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In the Loop
Issue 257 - November 18, 2020

Benign Paroxysmal Positional Vertigo (BPPV) 

Vertigo is a condition where you experience a dizzying sensation when you turn your head and the world starts to spin. The UK National Health Service explains that it is “more than just feeling dizzy.” Losing your equilibrium puts you at risk of falls and fractures. While vertigo is not life threatening or considered a serious health problem, it can interfere with one’s quality of life.  BPPV, an inner-ear condition/disorder, stands for benign paroxysmal positional vertigo. Benign means that it is not life threatening, although it can disrupt one’s quality of life and have intense symptoms. Paroxysmal means that it comes in sudden short spells. Positional means that certain head positions or movements can trigger a spell. Vertigo is the feeling that you are spinning or moving or that the world is spinning around you. Often the vertigo comes under the umbrella term “dizziness” accounting for an over 3 million emergency department visits every year. One study found that at least 20 percent of patients complain of vertigo during a clinic appointment.

BPPV is fairly common and is the most common cause of vertigo, with an estimated incidence of 107 cases per 100,000 per year. Up to 10 percent of adults will be affected by BPPV by the time they reach 80 years of age. Other causes of vertigo include Meniere’s disease (inner ear disorder with the build up of fluid and changing pressure in the ear), labyrinthitis (caused by an infection in the ear that is usually a virus), injury of the head or neck, brain problems such as a stroke or tumour, medications that can cause damage to the ear, and migraine headaches. According to Palmeri & Kumar (2020), it is very important to identify BPPV versus other causes of vertigo as there is a spectrum of disease processes that range from non-life threatening to life-threatening.

What happens?
The brain uses different systems to maintain a sense of balance and orientation to surroundings. They include the visual system (important part of the system that often overrides information from the other systems), sensory system (in your joints to allow your brain to keep track of the position of your body parts to make tiny adjustments to maintain balance), and the vestibular system or inner ear (structures that function like a carpenter’s level).   

BPPV has to do with the vestibular system. The system has three semicircular canals filled with fluid and sensory hair cells that tell the brain about the head’s position. Signals are sent to the brain about head and body movements relative to gravity. Otoliths (calcium carbonate crystals) sit in a gel-like substance. The role of these crystals, according to the Berkeley Wellness Letter, is to “help sense your body’s orientation to gravity as you move.”

Problems arise when the otoliths are dislodged by injury, age, or other factors. They end up floating in the canals so that when you move your head, the crystals can bump into the sensory hair cells resulting in a false sensation of movement.

Symptoms
According to HealthLink BC, the main symptom is the feeling of spinning or tilting. This experience of movement may occur when you move your head in a certain way e.g., bending over, turning your head quickly or when you turn over or sit up in bed. Other words used to describe the experience include swaying, unbalanced, and pulled in one direction. Symptoms come on suddenly, are intense for seconds to minutes, are triggered by movement and decrease with rest. Everyone will experience symptoms differently. Symptom intensity is linked to how long it takes for the crystals to settle down after a change or movement of the head or body position. In more severe cases, individuals may experience symptoms such as nausea/vomiting, headache, and sweating. The experience for adults over 70 years of age may be a feeling of being off-balance rather than feeling dizzy. Standing or walking may be challenging because you can lose your balance. BPPV has also been associated with depression.

The American Academy of Neurologic Physical Therapy (AANPT) advises people to contact their health care provider immediately if they experience vertigo accompanied by double vision, difficulty speaking, a change in alertness, arm or leg weakness or if they are unable to walk.  

Frequency of attacks
People often say that the first attack is the worst and subsequent attacks are less severe. Johns Hopkins Medicine reports that many people with BPPV can feel a low level of unsteadiness between repeated attacks. Episodes of BPPV last 1 to 2 minutes and can come and go but several dizzy spells can be experienced over a two week period. BPPV will usually go away on its own in a few weeks.

Cause
In most cases the cause is not known. The cause of BPPV is not always clear in people over 50. When a cause is not known, it is called idiopathic BPPV. In some cases it can be related to aging. In the case of aging, the Berkeley Wellness Letter reports that probably degeneration over time wears down and loosens the crystals. More women than men have BPPV with a ratio of female to male of 3 to 1.  While it can affect people of all ages, it is most common in people over the age of 60. An attack can be brought on by mild to severe head trauma, keeping the head in the same position for a long time e.g., at the dentist office, bike riding on rough terrain, doing high intensity aerobics or having other inner ear disease. It can also be associated with diabetes and osteoporosis, according to a 2017 article by Neil Bhattacharyya, MD and colleagues.

