Category: RECIPES

Like many autoimmune disorders, lupus (systemic lupus erythematosus, or SLE) disproportionately affects women during child-bearing years. Lupus is one of more than 80 autoimmune illnesses that affect an estimated 23 million people in the US — and nearly 350 million people worldwide. If you have lupus or another autoimmune illness and you’re planning to have kids, it’s safest to think ahead.

Years ago, people with lupus or other autoimmune disorders were advised to avoid pregnancy. The thinking was that it was simply too risky for mother and fetus. That’s no longer true: in most cases, following expert guidelines now available can make a successful pregnancy possible. These guidelines explain good practices for a range of family planning issues. Below, we answer several common questions about fertility, pregnancy, birth, and breastfeeding.

How might lupus or its treatment affect my fertility?

About 90% of people with lupus are biologically female, and the disease tends to begin between the ages of 15 and 35. So, family planning is a crucial part of lupus care.

Doctors once believed that active lupus interfered with fertility so much that pregnancy was unlikely. While this myth was debunked long ago, people with lupus may take longer than expected to become pregnant. This is more likely if you have active disease requiring aggressive treatment, or if you have certain antibodies (called antiphospholipid antibodies) in your blood.

Your prenatal provider or rheumatologist may recommend that you see a maternal fetal medicine specialist experienced in taking care of pregnant people with fertility issues to fully review your situation.

For people with lupus who experience infertility, in vitro fertilization may be a good option. Because certain medicines, such as cyclophosphamide, may reduce fertility, your doctor may recommend adjusting these.

Egg freezing is another option. It can be done before starting medicine that reduces fertility, or to save younger, healthier eggs for the future in case pregnancy must be delayed for a while.

Will I need to change my treatment before pregnancy?

This depends on which medicines you take and how well controlled your illness is. Good control for at least three to six months before getting pregnant is ideal. An unplanned pregnancy can put both you and the pregnancy at risk.

If your lupus has been poorly controlled, or if it affects major organs such as the heart, lungs, or kidneys, you may be counseled to avoid pregnancy, at least for a while, or to change medicines to better control your disease.

Some medicines taken for lupus are unsafe for a developing baby, and are generally avoided during pregnancy. Examples include methotrexate, mycophenolate, and cyclophosphamide. But the health and well-being of the mother must also be considered, since changing medications could put the mother’s health at risk. With advance planning and coordination among your doctors, you can make changes to improve treatment safety.

What else should I do before trying to get pregnant?

It’s a good idea to take a prenatal vitamin and/or a folic acid supplement. Check with your doctors for specific recommendations.

If you smoke, make every effort to quit. Nicotine products have many health risks, such as an increased risk of cancer, heart attack, stroke, and lung disease. And the combination of lupus, pregnancy, and smoking can markedly increase your risk of having abnormal blood clotting. If you’ve found it difficult to quit, talk to your health care team for help. Your doctor may recommend medicines or nicotine replacement therapy to help you quit.

How might pregnancy affect my illness?

Many people with lupus don’t notice a major difference in their disease during pregnancy. However, studies suggest that flare-ups of lupus tend to be more frequent during pregnancy. High blood pressure, preterm delivery, miscarriage, and impaired fetal growth are among the most common complications of lupus pregnancies.

Your doctor will likely recommend continuing treatments for lupus that are considered safe for the developing fetus, such as hydroxychloroquine, and also taking aspirin to help prevent complications. Closely monitoring you during pregnancy is warranted, to detect and treat lupus flare-ups or any of these complications.

Will my prenatal visits be any different because of lupus?

Because people with lupus have higher than average risks for pregnancy complications, a maternal fetal medicine doctor is often recruited to be part of your medical team. The schedule of routine tests to monitor pregnancy may be modified, too. For example, the risk of diabetes during pregnancy may be higher for people with lupus, possibly due to steroid treatment. So screening for diabetes may be recommended earlier than at the usual 24 to 28 weeks of pregnancy.

If you have certain antibodies in your blood (especially ones called anti-Ro and anti-La), your doctors may recommend more frequent fetal monitoring, with particular attention paid to the developing heart.

Even if everything is progressing normally, it’s important not to skip regularly scheduled prenatal care.

Do people with lupus have more pain during pregnancy?

With or without lupus, pregnancy can be uncomfortable! Many women with lupus have arthritis pain, fibromyalgia, or other pain disorders. Daily activity can help. Yoga, walking, and swimming are all great forms of exercise before, during, and after pregnancy.

What about birth?

