Category Archives: Preventative Medicine

Sustainability in its truest sense is much more than just being about the environment. It is also about the sustainability of professions and individual companies. A truly sustainable company has good team retention and the individuals in the team flourish because of the positive environment of the team.

The senior managements role in a business is to set the culture and strategy and be the encourager and enthusiast in the business. Its to help the wider team to decide what the values to live by are.

In the narrower sense, of course, we understand it as how businesses can help the environment. OneHealth is a current concept that is creating waves in the veterinary and medical world and suggests how all health must be viewed holistically. Health in mind and body and including the animals in our world and the environment all add up to give a sum greater than its parts.

There is increasing evidence that access to nature is good for physical and mental health. Research has shown that people experiencing stress can use green and blue spaces to improve well-being through walking and exercise.

In a recent webinar at The Webinar Vets 10th annual virtual congress, Dr. Catriona Mellor, a psychiatrist, introduced the concept of solastalgia which can be defined as a form of emotional or existential distress caused by negative environmental change or worrying about what may happen in the future to our planet.

When employees can see that their company cares about the planet and is making positive steps to improve local and international areas then this will help them realise that improving our planet is still possible if enough people, individually and corporately, make an effort. It takes the employee in the opposite direction to solastalgia. When companies have clear targets for becoming carbon neutral or being accredited by Investors in the Environment or the Carbon Trust, employees feel that the business exists for more than just making a profit but to help all stakeholders including themselves and the environment.

Planting wildflowers at the workplace on waste pieces of ground or where more traditional gardening has been previously, been will encourage wildlife like butterflies and bees. Preparing this area and seeing the beautiful flowers growing, gives people a sense of achievement and also helps to slow them down when they want to study the flowers and animals that thrive there.

The benefits of appreciating nature have become so well recognised that GPs have begun green and blue prescribing under the banner of social prescribing.

A recent article in the Wildfowl and Wetland Trusts magazine, Waterlife discussed five ways to well-being wellbeing in nature:

In the Lancashire Wildlife Trusts spring 2022 magazine, Lapwing, it was noted that green and blue social prescribing to a group of people suffering from loneliness, depression and anxiety delivered 6.88 of value to participants and the wider society for every 1 spent. There are many of these schemes springing up in North West England. As a vet, Im a big believer in preventative medicine. Spending time in nature as part of a companys sustainability activities or as an individual will protect the person from beginning to feel depressed or anxious.

When I am feeling stressed or sad, I often jump on my bike and cycle along the River Mersey amongst the dunes of Waterloo and Hightown. I enjoy the sights and sounds of the sea and the beautiful plants and animals that live at the coast as well as exercising and keeping myself fit. I can recommend it!

Anthony Chadwick is founder and CVO of Alpha Vet International

Anthony Chadwick BVSc CertVD MRCVS qualified from Liverpool University in 1990 and received his certificate in Veterinary Dermatology in 1995 from the Royal College of Veterinary Surgeons. Anthony was involved in first opinion practice and dermatology referrals until 2016. In 2010 Anthony set up The Webinar Vet, the first online training platform for veterinarians and nurses, in an attempt to make veterinary education more accessible and affordable across the world.

Since that time tens of thousands of veterinarians and nurses have accessed the platform from all over the world. The Webinar Vets first virtual conference took place in 2013. During the pandemic, The Webinar Vet helped to take over 40 veterinary meetings and conferences online including WVAC2020 and WCVD9.

In 2021, Anthony took the business carbon negative, helping to stand by The Webinar Vets principles of being as sustainable as possible and delivering exceptional quality training, internationally via remote means. The Webinar Vet is an Investor in the Environment Green Accredited business.

The rest is here:
Can Sustainable Initiatives Benefit Your Team's Mental Health As Well As The Environment? - MinuteHack

Introduction

Migraine is a primary headache disorder affecting up to 7 million children and adolescents in the United States.13 Females are disproportionately affected by migraine, and the prevalence of the disease increases over the course of development.4,5 The impact of migraine on quality of life among children and adolescents is comparable to that of other chronic illnesses such as rheumatic disease and cancer,6 and unfortunately, migraine tends to persist into adulthood.7

Chronic migraine is a subtype of migraine that affects approximately 12% of youth,5 and is typically characterized by a gradual progression (ie, chronification) of episodic symptoms over the course of weeks or months.8 Youth with chronic migraine may experience co-occurring medical concerns for which subspecialty care may be required, including abdominal or musculoskeletal pain complaints, clinically significant sleep disturbances, and other neurological conditions such as epilepsy.9 Children and adolescents with chronic migraine often report substantial impairment in school-related functioning,10,11 challenges related to engaging in leisure activities and spending time with friends,12 and difficulties in family relationships.13,14 Thus, the management of chronic migraine in children and adolescents requires a holistic, integrative, and multimodal intervention approach that incorporates both medical and non-pharmacological treatments to address the symptoms and functional impairment associated with this debilitating headache disorder.

The purpose of this narrative review is to provide an overview of current best practices for acute and preventive treatment of chronic migraine in children and adolescents, direct attention to the most recent developments in the field, and emphasize important avenues for clinical research. In this review, we use guidelines set forth by the American Academy of Neurology (AAN) and the American Headache Society as frameworks to highlight treatments that represent the current standard of care for pediatric patients with chronic migraine and identify relevant gaps in intervention research. We then highlight treatment options that are currently receiving rigorous clinical research attention, provide a discussion of novel directions for research focused on improving existing interventions for chronic migraine in pediatric populations, and describe targeted research strategies that may expand access to evidence-based care for these patients and their families.

Accurate diagnosis of chronic migraine requires thorough physical and neurologic examinations and assessment of headache history including pain location(s), headache frequency, severity, and associated symptoms. The diagnosis of migraine and chronic migraine is made in accordance with the International Classification of Headache Disorders, 3rd edition (ICHD-315) criteria. Accurate diagnosis typically requires a recorded history of headaches and symptoms that occur during an attack using a headache diary.

The majority of treatment-seeking patients present with migraine or probable migraine; a diagnosis of probable migraine may be assigned when a patient meets all but one of the ICHD-3 diagnostic criteria for migraine. As Table 1 highlights, migraine is characterized by headaches of moderate-to-severe intensity that are accompanied by nausea, vomiting, photophobia, and/or phonophobia. The primary differentiating feature between youth with migraine and chronic migraine relates to headache frequency, as youth diagnosed with chronic migraine must experience 15 or more days with headache per month for at least 3 months, and the majority of these headaches must have migraine features.15 Some patients experience an aura (ie, a warning signal) with their migraine, which include visual, sensory, motor, and other central nervous system disturbances that precede headache onset.

Table 1 International Classification of Headache Disorders (ICHD-3) Diagnostic Criteria for Migraine without Aura and Chronic Migraine

Some children and adolescents also present with chronic tension-type headache (CTTH), a headache disorder in which the frequency of headache episodes is similar to that of chronic migraine. However, patients with CTTH typically do not experience migraine features such as photophobia, phonophobia, and severe nausea or vomiting, and their headaches are typically not as severe in intensity. In rare cases, youth may present for treatment with new daily persistent headache (NDPH), a primary headache disorder characterized by a rapid onset of unremitting headache. Patients with NDPH may or may not have migraine features with their continuous headache. Patients often recall the date their unremitting headache began due to its abrupt onset, and therefore do not endorse a history of increasing headache frequency. Chronic migraine can also be characterized by daily or continuous headache presentations; however, this presentationas highlighted abovetypically occurs via gradual chronification of headaches over time.

One other type of continuous headache presentation is hemicrania continua. Patients with this headache disorder may experience migraine-like symptoms with their continuous headache, but their pain is isolated to one half of the face and head with ipsilateral autonomic features such as conjunctival injection or with agitation, and the headache is responsive to one particular drug (indomethacin). This is incredibly rare in youth16 but is important to consider in those with unremitting unilateral pain that is refractory to treatment. Similarly, clinicians should consider idiopathic intracranial hypertension as a possible diagnosis for pediatric patients, as these youth most commonly present with intermittent diffuse headache that often occurs with migraine-like symptoms such as nausea and vomiting. However, IIH is most clearly identified by the presence of papilledema, significant visual disturbances (eg, blurred or double vision), tinnitus, and neck stiffness.17

Once a chronic migraine diagnosis has been established, a biopsychosocial approach to care that incorporates both medical treatment and non-medicine intervention strategies is recommended. The gold-standard biopsychosocial intervention plan incorporates acute treatment, preventive treatment, healthy lifestyle habit recommendations, and relaxation and/or cognitive-behavioral interventions. Goals of treatment include reducing headache frequency, reducing disability associated with headaches, and improving the child or adolescents quality of life.18 The following subsections will review each of these treatment components in more detail, and a summary of the reviewed acute and preventive treatment options is presented in Table 2.

Table 2 Summary of Reviewed Acute and Preventive Treatment Options for Chronic Migraine in Children and Adolescents.

One challenge that can complicate a child or adolescents diagnostic picture and treatment planning relates to use of acute medications. Some youth with migraine can experience headache chronification related to overuse of analgesic or headache rescue medications (see Acute Treatments section for more information). Medication-overuse headache (MOH) can be diagnosed if a patient with a pre-existing primary headache disorder (eg, migraine, chronic migraine) uses acute medication on 10 or 15 (depending on the medication) or more headache days per month for more than 3 months. Research suggests that approximately half of youth with chronic migraine overuse acute medications to manage their symptoms.19

According to ICHD-3 criteria, a diagnosis of chronic migraine should still be assigned even if a patient also meets criteria for MOH. This is notable because epidemiologic studies have shown that the estimated prevalence of chronic migraine decreases from approximately 2% to roughly 0.8% when children and adolescents with MOH are excluded.19 Thus, it is imperative to diagnose MOH where appropriate to guide appropriate treatment planning and counseling. For patients with comorbid chronic migraine and MOH, a comprehensive acute medication weaning plan should be established. An emphasis on prevention therapy is also especially important for patients with MOH.20

The purpose of acute migraine treatment is to ameliorate pain and associated symptoms that occur during an attack, minimize side effects, and facilitate a return to typical functioning as quickly as possible.21 Headache specialists work with school systems and caregivers to ensure that children and adolescents are able to access acute treatments in school and at home to treat headaches at onset and minimize the disruptive impact of migraine on daily life. The most recent (2019) guidelines from the AAN emphasize early intervention that is tailored to the specific features of an individuals headache attack.22

The most commonly studied and prescribed acute migraine medications generally fall into three categories: nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, naproxen), analgesics (eg, acetaminophen), and the migraine-specific triptans (eg, sumatriptan). In addition, novel therapies known as gepants and ditans are used in adults and will be discussed later. Current evidence supports use of ibuprofen as an initial treatment for both children and adolescents experiencing an acute migraine attack. Naproxen and diclofenac are commonly used as well, though with less objective evidence for their efficacy. Oral sumatriptan plus naproxen or almotriptan may be also be prescribed for adolescents aged 12 and older. For patients who cannot tolerate oral formulations, sumatriptan and zolmitriptan are United States Food and Drug Administration (FDA) approved in nasal spray formulations for ages 12 and older. Of the seven triptans available, rizatriptan is the only FDA-approved triptan for use in children down to age 6.

Antiemetic treatments should also be offered for youth who commonly experience nausea and vomiting with migraine, as none of the available treatments demonstrate significant efficacy for treatment of these symptoms.22 Dopamine antagonists such as prochlorperazine, chlorpromazine, promethazine and metoclopramide have pain relieving attributes in addition to their antiemetic characteristics23 but patients should be warned about the potential for extrapyramidal side effects such as muscle stiffness, akathisia or agitation which is more common with recurrent use, in younger patients, and among those already taking antidopaminergic agents.24 Finally, ondansetron has not demonstrated pain relief but may be considered for those with prior adverse reaction to antidopaminergic agents or other contraindications to them.25 It is generally safe but may cause QT prolongation and dysrhythmia, especially with recurrent use.26

Because overuse of triptans and analgesics can be associated with MOH27 and migraine chronification,28 clinicians should recommend that all abortive medications be used on no more than three headache days per week21 and triptans be used no more than 2 days per week.29 There are currently no evidence-based recommendations to guide treatment of MOH in children and adolescents. In clinical practice, management of MOH may include abrupt cessation or weaning of acute medications with immediate or later initiation of preventive therapy.30 A 6-week washout period of all acute medications has been shown to result in recovery of specific gene expression changes related to medication overuse.29,31

Given that pill-based therapies can be associated with the development of medication overuse headache and migraine chronification, considerable clinical research effort has been dedicated to the development of nonpharmacologic treatment options for acute migraine management. Neurostimulation (also termed neuromodulation) has gained attention in the adult migraine literature as an alternative approach to migraine management for patients who do not respond to available pill-based treatments. Neuromodulation aims to inhibit pain signaling by delivering electrical impulses to nerves involved in sensory processing and pain perception. A number of non-invasive (eg, single-pulse transcranial magnetic stimulation or vagal nerve stimulation) and invasive (eg, occipital nerve stimulation) techniques have been developed and tested in adults with migraine, and these are generally associated with fewer side effects relative to traditional pharmacologic treatment options (see32 for review). The following two devices are FDA-cleared for use in adolescents with migraine.

