massage after a workout could reduce soreness by 30%. Research also suggests a therapeutic rubdown may lead to better sleep and strengthen our immune systems. Massage also has many mental health benefits. Even people who are focused on the physical benefits have reported feeling less stressed after getting a massage. The International Journal of Neuroscience found that levels of the stress hormone cortisol dropped 31% following a rubdown, while levels of feel-good hormones such as dopamine and serotonin increased roughly 30%. Other mental benefits include improved mood and relaxation, decreased anxiety, more energy and an increased feeling of wellness.

RECOVERY AND PREVENTION

“Our work is in neuromuscular massage techniques,” explains Stacy Desjardins, a certified massage therapist and owner of Santa Rosa Medical Massage since 2010.

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MASSAGE HAS MANY MENTAL HEALTH BENEFITS. “To become a certified neuromuscular therapist involves additional hours of training that goes deep into the study of anatomy, injury prevention and rehabilitation, pain management, and soft tissue injury and healing. Typically, we are trained up to 700 hours more — on top of the 500 hours that’s the national education requirement.” Because of this additional specialized training, Desjardins and her staff work primarily with clients in need of relief from sore muscles, or who may be recovering from surgery, cancer treatment, sports injuries or suffering from chronic pain. Chiropractors, as well as some orthopedic surgeons and physical therapists, have referred patients to Desjardins for neuromuscular massage that may add another level of healing to their recovery. “I can usually tell a new client what is wrong with them based on referral pain patterns and my education, but we don’t officially diagnose conditions. We’re not doctors.” Massage therapy offers many benefits, including increased joint mobility and flexibility, improved recovery of soft tissue injuries, reduction of stress hormones, and improved skin tone and circulation. Desjardins adds that massage and myotherapy, a specialized type of massage using trigger point therapy, helps with restricted joint movement caused by muscle or myofascia dysfunction (myofascia are the thin tissue coverings that wrap, connect and support muscles). “Trigger point therapy can be useful to relieve subacute/chronic low back pain,” she says. “Research indicates that massage and trigger point therapy methods are also effective in managing delayed onset muscle soreness, high blood pressure, insomnia, sciatica, carpal tunnel syndrome and TMJ [pain in the jaw and the muscles that control jaw movement caused by the temporomandibular joint].”

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BEYOND PAIN RELIEF

People with chronic disease or who are living with a life-threatening illness such as cancer can also benefit from massage and myotherapy techniques. “Massage for cancer patients is called oncology massage; it’s a very gentle, light touch, soothing overall massage,” says Desjardins. “Patients report massage being helpful, improving their overall psychological well-being and relieving some symptoms related to treatments. “For those with chronic illness, massage can reduce pain and anxiety. Massage can also calm the nervous system of those suffering from Parkinson’s disease, for example, which can temporarily alleviate some symptoms. ” Binbin Beecher, a certified massage therapist and co-owner of Essential Massage Therapy in Petaluma, is trained in many different massage modalities. She specializes in such specific methods as headache relief aromatherapy massage, targeted to people who experience recurrent headaches or migraines, and lymphatic draining aromatherapy massage, which can help improve circulation in the lymphatic system. The lymphatic system is a group of organs, vessels and tissues that protects us from infection and keeps a healthy balance of fluids throughout our bodies. Lymphatic system organs include bone marrow, thymus and lymph nodes, but the full system is a complex network of vessels that branch through all parts of the body. It is part of the immune system and complementary to the circulatory system. “The lymph system is the main medium for collecting toxins from various organs in the human body. Lymphatic massage effectively increases the flow of the lymph to promote the metabolism and remove unnecessary waste from the body to improve immunity,” she says. Desjardins is also adept in lymphatic facilitation in her practice. “Today, we welcome many post-operative patients with different underlying health conditions for our lymphatic work. When I was in training for my medical massage certification, I performed many extern hours with the Sutter Integrative Health Clinic, where I used lymphatic facilitation with cancer patients in various stages of recovery.”

FINDING A MASSAGE THERAPIST Like choosing other health care professionals, it’s important to be a conscious consumer when selecting a massage therapist. Ask your primary care provider or someone else you trust to recommend a reputable business or therapist.

ALLEVIATING COMMON SYMPTOMS

According to Beecher, massage can also provide symptom relief for more common ailments. “Many people seek relief from their seasonal allergies, so we offer a sinus relief aromatherapy massage,” she says. Following the principle of traditional Chinese medicine focused on the face and using different herbal essential oils while working on the sinus acupuncture points, “This massage can increase circulation to facilitate better drainage,” she says. “Clients who see me for this massage tend to get bad sinus infections at certain times of the year, and they seek relief from sinus pain and headaches.” For women, Beecher offers a prenatal massage similar to the popular Swedish massage technique. “But we give extra attention to areas where the massage will be most beneficial for the client at the stage of pregnancy [the mother] is in.” Two other massages aimed at women include an ovary care aromatherapy massage and a menopause aromatherapy massage. Ovary care focuses on the abdomen to help blood flow to the ovaries and uterus; menopause massage uses acupressure to decrease hot flashes and anxiety.

HEALING HANDS

TRAUMA HEALING

Perhaps unique to the North Bay, those who were traumatized by the wildfires — losing homes and/or fleeing for their lives — can seek a treatment from Desjardins called somatic experiencing. Developed by Dr. Peter Levine, somatic experiencing is designed for people who have been through a significant physical trauma or near-death experience. “After watching people walking around in shock following our major fires here, I started a program during the pandemic based on Dr. Levine’s work. It’s body sensing, and so, sensing where the body is holding the emotional trauma.

“These massages are popular with our clients, and we get many requests for them along with word-of-mouth referrals,” says Beecher. “Generally, the menopause massage is for women already having symptoms, and so we help them reduce those symptoms. The client begins by having a session with us every two to three weeks, and then we step it down to about once a month.”

