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TREATMENT for SCRIPPS SURGEONS PUT TWINS WITH A DEBILITATING
NEUROLOGICAL CONDITION ON THE PATH TO RECOVERY
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SAN DIEGO HEALTH | FALL 2021
TA B L E O F
HEALTHY LIFE Back-to-school tips, time change troubles, managing macros, a care team primer and more. 20 THE ROAD TO RECOVERY Scripps' COVID Recovery Program is helping long-haulers get their lives back.
2 SPOTLIGHT ON SCR IPPS MD ANDERSON CANCER CENTER Philanthropy has made the opening of Prebys Cancer Center possible, as well as other innovations to support cancer patients throughout San Diego. 2 DOC OFF THE CLOCK Scripps family medicine physician Julio Romero, MD, doesn't shy away from spooky subjects.
Prebys Cancer Center, part of Scripps MD Anderson Cancer Center, opens in September. The state- of-the art cancer center on the campus of Scripps Mercy Hospital, San Diego, is expanding services for cancer patients in central and southern San Diego.
WONDER TWINS These twins share everything, including the Scripps doctors who treat an incurable condition that causes tumors on practically every nerve in their bodies.
Siu Ming Geary, MD, Scripps Clinic
Here for You. Here for Good. Where you get your health care matters. As one of the leading health systems in San Diego, Scripps offers access to a vast network of primary care doctors, specialists and state-of-the-art facilities — right here, close to your home or work. You’ll also appreciate the convenience of our MyScripps online patient portal where you can make in-person or virtual appointments, manage your medical records, access most test results, get prescription refills and more.
Switch to Scripps today and find out just how good health care can be. To find the primary care doctor who’s right for you and your family, call 858-281-2606 or visit Scripps.org/ForGood .
T H E L AT E S T T I P S , A D VA N C E S A N D A D V I C E T O L I V E YO U R H E A L T H I E S T L I F E
Get Ready to Fall Back There's more to look forward to this fall than the end of Daylight Saving Time (though we have that covered on page 7). Now is the time to fall back into some routines and catch up on the important medical decisions that may have been put on the back burner. In this issue, you'll find a health care "who's who" that'll help you determine which type of provider would be best for your family, a refresher on the adult vaccine schedule and details on a couple conditions that are more common than you may think. There are also timely tips to get your little ones back to in-person school, an in-depth look at "macros" and a plant- based seasonal side dish that will complement any meal. We understand that reestablishing old routines can be daunting. Fortunately, Scripps is by your side every step of the way.
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T H E L AT E S T T I P S , A D VA N C E S A N D A D V I C E T O L I V E YO U R H E A L T H I E S T L I F E
the Dream Work
Scripps Health’s team approach puts the “care” in health care
WHEN IT COMES TO YOUR HEALTH, CHOOSING THE RIGHT PROVIDER IS ESSENTIAL. Whether for preventive care or a medical crisis, your doctor should be a trusted part of your health journey. At Scripps, your care is put in the hands of not only your primary care doctor, but also an entire team of nurses, advanced practice clinicians (APC)—like nurse practitioners (NP) and physician assistants (PA)—and specialty physicians for whom your health and wellness are their utmost priority. Here, a team of Scripps practitioners highlight why teamwork truly makes the health care dream work. “My philosophy is that your primary care physician is really a
“Your primary care doctor has a 360-degree view of your health,” explains Siu Ming Geary, MD, vice president, Scripps Clinic. “ey know your medical history, your risk factors and your preferences for how you want to approach your health care. Any doctor can tell you general guidelines for health. Having a primary care doctor whom you see on a regular basis ensures not only that you’re keeping up to date on all the preventive care you need to stay healthy, but they can help you make choices that are customized for you and your lifestyle. Plus, when you need specialty care, we have the insight into your preferences and can provide guidance to connect you to specialists that suit you.”
history, what conditions you have and what your preferences are,” he continues. “At the end of the day, it’s a collaboration. e doctor might have medical information and a recommendation, but if the patient is not in tune with the recommendation or if the information is not presented in a meaningful way, chances are, once that visit is over, the patient may not act on it.” at’s why, Dr. Chong adds, trust is key when it comes to choosing your primary care physician. “When it comes to your car, you take it to a mechanic you can trust. In the same way, your partnership with your physician should be built on a foundation of trust,” he says. “For me, as a family medicine physician, I may know a person from the time they were a child to when they start their own family. I’m connected to my patients. at longevity is very important to help create a bond between a patient and their physician.” Choosing the right primary care physician not only allows you to build a trusted personal bond, it also ensures you have someone closely following any health changes that occur as you age.
teammate—someone who is collaborating with you about your care. It’s a partnership,” says Anthony Chong,
Meet the Care Team When you choose your primary care
physician at Scripps, you’re also choosing an integrated team of providers that will be by your side throughout your health journey. In your primary care oce, you may also be seen by an NP or PA who is part of your care team. ey work with your physician to ensure you have continuous care that meets your needs.
