kry.co.uk > Your health

Health information, articles, news and advice for NHS patients.

kry.co.uk > Your health > Metainfo

Your health | KRY

## Quick facts
- Cytokine storm increases the risk of serious complications from Covid-19
- It happens when the immune system attacks the body’s healthy tissue
- Doctors are now starting to spot the early signs
- Medications can be used to reduce the risk of cytokine storm

We often see advice about ‘boosting’ the immune system. But an effective immune response is a balancing act that involves releasing the right chemical messengers and defenders, in the right amounts, at the right time.

If that goes wrong, all sorts of things can happen. Reactions like allergic asthma and hay fever, and auto-immune conditions like rheumatoid arthritis, multiple sclerosis and psoriasis are all examples of the body triggering an immune response when it should not. 

Cytokine storm is an example of one such auto-immune malfunction. This is how it works.

## How your immune system fights disease

Immune responses are driven by a family of chemical messengers known collectively as cytokines, that are released by the immune system to help fight illness. 

When the body perceives a threat, or tissues are damaged by an injury, bacteria, or virus, this triggers the release of pro-inflammatory cytokines. These quickly go to work recruiting and activating immune cells to fix the problem.

These inflammatory cytokines increase blood flow and instruct blood vessels to leak fluid into surrounding tissues. This leads to swelling, designed to trap foreign substances and stop them coming into contact with healthy tissue. It’s all part of the healing process.

These chemical messengers also step up production of T-cells and other ‘defender cells’. These seek out and destroy invaders such as viruses and bacteria.

In the short term, this flurry of activity by the immune system protects healthy tissue and promotes healing. 

But in the long term it’s not sustainable. So, our immune system also has a collection of anti-inflammatory cytokines, which put the brakes on these inflammatory responses. This should happen when the job of healing is done and you’re getting better.

## Cytokine storm — an immune system in overdrive

If this does not happen, the immune system continues its fighting process but then starts to damage healthy tissue. This happens with auto-immune conditions like multiple sclerosis and rheumatoid arthritis. It also happens to some Covid-19 patients — known as cytokine storm.

When these anti-inflammatory cytokines cannot switch off, they cause more inflammation. That leads to more cells damaged, and more pro-inflammatory cytokines flooding the body. 

As a result, blood vessels can become so leaky that the lungs fill with fluid, and blood pressure drops – which reduces oxygen levels throughout the body. Blood begins to clot, which further reduces blood flow to vital organs. As organs begin to fail, patients can go into shock and face permanent organ damage, or in the worst case, death.

## How spotting the early signs of cytokine storm is saving lives from Covid-19

Unsurprisingly, cytokine storm dramatically increases the risk of becoming seriously ill with Covid-19, and it is thought to be a factor in most Covid-related deaths.

But the good news is that this knowledge is already saving lives and improving outcomes.

It’s early days but by spotting the signs of cytokine storm, doctors are beginning to find ways of taking steps to help prevent it from making a patient seriously ill. 

These signs include raised blood levels of certain inflammatory biomarkers. By checking for these markers, doctors are starting to identify patients most at risk and treat them before cytokine storm takes hold.

Steroid medication can be used to damp down inflammation and minimize tissue damage, especially in the lungs, while blood-thinning drugs can be administered to prevent potentially life-threatening blood clots. ‘The use of steroids and blood-thinning drugs were 2 major milestones in the standard of care at the intensive care units during spring to help prevent life-threatening serious complications for Covid-19 patients’. 

However, there’s still a lot that doctors don’t know about cytokine storm, and the different chemical messengers that switch inflammation on and off. There are no simple answers. 

Genetics, individual immune memory, and any number of other factors such as our general health and nutrition, are all likely to influence our immune system responses. 

What’s needed now is more research to work out how, and when, to accelerate our immune responses to Covid-19: and how, and when to put the brakes on before they can spiral out of control.

__This article has been medically approved by Dr Annette Alaeus, Head of Infectious Diseases at Livi.__


Livi.co.uk > Your health > What is cytokine storm?

Header-GettyImages-1220126596

People with Covid-19 can experience an extreme immune system response known as cytokine storm. Dr Alaeus, Head of Infectious Diseases at Kry, explains

Kry.co.uk > Your health > What is cytokine storm?

What is cytokine storm?

General health

General health and seasonal

A desperate urge to go to the toilet, and a burning sensation when urinating, are just two of the common symptoms of a Urinary Tract Infection (UTI), that millions of people suffer from every year. 

But while uncomfortable and inconvenient, they’re incredibly common and over half of female adults say they’ve had at least one UTI in their lifetime. 

At Kry, we’ve seen an increase in patients calling our doctors with UTIs, so we’ve compiled a guide to answer the most frequently asked questions.

## What is a UTI?

Urinary tract infections (UTIs) are common infections that can affect the bladder, the kidneys and the tubes connected to them. 

Although men and children can get them, they are more common in women. In fact, according to the World Health Organisation (WHO), an estimated 50% of women will report having a UTI at some point in their lives.

## What are the symptoms of a UTI?

The main symptoms of a UTI are: 
- pain while passing urine (typically described as a burning, stinging pain)
- passing urine more frequently 
- an urgency to need to pass urine
- smelly or cloudy urine
- pain in the lower abdomen 

‘Often a UTI will also cause a sense of fatigue in addition to those symptoms, and some people may experience blood in the urine too,’ says Kry GP Dr Rhianna McClymont.

## What causes UTIs?

‘There are many different bacteria which can cause a UTI,’ says Dr McClymont. ‘Bacteria enter the urinary tract via the urethra and then rise to the bladder where they cause an infection’. 

This is why they’re more common in women as the urethra is shorter, which makes it easier for the bacteria to get to the bladder, Dr McClymont explains. 

As a woman, you can’t pass your UTI onto your male partner through sex, although sex may be uncomfortable.

The bacteria may enter the urethra after wiping your bottom or having sex. Other causes of a UTI may include using a contraceptive diaphragm, condoms coated in spermicide or a weakened immune system.

## How is a UTI diagnosed?

For women, a urine test will confirm if you have a UTI and also help rule out other conditions that might be causing your symptoms, like a sexually transmitted infection. Men may be offered a painless swab test to check for other conditions.