Whether you’re seeking relief from pain or injury, or simply looking to reset your physical well-being, you can find beneficial and life-enhancing massage therapy from experienced, certified massage therapists in Sonoma County. They can provide a wide range of massage techniques to alleviate chronic pain and help improve recovery when you push your body beyond its limits.

Jean Saylor Doppenberg is a lifelong journalist based in Sonoma County. She has written extensively about healthrelated topics.

(Note: National Holistic Institute in Santa Rosa, a local college of massage therapy, did not respond to several requests to participate in this story.)

“Somatic experiencing isn’t massage, it’s working with clients on facilitating the completion of the selfprotective motor responses and the release of thwarted survival energy bound in the body,” explains Desjardins. Techniques are bodyfocused to help us calm our nervous systems that have been overloaded by stress. “The body interprets trauma much differently from the brain, so we work on the body.”

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GOOD AS NEW

The ins and outs of knee and hip replacement surgery B Y G A R Y S T E I N, M D 68

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BETWEEN 50 AND 100 MILLION ADULTS in the United States suffer from doctor-diagnosed arthritis involving the lower extremities, especially in the hips and knees. A type of cartilage damage in the joint, arthritis is a common condition that can be painful and worsen over time, affecting both mobility and quality of life.

Some common symptoms of arthritic hip and knee joints include: • Pain that worsens with certain movements and exercises, including prolonged walking or standing; • Stiffness that makes it difficult to extend and contract the joint; • Catching and locking, which occurs when damaged and rough cartilage makes smooth movement difficult; • Crepitus, or the audible cracking, crunching, clicking or snapping sound made when moving a damaged joint; and • Weakness, which is often a result of reduced activity and resulting muscle atrophy (wasting).

TREATING ARTHRITIS PAIN

Arthritis is the most common cause of disability in the United States. Common treatments for arthritis consist of anti-inflammatory oral medications and analgesic medications, such as acetaminophen (Tylenol), ibuprofen (Advil), naproxen (Aleve) and prescription NSAIDs. Injections of hyaluronic acid, a natural substance within the joint, can provide lubrication and anti-inflammatory effects for symptomatic relief. Steroid injections may also provide temporary relief. Other interventions are more controversial. Platelet rich plasma injections (PRP) and stem cell injections, for example, are of unproven benefit for treatment of an arthritic joint. They are also not covered by Medicare or any standard insurances for this purpose. Physical therapy and appropriate low impact exercising are helpful to maintain muscle tone and strength. And, if a patient is overweight, weight loss is an important component of controlling symptoms and preparing for a successful surgery.

TIME FOR REPLACEMENT

When nonoperative measures do not adequately control symptoms or allow for a continued active lifestyle, joint replacement surgery is recommended. Joint replacement surgery can be thought of as joint resurfacing, using synthetic materials, highly specialized alloys and plastics. The success rate (defined as

relief of symptoms and a return to a more active lifestyle) is 95% to 99% for overall improvement and satisfaction. Anesthetic and surgical treatment measures have improved significantly so that patients can mobilize (that is, get back on their feet — literally) quickly. Pain is controlled through anesthetic regional blocks and multimodal modalities (including e-stim, oral analgesics, NSAIDs and cold therapy) for pain management, meaning less dependence on opiates. Joint replacement has become routine and is often now performed as an outpatient procedure without the necessity of spending a night in the hospital. Patients are mobilized on the day of surgery and are usually able to put weight on their extremities almost immediately. Outpatient physical therapy starts early in the postoperative period, usually within the first 5 to 7 days. Patients can usually return to driving within 1 to 2 weeks and, if they have a nonphysical job, can frequently return back to work within 2 to 4 weeks. Most will notice significant improvement at 2 months — many report feeling better than before surgery — and will experience continued improvements thereafter for 6 to 12 months before achieving 100% maximal improvement.

JOINT DEGRADATION

Only about 1 centimeter of bone is removed during knee replacement surgery, and less invasive techniques for hip replacement sur-

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JOINT REPLACEMENT

gery preserve bone stock as well. Both anterior and posterior approaches for hip replacement surgery have very successful outcomes with no specific proven benefit of one approach over the other. As the names indicate, procedures differ primarily based on where the surgeon makes his entry incision. Unlike the hip, which is a ball-and-socket joint, knees consist of three main compartments: the patellofemoral compartment, medial compartment and the lateral compartment. Total knee replacement surgery consists of resurfacing the entire joint, which happens 80% to 90% of the time. However, if the arthritic disease is isolated to only one of the three compartments, then a partial knee replacement (or resurfacing) is less invasive and requires less recovery time. What’s more, all of the patient’s ligaments remain intact, as opposed to a total knee replacement, when the anterior and, frequently, the posterior cruciate ligaments are sacrificed. The implant design then makes up for the required stability. Joint replacement surgery usually involves a polyethylene-type material, which can be thought of as a very highly specialized plastic material. Highly cross-linked polyethylene with vitamin E, which is embedded within the polyethylene, reduces oxide degradation and improves longevity and wear characteristics of those surfaces. Technological advancements have greatly improved outcomes as well. Implant sizes and options are extensive and allow custom fitting to accommodate most patients. The modularity of the implants allow customization for each patient intraoperatively to restore the specific joint geometry. Titanium and tantalum are common materials that allow great bio-compatibility and bone ingrowth — the implant itself actually integrates with the bone of the patient. Some materials, such as titanium trabecular-metal, simulate actual bone marrow. Others, such as cobalt chrome molybdenum alloys, provide very low friction surfaces and scratch resistance to improve longevity. Ceramic surfaces are also used in hip replacements, which lowers the friction coefficient and particulate wear. When fitted against a metal surface, ceramic surfaces avoid corrosion as compared to two different metals being in contact.