A non-invasive vagus nerve stimulation (nVNS) device is FDA approved for acute and preventive therapy of migraine and other headache disorders in adults and adolescents over age 12. The device is held at the neck for two cycles of 12 minutes, which can then be repeated after 20 minutes and again after 2 hours if needed. A small open-label study by Grazzi et al33 showed that nearly half (46.8%) of attacks were effectively treated without need for rescue medication and did not report any device-related adverse events. This pilot study provides the foundation for larger studies of nVNS for acute and preventive migraine therapy in adolescents.

Recently, an open-label study conducted by Hershey et al34 examined the safety, tolerability, and initial efficacy of a remote electrical neuromodulation (REN) device for treatment of acute migraine attacks among adolescents with migraine. This sample included a subset of participants who met criteria for chronic migraine based on their number of monthly headaches with migraine features. In the study, participants used the REN devicewhich was worn on the lateral upper armto deliver electrical stimulation during four migraine attacks over an 8-week period. Results showed that use of the device was not associated with any significant adverse events or participant study withdrawal; 71% of the participants experienced pain relief and 35% achieved pain freedom within 2 hours of symptom onset. Sustained pain relief was demonstrated among 90% of the participants at 24 hours. These preliminary data resulted in FDA clearance for use among adolescents for acute treatment of migraine.

Further studies are underway to assess the utility of the REN device in the Emergency Department setting, and others are being planned as a preventive option. Though preliminary, the promising findings discussed above suggest that the safety and efficacy of REN should be tested in a larger, randomized placebo-controlled trial to determine whether this acute treatment option could be integrated into routine clinical practice, or even in the Emergency Department setting for youth with chronic migraine, particularly those who present with comorbid MOH.

Counseling patients about the roles of lifestyle and behavioral factors that reduce the likelihood of headaches occurring is a primary emphasis of preventive care. Inadequate hydration, skipping meals, poor sleep, and insufficient exercise are factors associated with increased headache risk.35,36 Conversely, engaging in routine aerobic activity, eating regular meals, getting sufficient sleep, and obtaining sufficient daily fluid intake can reduce headache frequency and intensity.3739

Recently, Robblee and Starling40 published practical guidelines for clinicians with detailed information about lifestyle factors that promote migraine prevention. These guidelines recommend that clinicians provide patients with guidelines about obtaining a sufficient number of hours of sleep for their developmental stage (eg, 912 hours for school-age children; 810 hours for teenagers); practicing good sleep hygiene (eg, maintaining a consistent sleep-wake schedule, discontinuing use of electronics 3060 minutes before bedtime; and practicing a consistent bedtime routine that can incorporate relaxation practices); maintaining a healthy and well-balanced diet that includes protein, leafy green vegetables, and fruit; avoiding skipping meals; engaging in regular aerobic exercise; and obtaining adequate daily fluid intake. For teenagers with chronic migraine, between 80 and 100 ounces of fluid per day is recommended.

A variety of medications are currently used for pediatric migraine prevention, and include antidepressants (eg, amitriptyline), antiepileptics (eg, topiramate, gabapentin), and calcium channel blockers (eg, flunarizine).41 One preventive medication that is frequently used as a first-line drug therapy is amitriptyline, which is a tricyclic antidepressant that has shown to be effective in reducing headache frequency and disability in children while minimizing side effects when titrated slowly.42 Topiramate, a drug of the anticonvulsant class, is the only FDA-approved pediatric preventive migraine medication. Although topiramate has been shown to reduce headache frequency in youth,22,43 it is associated with more side effects than amitriptyline.44 Valproic acid, another anticonvulsant, has shown efficacy in youth with migraine, but its teratogenic (class X) and ovarian effects limit its use in females.45

Practice guidelines emphasize a 50% reduction in headache frequency as a benchmark for which the effectiveness of a preventive treatment can be evaluated. That all said, it should be noted that the largest comparative effectiveness trial of preventative medication for youth with migraine to datethe Childhood and Adolescent Migraine Prevention (CHAMP) trialwas discontinued early due to futility after interim results revealed that amitriptyline and topiramate were not superior to placebo in reducing headache days.44 Results from this study showed that up to 70% of youth in both the active drug and placebo groups exhibited a 50% reduction in headache days over the course of the trial. Further, meta-analytic evidence has demonstrated that there are limited data to support use of medication alone as an effective preventive treatment for youth with chronic migraine.46 These findings have led to an increasing call for pediatric headache providers to promote behavioral treatments as frontline preventive interventions.

The best available evidence, as described in current guidelines from the AAN and American Headache Society, supports use of a combined pharmacotherapy (ie, amitriptyline) and behavioral approach (ie, cognitive-behavioral therapy) for migraine prevention in children and adolescents. These recommendations were created after a large randomized controlled trial demonstrated that the combined treatment with cognitive-behavioral therapy (CBT) and amitriptyline was superior to amitriptyline and headache education in reducing youth headache frequency by at least 50% (from a baseline average of 21 headache days per month to approximately 10 after 20 weeks).47 An ancillary analysis from this trial revealed a linear trend and quadratic trend in headache day change, indicating that although decreases in headache days continued throughout the trial, the majority of clinical improvement occurred by the 8-week time point in the CBT+AMI group.48 These data suggest that these youth make relatively rapid treatment gains that can be sustained over time. The evidence base for CBT for pediatric migraine prevention continues to grow; a 2018 Cochrane review of all published clinical trials concluded that CBT is effective in reducing headache days and headache-related disability among youth with migraine.49

CBT is a skills-oriented treatment that provides training in coping techniques and behavioral strategies that can be applied to manage and prevent headaches.50,51 Typically, treatment begins with headache education and an introduction to the gate control theory of pain.52 In the initial stages of treatment, the therapist reviews family guidelines with youth and their caregivers; these guidelines offer practical steps to support the childs pain management and address family factors that may interfere with the patients daily functioning or increase their focus on current symptoms. Patients then receive instruction and practice several relaxation exercises including diaphragmatic breathing, progressive muscle relaxation, and guided imagery. These techniques decrease autonomic arousal and muscle tension that can be associated with pain, and serve as a means of distraction from symptoms. Relaxation training may be used in conjunction with biofeedback technology to allow youth to see for themselves how practicing relaxation skills results in physiological changes such as increased peripheral body temperature and decreased muscle tension.

Psychologists providing CBT also facilitate activity pacing and adherence to healthy lifestyle recommendations through instruction and collaborative problem-solving. This additional layer of intervention may be especially important given that youth with migraine frequently report difficulty with adherence to medical recommendations related to eating and hydration.53 Finally, cognitive reappraisal skills are provided to teach youth how thoughts and feelings are connected to the pain experience, and challenge negative or unrealistic thinking that can contribute to worsening pain and associated symptoms.

Despite the growing evidence base for CBT as an effective intervention for pediatric migraine prevention, it is important to consider that it is not a one-size-fits-all treatment, and may not meet the needs of each patient with chronic migraine. For example, although a majority of youth with migraine do not meet criteria for a co-occurring psychiatric disorder,54 children and adolescents with migraine are more likely than youth without migraine to report elevated internalizing symptoms (eg, anxiety, depression), attentional difficulties, and somatic complaints.55 Furthermore, the presence of co-occurring clinically elevated depressive or anxiety symptoms is associated with greater disability and diminished quality of life in youth with migraine.56,57 Thus, routine screening for co-occurring psychiatric comorbidities and appropriate follow-up should be routinely provided in specialty headache centers. If a clinically significant psychological disorder is detected in this assessment process, it should be considered a treatment priority.

The severity and disabling nature of chronic migraine in youth also presents numerous challenges for which traditional CBT may not promote effective management of symptoms. For example, some children and adolescents with chronic migraine have undergone several trials of preventive medication with varying success, and may therefore have different beliefs about how to best manage pain, what to expect from treatment, and goals for treatment relative to youth with less frequent or disabling headache presentations. The primary aim of CBT for migraine is to improve a patients functioning while reducing the frequency of symptoms. Other interventions may be needed to more specifically target disability and psychological factors that can impact day-to-day functioning in this patient population.

Third-wave psychological interventions, such as Acceptance and Commitment Therapy (ACT) and mindfulness-based approaches, focus primarily on increasing patients psychological flexibility and engagement in activity that they value as opposed to focusing on decreasing their pain or symptoms. Mindfulness, which is a core component of ACT, is derived from Buddhist spiritual traditions and involves bringing attention to the present moment, adopting a nonjudgmental, accepting stance about pain and symptoms, and flexibly adapting to daily fluctuations in pain and symptoms.58 The evidence for ACT in the treatment of pediatric chronic pain is growing.59 Two investigations of mindfulness-based interventions for chronic migraine in children and adolescents, including one recent open-label trial, have shown promising results in reducing migraine-related disability,60,61 mirroring findings from trials of mindfulness-based interventions among adults with migraine.62,63

Clinical research efforts have been devoted to studying alternative treatments that reduce risks associated with traditional pill-based migraine therapies given current practice guidelines. What follows is a discussion of alternative treatment options that have been studied extensively in adults with migraine, and may be recommended for pediatric patients who have not responded to available preventive treatments.

Youth with chronic migraine and their families often request trials of dietary supplements or nutraceuticals as alternative pill-based treatment options. Nutraceuticals, which are compounds derived from foods such as fruits and vegetables, are a form of complementary and integrative medicine (CAM) and are among the most commonly used treatments among pediatric patients with chronic pain conditions, including migraine.64 Despite the popularity and widespread use of nutraceuticals in pediatric pain populations, there are no practice guidelines regarding their use for acute migraine treatment or prevention.

Orr65 published, to our knowledge, the only existing review of nutraceuticals for the treatment of migraine in youth. The review summarized results from 11 observational studies, seven randomized controlled trials, and three systematic reviews. The reviewed nutraceuticals included vitamin D, riboflavin, coenzyme Q10, magnesium, butterbur, and polyunsaturated fatty acids. The review concluded that, given the relative absence of rigorous clinical trials, there is limited evidence for the efficacy of nutraceuticals for migraine prevention and acute treatment in children and adolescents. Coenzyme Q10 has demonstrated initial efficacy for migraine prevention compared to placebo, and oral magnesium may reduce pain intensity when acute headaches are treated with ibuprofen or acetaminophen. However, in the absence of clear, rigorous safety and efficacy data for nutraceutical use, clinicians should discuss with their patients that there is currently no evidence that these treatments are superior to placebo.

Orr65 also informs clinicians about differences in regulatory practices between pharmaceuticals and nutraceuticals, and encourages providers to educate patients about risks associated with nutraceuticals given the frequent assumption that they are safe if available without a prescription.66 For example, butterburwhich has a long history of use in adults with migraine and has been recommended in guidelines from the American and Canadian Headache Societieshas hepatotoxic properties and is generally not recommended for treatment of migraine among children and adolescents.65

OnabotulinumtoxinA (OBTA; ie, BOTOX) was approved in 2010 by the FDA for treatment of chronic migraine in adults. Data examining the efficacy of OBTA for treatment of youth with chronic migraine are limited. OBTA did not gain FDA approval in adolescents after failing to demonstrate greater efficacy compared to placebo.67 A later crossover trial of OBTA for treatment of youth with chronic migraine showed that, compared to a placebo group, youth who received a trial of OBTA injections administered in 3-month intervals and 6-week follow-up visits demonstrated a statistically significant decrease in migraine frequency and intensity, but not duration.68 Multiple retrospective reviews of outcomes for pediatric patients with chronic migraine who received treatment with OBTA after failing oral therapies showed a statistically significant reduction in headache days and disability, and that OBTA was well-tolerated.69,70 Current guidelines from the AAN state that there is currently insufficient evidence to support the use of OBTA for migraine prevention in youth. In practice, OBTA injections may be recommended when a patient with chronic migraine has not responded to two or more preventive therapies.

The calcitonin gene-related peptide (CGRP) is an amino acid peptide found in sensory fibers throughout the body, and particularly in the central nervous system. The CGRP pathway is involved in sensory processing and pain modulation, and has been implicated in the pathophysiology of migraine.71 In adults, antagonism of the CGRP pathway is associated with diminished headache days and medication usage.72 Monoclonal antibodies (mAbs) to CGRP or its receptorwhich require subcutaneous (erenumab, galcanezumab, fremanezumab) or intravenous administration (eptinezumab)have shown safety and efficacy in trials of adults with migraine,7377 some with open-label data for 1 to 5 years.78,79

To date, there are no published placebo-controlled trials of mAbs in children and adolescents with migraine. In 2018, Szperka et al published a set of recommendations for the use of anti-CGRP mAbs in children and adolescents with migraine.80 These guidelines emphasized that consideration of anti-GGRP mAbs should be limited to youth with a frequent migraine presentation and for whom established migraine preventive therapies have not been effective. These therapies should include oral treatments and may also include CBT, neuromodulation devices and nutraceuticals. The authors note that rigorous clinical research effort is needed to establish long-term safety and efficacy data for use of anti-CGRP mAbs in children and adolescents with migraine, and emphasize those youth with more severe migraine presentations (eg, continuous headache) should be included in future trials as these youth have the greatest need for targeted therapeutics.