MD, chief medical ocer, Scripps Coastal Medical Center. “You want a physician
who knows your family history, your personal medical
4 SAN DIEGO HEALTH | FALL 2021
“Specialist access allows for improved care across the board, and the process works both ways. Our system allows me to review imaging and history to inform our primary physicians and referring physicians of the need to expedite care for certain patients and conditions, but also to inform those physicians when subspecialty care is not really needed and provide assistance in primary care management of those patients and their conditions,” he says. “at way I can maximize the eciency of my schedule to really see patients in a timely fashion. It also improves patient satisfaction by having them avoid visits and referrals and their associated costs when subspecialty care is not really indicated or needed.” Just like in a primary care setting, APCs enhance a specialty practice with their team approach. “As APCs, we allow for the extension of the physician’s ability to manage their patients both in the surgical and clinical settings,” explains Terri Abbott, PA, Scripps Clinic. “is team approach also brings a more comprehensive and expansive approach to the overall care of the patients. We reinforce the recommendation and treatment plans both surgically and nonsurgically for patient care. Patients seem to appreciate the team approach, especially when we connect with the patient in the clinic and in the surgical setting as the surgical assistant.”
“Even doctors may take a day o or occasionally get sick,” explains Dr. Geary, “so there may be times when your doctor is out of the oce. However, your health is important every hour of every day. Having multiple providers who know you and understand your health care needs helps to ensure access of care. At Scripps, our team approach includes NPs and PAs.” Bonnie Marblestone, FNP, agrees that the collaborative practice between nurse practitioners and physicians is a true benet to patients. “APCs increase access of care for the patient. If the physician is unavailable for days or weeks, the NP or PA is usually available to see the patient that same day and provide for the patient’s health care needs in a timely fashion, while also providing excellent care,” she says. “e APC can also assist the physician in answering patient messages, relling medications and following up on the care needs of patients with chronic conditions like diabetes and hypertension. We help to support the physician in providing complete and consistent care of patients.” Specialty Care Done Right When your health needs require specialty care, you can rest assured that the same exceptional teamwork extends to your Scripps specialist oces. From cardiology to orthopedics and everything in between, Scripps’ specialty departments work in concert with primary care to provide the comprehensive care you have come to expect from Scripps. anks to an integrated electronic health record, primary care physicians can work seamlessly with specialists to coordinate care. “Our electronic medical record and email system allow for direct messaging from primary care physicians to subspecialists. is can signicantly improve patient access to subspecialty care,” explains James Bruey, MD, a Scripps Clinic orthopedic surgeon. “Several of our primary physicians use this routinely, which helps me coordinate my care of their patients and allows me to expedite those patients that require more urgent evaluations and treatment recommendations.” Dr. Bruey adds that this seamless integration between primary care and specialty care signicantly improves the patient experience.
agrees. “Our APCs are utilized to improve patient access to care and the timeliness of that care,” he says. “ey are well trained and
extremely eective at extending our ability to see orthopedic patients. We can use them for independent evaluations when indicated to improve access, and their training allows them to recognize when direct surgeon intervention or more subspecialized assessment is required. In addition, their care of patients allows for improved eciency with regards to imaging and laboratory testing when indicated. Patients should look at them as extensions of their physicians. ey can oen spend more time to get the nuances of a patient’s condition and their care needs, as our scheduling process aords them the time to do these assessments.” Whatever your health care needs, you can trust that Scripps has a team for you.
Learn more about Scripps’ comprehensive care team at Scripps.org/SDScrippsCare .
Scripps' integrated network of primary care doctors, APCs and specialists ensures you always have access to the right provider for your health needs.
PRIMARY CARE PHYSICIAN
ADVANCED PRACTICE CLINICIANS
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T H E L AT E S T T I P S , A D VA N C E S A N D A D V I C E T O L I V E YO U R H E A L T H I E S T L I F E
Going Back to School — Safely
Tips to prepare for in-person learning this fall
Easing Anxiety About Entering the Classroom Though physical health is a high priority, emotional health has also taken center stage, as more parents and children struggle with the anxiety that comes from facing the unknown. Michael Campbell, EdD, a Scripps psychologist, suggests that the best way for parents to ease the anxiety of going back to school—for both themselves and their children—is to have a plan. “We are seeing a lot of anxiety in people who do not know how to transition back into normal life,” he says. “Planning and communicating that plan in an age-appropriate way can help ease this transition.” Campbell emphasizes that the first step to ease a child’s anxiety is for their parents to get on the same page with each other and tackle their own fears first. “It’s a top-down strategy,” he says. “Parents first have to address their own anxiety, and then be mindful about what they’re communicating to their kids. If your child is 4, you don’t want them to think the world is a scary place, so communicating about going back to preschool will look different than it does with a 14-year-old high schooler, with whom it’s more important to be real.” Finally, he says, regular family check-ins are important. “It’s a circular process. Parents, check in with your children about how they’re feeling about being in school and any concerns they may have. In turn, this will encourage them to check in with you to communicate their needs.”
