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Before yesterdayHarvard Health Blog

5 inflammation-fighting food swaps

10 May 2021 at 07:30

Inflammation: if you follow health news, you probably hear about it often. When is inflammation helpful? How can it be harmful? What steps can you take to tone it down?

What is inflammation and how does it affect your body?

If you’re not familiar with the term, inflammation refers to an immune system reaction to an infection or injury. In those instances, inflammation is a beneficial sign that your body is fighting to repair itself by sending in an army of healing white blood cells. As the injury heals or the illness is brought under control, inflammation subsides. You’ve probably seen this happen with a minor ankle sprain: the initial swelling disappears within days as the injury heals.

But inflammation also occurs without serving any healthful purpose, such as when you experience chronic stress, have an autoimmune disorder, or obesity. And instead of solving a problem and receding, inflammation like this can last over a period of time, damaging the body and potentially leading to health problems like arthritis, heart disease, Alzheimer’s disease, depression, and cancer.

This is why inflammation has taken center stage in recent years, and why strategies aimed at reducing it are so popular. Many of these anti-inflammation recommendations relate to your diet.

Can changes in your diet reduce unhelpful inflammation in your body?

The truth is, there are still many unknowns regarding diet and its connection to inflammation and disease. What is clear is that having a healthy diet can help improve overall health and longevity. There is also some evidence to support the notion that eating a host of nutritious foods can reduce inflammation. For example, people who eat lots of fruits and vegetables tend to have lower levels of a substance called C-reactive protein, a marker of inflammation inside the body.

In addition, some research has found a link between diets heavy in foods that promote inflammation and a higher risk of certain health problems. For example, a study in Journal of the American College of Cardiology found that people who consumed pro-inflammatory foods, including red and processed meat, refined carbohydrates, and sugar-laden beverages, were more likely to develop cardiovascular disease than those who regularly reached for anti-inflammatory foods, such as leafy greens, beans, and tea.

It may be too soon to draw a direct line between the food you eat and levels of inflammation in your body. Fortunately, the foods that appear to reduce inflammation also tend to be good for you for other reasons. So, focusing on eating these foods can likely benefit your body in more than one way.

5 food swaps to help fight inflammation

A complete overhaul of your diet is challenging, so experts advise making smaller changes over time. Trying a series of simple swaps may add up to better health in the long term.

Below are five substitutions you can use to help reduce the number of inflammation-promoting foods in your diet.

  • Instead of a plain bagel with cream cheese, have a slice or two of whole-grain toast drizzled with olive oil. Whole grains contain substances that help promote the growth of healthy bacteria inside your body. That bacteria may then produce compounds that help to counteract inflammation. Regular consumption of olive oil also has benefits: along with anti-inflammatory effects, it may also help lower blood pressure and improve cholesterol levels.
  • Instead of a carbonated soda, try a cup of green tea. Green tea contains substances called catechins, a flavanol thought to combat inflammation. (Just be careful not to load your cup down with sugar.)
  • Instead of a corn muffin, substitute a handful of unsalted mixed nuts and an apple. Nuts bring a number of health benefits, including offering up a dose of healthy fats, protein, and (depending on the variety of nuts you are eating) phytochemicals. These phytochemicals contain antioxidants, which help clean up harmful substances called free radicals in the body. They are thought to have anti-inflammatory properties, as well. Fruit such as apples also contains fiber and phytochemicals.
  • Instead of a steak and baked potato, have a serving of salmon with a side of broccoli. The omega-3 fatty acids in salmon and other types of fish, such as tuna, sardines, and mackerel, have been linked with better heart health, possibly due to their anti-inflammatory properties. Broccoli is also a good source of fiber and is rich in vitamins C, E, K, and folate. It also contains carotenoids, a phytochemical.
  • Instead of a slice of cake, mix up a fruit salad using various types of berries. Fruits such as berries are rich in vitamins and inflammation-busting phytochemicals.

The post 5 inflammation-fighting food swaps appeared first on Harvard Health Blog.

Is IBD an underrecognized health problem in minority groups?

As many people know, inflammatory bowel disease (IBD) is a complex condition affecting the intestine, which is the part of the digestive tract that helps digest food and remove water, salt, and waste.

But you might not know this: in recent years in the US, IBD is being diagnosed more often among people who are Black, Hispanic/Latinx, East and Southeast Asian, or from other minority groups than it was in past decades.

Is this a true rise in cases? Is IBD underrecognized in minority populations? While we don’t have all the answers yet, exploring health disparities in IBD and explaining its symptoms may encourage more people to get the health care they need.

What is IBD?

IBD is a chronic inflammatory condition in the intestine that may steadily progress, or repeatedly flare up (relapse) and calm down (remit).

The two main types of IBD are ulcerative colitis (UC) and Crohn’s disease (CD):

  • Ulcerative colitis affects the rectum and colon alone.
  • Crohn’s disease can affect any portion of the intestinal tract from the mouth to the anus, and can lead to complications such as abscesses, strictures, and fistulas.
  • Both conditions frequently involve organs outside of the gastrointestinal tract, such as the joints, skin, and eyes.

What do we know about IBD among minority groups?

Traditionally, IBD has been thought of as a disease that largely affects people who are white. For every 100,000 individuals, IBD occurs in about 10 Hispanic/Latinx individuals, 25 Black individuals, and 70 non-Hispanic white individuals, according to estimates published in 2014. However, more recently we’ve observed an increase in IBD among other racial and ethnic groups in the US and across the world.

Is inflammatory bowel disease underrecognized in minority groups?

Some experts believe that IBD might be underrecognized or underappreciated in minority populations, which might lead to delays in diagnoses. A delayed diagnosis could mean longer periods of untreated inflammation, which also increases risk for complications, such as

  • strictures (areas where the bowel narrows due to scarring)
  • fistulas (a passage between organs or nearby tissues that isn’t normally there)
  • abscesses (an infection that may result in a fistula if not treated)
  • surgery
  • cancer of the bowel.

One study looked at people receiving health care who had two symptoms suggestive of IBD: iron deficiency anemia (a low red blood count) and diarrhea. The researchers found that certain groups were less likely to receive an appropriate workup to find out why they had these particular symptoms. Those who were Black or publicly insured were less likely to receive the appropriate workup, compared with those who were white or privately insured. These findings further support the hypothesis that IBD might be underrecognized in minority populations.

What do we currently know about health disparities in IBD?

Preventable differences — called health disparities — in health and well-being are seen among people with inflammatory bowel disease. These disparities may be due to a range of factors affecting certain groups, including inequities in the social determinants of health, unconscious biases of medical providers, barriers to care, and differences in the complex genetic and environmental driving forces of IBD that haven’t been sufficiently studied.

Black patients who have IBD experience higher rates of emergency department use — and, in one study, higher rates of hospitalization, possibly because they are less likely to receive regular care from a gastroenterology specialist. Further, while the hospitalization rate in white patients with IBD has decreased, it remains unchanged for Black patients.

Additional research shows that Black patients with Crohn’s disease are less likely to be in remission, more likely to undergo surgery, and more likely to experience complications after surgery. Socioeconomic status matters, too: lower income is linked with a higher risk of severe disease, IBD-related hospitalizations, ICU stays, and death. Another study reports that approximately 14% of Americans with IBD are food insecure. Further, it links food insecurity with inability to take prescribed medications because of cost and difficulty paying medical bills.

What symptoms may be signs of inflammatory bowel disease?

A variety of symptoms may be signs of inflammatory bowel disease:

  • Blood in your stool, and urgency and increased frequency of bowel movements, may be signs of ulcerative colitis.
  • Abdominal pain, nausea, vomiting, blood in your stool, and diarrhea may be signs of Crohn’s disease.

If you have any of these symptoms — especially if you notice blood in your stool — talk to your healthcare provider. After a medical history and exam, the next steps may be further evaluation with a colonoscopy to look at the bowel, and/or an upper endoscopy to look at the upper part of the digestive system. Imaging studies may also be necessary. This evaluation will help your health provider diagnose IBD or another health problem causing similar symptoms.

Getting effective treatment makes a difference

Fortunately, ulcerative colitis and Crohn’s disease are both treatable conditions. Our goal in treating IBD is stable remission to stop or ease symptoms and ensure a high quality of life. Everyone with IBD can attain this with good care. Treatment may include medicine taken by mouth or given as infusions, dietary changes, surgery, or a combination of these. It’s important to find the right treatment and monitoring plan for each person early in the course of their illness.

I assure my IBD patients that we will work together to find the best and safest treatment options for them. IBD care requires a team approach, which might include a primary care doctor, gastroenterologist, pharmacist, surgeon, dietitian, and other health providers. If you have IBD, you’re the central member and captain of the team; as providers we are just coaches. It is important that you feel heard, understood, and empowered as you navigate life with IBD.

Follow me on Twitter @AdjoaGIMD

The post Is IBD an underrecognized health problem in minority groups? appeared first on Harvard Health Blog.

Sickle cell disease in newborns and children: What families should know and do

If you’ve learned that your newborn or young child has sickle cell disease, you — and other family members and friends — may have many questions.

These days, most cases of sickle cell disease in the US are diagnosed through newborn screening. It’s important to make the diagnosis early, so that babies can be started on penicillin (or another antibiotic) to prevent infection. Getting connected early to a pediatrician for primary care — and to specialists in blood disorders who can work closely with the child as they grow, and with their families — can help prevent complications of the disease.

The basics

Hemoglobin is the part of the red blood cell that carries oxygen. In sickle cell disease, the hemoglobin can change the rounded shape of red blood cells into a C-shape that is crooked, like the tool called a sickle. When that happens, the cells get sticky and can clog up small blood vessels. It also makes the red cells more fragile and likely to break apart, causing anemia.

Millions of people around the world have sickle cell disease, or SCD. In the US, the Centers for Disease Control and Prevention (CDC) estimate it affects about 100,000 people. It occurs in about one out of 365 Black or African American births, and one out of 16,300 Hispanic American births.

Is SCD a genetic disease?

Yes. All of us have two genes that decide what kind of hemoglobin we have, one from each parent. People with sickle cell disease have two copies of the sickle gene, inherited from both parents. If someone has one copy, they have “sickle cell trait,” meaning that they are a carrier of the gene.

Sickle cell trait is common, affecting one in 13 Black children. While there are some problems associated with sickle cell trait, people with sickle cell trait are generally healthy; in fact, they are thought to be less likely to develop severe cases of malaria, which is why the disease was thought to have evolved in people from areas around the equator where malaria is common.

There are other kinds of genetic hemoglobin diseases, such as thalassemia or hemoglobin C. Sometimes people are born with one sickle gene and one gene for a different hemoglobin problem. The severity of their condition depends on the particular hemoglobin combination.

Currently, there is no cure for sickle cell disease or the other genetic hemoglobin diseases, except for bone marrow transplant or stem cell transplant.

What health issues could SCD cause?

When sickle cells clog up blood vessels, it can lead to pain and damage to organs or tissues due to lack of blood flow. When coupled with the effects of anemia, this means that babies and children with sickle cell disease are more likely to have complications from infections, such as pneumonia; vision problems; blood clots; and breathing problems. Children with sickle cell disease can also get swelling of the spleen if sickled cells get stuck there.

How can you help your child live a healthy life as they grow?

Children with sickle cell disease and their families can work together to help prevent complications by taking these steps:

  • Stay well-hydrated, as dehydration can make cells more likely to sickle.
  • Avoid extremes of temperature, especially cold, as this also can trigger sickling of the cells.
  • Avoid areas of high altitude, where there is less oxygen.
  • Take care with very vigorous exercise, which may decrease the amount of oxygen available to the blood.
  • Wash hands regularly and avoid sick people to the extent possible.
  • Get all recommended vaccinations.
  • Learn all the signs and symptoms of blocked blood vessels, anemia, a swollen spleen, infection, blood clots, and lung problems, so that they know when to get medical care immediately. Ask your child’s doctor or medical team to help you understand key warning signs for each of these based on your child’s age.

Also, see this helpful toolkit created by the CDC and the American Society of Hematology. It explains common complications of sickle cell disease and steps to take for better health.

Being closely connected to medical care is crucial, because the sooner complications are diagnosed, the sooner and more successfully they are treated. There are also treatments such as hydroxyurea that can help prevent complications in the first place. Children with sickle cell disease should regularly see their primary care pediatrician and their specialist, whether they are having symptoms or not, so that they can work together to help live the healthiest life possible.

Follow me on Twitter @drClaire

The post Sickle cell disease in newborns and children: What families should know and do appeared first on Harvard Health Blog.

COVID-19 vaccines for children and teens: What we do — and don’t — know

Vaccines have been heralded as a key measure to slow the COVID-19 pandemic and one day bring it to an end. Every day, millions of American adults are receiving one of the authorized vaccines proven highly effective at preventing severe illness that might otherwise lead to hospitalizations and deaths. In the US, most people over 65 have now been fully vaccinated, protecting the most vulnerable in our population.

As an infectious disease specialist, my responses to the questions below are based on what we know so far about infection and vaccines in children and teens. We’ll need to continue filling in gaps as research is done and our understanding evolves.

What do we know about how COVID-19 affects children and teens?

Most COVID-19 infections in children are mild or cause no obvious symptoms. However, a small percentage of infected children

  • develop a serious inflammatory condition called MIS-C in the two to six weeks following COVID-19 infection. This may happen even in children who have mild symptoms or no symptoms.
  • get very sick and need hospitalization or intensive care.

Over 400 children have died from COVID-19 infection. That’s greater than the number of childhood deaths during the deadliest flu season in the past two decades.

Vaccinating children to prevent these outcomes is one of the most important reasons driving vaccine studies in children. Further, vaccinating children will be critical to achieving a population-wide level of immunity — herd immunity — sufficient to slow the emergence of dangerous variants and bring an end to the pandemic.

What do we know so far about COVID-19 vaccines in teens?

  • The Pfizer/BioNTech vaccine is authorized for use in people ages 16 and older.
  • The Moderna and Johnson & Johnson vaccines are authorized for use in people ages 18 and older.
  • These authorizations were based on data from participants of these ages in randomized, placebo-controlled trials that demonstrated the safety and efficacy of these vaccines. Efficacy measures how well a vaccine works in the controlled circumstances of a study. Effectiveness is how well a vaccine works outside of a study, when people in the community receive it.

