Archives for October 2011

Breastfeeding — Fundamental to Survival

…and yet, one of the hardest things I’ve ever done!

I lecture my patients about the benefits of breastfeeding.  For babe this results in reduced rates of asthma and eczema along with childhood obesity and diabetes.  Benefits for mom include more rapid weight loss following pregnancy and reduced breast cancer rates.  The science supports breastfeeding!

As a species, we’ve been doing it for millennia.  Babies in many countries are strictly breastfed.  How hard could it be?  I was not prepared for how truly difficult it could be!!  Why didn’t anyone tell me???

After my midwife handed me our new little bundle of joy, I recall asking, “now what?”  It all started with the fun game of trying to latch. I’d borrowed a Boppy breastfeeding pillow from my sister-in-law, which helped with support.  The latch was indeed a struggle but besides the intense pain, bleeding, and lipstick shape of my nipples (sorry, TMI) following feeding I thought he was at least getting something.

We continued to think we were latching just fine and since those first couple days only colostrum is produced, it seemed as though he was getting enough.  Likely, because I was an obstetrician-gynecologist the lactation consultant came in and checked, provided a mini lesion, and gave me a rapid seal of approval.  We thought things were going well except for the pain I was experiencing.  Just figured this was standard and onward we went, leaving the hospital 26 hours after his birth and admittedly, feeling a little lost.  I was used to just delivering the babies and handing them to new parents, what happened after that was beyond me.

Fortunately, because of our type of insurance we had a home health aid come to see us after being home for just two days.  I thought actually that those patients who needed this most probably wouldn’t receive a home health visit, because of their insurance (that is for another blog:).  We’d noticed he was looking a little yellow from our partly opened eyelids. However, in a state of exhaustion and shear overwhelmingness of bringing home this little creature that depends entirely on you, I wasn’t up to making medical judgments at that point.  His bilirubin was high, but not necessitating a trip to the hospital for bili-lights, just some window sunlight and working on getting more feedings in. He’d also lost more than 10% of his weight by this time so that meant we’d be seeing the pediatrician sooner.  It also meant we had to supplement with formula, which was a devastating blow to my well laid out plan.

The paper we were sent home with to record this information became too chaotic.  So, Kadin got his own iPhone to start recording on an everything-Kadin app.…time on each breast, which breast, weight before and after each feed (yup, we rented a scale), weight of each pee and poop, and keeping a timer set so he received his every two hour feeds.  I recall more than once being in the middle of feeding and the alarm would go off and it’d be time to feed again.  “But we’re still feeding”, I recall asking my husband tearfully, “What should we do?”  I’d already been curling my toes for the past two hours and he got, oh about 2 mL of breastmilk. (yes, that’s basically 4 drops).  In between the attempts at feeding I was pumping so that there was milk to supplement him with in addition to the formula.  I was also trying to stock up so that when I did have to go back to work at the end of the month, I’d be able to have a store in the freezer.

Ugh, feeling like you are a dairy cow your first days home with your new baby, while being sleep deprived, hormonal and stressing over how much your little one is getting made things a little rough in the beginning.  Thank goodness for a very supportive husband!  I could see how easy it would be to just say, “Okay, go ahead and give him formula.  I’m sleeping tonight”.  Ahhh, it would’ve been so easy but my husband believed in breastfeeding as much as I did.  It’s hard to deny the literature when you are scientifically minded.

There was a “Day One” center near our home in San Francisco and near daily trips filled our first week to get breastfeeding supplies.  Thank goodness for such a resource!  I’d love to be a resource for others in such a way.  A Medela Supplemental Nursing System was our first attempt.  That was no easy task to tape that to the nipple, wear a necklace with a small plastic container on it and get him to take it in.  It was constant feeding, weighing, diaper changing, weighing, and pumping, repeat.

I recall our first pediatrician visit.  Immediately before the appointment he had a pee and I cried, “that’s 30mL lighter he is going to weigh!”  The pressure to weigh in daily a pound or so heavier was intense.  Looking back, it was a lot of pressure that I put on myself to breastfeed.  How can I counsel my patients about it, if I couldn’t do it myself?

Our first visit was with a nurse practitioner who was a lactation specialist.  She helped us latch and yet he still only got a minimal amount.  I cried.  I’d asked her about a breast shield and she recommended we wait.  We sat in there an hour trying to get him to feed.  Our new assignment was to get additional breastmilk/formula mix via a syringe following attempts at breast feeds.  We’d see her tomorrow.  So, for the next 24 hours I remember stressing about getting enough into him and hoping he didn’t pee or poop right before our appointment weigh in.

So, the cycle continued.  This next 24-hour cycle, intermittently giving syringe feeds to get enough in.  I’d been pumping like mad in between feeds too so that we could get rid of the formula.  Oh, how obsessive we were about this whole breastfeeding thing.  It’s all recorded on Kadin’s App on the iPhone.  I’ll have to figure out if I can download this data at a later date, just to show.

We had an appointment the next day with another lactation consultant in addition to the pediatric nurse.  Thanks to syringe feedings overnight he got enough and made his weigh-in that visit.  We again tried to feed in the office and the amount was minimal, again she recommended we wait on the breast shield.  I wanted to try something and was beginning to feel more than a little frustrated.

