As children and teenagers become more immersed in their electronic devices, families are challenged to control the negative fallout.
In a Pickle? Sports medicine docs discuss pickleball safety | 34
Pickleball, the fastest growing sport in the country, is easy to learn and fun for the whole family. But as its popularity grows, so do associated injuries. Learn how to improve your odds of staying injury-free on the courts.
The microorganisms that live in and on us are proving important to our health in countless ways.
On Life and Love | 28
When William Sanders’ heart failed him at 68, he was put at the top of the transplant list. His medical team, from heart surgeon to rehab therapists, helped secure his future.
don’t miss
Adding Folic Acid to Salt 5
Folic acid–fortified iodized table salt can prevent multiple severe birth defects.
Alzheimer’s and Air Polllution 6
“
[Before COIVD,] no one
really
thought about the capability to diagnose an infectious disease in their living room. Now I think that’s here to stay. The question becomes, how do we apply that to other diseases?”
Adults exposed to high levels of air pollution are at increased risk of Alzheimer’s disease.
the well
To Our Readers 4
A message from Ravi Thadhani, executive VP for health affairs, executive director of WHSC, and vice chair of the Emory Healthcare Board.
The Well 5 Folic acid–fortified salt prevents birth defects. Alzheimer’s and air pollution. Improving the health of new and expectant mothers in Georgia. Global health outreach in the
Dominican Republic and Guatemala.
Dangers of secondhand vaping. Snake bites and hot weather. Blood pressure sync in couples. Migraine mitigation. and more Policy Wise 46
The US has staggeringly high maternal mortality rates. Georgia Representative Jasmine Clark 13G offers solutions.
Emory Health Digest
Ravi Thadhani, Executive VP for Health Affairs, Executive Director of the Woodruff Health Sciences Center, and Vice Chair of the Emory Healthcare Board
Brian Katzowitz, AVP, Health Sciences Communications
Mary Loftus, Editor
Peta Westmaas, Art Director
Jack Kearse, Photography Director
Martha Nolan, Associate Editor
Jasmine Clark, Quinn Eastman, Jacob Gnieski, Kelly Jordan, Michelle Ricker, Rob Spahr, Tony Van Witsen, Contributors
Emory University is an equal opportunity/ equal access/affirmative action employer fully committed to achieving a diverse workforce, and complies with all applicable federal and Georgia state laws, regulations, and executive orders regarding nondiscrimination and affirmative action in its programs and activities. Emory University does not discriminate on the basis of race, color, religion, ethnic or national origin, gender, genetic information, age, disability, sexual orientation, gender identity, gender expression, or veteran’s status. Inquiries should be directed to the Office of Equity and Inclusion, 201 Dowman Drive, Administration Bldg, Atlanta, GA 30322. Telephone: 404-727-9867 (V) | 404-712-2049 (TDD).
24-Emory Health Digest Summer
Students from the Nell Hodgson Woodruff School of Nursing discuss care strategies during a service immersion trip to the Dominican Republic during spring break 2024.
INNER VISION
PHOTO KAY HINTON
Ravi Thadhani, executive vice president for health affairs, executive director of the Woodruff Health Sciences Center, and vice chair of the Emory Healthcare Board
For more on the Emory Microbiome Research Center
A few months ago, I celebrated my first anniversary as leader of Emory’s health sciences schools, centers, and institutes; health system; and research enterprise. I’ve learned much about what sets Emory apart from its peer institutions. The breadth and scope of our work cover the full spectrum of health and healing, while a deep commitment to collegiality and collaboration really distinguishes us among other academic health centers and amplifies the impact of our scientists, medical professionals, and educators.
The Emory Microbiome Research Center (EMRC) is a perfect example. The human microbiome is the community of trillions of microorganisms living on and in our bodies. Some of these microorganisms can cause illness, but the vast majority work in concert to help us digest food, boost our immune systems, support heart and brain health, and more. They may even help us fight disease.
These microbes have a pervasive influence on all human life. That’s why Emory launched the EMRC to better understand the microbiome and how we might manage it to promote optimal health. The center embraces Emory’s distinctive spirit
of collaboration to foster multidisciplinary research among scientists in wide-ranging disciplines including immunology, cell and development biology, metabolism, bioinformatics, genomics, and many others, along with leading-edge analytical and computational technologies.
With our tripartite, co-equal core missions of research, education, and patient care—and our commitment to collaborating across disciplines to maximize results —Emory is uniquely qualified to advance our understanding of the microbiome and to develop opportunities to apply that knowledge to improve lives and provide hope.
I hope you will enjoy reading more about Emory’s innovative microbiome research (page 40), along with many other exciting and transformative projects underway here. And thanks to our health science communicators for another outstanding publication highlighting our collaborative efforts to promote health and well-being for our patients, faculty, staff, students, and community.
Kind regards,
Ravi Thadhani
PHOTO COURTESY
MASS GENERAL BRIGHAM
the well
CLOSING THE PREVENTION GAP
BY ADDING FOLIC ACID TO SALT
A team of international researchers— including experts from the University of Central Florida and Emory—has proven that folic acid–fortified iodized table salt can prevent multiple severe birth defects.
The importance of women having enough folic acid before and during pregnancy to prevent permanent, life-threatening birth defects such as spina bifida and anencephaly has been known for decades. The World Health Organization recommends all women take supplement pills with 400 micrograms of folic acid daily, from attempting to conceive through the first three months of pregnancy.
Mandatory staple food fortification with folic acid is a cost–effective, safe and equitable way to address the issue. In 2023, the World Health Assembly adopted a resolution promoting food fortification with folic acid.
Yet approximately 260,000 births worldwide—about 20 per 10,000 births—are still affected by spina bifida and anencephaly, contributing to a high number of stillbirths, pregnancy
terminations, and deaths of infants and young children. While folic acid has been added through mandatory staple grain food fortification in about 65 countries, including the United States, more than 100 countries have yet to implement fortification due to challenges including limited capacity for large-scale fortification or lack of political will.
A recent study in JAMA Network Open showed a convenient solution: adding folic acid to iodized table salt based on existing average consumption of salt. This increased serum folate levels among participants to levels needed for prevention of spina bifida and anencephaly in their infants. The increase was significant: a 3.7-fold improvement before and after a four-month period of using the study salt with iodine and folic acid.
Colleagues from multiple institutions in India co-led the study and recruited and monitored 83 non-pregnant women between 18 and 45 from four villages in southern India. They consumed the folic acid–fortified salt
as part of their regular diet. India has a high prevalence of spina bifida and anencephaly.
“This is a global goodwill effort involving the health of mothers and babies. We are making sure we apply the knowledge we have,” says Vijaya Kancherla, associate professor of epidemiology at Rollins School of Public Health. At least 50 percent of current global spina bifida cases could be prevented if already existing iodized salt programs add folic acid, researchers say.
Godfrey Oakley Jr., director of the Center for Spina Bifida Prevention at Rollins, says, “The stage is now set for a rapid acceleration of prevention in many countries.” – Rob Spahr
Vijaya Kancherla, associate professor of Epidemiology at Rollins School of Public Health
Wildfires lead to an increase of anxiety-related emergency department visits, found researchers at Emory’s Rollins School of Public Health, amplifying a concerning parallel trajectory of two escalating public health crises—mental health and climate change.
“Many people are already dealing with mild or moderate mental health symptoms. Now imagine they wake up and see
WHERE THERE’S SMOKE, THERE’S ANXIETY
the sky covered in smoke, they’re likely going to feel even more anxious,” says the study’s lead author Qingyang Zhu, a postdoctoral fellow in the Gangarosa Department of Environmental Health at Rollins.
The NIH-funded study, published recently in Nature Mental Health, is among the largest and most comprehensive on the association between wildfires and anxiety disorders.
Analyzing satellite-driven data and nearly 1.9 million emergency department visits
Alzheimer’s and Air Pollution
Adults exposed to high levels of air pollution are at increased risk of developing Alzheimer’s disease, found Emory researchers. Published in Environmental Health Perspectives, the study gathered data from 1,113 participants in the Atlanta metropolitan area.
Analysis revealed positive biomarkers for Alzheimer’s disease among participants exposed to ambient and traffic–related air pollution at their homes. The study backs up the results of previous findings that have suggested air pollution contributes to degeneration in the brain.
“In our previous study, we showed associations between residential exposure to air pollution and Alzheimer’s-related changes in the brain in an autopsy cohort,” says Anke Huels, lead author and assistant professor of epidemiology at Rollins School of
across five states (California, Arizona, Nevada, Oregon and Utah), researchers showed wildfire smoke events—when wildfires become the main source of ambient pollution within a ZIP code—were associated with a 6.3 percent increase in mental health–related ED visits.
“The scary thing about climate change is it doesn’t have a clear boundary; you fear a lot about the unknown,” says co-author Yang Liu, chair and Gangarosa Distinguished Professor in Environmental Health at Rollins. – Rob Spahr
Public Health. “And now, we found similar results in a study of living adults who were on average 15 years younger and cognitively healthy. This shows residential air pollution can negatively affect our brain even decades before we actually develop Alzheimer’s disease.”
James Lah, principal investigator of the Emory Healthy Brain Study and associate professor of neurology at Emory School of Medicine, adds that we know that air pollution is generally bad for human health, including brain health.
“But by showing a relationship to levels of the amyloid protein in the cerebrospinal fluid, this study suggests that air pollution might increase the risk of developing Alzheimer’s disease. The flip side of that is, by cleaning up our environment, we might also help reduce the burden of Alzheimer’s disease.”– Kelly Jordan
Improving the Health of Mothers in Georgia
Tens of thousands of pregnancy-related complications occur in the US each year, and stark disparities exist in maternal health outcomes, depending on one’s racial and ethnic group.
Maternal health is one of the major themes in the Woodruff Health Sciences Center strategic plan. Finding innovative ways to reduce pregnancy-related complications and deaths and to promote maternal health equity is the aim of a new center that includes researchers from Morehouse School of Medicine and Rollins School of Public Health. The Maternal Health Research Center of Excellence is one of 10 research centers chosen for a National Institutes of Health initiative. Researchers will collaborate with a robust
Tracking Disease Outbreaks in Jails
An innovative partnership between infectious disease researchers and the Fulton County Jail in Atlanta has produced insight that could help detect and track future disease outbreaks.
A study of samples of the jail’s wastewater collected nearly every week between October 2021 and May 2022 found a correlation between the percentage of positive COVID-19 tests among jail residents and the COVID-19 levels detected in the wastewater.