Greene et al reported a multicenter retrospective study of children and adolescents treated with mAbs for chronic headaches including chronic migraine, persistent post-traumatic headache and NDPH.81 This report of 112 patients with nearly daily or continuous headaches was the first to provide safety and efficacy data in this group. Their data showed that side effects in adolescents are similar to those reported in adult trials and that mAb treatment may benefit youth who are otherwise refractory to other prevention therapies. Notably, severity of pain and functional status improved in more than half of cases. Several randomized controlled trials of mAbs in children and adolescents with episodic and chronic migraine are underway.

Newer targeted therapies known as gepants and ditans have made their way to market after decades of translational research. Gepants act as antagonists to calcitonin gene-related peptide (CGRP) receptors,82 while ditans likely act as agonists of the serotonin 5HT-1F receptors. In contrast to triptans, gepants and ditans do not cause vasoconstriction and are therefore safe for use in patients with history of cardiac or other vascular conditions including stroke.83 Rimegepant, ubrogepant and lasmiditan are currently FDA-approved for acute therapy in adults with migraine and studies are underway in children and adolescents. These drugs may therefore represent third- or fourth-line options for off-label use in youth with attacks refractory to other medications, or with contraindications or adverse reactions to triptans. Although no head-to-head studies have compared gepants and ditans to other pharmacologically active drugs, a meta-analysis showed that gepants and ditans were associated with a lower odds ratio than most triptans for pain relief or freedom at 2 hours.84

Rimegepant also recently gained FDA approval for migraine prevention in adults after showing superiority to placebo at reducing headache days in those with episodic and chronic migraine when dosed every other day.85 Adolescents who experience excellent and sustained (2448 hours) relief from headache with acute rimegepant use may be particularly good candidates for preventive therapy with rimegepant. In addition, atogepant is the only gepant with FDA approval solely for preventive therapy in adults with migraine. Finally, though not exclusively a pill-based therapy, zavegepant is currently being studied for prevention in its oral form and has evidence of efficacy for the acute treatment of migraine in its nasal form.86

Although there have been numerous advances in acute and preventive treatment over several decades, treatment of youth with chronic migraine continues to evolve. As highlighted in this review, available evidence suggests that pediatric patients with chronic migraine do experience a reduction in headache days when they receive multidisciplinary, biopsychosocially oriented intervention,87 and treatment gains made through preventive care are often maintained over time.88 Current practice guidelines for the prevention of migraine in youth emphasize a combined pill-based and nonpharmacological approach. We anticipate that a holistic approach to migraine management will continue to represent the best standard of care moving forward, even as considerable attention is being devoted to establishing an evidence base for the use of novel interventions such as neuromodulation, GGRP monoclonal antibodies, and targeted pill-based therapies for both acute and preventive treatment. In the following sections, we highlight important and novel avenues for advancing evidence-based care through future clinical research.

Despite the range of interventions that have been developed for the treatment of chronic migraine, additional research is needed to tailor available treatments for the clinical presentation and treatment needs of youth with chronic migraine and their families. Much of current clinical guidance has been gleaned from studies in adult patients; however, it has become increasingly apparent that children and adolescents with headache disorders can differ substantially from adults in terms of their responses to pharmacological treatments.

Given this, studies highlighted in this review underscore the importance of taking a developmental approach to research involving novel medical and nonpharmacological intervention approaches for youth with chronic migraine. As the field continues to evolve, prospective longitudinal research will be needed to advance our understanding of the developmental contributors to the progression and course of chronic migraine in children and adolescents. For example, epidemiologic studies have shown that pre-pubertal males have a higher prevalence of migraine relative to females, but there is a dramatic increase in migraine prevalence among females post-puberty.89 Prospective longitudinal studies that examine the roles of age and development (eg, puberty, hormonal changes) in relation to the presentation of migraine, or investigate neural changes associated with migraine progression may enhance our identification of targets for early intervention tailored to the needs of each individual. Further, given the strong link between genetics and migraine, studies identifying the monogenic and polygenic contributors to the pathophysiology of migraine disease are crucial as the field works toward precision medicine as a standard of care.31,90

The effectiveness of CBT for prevention of pediatric migraine also raises important questions about how and why this treatment approach works. Recently, our research group published an overview of psychological interventions for pediatric headache disorders,51 in which we discuss the role of mechanistic studies and their importance for elucidating neural alterations associated with CBT treatment. Research has demonstrated that pre-post CBT alterations in resting state brain activation and functional connectivity occur among youth with migraine who have received this intervention for headache.91 Our group is also conducting an ongoing mechanistic study (funded by the National Center for Complementary and Integrative Health and the National Institute of Neurological Disorders and Stroke) may be able to answer why patients with migraineincluding chronic migrainemake such rapid treatment gains in response to gold-standard preventive care by determining the extent to which components of CBT intervention are associated with particular neural changes among youth with migraine.

Empirical support for the treatment of migraine in youth is largely based on studies that have included patients recruited from specialty headache centers, patients who meet very specific diagnostic criteria, and patients without medical or psychiatric comorbidities. While this level of rigor in clinical trials increases our confidence in the benefit of available interventions, it is possible that the stringent nature of referrals from tertiary care clinics and inclusion criteria has resulted in many youth with chronic migraine being excluded from clinical trials, leaving a gap in our fields ability to conceptualize and understand which treatments work best for which patients. Furthermore, participants in migraine research studies tend to be predominantly White, female, and from upper middleclass backgrounds.92 Improving the representativeness and generalizability of our treatments will require prioritizing the inclusion of patients from underrepresented backgrounds in all aspects of the research process, from recruitment and retention to intervention development and dissemination of findings.

As discussed previously, a subset of treatment-seeking children and adolescents who meet the criteria for chronic migraine present with continuous (ie, unremitting) headache. Unfortunately, these patients are often excluded from research studies as they are considered to be much more complex in terms of their psychosocial profile and refractory to treatment relative to other youth with less frequent headache presentations. As the field moves forward, it will be important to recruit subpopulations of pediatric patients with chronic migraine experience continuous headache to determine their patterns of treatment utilization, preferences for treatment, and whether available treatments are also effective for patients with this headache presentation. Understanding the treatment priorities and goals of patients with more severe and disabling chronic migraine presentations may also lead to the development and testing of tailored interventions. It will be exciting to learn whether ACT and mindfulness-based approaches demonstrate efficacy for treatment of headache days and disability among youth with migraine, and whether principles of these treatments could augment traditional CBT intervention.

Population-based studies have shown that migraine is more prevalent among youth from lower socioeconomic (SES) backgrounds.93 Moreover, there are considerable racial and ethnic disparities in the prevalence of migraine. For example, in the United States, the prevalence of migraine is highest among Native Americans. These disparities reflect inequities in access to care and treatment practices that lead to poorer long-term health outcomes.94

An unfortunate reality stemming from differences in health equity is that many of the newer and investigational treatment options discussed in this paper, such as neurostimulation and anti-CGRP antibodies, are not consistently covered by third-party payors and have extremely high out-of-pocket costs. Access to adequate healthcare in the United States remains poor for many pediatric patients and their families, and this is a substantial barrier to evidence-based migraine treatment that has not improved in recent years. Indeed, a recent review published by Yu et al showed that percentage of children and adolescents experiencing underinsurance rose from 30.6% in 2016 to 34.0% in 2019.95 Even gold-standard preventive treatments, such as cognitive-behavioral therapy, are not consistently covered by insurance providers. The result of inequality in healthcare access is that under-resourced children and adolescentsthe young people who need the best available care the mostare not being seen for care in specialty headache centers. These children and their families understandably rely on the types of care that are available to them, and community clinics or hospitals may not employ neurologists with a specialization in headache medicine or pediatric psychologists who practice behavioral headache medicine.

One tangible approach that begins the process of addressing barriers to patients access to equitable care involves leveraging the potential of innovative study designs to expand the reach of evidence-based interventions. For example, a current study funded by the National Center for Complementary and Integrative Health (NCCIH U01 AT010132) is employing a multiphase optimization strategy (MOST;96) to develop a cognitive-behavioral intervention delivered by nursing staff in outpatient neurology clinics. The goal of this study is to identify which components and doses of CBT are most effective to promote change in key headache outcomes, with treatment being provided by healthcare professionals besides trained psychologists. The data gleaned from this study will inform the development of a large pragmatic or sequential multiple randomization (SMART) trial that will be conducted in neurology clinics and, in the long term, could also be conducted in primary care or pediatric practices. Expanding the availability of evidence-based pediatric behavioral medicine beyond secondary and tertiary care should be considered a priority as our field works to increase the accessibility of care for all patients and their families.

It is also crucial that clinicians and researchers continue to advocate for their patients as the field of pediatric headache medicine works toward a more equitable and inclusive scientific practice. The COVID-19 pandemic has exposed vulnerabilities in the healthcare system and further underscored racial and ethnic disparities in healthcare.97 Yet, the proliferation of telemedicine over the past 2 years perhaps represents an opportunity to rigorously study the efficacy of interventions that can be feasibility delivered remotely in the context of a pragmatic clinical trial. As the field works to expand care beyond specialty clinics, pragmatic trials may represent one clear opportunity to advance clinical practice and facilitate the successful dissemination and implementation of migraine treatment. For example, a trial examining the efficacy of CBT delivered entirely remotelyand casting a wide net to include patients with chronic migraine, including those who may have been historically excluded from trials (eg, youth with continuous headache)could facilitate the eventual integration of CBT into traditional clinical practice, thus increasing its accessibility to patients and families. If researchers can leverage the potential of innovative study designs to improve the availability of evidence-based care in a manner that allows patients to access it earlier, the field of pediatric headache medicine may be better positioned to prevent chronic migraine from progressing further and persisting into young adulthood.

Chronic migraine is a disabling migraine subtype that affects a substantial proportion of children and adolescents and tends to persist into adulthood. Over the past several decades, substantial gains have been made in advancing both acute and preventive treatments for this debilitating headache disorder. We have learned that a biopsychosocial approach to the conceptualization and treatment of migraine is most beneficial to patients, and current research is advancing our understanding about why nonpharmacological treatment strategies for migraine prevention work. As the field moves forward, considerable clinical research effort should focus on expanding access to evidence-based care, testing novel therapeutics, leveraging the potential of innovative study designs such as SMART and pragmatic trials to inform precision medicine and wider dissemination of interventions, recruiting patients for research studies who have traditionally been underrepresented, and tailoring existing nonpharmacological interventions to meet the unique needs of each child and their family. We believe the future of pediatric headache medicine is bright, and feel confident that the coming years will provide new insights into the optimal management of chronic migraine in children and adolescents.

This work was supported by R01 (R01AT010171) and U01 (U01AT010132) grants from the National Center for Complementary and Integrative Health, an R01 grant (R01NS101321) from the National Institute of Neurological Disorders and Stroke, and a training grant from the National Institute of Diabetes and Digestive and Kidney Diseases (T32DK063929).

Dr Robert C Gibler reports grants from National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases T32 Training Grant (T32DK063929), outside the submitted work. Dr Brooke L Reidy reports grants from NIH, during the conduct of the study; Frontiers in Headache Research Scholarship (travel award to attend Conference) in 2018 from American Headache Society, Travel Award to attend conference 2018 from International Society for Developmental Psychobiology, outside the submitted work. Dr. Powers reports funding to the Cincinnati Childrens Hospital Medical Center Research Foundation from the National Institutes of Health. The authors report no other conflicts of interest in this work.