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Approximately

750,000 KNEE REPLACEMENTS and

300,000 HIP REPLACEMENTS are performed annually in the United States.

STUDIES SHOW THAT 80% OF HIP AND KNEE REPLACEMENTS REMAIN VIABLE AT 30 YEARS.

SUCCESS RATES

Newer techniques that involve less invasive dissection also facilitate more rapid recoveries. Robotics have recently been introduced into knee replacement surgery, but have not been proven to show better results than conventional measures (which include preoperative templating and precise instrumentation used in the operating room by a skilled surgeon). Today, the best indicator of quality outcomes remains correlated with the volume of joint replacements a particular surgeon performs; the more procedures a surgeon does directly correlates with improved outcomes. Studies show that 80% of hip and knee replacements remain viable at 30 years. The longevity of a hip or knee implant in an individual depends on a multitude of factors including the quality of the bone, the size and weight of the patient, as well as the activity level of the patient. When an implant ultimately fails, today’s orthopedic surgeon has many available options at their disposal, including revision-style implants that can be customized to the patient. This involves improved fixation and accommodation for bone loss. One of the concerns with joint replacement surgery is potential infection. Extensive precautions are made intraoperatively to avoid this, including giving the patient intravenous antibiotics, antibiotic irrigation in the wound and distribution of antibiotic powder in the wound at closure. With these measures, infection rates are well below 1%. Final skin closure is usually carried out with either Dermabond, a form of glue, and/or

staples. Patients are given a waterproof dressing that looks like a large Bandaid so they can shower at home. After a few hours post-op, they’re discharged. Patients start outpatient physical therapy early on and will see their surgeon for an in-office follow-up usually within 7 to 10 days. Other risks related to surgery include risk of a deep venous thrombosis (a blood clot occurring in a leg vein), which can break free and travel upward, causing pulmonary emboli (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs). This is a serious complication that can be fatal and requires immediate attention for anticoagulation. Fortunately, the incidence of thrombosis is quite low and this lower risk can be attributed to earlier mobilization of the patient and shorter operative times. Usually, the patient is treated with some form of anticoagulation therapy for the first three weeks postoperatively. The most common anticoagulant used today is aspirin.

GET MOVING

Joint replacement surgery can be life-changing for people, eliminating their pain and returning them to the activities that they used to enjoy but had to discontinue because of their arthritis. Activities such as snow skiing, golf, hiking, pickleball, tennis, waterskiing, and generalized fitness activities are once again allowed (with physician approval, of course). We are fortunate to have facilities in Sonoma County that provide the highest quality of care for our population for joint reconstructive procedures.

ANATOMY OF A JOINT Joints are areas of the body where two or more bones meet. In addition to the joining bones, joints consist of connective tissues (tendons and ligaments) and protective components that provide cushion and lubrication to facilitate smooth movement. Among these protective components is cartilage, a type of tissue that covers the surface of a bone at a joint. When cartilage is damaged, it becomes rough. Thinning of cartilage narrows the space between the bones. In advanced cases, bone rubs on bone, and any movement can cause pain and stiffness. When there is friction at any point between bones, it can also lead to bone spurs — bone growths on the edges of a bone that change its shape. SONOMA HEALTH

What health care professionals know about getting to the source of pain and a few less common, drug-free alternatives for pain management By Karen Hart AN ACTIVE 60-YEAR-OLD WOMAN NAMED ROSE was on the court, playing a pickleball match with friends, when she stooped down for the ball she missed. Suddenly, she was overcome with pain in her lower back. It was swift, sharp and excruciating. “I could barely walk,” she says, explaining that an injury on a rope swing in her 20s is the root of the problem and has caused regular anguish and flareups over the past 40 years. She’s seen numerous physicians and tried various pain medications and muscle relaxers, but the search for relief is a constant struggle. “Navigating the road of pain management is chaos,” says Rose, who prefers not to disclose her last name. In the last five years, she’s turned to alternative treatments that she’s found to be more effective. Everyone experiences pain at some point in their life and, for those who experience chronic pain, it’s a callous companion that attacks the body physically, mentally and emotionally. It may be mild or excruciating, but chronic pain is persistent, inconvenient, sometimes incapacitating, and it can lead to depression and anxiety.

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According to the National Pain Advocacy Center, one of every six Americans experiences daily pain. Some of the most common forms include back or neck pain, arthritis or joint pain, headaches and migraines, fibromyalgia and pain from cancer and its treatment. Chronic pain — defined as pain that lasts for more than three months — affects more Americans than any other disease, including heart disease, cancer and diabetes, and it’s the number 1 cause of disability. “Pain is a big reason people miss work,” says Andrea Rubinstein, MD, chief of pain medicine for Kaiser Permanente in Santa Rosa.

ACCORDING TO THE NATIONAL PAIN ADVOCACY CENTER, ONE OF EVERY SIX AMERICANS EXPERIENCES DAILY PAIN.

THE SOURCE OF PAIN

When it comes to chronic pain, the first step in treatment is to understand the source of pain, which is akin to viewing a hologram that contains physical, environmental, emotional and behavioral aspects simultaneously. “Pain comes in many different types and each person experiences pain differently,” says Daciana Iancu, MD, who is board certified in integrative and internal medicine and practices in Sebastopol. “There is always a strong emotional component to pain. Stressful experiences and trauma cause us to tense our bodies, and sometimes that tension stays trapped for a long time.” Iancu’s integrative approach begins with listening to her patients’ stories, which, she says, “reveals a lot about their pain: the cause, contributing factors and what type of treatments would benefit them.” The cause of back pain, for example, could be muscular, or problems with the nerve, joints and bone, or a combination of all these things. “But what is the underlying cause of that?” Iancu asks. “Is it lifting something heavy, sitting too much or bad posture? Or, is it from being stressed, sleep deprived or overwhelmed? “If we’re stressed out, sit too much, maybe don’t eat well or get sufficient sleep, and then lift something heavy and ‘slip a disc,’ [the true cause of injury] could be heavy lifting, or it could be wear and tear. Or, maybe we were too tight and contracted and disconnected from the body due to stress and lack of sleep.” If a doctor only treats the slipped disc with pain meds and steroids, and fails to address the underlying issue, healing will only be partial, says Iancu, which could lead to chronic pain. “When patients work with me, they’re often surprised how we reach the true root cause of their pain just from sharing their stories,” she says. “Then, we can explore together their options for improvement.”