The 2020–2021 school year already threw many parents and students for a loop, and transitioning back to in-person learning after more than a full year of virtual instruction may involve an even greater learning curve for adults and children alike. Here, two Scripps Health experts offer advice on how to ease back into the classroom this fall. Taking COVID Concerns into Consideration Will masks be required? What about vaccines? Will social distancing still be enforced? At press time, many questions remain about what in-person learning will look like, whether it’s masked or unmasked, hybrid or full-time. Allison Casciato, MD, pediatrician, Scripps Medical Center, Jefferson, offers reassurance for parents who may be concerned about sending their kids back to school. “I tell parents who are nervous that studies have shown in- person learning is not associated with a substantial increase in community transmission of COVID,” she says. “We don't think that kids going back to school will significantly raise the rates of COVID in the community. However, if community rates of COVID are elevated, there is likely to be more transmission occurring at school.” The return to school also means a return to group activities, like sports, band practice and even communal lunch. Dr. Casciato explains that activities like these are best done outdoors or in well-ventilated areas. She also highlights studies that found that three feet is a safe distance for group learning, allaying fears about the need for desks and tables to be 6 feet apart. Finally, Dr. Casciato reminds parents that even though the CDC guidelines help minimize COVID risks at school, the pandemic is still not over. If your child exhibits symptoms of COVID-19, the flu or any other communicable illness, the best bet for them, their peers and the overall community is to keep them home. “We do have to remember that we're still in a pandemic. If your child is not feeling well, do not send them to school,” she says. “Finally, if your child is age 12 and up, we recommend they get the vaccine. The mRNA vaccine has been studied in this age group; it is well tolerated, effective and may allow children to participate in more group activities and socialization.”
6 SAN DIEGO HEALTH | FALL 2021
Stick to the Sleep Schedule
A good bedtime routine can go a long way regardless of the time of year. These tips from Dr. Loewy will help you make the most out of bedtime, anytime. BE CONSISTENT. Try to have a regular evening routine leading up to bedtime. Whether that’s watching your favorite stress-free shows, taking a bath, or having a light snack, find activities that will signal your body that it’s time to wind down. Designate a set bedtime (and wakeup time, since this is the start of the 24-hour sleep-wake cycle) and stick with it as best you can, though a few minutes earlier or later here or there probably won’t hurt. DITCH THE DEVICES. Limit light from screens in the last 30 to 60 minutes before bed. LIMIT CAFFEINE LATER IN THE DAY. Caffeine has a fairly long half-life, meaning it stays in your system for quite a while. Cut off your caffeine intake after lunch. SKIP HAPPY HOUR. Alcohol can make you feel sleepy at first, but it also metabolizes quickly, which has an arousal effect and can lead to restless nights. TALK TO YOUR DOCTOR IF YOU’RE REGULARLY HAVING TROUBLE SLEEPING. They can recommend a natural approach, such as cognitive behavioral therapy for insomnia, or medication.
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Daylight Daze Don’t let the time change disrupt your ZZZs
WITH THE FIRST SUNDAY IN NOVEMBER QUICKLY APPROACHING, IT’S TIME TO BRUSH UP ON YOUR SLEEP HYGIENE. The end of Daylight Saving Time isn’t quite as disruptive as its start in the spring, but setting the clocks back can still wreak havoc on your circadian rhythm. “One hour can throw you off for a good couple of weeks,” says Derek Harry Loewy, PhD, Scripps Clinic sleep specialist. Though we’re gaining an hour of precious sleep in the morning, it behooves you to hit the hay a bit later to compensate. Dr. Loewy recommends that people start prepping for the time change a week to 10 days out. Start moving your and your kids’ bedtimes forward gradually in the days before the switch, by 10 to 15 minutes each night. “The morning will kind of take care of itself; it's all about making the adjustment on the bedtime side,” says Dr. Loewy. “In anticipation of the change, you want to get your body rhythm in a position to adapt smoothly.”
Another thing that can help your body adapt is getting a little extra light later in the day. The release of the hormone melatonin determines when a person naturally falls asleep at night. Melatonin usually begins signaling that it’s time to wind down about an hour or so before bed, but light—ideally sunlight, but any bright interior light will do—can push this further out. “If your goal is to delay sleepiness leading up to the change, lots of light late in the evening has a suppressive effect on melatonin,” says Dr. Loewy. Sunlight-mimicking lamps are very effective in delaying the release of melatonin and altering the body’s sleep-wake cycle, but they can be costly. They're probably not crucial for a one-hour time shift, but these special lights can help those who have chronic sleep irregularities that impede on their everyday lives, such as extreme night owls.