Getting a diagnosis
Palmeri & Kumar report that BPPV is often misdiagnosed and encourage health care providers to be aware of this disorder and its management. The National Health Service reports that vertigo gets better in most cases without treatment, but if it affects your quality of life and keeps coming back, it is time to see a doctor. A sign of BPPV is nystagmus. This is when your eyes will have rapid, involuntary back and forth movements which a doctor will see when you are asked to turn your head and then lie on your side (this is called the Dix-Hallpike maneuver).

How to help your doctor make a diagnosis
The Berkeley Wellness Letter lists tips from the Vestibular Disorders Association to help you determine the cause of vertigo and an early diagnosis.
  • Share information with your doctor e.g., list all over-the-counter and supplements taken, medical history, family medical history, type of symptoms and when they occurred, what makes symptoms better/worse. Also indicate if you have had any blows to the head, even if it was a minor accident or injury. 
  • For a second opinion, you may be referred to a specialist such as ear, nose and throat (ENT) specialist or a neurologist (doctor who specializes in the brain and nervous system).
  • Ask questions if you do not understand anything and advocate for yourself if you are concerned about falling.
Treating Vertigo
The aim of treatment is to treat the underlying cause if known, relieve symptoms and help with recovery. The Mayo Clinic states that there is no cure for BPPV, but the condition can be managed with physical therapy and home treatments. The good news is that BPPV is the easiest type of vertigo to treat. The first line of treatment is the Epley maneuver unless a person has a neck or spinal injury or condition, certain vascular disorders, or a detached retina. The Harvard Health Letter comments that research has found that the Epley maneuver is the most successful of these moves. Other movements, also known as repositioning procedures, include the Semont maneuver, Foster maneuver and Brandt-Daroff maneuver. The AANPT reports that the maneuvers work 80 to 90 percent the first time they are used.  Symptoms go away about 4 to 6 weeks after treatment.  

The Epley maneuver is a series of head and body movements to move the debris out of the canal i.e., shift the crystals out of the semicircular canals into an open area so they can dissolve. HealthLink BC reports that most people respond to this procedure or to the Semont maneuver. The Epley maneuver is repeated up to 5 or 6 times until the nystagmus goes away. This maneuver is not successful in all cases, and can cause negative side effects such as temporary nausea, vomiting and fainting. These repositioning maneuvers are done under the guidance of a doctor or physiotherapist, but the Mayo Clinic states that your doctor will likely teach you how to do the procedure yourself so you can do it at home if you need to, called “self-repositioning.” The American Academy of Otolaryngology - Head and Neck Surgery Foundation, however, advises individuals with severe disabling symptoms, older adults with a history of falls or a fear of falling, and individuals with mobility issues (e.g., joint stiffness especially in the neck or back and/or weakness) to not do these maneuvers on their own. 

Residual dizziness can linger for up to 3 weeks after the maneuvers. The American Academy of Otolaryngology - Head and Neck Surgery Foundation urge people to follow-up with their healthcare provider if symptoms continue. It may mean additional testing to confirm a diagnosis or to look at further treatment options.  

As mentioned above, an alternative to using maneuvers is to “wait it out” as there is evidence that if BPPV is left untreated, it can go away on its own within a few weeks. During this time, however, it is important to take measures to prevent falls.
Medicine may be taken for severe nausea/vomiting. According to Vestibular Disorders Association, although many people are given medication for BPPV, there is no evidence to support its use in treatment of this condition. The Physiopedia website reports that drug treatments are not presently recommended for BPPV and no medications exist that directly treat BPPV. Surgery is used rarely and when other treatments have failed to be effective.

Recurrence
BPPV is a condition that can re-occur from time to time with long-term recurrence rates of 15 percent at one year to as high as 50% within 5 years, especially if the BPPV is a result of trauma. According to Johns Hopkins Medicine, symptoms can last for years in rare cases.  Unfortunately, researchers have not yet figured out how to stop BPPV from coming back. Recurrence is higher in females, older patients and people who have psychiatric conditions.

For people who have repeated episodes of vertigo, WebMD indicates they may receive vestibular rehabilitation, a type of physical therapy that helps strengthen the vestibular system so that other senses can compensate for the vertigo.

Avoid falls
If you are having sudden episodes of vertigo, prevent accidents by avoiding driving, cycling, operating tools and machinery, and heights. Keep your environment clutter free to avoid falls.

