Podcasts Archive - Sanford Health News

Navigating senior care from the sandwich generation

Sarah Yoder:

There is joy along this journey. If you’re taking care of young children and caring for elderly aging parents there’s a tendency to feel like one is just a burden and one you want to tend toward doing, caring for your kids or just having to meet the needs of your elderly parent. And I would just say find the joy.

Cassie Alvine (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about the sandwich generation and the various challenges of children caring for older parents. Our guests are Sarah Yoder, Alicia O’Neill, and Kelsey Nicola. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

This is the “Health and Wellness” podcast. I’m Alan Helgeson, and we’re talking about the sandwich generation and their challenges of caring for older parents and young children. And we have several guests joining us today, Alicia, Kelsey, and Sarah all around this round table here as we discuss this topic. Alicia, could you introduce yourself?

Alicia O’Neill (guest):

Yes. Hi. I am Alicia O’Neill. I’m the administrator for senior living within Good Samaritan here in Sioux Falls. So I oversee several of our independent living and assisted livings in the Sioux Falls area.

Kelsey Nicola (guest):

My name is Kelsey Nicola, and I am the manager for Prairie Creek memory care assisted living here in Sioux Falls.

Sarah Yoder (guest):

And my name is Sarah Yoder, and I have a parent who has lived in Good Samaritan for probably about seven or eight years and moved through the system and we’ve kind of lived out this sandwich generation theme here.

Alan Helgeson:

Well, I’m so grateful that you guys are taking time out of your day to talk about this very important topic. You hear this term sandwich generation and you know, it’s not about something with cold cuts and rye bread and mayonnaise. It’s a very important topic, and as we hear about the baby boomer generation getting bigger and bigger and the health needs that are coming, we’re trying to put some definition around this. So, Alicia, wondering if you can help us define what is the sandwich generation?

Alicia O’Neill:

The sandwich generation can be defined as a group of people that probably find themselves, they have young children at home, but they also have aging parents that are starting to need help, and they identify that now they need to become the caregiver for those parents as well as their children.

Researchers found that it’s usually people in their 30s, 40s, and 50s that tend to find themselves – I was astonished to hear even one out of 10 people, parents, find themselves caught in that generation of caring for children as well as their parents. That was a lot to me. I thought one in 10 and 66% of those caregivers are female as well and are still working outside the home. So balancing that work life and their children as well as then being the caregiver for their parents.

Alan Helgeson:

It can be so much. We know that a lot of folks as even single parents these days that it’s just so much that you spend a lot of time working, you care for your kids that there just isn’t any downtime. Right? So some of those characteristics you talked about with all of that going on here as we’re dealing with this, what we’d like to do is through the course of this episode is we hear about sandwich generation is putting a face on it and talking about that and explaining that. And Sarah’s here today as somebody that’s living and going through this. And Sarah, you talked about for the last several years you’ve been going through this with your family member. Tell us a little bit about your story.

Sarah Yoder:

Yeah, so thank you for having me, Alan. I really appreciate it. It’s kind of, as I was thinking about this, I was thinking about other people in my situation that may have young kids right now and what they may be facing. So my story really begins, my mom was a single parent and raised me as a single parent her entire life. And so there was always kind of a sense that I was parenting my parent all along the way.

However, in 2014 began the journey of really increased caregiving for me.

Mom was diagnosed with the first of five cancers over the next three-and-a-half years, between 2014 and 2017. And there were lots of surgeries, procedures, tests, doctor’s visits, chemo, radiation. At that time I had three children under the age of 10 at home, a 3-year-old, 6-year-old, and 10-year-old. And so it was a lot to try to find ourselves in a place where Mom needed care. There was really nobody else to do that. And then our children were growing and needing, of course, the nurturing and development that come with that stage for them. So yeah, it was a lot to juggle.

Alan Helgeson:

Do you have siblings around in the area too? Or are you an only child around here that it fell to? Or how did that dynamic work?

Sarah Yoder:

Yes, that’s a good question. I do want to say I probably cannot do this at all without the care of my husband. He has just been the absolute best partner and caregiver. I do have one sister, one sibling, and she moved away and has not been able to participate in caregiving. And so it really has fallen to me.

We do have both my husband and an aunt and uncle who have just been wonderful. There have been people absolutely that have journeyed with us through this process. But I think all along the way you can still begin to feel this overwhelm. You can feel the fatigue. You can start to feel how in the world do I balance all the demands with everybody needs something all the time? (laugh)

Alan Helgeson:

So Sarah, have you had to, during the course of this, maintain work as well too, in some role or capacity?

Sarah Yoder:

Yeah, I worked part-time here and there, but I also volunteered. Probably the bigger chunk was volunteering in my kids’ classroom. I was in their school half a day every week for nine years. And so because of my husband’s work, I was able to primarily stay home and really spend a lot of time volunteering in the community. I volunteered with our church.

And then I also was a caregiver to my aunt who had Alzheimer’s. She was in our home for several years. So there was, I’m a natural caregiver kind of a person who kind of enjoys that, and people describe me as very empathetic and it comes naturally to me, but it’s still very difficult.

There are friends that I have that would not describe themselves as natural caregivers or maybe not have the history of moving through health care systems or navigating that quite as easily. And, you know, people really need a lot of support.

Alan Helgeson:

Knowing just the medical piece alone takes so much time, and then dealing with some chronic conditions. You talked about several types of cancers. Talk about all these medical appointments and trying to juggle that in with an aging parent.

Sarah Yoder:

That’s really true. The medical appointments and even just navigating the health system can be really a daunting task in and of itself.

My mom was a nurse. She was a health care administrator growing up my whole life. So there was a little bit of familiarity there, but even with that, I found myself in a place where I would have to repeat myself often. I would have to make a case for what was going on. I would transport her.

Even just the scheduling of transporting, arriving, juggling kids’ activities or kids’ school pickups, all of those things kind of coincide together and really become kind of this perfect storm that really just kind of has the potential to really be burdensome and produce some anxiety or strain on the family.

I would say as far as health care, navigating health care, you know, sometimes you need an expert. Sometimes you need somebody who is an expert in their field to come along and figure out some health care things.

But I would say for the sandwich generation as an encouragement, more than that, you need a relationship. You need somebody – you need caregivers who know your parent well. They know the story. They know they history. I could give you tons of names of wonderful caregivers. And Sanford, Dr. (Stephen) Foley, Annie Bettcher (RN care manager), they’ve walked with us for years through some of these things. I can tell you countless nurses have walked into rooms with me, and they just know. They just get it in ways that other people don’t because they’re caregivers themselves.

Alan Helgeson:

Those relationships are so important, aren’t they, Sarah?

Sarah Yoder:

Yes, absolutely.

Alan Helgeson:

I mean, you had the benefit of your mother actually coming from that health care background. You had a little bit of a kind of that seed of knowledge. I mean, it helps a little bit, right? I mean, knowing some of that stuff, sure.

But let’s switch now. At some point you needed to make that decision or come to that decision where you needed to move into some care choices where your mother could be and to find a place where she could live and to be cared for, right? So a Good Samaritan was the place where you chose. Talk about how you got to that decision and what it looked like to get to that decision.

Sarah Yoder:

That’s a really good question actually, Alan. You know, in 2014 when Mom was diagnosed with the first of five cancers, we really began kind of this intense season of all these tests and doctor visits. And Mom moved into our home for a while because that was really the only way that I could care for her and our children who were very young. And so we had this blended home with Grandma who was losing her hair and having doctor’s appointments and juggling kids’ activities as well.

And you know, at the end about in 2017, after about three-and-a-half years of kind of walking that road, it just became really apparent to me that I needed help. I needed a support system. I needed some professionals to come alongside. And we began to look at several different places. The Good Samaritan really stood out.

Mom being in health care really wanted the continuity of care that Good Samaritan offered. And so she began looking. I began supporting her in that process and encouraging her. There was a lot of resistance and hesitation to do that because that’s a really big step in giving up independence. But she lived in Good Samaritan for years and really received wonderful care there.

Alan Helgeson:

One of the things that you have to look at too is as things move along as you may need additional levels of care, is that a consideration that was part of your decision making as well?

Sarah Yoder:

Absolutely. Absolutely. You know, Mom’s terminology was always the continuity of care, that she could move along through the system as care needs increased. And you know, for me, I guess part of that was knowing that that was available, but also just having relationships with folks that knew my parent, knew where she was at and really could help us discern what she needed at the time, what was going on, how she could be best supported, what services they would offer.

Alan Helgeson:

So during this time, a lot of folks maybe feel that they’re pushing a parent towards a decision like this. How was that relationship with you and your mom? Was she making that decision on her own or were you helping to nudge her in this role? What was that like?

Sarah Yoder:

Yeah, that’s a good question. I would say it was a dance. Yes, it was (laugh) not easy for sure. Sometimes there’s resistance because there’s a lot of loss of independence. Or that’s the feeling, that there’s loss of independence. There’s a desire to continue to keep trying things and just maybe situations will change and then they’ll be able to navigate things.

So again, that’s where kind of the outside perspective really became beneficial. These are people who work with this population all the time and know what people need. They know and can observe the needs of your parent as well as you discuss those things. So yes, there was absolutely some, “Hey, I think we’re at this point, I think you need this.”

But after several years of all those health care appointments, we’d been on quite the journey. And so there was also some awareness, some comfort of, OK, I’m going to be in a place where I can have the care that I need and the support that I need.

Alan Helgeson:

Did you feel like you were alone and on an island of your own going through this?

Sarah Yoder:

That’s a tough question. I think those feelings can come anytime. I think that can be when you’re just beginning this journey and kind of wondering. One of the things as I was reflecting on this and what it was like for me is there are so many responsibilities, especially when my kids were young, sandwich caregivers really struggle from fatigue.

There’s around-the-clock caregiving, someone always needing something. It can feel like you personally have no free time, no margin in your life. Your friends may have hobbies or do things that you absolutely just don’t have time for. It’s an attempt to balance all the demands, the good things like children’s activities, and then also kind of just desiring to invest in their own growth and development, their shaping, their guiding.

So it can feel really like a role reversal and it can feel lonely and overwhelming, emotionally draining to have to give support when you feel like you’re the one who needs the support yourself.

Alan Helgeson:

Up and down all over the place. And then you mentioned talking about the comfort of having that external support, like the health care, the caregivers, like the doctors, the nurses, all of them being supportive. Did they play an important role at this time as well?

Sarah Yoder:

Absolutely, yes. I think I said before there were just kind of relationships with people that would just kind of know. There are some times where you will find yourself explaining situations or trying to grasp situations or trying to explain things you don’t understand medically or from a health perspective. And you need people to come along and help you discern that.

But then there are other times where there are just people who are excellent caregivers who really can come alongside you in really beautiful ways. They can put their hand on your shoulder and just say, you know what? I see you. I get it. I know what you’re carrying. Sometimes not even fixing things, but just being known.

Alan Helgeson:

You started out with your mom several years ago at one place. Where are you at today with your mom and Good Samaritan?

Sarah Yoder:

Well, that’s actually kind of funny that you ask because I was thinking, you know, we’re through this season. My kids are now 20, 16 and 13. They’re off to college and driving. And then yesterday I found myself scrambling as I’ve been working on Mom’s taxes and trying to get all that paperwork done and there’s all these hiccups and roadblocks along the way trying to navigate those things and get exactly the paperwork that I need.

Yesterday I found myself at her apartment having her on speakerphone with another administrator, trying to get authorization to get the paperwork we needed. All the while she’s having a low blood sugar, so I’m fixing her a snack and trying to get to my son’s band concert in time. I was driving to Brookings for his band concert. So just continuing to juggle all of those things.

Alan Helgeson:

And you just become a master scheduler, and it just becomes what you do, right? What services or what level of care is your mom at today? Has she moved to different levels?

Sarah Yoder:

Yeah, she lived in independent living for quite a while. She’s currently living in assisted living and they’re wonderful to her.

Alan Helgeson:

Appreciate you sharing your story and we’ll come back with some more of those things.

Alicia and Kelsey, I want to talk to you – and let’s talk about some numbers here. Have you noticed any recent trends or changes in the demographics or experiences of the sandwich generation? As we’ve been talking about this, we had a really nice lead in here in getting that phase to what really the sandwich generation is, and what it really means of what somebody’s going through.

Kelsey Nicola:

Like you had mentioned, Alan, we have more people than the baby boomer generation with chronic illnesses, which means that they’re needing support a little bit earlier than what we’ve seen before. So we’re getting people younger coming into our facilities and into assisted living and into my memory care.

That means typically that their spouses are still working. And so it really puts a strain on those spouses and children, if they have them, because we might call them and say, “Hey, something’s going on. We need your help today.” But they’re working and they have to try to juggle getting out of that. Or like Sarah said, going to children’s activities. All the while we’re trying to still learn their loved ones and how best to support them, especially at younger ages.

Alan Helgeson:

Are you finding a good level of employer flexibility in this too, these days? Is that being helpful to these working spouses?

Kelsey Nicola:

I have seen people who back down to part-time hours to have that flexibility, and then I’ve also seen people who have had the ability to no longer work to help support their loved ones in the facilities. I wouldn’t say that employers are always as forgiving as they need to be or flexible with people’s loved ones, which really puts a strain and brings a lot of guilt into their spouses’ lives.

Alan Helgeson:

It’s really all over the place. You talked about specifically that Kelsey, you work in the memory care area. Can you explain a little bit more about what the memory care area covers and serves for Good Sam?

Kelsey Nicola:

Yeah. Our building specifically, it’s a memory care assisted living. We have 32 private suites, so all of our residents do get their own rooms with a bathroom, and we serve populations who have to have a diagnosis of dementia.

People come in maybe needing just queuing support, getting to activities or to the dining room. And then we also go up to people needing full assistance with all of their activities of daily living. We do support a little bit higher level of care than what Sarah’s mom, the facility Sarah’s mom is at, but at the end of the day it’s still assisted living. So we give as much support we as we can and a lot of cognitive support.

Alan Helgeson:

So can you give an idea of like the age range that you may support?

Kelsey Nicola:

My youngest resident currently is 60 and my oldest one is almost 97.

Alan Helgeson:

Well let’s talk about some of the common emotional and mental health challenges faced by the sandwich generation.

Kelsey Nicola:

We see a lot of grief, a lot of guilt that is associated with having to make that decision to move to a facility where they can receive care. We all know that people want to stay at home as long as they can, and we support that. And also spouses really take those vows to heart and they want to care for people in sickness and in health and be with them. It’s very hard for people to come to the decision that they need that support.

And it’s not just spouses. It’s children too. We often, in my building, will find we have family members, children, spouses who are in our offices asking us to give the answer what do they do? And we don’t always have that answer, but we can be there to support them and talk about other experiences that we’ve seen with people and as they go through guilt and grief.

Alan Helgeson:

Not having any answers here, but I’m guessing everybody wants you to tell them what to do, don’t they?

Kelsey Nicola:

Yes, they do. (Laugh)

Alan Helgeson:

They want you to give them the magic answer because they have no idea, right?

Kelsey Nicola:

They don’t. Nope. And it’s a hard journey for everybody, and every journey’s different.

Alan Helgeson:

What can they do? How do you maybe guide them with some of these mental health challenges and some of this grief? Where do you guide them and maybe direct them to help them go through some of these things?

Kelsey Nicola:

In Sioux Falls, we’re very lucky to have a number of different programs available. We have the Alzheimer’s Association and we’ll give them information on that.

And we also have Active Generations, which is a fantastic resource for people where they can go. If they’re not ready to move into our building, we often will lead them to Active Generations and let them know of the services that they have there.

We also have good partnerships with Home Health in Sioux Falls and we can refer them to Good Sam Home Health or Sanford for a little bit of extra assistance in the home.

We also let them know that what they’re feeling is not uncommon and it doesn’t mean that they’re doing anything wrong. We let them know that their journey is individual, and that’s OK. They’re going to come to that decision when they need to, but we’re going to be there for support and resources when they need us.

Alan Helgeson:

Are there any support things or guidance that you offer for those family members? Are there some things that you can help them with?

Kelsey Nicola:

Yeah, we have a library at Memory Care in our building that has a ton of books on resources, different types of dementia, people’s own individual stories and kind of how-to books. And we also partner with people to come in and do like education series, education talks. We have numbers for clinics that they need to get ahold of and pamphlets and business cards for different groups. Like associated with the Alzheimer’s Association.

Alan Helgeson:

Are there resources as well, Kelsey, for family members and the children as they’re looking for this stuff? And where could they find that?

Kelsey Nicola:

There is a really good resource online. It is www.good-sam.com.

One thing that is wonderful on that website is a connection to what is called our connection center. So somebody can call in, say I have my parent who’s needing extra support and I just don’t know where to start. If they give us the location that they’re from and where they’re kind of looking and just a little bit of background on what that parent is maybe needing, they have people who will take all that information down and then email it to those locations so that we can reach out to them, then get a little bit more of an idea of what they’re needing and set up tours, ask if they want more information and send that out.

Alan Helgeson:

Kelsey, what is the Good Sam Connection Center phone number?

Kelsey Nicola:

It is a toll free number. It is (855) 466-3726.

Alan Helgeson:

Can you repeat it one more time in case people are running, grabbing a pencil and we’ll hit it again here at the end of the program.

Kelsey Nicola:

Sounds good. The toll free number for the connection center is (855) 466-3726.

Alan Helgeson:

Alicia, can we talk about some of the financial things here? How does being a sandwich generation caregiver impact someone’s financial situation?

Alicia O’Neill:

You’re in a position of not only planning maybe for college expenses and your own retirement planning and then looking out for your loved ones, the funds that they’ve spent their years earning, and how do I best utilize those funds to get my mom or dad on the best care that they need?

And so really just balancing that out and as much as you maybe feel guilty about it, you need to look to protect yourself first. And so I think really working with a financial advisor too on making sure you know your own financial situation and what do you need to set yourself up for the next few years and then having that difficult conversation early, I think with family members is very important.

Maybe even before you get to the point where you’re a caregiver to understand your parents’ finances, where are their accounts, what do they have for insurance accounts? What do they have in savings so that when you are in a caregiving situation where they can’t make those decisions on their own anymore, you’re a little more prepared.

And then putting all of that in one spot. So making sure you have your loved one’s accounts and all of that information together so that it’s easy to grab when you are having to do taxes or things like that that you hadn’t really thought that you’d have to do someday.

And then just working with that financial advisor I think would be helpful too, to then what’s out there for grants or scholarships or programs then for my kids. So the important message is don’t forget yourself in that and maybe make sure you’re protected that way too.

Alan Helgeson:

At Good Sam, how do you help somebody navigate those discussions and plan for things like that as they’re looking for care options?

Alicia O’Neill:

So it’s really just sitting down and looking at what they have for finances and then looking at our different levels of care to see where maybe they could afford to receive the care.

Like Kelsey said, within Good Sam and Sanford, we have a lot of different ways that support and caregiving can be done. So maybe it is caregiving in the home and so maybe that’s where they need to start and to understand the financial implications of maybe they can afford to bring in a home health caregiver.

Or maybe it is moving into one of our locations within independent living or assisted living. So just trying to balance through that. We really refer people more to their financial planners and things as far as their investments and things like that, especially people that are starting this journey and just starting to look out. It’s things to think about as they’re planning for what does it cost for assisted living?

You know, there’s long-term care insurance out there. Some people don’t even know that. And so just giving them the questions to ask maybe of their financial planner, how do I protect my estate? And things like that as I go through this journey from maybe independent living all the way up to skilled nursing care and giving them those resources.

But typically we would refer them back to their financial planner for the details to work out what works best for them. But like Kelsey said, we try to be that resource and having those business cards or flyers or things to refer them on for that, but at least we can give them those questions to start asking and thinking about.

Alan Helgeson:

So, really big takeaway: Start now and remember, you have lots of options. So the key thing here, just you have to start now.

Let’s go back to looking at some effective ways for individuals in the sandwich generation like Sarah. Give us some strategies that we can put to use and think about those things as we’re starting that.

Alicia O’Neill:

I think back to that financial question as well as, you know, when Sarah talked about all of those different emotions and burnout is what I think about sometimes is don’t be afraid to ask for help. And I think this is a great resource for people to even know what is out there for help.

A lot of facilities maybe offer respite care. So is there an opportunity where I can get a break? Kelsey mentioned the Active Generations. They’re a great place here in our location, and I’m sure others across the country maybe have like a daybreak kind of program or a respite care kind of program where you can have your loved one go for some time so that you can get a break.

And again, reaching out to, you know, our Good Sam Connection Center to connect you with different resources, just asking some of those questions of us, we can help navigate that circumstance or have that conversation with your loved one too, of what’s out there.

And so maybe if they aren’t quite ready to make that move, we can again pair them up with our home health or other services that we’ve just kind of been learning about too within our state, with the Department of Human Services, they’ve got Dakota at Home, and there are a lot of different caregiving grants out there, other caregiving programs that can help people finance some of these respite stays as well that we’ve just learned about in the last few months too.

So we can help make that call. We can help you kind of get some of those resources, whether you’re ready to move into one of our locations or if we can help pair you up with some of the other resources in this state as well as within our organization.

Alan Helgeson:

Alicia talked about, you know, some of these big things, the financial things, but are there some more basic things on that to-do list that we could do?

Kelsey Nicola:

One thing that sticks out into my head is that we are not a population anymore that stays in one spot. People might have kids who have moved across the country, just even across the state or out of the country.

One of the things I think is very important is having a conversation before you need assistance about do you want to stay where you are living now or do you want to get closer to where your family is? Just having a very honest conversation about that. It is uprooting the life of somebody, but it also in the end does provide more support for the person who is needing that support at the time.

Something else is, like Sarah had mentioned, her mom and her started looking for different locations, looking at different locations where her mom could get that support. It’s important to know what your options are in the area that you live or in the area that you want to live so that when the time comes that you need that support, it’s not a last minute thing and you end up someplace where maybe you didn’t want to at that time.

I think those are a couple of the biggest things, building your support system. Also, it doesn’t have to be family. It doesn’t have to be people who you are necessarily close with. Ask your friends, ask your loved one’s friends if they are somebody who can help support when that time comes.

We have a resident who gets support from friends and a friend of a friend. And she has just a wonderful support system here, which is so comforting to her kids who are not here. So building that support system is something that is crucial to caregiving for anybody out as well.

Alan Helgeson:

Can you again, run through those resources that are available at Good Sam and Sanford Health?

Kelsey Nicola:

We have on Good Sam’s website, it’s www.good-sam.com, resources that talk about the different level of cares that Good Samaritan offers. So we have independent living, assisted living, memory care assisted living’s in there, respite care, and then also our skilled nursing facilities. Those are wonderful websites and resources just to give a brief overview of what those levels of care are.

And we also have that connection center that people can call into. They talk to somebody and tell them just a little bit about the situation that’s going on, the location that they’re at, and then the connection center will email the location. Then the location can reach out and give resources as well.

Alan Helgeson:

Kelsey, what is that number for the connection center?

Kelsey Nicola:

The connection center number, it’s a toll free number. It is (855) 466-3726. And if you call and it’s after hours or on a weekend, you’re able to leave a voicemail and we get back to you.

Alan Helgeson:

Can you hit that number one more time please?

Kelsey Nicola:

(855) 466-3726

Alan Helgeson:

As we’re winding down the episode today, it’s been so much great information to share. What advice would you give someone who is just beginning to navigate the challenges of being in that sandwich generation from your perspective?

Alicia O’Neill:

Just know that we’re here to help, and there are many resources out there. You don’t have to do this alone. That’s what we’re here for. And that’s, I think, our favorite part of our positions and our jobs is being able to help guide families with these decisions and help give them the resources that they need and the support that they need to navigate this journey.

Get them the care wherever they desire, whether it’s home or in one of our locations. That’s my favorite part is being able to see how we can support and guide them, get them the help they need, and then ultimately, if they do decide to move in, see them flourish in our environment.

So don’t do it alone. There are many resources out there to help you.

Alan Helgeson:

Well, we’re so grateful that both of you are here and helping people feel comfortable because it is scary for somebody starting that journey and you’re making it better for people and for the people that are becoming residents and calling Sanford Health and Good Samaritan home.

So we want to turn to you as we wind down the episode today. Sarah, we are so grateful that you chose to come and share your story here and putting a face to what the sandwich generation is and can’t think of anybody better to give us advice as somebody that is going to be starting this journey. Tell us what would you offer as advice to somebody that’s starting.

Sarah Yoder:

I thought of those people who are just beginning this journey and really wanted to be a voice of encouragement and support for them. I think it’s important to just be aware that Good Samaritan and Sanford Health really are excellent at resourcing services. They can really help people who are beginning on this journey asking questions, where do I turn? How do I find resources? Even just filtering through that can feel overwhelming, and so they can do a wonderful job at providing those.

But I would just really encourage the person out there who’s listening that it goes so far beyond just services. You need to begin within those services to develop relationships with people that will come alongside you for a long time.

Yes, I have been in this caregiving sandwich generation role for over 10 years. I think it’s been about 13 years. So within the financial advisor, having the person that when you call, they know your name, the physician or the nurse advisor that really knows your situation and journeys with you, the person at Good Samaritan who knows your mom and her favorite preferences or activities, those kinds of things really help to develop those relationships and will sustain you in different ways.

I would also just say there is joy along this journey. If you’re taking care of young children and caring for elderly aging parents there’s a tendency to feel like one is just a burden and one you want to tend toward doing, caring for your kids or just having to meet the needs of your elderly parent. And I would just say find the joy.

Children can bring such joy with creativity and laughter and discovery as they’re growing. Children themselves can benefit from observing good caregiving. It can contribute in very healthy ways to their development. They themselves can feel like they’re contributors by bringing a glass of water. When Grandma needs her pills or taking out the garbage and having additional responsibilities, it can make them feel proud. It’s not necessarily something to shy away from, but involve them.

And then I would just say, look for support within the entire community. Find a church. The church is a place where we can bear one another’s burdens. We can be known. For me, finding rest and peace, hope and comfort in knowing and abiding in Christ, Good Samaritan was so important to Mom that there was a faith component in that. And I would agree wholeheartedly.

And then look to the community. There are excellent educators within the schools that will come alongside your children and provide some of that support to speak into their lives, notice their giftedness in there, and encourage them, guide and support them.

And then just the advice I would give: Don’t be afraid to establish healthy boundaries. Acknowledge your limits. You’re only human. There are limits to what you can do. So don’t put extra burdens on yourself. Be gentle with yourself along the way. You’re learning. You’ve never done this before, so give yourself some grace. Again, find a faith community. We need each other and we can share each other’s burdens along the way.

And then find that relational support, not just online chats, not just searching on your computer, but find people who will call and check in on you, who will send you a card or might just show up with a casserole. Sometimes you just need a casserole.

Alan Helgeson:

Sarah, Alicia and Kelsey, thank you for being here today because you’re sharing great information, really being a lighthouse to folks that are trying to find information, valuable information as they’re going through the challenges here and caring for older parents. And they also have young children at the same time learning about the sandwich generation. I’m Alan Helgeson. This is the “Health and Wellness” podcast.

Cassie Alvine:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, find us on Apple, Spotify, and news.sanfordhealth.org.

Get more episodes in this series

Mission mindset will help senior care meet growing needs

Alan Helgeson (announcer):

“Reimagining Rural Health,” a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high quality, low-cost services in rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, Courtney Collen with Sanford Health News talks with Dr. David Gifford, chief medical officer for AHCA/NCAL (American Health Care Association and National Center for Assisted Living), on the topic of how the association is advancing quality care for seniors.

Courtney Collen (host):

Dr. Gifford, it’s so nice to have you.

Dr. David Gifford (guest):

Nice to meet you, Courtney.

Courtney Collen:

I’d love to start by learning more about your role as chief medical officer at the American Health Care Association and National Center for Assisted Living, and then some of your background up to this point.

Dr. David Gifford:

Well, my son often says when asked what do I do, I spend most of my time in meetings and doing email and phone calls. But really I’d say a lot of time is spent really trying to focus on how to help members address quality. And that’s either through payment, regulatory measurement or quality improvement efforts.

Courtney Collen:

You recently co-authored a book about successful long-term care providers. What was your biggest takeaway or “aha” moment, if you will, that you experienced while writing this book?

Dr. David Gifford:

It was a lot of fun writing this book. And you don’t get to go up and talk to people who are really doing very well and say, “Why are you so good?” And so that was a lot of fun. And you know, Good Sam was one of those in there.

The take-home message was discipline to the mission, being very mission driven and letting the mission really drive all the things you do. I conceptually understood that before the book, but it really came through in talking to everyone.

Courtney Collen:

Yeah, certainly. Thank you. What are the American Health Care Association and National Center for Assisted Living’s priorities around quality care?

Dr. David Gifford:

We look at how quality of care is delivered and achieved through a wide lens. So how do we address payment policy? Because that affects quality. How do we address regulatory issues? Because that affects quality. How do we address the public reporting and five star (CMS Five-Star Quality Rating Program)? Because that affects quality. How do we do educational programs? Because that affects quality.

So we really focus on all those different areas to try to address it. Some are more directly impactful in the sense that they work closely one-on-one with a member and others. We’re working with federal agencies to try to make the changes.

Courtney Collen:

What innovation or action do you think will move the needle the most on expanding access to high-quality care?

Dr. David Gifford:

You know, what came out in the book and also in the keynote we just heard, right? The inspirational speaker Chad Foster, who’s blind. It was mindset, actually. It’s the mindset of how are we going to try to achieve quality and that it is achievable. And when you sort of set that aside, you’re able to sort of come up with new and innovative ways to address it and how do you really use the mission and the IDT team (interdisciplinary team), the team that we have working together to address that.

And when you do that, sort of everything else sort of suddenly figures out ways to overcome all these external challenges. That as Chad Foster said in his speech, often is used as crutches to explain why we can’t do what we want to do. And that really came through in the book.

Courtney Collen:

What in your eyes is the biggest threat, especially to rural communities?

Dr. David Gifford:

I think the biggest threat to rural communities, well, I’ll answer it in two ways.

One is I think staffing. You know, there has been an inward migration from rural areas into cities. And the pandemic helped slow that down a bit. So I think it staved off some of the challenges in rural areas.

But I would say the other threat in the rural areas with staffing, and it’s related to that, is that we’re all –the different health care providers in the rural community are competing with each other for staffing and competing with each other for resources. And there needs to be a way to really come together and collaborate, to work together to try to address that and overcome some of the regulatory payment silos that have been created. And there are ways to overcome that. And I think that the biggest challenge is overcoming the sort of the siloed nature of health care and that we have.