Fortunately, most women with lupus have a normal birth experience. If you were on blood thinners to prevent abnormal clotting during your pregnancy, your health care team may be more cautious about your risk of bleeding after birth, and will prepare for this by having medicines and blood transfusions ready. Epidural anesthesia, cesarean sections, and other options are generally available as needed for women with lupus.

What else is helpful to know?

In the weeks following a birth, some women do experience a lupus flare. Your health team will monitor you closely for this possibility.

If you hope to breastfeed, ask your care team about the medicines you take. Several medicines, including hydroxychloroquine, are safe to use during breastfeeding.

The bottom line

Most women with lupus can safely and successfully pursue pregnancy if they wish. When it comes to family planning for people with any autoimmune illness, it’s essential to choose reliable sources of information, plan ahead, communicate regularly with your health care team, and — importantly — ask lots of questions.

About the Authors

Alison Shmerling, MD, MPH, Guest Contributor

Alison Shmerling, MD, MPH, is a family physician practicing full-scope family medicine, including low-risk obstetrics. She completed her medical degree and master of public health at Tufts University School of Medicine. She is now affiliated with … See Full Bio View all posts by Alison Shmerling, MD, MPH

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

Editor’s note: in honor of Pride Month, we’re re-publishing a 2019 post by Dr. Cecil Webster.

Generally speaking, discussing what happens in our bedrooms outside of the bedroom can be anxiety-provoking. Let’s try to make your doctor’s office an exception. Why is this important? People in the LGBTQ+ community contend not only with a full range of health needs, but also with environments that may lead to unique mental and physical health challenges. Whether or not you have come out in general, doing so with your doctor may prove critical in managing your health. Sexual experiences, with their impact on identity, varied emotional significance, and disease risk, are a keystone for helping your doctor understand how to personalize your healthcare.

Admittedly, talking about your intimate sexual experiences or your gender identity may feel uncomfortable. Many LGBTQ+ patients worry that their clinicians may not be knowledgeable about their needs, or that they’ll to have to educate them. Finding a LGBTQ+ adept doctor, preparing ahead of time for your next appointment, and courageously asking tough questions can give you and your health the best shot.

Finding a skilled clinician who is LGBTQ+ adept

Many large cities have healthcare institutions whose mission centers on care for LGBTQ+ peoples. However, these organizations may prove inaccessible to many for a variety of reasons. Regardless of your location, asking friends, family, or others to recommend a clinician may be a game changer. If your trans friend had a relatively painless experience visiting an area gynecologist, perhaps your Pap smear may go smoothly there as well. If your coworker has a psychiatrist who regularly asks him about his Grindr use, perhaps it may be easier to navigate your gay relationship questions with her.

Word of mouth is often an undervalued method of finding someone skilled and attentive to the needs of LGBTQ+ individuals. Online, many clinicians offer a short bio with their areas of expertise, and there are provider directories featuring trusted clinicians. Further, some doctors regularly write articles and give talks that may offer clues about desired knowledge. A simple Google search of your provider may yield a bounty.

Next, give your doctor or healthcare organization a call. Don’t be shy about requesting someone whose practice matches your specific needs. Your health information is protected, and generally, physicians hold your clinical privacy dear. Keep in mind that not all clinics will know or share whether or not your doctor is, for example, also a lesbian, but they may pair you with someone well suited to your request or point you in the right direction.

Preparing for your appointment

Let’s say you are nervous about coming out to your doctor. A little preparation may ease this burden. Here are some quick tips:

• Let them know you’re nervous at the start of the conversation.
• Be as bold as you can tolerate.
• Write down what you are excited about, nervous about, and/or curious about.
• Go in with a few goals and start with what’s most important.
• Maximize your comfort. If your partner is calming, bring them. If Beyoncé soothes what ails you, bring her along too.
• Lightly correct or update your clinician if they get something wrong.

Ask tough questions, give clear answers

As a psychiatrist who works with kids and adults, I often hear questions like, “I don’t know really how to say this, but I started experimenting with other guys. Does this mean I’m gay?” I may start by asking if you’ve enjoyed it. My colleagues in health care might begin with the same question.

Pleasurable experiences come in all sorts of constellations, and healthy exploration is part of being human. Additionally, clinicians need to assess and address your safety. Many LGBTQ+ people are at higher risk of intimate partner violence. We may ask about your use of condoms, how many partners you’ve had recently, your use of substances during sex, and how these experiences may shift how you see yourself. Give clear answers if possible, but don’t fret if you’re uncertain. Your doctor will not likely provide a label or pry unnecessarily. They may offer constructive information on the use of condoms, reasons to consider using PrEP (which can effectively prevent HIV), and places you can go for more guidance. Physicians enjoy giving personalized information so that you may make informed healthcare decisions.