Resources
  • Vestibular Disorder Association website 
  • Video by University of Pittsburgh Medical Center
Sources: HealthLink BC website, Johns Hopkins Medicine website, WebMD website, WebMD website, University of Michigan Medicine website, Mayo Clinic website, Harvard Health Blog website, Vestibular Disorder Association article,  Physiopedia website, American Academy of Otolaryngology - Head & Neck Surgery website, Berkeley Wellness Letter website, Otolaryngology–Head and Neck Surgery journal website, UptoDate website, UptoDate website, Academy of Neurologic Physical Therapy article
 


New 24-Hour Movement Guidelines for Adults 

The Canadian Society for Exercise Physiology (CSEP), the Public Health Agency of Canada, Queen’s University, ParticipACTION, and a network of researchers and stakeholders from across Canada have developed the first-ever 24-Hour Movement Guidelines for Adults. The message in a nutshell - move more, reduce sedentary time, and sleep well.

Guidelines are provided for adults aged 18 to 64 and 65 and older. They include recommendations on various types of physical activity along with guidance on sedentary and sleep. Unfortunately, COVID-19 has caused physical and mental stress. The new guidelines on sedentary behavior include:
  • Limit sedentary time to 8 hours or less
  • No more than 3 hours of recreational screen time per day
  • Break up long periods of sitting as often as possible
For sleep, the guideline is get 7 to 9 hours of good-quality sleep on a regular basis, with consistent bed and wake-up times.  

The Canadian 24-Hour Movement Guidelines are available by visiting the website csepguidelines.ca. The guidelines are also available on the ParticipACTION website, as well as resources and tips for adults to stay active.
 

 


Active Aging Canada Resource

ParticipACTION is telling Canadians that "everything gets better when you get active," from the ability to sleep better to heal better. Research has found that physical activity is a critical factor in maintaining the physical, mental, social and economic wellness of our aging population, allowing adults living in Canada to age better and maintain a high quality of life. During COVID-19, the non-profit organization Active Aging Canada reminds us that “keeping physical distancing from others does not mean that you still cannot be active.” The mission of Active Aging Canada is to support lifelong healthy active aging of adult Canadians through participation, education, research, and promotion. To support you to keep active at home during COVID-19, their website provides several resources including links to exercise videos and pamphlets. One feature is the Active Aging Minute video series, providing a new healthy tip in just one minute. They also have information for people with disabilities, limited mobility, and osteoporosis.   


Nearly Half of Dementia Cases Could Be Prevented or Delayed

Currently, about 50 million people around the world are living with dementia. By 2050, the number is estimated to reach 152 million. The increase will be more in low- and middle-income countries which currently make up 2/3 of people with dementia. Back in 2017, the Lancet Commission on Dementia Prevention, Intervention, and Care, made up of 28 world-leading dementia experts, listed 9 preventable risk factors for dementia. In 2020, this list was updated. Lon Schneider, MD, of the University of Southern California presented the updated risk factors at the 2020 Alzheimer's Association International Conference (AAIC) annual meeting, July 26 to 30, 2020. Back in 2017, Dr. Schneider stated, “We are learning that tactics to avoid dementia begin early and continue throughout life, so it’s never too early or too late to take action.” The 9 risk factors identified in 2017 included:
  • Having too little or no education - focus on providing all children with primary and secondary education as education to the age of 20 makes a difference
  • Hypertension (high blood pressure) - based on the SPRING MID trial, aiming for a target systolic blood pressure of 120 mm Hg reduced the risk of future mild cognitive impairment. Aim to maintain a systolic blood pressure of 180 mm Hg or less in midlife (around 40 years of age).
  • Untreated hearing impairment - encourage people to use hearing aids and reduce hearing loss from exposure to high noise levels. Lead author Gill Livingston, MD, professor, University College London, commented that hearing loss is something that we can reduce relatively easily by encouraging the use of hearing aids and this “could make a huge difference in reducing dementia cases in the future.”
  • Smoking - stop people from starting to smoke, support people to quit smoking (quitting was beneficial at any stage in life, even when older) and reduce exposure to smoke and second-hand smoke (a study found that  second-hand smoke exposure, found in 35% of nonsmoking adults, was associated with more memory deterioration)
  • Obesity - support people to manage their weight 
  • Depression
  • Physical inactivity - encourage people to be active in mid-life and possibly later life
  • Diabetes - the 2017 Lancet Commission report indicated that diabetes was associated with an increased risk of dementia and the risk increased with the duration (how long someone had diabetes) and severity (how bad the diabetes was). The action is to reduce the number of people with diabetes
  • Low social contact
In 2020, and based on sufficient evidence, the Lancet Commission report was updated by adding 3 more modifiable risk factors:
  • Head injuries (traumatic brain injuries or TBI) or excessive alcohol consumption in midlife - to prevent head injuries, the focus should be on people in high-risk occupations and transport. TBI significantly increases the risk of long-term dementia. With regard to alcohol, drinking should be limited to less than 21 units per week.
  • Air pollution exposure in later life - efforts need to be made to reduce exposure to air pollution
These three risk factors are associated with 6 percent of all dementia cases (3 percent for head injuries in mid-life, 1 percent to excessive alcohol consumption in midlife, and 2 percent to exposure to air pollution in later life). The risk factor contributing the most is hearing loss in mid-life, associated with 8 percent of dementia cases. By addressing these 12 risk factors, 40 percent of dementia cases could be prevented or delayed.
The biggest impact can be made in low and middle-income countries and people from vulnerable populations e.g., Black, Asian, and minority ethnic communities. Dr. Gill Livingston, chair of the expert panel, believes now is the time to address inequalities to improve the circumstances in which people live their lives and beyond just promoting good health. To reduce the risks, society can create active and healthy environments for communities, make healthy diets accessible, and reduce excessive alcohol consumption.  

