Tag: health newsletters

Some studies suggest milk is better than water, but evidence is weak.

Driving along the freeway recently, a billboard caught my eye. In bold letters it proclaimed:

Milk hydrates better than water.

Wait, could this be true? And if so, should I be rehydrating with milk after a workout? And should we all have milk, rather than water, in our water bottles?

What’s behind the claim?

Unsurprisingly, the ad is sponsored by the milk industry. And while I’d never heard this claim before, the studies behind the idea aren’t particularly new or compelling. The website supporting this ad cites three small studies dating back more than a decade:

• A 2007 study enrolled 11 volunteers (five men, six women) who exercised until they were markedly dehydrated on several occasions. Each time they rehydrated with a different drink, and their urine output was measured over the following five hours. After drinking milk, the study volunteers produced less urine (and therefore retained more fluid) than with water or a sports drink (Powerade). Therefore, milk was considered to provide better hydration.
• A study published in 2016 described seven men with marked dehydration following exercise who drank fat-free milk, water, or Powerade. The results were similar.
• A 2016 study enrolled 72 healthy, well-hydrated men who drank various fluids and then had their urine production measured over the next four hours. The drinks used in this study were water, whole milk, skim milk, beer, Dioralyte (an oral rehydration solution used after fluid loss from diarrhea), tea, coffee, diet cola, regular cola, orange juice, and Powerade. The researchers found that fluid retention was best after drinking either type of milk or the oral rehydration solution; results for the other drinks were similar to water.

Sounds like milk is a winner, right? Maybe. But there are other things to consider.

The study details matter

The findings of these studies aren’t definitive. As with all research, there are important limitations. For example:

• The small number of participants in these studies means that just a few people could have an outsized impact on the results.
• Two of the three studies involved significant dehydration by intensely exercising in a warm environment, leading to several pounds of fluid loss. Therefore, the results may not apply to people engaged in more typical daily activities or workouts. In addition, the studies equated better hydration with less urine production in the hours after drinking various fluids. This is only one way to define hydration, and not clearly the best one.
• The advantage of milk reported in these studies may be too small or too temporary to matter much. For example, in the study of 72 people, milk drinkers produced about 37 ounces of urine over four hours while water drinkers produced 47 ounces. Does the 10-ounce difference have a meaningful health impact? If the study participants had been monitored for a longer period, would this difference disappear?
• The amount of milk consumed in the study of seven men would contain more than 1,000 calories. That may be acceptable for an elite athlete after hours of intensive exercise in the heat, but counterproductive and costly for someone working out for 30 minutes to help maintain or lose weight. Tap water is free and has no calories!

Hyping hydration: Many claims, little evidence

The billboard promoting milk reflects our relatively recent focus on hydration for health. This is promoted — or perhaps created — by advertisers selling sports drinks, energy drinks and, yes, water bottles. But does drinking “plenty of water” translate to weight loss, athletic performance, and glowing appearance? Does monitoring urine color (darker could indicate dehydration) and downing the oft-recommended eight glasses of water daily make a difference in our health? On the strength of evidence offered so far, I’m not convinced.

But wait, there’s more! Emotional support water bottles, a trend popularized recently in Australia, offer one part public expression of your commitment to health and one part security blanket. (Yes, it’s a thing: #emotionalsupportwaterbottle has more than 80 million views on TikTok.) And then there’s intravenous hydration on demand for healthy (and often wealthy) people convinced that intravenous fluids will improve their looks, relieve their hangovers, help with jet lag, or remedy and prevent an assortment of other ailments.

Is this focus on hydration actually helpful?

Before water bottles were everywhere and monitoring fluid intake became commonplace, medically important dehydration wasn’t a problem for most healthy people who were not rapidly losing fluids due to heat, intense exercise, diarrhea, or the like.

The fact is, drinking when thirsty is a sound strategy for most of us. And while there are important exceptions noted below, you probably don’t need fluids at hand at all times or to closely monitor daily fluid intake to be healthy. There are far more important health concerns than whether you drink eight glasses of water each day.

When is dehydration a serious problem?

Weather, exercise, or illness can make dehydration a major problem. Particularly susceptible are people who work or exercise outside in hot and humid environments, those at the extremes of age, people experiencing significant fluid loss (as with a diarrheal illness), and those without reliable access to fluids. If significant dehydration occurs, replacing lost fluids is critically important, and may even require a medical setting where intravenous fluids can be provided quickly.

The bottom line

Despite the claims of milk ads and the iffy studies justifying them, the idea of replacing water with milk for rehydration may not convince everyone: the taste, consistency, and extra calories of milk may be hard to get past.

As for me, until there’s more convincing evidence of an actual health advantage of milk over water for routine hydration, I’ll stick with water. But I’ll forego the water bottle.

Follow me on Twitter @RobShmerling

How will we know when it ends — and does it matter?

It seems like a long time since the pandemic began. And now, as so much of life looks like it did before the pandemic, it’s reasonable to wonder: is it over? It sure seems like it — even the president said so in September, and COVID precautions are barely seen in some locales.

Still, we continue to have thousands of new COVID-19 infections and hundreds of related deaths in this country each day. So, is it truly over? And what changes if that determination is ever formally made?

Defining a pandemic’s start is tricky; the same goes for its end

When the pandemic began, I thought declaring an end would be straightforward: experts would count up conditions that marked a starting line, and once those conditions evaporated the pandemic officially would be over.

Unfortunately, it’s not that easy.