There is no end to what is on people’s minds. Be bold. Will tucking reduce my sperm count? Maybe. Does binding my breasts come with risk? Likely. Was Shangela robbed of her RuPaul’s Drag Race: All Stars 3 crown? Utterly, but let’s get back to your cholesterol, shall we?

Remember that it is often impossible to squeeze everything into one appointment. Afterward, take time to catch your breath, reflect on what you’ve learned, and come up with more questions for next time. We’re here for that.

About the Author

Cecil R. Webster, Jr., MD, Contributor

Dr. Cecil R. Webster, Jr. is a child, adolescent, and adult psychiatrist in Boston. He is a lecturer in psychiatry at McLean Hospital and Harvard Medical School, and consultant for diversity health outreach programs at the … See Full Bio View all posts by Cecil R. Webster, Jr., MD

As of June 2022, 37 US states have passed medical cannabis laws and 19 states have legalized recreational cannabis. Cannabis has proven beneficial for a range of conditions such as childhood seizure disorders, nausea, vomiting, and loss of appetite in people with HIV/AIDs.

In the meantime, a new generation of cannabis products has exploded onto the scene, driven by marketing that fuels a multibillion-dollar industry. The average content of THC (tetra-9-tetrahydrocannabinol, the psychoactive and potentially addictive chemical in cannabis) in smoked whole-plant products has risen from 1% to 4% in the 1970s to 15% to 30% from today’s cannabis dispensaries. Edibles and vapes may contain even higher concentrations of THC.

While public perception that cannabis is a harmless substance is growing, the long-term benefits and risks of cannabis use remain unclear. However, one consistent pattern of research has emerged: heavy long-term cannabis use can impact midlife cognition.

New research on cannabis use and cognition in midlife

Recent research published in The American Journal of Psychiatry closely followed nearly 1,000 individuals in New Zealand from age 3 to age 45 to understand the impact of cannabis use on brain function. The research team discovered that individuals who used cannabis long-term (for several years or more) and heavily (at least weekly, though a majority in their study used more than four times a week) exhibited impairments across several domains of cognition.

Long-term cannabis users’ IQs declined by 5.5 points on average from childhood, and there were deficits in learning and processing speed compared to people that did not use cannabis. The more frequently an individual used cannabis, the greater the resulting cognitive impairment, suggesting a potential causative link.

The study also found that people who knew these long-term cannabis users well observed that they had developed memory and attention problems. The above findings persisted even when the study authors controlled for factors such as dependence on other drugs, childhood socioeconomic status, or baseline childhood intelligence.

The impact of cannabis on cognitive impairment was greater than that of alcohol or tobacco use. Long-term cannabis users also had smaller hippocampi (the region of the brain responsible for learning and memory). Interestingly, individuals who used cannabis less than once a week with no history of developing dependence did not have cannabis-related cognitive deficits. This suggests there is a range of recreational use that may not lead to long-term cognitive issues.

More studies are needed on cannabis use and brain health

The new research is just one of several studies suggesting there is a link between long-term heavy cannabis use and cognition. Still, future studies are needed to establish causation and explore how long-term cannabis use might impact the risk of developing dementia, since midlife cognitive impairment is associated with higher rates of dementia.

What should you do if you experience cognitive effects of cannabis?

Some people who consume cannabis long-term may develop brain fog, lowered motivation, difficulty with learning, or difficulty with attention. Symptoms are typically reversible, though using products with higher THC content may increase risk of developing cognitive symptoms.

Consider the following if you are experiencing cannabis-related cognitive symptoms:

• Try a slow taper. Gradually decrease the potency (THC content) of cannabis you use or how frequently you use it over several weeks, especially if you have a history of cannabis withdrawal.
• Work with your doctor. Be open with your doctor about your cognitive symptoms, as other medical or psychiatric factors may be at play. Your doctor can also help you navigate a cannabis taper safely, and potentially more comfortably, using other supportive means. Unfortunately, most patients are not comfortable talking with their doctors about cannabis use.
• Give it time. It may take up to a month before you experience improvements after reducing your dose, as cannabis can remain in the body for two to four weeks.
• Try objective cognitive tracking. Using an app or objective test such as the mini-mental status exam to track your brain function may be more accurate than self-observation. Your mental health provider may be able to assist with administering intermittent cognitive assessments.
• Consider alternative strategies. Brain function is not static, like eye color or the number of toes on our feet. Aerobic exercise and engaging in mindfulness, meditation, and psychotherapy may improve long-term cognition.

