Can You Gain Muscle & Lose Fat At The Same Time?
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It’s Q&A Day at 10almonds!
Have a question or a request? We love to hear from you!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small 😎
❝Is it possible to lose fat and gain muscle at the same time, or do we need to focus on one and then the other, and if so, which order is best?❞
Contrary to popular belief, you can do both simultaneously! However, it’s not as easy as doing just one or the other, which is why most bodybuilders, for example, have a “building phase” and a “cutting phase”.
The reason it’s difficult is because of the diet. Growing muscle doesn’t just take protein and micronutrients; it takes energy as well, which must come from carbohydrates and/or fats. Therefore, it is tricky to eat enough to build muscle and to fuel the workouts that are required to build the muscle (you can’t hit the gym in a state of rabbit starvation* and expect to perform well at your workout), while at the same time not eating enough carbs/fats to have any excess to store as fat.
*So-called because rabbit-meat is very lean, such that when during times of famine, European peasants tried to subsist off mostly rabbits, their health quickly plummeted for lack of energy. It’s also been called “salmon starvation”, apparently, for the same reason:
In French it’s called “Mal de caribou” (caribou sickness), by the way. But you get the idea: eat too much lean protein without enough carbs/fats, and woe shall befall.
So, if you want to do both at once, you need to be incredibly on top of your macros, and the bad news is, only you (or a coach working directly with you) can work out what precise macros requirements your body has, because it depends on your body and your activities.
The easier “half-way house”
We will get to the “building phase” and “cutting phase” of bodybuilders, but first, here’s an option that’s very worthy of consideration, and it is: forget about your weight and just focus on health while incidentally doing regular resistance exercises and HIIT.
What will happen if you do this (assuming a healthy balanced diet, nothing special and without counting anything, but we’re talking at least mostly whole-foods, and at least mostly plants; the Mediterranean diet is great for this, as it is for most things) is:
- The dietary approach described will gradually improve your metabolic health if it wasn’t already good. If it was already good, it’ll likely just maintain it, rather than improve it.
- The resistance exercises will, if engaged with seriously (it has to be difficult to do, or your muscles won’t have any reason to grow), gradually build muscle. This will be very gradual, because you’re not eating for bodybuilding, nor optimizing your general lifestyle for same. Historically many women have feared lifting weights because they don’t want to “look like a weightlifter”, but the kinds of bodies that word brings to mind are not the kind that happen by accident (especially for women, with our different hormones guiding our bodies to a different composition); it takes a lot of single-minded dedication to specifically optimize size gains, for a long time.
- The high-intensity interval training (HIIT) will more rapidly improve your metabolic health, and unlike most forms of exercise, it will actually result in a gradual reduction of fat, if you have superfluous fat to lose. This is because whereas most forms of cardio exercise increase the heartrate for a while but then have a corresponding metabolic slump afterwards to make up for it, HIIT confuses the heart (in a good way) which results in it having to grow stronger, and not doing any compensatory metabolic slump:
How To Do HIIT (Without Wrecking Your Body) ← as well as the “how to”, this also gives some of the science behind it, too
This will, thus, result in gradual gain of muscle and loss of fat—or if you take it easier with the exercise, then you can easily settle into just maintaining your body composition as it is, but that wasn’t the question today.
So, there you have it, that’s how to do both at once! Now, if you want more dramatic results, then more dramatic methods are called for:
What bodybuilders (mostly) do
Matters of genetic predisposition and commonplace use of steroids aside, here’s how bodybuilders get that “lots of muscle, no fat” figure:
- First, get into “moderate” shape if not already there.
- Bulk up: eat amounts of food that will seem unreasonable to a non-bodybuilder; eating 2x or even 3x the “recommended” daily calorie amount is common; focus is typically on getting adequate (for bodybuilding purposes) protein while also carb-loading for workouts and getting at least enough fats for fat-soluble vitamins to work. In the gym, focus on doing sets of very few reps with the heaviest weights one can safely lift, while doing minimal cardio, and also sleeping a lot (9–12hrs per day), which is essential because this is putting a huge strain on the body and it needs a chance to recover and rebuild.