Diet and sleep
Diet and sleep did not make the list for modifiable risk factors because, while more research has been published, the evidence currently is not strong enough to justify their inclusion. When it comes to diet, a deficiency in a particular vitamin has not been associated with dementia.  While the Mediterranean and Nordic diets can probably make a difference, Livingston reports that there “doesn’t seem to be anyone particular element that is needed.” Because diet and socioeconomic status are connected, it is a challenge to separate out diet. The bottom line, according to Livingston, is to eat a healthy diet and maintain a healthy weight.  

Keeping people with dementia at home
More recent evidence included in the review finds that people with dementia do not do well when hospitalized, so efforts should be made to keep people at home.

Dementia is more common in marginalized groups
Dementia had been regarded as a disease of high-income countries, but low and middle-income countries are developing more dementia because of higher rates of risk factors such as smoking and low education levels.

COVID-19
The 2020 report comments that people with dementia are particularly vulnerable to COVID-19 because of age, having more than one disease, and the challenges of practicing physical distancing. In fact, the report cites US data showing that people with dementia in care homes made up 52 percent of COVID-19 cases but represented 72 percent of all deaths. To address social isolation, the authors of the report suggest that measures should be put in place to allow relatives to visit people with dementia living in care homes.  

Sources: National Health Services website, NeurologyLive website, Lancet website
 
 


Nutritional Yeast

Yeast has been present in our diets for thousands of years. Nutritional yeast is well known among vegans and lesser known with the general public. Also called “nooch,” this type of yeast is different than Brewer’s yeast or the yeast used to make bread.
 
What is nutritional yeast?
Nutritional yeast is from a species of yeast called Saccharomyces cerevisiae. It can be grown on sources such as blackstrap molasses, whey, and sugar beets. It is an inactivated (dead) form of yeast made with a heating and drying process, unlike yeast used to make bread which is activated (alive). It comes as a golden coloured granules, powder or flakes and can be used as a condiment or for seasoning. Registered Dietitian Desiree Nielsen considers nutritional yeast a key staple in the list of foods for a plant-centred pantry.
 
Nutritional yeast’s popularity comes from its “superfood” profile. It is high in protein with 8 grams per ¼ cup, low in calories and most brands are fat-free. It has no cholesterol, sodium or monosodium glutamate, and because it is dairy free it can be used by people with lactose intolerance. It is gluten, soy, sugar, artificial colour and ingredient free and adds a savoury umami-like taste to foods. It has a nutty, cheese-like flavour. Other benefits include that it is relatively inexpensive and shelf stable (can be kept up to 12 months in an airtight container, but once opened, the Very Well Fit website suggests refrigerating it so it will keep longer and be aware of the expiration date). Registered Dietitian Joanne Foley of the Food and Nutrition blog points out that it contains the compound glutathione, an important antioxidant that plays a role in proper immune function. A ¼ cup serving of a nutritional yeast also contains 3 grams of dietary fibre and more than the daily recommended intake of vitamins B12 (when fortified), thiamin, niacin, folate, riboflavin and B6. B vitamins are essential, and the body does not produce B vitamins, so they must be sourced from the foods we eat. Nutritional yeast is considered a complete protein as it contains all nine essential amino acids required for muscle structure.

What about people with sensitivity or an allergy to yeast?
The Livestrong website advises people with these restrictions who are concerned about using nutritional yeast to speak to their health care provider to see if it is right for them. According to the Very Well Fit website, other groups who may need to avoid using nutritional yeast include people with irritable bowel syndrome (IBS) or migraines, as the yeast may be a trigger for symptoms.
 