Later that afternoon I had another appointment with a different lactation consultant.  She worked with us for nearly two hours and we had moments of success.  Again, I asked if a nipple shield will help and yippee, she gave me approval to give it a shot.

Thank you Medela!  The partial coverage nipple shield maintained a sense of contact with my little one and amazingly, once I figured out how to put it on, our feedings instantly improved.

We still had to supplement with syringe feeds and he seemed to always be feeding but by the end of the first week we were released from further regular weigh-ins and we returned the scale.  We finally got to enjoy our little one and stopped our obsessive recordings.

It took about a week to finally get rid of our “training wheels” so to speak.  One day when feeling particularly confidant I decided to pull it off mid-feed.  While I wouldn’t say it was comfortable exactly, I had nowhere near the pain I’d experienced before and it finally seemed he got enough during the feed, we both just clicked and it FINALLY, seemed like the natural thing to do.

Even with it being my Chief year of residency we actually made it nearly ten months of exclusive breastfeeding!  My goal was a year so I was shy of that goal but felt okay when the day came that production was down, the stores in the freezer were decreasing, and he was taking in more solid food.  However, the benefit of that effort was worth it!  He got all the benefits of breast milk and I got to bond with my child.  It’s hard when you are in the midst of a hormonal and sleep deprivation haze to be rational so I decided to write down for myself what I’d um, tell myself next time.

Basic Breastfeeding Recommendations:

  1. Don’t stress too much!  If you are pumping and feeding your little one breast milk, they are getting the needed nutrients and immune cells, even if it’s administered via a bottle.  It’s okay if you have to supplement with a little formula, it won’t kill them.  Plenty of children were raised on formula alone.  I even found out from my mom that starting with my second week of life she switched to formula only.  I like to think I turned out OK. Get support from family/friends!  Thank goodness for my husband who was so incredibly supportive and when Kadin and I would get frustrated, he was a calming voice.
  2. Get support from family/friends!  Thank goodness for my husband who was so incredibly supportive and when Kadin and I would get frustrated, he was a calming voice.
  3. Get outside help early!  It helped to know that I had appointments with lactation specialists.  Even if we weren’t solving all the problems yet I was checking in with someone else who always had some new suggestions to try.
  4. Breast shields may actually help!  I understand the concern of the pediatric nurse and Kadin not getting enough milk or using it as a crutch but once we started using it things seemed to dramatically improve.   At least I wasn’t in tremendous pain anymore and I could help express milk into the shield for Kadin to drink.  It was a crutch for just about a week but allowed us to get the feeding latch down so when I took it off we were both ready.
  5. Breastfeeding pillows can help!  Borrow from others and use your own cover until you find something that works for you.  I know people who bought a bunch of different ones.  Seems kinda wasteful to me but when you have a new little one you are just trying to find the best thing around.  I found the borrowed Boppy worked fine for me.  My sister-in-law ended up using My Brest Friend.

Since I’ve been reading more about organic products, while the Boppy and My Brest Friend have organic versions of their products, there are a couple of smaller companies that I wish I had known about before.  If you are thinking about buying one maybe support one of these smaller companies who practice a sustainable business model.

Holy lamb is a company with a great ‘feel’ when you read about them.  They produce essentially an organic wool Boppy.  They make their products in the United States using locally raised wool, re-use, recycle or compost all their materials, and subscribe to green practices in their facilities.

Another small company with sustainable practices and a small town feel is Blessed Nest.  ”Made locally by hand, by moms, aunties and grandmas” as their website proclaims.  They make an intriguing half-moon nursing pillow I would’ve liked to try, may be more comfortable for larger women or those who had a cesarean section and don’t want to put something around their middle.  It’s made from 100% organic cotton fabric and stuffed with buckwheat hull filling.  They claim the buckwheat hull filling latches and help it conform for support.

Just keep working at it and it will eventually click!  You may have to feel a little like a dairy cow, pumping to keep up your supply, but persistence really did pay off.  I feel like I gave my little one the best start possible and once we both got it, it was sooo worth it!

Friends of ours recent birth of a little boy, who are having difficulty breastfeeding, reminded me of our own experience, not that long ago and yet a lifetime ago.  This is dedicated to all mommies having a tough time breastfeeding and thanks to their support crew.  Keep it up; you’ll get there!!

Be sure to see your lactation consultant if you are having difficulties!


Bikram, Baby!

Pregnancy and Bikram Yoga

As an obstetrician-gynecologist whose primary mode of exercise and personal well-being has become Bikram yoga, I wondered what was out there in terms of research on Bikram yoga and pregnancy.  There has been so few pregnant women attending the classes I’ve been in; I began to wonder if women just stopped during pregnancy. There are no prenatal Bikram yoga classes, so an entire group of women seemed alienated from the practice.  So, what is there in terms of research pertaining to pregnancy outcomes in Bikram yoga practitioners?  Basically nothing!

Given that fact, one has to extrapolate from physiologic changes in pregnancy and those occurring during the Bikram series to make recommendations. Here’s what I’ve concluded to tell my patients who are Bikram yoga practitioners and want to continue during pregnancy.