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Management of Chronic Migraine in Children and Adolescents | PHMT - Dove Medical Press

Background

The World Health Organization (WHO) recommends that women who, before pregnancy, habitually engaged in vigorous-intensity aerobic activity or who were physically active, can continue these activities during pregnancy and the postpartum period.1 The last three decades produced an increasing amount of scientific evidence on the positive effects of the prenatal physical activity on the maternal and fetal health, as well as in pregnancy outcomes, as shown by recent systematic reviews.218 Practice guidelines have become an increasingly popular tool for synthesis of clinical information.19 Clinical guidelines are commonly defined as systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances, which objectives are to enhance appropriateness of practice, improve quality of care, lead to better patient outcomes, improve cost effectiveness, help authorities to decide on the approval of drugs and devices, and identify areas of research needed.20 A profusion of guidelines has been issued over the past 6 years by different national and international obstetrics, gynecology, or sports medicine organizations, which are a trustworthy and comprehensive source of information in terms of safety and health benefits of exercise during pregnancy. Several official guidelines on physical activity during pregnancy have been updated recently.1,2129 Most of these guidelines were reviewed by other authors30 and in our textbook.31 Moreover, other organizations published these guidelines in a more accessible language to reach pregnant women.3235 Yet, the physical inactivity epidemic is considered the biggest public health problem of the 21st century.36,37

Challenges for practicing physical activity during pregnancy are numerous and include lack of knowledge about existing recommendations, unawareness of how to engage in physical activity, lack of social support, and unavailability of physical activity offers.38 Despite the above stated scientific evidence, health professionals often lack either knowledge of existing recommendations and pregnancy-related benefits or resources to adequately address the topic.39,40 Among health professionals, midwifes are ideally placed to promote physical activity during pregnancy consultations as part of a wider network of practitioners.40,41 After the assessment of potential contraindications for exercising, health-care providers should provide counseling on an active lifestyle and refer pregnant women to a qualified exercise professional (ie, exercise physiologist or prenatal exercise specialist), with a background and experience in pregnancy and/or postpartum physical activity and/or exercise.42 Interprofessional settings (including health-care providers and exercise experts) can help to reach fitness goals, tailor exercises according to abilities and - most importantly - minimize the risk of injury. Therefore, interprofessional collaboration is essential.43

When exercising during pregnancy, women need to feel safe and professionally guided to ensure proper technique, confidence, and appropriate progression of intensity and complexity.44 The exercise professional should provide proper exercise prescription and selection, along with regular feedback, positive reinforcement, and behavioral strategies to enhance adherence.45,46

The American College of Sports Medicine (ACSM)32,33 recommends that physical activity programs should be individualized for each woman based on situation, experience, and current health status. Exercise professionals can notably support aerobic training, strength training, flexibility, balance, pelvic floor muscle training, during pregnancy and postpartum.32,33,45,46 The National Health Services (NHS) guidelines34 advise pregnant women to make sure that exercise professionals are properly qualified and informed about their pregnancy status. The Sports Medicine Australia (SMA) guidelines21 advise pregnant women to ask for a medical doctors recommendation to consult exercise specialists in view of an individually prescribed exercise program including appropriate types of activities and ways to progress at a safe and steady pace. The Canadian guidelines24 and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) guidelines26 highlight fitness professionals and exercise physiologists as target users of their evidence-based guidelines in view of maternal, fetal, and neonatal health outcomes of prenatal physical activity. The Physical Activity Guidelines for Americans23 state that physical activity specialists can encourage to attain and maintain regular physical activity by providing advice on adapted activities and ways to progress at a safe and steady pace, even for individuals with chronic conditions. These statements included in the official position documents highlight the increasing importance of the exercise professional in promoting and implementing adapted effective and safe exercise programs.

In 2016, EuropeActive published the role and standards of the Pregnancy and Postnatal Exercise Specialist, based on the European Qualification Framework.47 According to this professional educational standard, the role of the prenatal exercise specialist is to encourage exercise participation for beginners and already active women at all stages of pregnancy and during the postpartum period47 including the assessment of overall physical fitness, the development of adapted exercise programs, providing feedback on progress, adherence, and outcomes to relevant stakeholders.

The lack of information among women on the exercises during pregnancy, and lack of social support are two of the reasons hindering engagement in a prenatal exercise program.38 However, pregnancy may provide a teachable moment for positive health behaviour change,48 and a positive relationship was observed between the mothers knowledge about physical activity during pregnancy and their daily physical activity.49 Thus, promoting the guidelines and educational materials providing information about physical activity during pregnancy is expected to help pregnant women to engage in proper exercise programs.48,50

To sum up, the knowledge of health benefits is expected to lead to more favorable attitudes towards exercise during pregnancy, among pregnant women, exercise professionals and health-care providers.

With this background, a one-day workshop on promotion of physical activity in pregnancy for exercise professionals was planned and facilitated by an Associate Professor, coordinator of the masters in sciences program in Physical Activity and Health, of the Sport Sciences School of Rio Maior (ESDRM), Polytechnic Institute of Santarm, Portugal. The workshop was delivered at the ESDRM and in partnership with other higher schools of the Polytechnic Institutes of Beja and Leiria, Portugal, during 2021, to five groups of exercise professionals.

The main aim of this workshop was to motivate and prepare exercise professionals for promoting physical activity and implementing prenatal exercise programs, in their respective professional fitness center, or in remote settings, in personal training, or group exercise sessions.

The contents of the workshop were focused on six topics: 1) Role and professional development of the Pregnancy Exercise Specialist; 2) General physical and physiological adaptations during pregnancy; 3) Evidence-based benefits of physical activity during pregnancy; 4) Current guidelines for exercise during pregnancy; 5) Pre-exercise assessment and fitness testing; and 6) Exercise prescription and exercise adaptations, based on the Pregnancy and Postpartum Exercise Specialist educational standards by EuropeActive47 and on the Exercise and Physical Activity during Pregnancy and Postpartum textbook published by Springer.51,52

The following sections will mainly be structured as the report of the workshop event.

Exercise professionals attending advanced higher education programs were invited to participate in the workshop, free of charge. Participants were informed about the objectives and nature of the study, the potential benefits for future programs, that they were free to provide feedback or not, without any consequences, and that the feedback was anonymous. All participants (N = 137) were informed and agreed with the participation in the online questionnaires. Informed consent was checked upon responding to an online questionnaire. All educational materials produced by the research team were made available to the participants, free of charge. The study was conducted in accordance with the Helsinki Declaration. This study is part of the study protocol that was approved by the Ethics Committee of the Polytechnic Institute of Santarm, Portugal (approval number 9-2021-ESDRM).

The objectives of the workshop were:

The workshop was delivered in three Portuguese cities (Rio Maior, Beja and Leiria), at the facilities of the higher schools of sports and education of the respective public polytechnic institutes, and online, during 2021, to five groups of exercise professionals. Three workshops were delivered presently, and two workshops were delivered online by means of the zoom platform. The interactive teaching-learning methods were utilized in all sessions of the workshop.

The workshop was facilitated by an Associate Professor, which is the first author of this article, and it was conducted in the Portuguese language. The facilitator academic background includes a BSc in sport sciences, a MSc in exercise and health, a PhD in health and fitness, as well as professional background as exercise physiologist and fitness instructor. Each event was inaugurated by the program coordinator of each of the higher schools where it was delivered.

Between 23 and 42 persons (61% female) participated in each workshop, totaling 137 attendees including graduated exercise professionals, third year exercise science students, and master students, with 1 to 10 years of professional experience in conducting exercise classes and personal training. Only 30% of the attendees had professional experience in conducting classes for pregnant women. The academic background of all participants was a bachelors degree in exercise and sport sciences. The ages of the attendees varied from 21 to 55 years.

The contents of the workshop were inspired by the EuropeActives official document educational standard for the prenatal exercise specialist47 that the three authors of this article produced in 2016, and on the chapters developed in the textbook Exercise and Physical Activity during Pregnancy and Postpartum textbook published by Springer in 2019,51 and the second edition in 2022.52

The contents of the workshop were focused on the following six topics, delivered in 3h plus 3 hours (about one hour for each topic). The key points of each content are described as follows:

Participants were motivated for promoting physical activity, by understanding their role and the barriers and facilitators for exercising during pregnancy. Main points were: The medical and social need for Pregnancy Exercise Specialists (regarding the national laws, in this case, the Portuguese Law nr. 39/2012 of 28-08-2012); The place of the Pregnancy Exercise Specialists in the healthcare system and the cooperation of a multidisciplinary task force of health-care professionals (Obstetrician/Gynecologist, Midwife, Nutritionist, Exercise Physiologist, Exercise Psychologist, Physiotherapist); Specific evidence-based sources related to the benefits of exercise for pregnant women; National legislation, policies and guidance relating to the provision of exercise services to pregnant women; Ethical issues regarding working with pregnant women. Main references for this content: educational standard for the prenatal exercise specialist,47 chapter,43 and national Law nr. 39/2012 of 28-08-2012.

The main points were to describe the pregnancy-related symptoms and the body adaptations to pregnancy and to physical exercise, which require supervision of technique, adaptations of exercises, and safety considerations: The risk factors and prevalence of discomforts and health conditions associated with pregnancy and postpartum (eg, gestational diabetes, overweight, obesity, edema, low back pain, hypertension, pre-eclampsia, musculoskeletal disorders, diastasis recti abdominis, stress urinary and fecal incontinence and other pelvic-floor disorders, stress and anxiety, oral health, sleep disorders, headache, digestive disorders, etc.); Interactive effects of morphological, physiological and hormonal adaptations to pregnancy phases, and to exercise (eg, adaptation of cardiovascular and thermoregulation systems, metabolic changes); Musculoskeletal changes and biomechanical adaptations of posture and gait in pregnancy; Psychosocial adaptations to pregnancy and the main barriers to participation in exercise. Main references for this content: chapters.38,5356

The main points were to search the recent systematic reviews that support the positive impact of physical activity in the maternal health and fitness parameters, and how to utilize research outcomes when promoting physical activity and planning exercise programs. Participants were updated on the importance and evidence-based knowledge underlying physical activity during pregnancy, and were motivated for multidisciplinary research: The improved sense of well-being and enhanced quality of life as an effect of regular exercise during pregnancy; The acute and long-term effects of exercise in pregnant women and babies, related to all fitness and well-being parameters (eg, cardiovascular, muscular strength and endurance, flexibility, neuromotor, posture, body composition, mental health); The effect of exercise on increased energy expenditure (eg, excess post-exercise oxygen consumption, increased fat loss, preservation of lean body mass, increased metabolic rate, prevention of overweight and obesity in mother and child); The association of exercise with fertility, fetal development, birth outcomes and infant health; The preventative role of exercise in relation to any potential future cardiac health risk related to chronic disease; The preventative role of exercise in relation to gestational diabetes and diabetes mellitus type 2 (eg, lower blood glucose concentration during and after exercise, improved insulin sensitivity and decreased insulin requirement, lower glycated hemoglobin levels); The preventative role of exercise in relation to dyslipidemia (eg, decreased triglycerides, slightly decreased low-density lipoprotein, increased high-density lipoprotein); The preventative role of exercise in relation to hypertension and pre-eclampsia (eg, improvement in mild to moderate blood pressure); The preventative role of exercise in relation to the most prevalent musculoskeletal disorders (eg, low or upper back pain, pelvic floor disorders, osteoporosis and poor posture); The potentially preventative role of exercise in relation to other specific conditions of pregnancy and postpartum (eg, macrosomia, diastasis recti, pelvic girdle pain, postpartum weight retention, coronary heart disease prevention postpartum, etc.). Main references for this content: systematic review studies.218

The main points were to address and discuss the official position documents of the leading international organizations regarding physical activity and exercise during pregnancy and postpartum, published since 2018 (eg, WHO, US Department of Health and Human Services, UK Department of Health and Social Care, ACOG - American College of Obstetricians and Gynecologists, RANZCOG, CSEP - Canadian Society for Exercise Physiology, ACSM, etc.): Main guidelines for exercise during pregnancy included in the official statements and evidence-based guidelines for exercising during pregnancy and postpartum; Absolute and relative contraindications for exercising during pregnancy and postpartum; Reasons to stop exercising in pregnant and postpartum women; Sports and physical activities to avoid for pregnant and postpartum women; Safety and emergency procedures during a training session for pregnant and postpartum participants. Main references for this content: guidelines1,2129,3235 and chapter.31

The main points were to prepare participants for planning prenatal exercise programs by starting with basic assessment tools based on questionnaires of perception of health and readiness for exercising, weekly volume of physical activity, and perception of fitness and quality of life. Basic aspects and importance of fitness testing with pregnant women were addressed: Interviewing of pregnant and postpartum women and building rapport, taking into consideration the medical clearance for exercise; Preliminary screening tools, such as: the PAR-Q+ questionnaire; the new Get Active Questionnaire for Pregnancy (previously the PARMED-X for pregnancy questionnaire), to assess safety or possible contraindications to exercise; Physical activity and lifestyle assessment (eg, pedometers, accelerometers, and/or questionnaires such as the 7-day PAR - 7-day Physical Activity Recall interview and the PPAQ - Pregnancy Physical Activity Questionnaire); Safety considerations in exercise testing for pregnant women; Assessment of the pregnant womens body composition (eg, body circumferences, body fat distribution markers and other body indexes), heart rate and blood pressure, during rest and exercise; Cardiorespiratory tests (eg, Astrand, Rockport, 6 minutes walking test, Balke and Bruce tests using a treadmill or cycle ergometer); Static and dynamic tests to assess posture, functionality and overall autonomy in pregnant women. Main references for this content: chapter45 and ACSM textbook.57

The main points were to prepare participants for implementing prenatal exercise programs by following the steps of an exercise prescription plan and workout features which requires adaptations to each trimester of pregnancy. Motivational techniques for starting exercise or keeping adherence to exercise (eg, diary of behavior, active listening and communication, motivational interviewing, giving feedback on fitness tests, available educational resources, etc.); Motivational techniques to be used during exercise sessions (cuing, voice modulation, stressing the goals of exercises, feedback on exercise performance); Prescription of an exercise program (type of exercise, intensity of exercise, duration of the sessions, weekly frequency of sessions) relevant to pregnant women, their goals, medical history and exercise environment; Selection of exercises and their techniques with regard to womens well-being, functional readiness and the course of pregnancy, in particular the appearance of pregnancy discomforts (eg, back pain, stress urinary incontinence); The structure of the exercise session; The most recommended forms of exercise (eg, walking, low-impact aerobics/step exercise, water exercise, swimming, indoor cycling, strength training, pelvic-floor training, stretching); Adaptation of the so-called risky sports (eg, skiing, skating, cycling, running, etc.); Exercise equipment (eg, fitballs, step, barbells, bands); Monitoring, control and evaluation of all parameters of the exercise program (type, intensity, frequency and duration), and their adaptation to womens condition and stage of pregnancy; Portable equipment controlling the parameters of the exercise session (eg, heart rate monitor); Reports on the outcomes of an exercise program (including charts, notes and diagrams) to enhance their readability to the client and other health professionals. Main references for this content: chapters45,46 and ACSM textbook.57

Several educational materials were pointed and/or delivered, as follows:

The feedback of the participants was taken on semi-structured feedback format in order to evaluate effectiveness of the workshop, the satisfaction with the contents, as well as the venue of the event. Thus, an anonymous feedback questionnaire was provided to each participant in google forms, immediately after of the completion of the workshop. The overall response rates from the total number of attendees (in place groups = 74, online groups = 63, total attendees = 137) was 94.1% (in place groups = 67, online groups = 62, total respondents n = 129).