Vitamin B12
The role of vitamin B12 is to produce red blood cells and maintain a healthy nervous system. People who are deficient in vitamin B12 are at risk for anemia, a reversible blood disorder that causes fatigue and problems with thinking and concentrating. This vitamin can be lacking in vegan diets because vegans avoid animal foods (meat, fish, dairy and eggs) and vegetarians avoid meat and fish, and vitamin B12 is naturally found in animal foods. The Harvard Health blog reports that there are only two reliable vitamin B12 sources for vegans – fortified foods and supplements. Not all nutritional yeast is fortified with vitamin B12, so check the label. It may not be possible to know if the nutritional yeast in the bulk section has been fortified with vitamin B12. Registered Dietitian Desiree Nielsen points out that a mistaken belief is that nutritional yeast is naturally rich in vitamin B12, but it has to be fortified to provide this vitamin. Registered Dietitian Cynthia Sass of the Health website cites a study finding that people who ate a vegan diet for up to four years met the recommended vitamin B12 needs by including nutritional yeast.
 
Where can you purchase nutritional yeast?
It can sometimes be found in the bulk section of a grocery store and in health food stores. More and more conventional grocery stores are carrying nutritional yeast.  
 
How can you use nutritional yeast?
There is a long list of ways to use nutritional yeast:
  • Use it as part of a breading recipe to add extra flavour to what is often just a bland coating
  • Sprinkle on popcorn
  • Use to thicken salad dressings
  • Use to make a cheese sauce
  • Use as a substitute for Parmesan cheese (you need about half the amount)
  • Add to soups, salads, steamed vegetables, mashed potatoes, pasta, and dips
A tip from Registered Dietitian Desiree Nielsen is that nutritional yeast enhances saltiness, so be aware of this when adding salt to foods.

Sources: Very Fit Well website, Harvard Health Blog website, Harvard TH Chan School of Public Health website, Women's Health website, Health website, Unlockfood website, Medical News Today website, Livestrong website, Chatelaine website, Food & Nutrition website, Desiree Nielsen, RD website    
 
 


Staying Positive During COVID-19

It has been eight months since COVID-19 has changed the way we live. These are unprecedented times – job losses, home schooling, social isolation and the loss of our “normal” way of life. We are experiencing stress, anxiety, fear, depression and hopelessness and these feelings can be amplified as we approach the dark days of fall and winter. Dr. Keith Dobson of the University of Calgary points out that COVID-19 has three characteristics that drive anxiety – unpredictability, uncontrollability, and salience (importance because COVID-19 can cause serious illness or even death). Michele Tugade, a psychology professor at Vassar College, explains that stress is natural and is actually necessary during times of adversity. The role of stress is to help the mind and body prepare for action and to focus on what is important. The bottom line is to know how to use that stress effectively.

