Hawai‘i Doctors Answer Your Health Questions
We asked some of the state’s top physicians, many of them straight off this year’s Castle Connolly list of top doctors, about everything from GLP-1s to brain health and hormone replacement therapy.
Dr. Ankur Jain
Gastroenterologist and associate clinical professor, John A. Burns School of Medicine
How worried should we be about the dangers of microplastics? Should we be revamping our habits?
Scientists are finding that microplastics are everywhere—in our food chain, air, clothing, and even our bodies. “Recent research has shown that adults are likely ingesting the equivalent of about one credit card of plastic a week,” Dr. Ankur Jain says. This could negatively impact our health. One study published in The New England Journal of Medicine in 2024 suggested a link to various conditions, including cardiovascular disease. “Other studies have potentially shown risks to productive problems, like infertility, cancer,” Jain adds. This is due to the biological changes the plastics are inducing, including increased inflammation, disrupted immune systems, tissue breakdown, metabolic problems and developmental disorders. Microplastics may also disrupt the gut microbiome, which could lead to conditions like IBS and colon cancer.
If you’re curious about the microplastics in your body, there are commercially available tests, but Jain urges caution. “You can check for these things, but what exactly you’re checking for and the levels that are actually concerning, we don’t really know,” he says.
To reduce microplastics consumption, Jain advises lifestyle changes. “The consensus from a lot of experts is that we should start cutting down day-to-day use as much as we can, especially the single-use plastics, which tend to be more harmful.” Heat can cause plastic breakdown and leaching, so Jain recommends avoiding nonstick and plastic cookware, skipping plastic dishware when warming up food, and handwashing plastic items. He also suggests using glassware for leftovers, wearing clothes made of natural fibers, and using plastic-free toiletries and cosmetics. —BT
Dr. Jessica Johns
OB-GYN, Kapi‘olani Medical Center for Women & Children
Now that the black box warnings on hormone replacement therapy have been removed, should perimenopausal and menopausal women consider it?
Late last year, the FDA removed several of the black box warnings for hormone replacement therapy products for menopause, including the risk for breast cancer, cardiovascular disease and dementia. (There is still a warning for endometrial cancer for systemic estrogen-alone therapy.)
Dr. Jessica Johns sees the FDA decision as a positive development for the millions of perimenopausal and menopausal women experiencing symptoms. “It was too overarching,” she says of the previous warnings, applied in 2003 after a study from the ’90s. “We’ve had more robust research done over the last two decades, and a more significant safety profile has been established from that research.”
The average age for menopause for women in North America is 51, and most of the women in the previous study were in their 60s. “What wasn’t well-established at the time but has been since it’s been reevaluated in the last 30 years is that a lot of those women already had preexisting conditions, or perhaps risk factors that put them at risk,” Johns says. As for the link between HRT products and breast cancer, the current data doesn’t eliminate it, but the at-risk population is smaller than originally thought.
Starting hormone replacement therapy “in your 50s carries less risks than starting in your 60s,” Johns says. “The ideal timing is within 10 years of going through menopause.” She begins discussing it with perimenopausal patients when they’re in their 40s. Symptoms are subjective, but if you don’t feel like yourself and “this is something you’re experiencing on a routine basis that’s interfering with your daily living, with your daily sleeping, it’s carrying over into work or relationships, it’s really something we should chat about.”
There are several FDA-approved options. “The usual treatment that helps patients feel better when they are wanting to start hormone replacement is the estrogen component,” Johns says. It’s available as a patch worn on the skin, an oral form and a topical gel. Some women may need to balance the added estrogen with progesterone therapy, which protects cells in the uterus. “Going in for a full hormone testing panel is not actually recommended because those numbers fluctuate so significantly on a day-to-day basis,” Johns says. Someone who’s not fully menopausal will have changing values at various stages throughout the month. —BT
Dr. Gina Kellner
Child and adolescent psychiatrist, Kaiser Permanente Hawai‘i
How do you determine whether your anxiety is normal or if you should seek professional help or need medication?
Everyone has some anxiety, says Dr. Gina Kellner. “That’s our physiological response, that fight-or-flight when there is some kind of danger or fear.” An anxiety disorder is when you have an excessive or exaggerated response to a person, perceived threat or fear. “I often call it fight-or-flight on steroids,” she says. When the level of stress and anxiety is so overwhelming that it interferes with daily functioning, that may be an indication to seek professional help.
