Most of us need our coffee. It is the most commonly ingested pharmacologically active substance in the U.S.A. and, not to be too become too national, I should point out ….in the world! We cosume caffeine in our coffee, tea (black and green), soft drinks, chocolate (although white chocolate, which is mostly sugar and butter is exempt), coffee flavored food, over-the counter medications such as Excedrin, Anacin and Midol as well as prescription meds for pain such as Fiorinol and Darvon Compound to name a few. Our average daily consumption is 280 mgs which is the equivalent of two and a half cups of brewed caffeinated coffee a day.

And we are so addicted. This very time honored substance (yes, it was much sought after and cultivated before the creation of Starbuck’s) is similar in its affect on our brains to amphetamines, nicotine, ephedrine and even cocaine. At high doses (200 to 800mgs) it stimulates neurotransmitters that activate the award system in our brains. And if we suddenly withdraw, the symptoms may be most unpleasant: headache, fatigue, irritability, depressed mood and problems with concentration. (I can attest to all these, I tried to stop in order to deal with heartburn…I won’t go into the results, but perhaps my husband will.)

So what should women do who want to get pregnant….or have been pregnant and now want to analyze whether their caffeine consumption caused their progeny to be born prematurely, grow up too fast, act out or not get into an Ivy League School. (For the sake of full disclosure….mine did not; and yes I drank coffee.)
Here’s where I bring in study results. Medical therapies and advice should be based on evidence based, randomized investigations….and the best and brightest are chosen by the Cochrane Review. They scan biographies and/or published studies and often correspond with the investigators. They look for randomized and at least quasi controlled trials. They did this when they investigated the effect of caffeine and/or supplementary caffeine versus restricted caffeine intake or placebo on pregnancy outcome. Only one study out of 80 met their standards! Caffeinated instant coffee (which has about 95 mgs of caffeine per cup) was compared with decaffeinated instant coffee (3 mgs a cup). Reducing the caffeine intake of the regular coffee drinkers from 3 cups a day to one or less did not affect birth weight or length of gestation. The conclusion was that “there was insufficient evidence to confirm or refute the effectiveness of caffeine avoidance on birth weight or other pregnancy outcomes”.

More investigations will probably be forthcoming (some may be sponsored by caffeine and pharmaceutical industries) … but many won’t be appropriately controlled. So let me go on the line (or in a cup) right now and give the reassurance many of us would like. Coffee, cola drinks or chocolate are not harmful in pregnancy. I would suggest, however that you limit all the above to no more than the equivalent of 3 cups of coffee. That should be enough to reward those neurotransmitters in our brains. And, while addressing cravings …alcohol (and of course smoking) in pregnancy is and will always be a no no.

I practice in the heart of California- must-be-thin- land (to be exact in Westwood, which in realtor terms is adjacent to Beverly Hills) and find that the majority of my patients who are over 40 and are not Pilate’s instructors complain that they are losing their flat stomachs and thin waists. I sympathize with their (and my) inability to wear those jeans that, when successfully closed, rise one centimeter above the pubic hairline.  (I also strongly advise women who cannot breath or whose abdomen is pushed into an unsightly overhang once the jeans are fastened to abstain and give said jeans to a pre-pubertal adolescent.)

Is the pouch of middle-ish age (I no longer know how to define middle as I get older) due to hormonal changes, menopause, the absence of hormones or hormone therapy? Probably not.  Most studies show that there is a change in fat distribution as we get older. In women it goes from the hips and thighs to the abdomen and the breasts. Add to this the fact that our metabolic rate diminishes by 5 % every decade, we are destined to lose the flat stomachs and hourglass figures we had as young women. Let’s just consider that 5%: if your food intake consisted of 2000 calories, 5% of that is 100 calories. If you add 100 calories to what you burn off each day you get an excess of 3000 calories a month. It takes 3500 calories to “construct” one more pound on your body. So let’s see…. one pound gained every 6 weeks comes out to 9 pounds a year. Simple physics and math take control; if your caloric intake remains unchanged, you don’t exercise more and live for 2 more decades, say from 30 to 50…you could now be at least 18 pounds heavier! And if much of that extra weight went around your waist…you now have to go up 2 sizes because of your waistband requirements. And to make matters worse, way worse, you and your expanded waist may now be medically overweight or if you have added much more than those daily 100 calories, obese.