Courtney Collen:

I appreciate that insight. Do you see access to rural care, rural health care specifically as a public health issue?

Dr. David Gifford:

Absolutely. I mean, the public in rural areas need access to care and it is threatened with closures. It’s threatened with not having enough staff or qualified staff in the area. It’s threatened by not having access to, you know, high bandwidth Wi-Fi that you could use telemedicine to overcome. And so I think all of those things need to sort of be addressed.

And I see the health care not as an individualistic approach where I just sort of wait for someone to come to me for care, but more as how do we take care of the whole population and then how do we design the system to do that. When you do that, it changes the dynamic and it makes it more of a public health issue than just a health care clinical issue.

Courtney Collen:

Sure. Despite the challenges of the last few years, how have you seen organizations like Good Samaritan innovate and continue to raise the bar on quality care?

Dr. David Gifford:

I think that those that are being successful, A, are really looking back and relying on their mission. And I think Good Sam has got a great mission and we actually highlight in the book a lot of what Good Sam does with their mission and everything else. So you all have it right.

I think the others, the other way is to begin to think beyond what I would term a fee for service, a per diem sort of payment approach, and begin to think about it in a more of a population health approach. So, like with Good Sam, with I-SNP (Institutional Special Needs Plan) development we’ve been pushing the networks and bringing providers together so we could work collaboratively together, because that’s what’s going to take to address the problems beginning to sort of diversify.

And I think Good Sam even did that with a partnership with Sanford and a number of other issues. So I think Good Sam is really well-positioned and is not an organization I’m actually worried about going into the future because you all really sort of get it and are always thinking about innovative ways to approach the situation.

Courtney Collen:

Wonderful to hear, Dr. Gifford. Lastly here, are you optimistic about the future of senior care? What would you say are the biggest opportunities to improve?

Dr. David Gifford:

Well, the growth of older Americans, particularly over 80, who utilize a lot of our services, is going to double or triple in the next five to 10 years. So, the demand is going to be huge. So, in that sense, there’s going to be huge opportunities. And I think it’s going to cause us to think about different ways of providing the care. Which I think will, in the long run will be good for that.

So I’m very sort of bullish on the future for geriatric care in America. There will be challenges but there will be high demand. And with high demand, it usually brings innovative opportunities, which are always just exciting to see.

Courtney Collen:

Absolutely. Well, we really appreciate your insight here and your time, Dr. David Gifford and all that you do. We appreciate you.

Dr. David Gifford:

Well, thank you, Courtney. Thank you.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series wherever you get your podcasts and at news.sanfordhealth.org.

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Fight your body’s ‘decay code’ with daily movement

Anthony Morando:

I think with exercise, even with movement, you want to constantly try to reduce inflammation. Life is inflamed. Life is inflammation, mentally and physically. When we move, when we exercise, when we have that emotional commitment to something, well-being, we feel better.

Cassie Alvine (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about movement and the basics of how to get moving for your health. Our guest is Anthony Morando with Sanford Sports Performance. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

Anthony, thank you for joining us here today on the podcast. And I love this topic because it applies to me. I mean, I’m going to take stuff away from this and I do from every podcast we get, but I think there’s things that everybody’s going to get out of this one.

We’re talking about movement and knowing that you work with Sanford Sports and you deal with some of the biggest, brightest stars and people that have the potential to go on to do some of the greatest things and the athletes that you’re working with, but you also work with regular people, people that just need to get moving, want to move more, want to move better.

Let’s talk about folks that want to just start doing that. So our podcast today is about helping people with a basic nuts and bolts of getting movement. So how can movement look different within the different age groups? Now, we’ll break down the age groups, and you can go into some of these different areas as you want to, but we’re talking pre-teen for folks that have young kids, teens, those young adults, 20s, 30s, middle age, older adults, seniors. And I’m guessing it’s all a little bit different. So that’s a pretty wide open question to start. Where you need to jump in, just go ahead and do it.

Anthony Morando (guest):

Yeah, you got it. First off, thanks for having me. I think that the centric point today will be movement, which movement is essential for everyone’s health and well-being, no matter what age you are from cradle to grave.

And I think where we start with this is basically just given a range of the ages that we have in our facility at Sanford Health. And we have kids in the fourth grade who are learning how to be better movers through competency, through checklists, through specific exercises that are going to provide that competency through a checklist.

And then you have our high school athletes who are more consciously competent along with the collegiate and professional. But then you have our adults and our general population, and everybody’s trying to move. The differences, with the ages, are competency. The differences, with the ages, are sometimes full range of motion. As we get older, as our body gets older, we start fighting that decay process.

And decay might sound negative. I like to call the decay, the tide – the tide’s coming. So how do we fight the tide? And the way we fight the tide is through movement, resistance training and conditioning. I think in the general population setting, if somebody has some type of significant difference in movement, chances are they can’t go through a full range of motion. And then the pattern could possibly be dysfunctional if there’s weight attached to it.

So the first thing we try to do is groove the pattern, see if the pattern can become a little bit more functional. And if it looks pretty good, then maybe they start moving weight through a partial range of motion.

With athletes, it’s a little bit different. Chances are with an athlete, if there’s some type of limitation or lack of range of motion and a specific pattern, it could be due to an injury. It could be due to some other type of limitation on top of that limitation. So we have to be chief mechanics of movement. Our goal is to use movement, exercise, as our platform to create a better scenario for that individual person.

Alan Helgeson:

So when you and your team are working with somebody that might be in middle school training to be better at that football or baseball level, as opposed to somebody like me just trying to do a little bit better, trying to incorporate some more activity for heart health. Let’s talk about what qualifies as a movement and how might that be different with some examples from person to person.

Anthony Morando:

I think with movement, with a younger athlete, a kid, and take it again, take it from that fourth grade age, all the way through a senior in high school, their movement demands, when they’re training for specifically a sport or sports, their movement demands differ on a consistent basis. Some days they’ll move in a linear fashion. Some days they’ll move in a lateral fashion. And then there’s some days where they’re moving in a multi-directional fashion.

Now, if we’re going to link that to a scientific term, they move in a sagittal, a frontal, and a transverse plane. So our intent with all three planes is to create an environment, a climate that is specific to sport. Because sport is played in all three planes unless you’re a rower, right? And we don’t have many rowers around here in the Dakotas-slash-Minnesota, but you know, there are few sports that are only that one-dimensional plane.

So we train all three planes of biomechanical movement in order to create a stimulus that they can adapt to, whether it’s inside the weight room, on the field, on the ice, on the court.

Now those movements include all types of variations, meaning they’ll activate their glutes in that plane, they’ll dynamically move in that plane, they’ll perform plyometrics in that plane. They’ll lift weights in that plane, they’ll condition in that plane.

The difference with someone like yourself is as we get older, we have to fight that decay code differently because now it’s fitness for life. Once you surpass sports, right? Now, the great thing about sports is sports teach that fitness is an important part of life. But then when we’re done playing a sport, we still have to be fit. That should be the goal. And those planes change as you get older.

Some adults don’t necessarily move in the transverse plane as much as they used to due to a knee injury, you know, so what do you do? Some don’t move in a frontal plane because of a hip injury. So what do you do? So those are the differences that start happening when it comes to specific movement patterns.

Alan Helgeson:

Let’s talk about walking as good exercise. Tell us about why that’s a good thing to do. What can a person try to do to make an impact? And how many steps a day can make a difference?

Anthony Morando:

So right out of the gate, I’ll say that 10,000 steps a day is a cheat code for life (laugh), right? If you are getting 10,000 steps a day, it means that you’re moving significantly and you’re burning at least five (hundred) to 600 calories a day if you do have a wearable, right? And wearables, I’m sure we’ll get into that, but it’s easy to track.

But movement is life. And fitness – under the fitness umbrella, walking is included in fitness. And I would say that walking is like, you know, it’s, it’s funny. I have some Chapstick with me right now. Some would call this lip balm. I think walking is a great version of hip and back balm, right? Like, it’s soothing. It’s therapeutic.

You’re outside, you could be inside, but either way, you’re moving. And whether you’re listening to music or you’re moving in just silence, it’s a great way to generate at least three new ideas. Simultaneously, you’re performing aerobic exercise. Not everybody is capable to walk. There are people out there that have limitations that don’t allow them to walk. So what do we do? How do we find a way for them to move and get that same type of hormonal endorphin type of effect that’s going to still benefit their body? And there are machines, there are ways to still resist whatever type of mechanism they’re using, right? But we have to find a way to move.

Now, walking, again, it’s the bedrock of movement. If you can walk, it’s a great thing to do every single day. So we’ll start with that.

Alan Helgeson:

Great stuff about walking, but let’s take that even bigger. Let’s talk about the suggested minimum amount of exercise for benefits. And how much exercise a week does that look like?

Anthony Morando:

Yeah, Alan, you, you’re going to see the U.S. Department of Health is going to suggest 150 minutes a week. They’re going to suggest 30 minutes a day, five days a week. That’s what they’re going to suggest. I think that, say if I’m the one making the decisions for the country: one, right here we go, yep, I’m the guy for the job, right? I’m going to suggest at least 300 minutes a week. Now, that’s not to say that that answer is wrong, that they give, that recommendation is wrong. That’s taken into effect that I think we do need to exercise more.

Now, simultaneously, life is busy. People are busy. They can’t fit in a half hour some days. My job is to encourage them to fight that human nature. If somebody’s able to watch a show for 45 minutes, then you can still watch the show. Watch it on a bike, or watch it on a treadmill. You know, it’s significant to understand that if we don’t move, we slow down and the tide comes closer. Exercise, moving is the single most important thing you can do. And if you do it for an hour a day, it’s 4% of your day.

Alan Helgeson:

Anthony, that should be on a billboard. I love it. But we’re going to take it here to the benefits of all this movement. Let’s talk about how exercise can work towards our blood pressure. Can you give us a little insight on that?

Anthony Morando:

I think the blood pressure question is pretty simple. I think you have to think of pump efficiency. If we have a pump, and a pump is a contributing factor to a lot of different entities in this world. Our pump allowance happens with exercise. We create a better pump. And if we have a better pump, then there’s less pressure on our blood vessels and opportunities for our cardiovascular health just continue to stay open.

We have an open opportunity to be healthier if our blood pressure is lower. And there are three quick ways to lower your blood pressure in the natural remedies:

• A, going back to walking, you can walk every single day. That’s going to give you a chance to lower your blood pressure.
• B, strength training. Strength training is another form of lowering your blood pressure.
• And C, putting it all together where I can do a strength training exercise, and then maybe I can walk for 60 seconds on an incline treadmill, go do another strength training exercise. And then maybe I can crawl on the floor for 10 yards. That’s another example of aerobic and anaerobic exercise that are combined to decrease blood pressure.

Alan Helgeson:

Making us feel good about the benefits of movement. But Anthony, we’re about 10 minutes and change into this podcast. Let’s talk to the folks that maybe haven’t incorporated movement into their day-to-day routine, or for whatever reason, just start doing things. Life has changed. They haven’t found the time or made the time, whatever the reason is. What are those small steps? We could just get started, get the jumper cables out and just get started.

Anthony Morando:

You know, Alan, I think the first step to all of this is we have to connect with people psychologically and emotionally before they take that journey. You know, before they actually say, OK, I’m going to try to become fit. Like everybody has some type of blockage on the reason why they can’t or won’t do something. And you have to connect and commit. It’s easy to get a customer. It’s hard to get a client.

And I’m going to emphasize, I’m going to hit on that point because I feel like it’s important. It’s easy to have a customer – knock, knock, hi, I would like a personal training session for 60 minutes (laugh), right? That’s great. And that’s a quick transaction. Got a couple bucks in the pocket and life is good, but life becomes better for you and for them through longevity. So connect and commit. That transaction needs to become a transformation.

So that customer, you want that customer to become a client. And the only way to do that is to care about them and is to create a relationship first. And then, they become a client and then they don’t leave. And that’s simple. That’s simple math right there, right? That’s the T plus T equals, I don’t know what the equals sign is yet, but transformation. How about a T equals a TA transformation equals a transaction. And vice versa. They go hand in hand.

I believe that it doesn’t matter where you start. It matters that you keep it up forever because that will work. You can start by walking. You can start by doing five pushups a day, right? You can start by pulling a band apart five times a day. It doesn’t matter. What matters is that you do it and then you do it again the next day and then you do it again the day after that, and so on and so on. And then on top of that, why are you doing it? Why are you doing it?

Alan Helgeson:

Well, Anthony, let’s get into it here. Let’s start naming names. Let’s talk about some good forms of movement for beginners, those exercises and certain ones for certain age groups. So let’s even break it down here by some of those age groups for fitness levels, and let’s even talk about maybe some modifications if we want to get into that a little bit after the fact. But let’s go.

Anthony Morando:

Yeah, you got it. What’s important to understand when you’re classifying exercises in movement patterns? It’s important to understand something called the LTAD model – the long-term athletic development model. That was established through the late ‘80s, ‘90s and early 2000s compiled over time.

I think it’s important to understand that if I have a fourth through sixth grader or even, you know, Alan, I have four kids, right? They all move constantly. When you have these little kids up until the fourth grade, you’re working for suppleness. You are working for coordination. So what are the exercises that you can give somebody at a young age? They can body weight squat. They can learn how to do a hang, right? A lat hang or a hanging pull up. They can learn how to do a pushup. They can learn how to do a TRX row.

We have a lot of our little kids doing TRX rows, which is just suspended handles from a higher surface, and they can pull their body weight up. Body weight, split squatting body weight exercise is done in a real efficient and functional pattern along with sprinting and along with jumping and landing. That’s really good for a little kid. And they also get that within their sports.

And then to put the cap on the bottle with the kids, games, small area games, obstacle courses, teaching kids how to play, hang, jump, roll. That’s all effective for their motor development and for their overall development as the years go on. As they grow, as they get into that sixth through eighth grade range, Alan, and some of them start hitting puberty, that’s when we start introducing load to these patterns, meaning we’re going to give them weights. That body weight squat now turns into a possible goblet squat, right?

That pushup turns into a bench press. That lat hang turns into a pull up. Now the exercise is the basic movement patterns that we gave those kids become more demanding. Through high school, they’ve become more demanding and along with college and professional.

General population adults change due to mileage on the body. Adults still squat. Adults still hinge. They still pull, they still push, they carry things. The only difference now is for an adult client, when they’re squatting their squat might not be on their back barbell. We don’t load our adults in that axial formation where their skeleton is loaded, where their spine is loaded. Instead, we load them maybe from the bottom and maybe their hips tap a box or their glutes tap a box when they squat. There’s all kinds of modifications for an adult to squat because we still need to squat.

For pushups, if somebody is unable to do a pushup from the floor, we’ll elevate their hands. If somebody is not doing a pull up due to a shoulder issue, then that pull up turns into a lap pull down. So there are modifications, there are ways, but there are cans versus can’ts for everybody that wants to train. And everybody can train. Every body can train. And I’ll almost put the “have to” in there because it’s important. Because guess what? It keeps you alive longer.

Alan Helgeson:

Well let’s move to some of those basic rules here, Anthony. Someone who’s maybe not been very active or getting going into this stuff. You want to be watching out for things, you know, that you want to be careful not to overdo things as you’re kind of moving into this stuff and you don’t want to go from zero to 10 right away. What are some of those things we should be looking out for?

Anthony Morando:

I think no matter what, strength training, learning how to strength train properly is extremely important. You’re going to need to learn how to squat in a functional pattern, performing a upper body push exercise, an upper body pull exercise. And I say hip hinge, RDL is common when I say when hip hinge or deadlift. And I don’t say deadlift right away though, because everybody thinks that that’s just picking up heavy weight from a floor. Deadlift, meaning you’ve got to pick up a heavy bag of groceries at some point off the ground. So we want to still teach that pattern along with aerobic exercise.

If somebody’s just starting out, you don’t want to throw them into interval training right away. We have a great group here right now who, it’s called the transformation group, where six, seven weeks ago we didn’t give them any interval-based training, but now we do because they’re six or seven weeks in. But their cardio or their conditioning started off with a brisk walk. There needs to be integrity in the weight room because if there’s not, somebody can get hurt. And our first rule, no matter what, is do no harm.

Alan Helgeson:

Next question, Anthony. We know a little internet can be dangerous for everybody involved. So we’ll do some looking at different things and then we see terms like intensity, endurance or both. So as we’re starting with things like this, people may think they should focus on these things. You tell us as an expert, how do we decide what we should focus on as beginners when we’re getting into something like that? How do you make that determination?

Anthony Morando:

Number one, if you’re starting anything, it needs to be, the word fragmentation needs to exist. Small fragments over a long period of time. So if you’re starting out with fitness, first thing I advise is some type of low level aerobic activity for 30 minutes, along with two to three strength training exercises. That’s a 45 minutes to one hour piece of your day. If you’re unable to fit that in or fit both in, then maybe that day one would be some type of low level aerobic exercise.

And day two, you focus on more than two to three strength training exercises instead. And then you alternate that. I’m always going to push for six to seven days a week. You can do something every day if you gauge the intensity properly.

Engaging the intensity properly comes down to fragmentation. Leave a little bit of gas in the tank every single day so you can wake up and go back to more the next day. Over time, again, if you keep it up and if you get into a groove, then it becomes good for you because it’s something that you’re doing on a consistent basis. Consistency is key when it comes to fitness, but it needs to be fragmented.

Now, intensity and endurance and all the training variations and attributions out there, they’re different for everybody. That’s why it’s important to have an assessment.

Alan Helgeson:

Anthony, the next question I want to jump to is that word, the big M word here, “modification.” So I may have taken a tumble down a mountain from skiing and I’ve had some snowboarding incidents where, you know, I’ve got some orthopedic issues and there are people out there that have bad knees. They might be overweight, or if you’re pregnant, let’s talk about modifications. How do we figure these things out?

Anthony Morando:

Modifications are just, they are magic bullets within exercise, right? Like exercise is the magic bullet, right? That’s the magic pill that that’ll keep your life better and it’ll keep you around longer. But the modifications in the magic bullets within the magic bullet. I mean, they really work too. I mean, imagine going to the gym and your shoulder’s killing you, but then all of a sudden a coach could say, oh, wait a minute, wait a minute.

You know what, maybe you shouldn’t be pressing this over your head, but I bet you if you do it at 45 degrees, it’ll lessen the intensity on the shoulder. And then boom, Alan, all of a sudden you’re pressing at 45 degrees and you look at me and you go, whoa. Mind blown. We do that every day.

Alan Helgeson:

What I’d like you to speak just a few seconds about here, the modifications. I think modifications keep a lot of people away because they can’t do what they maybe used to be able to do. Or if they feel they’re having to do something different than what everybody else does, they feel different about it. Nobody wants to look different from what other people do. That’s a big deal. Can you speak a little bit about that?

Anthony Morando:

I appreciate that too. Because that’s certainly the other side of the coin while we’re talking, right? If we just talked heads, now let’s talk tails. It goes back to psychologically connecting with your clients. It goes back to saying, OK, you know what Emily, you’re not going to do this because we know this is going to light your knee up. I’m going to, or one of our coaches are going to say to ourselves, due to our experience in education, we don’t want the modification to necessarily be easier.

We want it to still be challenging. So we might manipulate the sets and reps for that individual. We might make that individual load, that modification, a little bit more than they would with a normal exercise. We want them to feel probably more challenged. That way they have the sense and feel internally that, OK, this is modified, but this is still really challenging for me.

There’s two things that happen. They’re either going to be satisfied with that modification or they’re going to want to go back to the normal exercise because the modification is too challenged, right? And with the athletes, it’s a little bit different because the way I modify an athlete, it’s like, OK, here’s the deal. If that’s hurting, that’s fine. I’m not going to try to put you in more pain. But if you’re not going to run, then I’m going to give you a low impact exercise or a low impact protocol on this bike, and this bike might be worse than the run. And I bet you four out of seven of them start running again. (Laugh)

You know, that’s not that bad. I think I’ll take the run and I’m not walking around like a little demon, but simultaneously I’m going to be demanding. Yet I’m going to be fair.

I’m going to give you both sides of that coin. And if you can run, you better run because you’re going to take away from the specificity of your sport. But if you can’t run, it’s not going to be easier. You can see, I can, you know, we flick the switch, right? With an athlete, you’re still connecting with the athlete. You are not degrading them in any way. You’re giving them an option. It’s democratic.

With the adults, it’s different. You have to give them something where they’re going to want to feel more challenged. So it is just, it’s just knowing people, right? It’s people. Modifications have to do with people too. Not just you being the expert on the exercise.

Alan Helgeson:

Let’s talk about something that we know people hear when they go to their doctor’s office and they hear the term, if they haven’t been active, that they hear these words. Muscle atrophy. What is it? And can you reverse this?

Anthony Morando:

Muscle atrophy is just decrease in muscle mass. It’s decrease in strength. Can you reverse it? Yeah. It’s one of those scenarios where we get older. We all have a genetic pool. People lack activity. There’s some medications out there, there’s injuries out there, there’s limitations.

But either way, finding a way to strength train two to three times a week will fight against the atrophy. That atrophy is just another word for the decay code. Daily exercise, emotional commitment, reasonable nutrition, and a real engagement with living will fight against any type of atrophy. It’s just going to. I mean that. That’s it. And it starts with exercise. It starts with exercise.

So atrophy, defeating the atrophy or working against it to delay it, starts with exercise. Whoever out there is listening. If you feel like, “oh, it’s too late to start.” It’s never too late to start. It’s great if you committed to this before, when you look back, if you’re 42 right now and you don’t start till you’re 60, you don’t want to look back and say, you know what? I wish I started with 42. It’s a lot harder at 60. That’s not going against any 60-year-old out there. That gap, that 18-year gap is a big difference.

You can start today. All you have to do is move. If you don’t know what type of movement that is needed for your body, then just walk.

Alan Helgeson:

But let’s talk about tracker watches, apps, those kinds of things. What are some of those things that Anthony recommends to people he works with? Or your family comes over for Thanksgiving and they say, oh, Anthony, tell us what’s going to help me on the tech side.

Anthony Morando:

The trends of fitness, we always have to be aware of. I think wearables have become a really big deal. Everybody I see is, is chances are they’re wearing an Apple watch. I love my Apple watch. I get to track my workouts. I get to track my heart rate. I think wearing an Apple watch is important because you can track your intensity, right? You can track how often you’re training. It rewards you and almost gives you this little technological incentive. Like, “good job,” “keep moving,” right?

But some people need to see that or hear that. Some people have never worked out seven days in a row before. Some people have never worked out four out of seven days before. That wearable is going to give you some type of award. It gives you a little medal – it pops up, right? Some people think that’s cool.

The wearables are important, I think, for heart rate, especially because heart rate is going to dictate the intensity zone that you’re training in. A heart rate monitor in general, a heart rate monitor, keeping track of what your heart is doing, what the pump is doing during your least intense zones and your most intense zones. That’s important too.

As for a smartphone or an iPhone, there are several apps. Now, I’ll say from a technological standpoint, having some type of online training software app is significant for people because online fitness has become a popular entity throughout the world. It’s global. And I’ll take one more step above that, and this might not be too technological, but YouTube is still a go-to when it comes to education. Not Instagram, not Facebook, not Twitter. It’s YouTube. YouTube still holds strong and there’s bad content everywhere. There’s good content everywhere. But if you can find the right coaches on YouTube, there are so many videos with great coaches performing exercises.

That would be my answer when it comes to technology in the fitness realm. Now there’s probably 19 or 20 more Alan, but just to keep it simple, that would be a baseline.

Alan Helgeson:

Let’s get to hydration and water. How important does that play a role in any movement and activity and why?

Anthony Morando:

Water is 75% of our body. So hydration plays an important role for multiple factors. A couple that come right to my head would be vitality. In order to function, in order to live, to sleep well, to move well, to breathe well, you’re going to need to be hydrated. While you work out, you’re going to need to sweat. If you’re dehydrated, then you might not sweat as much as you should be.

The other piece of it too is you need to drink water to feel better. Like you feel good when you drink water. You feel alert when you drink water. The fact that you’re hydrated is another version of meaning “I am” right? Like, I am. Just like when you drink your coffee, that stimulant, it gives you a bigger version of “I am.” You feel great when you’re doing it, but water’s a constant. It’s like anything else. It’s like exercise that’s constant. It needs to happen on a consistent basis because if it doesn’t, there are significant health dysfunctions that come with dehydration.

Alan Helgeson:

I’ve got a friend here that I work with and says, when he’s not drinking enough water, you don’t feel it necessarily the same day. He can really tell the next day. That’s a big thing. You can tell the following day.

Anthony Morando:

Yeah, you’ll get a headache, feel fatigued, feel lethargic, you know, you might even have some type of delayed onset muscle soreness. I’ve heard that in a lot of people who are frequently dehydrated and believe it or not, people have trouble drinking water.

Alan Helgeson:

Anthony, we’ve had a great program here today, but as we wind things down here, let’s kind of tie a bow around everything here with final thoughts about why we should get moving. Is it that hard? I want you to really leave us with something inspirational that’s kind of like your big job and what you do. Send us out the door here with making us feel good that we can get this done.

Anthony Morando:

Well, I think with exercise, even with movement, you want to constantly try to reduce inflammation. Life is inflamed. Life is inflammation, mentally and physically. When we move, when we exercise, when we have that emotional commitment to something, well-being, we feel better.

And if we feel better and our physical self-perception is heightened, things go better. I don’t know if I’m too inspiring, but I will say that I try to be factual when it comes to exercise because I love and appreciate it and it’s done a lot for me in my life. Overall, if you’re going to leave you with something, it’s fitness is the celebration that we’re alive and we can move. That’s it. If we’re given this body, we might as well do the best we can with it. So don’t fill it with sugar. Move it more. Try to read more to make sure that that brain is feeling better, and engage in good activities that make you feel better. Lift a couple weights. Be reasonable with nutrition. Drink a lot of water and keep moving and things might just feel a little bit easier and you might look better and feel better.

Alan Helgeson:

Anthony Morando, thank you for joining us here today. Anthony, general manager of Sanford Sports Performance in Grand Forks. Great stuff. My big takeaway here among all of it, I wrote this down here too, that movement is life.

Cassie Alvine:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, find us on Apple, Spotify, and news.sanfordhealth.org.

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Why breast density affects your mammograms

Dr. Andrea Kaster:

One of the things we want to drive home is that if you know you have denser breast tissue and that mammograms are still very valuable – they’re still the gold standard for screening – but we know that there are certain things that we cannot see on them and that it’s important to pay attention to your breast. Know what feels normal for you so that you’re more likely to notice a change. And if you do notice a change, we want you to come in and get it checked out.

Courtney Collen (host):

This is “One in Eight,” a podcast series by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. One in eight women will be diagnosed with breast cancer during her lifetime. So we want these conversations to shed light on awareness, featuring expertise from our Sanford Health providers that could save your life or the life of someone you love. We’re glad you’re here.

In this episode, we are talking about breast density, what it is and why it’s important in your care journey at Sanford Health. Joining me is Dr. Andrea Kaster, a breast health specialist who provides care to patients at the Edith Sanford Breast Center in Fargo, North Dakota. Welcome, Dr. Kaster. Thank you so much for being here.

Dr. Andrea Kaster (guest):

Thank you for having me. I’m glad to be here and talk about this timely issue.

Courtney Collen:

We’re so happy to have your insights and we’ll get started with this question: What is breast density and how is it determined?

Dr. Andrea Kaster:

Breast density is essentially a mammographic finding. And that’s a very important point to drive home, is really we know density based on how the breasts image on their mammogram. And so what it is, is the relative amount of glandular lobular structural tissue, or connective tissue, relative to fatty tissue in the breast.

And so the reason that matters is that the more fibrous tissue and glands and ducts show up white on a mammogram, whereas fatty tissue shows up more gray appearing. And so the whiter the background is, the more dense your breast tissue is essentially on the mammogram.

So cancer shows up white on a mammogram as well and so if you have a very white background, you’re looking for a white mass within a white background.

Courtney Collen:

Why is breast density an important factor in mammograms?

Dr. Andrea Kaster:

So, breast density has two major implications on mammography. One is that it can make it harder to see masses. So like talking about the masking effect of that glandular tissue relative to the fatty tissue. So harder for radiologists to see masses and sometimes then the masses actually have to get bigger before they can be seen.

And then the other thing is, which is not completely understood, is that women who have dense breast tissue do tend to get breast cancer more often. So whether it’s just the relative amount of more active cells in their breasts, there’s not really sure what that connection is, but it is an independent risk factor for breast cancer. So it’s a twofold risk.

Courtney Collen:

OK, good to know. How common is it for women to have dense breasts? Is it common?

Dr. Andrea Kaster:

It is common. And that’s a very good point to make is that actually 50% of women have what would be considered dense breast tissue.

So the American College of Radiology has four categories of density that are given with every mammogram that’s done. And that is a category A, B, C, or D, which means primarily fatty-replaced breasts, scattered fibroglandular changes, heterogeneously dense, or extremely dense breast tissue. And it’s the heterogeneously dense or extremely dense categories that count as dense breast tissue.

So 50% of women fall into one of those two categories on average, it depends somewhat on age, but we would say about 10% of women have fatty-replaced breasts, 40% have scattered fibroglandular changes, 40% have heterogeneously dense and about 10% have extremely dense. So it is not uncommon or abnormal to have dense tissue.

Courtney Collen:

Are there any lifestyle factors that contribute to having dense breasts? Why do some women have more of that dense breast tissue than others?

Dr. Andrea Kaster:

Density is primarily determined by your genetics, just how your breasts were kind of genetically predisposed. So we will see family where, yes, all the women have denser tissue. And so that is the primary reason that we will find dense breast tissue in some women compared to others.

There are definitely other things that go into it. So, you know, genetics is a big deal. As you get older, your breast density tends to go down. So we lose some of the more ductal and the lobular tissue and it’s more fatty-replaced with age.

If any individual has a dramatic change in their weight, that can change their breast density. Pregnancy can make a difference. So pregnant breasts on imaging tend to be much more dense. Menopause with a drop in estrogen will decrease your breast density. If you’re on hormone replacement therapy or hormone blocker therapy, those can either increase or lower your density.

So there are definitely things in our life that can make a little bit of difference, but it’s primarily genetics. And as we go through life, you will look back on a mammogram and you can compare to, and there may be a difference that you see, it’s not a like one year from the other, you’re seeing a dramatic difference unless we add in some of these other factors.

Courtney Collen:

What challenges do dense breasts present in detecting breast cancer through mammograms?