Kellner says there are different types of anxiety disorders. Generalized anxiety disorder is a common one. “If you notice that you do a lot of overthinking and the worries linger, if it’s affecting your daily functioning, like your sleep—you’re lying in bed ruminating, replaying scenarios, what I could have done, should have done, worried about the what ifs—that might be a sign,” she says.
You should also take note of your anxiety levels during social situations. “If you text someone and they don’t respond right away, do you jump to the worst-case scenario?” Kellner says. “Can you order your own food in restaurants? If you can’t find something in the store, do you walk around the whole store and then leave, or do you ask a salesperson for help?”
Common physical symptoms of anxiety include a racing heart rate, shortness of breath and gastrointestinal symptoms such as nausea, diarrhea and constipation. Genetics also play a part. “If there is a strong family history of anxiety disorders, not even if people were just diagnosed, but if it’s suspected, that might be an indication,” she says.
Whether you should be taking medication depends on how disruptive your anxiety is, Kellner explains. She recommends consulting with a doctor, but there are things you can do to improve your mental health, including prioritizing sleep, being physically active and maintaining a healthy diet. “The gut and brain are connected,” Kellner says. “Having a healthy gut biome can help with anxiety.” She advises staying away from energy drinks and processed foods, and making sure you’re eating fruits, vegetables, and both prebiotic and probiotic foods.
Kellner also suggests practicing mindfulness and relaxation techniques. “I encourage having what I call a daily dose of awe, where you’re paying attention to something in nature—the birds, flowers, clouds, sunrise, sunset—just being in the moment,” she says. Staying connected socially with friends and family is also helpful, as well as limiting social media. —BT
Dr. Gregory Gatchell
Bariatrician and lifestyle medicine physician, The Queen’s Medical Center, Comprehensive Weight Management Program
GLP-1s like Ozempic are all the rage. Who should be taking them, given the side effects? And who should not be taking them?
Dr. Gregory Gatchell says he follows FDA indications. Initially, GLP-1s were indicated for diabetes, but over time, it’s expanded to those with moderate-to-severe obstructive sleep apnea and for weight management, specifically for people with body mass indexes of 30 or higher or BMIs of 27 plus “weight-related comorbidities,” he says.
GLP-1s are also prescribed to prevent cardiovascular events, particularly for those who have had a prior cardiovascular event like a heart attack or a stroke. GLP-1s also treat peripheral artery disease when it’s a certain severity, Gatchell says, adding that the newest indication is for something called MASH, which is a more advanced fatty liver disease.
In Gatchell’s weight management practice, GLP-1s are popular, and he sees them as a very helpful tool to manage weight, though he still stresses the importance of a healthy lifestyle. “What we’ve found is that the medications can help achieve greater weight loss than what typically is achieved with lifestyle alone,” he says.
Estimates suggest that by 2030, about half of the country’s population will be in the obese category, and as such, Gatchell expects even more people will consider GLP-1s, especially as their price continues to come down. The FDA indicates that GLP-1s shouldn’t be prescribed for children under 12; there’s no cutoff for older adults. “We do treat some seniors,” Gatchell says.
While all prescription medications have a long list of side effects, the most common ones for GLP-1s are gastrointestinal, typically nausea and constipation, Gatchell says. “But in my clinical experience, people typically tolerate them quite well. We do make patients aware of muscle loss along with fat loss. That’s something we’re very careful to work on minimizing, so making sure patients are getting enough protein and strength training.” —DS
Dr. Jennifer Loh
Chief of Endocrinology, Kaiser Permanente Hawai‘i
How early should women start preventive care for osteoporosis, and what can be done to protect bone density?
We need to think of our bone health as kids, Dr. Jennifer Loh says. “You reach your peak bone density by your early 20s, then it doesn’t go higher. From there, you’re just losing.” Girls, she says, are most rapidly accruing bone density between the ages of 11 and 14, and that’s often when they stop drinking milk. “If you don’t pay attention to accruing bone mass during that time, you won’t achieve your peak bone mass.”
To build bone mass during this critical time and beyond, both girls and women should be eating dairy products, fatty fish like salmon, leafy greens, tofu and nuts, and doing weight-bearing exercises. “For our athletes, we want to avoid restrictive energy deficiency, which used to be called anorexia or eating disorders,” Loh says. “You want to make sure you’re having regular periods, eating enough high-quality food, avoiding smoking [and] drinking excessive alcohol—those types of things that can worsen bone density.”
Loh says osteoporosis is a concern particularly in Hawai‘i because of its large population of Caucasian and Asian women, especially those who are small-framed as they are at increased risk of bone loss. Most insurance companies, she says, will pay for bone density scans earlier than age 65 if you have risk factors, such as earlier menopause. “If you have a small, bony frame, your physician might think about screening you earlier, especially if you have family members with fractures, especially hip fractures.”