As strange as it may seem, there is no single, agreed-upon definition of pandemic that all countries, public health agencies, and world leaders use.

The word itself comes from the Greek words pan (meaning all) and demos (meaning people), which makes sense: a key feature of a pandemic is that it can affect just about everyone. More common definitions include:

• an outbreak of a disease that occurs over a wide geographic area (multiple countries or continents) and typically affects a significant proportion of the population (Merriam-Webster Medical Dictionary)
• a sudden outbreak that becomes widespread and affects a whole region, a continent, or the world due to a susceptible population (MedicineNet.com)
• a disease prevalent throughout an entire country, continent, or the whole world (dictionary.com)

These standard definitions aren’t particularly specific; what, exactly, does “multiple countries” or “a whole region” mean? How prevalent (widespread) does a disease have to be to be considered a pandemic?

And even if we could all agree on its definition, no single person, government agency, or public health organization has the authority to declare that a pandemic has begun or ended.

Moving from pandemic panic to endemic acceptance

Some people have suggested a pandemic is over when everyone is behaving as though it is: no more precautions, restrictions, or changes in behavior compared with the period of time before these started. But if that’s true, people growing weary of restrictions, or those skeptical about their value, could ignore recommendations and create the impression that the pandemic is over — even as significant numbers of daily cases and deaths continue in the US and worldwide. That seems to be where we are with COVID right now.

Many pandemics eventually become endemic, meaning the infection is still present in a region or population but its behavior is predictable and the numbers of cases and deaths no longer spike. Learning to live with a virus is a key feature of an endemic virus; think flu or even the common cold. But it’s probably true that the transition from pandemic to endemic can only be recognized after it happens.

What to do until the COVID pandemic is clearly behind us?

Perhaps setting a firm end date on this pandemic doesn’t matter, anyway. What matters most is the number of ongoing infections, suffering and death, and the measures we should take to avoid infection. No one can say whether the coming winter months will bring a decline in infections, a continuation of the current situation (with hundreds of deaths and thousands of new infections each day in the US), or a spike in illness and death as more people are inside with relaxed precautions.

Common sense precautions still make sense, including these:

The bottom line

It’s possible that experts will agree one day on a standard definition of “pandemic” and how to mark its arrival and departure. Already, policies regarding the pandemic (including financial assistance), and efforts to increase vaccination acceptance, are complicated by suggestions we’re past the pandemic when we’re actually not.

There’s a lot that’s still uncertain about the COVID-19 pandemic. Unfortunately, one thing seems clear: we can’t call it fully over yet.

Bright light therapy can help ease SAD, major depression, and perinatal depression.

The transition from fall to winter means grayer skies, shorter days, and for some people, the return of seasonal affective disorder. With the apropos acronym of SAD, this disorder has symptoms similar to depression (such as feeling sad, listless, and sluggish) but occurs only during the late fall and early winter.

Light therapy — which involves sitting close to a special light source every morning for at least 30 minutes — can help improve SAD. But many people don’t realize that this therapy can also be effective for major depression and depression that occurs during or after pregnancy, known as perinatal depression.

“For both seasonal and nonseasonal depression, the effectiveness of light therapy is approximately the same as antidepressant medications, or popular forms of psychotherapy such as cognitive behavioral therapy,” says Dr. Richard S. Schwartz, associate professor of psychiatry at Harvard Medical School. Although evidence varies from study to study, each of these different therapies reportedly improves symptoms in between 40% to 60% of people. Combining two of these therapies together — light therapy and medications — tends to help even more.

Why do people experience SAD?

SAD seems to be triggered by a drop in daily sunlight exposure. Light affects complex systems that govern the 24-hour circadian clock in the brain, which regulates not just our sleep and wake cycles but also digestion, hormonal activity, and other important bodily functions.

Special receptors in the retina (the light-sensitive portion of the eye) transmit information about light in our surrounding environment to the superchiasmatic nucleus — that’s the body’s master clock — deep in the brain. In recent years, scientists have discovered additional nerve pathways from light receptors in the retina to other parts of the brain. This includes the prefrontal cortex, which is involved in regulating mood and cognition, Dr. Schwartz explains.

“Beyond setting our circadian clock, light exposure also seems to affect higher-functioning areas of the brain,” he says. That’s why light therapy may help treat SAD, which, like major depression, can also be treated with medications and therapy.

Light therapy may prompt improvement with few side effects

For both SAD and other types of depression, light therapy has unique characteristics that make it an attractive alternative to medications, Dr. Schwartz notes. Antidepressant drugs often take several weeks to start working, and sometimes cause bothersome side effects including nausea, weight gain, and sexual dysfunction. In people who respond well to light therapy, depression symptoms usually start improving within a week, and the side effects, which include eye strain and headaches, are uncommon and mild.

For people with depression who are pregnant or elderly, trying light therapy makes sense because these groups often need to avoid or reduce medication use. And older people, especially those with limited mobility, often spend a lot of time in dim environments and are prone to depression, Dr. Schwartz says.

How to use light therapy

Light therapy requires a light box that emits 10,000 lux (a measure of light intensity). You sit in front of the light for about 30 minutes every morning, as soon as possible after you wake up. Light boxes aren’t regulated, so it’s important to make sure you buy one that meets certain specifications. Dr. Schwartz recommends checking out the Center for Environmental Therapeutics, a nonprofit organization that does research on light boxes and related therapies and provides advice for selecting a light box. Prices range between $100 and $200.