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H E A LT H Y L I F E
Innovations in Valve Repair A Scripps Health clinical trial explores a state-of-the-art heart valve procedure
Roughly the size of a dime, the MitraClip TM is small enough to be inserted via catheter, eliminating the need for open-heart surgery.
to a weak heart. We are now participating in a clinical trial to determine if the MitraClip is as good—or even better—than open-heart surgery for people who are surgical candidates.” Scripps Health is one of 60 sites in the United States and the only hospital system in the greater San Diego region participating in the REPAIR MR clinical study. It was selected for the high volume of patients in need, as well as its exceptional outcomes and reputation for excellence. Scripps is leading the way in bench-to-bedside research with this and other clinical trials. Dr. Price is currently recruiting patients
BNORMAL HEART MURMUR. SHORTNESS OF BREATH. FATIGUE. PALPITATIONS. ese symptoms could indicate the presence of any number of heart conditions. But for roughly 4 million people in the United States, they point
to the most prevalent heart valve disease in the country: mitral regurgitation (MR). A structural problem caused by degeneration of the mitral valve, which prevents blood from owing the wrong way back into the heart, MR can lead to an enlarged heart and heart failure. e most common
for this randomized trial, and he encourages anyone who has a leaky mitral value due to valve degeneration to talk to their doctors about the trial, and the potential benets of the minimally invasive transcatheter procedure versus open-heart surgery. “For this randomized study, we’re looking for symptomatic patients who are older than 75 or, if younger than 75,
treatment for MR is open- heart surgery, but Scripps Health, a national leader in cardiac care, is participating in groundbreaking research to determine the ecacy of a minimally invasive technique
"We are now participating in a clinical trial to determine if the MitraClip TM is as good—or even better—than open-heart surgery for people who are surgical candidates.”
to repair this leaky valve. Called the MitraClip , the procedure uses a catheter inserted into the upper leg to repair the valve instead. “Obviously, open-heart surgery has its risks and
with modest risk of surgery,” Dr. Price says. “e idea is to demonstrate that the MitraClip will be just as eective, safer, and provide as excellent an outcome and improvement in quality of life as surgery does, without the risks and recovery of open-heart surgery. Indeed, even older patients who are not candidates for surgery who get the MitraClip usually go home the next day following surgery.” To learn more about the REPAIR MR clinical trial, visit Scripps.org/SDRepairMR .
complications—it requires opening the chest and stopping the heart to complete the repair,” explains Matthew Price, MD, a Scripps Clinic interventional cardiologist. “During the past 10 years, we have been very successful at repairing the mitral valve with a catheter rather than with surgery. Personally, I have performed the MitraClip on over 500 patients. However, the procedure is currently indicated only for patients who are not candidates for surgery, due to age or other existing conditions that make them high risk or who have a leaky mitral valve due
8 SAN DIEGO HEALTH | FALL 2021
W E L L N E S S
Your Best Shot Stay healthy by staying on top of your routine vaccines
Finally, Dr. Alonzo advises patients to be their own vaccination advocates. While your primary care physician may remind you that it’s time for your routine vaccines, being accountable for your own vaccine records can only help. “I always recommend that patients be their own health advocate no matter what,” she says. Because people can get vaccines outside of their doctor’s oce—at local pharmacies or vaccine clinics, for example—records can fall through the cracks. “Keep your own vaccination card or record in a le folder that you can review with your doctor on a regular basis.” Get tips on ways to stay healthy and download our Guide to Good Health at Scripps.org/SDGuide .
NOW THAT COVID-19 VACCINES are on everyone's mind, there’s no better time to protect yourself from infectious disease of all kinds. Flu, pneumonia, shingles and measles; in annual shots or 10-year boosters—there’s an abundance of immunizations available to keep you healthy throughout adulthood. “Due to the current worldwide pandemic, the most important vaccine to get is the COVID-19 vaccine,” says Shirin Alonzo, MD, a primary care physician with Scripps Coastal Medical Center with expertise in global health. “But there are a lot of other vaccines adults need based on age and any chronic conditions. It’s important to stay up to date with current guidelines from the CDC.” For example, Dr. Alonzo says, the pneumonia vaccine is recommended starting at age 65 for everyone, and may be needed sooner based on chronic conditions. At age 50, adults are advised to start getting the shingles vaccine. And all adults are recommended to receive their Tdap (tetanus, diphtheria, pertussis) booster every 10 years. Additionally, immunizations are required for young adults entering or returning to college. A number of vaccines are also either required or recommended for people traveling to countries where infectious diseases that aren't common in the United States are prevalent. “Scripps Health has travel vaccine clinics that oer protection against diseases like typhoid fever and hepatitis A that can be contracted when traveling abroad,” Dr. Alonzo says. “It’s always good to review guidelines before traveling out of the country and make sure you’re protected. e whole point of vaccines is to prevent contracting and carrying an infectious disease in you.” For anyone concerned about any potential vaccine side eects, she has this important feedback: “In almost all cases, the benets of the vaccine outweigh the risk.” Potential vaccine side eects vary from person to person and vaccine to vaccine, but the most common side eect is arm pain for a few days aer getting vaccinated. “If you’re concerned about potential side eects or allergies, it’s important to speak to your doctor,” she adds. “ere are a lot of misconceptions about vaccines, but the truth is that staying up to date with vaccinations is critical for adults, just as it is for children. As we get older, we are still at risk of catching certain infectious diseases that can lead to hospitalization, or worse.”