## How are they treated?

Most UTIs can be easily treated with antibiotics, although in some severe cases hospital treatment may be needed.

To help alleviate pain while the symptoms clear up, you can take paracetamol and place a hot water bottle on your tummy, back or between your thighs. 

Try to rest and drink plenty of fluids which helps flush out the bacteria. 
Don’t take ibuprofen or aspirin if you have a kidney infection as it may increase problems. Kidney infections are diagnosed with a urine test and a GP will ask about your symptoms and recent medical history. 

## How long does a UTI last?

If treated quickly with antibiotics, mild UTIs normally pass within a few days. 

But sometimes they come back – a condition known as Recurrent Urinary Tract Infections (RUTIs). Although there are few studies into RUTIs, one found that 27% of women aged 17-39 would experience a second UTI within six months of the first, while a further 3% would experience a third in the same period.

## Why do UTIs keep occurring?

Some women are genetically predisposed to having recurring UTIs (for example, if your mother or sister has had them, you’re likely to have them too). The risks vary depending on your age. One recent study found that recurrence can range from 16-36% in premenopausal women to 55% following menopause.

## Does anything increase the risk of a UTI?

Before menopause, the most common risk factors are sexual intercourse which is thought to increase the number of bacteria in the bladder. That’s why experts often advise women to urinate after sex to flush them out. 

The use of spermicides may also cause UTIs in younger women, as they kill off beneficial bacteria in the vagina making it easier for the damaging bacteria to infect. 

After menopause, the number of beneficial bacteria in the vagina naturally decline. The bladder also contracts less strongly than it once did, making it more difficult to empty completely. 

## What helps prevent UTIs?

There are several things you can do to prevent an infection:
- drink plenty of water to stay hydrated
- take showers instead of baths 
- for women, make sure you’re wiping ‘front to back’ when going to the toilet

‘The evidence is conflicting as to whether cranberry juice is actually beneficial, but drinking it isn’t harmful so there’s no problem in trying it to see if it helps your symptoms,’ says Dr McClymont.

Some people may also wish to try D-mannose (a type of sugar you take every day as a tablet or powder), as some research has shown it can help in women who are not pregnant.

## Can UTIs be dangerous?

Most UTIs are in the lower part of the urethra and are not usually a cause for major concern. But occasionally, if left untreated, the bacteria can travel into one or both kidneys, which can become a kidney infection and you may need emergency treatment.

‘Watch out for a very high temperature, feeling unwell, weak and shivery, or pain in your back or sides – which can be a sign of a kidney infection,’ says Dr McClymont. It’s important to seek emergency treatment if suffering from any of these symptoms. 

If treated quickly, antibiotics can clear a kidney infection. But if left untreated it can cause damage to the kidneys or the infection can enter the bloodstream.

## Should you see a doctor?

If your symptoms do not improve within a few days or your symptoms come back after treatment, it’s wise to see your doctor. You should also check with a GP if you have blood in your urine, if you’ve never had a UTI before or if you’re pregnant and have symptoms. 

__This article has been contributed to by Dr Rhianna McClymont,Lead GP at Kry__


Kry.co.uk > article page > UTIs: your questions answered > call out

Kry.co.uk > Your health > UTIs: your questions answered

UTIs: your questions answered

UTIs are incredibly common. They affect an estimated 50% of women at some point in their lives. Our experts have compiled this guide

Family

Family health

## Quick facts
- Young children catch 8-10 colds a year before they’re 2 years old
- Vitamin D reduces the risk of respiratory infections
- Sleep really is an effective medicine 

Your child’s immune system is not fully developed until they’re around 8 years old. Until then it can feel as though they catch every cough, cold and infection they encounter.

‘Between 6 and 18 months of age, children are particularly prone to infections because the protective antibodies they inherit from their mother are waning, but they’ve not yet developed their own antibodies,’ says Kry Paediatric Consultant Dr Tommy Södergren.

On average, children catch between 8 and 10 colds a year before they’re 2 years old. This is not a sign of a weak immune system — it simply means they’re coming into contact with a lot of cold viruses for the first time.

Immunity works in 2 ways. First, there’s innate immunity, which we’re born with, providing a general defense. Then there’s adaptive immunity which responds to the threats or antigens we encounter, and creates custom-made defense gadgets, called antibodies. This is also what happens when we’re vaccinated with a weakened version of a virus or bacterium.

Because children encounter so many new infections, their immune systems are on constant alert — which may explain why they’re less likely to become ill with Covid-19. Scientists think they may be identifying and destroying the coronavirus before infection can take hold.

Unfortunately, occasional colds and coughs are inevitable for children. But you can take these 7 steps to support your child’s immune system.

## 1.	Take vitamin D

Many experts believe it’s no accident that colds peak in winter, when our levels of vitamin D are low. Vitamin D supplementation reduces the risk of getting respiratory infections and studies confirm it boosts production of infection-fighting T-cells.

In the UK and Europe, daily vitamin D supplements (usually 10mcg) are recommended for all young children – although the advice on dosages and how long to give them varies slightly. Infant formulas are fortified with vitamin D, but breastfeeding mothers are advised to give their babies a supplement of 8.5mcg to 10mcg a day.

‘In the northern hemisphere it’s been recommended for centuries to give babies vitamin D,’ says Dr Södergren. ‘We’re now starting to recommend giving it to older children too, at least during the winter.’

## 2.	Make sure they get plenty of rest

There’s a saying that a good night’s sleep is the best medicine, and sleep and strong immunity are intertwined. Getting plenty of sleep reduces inflammation and gives our body time to repair damaged cells, which strengthens immunity. And when we’re unwell and our immune system is fighting a threat, our immune response makes us feel sleepy, because the body’s resources are focused on fighting the infection or repairing the injury.

Babies and toddlers need at least 11 hours a night plus a nap during the day. From ages 4 to 9, children need 9.5 to 11.5 hours a night and older children and teens need between 9 and 10 hours a night.

A good bedroom routine is the key to getting children settled. A warm bath, dim lights and quiet time will help them wind down. Ban screen use before bed and keep their bedroom well ventilated and between 16°C and 20°C. Here are some more [tips on helping children sleep](/your-health/tips-to-help-children-get-to-sleep/).