As states expand eligibility for COVID-19 vaccines, teens 16 and older can receive the appropriate vaccine through the same sources adults have had access to so far. Available vaccine sites may vary by state and where you receive health care. Check the searchable map on VaccineFinder, or your state board of health.

Vaccine research done so far, or now underway, includes the following:

  • Pfizer/BioNTech has completed a trial in 12-to 15-year-olds. This trial used the same dose and schedule of the vaccine as is used in adults: two doses given three weeks apart. The company announced in a press release that the vaccine was safe and well tolerated, elicited strong antibody responses, and had 100% efficacy in preventing mild to severe infection in this age group. The FDA is reviewing the data and will consider authorizing this vaccine for use in this age group. If all goes well, we might expect this vaccine to be available to 12-to 15-year-olds in the coming months.
  • Moderna completed enrolling 12-to 17-year-olds in a similar trial using the same dose and schedule as in adults: two doses given four weeks apart. Data from this trial are expected within the next few months.
  • Johnson & Johnson has started a trial of its vaccine for a small number of 16-to 17-year-olds. If the vaccine proves to be safe and effective in that age group, the trial will continue with 12-to 15-year-olds.

What about COVID-19 vaccine trials for younger children?

  • Pfizer/BioNTech and Moderna have both begun trials in children 6 months to 11 years old.
  • These trials will each begin by testing smaller doses than those given to older children, teens, and adults. This allows researchers to determine which dose is well tolerated and still elicits strong antibody results in younger children.
  • Once the dose is set, larger numbers of children in these age ranges will be enrolled in placebo-controlled trials to evaluate the efficacy of these vaccines.

All of these steps will take some time so that they can be done without cutting any corners on safety. The earliest vaccines will likely be available for younger children is late 2021, or perhaps early in 2022.

What is not yet known about COVID-19 vaccines in children and teens?

  • How long vaccine-induced immunity against COVID-19 infection lasts in children will need to be followed over time. Findings from such studies will help experts decide whether children will need boosters of COVID-19 vaccines in the future.
  • Researchers also need to study whether COVID-19 vaccines can be combined with other vaccines that children routinely receive. For now, the CDC recommends not giving any other vaccines within 14 days of a COVID-19 vaccine. This is true for people of any age.
  • Researchers will need to evaluate the impact of these vaccines on protecting children from infection with COVID-19 variants. But biologically, there would be no reason to expect differences in vaccine coverage of variants in adults versus children.

The post COVID-19 vaccines for children and teens: What we do — and don’t — know appeared first on Harvard Health Blog.

Happy trails: Take a hike, now

4 May 2021 at 07:30

While the COVID-19 pandemic is not over by any means, more people are getting vaccinated, and restrictions are gradually lifting. After too much time spent inactive and indoors, what better way to move your body and enjoy nature than by taking a hike? In many ways, hiking is the ideal antidote to a global pandemic, as it can heal both body and soul.

Enjoy the benefits of a hike

  • Like power walking, hiking offers a moderate-intensity cardio workout, provided your route includes some hills or inclines. Trekking on uneven surfaces engages your core muscles and improves your balance.
  • Hiking also is a mood booster. Research shows that spending time in green spaces, like nature trails and wooded areas, can reduce stress, anxiety, and depression. It doesn’t matter if you hike alone or with others.
  • The CDC still suggests people maintain social distancing during outdoor activities, including hiking, since it’s not possible to know who is fully vaccinated. You also should wear a mask around people who are not in your household or in your personal pod.
  • Many local, state, and national parks are still closed or have limited access, but some trails may be open in your area or will reopen soon. (Check out these sites to find the status of local trails near you: National Park Service, American Trails, and American Hiking Society.)

Ready to hike?

Before you lace up your hiking boots, make sure you’re well prepared. After all, it’s probably been a while since you’ve been out in the world. Here are some tips.

Work on your walking. If your walking endurance needs some work, begin a regular walking program in your neighborhood. Walk daily for 10 to 20 minutes, and wear a step counter to motivate you.

Safety first. If you can’t hike with someone, let a friend or family member know where you will hike and for how long. Bring your cell phone and a local map, if needed.

Apply sunscreen. Even if you mostly hike in the shade, you can still get sunburned. Always wear sunscreen with at least 30 SPF that blocks both types of ultraviolet rays — UVA and UVB —and a lip balm with sunscreen. Apply about 20 minutes before your hike, and then reapply every two hours.

Protect against ticks. Ticks are common in the US and can spread serious illnesses, such as Lyme disease and Rocky Mountain spotted fever. Ticks are often found in wooded, bushy, or grassy areas. Wear light-colored clothes with long sleeves and long pants, if possible. Use insect repellent that is effective against ticks on exposed skin, clothes, and hiking gear. Do a thorough tick check after hiking. Know what to do if you find a tick on your body — and what signs suggest you might have been bitten by one, such as a rash or flulike symptoms. Contact your health provider right away for advice and appropriate treatment.

Stay hydrated. Drink water before, during, and after your hike. Pay attention to your thirst (if you are thirsty, you are likely already dehydrated.) Set a timer on your phone or sports watch to remind you to drink at regular intervals.

Watch the weather. If you are not sure about the forecast, wear layers that you can add or take off depending on the temperature. Carry a rolled-up windbreaker, rain jacket, or poncho in a backpack.

Support yourself. Invest in hiking or trail shoes with good ankle support. Wear calf-length socks to protect your legs. Hiking with walking poles can help you navigate tricky terrain and support your knees.

The post Happy trails: Take a hike, now appeared first on Harvard Health Blog.

Sleep well — and reduce your risk of dementia and death

In a recent blog post I discussed how beneficial sleep is for memory function. But sleep isn’t just good for your memory; it can actually reduce your risk of dementia — and death. Although it has been known for some time that individuals with dementia frequently have poor, fragmented sleep, two new studies suggest that if you don’t get enough sleep, you are at increased risk for dementia.

Sleep six to eight hours each night

In the first study, researchers at Harvard Medical School studied more than 2,800 individuals ages 65 and older participating in the National Health and Aging Trends Study to examine the relationship between their self-report of sleep characteristics in 2013 or 2014, and their development of dementia and/or death five years later. Researchers found that individuals who slept fewer than five hours per night were twice as likely to develop dementia, and twice as likely to die, compared to those who slept six to eight hours per night. This study controlled for demographic characteristics including age, marital status, race, education, health conditions, and body weight.

In the second study, researchers in Europe (including France, the United Kingdom, the Netherlands, and Finland) examined data from almost 8,000 participants from a different study and found that consistently sleeping six hours or less at age 50, 60, and 70 was associated with a 30% increase in dementia risk compared to a normal sleep duration of seven hours. The mean age of dementia diagnosis was 77 years. This study controlled for sociodemographic, behavioral, cardiometabolic, and mental health factors, although most participants were white, better educated, and healthier than the general population. In addition, approximately half of the participants had their sleep duration measured objectively using a wearable accelerometer — a device that tracked their sleep using body movements — which confirmed the questionnaire data.

Inadequate sleep in midlife may lead to dementia

What’s new here is that inadequate sleep in midlife raises one’s risk of dementia. There are many reasons for poor sleep in middle age: shift work, insomnia, caretaking responsibilities, anxiety, and pressing deadlines, just to name a few. Although not all of these are controllable, some are. For example, if you’re currently only sleeping four to five hours because you’re up late working every night, you might want to change your habits, otherwise you risk developing dementia by the time you retire!

This relationship between sleep in midlife and dementia in late life is important not only from a clinical perspective, but also from a scientific one. It had always been a bit of a chicken-and-egg problem when trying to interpret the relationship between poor sleep and dementia. Was it really poor sleep that caused dementia, or just early dementia symptoms causing poor sleep? By looking at individuals who were initially studied in midlife — some as young as age 50 — we now have greater certainty that poor sleep can increase one’s risk of developing dementia 25 years or more in the future.

Flush your brain while you sleep

Although it is not totally understood why inadequate sleep increases your dementia risk, one possible reason relates to the deposition of the Alzheimer’s protein, beta amyloid. Beta amyloid is the protein that clusters and clumps together to form Alzheimer’s plaques. No one is completely certain what its normal function is, although there is increasing evidence it is involved in the brain’s defense against invading microorganisms.

During the day, we all make some of this beta amyloid protein in the brain. When we sleep, however, brain cells and their connections actually shrink. This shrinking allows more space between the brain cells, so that beta amyloid and other substances that accumulate during the day can be flushed away.

So the theory is, if you don’t get enough sleep, your brain won’t have enough time to drain away beta amyloid and other substances. These substances then continue to accumulate, day after day, until they cause dementia.

The good news

The good news is that you can reduce your risk of developing dementia by getting adequate sleep. One study from researchers in Toronto and Chicago examined people who were at increased genetic risk of developing Alzheimer’s. They found that better sleep not only reduced the likelihood of developing clinical Alzheimer’s disease, but it also reduced the development of tangle pathology in the brain — another substance that accumulates in Alzheimer’s disease.

The bottom line

Sleep isn’t merely an annoying interruption between the important aspects of our waking lives. Just like eating right and exercising, sleep is absolutely essential for good brain health. These two new studies show that the harmful effects of inadequate sleep can start at age 50 (if not earlier), and they can lead to early dementia and death. But the good news is that you can reduce your risk of dementia by simply giving yourself six to eight hours of sleep each night. Try to avoid sleeping pills, as they don’t give you the deep sleep you need. If you’re having trouble sleeping, nonpharmacological approaches are best.

The post Sleep well — and reduce your risk of dementia and death appeared first on Harvard Health Blog.

COVID-19 vaccines and the LGBTQ+ community

I have a confession: in late 2020, when the first COVID-19 vaccines were approved by the FDA, I was hesitant to get one myself. Despite working in public health and believing strongly in vaccines to keep our community healthy, I was anxious about putting something in my body that seemed so new. I thought: “What if the vaccine is dangerous?” “What about long-term side effects?”

I am part of the LGBTQ+ community. Our history may help explain why I hesitated.

Are LGBTQ+ people more hesitant to get the vaccine?

In March a New York Times article reported that LGBTQ+ people are more hesitant to get the COVID-19 vaccine. A research study from the Human Rights Campaign reported mixed findings: while LGBTQ+ people overall are more likely to get vaccinated, certain subgroups, such as LGBTQ+ people of color and bisexual women, are less likely to get vaccinated.

LGBTQ+ people have good reason to be hesitant about vaccines. Historically, this population has experienced — and continues to experience — discrimination in multiple settings, including in healthcare. At the same time, this population is more vulnerable to COVID-19 (see this study and an earlier blog post I wrote). LGBTQ+ people who are also people of color may be even more hesitant to get the COVID-19 vaccine, because of trauma and oppressions based on multiple intersecting marginalized identities that set the stage for mistrust in healthcare and medical research. We can include racism, transphobia, biphobia, and homophobia among such oppressions.

Weighing the risks and benefits of the COVID-19 vaccine

When I was trying to decide whether to get the vaccine, I began reading about the vaccine from trusted sources like the Centers for Disease Control and Prevention (CDC). I also talked to people I know and trust, like close friends, family members, and physician colleagues. I asked them: “Will you get the vaccine when it’s offered to you?” All of them gave me a resounding “yes!” Most shared this rationale: while we still don’t know about long-term side effects, this vaccine is similar to other vaccines that have been around for a while, and the benefits of getting vaccinated far outweigh the risks of getting seriously ill or even dying from COVID-19.

When the vaccine was offered to me earlier this year, I booked my appointment immediately, without hesitation, and I haven’t looked back. As soon as I got the first shot, and certainly when I was fully vaccinated two weeks after my second shot, I felt a profound sense of relief. I also felt empowered about taking an important step toward keeping myself, my family, and my community safe from COVID-19. I now feel safer and freer in my daily life. I go into stores (wearing a mask) without feeling anxious, and I have been able to visit in-person with other fully vaccinated people, like my mom, without masks.

If you are struggling to decide whether to get the COVID-19 vaccine, this decision-making grid may be helpful (note: auto-download). The grid walks you through the benefits and short-term and long-term risks of not getting the vaccine compared to getting the currently available vaccines.

Why the vaccine is critical for LGBTQ+ communities

Numerous “pandemics” have already wiped out large numbers of the LGBTQ+ community: HIV/AIDS, violence, suicide. In addition, the COVID-19 pandemic has already disproportionately harmed LGBTQ+ people (see this study and this report). LGBTQ+ seniors and people of color are at greatest risk for serious, possibly life-threatening illness from COVID-19. If each of us takes steps to get vaccinated, we can prevent more deaths and negative health outcomes in our communities.

How can you empower yourself to get the COVID-19 vaccine?

  • Educate yourself on what COVID-19 vaccines are, how they work, and why they are safe.
  • Talk to trusted experts and people in your life about your fears.
  • At this time, everyone in the US who is age 16 or older is eligible for the vaccine, so you can make an appointment where you live to get vaccinated.

Additional resources

The post COVID-19 vaccines and the LGBTQ+ community appeared first on Harvard Health Blog.

Polycystic ovary syndrome and the skin

Often, the skin can be a window to what is occurring inside your body. For women with polycystic ovary syndrome, or PCOS, this this may mean acne, hair loss, excessive facial or body hair growth, dark patches on the skin, or any combination of these issues.

What is PCOS?

Skin and hair issues can be the most readily perceptible features of PCOS, and thus sometimes the reason for seeking medical care. However, features of PCOS also include menstrual irregularities, polycystic ovaries (when the ovaries develop multiple small follicles and do not regularly release eggs), obesity, and insulin resistance (when cells do not respond well to insulin).

The cause of PCOS is not entirely understood, but scientific evidence points to hormonal imbalances, specifically excess testosterone (also known as hyperandrogenism) and insulin resistance. PCOS is the most common cause of infertility in women. The hormonal imbalances in PCOS disrupt the process of ovulation, and without ovulation pregnancy is not possible. PCOS exists on a spectrum, meaning not every woman with PCOS has the same signs and symptoms. Because of the variation in characteristics of this syndrome, it can be difficult to diagnose.

How do I know if I have PCOS?