To use a light box, place it in front of you or slightly off to the side. Don’t look directly at the light but keep your eyes open. You can eat, read, watch television, or work on a computer while you’re under the light.

People who have bipolar disorder should consult a psychiatrist or other mental health professional before trying light therapy, says Dr. Schwartz. In rare cases, the therapy may trigger a manic episode, a risk that’s also possible when first starting most antidepressants. People with severe depression also should not try light therapy without a psychiatrist’s guidance.

An early morning walk

For everyone else who’s feeling down or depressed — whether related to the season or pregnancy, or not — an early morning walk can offer similar light therapy benefits. A bright sunny day is about 50,000 lux, and a gray day is around 10,000 lux. “Strolling outdoors soon after sunrise, even on a cloudy day, provides almost the same amount of light exposure as a light box,” says Dr. Schwartz.

On sunny days, the sun is bright enough to get a therapeutic effect even if you wear sunglasses (which protect your eyes from the sun’s ultraviolet radiation, he adds). If you walk for 30 minutes, you’ll also get a healthy dose of mood-boosting exercise. But if time or mobility constraints make that goal too challenging, sitting outside for just 15 minutes at any time of day may make a difference in your mood, says Dr. Schwartz.

Expert consensus focuses on individual planning to bring down elevated LDL.

Recently I met with Nancy, a 72-year-old woman with coronary artery disease, to review her latest cholesterol results. Despite taking a statin, following a healthy diet, and exercising regularly, her low-density lipoprotein (LDL) cholesterol remained above our target. “What else can I do?” she asked. “When I increase my statin dose I get terrible leg pains. But I don’t want to have another heart attack!”

When elevated, LDL contributes to cardiovascular disease, which can cause a heart attack or stroke. Taking statin drugs can drop LDL levels in most people by about 30%, substantially lowering this risk. Usually, these commonly prescribed drugs work effectively with tolerable side effects. But what if a person’s LDL level remains too high on their maximally tolerated dose? An expert consensus report issued by the American College of Cardiology lays out a clear path for next steps.

What is a healthy target for LDL cholesterol?

Target LDL depends on many factors, including your age, family history, and personal history of cardiovascular disease. For people at intermediate risk, LDL should be lowered by 30% to 50%. For those who have already had a heart attack, target LDL is no more than 70 mg/dl (note: automatic download).

Which non-statin therapies are recommended first?

Five non-statin therapies described in this post aim to help people achieve target LDL goals while minimizing side effects. They may be combined with a statin or given instead of statins.

Each helps lower LDL cholesterol when diet and statins are not sufficient, such as when there is a family history of high cholesterol (familial hypercholesterolemia). But so far, only two options are proven to reduce cardiovascular risk — the risk for heart attack, stroke, heart failure, and other issues affecting the heart and blood vessels.

Ezetimibe (Zetia)

What it does: Lowers LDL and cardiovascular risk by reducing cholesterol absorption.

How it’s given: A daily pill

Relatively inexpensive and often given with statins.

PCSK9 inhibitors, alirocumab (Praluent) and evolocumab (Repatha)

What it does: A protein called PCSK9 controls the number of LDL receptors on cells. These medicines are monoclonal antibodies against PCSK9 that increase LDL receptors on the liver, helping to clear circulating LDL from the bloodstream.

How it’s given: A shot every two to four weeks

Highly effective for lowering LDL, but expensive and may not be covered by insurance.

Three newer non-statin therapies

Three newer, FDA-approved non-statin therapies are highly effective for lowering LDL cholesterol. Whether these lessen cardiovascular risk is not yet known.

Bempedoic acid (Nexletol)

What it does: Like statins, bempedoic acid tells the liver to make less cholesterol.

How it’s given: A daily pill

Bempedoic acid is activated only in the liver, whereas statins are activated in liver and muscle tissue. Experts hope that this difference will translate to a similar LDL lowering effect, but without the muscle aches that some people who take statins report. Indeed, early trials show this medication lowers LDL cholesterol by about 20% to 25% compared to placebo.

Potential downsides include high cost and a possible increase in the risk of tendon rupture, gout, and a heart arrythmia called atrial fibrillation. Results of larger trials are expected in late 2022.

Evinacumab (Evkeeza)

What it does: Rare individuals born without a cholesterol-processing protein called ANGPTL3 have extremely low LDL and triglyceride levels, which lowers their risk for coronary heart disease by about 40%. Taking a cue from nature, scientists developed evinacumab, a monoclonal antibody that turns off ANGPTL3, mimicking this rare condition and resulting in dramatic LDL lowering of almost 50% in one trial.

How it’s given: Monthly intravenous infusion

Currently, the FDA has only approved evinacumab for people with familial hypercholesterolemia. Evinacumab appears safe in early trials, but is very expensive and can only be given in a doctor’s office.

Inclirisan (Leqvio)

What it does: Inclirisan blocks PCSK9. However, unlike alirocumab and evolocumab, which inactivate PCSK9 after it is produced, inclirisan inhibits production of PCSK9 in the liver. Inhibition of PCSK9 leads to an increase in the number of LDL receptors on the surface of the liver, speeding clearance of LDL from the bloodstream and dropping LDL by about 50% (see here and here).

How it’s given: A shot every six months

Potential downsides include increased rate of urinary tract infection, joint and muscle pain, diarrhea, and shortness of breath. This medicine is expensive and insurance may not cover it.