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Without treatment, this chilling condition can limit movement for up to three years Frozen Shoulder
dhesive capsulitis, also known as frozen shoulder, isn’t especially common, but those whom it does affect can be left with debilitating pain and a limited range of motion for months, even years. Frozen shoulder hinders both your active and passive range of motion, meaning that movement is restricted both when you try to move on your own as well as when someone else, such as your doctor, tries to move your arm for you. “In the shoulder, we have rotator cuff muscles, and tendons and ligaments within the joint itself, all encapsulated with connective tissue,” says Lance Johnson, MD, family medicine, Scripps Clinic, specializing in sports medicine. “The main culprit behind frozen shoulder is essentially this connective tissue. Inflammation leads to fibrosis or scarring, to the extent where the joint capsule contracts on itself. When that happens, the joint is not able to move as freely as it should.” Dr. Johnson says that frozen shoulder’s progression can be broken down into three stages: THE FREEZING STAGE Shoulder pain and limited range of motion begin. Shoulder pain can be moderate to acute and may be severe enough to disrupt sleep. On average, this stage lasts 1 to 3 months. THE FROZEN STAGE The shoulder becomes stiffer, but the pain lessens. This can extend from 9 to 15 months. THE THAWING STAGE Pain continues to improve and range of motion gradually returns. “When patients come see me in the office, they typically present with pain and significant stiffness of the shoulder joint,” Dr. Johnson says. It’s not known what causes frozen shoulder, but certain factors can raise a person’s risk, including age and sex (it’s most common in people ages 40–60 and affects more women than men), diabetes, autoimmune disease, thyroid issues and prior injuries or surgeries that required the shoulder to remain immobilized for a significant period of time. For most people, frozen shoulder resolves itself over time even without treatment, but medical intervention, pain relievers and physical therapy can significantly shorten the recovery process. Surgery for frozen shoulder is a last resort. “We just have to make sure that the patients are diligent with these stretches and exercises,” says Dr. Johnson. “This is not going to be a big turnaround in a matter of days or weeks. It can take several months of doing physical therapy before they can gain full function of that shoulder joint.”
10 SAN DIEGO HEALTH | FALL 2021
Prevention and treatment options to ensure
your renal health is just a stone’s throw away
very year, more than half a million people go to the emergency department for kidney stones, according to the National Kidney Foundation, and an estimated one in 10 people will have a kidney stone in their lifetime. These hard particles accumulate from
Symptoms of kidney stones include severe pain in your lower back, cloudiness or blood in the urine, nausea or vomiting, fever and chills. You could also have intense flank pain (on the upper side of your back) that comes on suddenly. Evaluation of your symptoms can include an X-ray and ultrasound, blood work, urinalysis or CT scan. “If you suspect that you have a kidney stone, contact your primary care provider. You could also be evaluated at an urgent care, or emergency department if it is after hours,” says Tara Robbins, MD, Scripps Clinic family medicine practitioner. “If you have uncontrollable pain, are unable to eat or drink anything, or have a fever, then go to the emergency department.” While treatment options for kidney stones vary depending on their size and location, the first step, Dr. Robbins adds, is to increase fluid intake. “Certain medications can also be given to help the body pass the stone,” she says. “If the stone does not pass or is too large to pass, then other treatments are warranted.” Scripps offers a full range of treatment options. “At Scripps, we have the capability to treat all sorts of kidney stones—those that are within the kidney or the ureter,” explains Dr. Kashefi. “We take a conservative approach and try not to operate on stones that aren’t causing any obstruction, but we also take a proactive approach on stones that are likely to cause problems in the future. We work closely with our nephrologists (kidney specialists) by doing metabolic workups to help find the causes specific to each patient’s kidney stones, especially if they have recurring stones. In this way, we try to not only treat the stones, but to prevent them as much as possible.”