There is no one specific test that can be used to diagnose PCOS, so a thoughtful and thorough workup, including lab tests and imaging, is needed. Lab tests typically involve measuring levels of various hormones, such as androgens. Imaging tests may include ultrasound of the ovaries. Seeking care from an experienced team, including primary care physicians, gynecologists, endocrinologists, and dermatologists, can establish the diagnosis.

What are the skin manifestations of PCOS?

PCOS-related acne often flares on the lower face, including the jawline, chin, and upper neck. Although not a hard and fast rule, these areas are considered to be a hormonal pattern for acne. Women with PCOS may notice that acne lesions are deeper, larger, and slower to resolve. Acne in PCOS usually worsens around the time of menstrual periods. Dermatologists often recommend the use of oral contraceptive pills or a medication called spironolactone to treat this type of acne. These treatments, when used in the right patients who have no contraindications to them, can be very helpful in clearing acne.

Hirsutism, or excessive hair growth in places where hair is usually absent or minimal, is another dermatologic sign of PCOS. Common areas of hirsutism include the chin, neck, abdomen, chest, or back. On the scalp, however, balding or thinning of the hair can be seen. Both of these hair issues are driven by an excess of testosterone.

Occasionally, another skin condition appears called acanthosis nigricans, which are dark, velvety areas of skin, usually in skin creases such as around the neck and underarms. This type of skin condition is also associated with insulin resistance, and may be due to stimulation of skin cells by insulin, causing them to overgrow.

Treatment options and a tailored approach

Although there is no cure for PCOS, there are many treatment options for managing various symptoms of this syndrome. The types of treatments used depend on a woman’s priorities and symptoms. For example, being at a healthy weight can lead to improvement of symptoms, so lifestyle modifications to nutrition and exercise may help. Hirsutism can be treated with laser hair removal or electrolysis. Some patients may try birth control pills to improve menstrual regularity. Metformin, a commonly used medication for diabetes, can be used to help improve the body’s response to insulin.

Treatment planning is tailored to each person and depends on whether or not pregnancy is a short-term goal. Certain medications, including spironolactone and retinoids for acne, should be avoided if a woman is trying to become pregnant.

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Dental appliances for sleep apnea: Do they work?

28 April 2021 at 07:30

Keeping your partner — or yourself — up at night with loud snoring? This might be more than a nuisance. About 25% of men and nearly 10% of women have obstructive sleep apnea (OSA), a serious sleep disorder characterized by explosive snores, grunts, and gasps. Tissue at the back of the throat temporarily obstructs the airway, leading to breathing pauses (apneas) throughout the night. Not only does OSA leave people tired and groggy, but it also puts them at risk for a host of health problems, including high blood pressure, depression, and heart disease.

The most effective and best-studied treatment is positive airway pressure (PAP), a small bedside machine that blows air through a mask to prevent your airway from collapsing. But people with mild or moderate OSA sometimes find PAP challenging to use, and often wonder about alternatives. Dental devices (also known as oral appliances) are an option for some people. But do your homework before going this route, cautions Sogol Javaheri, MD, MPH, MA, a sleep specialist at Harvard-affiliated Brigham and Women’s Hospital.

Who might benefit from a dental device for sleep apnea?

“These devices are supposed to reposition your jaw or tongue to open your upper airway. But they can be really uncomfortable and only work about half the time,” Dr. Javaheri says. It’s hard to predict who might benefit from using an oral device, and people with very mild OSA and few symptoms may not notice any difference. As a result, she generally doesn’t recommend them except for people with mild to moderate OSA or those with severe OSA who can’t tolerate PAP.

Three main categories of dental devices for OSA

Mandibular advancement devices. Made of molded hard plastic, these devices snap over your lower and upper teeth, and also feature metal hinges and screws that can be tightened to push your lower jaw forward. Some dentists make custom mandibular advancement devices, but before you consider buying a custom device, be sure to ask whether your dentist has experience in sleep-related breathing disorders and is certified by the American Academy of Sleep Medicine. Some non-certified dentists simply take a mold of your teeth, send it to a company that makes the device, then sell it to you at a large markup — sometimes totaling $4,000 or more. What’s more, it’s unlikely to be covered by your dental or medical insurance if it’s used for snoring.

Mouth guards. Similar to mandibular advancement devices, these devices also help reposition your lower jaw, although to a lesser degree. Some sleep physicians recommend SnoreRx, which you can purchase online for less than $100. Instead of starting with an impression of your teeth created by a dentist, you use what the company calls the “boil and bite” method. You place the device in a cup of boiling water for a minute and then bite down on the softened plastic so it molds to your teeth.

Tongue-retaining devices. These devices consist of a soft plastic splint placed around your tongue that holds it forward and out of your mouth throughout the night. They tend to make your mouth very dry and can be quite uncomfortable.

Most insurance plans at least partially cover these devices when used for OSA, but not if they’re used for simple snoring. Don’t be tempted to try one unless you’ve been formally diagnosed with OSA, says Dr. Javaheri. And even if you have OSA, be sure to call your insurance company so you understand how much is covered before you have a device made.

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Terrified of needles? That can affect your health

No one likes getting stuck by a needle. Whether for a blood test, vaccination, or blood donation, needle sticks are something most people would prefer to avoid.

Yet, judging only by schedules for routine vaccinations and tests, the average healthy person can expect at least 165 needle sticks over a lifetime. Get hospitalized? That might add dozens or even hundreds more. And the number of needle sticks experienced by people with diabetes, HIV, and some other illnesses hovers in the “don’t ask” range.

For many, this may be more of an annoyance than a real problem. But if you have a strong fear of needles or aversion to the sight of blood, getting a vaccination or any other needle stick is a big deal. If this sounds like you, you may have trypanophobia.

What is trypanophobia?

Fittingly, the name combines the Greek term trypano — meaning puncturing or piercing — with phobia, meaning fear. This remarkably common condition is marked by irrational, extreme fear or aversion to blood or needles. It’s estimated that fear of needles affects up to 25% of adults, and may lead 16% of people in the US to skip vaccinations. Many people who strongly fear needle sticks may avoid doctors and medical care, so it’s likely that the magnitude of this problem is underestimated.

Just to be clear: this phobia is not limited to people who are overly sensitive to pain or aren’t “tough enough.” It can affect anyone. The cause is often unknown, but a particularly traumatic experience during childhood medical illness may set the stage for some people. And there may be a genetic component. Researchers have found genes linked to fainting after needle sticks, and trypanophobia sometimes runs in families.

What are the symptoms of this phobia?

People with trypanophobia who are contemplating a needle stick may experience

  • fear or anxiety
  • panic attacks, nausea, or sweats
  • palpitations
  • fainting (due to a reflex in which pain or the sight of blood triggers a drop in blood pressure)
  • insomnia in the days or weeks before an expected needle stick.

How does being afraid of needles affect you?

This fear can affect your

  • quality of life: It’s quite unpleasant to spend weeks dreading an upcoming doctor’s appointment.
  • health: Skipping recommended tests and treatment to avoid needle sticks can lead to missed diagnoses, poorly monitored medical conditions, and undertreatment. A timely example is foregoing a vaccination against COVID-19, which can have serious or even deadly consequences. Also, drug marketers sometimes play on fear of needles in their advertising, or might downplay the fact that a medication requires an injection.
  • longevity: Skipping routine medical care can contribute to avoidable suffering and death. For example, a cancerous breast lump that might have been detected during routine examination may go unnoticed until much later, when it’s no longer curable.

What can you do to cope with a fear of needles?

There’s not much high-quality research regarding how best to treat trypanophobia. Still, experts suggest a number of options to help people cope with it.

  • Bring support, if allowed. That’s routine for small children. But holding the hand or hearing the voice of a spouse, trusted friend, or family member can calm adults, too.
  • Harness the power of distraction (see this amazing video of a pediatrician distracting a young child before a vaccination). Focus on anything other than the needle stick: a spot on the floor, the positive effects of getting a COVID-19 vaccine (soon you can hug your family!), or your upcoming vacation.
  • Tell the person giving you a shot or drawing blood that you struggle with this, and let them know what works best for you. Some people prefer to hear about each step before it happens so there are no surprises. Ask if the healthcare provider has tricks of the trade to help you get through it.
  • Ask the person giving your shot or drawing blood if they can use a numbing agent similar to novocaine, or a freezing spray to numb skin before a needle stick.
  • Don’t watch! It’s not helpful to watch all of the preparation for the needle stick or see the needle itself. Watching may make things worse.
  • Learn ways to relax. Try deep breathing or other relaxation techniques that you can practice before having the needle stick.
  • Relax the muscle receiving the injection, too. Some shots, such as vaccines that protect you against tetanus or COVID-19, are given in a muscle. Relaxing the muscle can lessen the pain of these shots.
  • Lie down before having the needle stick, if you’ve fainted or felt woozy in the past with needle sticks.

Can therapy help?

Seeing a mental health specialist may be helpful. He or she may recommend

  • cognitive behavioral therapy, or CBT, which teaches people ways to reframe unhelpful ways of thinking and build coping strategies.
  • exposure therapy, a gradual and supervised increase in your exposure to needles, which can lessen the panic they cause. For example, over a number of weeks you may be instructed to look at photographs of needles, then hold a syringe without a needle, then hold a syringe with a needle, and then imagine injection — all with guidance from a therapist — before actually having one.
  • medications, such as anti-anxiety or sedative medications, may be prescribed if other measures aren’t effective, and the anxiety around needle sticks is getting in the way of medical care (or just making you miserable).

The bottom line

It’s natural to have an aversion to pain, even when you know it’s coming and even though it’s for a good reason. So, if you’re one of the millions fretting about getting a COVID-19 vaccine or a blood test or any other needle stick, know that you’re not alone, and that there are things you can do to improve the situation. Talk to your doctor about your fear and get help if you need it. Your quality of life, health, and longevity could depend on it.

As for me, I’m going to do what I always do: avert my eyes and stare at that spot on the floor.

Follow me on Twitter @RobShmerling

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Life expectancy: How can we address uneven declines?

26 April 2021 at 07:30

Not long ago, during pre-pandemic 2019, the reported life expectancy at birth for non-Hispanic Black, non-Hispanic White, and Hispanic populations was approximately 75, 79, and 82 years, respectively. The higher life expectancy of Hispanic people compared to others in the United States may come as a surprise to some.

This phenomenon, known as the “Hispanic paradox,” was first noted in the 1980s, and its legitimacy has been debated since. A host of explanations have been proposed, including hypotheses about the “healthy immigrant” (people who migrate to the US are healthier than those who stay in their native countries) and “salmon bias” (less healthy US immigrants are more likely to return to their countries of origin). Other experts note that Hispanic communities have lower rates of smoking and greater levels of social cohesion, which certainly may contribute to their presumed higher life expectancy. In the end, this difference remains poorly understood, and is further complicated by research noting US-born Hispanic individuals may have lower life expectancy compared to their foreign-born counterparts.

Now, recent estimates for life expectancy from the Centers for Disease Control and Prevention (CDC) show an alarming change that highlights the disproportionate impact COVID-19 has had on communities of color. Between 2019 and 2020, life expectancy dropped more sharply among Black and Hispanic populations compared to their White counterparts, by three years, two years, and one year, respectively. In fact, the gap in life expectancy between Black and White populations widened from four to six years, the largest gap since 1998. And the advantage in life expectancy previously held by Hispanic populations over Whites decreased from three to two years. In other words, the COVID-19 pandemic has led to a decrease in life expectancy among all individuals in the US, but this impact has been felt most by communities of color.

Many reasons for greater vulnerability to COVID-19

Many factors contributed to this uneven drop in life expectancy. But these remarkable numbers remind us of the vulnerability of Black, Indigenous, and People of Color (BIPOC) in the US, the result of longstanding unequal access to health care and resources needed to achieve upward economic mobility. Many BIPOC populations in the US live on the brink of collapse. With little health or financial reserves, these communities are increasingly vulnerable to sudden events, like the financial collapse of the early 2000s or a global pandemic.

Racism functions largely through structural barriers that advantage some groups and disadvantage others. Rather than causing new disparities, the COVID-19 pandemic simply unmasked chronic failings in our social policies and healthcare delivery for our BIPOC communities. Recently, the CDC acknowledged this and declared racism a public health threat that harms the health and well-being of BIPOC populations.

Longstanding systemic failings lead to poor overall health

Abnormally high and sustained exposure to stress during pregnancy and early childhood leads to sustained release of inflammatory and stress-related hormones such as cortisol, which results in toxic levels of chronic stress. Racism causes chronic stress, which detrimentally affects the development and well-being of BIPOC children. Moreover, many BIPOC children have less overall opportunity to thrive. They live in neighborhoods plagued by pervasive poverty caused by longstanding discriminatory policies such as redlining and residential segregation. These factors compound, ultimately resulting in higher levels of cardiovascular disease, mental illness, and health-risk behaviors. Known as weathering, this contributes to both decreased lifespan and healthspan (the period of a life during which a person is in good health).

Further, BIPOC individuals in the US persistently face barriers in access to quality health care. Examples include higher rates of no insurance and underinsurance, and lower health care literacy. Pervasive bias and discriminatory policies are deeply embedded into our healthcare delivery infrastructure. So, the results of the CDC report should come as no surprise: a population chronically deprived of accessible preventive services would be expected to fare poorly during a pandemic.

Moving forward: What changes could help?

We can all raise our voices to persuade and support the efforts of government officials at every level, and healthcare leaders, to address immediate disparities related to the ongoing pandemic and the chronic flaws that leave BIPOC communities increasingly vulnerable. Below are several measures that could get our system moving in the right direction.

Regular citizens can

  • Vote in all elections — especially local elections. Local elected officials, such as a city mayor, town manager, city council members, and county sheriff, can affect the lives of citizens even more personally than state or federal officials. Local news media and websites may have information on policy views and track records to help you choose candidates.
  • Be wary of fake news promoted on social media. Social media places a wealth of information at our fingertips, yet also offers ways to spread false information that can greatly affect our decisions. Try to maintain a healthy level of skepticism. Check information with trusted sources. These common-sense tips can help keep you from falling victim to fake news.
  • Support local organizations. Local nonprofits and community organizations play a major role in helping to address COVID-19 disparities affecting BIPOC communities and fighting for testing and vaccine equity. If you’re financially able, consider donating to local nonprofits, food banks, and community organizations so that they can keep helping in times of need.