What does the report recommend?

It reinforces the importance of personalizing a plan to lower LDL by accounting for individual risk, cost of medication, and genetic factors. A combination of lifestyle changes and medicine can help people achieve better control of LDL. So, if you have elevated LDL cholesterol, try to follow healthy eating patterns, exercise regularly, avoid smoking and vaping, and maintain a healthy weight.

• Statin drugs are the first choice to treat anyone who has elevated cholesterol and cardiovascular risk factors, such as diabetes and high blood pressure.
• If statins aren’t sufficient to help you reach your LDL target, or if side effects aren’t tolerable, ezetimibe should be added next. PSCK9 inhibitors are then considered for those who remain at increased risk after adding ezetimibe.
• If LDL targets still cannot be achieved in people with cardiovascular disease, bempedoic acid and inclirisan are considered.
• For those with familial hypercholesterolemia, evinacumab may be appropriate.

Cardiologists eagerly await the results of studies looking at whether the three new LDL-lowering medications also lower risk for heart attack, stroke, and other poor cardiovascular outcomes. Until then, their use is likely to be limited to people at high risk for whom proven, less costly drugs cannot achieve LDL goals.

A common condition in newborns occasionally signals a serious health problem.

Most newborn babies turn at least a little bit yellow. Known as jaundice, this condition is a very common and usually normal part of the newborn period. But in some very rare cases it can lead to, or be a sign of, a more serious problem. That’s why parents need to know about it.

What causes jaundice?

The yellow color of newborn jaundice is caused by high levels of a substance called bilirubin in the blood. Bilirubin mostly comes from the breakdown of red blood cells. It gets processed in the liver to make it easier for the body to get rid of through the urine and stool.

Newborn livers need some time to get up and running when it comes to getting rid of bilirubin. Newborns also have more red cells than older children and adults, and those brand-new red cells don’t last as long as red cells made as babies grow older. The combination of these two factors is what makes jaundice so common.

Jaundice usually peaks in the first two to five days of life, and lasts about one to two weeks. In babies who are breastfed, it can last longer; we don’t know exactly why this happens, but it isn’t anything to worry about.

Jaundice may actually protect babies, because bilirubin is an antioxidant that may help fight infection in newborn infants. This is another reason why parents shouldn’t be too worried by a bit of yellowness: not only is it temporary, but it may also be helping their baby as he or she leaves the security of the womb.

Rarely, jaundice may signal a problem

Sometimes, though, jaundice can be a sign of another problem, and when bilirubin levels get very high it can affect the brain, sometimes in a permanent way. Called kernicterus, this is very, very rare, affecting far less than 1% of infants.

Many conditions make it more likely that bilirubin levels will be high, including:

• Dehydration or inadequate calories. This most commonly happens when babies are exclusively breastfed and a problem with breastfeeding goes unrecognized.
• ABO or Rh incompatibility. When mother and baby have differences in their blood types, it can lead to more breakdown of red cells than usual. Obstetricians are very aware of this issue, and all mothers should have blood tests to assess this risk.
• The systems that work to get rid of bilirubin may not be ready yet in babies who are born early.
• Infection, or a blockage of the intestine. Jaundice would not usually be the only symptom of this.
• Bruising or a cephalohematoma (a lump or a bruise on the head). Both can happen during a difficult birth. This leads to more red cells breaking down.
• Liver diseases. A number of different liver problems can make it harder for the baby’s body to get rid of bilirubin.
• Diseases that affect an important enzyme. One common disease is glucose-6-phosphate dehydrogenase (G6PD) deficiency, which can cause red cells to break down. Other diseases, such as Gilbert syndrome or Crigler-Najjar syndrome, lead to a problem with an enzyme that is important for getting rid of bilirubin.
• Genetic factors. Not all of these factors are well understood. If one baby in a family has jaundice, future babies may have a higher risk too. Babies of East Asian descent, for example, are more likely to have higher bilirubin levels.

What do the new guidelines recommend?

The new guidelines stress the importance of preventing and assessing jaundice. Doctors and parents can work together to

• Make sure that the mother’s blood type and antibodies have been checked. If there is a concern, the baby should be checked, too.
• Assess all possible risks for jaundice: not just the mother’s blood type but also gestational age, family history, any bruising, how early jaundice appears, and other factors.
• Use a device to check bilirubin level at 24 to 48 hours of life, or sooner if a newborn looks jaundiced or is going home earlier.
• Make sure mothers get good support with feeding. When babies don’t get enough to eat in the first three to five days of life, they have a higher risk of getting jaundice.
• Set up a follow-up appointment with the baby’s doctor. The best timing for this depends on bilirubin level and risk factors. Parents, it’s important to follow these instructions!

How is newborn jaundice treated?

The most common treatment is phototherapy. The baby is put under a special light (or wrapped in a special blanket with the light inside it) that helps the body get rid of bilirubin. This is safe and effective. When bilirubin levels are extremely high and there is concern for the possibility of brain damage, therapies such as exchange transfusion, where blood is taken out and new blood put back in, are necessary. However, this is extremely rare.

Feeding is an important part of therapy as well, because it helps the body get rid of bilirubin through the blood and urine. Feeding a newborn frequently also helps prevent problems with jaundice. Babies should wet at least six diapers over a 24-hour period, and should have stools regularly. The stool should change from the normal newborn black, tarry stools to stools that are lighter in color, looser, and “seedy.”

What else do parents need to know about newborn jaundice?