Cannabis is an exciting yet controversial topic that has drawn both hype and skepticism. It is important for individuals and healthcare professionals to place emphasis on research studies and not on speculation or personal stories. Emerging studies suggesting the connection between long-term heavy use of cannabis and neurocognition should raise concern for policymakers, providers, and patients.

About the Authors

Kevin Hill, MD, MHS, Contributor

Dr. Kevin Hill is director of addiction psychiatry at Beth Israel Deaconess Medical Center, and an associate professor of psychiatry at Harvard Medical School. He earned a master’s in health science at the Robert Wood Johnson … See Full Bio View all posts by Kevin Hill, MD, MHS

Michael Hsu, MD, Guest Contributor

Dr. Michael Hsu is a resident psychiatrist and is currently the chief resident of outpatient psychiatry at Brigham and Women's Hospital, a teaching hospital of Harvard Medical School. After graduating from the University of Pennsylvania with … See Full Bio View all posts by Michael Hsu, MD

Weight stigma, as defined in a recent BioMed Central article, is the “social rejection and devaluation that accrues to those who do not comply with prevailing social norms of adequate body weight and shape.” Put simply, weight stigma is a form of discrimination based on a person’s body weight.

The authors of this article assert that weight stigma can trigger changes in the body, such as increased cortisol levels, that lead to poor metabolic health and increased weight gain. In addition, those with higher body weight may cope with weight stigma by increasing alcohol and substance use, overeating to deal with negative emotions, and avoiding health care settings or social encounters. The subsequent negative health outcomes are a result of what they call chronic social stress, and studies have found the harmful effects of weight discrimination resulted in a 60% increased risk of death, even when body mass index (BMI) was controlled for.

What can be done to combat weight stigma?

There are many ways to address weight stigma. The first is to acknowledge that it exists, since we cannot combat something if we do not first acknowledge it.

Another step we can take is to make changes in the way we think and speak about people who have excess weight. One important way to do this is to remove the word “obese” from our vocabularies. When referring to someone who has excess weight, we should aim to keep in mind that they are a person with a disease, and strive to identify them as a person instead of as the disease they have. For example, the phrase “person with obesity” should be used instead of “obese person.” This way of speaking is called using person-first language.

Addressing weight stigma in health care settings

The health care setting is one in which weight stigma is particularly rampant, leading to significant health consequences for people with overweight or obesity. Studies have shown that physicians show strong anti-fat bias in health care situations. This bias results in reduced quality of care, and is yet another way in which weight stigma contributes to poor health in people with overweight and obesity.

Just as in everyday situations, there are many ways to address stigma in health care settings. Clinicians should of course follow the same recommendations as above, to acknowledge the existence of weight stigma and strive to use person-first language in their speech and medical documentation.

In addition, dispensing with the standard cookie-cutter advice to eat less and exercise more to lose weight would be of great benefit to patients. This type of advice doesn’t take into account the many environmental, genetic, and physiologic causes of obesity, and puts blame on the patient as the sole cause and contributor of their obesity.

Clinicians should also take care not to assume a patient with obesity is automatically engaging in overeating behaviors, and should believe their patients’ reports of dietary intake and physical activity. The clinical visit should be focused on information gathering and understanding of a patient's particular situation. Referral to an obesity specialist may be warranted if the clinician is not comfortable with discussing or prescribing different treatment options.

It is of utmost importance for patients with obesity to seek care from compassionate and knowledgeable health care providers, to optimize the quality of their care and reduce the negative effects of weight bias.

Where to go for more information and resources

The following organizations have plenty of information and resources for both patients and health care providers to learn more about obesity as a disease and how to combat weight stigma.

The Obesity Action Coalition is an organization that works to help individuals with obesity improve their health through education, advocacy, awareness, and support.

The Obesity Medicine Association has a search tool to find a clinician who is board-certified in obesity medicine within a specific geographic area.

The American Society for Metabolic and Bariatric Surgery has information for those with severe obesity, or with milder obesity and other medical complications, who are interested in bariatric surgery.

About the Author

Chika Anekwe, MD, MPH, Contributor

Chika V. Anekwe, MD, MPH is an obesity medicine physician at Massachusetts General Hospital (MGH) Weight Center and Instructor in Medicine at Harvard Medical School (HMS). Her professional interests are in the areas of clinical nutrition, … See Full Bio View all posts by Chika Anekwe, MD, MPH