The study, led by researchers at Rollins School of Public Health, was recently published in the Center for Disease Control and Prevention’s open-access, peer-reviewed journal Emerging Infectious Diseases.
network of community partners to translate research into interventions.
Hannah Cooper, Rollins chair in Substance Use Disorders, says maternal behavioral health conditions such as anxiety, depression, and birth-related PTSD are the most common complications of pregnancy and childbirth. One in five women is affected, with a disproportionate impact on Black women.
“Pregnant and postpartum women who are Black live at the intersection of three of the gravest public health threats confronting the US: the maternal morbidity and mortality epidemic; the behavioral health crisis; and intersectional discrimination,” says Cooper. EHD
Results from the feasibility study show that wastewater-based surveillance could not only help detect and mitigate future COVID-19 outbreaks but also detect other viral infection trends in jail settings. “We knew the technology worked in college dormitories, but jails are settings that needed to be studied,” says Anne Spaulding (above), associate professor of epidemiology at Rollins. “Because so many people pass through jails, protecting the health of detained individuals impacts the health of entire communities.” – Rob Spahr
Global Out reach
Building surgical capacity in Guatemala
One patient had a basketball-sized mass on her hip removed. Another had painful bilateral hernias fixed. The Emory Global Perioperative Alliance provides essential surgical care to patients in underresourced regions of Guatemala. It’s currently building surgical capacity in the state of Huehuetenango. “The peace of mind that comes from people learning what their condition is, getting it fixed, and gaining support is such an incredible thing,” says MD/PhD student Dani Farchi, who is Guatemalan and helped establish the project with Helps International. “That we’re working in my country, with my people, is fulfilling beyond words.” Henry Biermann, a fourth-year medical student and trip lead, says, “Being welcomed by the community, learning with them, creates lasting bridges.” Physicians Steven Roser, David Elwood and Barbara Pettitt are faculty advisors. Medical students Savanah Rumbika and Ambika Menon also served as trip leads. “It was a joy and the largest thing either of us has ever put together,” Menon says. “It gave me a lot of confidence going into the next phase of medical training.”
GENETIC TESTING should be considered by everyone planning a family, says Karen Grinzaid, assistant professor of human genetics at Emory School of Medicine. “There are genetic diseases that can happen that haven’t shown up in your family yet,” she says. But a whole genome test might make would-be parents more nervous than is necessary. “When you do broader testing like that, it may turn up problems where it’s not clear what the implications are,” Grinzaid said. “So, I just can’t overemphasize the importance of genetic counseling to help people through this journey.” – Georgia Public Broadcasting, “80% of Rare Diseases Are Genetic.”
CLIMBING STAIRS comes with a lot of health benefits. For starters, it’s good for your heart health. “We know just changing the grade or slope–the equivalent of walking up stairs–provides a greater stress on the heart, lungs, and body,” says Laurence Sperling, a cardiologist with Emory Heart and Vascular and the Katz Professor in Preventative Cardiology at Emory School of Medicine. This makes stair climbing a great way
COCHLEAR IMPLANTS have improved hearing loss for decades, but few who qualify for an implant get one, even in countries with universal health care. Esther Ximena Vivas, an otolaryngologist who runs the cochlear implant program at Emory School of Medicine, says: “So, maybe it’s not just access to health care but more cultural things, and basic information and knowledge on the provider side.” – STAT, “Why Very Few People Who Are Eligible for a Cochlear Implant Actually Get One.”
to improve one's aerobic fitness, he says. “If you take the stairs whenever you have an opportunity or walk up a hill whenever you have an opportunity, there are cumulative health benefits to that.” Along with strengthening the glutes and muscles in the legs, stair climbing is also a good indicator of overall health. “[Personal fitness] can be gauged by your ability to walk up a flight or two flights or five flights of stairs,” says Sperling. “If you’re noticing a decline in the ability to climb stairs, more from a fitness and/or respiratory capability standpoint, that’s really helpful to bring up to your doctor or clinical team because that might be a clue to underlying health concerns.” If stairs are easy for you, you can do things like put on a weighted vest or skip a step, which forces the muscles to work harder. People can also walk up the stairs sideways to work the side of their hips. – Yahoo! Life, “Make the Most Out of Climbing Stairs.”
ARTIFICIAL INTELLIGENCE
( AI)—computational analytics with routine imaging via radiology or pathology—can advance precision medicine in breast cancer, specifically by predicting response to therapy and calculating prognosis, according to a pioneer in the field, Anant Madabhushi, Robert W. Woodruff Professor in the Emory and Georgia Tech Department of Biomedical Engineering and director of the Emory Empathetic AI for Health Institute (AI.Health).
In his keynote at the 2024 Miami Breast Cancer Conference, Madabhushi described his team’s research using computational analyses aimed at improving cancer outcomes. “One of the biggest challenges is the issue of overdiagnosis and overtreatment of a number of cancers,” Madabhushi said. “A case in point is prostate cancer, where 1 in 7 men will be diagnosed with it but only 1 in 40 will actually die from it. Yet we throw the proverbial kitchen sink—in terms of treatment—at a number of these cancers, even though many of them are indolent and less aggressive.”
Novel treatments such as immunotherapy have enhanced outcomes but do not work in all patients and often create “financial toxicity,” so more streamlined approaches are needed. “Our group is looking at the role of AI, not just in developing better diagnostic tools but also better prognostic and predictive tools, so we can appropriately tailor therapy,” Madabhushi said. “There’s so much information we are not currently capturing, and with the power of AI we can pull out features in areas we have not been typically used to evaluating.” – The ASCO Post, “Can Artificial Intelligence Predict Treatment Response and Outcomes in Breast Cancer?”
Rock-Solid Rankings
Four Emory Healthcare hospitals have ranked prominently in this year’s regional rankings of US News & World Report’s Best Hospitals issue.
For the 12th year in a row, Emory University Hospital ranked No. 1 in Georgia and metro Atlanta in the 2023–2024 Best Regional Hospitals rankings. (Emory University Hospital includes Emory University Orthopaedics & Spine Hospital and Emory University Hospital at Wesley Woods.) Emory Saint Joseph’s Hospital ranked No. 2 in Georgia and metro Atlanta for the eighth consecutive year, while Emory University Hospital Midtown ranked No. 4 (a tie) in Georgia and metro Atlanta. For the first time, Emory Johns Creek Hospital ranked No. 8 in Georgia and No. 7 in metro Atlanta.
In the 2023–2024 Best Hospitals Specialty Rankings, Emory University Hospital ranked nationally in the following adult specialties: cancer, geriatrics, neurology
and neurosurgery, ob/gyn and urology. The hospital was considered high performing in cardiology, heart and vascular surgery, gastroenterology and GI surgery, orthopaedics and pulmonary and lung surgery. Emory Saint Joseph’s ranked high performing in diabetes and endocrinology, gastroenterology and GI surgery, geriatrics, orthopaedics and pulmonary and lung surgery. Emory Midtown ranked nationally in ENT and high performing in geriatrics. Emory Johns Creek ranked high performing in gastroenterology and GI surgery, geriatrics, neurology and neurosurgery and orthopaedics.
“We’re proud that four of our hospitals ranked regionally and two nationally in various specialty areas,” says Joon Lee, CEO of Emory Healthcare. “Congratulations, and thank you to our team members who helped us reach these successes by providing expert, high-quality and compassionate care to our patients.”
Michael Halkos, chief of cardiothoracic surgery, checks his progress during a surgery at Emory Saint Joseph’s Hospital. Halkos and fellow Heart and Vascular cardiothoracic surgeon Douglas Murphy lead one of the largest robotic cardiac surgical programs in the world.
MACHINE LEARNING
PHOTO JACK KEARSE
I am an Emory rEsEarchEr
Wilbur Lam Wants to Solve All the Problems
WILBUR LAM IS MANY THINGS.
He is a professor of pediatrics and biomedical engineering, contact principal investigator of the Atlanta Center for Microsystems Point-of-Care Technologies, associate dean of innovation at Emory School of Medicine and director of the new center for the Advancement of Diagnostics for a Just Society. And he’s recently been named Emory’s inaugural vice provost for entrepreneurship.
During residency training in pediatrics at the University of California, San Francisco, Lam was astounded by how antiquated clinical care technology was compared to the innovative research going on in labs at the same university—sometimes even in the same building. “There’s always been a significant disconnect between the most cutting-edge stuff that’s being developed scientifically and what is serving patients,” he says. In fact, that lag could be 10, 20, even 30 years. “So that’s what I decided to take on: to accelerate the time it takes to invent a technology and enable it to improve lives.” He combined his subspecialty training in cancer and blood diseases for children—pediatric hematology oncology—with a PhD in bioengineering.
Lam moved to Atlanta to work at Emory and Georgia Tech in their combined biomedical engineering research program more than a decade ago.
One of the elements that drew him to this academic medicine ecosystem was the culture. “The level of collaboration among different investigators, departments and universities is unlike anything I’ve seen across the country,” he says.
Lam decided to start a laboratory that lived in both the department of pediatrics and the department of biomedical engineering, with a footprint on the clinical and technological sides.
“It’s truly a 50/50 split,” he says. “From a basic science standpoint, we study blood and the biophysics of blood, but we’re also what I call a ‘gadget lab’ where we develop new technologies.” A one-stop shop, the lab is home to a versatile group of bioengineers, electrical engineers, mechanical engineers, physicists, biologists and physicians who can take technologies from “basement to bench to bedside” says Lam, or “from PhD project to publication to product.”
TESTING THE HOME TESTS
In a fortuitous move, Lam and colleagues from Emory and Georgia Tech saw the need for a diagnostic research center. In 2018, the Atlanta Center for Microsystems Engineered Point-of-Care Technologies (ACME POCT) was established as part of the National Institutes of Health’s (NIH) research network. ACME POCT fosters the development of new tests and technologies used in point-of-care settings. Before the pandemic, there were only a few such tests commonly used in ERs, pharmacies and people's homes. Glucose monitors and pregnancy tests were some of the well-known tests available over the counter. Once the pandemic hit full force, however, the need for rapid, accurate home testing became paramount. “The NIH saw that Emory, in our unique ecosystem with Children’s Healthcare of Atlanta and Georgia Tech, had the medical know-how, the large patient populations, and the technical capabilities to have a robust center for new point-of-care diagnostic tests,” Lam says. Emory was poised to play a large part in the effort to bring simple, effective home testing directly to consumers. Specifically, the NIH wanted to dra-
PHOTO BRYAN MELTZ
matically shrink the timeline to develop, test, and market COVID-19 home tests. “And that,” says Lam, “was the incipience of the NIH’s RADx program, which stands for ‘rapid acceleration of diagnostics.’ ”
STAMP OF APPROVAL
ACME POCT became the validation center for most technologies the NIH was planning to fund and scale up. “COVID tests you’ve seen when you go to CVS or Target, or that you ordered on Amazon, by and large came through us first for our stamp of approval,” says Lam. The FDA uses Emory data to determine whether a diagnostic technology gets authorization and is made available to the public.