The following are some tips from the field of positive psychology to support us to navigate these trying times. Positive psychology is defined by Ron Siegel, PhD, assistant professor of psychology at Harvard Medical School, as not a case of denying difficult emotions, but rather “opening to what is happening here and now, and cultivating and savoring the good in your life.” Ways to increase positive feelings and help you gain perspective include:
  • Count your blessings or have gratitude for things in the past, present or future - Dr. Tugade’s research has found that resilient people who experience significant loss and tragedy are able to move forward and be happy again. They do this through practicing gratitude e.g., thinking about the people who love them and thinking about experiences that have brought them joy. Doing so has been found to result in fewer depressive symptoms and lower rates of post-traumatic stress disorder in the months following adversity. Other benefits include less pain, faster recovery, and lower blood pressure during stressful events. Psychology professor Tim Bono of Washington University in St. Louis reminds us that while we may not be able to control the situation or outcome, we can control our attitude and how we deal with the pandemic. Dr. Tugade cites the words of Robert Emmons, a researcher in the area of gratitude, that "Gratitude is a conscious choice.” Because the brain is wired to take note when things go wrong, starting a gratitude journal can make you more aware when things go right.  Write down three things you are grateful for each day or do this as a sharing exercise at your family dinner. Another activity is to write a gratitude letter to someone you are grateful for having in your life. Be as specific as possible, according to Kendall Cotton Bronk, PhD, a professor of positive psychology.
  • Start a journal - Kira Newman of the University of California - Berkeley’s Greater Good magazine comments that when writing, an individual is forced to confront ideas one by one and give them structure and may result in new perspectives. As she puts it, “We’re actually crafting our own life narrative and gaining a sense of control.”
  • Maintain social connections - social connections are one of the strongest predictors of well-being. Our ancestors needed to connect in order to survive. Be creative with the ways you can connect with others while practicing physical distancing.  
  • Surround yourself with happy things - Dr. Kerri Palmara of Massachusetts General Hospital encourages people to use “Happiness Boosters.” Identify your booster e.g., listening to a favourite song or video, dancing, or doing jumping jacks. Being cheerful and positive actually makes it less likely that you will get sick, and if you do get sick, you will have a faster recovery, less symptoms and increased resistance to the virus.
  • Prioritize sleep and exercise - sleep strengthens the neural circuits that support well-being and regular exercise releases the body’s “feel good” endorphins.
  • Help others - research has shown numerous benefits from volunteering. Volunteering is a positive cycle because when you help others, you get positive feelings and these positive feelings encourage you to help again. Volunteering can be done online, or you can donate to a cause.  
  • Practice breathing and touch - Dr. Tugade explains that by placing your hand on your heart and taking deep breaths, you are stimulating the vagus nerve which initiates the relaxation response of the body, releasing the feel good hormone oxytocin and lowering levels of the stress hormone cortisol. One method of breathing is called “Square Breathing.” This method involves breathing in for four seconds to fill your lungs and stomach, holding the breath for 4 seconds and then breathing out for four seconds. This can be done regularly anywhere at any time.
  • Be kind to yourself - take a nice relaxing bath, read a book, take a walk in nature (research has found that following a stressful event, being in nature can reduce the effects e.g., lower heart rate, muscle tension and blood pressure).
  • Be more mindful - mindfulness is defined as the practice of “purposely focusing your attention on the present moment and accepting it without judgement.” Dr. Siegel provides free mindfulness guided recordings on the website www.mindfulness-solution.com.
  • Limit exposure to negative news, especially if you are feeling anxious - the news has very little  new information on COVID-19 but lots of negative coverage.
  • Use resources in the community and your workplace - these include helplines, health professionals, spiritual leaders, and employee assistance programs.
  • Determine what you can control - evaluate your level of control over a situation. You can ask yourself, “What can I take responsibility for in this situation?” This allows you to focus on working towards change that is possible and not focusing on blaming others.
According to the Positive Psychology UK website, one could make the argument that resilience is the end product of the intuitive application of positive psychology to the management of personal adversity.

What is resilience?
The American Psychological Association (APA) states that psychologists define resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress such as family and relationship problems, serious health problems, or workplace and financial stressors.” Dr. Keith Dobson of University of Calgary’s Department of Psychology, featured on the Mental Health Commission of Canada website, comments that it is critical to stay resilient during the pandemic.  Ann Masten, PhD of the University of Minnesota explains that resilience refers to positive adaptation to adversity, but there are different perspectives on how to exactly define resilience. She thinks of resilience as a system’s capacity (the system can be an individual, a family or community) to adapt successfully to challenges to the system. The Mayo Clinic describes an individual lacking resilience as someone who might dwell on problems, feel victimized, become overwhelmed or turn to unhealthy ways of coping such as substance abuse. Another way of describing resilience, provided by Kathleen Smith, PhD, is the ability to cope with change.

Our level of resilience, according to Dr. Masten, is always changing. Situations that can decrease our resilience include a lack of sleep, neglecting our diet, and working too much.  When dealing with challenges, we can feel exhausted and overwhelmed. Therefore, taking the time to replenish and restore resilience capacity is important. Someone who is resilient knows how to manage stress effectively and also allows themselves time to rest so that they can again focus their attention on difficult tasks. Activities such as those listed above e.g., mindfulness, practicing gratitude, keeping socially connected and maintaining a healthy lifestyle by following a nutritious eating plan, regularly exercising and getting adequate sleep will build resilience, or make deposits in the resilience bank account.

Because people do not always realize they are getting anxious and tense, the Mental Health Commission of Canada provides a chart entitled “Mental Health Continuum Self Check.” Mental health is never static - people move along the continuum. Dr. Dobson advises people to “check in” and pay attention to changes in mood, thinking and attitude, behaviour and performance, and physical changes. The spectrum is available on the Mental Health Commission of Canada website. You can take action based on where you find yourself on the spectrum.