Dr. Andrea Kaster:

We know that the denser the breast tissue is, the whiter the background or the whiter the appearance on a mammogram. And cancers show up white on a mammogram, so if you have a very white background, it’s like a polar bear in a snowstorm. It’s just a lot harder to see a white change within that.

And so we find that cancers are found at a slightly larger size when women have denser breast tissue. They tend to have pathology with some more high risk features related to it. And we know that the sensitivity of the mammogram, meaning the number of cancers found on a positive test, is lower with dense breast tissue.

So whereas a mammogram in a woman who has a very fatty-replaced breast, their mammogram’s going to catch, we would say, and the numbers vary, but we would say a nine out of 10 breast cancers on initial. And that goes as low as 62% or 6.2 out of 10 breast cancers in extremely dense breast tissue. So the difference between the sensitivity of the mammogram is quite a bit.

And so a big take home message for patients is really that we know mammograms are great and a lot of this information that we share with women, because we’ve always talked about density, but it hasn’t always been something we talked about with patients.

But one of the things we want to drive home is that if you know you have denser breast tissue and that mammograms are still very valuable – they’re still the gold standard for screening – but we know that there are certain things that we cannot see on them and that it’s important to pay attention to your breast. Know what feels normal for you so that you’re more likely to notice a change. And if you do notice a change, we want you to come in and get it checked out.

The whole idea behind this started with a woman who was a stage 4 breast cancer diagnosis, and she felt a lump after a mammogram and sort of thought, well, I just had my mammogram, it’s going to be fine. This can’t be anything. And delayed going in with that sort of sense of security.

So for all densities, we want women to report changes, but that’s especially the case knowing in women with denser tissue that the mammograms are just not quite as sensitive as they are for women with less dense breasts.

Courtney Collen:

Are there any additional screening methods recommended for women who have dense breasts?

Dr. Andrea Kaster:

Yes, there have been some current guidelines that are suggesting that patients should at least talk to their providers about their density. And talk about if there are supplemental screening options for them that would be useful. So it kind of depends upon the area of the country you’re in or even what Sanford facility that you are going to and what those options are.

For women who have extremely dense breast tissue, or heterogeneously dense breast tissue, and have an increased risk of breast cancer, the best supplemental screening is an MRI. That’s kind of the most well-studied supplemental screen we have. We typically do that at about a six-month interval from the mammogram. So they’re actually, again then getting screened twice a year.

MRIs are a completely different type of study. They’re a magnet and they use a contrast material called gadolinium to look for areas of blood flow changes within the breast. And so they look at things totally differently. They do not replace mammograms. They are in addition to mammograms and so that is a good option for women who are higher risk.

For women who might have dense breast tissue, but don’t necessarily qualify for a breast MRI or to qualify for being higher risk, then we have other options. One of them that we use most commonly is a contrast enhanced mammogram that again, uses a contrast material to highlight any areas of increased blood flow.

Some facilities do whole-breast ultrasound. The sensitivity on whole-breast ultrasound is not as high as some of those other studies I talked about so we don’t use that here. And some do like a molecular test on the breasts as well. But again, that’s not something that we use here. So typically it’s either adding an MRI or a contrast enhanced mammogram.

Courtney Collen:

In talking about risk, which you mentioned a moment ago, how would breast density or how does breast density affect a woman’s risk of developing breast cancer?

Dr. Andrea Kaster:

Like we talked about, it does increase your risk probably about 1.2 to twofold increased risk of breast cancer in women who have denser breast tissue. So it does increase the risk and that is part of the overall picture.

There are many things that can affect your breast cancer risks. Some of them are much more kind of prominent than others. Certainly if you have a history of an early breast cancer yourself, if you’ve had an abnormal biopsy with you know, atypical hyperplasia or LCIS, if you have genes that increase your risk, all family history, that all can make a difference.

And so it really takes doing using a risk assessment tool that includes density as part of your risk in order to determine that cutoff. And typically we would use the cutoff at about 20%. So women whose lifetime risk is above 20% are considered to be high risk, and then there’s kind of a moderate risk category around 15 to 20%. And then the average risk below that.

We currently recommend starting annual mammograms at age 40 based on the fact that that is the way to save the most lives. And so that is our recommendation definitely for women who are identified at being higher risk or say for example, have a mammogram for diagnostic purposes because you wouldn’t necessarily know if you have dense breast tissue unless you’ve had a mammogram because we can only know by the mammogram findings.

And so say somebody comes in with a problem and they get a mammogram and they’re found to have extremely dense breast tissue, that is a patient who we may want to do a risk assessment model on to see if they would qualify for earlier screening. And there are many studies that show that for women who do have extremely dense breast tissue or heterogeneously dense breast tissue in their 40s, that there is a very high benefit to having that annual mammogram.

Some guidelines will say you can go every other year or you can wait till 45. That does not apply to women who have dense breast tissue.

Courtney Collen:

Can you determine dense breasts by like a physical exam or it needs to be determined by a mammogram?

Dr. Andrea Kaster:

It can only be determined by a mammogram. Because it really is, when we’re talking about density in this form, in the technical scientific form, it is the relative amount of fibrous tissue to fatty tissue. And you can’t tell by feeling.

Courtney Collen:

You can’t just touch your breast and say, you know, these feel dense.

Dr. Andrea Kaster:

(Laugh) No, and that’s a very common – I have people tell me all the time that they have dense breast tissue and they’re talking about the way that their breasts feel. Right? Sure.

So what breast density is not, it is not lumpy breasts, it is not firm feeling breasts, it is not size of the breast. All of those things are commonly kind of misconstrued as I have dense tissue because it’s really lumpy. Well, breasts are actually mostly lumpy and that does not have anything to do with what they’re going to necessarily look like on imaging.

Courtney Collen:

What should women with dense breasts know about their mammogram results?

Dr. Andrea Kaster:

I think that they should first of all know some of the things we talked about. Like we just know that it is not considered abnormal to have dense breast tissue. That it’s actually very common.

I think it’s important for them to know that yes, it does increase their risk, but it’s part of the whole picture. And so talking to your provider about what your other risk factors might be in order to get a better whole picture, I think it’s very important for them to know that mammograms still work. They are still considered to be the gold standard for screenings because a lot of times women will come in and think, well, I don’t need to have a mammogram because my breasts are too dense. And it’s like, and that is not the case.

We still want use mammograms as our best screening tool for breast cancer. 3D mammography is important in women who have dense breast tissue. So most facilities now use tomosynthesis or what is more commonly called 3D mammograms. That is really important for women with dense breasts.

So I’d say if you do know you have a denser half of tissue, that it’s very good idea to make sure you’re getting a mammogram where they have 3D mammography because that improves cancer detection rate. And it also reduces callbacks because that’s another very stressful time for women when getting mammograms. And if you have dense tissue, you’re more likely to have that overlapping effect of the tissue. And so 3D really helps with that. So I would definitely tell those women, make sure if you are getting it at a facility that whatever facility that is, that they’re using 3D mammography.

And then just to know that it might change a little bit. So one of the things that can be a little bit frustrating or hard to understand is that density can change from year to year or even radiologist to radiologist. So you could have two radiologists look at the same mammogram and one might give one category and one might give a different category. It’s not that your breast density is different in those different pictures or from, you know, even maybe from year to year. It has more to do with variations in the way that a radiologist actually reads those pictures.

And so you may get heterogeneously dense breast tissue one year and extremely dense breast tissue the next year and it doesn’t necessarily mean that your density has changed. It just means that it can vary slightly on lots of factors essentially. So the big overall picture would be that you’re in that denser half.

And then we talked about reporting changes and not, you know, for everybody not relying that if the mammogram is normal, you can’t have breast cancer. That’s never the case. And so we always want to make sure that you’re still paying attention to your breasts and reporting any changes.

Courtney Collen:

Good to know. Are there any recent advancements or studies related to breast density and mammograms?

Dr. Andrea Kaster:

Yes. There are a lot of ongoing studies. There’s still studies ongoing between using 3D mammography like we talked about, or 2D and also an abbreviated MRIs for screening women with dense breast tissue. So there’s all kinds of research going on how we can best screen these women.

There have been some new recommendations or guidelines. The Mammogram Quality Standards Act, which is through the FDA, in September of 2024 came out with guidelines suggesting that all women be advised of their breast density. So it kind of was state to state for a while and now it’s like, nope, all women need to know what their breast density is when they have a mammogram and that they should discuss supplemental screening with their primary care provider. So those are new guidelines that are pretty specific about that.

We need to be having these conversations and at least discussing options for supplemental screening. As far as the American college of Radiology in 2018, they recommended an annual MRI for women who have had a history of breast cancer and have dense breast tissue. And so that is new related to breast density specifically, new recommendations there.

So there have been these more recent changes. Along with people being more aware of it, they’re giving us guidelines on how to best utilize that information.

Courtney Collen:

It’s such valuable information and really the more that we know about our own bodies, the more proactive we can be about our health. Like now leaving this conversation, I want to know what my breast density is and I should probably wait until I’m 40 to get that mammogram. But no, it’s all fascinating. And we appreciate the update in those advancements and studies.

Dr. Kaster, if a woman is concerned about her breast density or the risk of developing cancer with dense breasts, what would you tell her?

Dr. Andrea Kaster:

So, I mean, I start by trying to make it seem that, to understand that it is more normal than we might realize, so that it’s not a bad thing. It’s not that there’s something wrong or that it’s even that unusual. That we just, it’s just more common than people realize. And so to try to think of it that way. A lot of people are relieved to find out that it’s actually not a rare thing and that there’s more women out there than they might realize.

And then just to talk to their providers about their overall risk because it is part of the picture but not the whole picture. And so that it’s important for them to talk with their primary care providers about if they need to have a more formal risk assessment or if they need to do any extra testing because of that.

And then continue with their breast awareness, continue with their annual mammograms, request a clinical breast exam if they feel like they have dense tissue and want to make sure that they’re getting checked out. That would be important as well.

Courtney Collen:

Well, this has been such valuable information, Dr. Kaster, learning so much about breast density, which is going to be great information for our patients listening.

Dr. Andrea Kaster:

We are here at the breast center anytime people have questions or providers have questions and they want to reach out, we’re happy to discuss this with them. I do think it’s important to have a good discussion about it kind of early on with realizing if you are in that denser half so that people have a good understanding of what the recommendations are going forward.

We will be keeping abreast of all new changes and changes in guidelines and making sure that we keep updating that all the time through our facility and through our Edith Sanford initiative and just making sure that we’re doing the best we can for screening.

We know that screening helps, but we also know that breast cancer is a very common cancer. It’s common in younger women and the sooner we can find it, the better options we have for treatment and the less aggressive treatment that is needed for cures. So it is important to try to find it as early as possible and that takes the whole team working together to do the best we can for women.

Also, just a reminder for patients too, is that you can get breast cancer before 40. So make sure that you’re paying attention to your breasts as well. If you have a family history, reaching out and trying to see if you might be a candidate to start screening sooner is also really important.

Courtney Collen:

So important. Dr. Kaster, thank you so much for all of your information and expertise on this topic and for all that you do for patients at Sanford Health.

Dr. Andrea Kaster:

Thanks for having me.

Courtney Collen:

This episode is part of the “One in Eight” podcast series by Sanford Health. For additional podcast series by Sanford Health, find us on Apple, Spotify, and news.sanfordhealth.org. I’m Courtney Collen. Thanks for being here.

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What to expect with a low-intervention birth

Kayla Quinn:

Some people might think, “well, if I’m in the hospital, it has to be X, Y, Z, this way.” And that’s really not true. You don’t have to have Pitocin, you don’t have to have an IV, you don’t have to push on your back if you’re in the hospital. That natural birth experience really can happen. It can happen in the hospital just as well as it could at home.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. We are starting new conversations about age-old topics from pregnancy to postpartum, managing stress, healthy living, and more. “Her Kind of Healthy” is here to bring you the honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.

In this episode, we are talking about a low-intervention birth and the options that you have at Sanford Health. I have two guests joining me for this conversation. Kayla Quinn and Stephanie Metzler are both certified nurse midwives at the Sanford Medical Center in Fargo, North Dakota. Kayla, Stephanie, welcome. Thank you both for being here.

Both guests:

Thanks for having us.

Courtney Collen:

Happy to have you. Let’s jump right in here. When we say low-intervention birth, what does that mean?

Stephanie Metzler (guest):

So low-intervention birth usually involves limiting the medical interventions. So I feel like that really starts with prenatal care, with providing education on pregnancy changes to be expected, what labor really looks like physiologically. And our goal really with low-intervention birth is to allow the body to go into labor on its own naturally and progressing through the birthing process without us adding a bunch of extra medical interventions that aren’t necessary.

So we do promote interventions when they’re appropriate for safe care, and we’re constantly evaluating that safety plan. So each individual client is different of what we’re doing, but the outcome is safety and best outcome for what Mom wants.

Courtney Collen:

Yeah, absolutely. Thank you for that. And at Sanford Health, what does that experience look like? In other words, how does a patient have a low-intervention birth? Like, what options do they have and how soon would they need to know that’s what they want?

Kayla Quinn (guest):

I think that it’s important to start thinking about those things early on in your pregnancy for a couple reasons. You know, at Sanford we have a lot of options for providers. You can see throughout your pregnancy, you have the options of OB/GYNs, obstetricians who are medical doctors, or you have the choice of certified nurse midwives. And a lot of it comes down to personality too, and really finding that provider that really meshes with you and someone you feel comfortable having a conversation with.

You know, low-interventional birth really comes down to planning and open communication more than anything. And so having the discussion in advance before you get to the labor part of, OK, what do you want? What does that mean to you? What does low intervention mean to you? Does that mean not breaking your water? Does that mean not having an induction? Does that mean no medication? Does that mean maybe just IV medication versus an epidural? It’s really kind of what does that mean for you?

And we do have all of those options at Sanford. You know, you can do low interventional with medication, you can have no medication and have interventions. And so you know, there really is a lot of options, but really having the conversation in advance is really important. What that might look like, though, would be if maybe … I don’t want to use the word avoiding, but kind of avoiding an elective induction or, like Steph said, trying to let labor just progress naturally on its own.

And there are things we can do to to help your body get ready for a natural labor, things like staying active, walking beyond the birth ball, using the miles circuit and spinning babies, raspberry leaf tea, pumping and nipple stimulation. These are all things you and your provider can work through prior to labor to try to get your body kind of set up in the best way possible to get it to go into labor naturally.

There are things during labor if you want low intervention, being up and moving, staying out of that bed is going to be really helpful. Being up and moving on the birth ball, walking, using the jacuzzi tubs and really just, you know, staying active up to that whole point. And being prepared before you come in is going to be the big thing.

Courtney Collen:

Yeah. Thanks, Kayla. Why would a woman opt for this type of birthing experience? And are you seeing an uptick in women wanting an unmedicated birth?

Stephanie Metzler:

Yeah, I feel like we are seeing more women that are seeking out this more natural, unmedicated birth option. And I know for each individual woman, it’s a very varied reason. It’s a very personal reason usually of why they’re wanting this natural birth. Sometimes they want to be more in control of their body throughout the labor experience. They want to experience the natural hormone cascade. They want that more bonding experience of being able to, you know, get up right away after having your baby and not having the epidural.

So there’s a lot of different reasons why people are wanting this experience. So I think it goes back to what Kayla had said – that communication piece of finding a provider that is wanting to support your experience and what that looks like for you.

And so having a low-intervention birth doesn’t necessarily mean you have to stick with not having any medications. You can go into labor with the plan of low intervention, and we can respect that and honor that. And sometimes that plan changes and evolves as labor progresses. And that looks like maybe adding a pain medication on board of labor, adding nitrous oxide to cope with the labor pains, or getting an epidural if it’s a longer labor. So I think, the choice of why you’re wanting that low intervention or unmedicated birth really is unique to each person. But we as providers, we want to come alongside and meet them where they’re at for what the reasonings are for that choice.

Kayla Quinn:

I do think that social media plays a part in this too. People see the good and the bad, right? I think a lot more patients have access to seeing other people’s stories. I think we talk about our birth stories a lot more now. And so if they see someone who had a poor birth experience or know someone who had a poor birth experience because of interventions, then they might be more wanting to have that low-intervention option.

So, I just think we’re talking about our birth experiences a lot more. And so it gives people the freedom to really think about, oh, I do have the options. What might that look like for me? And we see both sides. We see that “absolutely, I want nothing,” and we see the other side of “whatever you can do to get this baby out.”

Courtney Collen:

Yeah. Well, thank you for the insight there. And I would imagine social media and people sharing their stories does, you know, increases the conversation. Talk through the benefits of having this experience, like a more low-intervention experience, in a hospital setting.

Stephanie Metzler:

I think one of the biggest benefits of the hospital is the access to resources. If you’re needing interventions for either Mom or Baby, the resources are right there. You’re not having to wait for the drive time of either, you know, driving to the hospital to get those resources or a transfer with possibly EMS. So, I think that’s the biggest reason of choosing hospital versus home that some people like to consider.

Kayla Quinn:

I think we know that birth can be very natural in a very beautiful and peaceful process. But sometimes things can go wrong, and I think that the main benefit, like Steph said, is just being close if something does go wrong and having those options if you need them.

Courtney Collen:

Yeah. Thank you. At what point would more medical intervention be necessary?

Kayla Quinn:

There’s a few different points in a labor process. If it’s been a really prolonged labor and Mom’s been laboring for multiple days, but there’s really been no changes, that can be necessary for not necessarily even for fetal distress or anything, but just moms get exhausted. When you have a prolonged early labor phase like that, moms lose a lot of energy and sometimes need just a little help to get some of that energy back to make the rest of the process a little smoother.

Fetal distress is a big one where intervention might be necessary. I always tell my moms: you’re the boss of me. I want to make this a good experience for you. However, your baby is the boss of all of us. If Baby’s in distress, then that’s going to change how we react to things because our goal is just to have a healthy baby and healthy mom at the end of this.

Infection is another one. If Baby or Mom develops an infection throughout the process, that’s another big reason why we might discuss interventions.

Stephanie Metzler:

We’re constantly evaluating the safety of the labor, the safety of the birthing experience. So we’re listening to both Mom and Baby of what that looks like. So each labor is different and what we’re needing for interventions possibly could be different. So really just, you know, validating that everybody has a unique experience and if we see concerns, we’re talking about it. We’re constantly evaluating what plan of action is appropriate for this labor.

Courtney Collen:

Thank you. What questions do you hear most often from patients during their prenatal care journey about this topic as they look ahead to play in their own labor and delivery experience?

Stephanie Metzler:

Yeah, I think the biggest one that I hear from patients is do I need a high pain tolerance to be able to handle labor unmedicated? And the answer is no. I feel like somebody that can self-report saying that they have a very low pain tolerance, they can manage those contractions. The biggest thing that comes back to that is prepping yourself for labor. You know, doing that mental work ahead of time, knowing what it’s going to kind of take to have a vaginal birth and have a natural labor, low interventions.

So I think that’s the biggest question is like, do I need to have a high pain tolerance and how can I prepare myself for this natural birth? So that looks different for everybody.

Some people like a formal childbirth education class where they go in person and have structure of educating what labor looks like, what coping mechanisms, like how do we get from having labor to having a baby? What does that look like?

Other people choose online education, self-educating themselves, talking to their friend groups, looking at social media, kind of educating to prepare yourself for what labor and birth will look like and how you can best manage coping with it.

Kayla Quinn:

And I think sometimes people ask, OK, well what does Sanford have to help me with that? And we do, like Steph said, we’ve got the birthing classes. Once you get to the hospital, we have jacuzzi tubs, we have birth balls and peanut balls. We have combs that people can use to squeeze in their hands to help with counteracting the pain. We’ve got the peaceful music on for the room. You can bring your own music. We have Bluetooth speakers.

Stephanie Metzler:

We have an overhead star projector for like the calming atmosphere and battery-operated candle lights to kind of set the atmosphere a little bit calmer. We have little massage roller balls and like finger massage roller things. Coloring is an option. We do have interventions and tools with how to cope through those early labor, active labor pains.

And I think another question that sometimes comes up is, can I have an unmedicated or low-intervention birth for my first baby? Or do I have to have had a baby before to be able to do this? And the answer is yes, absolutely you can have an unmedicated, low-intervention birth for your first baby. I feel like women are so amazing and their bodies are amazing and they’re able to do it. So it’s definitely not something that’s off the table. You don’t have to have had a previous baby to be able to have an unmedicated or low-intervention birth.

Courtney Collen:

Sure. Thank you. Are there any common myths or misconceptions around a more natural birthing experience?

Kayla Quinn:

People might think you can’t have a natural birthing experience in the hospital, that that’s only something you can do as a home birth, which like we have talked about. We’ve got the tools to help you do it very naturally in the hospital as well.

Some other myths people have, well, as soon as I get there, they’ll put an IV in me. That’s a discussion you can have with your provider. Some providers are really comfortable with, if it’s not necessary, you don’t have to have one in until it becomes necessary, if it becomes necessary.

Other questions, you know, the myths of, well, if I’m in the hospital, I have to deliver on my back, and that’s absolutely not true either. Again, it’s having that conversation of I want to deliver in a different position, side lying, squatting hands and knees, whatever.

Some people might think, “well, if I’m in the hospital, it has to be X, Y, Z, this way.” And that’s really not true. You don’t have to have Pitocin, you don’t have to have an IV, you don’t have to push on your back if you’re in the hospital. That natural birth experience really can happen. It can happen in the hospital just as well as it could at home.

Courtney Collen:

Well, thank you for clarifying, because that is such an important piece to this conversation as well. Earlier, Kayla, you mentioned Baby’s the boss. If Baby is in distress, then you know, you and your team intervene as necessary. So for a mom and partner, this is maybe not part of the birth plan.

So when it’s time to kind of shift gears a little bit and you really need to ease any anxieties or fears because this is not going according to their plan, what do women, what do partners need to hear in those moments, and what do you tell them to ease their anxieties, to calm their fears, to keep them going?

Kayla Quinn:

A big thing for them to hear is, you know, our goal is to keep you and this baby safe. We’re all here to protect both of you. And it’s OK. It’s not their fault. I think sometimes when things don’t go according to a birth plan, moms feel guilty like they did something wrong, or it’s their fault that it’s not going right. And that’s absolutely not true. Although we know what our body should do, it doesn’t mean it always does do what it’s supposed to.

And so I think really just being reassuring and letting them know we’re here, our goal is still to have a healthy delivery, healthy baby, healthy mom.

And sometimes some interventions are just short-term. Maybe we just have to do a quick short-term intervention and then we can continue with the birth plan. Really just being there and then also, when we can, giving them the time and space to come to terms with the fact that things have changed.

But also I think it’s really important when things happen quickly, which we know they can, to give those parents the ability to talk about it afterwards and just be able to talk about what maybe didn’t go according to their plan so they’re not bottling it up because it can be a little traumatizing if things don’t go the way they want it to. And so really just, again, open communication, having the conversations with them about, you know, let’s talk about maybe why things didn’t go according to plan, or tell me how you’re feeling about it.

Stephanie Metzler:

I love that. Yeah. The open communication and talking through what we’re seeing, why we are making recommendations to do interventions when it’s happening. So things aren’t just being done to the woman. Like things aren’t out of their control. They’re still in control of things.

Maybe we’re making a recommendation that’s different than what their birth plan has, but this is why we’re making this recommendation. This is what we’re seeing, and yeah, we want a safe baby, we a safe, healthy delivery. That’s our ultimate goal.

But talking that through and then going back full circle after the delivery and say, “I know that X, Y, Z happened. This is why we had to move to this plan. You know, what are your feelings on this? How are you processing through this?” And making that space so they have that time to validate their feelings and feel heard and respected.

Courtney Collen:

Yeah. So important. Absolutely. What advice do each of you have for listeners of this podcast who might be looking ahead to their own birthing experience and may choose a more natural, unmedicated option?

Stephanie Metzler:

I feel like the most important thing is doing your research of what you want and what you want your labor to look like. Interview with providers. Have your first meeting for your initial OB appointment. And if you don’t jive with that provider, don’t be afraid to seek a different provider. Switch options and gather more information. Get recommendations from your friends, from family members of who they had for their experiences, and find somebody that you fit well with and somebody that, as a provider, will respect your wishes for what your labor plans look like.

If you’re wanting that low-intervention unmedicated birth and you’re low risk, maybe looking at a midwifery team and seeing if we’re a good option for you. There’s so many resources that we have available during pregnancy to prepare you for that labor and birth that making those decisions like Kayla had mentioned in the beginning of your pregnancy kind of helps guide the rest of the pregnancy.

Kayla Quinn:

And also really just doing your research about what to expect within unmedicated or low-intervention birth. And like we talked about – prepping for those things in advance. Looking at what are focal points or what breathing techniques are there. Talking with your partner, your support person, who’s going to be there on, how can they help? And starting to have those conversations. You know, how are they going to be able to help throughout your labor to keep you on track and help you through the pain of the labor.

And like Steph said, the conversations with your providers and kind of just that it’s really open communication. I think the absolute key point of having a low-intervention or an unmedicated birth is truly communication and just being prepared.

Stephanie Metzler:

The greatest birth plans sometimes don’t happen and that’s OK. We pivot all the time in the health care field during labors and births. And if you have this beautiful plan laid out and things have to shift, that’s OK. At the end of the day, knowing that, like Kayla said, it is not your fault that things had to shift. Baby is ultimately in control and it will help you process the shift in those plans. But we want to be there and support you along whatever journey that you have as providers to have a baby.

Courtney Collen:

That’s the beauty of the journey. Every pregnancy, prenatal journey looks different. Every labor and delivery experience looks different, and I’m sure the two of you have seen it all. Anything else that I didn’t ask you, Stephanie, Kayla, that you’d like to share on this topic?

Stephanie Metzler:

My biggest recommendation as a provider is those childbirth education courses. If you’re planning that unmedicated birth or more natural birth, being well-informed of what to expect is really helpful in achieving that goal.

Kayla Quinn:

And the beauty of it is, is you can do them in person, you can live online. There’s a lot of options now. And I agree, just having that preparation in place beforehand is really key.

Courtney Collen:

Well, this has been so insightful. Stephanie, Kayla, thank you so much for your expertise on this topic, for all that you do as certified nurse midwives in Fargo, North Dakota. We appreciate you and appreciate your time today.

Stephanie Metzler:

Thank you so much for having us.

Kayla Quinn:

Thanks.

Courtney Collen:

This episode was part of the “Her Kind of Healthy” podcast series by Sanford Health. For more by Sanford Health, visit Apple, Spotify and news.sanfordhealth.org.

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Make consistency a ‘trend’ when it comes to your diet

Simon Floss (host):

Hello and welcome to the “Health and Wellness” podcast series, brought to you by Sanford Health. I’m your host, Simon Floss with Sanford Health News.

Various studies suggest that nearly half of Americans say that they want to lose weight. If you simply scroll any social media feed, there’s countless people touting different diets as the best way to shed a few pounds or simply achieve your best health.

And I’m sure you’ve heard of them – diets like keto, plant-based, carnivore, Mediterranean, intermittent fasting – and I’m sure you actually probably know someone who is on one of those diets right now. It can be hard to find a diet that fits you best and sets you up for success.

So, to talk through all of the trendy diets you see online and weigh the pros and cons is the one and only Natasha Hansen. She’s the senior sports dietitian at Sanford Sports. Natasha, how are you doing today?

Natasha Hansen, RD, LRD (guest):

I’m great. Thanks for having me.

Simon Floss:

Yeah. So last time we spoke, I think you said that you were like in the middle of training for a marathon or a half marathon. Is that right?

Natasha Hansen, RD, LRD:

Yeah, I did. I ran the half marathon, the Sioux Falls half marathon in August.

Simon Floss:

How did it go?

Natasha Hansen, RD, LRD:

Well, it was really hot. They actually canceled the full marathon.

Simon Floss:

I remember that now.

Natasha Hansen, RD, LRD:

So, I was like, well, good thing I didn’t sign up for the full, even though after I finished the half I was like, I can’t even imagine this being half. Like it blows my mind.

Simon Floss:

For the people, I don’t know where you’re listening from, but we’re recording from Sioux Falls, South Dakota, where like in the Midwest, that humidity in the summer is just ruthless, you know?

Natasha Hansen, RD, LRD:

But I finished it, and it was my first half, so I didn’t really have a time expectation, so that was kind of nice. I just finished it.

Simon Floss:

I’m sure, I’m sure you were flying, my friend. Well, let’s get started here. So, we’re going to talk about a handful of diets here. Wondering if you could first give a brief overview of each diet that we’re going to talk about and a big one that’s been around for the last five, six years-ish, is the ketogenic diet or keto diet. Quite a few folks listening to this have heard of it, but can you give us a brief overview of what keto is?

Natasha Hansen, RD, LRD:

Yeah, the keto diet is essentially a low-carb diet where you kind of put your body into what we call ketosis, and you start using ketones as energy instead of carbohydrates. And then essentially you’re using more fats for energy instead of those carbs. The thought process behind it is that you’re burning more fat.

Simon Floss:

I’ve seen people online and I’ve personally tried every single one of these diets myself, but I’ve seen a lot of people like have great success if they’re looking for like weight loss specifically with the keto diet. But how might that diet impact overall health and wellness?

Natasha Hansen, RD, LRD:

What I’ve seen is that it will lead to a big initial significant drop in weight, but it’s really hard to sustain that diet. Carbs are the energy source literally for your brain and for your muscles – the preferred energy source I should say, because then you start using fats. But since carbs are kind of that energy source to the brain and the muscles, fatigue is a huge symptom or side effect that I hear about a lot.

Simon Floss:

And especially if you’re going to pair that with training, like athletic training and performance, you need energy. So if you’re fatigued going into your workouts, imagine how hard that’s going to be and how bad you might feel afterwards.

Natasha Hansen, RD, LRD:

Yeah. It’s definitely not a diet that I’m recommending to athletes. And actually the ketogenic diet was originally designed for epilepsy, which is super interesting. And when I tell people that, they have no idea, but that’s actually what the diet was originally designed for. I don’t know the science behind it necessarily, but that is what it was originally designed for.

Simon Floss:

Fascinating. I am today years old learning that information.

So, with keto, like you said, it’s primarily fats. And what would be the percentage of people who are listening to this and macro tracking? What’s like the percentage of fat out of the diet? I’ve heard some people say 70 to 80% and I’m like, are you only eating avocados?

Natasha Hansen, RD, LRD:

Yeah, it’s definitely super high in fats. Percentage, I think people are going as low as like 10% of their calories from carbs. General recommendations are usually about 50%. So going down to 10% and then you’re increasing your fats and proteins. But I think it is more heavily focused on fats.