“Our center helped the entire country and world get through the pandemic,” Lam says. “At the same time, our team developed valuable skills.” ACME POCT has now been selected as the RADx Innovation Funnel validation center and received contracts of more than $57 million since 2022 to research diagnostic tests for other diseases as well, such as hepatitis C and mpox. Prepandemic, Lam says, “no one really thought about the capability to diagnose an infectious disease in their living room. Now I think that’s here to stay,” he says. “The question becomes, how do we apply that paradigm to other diseases?”
HONEY, I SHRUNK THE TECHNOLOGIES
The Lam lab studies, specifically, diseases of the blood such as clotting disorders and sickle cell, which often involve microfluidics or nanotechnology. “A lot of what goes on in terms of those disease processes happens at this really, really small level, at the single-cell level,” Lam says. “And the only way to study that is to create technologies also at that scale. We can manipulate molecules and provoke or coax certain biological processes to behave in certain ways.”
At the same time, Lam is interested in shrinking very large medical technologies and devices to the point where they become portable.
“When I was a graduate student, one of the first technologies I co-invented was an ear scope that we could attach to the iPhone,” he says. The smartphone ear scope inspired Lam’s first company, which he cofounded and then sold to Johnson & Johnson a few years ago.
A JUST SOCIETY
The new Center for the Advancement of Diagnostics for a Just Society (ADJUST) is focused on helping underserved populations get equitable access to diagnostic technologies as well as simplifying the user experience. “What the tech developer thinks is easy to use is probably completely different than what the ultimate end user thinks is easy,” says Lam, the center's director. The ADJUST Center will be dedicated to ensuring that new diagnostic technologies serve those who need them most.
Lam is convinced the potential for problem solving is unlimited if the right questions are posed: “Who are you trying to serve? What problem are you trying to solve? How will you solve it? And if you do solve it in this particular manner, will it be used? Those are the questions we need to be asking.” – Mary Loftus
Get the full story on Wilbur Lam and other Emory researchers
Most COVID-19 home tests were approved by ACME POCT at Emory, Georgia Tech and Children’s Healthcare of Atlanta.
5,000 TAVRs
Innovative Heart Procedure Reaches
Landmark Status
Emory Heart and Vascular has performed the
Transcatheter Aortic Valve Replacement (TAVR) procedure on 5,000-plus patients.
TAVR revolutionized treatment by allowing cardiologists to replace a patient’s impaired aortic valve with a new prosthetic valve via a catheter. Emory was the first in Georgia (and one of the first in the nation) to perform the innovative, minimally invasive procedure in 2007. TAVR is considered a safer and less invasive alternative to open-heart surgery for many aortic stenosis patients, says Vasilis Babaliaros, founder and co-director of the Emory Structural Heart and Valve Center. Before TAVR, aortic stenosis—a narrowing of the aortic valve opening—was typically a death sentence without surgery. – Martha Nolan
Hidden Dangers of Secondhand Vaping
Vaping parents may be exposing their children to hazardous chemicals, despite a widespread belief that the use of e-cigarettes is safe to household members.
A new study by researchers at Emory’s Nell Hodgson Woodruff School of Nursing and Rollins School of Public Health shows that children living in households where e-cigarettes are used are indirectly inhaling substances that could harm their developing bodies.
“Many people who smoke have switched to using e-cigarettes, thinking it’s safer for them and others nearby,” says Jeannie Rodriguez, associate professor of nursing and lead author of the study.
“However, there are chemicals in the liquids used in a vape that are hazardous for you and those you care about, who are exposed to the vapors you exhale.”
Rodriguez is a clinician scientist, whose research focuses on understanding the direct and downstream effects of exposures on children’s health using metabolomics and other methods. This study employed the traditional use of
blood tests along with less invasive saliva and exhaled breath tests to determine the exposure to secondhand e-cigarette vapor. The results were telling: Children ages 4 to 12 exposed to secondhand e-cigarette vapor showed significantly higher levels of metabolites linked to chemicals found in e-cigarette liquids compared to unexposed peers. These metabolites interfere with the body’s normal operations by disrupting dopamine levels and causing inflammation and oxidative stress. Oxidative stress leads to cellular damage throughout the body and is linked to numerous diseases including diabetes, heart disease and cancer.
Many parents seem unaware of the risks. In focus group discussions with Emory researchers, more than half of participating parents said they considered vaping around their children a minor concern, if a concern at all. This underscores the need for education on the subject. Co-authors include Irene Yang of the School of Nursing and Donghai Liang of Rollins School of Public Health. – Jacob Gnieski
Hot Outside? Watch Out for Snakes
Snakes are cold blooded, which is why they spend a lot of time basking in the sun. In fact, Emory researchers have found a significant jump in the likelihood of being bitten by a snake for every degree Celsius daily temperatures increase.
The study analyzed ER visits reported by the Georgia Hospital Association from 2014 to 2020—during which time there were more than 5,000 hospitalizations due to snake bites, including 3,908 reported venomous snake bites. Researchers compared that data to the minimum and maximum temperatures, air pressure and
humidity on the dates the bites occurred. The findings, published in GeoHealth, found the risk of being bitten by a snake increases 6 percent for every degree Celsius daily temperatures increase. “This is certainly higher than we often see from other types of health outcomes linked to heat,” says Noah Scovronick, assistant professor of environmental health at Rollins School of Public Health and the study’s lead author. “Our results show we need to spend more effort understanding the potential health burdens from snakebite in the context of climate change.” – Rob Spahr
Under PRESSURE
If one spouse or partner in a relationship has high blood pressure, the other often does too, finds new research co-led by the Emory Global Diabetes Research Center. For the study, published in the Journal of the American Heart Association, researchers investigated whether heterosexual partners in the US, England, China, and India mirrored each other’s high blood-pressure status.
“Our study is the first to examine the union of high blood pressure within couples from high- and middle-income countries,” says Jithin Sam Varghese, research assistant professor at Rollins School of Public Health. “We wanted to see if married couples, who often
have the same interests, living environment, lifestyle habits and health outcomes, also share high blood pressure.” The researchers analyzed 3,989 US couples, 1,086 English couples, 6,514 Chinese
couples, and 22,389 Indian couples. Participants considered to have high blood pressure had one of the following: systolic greater than 140 mm Hg; diastolic greater than 90 mm Hg, or a
Noah Scovronick, assistant professor of environmental health at Rollins School of Public Health
history of high blood pressure as reported by a health care provider. Study findings included:
• The rate of both spouses or partners having high blood pressure was about 47% in England; 38% in the US; 21% in China; and 20% in India.
• Wives whose husbands had high blood pressure were 9% more likely to have high blood pressure in the US and England, 19% more likely in India and 26% more likely in China. Similar observations were made for husbands. The study highlights the potential for using couple-based interventions for high blood pressure diagnosis and management such as joint screenings or mutual education programs. – Myra Patrick
“Nutmegs were so valued that, at their trade’s peak, they were worth their weight in gold. Today, we often sip lattes containing this precious commodity without realizing its historic importance.”
—Cassandra Quave, curator of the Emory Herbarium, Thomas J. Lawley, MD, Professor of Dermatology and a 2024 Guggenheim Fellow, who also cautions that the spice in larger amounts can be toxic.
PHOTO CREDIT: CLAIRE CASTELLANO MD/MPH 23, “The Powerful Nutmeg,” Zanzibar, Tanzania. First place, Emory Global Health Institute student photography contest.
Qs: Migraine Mitigation
Sufferers
describe migraines in different ways—everything from feeling like their head is on fire to throbbing “brain pain.” “These headaches are intense,” says Vinita Singh, associate professor of anesthesiology at Emory School of Medicine and pain medicine specialist with Emory Healthcare. “They’re incapacitating. They can stop you from doing anything at all.”
Singh answers Emory Health Digest’s four questions about migraines:
Can I predict when a migraine is coming on? In some cases, but not all, a migraine is preceded by an aura. Auras are experiences such as visual disturbances, sensitivity to light or sound, or nausea. Some people feel odd sensations or have problems with speech. If you can predict a headache is about to start, it’s often a sign of a migraine. Usually, these headaches come and go. They might last a few hours or even a few days, but the pain disappears, at least for a while.
1 3 2 4
How can I help my doctor better understand my personal migraines? The pattern of your migraines can guide treatment decisions, so keep track of symptoms, triggers and impacts in a diary. Each time you have a headache, note:
n When your headache started and its duration
n Your pain and its severity
n What you ate before
n Where you went that day
n How well you slept
n How much water you drank
n What the weather was like
n Exposure to something out of the ordinary, like flashing lights
n Treatments you’ve tried
n Activities your headache prevented Also, tell your doctor if migraines run in your family.
Is there anything I can do to prevent migraines?
Another unique thing about migraines is that they have triggers. The American Migraine Foundation lists a wide range of factors that can trigger a migraine including: certain smells; dehydration; specific foods, such as chocolate or aged cheese; alcohol and caffeine; stress; weather changes; menstrual cycle.
Are there different treatment plans for different types of migraines? Your treatment plan will take into account how many migraine-free days you have each month. If you have just a few headache days—let’s say you’re headache-free 25 days a month—then we would treat your headaches when they occur. If you take certain medicines more than 10 days a month, they can actually cause more frequent headaches or make them worse. If you have a headache more frequently, the focus turns to prevention. Doctors typically start with the most conservative therapies. If they don’t provide relief, other options are considered:
VITAMINS AND SUPPLEMENTS. Research shows vitamins such as riboflavin and supplements like magnesium, butterbur and feverfew may help prevent migraines. It’s important to talk with your primary care provider before taking herbs or supplements on your own.
MEDICATIONS. Nerve stabilizers, such as gabapentin and topiramate, help calm abnormal excitement in your brain. Calcitonin gene-related peptide (CGRP) inhibitors include several newer drugs specifically developed to prevent migraines.
NERVE BLOCKS. Doctors inject medication near certain nerves to block pain signals.
BOTULINUM TOXIN. Doctors use it to treat frequent migraines, but usually only as a last resort. When injected near nerve endings, botulinum toxin interferes with pain signals.