One of the most important issues that all health care professionals have to address is how to prevent and treat obesity.  Unfortunately my patients, like the rest of the nation are succumbing to the overweight and obesity epidemic that will leave 1 in 3 adults in this life-ruining category (think diabetes, hypertension, cardiovascular disease, cancer and shortened life).

Our shrinking ability to be svelte has helped create a huge weight loss industry and hundreds of published (or pictured before and after) devotees to a myriad of diets. Most promote low carbohydrates or low fat. Then there is hefty marketing of weight loss foods, programs and non-approved weight loss supplements. Reality shows and web marketing sites reap huge financial benefits from the quest to lose weight. So what works?

I always thought that a low fat, Mediterranean type of diet was best for weight maintenance and health…. you know, lots of fruits, vegetables, non fat milk products, fish, olive oil and whole grain bread  (and in my case no red meat). And of course at least 30 minutes of exercise a day. I have to admit that I have remained fairly thin adhering to this type of nutrition. I  also stop eating when I am full, have no qualms about leaving portions on my plate and when possible make 2 meals out of one. I also don’t crave sweets (chocolate is not a sweet!)

But let’s get back to those diets. A recent study published in The New England Journal of Medicine gave one of the best long-term views of what works. They followed  811 overweight adults assigned to 1 of 4 diets for 2 years. The diets were similar in low caloric intake but reduced the amount of energy derived from fat, protein and carbohydrates respectively. (If you are interested, the different diets contained 20%, 15% and 65% fat, protein and carbs ; 20%, 25% and 55% , the third type was 55%, 40%, 15% and finally 40%, 25% and 35%).  The participants were also offered group and individual session for 2 years.

After 6 months all the participants had lost an average of 6 kg (13 pounds), which was 7% of their initial weight. They began to regain the weight at 12 months. Of the 80% of those that completed the trial at 2 years the average weight loss was 4kg ( about 9 pounds). Close to 15% had lost 10% of their initial body weight. Here’s the extraordinary finding: The type of diet (low fat, low carb or low protein) didn’t make a difference to success! Satiety, hunger, satisfaction with the diet and attendance at group sessions were similar for all diets. It was the attendance at the group sessions that seemed to make a difference…as much as of 0.2 kg (half a pound) weight loss for each session attended. Also all the diets improved lipids (blood fats) and fasting insulin levels (which constitute a diabetes risk). The authors then concluded the “reduced-calorie diets (coupled with regular sessions) caused meaningful weight loss independent of the ratio of fat, carbohydrate and protein.

So to reduce your weight (and as the pounds come off a little of that abdominal pouch may follow) reduce your caloric intake. Weight Watchers or similar programs that have frequent counseling and motivation sessions will help. My advice to many of my patients is to put what they normally place on their plates…. take a knife and remove 1/3 to 1/2 for next day consumption (or if necessary throw it into the garbage), eat the rest and exercise. The latter should include pushing the chair back from the table. We may not get into our old jeans but we don’t want to get into an early grave!

Most of us can point to depressing episodes in our lives….woes befall all of us: the economy, personal loss, worries about errant spouses, children (remember, we are only as happy as our most unhappy child) and aging parents. And I haven’t even begun to list the enormity of the global energy problems, international conflicts and consequences of disease. (If I keep going, I’m bound to find something that depresses you!) There is, of course, a difference between having to deal with either personal or large scale social issues that lead to sadness and worry and the occurrence of true clinical depression. The best way to define the latter, without going into treatises put out by the American Psychiatric Association, is that nothing gives you pleasure; nor can you function in your everyday mode of life. If you feel that you are in a dark tunnel with no light at the other end, day after day; you are clinically depressed. And a huge number of us are… up to 25% of women develop clinical depression at some point in their lives (more then twice the prevalence of clinical depression in men, which may be a reflection of our genetic capacity for concern and sensitivity).