A woman has to consider that there are numerous changes that take place to maintain a pregnancy.  Briefly, in the first trimester, basal metabolism begins to increase and ultimately requires an increase by as much as 300kcal/day to support mother and growing fetus, while increased rates of filtration at the level of the kidneys can lead to loss of important nutrients (Weissgerber 2006).  The addition of any exercise requires additional calorie intake to support a growing pregnancy.  Blood volume increases but with greater plasma volume than red blood cell volume, resulting in physiologic anemia.  This makes the transport of oxygen to the mother decrease to some degree.  Systemic vascular resistance decreases, leading to a decrease in blood pressure and this leads to an increased heart rate, which nadirs in the second trimester. Decreased blood pressure can lead to decreased blood flow to some important areas of the body such as brain or placenta potentially.  As uterine size increases there is increased pressure on the venous system that can lead to lower extremity swelling, influences respiratory changes that lead to an increased perception of need to breath, and alters a woman’s center of gravity.  All aspects of exercise tolerance. The hormone relaxin leads to musculoskeletal system changes with softening and relaxation of joints in preparation for childbirth, increasing flexility but also increasing risk of injury.

Research now supports that pregnancy should include a component of exercise, as moderate intensity activity has been shown to be beneficial in healthy women with normal pregnancies.  Key in that statement is HEALTHY women with NORMAL pregnancies.  In 2006, a Cochrane Review found 11 studies, with 472 participants, looking at exercise effects on maternal and newborn outcomes (Kramer 2006).  The conclusion was that exercise improved or maintained fitness, but they ultimately determined that data were “insufficient to conclude that exercise during pregnancy influences maternal and newborn outcomes”.  More recently, a Medscape review article, “The Effect of Exercise During Pregnancy on Maternal Outcomes: Literature Review of Exercise During Pregnancy” (Lewis 2008) identified 40 articles including observational and randomized studies and concluded there were reduced rates of hypertensive disorders of pregnancy, gestational diabetes, cesarean section rates, pregnancy symptoms, decreased weight gain, and psychological issues during pregnancy in women who exercised (Morris 2005, Impact 2006).  The American College of Obstetricians and Gynecologists now recommends that women with low risk pregnancies participate in moderate intensity activity, a minimum of 30 minutes, most days of the week (ACOG Committee Opinion).   This does not apply to anyone deemed a high-risk pregnancy and there are obvious activities that pregnant women should avoid such as anything where impact may occur (ie. football, soccer), falls could be sustained (ie. horseback riding, biking) or significant pressure changes encountered (ie. scuba diving).

So, given the physiologic changes in pregnancy and recommendations for some exercise with pregnancy, how does Bikram Yoga fit into this recommendation and what are some of the concerns?  The 90-minute, 26 posture series, can be intense at times especially given the heat of between 95-105 degrees fahrenheit and 40-60 percent humidity.  However, for practitioners who have been doing the series for a minimum of 6 months regularly, there appears to be no reason it can’t be continued with precautions and modifications.  One should proceed with exercise after approval by one’s personal obstetrician-gynecologist, knowledge of your pregnancy by your Bikram yoga instructor, and at the practitioner’s discretion.  The main concerns that arise with practicing Bikram yoga during pregnancy are what occurs with core body temperature during the series.  This is especially true during early pregnancy when the neural tube (ie. central nervous system) is forming.  An additional concern throughout the pregnancy is uteroplacental blood flow with adequate oxygenation, hydration, and substrates to support a growing fetus.

A core body temperature of greater than 102 degrees fahrenheit for more than 10 minutes has been shown to increase risks of neural tube defects in a developing fetus and in a more developed fetus lead to dehydration and potentially reduced amniotic fluid volume.  This most often occurs during fevers but also can be caused by extremely heavy exercise or prolonged exposure to heat sources such as hot tubs or saunas.  Although there are suggestions that extreme temperatures may increase the risks of gastrointestinal and cardiac defects, the only consistently seen defect are those of the neural tube.  Avoiding excessively increased core body temperatures in the first trimester is one way to reduce the risk of neural tube defects, along with taking supplemental folic acid.

The key question is:  If Bikram yoga or ‘hot’ yoga changes core body temperature to above the 102 degrees fahrenheit level for long enough to cause neural tube defects or dehydration in a developing fetus?

Normal range of oral temperatures for females is 36.5-37.3 celsius (97.7-99.1 fahrenheit), with the lowest temperatures being in the early morning hours and peaking in the late afternoon and early evening.  Therefore, ‘hot’ yoga in the morning would be less likely to increase core body temperatures to a concerning level.  Our bodies are expert at regulating and maintaining our core temperature when the surrounding temperature changes, especially if the body grows accustomed to the heat and humidity.  This is one reason why only women who have been practicing Bikram yoga should even consider continuing. This is not a form of exercise I’d suggest starting during pregnancy.  Studies have shown that individuals become acclimatized to heat, developing increased tolerance in hot and humid conditions in 1 to 3 weeks (Guyton, 2006).  The primary way the body maintains the internal temperature in Bikram yoga is through evaporation in the form of sweat glands and dilation of blood vessels, which helps to cool the body.  However, with increasing humidity thermoregulation can be inhibited by limiting sweat evaporation and heat loss (Guyton 2006) and external cooling, with a cool towel or water may aid with temperature regulation.  Increased blood flow to the skin and expanded skin surface area actually have been shown to increase a pregnant woman’s efficiency with temperature regulation, helping her rid her body of excess heat when compared to non-pregnant women.