Simon Floss:

I’ve heard of people felt going into like when they get into ketosis, the keto flu. Have you heard of that? How can that be healthy? You know, if like your body gets sick doing a diet –

Natasha Hansen, RD, LRD:

Yeah. And I think that’s all that fatigue, you know? The fatigue kind of setting in almost making you feel like ill.

Simon Floss:

Ugh, yuck. So what are maybe some pros and cons to this diet?

Natasha Hansen, RD, LRD:

It may lead to some of that quick initial weight loss because you are using more fats as energy, but there are nutritional deficiencies that can go along with this diet as well because you’re not getting much fiber, you’re not getting many of those B vitamins that come in our whole grain carbohydrates. So again, that fatigue, the increase in fats, ideally, you’re increasing your healthy fats, but if your fat percentage is 75% of your intake’s coming from fats, you’re likely increasing your saturated fats in those unhealthy fats as well. So, those would be some of the cons.

Simon Floss:

What are examples of like saturated fats or unhealthy fats?

Natasha Hansen, RD, LRD:

Sure. Yeah. So anything, unfortunately it’s a lot of foods. (Laugh) It’s really unfortunate because there’s a lot more saturated fats than there are unsaturated fats, which are going to be your healthy fats.

But anything that’s fried is going to be higher in saturated fats. There’re certain condiments like ranch and mayo, and alfredo, really tasty things, that are high in saturated fats, certain cuts of meat. You can actually see the fat on some cuts of meat. And those are going to be higher in saturated fats.

And that’s actually the difference between like your whole milk and skim milk is the amount of saturated fats.

Simon Floss:

Whole milk obviously would have more.

Natasha Hansen, RD, LRD:

Correct.

Simon Floss:

So, are there any, I mean other than initial weight loss, are there any positives? I’ve heard a lot of diabetics go on the keto diet and obviously they would have to have that guidance from someone like you or medical provider, you know. But are there any positives to this diet?

Natasha Hansen, RD, LRD:

It’s also not a diet that I would recommend for diabetics, and I’m certainly not an expert in diabetes, but with diabetes, you want to have a consistent carbohydrate diet, not necessarily a very low carbohydrate diet because then you can go into hypoglycemia as well. And so, and that’s a concern for diabetics as well. So, I don’t think it would be a diet that I would recommend for those with diabetes either.

Simon Floss:

So, we sort of already alluded to it, but how does that diet affect fitness? Some folks say that when they quote, “know that they’re in ketosis,” they actually feel better as far as being endurance athletes, but as we’ve talked about, carbs are super beneficial in overall athletic performance and training.

Natasha Hansen, RD, LRD:

Yeah, I think eventually, it depends if you’re more of an endurance athlete, depending on the duration of your event or what you’re training for, you’re eventually going to hit a wall and you’re eventually going to hit that fatigue that’s going to set in without those carbohydrates. And so I don’t think it’s sustainable for especially endurance type training.

Simon Floss:

So, switching gears here, with both of these two diets sounding pretty fat forward, would you classify the BBBE diet or that stands for beef, butter, bacon and eggs diet, technically as a keto diet?

Natasha Hansen, RD, LRD:

Yeah, so the carnivore, the BBBE diet, the keto diet, they’re all very low in carbs. And I think that’s the overarching theme. And I will say too, like I think carbs get a bad rep. There’re so many different types of carbs, right? Sugar is technically a carb, so like the sugar in your soda is a carb, probably not the best carb, probably going to lead to weight gain. But then you have your whole grain type carbohydrates that are higher in fiber.

Simon Floss:

And sweet potato. Yeah, sweet potatoes: amazing. And healthy.

Natasha Hansen, RD, LRD:

Exactly. There’s better carb choices and I think that’s where maybe we get this idea that all carbs are bad, and I just don’t agree with that. So, that’s essentially the overarching theme I think of the carnivore and the BBBE diet as well.

Simon Floss:

I actually had never heard of that (BBBE) diet.

Natasha Hansen, RD, LRD:

I had to look it up too. I didn’t know what it was, and I think my jaw dropped to the floor. This is all you’re eating? Sounds like a heart attack to me.

Simon Floss:

Seriously. Like, and how can that taste good? I imagine you get sick of that. Like I could maybe do that for like two days tops and then I would be miserable. How does BBBE diet, how would that affect your overall health and wellness? And would it have any positives or negatives to sports performance?

Natasha Hansen, RD, LRD:

Well, I think just to compare it to keto too, at least with the keto, you’re getting some fruits and vegetables in there as well. With the carnivore and the BBBE diet, there’s no fruit or vegetable intake because it’s just animal proteins.

So, that’s even more risky for your saturated fats. I mean the bacon, beef, butter and egg, all of those have saturated fats in them. And so, to me, that’s going to increase your risk for heart disease. And then you’re not getting all those nutrients from fruits and vegetables, so you’re missing out on all these nutrients.

Simon Floss:

I’m sure some people are listening and would say something like, oh, well I could just take a multivitamin or a handful of supplements. How would you respond to that?

Natasha Hansen, RD, LRD:

Supplements, there are certain cases where I recommend supplements, but supplements certainly don’t replace food. The nutrients, vitamins, and minerals from your food are way better absorbed than from a supplement.

Simon Floss:

What are some of those instances where you would recommend a supplement?

Natasha Hansen, RD, LRD:

If somebody’s deficient. If we’ve actually gotten some blood work, somebody’s deficient in a certain nutrient, then we definitely need to think about adding some sort of supplement or adding that.

Iron deficiencies are a common one that I see. Then we’re adding a specific iron, not necessarily a multivitamin. If somebody, and this happens sometimes, they get clients that just refuse to eat, you know, vegetables and so this is a case where at least let’s get that multivitamin in.

Simon Floss:

Why wouldn’t you eat vegetables? Veggies are great.

Natasha Hansen, RD, LRD:

It’s all about how you cook them.

Simon Floss:

OK, so I’m curious. What’s technically better for you? Cooked or raw vegetables?

Natasha Hansen, RD, LRD:

The cooking process does decrease some of the nutritional value, but you’re still getting such a great value from a nutritional standpoint, even if you’re cooking your vegetables. So, most people prefer cooked vegetables over raw vegetables. We’re still getting a good value of nutrients from cooked vegetables.

Simon Floss:

And are cooked vegetables easier to digest?

Natasha Hansen, RD, LRD:

Yeah, you could say that part of the reason is because, so this could be a positive or a negative I guess, but part of the reason is because you’re decreasing that fiber. Fiber takes a little bit longer to digest. And so, it could be easier to digest if you’re cooking them.

Simon Floss:

Talking about vegetables. Well, I don’t want to glance over the carnivore diet, so maybe really quickly we could go back to that, but I feel like we’ve already talked a lot about it. But what is the carnivore diet and how can it impact health and wellness?

Natasha Hansen, RD, LRD:

Yeah. The carnivore diet is really only eating foods that come from an animal. So, you’ve got any sort of animal meat, right? But dairy products as well, eggs, milk, and you’re missing out on the nutrients from fruits and vegetables and plant foods as well. And ultimately compromising immunity when you’re missing out on all those nutrients from fruits and vegetables.

Simon Floss:

So, talking about fruits and vegetables, let’s talk about a plant-based diet. Walk me through that and weigh out some of the positives and negatives.

Natasha Hansen, RD, LRD:

There are definitely a lot of positives of trying to eat more of a plant-based diet. You’re getting your fruits and vegetables. Most plant-based diets also include like more of those whole grain, those better carbohydrates that I mentioned. And the only risk that I really see with the plant-based diet is not getting enough protein, if you think about it.

There’s protein in plant sources. There’s certainly a lot of like plant sources that have protein, but the best way to explain that to people sometimes is like, OK, if you take let’s say a turkey burger or a veggie burger, you’re probably going to have to have like three veggie burgers to get as much protein in a turkey burger. So, I’ll talk that through with people who are considering the plant-based diet. You might have to eat more to be able to get the amount of protein that you need.

Simon Floss:

And if people are trying to, you know, lose weight –

Natasha Hansen, RD, LRD:

Correct. I mean, you’re technically having to eat more quantity to get all the protein that you need. And then we’re risking loss of muscle mass and things like that too.

Simon Floss:

I’ve heard people who say like, oh yeah, I switched to vegan, or I switched to plant-based, and I’ve just never felt better in my life. When it comes to vegetables and fruits, there are a lot of like quote unquote, and we should get to this later, “superfoods.” So, of course you’re going to feel better because you’re eating a wider variety of fruits and vegetables are quote unquote “superfoods.” But in the long run, much like the diets that we’ve discussed, it might not be the best for you. Is that right?

Natasha Hansen, RD, LRD:

Yeah, I mean, you’re missing out on an entire food group. And that’s what I always come back to is OK, are we missing out on any food groups here? And then which nutrients from that food group? So, what specific nutrients are we missing from there? Which, from animal proteins, would be like vitamin B12. So yeah, always kind of coming back to like, what are we missing from this, from this fad diet?

Simon Floss:

The buzzword “superfood.” Are there any actual superfoods? I’ve heard that like kiwi and blueberries are the greatest superfoods that you can possibly have. But we obviously need to talk to the pro.

Natasha Hansen, RD, LRD:

I’m not a big fan of this word, and I do get asked this a lot. There’s not one food that is going to give you everything that you need. And so, I’m just not a big fan of that word. There’s certain, especially when it comes to a lot of fruits and vegetables that are super high in like antioxidants. And I think a lot of people use superfoods and antioxidants. Like typically when I hear of a food being a superfood, it’s high in antioxidants, but it’s always good to get a well-balanced of all foods.

Simon Floss:

(Laugh) And speaking of well-balanced, let’s talk about the Mediterranean diet. A lot of places online say that this is the best overall diet one can follow. What comprises of this diet?

Natasha Hansen, RD, LRD:

Yeah, so this diet limits red meats and added sugar and it emphasizes on like healthy fats and whole grains. This out of the diets we’ve talked about so far, I like this diet the best because you’re not eliminating any specific food group, you’re increasing your healthy fats, you’re limiting your red meat. It doesn’t say you have to completely eliminate; you’re just limiting your red meats and red meats are going to be higher in those saturated fats like I mentioned. And so I think this is a good, well-balanced diet.

Simon Floss:

And increasing your healthy fats. What are examples of healthy fats?

Natasha Hansen, RD, LRD:

So, healthy fats (include) avocados, olive oils, olives, nuts and seeds, any sort of nut butter. So, you know, you got peanuts, peanut butter, any sort of seed, sunflower seeds, pumpkin seeds, flax seeds, chia seeds, any sort of nut or seed is going to be a good healthy fat as well. And fish.

Simon Floss:

Ugh, I love fish. If I had it my way, I would eat salmon every single day of my life.

Natasha Hansen, RD, LRD:

Good for you. A lot of people are not like that.

Simon Floss:

I love it. It’s really good. So, speaking of like nut butters, I’m curious, have you ever had, it’s from this brand called 88 Acres. It’s pumpkin seed butter and they like grind up pumpkin seeds until it has the consistency of like butter and it’s green. It’s so good. I’m not sure if you’re a fan of nut butters?

Natasha Hansen, RD, LRD:

I am a fan of nut butters. I’ve heard of that brand, 88 Acres. Yeah. They have good granola bars that I’m often recommending to clients because they’re really low in added sugar. They’re higher in fiber, a little bit higher in protein. But I have not tried their nut butter. But I do think that sounds like something I would like.

Simon Floss:

Well, I will also caveat it by say by saying you know be careful because it’s so good (that you can end up eating the whole jar).

Natasha Hansen, RD, LRD:

Probably not very cheap either.

Simon Floss:

No, no it’s not. But you know, no good things are. Lastly here as we’re rounding third, the intermittent fasting, what is that?

Natasha Hansen, RD, LRD:

Intermittent fasting. There’s so many different variations to this diet, but basically, you’re limiting what I call fueling window. You’re limiting that to like a certain timeframe. Sometimes people even go like, I’m going to fast every other day, so I’m only going to eat every other day. Or sometimes it’s like, I’m only going to eat between like 10:00 AM and 6:00 PM so you’re kind of limiting your fueling hours.

Simon Floss:

I was huge into intermittent fasting. And I feel like there might be some pros and cons that we could talk about, but maybe one of the cons, if you’re only giving your body a specific window to eat, then in theory your body’s hanging on to what you just gave it for as long as possible, because it’s like, oh, I don’t know when we’re going to eat next. So, in theory, could your metabolism actually slow down because of intermittent fasting?

Natasha Hansen, RD, LRD:

Definitely. Yep. So, if you get to the point where your body kind of starts to switch into starvation mode, no matter what you’re eating, your body’s going to store that as fat because it’s in starvation mode. And it’s like, and when you store things as fat, your body can hang on to that energy a little bit longer. And so that’s why our body does that when we’re in starvation mode.

But yeah, you’re kind of tanking your metabolism, or there’s certainly better ways to do the intermittent fasting. But I think essentially the overall thought process behind it is like, if you’re decreasing your window of eating, you are decreasing your calorie intake, which isn’t always the case. I’ve ran into situations with clients where it’s like, you’re eating a lot (laugh) in a short, short period of time. Yeah. Like that cannot feel good on your stomach.

So, I think since there are so many different variations of this diet. It really just depends how somebody’s doing it.

Simon Floss:

You said there’s good ways to do it, or a smart way to do it. What’s a smart way to do it? I’ve heard that you shouldn’t eat three hours before bed or something like that. Is there any truth to that or merit to that?

Natasha Hansen, RD, LRD:

Yeah, I do get asked what time should I stop eating? I get asked that a lot. And it really depends what time you’re going to bed, because I don’t give people a specific time – you should stop at 7:00 p.m. – because it depends on your work schedule. Like what if you’re not going to bed until 2:00 a.m.? Well, that’s a really long time to go without having some sort of snack.

I generally don’t recommend the intermittent fasting diet. There’s really no scientific proof that it’s any more effective than your traditional low-calorie diet because again, I think that’s the overarching idea is that OK, you’re consuming less calories, but there’s no difference between that or the intermittent fasting or just going on a lower calorie diet.

Simon Floss:

Everybody talks about whole foods. And not just the, you know, the grocery store. Although I love Whole Foods grocery stores.

Natasha Hansen, RD, LRD:

I do too. It’s incredible.

Simon Floss:

Those macaroons. Oh my gosh.

Natasha Hansen, RD, LRD:

I also love Trader Joe’s, and I wish we had one here in Sioux Falls.

Simon Floss:

Man, I know. I think there’s been like some sort of like write to the mayor movement to get a Trader Joe’s into Sioux Falls and, you know –

Natasha Hansen, RD, LRD:

Well, I will join (laugh). I’ll be right out there if anyone else wants to join me (laugh).

Simon Floss:

And all of their stuff’s actually like really cheap too.

Natasha Hansen, RD, LRD:

Exactly. It’s amazing.

Simon Floss:

So, “whole foods,” very high search volume online. What are whole foods and how are they incorporated or not incorporated into these diet trends that we’ve discussed?

Natasha Hansen, RD, LRD:

I would say when you’re, when referring to whole foods, it’s a really broad terminology. It really means like unprocessed or minimally processed foods that are close to their natural state. So basically, you’re choosing less processed, less packaged, less fast foods.

And also another thing that I think of when I think of whole foods is like one ingredient foods. Sometimes I’ll talk to my clients about this, like, OK, chicken, egg, fruit, a piece of fruit, a vegetable, you know, one ingredient foods. And try to incorporate those more into your diet.

Simon Floss:

We’ve already talked about it a little bit, but which of these diets that we discussed are good and which ones should maybe consumers ditch? Or is it maybe more about just finding out what works for you based on your individual needs?

Natasha Hansen, RD, LRD:

Nutrition is very individualized, and that’s, I honestly take pride when I work with my clients of taking a very individualized approach.

But really the best diet is the one that you can sustain for the longest period of time and one that’s going to fit within your life.

Based on the diets that we’ve talked about, I like the Mediterranean diet. Again, you’re not excluding any specific foods. And I like the idea of like eating more of a plant-based diet, but maybe not only limiting yourself to just plant-based foods, but maybe your diet is higher in plant-based items.

Simon Floss:

And you talk about taking an individual approach for each of your clients. How do people contact you or other dietitians at Sanford and why should someone choose Sanford for their nutritional needs?

Natasha Hansen, RD, LRD:

Yeah, so people can just call the Sanford Fieldhouse front desk. The Sanford Fieldhouse is just located right across from the Pentagon. I’ve also had people just stop in, ask about me at the front desk, and if I’m available, I’ll just come out and talk. We also have a webpage, the Sanford Sports webpage, where you can find, if you go under nutrition, there’s a way where you can contact me directly right through there as well. And then I’ll get that email and then I’ll reach out.

But you know, I’ve been a registered dietitian for nine years now. I have lots of experience with a wide variety of population. I’ve had a 9-year-old and I’ve had a 70-year-old. So, I have worked everywhere in between too.

Simon Floss:

Didn’t this summer, didn’t you say you were the lead sports nutritionist for Kansas University or something?

Natasha Hansen, RD, LRD:

Yeah. So, before starting at Sanford Sports in November of (20)23, I was the director of performance and nutrition at KU from 2018 to 2023. So, a lot of experience within the collegiate athletic setting as well.

Simon Floss:

Did you did you meet, oh, what’s his name? He plays for the Raptors now. Grady Dick?

Natasha Hansen, RD, LRD:

Yeah.

 Simon Floss:

Cool. Nice. Wow, small world.

Natasha Hansen, RD, LRD:

He was only on the KU team for one year, so I got to know him as much as I could in that one year, but yes, I did work with him. Yeah.

Simon Floss:

I watched the Raptors game last night and I was like, oh, yeah. I went to a KU game once and I got to see him play, so it was kind of cool. But I’m so sorry I interrupted. But that’s just a very cool thing that I think a lot of people would want to know. You really know your stuff.

Natasha Hansen, RD, LRD:

Yeah. And I think another reason to work with me is just because I take that individualized approach. And what I mean by that is like, I want to work with my clients, whatever’s going to work best with them.

And I’m very flexible. I’m not someone who’s going to be like, super strict. I really do think that all foods fit within your diet. It really is about moderation and being able to not overindulge. And so, I’m never going to say like, you can’t eat this. And I think people really appreciate that.

Simon Floss:

I was listening to something online and the someone said, “I don’t view like, cheat meals as like a cheat meal. I call it a treat meal,” so that way there’s like a little bit of positivity associated.

Natasha Hansen, RD, LRD:

I do like that better.

Simon Floss:

Well, we actually ran out of time. I could talk about this for hours and hours and hours but thank you so much for letting us come out and talk to you today.

Natasha Hansen, RD, LRD:

Thanks so much for having me.

Simon Floss:

A reminder that you can find this podcast and many others on your favorite podcast apps like Apple, Spotify, YouTube, or by heading on over to our website, news.sanfordhealth.org. Thanks again for listening. I’m Simon Floss with Sanford Health News.

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What it means to get your tubes tied

Dr. Erica Schipper:

A woman who is wanting to make this decision for herself is able to do so. We certainly encourage you to have conversations with loved ones who are important to you, but that is your decision.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. These are new conversations about age-old topics from pregnancy to postpartum, managing stress, healthy living, and more. “Her Kind of Healthy” is here to bring you the honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.

In this episode, we are talking about the tubal ligation procedure to prevent pregnancy, most commonly referred to as getting your tubes tied. I have Dr. Erica Schipper joining me for this conversation. She is chief medical officer at Sanford Health in the Sioux Falls region and a practicing gynecologist. Dr. Schipper, hello. Welcome.

Dr. Erica Schipper (guest):

Hello, Courtney. I’m glad to be here.

Courtney Collen:

I so appreciate you being here to talk through this with me. Starting really broadly here to define tubal ligation. What happens during this procedure, Dr. Schipper? Are we actually tying tubes?

Dr. Erica Schipper:

So sometimes yes. We tend to refer to it more generally as tubal sterilization. The idea being that we are somehow disrupting the fallopian tube to prevent the egg and the sperm from coming together in order to prevent pregnancy. And there’s multiple techniques by which that can be done.

We can sometimes tie the tubes. We can cut or burn the tubes. More often now, we are frequently removing the tubes completely. And the reason for that is, first, when we just cut or tie or burn the tubes, there is a risk of failure. It’s less than 1% in most cases, but, you know, if a tubal sterilization fails, there’s a higher risk of having a future pregnancy that could either be a normal pregnancy or it could be an ectopic pregnancy. That’s a pregnancy in the tube, and that is, that’s an emergency.

And so, we learned one that if we take out the tubes, that’s much less likely of course, but also we’ve learned that removing the tubes can lower a woman’s risk of ovarian cancer. So even though she’ll still have her ovaries and she’ll still have her hormones, she will not have those tubes.

And a lot of what we thought were ovarian cancers, we now know start in the tube. So, the society of gynecologic oncologists, the cancer surgeons told us that, “Hey, if a woman does not want to be able to get pregnant in the future, perhaps removing the tubes would be a better option than just tying them.”

Courtney Collen:

Is it effective for women who really do not want to get pregnant anymore?

Dr. Erica Schipper:

It is extremely effective, particularly if the tubes are removed. Risk of pregnancy, I will never say zero. There are always weird cases where strange things happen. But it’s very close to zero.

Courtney Collen:

Is it reversible?

Dr. Erica Schipper:

If the tubes are removed, it is not reversible. Pregnancy would still be possible, but it would only be through in vitro fertilization if the tubes are quote “tied” or cut or burned. Sometimes it’s reversible, but not always. And that’s kind of an intricate procedure. A limited number of physicians do that, and it doesn’t always work. So I do tell my patients, you should be very sure that you want a permanent form of contraception if you go ahead with this.

And the other thing to consider is that we do have great forms of long-acting reversible contraception. So if you want highly dependable contraception that isn’t permanent, those are out there.

For example, an intrauterine device or the Nexplanon arm implant or even the Depo-Provera shot are things you don’t have to worry about every day that are very effective in preventing pregnancy. The IUD is actually as effective as a traditional tubal ligation.

Courtney Collen:

Let’s talk through some of the benefits of a tubal ligation. Why would a woman want to get this done?

Dr. Erica Schipper:

I think first is just to not have to worry about an unplanned pregnancy. I think for some women, one of the reasons it comes to mind, and I’ve seen this in my practice, is, you know, maybe they’re not in a stable relationship or maybe they’ve been a victim of sexual violence. And we know for women, sometimes sex is not always their choice. And so this is a way for them to have that control if they don’t want to be pregnant in the future.

And for some women, it’s just a matter of they don’t tolerate hormonal birth control very well, and they know their family is complete, and so this is just the most logical option.

Finally, there are some reasons that women would do a tubal instead of hormonal birth control. For example, a woman who’s had an endometrial ablation or is having an ablation for heavy periods, pregnancy is contraindicated after an ablation, but it’s not in itself a form of birth control. So we’ll often do those two things together.

And then some women who have to be on long-term medications that could be harmful to a fetus would potentially want to have reliable long-term contraception. Some women who know they have an inherited condition in their genetics that they don’t want to pass on may choose a permanent form of contraception, and then choose to either do donor egg or adoption if they want to have a family.

Courtney Collen:

What would qualify a woman for this procedure?

Dr. Erica Schipper:

Any woman who is of course, an adult and can make her own medical decisions and who is certain that her childbearing is complete and she doesn’t want any more children or in some cases any children at all, and who is a reasonable candidate to undergo a general anesthesia and have surgery would all be reasonable candidates for a tubal sterilization procedure.

Courtney Collen:

Thank you. What should a patient consider or know before having this done? Are there any risks involved?

Dr. Erica Schipper:

There are risks. Tubal ligation or tubal removal called salpingectomy is a surgical procedure. It does require that the woman go under general anesthesia and then it’s done laparoscopically. So if it’s just a tubal ligation, it’s usually two incisions in the abdomen. If it’s a tubal removal, it’s usually three.

And so it carries all the surgical risks of any abdominal surgery. So there’s a risk of bleeding, there’s a risk of infection, and then there’s a risk of injury to anything else in the abdomen. There’s always a risk of needing a larger incision or encountering scar tissue, meaning we can’t complete the procedure. Any risk that comes with any laparoscopic surgery comes with this one.

That said, this is a procedure that is done quite frequently and usually goes very well.

So the risk of regret is something to take into consideration. We know that the rate of regret is higher under the age of 30 and even higher under the age of, say, 25. And those are the times to maybe think about doing a long acting reversible until you’ve had more time to be sure. But that is very much a patient decision. One of the things I will ask my patients, because I want to ensure that they’ve really thought about this, is, you know, if something were to happen to your partner and maybe you would meet someone else and they wanted a child, would you still be sure that wasn’t what you wanted?

Courtney Collen:

Yeah. If a woman just gave birth, she’s certain that her childbearing years are over, can this be done right after childbirth?

Dr. Erica Schipper:

Yes, it can. In fact, sometimes we do it when if a woman has an epidural in labor, we can even leave the epidural in place and use it to help with pain management. It’s done a little bit differently immediately postpartum because the uterus is enlarged. Oftentimes, it’s done through a very small incision just below the belly button rather than laparoscopically.

Courtney Collen:

Let’s talk through recovery and what this looks like.

Dr. Erica Schipper:

Yeah, so this varies a little bit from patient to patient, but for most patients it’s typically about a week off of work or resting. I usually tell patients you might want to limit your lifting for about two weeks to really allow those incisions to heal.

Now, that can be a little hard on new moms, so you want to take into consideration lifting a baby in a child carrier seat. But that can usually be accommodated.

Typically, there will be a little bit of pain, some incisional pain, and so you’ll be on some pain medicine. Some women only need, say, Tylenol and ibuprofen, while some women do need a little bit stronger medication for a little while. And so as OB/GYNs, we’re very careful to ensure we prescribe something that’s safe in breastfeeding if we have a breastfeeding mom.

Courtney Collen:

Now let’s talk about life after the procedure. Any side effects, hormone changes, like will a woman continue having a period or need any birth control after a tubal ligation?

Dr. Erica Schipper:

That’s a great question and really important to consider. So first of all, because we’re removing the tube, we’re really not disrupting the whole hormonal cycle. Hormones are produced from the brain to the ovaries, and really the uterus and the tubes are not involved in the hormones themselves. The hormones do talk to the uterus, which is how we have our periods.

So a woman who’s had her tubes tied or removed will continue to have periods the way she would have otherwise. Some women, when they get their tubes tied, they’re coming off of having been on hormonal birth control. And often that’s a pretty big change.

So if you’ve been on, say, a birth control pill or you’ve had a progesterone-based therapy like an IUD or the shot, you might find that your periods are heavier or maybe a little more painful because the hormonal birth control was keeping them a little bit better under control for you.

Additionally, a lot of women undergo tubal sterilization at a time in their lives when periods are starting to change anyway. Often in that sort of early perimenopausal period where periods can get a little bit heavier or irregular, there’s not really an obvious medical reason why a tubal itself should affect periods. But some patients do report that they feel their periods are different after their tubal and that’s still something we don’t fully understand.

Courtney Collen:

What about birth control?

Dr. Erica Schipper:

You should not need birth control. Once again, there is a small risk of failure if the tubes are ligated as opposed to being removed. And so if you wanted extra reassurance, you could certainly use additional birth control.

And of course the other option that we haven’t talked about yet is the option of a vasectomy. For a woman who’s in a monogamous heterosexual relationship, her partner can certainly get a vasectomy, which is really as effective as a tubal and less invasive. And so that’s something to consider when you’re thinking about your options, if you as a couple have decided you’ve completed your family.

Courtney Collen:

If a patient is interested in getting this done, where should they start?

Dr. Erica Schipper:

Generally, you want to start with your OB/GYN, and if you don’t have an OB/GYN, you can certainly ask your primary care provider for a referral.

Courtney Collen:

And is there a consultation involved? Like what does the conversation look like at the beginning? And maybe what questions should a patient bring to the table?

Dr. Erica Schipper:

So when they first meet with the OB/GYN, there will be a pre-surgical consultation. Questions about, for instance, your periods. Are you having undiagnosed abnormal bleeding or pelvic pain, things that we should address before we do a surgery?

And of course, if you’re absolutely certain that your childbearing is complete, one of the other risks of tubal sterilization is regret. And we know that regret is greater in women under the age of 30. That doesn’t mean you can’t do it before the age of 30, but you just want to be really sure about your decision.

And so I think some good questions for women to bring are, you know, certainly go over those surgical risks and ensure that your questions are all answered about what those risks entail and what your recovery’s going to be like.

And then I think the bigger conversation really needs to happen before you get to your consultation with whoever’s important in your life, that needs to be a part of that decision. So whether that’s a spouse or a partner or a supportive friend or family member or your faith leader, it’s critical to have those conversations that weigh on your decision before you move forward.

Courtney Collen:

Thank you for that. Is there anything else that we didn’t talk about here that you hear from patients topics around a tubal ligation that are important to share?

Dr. Erica Schipper:

I would say historically there was some misunderstanding, and historically there has been some paternalism by the medical community around tubal ligation. It used to be that a woman had to get her husband’s permission to have her tubes tied. There were physicians who would not do a tubal in a woman who’d never had children. That is not a requirement.

So a woman who is wanting to make this decision for herself is able to do so. We certainly encourage you to have conversations with loved ones who are important to you, but that is your decision. There’s no requirement to have a partner sign a piece of paper saying that you can do this. There’s no requirement that you have to have had a child before saying that you can have your tubes tied.

Courtney Collen:

Very insightful. Such good information and really appreciate your time and all of your insights and all that you do here at Sanford.

Dr. Erica Schipper:

Well, thank you, Courtney. It was a pleasure to do this.

Courtney Collen:

Thank you. I sure hope you learned as much as I did from our conversation today. This was another episode of the “Her Kind of Healthy” podcast series, brought to you by Sanford Health. For Sanford Health News, I’m Courtney Collen. Thanks for being here.

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Best innovations address patient needs, says Yale Health CEO

Alan Helgeson (announcer):

“Reimagining Rural Health,” a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high-quality, low-cost services in rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, host Courtney Collen with Sanford Health News talks with Christopher O’Connor, CEO of Yale New Haven Health System. Christopher is a speaker at the 2024 Summit on the Future of Rural Health Care.

Christopher O’Connor (guest):

It’s a delight to be here.

Courtney Collen (host):

Good to meet you. “Leading Through Change: Driving Innovation and Collaboration to Strengthen Access, Quality and Sustainability” was a panel that you participated in here at the summit. I’d love to know a takeaway or two that you wanted to drive home.