- Cut down: maintain protein intake (to at least mostly maintain muscles) while keeping carbs and fats low, doing cardio work (HIIT is still ideal) and running a calorie deficit for a short while (there is no use in trying to maintain a long-term calorie deficit; your body will try to save you from starvation by storing any fat it can and slowing your metabolism).
Phases 2 and 3 are then cycled, alternating every month, or every 6 weeks, or every 2 months or so, depending on personal preferences and scheduling considerations (bodybuilders will often have competitions they are working towards, so they need to time things to be at the end of a cutting phase to look their “best” by bodybuilder standards).
Disclaimer: bodybuilding is complex, and can be ruinous to the health if practised inexpertly, because of its extreme nature. We don’t recommend serious bodybuilding per se in general, but if you are going to do it, please consult with a professional bodybuilding coach, and do not rely on a few paragraphs from us that are intended only to give the most basic overview of how bodybuilders can approach the “gain muscle, lose fat” problem.
Want to know more?
We’ve written on some related topics previously; here’s a three-part series:
- How To Lose Weight (Healthily!)
- How To Build Muscle (Healthily!)
- How To Gain Weight (Healthily!) ← this one’s specifically about gaining healthy levels of fat, for any who want/need that
And also:
Can We Do Fat Redistribution? ← yes we can, but there are caveats
Take care!
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Eye Exercises That Measurably Improve Your Vision
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Our eyesight, like most of the rest of our body’s functions, will decline if not adequately maintained. Modern lifestyles see most of us indoors for most of the day (which means a reduced maximum focal length) and often looking at screens (even further reduced focal length), which means that part of our eyes responsible for focus will tend to atrophy and wither. And if we want to see something better, we adjust the settings instead of adjusting our eyes. However, it is perfectly possible to recover our clear youthful vision:
See the results for yourself (and see them clearly!)
The exercises that gave him the results he showed between the two tests, are:
- Blink for 30 seconds
- Focus on something in front and (keeping your focus on that stationary point) move your head left & right, upwards & downwards, and diagonally
- Take a break and blink for 30 seconds
- Keep your head still while you move your eyes left & right, upwards & downwards, and diagonally
- Focus on something in front while you move move your head left & right, upwards & downwards, and diagonally
This should temporarily improve your vision immediately, because of what has been going on in the capillaries in and around your eyes, but sustained results require sustained (i.e. daily) practice. This is because the vasculature is only part of the mechanism; it’s also a matter of improving the muscles responsible for focusing the eyes—and like any muscles, it’s not a case of “do it once and enjoy the results forever”. So, even just 2–3 minutes each day is recommended.
For more on all of this plus a visual demonstration, enjoy:
Click Here If The Embedded Video Doesn’t Load Automatically!
Want to learn more?
You might also like to read:
Are Your Glasses Making Your Eyesight Worse?
or, if you are very serious about having excellent vision for life:
Vision for Life, Revised Edition – by Dr. Meir Schneider ← this one’s a book, and a very good one at that
Take care!
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Nudge – by Richard Thaler & Cass Sunstein
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How often in life do we make a suboptimal decision that ends up plaguing us for a long time afterwards? Sometimes, a single good or bad decision can even directly change the rest of our life.
So, it really is important that we try to optimize the decisions we do make.
Professors Richard Thaler and Cass Sunstein look at all kinds of decision-making in this book. Their goal, as per the subtitle, is “improving decisions about health, wealth, and happiness”.
For the most part, the book concentrates on “nudges”. Small factors that influence our decisions one way or another.
Most importantly: that some of them are very good reasons to be nudged; others, very bad ones. And they often look similar.
Where this book excels is in highlighting the many ways we make decisions without even thinking about it… or we think about it, but only down a prescribed, foreseen track, to an externally expected conclusion (for example, an insurance company offering three packages, but two of them exist only to direct you to the “correct” choice).
A weakness of the book is that in some aspects it’s a little inconsistent. The authors describe their economic philosophy as “libertarian paternalism”, and as libertarians they’re against mandates, except when as paternalists they’re for them. But, if we take away their labels, this boils down to “some mandates can be good and some can be bad”, which would not be so inconsistent after all.