There are two main routes of intervention when it comes to low bone density—medication or adopting healthier habits. “We’ve moved away from supplements and are now encouraging patients to get as much calcium and vitamin D through healthy foods,” Loh says. “And weight-bearing exercise cannot be stressed enough. You have to bear your own weight in some way, which can even be done walking. Some people are wearing weighted vests as they walk. But it’s even better if you can lift weights and do strength training.”
For kūpuna, it’s about fall prevention, and some work on their balance with physical therapists. “We do have a threshold where we say, ‘Your bones are looking so weak, and you’re at high enough risk for fractures that we need to start medications,’” Loh says. “But we have lots of newer medications that help you actually build back bone, not just like the older medications that keep the bones stable.” —DS
Dr. Todd Miller
Chief of Urology, Hawai‘i Pacific Health Medical Group Urologist, Straub Benioff Medical Center
What are early signs of low testosterone in men? What are the most effective therapies?
When it comes to low testosterone, libido and sexual health issues get a lot of attention, but they’re not necessarily the most affected areas. The hormone also plays a vital role in muscle strength, memory, clarity and one’s overall well-being, says Dr. Todd Miller. “The biggest thing is watching to see if people go out and walk and their recovery time is longer to get back to being able to do things, if they feel like they’re in sort of a fog, if muscle strength is deteriorating or muscle mass seems to be decreasing,” he says.
Symptoms typically begin in men in their mid-to-late 50s, although Miller has had patients in their 20s. If you’re experiencing symptoms, he advises getting tested by your doctor to establish your levels.
There are a variety of treatments, including gels and creams, which are applied to the upper arms, inner thighs or abdominal wall and absorbed through the skin. They’re convenient but need to be used cautiously as they can transfer to a partner.
Another therapy involves self-injections of testosterone every one to two weeks. “The big thing with injection therapy is you get sort of a roller-coaster effect sometimes of highs and lows because when the first injection goes up, the first couple days, you feel really good, and then as it’s coming down before the next injection, you sort of feel low again,” Miller says.
Testopel is a testosterone pellet implanted in the butt cheek that lasts four to six months. There are also newly developed FDA-approved oral forms, although they may not be covered by insurance. “These are different from the original testosterone oral supplements used in the ’80s, which were causing liver toxicity,” Miller says.
Although testosterone replacement therapy does not cause prostate cancer, if someone is already predisposed to it, therapy could cause it to occur at a younger age, Miller says. Common side effects include acne, oily skin, some breast enlargement or tenderness, fluid retention and skin irritation. “The reproductive effects are sometimes a decrease in sperm count and possibly a shrinkage of testicles over time—that’s the common thing you see with people using it for muscle mass or weightlifting,” Miller says. But long-term use is safe with ongoing monitoring by your doctor. —BT
Dr. Katsuya “Andy” Iizuka
Family medicine physician, Straub Benioff Medical Center – Ward Village Clinic & Urgent Care
There are lots of medical tests now available for people to pursue on their own, covering everything from the gut microbiome to cancer risks. Are the tests helpful?
We have to approach it with caution, Dr. Katsuya “Andy” Iizuka says, adding that many of his patients are inquiring about the various medical tests now available. “I think some of it can be good, but it’s important for people to consult primary care physicians and get their take on specific tests they might want to order,” he says. “Let’s say it’s a DNA test and it gives you a probability for different cancers. Who are patients going to take that result to? If it’s their primary care physician and the primary physician says, ‘That wasn’t ordered by me, I don’t know what to do with that,’ then they just wasted their money. They need to talk about it with their primary care physician ahead of time, so that physician is prepared to go over the results with them.”
The costs of testing, advertised heavily on social media, range from less than $100 to thousands of dollars, and they’re becoming more common. “I don’t have problems with common tests for cholesterol, electrolytes, that sort of thing, but the more problematic ones are DNA testing,” Iizuka says. “I’ve also seen microbiome testing for the gut. When patients come and ask me whether they should do those tests or not, I don’t necessarily tell them not to, but I tell them approach it with caution. So far, I have not found these tests to be helpful because you have to wonder how valid they are. Is it FDA regulated? Has it passed sort of these requirements to know that it’s a trustworthy test? And what do the results mean? Has it been proven in medical literature through research that it is of value? How trustworthy is it?”