ALTERNATIVE TREATMENTS

Some of the most common alternative, drug-free treatments used as a front-line approach to pain include: acupuncture, a key component of traditional Chinese medicine to balance the flow of energy and treat pain; Reiki, which means “universal life energy,” a hands-on or hands-over-the-body energy healing technique that promotes relaxation, reduces stress and anxiety to improve the flow and balance of energy, and relieve pain;

Chi New Tsang, an abdominal massage therapy, the name itself meaning “working the energy of the innermost organs”; and chiropractic care, a therapeutic treatment that involves manipulating joints to realign the spine and reduce discomfort. How do these types of energy medicine work? Pain and illness may reflect that we’re too out of balance physically, mentally or emotionally, says Iancu, and alternative treatments can help restore that balance: “The treatments are subtle, but they help people return to a more balanced way of being.”

ACCORDING TO THE NATIONAL PAIN ADVOCACY CENTER, ONE OF EVERY SIX AMERICANS EXPERIENCES DAILY PAIN. These non-Western treatment modalities often bring comfort to those suffering from chronic pain. But for those who aren’t finding relief from these methods, here are a few lesser-known treatments available in the North Bay.

TENS

Transcutaneous electrical nerve stimulation (TENS) involves using a mild electrical current to change the perception of pain. A TENS machine is a small, battery-operated device with two electrodes and sticky pads. The pads are attached directly to the skin. “TENS has always been popular with some patients, though it’s not as widely used as it could be,” says Kaiser’s Rubinstein. “It works by delivering a small electrical impulse

to nerves, which changes the way pain is perceived. TENS works best for at least 30 minutes per session and can be used as often as needed.” Units can be purchased online and range in price from $30 to $100, though Rubinstein recommends beginning with an appointment with a professional first (often a physical therapist) to determine whether the pain responds to treatment and to find the optimal placement of the pads. TENS is used to help reduce pain caused by conditions such as arthritis, knee pain and sports injuries. Treatment with TENS provides short-term relief. According to Rubinstein, it’s not recommended to relieve pain from cancer, heart disease or bleeding disorders and shouldn’t be used on or near open wounds. “TENS can be quite effective for some patients and feedback is generally good, but it doesn’t work for everyone,” says Rubinstein, adding that it’s best when used as part of a multi-disciplinary approach that includes physical therapy.

RADIOFREQUENCY ABLATION

Radiofrequency ablation (RFA) — also known as rhizotomy — is primarily intended to treat arthritis or joint pain of the spine. There are small sensory nerves along our spinal joints, and their job is to tell the brain how the joint feels. These nerves are the primary source of pain signals coming from the joints of the back. “It’s a fairly interventional technique,” says Rubinstein. “Though there’s no incision, it’s usually performed in an operating room. The procedure is done using fluoroscopy [a form of X-ray] and needle placement to find the nerve you’re trying to ablate — or knock out — using radiofrequency.” RFA uses heat produced from radio waves to target diseased tissue. For pain management, radio waves are sent through a precisely placed needle to heat an area in the nerve, which damages the nerve tissue and prevents pain signals from being sent back to the brain. RFA is considered for long-term pain conditions, especially of the neck, lower back or arthritic joints that haven’t been successfully treated by other methods. The goal of RFA is to stop or reduce pain, improve function, reduce the number of pain medications taken and avoid or delay surgery.

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PROLOTHERAPY AND PRP

The procedure is reserved for patients with facet-mediated pain that responds to medial-branch blocks (See sidebar on opposite page). Even then, it’s not always appropriate. “In some instances, [treatment] doesn’t work because medial branches have been overgrown by severe bony arthritis, or there is another reason for the pain,” says Tabitha Washington, MD, an interventional pain specialist at Kaiser Permanente’s Santa Rosa Medical Center. “However, for those patients who qualify, the medial branches on the outside of the facet joint capsules are heated,” says Washington. The procedure disrupts the connection between those pain fibers from

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the pain pathways that travel up the spinal cord to the brain, she adds, “so pain from the joints cannot be perceived by the brain.” RFA treatment takes at least four to six weeks to take effect, says Washington, and often patients will experience a slight increase in pain for at least two weeks. Though results vary among patients, the effectiveness of RFA may last 10 to 12 months. Generally, the cost of RFA procedures ranges from $2,000 to $5,000. Kaiser Permanente offers RFA at some of its clinics, and the treatment is part of its medical plan. However, most insurance companies do not cover treatments.