The questions and the descriptive analysis of the feedback answers were rated by means of a Likert scale 15 (5 = excellent, 4 = very good, 3 = good, 2 = poor, 1 = very poor), as shown in Table 1.

Table 1 Opinions of the Participants on the Quality and Effectiveness of the Workshop

Thus, most of the attendees responded that the objectives of the workshop were obtained, the contents are useful for professional practice, the venue (either school or online) is adequate, the experience of the speaker, the time management and the educational resources are excellent. The best features of the workshop were the contents, speaker, time management and educational resources. Overall, the attendees were enthusiastic about the quality of the workshop, either in person or online, and the topics addressed.

The dissatisfaction about the workshop was obtained by means of an open-ended question format. The categories included in dissatisfaction about the workshop provided by the attendees were: the short length of the workshop (17.1%), lack of practical sessions (14.7%), fewer interactions/group discussions during the workshops (14%), lack of specific fitness tests and health questionnaires for pregnancy (7%).

The various recommendations were obtained for improving future workshops, but only 27 attendees provided feedback. The aim of obtaining the recommendations was to understand the participants opinion about future workshops, particularly regarding the organization, the content and objectives of workshop and educational resources (ie, books and YouTube channel).

The answers to the open-ended question format were reported as follows:

The main recommendations and demands were the organization of more short duration workshops with round table discussion, the inclusion of practical sessions, and the separation of the contents addressing the postpartum period.

The present workshop on promotion of physical activity in pregnancy for exercise professionals was delivered to 137 exercise professionals with similar academic background (ie, graduated exercise professionals with bachelors degree in exercise sciences, third year exercise sciences students, and master in exercise sciences students) in the context of a higher education institution. The main aim of this workshop was to motivate and prepare exercise professionals for promoting physical activity and implementing prenatal exercise programs, in their respective private or public fitness centers or in other physical activity settings.

The contents of the workshop were focused on six topics based on the Pregnancy and postpartum exercise specialist educational standards by EuropeActive47 and the Exercise and Physical Activity during Pregnancy and Postpartum textbook published by Springer.51,52

The most important finding of this work is that the participants rated the content of the training and the achievement of the educational goals very highly. Therefore, the authors believe the knowledge gained could be beneficial for the participants in the future, regarding the promotion of evidence-based knowledge underlying physical activity during pregnancy, the preparation for implementing prenatal exercise programs, and the motivation for applied multidisciplinary research. However, future studies should include knowledge and skill testing, before and after the training, in order to understand how it can improve knowledge and impact practice.

Conducting such workshops is particularly important because exercise professionals play a key role in maintaining an appropriate level and quality of physical activity during pregnancy. In nine guidelines recently published by credible obstetrics, gynecology, or sports medicine institutions, experts recommend pregnant women consult with a physical activity or exercise specialist, or exercise physiologist.1,2126 This means that this professional group must be well educated and ready to cooperate both with women in the perinatal period and with obstetric care providers.42 Unfortunately, in our survey conducted a few years ago we have shown,64 that although the future exercise professionals are generally aware of the positive impact of prenatal physical activity, they lack detailed knowledge, allowing the implementation of exercise sessions with pregnant clients.

The regular organization of training workshops in this topic is also justified by the fact that in recent years there has been a dynamic increase in scientific evidence about the effectiveness of physical activity during pregnancy and after childbirth. As a result, trends in pre- and postnatal classes are also changing. One example of such a shift is high-intensity interval training (HIIT), which is gaining popularity in a wide variety of populations, including pregnant women.65 As shown by Nagpal et al,66 publicly available sources of information on how to implement HIIT in pregnancy are inconsistent and not evidence-based, which can lead to uncertainty in women and discourage them from continuing their favorite form of exercise. Another example of a significant change in the approach to exercise during pregnancy in some countries is the emphasis on the responsibility of the pregnant woman for her own health and that of the child.67 In Canada, women are encouraged to self-assess their health, pregnancy, and readiness to exercise, eg, based on the Get Active Questionnaire for Pregnancy (GAQ-P).68 Thanks to this, they do not need a doctors approval to participate in the prenatal classes. Short workshops on the new trends and tools allow exercise professionals to quickly update their knowledge and skills. The overall workshop evaluations also showed that most of the participants were satisfied with the venue and the speaker with a major recommendation as to the organization of more short duration workshops and the inclusion of practical sessions. However, few complained about the length of the workshop (ie, two sessions of 3 hours, totaling 6 hours), demanding for more workshops in near future with more group discussion and longer duration. These different opinions of participants indicate the need to properly balance the length of training and the volume of educational content. In 2021, our response to this need was the start of the work on updating the EuropeActives Pregnancy and Postpartum Exercise Specialist Standards.69,70 After careful analysis and based on a global external consultation process, in the new document we have left only those professional competences that are most needed on the labor market to work effectively and safely with pregnant and postpartum woman. This makes the knowledge and skills related to planning and conducting exercise programs for pregnant and postpartum women much more accessible to exercise professionals in less time. Although the training based on these standards should be shorter, we paid a lot of attention to practical competences.

Despite the fact that most participants were graduate exercise professionals, they demanded the organization of more workshops, either in-person or online, including practical sessions, for instances, in two days or 4 slots of 3 hours, balancing theory and practical approaches. Moreover, there is the need to upskill exercise professionals, to work as part of a wider network of professionals (eg, doctors, midwives, physiotherapists, etc.), delivering the same messages, in order to maximize the benefits to pregnant and postpartum women.71,72 These opinions were inspiration to develop an international online workshop The NEPPE The New Era of Pre- and Postnatal Exercise project, supported by the Polish National Academic Exchange Agency (NAWA).73

One-third of the participants recommended the separation of the contents addressing the exercise prescription and adaptations during the pregnancy and postpartum periods. Moreover, participants are aware that, from the perspective of exercise planning and intervention, pregnant and postpartum women are two different populations, which require different skills and expertise from exercise professionals. These opinions were inspiration to develop two separate educational modules in the new EuropeActives standards: Exercise in Pregnancy and Exercise in Postpartum. Based on our experience and observation from this workshop, the training providers should plan a separate time for the educational process aimed at achieving learning outcomes defined for these two modules. These opinions were also an inspiration to develop a new chapter on exercise prescription and selection during the early postpartum period.74

Almost 15% of the participants underlined the importance of the accreditation of this workshop as a lifelong learning (LLL) training. The issue of the recognition of LLL activities undertaken by the exercise professionals has been raised recently by EuropeActive experts.75 From the learners perspective it will contribute to professional competitiveness. Moreover, such a system will address skills shortages in the labor market and support the overall professionalization of the sector. It is also in accordance with the Council Recommendation on the European Qualifications Framework for lifelong learning.76 However, in order to enable the recognition of LLL and the accreditation of training workshops, it is necessary to develop appropriate education quality standards. One of the solutions to make the workshops accreditation process more transparent and the educational and vocational programs more comparable, is the use of educational credits. Therefore, in the updated version of the Pregnancy and Postpartum Exercise educational standards we decided to use European credit system for vocational education and training (ECVET)77 and the European Credit Transfer and Accumulation System (ECTS).78 We assume it will also facilitate the transferability of the educational modules or individual learning units between vocational education and training (VET) and higher education (HE) systems.79

In conclusion, the workshop on promotion of physical activity in pregnancy for exercise professionals was successfully organized, either in person or online, and the participants are looking forward to future workshops. Most of the workshop attendees were convinced that the participation improved their level of knowledge. Moreover, the feedback gathered during the workshop significantly contributed to updating the European educational standards for Pregnancy and Postpartum Exercise Specialists and the commencement of work on the lifelong learning offer for exercise professionals. Therefore, the updating and improvement of knowledge about the importance of physical activity in pregnancy may be translated into a more effective cooperation between exercise professionals and pregnant women in terms of planning and implementing exercise programs.

A one-day workshop on promotion of physical activity in pregnancy for exercise professionals was delivered during 2021. The main aim was to motivate and prepare exercise professionals for promoting physical activity and implementing prenatal exercise programs. The contents of the workshop were focused on six topics based on the Pregnancy and Postpartum Exercise Specialist educational standards by EuropeActive and the Exercise and Physical Activity during Pregnancy and Postpartum textbook published by Springer. The workshop was successfully organized, and the participants are looking forward for future ones.

IPDJ Instituto Portugus do Desporto e da Juventude (Portuguese Institute of Sport and Youth) for the support in the production of the educational materials. EuropeActive for the support in the production of the educational standards.

The APC of this article was funded by CCISP (Portugal) HES-SO (Switzerland) collaborative research: ACTIVE PREGNANCY - PROMOTING PHYSICAL EXERCISE AND A HEALTHY LIFESTYLE DURING PREGNANCY AND POSTPARTUM. IPSANTARM - Polytechnic Institute of Santarm, Portugal: ESDRM Sport Sciences School of Rio Maior; ESSS Health School of Santarm; ESAS Agrarian School of Santarm, and University of Applied Sciences and Arts Western Switzerland (HES-SO) - School of Health Sciences, Lausanne (HESAV).

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

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Workshop on promotion of physical activity in pregnancy | JMDH - Dove Medical Press

Men make up a little less than half of the population but are overrepresented when it comes to health issues. While this is a consequence of environmental factors such as work stress or lifestyle factors such as diet and alcohol consumption, theres an additional stigma that men are often busy and dont always prioritise their own health.

The highly skilled and experienced medical team at The Emeline want to transform the notion of a doctors visit being an unpleasant experience that men dread, into a positive and pleasant experience that they almost look forward to.

A new medical practice in Malvern, The Emeline not only focuses on diverse and high-quality medical care for patients, but also the power of preventative and individually tailored medical care in ensuring ones happy and healthy future.

Dr Ion Pop, a specialist general practitioner at The Emeline, has observed changes in mens attitude towards healthcare following the COVID-19 pandemic, thanks to the opportunities for reflection throughout Melbournes lockdowns.

We have actually seen a stronger focus on men being proactive when it comes to implementing positive changes in their lives in line with their goals, Dr Pop said.

Whether its losing weight, improving body strength, exercising more, eating better, drinking less alcohol or smoking less, many men have been more motivated to look after their bodies so that they can continue to do all of the things that they value, he said.

Mens health services at The Emeline are delivered by a caring and professional team who weaves evidence-based medicine with their clinical experience and patient priorities to make health decisions and implement management plans.

Among other services, gastroenterologists Dr Michael Braude and Dr Ashley Bloom consult on site to support male gut and liver health; dietitian Mr Jordan Psomopoulos has over 20 years of experience; a range of amazing psychologists in partnership with Catalyst Psychology are on offer; and Dr Pop has previously worked at a large industrial facility managing a range of occupational health concerns including asthma, COPD, musculoskeletal injuries, hearing loss, mental health concerns and WorkCover.

For specialist general practitioner Dr Daniel Lichtblau, former cricketer Shane Warnes recent passing highlighted not just the importance of heart health, but also encouraging men to feel confident in taking charge of their health.

Our bodies are in many ways like very complicated machines, and much like with our cars, if you dont service it as often as recommended it might keep working but then you could end up with a more serious problem down the track, Dr Lichtblau believes.

Simply monitoring ones health regularly and maintaining a good relationship with a doctor who knows you well can take the friction out of the process, helps to prevent medical issues from materialising and increase the chances of detecting medical conditions sooner and initiating treatment earlier.

For more information, visit emeline.com.au

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Men at The Emeline: how preventative medical care can help keep you on track - Australian Jewish News

According to a UChicago Medicine article from earlier this month by Devon McPhee, if primary care physicians followed national recommendation guidelines for preventative care, chronic disease care, and acute care, it would take them 26.7 hours per day to see an average number of patients, according to a new study. The study is entitled Revisiting the Time Needed to Provide Adult Primary Care, and is published in the Journal of General Internal Medicine.

The article says that The research, conducted by the University of Chicago, Johns Hopkins University, and Imperial College London, used a simulation study to compute time per patient based on data from the National Health and Nutrition Examination Survey.