## 3. Choose the right foods

Our immune system needs the right fuel to fight infections, and studies confirm that eating plenty of fruit and vegetables improves immune function. It even makes vaccinations more effective. 

Protein is also important— particularly an amino acid called arginine, which is found in meat, nuts and beans. These foods also provide plenty of zinc, which reduces the risk of respiratory tract infections and diarrhoea in children. Probiotic yogurts and drinks boost levels of friendly bacteria in the gut, and this can help reduce the risk of respiratory infections. Try these [6 tips for healthy cooking for the family](/your-health/6-tips-for-healthy-cooking-at-home/).

## 4. Encourage exercise

Getting the family active could help keep colds away, as exercise helps the immune system seek out and destroy infections, Dr Södergren says. ‘Winter is the high season for common colds because we spend more time indoors, where it’s easier to transmit viral infections. By staying outside more and practising social distancing we could reduce the spread of common colds.’

## 5. Consider pet therapy

Children with pets also have stronger immune systems. Some scientists even believe that owning a pet provides protection from Covid-19, because pet owners will have encountered other coronaviruses carried by animals.

Stroking a pet has been shown to increase levels of an infection-fighting substance in the body called immunoglobulin A. Pet owners are less likely to get repeat bouts of some stomach bugs. And, growing up with a pet may also help the immune system spot the difference between dangerous pathogens and harmless allergens.

## 6. Avoid unnecessary antibiotics

Don’t ask your doctor for antibiotics when your child has a cold. They don’t work against the viruses which cause most colds and coughs, Dr Södergren says. ‘The only thing that will happen is that you will add diarrhoea to their symptoms.’ Antibiotics can also leave us more vulnerable to infections because they disrupt beneficial bacteria in the gut.

Most coughs and colds can be treated at home with rest, fluids and paracetamol or ibuprofen. 

‘In rare cases, children get a bacterial infection — like streptococcal tonsillitis, ear infection or pneumonia — as a cold “complication’’,’ Dr Södergren adds. ‘Even then, in most cases antibiotics are not necessary.’

See a doctor if the cold is not getting better after a week, if it’s getting much worse after 3 days, or if your child has a very high temperature. ‘A sniffle or cough are signs that the immune system is working to clear the body from antigens and mucus and these symptoms can linger for some time after the common cold,’ Dr Södergren asserts. ‘If symptoms persist for more than 6 weeks, see a doctor.’

## 7. Practice great hygiene

Encourage your children to wash their hands with soap and water every time they use the toilet and before eating. To make sure they wash thoroughly, suggest they sing ‘Happy Birthday’ twice.

If someone in the family has a cold, keep their toothbrush away from the rest of the family’s brushes, and replace it as soon as symptoms have passed. Use tissues, rather than handkerchiefs, to avoid spreading germs.

Discourage your child from rubbing their eyes or chewing fingernails, and pop some wipes or hand sanitiser into their school bag to make sure they can always clean their hands.

But don’t worry if they get a bit dirty when they’re playing. Studies show that being exposed to germs and everyday infections strengthens immunity, while going overboard with hygiene may not be helpful for the immune system.

## Children and coronavirus

Rest assured that according to the NHS, while children can get coronavirus, they get it less often and it’s usually less serious. 

### Symptoms of coronavirus in children:
- A high temperature 
- A continuous cough — this means coughing a lot, for more than an hour, or 3 or more coughing episodes in 24 hours
- A loss or change to sense of smell or taste

### Call emergency or a GP immediately if your child:
- Is under 3 months old and has a temperature of 38°C or higher, or if you think they have a fever
- Is 3-6 months old and has a temperature of 39°C or higher, or if you think they have a fever
- Has other signs of illness, like a rash, as well as a high temperature
- Has a high temperature that’s lasted 5 days or more
- Does not want to eat or is not their usual self and you’re worried
- Has a high temperature that does not come down with paracetamol
- Is dehydrated — for example, their nappies are not very wet, they have sunken eyes and no tears when crying

### When to speak to a doctor

This is an unsettling time for everyone, especially parents. If you’re unsure about whether to check a symptom with your GP, err on the side of caution. Kry GPs are here to help. 

__This article has been medically approved by Dr Tommy Södergren, Kry Paediatric Consultant__


Kry.co.uk > article page >How to boost children’s immunity this winter: 7 tips > call out

Kry.co.uk > Your health > How to boost children’s immunity this winter: 7 tips

How to boost children’s immunity this winter: 7 tips

It’s understandable to be more concerned than usual about preventing colds and coughs in your children this winter. Here’s some expert help

Most people have moles and, most of the time, they’re nothing to worry about. 

But if you or someone in your family has moles, it’s important to become ‘mole aware’ because, in rare cases, they can develop into a serious form of skin cancer called malignant melanoma.

Mole awareness simply means knowing where on the body your moles are and checking them regularly for changes in size, colour and shape. 

## What are skin moles?

The good news is, most moles are round or oval shaped, coloured, benign (non-cancerous) tumours on the skin. They can be flat or raised, rough or smooth and even hairy. 

Moles are not usually present in babies and often begin to appear in children and young adults. 

Although most moles are harmless, some people have them removed for cosmetic reasons by laser treatment, mole ‘shaving’ or excision. 

## Why is checking your moles so important?

‘Melanoma develops in cells called melanocytes which produce melanin — the pigment that gives the skin its colour,’ says Dr Vasiliki Vanky, Kry doctor. 

‘This happens when something goes wrong in the melanocytes and they start to grow out of control. It can occur on all parts of the skin — even on nails and eyes — but usually on areas that are exposed to the sun like the legs, trunk and head.’ 

In fact, melanomas are most commonly found on the back in men and the legs in women. They’re rarely found in areas that are protected from sun exposure, like the scalp and buttocks. 

Melanoma is one of the fastest rising forms of cancer. Melanoma of the skin (and eye) reaches 90,000 new cases annually in Europe and kills around 20,000 people each year. 