minerals in urine, and they have multiple causes, sizes, pain levels, treatments and outcomes. Here, two Scripps Health physicians offer tips on how to keep your kidneys in the clear. “The most common cause of kidney stones is dehydration,” says Carol Kashefi, MD, a Scripps Clinic urologist. “Genetics also plays a role—having a family history of stones—as well as metabolic disorders that affect how your kidneys filter blood. More and more over the past 30 years, people are forming stones due to poor diet or obesity. Some types of gastric bypass surgeries can also increase the risk of kidney stones. Less common causes are medication- or supplement-induced stones.” Because dehydration is the most common cause of kidney stones, the simplest prevention method is to rehydrate. “It’s a good idea to drink 6 to 8 cups of fluid a day, but if you have a history of stones, you should drink at least 8 cups per day, keeping in mind that 1 cup equals 8 ounces,” Dr. Kashefi suggests. “The second piece of advice I usually give is to minimize sodium intake to 2,400 milligrams per day—that’s the equivalent of 2 teaspoons of salt per day for all your meals combined. Sodium is sneaky, and it’s not just in saltshakers. It’s in things that aren’t even salty, like bread, and high in most restaurant or packaged foods. Your best bet is to cook for yourself so you can control your sodium intake. Finally, if you can have calcium in your diet, stick to roughly 1,000 milligrams per day, through diet and/or supplements.”
“At Scripps, we have the capability to treat all sorts of kidney stones.”
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Max Out Your Macros
You’ve probably also heard about good fats and bad fats. Trans fats are linked to heart disease and other chronic conditions and are banned in the U.S., but can still pop up on food labels as partially hydrogenated oils. Saturated fats, which are oen found in animal products and fats that are solid at room temperature, should be consumed in moderation as they have the potential to increase cholesterol. Unsaturated fats, found in olive oil, nuts, seeds and avocados, are considered healthier fats. Some proteins are healthier than others, too. Plant-based proteins like tofu and beans are more nutrient dense than animal products and don’t bear the same cholesterol risk. at’s not to say that meats (and processed vegan meat substitutes) are necessarily bad, but try to stick to those that are unprocessed. Two big indicators of processed food are unfamiliar ingredients and a sodium count that’s above a one-to-one ratio with the calorie content.
NOT ALL CALORIES ARE CREATED EQUAL. In recent conversations about diet, one term has gained prominence: macros. Short for “macronutrients,” macros are the protein, fat and carbohydrate components that make up the foods we eat. “We need to have a good balance between the three groups because they're each lling dierent roles in our body,” says Jennifer Chronis, MD, primary care physician, Scripps Medical Center, Jeerson. Carbohydrates, weighing in at four calories per gram, are essential, though sometimes they get a bad rap. Once ingested, carbs get broken down into glucose, which fuels your body and brain. Proteins also have four calories per gram; they build and repair cells throughout the body. Fats are the most calorie-dense, at nine per gram; they aid in the production of certain hormones, act as building blocks at the cellular level and also are used for energy. Focusing on macros as opposed to strictly counting calories could shed light on any dietary deciencies and help you get closer to your health goals. Dr. Chronis says that a typical person in good health should aim to get about 50 to 60 percent of their calories from carbs, 20 to 30 percent from protein and 20 to 30 percent from fats (foods contain dierent combinations of macros, so certain apps can help you stay on track). ose working to lose weight, manage diabetes or control another condition should work with their doctor to nd a ratio that suits them best.
“It’s important to have a good balance of these within the diet, not just overall, but with each meal,” Dr. Chronis says. “A good ratio of these dierent groups helps us process foods better and helps us feel more satised when we’re eating.” One caveat: Not all macros are created equal, either. Dr. Chronis says the quality of their source matters most. Rened and processed carbs, found in foods like white bread, pasta, cookies, chips and crackers, have been stripped of their ber and other nutrients and oen have added sugars (ingredients ending in “-ose” or “-itol” are a telltale sign). ough these do provide a quick burst of energy, they have a negative eect on our insulin and cause us to put on body fat in the long run. Fruits, vegetables, legumes and whole grains are complex carbs, which the body breaks down slower and uses dierently.
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T R Y T H I S
IF YOU’RE SEARCHING FOR A HEART-HEALTHY SEASONAL SIDE, YOU ARE IN FOR A TREAT. is barley and curried vegetable stued acorn squash is a plant-based powerhouse that’s low in calories and sodium, making it a smart swap for traditional starchy sides like stung and potatoes. “ere’s minimal carbohydrate content, and the total calories are only 237,” says Varinthrej Pitis, MD, internal medicine physician at Scripps Clinic, Carmel Valley. “It has nutrients and healthy fat, which will give you a satised feeling for longer, but it doesn’t weigh you down.” is recipe’s benets are many, says Dr. Pitis. Acorn squash is high in vitamin C, vitamin B, and magnesium, while barley is known for providing iron and ber. Olive oil, onion, garlic, and ginger can all improve cardiac health (though people who bloat easily should use onion and garlic sparingly), and garam masala and curry contain antioxidants. Pecans and almonds are also an excellent addition, she says. “ey give it a little more umami avor and make it more lling.” Fall Flavors Spice up your dinner table with this savory, nutrient-packed stuffed acorn squash
“There’s minimal carbohydrate content and the total calories are only 237. It has nutrients and healthy fat, which will give you a satisfied feeling for longer, but it doesn’t weigh you down.”