The breakdown of the 26.7 hours, according to the article, is 14.1 hours/day for preventive care, 7.2 hours/day for chronic disease care, 2.2 hours/day for acute care, and 3.2 hours/day for documentation and inbox management.

Justin Porter, M.D., assistant professor of medicine at the University of Chicago and lead author of the paper was quoted in the article saying that There is this sort of disconnect between the care weve been trained to give and the constraints of a clinic workday. We have an ever-increasing set of guidelines, but clinic slots have not increased proportionately.

Further, The study also looked at physician time as part of a team, where nurses, physician assistants, counselors and others help to deliver recommended care.

It found that team-based care reduced the time a physician needed to deliver care to 9.3 hours/day, broken into 2.0 hours/day for preventive care, 3.6 hours/day for chronic disease care, 1.1 hours/day for acute care, and 2.6 hours/day for documentation and inbox management.

The article adds that a 2003 study from Duke University estimated it would take a primary care physician 7.4 hours a day to provide preventative care for an average-sized patient population. In a 2005 study from Mount Sinai, the estimated time per day was 8.6 hours.

The new study went one step further by including all types of care a primary care physician providespreventive, acute, and chronicas well as administrative tasks, and accounted for changes to the guidelines that have occurred since the earlier studies were published, the article adds. It also used a different methodology, employing real patient data from an annual national survey to calculate its results. The earlier studies used hypothetical patient populations based on the U.S. population.

Moreover, The researchers used the Comprehensive Primary Care Plus (CPC+) model to develop the estimates for team-based care. The model allows physicians to focus on advanced care and brings in specialized medical professionals to take over other areas. Dietitians, for instance, would handle nutritional counseling for patients with diabetes or obesity, a time-intensive task. Overall, the researchers determined that 65% of primary care services could be handled by other team members.

The article concludes by explaining that time constraints are a major factor in physician burnout and a main reason that medical students are leaving the field.

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Study: PCPs Need 26.7 Hours Per Day to Provide Recommended Care - Healthcare Innovation

Midlife is a time of enormous change in a womans life, both good and bad. Its a time for reaching professional peaks, gaining confidence, and discovering new passions. But midlife also brings about many less-than-savory hormonal shifts, which can lead to changes in our skin, hair, and weight.

Changes to the skin and hair can be frustrating, but theyre not particularly dangerous. Weight gain, however, does pose a notable risk to a womans overall health. Obesity can increase the risk of disorders and diseases including hypertension and type 2 diabetes. It can also lead to heart disease, stroke, and all-cause mortality. Obesity has even been linked to ovarian, breast, and endometrium cancers.

A recent study published in the Annals of Internal Medicine by the Cedars-Sinai Medical Center sought to formulate new guidelines with the aim of preventing obesity in midlife. According to Kimberly D. Gregory, MD, MPH, the corresponding author of the clinical guidelines, more than two-thirds of middle-aged women are overweight or obese. Given womens increased risk for weight gain in midlife, there is a critical need for intervention aimed at preventing obesity and the host of serious health outcomes associated with it.

While the research suggests its time we start shifting the national weight guidelines, how the study reached its conclusion is somewhat controversial.

The Womens Preventive Services Initiative (WPSI) created the new obesity guidelines, which strongly encourage healthcare providers to begin addressing the issue of weight with their patients early. The WPSI guidelines suggest discussing these risks with all middle-aged women, even those who might be at a healthy weight.

This preventative treatment would involve behavioral counseling for women aged 40 to 60, which includes speaking to women about healthy eating and physical activity. These interventions, and the study itself, refer to the traditional BMI, or body mass index (more on that later).

The study included seven randomized clinical trials with over 50,000 patients aged 40 to 60. Participants went through various behavioral and counseling interventions. According to the study, trials indicated favorable weight changed with interventions that were statistically different from the control groups.

Interventions varied in intensity, frequency, and approach and, in turn, had varying degrees of effectiveness. The WPSI recognized that research studies might not answer all of the clinical questions regarding the efficacy of prevention rather than treatment. Nevertheless, this shift in perspective could be extremely positive.

RELATED: The 5 Key Health Appointments To Start Scheduling In Your 40s

Western medicine has often approached healthcare from a treatment standpoint instead of prevention. These reactive measures have made great strides in the biomedical world, including the eradication of smallpox. But after the Affordable Care Act passed in 2010, the medical world shifted toward preventative health care.

Still, its difficult to provide preventative health care when youre unsure of what, exactly, youre preventingor why. Popular health care often overlooks midlife women. Many doctors arent trained to understand perimenopause and menopause and other health issues that arise in this phase of life. If they dont fully understand females changing hormones, then how can they counter, let alone prevent, its adverse side effects?

RELATED: The Brain Drain In Real: How Women Over 40 Can Fight Brain Fog Caused By Perimenopause

This creates a cycle of frustration: a woman assumes her doctor wont understand her needs and so doesnt bother to share them. The doctor, none the wiser, continues to not treat her menopausal symptoms, either out of ignorance or lack of experience.

A shift toward preventative care could flip this narrative. Preventive care promotes research and proactive thinking instead of problem-solving and troubleshooting. According to the Mayo Clinic, there can be many contributing factors to midlife weight gain, both lifestyle and genetic. A preventative approach to treatment seeks to mitigate these causal factors before they do significant damage.

In theory, the study sounds positive. However, many critics hesitate to use BMI to measure health. Not only was BMI originally used to describe entire populations, not individuals, but its based on a white European man as the average, which is decidedly unhelpful for American women of all races and ethnicities.

Consequently, the inaccuracies of BMI can put people at risk of being over or underdiagnosed for certain conditions. Today, traditional BMI classifies anything between 18.5 and 25 as a healthy weight. The index considers 25-30 as overweight and over 30 as obese.

But depending on your genetics and ethnicity, BMI will not always capture an accurate picture of your health. This can lead to distortion of health assessments and increases the risk of developing a negative body image. Moreover, BMI-specific treatment could produce little to no significant results.

Therefore, its critical to find an OBGYN or PCP who takes your personal history into account. Preventative treatment for obesity can certainly be beneficial to all body types and sizes, not just those who are currently overweight, but until western healthcare starts acknowledging each patients unique background, we still have a long way to go.

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New Guidelines Target Preventing Obesity In Midlife Women, But The Conclusion Is Somewhat Controversial - Suggest

College students are heading back to campus for the first time since the monkeypox outbreak gained traction in the United States, and many health experts say their schools need to develop plans for handling potential cases.

Several schools, including West Chester and Bucknell universities in Pennsylvania, experienced cases earlier this summer. More monkeypox infectionsare a possibility given that college students commonly engage in many activities that involve skin-to-skin contact, including sex, dancing and contact sports, experts say.

Schools need to prepare strategies similar to those they implemented in response to COVID-19, experts say. That includes testing, contact tracing and clear communication on preventive measures and how students should respond if they become symptomatic.

Dr. Brett C. Gilbert, chief of the Division of Infectious Diseases and Preventative Medicine at Main Line Health, said it's possible that monkeypox could spread on college campuses this fall.

"The prevalence and severity are unknown at this time," he cautioned. "There should be appropriate infection control policies put in place at college infirmaries."

Dr. Martin Topiel, chief of infectious disease prevention at Virtua Health, said he doesn't think monkeypox will be a major problem on college campuses, but he said people who are sexually active need to take precautions.

Monkeypox is not a sexually transmitted disease, but it primarily spreads through close skin-to-skin contact, including during sex, hugging and kissing. It also can spread through contact with an infected person's bedding and other fabrics.

People should alert their sexual partners about any lesions or rashes they may have and avoid intimate contact with anyone who has them, Topiel said. And though this monkeypox outbreak has mostly spread among men who have sex with men, transmission is possible among anyone.

Though monkeypox also can spread through respiratory secretions, that's not viewed as a common source of transmission unlike more airborne-dependent illnesses, like COVID-19.

"While there is some concern about respiratory secretions, it appears it takes a long duration about 3 hours or more for someone to be infected," Topiel said.

Colleges need to focus on public health awareness, Topiel said. That includes educating students about how to protect themselves from infection and promoting vaccination for people considered at high risk.

Philadelphia health officials "expect there to be some level of spread to colleges and universities," said Matthew Rankin, a spokesperson for the Department of Public Health.Through Monday,Phillyhad recorded 257 monkeypox cases since the outbreak began.

"Currently, the monkeypox virus seems to have been limited to specific social networks," Rankin said. "At this time, we have not seen advancement of spread to the city at large. However, we do expect to see spread outside of these communities and possibly into colleges and universities," Rankin said.

Rankin said college students should take the same precautions as everyday residents:

"We know that this particular virus spreads in a couple specific ways," Rankin said. "It is important to know this disease does not spread through casual contact. It is spread through direct skin-to-skin contact or prolonged face-to-face interaction."

The U.S. Centers for Disease Control and Prevention has not released any specific monkeypox guidelines for college campuses. However, it has issued recommendations for congregate settings. They include:

The American College Health Associationreportedlyis working on drafting best practices for preventing and containing monkeypox infections on college campuses. Many schools in the Philadelphia region have begun preparing for potential cases, including the possibility that infected students will need to isolate.

West Chester University is finalizing its monkeypox protocols for the fall semester with the help of the Chester County Health Department and the CDC, spokesperson Nancy Santos Gainer said.

The university's student health services has monkeypox test kits on hand and is prepared to answer students' questions and provide testing, if needed, Gainer said. Comprehensive educational information, including FAQs, will be included on its website. The Chester County Health Department also will be conducting collaborative training with student health services and different on-campus groups.

"When the vaccine becomes available for the university to access, there has been talk with the Chester County Health Department about the university's willingness to provide the vaccine on a voluntary basis," Gainer added. "The university is committed to following the guidance of the Chester County Health Department and the CDC, and have students self-isolate should they contract monkeypox."

Temple University is focused on educating students, testing people with symptoms and helping high-risk people get vaccinated.Thomas Trojian, assistant clinical director at Temple's Student Health Services, emphasized that monkeypox can be spread as soon as a person develops a fever, feels unwell or has a rash or lesions. Infected people can continue to spread monkeypox until the lesions have scabbed over, fallen off and new skin has grown back.

The University of Pennsylvania is working with health agencies to "continually assess" the risk monkeypox poses to the university community and access to vaccines and treatments, spokesperson Mary Kate Coghlan said. "Risk on campus remains extremely low," Coghlan added.

AtLa Salle University, Assistant Vice President of Student Wellness Scott Cook sent out a message linking to campus resources and preventative information.

Holy Family University is "preparing an education and awareness campaign to ensure that students and the broader community are armed with the information they need to prepare, prevent, and stay safe," spokesperson Sherrie A. Madia said.

The U.S. declared monkeypox a public health emergency earlier this month. As of Tuesday, there were 15,433 confirmed cases in U.S., including 422 in Pennsylvania and 420 in New Jersey, according to theCDC.

In previous monkeypox outbreaks, the spread of the virus was very limited. Scientists are trying to determine why it has spread more broadly during this outbreak. They believe the virus hasn't changed, nor has the way it moves from host to host.

In West and Central Africa, where the virus has been endemic for decades, a single case or small cluster occasionally occur, primarily among hunters and people who handle or are bitten by infected animals. But it rarely spread widely within communities. In this outbreak, scientists believe the social networks the virus has found may be helping it spread more widely.

The good news, infectious disease experts say, is that monkeypox is not good at infecting humans, so it requires high amounts of the virus for a person to become infected. The three most common ways to contract the virus are direct skin-to-skin contact with a lesion, touching contaminated objects and close contact with respiratory secretions, like saliva from a person with lesions in the mouth or throat.

It remains unclear whether urine, feces, blood, semen or vaginal fluids can spread the virus and whether asymptomatic people can still infect others. It is also not clear how big a role inhaled respiratory particles may be playing in the latest outbreak.

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Colleges need to prepare for monkeypox to spread among students, infectious disease experts say - PhillyVoice.com

LOS ANGELES, Calif., Aug. 25, 2022 (SEND2PRESS NEWSWIRE) The Black Hollywood Education Resource Center is proud to welcome an incredible lineup of Films, Filmmakers and Healthcare Professionals to the stage of speakers for our 28th Annual Film Festival and First Annual Health Conference: SUPLLEMENTALLY: Mastering Mental and Brain Health After the Pandemic Across the Globe: Recovery, Healing, Hope, Reimage, taking place August 27, 2022, Cinemark 18 & XD, 6081 Center Drive, Los Angeles, CA., 90045 and virtually.

Image Caption: Event poster, 28th Annual Film Festival and First Annual Health Conference.

Just-announced special experts:

historical, intergenerational, interpersonal and community trauma. She also hosts the

podcast Healing is the Revolution in which her guests share and explore their healing journey through their traumas.

During the Black Hollywood Education Resource Centers Annual film festival, we will bring together a distinguished group of mental health experts, affiliates, peers, providers, government officials, media, and key stakeholders to talk about what it means to recover mentally from the COVID-19 pandemic. We continue to see the increasing number of people experiencing anxiety, depression, psychosis, loneliness, suicide, mass shootings and other mental health concerns these past two years, in addition to the largest number of opioid deaths in our history.