Over the course of pregnancy, potentially because of an increasing metabolic rate and body surface area, core temperatures have been shown to decrease.  A small longitudinal study of 15 women (GA 8, 16, 26, 36, and 12, 24, 52 weeks postpartum) found maternal core temperature to be highest in the first trimester with a decrease during pregnancy.  At 8 weeks temperatures averaged 37.1 celsius and decreased to term with the nadir of 36.4 celsius at 12wks postpartum, then stabilized by 24 weeks postpartum (Hartgill 2011).  In a general search on the web and in speaking with my yoga instructors, there are many anecdotal stories of women who continued with Bikram yoga during pregnancy without complications.  Simply because there are reports of women and their infants doing fine when the woman practiced Bikram yoga during her pregnancy, does or does not mean it is necessarily not hazardous.  I’d equate it with women who smoke or drink during pregnancy, there are reports of normal pregnancies in those situations as well.  Even initial studies are needed.  Something as simple as a retrospective review of rates of complications in women continuing Bikram yoga practice while pregnant are lacking.

In trying to find information about core body temperature changes during Bikram yoga, one yoga studio conducted an informal “experiment” by having two pregnant women take their oral temperatures before class, three different times during class and again following class.  Neither saw a noticeable rise in temperature, with one reporting lower temperatures during class than at other times during the day.  During another class this studio took the temperatures of 12 non-pregnant individuals before and immediately following class and noted the highest body temperature recorded of 101.5 with an average post-class temperature of 99.7.  However, considering core body temperature differs from oral temperatures by approximately 0.8 degrees, the highest temperature of 101.5 would be above the recommended maximum of 102 degrees. However, we do not know how this fluctuated during class or how long the temperature was maintained.  Although they do not specify women versus men or the time of day these temperatures were taken.  Some general recommendations, if a woman wanted to continue practicing, would be to go in the morning, ask the instructor where the coolest spot in the room may be, drink plenty of fluids to maintain hydration, take a thermometer to monitor one’s temperature during the sequence as everyone will have a different range, take a squirt bottle with cold water in to provide external cooling if necessary, listen to your body by substituting the postures with appropriate pregnancy postures and by taking breaks to cool down and if it requires leaving the class to cool down, yoga etiquette or not, for your safety, exit quietly.

Another issue of concern is uteroplacental blood flow, dehydration and maintenance of nutrients to the fetus throughout Bikram yoga practice.  With increasing basal metabolism and increased filtration at the kidneys it is important that pregnant women maintain adequate nutrition through diet and supplements.  I’ve heard that a session of Bikram yoga burns 600-800 calories for the average woman, increasing calorie intake and taking appropriate supplements is necessary for women to continue practicing.  Eating before class and taking a snack for immediately after would be encouraged.  Even when not pregnant, going to class hydrated and maintaining hydration throughout class is important.  Supplying additional electrolyte rich fluids can help maintain osmotic pressure intravascularly to prevent further decreased blood pressure.  With further vasodilation for cooling, pregnant women may begin to feel light-headed easier as the blood flow is diverted to the skin.  Fetal hemoglobin will insure the fetus will obtain sufficiently oxygenated blood flow but staying well hydrated and sitting if any indication of feeling light headed would be important for mom.

Some general concerns is that first trimester is very critical to fetal development with organogenesis occurring by the end of the twelfth week of gestation.  Any teratogen will have it’s greatest influence at this critical time.  A difficult aspect is that women often don’t know they are pregnant in the very early weeks and because spontaneous miscarriage rates are greater during the first trimester, the legal climate of obstetrics, and often a fear of the unknown, most physicians would likely recommend avoiding many activities in the first trimester.  Rajashree, Bikram’s wife, states that from the second trimester on you can practice her pregnancy yoga sequence.  I was unable to find a statement from Bikram or Rajashree regarding practicing during the first trimester. Think I’ll send her an email.  However, for myself, the thought of not going to Bikram yoga for twelve weeks, if I were to be pregnant, and the effect it would have on my physical and mental well-being would be worth the theoretical risk as long as precautions mentioned above were taken.  Although as I recall during my first pregnancy, from about 7-12 weeks gestation I have never been as tired or nauseous in my entire life so one may not feel up to going to class anyway.  Because of the hormonal mileau wrecking havoc and the energy requirements of the first trimester, there may be times where fewer classes would be in order, more breaks during the series, or incorporating the pregnancy sequence should prevail.

As the pregnancy progresses and the uterus grows, the change of the center of gravity may lead to imbalance during the yoga series.  Taking this into consideration, positioning oneself near a wall, using a bar during some of the series, or adjusting the series as necessary may be required.  Additionally, the hormone relaxin allows for softening of the joints and increased flexibility.  Keeping this in mind, the heat already improves flexibility so women should be particularly cautious when doing postures as to not overstrain or injure themselves by doing something they wouldn’t normally be capable of doing prior to pregnancy.