“People are seeking relief for their pain outside of traditional medicine because there are really effective treatments,” says Gloria Tucker, MD, a board-certified sports medicine specialist, instructor of proliferative therapy and a founding member of the International Association of Regenerative Therapists. Tucker, who practices in Novato, specializes in treating the ligaments and tendons that support the body’s joints. She uses prolotherapy and platelet-rich plasma (PRP) treatments. These are treatments she first learned about when she was seeking help for her own chronic, low-back pain, a result of her passion for long-distance running and mountain biking. She eventually switched from those high-impact sports to swimming, but her back still hurt. She tried chiropractic treatments, which would help for a few hours, but then the pain returned. Finally, a doctor recommended she try prolotherapy. “It saved my life,” says Tucker. “I felt so hopeful again.” Prolotherapy is an injection treatment used to relieve pain by jumpstarting the body’s natural healing abilities. Tucker uses two types of injection treatments: PRP and dextrose prolotherapy. PRP prolotherapy involves using a patient’s own blood. The benefits of using PRP — sometimes called “liquid gold” — are the growth factors contained in the blood that can help heal tissue more effectively than dextrose therapy. Dextrose (sugar) is the most commonly injected material. PRP and dextrose inflame the ligaments. “The reason we want to inflame the tendons and ligaments,” says Tucker, “is so the patient’s own body will heal itself naturally. The healing process takes four to six weeks following treatment.” How do PRP and dextrose prolotherapy work? Though blood is mainly liquid (plasma), it also has small solid components (red cells, white cells and platelets). In addition to helping clot the blood, platelets also contain hundreds of proteins. According to Tucker, these proteins, called growth factors, are extremely helpful for healing injuries. When a patient needs PRP therapy, blood is drawn (usually about 60 cc, which is about two ounces or six vials) and placed into a centrifuge, which spins to separate out the platelets. Then, the platelets are mixed

PA I N M A N AGE M EN T

together with the plasma, producing about 6 to 8 cc of fluid. “This greatly increases the concentration of the growth factors found in this small amount of fluid,” explains Tucker. Using ultrasound and very precise palpitation skills, the PRP is injected into the area with the most damage. Generally, dextrose prolotherapy is used around the joint to help stabilize it, provide further healing and prevent additional damage to the area. To understand what conditions PRP and dextrose prolotherapy help, says Tucker, you must understand the process of what’s happening when someone has joint pain. “A joint is the space between two bones. The structures holding those two bones together are the ligaments and tendons, which are like short pieces of thick twine. When someone has a long-term, overuse syndrome — tennis elbow, for instance — the tendons become worn out, like a frayed rope. This occurs because the muscles aren’t strong enough to handle the excessive action of the joint, so the tendons do the work.” When that happens, she says, the avid tennis player is going to feel pain. “We can inject PRP or dextrose to strengthen those tendons, and return the player back to her activity.” PRP therapy can be used for most conditions that cause pain as a result of movement that involves overuse of the tendons and ligaments (known as degeneration). “It’s also fantastic for hypermobility syndromes,” she says. Joint hypermobility syndrome is when a person has very flexible joints and it causes them pain (it’s often referred to as being doublejointed). This syndrome is often mistaken for fibromyalgia. Other common syndromes that prolotherapy may help include golfer’s elbow, wrist strain or over-use of the thumb; instability of the neck, back or sacroiliac joint; plantar fasciitis or shoulder pain; early bunions and hip pain, among myriad others, says Tucker. Studies are ongoing as to its efficacy in treating osteoarthritis. Interestingly, these conditions usually look normal on an X-ray and MRI, she adds, so it can be frustrating for both the patient and doctor. “When a patient tells me that they feel much better after seeing their chiropractor or osteopath, but [the treatments] don’t hold, I know I can help them,” says Tucker. The risks of prolotherapy are minimal. Generally, there will be bruising of the treatment area. Occasionally, patients report

feeling faint or dizzy right after treatment (this typically clears quickly). Those who are living with conditions such as diabetes, heart disease or pulmonary edema should check with their primary care doctor before undergoing treatment. There are other risks, says Tucker, but they are rare. “The feedback we receive is heartwarming. We change people’s lives every day,” she says. “I feel grateful to have something to offer people in pain that really works. As we strengthen the structures around the joint, our patients can function better and better. It may take a single round or multiple rounds of treatment to obtain permanent results.” Generally, PRP therapy ranges from $700 to $2,000 per treatment, which involves multiple injections during one session. Most insurance companies do not provide coverage.

MANAGING PAIN FOR A LIFETIME

Everyone navigates pain at some point during their life. Injuries happen and as people grow older, chances are there will be some physical aches and pains to navigate as well. “As people live longer and spend more and more years in the over-age-60 category, well, their bank accounts may be good, but their bodies might keep them from traveling and playing with their grandchildren,” says Rubinstein. “If we take better care of our bodies and treat them as well as our bank accounts, there’d be a lot less pain.” What are her go-to strategies for preventing or navigating pain? “Stay strong, flexible and have good balance — the body is a use-it or lose-it machine.” She offers some practical advice she’s learned from a career in pain management: Take care of your body. Be active. Eat well. Get enough sleep. Learn how to manage stress. Avoid excessive alcohol and don’t smoke. “Take good care of your body, and that means don’t abuse it,” she says. “It has to last you to the finish line.” Karen Hart is an author and writer, who’s been writing about health for 30 years. She has a passion for health and wellness, and believes in the healing power of nutritious food and exercise. Hart’s goal is to break a sweat every day. She lives in Santa Rosa and can be reached at writerlady.sonomacounty@gmail.com.

BACK PAIN 101

In between each of the 26 bones that make up your spine, called vertebrae, are discs made up of a jelly-like substance that act as cushions. A herniated (or slipped) disc occurs when all or part of a disc is forced through a weakened part of the spine. This may place pressure on nearby nerves or the spinal cord. Another common cause of back pain is facet joint syndrome. Facet joints lie behind the disc and join vertebrae together. Facet joint syndrome is an arthritis-like condition, caused by degenerative changes to the facet joints, that can be a significant source of back and neck pain. Medial branch nerves are very small nerve branches — that cannot be seen by X-ray — that carry pain messages from facet joints to the brain where they are experienced.