Policy makers and government leaders can

  • Fix unemployment insurance. Inject federal funds into refurbishing crumbling state unemployment insurance infrastructures, and pass legislation mandating that standard minimum benefits be provided by all states.
  • Make universal healthcare happen. Ensure universal health insurance is achieved, whether via a public option, single payer, or a host of other alternatives. Americans deserve equitable access to quality healthcare, especially preventive care.
  • Eliminate historically racist and discriminatory policies. Eliminate discriminatory practices like gerrymandering that contribute to ongoing disempowerment of voters, residential segregation, and pervasive poverty, leaving communities of color in destitute circumstances without a voice.

Editor’s note: At the request of Dr. Perez, terms used to describe all races and/or ethnicities are capitalized in this post, to reflect his view of identity and racial equity.

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Edibles and children: Poison center calls rise

23 April 2021 at 03:30

If a 3-year-old finds a cookie on the table, chances are they are going to eat it.

Even if it is made with marijuana or THC, CBD, or other components of cannabis.

As more states have legalized the use of marijuana and an ever-widening range of derivative products, it’s not surprising that more children are being exposed — including by eating marijuana edibles. A research brief published in the journal Pediatrics found that between 2017 and 2019, there were 4,172 calls to regional poison control centers about exposures to cannabis in babies and children through age 9. About half of the calls were related to edibles.

The frequency of these calls, and the percentage related to edibles, went up over the two-year period. Not surprisingly, the exposures were about twice as common in states where marijuana use is legal as in those where it is not.

More calls about edibles involving younger children

The most common age group involved was 3- to 5-year-olds, which makes sense: this is the age where they are old enough for parents to take their eyes off them for a minute or two, but not old enough to understand why they shouldn’t eat that brownie, gummy bear, or piece of chocolate.

Thankfully, the effects of these exposures were mostly minor — but in 15% they were moderate, and in 1.4% they were severe. In rare cases, significant ingestion can lead to trouble breathing or even coma. That’s the problem with edibles: it’s hard to know how much cannabis is in each one, it’s easy to ingest a lot, and the effects can last a long time.

It’s important to remember, too, that this was just a study of calls to poison centers. It’s impossible to know how many exposures there have been that were never reported — including how many went completely unnoticed by parents or caregivers.

Safety first: Children and cannabis

Clearly, there will need to be some regulation around labeling and child-safe packaging. But as an immediate step, parents and others shouldn’t buy marijuana edibles that might appeal to children (just like it’s best not to buy detergent pods that look like candy). If you do buy marijuana edibles that a child might want to eat, they need to be stored securely, out of reach, always.

When parents bring their children to visit friends, it may be a good idea to add marijuana edibles to the list of safety issues to ask about. Think of something along the lines of, “Hey, our daughter is still little and curious, so we like to ask about things like matches, guns, medications, marijuana edibles, or other things that might be dangerous for her if she gets into them. Is there anything that might be in her reach?”

It might be a bit awkward, but if you make it quick and routine, you can decrease the awkwardness. And ultimately, it’s worth a bit of awkwardness to keep your child safe.

Follow me on Twitter @drClaire

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Pills and the planet: Environmentally-friendly steps for your medicine cabinet

22 April 2021 at 07:30

Most people might not guess that pills (or creams, patches, and inhalers, for that matter) have a big impact on the environment — but they do.

Climate change is leading to noticeable effects on the environment, as well as to consequences for our health, such as rising rates of asthma and new patterns of infectious diseases. The key driver of climate change is greenhouse gas emissions. Our health care system plays a large role, contributing close to 10% of our nation’s greenhouse gases. The US is also responsible for more than 25% of the world’s total health care emissions.

Within our health care system, pharmaceutical drugs and chemicals are the largest line-item contributor to greenhouse gas emissions. In addition, pharmaceutical waste throughout the global supply chain can lead to environmental and animal toxicities, and in the case of antibiotic residues, to antimicrobial resistance (aka “superbugs”). In 2018, 5.8 billion prescriptions were filled in the US. Meanwhile, consumers spent $34 billion on over-the counter medications.

Many of these drugs are lifesaving, offering us enormous benefits and healthier lives when taken correctly. But with some thought, there may be a few things you can do to make your medicine cabinet more environmentally friendly, while still keeping your health front and center.

Minimize waste when buying medicines

Less is more. Filling 90-day supplies of medications can reduce the overall cost per pill, offer more convenience, and require less packaging. But in some situations, it makes sense to request smaller quantities, such as when you are trying a new medicine, or buying over-the-counter medications that you use infrequently and do not expect to finish before the expiration date.

Do the math. If your doctor is recommending a dose change and the math works out, consider halving or doubling your current pills first. If this is working, you can then request a prescription for the new dose strength for your next refill.

Fill it when you use it. Don’t pick up a prescription unless you are going to use it, except for an emergency medicine you should have on hand. If you are given the option of getting a medication to take if your symptoms get worse or don’t improve, ask your doctor to send the prescription to the pharmacy, and notify the pharmacy that you will let them know if you want it filled.

Downsizing your medicine cabinet

Review the benefits versus harms. Bring all your prescription and over-the-counter medications to your appointments, and periodically review them with your primary care doctor. Make sure your drug regimen offers more benefits than harms for your situation. This is especially helpful if you see a lot of different doctors who prescribe medications for you. Sometimes, people stumble into a cascade, where one drug is added to treat symptoms that are side effects of another. But be sure to discuss with your doctor before making any changes; it may be harmful to stop some medications, and others may need to be tapered slowly.

Incorporate lifestyle medicine. Talk to your doctor about lifestyle medicine, which focuses on healthy habits like regular exercise and healthful foods to prevent disease and promote longevity. Often, these lifestyle changes can help reduce or eliminate the need for medications.

Inhalers: Know your options

Explore options. If you have asthma or chronic obstructive pulmonary disease (COPD), ask your doctor what your options are for inhalers. Metered dose inhalers (MDIs) use hydrofluoroalkane propellants, which are greenhouse gases, to deliver the medication. Check if there is an equivalent dry powder inhaler (DPI) option for you. However, not everyone can use DPIs, which rely on patients to take quick deep breaths to draw the medication into the lungs. (For this reason, rescue inhalers used during an asthma attack are usually MDIs.) Your inhaler choices will also depend on cost and coverage from your insurer. In the end, the important thing is to use the inhaler device that works best for you in controlling your condition.

Proper disposal of medicines

Know when to flush. Do not put medications down the toilet or sink (unless they’re on the FDA flush list), as this may contaminate lakes, rivers, agriculture, and drinking water. Read the packages for any drug disposal instructions. Many pharmacies or local public safety agencies like the police will accept unused medications and dispose of them safely. National Prescription Drug Take Back Day is April 24, 2021, so check for safe collection sites near you.

Some medicines can be discarded in trash. Remove personal identifying labels first, and then mix the medication in a container with coffee grounds, cat litter, or soil. (This is not recommended for controlled substances like opioids and other addictive medicines.) Visit this FDA web page for more information about drug disposal.

Health care is a partnership, and with thought and care, we can work together to have the best of both worlds — a healthier you, and a healthier planet.

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Diet, disease, and the microbiome

There is growing interest in the human body’s microbiome and its connection to chronic disease. A new study examines that connection, along with how the foods we eat influence the composition of our microbiome.

Microbiome protects host and plays role in disease risk

The microbiome consists of the genes of tiny organisms (bacteria, viruses, and other microbes) found in the gastrointestinal tract, primarily in the small and large intestine. The normal gut flora — another term for the microbiome — protects its human host. For the microbiome to flourish, the right balance must exist, with the healthy species dominating the less healthy.

Scientists do not fully understand how the microbiome factors into the risk of developing chronic diseases, such as heart disease, obesity, and type 2 diabetes. Many factors, including differences between individuals and individual diets, have made this a difficult area to investigate.

Study investigates relationships between diet, microbiome, and disease risk

But a new study, published in Nature Medicine, accounts for these factors and sheds light on how our diets shape our microbiome and how our microbiome, in turn, influences our disease risk.

The researchers studied more than 1,100 individuals enrolled in PREDICT 1, a large trial looking at individual responses to food. They used a technique called metagenomic sequencing to identify, classify, measure, and analyze genetic material from the study participants’ microbiomes. They also collected detailed, long-term dietary intake information from all of these individuals, so they could analyze their dietary patterns, including their intake of different food groups, foods, and nutrients. In addition, they collected information from the study participants on a variety of factors that are known to influence metabolism and disease risk, including pre- and post-meal measures of blood sugar (glucose), cholesterol, and inflammation. Finally, they measured personal health attributes of the study participants, including age, weight, body mass index (BMI), body fat, and blood pressure.

Diet influences microbiome and microbiome influences disease risk

The study found that the health of the microbiome is influenced by diet, and that the composition of the microbiome influences the risk of health outcomes. The results showed that specific gut microbes were associated with specific nutrients, foods, food groups, and overall diet composition. Health conditions such as heart disease, type 2 diabetes, obesity, and general inflammation appeared to be most impacted by diet-influenced changes to the microbiome.

For example, less healthy dietary patterns (dairy desserts, unhealthy meats, processed foods) supported gut species that were associated with measures of blood sugar, cholesterol, and inflammation that are significantly associated with higher risk of cardiac events, strokes, and type 2 diabetes.

In contrast, a more diverse gut microbiome was tied to healthy dietary patterns (high-fiber vegetables like spinach and broccoli, nuts, and, heathy animal foods such as fish and eggs) and was linked to measurements tied to lower risk of certain chronic diseases. In addition, the study found that polyunsaturated fats (found in fish, walnuts, pumpkin, flax and chia seeds, sunflower, safflower, and unhydrogenated soybean oils) produce healthy gut species linked to a reduced risk of chronic disease.

Minimally processed, plant-based diet is good for the microbiome and for reducing disease risk

So what do these findings mean for us? First, the study showed that eating more unprocessed plant foods — fruits, vegetables, nuts, seeds, and whole grains — allows the gut microbiome to thrive. Some animal foods, such as fish and eggs, are also favorable. Avoiding certain animal foods, such as red meat and bacon, dairy foods, and highly processed foods (even processed plant foods such as sauces, baked beans, juices, or sugar-sweetened drinks and desserts) prevents less-healthy gut species from colonizing the gut.

It is important to note that food quality matters; processed or ultra-processed plant-based foods were not associated with heathy clusters of gut microbes. When choosing foods, consider whether they are processed or unprocessed, in addition to whether they are a plant or animal food.

It can also be helpful to think in terms of dietary patterns, rather than individual foods or food groups. Meal patterns that emphasize foods beneficial to the microbiome are the whole-food, plant-based dietary patterns. These include vegan (no animal products) and ovo-vegetarian (vegetarian plus eggs) diets. The pescatarian eating pattern, in which oily and white fish are the meats of choice, is also good for the microbiome.

Emphasizing minimally processed plant foods allows the gut microbiome to thrive, providing protection against, or decreasing the risk of, chronic diseases such as heart disease, diabetes, metabolic disease, and obesity.

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Want healthy eyes? What to know at 40 and beyond

20 April 2021 at 07:30

Did the print on that label suddenly shrink? If you’re in your 40s or beyond, you may have asked yourself that question as you struggled to read something that you used to be able to see clearly with no problem.

Blame your aging eyes. Much like our joints, our eyes undergo age-related changes. While eye problems can affect people of any age, some conditions become more common after age 40.

Getting older? Three common eye conditions

Presbyopia. The lens of the eye gets stiffer with age, which makes it harder to focus on objects nearby — hence your label-reading struggles. Many people find satisfaction with inexpensive reading glasses, but once you need them, it’s time for a midlife vision check-up.

Cataracts. Another common condition that can crop up as you age is cataracts, a clouding of the lens of your eye that can impair vision. Cataracts affect about half of people ages 65 to 74. Treatment typically involves an outpatient surgical procedure to replaces the clouded lens.

Dry eye syndrome. This condition affects more than 15 million adults in the United States, and occurs due to a reduction in tear production. With less natural lubrication your eyes can become irritated, sticky, or you may feel a burning or scratchy sensation in the eye. Depending on severity, symptoms can be treated using eye drops that simulate your natural tears, a topical prescription drug, or a device to increase tear production.

Additional eye conditions that may occur with age or illness

Posterior vitreous detachment (PVD). Signs of this condition include visual disruptions, such as seeing light streaks, floaters, or a cobweb-like haze. These occur because the jelly-like substance called vitreous in the eye starts to liquefy and shrink, causing it tug on the retina.

Call your medical team right away if you notice these signs. While most people experiencing PVD won’t need treatment, in some cases the vitreous can completely detach from or tear the retina. A tear or detachment can cause vision loss, and requires a laser procedure or surgery to repair the problem, according to the American Society of Retina Specialists.

Glaucoma. Another condition that becomes more common after age 40 is glaucoma. This painless, often symptomless condition damages the optic nerve that transmits information from your eyes to your brain. When not treated, glaucoma can lead to peripheral or central vision loss. Most often, glaucoma is treated with prescription eye drops designed to reduce the pressure in your eye. Less commonly, your doctor may recommend a laser procedure or surgery.

Age-related macular degeneration (AMD). This condition causes degeneration of the retina, a thin layer of tissue at the back of the eye. Light-sensitive cells of the retina capture images and transmit them to the brain through the optic nerve. AMD affects a central part of the retina called the macula. It can lead to blurred or distorted vision, and possibly a blind spot in a person’s field of vision. Treatment, which may include medication or laser therapy, can often help prevent or at least delay vision loss.

Diabetic retinopathy. This condition also causes damage to the retina. For people with diabetes, keeping blood sugar and blood pressure under control helps prevent diabetic retinopathy. If it is detected, your eye specialist will recommend treatment, usually eye injections or laser therapy.

Easy ways to maintain eye health

Many eye conditions can be effectively treated to protect your vision if they are caught early. That’s why it’s wise to get regular eye exams, to spot potential problems and address them before they affect your eyesight.

You can also take other steps to ensure that your eyes stay healthy, such as exercising, eating a healthy diet, quitting smoking, and protecting your eyes from ultraviolet rays by wearing sunglasses outside.

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Could COVID-19 infection be responsible for your depressed mood or anxiety?