Clinical depression peaks in our reproductive years. Nine percent of women will have an episode during or within 3 months of pregnancy. The consequences can be harmful to both mother and child. There are entire medical journals dealing with “the safest way” to deliver a baby, the pros and cons of Cesarean vs. natural delivery, the concerns about vacuums, forceps, routine episiotomy, not to mention tables to ascertain desired weight gain, concerns about preterm deliveries and of course tests to ensure the genetic integrity of our offspring. But few Ob Gyns are trained to either recognize or treat clinical depression in pregnancy. When asked by a patient whether it is safe to start or continue antidepressant medication during pregnancy….we hem and haw. Here is what I now tell my patients:

Women are more apt to develop depression during pregnancy if they:

  • Have a history of depression at any time including a previous pregnancy or postpartum.
  • Have been diagnosed with clinical depression in the past.
  • Have a family history of depression, especially during pregnancy or postpartum.
  • Have other psychiatric illnesses (panic disorder, obsessive-compulsive disorder, bipolar disorder, substance abuse).
  • Marital instability…this cover a lot of issues, I translate it as a non supportive, or worse yet, abusive spouse.
  • Unplanned pregnancies …unfortunately as many as 50% of pregnancies are not planned).

Depression can harm a pregnancy:

Studies have shown that women who are depressed during pregnancy have twice the risk of cesarean section, premature delivery and neonatal intensive care admissions of the newborn as well as four times the risk of delivering a low birth weight infant when compared to women who were not depressed. Depression and severe stress can cause changes in the hormonal environment in which the fetus is developing (This includes steroids such as cortisol, maternal brain hormones, estrogen, progesterone, insulin and growth hormones to name a few). The theory is that this “upset” hormonal milieu can impact fetal growth and fetal programming so that the infants, especially those born at lower than expected birth weights to women who were significantly depressed or stressed during their pregnancy are at future increased risk for schizophrenia, cardiovascular disease, type 2 diabetes osteoporosis and depression.

Treatment: Is it Safe in Pregnancy?

All psychiatric medications cross the placenta. If a pregnant woman is mildly or even moderately depressed (a brief definition: she has no thoughts of suicide, has not needed medication for depression in the past and is able to continue her usual functions) then traditional psychotherapy may be all she needs to successfully deal with her depression. (And we have all become more familiar with therapy sessions after watching Gabriel Byrne). But if her depression is moderate to severe and medication has helped in the past, her best option would be pharmacologic….i.e. antidepressant medication. And the current recommendation is to use the drug that previously worked. Clinical depression is a medical disorder that, like diabetes or hypertension can adversely affect the outcome of pregnancy…not treating it will create a greater risk for a woman and her unborn child than treating it. There has been a reluctance to include pregnant women in many pharmaceutical studies conducted in the past, but as the need to address depression in all women becomes apparent, antidepressants are now being investigated for use during pregnancy.

SSRI’s (Selective Serotonin Reuptake Inhibitors)
There are many….each with a slight change in chemistry, indication and side effects. Medications in this category include Zoloft, Paxil, Celexa, Lexapro, Effexor, Cymbalta, Wellbutrin, and Serazone. As I write this, more are being introduced. Multiple studies have shown there is a very low absolute risk of congenital anomalies when these medications are used during pregnancy. But the pharmaceutical companies and prescribing physicians must include appropriate reports of adverse effects….sort of like the list of everything that can go wrong at the end of those direct-to- consumer ads you see on television (usually stated in a hurried, breathless manner by a male voice) or read in the patient information provided with the prescriptions.

So here are some: There have been studies that describe an increased risk of abdominal and skull defects with first trimester use of SSRI’s and a rare cardiac defect with Paxil. (Although a Canadian study contradicted the latter.) There has been no evidence of fetal malformations due to use of Prozac in pregnancy…this is indeed the most studied (and oldest) SSRI.

There maybe a sight increase in miscarriage rates among women who take antidepressants compared to nondepressed women: 12.5% v. 8.7%. (It’s difficult to establish if this is due to the meds or their underlying depression). There are also reports that third trimester exposure to SSRI’s can cause tremor, breathing, sleeping and feeding problems in newborns, but this is usually mild and disappears after 2 weeks. The long term good news is that these medications appear to have no effect on exposed children’s IQ, language development or temperament.