Christopher O’Connor:

One of the things I walked away with is that really, regardless of where your environment is, rural, urban, I mean, the challenges that we are facing and potential solutions are pretty ubiquitous. And that’s where the collaboration and working across I think the field is going to be really essential to drive that change and to drive improvements that ultimately benefit, as Bill (Gassen, Sanford Health president and CEO) said eloquently, around the patient at the center of that change.

Watch the Sanford Health News vodcast of this episode

Courtney Collen:

What has been your most surprising, hottest take or something that you’re looking to take away from the dialogue today?

Christopher O’Connor:

Well, you know, I think that obviously listening to Dr. Shereef Elnahal and hearing about the veteran structure is obviously a very different component to what I think Bill and I are used to dealing with. And so hearing some of those challenges is sobering, but also really invigorating to know that you have people like Shereef who are trying to drive that change and improve the health of the veterans. And I think Bill and my perspective is a little bit different in our communities and so I think that was a big takeaway for me.

Courtney Collen:

What do you think is the biggest misperception about rural America?

Christopher O’Connor:

Well, I think, first that there’s no care, and you have great entities like Sanford that are out there providing care and enabling the technology and the access that I think people need and deserve.

Courtney Collen:

How do we strengthen trust in health care during this time of rapid disruption?

Christopher O’Connor:

I still believe there’s enormous trust that the sanctity of the relationship between a provider and the patient is still sanctimonious, is still the premier driver of what trust is all about. And so I think as a health system, our job is to support that relationship, enable it to have, one, immediate access or one, appropriate access, and two, different mechanisms to gain access to that trustful relationship. So whether it’s in-person or whether it’s via virtual systems, we support that technology.

Courtney Collen:

Thank you. Let’s talk about AI in health care for a moment. What do you think – overhyped? Real? Where do you stand on how it’s impacting health care?

Christopher O’Connor:

It certainly is the bright, shiny object of the day. But, I absolutely believe it’s real. I mean, we have implemented Abridge, the ambient listening software that has really done wonders for physicians and creating these amazing comprehensive notes that have just tremendous value and efficiencies to providers.

But it’s not going to solve everything. And so, while it certainly is a technology we’re going to gain great deal of insight and innovation around, I don’t think it’s a panacea for all the challenges that we face.

Courtney Collen:

Thank you for the insight. Now stepping away from the office for a moment, what book are you reading right now? What’s on your shelf? And, I’d love to know what has had the biggest impact on your career thus far?

Christopher O’Connor:

Wow … The book I’m reading now is “Power in the Middle,” and so it’s a book that was recommended by my president of the health system, Pam Sutton-Wallace, around the power of middle management and the importance of it. So I read a bit on the flights out. I’m going to hopefully finish it on the way back.

Most influential, I think it’s been the relationships. I have been fortunate to have just tremendous relationships with mentors and colleagues. And I think that has been the greatest influence on who I am and how I can evolve as a leader going forward

Courtney Collen:

As the CEO of Yale New Haven Health System, what do you love most about what you do?

Christopher O’Connor:

I love everything. Honestly. I tell my kids who are in that space where they’re beginning to move into careers. I truly embrace that saying that “if you love what you do, you’ll never work a day in your life.” And I’ve been extraordinarily fortunate to be in this field and to work amongst amazing colleagues that we have working in this field.

Courtney Collen:

Wonderful. Well, we’re so grateful for you, Christopher, for being here in Sioux Falls for our third rural health summit. Safe travels home and appreciate all that you do.

Christopher O’Connor:

Thank you very much.

Courtney Collen:

Thank you.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series on Apple, Spotify, and news.sanfordhealth.org.

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What does a heart attack feel like?

Cassie Alvine (announcer):

This is the “Health and Wellness” Podcast brought to you by Sanford Health. The conversation today is about heart health and the question, what does a heart attack feel like? Our guest is Dr. Nayan Desai, interventional cardiologist with Sanford Heart Bismarck. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

A note for our listeners: At the time we recorded this interview, Dr. Desai was on his way to provide outreach care at another Sanford location, so you might hear highway traffic noise in the background.

Dr. Desai, thank you for joining us today and very important stuff that we’re talking about as we talk heart health, and let’s get right to it. People are always wondering, they’re always wanting to know about a heart attack. We hear so much about it, so let’s ask that question. It’s a big one, and we can dive into all the details. What does a heart attack feel like?

Dr. Nayan Desai (guest):

Sure, yeah. Thank you Alan for having me. My name is Dr. Nayan Desai, one of the interventional cardiologists here at Sanford Hospital in Bismarck.

When we think about a heart attack, it basically, in common terms what’s happening is the artery is getting clogged off with either a blood clot or a blockage, and that is causing low blood flow to the heart muscle itself. And that’s why some of the symptoms which you are feeling are coming from that. Symptoms or common problems which people will experience will include chest pain, chest tightness, shortness of breath.

Pain is kind of very nonspecific and pain differs in different individuals. Every patient has a fingerprint of their chest pain description in terms of where it’s going to go. Typically we hear the description of elephant sitting on the chest, but that’s not always the common feature when patients come into the hospital.

Alan Helgeson:

This is a question, kind of a follow up to that. How long does your body warn you before a heart attack?

Dr. Nayan Desai:

There are two variations of heart attack if you will. Some patients would have chest pain, chest tightness, or shortness of breath going on for a period of months. And if they ignore those symptoms, they would come into the hospital with the heart attack or in myocardial infarction if you talk it in medical terms.

The other variation of it would be suddenly somebody wokes up and has a heart attack. It’s very sudden and severe and acute.

Symptoms can vary. Some patients may just have minimal shortness of breath or chest pain. Indigestion is more frequent in women as well as men might describe that. I typically like to ask the question to patients is if you have had heartburn before, is this similar? There is always something different if that heartburn is coming from a heart attack, right? It does not feel the same reflux pain you have had before. And if that’s the case, you need to go and see your doctor. Get checked out.

Alan Helgeson:

This question, I know what the answer is, should I ever ignore symptoms?

Dr. Nayan Desai:

It’s human nature, right? I think to kind of chuck it off to something else, “oh, it’s just my heartburn. I’m going to take some antiacid medications and sleep and it’s all going to go well.” The downside of that is you might not wake up next morning. So if you are experiencing any symptoms from the jaw to the tightness right within that territory could be related to any pain in that area.

Typically, chest tightness is commonly described, but it does not always have to be chest pain. Yesterday I saw a patient with a heart attack had just throat pain and passed out at work. Sometimes it could be back pain. Men often describe it also as a pain in their arm. And again, it can go to both right or left arm, but left arm strikes more with common population thinking that, oh, if it’s going to the left arm, maybe I need to worry about it because it could be more heart related.

Sometimes, unfortunately, when we say silent heart attacks, people don’t usually recognize their symptoms and that’s why it’s silent. If you pay close attention to your body in that last two to three months when you’ve had a silent heart attack, there were some symptoms, but likely you ignored it. You just thought that I’m more tired, I’m more fatigued, I’m stressed. I could have had some chest pain, chest tightness. It could be my muscles acting up. I took something because I thought it was from the acid building up in my stomach.

So yes, there are some true silent heart attacks, which typically happen in patients with diabetes or in women. Women have atypical symptoms that men do. So I would say never ignore your symptoms with heart attack. Always, you know, Sanford Health has walk-in clinics, urgent cares, emergency room departments, as well as your regular clinic provider, always available to get you seen that same day.

We want to act fast on it. We want to get you to the right treatment and make sure that it is up to the experts for us to decide if it is your heart or not. And it’s OK to be wrong. It’s OK that you’re going to an emergency department or a cardiology clinic and they tell you that it’s not your heart, it’s likely your muscle or something else, but it’s OK for a medical personnel to make that decision rather than patients taking that decision on their own.

Alan Helgeson:

And I’ve experienced family members that have come in and they’ve had something like that where they’ve said, I’ve had some of these symptoms. The orchestrated medical team that comes in, I mean, they move like lightning in taking care of something like that. There’s no messing around with that and it’s something to see how they take care of things like that. So thank you again for reiterating the importance of that.

You’d mentioned early on when I asked you that question about times of day and seeing some things at various times. So I want to get right into that. Are there times of the day that are worse? And then a follow up to that, are there times of the year that are worse for heart attack?

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Dr. Nayan Desai:

Most of the heart attacks do happen in the early morning hours. So typically from 5:00 a.m. to up to, I would say noon. And the reason for that is your blood pressure is higher that morning. Your cortisol, which is a stress hormone, is high in the morning and that predisposes the blood to clot more. So heart attacks are definitely more happening earlier in the day, but again, if you have ignored your symptom earlier in the day, you could present to the hospital much later in that evening or afternoon. So with the diagonal variation more common in the morning as compared to evening, but again, early morning heart attacks, it’s not uncommon for us to jump in our car and go to the hospital to take care of a heart attack patient, typically between the hours of four to seven.

And then when we think about the times of the year when a heart attack can happen, we’re right in the middle of the winter.

So heart attacks are definitely more common and more prevalent during the winter months. And the reasoning behind that would be the cold weather stress and activity like shoveling, contributing to a plaque rupturing, which means that a blood clot forming in those arteries in the heart and causing a heart attack. So more common in winters and more common during the early morning hours during wintertime.

As we’re right here we’re talking about should we shovel, what symptoms are we looking for? You know, if you’re trying to shovel and you smoke a cigarette before shoveling, definitely a no-no. Because that’s going to increase your risk of a heart attack. After a heavy meal, most of your blood circulation is going into your gut at that time and then it’s depriving the heart of some blood flow. It’s causing like a steel phenomenon.

So some of the “do nots” is when you’re trying to shovel, if you have any cardiac condition, I would recommend not extreme shoveling, especially when it’s freezing cold. Definitely no smoking cigarettes and not eating a heavy meal before shoveling. That would be some good common practice.

Alan Helgeson:

You’ve talked a little bit about times of day, times of year and we’ve talked a little bit about symptoms and more to come on that. If someone is having a heart attack, is there anything that a person can do or a loved one can do until medical help arrives?

Dr. Nayan Desai:

That’s an excellent question. If you are experiencing a symptom of heart attack the first response would be to call 911. This is not the time waiting for a family member to arrive, get you in a car and then drive you to the emergency department. This week I have taken care of at least five or six patients with heart attacks.

One patient comes to mind where, you know, he is at home, he’s a young man in his sixties having dizziness and some chest pain, not really your typical symptoms of a heart attack. Calls 911, fire arrives, his front door is open and they go ahead and shock, write him in and save his life. Comes to me, put a stent in his widowmaker and open up the blockages of his heart. So when you’re experiencing a heart attack, I would say call 911. Even if you have five minutes away from the emergency department, if you’re coding in the passenger seat, your wife or your spouse or your friend cannot help you. That’s why medical help is so important.

The second thing which brings you in is of course do not drive yourself. Right? That would be the worst thing you would be putting yourself and more importantly, others in danger. When you’re having active chest pain, we had a patient come in taking nitroglycerin in the car and driving to the emergency department. That’s a total no-no.

Medication wise, I think it’s more selective. It all depends on the patient’s bleeding risk. If you have an aspirin at home, it’s not a bad idea to chew it, but again, that depends on your individual risk factors. I’m not making a common advice for somebody to just start doing aspirin every time they’re having chest pain.

So while you’re having that, sit down, definitely if you are getting a strong urge to go to the bathroom and you’re super sick, that’s also a bad sign. Just wait there. People can pass out or die if they’re trying to pee or go to the bathroom when they’re experiencing a heart attack. Let the medical personnel come in and take good care of you. EMS medical people come and get you to the nearest hospital.

But recognize the symptoms. I think the biggest message I want to convey with this question is recognize the symptom that you’re having a heart attack. You have to come to terms with your own body and not be in a state of denial. We all, as humans try to always think that it’s not something significant, right? We think it’s my acid reflux, it’s my muscles, it’s my nerves, it’s not my heart. So patients usually, and you know, general population, know their body the best even more than their regular doctors.

If you’re aware about your body and if that symptom is not making sense, like this is not feeling like my heartburn, I’m just sweating profusely, something is not feeling right, my chest is, you know, knotting up, call 911 if that is happening, especially at rest.

Alan Helgeson:

Dr. Desai, are there any myths about heart attacks?

Dr. Nayan Desai:

That’s a great question. As I said, the most common myth is I was just having heartburn and not realize that.

Some of the other common myths are that every time the chest pain has to happen in the center of the chest and go to the left arm.

That’s also a common myth and that is something which people need to know about – men and women present differently with chest pain.

Americans, number one cause of death in our country is still heart attacks or myocardial infarction. And the main reason is not recognizing the symptom.

One of the myths about symptoms and as you were kind of alluding to, you’re going to dive into what about the treatments, right? If you are having a heart disease, what about the treatments? “I’m on a cholesterol medicine and a blood thinner. I could not have a heart attack.” That is not true. People can still have heart attacks if they are on cholesterol medications or blood thinners.

Some of the other myths: I have never had blood pressure issues or have not been a diabetic. I don’t smoke. I could not have a heart attack. That is not true as well. Heart attacks can affect any age of person. I have seen with a heart attack as recent as in their 20s.

Diabetes won’t cause heart disease. That’s the common myth: because I’m taking diabetes medication or trying to say that my diabetes is well controlled, I don’t have diabetes or my blood pressure is well controlled, I don’t have high blood pressure. That’s not why your blood pressure is controlled on medications. That is a strong risk factor for having a heart attack.

Taking vitamins and supplements. People believe in natural medications, believe in heart healthy diet is one thing, but trying to take supplements and thinking that, oh, I’m on this good supplement, it’s going to take my blood and clean up all my arteries and keep me free of any heart diseases.

I always tell my patients if something was so good, the FDA would’ve approved it as medication. So yes if you are believing in vitamin and supplements, make sure you know the contents but also recognize your symptoms. Just because you’re taking a supplement or over the counter pill. Or let’s go to a chiropractor or doctor because I think it’s more my muscle in the neck which is hurting me and it’s not my heart. Get it checked out first. Get a professional opinion and then do massages or something else once you have had a clear answer from your doctor that it’s not your heart.

Well, I have not smoked for years and now there is no chance that I’m going to get a heart attack. That’s also one of the common myth which men come in with and that’s not true either. Any history of smoking in your lifespan increases your risk of having heart diseases and heart attack. Heart attack is still the leading cause of death in men and women. So how can you prevent that is by taking appropriate precautions.

Alan Helgeson:

We learn all sorts of things on social media and I’m guessing as a physician you just roll your eyes probably 20 times a day when people come in and hear things, see things. But I got to ask you this question. Is there such a thing as a pre-heart attack?

Dr. Nayan Desai:

Yes. I would say pre-heart attack, what we call is an impending heart attack or something which is leading to a heart attack, right? And again, that those are symptoms which you would start experiencing a little bit of chest tightness with walking and now it’s getting worse. Initially it just started to happen with walking, but now I’m having chest pain, even going to the bathroom, I’m getting chest pain and I’m going to the kitchen. That’s a sign that something is getting worse, that you don’t need to ignore that heart attack or pre-heart attack warning symptoms.

Alan Helgeson:

Let’s switch gears a little bit and we hear about different things relating to men and women and their health needs. Let’s talk about specifically heart attack. Are there signs, symptoms that are different for men and women?

Dr. Nayan Desai:

Men, as we just touched briefly on in our prior questions, would have those typical symptoms, right? They would have that chest tightness, chest discomfort, a feeling of pressure in their chest associated with shortness of breath, sweating, as well as some nausea and vomiting. If they’re experiencing some bad air weakness, which means a bad electrical problem during their heart attack, they can pass out, feel dizzy.

Women typically don’t have the typical just pain symptoms. They would come in with, you know, feeling tired or fatigue related to physical exertion being more in the upper back or the jaw area, the throat becoming tight, heartburn symptoms, symptoms of having indigestion like pain in the upper part of their abdominal area. And then they would think like, oh, it’s maybe gallbladder, it’s my acid. But as we said, the heart pain symptoms can go all the way from their neck or the jaw to the middle of the abdominal. So any pain in that area is or should be ruled out for having a heart attack first before we label it to something else. And the reason to do that is that’s going to kill you versus some of the other things.

Alan Helgeson:

Let’s move on to risks. And we always hear about the health risk, about heart health, but it’s always good to talk about these things and go back into risks that increase a chance of a heart attack. You can never talk about this enough.

Dr. Nayan Desai:

Being an interventional cardiologist, I do procedures in the hospital and see patients in the clinic as well as educating patients every day about their risk of having a heart attack, right? And the main risk, which we think or talk about, it’s a combination: it’s lifestyle, it’s medical risk factors, it’s genetics and it’s something in the environment. And let’s kind of break these down because it’s just going to be a lot of good information.

Talking more about lifestyle. This is something new our patients can do on a day-to-day basis to prevent a heart attack. And that’s where lifestyle comes in as the most important choice. Every day, your goal should be, how can I live a heart healthy lifestyle? Right? What that means is no smoking, we talked about smoking, damaging the blood vessels, decreasing the oxygen supply to your capillaries, to your heart, increasing the buildup of cholesterol plaque in those arteries contributing to heart death.

So no smoking should be the key message in the lifestyle choice.

The next one is heart-healthy diet. We all know what is good for our body. Whatever is good for our tongue, as commonly said, is not good for our heart. But that’s not true all the time. High fat, saturated fats which are high in sodium content leading to obesity, high cholesterol and high blood pressure, those should be avoided. Common examples would be, I would say, seeing a patient in the clinic, just replace one bad habit. If you’re trying to have that ice cream bowl every night, replace that with nuts on the counter. If you’re having, you know, a cookie, replace that with some seeds like flax seeds, walnuts, pistachios, avocados, those are all heart healthy and good if taken in an appropriate amount.

Next is going to be physical activity. Trying to have a sedentary lifestyle is not helping your heart. Movement, you know, doing household chores, moving around the house, setting apart a regular time in your daily behavior. I’m going to be walking for 20 minutes or 30 minutes a day. Getting my heart rate up is good for your heart. Your heart being a muscle leads that exercise to work efficiently. And excessive alcohol consumption, excessive alcohol can contribute to, you know, high blood pressure, depression as well as leading to alcoholism.

So these are the four factors which I would like to highlight in the lifestyle factors. Trying to avoid smoking, trying to avoid alcohol, have a heart healthy lifestyle and walk and move more.

Next thing we would move on to, what about some of the medical risk factors we see which contribute to having heart attacks? That’s where comes in your diabetes, your cholesterol, blood pressure, as well as obesity. So getting a blood pressure checked, we have a fantastic program here at Sanford with heart screenings and that’s where we talk about this combination of factors, which is a prevention with heart screening, which means we want to screen the heart of healthy adults between the ages of 40 and 75.

Do a good examination of their cardiovascular system, get a good history, check their blood pressure in the clinic, check their cholesterol numbers, make sure they don’t have diabetes, and then if indicated do a special test to screen if they have plaque in their arteries of the heart. So medical conditions is very important.

Go to your regular doctor. High blood pressure can often be silent. If it’s not checked, you won’t know about it. Same thing about your cholesterol. You might think that you might be following a very heart-healthy lifestyle, but you might still have high cholesterol because of either genetic factors or from lifestyle choices and stress. Trying to take time away from work. Meditate. Stress level increases the risk of hormones in the body and also causes increase in the risk of heart attacks. So these are some of the modifiable factors, which means that you yourself can take charge of these factors and change it.

What about family history? That’s why we talk about non-modifiable factors. Your age, you cannot control that. If you’re a man or a woman, you’re not going to control that. Same thing about your family history. You cannot choose who your parents are and what genetics you inherited from that, but that’s a small proportion. If you are following a heart-healthy lifestyle, taking care of your risk factors, your risk of heart attack still decreases. Even though you have genetic history, you get older and as we know men have higher risk of having a heart attack.

Alan Helgeson:

Dr. Desai, what would you want someone to do if they think they’re having a heart attack?

Dr. Nayan Desai:

As we have talked about, if you are having any symptoms at rest – chest pain, chest tightness, shortness of breath – even if you don’t think it’s your heart, sit down and call 911. You might not have a lot of time left before making that call. If you are not prompt enough, call emergency services immediately. Do not delay seeking help even if the symptoms are mild or unclear. Any symptom at rest is not a good sign.

Sit or lie down in a comfortable position. Make sure your front door is open. If you are passed out or if you have died and your heart needs to be shocked, EMS and fire can come in and appropriately save your lives.

Take that aspirin 25 if you have it at home. I don’t want to get this message out routinely that people should be chewing aspirin, but taking an aspirin if you believe or think that it’s heart attack related, unless you have an allergy to that medication or if you have any bleeding issues. Then of course don’t take aspirin. If you have nitroglycerin at home and you have been prescribed that by your doctor, take it as per their instructions.

Avoid driving yourself to the hospital, stay calm, monitor for symptoms and call for help.

Alan Helgeson:

Can you talk about some of the recent advancements in the treatment and management of heart attacks?

Dr. Nayan Desai:

Sure. Sanford, being a leader in cardiac care, significant advances have been made in the treatment and management of heart attacks in recent years. These innovations have allowed us to make not only rapid diagnosis for our patients, but also improved treatment with personalized care.

And talking about some of the recent advances we have is if you come into our emergency department with any symptoms of chest pain, we just rolled out something called a high sensitivity troponin. It’s a blood test which tells us if there is any sign of heart damage and that makes us easy to have a diagnosis of heart attack early on and quickly.

AI is everywhere these days. AI and machine learning and EKG rhythm analysis, that also helps us to vastly improve the diagnosis of if somebody’s having a heart attack.

Pre-hospital care. Faster door to balloon time. And that’s the mantra which I strive for, is what is my door to balloon time? And to explain that if that is the time when somebody hits their door in the emergency department till I blow open the balloon in their artery, that is the time we are monitoring. We’re trying to make that time as shorter as possible because every minute wasted while somebody’s having a heart attack is going to increase the risk of heart damage. So that’s why we want to act fast. We want to act promptly, we want to make sure we decrease our door to balloon time which means we’re trying to open up the balloon in that artery.

So I would just run your, typically what happens when our patient comes in, they get an EKG. If the EKG is showing a sign of a heart attack, I get a call immediately. I and my team of our nurses and technicians in the cardiac cath lab are there in the hospital in 10 minutes, even in the middle of the night.

That’s how we have our system operated. We can even kind of have an EKG sent directly from the EMS or our referring outlying hospitals in our community right away to my phone without going the operator or without trying to figure out which doctor to call.

We have tried to make it easy for a community so that we recognize heart attack early on and then get them right away to my hospital or any nearby hospital, make sure they get that aspirin, they get a blood thinner and off we roll them to a cardiac cath lab. And what a cath lab is, is where we do a procedure with an X-ray machine or a camera, I put a small IV in their artery, in the wrist. Typically go up in their heart, check if there is a sign of a blood clot in their arteries and then open up for us to the balloon and then a stent.

Alan Helgeson:

At Sanford Health, heart screenings are an important tool in prevention when it comes to heart care. Could you explain what that is and who it’s intended for, Dr. Desai?

Dr. Nayan Desai:

The heart screening is a unique program which is rolled out by Sanford Health and it’s available to anybody who thinks or believes they need to take care of their heart or just need some more answers. So I want to emphasize heart screening is for healthy people. It’s for people in the age group of 35 to 75 and more importantly, trying to help them understand what risk factors do they have for heart diseases.

What we do in that clinic is anybody can sign up through any of our programs at any of the Sanford locations, you come in, you get examined by a nurse, you get your blood pressure checked, you get an EKG done at that time. The EKG is reviewed by the cardiologist. We go over talking about your risk factors, about checking your cholesterol number that same day. Of course getting your blood pressure as well as getting your sugars checked.

And then we make the personalized plan based on that factors. We put that in a calculator and try and estimate what is the risk factor of that individual patient. If that patient is at high risk, we offer a cardiac screening test called calcium score. And that is basically a specialized CT. It takes about 15 minutes. There is no prep required for that cardiac CT. You come into the hospital, go straight into the scanner, and 15 to 20 minutes you are checked out. That CT scan does not need any contrast or dye to be administered.

And in that, what we are looking for is if there is any plaque or cholesterol or calcium particles built up in their heart because any plaque in their arteries would be a risk factor for having a heart attack. We would like patients to have a score of zero, but we don’t live in a perfect world.

Some of our patients who are heart healthy have a score of zero. But if your score is not zero, then you get to see a cardiologist and we make a personalized plan about which direction we need to go with regards to your heart care. I would say everybody, I encourage you to get a heart screen at least once in your lifetime if you have not had it. And if you want to be in charge of your cardiac health, give this yourself as a birthday gift. Do it on your birthday.

Alan Helgeson:

Dr. Desai, as we come to a close, what would be that one thing you want someone to take away from this conversation on heart health?

Dr. Nayan Desai:

I’m going to say two things, Alan, instead of one thing. The first thing is recognize symptoms and get checked out immediately. There is not enough, which we can emphasize on this message. If you do not come and get medical attention, there is no way I’m going to know that somebody is having heart attack. They need to make that phone call and be in charge of their health. Any symptoms, do not ignore if you think are related or unrelated even to your heart.

And make a healthy lifestyle choice. Before getting to that heart attack phase, make sure you can do some preventive stuff as we talked about, trying to move more, no smoking, no alcohol, as well as eat a heart healthy diet.

Alan Helgeson:

We thank Dr. Nayan Desai, interventional cardiologist with Sanford Heart in Bismarck, North Dakota for joining us on this very important conversation on heart health.

Cassie Alvine:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, find us on Apple, Spotify, and news.sanfordhealth.org.

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How to find a mental health provider who’s right for you

Simon Floss (host):

Hello and welcome to the latest edition of the “Health and Wellness” podcast series, brought to you by Sanford Health. I’m your host, Simon Floss, with Sanford Health News.

Mental health challenges are on the rise. Statistics show one in five U.S. adults experience mental illness each year, and one in six U.S. youths between six and 17 years old experience a mental health disorder each year. This according to the National Alliance on Mental Illness.

If you or a loved one are experiencing these concerns, you may wonder when it’s time to seek care or what kind of mental health provider best fits your needs. Here to offer guidance and support is Kayla Nalan-Sheffield and Kate Andal. Both are psychologists at Sanford Health in Sioux Falls, South Dakota. Thanks so much for being here today, both of you.

Kate Andal, PhD (guest):

Happy to join you.

Simon Floss:

So, we’ve got a lot of ground to cover in a short amount of time to get there. So, we’re going to hit the ground running here. First, when it comes to the types of mental health providers, can you explain the differences between them?

Kate Andal, PhD:

I think the first biggest distinction is the difference between psychiatry and psychology.

So, psychiatry (providers) are providers that have gone to medical school or PA school, or nurse practitioner school, and they have a prescription pad, and they help you. They prescribe medications to help you manage your mental health difficulties.

Psychology providers, which would be therapists, counselors, or psychologists, they have a graduate level education, either a master’s degree or a doctorate degree in psychology or social work or counseling, something like that. And they provide therapy services to help you develop skills to help manage your mental health difficulties.

Simon Floss:

And Kayla, all of this is so important to keep in mind when choosing the right mental health provider for you. Say someone’s noticing some things about themselves and they just don’t know where to begin. How do you get matched with the right provider?

Kayla Nalan-Sheffield, PhD, LP (guest):

Here at Sanford, we do have mental health providers, primarily counselors, embedded in all of our family med clinics. And so asking your primary care physician for a referral to there is a good place to start. Otherwise, you can reach out to the psychiatry and psychology clinic yourself and get referred to somebody.

We do have provider bios on the website as well. And so you can peruse that, see who you might think be a good fit. And the reality of our profession is that sometimes it does take a while to find somebody that you gel with. And that’s okay. So it’s not uncommon for me to see people who have seen several providers before just because they haven’t felt like they’ve found the right fit, either in personality fit, or fit in terms of type of therapy that you want to do.

Simon Floss:

How do you decide what the right fit is?

Kate Andal, PhD:

That’s a really good question. Some of it starts with thinking about what it is you can commit to in therapy. Does that particular therapist require you to come weekly? Sometimes that doesn’t work for people. Or can they only get you in monthly? Which sometimes feels like not enough to help you. Also, personality fit really is probably the biggest, biggest predictor. You should sit in that room with them and really feel like they understand what’s going on with you and they have a good plan. And you feel like they have your back.

That is the biggest predictor of success in therapy. Beyond all of the techniques that we learn and all of the other things there are, that fit is the biggest, and it’s a very qualitative thing. It’s hard to describe, but when you feel like you have it, that’s the person who’s probably going to help you.

Simon Floss:

And Kayla, piggybacking off of that, is there anything else you would add as far as anything specific that one should look for in a mental health provider?

Kayla Nalan-Sheffield, PhD, LP:

I think whatever condition you are struggling with or symptoms you’re struggling with, if you’re looking for a specific therapy modality, trauma treatment for example, there are pretty well-known treatments for addressing those concerns. And so if you’re looking for cognitive processing therapy or prolonged exposure, another kind of trauma treatment, making sure that the providers that you are potentially going to connect with have training in providing those treatments.

Simon Floss:

So, if someone has never seen any type of mental health provider, what would you say to them if they’re feeling overwhelmed and concerned, and when you’re experiencing some of these things, mental health concerns, that’s scary in and of itself. And then starting this whole journey of, “oh, I want to feel better,” and you don’t know where to begin, that’s a lot too. What would you say to people who are listening to this and might find themselves in that situation?

Kate Andal, PhD:

I think, and this is coming from my own ideas of how I would feel about it. I think the most important thing is to just start somewhere. If you go to psychiatry and you really meant therapy, no one’s going to judge you. It happens all the time. We’ll get you to the right person so you don’t have to have it all figured out or know exactly what you want before you step into the office. Just be open to having a conversation about it and we can help guide you from there.

Kayla Nalan-Sheffield, PhD, LP:

I would also add to that, I think a lot of people feel that they are alone in whatever experience they are going through. And just recognizing that that’s not reflective of reality. Lots of people struggle in very similar ways. So, just taking that first step, I do think in and of itself is helpful for people in healing, for people just kind of admitting that they do need help and kind of breathe that out, so to speak. And of course, as Dr. Andal said too we can help you connect with whatever you need, just connect with somebody.

Simon Floss:

Some people might say asking for help is a sign of weakness, but it’s actually the complete contrast – when you notice you’re going through some challenges and you might need a little bit of help, asking for help is actually one of the most courageous things that you could possibly do. Is there anything that either of you two would piggyback off of that?

