A bummer for kids: Nasal flu vaccine not effective

Family caregiving is a huge topic nowadays. With over 75 million “baby boomers” poised to become the largest generation in American history to require such caregiving, how can it not be? Already, family members — people like you and me — provide $642 billion worth of unpaid care for our spouses, parents, and relatives each year. But what is the price we pay in terms of our personal well-being, physical and otherwise?

While caregiving has been shown to have benefits — it helps to build character, enrich one’s soul, and even ward off cognitive decline —its burdens can be just as significant, if not more so, as demonstrated by a new study published in a recent issue of The New England Journal of Medicine.
Realities of caregiving

Researchers at the University of Toronto followed a group of 280 caregivers of critically ill family members who had received seven or more days of mechanical ventilation (“breathing machine”) in the ICU for 12 months. The goal was to assess the impact of caregiving on the caregivers’ well-being and quality of life. The average age of caregivers in the study was 53; 70% of the caregivers were women, and 61% were caring for their spouse. Here’s what the study found:

    More than half of caregivers had high levels of depression (67% were depressed at the start of the study, and 43% were depressed after one year of follow-up).

    The depression decreased somewhat with time in 84% of the caregivers, but did not in 16%.

    Caregivers who were younger, who had to give up regular activities for caregiving, and who had lost a sense of control over their lives tended to be worse off than the rest.

Notably, older caregivers were better off health-wise than younger caregivers, perhaps because they had more free time and faced fewer work-related pressures. Those who fared better also had higher income — so were likely able to afford more paid help and to take more time off work — and had better support from family, friends, and community.

One of the study’s most important findings is that caregivers of critically ill family members may still be at risk for clinical depression for months, if not years, after the crisis is over — and that this risk is higher for these caregivers than for most of us, including those who look after loved ones with chronic progressive illnesses such as Alzheimer’s disease. The study also notes that there is currently a lack of resources for caregivers.

Statistical data can hardly convey the anguish that many caregivers of critically ill patients face day-to-day: the anger, sadness, frustration, and loneliness of it all. And yet these are the feelings one hears about most often in the consulting room. Spouses may feel cheated out of their golden years and harbor resentment. (One client described caring for her husband with brain damage to be “as close to hell as it can get.”) Adult children can be in denial of a parent’s condition and blame the caregiving parent for not doing the “right thing,” or can sometimes expect the caregiver to be superhuman.
What caregivers can do to care for themselves

As medical science continues to make advances in prolonging the life span, more and more of us may find ourselves in the role of a family caregiver. The Toronto study reminds us that health crises may be unavoidable and that their effects can be profound. But there are strategies we can employ to mitigate their potential stresses and strains, such as:

    Not doing it all alone. Get as much support as you can. Schedule a regular walk with a walking partner. Find a support group. Let friends and neighbors help out with cooking and errands.

    Timely financial planning. Do not wait for a crisis to put your affairs in order.

    Talking with our loved ones about their goals and wishes for care while they are still in good health, and drawing up “advance directive” documents that put these wishes in writing.

    Last but not least, taking good care of ourselves, both physically and psychologically. Make sure you get enough sleep. Go to the gym. Take a yoga or meditation class.

As the Family Caregiver Alliance reminds us, when your needs are taken care of, the person you care for will benefit, too. I grew up in the 70s and 80s, and every once in a while a TV commercial would tout a product with the “goodness of whole grains,” like it was some earth-shattering news that would make your mom floor it to the grocery store. Back then it probably was impressive, since many popular foods were loaded with refined grains and added sugar (I’m talking to you, spongy lunchbox treats and cereals with prizes inside the box).

These days, it’s common knowledge that whole grains like oats and wheat are important for maintaining health: they raise “good” HDL cholesterol levels and lower “bad” LDL cholesterol, triglycerides, and blood pressure.
More evidence

A Harvard study published online on June 13, 2016, in the journal Circulation found that, compared to people who didn’t eat many whole grains each day, people who ate four servings of whole grains daily (about 70 grams) during the study period had a 22% lower risk of death from any cause, a 23% lower risk of dying from cardiovascular disease, and a 20% lower risk of dying from cancer. The study doesn’t prove that whole grains prevent early death, but it adds to increasing evidence that whole grains really are full of “goodness.”