With so much health information now accessible through Google searches or AI queries, Iizuka believes health anxiety is escalating. “I do think testing can create more anxiety, especially when it’s testing for cancers and heart disease,” he says. “There’s also genetic testing for Alzheimer’s disease, and some studies say you can detect it 10 years before the onset of symptoms. So what do you do with that data?”
Another concern: data security. While doctors and licensed medical practices adhere to strict protocols to protect patients’ privacy and electronic health records, Iizuka questions whether the companies offering direct-to-consumer medical testing are doing the same. “Have we thought about it if our DNA data got released? Let’s say if my risk for heart attack and cancer was extremely high, if a life insurance company got a hold of that information or health care insurance got that information, I may not be able to get health care coverage or life insurance. These things that are offered online, we need to know how secure it is.” —DS
Dr. David Kaminskas
Neurologist, Adventist Health Castle
How can I keep my brain healthy?
When it comes to brain health, Dr. David Kaminskas advocates a holistic approach. “Brain health is often talked about as if it’s an isolated thing, but we now understand that brain health correlates with good physical health.” That means focusing on eating healthy, sleeping well, exercising on a regular basis, socializing and having meaningful and purposeful interactions. Mental health plays a very strong role in memory, and two major contributors to dementia are social isolation and loss of hearing, so having interpersonal exchanges is key, Kaminskas adds.
To keep the brain healthy, activities such as learning a second language are helpful. Recent data also suggests that people who are physically
active and exercise daily are at less risk. “We think that the very same things that are good for your heart health are probably also really good for your brain health,” Kaminskas says. Dementia and heart disease share a lot of the same risk factors, including a sedentary lifestyle, diabetes, hypertension and elevated cholesterol. “When I look at the healthiest people that I see and spend time with—individuals in their 70s, 80s and even 90s who are really healthy—those are the people who are playing tennis and gardening, who are actively contributing and are engaged in the community, volunteering and caring for others,” he says. “Those are the people who really seem to be beating the odds.”
Supplements for brain health get a lot of buzz, but Kaminskas prefers to focus on healthy diets. He points to eating habits common to the “blue zones,” the five places around the world where people consistently live more than 100 years and have very low rates of dementia. Diets there consist primarily “of whole, unprocessed foods and mostly plants,” he says. Kaminskas recommends whole grains, fruits and vegetables, along with limiting processed foods. Omega-3s are important and best from natural sources. And people should choose a diversity of food types. “It’s really a whole constellation of things,” he says. “You really want to eat the rainbow.” —BT
Dr. Jennifer Mbuthia
Allergist-immunologist, The Queen’s Medical Center
What are the most common food allergies? Are there trends in the types of allergies people are getting today?
In toddlers and preschool-aged children, milk and egg are common early allergies, says Dr. Jennifer Mbuthia. Other common ones in older children and adults are peanut and tree nuts, which include cashews, walnuts and pistachios. While shellfish allergies tend to be more common than allergies to finned fish, Mbuthia says she sees a good amount of both with seafood being so prevalent in the local diet. “I also see a fair number of people who have soy protein allergy, although what I’m noticing more are people who are allergic to sesame, sesame seeds or sesame paste, more so than soy or wheat.”
But a lot of so-called allergic conditions are not true allergies at all, Mbuthia cautions. “I’ve seen increases in true food allergies among children over the last 25 years, but I’ve also seen people with food sensitivity or food intolerance, which are not the same as a food allergy.”
Doctors diagnose food allergies after considering patients’ clinical histories, symptoms that developed, and the timing from when they ate the foods and the start of symptoms. “The testing that does exist for food allergies is only valuable if I suspect your allergic reaction was anaphylaxis,” Mbuthia says. “I’m always encouraging people to leave the interpretation up to the allergist, who can determine what the best testing should be.”
One of the most significant developments has been changing guidelines. “As a former general pediatrician, I remember when we used to encourage parents to avoid allergenic foods, like peanuts, for the first few years of their baby’s life. Then a study came out a little over a decade ago basically saying that’s wrong,” Mbuthia says. The delayed introduction of such foods contributed to an increase in food allergies that developed in childhood and carried into adulthood, Mbuthia says. “It turns out the earlier you introduce peanut protein and allergenic foods, the more likely the immune system accepts that food as being normal and not ‘dangerous.’ I put dangerous in quotes because it’s not peanut that’s dangerous, but the immune system sees it as such. So now the recommendation is to introduce a variety of foods early, and statistically, we are seeing a decrease in food allergies for the first time in probably about 20 years.” —DS
Diane Seo is the editorial director of HONOLULU Magazine.
Brie Thalmann is the home and style editor of HONOLULU Magazine.