Kate Andal, PhD:

There’s actually a whole bunch of research particularly about Midwestern and rural Midwestern values of self-sufficiency and the ideas that seeking help and helping and those kinds of behaviors somehow represent your inability to be self-sufficient, which Midwesterners will agree is not a thing any of us want to be. And I think the mental health community has worked really hard over the last couple of decades really trying to combat that idea because none of us are truly self-sufficient.

And I would argue that humans are not meant to be self-sufficient. We are meant to have connections and relationships and depend on each other and have a sense of community, that all of those things are really important. And seeking mental health services, I think, falls neatly into that package as opposed to just trying to do the whole “I can handle it” thing.

Simon Floss:

And we’ve talked a lot about if you’re noticing some challenges within yourself, and I think we should identify some of those so we’re not speaking so broadly. So, at what point should an individual take steps to get help, or maybe what are some signs that someone isn’t doing well?

Kayla Nalan-Sheffield, PhD, LP:

Sure. I think biggest thing that I would encourage people to look for is whether they’ve noticed a change in their functioning, whether that’s at school, work, relationships. If you’re not sleeping well, if your appetite changes, if you just notice any difficulty with coping like you normally would or you’re used to coping with, that would be a sign that you might need to ask for some help.

Simon Floss:

Sleeping is a big one. When I have experienced challenges myself, I could not fall asleep at all – and then it took every single possible thing (I had) to get out of bed in the morning. And at that point I was like, OK, something’s going on (laugh) and I’ve got to do something about it. How should someone prepare for their initial appointment?

Kate Andal, PhD:

Well, it’s not a test. (laugh) You don’t have to study for it like it’s homework. But just have a general idea and be ready to talk about what’s going on with you. Sometimes I see patients who try to control the narrative by having certain topics be off limits because they’ve decided that it’s not important. And sometimes that can hinder our progress because sometimes things you think aren’t important are in fact important.

Simon Floss:

So similar to any sort of provider, you two can only help someone if they’re honest, you know what I mean? If you go to your primary care provider and let’s say you’re having some digestive issues, they don’t know that unless you tell them. And so how important is it to – it takes a lot of courage and it’s really hard – but how important is it to be completely honest in therapy and talking with providers?

Kayla Nalan-Sheffield, PhD, LP:

Yeah, you’re exactly right. We don’t know what we don’t know. We can’t treat what we don’t know is a concern. And at the same time, that first visit in and of itself does take a lot of gumption to get up and do. So we also recognize that we might not always know the full picture in that first visit. And there are certainly things people might not feel comfortable disclosing until later on, but we obviously would hope that you get to a point with your provider where you trust them and feel comfortable with them enough to be able to talk to them about that at some point.

Kate Andal, PhD:

I think it was your patient and you’d been doing depression treatment with them for a long time, and they just weren’t getting better. They weren’t getting better and we couldn’t figure out why because they were doing all this stuff, but it just, it wasn’t getting better. And then they disclosed they had trauma. And we were like, oh yeah. So that would’ve been useful to know a while ago.

Kayla Nalan-Sheffield, PhD, LP:

And they did trauma treatment.

Kate Andal, PhD:

And then they got better.

Kayla Nalan-Sheffield, PhD, LP:

Yeah. Yep.

Simon Floss:

So, what are some of the differences, or if there’s even similarities too, between things like depression, anxiety, bipolar disorder, a lot of the mental health challenges that you see people facing?

Kate Andal, PhD:

Sure. So, one of the things I always think about with things like depression, anxiety is those are also emotions. They’re emotions and then they can also be a disorder. So if you’re feeling depressed, that doesn’t necessarily mean you have depression because we all get depressed sometimes.

But if you are feeling sad or depressed or down, or if you’re just feeling kind of blah and nothing sounds good or fun or interesting anymore and that persists for a couple of weeks, then you’re looking at more of a depression. Like a clinical level of depression.

Anxiety on the other hand tends to be more worry-based or future fear-based kinds of, you know, thinking something bad’s going to happen or you have to be in control of everything and it’s a little more agitated, I would say.

And then bipolar disorder specifically is episodic. So you have episodes of depression that last a few weeks and then periods of stability and then you have manic episodes. And those manic episodes involve, you know, feeling amazing. Doesn’t usually work out well, but you feel pretty good for a while with impulsive behavior and risk taking and really poor sleep.

Kayla Nalan-Sheffield, PhD, LP:

Yes. Sleeping very little, but not being tired. Starting a lot of projects, not finishing them.

Kate Andal, PhD:

Things like that. And the sleep thing is important because it’s not “can’t sleep,” it’s “don’t need to sleep.” Most disorders have sleep disturbance as a criteria for them, but it’s usually either feeling tired all the time and trying to sleep all the time or being unable to fall asleep either because you can’t quiet your mind or you’re just restless or you’re ruminating or whatever. But with manic episodes, you don’t feel the need for sleep. You’re not tired.

Kayla Nalan-Sheffield, PhD, LP:

I think there’s a lot of misconception about bipolar disorder in particular because a lot of people will experience mood swings that are fairly rapid.

But in bipolar disorder, the highs and lows do tend to last longer. Four or more days, two or more weeks, kind of depending on whether you’re talking about the depression side or the mania or hypomania side.

So, I just wanted to kind of clarify that because I do think that is one thing that I see often is people say, “well, my mood changes a lot and very quickly I think I have bipolar disorder.” It’s a little bit different than that.

Simon Floss:

So, it might be a little bit longer timeframe, what you’re saying, than people might expect?

Kate Andal, PhD:

Right. The highs. And when people tell us that they’re experiencing mood swings lasting a couple of hours or even a day or so, that’s not likely to be a manic episode. That is more likely to just be having trouble regulating your emotions, or being emotionally labile is the term for it.

Simon Floss:

Hmm. What are some tips to regulate your emotions?

Kayla Nalan-Sheffield, PhD, LP:

One of my favorite skills to teach is the tips skill from dialectical behavior therapy, specifically the temperature change. So, if really dysregulated, changing your temperature and this time of year in the winter is kind of nice because you can just walk outside and you’ll be cold, right? In the summertime and really cold shower or splashing cold water on your face, something like that.

Intense exercise. So, doing some squats pretty rapidly or running in place, just trying to get your heart rate elevated. Paced breathing, muscle relaxation. That’s kind of my go-to. I feel like a lot of patients respond pretty well to that.

Kate Andal, PhD:

And you can teach kids that.

Kayla Nalan-Sheffield, PhD, LP:

Yes. Yeah. My daughter responds well to ice packs (laugh) on the face.

Simon Floss:

Yeah. Yep. I take cold showers, so yeah. Not during the winter, obviously, because it’s like, I just, I don’t need that much cold in my life.

Kayla Nalan-Sheffield, PhD, LP:

(Laugh)

Simon Floss:

What would maybe be like, what are some of the biggest misconceptions that you see in your line of work?

Kate Andal, PhD:

The fact that we don’t have a magic wand. You’re not going to come to therapy for one session and you’re not going to walk out with a cure. That’s not how it works. Therapy is really an investment and in developing a skill to manage your symptoms, I would say the other one just left my brain. I had it in my head and then I left it. So (laugh), I got nothing.

Kayla Nalan-Sheffield, PhD, LP:

No, I would agree. I do think people sometimes do expect us to be able to solve whatever their struggle is. But honestly, most of the change in therapy happens outside of our office. And it’s what changes they make, how often they practice the skills that we talk about. And it’s really, really a patient driven process.

Kate Andal, PhD:

I remembered it. We are not advice givers. A lot of people, they get kind of really mad when they sit in your office and they’re telling you about things, but you’re not telling me what to do. Nope. I sure am not. And that is not actually part of what we do. We help you figure out what’s important to you and strategies that you can use to make your decisions. We don’t make them for you.

Simon Floss:

Wrapping up here, I always like to ask this question: what’s a take home message that you want people to know?

Kate Andal, PhD:

I would say the biggest take home in general is we are not scary people. I mean, we are, but – (laugh)

Simon Floss:

No, I’ve hung out with you guys a couple times. You’re pretty fun.

Kate Andal, PhD:

(Laugh) I understand that it can be scary and intimidating, but really, mental health providers are just here to help. You can tell us anything and we will help you figure out where the place you need to go is next. So, if you’re afraid that you just can’t quite make that step yet because you don’t know if it’s the right step, that’s something you can talk about with a therapist or a psychiatrist or your doctor as well. We will help you help figure that out.

Kayla Nalan-Sheffield, PhD, LP:

One thing I talk about often with a lot of my patients, just to kind of demonstrate shared humility, right? Like we all struggle with very similar things. I remember one of my first semester of grad school is when we have one of our hardest class, this big book of diagnoses, right? I’m never going to remember this stuff. How am I going to make it in this profession?

And then you get into it. And the more experience you get, you realize that people with similar experiences do really have internal worlds that are quite similar. People with trauma history have very similar thought process, yet also feel like nobody understands them or that they’re alone, right?

And so, I think just recognizing that you really are similar to your peers. We just don’t talk about it enough. If we talked about it more, we’d probably be in a better spot as a society in general. So, I think that’s my biggest takeaway is just really understanding that we truly are much more similar to those people around us than we think we are.

Simon Floss:

What resources are there at Sanford and what makes mental health care at Sanford so great?

Kayla Nalan-Sheffield, PhD, LP:

One thing that I think is nice about getting services in a health care system is that your providers are able to communicate with one another more effectively. I like it when my patients are seeing psychiatry here versus psychiatry outside of here because I can very easily secure-chat their psychiatry provider or talk with their psychiatry provider rather than having to play phone tag or faxing. So I think it, from that perspective, can create a more well-rounded care, I don’t know if that makes sense. More comprehensive.

Same thing is true, especially depending on the condition we’re treating because our brains and bodies are so connected, right? And so being able to touch base with their primary care provider, Kate talks with neurology all the time. And so having those shared records and just ease of access to other providers, I do think benefits patient care in ways that they might not see.

Kate Andal, PhD:

And I would add that I think we have amazing providers here. I know all of them personally because I work here, but I’ve known most of them for a long time, which is not to say that providers elsewhere aren’t also good. And there is enough mental health need in the community right now that I would certainly never discourage you from seeking help anywhere, even if it isn’t Sanford. But we do have a really strong focus on evidence-based treatments with really skilled providers. And I think add that to all of the things Kayla already said.

Simon Floss:

Well, thank you both so much for being here today.

Kate Andal, PhD:

Yeah, thank you.

Kayla Nalan-Sheffield, PhD, LP:

You’re welcome. Thanks for having us.

Simon Floss:

A reminder, you can find this podcast, and many more, on your favorite podcast listening apps like Apple, Spotify, or YouTube, or by going to our website, news.sanfordhealth.org.

Thanks again for listening. I’m Simon Floss with Sanford Health News.

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Physician leader passionate about tech, AI and transformation

Alan Helgeson (announcer):

“Reimagining Rural Health,” a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high-quality, low-cost services in rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, host Courtney Collen with Sanford Health News talks with Dr. Eve Cunningham, chief of virtual care and digital health at Providence, as well as founder and CEO of MedPearl.

Dr. Cunningham is a speaker at the 2024 Summit on the Future of Rural Health Care.

Courtney Collen (host):

Thank you so much for your time.

Dr. Eve Cunningham (guest):

Thank you for having me. I’m really excited to be here.

Courtney Collen:

You are participating in a panel called “Expectation to Experience: Rethinking Health Care to Serve Today’s Consumer.” What is something that you’d like the audience to take away?

Dr. Eve Cunningham:

I think that the important thing to take away is obviously there’s a lot of innovation happening now. There’s a lot of engagement from clinicians. We’re starting to get really excited about the possibilities and the changes that we see coming.

And so, from my perspective I think there’s a way forward for us to start to reimagine how we deliver health care, and technology is going to be such a critical aspect of that. As clinicians having competency and skills in technology and understanding technology and integrating that into our work is going to be really important going into the future and impactful in our ability to deliver care in a more meaningful way to our patients.

Courtney Collen:

Yeah. Wonderful insight. Thank you for that. Do you have a surprising, hottest take from the day so far that you’d like to share or something that you are going to take home?

Dr. Eve Cunningham:

Well, the panelists have all been super impressive. I’m really impressed with the lineup. Your CEO Bill Gassen, he is a really phenomenal speaker, very inspiring. And some of the things when he was speaking, I was like, “Wow, he sounds like a clinician.” I know he doesn’t have a clinical background, but he really understands how to speak health care and speak to the clinicians in the room. So that really resonated with me.

And then Dr. Bruce Scott, the president of the AMA, I wanted to applaud him when he started talking about the pain of prior authorization, that we’re feeling the strain, and the stress that we feel with the overwhelming amount of prior authorization that we as clinicians have to deal with. It’s becoming more and more intense every year, and that we really need to address that issue. I just thought that was such an important thing, and I think it’s an area of opportunity from an innovation perspective.

Courtney Collen:

And speaking of innovation, is there an innovation or action that you feel will really move the needle in the coming years, at least the next one to two years?

Watch the Sanford Health News vodcast of this episode

Dr. Eve Cunningham:

Yeah, I mean, I think probably one of the biggest things that’s on the horizon right now is the ambient technologies that we’re starting to bring in. So we use DAX at Providence. I know Abridge is another one that’s really popular with the clinicians, but all of those ambient scribe technologies really are going to unburden our clinicians.

And then I think the next frontier is around clinical decision support. As clinicians, we want to do the best we can for our patients, but the amount of information, knowledge, and both patient data for which we’re responsible at the point of care – it’s just too much for us to consume. So being able to filtrate out that information at the point of care so that we can make quick, meaningful and impactful decisions with our patients is going to be really critical going into the future.

Courtney Collen:

When it comes to rural health care, serving rural patients in rural America, what are some of the challenges or opportunities that you see?

Dr. Eve Cunningham:

I think one of the biggest challenges with rural health care is the fact that it’s very hard to recruit clinicians into rural health care settings. And there are many parts of this country that are underserved as a result of that. I mean, it’s estimated that 65% of non-metro areas do not have a psychiatrist living in the community.

So in order to address that, one of the best ways to be able to do that is through virtual and digital care encounters. And so it’s such a critical factor in these communities to be able to reach patients, even if we can’t do it in-person, to reach patients or to bring specialty expertise and beam it into a critical access hospital so they can keep a stroke patient in their community, for example, and not have to transfer. So those things are going to be critical.

And we experience that at Providence. We have a lot of critical access and rural community facilities, clinics, and hospitals and rural clinics. So we’re scaling out programs to reach those communities in new and innovative ways.

Courtney Collen:

Thank you. How do you think we need to strengthen trust in health care during a time of rapid disruption?

Dr. Eve Cunningham:

I mean, that’s a great question. I think that the trust has been broken to some extent in the past just because, especially with the EMR and the computer coming into the room. And the clinicians looking at a keyboard rather than being able to look in their patient’s eyes.

So I think these supportive technologies, I call it a supportive technology stack, that can sort of hug the clinician and surround the clinician so that they can actually reengage in what they love the most, which is relationship building and sacred encounters with their patients, I think that’s really where it starts for me as far as how we can start to rebuild that trust.

Courtney Collen:

Let’s talk about AI in health care for a moment and how you feel about it and its impact so far on the health care industry.

Dr. Eve Cunningham:

At Providence, I co-lead the clinical AI work group. We have a governance structure that was just set up and we have several use cases that we’re evaluating. I think there’s a lot of interest and engagement. We’ve deployed ambient technology. We have a digital assistant clinical intelligence hub for clinicians called MedPearl that leverages some AI. We have an in-basket management solution called Prevaria that helps with processing messages that uses AI. So we’re already starting to use it in a meaningful way.

I think that obviously you need to be careful. You need to be thoughtful about how you start to bring these things in. You have to take a lot of things into consideration, but we really, we believe that it is going to be the way forward into the future, and it’s going to change the way we practice and deliver care in a positive way. I truly believe that and give us more time to do the things that we love the most with our patients.

Courtney Collen:

It sure is here to stay, right? Now, Dr. Cunningham, as group vice president and chief of virtual care and digital health at Providence and the founder of MedPearl, I’d love to know – and an OB/GYN by trade – what do you love most about what you do?

Dr. Eve Cunningham:

You know, I think for me I would say my personal brand and my personal interest has been, I came up as a physician leader. I’m an OB/GYN physician, but then I came up the ranks as a physician leader, and I lead physician groups and I was the chief medical officer of a medical group for several years at Providence, before I moved into doing what I do today which is more around technology and innovation.

And the reason why I made that shift in that change is because I knew that my peers and colleagues were really struggling and they were having such a difficult time, and I didn’t feel like I had the ability to improve their experience with care delivery in a meaningful way without being on the technology side to be an advocate for them.

So for me, what I love most is bringing joy back to my peers and supporting my peers and having them come to me and say, I’m so glad we brought this program in, or the solution in, or, I love using MedPearl, or, I love using the ambient scribe. It unburdens me. It gives me more time in my day. It brings me joy. Because we need to restore joy in the practice of medicine so we can do what we do best with our patients and deliver the best care.

Courtney Collen:

Thank you for all that you do and for being here in Sioux Falls. Hopefully we’re making a lasting impression on you here at the Summit on the Future of Rural Health Care.

Dr. Eve Cunningham:

It’s really awesome. Yeah.

Courtney Collen:

Good. Well, thank you for being here for your time for this podcast and for all that you do. Thank you.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health Series on Apple, Spotify, and news.sanfordhealth.org.

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Your perimenopause questions, answered

Dr. Breanne Mueller:

Number one, find someone that you trust and that cares about you. And if you don’t feel like you have a connection or someone who’s motivated to help you, change. There’s a hundred doctors out there. Find someone that you jive with and who’s treating you appropriately. If someone is saying, you know, it’s just menopause, we’ll see you later. That’s not appropriate anymore in 2024. I think there’s more investigation to be done. And so definitely don’t get dismissed and stand up for yourself and know that there are plenty of healthy, well researched, safe, affordable options to treat problems that arise.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. We are starting new conversations about age-old topics from pregnancy to postpartum, managing stress, healthy living, and more. “Her Kind of Healthy” is here to bring you the honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.

In this episode, we are talking about perimenopause. I have Dr. Breanne Mueller joining me for this conversation. She specializes in obstetrics and gynecology at the Sanford Aberdeen Clinic in Aberdeen, South Dakota. She is a National American Menopause Society certified practitioner, one of the only practicing providers in this space in the state of South Dakota. So I’m so happy to have her here with me. Dr. Mueller, thank you so much for your time and welcome.

Dr. Breanne Mueller (guest):

Thank you so much for having me. I really enjoy being able to talk about this topic.

Courtney Collen:

Yeah, we’re so excited to have you for this. It wasn’t until recently, I’ll be honest, that I learned menopause can be grouped into three phases or stages. They are perimenopause, menopause, and postmenopause. And while we’re focusing specifically on perimenopause during this conversation, Dr. Mueller, I’d love to have you start with an overview of menopause in general to help us level-set.

Dr. Breanne Mueller:

Totally. So I think menopause is, I mean, first of all, to understand menopause, I think you can compare it to adolescents and puberty. So most people understand what puberty is and what puberty isn’t, because we get classes on it in high school, or not high school, elementary school. They start at elementary school letting you know your body is going to change. This is normal; this is abnormal. And most parents and most people are like, oh, my kid is a little grumpy, or my kid is getting acne or something like that. And they have like a halfway decent expectation of what’s going to happen. So they aren’t spooked. Most people make it through.

Some people need help going through puberty, like they have some problems, but most people make it through and they’re fine. And I think that menopause is puberty in reverse. So the only difference is that we don’t get classes on it. Nobody’s educated on it. And so it can be really scary. It can be really unsettling for people because it’s as life-changing as puberty. But we just have no really societal standard for educating women on “this is normal” and “this is abnormal.” So it can be really upsetting.

Courtney Collen:

That is so fascinating. Puberty in reverse.

Dr. Breanne Mueller:

So the term perimenopause just means around menopause. So what the clinical definition of perimenopause is: it begins with the onset of cycle problems or differences. So if your menstrual cycle is irregular, plus or minus like seven days from your normal and other menopause related symptoms, so like we can go over the symptoms later.

But basically any change from your normal, it starts at that and an extends past through the menopause transition more than a year. So what is the clinical definition of menopause? It is 12 months without a period. It’s, like that simple, but also there’s a lot more to it than that because you know, you can have symptoms before, you can have symptoms after. But perimenopause encompasses the beginning stages, the actual transition, and one year after that menopause, one year without a period. I know. Clinical, huh? So kind of dry.

Courtney Collen:

As far as symptoms, and you said simply put that it’s 12 months without a period. Are there other symptoms or things that we can be looking for that are associated with perimenopause?

Dr. Breanne Mueller:

Totally, and I think it’s nice to distill it down to like what it is. What it is: 12 months without a period. I mean, so it’s not this nebulous thing. It’s this. I mean, I think to just have nail it down and say this is what it is. However, that’s a retrospective diagnosis, right? I can’t tell you are through menopause yet if you haven’t had a period for nine months. Right? Technically, but it’s a little bit irrelevant.

What’s relevant is people’s symptoms. And I think that’s really important. Also, we can talk about hormone testing later, but what’s most relevant about perimenopause is how you are feeling and what your symptoms are. And I think that when people realize that, I think it’s really hard in our society today to not think about it like a thyroid test or hemoglobin A1C, right? My thyroid is two, when it should be four, that means I need medicine to regulate it.

And it’s important to understand that hormones aren’t like that, especially female hormones. There’s no range that’s perfect for everybody. They’re supposed to fluctuate. And in those fluctuations, are you doing well or are you not doing well? And that’s where someone like me can come in and say, OK, is this what we’re talking about? Is this perimenopause? Is this something I can help with? Or is this something else? So it’s nice to have someone who has the context and kind of knows you to go through it and figure it out.

Courtney Collen:

What is the general age range for when this starts?

Dr. Breanne Mueller:

Totally. So the average age of menopause is 51.6 (laugh), which again, it differs on ethnicity. It differs on health status. It differs on genetics. But if you have all comers in America, it’s 51.6. So and then if people go through a menopause way early, for us that is 40, sometimes 45, that’s called premature ovarian insufficiency. So that’s not menopause. That’s something else completely. And later menopause is also a different animal. But you know, that’s the average age of women, all comers. Of people who go through, like I said, that 12 month months without a period.

Courtney Collen:

What does a woman’s care journey look like? Like at what point do they need to come see you for care? Or are there specific questions they should be asking their providers, say, at a yearly wellness checkup?

Dr. Breanne Mueller:

To be a hundred percent honest, by the time they see me, by the time most women see me for “menopause,” the wheels have completely come off the bus and they’re struggling with life and they’re like, I don’t know what’s happening, but I feel like everything’s wrong. You know, like it’s not something that people usually preemptively come to me for, but sometimes, but not usually.

And honestly, like being a hundred percent transparent, usually by the time they come to me, it’s like, this is happening, and this is happening, and I feel crazy. and what’s going on? And I’m like, whoa, whoa, whoa. We’re going to be OK. We’re going to get through this.

But you know, I think what a different approach could be is, you know, at your yearly visits kind of prep things and be like, Hey, you may find that your period, there’s more time between your periods. You may find that your periods are strange, maybe they’re heavier, maybe they’re lighter and maybe they’re more painful. Maybe they’re not. Here are reasons to call me. If you start having this, this, this, and this, please call me. You don’t have to put up with that.

And I think it’s because of that lack of education on the front end that it’s anxiety provoking. You know, I feel off, I feel like I’m waking up all the time and I’m hot, or I’m not, and I’m trying to Google if this is good or not. And you could just get lost in the weeds a little bit. And I wish we had like a uniform, not a class everyone had to take right? (laughs) But something just to give people some ground to stand on.

Courtney Collen:

Can a woman get pregnant during perimenopause?

Dr. Breanne Mueller:

So it’s possible. And so that is actually a matter of debate. How long do we need to put people on contraception before we can safely say you’re good to go, right? And there’s no agreement on that. And it really boils down to each individual person. How strongly do you feel about not getting pregnant? That’s kind of my question to people.

And if you feel very strongly that you absolutely do not want to get pregnant, then let’s continue contraception kind of above and beyond maybe. There’s no harm in continuing contraception into your mid-50s if you wish. But if you’re like, you know, it’d be fine. I’m OK either way, whatever. Then maybe we start earlier and maybe you go off your reliable contraceptive earlier if that doesn’t matter to you. So, I really think it depends on each individual person and how much of a negative outcome they view that as. That’s kind of clinical, but you know what I’m trying to say.

Courtney Collen:

Yes. Are there medications or therapies that can treat perimenopause symptoms? Let’s talk through some of those either hormonal or non-hormonal options for women.

Dr. Breanne Mueller:

And there is plenty of medication. So if you go through a doctor who knows, who’s trained in this and knows what they’re doing, there’s pills, patches, vaginal rings, tablets, creams – all kinds of things that are through a pharmacy that are FDA-approved that go through your insurance, and they’re pretty affordable.

Honestly, most hormone treatment is extremely affordable. Treatment for menopausal symptoms is based entirely on symptoms. So the National American Menopause Society and ACOG, which is the American College of Obstetrics and Gynecology, they don’t necessarily recommend basing it on hormone blood tests or any other hormone tests. They really recommend doing it based on your symptoms because that’s way more meaningful in a medical way.

So as an aside, but also an interesting aside, the hallmark of menopause is hormonal variability. Meaning it’s not that your hormones are doing like this, like it’s steady downward decline that’s very predictable. It’s very much not like that. It’s actually very erratic. So have you ever run your car out of gas?

Courtney Collen:

Yes.

Dr. Breanne Mueller:

So I have too, and it’s really crappy. But here’s the thing is you know how you turn it over and like, you kind of get a little juice and you’re able to like lurch forward a little bit and then it dies, and then you turn it over again and you’re like, maybe I can get through this intersection. Ah, you know, you try to like give it a little gas and you’re like, oh yeah, I can go a little further (laugh), and then you stop again.

So I think of the ovaries doing that in the end here. So, the brain is telling the ovaries, “Hey, produce estrogen, produce these hormones that are going to make people ovulate, the woman ovulate.” So when the brain is like, “ovaries go, ovaries go, ovaries go,” and the ovaries don’t got anything left, they’re like, your gas tank that’s out of gas, they can kind of do some last minute spurts. Like, OK, let’s try our best. And you get like a little lurch out of it and sometimes you don’t. But the hallmark is just this crazy inconsistency in it, right?

And so you could have a normal cycle and then you could have three cycles that are not normal. You could have actually a very high cycle where you actually have more hormones than a teenage girl in your 50s, but then the next cycle is like dead, like nothing. So that is the hallmark of menopause. So that’s why hormone testing isn’t especially helpful because it could be anything. It doesn’t mean that you don’t deserve treatment or don’t need treatment or aren’t in perimenopause. So just as a caveat of that.

Another way to say that is like, OK, the other way I think about menopause or women’s cycles – do you play music or piano or anything like that?

Courtney Collen:

Yeah. Piano growing up, violin. Yeah.

Dr. Breanne Mueller:

So think of a song. So like each person, like think of like “Für Elise,” like, don’t judge me on my singing, but everybody can recognize that tune. And they kind of understand what it is. So when I meet a woman, I’m like, OK, this is her tune. May be in a different key. It may be in a different tempo, but it’s a tune and it’s recognizable, right? So when we’re doing hormone testing and come, like, think about trying to evaluate “Für Elise,” that classical music song by just saying, OK, the notes are on the piano. Well, yeah, they are (laugh), but that doesn’t mean that the song is playing correctly, right? And so what I do, how I think of hormone testing is like if I test you today and we get like an F sharp, maybe it’s an F sharp that belongs in the song, maybe it’s not, but it’s not really relevant.

What we need to evaluate is the whole song. Is it playing correctly for you? Does it sound good? Is it working? Yeah. Then that’s what matters. It doesn’t matter that on this Tuesday in December, your hormone level was this. What matters is your body, how it’s functioning, what the cycle of it is, and what that means for you.

So anyway, maybe that’s off topic or whatever, but anyway, when we’re looking for hormone treatment, what I’m looking for is what’s going to make sense for you? What are your symptoms, what are your goals? And oftentimes I just ask people, what is your goal here? And honestly, it’s been the best question I’ve ever asked people because my goal is not always congruent with their goals. And then we just cut to the chase and say, OK, my goal is actually my mood. Cool, let’s tackle it. And then after that we can tackle a different thing.

But as far as hormones, treatments, so basically when you’re thinking about menopause, every cell in the human body, and again, I’m talking about women now, I only deal with women, I don’t deal with men sorry, (laugh), but every cell almost in a woman’s body has an estrogen receptor on it. So that means that in menopause, potentially any system can have changes to it. Yeah. So people can have hot flashes, night sweats, you know, and that is actually a function of you withdrawing, same as you would withdraw from a drug, you are withdrawing from estrogen. And that’s what that feels like which I think is kind of interesting. So how do we fix that problem? It is very acceptable and very, very safe and effective for many, many women to be put on a dose of estrogen. And it literally fixes that problem.

Courtney Collen:

So fascinating that any part of the body could feel the effects or show the effects, present symptoms during this phase. OK. I’m learning so much.

You mentioned mood a couple minutes ago. What are some mood changes or mental health concerns that we could be on alert for during perimenopause? And if a patient is struggling during that time, what are some of the signs and where or how or when should they seek help?

Dr. Breanne Mueller:

Being an obstetrician/gynecologist, basically I specialize in assisting women through major phases of their life. Like that’s kind of how I see myself. I’m walking alongside, but also easing the transitions of life. Transitions of adolescence, transitions of pregnancy, of motherhood, of contraception and then the menopause, right? And any transition in life, you have a risk of having mental health changes, right?

So pregnancy people, some people struggle. It’s just a huge change. Your whole identity is changing. And I think menopause is the same. And it’s complicated by the fact that there is very little education. So it’s anxiety provoking for a lot of people, not everybody, but you feel different than you have for 40 years, right? And so I think that there’s been debate, there’s been randomized control trials, there’s been a lot of research on is menopause itself a risk factor or a cause of anxiety, depression and other mental health disorders? And there’s mixed data on that, quite honestly. And is it truly menopause or is it the transition or whatever?

I don’t know that anyone has a solid, solid answer on that. But I will tell you: anyone who’s had an episode of depression earlier in their life is at increased risk of having a recurrence of that major depression in menopause. I can say that for sure. So what that means is, so this is actually one of the things that I screen for all the time. I see a ton of people sometimes who come in and they’re like, I think my hormones are off. That’s always the complaint, right? I think my hormones are off. And I always love delving into that more because I just saw someone the other day. Love her to death. I think she’s outstanding.