But early diagnosis and better treatment mean that someone diagnosed with skin cancer has a positive chance of surviving it. The five-year survival rate in Europe is above 86%, and more women than men survive the disease.

## How is skin cancer (malignant melanoma) treated?

‘The main treatment for most melanoma is surgery, called wide excision,’ says Dr Vanky. This is where the skin cancer is removed. ‘Sometimes melanoma can be treated with immunotherapy which stimulates a person’s own immune system to recognise and destroy cancer cells. Other types of treatment are chemotherapy and radiation.’

## Who is at risk of developing skin cancerous moles?

‘Your risk of developing melanoma depends on several factors,’ Dr Vanky explains. These include: 
- Your lifetime exposure to UV radiation, not only from the sun, but also from tanning beds and a history of sunburn 
- Having fair skin and blonde or red hair
- A family member that has had skin cancer
- Having many moles (see below) or unusual moles
- A weakened immune system

## What’s the risk in people with darker skin?

People with darker skin can also get skin cancer but have more natural protection against it, as they have more melanin in their skin. However, this can mean that people of colour can often miss vital signs of melanoma and then present as a patient when the disease is more advanced. 

In African or Asian people, the cancer is often a type of melanoma called acral lentiginous melanoma, which develops on the soles of the feet, the palms of the hands or under the nail. 

## How can I know which mole changes to report?

Early diagnosis of skin cancer is critical. Report any new mole that arises on your skin, a sore or spot that does not heal, any existing mole that starts changing or any spot, mole or lesion that looks unusual to a GP. 

An easy guide is to think of the ABCDE of features that can help you spot if a mole is becoming cancerous: 

__A. Asymmetry:__ A healthy mole is usually round because it grows evenly. See your doctor if your mole has an irregular edge or is growing unevenly.

__B. Border:__ Normal healthy moles tend to be round, with smooth, clearly defined borders. Melanomas often have ragged or blurred edges.

__C. Colour:__ Normal moles are usually one colour. But melanomas are often uneven in colour and can have two or three shades of brown or black, or shades of red and pink. Be especially aware of any moles that are darkening, as this can also be a possible sign that it’s becoming cancerous. 

__D. Diameter:__ Melanomas are usually larger than 6mm (approximately the width of a pencil). But this is not a sure sign of malignant melanomas, as a perfectly healthy mole can be larger while a cancerous mole can be smaller. 

__E. Elevation or enlargement:__ A melanoma will often change in size, shape and colour over time and may become raised above the skin’s surface. Inflammation or swelling is another sign that it could be cancerous. Often, the original mole remains the same size but the area around or under it appears to spread or swell. 

## Any other signs to watch for?

Any new mole changes like bleeding, crusting or itching may also be caused by melanoma, so report these immediately. 

Another sign to look out for is the ‘ugly duckling’ mole, which simply looks different to other moles on your body. One study showed that skin cancer is 4 to 10 times higher in people with unusually shaped or large moles. The risk is nearly 7 times higher in people with more than 100 common moles compared with people with fewer than 15. 

Scientists also think that around 10% of melanomas — at any age — may be linked to an inherited gene called CDKN2A.

## What about skin cancer and children?

Malignant melanoma is incredibly rare in children and the majority of cases are related to damage caused by UV light on children with white skin. 

In children under 11, there are further signs to look out for as the melanoma is more likely to be red in colour, there may be bleeding or bumps, the colour is often uniform and it could be any size. 

__This article has been medically approved by Dr Vasiliki Vanky, Kry medical doctor__


Kry.co.uk > Your health > Do your skin moles need checking by a doctor?

Do your skin moles need checking by a doctor?

Most skin moles are harmless — but a minority are not, which is why ‘mole awareness’ is so important. Our doctor’s guide has what you need to know 

## Quick facts
- Underlying anxiety and a history of trauma may be one of the reasons for panic attacks
- Cognitive Behavioural Therapy (CBT) can be used to treat panic disorder – it can also provide tools that help you manage a panic attack
- Low blood sugar can trigger a panic attack — eating regular meals emphasising wholegrains and proteins may help

If you’ve ever experienced a panic attack, you already know how distressing they can be. ‘A panic attack is a sudden episode of intense fear that triggers a range of unpleasant sensations,’ says Dag Härdfeldt, Licensed Psychologist at Livi. ‘Typical symptoms may include a dry mouth, shortness of breath, a racing heartbeat, feeling faint, dizzy, chest pains, trembling, shaky limbs, nausea, sweating and tingling in your fingers. There may also be feelings of impending doom, terror and being out of control. You may even fear that you are having a heart attack. A panic attack can occur at any time and typically lasts for 5-20 minutes.’ 

## What’s going on in your body during a panic attack?

‘The physiological reactions that occur during a panic attack come from the body’s “fight or flight” response,’ says Härdfeldt. This is an automatic ‘somatic’ response — meaning it occurs in the body — but is activated by the sympathetic nervous system, whenever you feel you’re in danger. 

This stress response begins in the brain where the amygdala, the area to do with emotional processing, sends a signal to the hypothalamus, the area that communicates with the rest of the body. The hypothalamus activates the sympathetic nervous system, which signals to the adrenal glands to produce more adrenaline. As a result, your heart beats faster, breathing is quicker and more blood and oxygen go to your muscles, preparing your body to fight or run away. This can make you feel shaky, sweaty, dizzy or sick. 

‘The fight or flight response is an important survival mechanism that we all have,’ Härdfeldt points out. ‘It becomes a problem if this response is repeatedly triggered when there is no actual danger, as it does during a panic attack, because your brain can’t distinguish between a real or perceived threat.’

Panic disorder is when you regularly have feelings of anxiety and fear that lead to panic attacks, often for no apparent reason. ‘Sometimes, people who have had a panic attack become so worried about it happening again that they misinterpret certain bodily signs,’ says Härdfeldt. 

‘For example, if they get up quickly and feel dizzy, they worry that they’re about to have a panic attack. This fear triggers a fight or flight response that causes a panic attack. This makes them even more scared. It’s a vicious circle.’ 

## Reasons for panic attacks

‘The causes of panic disorder are not yet fully understood — but research has shown a link between the disorder and factors such as genetic composition, major life transitions, overwhelming stress, and a history of trauma.’