Before going home, you should receive written information about jaundice, information about your baby’s bilirubin level and other lab tests, and clear instructions about when the baby should see the pediatrician.

It’s important to keep an eye on your baby’s jaundice after you go home from the hospital. Jaundice can be harder to see in dark-skinned babies. A good way to look for it is to press down for a moment on the baby’s skin in a spot where the bone is close (the forehead, nose, chest, or shin are good places to do this). This pushes out the blood briefly and should make the skin paler for a few seconds. If it looks yellow instead of pale, there may be jaundice.

Jaundice tends to spread from the face downward as bilirubin levels go up. For that reason, doctors worry far less about a baby who is yellow just in the face and upper chest than one who is yellow below the knees.

Call the doctor if your baby:

• is looking more yellow, especially if it is spreading down below the knees
• is feeding poorly, and/or isn’t wetting at least six diapers in 24 hours and having regular stools
• is very sleepy, especially if they don’t wake to feed
• is very fussy and hard to console
• arches their head or back, or is otherwise acting strangely
• has a fever or is vomiting frequently.

Remember: jaundice is common, and serious problems are rare! But call your doctor if you are worried; it’s always better to be safe than sorry.

Follow me on Twitter @drClaire

A new study suggests that a daily multivitamin might improve memory in older adults.

Millions of people take a multivitamin each day. Some believe it’s a sort of insurance in case their diet is missing some essential nutrient. Others believe it will ward off disease by boosting immunity, improving brain health, or regulating metabolism. It’s easy to see where these ideas come from: ads tout wide-ranging health benefits, even though most offer little or no evidence to back up the claims.

But research on the health benefits of multivitamins has been mixed at best. This year, for example, the US Preventive Services Task Force, a leading authority on preventive healthcare, reviewed 90 of the best available studies on supplements and vitamins, concluding the products didn’t protect healthy adults lacking nutritional deficits against cardiovascular disease, cancer, or death from all causes.

Might research on different doses, supplement combinations, or populations prompt a different conclusion? Well, yes — in fact, that may have already happened, according to a new study that focused on memory and brain function.

Can a daily multivitamin improve brain function in older adults?

Our current options for improving brain health are limited. For example, regular exercise, optimal weight, and a heart-healthy diet can improve cardiovascular health and lower the chances of certain types of dementia, such as dementia due to strokes. Beyond such common-sense measures, no available medicines, supplements, or treatments reliably improve brain function over the long term, despite advertisements claiming otherwise.

That’s why researchers continue to explore whether certain foods or supplements could prove effective. In a recent study published in Alzheimer’s and Dementia, more than 2,200 volunteers ages 65 and older were randomly assigned to receive cocoa or a placebo, a multivitamin or a placebo, or both cocoa and a multivitamin for three years. The multivitamin chosen for this study was Centrum Silver, which contains 27 vitamins, minerals, and other nutrients in various amounts.

When tests of cognition were analyzed at the end of the trial, those receiving cocoa did not demonstrate any improvement. But those assigned to take a multivitamin had improved scores on tests of

• overall brain function (especially in people with cardiovascular disease)
• memory
• executive function (tasks such as planning ahead or remembering instructions).

Based on these findings, the researchers estimated that three years of multivitamin use could slow age-related decline in brain function by as much as 60%.

Notably, study participants were mostly white (89%), had an average age of 73, and more than half were female (60%). They were followed for only three years. However, it was a randomized, double-blind trial, which is considered the most powerful study design.

Should we all be taking multivitamins?

This study alone isn’t enough to suggest routine use of multivitamins for people of all ages. It may turn out that the benefits for older adults seen in this study were due to deficiencies in certain nutrients among some of the study participants. We don’t know if this is true because it wasn’t part of the study.

Or we might learn that the benefits reported here are too small to make much difference in real life, or wane over time, or have no effect on preventing common types of dementia. And it’s hard to ignore an earlier randomized, placebo-controlled trial that was actually larger and longer-term: it found no improvement in brain function among male physicians ages 65 and older taking multivitamins.

But it does mean that more study is warranted. We need to understand who is most likely to benefit from multivitamin use, what dose is optimal, and what parts of the multivitamin are most important. We also need trials that are larger, last longer, and include a more diverse group of participants. And certainly, there’s a difference between improving cognitive function and preventing dementia. We still need to know if conditions like Alzheimer’s disease can be prevented by multivitamin use or other supplements.

The bottom line

Claims that certain supplements can improve brain health are everywhere you look. But sound scientific evidence backing up those claims is much rarer. That’s one reason this new study is important: if confirmed, it means that a safe, widely available, and inexpensive vitamin supplement could improve quality of life for many millions of aging people.

In the past, claims made by the makers of various supplements and vitamins have gotten far ahead of the science. Studies like this one should help science catch up and sort out which claims are valid.

Pulse oximeters and other devices to monitor aspects of our health may work better for some than for others.

In recent years, there’s been a veritable explosion in the number and type of health monitoring devices available in smartphones and fitness apps.

Your smartphone is likely tracking the number of steps you take, how far and fast you walk, and how many flights of stairs you climb each day. Some phones log sleep, heart rate, how much energy you’re burning, and even “gait health” (how often are both feet on the ground? how even are your steps?). And, of course, nonphone wearables and fitness gadgets are available, such as devices to measure your heart rhythm, blood pressure, or oxygen levels. The accuracy of these devices varies — and, in some instances, your skin tone may make a difference.