Bottom line: if you’d like to better understand your own decision-making processes through the eyes of policy-setting economists (especially Sunstein, who worked for the White House Office of Information & Regulatory Affairs) whose job it is to make sure you make the “right” decisions, then this is a very enlightening book.
Click here to check out Nudge and improve your decision-making clarity!
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The Dopamine Precursor And More
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What Is This Supplement “NALT”?
N-Acetyl L-Tyrosine (NALT) is a form of tyrosine, an amino acid that the body uses to build other things. What other things, you ask?
Well, like most amino acids, it can be used to make proteins. But most importantly and excitingly, the body uses it to make a collection of neurotransmitters—including dopamine and norepinephrine!
- Dopamine you’ll probably remember as “the reward chemical” or perhaps “the motivation molecule”
- Norepinephrine, also called noradrenaline, is what powers us up when we need a burst of energy.
Both of these things tend to get depleted under stressful conditions, and sometimes the body can need a bit of help replenishing them.
What does the science say?
This is Research Review Monday, after all, so let’s review some research! We’re going to dive into what we think is a very illustrative study:
A 2015 team of researchers wanted to know whether tyrosine (in the form of NALT) could be used as a cognitive enhancer to give a boost in adverse situations (times of stress, for example).
They noted:
❝The potential of using tyrosine supplementation to treat clinical disorders seems limited and its benefits are likely determined by the presence and extent of impaired neurotransmitter function and synthesis.❞
More on this later, but first, the positive that they also found:
❝In contrast, tyrosine does seem to effectively enhance cognitive performance, particularly in short-term stressful and/or cognitively demanding situations. We conclude that tyrosine is an effective enhancer of cognition, but only when neurotransmitter function is intact and dopamine and/or norepinephrine is temporarily depleted❞
That “but only”, is actually good too, by the way!
You do not want too much dopamine (that could cause addiction and/or psychosis) or too much norepinephrine (that could cause hypertension and/or heart attacks). You want just the right amount!
So it’s good that NALT says “hey, if you need some more, it’s here, if not, no worries, I’m not going to overload you with this”.
Read the study: Effect of tyrosine supplementation on clinical and healthy populations under stress or cognitive demands
About that limitation…
Remember they said that it seemed unlikely to help in treating clinical disorders with impaired neurotransmitter function and/or synthesis?
Imagine that you employ a chef in a restaurant, and they can’t keep up with the demand, and consequently some of the diners aren’t getting fed. Can you fix this by supplying the chef with more ingredients?
Well, yes, if and only if the problem is “the chef wasn’t given enough ingredients”. If the problem is that the oven (or the chef’s wrist) is broken, more ingredients aren’t going to help at all—something different is needed in those cases.
So it is with, for example, many cases of depression.
See for example: Tyrosine for depression: a double-blind trial
About blood pressure…
You may be wondering, “if NALT is a precursor of norepinephrine, a vasoconstrictor, will this increase my blood pressure adversely?”
Well, check with your doctor as your own situation may vary, but under normal circumstances, no. The effect of NALT is adaptogenic, meaning that it can help keep its relevant neurotransmitters at healthy levels—not too low or high.
See what we mean, for example in this study where it actually helped keep blood pressure down while improving cognitive performance under stress:
Effect of tyrosine on cognitive function and blood pressure under stress
Bottom line:
For most people, NALT is a safe and helpful way to help keep healthy levels of dopamine and norepinephrine during times of stress, giving cognitive benefits along the way.
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I’m iron deficient. Which supplements will work best for me and how should I take them?
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Iron deficiency is common and can be debilitating. It mainly affects women. One in three premenopausal women are low in iron compared to just 5% of Australian men. Iron deficiency particularly affects teenage girls, women who do a lot of exercise and those who are pregnant.
The body needs iron to make new red blood cells, and to support energy production, the immune system and cognitive function. If you’re low, you may experience a range of symptoms including fatigue, weakness, shortness of breath, headache, irregular heartbeat and reduced concentration.
If a blood test shows you’re iron deficient, your doctor may recommend you start taking an oral iron supplement. But should you take a tablet or a liquid? With food or not? And when is the best time of day?