### 1. Psychological triggers
‘One of the most common reasons for panic attacks is if you’ve experienced an event that triggered an intense fight or flight reaction,’ says Härdfeldt. ‘For example, if you had an accident as a child, that experience is stored in your emotional memory. Then, when you undergo extreme stress in later life, you might be susceptible to a panic attack.’

People who have been through trauma have an increased risk of panic attacks. ‘The brain has a tendency to favour emotionally-charged memories. If you experience something during strong emotional distress, that memory can come to play a big role in the anticipation of future events. So, if you’ve experienced immense emotional danger and fear before, your brain will be more inclined to interpret stressful events as dangerous in the future. Another way of putting it is that your fight or flight system has become hypersensitive.’

### 2. Caffeine
Caffeine in coffee, energy drinks and certain medications may be a reason for panic attacks in people susceptible to anxiety. ‘Caffeine increases heart rate and can make you nervous and jittery,’ says Härdfeldt. ‘In people who are sensitive to caffeine’s effects, these physiological reactions can exacerbate anxiety and trigger a panic attack.’ Conversely, caffeine may be used in controlled doses as a treatment — see below.

### 3. Medications
‘Antihistamines and benzodiazepines almost always have great anxiety-reducing effects in the moment, but can make the anxiety worse in the long run, because you’re conditioning your brain to believe that panic attacks are something so dangerous, they need to be medicated away,’ says Härdfeldt.

‘In contrast, caffeine almost makes the anxiety worse immediately, but in some treatments you actually increase the caffeine amount in order to “expose” the patient to its effect,’ he explains.

A recent study showed that some antidepressants can increase anxiety in the first few weeks of use. If you’re concerned about any medications you’re taking, always talk to your doctor.

### 4. Carbohydrates and sugar
Eating too many refined carbohydrates and sugary foods and drinks can worsen symptoms of panic attacks. A recent study reported that dietary carbohydrates may be significantly related to emotional and cognitive symptoms such as anxiety and difficulty in concentrating.

### 5. Low blood sugar
Low blood sugar (hypoglycaemia) is when your blood sugar drops too low, causing symptoms such as dizziness and, in some cases, shaking and sweating — similar to the symptoms of a panic attack. Eating a healthy diet of whole, unprocessed food with the emphasis on wholegrains and good quality proteins can help keep your blood sugar stable between meals. Eating regular meals can also help to keep blood sugar levels balanced. Sugary foods and drinks can also increase anxiety levels, so try to avoid them. 

### 6. Alcohol
Alcohol lowers chemicals in the brain such as serotonin, which help to regulate and balance mood. Drinking too much alcohol can contribute to feelings of depression and anxiety, and can be a cause of panic attacks.

## Can anything help to prevent panic attacks?

The best approach to panic attacks is to try to prevent them from happening. The time to act is when you start to feel anxious. By dealing with the anxiety and fear that triggers the fight or flight response, you’ll lessen the likelihood of a panic attack occurring. 

### Relaxation practices
‘Relaxation techniques can help to reduce stress and anxiety and manage the symptoms of panic attacks,’ says Härdfeldt. ‘Deep breathing exercises, visualisation, progressive muscle relaxation, meditation and yoga help to lower the heart rate, slow breathing, reduce muscle tension and calm the mind.’ 

To be of benefit, you need to practice these skills regularly, even when you’re not feeling anxious. Aim to practise a relaxation technique for at least 5 to 10 minutes every day. This will make it easier to put the method into practice whenever you feel panicked and anxious.

### Regular physical exercise 
This will help reduce stress and tension. Walking, running, yoga, tennis, cycling and dancing can all help you to relax and help the body to process excess stress hormones, such as adrenalin and cortisol, in a healthy way. Additionally, ‘What happens in our bodies during intense physical training isn’t that different from what happens during a panic anxiety attack. Regular physical exercise can therefore help your brain to get used to the somatic symptoms,’ says Härdfeldt.

### Breathing techniques 
Learn a couple of breathing techniques to help ease symptoms when they occur (see below). ‘One of the most effective ways to manage anxiety and panic attacks is through breathing,’ says Härdfeldt. ‘Slowing down your breathing can help reduce symptoms.’

## Coping with panic attacks when they happen — a toolkit

These techniques will help you cope when a panic attack strikes. Choose the ones that resonate with you.

### Get into the moment — and wait 20 minutes
Don’t fight a panic attack. Breathe slowly and deeply, reminding yourself that the attack will pass. 

‘The fight or flight response cannot last forever,’ Härdfeldt points out. ‘It will eventually run out of gas. It usually peaks within 10 minutes then starts to wind down. 

‘So, the best thing you can do is to remind yourself that, no matter how difficult it becomes, it will be over in about 20-30 minutes. And, the peak usually only lasts a couple of seconds. Focus on keeping your body relaxed and your breathing steady. It’s important not to act like you’re in danger. Sit still, don’t run around. Don’t walk between rooms. Try to ride the panic like a wave. This is where mindfulness techniques can be helpful.’

### Deep-breathing exercises
Research shows that deep breathing (diaphragmatic breathing) can help to reduce anxiety and promote relaxation. The following can be done anywhere for a quick way to feel calmer:
- Stand up, or sit on a chair or the floor, or lie down on a bed or a mat
- If sitting or standing, place feet flat on the ground, hip-width apart
- Inhale through your nose, deep into your tummy 
- Gently exhale through your mouth
- Count 1 to 5 as you breathe in, and 1 to 5 as you breathe out
- Continue for 3 to 5 minutes

### How can your GP help?
‘If you experience panic attacks, consult a healthcare professional as soon as possible,’ says Härdfeldt. ‘Your doctor can refer you to a specialist. It’s usually possible to treat panic attacks in about 2 to 3 months.’ A GP may also carry out tests to rule out any underlying medical conditions that could be causing panic attacks. 

Talking and psychological therapies, such as CBT, are the main treatment for panic disorder. These can help you change your behaviour so that you find it easier to remain calm during an attack. In some cases, it might be helpful to prescribe medication.