Another helpful way to think of resilience comes from Harvard University’s Center on the Developing Child. Resilience is a seesaw with one side representing negative experiences tipping the scale towards bad outcomes, and the other side representing positive experiences tipping the scale towards positive outcomes. The centre of the seesaw, also called the fulcrum, is different for different people and can make it harder to tip the scale towards positive outcomes. Three ways to tip the scale include: reducing sources of stress or lightening the negative outcomes side by seeking out resources and practicing self-care; loading the positive side by maintaining social connections; and moving the fulcrum by strengthening core life skills. Core life skills are the essential skills to manage life, work and relationships to help us focus, plan for and achieve goals, adapt to changing situations, and resist impulsive behaviours. These skills are developed over time and are not innate. Some more facts about resiliency:
  • According to the Center on the Developing Child, resiliency is not innate; rather, it builds up throughout our life as our experiences interact with our unique genetics – this explains why the response to stress and adversity varies from person to person. As well, some people are more sensitive to adversity.  
  • Dr. Tugade points out that research has found that feeling positive emotions such as love, gratitude and joy can promote resilience. 
  • The Mayo Clinic indicates that resilience can help protect against mental health conditions such as depression and anxiety and protect against factors that increase the risk of mental health conditions, such as bullying and previous trauma. People with a mental health condition who are resilient are better able to cope.
  • Resilience is like a muscle that can be exercised, strengthened, and replenished by taking small actions every day. Building self-care into your daily or weekly routine can greatly improve resilience and prevent burnout.
  • 4 skills to build resiliency, according to Dr. Dobson, include deep breathing (reduces stress by increasing oxygen to the vital organs), visualization (getting mentally prepared for the what ifs – imagining proactively what you will say and do for a positive outcome which builds confidence and concentration), self talk (it is vitally important to challenge negative self-talk with factual thoughts or thoughts that are more gentle, positive or helpful, such as “I can do this” and “I have gotten through difficult situations”), and goal setting (setting daily goals such as speaking to 3 people per day or walking 10 minutes per day).
  • The APA outlines four core strategies to build resistance and these include connection, wellness, healthy thinking, and meaning. Connect with trustworthy and compassionate people who validate your feelings. For wellness, practice self-care by following a healthy lifestyle, practice mindfulness and choose healthy ways of coping by giving your body resources to manage stress as opposed to unhealthy ways, such as substance abuse, to eliminate/mask stress. Healthy thinking involves keeping things in perspective (how you think affects how you feel), being aware of irrational thoughts, accepting that change is part of life, maintaining a hopeful outlook by visualizing what you want as opposed to what you fear, and looking into your past to identify who or what was helpful in traumatic situations and what you learned from those experiences. Think of the transitions and challenges you successfully navigated in the past. For meaning, consider volunteering, be proactive to solve problems, move towards realistic goals and look for opportunities for self-discovery from the personal growth that comes from adversity.  Kathleen Smith, PhD, explains that people who are resilient see change as an opportunity and not something to fear. What are your priorities? What is important to you? Getting a clear sense of your goals and values helps you to be much more resilient.
Resources
  • Mental Health Commission of Canada's The Working Mind COVID-19 Self-Care and Resilience Guide 
  • Penn State University Positive Psychology Center website
  • The Resilience Institute website has free videos for youth 
Sources: MedicalXpress website, Psychology Today website, Josh Bersin website, Massachusetts General Hospital - Center for Physician Wellbeing article, Thrive Global website, Harvard University Center on the Developing Child website, Harvard University Center on the Developing Child website, American Psychological Association website, American Psychological Association website, University of California - Berkeley Greater Good Science Center website, Mayo Clinic website, Psycom website 
 
 


Time to Wear Three-Layer Masks

On November 3, Dr. Theresa Tam, the Chief Public Health Officer for Canada, made the recommendation that Canadians wear three-layer non-medical masks with a filter to prevent the spread of COVID-19. This announcement is a result of the evolving science on masks. Dr. Lisa Bryski, an emergency room physician in Winnipeg, tells Global News that we have gone from studies showing that a mask is better than no mask, then two layers is better than one, and then two layers with a filter is better than just two. You can find details on the recently updated guidelines on the Government of Canada website. Dr. Tam isn’t saying you necessarily have to throw out your existing masks, but rather that you add a filter to help with protection. In June, the World Health Organization recommended three-layer masks. Dr. Jing Wang, a clinical instructor at the University of British Columbia who has researched mask materials, points out that a two-layer properly fitted mask is about 60 percent effective at trapping coronavirus particles, but this can be increased to about 80 or 90 percent by adding a filter – on par with a regular single-use surgical with effectiveness between 60 to 90 percent. With fall and winter, we will be spending more time indoors and this is where there is more aerosol build up in the air. As Dr. Wang notes, this is a time “we should especially be wearing an effective mask.” 