Here are some tips to help you work out how, when and what iron supplement to take.
LittlePigPower/Shutterstock How do I pick the right iron supplement?
The iron in your body is called “elemental iron”. Choosing the right oral supplement and dose will depend on how much elemental iron it has – your doctor will advise exactly how much you need.
The sweet spot is between 60-120 mg of elemental iron. Any less and the supplement won’t be effective in topping up your iron levels. Any higher and you risk gastrointestinal symptoms such as diarrhoea, cramping and stomach pain.
Low iron can especially affect people during pregnancy and women who do a lot of sport. Kamil Macniak/Shutterstock In Australia, iron salts are the most common oral supplements because they are cheap, effective and come in different delivery methods (tablets, capsules, liquid formulas). The iron salts you are most likely to find in your local chemist are ferrous sulfate (~20% elemental iron), ferrous gluconate (~12%) and ferrous fumarate (~33%).
These formulations all work similarly, so your choice should come down to dose and cost.
Many multivitamins may look like an iron supplement, but it’s important to note they usually have too little iron – usually less than 20 mg – to correct an iron deficiency.
Should I take tablets or liquid formulas?
Iron contained within a tablet is just as well absorbed as iron found in a liquid supplement. Choosing the right one usually comes down to personal preference.
The main difference is that liquid formulas tend to contain less iron than tablets. That means you might need to take more of the product to get the right dose, so using a liquid supplement could work out to be more expensive in the long term.
What should I eat with my iron supplement?
Research has shown you will absorb more of the iron in your supplement if you take it on an empty stomach. But this can cause more gastrointestinal issues, so might not be practical for everyone.
If you do take your supplement with meals, it’s important to think about what types of food will boost – rather than limit – iron absorption. For example, taking the supplement alongside vitamin C improves your body’s ability to absorb it.
Some supplements already contain vitamin C. Otherwise you could take the supplement along with a glass of orange juice, or other vitamin C-rich foods.
Taking your supplement alongside foods rich in vitamin C, like orange juice or kiwifruit, can help your body absorb the iron. Anete Lusina/Pexels On the other hand, tea, coffee and calcium all decrease the body’s ability to absorb iron. So you should try to limit these close to the time you take your supplement.
Should I take my supplement in the morning or evening?
The best time of day to take your supplement is in the morning. The body can absorb significantly more iron earlier in the day, when concentrations of hepcidin (the main hormone that regulates iron) are at their lowest.
Exercise also affects the hormone that regulates iron. That means taking your iron supplement after exercising can limit your ability to absorb it. Taking your supplement in the hours following exercise will mean significantly poorer absorption, especially if you take it between two and five hours after you stop.
Our research has shown if you exercise every day, the best time to take your supplement is in the morning before training, or immediately after (within 30 minutes).
My supplements are upsetting my stomach. What should I do?
If you experience gastrointestinal side effects such as diarrhoea or cramps when you take iron supplements, you may want to consider taking your supplement every second day, rather than daily.
Taking a supplement every day is still the fastest way to restore your iron levels. But a recent study has shown taking the same total dose can be just as effective when it’s taken on alternate days. For example, taking a supplement every day for three months works as well as every second day for six months. This results in fewer side effects.
Oral iron supplements can be a cheap and easy way to correct an iron deficiency. But ensuring you are taking the right product, under the right conditions, is crucial for their success.
It’s also important to check your iron levels prior to commencing iron supplementation and do so only under medical advice. In large amounts, iron can be toxic, so you don’t want to be consuming additional iron if your body doesn’t need it.
If you think you may be low on iron, talk to your GP to find out your best options.
Alannah McKay, Postdoctoral Research Fellow, Sports Nutrition, Australian Catholic University
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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For Seniors With Hoarding Disorder, a Support Group Helps Confront Stigma and Isolation
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A dozen people seated around folding tables clap heartily for a beaming woman: She’s donated two 13-gallon garbage bags full of clothes, including several Christmas sweaters and a couple of pantsuits, to a Presbyterian church.
A closet cleanout might not seem a significant accomplishment. But as the people in this Sunday-night class can attest, getting rid of stuff is agonizing for those with hoarding disorder.