Generally, how accurate are health monitors?

I know from my experience with hospital monitoring devices that they aren’t always accurate. False alarms from EKG monitors often send medical staff scurrying into patient rooms, only to find the patient feeling fine and surprised about the commotion. A particularly common false alarm is a dangerous and unstable heart rhythm on a continuous heart monitor, which can be due to the motion from a patient brushing their teeth.

High-stakes devices with monitoring capability, such as defibrillators and pacemakers, are extensively tested by their makers and vetted by the FDA, so their accuracy and reliability are generally quite good.

But what about home health monitoring devices intended for consumer use that are not extensively tested by the FDA? Ever count your steps for a few minutes just to see if your phone’s tally agrees? Or climb a couple of flights of stairs to see if you are getting full credit for not taking the elevator?

The accuracy of consumer devices depends in part on what is being monitored. For example, one study assessed the accuracy of heart rate monitors and energy expenditure calculators in phones and health apps. Accuracy was quite high for heart rate (often in the range of 95%), but much less accurate for energy expenditure. Accuracy can also vary depending on who is being monitored.

Device bias: What it is and why it occurs

While no health gadget is perfect, some users get more reliable results than others. For example, if you’re wearing nail polish, a pulse oximeter — a device that clips onto the fingertip to measure blood oxygen through the skin — may not work well, because the polish interferes with proper function of the light sensor. In that situation, there’s a simple solution: remove the polish.

But in other cases, the solution isn’t simple. Increasingly, we’re recognizing that certain medical devices are less accurate depending on a person’s skin color, a phenomenon called device bias.

• Pulse oximeters. Although generally considered highly accurate and commonly relied upon in healthcare settings, their accuracy tends to be lower in people of color. That’s because the device relies on shining light through the skin to detect the color of blood, which varies by oxygen level. The amount of pigment in the skin may alter the way light behaves as it travels to blood vessels, leading to inaccurate results.
• Bilirubin measurement in newborns. Bilirubin is a breakdown product of red blood cells. Newborns are screened for high levels because this can cause permanent brain damage. When detected, phototherapy (light treatments) can help the baby get rid of the excess bilirubin, preventing brain damage. The screening involves examining a newborn’s skin and eyes for jaundice (a yellowing due to elevated bilirubin), and a light meter test to detect high bilirubin levels. But the accuracy of this test is lower in Black newborns. This is particularly important because jaundice is more difficult to detect in infants with darker skin, and dangerously high bilirubin levels are more common in this population.
• Heart rate monitors in smartphones. According to at least one study, smartphone apps may also be less accurate in people of color. Again, this is because the more skin pigment present, the more trouble light sensors have detecting pulsations in blood flow that reflect heartbeats.

Why device bias matters

Sometimes an error in measurement has no immediate health consequences. A 5% to 10% error rate when measuring heart rate may be of little consequence. (In fact, one could ask why anyone needs a device to monitor heart rate when you could just count your pulse for 15 seconds and multiply by 4!)

But pulse oximeter readings are used to help decide whether a person needs to be hospitalized, who requires admission to the intensive care unit, and who requires additional testing. If the oxygen level is consistently overestimated in people of color, they may be more likely to be undertreated compared with others whose readings are more accurate. And that may worsen previously existing healthcare disparities.

These examples add to the growing list of bias imbedded within healthcare, and other instances where failing to include diverse individuals has serious consequences. When you use a health device, it’s reasonable to wonder if it’s been tested on people like you. It’s also reasonable to expect people who develop medical and consumer health devices to widen the demographics of test subjects, to make sure results are reliable for all users before putting them on the market.

Sometimes a change in technology, such as using a different type of light sensor, can make health-related devices work more accurately for a wider range of people.

Or there may be no easy fix, and user characteristics will need to be incorporated into proper interpretation of the results. For example, a device could offer the user a choice of skin tones to match skin color. Then based on extensive data from prior testing of people with different skin colors, the device could adjust results appropriately.

The bottom line

The push to monitor our bodies, our health, and our life experiences continues to gain momentum. So we need to thoroughly test and validate health-related devices to be sure they work for diverse individuals before declaring them fit for the general public.  An expert panel at the FDA has advocated for better regulation and testing of pulse oximeters to ensure they are accurate for all.

With even the best testing, device bias may not disappear: bodies vary, and technology has its limits. The key is to know it exists, fix what can be fixed, and interpret the results accordingly.

Follow me on Twitter @RobShmerling

A dramatically different approach to transcranial magnetic stimulation is promising, but needs further study.

The basic tools we have for treating depression haven’t changed greatly in recent years. Medications and talk therapies are a mainstay. Lifestyle approaches, such as encouraging physical activity, sufficient sleep, and social connection, are often part of the package. If depression fails to lift, the next line of treatment for some may be a noninvasive form of brain stimulation called transcranial magnetic stimulation (TMS) that is helpful in certain cases and has very few side effects.

Yet TMS requires a serious time commitment — typically a total of 36 sessions over six to nine weeks. Studies show that about a third of people who try it find that it completely relieves their depression. Recently a small, short-term study in the American Journal of Psychiatry suggested that a radical rethinking of the way TMS is delivered may greatly boost effectiveness while shortening the treatment period to just five days.

What is transcranial magnetic stimulation?