Facts about masks
The degree of protection offered by a non-medical mask depends on three things: construction, materials and the fit.
  • Features - a mask should be made with at least three layers with the two outer layers being made of tightly woven fabric such as cotton or linen, and the middle layer for the filter or filter fabric. According to Dr. Tam, the virus “doesn’t really survive on cotton for very long.” She says that if you plan on purchasing more masks, choose those made with these three layers. The purpose of the filter is to add an extra layer of protection against COVID-19 by trapping small infectious particles. You can purchase disposable filters that are put into the pocket of a mask at many retail locations. You can make a filter using a non-woven polypropylene fabric found as a craft fabric or a washable non-woven fabric used in some reusable shopping bags. Dr. Tam notes that the unwoven aspect of the material is important because this traps particles. Dr. Wang, however, points out that some of the non-woven polypropylene fabric contain preservatives and therefore are actually hazardous for the body. James Austin, the owner of Canadian Fabrics in Amherst, Nova Scotia, has been in the textile business for more than 45 years, tells Global News that people should wash any non-woven polypropylene bought in a retail so that any traces of production chemicals will be washed away. He instructs people to rinse, wash, dry and iron the material prior to use. A hazard free option is dried baby wipes. Steven Rogak, a professor of mechanical engineering who studies aerosols and was part of the research team with Dr. Wang, reports that a three-ply dried baby wipe can filter out up to 80 percent of 3-micron particles and more than 90 percent of 10-micron particles. Dried baby wipes are made of spun lace polypropylene without bleach or other chemicals that can cause asthma or breathing problems. They are biocompatible (not harmful to living tissue) and breathable and need to be swapped out after use. A home-made mask made with two-layers of low-thread count quilting cotton and a dried baby wipe filter is as effective as a commercial non-surgical mask at stopping particles, and almost as breathable. While they are better than most cloths, they are not as good as N95 materials. What not to use? A folded paper towel is also listed by the Government of Canada as a material that can be used as a filter. Dr. Wang is not in favour of coffee filters because they can be thicker and interfere with breathing. The Public Health Agency of Canada website provides instructions on how to make a three-layer mask. 
  • Fit - Dr. Tam emphasizes that the mask’s fit is one of the most important things. A three-layer mask will not be more effective if it is ill-fitting. Dr.Wang says it is important to have a good seal around the mask. The highest leak rates are around the nose, so a good mask will emphasize a nose pinch and be large enough to fully cover the nose, mouth, and chin. The pleated-style masks tend to leak the most. Leakage is more of a problem for people with beards, thinner faces or more prominent noses. The advantage of making your own mask is that it allows you to customize the fit for your face. In addition to no gaps, a well fitted mask allows you to breathe easily, is comfortable, and doesn’t require frequent adjustments. It should fit securely on your face using ties or ear loops. As well, the mask should not sit flat against the mouth and nose because it would be less breathable; rather, it should have a bit of an air pocket with a bigger curvature in the front of the mask so the whole mask can exchange air.
  • Washing - replace and launder your mask after each use, or whenever it becomes damp or dirty. Disposable filters should be changed every day or according to the manufacturer’s instructions. The US Center for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommend these ways of washing: 1) washer and dryer with high heat, 2) soapy detergent soak/rinse and air dry, or 3) bleach soak/rinse and air dry. Maintain the shape of the mask after washing and drying the mask.
  • Storing - the Government of Canada recommends storing a reusable mask in a clean paper or cloth bag until you put it on again. Soiled masks or face coverings should be placed in a secure, waterproof bag or container until they can be washed in the laundry.
When to wear a non-medical mask or face covering
The Public Health Agency of Canada states:
  • When you are in public and might come into close contact with others
  • When you are in shared indoor spaces with people from outside your immediate household
  • When advised by your local public health authority
The Three Cs
Remember, wearing a non-medical mask or face covering alone will not prevent the spread of COVID-19.  In addition to masks, Dr. Tam is emphasizing we avoid the 3 Cs - closed spaces, crowded places and close contact with others. These 3 scenarios increase the risk of exposure to COVID-19 the most. The more time you spend in these and the more people present, the greater your risk.

Resources
- Government of Canada website has a webpage all about non-medical masks and face coverings, including a poster on how to safely use a non-medical mask and a video on how to properly wear a non-medical mask. 
- Free Mask Project - the project aims to use an evidence-based approach to design and fabricate reusable homemade masks that are as effective as surgical masks. These masks are provided free of charge for at risk individuals in our community - such as the essential workers and the elderly. Visit the website for more information. 

Sources: CBC News website, Government of Canada website, Global News website, Global New website, Global News website, UBC Faculty of Medicine website


 
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