Maybe that’s why some whole grains, called ancient grains, are now trending among foodies, even showing up on the list of the National Restaurant Association’s “What’s Hot in 2016” culinary forecast.
What are ancient grains?

Unlike modern grains such as wheat, corn, and rice, ancient grains have never been processed through hybridization or genetic modification; they’re grown just as they were a thousand years ago. They have exotic-sounding names like teff, einkorn, emmer, amaranth, millet, quinoa, black rice, black barley, and spelt. And they pack a nutritional wallop. “Generally speaking, they offer more protein, fiber, and vitamins than modern grains,” says Debbie Krivitsky, a registered dietitian at Harvard-affiliated Massachusetts General Hospital. For example, a cup of cooked teff has 10 grams of protein and 7 grams of fiber, compared with 5 grams of protein and 3 grams of fiber in a cup of cooked modern brown rice.

Nutrition isn’t the only difference. Ancient grains sometimes have more calories than modern grains. In our example of teff and brown rice, teff has 255 calories per cup, compared to brown rice, which has 216 calories. Furthermore, a cup of cooked modern oatmeal has only 124 calories, and a cup of cooked modern corn has only 74 calories. In addition to the higher calorie content, there is another difference between the two forms of grains: ancient grains tend to cost more than modern grains.
Whole grains, always in style

Just because ancient grains are “in” right now, it doesn’t mean you should discount modern whole grains. All whole grains are better for you than refined grains. Whole-grain kernels have three parts — the bran, endosperm, and germ — that give you phytonutrients, vitamins, and antioxidants, which protect against chronic disease. “Refined grains get rid of the bran and germ in the processing, and you lose the fiber and many of the nutrients,” says Krivitsky.

Many whole grains contain plenty of fiber, which helps lower cholesterol, improves digestion, and controls blood sugar. “It’s okay to eat lower-fiber whole grains. Just make sure you include other foods that are high in fiber, such as fruit and vegetables or high-fiber breads, cereals, and crackers,” says Krivitsky.
Where to start

The takeaway message is to vary your whole grains. “Keep eating oatmeal and brown rice if you like it, but add in some ancient grains from time to time,” suggests Krivitsky. Enjoy ancient grains as a side dish to a meal, or sample products that contain ancient grains, such as breads, cereals, and pastas.

When buying any whole-grain product, to ensure that you are getting an appreciable serving of that grain, make sure it’s one of the first ingredients listed; ingredients are listed by quantity, in descending order. Also, make sure there’s not a lot of added sugar, which takes away from the value of the food.

And remember to watch your calories when eating any grains. “Some of these are calorie-dense foods, so you really have to be mindful of portions or you may gain weight. But you can have less and still get more nutrients,” says Krivitsky. I grew up in the 70s and 80s, and every once in a while a TV commercial would tout a product with the “goodness of whole grains,” like it was some earth-shattering news that would make your mom floor it to the grocery store. Back then it probably was impressive, since many popular foods were loaded with refined grains and added sugar (I’m talking to you, spongy lunchbox treats and cereals with prizes inside the box).

These days, it’s common knowledge that whole grains like oats and wheat are important for maintaining health: they raise “good” HDL cholesterol levels and lower “bad” LDL cholesterol, triglycerides, and blood pressure.
More evidence

A Harvard study published online on June 13, 2016, in the journal Circulation found that, compared to people who didn’t eat many whole grains each day, people who ate four servings of whole grains daily (about 70 grams) during the study period had a 22% lower risk of death from any cause, a 23% lower risk of dying from cardiovascular disease, and a 20% lower risk of dying from cancer. The study doesn’t prove that whole grains prevent early death, but it adds to increasing evidence that whole grains really are full of “goodness.”

Maybe that’s why some whole grains, called ancient grains, are now trending among foodies, even showing up on the list of the National Restaurant Association’s “What’s Hot in 2016” culinary forecast.
What are ancient grains?

Unlike modern grains such as wheat, corn, and rice, ancient grains have never been processed through hybridization or genetic modification; they’re grown just as they were a thousand years ago. They have exotic-sounding names like teff, einkorn, emmer, amaranth, millet, quinoa, black rice, black barley, and spelt. And they pack a nutritional wallop. “Generally speaking, they offer more protein, fiber, and vitamins than modern grains,” says Debbie Krivitsky, a registered dietitian at Harvard-affiliated Massachusetts General Hospital. For example, a cup of cooked teff has 10 grams of protein and 7 grams of fiber, compared with 5 grams of protein and 3 grams of fiber in a cup of cooked modern brown rice.