So, how does the Bikram yoga pregnancy sequence differ?  First, according to the Bikram Yoga Website and Bikram’s wife Rajashree’s pregnancy video she recommends seeking the advice of a doctor before proceeding with Bikram Yoga (I would agree!).  If medically cleared by a physician, without any high risk pregnancy issues, have been practicing Bikram yoga for a minimum of six months, but preferably a year, and plan to continue Bikram yoga throughout your pregnancy then the following adjustments are recommended.  While Rajashree’s pregnancy video provides an alternative sequence and can be done at home, practicing with your normal class requires a few adjustments.   She notes that from the second trimester on you can practice her pregnancy yoga sequence and it can be practiced in a Bikram Yoga Class, but at the pregnant woman’s discretion.


Wishing you health and happiness in your pregnancy. In the end we all want a healthy mom and baby.  Please be certain to seek the advice of your physician to ensure safety during this or any other exercise during pregnancy!

While I am a physician, this article in no way a substitute for someone who knows you well, it an attempt to organize my thoughts for myself and for any patients who may ask me about Bikram in pregnancy.



ACOG committee opinion: exercise during pregnancy and the postpartum period.  Number 267, January 2002.  American College of Obstetricians and Gynecologists.  Int J Gynaecol Obstet.  2002; 77:79-81.

Bikram Yoga Website.  (Accessed: August 15, 2011)

Choudhury R. Pregnancy Yoga Video.

Guyton, AC & Hall JE (2006).  Textbook of Medical Physiology.  Philadelphia: Elselvier Saunders.

Hartgill TW, Bergersen TK, Pirhonen J. 2011  Core body temperature and the thermoneutral zone: a longitudinal study of normal human pregnancy.  Acta Phisiol Apr;201(4):467-74.

Impact of physical activity during pregnancy and postpartum on chronic disease risk. Med Sci Sports Exerc. 2006;38: 989-1006.

Jennings E (2010).  Online posting from Bikram Yoga Decatur. (Accessed 08.09.11).

Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Cochrane Database Syst Rev. 2006;(3): CD000180.

Lewis B, Avery M, Jennings E, Sherwood N, Martinson B, Crain L.  The Effect of Exercise During Pregnancy on Maternal Outcomes: Literature Review of Exercise During Pregnancy. (Accessed: August 8, 2011).

Morris SN, Johnson NR. Exercise during pregnancy: a critical appraisal of the literature. J Reprod Med. 2005;50:181-188.

Weissgerber TL, Wolfe LA. Physiological adaptation in early human pregnancy: adaptation to balance maternal-fetal demands. Appl Physiol Nutr Metab. 2006;31:1-11.

World Food Day 2011

What’s for dinner?

Today, October 16th is World Food Day!  I admit, I hadn’t heard about this until recently but I’m learning.

The first World Food Day was celebrated in 1981 and is held in recognition of the founding of the United Nations Food and Agriculture Organization. In essence, the reason for its existence is to increase awareness of hunger and spark conversation on how to alleviate hunger worldwide.

According to the World Bank, in 2010-2011 rising food costs pushed nearly 70 million people into extreme poverty.  Feeding America estimates, even in the United States, 49 million people are forced to skip meals or go days without eating because of their financial situation.  This equates to 1 in 6 people but statistics show the rates are actually higher in children, 1 in 5 who go hungry.  Even with readily accessible food in grocery stores, it is not accessible to everyone.

This year’s World Food Day motto is “From Crisis to Stability”.  Where international markets are concerned, this is a complex topic and one I have very limited knowledge about. However, thinking community and bringing it closer to home, the World Food Day planners put together a nice Sunday dinner discussion guide to think about our relations with food.

It’s easy in the United States to forget “the story” of the items in your store, with farms generally being so separated from the supermarkets where we purchase the bulk of our food.  This guide suggests questions for your guests.  For instance, start by asking where your food comes from and taking a moment to remember the farmer’s who grew it. Other questions they suggest are:  if your guests know any farmers personally, do they grow any produce themselves, or have they personally been affected by price fluctuations in the market (ie. not able to make a favorite meal because of availability or price).

In my own home, before eating, this past year I started asking those at the table to share one thing for which they are grateful.  I found it a way to pause and acknowledge before eating. While there is so much conflict in the world, there too is positivity in our lives.

Do you have any rituals before eating to pause and acknowledge if you don’t have a formal prayer?

"hunger words" - World Food Day USA

Besides asking the questions, Oxfam provided a number of other aspects that affect the food supply chains.  I’ve chosen a few where we, in the United States, may make the biggest difference.

  1. Waste less.  According to Oxfam, sadly, even while some Americans go hungry, consumers here throw away as much as 25% of the food they buy.  In fact, we waste more than we donate in food-aid.  If we cut back on waste, at home and work, we could reduce the amount of food needed and ensure more than enough for others.  The best thing you could do is buy only what you need.  However, other ideas to reduce waste would be partnering with another family to go in on groceries or buy in bulk with others, share with your neighbors, church, family or friends if you realize things are going to go to waste, or donate to agencies and shelters with other families in your neighborhood regularly.
  2. Speak up about corn-ethanol programs.  The Environmental Protection Agency found that corn-based ethanol releases more greenhouse gas than standard gasoline. What a waste then to spend billions of tax dollars to turn corn into fuel!  Let your congress know to stop wasting the funds, write and vote.
  3. Support programs that support farmers.  We rely on farmers for our daily meals; yet, many of these individuals struggle to survive.  There are fewer legal protections for farm workers.  Let legislature know you want safe working environments for those who work on the farms.  In this country, many of the workers are immigrants, whether legal/illegal ask farms to grow responsible and ethical produce. There is w
  4. Voice your opinion via the almighty $$.  Only purchase from companies who support sustainable practices. Better yet buy locally grown food at your Farmer’s Markets or join food co-ops, delivering local fare.