YIELDS TWO SERVINGS Barley and Curried Vegetable Stuffed Acorn Squash
D I RECT I ONS : 1. Brush the inside of the squash with half of the olive oil, then season with salt and pepper. 2. Roast in a 350-degree oven for 30 minutes or until cooked through. 3. Combine the barley and 9 ounces of the vegetable stock in a pot and simmer until cooked. 4. In a separate pan, sauté the onions, garlic, ginger, celery, and carrots in the other half of the olive oil. 5. Once the onions and celery are translucent, add the barley and cook until the grains are coated with the mixture. 6. Add the curry powder, garam masala, dried cranberries, pecans and almonds. 7. Continue cooking until aromatic, then finish with the coconut milk, cilantro, and the rest of the vegetable stock until the liquid has thickened the mix. Adjust seasoning if needed. 8. Stuff the mixture into the acorn squash halves, then place back in the oven for 5–10 minutes or until the squash is heated through.
I NGRED I ENTS : 1 acorn squash, cut in half 1½ tablespoons olive oil
Salt and pepper 3¼ ounces barley
9½ ounces vegetable stock ¼ cup yellow onions, diced ¾ tablespoon garlic, chopped 1¼ tablespoons ginger, chopped
¼ cup celery, diced ¼ cup carrots, diced 2 teaspoons yellow curry powder ½ teaspoon garam masala 1¼ tablespoons dried cranberries 2 tablespoons caramelized pecans, chopped
2 teaspoons sliced almonds 2 tablespoons coconut milk 1 tablespoon cilantro, chopped
NUTRITION FACTS Serving size: one squash half. Per serving: Calories: 237 Fat: 7g Saturated fat: 2g Cholesterol: 0g Sodium: 135mg Carbohydrates: 45g Fiber: 12g Protein: 4g
Executive Chef Walfrido "Fri" Reyes adapted this dish from the Scripps recipe archives. It was reimagined to include seasonal ingredients, whole grains, nuts and aromatics. To see a video of Chef Fri making this dish, visit Scripps.org/SDSquashRecipe .
Identical twins Michelle Paixio and Melissa Romberg lean on each other for support while in treatment for NF1.
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F E A T U R E
Twin sisters fight twice as hard against a painful genetic condition
IDENTICAL TWINS SHARE SO MUCH MORE THAN THEIR BIRTHDAY AND THEIR LOOKS. They also share their complete genetic code—the DNA that is otherwise unique to every individual. For sisters Michelle Paixio and Melissa Romberg, age 46, that shared DNA also means they share a genetic condition called neurofibromatosis type 1 (NF1), a hereditary disorder that causes noncancerous tumors to grow on the nerves throughout the body. Usually diagnosed in children due to signature “café au lait”– colored spots on the skin, NF1 is the most common form of neurofibromatosis and is often mild—sometimes so mild that people don’t even know they have it unless they go looking for it. For Michelle and Melissa, however, symptoms came on later in life—and once they did, they came with a vengeance, and the sisters had to go looking for answers. “It wasn’t untilmy sister and I bothhadourfirst children—more than 26 years ago—that the chronic pain started,” Melissa recalls. “We went from doctor to doctor and kept hearing that there was nothing wrong with us.” But both sisters knew something was terribly wrong.
From there, Melissa told her sister, who had been struggling with chronic pain and unanswered questions for years, to conrm the diagnosis with her doctor as well. “Once Melissa was diagnosed, she told me, ‘Go to your primary care doctor and tell them your identical twin was just diagnosed with NF and you need an MRI,’” Michelle says. “Finally, I got the diagnosis. I changed my insurance so I could be seen by Melissa’s doctor, and we could be monitored together.” at doctor turned out to be Faith Barnett, MD, a Scripps Clinic neurosurgeon, who has now cared for the twins for more than two decades. Forces of Nature
“Although I was not the doctor that diagnosed them, I have known Melissa and Michelle since they were in their 20s,” Dr. Barnett says. “ey were in chronic pain for years, and people looked at these 4-foot- 10 dynamos and would never think anything was wrong with them. But nally, they had scans that showed thousands of tumors on their nerves—like clusters of grapes over all the nerves throughout their bodies. It’s a very painful condition, but they are forces of nature!”
Over the past 22 years since they’ve been in Dr. Barnett’s care, Melissa and Michelle have undergone radiotherapy, targeted radiation therapy to shrink the tumors, and have had countless surgeries at Scripps. Dr. Barnett continues to monitor the size of their tu- mors annually—and will do so for the rest of their lives.