Vinita Singh, pain medicine specialist
Predicting Transplant Rejection with AI
Using AI tools, CARE extracts features associated with the shape, texture and spatial architecture of muscle cells, immune cells, and stromal fiber in heart tissue specimen images to predict rejection outcomes for heart transplant patients.
Heart to Heart
A health+care conversation series
Emory Heart and Vascular physicians treat people with heart failure, high blood pressure, vascular disease, and so much more.
About4,500 heart transplants are performed in the US yearly.
While this lifesaving operation improves quality of life and longevity for most recipients, organ rejection remains a risk, with acute rejection occurring in up to 32 percent of recipients within the first year.
A team of researchers from Emory, Case Western Reserve, and the University of Pennsylvania developed artificial intelligence tools to examine cardiac biopsy images to improve the prediction of rejection.
Clinicians now rely on histologic grading of cardiac biopsies to diagnose rejection, but the current criteria is vague and lacks diagnostic accuracy.
These limitations subject patients to considerable risk of receiving excessive or inadequate treatment.
The research team created a new method for automated, comprehensive analysis of heart biopsy images, the Cardiac Allograft Rejection Evaluator (CARE).
“This facilitates the use of more aggressive treatments for those in need, leading to more effective prevention of heart transplant failure,” says researcher Sara Arabyarmohammadi of Case Western.
A study of 2,900 patients recently published in Circulation: Heart Failure showed that the CARE model, optimized to predict cardiac rejection severity, was far better at assessing a patient’s clinical outcome.
“What is most interesting is not just that the AI approach was able to better predict transplant rejection compared to pathologic grade, but it used a set of image features that were far more intuitive and explainable,” says senior author Anant Madabhushi, Woodruff Professor of Biomedical Engineering and executive director of the Emory Empathetic AI for Health Institute (AI.Health) at Emory. – Brian Katzowitz
Anant Madabhushi, executive director of AI.Health at Emory
A new video series, “Heart to Heart Conversations,” features these accomplished, passionate physicians, who often work together, speaking candidly with each other in 15-plus free-flowing, fascinating, and substantive discussions.
Sitting face to face, surgeons, preventive cardiologists, sports medicine physicians, and other heart and vascular doctors lean into their stories, sharing their often winding career paths, proudest or most challenging moments, best and worst advice they’ve received, and how they have learned to live with ambiguity.
– Alexis Hauk
For the full Heart to Heart experience
PHOTO SARAH BROWN, CRMC
TEENS SCREENS
SOCIAL MEDIA AND OTHER SCREEN TIME DOLE OUT THE DOPAMINE BUT TAKE A TOLL ON TEENS
By Martha Nolan • Illustrations by Jon Krause
My daughter is a “digital native.” She never knew a world without the ability to retrieve any obscure fact with a simple internet search or to virtually befriend people all over the world. She started playing on my computer when she was 8, got her first electronic device—a tablet—at 12, and a smartphone at 13.
Like most parents, I was concerned about the amount of time she spent on her phone and about how social media, in particular, could bring her to rages or tears.
But it wasn’t until years later that I discovered the extent of the damage all that screen time caused.
It turns out, during her teen years she was staying up most of the night texting friends and scouring posts and then slogging through her classes in a bleary-eyed haze. She brooded over friends’ posts of the antics at unchaperoned parties that her father and I had not allowed her to attend. And she became convinced she was overweight (she was not) by comparing herself to unrealistic—probably Photoshopped— bodies she saw in online ads.
She nearly stopped eating, covering her shrinking body with bulky clothes so I wouldn’t notice.
Screens and social media were not the only culprits in my daughter’s adolescent trials by any means. She says they were not even the
primary cause of her bouts with depression and anxiety. I’m not so sure.
Today, my daughter is 24. She’s still glued to her phone, but she has a job she likes, a thoughtful, steady boyfriend and a loyal circle of friends. In other words, she is doing okay. I do wonder, however, if those screens have left any scars.
I’m hardy alone. Parents, along with educators, health professionals, and policymakers all over the world are grappling with the herculean hold technology and screens have over the lives of children.
Concern has risen to such levels that in May 2023, US Surgeon General Vivek Murthy issued an advisory warning about the impact social media is having on the mental health of young people.
Advisories are reserved for significant public health challenges that require the nation’s immediate action. Murthy, who calls youth mental health the defining public health issue of our time, said children and teens have become unknowing participants in a decades-long experiment and stressed the urgent need for more research and action.
“I was heartened by the Surgeon General’s report drawing attention to this issue,” says Daniele Fallin, James W. Curran Dean of Public Health at the Rollins School of Public Health. “As a parent of a teen and preteen, I feel this concern deeply. Navigating screen time and social media is a constant struggle, and we don’t have a clear roadmap based on evidence about what is best for our children and feasible in our society.”
“
What is going on? Why is the mental health of youth and teens nosediving? We should all be asking ourselves what has changed, what is behind this trend.”
Janet Cummings, professor of health policy and management in the Rollins School of Public Health
Janet
Cummings, professor of health policy and management at Rollins School of Public Health
Justine
Welsh, director of Emory Healthcare Addiction Services and medical director of the Addiction Alliance of Georgia
Daniele Fallin, James W. Curran Dean of Public Health at Rollins School of Public Health
DEPRESSION AND ANXIETY SKYROCKETING AMONG TEENS
Alarms began being raised about mental health issues among children and teens more than a decade ago. Since 2010, reports of depression and anxiety among teens and young adults have risen steadily, along with emergency rooms visits resulting from self-harm or suicide attempts. By 2018, suicide was the second leading cause of death for people ages 10–24 years.
The pandemic, with its isolation and uncertainly, added fuel to an already alarming fire. To take but one example, emergency department visits for suspected suicide attempts increased nearly 51 percent among girls ages 12–17 years in early 2021 compared to the same period in 2019, according to the CDC. The agency also found nearly 45 percent of high school students were so persistently sad or hopeless they were unable to engage in regular activities. The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared a national state of emergency in children’s mental health.
Why is the mental health of youth and teens nosediving? “We should all be asking ourselves what has changed, what is behind this trend,” says Janet Cummings, professor of health policy and management in the Rollins School of Public Health. “One thing that has certainly changed and that is severely underresearched is how teens are spending their time.”
They are spending it, more and more, on their phones, tablets, and computers. Consider the timeline. The internet started becoming mainstream in the early 1990s.
MySpace launched in 2002 and Facebook two years after that. Apple introduced the first iPhone in 2007, basically allowing teens to carry all the social media platforms in their pockets 24/7.
Fast forward to today and the use of social media by children and teens is almost universal. Up to 95 percent of youth ages 13–17 report using a social media platform, and more than a third say they use social media “almost constantly,” according to the Surgeon General’s advisory.
This is not happenstance. Video games and social media platforms are specifically designed to dole out dopamine hits with likes, shares, and intermittent reinforcement. In short, they are designed to be addictive. “We know apps and games are written to suck people in,” says Fallin. “Years ago, I had a friend with a PhD in clinical psychology, and he was employed by a gaming company. His entire job was to help build the programs in a way that encouraged gamers to play more and more.”
It has worked.
UNDERSTANDING THE DARK SIDE OF SCREEN TIME
“I see quite a number of adolescents presenting with depression and/or anxiety who spend massive amounts of time on screens each day,” says Justine Welsh, director of the Emory Healthcare Addiction Services and medical director of the Addiction Alliance of Georgia. “They struggle to balance their internet gaming or social media use with the other things they need to be doing. Reducing screen time can be a nightmare for parents. I’ve actually had young patients hospitalized after their parents took their phones away because they harmed themselves or threatened suicide.”
While Emory Healthcare adolescent psychiatrists don’t specifically treat screen addiction or screen overuse, they see it in their practices at a growing rate. Jennifer Holton, program director for Emory’s Child and Adolescent Psychiatry Fellowship Program, often deals with issues around screens in her practice. “I work with many families that struggle with screen use,” she says. “While screen time isn’t inherently a bad thing, for many children I work with getting off screens can be incredibly hard and can result in emotional and behavioral outbursts including aggression at times. I spend a lot of time working collaboratively with parents and problem-solving around this issue. Monitoring use and limiting access to appropriate material can also be challenging for parents.”
As Holton said, not all screen time is bad. Some children and teens find a community of like-minded people through social media and internet gaming they are unable to find in their neighborhoods. Children with
autism, or lesbian, gay, bisexual, transgender, queer, and other youths, for example, can connect with peers and find social support that might otherwise be lacking.
For many children and teens, however, the harms of excessive screen time outweigh any benefits. “There are two main issues,” says Holton. “There is the amount of time people are spending on the screens, and then there is what they are doing on the screens. You have to consider both.”
The time teens spend on their screens equals the time they are not doing other things. Consider the defining aspect of a teen’s life—hanging out with friends. In her book Generations, psychologist Jean Twenge found that since 1976, the number of times per week teens go out with friends—in person and without parents—held steady for nearly 30 years. In 2004, it slid a bit. Then in 2010, it fell off a cliff. “Forget about actually getting together with friends, this next generation doesn’t even call—they text,” says
Welsh. “They are constantly creating artificial barriers between each other.”
GETTING DOPAMINE HITS FROM GAMING
Time playing a video game or monitoring social media is also time not spent playing sports, doing homework, walking the dog, or sleeping—all elements necessary for healthy development.
What adolescents are viewing on their phones and tablets plays a large role in the mental health impact of such devices. Internet gaming, for example, seems to come closest to mimicking an addiction. “Gaming is based on intermittent reinforcement and surges of dopamine,” says Welsh. “Researchers have demonstrated by neuroimaging that gambling and gaming are very similar in their levels of reinforcement to other types of addiction.”
Social media, the focus of the US Surgeon General’s report, seems even more fraught. Through Instagram, Snapchat, TikTok and similar apps, teens see unrealistically filtered and photo edited images of friends and influencers living amazing lives and often come away feeling left out and unattractive. Girls especially seem prone to developing distorted body images after spending time on social media, which can lead to eating disorders.
“I’ve had patients who find ‘secret’ groups online that engage in self-harm, for example,” says Charles Gillespie, a psychiatrist with the Emory Child and Adolescent Mood
Program. “They would share pictures and talk about ways to engage with it. There are groups for anorexia that glamorize dangerously thin bodies and discuss ways to avoid eating. These teens are developing a sense of community, but in a way that is pathological and makes things worse.”
Social media challenges have resulted in deaths, and drug dealers and predators lurk online. Nearly six in 10 girls say they’ve been contacted by a stranger online in ways that make them feel uncomfortable, according to the report.
Cummings hopes the surgeon general’s report will be a clarion call.