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CANCER PAIN TAKES MANY FORMS. It can be dull, achy, sharp or burning. It can be constant, PALLIATIVE intermittent, mild, moderate or severe. The challenge is to keep it from being the entire focus of your

CARE

A Philosophical View

THE GOAL IS OFTEN TO RELIEVE PAIN TO A LEVEL THAT ONE CAN BE DISTRACTED FROM IT, SUCH AS 4 OR 5 ON A PAIN SCALE OF 10

life, says Andrew Wagner, MD, a family practitioner, who specializes in hospice and palliative medicine in Santa Rosa. Most cancer pain is physically manageable, he says, and that’s an important goal of any treatment plan. However, for many people, a cancer diagnosis is such a life-turning point, that it forces them to consider their pain in a broader context. “Pain is the physical aspect and suffering is the experiential aspect — what it means to live with that pain,” says Wagner. “Pain and suffering is very personal. In my practice, healing becomes the focus, and it’s a holistic event for the mind, body and spirit. With cancer, pain takes on this different context.”

FEELING HEARD Wagner’s approach begins with offering patients a safe place to talk and have the conversations that matter. For those living with cancer pain, it’s an experience that triggers questions: What will it be like to live with the condition? What does the pain mean? What does quality of life mean? What must happen to feel a sense of peace? For some, pain means feeling out of control or fearing there is no end-point. Next, Wagner will discuss the context of the diagnosis and create a care plan around the patient’s goals. “We do our best to have meaningful conversations about who they are, what they value and what’s important to them. Longevity is not always the goal,” he says. “Some people, in the course of their cancer journey, choose to focus more on quality of life and decide they don’t want to spend their days in hospitals getting additional treatment. “We can almost always treat physical pain,” Wagner adds. “But suffering is the experiential aspect of pain. For some people, the pain itself has meaning — it’s a purification process or a testing of the human spirit. Often with cancer, the pain experience carries with it a trigger for all the pain in their life. “Sometimes the biggest thing we need for the ‘healing’ process is to forgive others and forgive ourselves. That’s often the source of existential angst — the need to forgive yourself because you’re thinking you’re not good enough. When we address the suffering component of pain, [the pain is] significantly reduced and becomes notably more tolerable, for the most part.”

BEYOND MEDICATION An individual care plan may include morphine or other opioids to ease physical pain. “The goal is often to relieve pain to a level that one can be distracted from it, such as 4 or 5 on a pain scale of 10,” Wagner says. “When we are distracted, it’s possible to be with friends, talk, listen to music, enjoy a meal or watch a movie. Morphine is not a treatment for existential pain. It will numb you out, but it won’t address anxiety, fear, depression or existential angst. “There are different paradigms of healing,” he continues. “Western medicine is the ‘allopathic’ mode and focuses on diagnosing and treating the symptoms of disease; but that’s just one healing paradigm. In another paradigm, we are also an energy body. Eastern techniques, such as acupuncture, have been around for thousands of years. The belief is that “Chi or ki — one’s ‘life force’ — flows through the body, and when that energy is blocked, that’s what causes illness or disease.” Alternative treatments such as acupuncture or Reiki (a healing technique performed by a certified practitioner) can move stagnant chi, balance the energy and relieve pain. “In the realm of palliative care, we sometimes find ourselves at a fork in the road, where fixing and curing isn’t possible,” says Wagner. “And so, we expand our horizon, looking at the forest, and not simply the trees.” Do patients benefit from embracing both Western and Eastern practices? “Yes, and that’s why we now reference ‘integrative medicine,’ rather than ‘alternative medicine.’ It is critically important to expand our paradigm to ‘healing,’ versus ‘fixing and curing,’ and, our treatment modalities to address mind, body and spirit,” he says. “In this way, we attend to the many dimensions of pain and suffering. “Healing is an all-inclusive paradigm that encompasses who we are, what we value and the purpose and meaning of our life. It connects us to something greater than ourselves and touches on what we deem as sacred. It is empowering and lets each of us step into our life as ‘the hero’s journey.’ Healing allows for a deep sense of peace in the face of life-threatening illness. Healing allows us ‘to be busy living,’ even as we are approaching leaving the world as we know it.”

HEAR ME NOW OR PAY ME LATER A review of Greta Thunberg’s The Climate Book B Y B R I E N A . S E E L E Y, M D

RARELY DOES A NONFICTION BOOK cause enough shock to change the world. To compel its readers to action, such a book must fulfill the 3 Rs: it must be readable, reputable and directly relevant to a mass audience. Think of Rachel Carson’s The Silent Spring (1962, 50 million copies), which, 8 years later, led to the founding of the U.S. Environmental Protection Agency; or Darwin’s On The Origin of Species (1868, 50 million copies) with its undeniable, world-changing discovery of evolution. Greta Thunberg’s The Climate Book may well join this elite class. What Uncle Tom’s Cabin was to the Civil War, Thunberg’s The Climate Book should be to the climate crisis, for it certainly fulfills the 3 Rs and is a powerful shocker. It has already sold 1.5 million copies since its release on October 27, 2022. It offers such a current and condensed education about the climate crisis that it should be required reading for elected officials everywhere. The Climate Book consists of several bitesized essays covering the wide array of issues that affect the climate crisis, including its history of denialism, inaction and the geo-political conflicts it entails. These essays are written by a curated faculty of renowned expert scientists, journalists, specialists and activists. A recurring topic is that of the horrific global catastrophe that will befall us if we don’t take action.