The historical landscape and experience of mental health among the African American Community has and remains to be characterized by current and unresolved trauma and violence. To address the impact of mental and brain health in diverse and marginalized communities across the globe, the Black Hollywood Education and Resource Center will also present its first Health Matters Film Block, featuring films focused on mental health.

This years films will help us reimage therapeutic treatments and models of mental health care and to determine ways that we can adequately address the complex challenges of mental illness in marginalized communities, which accounts for approximately one-third of mental illness globally, stated Dr. Shirley Evers-Manly, Dean and Professor, Alcorn State University, who will moderate the session.

During the festival and beyond, participants will discuss alternative ways to heal from trauma and explore the intersecting equity issues that exist. These events unequally affect many African Americans, communities of color and marginalized communities the most, placing them more at risk of a mental health crisis.

These circumstances call for radical change in the paradigm and practices of mental health care, including improving standards of clinician training, and revisioning current models of mental health care delivery. Upon completion of this conference, participants will enhance their knowledge of evidence-based practices to improve the behavioral and clinical skills of nurses, social workers, and other health care professionals who care for persons and families of all ages and cultural / socioeconomic status living with mental illness across the globe through the lens of film and the sound of music.

REGISTRATION AND TICKETS

Event registration is available online at https://bherc.org/bherc-health-matters/

In Person Registration

$50.00- General Admission (4 CEU Credits & Breakfast) | $20.00- Student / Senior(Breakfast)

Live Virtual Attendance

$30.00- General Admission (4 CEU Credits) | $25.00- General Admission | $20.00- Student/Senior

Virtual Attendance

$30.00- General Admission (4 CEU Credits) | $25.00- General Admission | $20.00- Student/Senior

About Black Hollywood Education & Resource Center

Founded in 1996, by Sandra Evers-Manly, BHERC is a 501(c)(3) nonprofit, public benefit organization designed to advocate, educate, research, develop, and preserve the history and future of African Americans in film and television. BHERC programs include film festivals, mentoring, book signings, script readings, film and animation contests, scholarships, and other programs and special events. BHERC recognizes the contributions of African American men and women in front of and behind the scenes in the entertainment industry.

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SPEAKER BIOS

:: Shirley Evers-Manly, PhD, RN, FAAN is the founder and President of All Health Care, Imanis in Oakland, California and Interim Dean Alcorn State University School of Nursing, in Natchez, Mississippi.

She earned a PhD from the University of California, San Francisco, Bachelor of Science Nursing degree and a Master of Science Nursing degree from Samuel Merritt University in Oakland, California. Dr. Shirley Evers-Manly, has more than 35 years of experience developing and implementing clinical, academic, and community-based health promotion and prevention programs; as well as working with vulnerable populations and speaking about diversity locally and abroad. She served as the Principal Investigator for the Aim 2 Care Multiple Chronic Conditions training grant, Bridges to the Doctorate and Song Brown Student Success grants.

She has won numerous prestigious awards for her accomplishments and contributions to improve clinical practices, inpatient and community health outcomes, and academia success and was awarded Congressional Recognition for Outstanding Community Service by the California State Senate and United States Congress. In 2014, she was given the prestigious honor of induction into the Inaugural Leadership Hall of Fame, Sigma Theta Tau International, Honor Society of Nursing, Alpha Eta Chapter (UCSF).

:: Dr. Evers-Manly is an internationally recognized expert in oncology and health disparities throughout the life span. She has made significant contributions in advocating to eliminate health disparities and inequities throughout the world. She gives voice to those who feel they have no voice.

Dr. Evers-Manlys understanding of underserved populations brings a humanistic approach to strategic, safe, high quality and cost-effective healthcareshe has leadership assets and skills from which the health care arena will benefit.

For her significant contributions in the areas of service, scholarship, community, and leadership, she was inducted as a fellow in the American Academy of Nursing, which was established to serve the general public and nursing profession by advancing health policy and practice through the generation, synthesis and dissemination of nursing knowledge. Dr. Evers-Manly is on faculty at the University of California, San Francisco, School of Nursing, is a former Regional Chair for Sigma Theta Tau International Nursing Honor society where 26 nursing honor society chapters reported to her. Currently she serves as member of the National Black Nurses Association and is the Chair of the Associations Ad hoc Committee on the Global Health.

:: Dr. Denese Shervington has an intersectional career in public health and academic psychiatry. She is the Chair of Psychiatry and Professor at Charles R. Drew University. Dr. Shervington has held Clinical Professorships in the Departments of Psychiatry at Columbia University and Tulane University. A graduate of New York University School of Medicine, she also received a Masters of Public Health in Population Studies and Family Planning from Tulane University School of Public Health. She completed her residency in Psychiatry at the University of California San Francisco and is certified by the American Board of Psychiatry and Neurology. A Fellow of the American Psychiatry Association (APA) she is a recipient of the APAs Award for Excellence in Service and Advocacy; prior to which she received the Jeanne Spurlock Minority award. Dr. Shervington is also a member of the American College of Psychiatrists and serves on the Psychiatry Resident-In-Training Commission. Dr. Shervington has testified before the United States Congress on Childhood Trauma and co-chaired the New Orleans City Council Taskforce on Childhood Trauma. She is a member of the Scientific Board of the Centre for Society and Mental Health at Kings College, London. Dr. Shervington has authored several papers in peer-reviewed journals addressing health disparities, the social determinants of health and resilience in underserved communities.

Dr. Shervington is the author of Healing Is the Revolution, a guide to healing from historical, intergenerational, interpersonal and community trauma. She also hosts the podcast Healing is the Revolution in which her guests share and explore their healing journey through their traumas. She is the proud parent of two amazing children Iman and Kaleb, and three grandchildren Ayelet, Haddassah, and Yoav.

:: Dr. Clyde E. Glenn is a native of Cleveland, MS. He graduated from Alcorn State University and completed his medical school education at The University of Iowa College of Medicine in 1990. He completed residency training in Psychiatry at The Ohio State University in 1994 and is Board Certified in Psychiatry and Neurology. Dr. Glenn is the founder and proprietor of Rehoboth Psychiatric Services in Ridgeland, MS. He has over 30 years of experience of psychiatric practice in both outpatient and inpatient settings and treats children and adults across the spectrum of psychiatric disorders. He is president of the Essie B. and William Earl Glenn Family Foundation and the ACEs (Adverse Childhood Experiences) Awareness Foundation of Mississippi.

:: Dr. Stephanie A. Patterson, JD, DNP, MBA, MPA, MSN, RN-BC, PMHNP-BC, FNP-BC, PHN, is a Lifetime Member of the Council of Black Nurses-Los Angeles, a chapter of the National Black Nurses Association (NBNA), Inc. She is a practicing healthcare provider in California and a nurse scholar with a passion for providing high-quality, appropriate, patient-centered psychiatric care to clients who are from traditionally underserved and/or historically marginalized communities.

As a nurse leader, Dr. Patterson serves on the NBNA Ad Hoc Collaborative Committee on Mentorship, a program aimed at helping NBNA nurses/student nurses at various levels of their development. She enjoys mentoring nursing students through the NBNA Collaborative Mentorship Program, for the purpose of increasing the number of BIPOC nurses in the workforce.

Her long history of academic achievements, community-based accomplishments, as well as a demonstrated history of excellence in the clinical setting while improving client outcomes, makes her stand out. A highlight of some of the awards Dr. Patterson has received in the recent past include the 2022 Nurse Practitioner of the Year Award (San Francisco Bay Area), 2017 Millennial Nurse of the Year Award, 2016 NBNA Under 40 Award, and the 2015 NBNA Student Nurse of the Year Award. She also served as a Student Board Representative while enrolled in nursing school.

:: Tia Delaney, MSN-Ed, RN, CCM Born in Boston, MA, Tia currently holds a masters degree in nursing with an emphasis in education and

is a certified clinical case manager. As a registered nurse, with over 28 years in the healthcare industry, and having previous roles within those organizations as Director of Patient Care Services, Chief Operating Officer, and Administrator, Tia has overseen the various facets required to deliver quality and competent clinical care to thousands of home health, palliative, hospice, and hospital-based clients. With a focus on the baby-boom and geriatric population, she understands the current healthcare plight America is facing and remains a passionate and dedicated advocate for the enhancement of healthcare services to the frail, vulnerable, and elderly members within the community.

Her direct observation of the healthcare inequities, social determinants of health, and lack of clinician diversity within the Los Angeles population that she served, has led her to collaborate with various organizations to design policies, procedures, regulations, and resources, to improve the health-related outcomes of the marginalized and underserved. Innovation, leadership, and initiative are just a few of the qualities that define her work-ethic.

As Director of Diversity, Equity, and Inclusion for the Alzheimers Association, her goals are to cultivate relationships with diverse communities which includes sharing time, talent, resources, and exchanging ideas to ensure neutrally fair access to opportunities, resources, and fiscal support. Additionally, she oversees the organizations mission of creating and maintaining a culture of inclusivity to its diverse constituents and ensure interests and needs are welcomed and fully considered within its multiple communication platforms, mission activities, and business practices. As a commitment to paying it forward, Tia is a clinical instructor teaching both theory and clinical skills to our nations future nurses. Additionally, she volunteers her time providing community-based health & wellness seminars which focus on providing education and resources to empower others in areas such as chronic disease management, preventative care, and holistic-health awareness.

:: Dr. Pedro E. Morante DNP, LNC, PMHNP-BC, FNP-BC, NP-C, GERO-BC, MEDSURG-BC, PMH-BC, is a mental health advocate and a dual board certified as Family and Psychiatric Nurse Practitioner at Brain Health USA and Assistant Professor in the School of Nursing. He holds a Doctorate of Nursing Practice with subspecialty of PMHNP from Brandman University. He graduated from Charles R. Drew University with his MSN focusing on Family Nurse Practitioner track. He is also a dual board certified through AANP and American Nurses Credentialing Center as a FNP as well as a Psychiatric Mental Health Nurse Practitioner (PMHNP) through ANCC.

Dr. Morante has cared for adolescent and adult patients in a variety of settings, including in-patient hospitals, community group homes, and out-patient practices. He has dedicated much of her nursing career to working with individuals with geriatric and psychiatry across lifespan.

Dr. Morantespecializes in behavioral health and treating adults with i complex medical and behavioral conditions. In addition, he is the CEO of Morante and Associates Training Center. As both a clinical practitioner and professor, he has gained extensive experience delivering telehealth services to patients and educating nurse practitioners on using telehealth to improve access to care.

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Caption: Event poster.

News Source: Black Hollywood Education and Resource Center

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BHERC Presents Its First Health Matters Film Screening and Panel Focused on Mental Health During The 28th Annual African American Film Marketplace and...

This remarkable compound is racking up an impressive list of research-backed therapeutic credentials

Quercetin has a wide range of benefits, which has made it useful for a variety of different health conditions. In the past two years, the antiviral benefits of quercetin have been the focus of many studies. However, there are other, lesser-known benefits, including the effects as a senolytic agent against senescence-mediated cancer growth.

Cells become senescent as we age. They stop dividing and enter a kind of stasis. Instead of dying off as cells normally do, senescent cells persist but change shape and size and secrete inflammatory molecules that cause other nearby cells to become senescent. This process is one of the hallmarks of human aging and senolytic agents used to induce the death of senescent cells.

Quercetin is perhaps most well-known as a strong antioxidant and antiviral. For example, Elderflower extract, which is rich in quercetin, is a traditional tonic used to boost immunity. In supplement form, quercetin has been used to prevent and treat the common cold and influenza.

According to Mount Sinai, quercetin should be used with caution as it may interact with certain antibiotics by reducing the effectiveness of the drug. It may also enhance the effect of some blood thinners, which can increase your risk of bleeding. In addition to these, it may interact with corticosteroids, digoxin, cyclosporine, and fluoroquinolones.

A paper published in August 2022 in Nutrition Research analyzed the pro-apoptotic effect that quercetin has on aging cells. Apoptosis is the normal, healthy way cells are supposed to die. The paper reviewed preclinical and early phase data using quercetin as a senolytic agent and found the data showed it was effective in preventing or alleviating cancer formation.

The authors reviewed the importance of cellular aging in the development of cancer cells and the effect that quercetin may have on the suppression of cancer cell proliferation. Research has found that cellular aging can suppress tumor development, but paradoxically can also enhance cancer development.

Cellular senescence is a dynamic and multi-step process that is associated with alterations in metabolic activity and gene expression. This can compromise tissue regeneration and contribute to aging. On the other hand, by removing senescent cells, age-related dysfunction can be attenuated and potentially extend the lifespan.

One mini review published in Cancer Letters in 2008 looked at previous research and found that animal studies had demonstrated quercetin could prevent chemically induced cancer growth and epidemiological studies found it was associated with preventing lung cancer. One study focused on the effect that physiologically attainable doses of quercetin had on the inhibition of cancer cell proliferation. The researchers believed their study demonstrated quercetin had chemopreventive properties.