People with the diagnosis accumulate an excessive volume of things such as household goods, craft supplies, even pets. In extreme cases, their homes become so crammed that moving between rooms is possible only via narrow pathways.
These unsafe conditions can also lead to strained relationships.
“I’ve had a few relatives and friends that have condemned me, and it doesn’t help,” said Bernadette, a Pennsylvania woman in her early 70s who has struggled with hoarding since retiring and no longer allows guests in her home.
People who hoard are often stigmatized as lazy or dirty. NPR, Spotlight PA, and KFF Health News agreed to use only the first names of people with hoarding disorder interviewed for this article because they fear personal and professional repercussions if their condition is made public.
As baby boomers age into the group most affected by hoarding disorder, the psychiatric condition is a growing public health concern. Effective treatments are scarce. And because hoarding can require expensive interventions that drain municipal resources, more funding and expertise is needed to support those with the diagnosis before the issue grows into a crisis.
For Bernadette, the 16-week course is helping her turn over a new leaf.
The program doubles as a support group and is provided through Fight the Blight. The Westmoreland County, Pennsylvania, organization started offering the course at a local Masonic temple after founder Matt Williams realized the area lacked hoarding-specific mental health services.
Fight the Blight uses a curriculum based on cognitive behavioral therapy to help participants build awareness of what fuels their hoarding. People learn to be more thoughtful about what they purchase and save, and they create strategies so that decluttering doesn’t become overwhelming.
Perhaps more importantly, attendees say they’ve formed a community knitted together through the shared experience of a psychiatric illness that comes with high rates of social isolation and depression.
“You get friendship,” said Sanford, a classmate of Bernadette’s.
After a lifetime of judgment, these friendships have become an integral part of the changes that might help participants eventually clear out the clutter.
Clutter Catches Up to Baby Boomers
Studies have estimated that hoarding disorder affects around 2.5% of the general population — a higher rate than schizophrenia.
The mental illness was previously considered a subtype of obsessive-compulsive disorder, but in 2013 it was given its own diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5.
The biological and environmental factors that may drive hoarding are not well understood. Symptoms usually appear during the teenage years and tend to be more severe among older adults with the disorder. That’s partly because they have had more time to acquire things, said Kiara Timpano, a University of Miami psychology professor.
“All of a sudden you have to downsize this huge home with all the stuff and so it puts pressures on individuals,” she said. In Bernadette’s case, her clutter includes a collection of VHS tapes, and spices in her kitchen that she said date back to the Clinton administration.
But it’s more than just having decades to stockpile possessions; the urge to accumulate strengthens with age, according to Catherine Ayers, a psychiatry professor at the University of California-San Diego.
Researchers are working to discern why. Ayers and Timpano theorize that age-related cognitive changes — particularly in the frontal lobe, which regulates impulsivity and problem-solving — might exacerbate the disorder.
“It is the only mental health disorder, besides dementia, that increases in prevalence and severity with age,” Ayers said.
As the U.S. population ages, hoarding presents a growing public health concern: Some 1 in 5 U.S. residents are baby boomers, all of whom will be 65 or older by 2030.
This population shift will require the federal government to address hoarding disorder, among other age-related issues that it has not previously prioritized, according to a July report by the Democratic staff of the U.S. Senate Special Committee on Aging, chaired then by former Sen. Bob Casey (D-Pa.).
Health Hazards of Hoarding
Clutter creates physical risks. A cramped and disorderly home is especially dangerous for older adults because the risk of falling and breaking a bone increases with age. And having too many things in one space can be a fire hazard.
Last year, the National Fallen Firefighters Foundation wrote to the Senate committee’s leadership that “hoarding conditions are among the most dangerous conditions the fire service can encounter.” The group also said that cluttered homes delay emergency care and increase the likelihood of a first responder being injured on a call.
The Bucks County Board of Commissioners in Pennsylvania told Casey that hoarding-related mold and insects can spread to adjacent households, endangering the health of neighbors.
Due to these safety concerns, it might be tempting for a family member or public health agency to quickly empty someone’s home in one fell swoop.