__This article has been reviewed by Dag Härdfeldt, Licensed Psychologist at Livi__


Livi.co.uk > Your health > 6 causes of panic attacks — and expert tools for how to cope

6 causes of panic attacks — and expert tools for how to cope

If you suffer from panic attacks, read our expert advice to help you figure out why, and see what you can do to get them under control

Kry.co.uk > Your health > 6 causes of panic attacks — and expert tools for how to cope

Reasons for Panic Attacks - 6 Causes, Expert Tools & How to Cope

As the chill of winter creeps in, the temptation to stay inside is real. But if you’re happy to brave the outdoors, studies show that continuing to keep fit outside could be beneficial for both body and mind.

### 1. General health

There are several studies linking exercising in green spaces to lower risks of heart disease, obesity, asthma and diabetes. Exercising outdoors has also been shown to boost your mental health and overall happiness.

A study in June 2019 found that those who spent [at least 2 hours a week in nature](https://www.livi.co.uk/your-health/5-health-benefits-of-being-in-nature/) were 20% more likely to report overall satisfaction with their lives than those who spent no time outdoors at all.

The benefits to physical health were even greater, with 60% of those who spent more than 2 weekly hours outdoors reporting being in good health compared with those staying indoors. What’s more, it didn’t matter whether this outdoor experience was taken in one long session or broken up into smaller sessions.

### 2. Pain

Inflammation can be reduced with local exposure to cold – just think of the effect of putting ice packs onto sprains.

But there is some evidence to show that cold temperatures might suppress pain too. Finnish researchers discovered that women who plunged into cold water (just above freezing) for 20 seconds a day for 3 months had higher levels of norepinephrine levels in their blood. This is a chemical in the nervous system that – among other things – may help suppress pain.

### 3. Immunity

Exercise helps support immunity. As we head into winter during the Covid-19 pandemic – with many unable to visit gyms or sports clubs – experts are encouraging people to keep fit.

The World Health Organization (WHO) suggests adults do at least 150 minutes of moderate-intensity physical activity throughout the week or at least 75 minutes of vigorous physical activity.

### 4. Mood

Winter workouts also increase exposure to natural light, which itself may help to ward off seasonal affective disorder (SAD) – a type of depression that some people experience during the winter months.

Sunlight exposure stimulates the hypothalamus, a part of the brain that helps control your circadian rhythm which is the body’s 24-hour internal ‘clock’. Lack of light can disrupt this clock, causing your brain to produce too much of the sleep hormone melatonin and to release less of the ‘feel-good’ hormones such as serotonin. The result is that you feel low and may also experience sleeping difficulties.

A lunchtime walk in winter on sunny days could help begin to counteract this effect. But there is no evidence about the optimum amount of sunlight you need to be exposed to for your mood to be enhanced. Length of time will vary due to factors such as variation in skin colour and how close you are to the equator.

### 5. Metabolism

Cold temperatures may make your body burn more calories through a process called thermogenesis, in which your body generates its own heat to keep you warm. One study found that people who hiked in cold temperatures of -9ºC to -5ºC burned 34% more calories than people who hiked in temperatures of 12ºC. Of course, many factors influence how many calories you burn and being active is important all year around.

## 3 precautions to keep you well while exercising outdoors

### 1. Layer up

Cold air temperatures can cause vasoconstriction – narrowing of the blood vessels – which can lead to circulation problems and an increase in blood pressure. It’s a good idea to wear layers of clothing, starting with a thin layer of synthetic material such as polypropylene, which draws sweat away from the body. Avoid cotton, which absorbs sweat and can make you colder. Then add a layer of fleece or wool for insulation and top with a waterproof, breathable layer.

### 2. Use sunscreen

Apply sunscreen of at least SPF 30 and be careful not to underestimate the amount of UV radiation passing through clouds. Many surfaces reflect UV radiation and add to the overall UV levels you experience. Fresh snow, for example, is a particularly good reflector and almost doubles a person’s UV exposure. Even on cloudy days UV radiation can reach the Earth and cause sun damage, so it’s still important to apply SPF on an overcast day.

### 3. Stay hydrated

Several studies show that you are more likely to get dehydrated in winter. One piece of research found that exposure to cold reduced the signals between the brain and the kidneys to conserve fluid. The thirst sensation was also reduced. Make sure you drink water regularly when you’re exercising outside, even when you’re not feeling thirsty.

__Reviewed by Dr Rhianna McClymont, Lead GP at Livi__


Livi.co.uk > Your health > 5 reasons to keep exercising outside

KRY10003 KRY ColdWeather Header MC0924-02

Exercising outside was the norm for many of us during the summer. But as it gets cooler, there are benefits to continuing with outdoor workouts.

Kry.co.uk > Your health >5 reasons to keep exercising outside

5 reasons to keep exercising outside

A certain amount of stress can be energising. An urgent deadline can sharpen your concentration and push you to keep on going. But too much stress over long periods has the opposite effect, leading to a condition known as burnout.

‘Stress causes the body to release stress hormones, including cortisol and adrenaline,’ says licensed psychologist Linda Karlsson. ‘In the short term, this can temporarily boost performance and make you more alert. But if you’re under continuous and prolonged stress, without sufficient rest and recovery, this can increase your risk of developing burnout, which is when you feel mentally, physically and emotionally depleted.’

It’s important to spot the mental and physical symptoms of burnout as early as possible, to avoid them having greater implications for your health.

## What is burnout?

The term burnout was first defined in the 1970s by US Psychologist Herbert Freudenberger who described the key symptoms as loss of motivation, emotional depletion and cynicism caused by work-related stress.

According to the World Health Organization (WHO), 1 in 4 adults will be affected by burnout at some point. The WHO recently included burnout in its International Classification of Diseases (ICD-11), describing it as ‘chronic workplace stress that has not been successfully managed’. Its 3 main areas of symptoms include lack of energy and exhaustion, feeling detached, negative or cynical about one’s job, and reduced work performance.

A recent UK survey showed that two-thirds of employees experienced burnout: 23% reported they felt it often or always and 44% sometimes. The top reasons were unfair treatment at work, an unmanageable workload, lack of clarity, lack of communication, lack of support in the workplace and unreasonable time pressure.