And she goes, my hormones are off, my hormones are off. And then we ended up talking more and she lists off literally the clinical criteria for major depression. I have loss of interest in the things that I usually had interest in. I can’t get out of bed. I want to go to sleep and not wake up. And I’m like, oh, for Pete’s sake, we can fix this. But it is a depression issue more than it is a menopause potentially issue. You know what I mean? And so I think it’s a super important to get someone who is able to have, first of all, get to know you as a person. Because you matter as a person. “Für Elise” isn’t two notes. It’s a whole, you know, melody, and you’re a melody too. You’re not a one-note wonder. And I want to know all of that before I say, you know, piano’s a little out of tune, lady.

Courtney Collen:

1. Love the music analogy.

Dr. Breanne Mueller:

So I think if I had like a really bottom line message for people as far as menopause and medicine, I would say number one, find someone that you trust and that cares about you. And if you don’t feel like you have a connection or someone who’s motivated to help you change, there’s a hundred doctors out there. Find someone that you jive with and who’s treating you appropriately. If someone is saying, you know, it’s just menopause, we’ll see you later. That’s not appropriate anymore in 2024.

I think there’s more investigation to be done. And so definitely don’t get dismissed and stand up for yourself and know that there are plenty of healthy, well-researched, safe, affordable options to treat problems that arise.

But the other underlining message I have is be careful who you trust. So in this environment, it’s a money maker, right? You have people who are suffering and it’s oftentimes hard to discern who’s selling you something versus who’s treating a medical condition. And so I follow this lady on TikTok, Molly McPherson, and she’s a PR fixer, and she said, I always know who’s telling the truth because I follow the money. So if she’s talking about a PR nightmare or who’s in trouble and who’s not, she goes, I always know the truth because I follow the money. And I tell patients that all the time. If I say, you know, I could prescribe you this cheap testosterone or cheap estrogen, but if you buy my potion, lotion, pellet, whatever you just be aware of that, you know, if there’s money involved that is going directly to the person, I always just kind of like, I don’t know, maybe you view that as you would.

Courtney Collen:

That is such good advice, especially for this is a new transition of life. Like you said, you care for the women as they go through different transitions, and it can be scary and overwhelming and mentally taxing. And so that’s why we are so grateful for the advice that you just gave us as we go through that care journey, but also being mindful and aware of what we’re getting into and pay attention to our bodies of course, too.

Dr. Breanne Mueller:

I think one phrase that I think needs to be said is, what you’re going to see in this space when you educate yourself, which I always ask people like, how is it that you get information? How do you intake information? Do you go to TikTok? Do you go to Instagram? Do you read a book? Do you listen to a podcast? Do you listen to an audiobook? Do you talk to your friends? Like, how is it that you get information?

And then I try to provide people reliable resources in that space, whatever space that is comfortable for them. And I would say, you know, one term you’re going to see a lot is bioidentical. So there’s all this talk about bioidentical hormone therapy and how it’s safer or better, and you have to understand what that term is. It’s a marketing term.

So basically there was a time period where women weren’t really given hormones and they could kind of get a bad rap maybe a generation ahead of me, right? Where hormone therapy will give you breast cancer and kill you, right? That was the prevailing thinking. And so out of that space, unfortunately women were still suffering, but doctors weren’t prescribing medicine.

And so what you had was a space where people could sell products and not have it go through the FDA and not seem as scary, but accomplish a similar kind of symptom relief. It’s a product that hasn’t been studied, approved, researched, or has reliable dosing. And so because it’s not FDA approved, they don’t have to provide a warning label to it. And to some people, because they don’t have a warning label, they think it’s safer. But understand that there are safe prescription medicines that are better arguably for women.

Courtney Collen:

If a woman comes to you and is just overwhelmed and anxious … and she just needs some reassurance that it is going to be OK, and this is part of life and transitioning as a woman into midlife, what do you tell her?

Dr. Breanne Mueller:

I try to approach people where they’re at, and what is it that you want your life to look like and how can I help get you there? You know, if people want reassurance, again, it goes back to me asking what people’s goals are. And a lot of people’s goals are, tell me I’m normal. Tell me I’m not going to die. Tell me I don’t have cancer. Tell me that I’m not falling apart. Tell me this isn’t going to last forever. And I’m happy to do that. I’m happy to do that.

And I’ll be like, you know, let’s talk about it again in three or six months. Let’s digest a little bit. Let’s get some information and let’s talk again. I’m not abandoning you, I’m not dismissing you, but I’m telling you like, you aren’t going to die. Your life is just beginning. The rest of your life is just beginning, just like when you were 13 or 12 or 11. It’s not better or worse. It’s just different.

And then on the flip side, if she is like, no, really, my quality of life is actually circling the toilet bowl. I need some help. Then that’s totally different too. If they say that I want help medically, then we go that route. But it really boils down to who you are as a person and how I can understand you, but also help you and meet you where you’re at. I’m not pushing anything. I’m not selling anything. I want to help you wherever, whatever that means for you.

Courtney Collen:

And that’s why we’re so grateful for you at Sanford for your expertise and of course for this conversation. Like you are truly an expert in this space and we are so grateful for that and for your insight. Is there anything else that I didn’t ask you that you wanted to add on this topic?

Dr. Breanne Mueller:

I just want to reiterate that there’s so many good providers around the state, and I think the people that I love associating with are not people who are trying to isolate or keep information from anybody, but just supporting everyone in the space and being like women, doctors, providers, physical therapists, sex therapists, actual counselors.

Let’s all be on the same page to help women. Let’s work together to get women the best health care possible, and let’s help educate and get everybody care they need. And that’s the sort of people that I want to be around, and that’s the sort of people I want to be associated with.

And to be clear, I’m not the only perfect person out there for everybody, but I want you to find your perfect person for you. And I want you to understand that you’re not alone, that there are people out there who can help you. And whatever you are feeling or whatever we can help you with, understand that there’s options that are safe and good.

Courtney Collen:

Well, I love to hear it and I could not have said that better myself. Dr. Mueller, thank you so much for your time. Sanford Health, OB/GYN in Aberdeen, South Dakota, and a National American Menopause Society certified practitioner. We so appreciate you and all that you do for women, for patients all across the community. Thanks so much.

Dr. Breanne Mueller:

Thank you so much for having me. I super appreciate it.

Courtney Collen:

I sure hope you learned as much as I did from our conversation today. This was another episode of the “Her Kind of Healthy” podcast series, brought to you by Sanford Health. For Sanford Health News, I’m Courtney Collen. Thanks for being here.

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We ask a lactation specialist all your breastfeeding questions

Samantha Zeeb:

Find the people that support you no matter what. Breastfeeding is great. It has great benefits, but ultimately, Mom and Baby need to be healthy. You know, Baby needs a healthy, stable mom. And so you have to do what works best for your family. You have to do what works best for you, and everybody is human and everybody needs a break.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News.

These are new conversations about age-old topics from pregnancy to postpartum, managing stress, healthy living and more. “Her Kind of Healthy” is here to bring you the honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.

This is a topic near and dear to my heart and one I’m delighted to share as a newer mom. We are talking all about breastfeeding in this episode from frequently asked questions to tips and tricks and beyond. If you’re a new mom or an expecting mother, the breastfeeding journey looks different for everyone. No matter where you are in yours, know that you are not alone and there are so many resources available and people to help you feel confident in your journey.

Sanford Health has a team of full-time lactation consultants, and Samantha Zeeb, RN, IBCLC, is one of them. She is a registered nurse and Sanford breastfeeding specialist in Bismarck, North Dakota, and I am so happy to have her here for this conversation. Samantha, welcome.

Samantha Zeeb (guest):

Thank you. I’m excited to be here.

Courtney Collen:

What does a typical day or week look like as a Sanford breastfeeding specialist?

Samantha Zeeb:

You know, we are in different locations, whether it be in the clinic or in the hospital setting, but all the way around, obviously our focus is helping moms with lactation or anybody who may be lactating. So, in the hospital, our typical day, we get to the floor and we will go ahead and look at the bed board and see who is all delivered and what those moms’ wishes are. So that’s a perfect example of why having a birth plan or an idea going into labor and delivery of what your feeding wishes are, because we do look at that and make sure that you’re on our radar so that way we can make you a priority to go in and visit.

And we will go in – we try not to bombard you after delivery right away unless you’re wanting the help or needing the help. But we will go in and check with every breastfeeding mom and just see how things are going and assist with those first latches. I think a lot of times people equate breastfeeding to natural, but natural does not mean easy. So just teaching moms those tips and tricks for proper positioning and latching and encouragement.

And we often will see moms multiple times. And so the nice thing is I do work both in the hospital and the clinic setting. So I do get to develop a rapport with my patients. And so some of the ones that I helped right after delivery, I will then help the first few weeks after in the clinic just seeing how things are going because the biggest thing about breastfeeding is it is a journey.

Courtney Collen:

And for that, I am so grateful as a new mom because having that support during those first hours postpartum and even more so in the days and weeks that followed. Talk about some of the benefits of breastfeeding or why someone would choose to breastfeed.

Samantha Zeeb:

I could kind of nerd out and talk about this for days on end. But I will, for the sake of our listeners, we’ll limit it to the big ones.

So for Mom, there’s a lot of benefits. So there’s the decreased risk of ovarian and breast cancer. There’s the decreased risk of osteoporosis. It helps decrease the chances of cardiovascular disease. It might help you lose weight. You do burn more calories when you are breastfeeding. And then it also helps you produce a hormone called oxytocin, which is going to help you feel calm.

So while moms might have stresses with breastfeeding, overall, studies do show that breastfeeding and bonding with your baby can help with postpartum depression and help with some of those anxiety-like feelings that you have post-delivery.

And for Baby, it helps promote bonding. There’s studies that show that babies who have been breastfed have higher IQs. There’s decreased chance of allergies, decreased chance of diabetes, asthma, GI bugs.

The biggest thing for moms is knowing that the breast milk that they’re providing their baby with is giving them antibodies to help protect against any viruses or illnesses that they are around. And we’re getting right into that fall season. So that’s a huge one, especially with COVID. When we didn’t know what COVID was doing for babies, in the beginning there, everybody’s like, “oh, separate the babies from the moms.” But the studies are showing that the breast milk and breastfeeding that baby is the best thing that mom can do and provide those baby those antibodies.

Decreased chance of obesity, ear infections, protective for SIDS (sudden infant death syndrome), helps decrease the chances of SIDS. And not to mention it’s easier to digest. It’s free. Kids are sick less often, so moms don’t have to take off as much work. And it’s convenient. I mean, you don’t need a bottle and a milk warmer. You just bring yourself and the milk’s the perfect temperature and it’s available whenever they need it.

Courtney Collen:

You mentioned antibodies a moment ago. I would love to learn more about the benefits of breast milk.

Samantha Zeeb:

Breast milk is amazing and there is still more to be learned about it and the fact that it changes constantly. There are live components in it that cannot be replicated no matter how much time people spend in a lab to try to replicate breast milk. The truth of the matter is, you’re never going to be able to replicate it because it has live components that are constantly changing day by day, minute by minute, feed by feed.

So as that baby ages, that breast milk is going to change, it’s going to have more melatonin at night, so that’s going to help the baby fall asleep. It’s going to increase, if baby’s needing more fat content, it’s going to increase the fat content. If you were recently around a bunch of people that had a certain cold, your body is going to get those antibodies and it’s going to put that in your baby’s breast milk.

So the more that you can have that baby at the breast and stimulating and having that saliva contact with the areola, the more you’re going to have that communication. One thing that I do get a lot of, let’s not forget our pumping moms. So sometimes people are concerned, they’re like, well, if I’m pumping, is my baby still going to get those benefits? And your baby still does because you guys are still in the same environment, you’re still exposed to the same things and you can still do skin on skin contact. In fact, I encourage it because it’s going to help with the hormones.

Courtney Collen:

Yes. And those skin-to-skin moments during that newborn phase are just the best. No matter if we are breastfeeding or not. Sam, how does our body physically produce breast milk?

Samantha Zeeb:

The breast doesn’t completely finish developing until you are pregnant. So those tender breasts that you get in pregnancy are for a reason that is your breast revving up to be able to produce that breast milk. In fact, that’s one of the red flags. If you don’t notice a change during pregnancy, that would be something we would want to know.

But what happens is around 16 weeks in pregnancy, you are actually already starting to produce what we call colostrum, which is extremely high-impact, high nutrient-dense sticky-like milk, and it’s the first milk that you produce for your baby. And before I go down a rabbit hole but to answer your question, what happens is the infant starts to suckle on the nipple. And what that does is that stimulates nerve endings. And/or if you’re pumping, same concept, stretching of those nerve endings, that is going to signal the pituitary gland in your brain to release two different hormones. It’s going to release prolactin and oxytocin. The prolactin is what’s going to tell the alveoli to take nutrients from your blood and turn it into breast milk.

So that’s a really huge kind of a wow factor for people’s learning that breast milk is made from blood. So that’s why I’m making sure what you’re taking in is very important because you, your body turns that into breast milk.

Courtney Collen:

Are you speaking specifically to like medication or supplements or food in general?

Samantha Zeeb:

Yes, absolutely. Medications and then even just like pathogens. So if you are exposing yourself to risky behaviors or if you are getting a tattoo or Botox, stuff like that, there is a risk of if there is a transfer of any like HIV or Hepatitis C, you want to be leery of those things. And then same with like your nutrients, just making sure that you’re eating a well healthy rounded diet, healthy foods, because those nutrients are what’s needed to make that breast milk.

Courtney Collen:

Yes. So important. Thank you for that. I remember being super conscious during those early months. It was winter, we were sick a lot or so it seemed, so making sure the medication that I was taking was safe for baby also.

You mentioned colostrum. And if we start to see that before baby arrives, should we save it? What’s the difference between colostrum and regular breast milk?

Samantha Zeeb:

Colostrum is beginning to be produced by our bodies about 16 weeks into our pregnancy. You know, some people will leak during pregnancy and some people will not. And that is not a marker of how much breast milk you are going to have. So when moms come to me and they’re like, “I didn’t leak during pregnancy,” that to us is it, it’s null and void. We don’t worry about that because everybody is so different.

But if you are leaking, collect it, collect it, collect it, collect it. It is liquid gold. It does have that higher nutrient density to it. It’s more proteins, more antibodies. They call it the baby’s first immunization because it is providing all those beneficial protective factors to the baby.

But the one thing about the colostrum is it is more easily digested because it is designed for infants, so they do digest it quicker. So that’s where that frequent feeding comes into play. So that’s why in the beginning days we say, frequent feeding on demand because that colostrum is readily digested and easily digested. And it also helps line the digestion tract so that it helps create a healthy microbiome of the infant and might help decrease with like chances of any allergies or just the good gut flora.

But colostrum, you can start to collect that, we would say, no earlier than 36 weeks in pregnancy and I would absolutely not recommend it if there’s any risk factors in your pregnancy. So I would say if you are considering collecting your colostrum or stimulating, I should say, it’s one thing if it’s just leaking out and you’re collecting it. But if you’re going to actually be stimulating with a pump or hand expression, I would recommend reaching out to your OB/GYN so that way they can give you the go ahead just to make sure that there are no risk factors.

Courtney Collen:

How long does it take for milk to come in, and is it different for everyone?

Samantha Zeeb:

Everybody is different. Depending on what risk factors they have, depending on what their delivery was like, depending on how much stimulation and time they spent with their baby. But typically, the average is three to five days. You know, if you were a C-section, if you were on magnesium because you were pre-eclamptic, certain medications during delivery, rough labor, you lost a lot of blood. Things like that can kind of delay that milk coming in but the best thing that a mother can do is if you are with your infant and plan to feed at the breast, is to get that skin-on-skin contact going ASAP after delivery.

Put that in your birth plan that you want that skin-on-skin contact with the awareness that if Baby is needing immediate assistance, they will have to do that, but otherwise just encourage them to put that baby skin-to-skin. You can do that in the, or if you had a C-section, just make sure you communicate that with your team.

And then that’s going to help with the hormone production and then that frequent nursing on demand. So one thing that I sometimes hear is I’ll have moms say that they just want to offer bottles while they’re in the hospital and they’ll breastfeed when they get home. And I hate to be the party pooper on it, but unfortunately that does not theoretically work out the greatest for the mothers in the long run because scientific studies have shown that the sooner that a mother stimulates that breast milk production, either via a pump or baby, the better her chances are of having a really good milk supply in the long run. And we have studies that show the data for that. In fact, the recommendation is within the first hour after delivery.

Now, is that realistic for everybody? Absolutely not. But I think if we can do our best to get that baby or pump, get to that mom as soon as possible and educate her, the better off she’ll be.

Courtney Collen:

Certainly it is a journey, and worth repeating: Everyone’s will look different. You said that first hour is so important after baby arrives, Sam, that leads to my next question. OK, baby is here. How do we get a good latch and start that process as soon as possible?

Samantha Zeeb:

So the very first breastfeed, when that baby comes out and gets placed skin to skin, I would really just encourage moms to take in the moment. So babies actually will go through a series of movements that can take one to two hours. But they do what we call a breast crawl. And so if you leave an infant undisturbed on a mother’s chest, they have reflexes where they will actually start to kind of scoot themselves up towards the breast. And the amazing thing is, is your areola emits smells that are similar to the amniotic fluid that the baby was surrounded in, in utero.

So with that scent, and then your areola is darker that helps guide the infant towards the breast, and then they will actually take their little arms and start to kind of scoot the breast inwards and try to mouth around. So they’ll kind of start crawling up. They might take a break, they might nap for a little bit, they’ll wake up, they’ll start to lick, explore taste. We do that with our hands. Babies do it with their mouths so that baby’s going to start sucking on their hand.

They’re going to start licking around at the breast and before you know it, majority of babies, if they’re not implicated by certain medications during labor that might make them sleepy or just a rough delivery, but a baby can find the breast on their own. So we do like to give them the chance to do that because studies have shown that a baby-led latch in the beginning has been shown to be beneficial and babies tend to do better, but sometimes they just need help. And so that is when you can always request either most labor nurses are trained, but also you can request a lactation specialist to come in at that moment and we can help you kind of navigate that timeframe.

Courtney Collen:

That is so amazing. I had no idea about the areola emitting smells similar to the amniotic fluid. Again, learning something new every day. But our bodies are truly incredible. The baby’s natural instinct is incredible too. Here I was thinking, baby comes out, you do skin to skin, baby’s hungry, let’s try to latch, say a prayer, cross your fingers, let’s go …

Samantha Zeeb:

(Laugh). And sometimes they need that. Sometimes they need a little bit more extra assistance, but sometimes they don’t. Sometimes they do just fine on their own. So I do like to assess when I go in and help a mom with breastfeeding. I will assess what that baby’s doing. I will assess what that mother is doing and really try to only do that if I need to. But then some babies do need a little more assistance.

So when you latch on, my biggest encouragement for moms is to take a breastfeeding class. Sanford offers breastfeeding classes online, and we go over the nitty gritty of latching. You know, there is a technique to it. There is a way, and I’ll bring out my little toy boob and show you how to do that. And a baby doll – steal my 3-year-old’s baby doll. And we do like to go over and explain like how to position that baby to latch for optimal positioning to prevent both nipple pain and promote adequate transfer.

Courtney Collen:

Do some women have a harder time producing breast milk? Are there things like during pregnancy or preexisting conditions perhaps that could lead to the inability for a woman to make as much milk?

Samantha Zeeb:

Absolutely. So one of the things about being a lactation consultant is we are trained on red flags to look for on things that could put a mother at a risk of having a decreased breast milk supply. Along with certain assessment skills that when we are helping you breastfeed, we’re not only assessing your latch, but we are looking at the baby, we’re looking at the baby’s mouth, we’re looking at mom, we’re looking at mom’s breast, the shape of the breast, the shape of the nipples. And the rationale behind that is because there are things that we can see that sometimes will give us a red flag or help us predict potential problems that may arise.

Now the biggest thing is, I want to preface this by saying that these risk factors and red flags do not automatically mean that you are going to be unsuccessful with breastfeeding.

But some risk factors to watch out for is a history of low milk supply. That won’t always necessarily be a risk factor though, because every single pregnancy and delivery, a mother will make more glandular tissue. So with subsequent pregnancies, she has a better chance of being able to produce more breast milk. PCOS (Polycystic Ovary Syndrome), that’s a risk factor. Any breast surgeries or radiation, especially if they cut around four, eight o’clock on the nipple because that could cause potential damages to the ducts and the nerves. Thyroid problems, obesity, wide spaced breasts with no change during pregnancy and just because that could be a sign of glandular tissue or insufficient milk-making tissue. I like to tread with caution because this does not automatically do me, I think I’m very cautious when I talk to moms about this because the best approach for breastfeeding is wait and see because nobody knows the answers until we start doing it.

Courtney Collen:

Yes, such good advice. Thank you.

Samantha Zeeb:

And I think it’s also important too, that I just want to add in that any amount of breast milk is beneficial. It does not have to be black and white. I think a lot of moms come in and they have the mindset that they’re like, well, I’m only making a fourth of my baby’s intake as breast milk. And that fourth of breast milk, that fourth of the intake of the baby being breast milk is important. And it’s beneficial because that baby’s still getting protective factors.

Now of course, a mother has to kind of decide what’s best for her and her family because a baby also needs a healthy mom. And if it’s just not realistic for her and her family, that’s OK. That is OK. And I think sometimes too, moms need to be able to be told that.

Courtney Collen:

The most important thing is that baby is fed.

Samantha Zeeb:

Absolutely.

Courtney Collen:

Sam, why is breastfeeding painful for some and how can we alleviate that?

Samantha Zeeb:

Absolutely. So ultimately breastfeeding should not be painful. If breastfeeding is painful, we recommend working with a lactation consultant, whether it’s you’re still in the hospital, then I would encourage you that second I want to call for lactation support. So we can come in. Sometimes it’s a simple positioning or sometimes it’s a reminder that we need to move the baby’s body a certain way, so that way that latch

Often when we’re latching and there’s pain, typically it’s due to an inappropriate latch or a shallow latch. And so what that baby is doing is essentially that baby, instead of rubbing on the breast tissue, they’re chomping on the nipple. You know, we can examine the nipples and see what’s happening. So if there’s certain creases or marks, a lot of times that will give me markers for what might be happening when they’re latching and give them tips to try to remediate the pain.

Now once damage is done to the nipple, often the latches thereafter are going to be sensitive because that damage is already there on the nipple. So until that heals that can be a little bit sensitive. I have had some moms who just in general have a little bit more sensitive nipples and immediately postpartum, the latch may be good and there’s no signs of a tight frenulum. But that mom just has sensitive nipples and some of them work through it. Some it’s too much, some can’t, and that’s OK.

So really it just comes down to getting professional lactation support so that we can help troubleshoot what is causing this pain, how can we remediate it, what might this be. Another reason that might cause nipple pain is if you are an extended breast feeder and you get pregnant again, those hormonal changes during the pregnancy can cause your breast to be more sensitive.

Courtney Collen:

All the creams, all the creams at the beginning for me, I’ll raise my hand and say, it was painful to start because not so much the latch. I mean, it was a poor latch in the beginning, and we worked through that, thankfully with breastfeeding specialists on your team. But we were continuing to breastfeed through some of the pain and trying to work through healing creams and things like that. So it was just this ongoing cycle of, oh, this is painful because they’re sensitive, but I’m trying to feed my baby as well to get my milk to come in. So, absolutely. And solidarity for any moms who are listening who potentially could experience this too, but it does get better.

Samantha Zeeb:

And there are, like you said, there are creams, so the Lanolin, there’s hydrogel pads. But the best thing is like express breast milk, rubbing that in and letting it air dry. And then, there are routes sometimes there is so much nipple damage that that Mom has to take a break on that nipple from the breastfeeding, and pumping might work better for her until that nipple heals. So there’s options and, I’m going to say again, just reach out to your lactation professional because we can kind of help walk you through those.

Courtney Collen:

As a lactation professional, Sam, I’d love to hear the questions that you get most often, either in the clinic or out in the hospital setting.

Samantha Zeeb:

One of the most frequently asked questions or one of the things that I see quite commonly, outpatient-wise at least, is I will have moms come in the first few weeks postpartum and they are questioning their baby’s breastfeeding behaviors.

So, we do usually educate mothers that cluster feeding behavior can be expected and is normal, especially at night because your hormones are higher. But I don’t think we emphasize; we say those words, but there’s so much more going on behind the scenes that I think when moms experience, they’re like, oh my goodness, this must be cluster feeding. But it seems so extreme that they think it’s abnormal.

Historically with bottle fed babies, they get every three hours, they get so many ounces. Formula sits in the tummy longer. It’s harder to digest. So they’re fuller for longer, so they might sleep longer. Well, breastfed babies need to feed more frequently. That is biologically normal because that is more readily digested. And they also do that cluster feeding behavior because the more they’re at the breast and the longer they’re breastfeeding, the fattier the milk you will actually produce. It gives your body the message that there is a newborn. And so this is just a little bit of solidarity to all the moms. Like, you’re not alone at night feeding that baby all night. Unfortunately, it’s a rough patch.

I tell moms, they’re in the trenches of it. It gets better. Babies do have cluster feeding behaviors in certain periods. They might go through it. But babies breastfeed for a lot of reasons other than just for nutrients. You know, it’s comforting if you think about it. They were surrounded in your amniotic fluid and could hear your heartbeat and smell you and hear your voice and feel your breathing. So it makes sense that a bassinet that’s flat and hard and they can’t smell you, they can’t see you, they don’t hear your heartbeat, that it makes sense why they’re a little distressed. And so that’s where that cluster feeding and that contact behavior comes from.

So I always tell moms, you can expect that you’re going to have those frequent night wakings and prepare for it. So during the day, and this is the age old “sleep when the baby sleeps.” I used to hate it when I had my newborn, but truly sleep when the baby sleeps. I mean if you have somebody that can take your baby for a feed, breastfeed the baby or pump and feed the baby and then go lay down for three hours, that three hours of uninterrupted sleep is sometimes the difference between a mental breakdown. So having a support system in place, knowing that you’re not alone and knowing that it will come to an end. It’s not forever but it is normal.

Courtney Collen:

Teamwork is so important. And even in my own experience, having a partner, whether it’s a husband, a loved one, or a friend, helping you on this journey is so critical. Talk about the role of a partner or how they can help support someone who is breastfeeding.

Samantha Zeeb:

I think my husband would like to chime in on this part. (Laugh) I luckily had a very a very supportive husband who wanted to take part. And there are a lot of dads that want to help. And sometimes when moms are choosing to breastfeed, they don’t know how to help. And so there are plenty of ways for a father to help, especially with the breastfeeding baby. So if you’re breastfeeding, Dad can change the baby’s diaper and bring Baby to you. He can put pillows and blankets around you. He can refill your ice water, get you snacks. He can swaddle and sway and rock the baby when Baby gets done eating. He can burp.

At night you can develop a system where when baby first initially wakes up and needs to be changed, Dad can do the diaper changing and then bring Baby to you. You breastfeed. And then when you’re done, give the baby to Dad for him to settle. Or if you’re pumping, Dad can clean the pump parts and he can bottle feed the baby. And dads in these newer generations are a lot more involved, I think, and they want to actively take part. There’s actually studies that show that the more a dad is interacting and taking part in these cares, the more his brain will actually change like a mother’s brain will. And he will have more of those bonding behaviors.

Courtney Collen:

My husband was my milk manager, I joke. He would make sure pump parts and bottle parts were always clean, milk was getting stored properly. But even more so making sure that I was eating and staying hydrated because it was so easy to forget to eat, to drink things. Can you speak to that for a moment? How important is it to stay nourished when you are deep into the newborn trenches and breastfeeding as well?

Samantha Zeeb:

A little life hack is to get yourself a little rolling cart that you can put in wherever you mainly breastfeed. So say you breastfeed often on the couch. Have a little cart and have it stacked with protein bars and good snacks, healthy snacks, fruits, vegetables, crackers, water. And the other thing about water is it’s important to stay hydrated, but also, I’ve had some moms that come in and they’re like, I’m drinking three gallons of water a day. (Laugh) Drink to hydrate. Drink to your thirst. You don’t need to go overboard. The rule of thumb: eat to hunger, drink to thirst.

Courtney Collen:

Yes, do it. Self-care is so important. Healthy mama, healthy baby.

If there are new moms listening who might be in the thick of the newborn phase, trying to get into a groove with breastfeeding, maybe there’s a poor latch and some pain associated with that. Maybe she’s feeling overwhelmed with engorgement making too much milk or feeling like she’s not making enough because baby seems hungry all the time. And she’s unsure if she can continue. Sam, what would you tell that woman to help feel supported and encouraged and certainly not alone?

Samantha Zeeb:

So, I would absolutely tell her to find her village. And so what I mean by that, when I say find your village, is find the people that support you no matter what.

Find the people that support you no matter what. Breastfeeding is great. It has great benefits, but ultimately, Mom and Baby need to be healthy. You know, Baby needs a healthy, stable mom. And so you have to do what works best for your family. You have to do what works best for you, and everybody is human and everybody needs a break.

I usually will say, well, what would make you feel better? Would getting sleep help? Do you have someone to take the baby so you can sleep? Do you need to go and have a couple hours alone? Do you need to give a bottle so that way you can just have a weight lifted off your shoulder? I think that sometimes as lactation consultants, people think we’re kind of breast or nothing. And while we emphasize the importance of breastfeeding, we also are there to support you and recognize that sometimes you need a break and sometimes it doesn’t work. And so we’re here to help you feel supported and we will evaluate what your goals are and we’re there to meet you at your goals.

Courtney Collen:

What do you love most about what you do?

Samantha Zeeb:

I have the best job in the world. I have moms all the time and grandmas all the time that are like, oh, I bet you just love your job. And truly I do. I kind of fell into it. So I when I was in nursing school and I was picking my internship, I got matched with our public health department and lo and behold, I was matched with an IBCLC. So an IBCLC is an international board certified lactation consultant, and that is the highest education you can receive in the field of breastfeeding.

I had my two children and I breastfed them both. And there is something about feeding an infant from your body all alone and just feeling like you two are the only ones on this earth. Just watching that sweet little baby nuzzle in and hearing the little sounds and just the bond that it gives. And I wanted to be able to give that gift to other people, and I wanted to be able to help other people.

I think women, it’s hard for us out there. Sometimes we’re providers and we’re mothers and we’re cleaners and we’re errand runners and all the things. And I think that in solidarity with that, just trying to be supportive of each other and help each other through where we can.