“Every product aimed at children has to clear innumerable hurdles proving it is safe before it can be brought to market. Why is the same not true for technology?” she asks. “We desperately need more research so we can inform policies to put some guardrails around these technologies for our kids.” EHD
SOME TIPS FOR SCREEN TIME
STRIFE
For now, the onus of monitoring—and restricting—screen time falls almost solely on parents. “Children’s screen time is one of the biggest sources of strife in families today,” says Dean of Rollins School of Public Health Daniele Fallin. “It’s a near constant battle of parents saying, ‘No more screen time,’ and kids saying, ‘But this is the main way I socialize. It’s how I get my information. It’s the way I do homework.’ ” Here are some ways Emory experts suggest helping children and teens take control of their screen time:
Create a family media plan. Your plan can outline your children’s responsibilities in earning screen time and establish technology boundaries, including social media use. The American Academy of Pediatrics can walk you through creating such a plan at healthychildren.org/media plan.
Child and adolescent psychiatrist Jennifer Holton (below) created a system in which her 6- and 10-year-old can earn points and cash them in for privileges, including screen time. Even with enough points, though, screen time is generally off limits on week-
nights, and on weekends the most they might get is an hour and a half. “Every family is different, but things tend to go more smoothly in our home when screen time is limited that way,” says Holton.
Establish “tech-free zones” and encourage children to foster in-person relationships. We’ve all seen tables at a restaurant where everyone, even the parents, are on their phones rather than talking to one another. The same can happen in the home. Make sure it doesn’t.
Child and adolescent psychiatrist Justine Welsh’s children are 2 and 4, so she isn’t overly worried about screens just yet. “But my husband and I have already started talking about it,” she says. “We are starting to set expectations now. We have no phones at dinner—all phones are plugged into the charging station when we sit down to eat.”
Discuss tech’s benefits and risks. Talk to your kids about the importance of respecting privacy and protecting personal information in age-appropriate ways. Have conversations about who they are connecting with, their privacy settings, their online experiences, and how they are spending their time online. “I have a 6-year-old and her main source of screen time is TV,” says Rollins Professor Janet Cummings.
“But we’ve already started having conversations with her. One time she didn’t realize how long she had been watching cartoons, and we discussed how getting lost in screens
can happen to anybody and what we could be doing instead. We talked about setting goals for the time she spends watching TV to make sure she has time for all the other things she loves to do, like art projects and play dates. As she gets older, I plan to continue to talk with her as we introduce one platform at a time.”
Walk the talk. Parents need to have the relationship with their smartphone they want their kids to have, so don’t scroll through Facebook as your daughter is telling you about her latest friendship drama.
“Like everyone else, my husband and I are on our phones and computers quite a lot,” says Fallin. “But we make a concentrated effort to turn them off when we are with our children. We not only want to be present for our kids, we want to model that type of behavior.”
Limit notifications on smartphones. All those dings, rings, and buzzes draw teens’ attention back to their devices and demand immediate attention. Limit the number of apps that produce audio notifications.
Turn off the smartphone before bed. Teens are foregoing sleep to stay connected with friends and happenings on their smartphones and tablets. Nearly one in three teens report using screen media
until midnight or later. Fallin allows her 12- and 13-year-olds to have their phones in their bedrooms, but they are required to turn them in at a certain time every evening. “No one is allowed to have a phone in the room overnight,” she says. “Otherwise, I’d worry about their sleep.” Each child needs to be considered individually. “I start by asking parents what their child is doing on their device and how it is impacting them,” Holton says. “We need to meet them where they are and go from there. But one thing is clear—parents and kids need more guidance.”
EHD
“
Children’s screen time is one of the biggest sources of strife in families today.”
Daniele
Fallin,
Dean of Rollins School of Public Health
By: Michelle Ricker
William Sanders was diagnosed with a failing heart in his late 60s. He made it his mission to stay strong—for himself, his loved ones, and the future he still envisioned.
In 2018, Sanders was referred to Mahmoud Abdou, an Emory cardiologist, by his primary physician. Over the next few years, Abdou was frank—Sanders’ heart wasn’t functioning as it should be, but they would try all available treatments. Interventions ranged from medication to an implantable cardioverter-defibrillator to a pacemaker and beyond.
When none of those could keep heart failure at bay, Abdou continued to be candid, and told Sanders he needed a heart transplant.
“It didn’t really resonate with me until I got home,” Sanders remembers about that visit, “and after a while
Mahmoud Abdou, Emory cardiologist
I started to tell myself that I had to deal with these issues, that they weren’t going away.”
Sanders, 67 at the time and a retired criminal investigator, also started to notice changes. He couldn’t exercise or swim anymore, he had to sleep upright, and he was back and forth to the hospital every few months.
Then came the visit where doctors discovered that Sanders’ heart was functioning at roughly 10 percent, so Sanders was put on a temporary mechanical pump—Impella, a device designed to support the heart to allow it to pump more blood with each contraction and the blood to flow more easily.
Based on his condition, Sanders was moved higher on the transplant list. “Wow. It was a fight,” he says. “I was told by my nurses that every patient has to be physically ready and test well to receive a transplant. So, I walked around the nurses’ station every morning because I knew a heart was coming for me.”
Sanders got other cardiac patients to join him on those walks by stopping by their rooms. “I’d say, ‘Listen, you don’t
William Sanders was moved to the top of the transplant list after his heart failure worsened, and a heart became available soon after, resulting in a successful transplant.
know me, but I’m going to tell you something. You can lay in that bed all you want, but nothing is going to happen until you start getting up to walk. Until you move your body. I’ll come back and walk with you.’ ”
The walks had dual benefits: physical stamina and a mental reprieve during a lengthy stay.
But Sanders’ heart was still very sick, with his condition deteriorating. He was placed on ECMO (extracorporeal membrane oxygenation), a long-term “bypass machine” that supports the heart and/or lungs by taking blood out of the body, oxygenating it via an artificial lung, and pumping it back in. Sanders’ priority status was moved to the top spot on the transplant list.
When patients are on ECMO support, more and serious complications tend to occur, and if a suitable heart is not available after about a week, some difficult decisions need to be made on to how to proceed.
After nearly 10 days in the hospital, Sanders got some tough news from his doctor, Abdou. If a heart wasn’t available in the next few days, Sanders would have to
Emory cardiothoracic surgeon Tamer Attia, left, performed the successful heart transplantation surgery on Sanders, right.
choose whether to get an LVAD (left ventricular assist device), a surgically implanted pump used for patients with end-stage heart failure. “I was in my room, talking to myself and having a conversation with God, and an hour later, I’m told they have a heart available,” he says. Things happened quickly after that, and the next thing Sanders remembers is waking up with his loved ones standing over him, congratulating him on a successful transplant by Emory cardiothoracic surgeon Tamer Attia.
Every step of the way, Sanders says, he was surrounded by community he could lean on, including his fiancée-now-wife, Bernice “Bernie” Ward, and sister, Vera Gainey.
Sanders’ heart problems had taken Gainey by surprise. The brother and sister are just 11 months apart, with Gainey being older, and have always been close—particularly since they’ve lost their other siblings and parents over the years. The two grew up in Philadelphia, where Gainey still lives, but Sanders moved to Atlanta in 1981. That distance made it easier to play his
health concerns close to the vest. Gainey surprised him by being at the hospital less than 48 hours after he was admitted, thanks to a phone call from his son. She was struck by the number of machines in the room when she first arrived. “We went through some terrible moments, but he came back up and he persevered and was determined,” she says. “He always says this was his second birth, and that he’d do everything he could to make sure he wouldn’t leave me.”
Originally, Sanders hadn’t been forthcoming with his fiancée either. But Ward kept bringing food and checking in—after 28 years of friendship, she knew something was wrong. “Bernie is magnificent. I don’t know how I almost let her get away, but I’m holding on tight this time,” he says.
After the transplant, Gainey and Ward worked together to help Sanders. A support system is so critical to patient recovery that it’s one of the considerations for transplant eligibility.
Cardiac and pulmonary rehabilitation manager Meredith Hardie says one of her favorite
things about Emory Decatur Hospital’s cardiac rehabilitation program in the Wellness Center is that it allows families to get involved too.
Erin Hill, cardiac rehab RN, says rehab patients often come in with a fair amount of anxiety— and plenty of questions.
During his rehab intake, Sanders shared his concerns and goals with Hill, who walked him through his treatment plan. “He’s always positive when he comes in and receptive to what we have to say,” says Hill. “Organ transplant is a huge deal, and it involves frequent follow-ups and monthly biopsies, where patients have to return to the lab and have tests done to make sure there’s no organ rejection. There is also a huge number of medications they have to take, so the fact that he’s been able to maintain his positivity through all of it is incredible.”
Transplant patients have more restrictions around driving and heavy lifting, to let their sternums heal. And because transplanted hearts are not connected to the brain via nerves, heart transplant patients require
longer warm-up and cool-down periods, along with lower-intensity workouts.
Exercise physiologist Marcus Meadows has seen Sanders make significant progress. “Will was coming in with a completely different heart, trying to do anything to build himself back up,” Meadows says. “He was struggling to do three laps around the track, and his heart rate was really elevated—which is a normal response with a transplant. Now, he’s able to go six laps without shortness of breath.”
Cardiac output is closely monitored throughout rehab exercises so that potential problems can be stopped before they begin. Meadows says being able to look at reports with patients is essential to them feeling comfortable enough to exercise at home.
Originally challenged to walk around his car in the driveway, Sanders is now going to physical therapy, doing water aerobics, walking his dogs and traveling with friends. “The care team was phenomenal,” Gainey says. “The therapists couldn’t believe the energy he has, but
Sanders’ wife, Bernice, and sister, Vera Gainey (left with Sanders) worked together after his transplant to support Sanders—a huge factor in organ transplant success.
it’s really because of all the love he’s gotten from them throughout this process.”
Because patients go to cardiac rehab up to three times per week for two to four months, they develop deeply personal relationships with the providers. But the connection between Meadows and Sanders ran deeper than most. “Will brought up to me that I met him when I was about 5 years old,” Meadows says. Turns out, Sanders had worked with Meadows’ father in the Atlanta Police Department. “Once I told him my last name, he pieced it together and called my dad right on the spot,” Meadows laughs. “Having that connection with him and being able to help him through this process was really cool for me. It all comes full circle.”
Sanders is looking forward to volunteering at the hospital. “The level of care rendered to me here is second to none,” Sanders says. “It wasn’t only the doctors that made me feel good, but the nurses, therapists, custodians and beyond. You can’t put a price tag on that.” EHD
PHOTOS COURTESY WILLIAM SANDERS
‘So Scarlett Might Have a Better Future’
In 2019, two weeks after the birth of their daughter, Scarlett, the Alonzo family received a call from the state of Georgia’s newborn screening program.