Certain areas of the brain are known to be implicated in depression and other mood disorders. TMS uses powerful electromagnets to safely activate these regions. A device positioned on the upper forehead delivers short electromagnetic pulses. These pass through the skull to stimulate nerve cells in the targeted area. Over time, this technique leaves that part of the brain more active, which is thought to then affect entire brain networks responsible for regulating mood.

The most common side effect is temporary headache or discomfort at the site of stimulation. The most serious and rare potential side effect is seizure.

How effective is standard TMS for depression?

Despite advances since 2008, when the FDA first cleared a TMS device to treat depression, not everyone finds TMS to be effective.

When considering treatment options, it helps to understand the difference between response and remission. Depression symptoms often are measured using tools like the Hamilton Depression Rating Scale. Response to treatment means a 50% or greater reduction in symptoms; remission means the absence of symptoms defined in each scale.

Combined research on standard TMS shows about 30% of people experience a full remission from depression. This number varies somewhat across studies, devices, and treatment protocols. Notably, though, when antidepressants have failed to relieve depression, even this modest remission rate is higher than what would be expected if a person simply tried a different medication.

When TMS does help, depression starts to ease after a few weeks and continues to improve through the full course of treatment. These benefits last for about a year, on average. If depression returns, another course of TMS or a different treatment is often needed.

The staggering promise of the SAINT protocol

Researchers from Stanford modified standard TMS techniques to create a novel protocol called Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT or SNT), which

• uses MRI to select what is likely to be the optimal spot in the brain for stimulation
• triples the number of pulses per session
• increases the number of sessions to 50
• condenses treatment into just five days by doing 10 sessions per day.

In a single, one-month study, 29 people with treatment-resistant depression were randomly assigned to receive SAINT or a sham version. At the end of the month, 78% in the SAINT group had experienced full remission compared with 7% in the sham group. Remarkably, this efficacy surpasses even electroconvulsive therapy, the current gold standard for treatment-resistant depression. The SAINT treatment appeared to be safe and well tolerated, on par with standard TMS.

Many unknowns in new approach to TMS

Given its potential, the FDA granted clearance for Magnus Medical, a biomedical company working with Stanford, to market SAINT through a 510(k) pathway — a process that relies on the safety track record of previously approved devices for TMS. However, many questions must be answered before this novel treatment can be widely adopted.

• Will high rates of remission hold up across varied treatment sites and diverse populations? Ideally, new treatment options are vetted in larger, multicenter, randomized controlled trials before reaching the broader world.
• How long-lasting are the positive effects? A small, short-term study cannot show this, or suggest the best approach if depression recurs after a person completes accelerated treatment.
• Do side effects differ from standard TMS? While the adverse effects of standard TMS are well established and generally well tolerated, we do not yet know if the same can be said for the SAINT protocol, given the small number of people who have tried it to date.
• Which components in the SAINT protocol have the biggest impact on its striking remission rates? Can high response rates be achieved with more accessible techniques? The SAINT protocol, as described, requires extensive expert planning using high-tech approaches to neuroimaging that are not available in most parts of the country. Its implementation also requires dedicated equipment, staffing, and space that could disrupt other clinical operations. Perhaps adjustments can be made that can maintain the benefit while improving the accessibility for a wider array of TMS providers and their patients.

Moving forward with a novel treatment: Buyer beware

Depression care is an area of striking and ongoing need in this country. Advances like the SAINT protocol carry enormous potential, but also many unknowns. With such excitement about the results of the new approach, it is no surprise that clinics are springing up around the country offering similar accelerated TMS services. But how strictly will these clinics adhere to all elements of the SAINT protocol? We don’t have those answers, nor can we be sure yet that following all the elements will deliver the same results in larger, long-term studies.

For now, most sites offering variants of this new treatment approach will not be covered by insurance. Accelerated treatment will occur at substantial cost while still being limited by many of the unknowns discussed above. Before moving forward, people seeking treatment for depression and their clinical teams will have to determine what level of uncertainty feels comfortable to them.

The SAINT technique has the potential to transform the lives of millions of people living with depression, but the recent study and its subsequent FDA clearance are only the first steps. Figuring out exactly how this approach fits in is still to come.

Some people may be cautious when it comes to using oils in cooking or with their food. Eating fat with meals conjures thoughts of high cholesterol and, well, getting fat. The fact that some fats are labeled as “bad” adds to the confusion and misconception that all fats are unhealthy.

But that isn’t the case.

“It’s important to consume oils,” says Shilpa Bhupathiraju, assistant professor of medicine at Harvard Medical School and assistant professor of nutrition at Harvard’s T.H. Chan School of Public Health.

Oils and fats contain essential fatty acids — omega 3s and 6s, in particular — that are part of the structure of every single cell in the body, says Walter Willett, professor or epidemiology and nutrition at the Harvard T.H. Chan School of Public Health. They’re the building blocks of hormones, help decrease inflammation, and lower bad cholesterol and blood pressure. Oil also provides taste and satiety.

The key is knowing the right kind to use. It’s easier when you’re cooking at home, a little trickier when you’re eating out and you can’t control every step in the process. But it’s not just about picking the healthiest oils. They play a part in a healthy diet when they’re part of an eating plan that minimizes processed foods, simple carbohydrates, and sugar.

Healthy and not-so-healthy oils

In general, Willett says that the healthiest oils are liquid and plant-based. The one that comes to mind first is olive oil, and for good reason. “It’s stood the test of time,” he says. It helps lower blood cholesterol and provides antioxidants, and extra virgin is the ideal version, as it’s the first pressing and least refined.