## What are the early signs of burnout?

‘It can take weeks, months and, in some cases, even years to recover from burnout,’ says Karlsson. ‘So, ideally, you want to spot potential symptoms early before they become chronic.  That way, you can take steps to pull yourself back from the brink before the situation becomes too problematic.’

Here are the common early signs & symptoms of burnout to look out for.

### 1. Exhaustion
This is the kind of [persistent tiredness](https://www.livi.co.uk/your-health/whats-causing-your-tiredness/) that is not relieved by rest, so you feel mentally and emotionally drained and physically run-down most of the time. You’re low in energy and frequently feel overwhelmed. Research shows that when there is work overload, there is little opportunity to rest, recover and restore balance.

### 2. Loss of enthusiasm for work
The stress and frustration make you increasingly negative, cynical and resentful about work. You no longer feel enthusiastic about anything and start to distance yourself emotionally. You wake up every day with a feeling of dread about work. Studies have shown that lack of control, insufficient recognition and reward (financial, institutional or social) makes people more vulnerable to burnout symptoms because they feel devalued.

### 3. Reduced work performance
You have difficulty concentrating and you’re less efficient. You’re finding it hard to do work assignments, or are late with them when you never used to be. You’re forgetful. These are some of the common signs of burnout. The more stressed you are, the harder it is to deal with new stressors. Stress also affects the medial prefrontal cortex, the part of the brain associated with executive function – one of the physical symptoms of burnout it’s important to avoid.

### 4. Worry and anxiety
You feel anxious and worried, especially if it’s linked to your performance at work. You might feel better when you get home and do things you enjoy but the [anxiety](https://www.livi.co.uk/medical-advice/mental-health/anxiety/) returns as soon as you’re back at work. Research shows that burnout is related to the development of mood disturbance,
[depressive symptoms](https://www.livi.co.uk/medical-advice/mental-health/depression/) and anxiety.

### 5. Sleep problems
[Stress is affecting your sleep](https://www.livi.co.uk/your-health/3-ways-stress-can-disturb-your-sleep/). You may have developed insomnia and are finding it hard to fall asleep, keep waking in the night, or wake too early and then can’t get back to sleep.

### 6. Physical burnout symptoms
Chronic stress can lead to physical symptoms such as [headaches (caused by tension) and migraines](https://www.livi.co.uk/your-health/9-types-of-headache-and-what-you-can-do/), back pain, [skin problems](https://www.livi.co.uk/your-health/ultimate-guide-to-the-6-most-common-skin-conditions/) and general aches and pains. A review of the scientific literature on burnout has shown that it is a contributory factor for physical symptoms including headache, back ache, respiratory and gastro-intestinal issues.

### 7. Irritability and mood swings
You may feel moodier than usual. This is because the amygdala — the part of the brain associated with fear and aggression — is larger in people suffering from burnout. There are also strong connections between the amygdala and areas of the brain linked to emotional distress.

## 6 ways to help control early stage burnout

Here are Karlsson’s pointers for things that could help slow or stop your early signs of burnout.

### 1. Set boundaries
- Start and finish work at a reasonable time. Stick to regular hours, when you can
- Take regular breaks throughout the day
- Set aside a time each day when you completely disconnect from your mobile, computer, email and social media groups
- Always take your holidays and make sure you switch off from work in the evenings and during the weekend
- Don’t overextend yourself – you’re more likely to suffer from burnout symptoms if you find it hard to say no. Delegate if you can.

### 2. Maintain a healthy work/life balance
‘When you’re stressed it’s easy to forget that spending time with friends and family and doing things you enjoy is just as important as work,’ says Karlsson. ‘You can’t just work all the time and give up other activities. We’re not created to handle stress over a prolonged period of time.
Maintaining a balance between your work and personal life allows you to switch off and recharge, so that when you do get back to work you feel more energised. Even if you’re worried about losing your job, you need to remember that if you don’t have your health, you can’t work.’

### 3. Prioritise exercise
’Exercise is one of the best things you can do to protect yourself from burnout symptoms,’ says Karlsson. ‘Doing at least 30 minutes of cardiovascular exercise every day such as walking, cycling, swimming or dancing helps your body to discharge excess stress chemicals. You’ll also produce more endorphins (feel-good chemicals in the brain) to make you feel better.’

### 4. Stop trying to be perfect
‘If you’re a perfectionist you’re more likely to suffer from burnout,’ says Karlsson. ‘It’s likely that you put high demands on yourself. But, you need to ask yourself — does everything always have to be perfect? What’s the worst thing that can happen if you don’t make that call, send that email right now? It might not be as catastrophic as you think. Talking to a psychologist can be useful.’

### 5. Eat well
‘What you eat can have a huge impact on your mood and energy levels,’ says Karlsson. ‘Eating the right foods will help your body to cope better when you’re under pressure.’
- Avoid all processed foods, white carbohydrates and caffeine
- Eat fresh, healthy foods, including vegetables, fruit, wholegrains, lean proteins such as meat, chicken and oily fish, or eggs and dairy for vegetarians, tofu, beans and pulses for vegans, as well as healthy fats, nuts and seeds
- Eat foods that are high in Vitamin C. These include leafy greens, citrus fruit, kiwis and berries. Vitamin C helps to reduce cortisol levels
- Get enough magnesium. Magnesium is essential for energy production and can have a calming effect. It is found in dark green leafy vegetables, nuts, seeds, legumes and wholegrains. If suitable, you might also want to take a supplement. One study showed that daily supplementation with magnesium can lead to a significant decrease in symptoms of depression and anxiety
- Drink more water and herbal teas

### 6. Don’t be ashamed of getting help
‘If you’re worried that you may be at risk of burnout, always talk to a GP’ says Karlsson. ‘They will check that there aren’t any underlying physical causes for your burnout symptoms. If there’s nothing medically wrong, ask for a referral to a psychologist.

‘While there’s a lot you can do yourself, it’s not always easy to break certain deep-rooted patterns of behaviour and thinking. This is where a psychologist can help you to get to know yourself better.

‘This can mean that in the future you’ll know what signs to look out for and have the tools to stop yourself going in the wrong direction.’