The results of a blood test showed Scarlett had a rare deficiency in an enzyme that breaks down the amino acid arginine. Without changes in her diet, she could be expected to develop mobility problems, followed by a loss of developmental milestones and the ability to walk, and possibly seizures.
“We were very surprised—we almost didn’t believe it,” Scarlett’s father, Alonzo de Alonzo Peres, says. “Those were some very hard days.”
Soon after Scarlett’s birth, the Alonzos met with Emory medical geneticist Rossana Sanchez Russo, who specializes in metabolic disorders. She has evaluated most of the handful of children in Georgia with arginase deficiency, as well as some from neighboring states. Children with arginase deficiency tend to show symptoms starting around age 3, and some of her patients had spasticity.
The Alonzos also met with nutritionists at Emory’s Medical Nutrition Therapy for Prevention program, who provided them with medical information in Spanish since that is their household language. The family was instructed to provide Scarlett a special low-protein diet, along with nutritional supplements. “Prompt intervention can really make a difference in preventing unfavorable outcomes,” Sanchez Russo says.
approved enzyme replacement therapy. Sanchez Russo asked the Alonzos to participate in a clinical trial testing a potential treatment. The Alonzos got up at 5:00 a.m. and drove Scarlett from Ellijay to Atlanta once a week to receive an infusion providing a stabilized form of the arginase enzyme.
“We did it so Scarlett might have a better future,” says her mother, Magdalena Alonzo. “But also to help other children with this condition.”
Ensuring that people from diverse backgrounds join clinical trials is important for health equity, Sanchez Russo says.
At 2, Scarlett was the youngest participant in the study, which took place in the US and several European countries. The double-blind period, during which the family didn’t know whether Scarlett was receiving active enzyme or a placebo, lasted for 24 weeks. The study was eventually “unblinded” and the family learned she had been receiving active enzyme. So far, Scarlett doesn’t have the neurological symptoms typical for children with arginase deficiency, but her father says sometimes she shows periods of fatigue and low appetite. She’s also shown no excess ammonia in her blood, a complication that can require hospitalization.
Scarlett now attends pre-K in Ellijay, where the school’s staff is supportive of her special diet. She will say that a food has “too much protein” if she’s offered something she’s not supposed to eat.
Arginase deficiency is one of the rarer metabolic diseases. In some ways, it resembles phenylketonuria, where infants lack an enzyme that breaks down another amino acid, phenylalanine, and parents also are advised to modify their child’s diet, with the aim of preventing future complications.
But with arginase deficiency, symptoms may progress despite a restricted diet—and there is no
The study testing the experimental therapy was published in January, with Sanchez Russo as lead author. It showed the stabilized enzyme could control excess arginine levels in participants’ blood. Based on this, the treatment was approved in Europe. But in the US, the FDA has asked the manufacturer for more data on patients’ mobility outcomes. The company that makes the arginase enzyme is reapplying to the FDA. – Quinn Eastman
PHOTO COURTESY ALONZO FAMILY
In a Pickle?
Sports medicine physicians say players should embrace the fun, yet know how to stay safe playing pickleball
Pickleball is the fastest-growing sport in the country, with more than 36.5 million players, or “picklers,” according to the Association of Pickleball Players Pickleball Participation Report (try saying that three times fast).
Hundreds of newbies each month are picking up oversized ping-pong racquets, throwing on shorts and t-shirts, and facing off on pickleball courts sprouting forth like spring crocuses—whether at neighborhood swim and tennis clubs, dedicated pickleball facilities, or public parks.
A pickleball court is smaller than a tennis court—and, indeed, pickleball lines are sometimes painted on a court in addition to tennis lines for double duty. Some players even create their own courts with chalk or painter’s tape. The net is slightly lower, and a no-volley zone extends back from each side of the net called “the kitchen.” You serve underhand, and don’t get a second attempt if your serve goes out.
Played with perforated plastic balls (think wiffleballs) and wooden or composite paddles, pickleball is easy to learn, fast-paced, social, and good for your overall health. Studies have found picklers average a heart rate of 109 beats per minute and burn an average of 354 calories per hour: a mod-
BY MARY LOFTUS • ILLUSTRATION BY JOSIE PORTILLO
erately intense workout similar to yoga or water aerobics. Players can see improvements in cholesterol levels, blood pressure, and oxygen uptake if they play regularly.
A dog named Pickles?
Sometimes described as an amalgam of tennis, ping-pong, and badminton, pickleball was invented by a trio of dads on Bainbridge Island in 1965, after a golf outing. They were looking for a game their whole family could play together, according to USA Pickleball, so Washington State Representative Joel Pritchard, business executive Bill Bell, and entrepreneur Barney McCallum invented a game to play on an old badminton court with ping-pong paddles and a perforated ball.
As for the name, the story is that the Pritchard family dog, Pickles, kept chasing after the ball and taking it into the bushes. An alternative version suggests the name was inspired by a rowing term, “pickle boat,” which means a boat made up of spare or borrowed oarsmen from other crews. Pritchard’s wife, Joan, who was a competitive rower, thought that “pickleball” was an appropriate name because the game borrowed from other sports. (This may be
the actual story, since Pickle the dog seems to have joined the family AFTER the invention of the sport.)
The consensus is that pickleball caught on because it is easy to learn, fast-paced, social, informal and fun. You don’t need fancy equipment (although some racquets can cost upward of $300, a decent one can be had for $29), balls can be used again and again, and dress is comfortable and casual. Also, it’s good for your health.
“Racquet sports are among the healthiest sports there are,” says Neeru Jayanthi, a sports medicine physician and associate professor of orthopedics. “Large studies show a 56 percent risk reduction in cardiovascular events, and people who play raquet sports live almost nine years longer, on average. It’s not only the physical benefits, but also the social.”
Jayanthi, who leads Emory’s tennis medicine program, played and competed in tennis for 40 years before ever picking up a pickleball paddle. Now, he thoroughly enjoys the sport.
“My wife and I play with our neighborhood league, and we’re having a blast,” he says. “It’s a social outlet that involves an activity. There’s not as steep a learning curve as tennis, and the whole family can get involved. Tennis and pickleball can coexist.”
Indeed, while pickleball players have tended to come from an older demographic, that’s evolving as the sport’s popularity grows. In fact, players in the age group 18 to 34 now make up the largest percentage of pickleball players. “The landscape is changing,” Jayanthi says. “Pickleball is for younger athletic people too, and can be quite competitive. Students are playing it in high school, and there are college scholarships available.”
Play at Your Own Risk
Pickleball injury data show injuries tied to the sport among players 60 and older have been rapidly increasing for years, becoming an “important cause of injury” for seniors.
Lee Kneer, a sports medicine physician and assistant professor of orthopedics and physical medicine and rehabilitation at Emory, says he has played pickleball and understands its attraction. “It’s fun, fast, and social. But it can also lead to fairly catastrophic injuries,” says Kneer. “These are not three-day recovery kind of injuries. I am treating Achilles tendon ruptures, ankle fractures, knee
ligament and meniscus tears, disc herniations in the back, clavicle (collarbone) fractures, wrist fractures.”
The most common pickleball injuries reported nationally are strains and sprains, then fractures and contusions. More specifically, sprained wrists and ankles, damage to the anterior cruciate ligament (ACL), rotator cuff injuries, meniscus tears, and Achilles tendon tears/strains.
“There’s not a lot of pickleball injury distribution studies or rates yet,” says Jayanthi. “We did adult studies over one year for tennis players… and about half had some type of injury, pain, or mechanism that kept them from playing for 3 to 7 days. I would suspect adult pickleball players would have about the same injury rates.”
Body parts most frequently injured were wrists, lower legs/ankles, heads, and lower trunks. Other injuries involved the knees, shoulders, fin-
gers, and faces (65-year-old Michelle Pfeiffer recently posted a photo of a black eye she received from the sport on her social media, warning “Stay out of the kitchen!”).
Senior males were more likely to suffer a pickleball-related strain or sprain, whereas senior women were more likely to suffer a fracture, especially of the wrist and hand. Bone fractures related to pickleball have increased dramatically over the past few decades, with most occurring in adults ages 60 to 69 during a fall, according to a recent study by the American Academy of Orthopaedic Surgeons.
Young players receive injuries as well. One injury you see more often among young competitive players? Eye injuries. Some professional picklers have taken to wearing safety goggles due to fast-paced play in the kitchen. Injuries occur with any sport, say the doctors, and racquet
Sports medicine physician Neeru Jayanthi (above) and his family play pickleball on their neighborhood courts. “Racquet sports are among the healthiest sports there are,” he says.
Lee Kneer, Emory sports medicine physician
PHOTO JACK KEARSE
sports are no exception. “You do see a lot of the same injuries as in tennis, but for different reasons,” says Jayanthi. “The smaller court size and underarm serving in pickleball mean less impact on your legs and shoulders. But pickleball, by its nature, involves more elbow and wrist motion, and there’s rapid directional changes and a lot of forward and back movements in a short space. You’re taking quick, little steps, whereas bigger steps are more stable.”
Kneer says friendly pickleball games tend to be safer than highly competitive games with a lot of diving for balls and darting back and forth. “When playing a fast-twitch sport, you’re exposing yourself to more chance of injury,” he says, with those chances increasing as you get older. “The elasticity in your bodily structures decreases over time.”
Pickleball Elbow?
For an active GenXer who welcomed another way to stay physically fit, a pickleball injury was a surprising blow. “Our friends
asked my husband and me to play on some city courts nearby,” says Jaye Watson, 54, co-executive producer and host of Your Fantastic Mind on PBS with Emory Brain Health. “We met at 9:00 a.m. and had a ball. I had been kind of judgmental about pickleball previously. It has a silly name and I thought it was an ‘old people’s’ sport. But that morning was the hardest I had laughed all year.”
Watson walked regularly—an hour every morning—as well as doing yoga, Pelaton, and weightlifting.
But pickleball added a social element she had missed. “As adults, we don’t really play games for fun anymore,” she says. “Pickleball was so fun we never even kept score. We played once a week for about a month.”
Then she and her husband discovered the YMCA had new pickleball courts. They played singles and got competitive with a lot of cross-court action. “We played three days in a row and at the end of the third day, I noticed my elbow hurt,” she says.