MANY VOICES TOGETHER

Experts are now reinforcing Thunberg’s fervent message. On May 8, 2023, eminent climate scientist and 2007 Nobel Peace Prize winner Dr. Ben Santer published in

the Proceedings of the National Academy of Science (PNAS) his definitive new atmospheric study that “yields incontrovertible evidence of human effects on the thermal structure of Earth’s atmosphere.” Finally, climate deniers have no credibility. The Climate Book warns that people still mistakenly think that a 1.5°C to 2.0°C rise in global temperature sounds tolerable. They don’t realize that the extreme weather events this shift will cause can kill millions. These events include heatwaves, floods, hurricanes, tornadoes and wildfires that could wipe out our infrastructure. In a heat wave that causes a widespread power blackout, temperatures soar with no air conditioning. Highways gridlock with evacuating hordes. Gas pumps don’t work, leaving people stranded in vehicles with empty tanks. Water pumps fail. Hospitals overflow with emergencies. Internet and cellular phone service go dead. Hurricane flooding blocks escape routes and ruins drinking water. Tornadoes can level community shelters and fire stations. Wildfire smoke can choke millions. Mayhem and looting can ensue. Hundreds of millions of climate refugees, with mass deaths from famines, dehydration and vector-borne pandemics can occur.

DIRE CONSEQUENCES ARRIVE

The extreme weather and wildfire events from 2021 to 2023 underscore the fact that our climate is now worsening faster than predicted. These extremes include ocean water temperatures reaching 101°F off the coast of Miami. And, due to the loss of forest uptake

of CO2, roughly 33% of annual global CO2 emissions are now attributable to wildfires, surpassing those annually from all automobile exhaust. Globally, one million people per year are dying from excessive heat. Such extremes affirm the book’s warning that we have under-estimated actual CO2 emissions and are approaching irreversible tipping points. These dire prospects seem not unlike the zombie apocalypse depicted in The Walking Dead. One would expect them to compel urgent bold collective action. Instead, like the nagging chirp of a dying battery in a smoke alarm, the repeating plea for urgent and effective climate action gets ignored, much like in the Meryl Streep film Don’t Look Up, in which world leaders fail to act to save our planet from an incoming asteroid, even though top scientists warn it will impact Earth in just 6 months. As our elected officials primarily focus on winning re-election — not with bold climate initiatives, but by strategic posturing on hot-button issues such as banning books, transgender bathroom use and vaping rules — the main message of this important, truth-telling book is that dramatic reductions in CO2 emissions must happen now.

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Meet the Writers

Sonoma Health would not be possible without the local health care professionals who contribute articles for publication. Thanks to all who donated their time and knowledge to make this issue possible.

A native of Brooklyn,

DR. ALLAN BERNSTEIN attended

college and medical school in upstate New York, and trained in internal medicine in Los Angeles and neurology in Boston. He was professor of clinical neurology at UC Davis College of Medicine and chief of neurology at Kaiser Permanente in Santa Rosa. An author of more than 40 publications in medical journals and textbook chapters, Bernstein is currently professor of clinical medicine at UCSF and actively involved in research in the field of memory loss and Alzheimer’s disease. His article on maintaining balance can be found on page 52.

DR. INDRA CHALIHA , is a pediatrician

at Kaiser Permanente Santa Rosa. She completed her residency at UCSF Fresno and earned a master’s in public health at the University of Oklahoma Health Sciences Center. She worked in genetic research on cancer both during her masters program and later as a post-graduate researcher at UCSF. At Kaiser, she worked as a COVID-19 lead for pediatrics, is a member of various committees and is also involved in teaching residents and medical students. She is a board member in the SMLMA and in its house of delegates. She loves to educate her patients on healthy eating and lifestyle. Her article on food as medicine begins on page 32.

DR. GARY GREEN graduated from Georgetown School of Medicine in 1991 and completed his fellowship in infectious disease at UCLA in 1996. He is currently the infectious diseases specialist for Sutter Medical Group of the Redwoods, and the medical director of quality, infection prevention and antibiotic stewardship. He is the 2021 recipient of Sonoma County Medical Society Outstanding Contribution Award, and Sutter Santa Rosa Hospital Best Grand Rounds Lecture of the Year. He has published on many infectious disease topics, and his piece on tick-borne disease starts on page 20.

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DR. RACHEL SC FRIEDMAN

graduated from Yale School of Medicine in 2008 and moved across the country to train as a family physician. After completing residency and integrative medicine fellowship at the Sutter Santa Rosa Family Medicine Residency in 2012, she joined Kaiser Permanente Santa Rosa to build on her interests in preventive medicine and help found a new residency program. She is currently program director at the KP Santa Rosa Family Medicine Residency, and has a special interest in mind-body medicine, technology and innovation, and equity and belonging. Read about her family’s Digital Detox journey on page 24.

DR. STEPHEN HALPERN is a cardiologist who has been practicing in Santa Rosa for more than 40 years, most recently with Providence Medical Group. Prior to moving to Santa Rosa he was assistant professor of medicine at Cedars-Sinai Medical Center in Los Angeles. In addition to his cardiology practice he is medical director of NorthBay Clinical Research. He details the connection between blood pressure and cholesterol starting on page 44.

TATIANA LONGORIA is a multi-

DR. PETER MARINCOVICH earned

DR. ASISH SHAH founded Siyan

certified Aesthetic Registered Nurse with more than 10 years of experience. She specializes in aesthetic lasers and injectables, including neurotoxins and dermal fillers, as well as various body shaping procedures. Starting on page 18, she and Dr. Jeffrey Sugarman (see below), overview cosmetic laser procedures.

his graduate degree in communicative disorders from Louisiana State University, and his Ph.D. in Audiology from University of Memphis. A Santa Rosa native, Dr. Marincovich has practiced in his hometown since 1984. He works with patients of all ages and levels of hearing loss. He is also a frequent presenter at seminars and academic conferences. He holds specialized credentials in teaching the handicapped, and conducts courses at Santa Rosa Junior College. You can find his article about tinnitus on page 50.