That can backfire, Timpano said, as it fails to address people’s underlying issues and can be traumatic.
“It can really disrupt the trust and make it even less likely that the individual is willing to seek help in the future,” she said.
It’s more effective, Timpano said, to help people build internal motivation to change and help them identify goals to manage their hoarding.
For example, at the Fight the Blight class, a woman named Diane told the group she wanted a cleaner home so she could invite people over and not feel embarrassed.
Sanford said he is learning to keep his documents and record collection more organized.
Bernadette wants to declutter her bedroom so she can start sleeping in it again. Also, she’s glad she cleared enough space on the first floor for her cat to play.
“Because now he’s got all this room,” she said, “he goes after his tail like a crazy person.”
Ultimately, the home of someone with hoarding disorder might always be a bit cluttered, and that’s OK. The goal of treatment is to make the space healthy and safe, Timpano said, not to earn Marie Kondo’s approval.
Lack of Treatment Leaves Few Options
A 2020 study found that hoarding correlates with homelessness, and those with the disorder are more likely to be evicted.
Housing advocates argue that under the Fair Housing Act, tenants with the diagnosis are entitled to reasonable accommodation. This might include allowing someone time to declutter a home and seek therapy before forcing them to leave their home.
But as outlined in the Senate aging committee’s report, a lack of resources limits efforts to carry out these accommodations.
Hoarding is difficult to treat. In a 2018 study led by Ayers, the UCSD psychiatrist, researchers found that people coping with hoarding need to be highly motivated and often require substantial support to remain engaged with their therapy.
The challenge of sticking with a treatment plan is exacerbated by a shortage of clinicians with necessary expertise, said Janet Spinelli, the co-chair of Rhode Island’s hoarding task force.
Could Changes to Federal Policy Help?
Casey, the former Pennsylvania senator, advocated for more education and technical assistance for hoarding disorder.
In September, he called for the Substance Abuse and Mental Health Services Administration to develop training, assistance, and guidance for communities and clinicians. He also said the Centers for Medicare & Medicaid Services should explore ways to cover evidence-based treatments and services for hoarding.
This might include increased Medicare funding for mobile crisis services to go to people’s homes, which is one way to connect someone to therapy, Spinelli said.
Another strategy would involve allowing Medicaid and Medicare to reimburse community health workers who assist patients with light cleaning and organizing; research has found that many who hoard struggle with categorization tasks.
Williams, of Fight the Blight, agrees that in addition to more mental health support, taxpayer-funded services are needed to help people address their clutter.
When someone in the group reaches a point of wanting to declutter their home, Fight the Blight helps them start the process of cleaning, removing, and organizing.
The service is free to those earning less than 150% of the federal poverty level. People making above that threshold can pay for assistance on a sliding scale; the cost varies also depending on the size of a property and severity of the hoarding.
Also, Spinelli thinks Medicaid and Medicare should fund more peer-support specialists for hoarding disorder. These mental health workers draw on their own life experiences to help people with similar diagnoses. For example, peer counselors could lead classes like Fight the Blight’s.
Bernadette and Sanford say courses like the one they enrolled in should be available all over the U.S.
To those just starting to address their own hoarding, Sanford advises patience and persistence.
“Even if it’s a little job here, a little job there,” he said, “that all adds up.”
This article is from a partnership that includes Spotlight PA, NPR, and KFF Health News.
Spotlight PA is an independent, nonpartisan, and nonprofit newsroom producing investigative and public-service journalism that holds power to account and drives positive change in Pennsylvania. Sign up for its free newsletters.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Subscribe to KFF Health News’ free Morning Briefing.
This article first appeared on KFF Health News and is republished here under a Creative Commons license.
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A new emergency procedure for cardiac arrests aims to save more lives – here’s how it works
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As of January this year, Aotearoa New Zealand became just the second country (after Canada) to adopt a groundbreaking new procedure for patients experiencing cardiac arrest.
Known as “double sequential external defibrillation” (DSED), it will change initial emergency response strategies and potentially improve survival rates for some patients.
Surviving cardiac arrest hinges crucially on effective resuscitation. When the heart is working normally, electrical pulses travel through its muscular walls creating regular, co-ordinated contractions.