Doctors told you that your COVID-19 virus infection cleared months ago. However, even though you no longer struggle to breathe, and your oxygen levels have returned to normal, something doesn’t feel right. In addition to constant headaches, you find yourself struggling with seemingly easy tasks. The fatigue you experience makes moving from the bed to the kitchen feel like an accomplishment. But most troubling for you is a feeling of dread, a nervousness so severe you can feel your heart pounding. Constant worries now keep you from sleeping at night.

What are the mental health effects of COVID-19?

We are still learning about the long-term effects of COVID-19 on the brain. Data from Wuhan suggest that the virus may invade the brain, with more than one-third of infected patients developing neurologic symptoms. In addition to brain infection, we know that the pandemic has resulted in worsening mental health outcomes due to the psychological toll of isolation, loneliness, unemployment, financial stressors, and the loss of loved ones. The prescription of antidepressants has spiked, intimate partner violence has increased, and suicidal thoughts are on the rise, especially in young adults.

Does COVID-19 infection increase the risk of psychiatric disorders?

Until recently, mental health outcomes as a result of COVID-19 infection were not known. A new study of electronic health records of 69 million people found that COVID-19 infection increased the risk of developing a psychiatric disorder, dementia, or insomnia. Furthermore, people with psychiatric disorders were 65% more likely to be diagnosed with COVID-19, which may be related to behavioral factors, lifestyle factors (such as smoking), inflammation, or psychiatric medication. This is the first large study to show that infection with COVID-19 indeed increases the risk of developing psychiatric disorders.

The long-term mental health effects of COVID-19 infection remain to be seen. Following the influenza pandemic of 1918­–19, offspring of mothers infected during pregnancy were found to have higher rates of schizophrenia. It is thought that virus infection during pregnancy may be one risk factor for the development of mental illness related to the body’s immune response. If COVID-19 infection even slightly increases the risk of mental illness in offspring, this could have a large effect at the population level, given the high numbers of infections worldwide.

Do you have a psychiatric disorder as a result of COVID-19?

You may feel fatigued, stressed, or sad due to the effects of COVID-19 on your body, or due to life circumstances. However, even if you screen positive for depression or anxiety at your doctor’s visit, remember that screening tools are not diagnostic. People with physical symptoms of COVID-19 infection often screen positive for depression, as symptoms of infection often overlap with symptoms of depression. For example, poor sleep, impaired concentration, and reduced appetite may be due to a medical illness rather than depression.

For a doctor to make an accurate diagnosis, you may need to wait a period of time to monitor symptom development. Although antidepressants are often prescribed for mood and anxiety disorders, keep in mind that mild to moderate symptoms often go away on their own when life circumstances improve. If this is your first episode of depression or your first experience of anxiety, you may not require specialist treatment if your symptoms are mild. If you do start a medication, make sure to regularly review your treatment with your doctor and make changes as needed.

What steps can you take to minimize the mental health consequences of COVID-19 infection?

  • Get vaccinated. This is especially important for people with psychiatric disorders, which are independent risk factors for COVID-19 infection.
  • Continue to wear a mask and physically distance. However, aim to maintain social connections.
  • Make use of resources. Online therapies, workbooks, and mobile applications (COVID coach, CBT-I coach) can provide benefits without risking exposure during treatment.
  • Advocate for others. COVID-19 long haulers may not be in the position to advocate for workplace modifications, life insurance, or mental health coverage, especially if suffering from fatigue and brain fog.
  • Perform physical activity. in addition to being as effective as medications on mood and anxiety, physical activity also helps with memory and heart health.
  • Make use of relaxing rituals. When the world seems out of control, try establishing a ritual. Having control over even one part of your day can help you feel grounded.
  • Use caution with sleep aids and as-needed medications. Short-term use can quickly become long-term use, leading to medication tolerance, dependence, and rebound anxiety.
  • Limit alcohol and cannabis use. Prolonged stress from caring for sick loved ones, unemployment, increased time at home, and relationship stressors can result in increased and problematic substance use.
  • Be mindful of caffeine. If post-COVID fatigue is severe, discuss other options with your doctor, as excess caffeine can exacerbate anxiety and sleep problems.
  • Check in and ask how you can help your loved ones, friends, colleagues, and neighbors. It is often much easier to turn down help than to ask for help. If someone is privately struggling with thoughts of suicide, a simple check-in call or kind gesture can be lifesaving. The National Suicide Prevention Lifeline (800-273-8255) is available to anyone in severe distress.

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Are antidepressants also pain relievers?

Did you know that antidepressant medications are often prescribed for people without depression?

It’s true. Antidepressants are frequently prescribed for chronic pain, especially pain related to nerve disease (called neuropathic pain), chronic low back or neck pain, and certain types of arthritis.

In fact, some guidelines for the treatment of chronic low back pain and osteoarthritis (the most common type of arthritis) include antidepressants. One antidepressant in particular, duloxetine (Cymbalta), is FDA-approved for these conditions.

Just how antidepressants reduce pain is not well understood. One possibility is they affect chemicals in the brain involved in pain perception, a mechanism that differs from how they fight depression.

Not usually the first choice for pain relief

For people with chronic low back or neck pain or osteoarthritis of the hip or knee, an antidepressant medication is not usually the first treatment recommended. Other approaches, such as physical therapy, exercise, losing excess weight, nonsteroidal anti-inflammatory drugs (NSAIDs), or cortisone injections are usually tried first. But if these aren’t helpful, antidepressants such as duloxetine or amitriptyline might be a reasonable next step.

When prescribed for pain, the initial dose is typically low (often lower than the starting dose for depression). It’s gradually increased if necessary. Ideally, people notice a benefit within weeks of starting the drug, and the medication can be continued at the lowest effective dose. Switching to a different antidepressant may be recommended if pain is not well controlled, side effects develop, or there is an interaction with another medication.

A new study suggests antidepressants don’t work well for common types of pain

Past research on antidepressants for chronic pain, such as duloxetine for osteoarthritis of the knee, amitriptyline or duloxetine for chronic low back pain, and amitriptyline for chronic neck pain, demonstrated modest, short-term benefit. But the studies were limited: most trials were small and lasted only a few months or less. Notably, medication side effects, such as nausea, constipation, and erectile dysfunction, were common in these trials.

Now a 2021 study has combined the data from past research to get a better sense of just how safe and effective antidepressants are for these conditions. The news isn’t good:

  • On average, treatment with antidepressants minimally reduced pain and disability compared with placebo. The improvement in pain — about 4 points on a scale of 0 to 100 — was considered too small to be noticeable.
  • People treated with certain antidepressants for chronic pain often stopped taking the medication because it didn’t work, caused unacceptable side effects, or both.
  • People with both chronic pain and depression did not experience more improvement than people with chronic pain alone.

Sciatica may be an exception: antidepressants may have reduced pain for up to a year. However, the quality of the prior research was poor, so the study authors were not confident about these conclusions.

These findings cast doubt on the usefulness of antidepressant treatment for these common causes of chronic pain. However, they don’t rule out the possibility that some individuals may get more relief from these medications than others.

The bottom line

The available evidence suggests that, on average, the benefit of antidepressants for osteoarthritis or chronic low back pain and neck pain is modest at best, and tends to be temporary. That’s disappointing because, for many pain sufferers, there are no reliably effective treatments (short of joint replacement for osteoarthritis).

So, if you’re on an antidepressant for pain and you aren’t sure if it’s working, talk to your doctor about whether you should consider stopping it. But don’t stop it on your own. There may be other reasons your doctor is recommending this medication, and many antidepressants should be gradually reduced, not stopped all at once, to avoid discontinuation symptoms.

If you’re taking an antidepressant for pain, it’s worth revisiting whether it’s really doing anything for you and whether it might be time to shorten your medication list. Not only might you simplify your medical regimen, you may also reduce the cost of your medicines and the risk of medication-related side effects.

Follow me on Twitter @RobShmerling

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Anti-Asian racism: Breaking through stereotypes and silence

Like the rest of the country, I awoke on Wednesday, March 17 to the horrific news of a mass shooting in Atlanta that killed eight people. Six were Asian women, ranging in age from 44 to 74. I immediately went numb. Lulu Wang, the Chinese American filmmaker and director of The Farewell, gave voice to my pain on social media: “I know these women. The ones working themselves to the bone to send their kids to school, to send money back home.”

The fact is, I’ve been in a state of numbness for much of the past year. On top of the unprecedented strains that COVID-19 has placed on all of us, Asian Americans like me have had to confront skyrocketing rates of discrimination, verbal assaults, and physical violence. We have been punched, shoved, stabbed, spat at, told that the pandemic is our fault, we brought it this country, and we should go back to wherever we came from. Our most vulnerable — women, youth, and the elderly — are disproportionately targeted.

Racial trauma and fear in the news

The relentless drumbeat of headlines and viral videos depicting unprovoked violence against Asian Americans contributes to vicarious trauma, even for those not directly attacked. Fearful for the safety of my parents, both in their 70s in Virginia, I called home last March to warn them not to go outside too much, to always shop in daylight, to be very careful. My heart broke then thinking about their deeply held belief in the goodness and possibility of this country, which motivated their immigration here almost 50 years ago. And it broke again two weeks ago when my mother told me a teen had yelled a racial slur at her.

As a psychiatrist and director of the nonprofit, volunteer-operated MGH Center for Cross-Cultural Student Emotional Wellness, I am very aware that Asian Americans grappled with mental health issues long before COVID-19. We’ve been stereotyped since the 1960s as the “Model Minority”: a uniformly successful group that keeps its mouth shut and doesn’t rock the boat. That stereotype intersects neatly with cultural values prizing stoicism and self-sacrifice, and greatly stigmatizing anything perceived as shameful — including mental health struggles. Asian Americans are two to three times less likely than whites to seek mental health treatment, and more likely to find available services unhelpful. Our research shows that Asian American and Pacific Islander (AAPI) college students are about half as likely as white students to carry a psychiatric diagnosis such as anxiety or depression — possibly because they have never seen a mental health professional — but almost 40% more likely to have attempted suicide.

To that burden we now add racial trauma — the mental and emotional injury caused by race-based discrimination. As described by psychologist Robert Carter, racial trauma makes the world feel less safe, and lingers in the psyche long after the incident is over. Victims report anxiety, hypervigilance (a state of increased alertness), avoidance of situations that remind them of the attack, poor sleep, mood swings, and yes, numbness. These symptoms mirror those of post-traumatic stress disorder. Words actually can and do hurt us, contrary to a childhood rhyme — sometimes even more than sticks and stones.

The weight of racism, past and present

Time and again, events of this pandemic have driven home that being a Model Minority is not enough — AAPI doctors and nurses have been assaulted, even by patients they were caring for. What I never learned, either from my parents while growing up or from my high school history curriculum, is that anti-Asian racism is nothing new; it is woven into the very fabric of this country.

Looking back teaches us much. Fear of Chinese laborers taking American jobs in the mid-1800s fanned persecution and caricaturing of Chinese and Asians as the “Yellow Peril,” diseased, lewd, and treacherous. In 1871, a 500-person mob slaughtered, mutilated, and hung 20 Chinese men in Los Angeles during one of the deadliest lynching incidents in US history. The Chinese Exclusion Act of 1882 was the only law to prohibit a specific ethnic or national group from immigrating to the US and naturalizing as citizens. During World War II, President Franklin D. Roosevelt signed an executive order forcing more than 120,000 Japanese Americans into internment camps — over 60% of whom were US citizens. The hatred we see now echoes these earlier refrains of Asians as diseased invaders and disloyal, perpetual foreigners.

A different perspective on the Model Minority myth

I now see the Model Minority label in a different light. Who could blame Asian Americans for embracing a seemingly more positive reputation, given the pervasive discrimination they faced? But that stereotype is both damaging and wrong. It obscures the significant disparities and challenges faced by the extraordinarily diverse AAPI community, which has the greatest income inequality of any racial group in the US. And it encourages policymakers to overlook our issues. Most insidiously, it sets up a divisive contrast with other minorities, blaming them for their problems and perpetuating the fiction that structural racism does not exist. On top of all that, we now see how quickly the stereotype of the Model Minority reverts to the Yellow Peril.

Will the racism we’ve experienced during this pandemic be a turning point in our community’s racial awakening? Our Center can attest to a new hunger among AAPI parents for education and resources to help them talk to their kids about race and racism. More members of our community are organizing, becoming politically active, and speaking out about incidents of hate that previously went unreported. It’s long past time that we break our silence and speak out against AAPI hate, yes, but also that we stand proudly in solidarity with other marginalized groups against violence and oppression in all its forms.

Resources

Dr. Chen would like to acknowledge Ian Shin, MA, MPhil, PhD, an assistant professor at the University of Michigan, who contributed historical background for this post.

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Can some postmenopausal women with breast cancer skip chemotherapy?

15 April 2021 at 07:30

Breast cancer remains the most common cancer among women. In the last two decades, the treatment of breast cancers has become personalized. This has been possible due to the subtyping of breast cancers. Breast cancers have been subtyped based on the receptors on the breast cancer cell. The most clinically significant receptors — those that have targeted therapies — are the estrogen and progesterone receptors and the human epidermal growth factor receptor 2 (HER2). Cancers that have the estrogen and progesterone receptors are termed hormone receptor (HR)-positive cancers.

The development of hormone therapy for HR-positive breast cancers means that some women, for whom the risks of chemotherapy outweigh the benefits, may be able to forego chemotherapy. The development of genomic assays, tests that analyze genes expressed in cancer, have provided a way to help doctors and women decide who will obtain the most benefit from chemotherapy.

How does genomic testing help to personalize breast cancer treatment?

Increasingly detailed knowledge about breast cancers has led to the development of personalized therapy. In addition to knowing the type and stage of your cancer, genomic testing has further refined how we assess the risk of recurrence for breast cancer. One genomic test, Oncotype Dx, is a useful tool that can help predict the likelihood of benefit from chemotherapy, as well as the risk of recurrence for invasive breast cancer.

Not all women will require chemotherapy, but for some women hormone therapy alone is not enough. Oncotype Dx analyzes the expression of 21 genes in HR-positive, HER2-negative breast cancer and assigns a recurrence score (RS) based on risk of recurrence. The Oncotype Dx test places women into three groups: low, intermediate or moderate, and high risk of recurrence. Women with a low score do not need chemotherapy and benefit the most from hormone therapy, while women who have a high recurrence score benefit the most from chemotherapy in addition to hormone therapy.