Clinical in Santa Rosa, one of the largest private practices in the North Bay. With 20 years’ experience in psychiatry, including Kaiser Permanente and Sonoma County Mental Health, he specializes in a wide range of disorders, including depression, ADHD, PTSD and substance abuse. Learn about his programs at siyanclinical.com or by calling 707-206-7268. For Sonoma Health, he tackles the troubling trend of cyberbullying, starting on page 26.

DR. BRIEN SEELEY is a Santa Rosa

DR. GARY STEIN is a board-certified

DR. JEFFREY SUGARMAN is a practicing pediatric dermatologist in Sonoma County. He is the immediate past president of the California Society of Dermatology, a clinical professor in Dermatology at UCSF and in private practice as the medical director of Redwood Family Dermatology. He and Tatiana Longoria provide information about aesthetic laser procedures beginning on page 18.

ophthalmologist in private practice in Santa Rosa and is past president of the Frederick C. Cordes Eye Society. He has written numerous articles for Sonoma Medicine and Sonoma Health, including a review of Greta Thunberg’s important environmental manifesto The Climate Book in this issue (on page 77). He is also president of the nonprofit Sustainable Aviation Foundation, Inc. He can be reached at brienseeley@gmail.com.

specialist in orthopedic surgery, adult reconstructive surgery, sports medicine, hand and back care. A pioneer in developing minimally invasive techniques for hip and knee replacement surgery (which he writes about beginning on page 68), he is co-director of the Sports Medicine Center at SRO and a fellow of the American Academy of Orthopedic Surgeons. Stein has contributed to professional journals such as Orthopaedics and the Journal of Bone and Joint Surgery, while also maintaining a longtime practice of continuing professional education. For a consultation and appointment with Dr. Stein, please call 707-546-1922 x1.

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Listen and Lead

Meet Dr. Tanya Phares, the new public health officer for Sonoma County By Jean Saylor Doppenberg

“AS A PHYSICIAN, I LIKE TO LEAD BY EXAMPLE.” —DR. TANYA PHARES

INTEGRATE INTO THE COMMUNITY

DR. TANYA PHARES IS QUICKLY SETTLING INTO LIFE IN SONOMA COUNTY, where in mid-November, she assumed the role as the county’s public health officer. She has strong ties to Northern California, having been raised in the seaside town of Trinidad in Humboldt County. Phares earned her medical degree from Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, and completed residencies at UC Irvine and the California Department of Public Health. She earned a master’s degree in public health from the Tulane School of Public Health and was a research fellow with the Centers for Disease Control and Prevention. “My studies at Tulane are what sparked my interest in pursuing a career in public health,” she says. “I studied all areas of public health, with a focus on international and women’s health.”

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Phares moved from Reno, Nev., where she was working as a health care consultant in preventive medicine. Prior to that, she served in leadership roles, including chief medical officer of St. Mary’s Health Network and chief medical director of SilverSummit Healthplan. She’s now making her home in Petaluma with her husband and two teenagers, ages 13 and 16. The family enjoys skiing together, and Phares is also an avid runner. “I also love to cook and I follow a mostly plant-based Mediterranean diet,” she says. “I have an interest in culinary medicine and believe in food as medicine. Good nutrition is so important in maintaining a healthful lifestyle. As a physician, I like to lead by example. Through cooking, I can mix my professional side with my personal side.” To Phares, it’s important that she work with the community to strengthen health equity and open up better access to care and services for everyone. “[These priorities] parallel a lot of issues I work on in the scope of health, such as chronic disease prevention and promoting healthful lifestyles,” she says. “During the pandemic, many people fell behind in their health screenings and couldn’t get some of the care they needed. We should focus on the things that maybe didn’t get the attention they deserved at that time, such as making certain people are upto-date with their chronic disease prevention. We need to get back to that kind of focus to help us recover more quickly. “Compounding the problem is that many health professionals retired during or af-

ter the pandemic, and that has strained the health care system. The pandemic was a trying time for everyone. We’re all trying to learn from it, because it’s an opportunity to be ready in the event something like that happens again.”

DRIVEN TO HELP

Most people go into the health care profession, she says, because they want to help people and they have a higher calling to do so: “There’s a mission that drives us into the medical field.” A statement released by the Sonoma County Department of Health Services explains that the public health officer serves as the chief medical officer and the top health policy official for the county. In her role, Phares is granted authority from the state “to declare public health emergencies, issue health orders and impose penalties for noncompliance.” Says Phares, “I look forward to collaborating with community stakeholders to address health challenges and strengthen health in Sonoma County.” Phares says she enjoys engaging with communities — hearing from the people and learning what they really need. “I’ll be an approachable health officer here in Sonoma County,” she says. “In my career, I’ve learned to lead through good communication and listening, as well as taking a collaborative approach to solving problems. “It’s so important to have transparency and listen to everybody. It’s also important to build trust. If you want to make a positive impact on a community, you need to listen to the concerns of the people living there.”

Come meet us! Get a feel for life at The Meadows at a personal tour.

Some folks call us a retirement community. Others prefer “super-amazing friend finder.” The Meadows has been serving those 60+ in Napa Valley for over 30 years. So, yes indeed, we are a retirement community. But, with so many friendships forged here, “community” should get all the glory in that title. Truly. Sure, The Meadows is like a resort—a sprawling green campus, active and independent residents, and amenities straight out of your wildest dreams.

Please call 707.819.9786 today to schedule a tour.

But what really makes us special is our people— the residents and the staff. We invite you to come see for yourself at a personal tour. Please call 707.819.9786 to schedule. And see firsthand how a retirement community can double as quite an amazing friend finder, too.

1800 ATRIUM PARKWAY NAPA • 707.819.9786 RETIREMENT.ORG/MEADOWSNAPA An IOOF Community. A not-for-profit, resident-centered community. Equal housing opportunity. RCFE#: 286801070 • COA#: 334 • SNF#: 110000292.

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