Nutrition isn’t the only difference. Ancient grains sometimes have more calories than modern grains. In our example of teff and brown rice, teff has 255 calories per cup, compared to brown rice, which has 216 calories. Furthermore, a cup of cooked modern oatmeal has only 124 calories, and a cup of cooked modern corn has only 74 calories. In addition to the higher calorie content, there is another difference between the two forms of grains: ancient grains tend to cost more than modern grains.
Whole grains, always in style

Just because ancient grains are “in” right now, it doesn’t mean you should discount modern whole grains. All whole grains are better for you than refined grains. Whole-grain kernels have three parts — the bran, endosperm, and germ — that give you phytonutrients, vitamins, and antioxidants, which protect against chronic disease. “Refined grains get rid of the bran and germ in the processing, and you lose the fiber and many of the nutrients,” says Krivitsky.

Many whole grains contain plenty of fiber, which helps lower cholesterol, improves digestion, and controls blood sugar. “It’s okay to eat lower-fiber whole grains. Just make sure you include other foods that are high in fiber, such as fruit and vegetables or high-fiber breads, cereals, and crackers,” says Krivitsky.
Where to start

The takeaway message is to vary your whole grains. “Keep eating oatmeal and brown rice if you like it, but add in some ancient grains from time to time,” suggests Krivitsky. Enjoy ancient grains as a side dish to a meal, or sample products that contain ancient grains, such as breads, cereals, and pastas.

When buying any whole-grain product, to ensure that you are getting an appreciable serving of that grain, make sure it’s one of the first ingredients listed; ingredients are listed by quantity, in descending order. Also, make sure there’s not a lot of added sugar, which takes away from the value of the food.

And remember to watch your calories when eating any grains. “Some of these are calorie-dense foods, so you really have to be mindful of portions or you may gain weight. But you can have less and still get more nutrients,” says Krivitsky. Every year, many of my patients have been able to skip the needle — and still get vaccinated against the flu. That was the great thing about the nasal spray version of the flu vaccine, known as the LAIV (live attenuated influenza vaccine): kids scared of needles could get a squirt up each nostril and be all set.

This coming flu season, everyone is getting the shot.

It turns out that the nasal spray just didn’t work that well. Despite studies from the 2002-2003 and 2004-2005 flu seasons that seemed to show that the nasal spray actually worked better than the shot in children ages 2-8 years, over the past couple of years it became clear that it wasn’t working very well. Data from the 2015-2016 season showed that the spray only offered protection 3% of the time, as opposed to 63% with the shot.

We might as well have been squirting water up those noses, which is so upsetting to me as a pediatrician. I recommended the nasal spray. I told families it worked just as well. But it didn’t.

We don’t know why the nasal spray hasn’t been working well. Usually, “live attenuated” viral vaccines, the ones that are not completely inactive but aren’t active enough to cause infection in most people, work better than inactive ones. Usually, they cause a stronger immune response from the body and give better protection. It’s particularly puzzling since those earlier studies showed it worked better than the shot. In retrospect, those studies were done before the H1N1 virus became a big actor in the flu scene, and for some reason, the spray doesn’t seem to work as well against that type of influenza. Also, many of the children in the studies were getting a flu vaccine for the first time, and this may have skewed the results; the way the body reacts is different when it’s your second or third or tenth time being vaccinated.

That’s the thing about medicine: our understanding of diseases and treatments is always evolving. Diseases and treatments can be amazingly intricate and complicated. Sometimes we think we understand something, only to find out that we don’t — or that we misunderstood it. That’s why ongoing research is so important. We must always be questioning and studying — and always applying what we learn to what we do.

Having learned what we did about the nasal spray flu vaccine, we won’t be giving it anymore. I will always feel upset about my patients who didn’t get the protection I thought they were getting, the protection I told them they would get. But at the same time, I’m grateful to the researchers at the Centers for Disease Control and Prevention for always questioning and studying — and using what they learn to help us take better care of people.

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