__This article has been reviewed by Linda Karlsson, licensed psychologist__


kry.co.uk > article page >CTA

See a GP about low libido

Livi.co.uk > Your health > 7 early signs of burnout

Burnout

Most of us have days when we feel depleted, stressed and lacking in energy, but if you feel like that most of the time, you may be at risk of burnout.

Kry.co.uk > Your health > 7 early signs of burnout

Signs of burnout – 7 burnout symptoms to look out for

7 early signs of burnout and how to avoid it

Kry.co.uk > Womens health hub > Banner

Breastfeeding is a wonderful, natural process. But it’s not always as straightforward as you may see in the media.

‘There’s a common assumption that new mothers will automatically know what to do,’ says Dr Elisabeth Rosen, medical doctor at Kry. ‘But, even if you think you know what to expect, every woman’s experience is different.  

‘For some breastfeeding comes easily, but for the vast majority of new mothers, it can take a while to get used to and there may be a few stumbling blocks along the way. This is normal, and it’s important not to be hard on yourself at a time when you may be feeling more vulnerable than usual.’

## What happens to the body when breastfeeding?

‘The early production of milk (known as colostrum, see below) starts around week 16 of pregnancy,’ says Dr Rosen. ‘This is due to the increase of the hormone prolactin which stimulates milk production.

‘After you give birth, and immediately after the placenta comes out, oestrogen and progesterone levels drop and prolactin levels go up. This means you are ready to feed your baby straight away. Skin-to-skin contact further stimulates milk production and makes the baby want to feed. When the baby sucks your nipple, it sends nervous impulses to the brain, causing the release of more prolactin.

‘Suckling also releases the hormone oxytocin which stimulates the ‘milk ejection reflex’ where milk is pushed out of the breast through the nipple. Oxytocin induces feelings of calmness and relaxation and creates a powerful sense of bonding between mother and baby.’ Research shows that a suckling baby absorbs oxytocin from the mother’s milk.   

## A quick guide to infant feeding terms

### Colostrum
This is the fluid your breasts produce in the first few days after birth; a form of milk that’s highly nutritious. ‘Colostrum contains protein, vitamins, minerals and antibodies,’ says Dr Rosen. ‘Yet, it’s gentle enough for the baby’s delicate digestive system to handle. After a few days your breasts produce ‘mature’ milk.’

### Dysphoric Milk Ejection (D-MER)
D-MER is where women experience abrupt negative emotions such as sadness, depression, anxiety or irritability for a few minutes (or longer) just before milk release. ‘This is a relatively new diagnosis that used to be confused with postnatal depression,’ says Dr Rosen. ‘We’re not sure exactly why it happens’. If this is something you’re concerned about, talk to your doctor.

### Latching on
For a new baby to feed properly it needs to ‘latch on’ to the breast comfortably. Help your baby by:

- Always bringing your baby to your breast and letting them latch on themselves. Avoid leaning your breast into your baby’s mouth
- Making sure your baby can get a large mouthful of breast
- Placing your baby with their nose level with your nipple, letting their head tip back a little. This will encourage your baby to open its mouth wide and attach

### Engorgement
This is when your breasts get too full of milk, caused by increased blood flow and lymphatic fluid, and excessive milk production. This makes the breasts feel hard, tight and painful. This can happen in the first week or so while you’re still trying to get used to breastfeeding — or, any time while you’re breastfeeding. ‘Many women find breastfeeding painful to begin with and may also develop sore, painful, swollen breasts, inflammation (mastitis) or infections,’ says Dr Rosen. ‘Engorgement is common and your doctor can advise on what to do.’

### Foremilk and hindmilk
‘Focusing on the idea of foremilk and hindmilk is a bit of a myth,’ says Dr Rosen. ‘Foremilk refers to the watery, low calorie milk that comes out first when you start breastfeeding, and hindmilk to the higher calorie, more mature milk that follows. But this distinction can leave mothers concerned that changing breasts while breastfeeding could mean their baby doesn’t get enough hindmilk. But this is nothing to worry about. It’s the volume of milk taken in by the baby that matters and there’s no need to focus on the different milks, as the baby always gets what it needs.’ 

## It‘s normal to feel any of the following when breastfeeding...

### More tired
‘Breastfeeding takes up a lot of energy,’ says Dr Rosen. ‘You’re also going through an emotional storm and it can take time for your hormones to return to normal. This combination can leave new mothers feeling exhausted. Try to rest and sleep whenever you can.’

### More moody
It’s common to get ‘the baby blues’ a couple of days or so after giving birth, where you may experience low mood and feel slightly depressed. ‘The sudden hormonal changes that take place in the body after childbirth can make many women feel more moody,’ says Dr Rosen. ‘While you’re still breastfeeding, levels of oestrogen and progesterone remain low (to stop ovulation and prevent pregnancy) and this can cause anxiety, mood swings, irritability and depression. Although the calming benefits of oxytocin can help, not everyone reacts in the same way. Once you stop breastfeeding hormones gradually go back to normal. Talk to your doctor if you’re worried about how you feel.’

### Hungrier than usual
‘It’s normal to feel hungrier than usual as breastfeeding consumes so much energy,’ says Dr Rosen. Plus, being sleep-deprived can affect your levels of hunger and appetite hormones. If you’re wondering whether breastfeeding helps with post-baby weight, a systematic review of five studies found that after 12 months, breastfeeding mums lost between .6kg and 2kg more than mums who didn’t breastfeed.  If you’re exclusively breastfeeding, this will help you burn an extra 300 calories a day. 

__Reviewed by Dr Rhianna McClymont, Lead GP at Kry__


Kry.co.uk > Your health > Breastfeeding: What’s happening in your body?

Breastfeeding: What’s happening in your body?

Breastfeeding can be a confusing time for new mothers, and that’s okay. Here’s what’s actually going on....

Kry.co.uk > Your health >Breastfeeding: What’s happening in your body?

Fertility and pregnancy

kry.co.uk > Your health > Articles

All articles

See a KRY GP download app

Your health 

Kry UK

Kry is Europe’s leading digital healthcare provider. We combine digital technology with clinical expertise to help NHS services and health insurers solve the biggest challenges in healthcare.