One of Melissa's goals after her last surgery was to wear her high heels again.
Worsening Symptoms “My symptoms started aer I had my rst daughter. at’s when I started having chronic lower back and abdominal pain,” Michelle says. “Doctors could not determine the cause. I had a colonoscopy and countless tests, and I was told there was nothing wrong. When I got pregnant with my son—my second pregnancy—I was in pain from day one. e bigger he got, the more pain I was in.” Michelle and Melissa’s diagnosis nally came from an unlikely source: Melissa’s future mother-in-law, a retired pediatrician. “I underwent laparoscopic surgery because doctors thought I had endometriosis,” Melissa explains. “All they found, though, were white cotton-ball-type growths in my abdomen. My now-mother-in-law asked me if I had café au lait spots on my skin. When I said I did, she told me I had to go to my doctor and ask if I had NF. He looked at me and asked, ‘What’s that?’ Because it’s a pediatric condition, it’s very rare to be diagnosed as an adult. But it was conrmed that I had NF.”
“It takes a lot of psychological strength, and despite their constant pain, Melissa and Michelle both live veryll lives.” — F A I TH BARNE T T , MD , S CR I P P S C L I N I C
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What is Neurofibromatosis Type 1? Neurofibromatosis type 1 (NF1) is a genetic condition that results in the formation of neurofibromas, a type of nerve tumor that forms on or under the skin. Attached to nerves throughout the body, these tumors are usually benign, but can become cancerous and therefore require lifelong monitoring. A not-uncommon condition, NF1 occurs at a rate of about one in every 2,600 people. While symptoms are usually mild to moderate, the condition can also be severe, such as what Melissa and Michelle experience. Symptoms of NF1 are often noticeable at birth, and usually appear during childhood. In addition to the neurofibromas, symptoms of NF1 include: “Café au lait” spots—flat, light brown spots on the skin. More than six spots suggests the presence of NF1 Freckling in the armpits or groin Tiny bumps on the iris Bone deformities Optic tumors Learning disabilities Larger than average head size Short stature NF1 is an inherited condition and is therefore present at birth. “NF1 is autosomal dominant, which means it’s inherited in 50 percent of people with the gene,” explains Dr. Barnett. “If one of your parents has it, there’s a 50/50 chance you will have it too.” In the twins’ case, their mother also has NF1, but never knew it. “My mom was finally diagnosed with NF after I was,” Michelle says. “Hers was milder than mine and my sister’s, so she didn’t know she had it. She had balance and hearing issues, which we now attribute to the NF.” As for the next generation of the twins’ family, Michelle says, “My son is 22 and he has been ruled out for NF. My daughter is 26 and is a carrier of the gene, which means she doesn’t have the tumors, but she can still pass it on if she has kids. I do have a granddaughter who is being monitored for NF, but she’s only 5 and it’s too soon to tell. It’s usually puberty when tumors start to develop, because of hormones, so we won’t know for a while.” For Melissa, it’s a watch-and-wait situation with the youngest of her three sons. “One of my three boys—the 13-year-old—has the NF gene and the café au lait spots,” she says. “You have to have so many spots to be diagnosed with it, so his pediatrician monitored the size and width of his spots as he was growing up. Now, we just hope he doesn’t get the tumors like we have. I don’t want him to suffer.”
F E A T U R E
“You can have a near-normal life expectancy with NF1,” she explains. “Treatment involves a lot of surveillance imaging, and the prognosis diers depending on the patient. Some patients’ tumors do not grow very much; others have a malignant transformation into cancer. With Melissa and Michelle, because there are so many tumors, they have a lot of nerve pain. ey get MRIs once a year on the brain, neck, cervical spine, lumbar spine, lungs, abdomen, pelvis, and legs. I will also alternate with a PET scan, which uses radioactive glucose to see if any of the tumors have an abnormal uptake of sugar, which would mean they were becoming malignant. ey always let me know if
anything is hurting, so I can monitor it.” e pain, Dr. Barnett acknowledges, is constant.
“at’s what makes them particularly resilient,” she says. “It takes a lot of psychological strength, and despite their constant pain, Melissa and Michelle both live very full lives.” Prabhakar Tripuraneni, MD, radiation oncologist, Scripps MD Anderson Cancer Center and Scripps Clinic, agrees. “Melissa and Michelle are always impeccably dressed with a smile, in spite of all the pain.” He adds, “Radiation therapy is very useful and dramatically improves the quality of life inmany noncancerous conditions, such as neurobroma, pituitary adenoma, meningioma, Dupuytren’s contracture, keloids, heterotopic ossication, and others that most people and doctors are not aware of.”
Above: Scripps Clinic neurosurgeon Faith Barnett, MD, has helped the twins manage NF1 and the chronic pain it causes for 22 years.
Right: A scan of Melissa's sciatic nerve clustered with neurofibromas.
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