But if normal electrical rhythms are disrupted, heartbeats can become unco-ordinated and ineffective, or cease entirely, leading to cardiac arrest.
Defibrillation is a cornerstone resuscitation method. It gives the heart a powerful electric shock to terminate the abnormal electrical activity. This allows the heart to re-establish its regular rhythm.
Its success hinges on the underlying dysfunctional heart rhythm and the proper positioning of the defibrillation pads that deliver the shock. The new procedure will provide a second option when standard positioning is not effective.
Using two defibrillators
During standard defibrillation, one pad is placed on the right side of the chest just below the collarbone. A second pad is placed below the left armpit. Shocks are given every two minutes.
Early defibrillation can dramatically improve the likelihood of surviving a cardiac arrest. However, around 20% of patients whose cardiac arrest is caused by “ventricular fibrillation” or “pulseless ventricular tachycardia” do not respond to the standard defibrillation approach. Both conditions are characterised by abnormal activity in the heart ventricles.
DSED is a novel method that provides rapid sequential shocks to the heart using two defibrillators. The pads are attached in two different locations: one on the front and side of the chest, the other on the front and back.
A single operator activates the defibrillators in sequence, with one hand moving from the first to the second. According to a recent randomised trial in Canada, this approach could more than double the chances of survival for patients with ventricular fibrillation or pulseless ventricular tachycardia who are not responding to standard shocks.
The second shock is thought to improve the chances of eliminating persistent abnormal electrical activity. It delivers more total energy to the heart, travelling along a different pathway closer to the heart’s left ventricle.
Evidence of success
New Zealand ambulance data from 2020 to 2023 identified about 1,390 people who could potentially benefit from novel defibrillation methods. This group has a current survival rate of only 14%.
Recognising the potential for DSED to dramatically improve survival for these patients, the National Ambulance Sector Clinical Working Group updated the clinical procedures and guidelines for emergency medical services personnel.
The guidelines now specify that if ventricular fibrillation or pulseless ventricular tachycardia persist after two shocks with standard defibrillation, the DSED method should be administered. Two defibrillators need to be available, and staff must be trained in the new approach.
Though the existing evidence for DSED is compelling, until recently it was based on theory and a small number of potentially biased observational studies. The Canadian trial was the first to directly compare DSED to standard treatment.
From a total of 261 patients, 30.4% treated with this strategy survived, compared to 13.3% when standard resuscitation protocols were followed.
The design of the trial minimised the risk of other factors confounding results. It provides confidence that survival improvements were due to the defibrillation approach and not regional differences in resources and training.
The study also corroborates and builds on existing theoretical and clinical scientific evidence. As the trial was stopped early due to the COVID-19 pandemic, however, the researchers could recruit fewer than half of the numbers planned for the study.
Despite these and other limitations, the international group of experts that advises on best practice for resuscitation updated its recommendations in 2023 in response to the trial results. It suggested (with caution) that emergency medical services consider DSED for patients with ventricular fibrillation or pulseless ventricular tachycardia who are not responding to standard treatment.
Training and implementation
Although the evidence is still emerging, implementation of DSED by emergency services in New Zealand has implications beyond the care of patients nationally. It is also a key step in advancing knowledge about optimal resuscitation strategies globally.
There are always concerns when translating an intervention from a controlled research environment to the relative disorder of the real world. But the balance of evidence was carefully considered before making the decision to change procedures for a group of patients who have a low likelihood of survival with current treatment.
Before using DSED, emergency medical personnel undergo mandatory education, simulation and training. Implementation is closely monitored to determine its impact.
Hospitals and emergency departments have been informed of the protocol changes and been given opportunities to ask questions and give feedback. As part of the implementation, the St John ambulance service will perform case reviews in addition to wider monitoring to ensure patient safety is prioritised.
Ultimately, those involved are optimistic this change to cardiac arrest management in New Zealand will have a positive impact on survival for affected patients.
Vinuli Withanarachchie, PhD candidate, College of Health, Massey University; Bridget Dicker, Associate Professor of Paramedicine, Auckland University of Technology, and Sarah Maessen, Research Associate, Auckland University of Technology
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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