There is new research to help women make decisions about chemotherapy

Until recently, it was unclear how much benefit women with an intermediate risk score obtained from chemotherapy. A randomized clinical controlled trial, the Tailor Rx trial, answered this question. The trial randomized women with node-negative (cancer that has not yet spread to the lymph nodes), HR-positive, HER2-negative breast cancers with an intermediate risk score to hormone therapy alone, or to chemotherapy in additional to hormone therapy. The results showed that most women with an intermediate risk of invasive cancer did not get any added benefit with chemotherapy. However, the subgroup of women who did benefit from chemotherapy were premenopausal women under age 50.

While the results of the Tailor Rx trial were practice-changing, it did lead to questions about the benefit of chemotherapy in women whose cancer has spread to their lymph nodes and who had HR-positive, HER2-negative breast cancer. The RxPonder trial answered this question.

The RxPonder trial randomized 5,015 women with stage II/III HR-positive, HER2-negative breast cancer, with one to three positive lymph nodes, and an intermediate RS (≤ 25). Patients were randomized to receive hormone therapy alone, or hormone therapy with chemotherapy. The main goal of the study was to determine how many women did not get a recurrence of the invasive breast cancer while they were being followed.

There were many ways to compare the women in the study, but the main characteristics chosen for comparison were: menopausal status, RS, and the kind of axillary surgery they received. At a median follow up of 5.1 years, there was no association between chemotherapy benefit and RS value between zero and 25 for the entire population. However, there was an association seen between chemotherapy benefit and menopausal status. This trial provided evidence that even women with cancer in their lymph nodes, if they had a low or intermediate RS, could avoid chemotherapy.

Premenopausal women responded better to hormone therapy and chemotherapy

Of the women enrolled in the RxPonder trial, 3,350 were postmenopausal and 1,665 were premenopausal. Further analysis by menopausal status revealed that there was no difference in five-year survival for postmenopausal women treated with hormone therapy alone versus hormone therapy with chemotherapy.

However, for premenopausal women there was a 46% reduction in the risk of invasive disease. For this subgroup of women, the five-year, invasive disease-free survival rates were 94.2% in women treated with hormone therapy and chemotherapy, compared to 89% in women treated with hormone therapy alone. The premenopausal women who received both chemotherapy and hormone therapy had an additional benefit of around 5%. It is unclear if the survival benefit seen in premenopausal women is primarily due to chemotherapy’s effect, or indirectly by ovarian suppression due to chemotherapy

What does this mean for breast cancer treatment decision-making?

The treatment of breast cancer has truly become personalized. It has always been important to know the stage of your caner, but now it is also important to know the type of your cancer. With this information, women can make an informed discussion with their oncologist about the risks and benefits of chemotherapy.

If you are a premenopausal woman with a HR-positive, node-positive breast cancer, chemotherapy and hormone therapy may give you the greatest chance of decreasing your risk of the cancer coming back. However, for a postmenopausal woman with HR-positive breast cancer, chemotherapy may not add many treatment benefits to hormone therapy, and it carries risks that may affect your quality of life. Studies like the TailorRx and RxPonder trials have provided more information to help you make an informed decision.

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Stress may be getting to your skin, but it’s not a one-way street

Are you stressed out? Your skin can show it. Studies show that both acute and chronic stress can exert negative effects on overall skin wellness, as well as exacerbate a number of skin conditions, including psoriasis, eczema, acne, and hair loss.

But it’s not just a one-way street. Research has also shown that skin and hair follicles contain complex mechanisms to produce their own stress-inducing signals, which can travel to the brain and perpetuate the stress response.

Stress and the two-way street between your brain and skin

You may already have experienced the connection between the brain and skin. Have you ever gotten so nervous that you started to flush or sweat? If so, you experienced an acute, temporary stress response. But science suggests that repeated exposure to psychological or environmental stressors can have lasting effects on your skin that go far beyond flushing — and could even negatively affect your overall well-being.

The brain-skin axis is an interconnected, bidirectional pathway that can translate psychological stress from the brain to the skin and vice versa. Stress triggers the hypothalamus-pituitary-adrenal (HPA) axis, a trio of glands that play key roles in the body’s response to stress. This can cause production of local pro-inflammatory factors, such as cortisol and key hormones in the fight-or-flight stress response called catecholamines, which can direct immune cells from the bloodstream into the skin or stimulate pro-inflammatory skin cells. Mast cells are a key type of pro-inflammatory skin cell in the brain-skin axis; they respond to the hormone cortisol through receptor signaling, and directly contribute to a number of skin conditions, including itch.

Because the skin is constantly exposed to the outside world, it is more susceptible to environmental stressors than any other organ, and can produce stress hormones in response to them. For example, the skin produces stress hormones in response to ultraviolet light and temperature, and sends those signals back to the brain. Thus, psychological stressors can contribute to stressed-out skin, and environmental stressors, via the skin, can contribute to psychological stress, perpetuating the stress cycle.

How else can stress affect your skin?

Psychological stress can also disrupt the epidermal barrier — the top of layer of the skin that locks in moisture and protects us from harmful microbes — and prolong its repair, according to clinical studies in healthy people. An intact epidermal barrier is essential for healthy skin; when disrupted, it can lead to irritated skin, as well as chronic skin conditions including eczema, psoriasis, or wounds. Psychosocial stress has been directly linked to exacerbation of these conditions in small observational studies. Acne flares have also been linked to stress, although the understanding of this relationship is still evolving.

The negative effects of stress have also been demonstrated in hair. One type of diffuse hair loss, known as telogen effluvium, can be triggered by psychosocial stress, which can inhibit the hair growth phase. Stress has also been linked to hair graying in studies of mice. The research showed that artificial stress stimulated the release of norepinephrine (a type of catecholamine), which depleted pigment-producing stem cells within the hair follicle, resulting in graying.

How can you manage stress skin?

While reducing stress levels should theoretically help to alleviate damaging effects on the skin, there’s only limited data regarding the effectiveness of stress-reducing interventions. There is some evidence that meditation may lower overall catecholamine levels in people who do it regularly. Similarly, meditation and relaxation techniques have been shown to help psoriasis. More studies are needed to show the benefit of these techniques in other skin conditions. Healthy lifestyle habits, including a well-balanced diet and exercise, may also help to regulate stress hormones in the body, which should in turn have positive effects for skin and hair.

If you are experiencing a skin condition related to stress, see a dermatologist for your condition, and try some stress-reducing techniques at home.

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The art of a heartfelt apology

13 April 2021 at 07:30

If you’ve been stuck mostly at home with one or more family members over the past year, chances are you’ve gotten on one another’s nerves occasionally. When you’re under a lot of stress, it’s not uncommon say something unkind, or even to lash out in anger to someone you care about. And we all make thoughtless mistakes from time to time, like forgetting a promise or breaking something.

Not sure if you should apologize?

Even if you don’t think what you said or did was so bad, or believe that the other person is actually in the wrong, it’s still important to apologize when you’ve hurt or angered someone. “To preserve or re-establish connections with other people, you have to let go of concerns about right and wrong and try instead to understand the other person’s experience,” says Dr. Ronald Siegel, assistant professor of psychology at Harvard Medical School. That ability is one of the cornerstones of emotional intelligence, which underlies healthy, productive relationships of all types.

How to apologize genuinely

For an apology to be effective, it has to be genuine. A successful apology validates that the other person felt offended, and acknowledges responsibility (you accept that your actions caused the other person pain). You want to convey that you truly feel sorry and care about the person who was hurt, and promise to make amends, including by taking steps to avoid similar mishaps going forward as in the examples below.

According to the late psychiatrist Dr. Aaron Lazare, an apology expert and former chancellor and dean of the University of Massachusetts Medical School, a good apology has four elements:

  • Acknowledge the offense. Take responsibility for the offense, whether it was a physical or psychological harm, and confirm that your behavior was not acceptable. Avoid using vague or evasive language, or wording an apology in a way that minimizes the offense or questions whether the victim was really hurt.
  • Explain what happened. The challenge here is to explain how the offense occurred without excusing it. In fact, sometimes the best strategy is to say there is no excuse.
  • Express remorse. If you regret the error or feel ashamed or humiliated, say so: this is all part of expressing sincere remorse.
  • Offer to make amends. For example, if you have damaged someone’s property, have it repaired or replace it. When the offense has hurt someone’s feelings, acknowledge the pain and promise to try to be more sensitive in the future.

Making a heartfelt apology

The words you choose for your apology count. Here are some examples of good and bad apologies.

EFFECTIVE WORDING WHY IT WORKS
“I’m sorry I lost my temper last night. I’ve been under a lot of pressure at work, but that’s no excuse for my behavior. I love you and will try harder not to take my frustrations out on you.” Takes responsibility, explains but does not excuse why the mistake happened, expresses remorse and caring, and promises reparation.
“I forgot. I apologize for this mistake. It shouldn’t have happened. What can I do to avoid this problem in the future?” Takes responsibility, describes the mistake, makes the person feel cared for, and begins a conversation about how to remedy the error.
INEFFECTIVE WORDING WHY IT WON’T WORK
“I apologize for whatever happened.” Language is vague; offense isn’t specified.
“Mistakes were made.” Use of passive voice avoids taking responsibility.
“Okay, I apologize. I didn’t know this was such a sensitive issue for you.” Sounds grudging, thrusts the blame back on to the offended person (for “sensitivity”).

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How is treatment for myasthenia gravis evolving?

Myasthenia gravis (MG) — a medical term that translates as “serious muscle weakness” — is a rare neuromuscular disease. An estimated 30,000 to 60,000 people in the United States have this disorder, which affects people of all ages, sexes, and ethnicities. Recently updated consensus guidelines have added to our knowledge of different forms of myasthenia gravis and improved approaches to treatment.

What are the symptoms of myasthenia gravis?

Myasthenia gravis impairs the transmission of signals from nerves to muscles at a site called the neuromuscular junction (NMJ), where nerves make contact with muscle. This causes temporary weakness of muscles in use. When the affected muscle or muscle group is rested, it recovers strength.

Throughout the day, your body uses many muscle groups repeatedly; this is true even if you’re not especially active. Because myasthenia gravis is marked by use-related weakness in particular muscle groups, repeated activity of affected muscle makes weakness worse. The weakness improves with rest, only to recur as activity resumes.

Which muscle groups are affected may vary from person to person. Often, the muscles around the eyes are affected. Drooping of the eyelids and double vision are common symptoms. People may complain that they are fine when they wake up, but as the day goes on, their eyelids droop. After a nap, their eyes are wide open. They could start out seeing just fine when driving, but as they drive on they develop double vision. They cannot eat a whole bagel because their jaw gets tired after a while, although they can eat pasta without a problem. Their arms get tired halfway through blow-drying their hair and they have to stop, put their arms down for a while, and then go on.

What causes myasthenia gravis?

Several disorders and even some medications can affect the neuromuscular junction. I’ll focus here on a form of myasthenia gravis called autoimmune MG. If you have autoimmune MG, your immune system produces antibodies that inappropriately attack certain proteins at the junction. One such protein is the acetylcholine receptor (AchR), located on the muscle membrane at the junction.

This particular protein binds to a chemical messenger called acetylcholine (Ach). Ach is released by the nerve terminal when an electrical signal reaches it, causing a muscle to contract. But AchR antibodies destroy and reduce the number of AchR, so that the transmission of impulses from nerve to muscle is impaired and muscle weakness results.

Antibodies may also be directed against other important proteins at the neuromuscular junction that would normally help to maintain AchR proteins, causing the same end result. Two such proteins that may be targeted by antibodies are muscle-specific kinase (MuSK) and lipoprotein-related protein 4 (LRP-4).

How is myasthenia gravis treated?

Treatment is directed first toward improving symptoms. The drug most commonly used is pyridostigmine. Pyridostigmine prolongs the time that Ach stays in the neuromuscular junction, thus giving it more of a chance to bind to the reduced number of AchR receptors.

Additionally, people with autoimmune MG receive treatment to suppress the abnormal immune response underlying the disease. Many approaches are used to achieve this.

In 2016, the Myasthenia Gravis Foundation of America (MGFA) convened an international task force of neuromuscular specialists to develop guidance around treatment. This panel updated that guidance in 2020, adding new recommendations for a surgical procedure called thymectomy; treating ocular MG (MG confined to the muscles around the eyes); and the use of three medications to address abnormal immune response: methotrexate, rituximab, and eculizumab.

  • Thymectomy Located in the middle upper chest between the lungs, the thymus gland is believed to play a role in the autoimmune response in MG. During a thymectomy, the gland is surgically removed. A randomized controlled trial showed that thymectomy is effective in reducing the dose of prednisone (an immunosuppressive medication) needed by a specific subset of people with MG.
  • Methotrexate did not reduce the need for prednisone in a randomized controlled trial of people who have MG with AchR antibodies.
  • Rituximab is helpful for people with MuSK MG, according to the consensus report, but less so for those with AchR MG.
  • Eculizumab is a new drug with a novel mechanism of action found to improve physical function in people with MG who had not responded to previous treatments. Immunization against meningococcus (a group of bacteria that cause meningitis) is necessary prior to treatment. Eculizumab is given through an injection into a vein once a week for five weeks, then every two weeks after this initial period.

Many people with autoimmune MG need long-term immunosuppressive treatment to help them manage their disorder. The best options for treatment are decided through monitoring the course of the disease and response to treatments over time.

The treatment of MG is complex. Your neurology team will take into account several factors, including age, gender, pregnancy and breastfeeding, and other illnesses (such as high blood pressure, diabetes, or liver disease). They’ll also consider the presence and type of MG antibodies, the type of MG you’re experiencing (ocular MG or generalized MG, which affects more than the eyes alone), and your preferences and values.

As new information about treatment becomes available, discuss possible treatment changes with your neurologist, who can help ensure that the treatment choices you make align with your goals for improvement, as well as your personal values and preferences.

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Sleep, stress, or hormones? Brain fog during perimenopause

9 April 2021 at 03:30

Often when people think of perimenopause, irregular periods and hot flashes come to mind. But some women may notice another symptom: brain fog.

You’re reading a letter and suddenly realize your thoughts have drifted off and you need to start again. Or you draw a blank when you’re trying to remember someone’s name, or find yourself standing in a room, wondering what you came there to get.