Make everyday World Food Day!


Other things you can do:

Visit the World Food Day USA page –>

Sign the “One Billion Hungry” petition –>

Sign up to help in other ways throughout the year –> Text 30644, type the word OXFAM

                                (Can text STOP at any time)

Donate to Feeding America




Simple Call to Action

Just Think Before You Buy

The more I pay attention, listen to news programs, and read articles, the more I feel like I have to, as the famous quote by Mahatma Gandhi reads “be the change you want to see in the world”.

I can feel myself getting angrier about injustices toward each other and to the planet.  These ultimately are injustices towards ourselves.

Was it listening to NPR and the physician guest on there was speaking about all the harmful ingredients we were adding to our ‘health care’ products?  Seems ironic that health related products ultimately might make us sick.

Was it the day I was picking up my child’s toys and noticed everything had the embedded phrase “made in china”?  That same day I heard a story about a factory in China that was using developmentally disabled children as slave labor.

Maybe it was reading about the amount of chemicals used in producing our crops that are ultimately poisoning us in our food or water and then taking a drive down 5-South and seeing those crops being sprayed.

Could be wondering what potential issues with genetically engineered crops may arise in future years?  I’d much prefer an organically grown fruit/vegetable, I wonder those that aren’t marked as such where do they come from?

Although always aware, on some level I suspect we too often choose to ignore so that we can stay sane.  Ignorance is bliss but once you become conscious of injustices how can you not take action, say something, do something, even little things in your own life?

A simple way we can effect change as a consumer is with the all mighty American dollar.  While it may not be wielding the power it once did (with our credit rating downgrade and all) it still gets a point across.  So, at a minimum start thinking about your purchases.  I’m all about encouraging thrift store finds.  The sale of these items sometimes supports a good cause but at a minimum is at least re-using items. With my husband’s family size, we love to receive and pass along hand-me-downs and hey, once it falls apart those clothes can be used as rags.  When you do buy something new, a new motto for myself is: “be conscious” about where the item comes from.  I’m starting to think more when I shop.  Admittedly, this is not easy!  It takes time and the ease at which I used to purchase things has gone by the wayside.  A want exists and then I find I have to analyze it before I buy.

The Lowell Center for Sustainable Production in Massachusetts evaluates companies’ ecological health and they came up with these five questions to ask before you buy:

* Is the product healthy for consumers?

* Does production benefit local communities?

* Is the product economically viable?

* Is the product environmentally sound?

* Is the production process safe for workers?

Start asking yourself these questions.  We should only buy items if we morally support the answers.  Shop with integrity!

There is no reason that companies can’t be more innovative by designing and producing products with sustainability in mind. The future of industry should be one where they play a significant role in supporting communities and simultaneously working toward reducing their impact on the environment.

Ha!  Asking companies to have a conscience, is that too much to ask?  There are those that do and I’m now specifically looking for them.  Sure they have to make money, it is a business after all, but how much do they need at the expense of human life, health, and the environment?

“You may never know what results come of your action, but if you do nothing there will be no result “ – Gandhi

Bikram Yoga for ALL!!


“Ninety minutes of hell…sooo worth it”, Troy, my yoga teacher at the Tri-Valley Bikram’s Yoga studio, proclaims during class.  Enthusiastically, I inwardly agree while dripping sweat and struggling with the current posture du’jour.  With an ideal temperature of 95-105 degrees and 40-60% humidity, Bikram Yoga (also called “hot” yoga) can indeed feel like hell, especially for the new practitioner and even at times for the few month practitioner – like myself.

Before I go on, a little about Bikram Choudhury, the creator of the ‘hot’ Yoga series.  He began practicing yoga poses at age three with renowned guru Bishnu Gosh, and won numerous championships by age 14.  At the peak of his practice he was doing yoga 16-20 hours daily.  As an avid athlete in his youth he suffered a knee injury at age 18 and was told by physicians he would never walk again.  His guru put him on a strict regimen of rigorous yoga practice, which healed his knee.  When he arrived to the United States, he wished to share yoga with Westerners and reduced the hundreds of yoga postures to a 26 posture series, with two breathing exercises aimed to improve the entire body.

After practicing just over three months, the improvement I’ve noticed in my physical and mental health makes me believe that everyone should be prescribed a regular schedule of Bikram Yoga practice.  Let me tell you how I found myself in this room, why I continue to do this for myself, and why I think everyone should take up this practice.

Just over three months ago I was experiencing sciatic pain that I’d had for two years, since the birth of my first child.  The sciatic pain was becoming unbearable and I needed to find a way to alleviate the pain.  I’m also a doctor and really believe in diet and exercise as the first steps to improving one’s health.  I wanted to avoid relying on pain medications, if I could help it.  So I read and tried stretching, various exercise, and classes at my local gym, without much in the way of improvement of the sciatica.  In searching for options, I came across the story of a woman who had back pain that improved through Bikram yoga and I decided I had nothing to lose, except potentially the pain, and decided to give it a shot.