Her health saga has lasted nearly a year. Thinking it was a muscle strain, Watson iced and took Advil. But after a month, when the pain hadn’t subsided, she went to a sports medicine doctor who said it could be tennis elbow. “From playing pickleball seven times?” she asked. This was followed by three months of physical therapy and an MRI, which showed a partial tear of the extensor tendon.
“It’s been so humbling that I’m not invincible,” says Watson. “I’m still having pain in my elbow. I’m back to walking but, sadly, I don’t think I will ever play pickleball again.”
Risk Benefit Analysis
Kneer recommends focusing on foundational exercises that maintain or increase your body’s flexibility, strength, and stability, then “treating yourself with whatever gives your exercise life fulfillment. Pickleball shouldn’t be your primary or only form of exercise.”
Ultimately, Jayanthi believes the benefits of racquet sports counterbalance the risks. “The chance of an injury is always there for anyone engaged in physical activity, especially if someone is older and was not athletic previously,” he says. “But the social and health benefits, as well as living longer, clearly outweigh those additional risks.” EHD
Jaye Watson, Emory Brain Health producer/host of Your Fantastic Mind, sustained a pickleball injury.
PHOTO COURTESY JAYE WATSON
Reduce Your Chance of Injury
• Warm up before playing, by following a warm-up regimen developed by experts specifically for racquet sports (SEE TOP 10 LIST, attached to cover).
• Choose the correct shoe, with the proper construction to handle the lateral, side-to-side motions. Tennis shoes work but not old running shoes.
• Keep a wide stance while receiving during the game and avoid “backpedaling” to return an overhead shot.
• Learn to fall in a way that’s less likely to lead to injury. If you fall toward your side, going into a gentle roll, you can protect your head while not putting your wrists at risk.
• Pace yourself. If you play too often or maintain a high-intensity level, you will increase your injury risk. Start by playing once a week and assess how you feel after a few weeks. Then you can decide whether more or less pickleball makes sense for you.
• Return gradually. If you do get injured, return to play slowly. Test your limits and endurance.
• Improve flexibility and strength. Consider working out with a personal trainer or at a local gym to improve muscle strength, flexibility, and balance.
• Wear protective eyewear if you are so inclined or are playing at levels high enough for rapid back and forth drives at the net.
• Practice standing on one foot then the other, while brushing your teeth or in line at the grocery store, to improve balance.
While still a tennis enthusiast, Jayanthi has added pickleball to his sports regimen. “Tennis and pickleball can coexist,” he says.
PHOTO JACK KEARSE
New research shows how the microorganisms we live with –in our gut and elsewhere – are important to our health in countless ways
THE MIGHTY MICROBIOME
BY TONY VAN WITSEN • ILLUSTRATIONS BY KEN ORVIDAS
Irene Yang was a health researcher who wanted to know why people smoked. Maya Nadimpalli was a chemist concerned about environmental justice. Jinbing Bai was a nurse researcher in China who witnessed the suffering of children undergoing treatment for cancer. It might be only a coincidence that these different concerns led all three Emory researchers to their present involvement with the human microbiome—or it might also have something to do with the recent enhanced, near-superstar status of the microbiome in human health.
“I knew nothing about the microbiome before I came here,” says Yang, assistant professor in the Nell Hodgson Woodruff School of Nursing.
“When I came to Emory and I found out about the microbiome, I realized there was a connection between oral health and the rest of our body.”
That connection by itself is no secret. Researchers have known for decades that the human body harbors literally trillions of one-celled organisms in the intestine, the nose, the mouth, the skin and other body cavities. For the most part, it’s a peaceful coexistence.
Microbiota help us digest food, keep the immune system going, and help synthesize vitamins and amino acids. Occasionally, infectious diseases can disturb that healthy
balance. The microbiome’s transition from a supporting role to the limelight began just a few years ago, when powerful new gene–sequencing tools and advances in computing made it possible to track the different makeup of whole colonies of microbes in individuals as well as to determine the exact genome of each microbe species. For the first time, it was possible to catalog the whole spectrum of bacteria living on and inside the body.
“It just kind of blew open the field,” Yang says.
Researchers at Emory had joined the explosion of research that followed when the NIH created the Human Microbiome Project in 2007. Changes in microbiota could be linked to other changes in the body
Irene Yang, assistant professor in the School of Nursing
Maya Nadimpalli, assistant professor in the Rollins School of Public Health
Jinbing Bai, assistant professor in the School of Nursing
including antimicrobial resistance, cognitive impairment, bone health, premature births, even psychological stress. In 2018, the Rollins School of Public Health received a $3.5 million grant to study gut microbiome conditions among young children in Ecuador.
That research—which is still in progress—aims to find out whether more diverse gut microbiomes lead to kids with fewer intestinal infections acquired from their environment. Last fall, as part of an outpouring of new research, the NIH’s National Institute of Neurological Disorders and Stroke awarded a $3.9 million grant to the Nell Hodgson Woodruff School of Nursing to study how the oral microbiome contributes to risk of Alzheimer’s disease.
Yang (above, right), principal investigator on that project, says
oral bacteria have been found postmortem in the brain, leading to the theory that microorganisms from one part of the body can travel through the blood and cause trouble in other parts.
Another theory, which she’s investigating, is that microorganisms can send chemical mediators that cause reactions in another part of the body including the brain.
“Does a local infection influence neuroinflammation and does that contribute to Alzheimer’s disease risk?” she asks. “That’s the theoretical basis of my current study.”
Yang completed a study showing people with mild cognitive impairment have subtle differences in their oral microbiome, which she thinks is a clue. Her new project will spend three years following people whose family history puts them at high risk for Alzheimer’s, seeking links between cognitive impairment and the makeup of the oral microbiome.
“What we hypothesize,” she says, “is that even if we don’t see big cognitive changes in this population, a certain group of them are going to be moving closer toward Alzheimer’s disease. We’re hoping to see a relationship between the oral microbiome, local inflammation, systemic and neural inflammation, and Alzheimer’s disease risk.”
Current research is broadly divided between two approaches. One looks for correlations to determine whether changes in the body are associated with changes in the makeup of the microbiome, both in the kinds of organisms present and their relative abundance. Other researchers are moving beyond associations to a search for the underlying biochemical processes—the ways the different microscopic bugs impact the body. Not just the correlation, in other words, but the cause.
Endocrinologist Roberto Pacifici studies how the microbiome contributes to bone formation, such as fracture repair. He began his work studying how estrogen prevents osteoporosis and why women tend to get osteoporosis after menopause. “We discovered many years ago that the immune system was involved in the process,” says Pacifici, the Garland Herndon Professor and director of the Division of Endocrinology, Metabolism and Lipids at Emory School of Medicine.
He began by searching for a special form of white blood cells activated by estrogen deficiency, which he theorized were in the bone marrow. Then it became clear the cells actually live in the gut. “We decided if they live in the gut and were known to be regulated by the microbiome,” he says, “there must be a connection between the microbiome and postmenopausal bone loss.”
Pacifici and his frequent collaborator, Rheinallt Jones, use a dedicated Emory facility—the Gnotobiotic Animal Core—that houses germ-free mice; lab animals that, as Jones puts it, have
PHOTO BRYAN MELTZ
never seen a microbe in their lives. “That’s a state that’s never existed in history,” says Jones, director of the facility and associate professor of pediatrics. “You can take germ-free mice and colonize that germ-free mouse with a known microbiome.”
By introducing specific bugs into the gut of a germ-free mouse, researchers can compare the effects of that particular colony to the effects of genetically identical mice from the same litter that have a normal microbiome of 500 to 700 different microbes. This technique allowed them to track the way individual microbes produce specific metabolites, small molecules that emerge when food is converted to energy. One of these, butyrate, sets off a chain of successive molecular processes that ultimately result in more bone formation. Jones and Pacifici call it “the gut-bone axis.”
Jones and his collaborators discovered that multiple types of bacteria produce another metabolite, delta valerobetaine, which blocks the synthesis of carnitine, a substance essential to the body’s energy production. When that happens, by-products wind up stored as fat in the liver. Understanding more about this process might lead to ways to manage the microbiome’s role in obesity.
“We took germ-free mice,” Jones explains. “We either gave them a regular diet, a control diet, or a high-fat diet, a Western-style diet. Some of the mice we gave valerobetaine to. Germfree mice don’t gain much weight. But when we give them the Western style diet and the valerobetaine, there was dramatic weight gain.”
Jones suspects there’s an evolutionary reason why the gut bacteria have such an important role in fat storage. “Homo sapiens evolved on the plains of Africa, when you only ate perhaps once every three days,” he
says. “Storing fat might be a function that you needed to survive. So we’ve evolved this small molecule because of the scarcity of food during most of our evolution.”
Jones (below) and Pacifici expect to discover other microbes producing metabolites with equally powerful effects. Butyrate, says Pacifici, was just “low-hanging fruit.” More immediately, they recognize that some components of the gut-bone axis could be developed into a clinical target for people with bone loss. “Women with osteoporosis tend to have a different
microbiome than women without osteoporosis,” Pacifici says. “And there are definitely people that have a microbiome that tends to be more pro-inflammatory who tend to have more bone loss.”
Elsewhere at Emory, new discoveries about the role of the microbiome are sometimes running ahead of the explanations for them. Maya Nadimpalli, assistant professor in the Rollins
PHOTO JACK KEARSE
School of Public Health, found that children who were breastfed had a lower chance of having microbes that were resistant to antibiotics. That’s an especially important finding for kids in developing countries.
“I started thinking about the role of breastfeeding after investigating an outbreak of highly drug-resistant Klebsiella pneumoniae that affected neonatal intensive care units on an island,” she says. “The children died in the most horrific ways you could imagine. I thought, what is a mom supposed to do in that situation?”
Nadimpalli partnered with researchers in Peru to monitor breast feedings in children up to 16 months while examining their fecal samples for microbes that were resistant to major antibiotics. While exclusive breastfeeding had no effect for the first six months, every additional three days of breastfeeding after that was associated with a 6 percent lower risk of children harboring E. coli resistant to key antibiotics.
“When we talk about antibiotic resistance in low- and middle-income countries, we’re often thinking about big-picture infrastructure projects,” she adds. “We need to improve sanitation, we need to improve water, we need to improve hospital infection control. Big ticket items. So then I started thinking, could promoting breastfeeding be a way to help protect kids from drug-resistant bacteria in their environment?”
It’s important to focus on breastfeeding, Nadimpallli says, because baby formula manufacturers are increasingly marketing to low- and middle-income countries. “You have aggressive marketing of formula in settings where people don’t have access to clean water, where antibiotic resistance is already rising,” she says. “To understand whether breastfeed-
ing could be protective, it’s important to have that research done.”