Lab studies have also demonstrated that quercetin is a strong antioxidant and has pro-apoptotic effects on tumor cells, with the ability to block growth at different phases of the cell cycle. Research has also demonstrated that quercetin can promote the loss of cell viability and autophagy through several pathways, including those involving mitochondrial function and glucose metabolism.

Data indicate that quercetin could play a role in cancer treatment as it reportedly has synergistic effects in combination with chemotherapy agents or radiation therapy. Quercetin also has shown promising results with chemoprotective and radioprotective properties, by protecting normal cells against the effects of chemotherapy and radiation therapy.

One paper identified some of the anti-inflammatory, antioxidant and antiproliferative properties quercetin has that enhances breast cancer treatment, while another18 evaluated its effect on the treatment of ovarian cancer, which is a serious cancer growth and threat to womens health.

The strength of the antioxidant properties of quercetin is likely one factor in the ability to improve mood-related behaviors in animal studies in which the subjects underwent sleep deprivation. A study published in 2022 used a sleep deprivation model using 30 male albino mice. The mice were split into five groups.

The intervention groups received either astaxanthin or one of two doses of quercetin. Their activities were monitored, and brain samples were later collected. Researchers found that during persistent wakefulness, the animals experienced anxiety and depression-like behavior. In the sleep-deprived group, brain samples showed increased prooxidant activity. Prooxidants induce oxidative stress.

In the group pretreated with quercetin, these behaviors were reversed. The researchers found that quercetin could reduce anxiety caused by sleep deprivation in the animals. The structure of this study was similar to another published in 2021, in which the researchers split the animals into five groups that received the same intervention and sleep deprivation just described.

The researchers hypothesized, and the data showed, that quercetin ameliorated the effects of sleep deprivation on memory performance, depression-like behavior, and against the loss of prefrontal cortex neurons. Researchers have been interested in how the powerful antioxidant effects of quercetin might mitigate the damage and impairment commonly found following sleep disruption.

In one study published in 2016, the researchers hypothesized that quercetin could reduce the manic-like behavior induced by 24 hours of paradoxical sleep deprivation in mice. Paradoxical sleep is another name given to rapid eye movement (REM) sleep, the deprivation of which has led to chronic conditions such as obesity and stress disorders in people.

In the animal study, the researchers found that quercetin blocked hyperactivity that was induced by sleep deprivation. In another study, researchers hypothesized that the deficits in the hippocampal area associated with sleep deprivation could be ameliorated with a preparation of grape seed polyphenol extract, concord grape juice, and resveratrol.

They found the preparation improved sleep deprivation-induced memory deficits and quercetin, found in grape seed extract and grape juice, was an important factor in attenuating cognitive impairment caused by acute sleep deprivation.

Quercetin has been studied for its antiviral effect and has proven to inhibit the early stages of a flu infection. It is also a promising agent against the Epstein-Barr virus, Zika virus, Hepatitis B, and rhinovirus, the virus most often responsible for the common cold.

It was only logical then, as the COVID-19 pandemic emerged, that researchers would investigate the efficacy of quercetin against the SARS-CoV-2 virus. In the early months of the declared pandemic, a review was published that found the administration of bromelain, quercetin, vitamin C, and zinc showed promising results in improving clinical outcomes among COVID-19 patients.

In this paper, the researchers identified the antioxidants ability to inhibit proinflammatory cytokines and to clinically block human mast cell cytokine release as an important property in the fight against severe COVID-19 disease, which is associated with increased levels of cytokine production. They also identified the independent actions that bromelain has in activating a healthy immune system.

However, bromelain and vitamin C play another role in the administration of quercetin. Because quercetin generally isnt soluble in water, it can be poorly absorbed. When administered with bromelain or vitamin C, it increases the absorption and bioavailability of the antioxidant.

Bromelain is a proteolytic enzyme found in the stem of the pineapple plant. Independently, it has been used as a supplement to help reduce swelling after surgery or injury, or in the nose and sinuses. Its also applied topically to help treat burns.

The combination of quercetin with bromelain or vitamin C has also been a part of several successful protocols used to treat COVID-19. Quercetin is a zinc ionophore, which helps improve the cells ability to absorb zinc where it is effective as an antiviral.

Dr. Vladimir Zelenko was among the first physicians to discover and implement a treatment that has been credited with saving millions of lives around the world. His early protocol used hydroxychloroquine, another zinc ionophore. However, as research data showed that quercetin was as effective as hydroxychloroquine, his early treatment options for low-risk patients included quercetin with vitamin C and zinc.

Sadly, Zelenko died on June 30, at the age of 48 after a long battle with cancer. While treating patients, he oversaw the treatment of roughly 7,500 people using his protocol, during which time only three patients died.

The antioxidant and anti-inflammatory health benefits of quercetin likely contribute to the other lesser-known benefits of this supplement. The anti-inflammatory effects of quercetin are crucial since inflammation is at the root of many diseases, including autoimmune disorders, heart disease, and cancer.

One review of the literature found quercetin is a strong anti-inflammatory weapon that may be used in the fight against inflammatory diseases, such as obesity and type 2 diabetes. Another revealed that supplementation could reduce systolic blood pressure, and a third animal study demonstrated that supplementation with quercetin and exercise could reduce atherosclerotic plaque formation.

Quercetin has also shown promise in relieving the symptoms of allergies. It works by inhibiting histamine release and decreasing proinflammatory cytokine production and leukotrienes creation. The combination of quercetin and bromelain or vitamin C has also been promoted to help improve athletic performance based on the antioxidant potential of both flavonoids.

Quercetin has also been studied for the positive health benefits it has on:

Considering the wide-ranging benefits that quercetin has on human health, it could be a useful supplement for many, whether its used to treat an acute or chronic condition or as a long-term preventative measure. Its one of the supplements I recommend keeping in your medicine chest for times when you may be feeling as if youre getting an upper respiratory infection. If youre prone to colds and flu, consider taking it for a couple of months before the cold and flu season hits to support your immune system.

If you feel as if you have a cold or flu, consider using quercetin with bromelain or vitamin C in addition to zinc. Over-the-counter zinc lozenges make it easy to consume zinc for the short time its needed when youre feeling ill. Be sure to eat before taking zinc as it can make you nauseous.

On a long-term basis, quercetin has been useful for those with metabolic syndrome. However, it is much better to address fundamental issues to deal with metabolic syndrome, such as fixing a poor diet or getting enough exercise, and use a supplement only as an adjunctive therapy. If you have one or more conditions that make up metabolic syndrome, you would be wise to limit your total sugar intake to 15 grams per day.

For comparison, the American Heart Association61 reports that the average adult consumes 77 grams of sugar each day, which is more than three times the recommended amount for women. The number for children is even worse, with the average American child consuming 81 grams of sugar per day. Sugar-laden beverages are the leading source of added sugars in the diet.

Quercetin can function in several pathways to help reduce your risk of cancer. In addition to reducing the inflammatory response in your body and thus your risk of obesity and obesity-related cancer, it also promotes apoptosis at the cellular level to prevent cancer. When combined with exercise and reduced sugar consumption, you are making strong steps toward taking control of your health.

Sources and References

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The Antitumor Effects of Quercetin - The Epoch Times

Babies are being put at unnecessary risk of death and disability because the Governments recommended dose of folic acid for pregnant women is far too low, a leading scientist is warning.

The current daily intake needs to be 10 times higher than the 0.4mg currently advised in a change that would save hundreds of UK lives a year, according to Professor Nicholas Wald, an expert in preventative medicine.

Taking 4 milligrams of folic acid supplements a day would have a significant effect in preventing serious birth defects and associated stillbirths, neonatal deaths, miscarriages, elective terminations of pregnancies and the physical disability from spina bifida, Professor Wald said.

This amount of folic acid, taken from before conception to the 12th week of pregnancy, reduces by 83 per cent the risk of the foetus developing neural tube birth defects of the brain, spine, or spinal cord that can also cause anencephaly, in which a baby is born without parts of the brain and skull and encephalocele, another very serious skull defect; Professor Wald says in a new paper in The Journal of Medical Screening.

About 1,000 foetuses a year in the UK and 300,000 worldwide develop neural defects, with most women in Britain choosing to have a therapeutic abortion when they are identified through anti-natal screening. The defects are usually caused by a deficiency in folate, the natural form of vitamin B9.

Professor Wald said it was unlikely any women would already have high enough levels of folic acid and not need supplements since the blood levels of folate are really relatively low by any standards this is a vitamin deficiency disorder that is endemic throughout the world, including rich countries.

Dark green leafy vegetables such as spinach, romaine lettuce and broccoli, whole grains and beans are among the foods that are rich in folic acid. But the academic says eating them wont be enough to compensate.

To get the levels that will provide the maximal possible protection is extremely difficult to do just by changing diet and changing diet is pretty difficult, Professor Wald said.

At the moment, the biggest dose folic acid pill that is generally available is 0.8mg, which can be found in health food stores so taking five of these a day would be ideal, he said.

But even two or three a day would still be extremely worthwhile and provide most of the benefit, the expert advises.

A bit less will accomplish most of the protective effect, Professor Wald said. You get most from the first 0.8mgs. So you should certainly use at least one 0.8mg pill and if you want added effect you could take two, three or four additional ones.

He also recommends that women start taking the supplement before they know theyre pregnant.

If you wait till you know you are pregnant before you start taking folic acid there is probably no benefit because the neural tube develops in the first few weeks of pregnancy, he said.

Professor Wald led the landmark Medical Research Council Vitamin Study, that in 1991 definitively established folate deficiency as a cause of neural tube defects.

He dismisses as outdated, concerns in some circles including among some government advisers that larger doses of folic acid might mask signs of a vitamin B12 deficiency during pregnancy, which can lead to problems such as premature births.

The concerns about folic acid masking stem from the fact that folate or Vitamin B9 deficiency and vitamin B12 deficiency both cause macrocytic anaemia, a blood disorder that happens when your bone marrow produces abnormally large red blood cells.

Folic acid can, in large enough doses, correct the anaemia of vitamin B12 deficiency without mending the neurological damage that it can also cause.

This effect of folic acid has been referred to as masking vitamin B12 deficiency. But Professor Wald says the term is misleading because there is no evidence that a folic acid could lead to delayed or missed diagnosis.

He says that anaemia is not needed to diagnose the problem. Separate tests for measuring folic acid levels in blood and vitamin B12 have been available for decades.

However, the Government does not share that view.

A government consultation on the proposed fortification, in September 2021, noted concerns that consistent high intakes of folic acid from supplements could potentially increase the risk of masking (hiding or disguising) vitamin B12 deficiency in people with a condition known as pernicious anaemia.

And it indicated there were concerns about a daily folic intake exceeding 1mg just a quarter of Professor Walds recommendation.

Professor Wald also says there is no evidence to support concerns that a higher dose of folic acid could be neurotoxic.

Experts not involved in Professor Walds study are backing his recommendation.

I would strongly advise all women who might get pregnant in the near future to take 4mg/day of regular Folic acid 4mg/day, said Dr Miles Mack, chair of the Academy of Medical Royal Colleges and Faculties in Scotland and a GP in the Highlands town of Dingwall.

Dr Jonathan Sher, a senior fellow of the Queens Nursing Institute Scotland, said 4mg a day was safe and effective in preventing approximately 80 per cent of neural tube defects.

Lord Rooker, a former chairman of the Food Standards Agency and Minister of State at the Ministry of Agriculture, Fisheries and Food under Tony Blair, said: Four mg per day appears sensible.

In the longer term Professor Wald and others want to see folic acid added to flour and grains in quantities that would mean most pregnant women would automatically be well protected against neural tube defects without having to resort to supplements.

The Government is proposing to fortify non-wholemeal wheat flour or typical white bread with folic acid. But it would be in amounts which Professor Wald says are woefully inadequate, because the Government regards 1mg a day to be its upper limit because of concerns about masking, with flour concentrations to be determined accordingly.

The UK governments proposed folic acid fortification policy is seriously inadequate, not evidence-based and certain to fall well short of full effectiveness, Professor Wald and Professor Joan Morris, of Queen Mary College of London, argue in an opinion piece published yesterday in the British Medical Journal publication Archives of Disease in Childhood.

The exclusion of potential mothers with a diet that is not covered by the fortification policy is socially divisive and should not be acceptable. All flour and grains, such as rice, should be fortified at a sufficient level to achieve fully effective fortification across the whole population. It is not too late to do the right thing, they said, pointing out that the proposed fortification would only reduce the risk of neural tube defects by 8 to 12 per cent compared to more than 80 per cent at higher levels.

Of the Governments proposals to introduce folic acid fortification in white bread, guided by the notion of a 1mg ceiling, Dr Sher said: I see no wisdom in the UK government choosing to do too little for too few women and children when doing it properly is easily achieved.

Dr Mack said: I am extremely glad that the issue of folic acid fortification is finally being looked at but I am extremely concerned that the opportunity to maximise the benefit to the entire population will be missed if the level of fortification is set too low. The next generation deserve better from policy makers.

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Why 4mg of folic acid will dramatically reduce the risk of birth defects during pregnancy - iNews