After reading multiple stories of healing, I decided it was worth the drive to the closest studio open, Bikram Yoga East Bay, and I started attending.  The Tri-Valley is now fortunate enough to have a studio that just opened up in Pleasanton, Tri-Valley Bikram’s Yoga.

Admittedly, walking into the first class, it’s hard to ignore the heat.  By the time you finish the first pranayama (ie. breathing exercise) sweat beads are building on your skin and you start wondering just what you got yourself in to.  All that the instructor asked of me that first class was to do what I could, if I needed a break to sit and try to stay still, and whatever I do, don’t leave the room.  Sounded simple enough but I started to second-guess my choice almost instantly.  How would I endure 90-minutes in this heat doing yoga?  However, I bought an unlimited 10-day intro pass so I was determined to at least try a few times, unless this first class killed me.

By savasana (lying still, “doing nothing” ie. corpse pose) I am feeling light-headed.  As I lie there the ceiling seems to be closing in on me, my breathing became more rapid, and the Beatles line, “I am one-we are one-we are all together” starts to circle through my mind.  I realize I’m getting tunnel vision and I start to think I must be passing out, which doesn’t help the feeling of panic that feels like it is wafting over me.  Before I get the chance to pass out though, it’s time for the next posture and I find my body just starts moving, listening to the instructor’s words and doing the posture as best I can.  One of my teachers now jokes that I was such a mess those first few classes!  Keep that in mind when you go.  That person in the front row of class had to work to get there.

When the end finally arrives and I lie there for final savasana, I find that I somehow feel cleansed, both my mind and my body.  I’m soaked, as though I just jumped in the spa and then sat in a sauna with all my clothes on, but I feel great, and all before 730am.  At this point, I made the promise to come back…

Now fast-forward three-months and it’s become a habit, attending 4-6 times per week since I started.  Only regret is: I wished I started much sooner!   However, as Bikram notes as passed on by his guru, Bishnu Gosh, “It’s never too late, it’s never too bad, and your never too old or too sick to start from scratch once again”.  It’s also called ‘yoga practice’ so some days are better than others.  However, because it is the same 26 postures, from day to day your mind and body are different and you learn to be patient with the process.

I now can’t help but encourage everyone I know to at least give it a shot. Maybe hot yoga isn’t for you but yoga practice of all kinds has been shown to be beneficial for the mind and body.  My mother calls me the, “yoga pusher”.  I’d been talking about it so much that when she last came to visit I encouraged her to come with me.  She is so glad she did and has been going regularly since she started.  Her only complaint, is the same as mine, she wished she started earlier.  Don’t delay!

As for the reason I started in the first place, that sciatic pain…gone!  Still am working on those tight hamstrings but I no longer have the shooting sciatic pain that plagued me.  It didn’t happen immediately and there continues to be difficult classes but with perseverance and commitment, I now believe it can cure pain or at least reduce it. I’d prescribe it for my patients to help with pain and for overall improvement in their life and sense of well-being.  Not to mention helping me to get rid of trailing post-baby fat!

Another Bikram quote is, “sure it’s hard, but which would you rather do: suffer for 90 minutes in a Bikram class, or suffer for 90 years as you live your life without a truly healthy body and without realizing your potential?”.

So is the ninety-minutes of hell worth it?  Absolutely!!

If you live in the Tri-Valley Area:

Bikram Yoga East Bay is located in San Ramon at 3120C Crow Canyon Rd.

Tri-Valley Bikram’s Yoga is located in Pleasanton at  3283 Bernal Avenue, Suite #109.

See their websites for details, class schedule and rates.

 *Be sure to contact your personal physician before beginning this or any exercise program

Driver’s Guilt

Individual Carbon Offsets

After months of being home with my little boy, it’s time to return to work.  I should feel fortunate that I have been able to find a job, however, it’s 45 miles away.  That’s 90 miles per day of driving just for work travel alone.  In my previous life, I maybe drove that much weekly.  With time to think during my approximately 50 minute drive; I began to feel some guilt about my new commute.

Using the Cool Climate Network from the University of California, Berkeley calculator ( I determined my additional carbon footprint.  Annually, for commuting to and from my new job CO2 emissions total 13.3 metric tons or about 1.11 metric tons of CO2 monthly.

Ultimately, I’m hoping to find my way to a closer clinic but in the meantime, what can I do to alleviate my guilt?  With this being my first week of driving 90 miles daily, I’m not quite ready to buy an electric car, although that may be in our future, but for my conscious’ sake I decided to look into what carbon offsets are all about.

Paying in order to reduce pollution guilt probably has been going on for much longer, but one of the first examples I could find was in 1989.  Applied Energy Services, promised to plant millions of trees in Guatemala in exchange for building a coal burning power station.  California now has a law, Assembly Bill 32, which is aimed at reducing carbon emissions of larger companies.  An allotment of emissions is permitted and if companies go over this allotted amount they must purchase carbon offsets and if they are under can sell carbon offsets to other.

When I started, I naively assumed that there was a single place to purchase carbon offsets, a central government agency of some kind, but that is far from true.  In fact, there seems to be no government regulation of carbon offsets but rather independent certification agencies. There are numerous companies who finance and build projects that claim to reduce greenhouse gas emissions on your behalf.  From looking at many websites where you can purchase carbon offsets, most often these companies put the money into renewable energy or efficiency projects.  This actually is considered a renewable energy credit, not a carbon offset.