Jinbing Bai learned about the microbiome as a nurse researcher in cancer care. “A lot of times for children, their pain response or cognition has not been fully developed yet,” says Bai, assistant professor in the Nell Hodgson Woodruff School of Nursing. “Take a needle-related procedure. You can see how stressful and painful that is for kids. Children are always struggling, crying. That’s a very normal reaction. It’s important to study this population.”
Previous research and his own experience had shown Bai how children receiving chemotherapy for cancer frequently suffered not only pain but also fatigue, anxiety and depression. Perhaps these forms of stress had a link to the microbiome.
Seeking answers, he collected and analyzed gut microbiome samples and their metabolites from teenage patients at Children’s Healthcare of Atlanta, then compared their microbiota to those of healthy children. The cancer patients not only reported more psychological stress, particularly fatigue and cognitive dysfunction, but also had lower levels of gut microbes and more metabolites. This led him to suspect that the gut microbiome—and the metabolites produced—influence stress levels. Bai thinks the gut-brain axis actually works both ways. “It’s a bidirectional communication network,” he says. “A lot of times when the patient’s starting chemo treatment, that’s going to bother the bugs. And the bugs are going to change their brain. But the other thing is that, if you have more brain-related stress, that can be communicated back to the gut as well.” EHD
Gut HEALTH
Most experts agree that healthy microbiota are diverse, with lots of different species. This keeps pathogenic species such as C. difficile, the microbe that causes diarrhea and colitis,
from dominating. There’s less agreement on exactly which species are the best and in what proportions, or how this might differ among individuals or age groups.
SO WHAT CAN YOU DO TO HAVE healthy microbiota?
Avoid antibiotics where possible. They may be effective for specific illnesses but play havoc with your gut bacteria.
Probiotics (diet supplements containing live microbes) and prebiotics (foods that support microbiome health) are widely considered good for digestion. But be cautious. Commercial probiotics make a wide variety of health claims, but probiotics are considered supplements, not drugs, and are not regulated by the U. S. Food and Drug Administration.
“The specific type of probiotic to take for what conditions, we are not there yet,” says Pacifici. “At the end of the day, we have learned from mice that what matters is the absolute number of bacterial cells.”
Eat lots of fruits and vegetables. Foods that are naturally prebiotic include garlic, onions, leeks, asparagus, Jerusalem artichokes, dandelion greens, bananas, and seaweed. Fruits, green leafy vegetables, beans, and whole grains also contain the prebiotic fibers your gut bugs crave.
lurk in processed foods like peanut butter, smoothies, even salad dressings. “People seem to do better when they eat natural foods, non-processed foods,” says Jones. “There’s a big difference in microbiome diversity.” Instead, eat more complex sugars from foods such as honey, dark chocolate, coconut, whole grain, apples, berries, bananas, mangoes and sweet potatoes.
ecosystem will get out of balance, and clusters of more pathogenic organisms will collect and build up and contribute to disease.”
Reduce alcohol intake. Studies show alcohol can promote microbiome dysfunction.
Get a good night’s sleep—at least eight hours. Recent research found an association between less sleep and less microbiome diversity.
Manage stress. Studies have shown there’s a link between stress-producing conditions and afflictions that can change the balance of gut species.
Other prebiotic foods that can benefit the microbiome include kefir, yogurt with live active cultures, tempeh, kombucha tea or anything pickled, such as kimchi, miso, and sauerkraut.
Eat less of the wrong kind of food. Cut down on simple sugars that
Avoid eating high amounts of red meat, which seems to have a complex relationship with the gut microbiome.
Develop a good oral hygiene regimen. “The biofilm in our mouth is constantly building up, so clear it out daily and get regular cleanings,” says Yang. “If you don’t clear that away, there’s a good chance the
Get regular exercise. The microbiomes of more physically active people are more diverse.
Breastfeed. Babies who have been breastfed show a more diverse microbiome than babies who have been formula fed.
Drink enough water, which can help increase the proportion of good bacteria to bad bacteria. The recommended amount is enough ounces of water to equal half your amount of pounds in body weight (ex., if you are 160 pounds, about 80 ounces of water daily).
PHOTO JACK KEARSE
Connecting the Dots on Maternal Mortality
By Jasmine Clark 13G
IN MAY 2018, AFTER HAVING SOME PAIN WHILE BREATHING, I went to the emergency room and found I had blood clots in my lungs, a pulmonary embolism. It was completely unexpected, and after much testing, doctors were unsure where it came from. I am a mother of two who does not plan to have more children, but should I change my mind, I have a very real fear of how this previous, seemingly random clotting issue might manifest in a pregnancy. Especially since embolism is one of the leading causes of maternal mortality in the United States.
The US, in comparison to other “wealthy” countries, has a staggeringly high maternal mortality rate. A lot of effort has gone into trying to understand why people in America die from pregnancy-related deaths more often than in similar countries. Primary causes of maternal mortality include hemorrhage, mental health conditions, cardiomyopathy, cardiovascular and coronary conditions, embolism, and preeclampsia and eclampsia. If our country is going to lower its abysmal maternal mortality rate, we must use all options at our disposal. Most recommendations for addressing maternal mortality focus on provider and hospital protocols, patient education, and lifestyle modifications, such as proper nutrition and exercise. But many of these recommendations do not acknowledge systemic barriers beyond the health care system.
In the state of Georgia, for example, one glaring issue is the lack of access to obstetric care in many counties, with 82 counties lacking even one OB/GYN. This scarcity forces pregnant individuals to travel long distances for essential care, posing financial and logistical challenges, particularly for those with low incomes, no transportation, or without paid sick leave.
ILLUSTRATION
SANDRA
DIONISI
Policymakers like myself must adopt holistic approaches that address these systemic inequalities and empower all mothers to access the care and support they need to thrive.”
—Jasmine Clark, Georgia state legislator
While I have access to multiple options for obstetric care within a 15-minute drive from my home or workplace, many people in other parts of my state would have to drive more than half an hour to get to the doctor. Additionally, I have the type of job where if I need to go to a doctor’s appointment, I will still be paid for the day. In contrast, there are people who must choose between getting paid or driving over half an hour, one way, to go to the doctor. Even if they are experiencing symptoms that might be life threatening, they may prioritize work so as not to lose income. Not seeking proper or timely care may not be the result of a lack of education about risk factors, but instead the consequence of socioeconomic disparities that exist in so many communities.
These consequences can be exacerbated by the lack of access to affordable, nutritious foods. As chronic conditions like hypertension are a major contributor to maternal mortality in America, the link to diet cannot be ignored. All around the country are “food deserts,” where food options are scarce and usually consist of high-sodium, processed foods. Managing hypertension is difficult in places where there is a lack of fresh fruits and vegetables, and
the main “grocery” store is a Dollar General or a convenience store at a gas station.
And even if they have access to healthy foods, some families are unable to afford the healthier food choices. Policies promoting access to fresh and nutritious food in underserved areas, along with policies that increase access to SNAP (Supplemental Nutrition Assistance Program) and TANF (Temporary Assistance for Needy Families) could make more nutritious foods, which often carry a higher price tag than less healthy, processed foods, more attainable for families in need, which can mitigate the impact of food scarcity on common causes of maternal death, like hypertension.
Ultimately, if I were to decide to have another child, my medical history of blood clots would give me significant pause. I, however, have several advantages at my disposal, such as nearby health care facilities, health insurance, paid sick leave, several choices of grocery stores for fresh foods, and the financial means to afford them.
Despite all of these advantages, there is no guarantee that, if I were to get pregnant, it would be uneventful. Even welloff celebrities like Serena Williams have had life-threatening
issues during their pregnancies. Pregnancy is a time of anticipation, but also apprehension and anxiety. No expectant mother is 100–percent confident she and her baby will be fine.
But there is significant evidence that systemic inequalities and socioeconomic barriers are underlying contributing factors to maternal mortality. To truly address this urgent public health issue, policymakers like myself must adopt holistic approaches that address these systemic inequalities and empower all mothers to access the care and support they need to thrive.
Only then can we envision a future where maternal mortality rates in our country are no longer a cause for alarm, but a testament to our commitment to maternal health and well-being.
Jasmine Clark, PhD, is a senior clinical instructor at the Nell Hodgson Woodruff School of Nursing and State Representative of Georgia’s House District 108.
BEYOND GENEROSITY.
“The gifts my late father, Joey Mayson, made to Emory are remarkable. His generous financial endowment is funding ongoing Parkinson’s disease studies. And, by donating his brain to research after he passed, he is helping find a cure.”
Caroline Irvine
FIDUCIARY OFFICER | PENDLETON SQUARE
“Joey Mayson was a wonderful man who wanted to support our work in Parkinson’s research. His endowment will help develop treatments for these degenerative diseases and improve our patients’ lives.”
Stewart Factor, PhD
PROFESSOR OF NEUROLOGY | DIRECTOR OF THE MOVEMENT DISORDERS PROGRAM
VANCE LANIER CHAIR OF NEUROLOGY | EMORY UNIVERSITY SCHOOL OF MEDICINE
FACULTY CONVERSATIONS
Faculty Conversations is a video series in which diverse leaders across the Woodruff Health Sciences Center and Emory Healthcare join Emory’s Executive Vice President for Health Affairs Ravi Thadhani to discuss nimble decision-making, caregiver well-being, educating and training the next generation, research breakthroughs, transformative technology, and other topics that showcase Emory’s leadership and expertise in academic medicine.
Foodie Pharmacology Podcast
Ever wondered where your food comes from? Not just where it’s grown today, but where it originally popped up in the world?
Have you ever bit into a delicious ripe fruit and wondered, hey—why is it this color? What’s responsible for this amazing flavor? Is this good for my health? Could it even be medicinal?
Foodie Pharmacology is a science podcast built for the food curious, flavor connoisseurs, chefs, science geeks, plant lovers and adventurous taste experimenters of the world. Join Emory ethnobotanist Cassandra Quave on an adventure through history, medicine, cuisine and molecules as the amazing pharmacology of our foods is explored.
Your Fantastic Mind
Seasons 4 and 5
This Emmy-award-winning series, a partnership between Emory Brain Health and Georgia Public Broadcasting/PBS, has entered its fifth season. Past episodes have explored adolescent mental health, brain science in cows, tremor treatment, psychedelics, thrill seeking, menopause, and other topics that offer a fascinating glimpse inside the way our brain works. To stream full episodes, please visit the Your Fantastic Mind website.
HELPING HANDS abounded when Emory nursing students spent their spring break on an immersion service trip to the Dominican Republic. | 3
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