The good news is that these small cognitive blips are probably not anything you need to worry about long-term.

Sleep disturbances and stress may be part of brain fog

Those times when you are less focused and a bit forgetful are likely not just due to hormonal changes. Sleep quality, perhaps related to night sweats during perimenopause, could definitely contribute. Increased stress that sometimes accompanies this stage of life may also have you feeling frazzled and distracted. These factors can interfere with concentration and memory.

Not getting enough sleep can leave you feeling cranky and sluggish. This may be why you can’t remember what’s-her-name: you weren’t paying close enough attention when she told you her name in the first place.

Stress can have a similar effect by pulling your thoughts off task, because you’re preoccupied, worrying about something else.

What can you do to feel less foggy?

If this sounds like you, there are some things you can do to help lift the fog and get your brain re-engaged.

  • Slow down. Train yourself to recognize when you’re distracted, and take a moment to breathe and refocus on the task at hand. If you’ve just taken in some new information, try to find a quiet moment to give your brain a chance to process what you’ve learned.
  • Manage your stress. Using mindful meditation or other stress-reduction strategies can also help you to relax and be more present. This can help you absorb new information and recall it more easily.
  • Get regular exercise. Physical activity benefits not only your body, but also your mind. One study found that just three days a week of moderate-intensity exercise appeared to increase the size of the hippocampus, a part of the brain involved in memory and learning.
  • Improve your sleep habits. If you are experiencing poor sleep quality, work on strategies that can help you get more rest at night. Improve your sleep hygiene by making changes, such as staying off electronic devices close to bedtime and establishing a regular sleep schedule. Check with your doctor if at-home strategies aren’t doing the trick.
  • Use memory tricks. Did you ever use little tricks to remember things when you were studying for a test in school? Those same mental cheats can help you now as well. For example, make up a mnemonic or a rhyme to help you recall information. Or try using visual or verbal clues. Repeating information or instructions to yourself or someone else is another way to help your brain store information more effectively.

Know when to seek help

Most small memory lapses are nothing to worry about. If changes due to perimenopause — including irregular periods, trouble sleeping due to night sweats, or brain fog — bother you, talk to your doctor about possible solutions.

It’s also important to call your doctor if

  • memory changes come on suddenly, or are accompanied by hallucinations, paranoia, or delusions
  • memory lapses might put your safety at risk, such as affecting your driving or forgetting food cooking on the stove.

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Black peer support: A role in mental health recovery

It’s been a troubling year for millions of Americans, marked by public reckonings over inequities in justice, health care, and most certainly mental health care. None of these inequities are new. Estimates suggest that only 22% of Black Americans — fewer than one in four — who need mental health care actually receive treatment. In addition to financial and insurance barriers to mental health treatment, a long history of discrimination in medicine makes it difficult for some people of color to form trusting relationships with medical providers. And that’s one reason why peer support has been gaining traction to help address unmet needs.

What is peer support for mental health?

Peer support is a relationship based on mutuality — that is, people with similar experiences listening, sharing, and encouraging one another. In the US, peer support training, certification requirements, and availability vary by state. In Massachusetts, for example, mental health peer support groups are facilitated by certified peer specialists (CPS). Once trained and certified by the Massachusetts Department of Mental Health (DMH) through Kiva Centers, CPSs facilitate classes and support groups at Recovery Learning Communities throughout the state. They also work in hospitals, day treatment programs, emergency services, and residential services operated by DMH.

The National Alliance on Mental Illness (NAMI) has widely available Peer-to-Peer and Connection Recovery Support Groups programs. Local chapters of the Depression and Bipolar Support Alliance (DBSA) host peer and parent support groups for families and people living with these conditions. The National Empowerment Center has a directory of peer respite sites offering short-term, overnight crisis support in several states. New and expanded roles for peer support include forensic peer specialists and peer bridgers, who assist people living with mental illness who are transitioning to the community from state hospitals or incarceration.

Studies suggest peer support in traditional mental health settings improves engagement and well-being and reduces mental health hospitalizations. Yet, existing peer support does not address aspects of shared identity like race and ethnicity, or experiences of discrimination in treatment settings. Affinity peer support groups created around race and culture do.

Designing peer support that addresses the impact of race and ethnicity on mental health

In 2005 I created Black Voices: Pathways 4 Recovery (BV) at The Transformation Center in Roxbury, MA, for people of the African diaspora seeking safe spaces to talk about what it’s like living Black in America. It’s enormously valuable to be in the process of recovery with people who face that same daily reality. Together, we’re fighting to stay safe and well despite the fear of turning on the news or stepping outside our homes where we may face racism — directed at us, or someone who looks like us — at any time.

How do affinity groups support recovery and healing? Black Voices members say it’s important to have a group where they can talk about their challenges and frustrations coping with family matters or racism, while dealing with the stress of a mental health diagnosis like depression or schizophrenia, trauma, or addiction. There is so much healing we all need to do as a result of over four centuries of living within the context of the white racial frame. When it seemed like every other week brought a new murder of another unarmed, innocent Black person, all of us were out of sorts: depressed, angry, terrified to be out in public. One person who had seen a new psychiatrist during this time was afraid to mention how they were really feeling for fear of being viewed as “too symptomatic.” Having a place where you can truly be understood — among those who “get you,” your culture, and your needs — is priceless.

Working toward trust and a voice in research

During the past six years, Black Voices members have worked with researchers from the Health Equity Research Lab at Cambridge Health Alliance/Harvard Medical School, and researchers at Johns Hopkins Bloomberg School of Public Health and Albert Einstein College of Medicine. At first, members were skeptical of the researchers. People had a lot of questions, concerns, and pent-up grievances, and they wanted some airtime!

A wonderful co-learning experience gradually unfolded between BV members and the researchers, but mutual trust and respect had to be established first. We had to learn about research culture. Researchers had to learn our “person-first” language, leaving out the clinical terms of diagnosis that cause many people living with mental health issues to feel objectified — like a label rather than a human being. The more the relationship developed, the more we all felt compelled to share ideas for future work and outreach. BV members could see concrete evidence of steps taken. We could feel, heart-to-heart, and hear directly from the research team what this work means to them, and how our experiences contributed meaningfully to mental health care research. Over time, people felt more hopeful, empowered, and excited to collaborate.

Today, BV members welcome research participation, but only after having an opportunity to meet the research team, ask their 1,001 questions, and feel assured that they are not being viewed as “poor charity cases needing rescuing by a great white savior.” We look for respect, transparency, and sincerity. We want evidence that the research team is doing their own homework by continually addressing their own privileges and assumptions while being humble enough to acknowledge that their worldview is limited and biased. There is always more to understand.

Moving forward to make healing connections

In pre-pandemic days, a simple community conversation about mental health in the Black community drew well over 100 people. It was standing room only despite pouring rain: a room filled with young people, elders, caregivers, and providers. There were couples and singles with babies, people “out” about their mental health struggles and others who were not. Many voiced their questions or concerns.

Since that time we’ve moved our forums online, or shifted to venues that can accommodate everyone who wishes to join us. Over and over, we’ve found people want to learn, grow, and heal with one another. They want to be engaged in a mutual give-and-take without judgement or hierarchy from which to fear further trauma. And they seek a process where their opinions, voices, and experiences are not just taken into account, but are centered, valued, and respected. Let’s find a way to deliver that.

From time to time, the Harvard Health Blog invites guest authors who can shed light on different aspects of health, well-being, and the world in which we’re living. Along with Valeria Chambers, EdM, CAS, CPS, we’d like to acknowledge Ana M. Progovac, PhD, a senior scientist at the Health Equity Research Lab at Cambridge Health Alliance, who worked with Ms. Chambers on research and historical background for this post.

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What’s new in the updated asthma guidelines?

7 April 2021 at 07:30

In 2007, The Sopranos was a hit TV show, patterned jeggings were a fashion trend, and the National Institutes of Health–sponsored National Asthma Education and Prevention Program (NAEPP) published the second edition of the Asthma Management Guidelines.

A lot has changed since 2007, including in the area of asthma. The NAEPP recently published the third edition of the Asthma Management Guidelines to address these changes. This update reflects recent advances in our understanding of the disease mechanisms causing asthma, and the current best practices to manage asthma symptoms. As such, the updated guidelines are an important tool, enhancing the ability of physicians and patients to control asthma and minimize the impact of this disease on their lives.

The toll of asthma in the US

Asthma is a chronic lung disease afflicting approximately 5% to 10% of the American population. It is characterized by symptomatic periods of wheezing, chest tightness, and breathlessness alternating with periods of essentially normal breathing. The symptomatic episodes can be extremely debilitating, even life-threatening — every year approximately 3,500 people die from asthma, many of them children. Like many diseases, the impact of asthma is greater among minority and economically disadvantaged patients. There is no cure for asthma, so therapy focuses on preventing and treating symptom flares, called exacerbations.

New asthma guidelines update treatment recommendations

The major focus of the updated guidelines is asthma treatment. Most asthma therapies address two causes of asthma symptoms: airway inflammation and airway constriction. Airway inflammation in asthma is caused by an overabundant and/or inappropriate immune response. It is usually treated with steroids, which help control airway inflammation, or swelling, over time.

Airway constriction is controlled by nerves in the airways. There are two major types of airway nerves, sympathetic and cholinergic. The sympathetic nerve network, specifically the beta-2 nerve receptors, is the most frequent neural target in asthma treatment. Medications that activate the beta-2 nerve receptors are called beta agonists, and. they are usually given as inhaled medications. Beta agonists are bronchodilators; they relax muscles in the airways, allowing constricted airways to reopen. There are two basic types of beta agonists used in asthma: medications with rapid onset of action and short duration (SABAs), which are used for immediate symptom relief; and medications with longer duration of action and (usually) delayed onset of action (LABAs), which are used for maintenance therapy.

Previously, asthmatic patients requiring daily maintenance, or controller, therapy used separate steroid and beta agonist inhalers to manage airway inflammation and constriction. LABAs are favored for maintenance therapy because of their longer duration of action. But for patients already using a steroid and a LABA for maintenance therapy, using a SABA for breakthrough symptoms meant having a second (if the maintenance treatment used a combination steroid/LABA inhaler) or a third (if separate steroid and LABA inhalers are used for maintenance) rescue inhaler. This approach is cumbersome and disruptive for patients.

The update provides guidance for using a new type of inhaler that combines a steroid with a LABA as both a controller and rescue medication. Using one inhaler for both maintenance and rescue therapy is a more effective approach than one that uses multiple inhalers. First, it is easier to correctly use one inhaler than to take several doses from multiple inhalers. Second, using a combination inhaler for the rescue treatment both gives immediate symptom relief and increases the steroid dose. So, this approach increases the amount of both the anti-constriction and anti-inflammation medications.

However, not all combination inhalers are suitable for this approach. To be used for both maintenance and rescue, the LABA has to have a rapid onset of effect. One LABA, formoterol, has a rapid onset of action, and the guidelines outline which combination therapy is effective as both a controller and rescue therapy, and how to incorporate this into asthma treatment.

Recent evidence has shown that the cholinergic nerves also are important in regulating airway size in asthma. The updated guidelines incorporate these findings to include recommendations about using long-acting anti-cholinergic therapies (LAMAs), such as tiotropium (Spiriva HandiHaler) or umeclidinium (Incruse Ellipta), to treat asthma.

New treatment approach targets specific inflammatory cells

The most recent studies in asthma have focused on identifying subsets of asthma patients based on distinct patterns of inflammation. These studies have led to the development of new therapies that specifically target particular types of inflammatory cells and their products. These therapies are very specific, and don’t work for all asthmatics. And they can sometimes provoke serious, even life-threatening, allergic reactions. The updated guidelines provide general guidance as to when this new approach may be incorporated into a patient’s asthma management strategy. However, since this area is still new, this edition of the guidelines doesn’t give specific recommendations regarding these medications.

The new guidelines also address safe use of the leukotriene inhibitors, zileuton (Zyflo) and montelukast (Singulair). These are effective asthma therapies, but can sometimes cause serious side effects. In particular, montelukast has been associated with depression. The FDA has recently added a warning about this concern to this medication. The guidelines outline how it can be used safely.

Measurements of nitric oxide may be used for asthma diagnosis

The update also provides guidance on using new techniques to diagnose asthma. The activity of the cells causing inflammation in the airways of people with asthma results in a byproduct, called nitric oxide, which is exhaled as the person breathes. Reliable measurements of exhaled nitric oxide have become widely available, and the new asthma guidelines explain how to incorporate these measurements into asthma diagnosis.

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Women, alcohol, and COVID-19

6 April 2021 at 07:30

Excessive alcohol use is a common response to coping with stress. Alcohol use increased following the September 11th terrorist attacks and Hurricanes Katrina and Rita. The COVID-19 pandemic is following this same path. However, this pandemic is different in its scope and duration. COVID-19 is associated with both negative health and economic impacts, as well as grief, loss, and prolonged stress and uncertainty.

The emotional impact of COVID-19 on women

According to the U.S. National Pandemic Emotional Impact Report, compared to men, women reported higher rates of pandemic-related changes in productivity, sleep, mood, health-related worries, and frustrations with not being able to do enjoyable activities. Women with children under age 18 had higher rates of clinically significant anxiety, compared to men with children under age 18 and to women with no minor children. Women are more likely to shoulder the burden of household tasks, caregiving, and child-rearing than men. Stay-at-home orders to stop transmission of COVID-19 led to decreased childcare support and the additional burden of remote schooling.

Rising rates of alcohol use in women

You only need to glance at social media to get the message that there is a “cure” for pandemic-related stress: alcohol. Social media sites are rife with memes of moms drinking to relieve their stress. And alcohol is now easier than ever to obtain through delivery sites and apps. Therefore, it is not surprising that we are seeing a disproportionate effect of the pandemic on women’s alcohol use. Rates of alcohol use, heavy drinking (defined as four or more drinks on one occasion), and related disorders in women were rising even before the pandemic. Between 2001–02 and 2012–13, there was a 16% increase in the proportion of women who drink alcohol, a 58% increase in women’s heavy drinking (versus 16% in men), and an 84% increase in women’s one-year prevalence of an alcohol use disorder (versus 35% in men).