Benzodiazepines (such as Valium, Xanex, Dalmane, Ativan, Klonipen. Restoril)
There have been studies that may have shown an increase in cleft palate in infants exposed to benzodiazepines but other studies have not… quite frankly the literature is not definitive.

Lithium
This is considered relatively safe during pregnancy: but it may increase an exposed infant’s risk of a rare cardiac valve problem. The recommendation is to stop lithium 24 hours before delivery.

To Summarize: If you are on a medication for depression that works, especially an SSRI and you conceive….keep taking it. If you stop, chances are you will have a relapse and this can harm you and your pregnancy. Know that you may need higher doses as the pregnancy develops. (There are a lot of changes in the metabolism and dilution of any medication as you and your pregnancy grow.) After 4 to 6 weeks you and your doctor may decide you need to increase the dose every 2 to 3 weeks until your symptoms are in remission.

Every time the media reports on a new adverse effect from an antidepressant….remember that bad news makes news. If you suffer from clinical depression before or during pregnancy, treatment can make a very positive difference in your pregnancy outcome and the future health of your child.

I like millions of American women take one of the proton-pump inhibitors. Although I had many patients who, over the years of my practice, complained about heart burn and how it severely affected their well being I, perhaps did not commiserate as enthusiastically as I could have. (If their symptoms sounded serious I would refer them to a gastroenterologist for treatment and possible upper endoscopy to make sure they did not have GERD and/ or ulcers in their esophagus or stomach hence an increased risk for cancer). Then about 2 years ago, I too developed the symptoms and realized how distressing they can be. After trying the usual; not to eat before sleep, raising myself on extra pillows when I did, stopping caffeine, wine (so sad) and spicy foods to no avail I called my colleague the gastroenterologist. He prescribed one of the proton-pump inhibitors and after a few months when my symptoms recurred, performed that upper endoscopy (nothing was found). I have stayed on this medication and now encourage my patients who have similar symptoms to do so.

There have been studies that show the obvious….if you significantly decrease stomach acid you may affect the absorption of calcium, especially calcium carbonate which needs acid to be absorbed. Consequently women who take these medications are at risk for bone loss. Calcium citrate however does not require significant stomach acid for absorption, additionally it can be taken with or with out food. Hence I recommend to many of my patients that they supplement their calcium intake with calcium citrate.
We also have data that in getting rid of stomach acid, we may decrease our ability to “fight off” bacteria and spores that are ingested. There are studies that show an increase in diarrhea and a type if intestinal infection called Clostridium difficile. So if diarrhea does occur for more than a few days it’s important to notify your doctor who will often suggest you get a stool culture.

Now we have new information about another potential side effect from the use of these proton-pump inhibitors: A study published in JAMA showed that this type of acid suppressive medication was associated with a 30% increase in the risk of hospital-acquired pneumonia. Over 63,000 individuals who were hospitalized were followed; acid-suppressive therapy was ordered in 52% and of those 4.9% developed hospital-acquired pneumonia. Once the researchers did the numbers and extrapolated, this translated into 180, 000 cases of hospital acquired-pneumonia annually in the USA that were associated (or due to) the medication. There is an estimated 18% mortality for a hospital-acquired pneumonia, which would result in 33,000 acid reduction medication related deaths! (Don’t forget, however, that if individuals are in the hospital they are already sick, may be elderly and certainly may be more fragile when it comes to infections.) It’s postulated that acid reduction may modify the bacteria and viruses (strangely called “flora”…in this case not a very botanical term) in the upper gastrointestinal tract and subsequently in the upper respiratory system. The relatively good news for those of us on the medication long term….most of the risk appeared within the first 2 days of use. (Concerns about stress ulcers and acute gastrointestinal bleeding often cause physicians to prescribe the medication in acutely ill, hospitalized patients.) According to the study, the longer the duration of use of the proton-inhibitors the less likely the risk of developing this type of pneumonia.

There are more and more studies that show an association between pneumonia (not just hospital based infections) and acid suppression medications. There is as I like to say “no free lunch”…in this case no free heartburn relief for those of us who truly are suffering from acid reflux. This article is not meant to tell you to stop your necessary medication. Just make sure all your health care professionals know what you are taking….especially if you develop an unremitting cough, fever or other symptoms of severe respiratory infection.

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