I wanted to find a true carbon offset, where a reduction in greenhouse gas occurs, not just alternative energy produced or future trees planted.  Given that my new commute involves the central valley [in California] and this region is filled with farms, I sought out projects that seemingly reduce greenhouse gases directly.  This can be done by anaerobic digester systems, something I learned about during this research.  Animal manure is contained in these digesters, preventing methane gas release, which is about 20 times more potent than CO2 when combusted.  Instead of being released the methane can be transferred to a modified gas engine generator producing electricity.  It can be used on the farm or transmitted to the power grid for sale to power companies. Like everything there are issues, but reducing methane emissions and potentially producing power, is incredibly appealing.

Stop Methane Emissions

So, the search begins.  Immediately, articles about fraud began to surface.  It does seem easy to charge people for carbon offsets and then do nothing with the money, well, besides pad bank accounts.

Since the idea of carbon offsets seems like such an abstract thing but I am a tangible person, I wanted to narrow my carbon-offset purchases down to a specific project.  I’m one of those people who want to know the project’s story.  Maybe even visit the project. The more I read, the more complicated I realized this carbon offsets thing is and things I hadn’t thought about before began to surface.

A few of the pointers that arose were:

(1) being sure that the projects you ‘invest’ in wouldn’t have been funded without the carbon offset support

(2) the company where you purchase the carbon offsets can not re-sell

(3) projects are verified by an independent auditor

(4) tree planting carbon offset projects aren’t the way

(5) seek projects that are planned for the immediate future or already underway

How do you find a reputable carbon offset company?  I’m still not 100% sure! I read about the programs and found one that I particularly liked.  As a PG&E customer, I was surprised to find out that they have a branch called ClimateSmart and had partnered with California Bioenergy, a company that specifically works in this area. Through PG&E apparently one can offset their energy use based on monthly energy expenses. There is a video on the PG&E website about this carbon offset project:  I emailed California Bioenergy to find out if I could purchase directly through them but am awaiting a reply.

Since I was hoping to find a one-time offset for this month of commuting, I found another one in the United Kingdom that I could get behind.  As a Women’s Health provider, I couldn’t help but put my carbon-offset this month into this unique idea.   PopOffsets ( provides funding to programs for family planning to women in countries where they can’t afford access, preventing an undesired birth and potential births down the line.  Potentially, this offset may have the greatest impact of all.  They estimate $15 per cubic ton of CO2 as an offset.  So in my case, for driving to and from work alone this month totals $16.50 compensation in carbon offsets. Even if it is just a “donation” to a cause, it’s one I believe in!

Better yet would be reducing your carbon footprint instead of trying to rectify the situation.  I am still trying to walk when I can but as many Americans are probably doing now, you have to go where you can find a job.  Since this is a reality for me now, paying for carbon emissions at least makes me think about my contribution to global pollution on a regular basis and if I can’t reduce my drive to work, I will work to reduce my carbon footprint elsewhere and contribute to other ways to reduce carbon emissions, whether or not they are considered a true carbon-offset.

Organic Living. A Beginning.

I’m not sure exactly when it happened.

Definitely, after finishing residency and having time to think.  While in residency you are barely hanging on and I was lucky if I made it to the grocery store, let alone be conscientious about what I was purchasing.

Like, I’m sure it happens for many, the birth of my first child got me thinking more about my own health and my family’s health.  As a physician getting ready to enter her own practice, I also began to feel obligated to think more about what is in our food, our household products, our clothing, and our environment for the sake of my patient’s.  After all, they were bringing babies into this world too.

Once residency ended, I decided I needed to take time to devote to my son, born during residency at University of California, San Francisco, and figure out the next steps for my family.  It’s hard to get off the treadmill of a medical career when you’ve been on it for so many years but it gave me a chance to think about what is truly important.

My husband and I had toyed with the idea of moving to Hawaii, a place we both enjoy.  Instead we found ourselves in Livermore, just about the opposite of Hawaii.  My husband had grown up there and with our little one a Nana, Pop-Pop and Kiki (auntie) nearby had new meaning.  Other family members also live relatively close with their children.  With family and friends already there it felt like a naturally established community.  Finding somewhere where we could build our family and community became a top priority.  Funny how much a child changes your life, in so many ways!

After making the decision to take time off to care for my child, move to Downtown Livermore, and ultimately, revert to simplifying life it’s impossible not to begin to ponder other aspects of your life.  We planted a garden.  We shop at the weekly Farmer’s Market.   We walk everywhere we can, son in the red wagon for shopping trips a few blocks to the grocery store.  Just about every Sunday we spend the evening at my in-laws for dinner.

This simplicity of life translated into learning more about healthful living, natural ingredients, and ways to reduce our ecological footprint.  Our children’s futures depend on it.  The self-centeredness of caring only for yourself and hanging on just to get through residency evolved into thinking more family centered about how to improve the health of my family.  It’s further expanded to concern regarding these issues in my community.

As someone whose always liked to write and often kept journals, to solidify the information I am learning and make the commitment to the universe, I am now choosing to write about and share it.  While not an expert in these matters, you will be accompanying me on my learning journey and maybe find your own journey in the process.

Here’s to improving our health, the health of our community, and the world…one choice at a time!