This is in part due to changing social norms around female alcohol consumption and the alcohol industry’s targeted marketing to women. The pandemic has further increased rates of alcohol use in women. According to a RAND Corporation study, during the pandemic women have increased their heavy drinking days by 41% compared to before the pandemic. Additional research has shown that the psychological stress related to COVID-19 was associated with greater drinking for women, but not men.

Medical and psychiatric consequences of alcohol use

Physical health is adversely impacted by heavy drinking, including risks for hypertension, cancer, stroke, liver disease, and alcohol-impaired accidents. Because women absorb and metabolize alcohol differently than men, they are more susceptible to the negative physical consequences of alcohol, including liver disease, heart disease, and cognitive impairment. It is estimated that one-third of breast cancer cases could be prevented if women did not drink alcohol, were physically active, and maintained healthy weight.

Alcohol use can negatively affect mental health. Women have twice the risk of men for depression and anxiety, and heavy alcohol use exacerbates depression, anxiety, and insomnia — symptoms experienced by many people during this pandemic. Heavy alcohol use contributes to intimate partner violence, and the COVID-19 pandemic has created a dangerous situation of high stress, increased alcohol use, and decreased escape options for women living with an abusive partner.

Practical tips and resources for dealing with pandemic-related stress

It is important for women to find healthy coping strategies for the associated stress and anxiety of the COVID-19 pandemic. Prioritizing healthy eating, sleep, and exercise can help boost your physical and mental health. Although physical distancing is necessary to stop the spread of COVID-19, people should avoid socially isolating themselves from friends, family, and loved ones. Maintain a daily routine to avoid boredom, as boredom can often lead to alcohol use.

How to make changes in your alcohol use

Small changes in your alcohol use can be helpful:

  • Examine your drinking behavior in light of your mental and physical health risks, including a personal or family history of alcohol problems, and use of any medications that are contraindicated with alcohol.
  • Stay within the National Institute on Alcohol Abuse and Alcoholism (NIAAA) current guidelines for alcohol consumption: no more than one standard drink per day, and no more than seven in one week for women (a standard drink is 5 ounces of wine; 1.5 ounces of spirits; 12 ounces of beer).
  • Make use of resources such as the NIAAA and CDC
  • Consider alcohol intake and possible pregnancy. There is no safe limit of alcohol use while pregnant.
  • Seek help from your health care provider about the safest way to cut back on alcohol use.
  • People currently in recovery from alcohol use disorder, or those who need help, may benefit from telehealth and online support group meetings. The NIAAA Alcohol Treatment Navigator website provides information about telehealth and online support group meeting options.

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Do vitamin D, zinc, and other supplements help prevent COVID-19 or hasten healing?

The appeal of safe, natural treatments is undeniable. It’s true for age-old conditions such as the common cold, and for new diseases, especially if they have no known cure. So it makes sense that there would be a lot of interest in supplements for COVID-19, whether as prevention or treatment.

Indeed, zinc, melatonin, vitamin C, vitamin D, and other supplements have been commonly prescribed from the earliest days of the pandemic.

But do they work?

Why supplements might help prevent or treat COVID-19

While science can show whether a drug is effective, we may not always know why. When antibiotics were first discovered in the 1920s, there was limited understanding of the biology involved. But lacking an explanation for their benefit did not discourage doctors from recommending these highly effective treatments.

If it’s less clear whether a drug works, biologic plausibility — that is, a logical and well-understood reason why the drug should work — increases the expectation that it might.

So, what suggests that vitamin C, vitamin D, zinc, and melatonin might help work against any virus?

  • Vitamin C is an antioxidant that has long been promoted as a key player in healthy immune function.
  • Zinc may have antiviral activity, whether by improving immune cell function that counters viral infections or by reducing the ability of viruses to multiply.
  • Some evidence (see this study and this study) suggests that combining vitamin C and zinc may limit the duration and severity of cold symptoms.

The cases for vitamin D and melatonin differ. While there is also evidence that vitamin D and melatonin may have positive effects on immune function, a specific antiviral effect remains unproven.

What’s the evidence that supplements are helpful for COVID-19?

Though COVID-19 is a new illness, a few clinical trials have explored the possibility that supplements may be effective. And, unfortunately, most of the evidence is unconvincing.

For example, a few observational studies link lower blood vitamin levels with a higher risk of testing positive for the virus that causes COVID-19 (see this study and this one). But studies like these cannot prove that vitamin D protects people against infection. Further, a randomized controlled study of people with moderate to severe COVID-19 who received a high dose of vitamin D showed no benefit.

Similarly, a 2021 study of zinc and vitamin C demonstrated no benefit for people with mild COVID-19. In this study, people whose symptoms did not require hospital admission were randomly assigned to receive

  • only vitamin C, 8,000 mg/day (the recommended daily amount is 75 mg/day for women and 90 mg/day for men)
  • only zinc, 50 mg/day (the recommended daily amount is 8 mg/day for women, 11 mg/day for men)
  • both supplements at the doses above
  • neither supplement.

The researchers found that people receiving the supplements, whether individually or combined, had no improvement in symptoms or a faster recovery when compared with otherwise similar patients receiving neither supplement.

Proponents of melatonin for COVID-19 have encouraged researchers to perform trials of this supplement, but so far convincing evidence of benefit is not yet available.

Even without convincing evidence, why not take them anyway?

Despite questions about the overall benefit of these supplements, many doctors began prescribing them routinely in the early days of the COVID-19 pandemic. The logic may have been that with so little known about how to best treat this new infection and a long track record of safety for these supplements, why not?

But there are significant hazards to consider. These include side effects, allergic reactions, interactions with other drugs, the cost of unnecessary supplements, and the dangers of taking too much. For example:

  • High doses of vitamin C may cause diarrhea or stomach upset. There have also been concerns that high-dose vitamin C supplementation may interfere with blood thinners or cholesterol-lowering medications.
  • High doses of vitamin D can cause severe symptoms, such as stomach upsets, kidney injury, and pancreatitis, and may even be life-threatening.

That said, people with nutritional deficiencies should receive supplements. Zinc or vitamin D deficiencies are not rare, and may contribute to poor immune function. Therefore, even without specific evidence linking supplement use with improvement among people with COVID-19, these supplements may be appropriate for people in whom deficiency is suspected or confirmed. For example, a person with little sun exposure and a diet low in dairy products may be likely to have vitamin D deficiency. A simple blood test can confirm or rule out vitamin D or zinc deficiency.

If you do take supplements, it’s safest to follow the daily recommended amounts your body needs unless your doctor advises otherwise (see this information for people 51 and older, and this information on a full range of supplements).

The bottom line

Based on the science, there is reason to be hopeful that supplements such as vitamin C or D, zinc, or melatonin might help in the fight against COVID-19. While there’s no proof yet that they do, additional research could show a benefit in certain situations, or with a different dose or formulation of the supplement. So it’s worth keeping an open mind.

In the meantime, we should not dismiss the findings of negative studies just because the results weren’t what we’d hoped. When it comes to preventing or treating COVID-19, I’d rely more on the recommendations from the CDC than on unproven supplements.

Check with your doctor before starting a supplement. Ask about dosage, other medications you’re taking, and other health conditions you have. The last thing you want to do is to take a supplement that causes more harm than good.

See the Harvard Health Coronavirus Resource Center for more information on treatments for COVID-19 and many other topics.

Follow me on Twitter @RobShmerling

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An emerging treatment option for men with recurring prostate cancer after radiation therapy

2 April 2021 at 10:23

Prostate cancer is often a multifocal disease, meaning that several tumors can be present in different parts of gland at the same time. Not all of these tumors are equally problematic, however. And it’s increasingly thought that the tumor with the most aggressive features — called the index lesion — dictates how a man’s cancer is likely to behave overall. That concept has given rise to a new treatment option. Called partial gland ablation (PGA), and also focal therapy, it entails treating only the index lesion and its surrounding tissues, instead of removing the prostate surgically or treating the whole gland in other ways. Emerging evidence suggests that PGA controls prostate cancer effectively, but with fewer complications such as incontinence.

In February, researchers at Memorial Sloan Kettering Cancer Center (MSKCC) in New York published findings that could pave the way for focal therapy in men with reoccurring prostate cancer. They focused specifically on men whose cancer had returned three to four years on average after initial treatment with radiation.

Their findings, while preliminary, suggest that MRI and biopsy results can allow doctors to select which patients with reoccurring prostate cancer might be eligible for PGA. The research was headed by Dr. Gregory Chesnut, an MSKCC urologist.

During their study, Chesnut and his colleagues first identified 77 men who were treated for reoccurring prostate cancer at MSKCC between 2000 and 2014. All the men had initially been given radiation for their prostate cancer with an intent to cure the disease, but the cancer had returned. At that point they had their prostates surgically removed. Following that, sections of their tumors had been mounted on slides for a pathologist’s review, and then put into storage.

By looking at these slides with sophisticated instruments, Chesnut’s team was able to map out where the individual tumors in each of the men’s prostates were located. The team also had access to pre-operative information showing that 15 of the men were candidates for PGA according to current criteria. To be considered for PGA, men need to have a treatable index lesion and an absence of highly aggressive cancer cells outside that tumor’s immediate vicinity, according to biopsy and MRI findings.

What the results showed

What Chesnut and his colleagues wanted to know was if the men’s pre-operative findings were consistent with tumor details in their surgically removed prostates. And that turned out to be the case. The men truly did have treatable index lesions without other aggressive cancer, meaning that the biopsy and MRI results had accurately predicted PGA eligibility. Moreover, six additional men were found to be eligible for PGA based on tumor slide analysis, even though the pre-operative and MRI evidence had suggested otherwise.

Given that, the authors concluded that 21 of the initial 77 men, or 27% in all, had recurring prostate cancer that was amenable to PGA.

While the results are promising, the authors also cautioned that, given the small number of men evaluated and other study limitations, they are currently unable to recommend PGA as treatment for recurring prostate cancer outside of clinical trials.

“The authors have addressed a very important problem and one that has no easy answers, which is what to do about recurrent or persistent prostate cancer following radiation therapy,” says Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org.

“Performing a radical prostatectomy to remove the prostate after radiation therapy is a complicated procedure, associated with potentially significant urinary side effects. Alternatives that can help to eliminate persistent cancer in an irradiated gland, and thus lessen side effects, mark an important advance. These new findings should reassure men who undergo PGA that aggressive cancer in the prostate will not be left untreated. The findings are also important in that patients can be offered a second chance to remove residual or recurring cancer without having to undergo surgical removal of a prostate that’s already been treated with radiation. Further studies should explore these findings in larger numbers of patients.”

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Want to improve your memory? Get a good night’s sleep!

2 April 2021 at 03:30

There are few things that are as beneficial for your memory as having a good night’s sleep. Let’s understand why.

If you’re tired, it’s hard to pay attention, and memory requires attention

To remember information, you need to pay attention to it. If you’re tired, you simply cannot pay attention as effectively as you would if you were well rested. That statement seems straightforward, but it brings up another question: why do you get tired?

You may feel tired and have trouble paying attention either because you’ve been awake too many hours and sleep pressure is building up, or — even if you’ve had a nap — because it is the middle of the night and your circadian rhythm (your internal clock) is telling you to sleep. In either case, you’ll you have trouble paying attention, and thus trouble remembering.

Does caffeine help?

Caffeine blocks chemical receptors in your brain so that, temporarily, you cannot feel the sleep pressure. Thus, caffeine can enable you to be more alert, be more attentive, and remember better. But as you probably know from your own experience, caffeine can only delay the mounting sleep pressure, which eventually leads to overwhelming tiredness.

Get ready for new learning

When you learn new information during the day, it is temporarily stored in the hippocampus, a seahorse-shaped part of your brain behind your eyes. The hippocampus has a limited storage capacity. If you exceed it, you may have difficulty adding new information — or you may actually overwrite an old memory with a newer one.

Fortunately, that doesn’t usually happen. Each night while you sleep, the connections between neurons (called synapses) shrink to reduce or eliminate the memories you don’t need — such as what you ate for breakfast last week and the clothes you wore yesterday. This selective pruning of synapses during the night prepares you to form new memories the next day.

Sleep to consolidate memories

Sleep also helps us consolidate the memories we want to preserve, transferring them from transiently accessible memories to those that can be recalled years later. Memories for facts and skills both show greater retention over a 12-hour period that includes sleep versus a 12-hour period while awake. Much of this consolidation occurs during stage 2 sleep, a light sleep phase that occurs most in the hours prior to awakening. This means that if you get up early without a full night’s rest, you may be impairing your ability to hold onto your memories.

Interconnect your memories while you dream

Although you dream in several stages of sleep, your most interesting and vivid dreams usually occur during rapid eye movement (REM) sleep, so-called because while your eyes are moving rapidly, your body is otherwise paralyzed. It is during REM sleep that your newly consolidated memories become interconnected with your prior memories, including those of your life as well as your library of facts and knowledge. This connection between your recent memories and your prior memories and knowledge is one reason that you may wake up with a new and valuable perspective on a problem — or perhaps even a complete solution!

This actually happened to Dmitri Mendeleev, who was struggling for months with how the atomic elements should be placed in the periodic table. In a dream on February 17, 1869, he glimpsed where all the elements belonged and, after writing down what he dreamt, found only a single, small correction was needed.

You’ll feel better in the morning

Have you ever been terribly upset about something and, by the next day, it felt at least somewhat better? Sleep can also strip off the emotions related to painful memories while still retaining the memory content. Thus, you’ll be able to remember what upset you without having to relive the full emotional intensity of the event.

Do sleeping pills help?

Melatonin isn’t a traditional sleeping pill, but it can help regulate your sleep cycle if that’s the problem. Acetaminophen can relieve little aches and pains that can keep you up at night. All other sleeping pills, however, whether prescription or over the counter, sedate you and actually make your memory worse, both for what you learned earlier that day and what you’re trying to learn the next day! Nonpharmacological treatments for sleep are by far the best.

The bottom line

Want to maximize your memory whether you are studying for an exam, preparing for a client meeting, or looking forward to your 50th reunion? You’ll be more likely to remember the information for the exam, the documents for the meeting, and the names you’re reviewing of your classmates if you go over the material you wish to remember daily for several days, each followed by a refreshing seven to nine hours of sleep each night. Sleep well!

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