Courtney Collen:

Yes. Beautiful way to wrap this up. The lactation professionals at Sanford Health are angels on earth. (Laugh) Samantha Zeeb, thank you so much for your time and for all that you do.

Samantha Zeeb:

Thank you. It was a pleasure.

Courtney Collen:

I sure hope you learned as much as I did from our conversation today. This was another episode of the “Her Kind of Healthy” podcast series, brought to you by Sanford Health. For Sanford Health News, I’m Courtney Collen. Thanks for being here.

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Sober curiosity can inspire better relationship with alcohol

Mindy Broden (guest):

Overall though consumption still remains up, binge drinking is also higher, much higher than what it was I would say 10 years ago. And the most notable change in that is that women actually are drinking more frequently, consuming more alcohol than in previous times.

Cassie Alvine (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about sober curiosity and the rise of a sober generation. Our guests are Mindy Broden and Ashlea McMartin with Sanford Health Bemidji. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

Welcome Mindy and Ashlea. Why don’t you guys introduce yourselves and your roles. Mindy, let’s start with you. What is your title and what is your role?

Mindy Broden:

My name is Mindy Broden, and I am a licensed alcohol and drug counselor. I have been for the last 15 years and I’m also a licensed professional clinical counselor, which is the last two years. I am the clinical lead over our substance use disorder services, including our medication for opioid use disorder clinic.

I’ve been with Sanford for seven years. I’ve got the great opportunity to work residential prior to coming to Sanford and then now do a lot of outpatient education, working on prevention, all of those fun things. So this is kind of the vein of what I do is substance use.

Alan Helgeson:

The stuff you talk about every day, right, Mindy?

Mindy Broden:

That is correct.

Alan Helgeson:

All right, Ashlea, go ahead and talk about yourself and your role with Sanford.

Ashlea McMartin (guest):

Absolutely. So Ashlea McMartin, I am one of the directors of behavioral health for the Bemidji region. Similar to Mindy, I’m a licensed professional clinical counselor. Been with Sanford since we merged back in 2017, but really technically been with them since 2013. Then when we were Upper Mississippi Mental Health Center. I am not a licensed alcohol and drug counselor, as Mindy had mentioned that she is.

But really in mental health we see in our region a huge crossover, co-occurring disorders, which means both mental health needs and substance use disorder needs are present at the same time. And so my service lines, I work closely with those that are experiencing urgent or emergent mental health needs, and drugs or alcohol are often included in those experiences when someone’s having a mental health crisis. And so see the work ancillary through the work we do through our crisis services, but then also our long-term ongoing services as well.

Alan Helgeson:

Well, Mindy and Ashlea, again, glad to have you as part of this program today. And we’re talking about “sober curious.” It’s one of those terms that it seems like you didn’t hear anything really about. It’s one of those newer things, kind of a phrase that has come about here the last few years in regards to alcohol and alcohol addiction.

So Mindy, let’s start with you. Can you maybe share a few of those current trends in regard to alcohol consumption?

Mindy Broden:

Absolutely. Current trends per capita really are actually down compared to 2022, which is kind of the last statistics that we have. And the most notable ages of that are actually that 18 to 34. And part of that is some of that sober curiosity. And I would also say the incredible increase during COVID overall though consumption still remains up. Binge drinking is also higher, much higher than what it was I would say 10 years ago.

And the most notable change in that is that women actually are drinking more frequently, consuming more alcohol than in previous times. There’s been an increase of persons that are totally abstinent from alcohol overall as well in more recent time here.

But just in terms of what people are drinking, there’s a lot of craft drinks, health drinks, organic drinks. There is some mixing now currently, especially I would say in the state of Minnesota with the legalized cannabis. So there’s THC and alcohol drinks that are being produced. And so there are some trends I would say, just in terms of what people are consuming. But overall in the last couple years we have decreased, especially since COVID.

Alan Helgeson:

So Mindy, you talked about as it’s kind of gone down, which is good news, but those rates increased during the pandemic. Let’s talk a little bit about that and why that was and what was going on there?

Mindy Broden:

We talk about addiction being a disease of isolation and when the pandemic came, isolation was a huge factor in the increase of alcohol consumption as well as the decrease in activities, which I think Ashlea, I’ll reference after a little while here.

But the other part too was liquor stores were essential businesses. They remained open and increasing the amount of people that were drinking at home. So when people drink at home, sometimes they might not be as cognizant of how much they’re consuming or how often they’re consuming as they would be in a social setting like say a bar or a lounge or something, even out to dinner or something. So when working from home, having isolation, possibly boredom, lack of activity, the increase of consumption was the outcome.

Unfortunately for those who have a propensity for drinking, it moved the progress forward much quicker than if they were not isolated. For many, with the lifting of the restrictions and the return to normal life, their drinking did decrease to pre-COVID rates. But for others it began to become a problem, which we’re seeing now, and I suspect that we will still see an uptick in alcohol use disorder diagnosis based on the trends that we’ve been seeing in the treatment setting, kind of as the fallout from the pandemic.

Alan Helgeson:

And then the good news that we’re starting to see things trend downwards, which is again, great news. Ashlea, let’s switch to you now. It’s reported that binge drinking rates are highest in the Midwest, which is in Sanford Health’s footprint. Can you speak to that a little bit?

Ashlea McMartin:

We find that in the Midwest we’re very rural, right? So we have smaller communities very far apart. I think about, you know, the community of Bemidji that’s just shy of 15,000 is probably one of the bigger cities within a two-and-a-half-hour radius.

And so we have to Mindy’s point about her piece of isolation, we have communities that don’t have a lot going on. So I think sometimes drinking comes as a result of boredom and then it becomes part of the culture. And so we have this combination where alcohol is present at many different events and it just becomes part of what we do and who we are.

We also have in the last couple decades seen this increase in the craft beer and the brewery and the pub idea. And so again, it’s become this trendy, enjoyable social activity. And so it is something that brings people together. And so there’s that delicate balance between engagement and connection, but ensuring that it’s in a healthy venue, and alcohol is typically present at many of the different social activities that we see.

Alan Helgeson:

We do see that as kind of a foundational thing for getting together with the social thing. You go out with friends and you have that – it’s much like food, right? We always have that around and we have it present.

So let’s pop back to you Mindy. Let’s talk about binge drinking for men. What does that look like for men?

Mindy Broden:

Binge drinking for men is actually defined as having more than five drinks on one occasion. And then heavy drinking would be defined as having 15 drinks or more per week. And for women it’s more than four drinks per occasion or eight drinks per week.

The only thing that I would add to that is that back to that cultural context of the Midwest or we talk about with young people, binge drinking is a really common thing. I don’t think if we went out and did a kind of a poll of our college campuses, most people would not think that five drinks was anywhere near a binge. But nationally that is what we identify as binge drinking is five for men and four for women.

Ashlea McMartin:

I think it’s important to note, and Mindy correct me if I’m wrong, but like there’s binge drinking and then there’s also what maybe the medical field would suggest as excess. And women shouldn’t drink more than one drink a night and men shouldn’t drink more than two for the health components of things. So she’s mentioning binge drinking and how people would be like, what? Five? No, that’s not binge drinking, but if we talk about just overall health impact, like more than one a day is more than likely having a negative impact on her health.

Mindy Broden:

And our sleep and our emotional wellness and all of those things too. I agree with you Ashlea. Like I said, when we talk about this, there’s different kind of schools of thought with it. From a substance use kind of context or perspective, it’s not necessarily how much a person’s drinking. It is how it’s impacting their life.

So we can’t give a substance use diagnosis on how much a person drinks by itself. There has to be other components. It has to be negatively impacting their life in some way. And so a lot of times while we do binge drinking is part of kind of the way that we assess, it also includes is it impacting you emotionally, physically, relationally, socially, employment wise? Because that’s really what determines whether a person’s having a problem.

Alan Helgeson:

Alcohol is a depressant. So then what does that mean for those who might not know? Let’s take that a step further then.

Mindy Broden:

There’s three different drug categories. We have depressants, we have stimulants, and we have hallucinogenics. And alcohol falls into the depressant category and it acts just as the name implies, it slows the central nervous system down, slows breathing, slows heart rate. The challenge is that a lot of people experience what might be called a buzz or euphoria that they feel when they start to drink, but that isn’t because the alcohol isn’t still depressing the central nervous system. It’s because alcohol also impacts the brain, primarily the prefrontal cortex that has to do with judgment and reasoning.

So when that judgment and reasoning is skewed for a person, it gives people the feeling of feeling relaxed, of not caring what other people think. And that is a lot of times the feeling that people look for when they, especially when they’re in social settings.

Alan Helgeson:

So as you talked about that then, how does alcohol affect us emotionally?

Mindy Broden:

When a person usually starts to drink, it enhances positive emotions, decreases anxiety when they’re drinking, but when alcohol begins to wear off, there’s a boomerang effect. So people often will experience heightened anxiety when they are sobering up or when the alcohol’s coming out of their system. Sometimes they might be unable to sleep, have an increase of heart rate, breathing, racing thoughts, worry, et cetera.

As a person’s drinking often continues down the road, they will maybe have more, when I say like heightened emotions, so they might have a little bit of sadness, but then when they drink they might get uncontrollably sad. Or like what Ashlea talked about, a lot of the people that we see presenting in crisis situations have maybe alcohol or drugs on board is that will take maybe a little bit of a thought and it just blows it up.

And so somebody might be sad, once they drink, now they’re experiencing suicidal thoughts and because the prefrontal cortex is impacted by this, they now don’t have the reasoning or judgment not to do it. And so that’s a lot of times where Ashlea’s service lines will get involved with our patients as well.

Alan Helgeson:

So then let’s switch over to the physical side then Mindy.

Mindy Broden:

Sure. One of the reasons why men can drink more than women is because men have an enzyme in the stomach that starts breaking down alcohol prior to it reaching the large and small intestines. Women don’t have that same enzyme and so women are more greatly impacted because of that, plus usually the weight difference between men and women, muscle mass, all of those things.

But alcohol is broken down through all those various internal mechanisms. But namely the liver’s impacted by alcohol use, especially over time. Long-term effects have resulted in liver failure, kidney problems, stomach, digestive problems, and we often do see that in the medical field as well. The negative impacts of how alcohol is affecting a person physically.

Alan Helgeson:

Mindy, let’s talk next about those warning signs that someone might have a problem with alcohol.

Mindy Broden:

Absolutely. I think some of the of the greatest warning signs are increased use, needing to have drinks more frequently, more often maybe you started with having one to two drinks and now you’re having two to four drinks. That’s usually the first indicator.

Obviously some of the concerns would be use in which it’s physically dangerous. So if you do have a medical condition or driving under the influence, being unable to control drinking blackouts is something we see, especially with binge drinking. Some of the younger crowds possibly would be experiencing blackouts. That’d be a pretty good indicator there could be a problem.

But more than anything we talk about is it impacting your relationships? Are you not being able to fulfill obligations? Change in friend group is a pretty good indicator or you’re not hanging out with friends that used to be really important to you and now your friend group’s changing to people who maybe drink more. Relationship problems due to drinking. Legal problems. Those are some of the first signs that we see that somebody might be having a problem with alcohol.

Alan Helgeson:

So knowing about these warning signs when someone might have a problem with alcohol, we’re hearing a lot these days about sober curious, Dry January and awarenesses about paying attention to maybe overuse of alcohol. Let’s talk about sober curious and what is it Ashlea?

Ashlea McMartin:

Ironically, Alan, you mentioned at the kickoff that it’s a relatively new term, right? Just in the last couple years and there’s accuracy in that. Sober curious has its roots going back to the late 2010s. That sounds so strange to say, right? The 2010s (laugh).

In 2018, Ruby Warrington wrote a book called “Sober Curious,” sober curiosity. She started a podcast around it, really a millennial push around this content or context of mindful approach to alcohol use. And so what that looks like is being curious or questioning what our alcohol use is having an increased awareness of what our drinking habits look like, maybe taking a break from drinking during certain times, and then doing more sober activities, engaging with others that are taking maybe that sober curious approach.

Mindy Broden:

I would just add one thing too, Ashlea, and I absolutely love that answer. The additional piece I think is that there used to be a pretty harsh judgment on people who were maybe practicing sobriety or practicing abstinence, and it was very kind of almost shameful.

And so this shift of the sober curious movement I think has just brought in just a non-judgmental stance of you don’t have to be an alcoholic to go to a meeting or you don’t have to be an alcoholic to practice sobriety. It brought in just a totally different feeling to the idea of choosing not to drink.

Alan Helgeson:

Give us your expert opinion on putting some labels on different things like this in raising these awarenesses.

Mindy Broden:

I think that just these different campaigns that have came out have really done a lot to exactly what you said, raise awareness that these are issues, these are things people are doing, in some ways almost make it popular to maybe practice a month of the year that you’re going to not consume alcohol or use any substances.

But I think that the normalization of it has actually decreased the stigma as well because when you see these different campaigns for different months, I think we have a suicide awareness month, we have, like you said, Dry January, we have a sobriety month, we have all these different things and it just brings more normalcy to it and it gets people talking about it and puts out resources into the communities, which I think are just fantastic to be able to kind of all come around and reduce that stigma and judgment.

Ashlea McMartin:

I think it gives permission to, right, like when we talk about the Midwest having higher rates of binge drinking and why that might be, and with it being boredom and part of our culture, sometimes we need permission to be anti-culture.

And so picking maybe a month to say, can we collectively do this or try this, gives people the OK and a reason that if someone’s going to ask, oh, why aren’t you drinking at this event? Someone can say, I’m, well, it’s Dry January and I’m trying my hand at this. It can almost create a ripple effect where it creates greater curiosity around that. Right now we have the chance for someone, our acquaintance to say, tell me more about Dry January and why you would be committed to doing that.

Alan Helgeson:

Well let’s talk more about those specific tips for living a sober or sober curious lifestyle. Ashlea, can you share some of those?

Ashlea McMartin:

Yes, Alan, great question because as people are listening, maybe they are thinking, how can this even look? What would this even be? And so I oftentimes tell people, find your people, right? If the folks that you’re hanging around aren’t welcoming to the idea of you choosing to be sober curious, maybe it’s an opportunity to branch outside that initial circle that you have and create a wider net or a greater support system that would be willing to say, “Hey, that’s cool. That’s all right. Yeah, like, you know, maybe we’ll keep drinking. But you don’t have to.”

If you are running into people that are tearing you down or continuing to reinforce that you should be, it might be time to look a different direction to find support.

Coping forward is another strategy where maybe you’re working on. I really want to commit to Dry January, but I’m also going to this work event, or I’m going this family birthday party, sports event that I know there will be alcohol at.

And coping forward means that we just plan for that. So how do I want to approach that? Maybe I even practice what I’m going to say to people in the mirror to gain confidence in explaining why I’m not going to be participating in drinking or drinking to the same extent that others might be.

And then the last piece is don’t give up. When we start to change culture, it takes time. And I just recently read that there is a section yellow at the Green Bay Packer stadium and the section yellow is a sober curious or sober section where people go to celebrate the Packers. How incredible, right? Green Bay Packers are an NFL football team, very well decorated. And there are fans that have come together that have said, we want to support a community that doesn’t want alcohol to be part of football. And we can still come and be present around other people that are doing that. We’re also going to support each other. And they have a section, they have a color, they actually hand out pins. That’s one game at a time.

And if you’re familiar with AA, NA, they talk about one day at a time, one hour at a time, one minute at a time, and have laid that over top of football to say one game at a time. And I just think that’s fantastic. And it goes to show how this movement is growing and how it’s impacting people in positive ways.

Mindy Broden:

You know, we look back 40 years even, there was never a non-smoking section in a restaurant and then we started almost like the non-smoking movement. You know, you can’t smoke in any restaurants anymore. And I think about that and how when we look at the kind of trends of people who smoke, that has decreased exponentially because it normalized that not everybody smoked. So that is so cool to kind of usher in the sober curious generation.

Ashlea McMartin:

And I don’t remember if you guys recall when smoking was banned from restaurants and bars, there was a huge uproar, right? There was like, people were like, what are we going to do? People aren’t going to go out to eat, they’re not going to do these things.

And then we adjusted, right? And people, some people stepped away from smoking, others made adjustments so that it wasn’t as negatively impacting other people, children, people that didn’t have a choice whether they wanted to inhale secondhand smoke.

And so our culture evolved and I’m hoping with this sober curious movement, we’ll see this continued growth exponentially of people being curious about their use habits.

Alan Helgeson:

Mindy, let’s turn now to younger people like those middle school, high school and college students that maybe try new things. What are a few things to look for in someone that might be going through some of these changes and experiencing those changes with alcohol, and in a harmful way that they may not have previously? And how can we help a person?

Mindy Broden:

That’s a great question and I think something that every parent has struggled with and maybe a lot of different friends have struggled with. If they see some things, I’d say some of the number one things to look for if a person’s having some difficulty is you’re going to see a change in behavior. Might be a lack of interest in the things that they had before. A significant change in friends, sudden drop in grades, sudden drop in friends, all of those things. Kind of that idea of isolation over time, that’s what will happen is that isolation will kind of step in there.

I think one of the hardest things with youth is it’s much more difficult for youth to recognize that there might be a problem, even if someone that is watching them can see that it is. A lot of times youth have kind of that 10 foot tall and bulletproof mentality, not me, I can handle this, this isn’t a problem, this is normal.

And so I always just think communication is the starting point to connection with them, being cautious, not to accuse or shame and so on. Instead, using phrases like, “I’m really concerned for you because this is what I see,” or “Help me understand what this is doing for you.”

One of the greatest challenges with youth is that they’re not likely to experience the significant consequences that maybe somebody that’s further into their use disorder would, and then they also compare themselves to others. And so maybe somebody else was able to drink the same amount but didn’t have the same outcome. Like I said earlier, if a young person is blacking out from using alcohol, that’s always a pretty significant sign that they might need some help.

Alan Helgeson:

Well, as we switch now talking to both of you, which we know are great resources, what other resources does Sanford Health have?

Ashlea McMartin:

I think there’s many different starting spots for patients that are receiving care at Sanford or maybe they haven’t ever received care at Sanford. First and foremost, reaching out to your primary care provider and just asking questions and seeing what referrals that they can make for specialized care if you’re concerned about your drinking or really any substance use habits. And that can include things like binge eating, gambling, different addiction habits.

I know oftentimes we think of addiction as just alcohol or drug related, but really we have a wide spectrum of what addiction can look like. Many of our regions have specialty care in the form of behavioral health services, and that can include mental health services, but also substance use disorder services. It might be outpatient, it could be residential, it could be inpatient. And so really kind of getting a good lay of the land of what is close to you or what services are offered virtually.

We’re talking about rural health care, right, where we know that it might be a long drive in and a lot of resources for someone to receive inpatient or in-person care for a substance use disorder. And so also recognizing that we have virtual options that can help support people living anywhere to receive services that might be vitally important to their well-being.

And then the last resource I want to call out that isn’t Sanford specific, but that has been a huge push in the last two years since its rollout in 2022, is the phone number 988. 988 mimics 911 in the sense of when someone is in need of emergency services, whether it be an ambulance or law enforcement, you can call 911 and they will respond. 988 is linked to the national suicide hotline, so someone calling 988 can receive support as it relates to mental health services, mental health crisis, and that includes substance use disorder services as well. This is a national number, so you can call it from any state at any time. It’s answered 24 hours a day. And when people are like, where do I even just start? 988 is a great starting spot.

Alan Helgeson:

Someone listening today that might be struggling with alcohol, those final thoughts to share with them?

Ashlea McMartin:

I think we can mirror the one game at a time concept and say, let’s take it a minute at a time. And that’s relative to maybe sobriety, but also trying to figure out what your next steps are. When we have difficulty or a problem present, we don’t have to solve the whole thing today. And so breaking it down into bites that we feel like we can digest is very important. And so what is in the next minute or hour, something that you can do to support yourself?

And then along that same line, don’t hesitate to reach out for services, whether that’s formal or informal. There are many people that want to support you in this process. And hopefully as this sober curious culture shift takes hold, people will find more and more places to connect with others to say, I think I want to change my alcohol use habits.

Mindy Broden:

I was just going to add in addition to that too, and what Ashlea said is absolutely accurate, and we do have a lot of resources. But I think sometimes a person might be scared. “Well, maybe I’m not ready to quit. Maybe I just want to cut down,” or whatever. And most places – I can speak specifically for our teams – we really meet patients wherever they’re at.

And so if somebody’s having a problem, they just want to have a conversation about it, or maybe they just want to identify, am I having a problem or what am I getting from it? Or what is it giving to me? Alcohol isn’t prejudiced. It impacts any person, any color, any age, any culture. Some people’s bodies are more primed to have issues of substances than others. That’s a fact.

Like I said before, addiction thrives in isolation. So we have a saying in SUD (Sanford substance use disorder team) that says, you’re only as sick as your secrets. So the number one thing is to talk about it with someone. So just like Ashlea says, 988, talk to your primary care provider, case manager if you need to, but just talk to somebody about it. That is the number one thing.

Alan Helgeson:

Well, let’s move on to somebody that may have a loved one, a family member, friend, coworker that is struggling. What would you say to someone that’s listening that might be going through that?

Ashlea McMartin:

I think reiterating what Mindy said, that addiction doesn’t discriminate. When we look at supporting people that are experiencing addiction, some of the best ways to do that are to set really healthy boundaries for ourselves as those that aren’t experiencing addiction, to keep ourselves healthy for that other person oftentimes.

And Alcoholics Anonymous even has a parallel group for children of alcoholics because it’s not uncommon for a loved one colleague to feel responsible or like they did something or should have done more to help someone through addiction.

And addiction is just, it’s beast. And it takes many different people, a lot of different connections. And so keeping yourself healthy through self-care and also setting boundaries with that loved one or that colleague is very important. And even though it might feel at times like those boundaries are harsh or that person with that addiction is responding with words that are hurtful, knowing that maintaining those boundaries are extremely important for our own well-being because we can’t help those when we’re ourselves are unwell or struggling.

Alan Helgeson:

Wonderful information that you’ve both shared today. Mindy and Ashlea, we so appreciate your time and being part of this podcast and talking about sober curious and living a sober curious lifestyle.

Cassie Alvine:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, find us on Apple, Spotify, and news.sanfordhealth.org.

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Medical & tech leader predicts health care’s potential

Alan Helgeson (announcer):

“Reimagining Rural Health,” a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high-quality, low-cost services in rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, host Courtney Collen with Sanford Health News talks with Dr. Nworah Ayogu, head of Healthcare Impact at Thrive Capital. Dr. Ayogu is a speaker at the 2024 Summit on the Future of Rural Health Care.

Courtney Collen (host):

We’re so happy to have Dr. Ayogu in Sioux Falls. Welcome.

Dr. Nworah Ayogu (guest):

Thanks for having me. My first time in Sioux Falls and I’m loving it. I’ll be back.

Courtney Collen:

Love to hear it. So glad to have you. You’ll be speaking on a panel about expectation to experience, really rethinking health care to serve today’s consumer. What is one message or a couple of messages, golden nuggets as I like to call them, that you want to drive home with our audience here today?

Watch the Sanford Health News vodcast of this episode

Dr. Nworah Ayogu:

So, I spend a lot of time thinking about innovation. You know, I spent a bunch of time in startups, spent time in big tech at Amazon, and now I’m at Thrive. So we hear pitched startups all the time thinking about innovative ways to solve problems.

And to me, I think one of my biggest pieces and one of my biggest takeaways is going to be we used to say a lot, necessity is the mother of innovation. And when I think of where’s innovation going to take hold and where do I think innovation is going to come from for this next sector of health care innovation, I think we’re going to see it in densely urban areas and very rural areas.

So people think a lot about, you know, Silicon Valley and, you know, the Upper East side of New York. And there are two kinds of innovation people talk about. There’s sustaining innovation and there’s disruptive innovation.

Sustaining innovation is doing the same things we’ve always done. Doing it, you know, faster, doing it cheaper. Disruptive innovation is really thinking outside the box to say, how do we do things in a completely different way? And we need a more disruptive innovation in health care. But the way that we’re going to get that is through the communities that truly have needs, the communities where the current health care system is not serving them appropriately. And to me, that’s part of why I’m so excited about this summit because one of the big things I’m pushing, one of the big things I’m anchored on is that that’s where real disruptive innovation comes from, are people who understand the needs and necessity is the mother of innovation.

So it’s going to be our rural communities, and it’s going to be our densely populated urban communities that are going to drive that innovation because that’s where the need is. And honestly, there’s so much talent in these communities to drive that innovation as well.

Courtney Collen:

Is there anything that has surprised you, something that you’re taking away personally from the events so far today?

Dr. Nworah Ayogu:

So, honestly, one of my favorite parts has been talking with the Sanford Health leaders throughout. I think there are probably three pieces:

One is that they’re really leaning into virtual care as a modality, but also as a way to redesign how they connect and support patients. And not because, you know, it’s fun, not because it’s a shiny tool, because they’re saying, look, we know we have communities where the nearest doctor is literally miles away, tens, hundreds (of miles) away, depending on specialists. And they’re saying, this is what we need to actually serve the customer and serve the patient that we have. So the way that they’re embracing virtual care is one that’s been really amazing.

I think there’s a deep cultural aspect, and we talk a lot about reimbursement mechanisms in health care. We talk a lot about the technology. But culture is actually what ties together whether or not an organization can be successful.

And there’s a deep focus within Sanford and the leadership, the clinicians on the culture and the community. They care about the people around them because that’s their family, those are their pastors, those are their teachers. And that culture is actually very key for making sure that you’re innovating but also you’re innovating compassionately and with the patient in mind. And I’m, I really love that.

Courtney Collen:

I’m glad that you’re part of this and you’re part of the dialogue as well. Dr. Ayogu, what do you think is the biggest misperception about rural America right now?

Dr. Nworah Ayogu:

To me, it comes back to the fact that people who haven’t spent a lot of time in rural America can think that it’s stagnant and people don’t want to innovate and people don’t want to adopt new technology. And that’s, I’ve not seen that to be the case at all.

So I think the biggest misconception to dispel is that this is a community and these are areas that want to innovate, but they want to innovate on things that are truly going to solve their problems. So if you’re willing to engage the community and work back from their problems, you will find that these are communities and health systems that are eager and excited to really not just innovate, but actually to drive the innovation.

Courtney Collen:

And I’d love to know what innovation or action in your mind will it take to move the needle forward say in the next one to two years?

Dr. Nworah Ayogu:

I’m a big fan of AI. I spend a lot of time leaning in to understand and see sort of what that tooling is. And I think of three categories of AI.

There’s what we call Fortune 500 use cases, so things that are as useful to a Sanford Health system as they are to a Walmart. So that’s things like, making sure that your data and your engineers can move more rapidly, making sure that your call center when you call in, we can actually have that be automated such that you can get to your problem quickly without having actually having to talk to a person. You can solve your problems yourself. Whether that’s Sanford to use that the same way that American Airlines can use that.

Then we have clinical health care specific administrative use cases. So that’s things like scheduling and revenue cycle management and sort of prior auth and then we have clinical use cases. And it’s been interesting. I think there are less of those that people are deploying.

But one of the things I do is, every week, there are case studies in the New England Journal of Medicine. These are kind of the “House MD” level cases, the super sort of complex medical mysteries. And I put them in every single week and you know, chat GPT’s newest model just to see how does it perform. And we’re going on six weeks straight of me doing this.

And you know, me and my colleagues, the cases that we often can’t get, it does a thorough differential diagnosis. That with super complex esoteric, it gives us the treatment guidelines to the same level that the New England Journal of Medicine’s experts are giving. So it just shows that this technology is here and the clinical applications can really do a lot to improve access, but also make sure that no matter what your zip code, you’re getting that kind of same level of expert care.

Courtney Collen:

Isn’t it fascinating?

Dr. Nworah Ayogu:

It’s amazing.

Courtney Collen:

Yeah. Incredible. How do we strengthen trust in health care during a time of rapid disruption?

Dr. Nworah Ayogu:

So in my mind, trust comes down to two things. Say what you’re going to do and then do what you say. And that’s it. If we continue to do that, we will earn people’s trust.

But it’s remembering that trust is a thing that is earned. And if you go in with that mentality and you do those two things, you tell people what you’re going to do to set those expectations, and then you do it to earn the trust. And then you do that repeatedly over time, you’ll earn trust.

Courtney Collen:

Fantastic. OK, and lastly here, what book are you reading right now? And if not right now, what book potentially has been really key or influential in your career thus far?

Dr. Nworah Ayogu:

I’ll answer both. So the book I’m reading right now and is called – well actually, let me start with the one that’s been influential. So it’s called “Pathologies of Power.” It’s by Paul Farmer, who was a doctor and mentor of mine, did a lot of amazing global health work. But it’s really, it’s very much a values driven book. And one of the things he talks about is he was a great person and I think mentor of mine who I learned about a lot from, and one of the principles in it is the preferential option for the poor. It comes from a Catholic teaching, but it’s all about you should focus your time on the areas and people who need you most, about how do you triage? What do you focus on?

There’s some people will say, focus on the lowest hanging fruit. His was always focused on the most need and that’s how you order and prioritize your time. He did that in his global health work. He did that honestly in his personal time as well. And I, the more and more I think about it now is you’ll learn a lot of knowledge as you go through your career. You’ll learn to work with new tools, but you know, we’ll have AI that’ll make it easier for us to do all of our jobs.

But the one thing it won’t do is set our values. And I think to me, I think more and more that the things I learned early on, the people who taught me those values and the books that help me think about what are the values I want to exist in those, this world, I find that to be more and more important. I think it’s only going to get more and more important that we’re not afraid to talk about our values and live our values and make sure that our organizations and the systems we’re a part of our values aligned.

Courtney Collen:

What do you love most about what you do?

Dr. Nworah Ayogu:

I think it’s being able to work with amazing, talented people who are following their passion. So every day we hear from entrepreneurs, and we get to work with entrepreneurs who are spending all of their time focused on a problem that is near and dear to their heart and soul. That is kind of their passion, their meaning, their reason for being. And when you’re around that passion, it’s infectious.

And the fact that every day we get to, in some way, shape or form, assist them in that journey, that’s awesome. I think that’s my one wish is that everyone gets the chance to fully pursue their passion and hopefully has, you know, sherpas around them to support them.

Courtney Collen:

I love that. Well, we are so grateful to have you here in Sioux Falls for the third Rural Health Summit and for this podcast as a guest. Thank you for being here and for all that you do.

Dr. Nworah Ayogu:

Thank you for having me, and I will definitely be back.

Courtney Collen:

Looking forward to it.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series on Apple, Spotify, and news.sanfordhealth.org.

Get more episodes in this series