After that, corn, canola, sunflower, safflower, and soybean all fall into the healthy column. The last one wasn’t always considered a healthy choice because it used to be hydrogenated, but now it’s in a natural state and a good source, says Willett.

On the unhealthy side, there’s lard, butter, palm oil, and coconut oil. The commonality is that they come in a semi-solid state and have a high level of saturated fat. The consumption of that fat increases LDL cholesterol (the bad kind), and has been associated with increased risk for cardiovascular disease and diabetes.

While saturated fats provide none of the above-mentioned health benefits, they don’t have to be avoided entirely, just minimized to 5% of your diet, says Willett. For example, if you typically consume 2,000 calories a day, only 100 should come from saturated fats.

Eating out versus at home

If you’re eating at home and you’re using healthy oils, there is less concern about consuming the wrong fats or too much. Whether you’re frying, sautéing, or dressing a salad, you’re in control of all the factors. Using too much oil isn’t such a concern, Bhupathiraju says, since people usually regulate their intake through knowing when something will taste too oily.

Frying, in general, is often a worry, but it’s not necessarily unhealthy. It’s more about what’s being fried. Cheese, a saturated fat, wouldn’t be a great choice, but zucchini wouldn’t be bad, as Bhupathiraju says.

The concern with fried foods, and eating out in general, is what kind of oil is being used and how. With deep fryers, if the oil isn’t regularly changed, it repeatedly gets reheated and trans fats are created. These can produce inflammation in the body, which can lead to heart disease, type 2 diabetes, and contributes to the breakdown of cell membranes.

The easiest move is to avoid eating all fried foods. But Willett says that, again, that’s not always necessary. The use of trans fats was prohibited in 2018, so it’s likely a restaurant is using a healthier oil. Even so, eating fried foods occasionally isn’t too harmful.

Focus on maintaining a healthy diet, with good oils

Willett says that people get the majority of their calories from two sources — fats and carbohydrates — and “what’s important is both should be healthy,” he says.

When you eat healthy carbs and fats, you don’t have to worry about how much you’re eating of either. “The ratio doesn’t make much difference. They’re both healthy,” he says. The focus in on overall eating. A healthy diet can consist of mostly whole grains like brown rice, steel-cut oats, wheat berries, and quinoa. The less something is milled and made into a powder, the more slowly it will release into the body, preventing sudden spikes in blood sugar.

While low-fat diets had some popularity in the 1990s, low-fat products aren’t healthier. Willett says that research has shown that low-carb diets are more effective for weight loss than low-fat ones, and that low-fat diets are not more effective for weight loss than higher-fat ones.

The best approach to eating well is the science-backed recommendation of having lots of colors on your plate. Orange, yellow, green, and red foods supply various antioxidants and phytochemicals that may be protective to the body. When you compose your diet like this, chances are you’ll eat more slowly and consume fewer empty calories, Bhupathiraju says.

“Enjoy fats,” Willett says. “Good olive oil is good for you. It will help you enjoy the salad and make the eating experience and eating of vegetables more enjoyable.”

RSV is one of several viruses that may cause respiratory distress in some children and adults.

Respiratory syncytial virus (RSV) is a common virus that has become even more common in recent years — and is causing lots of problems.

RSV cases used to rise predictably in the fall and winter, but are essentially occurring year-round since the pandemic.

What are the symptoms of RSV?

The virus causes cold symptoms such as fever, runny nose, chest congestion, and cough. But RSV symptoms tend to be a bit worse, and last a bit longer, than those from most cold viruses. And for some people, especially infants, it can cause more serious problems. In fact, it is the leading cause of bronchiolitis and pneumonia in children under a year old.

Children, teens, and even adults who have asthma or other lung diseases can also be hard-hit when they catch RSV. So can people with congenital heart disease, neuromuscular disorders like multiple sclerosis or muscular dystrophy, and weakened immune systems. That’s why the increase in cases, and the fact that RSV isn’t just a fall and winter illness anymore, is really unfortunate.

Can RSV be prevented?

A monthly injection of a medication called palivizumab can help prevent the illness. Only certain young children are eligible for it, particularly those who are born prematurely, or have lung disease, neuromuscular disease, heart disease, or a weakened immune system. Talk to your doctor about this if you think your child might be eligible.

While palivizumab is generally given between September and March or April (the months we have traditionally seen cases), the American Academy of Pediatrics (AAP) encourages giving it in the months in between as well, due to the rise in cases outside of those months.

How is RSV treated?

There really aren’t effective medications for RSV infections; all we can do is help people get through it. Most of the time, this means using saline sprays, a humidifier, acetaminophen or ibuprofen, and other things we do for the common cold. But some children need to come into the hospital, usually because of trouble breathing known as respiratory distress.

What are the symptoms of respiratory distress?

Parents should be watchful when children develop cold symptoms. This is especially important for children who have any of the health problems mentioned above.

Watch for any signs of trouble breathing, such as

• a very frequent cough
• audible wheezing
• sucking in around the ribs with breathing
• flaring of the nostrils
• trouble talking, or a weak cry
• pallor or a blue tinge to the skin
• unusual sleepiness or weakness.

If any of those happen, seek medical attention immediately. If none of these are happening but the child has a bad cough or high fever, it’s worth a call to the doctor to check in.

Meanwhile, make sure you and your family cover coughs (with an elbow or a tissue, not your hand) and wash hands often with soap and water or hand sanitizer. While many people have stopped wearing masks, a well-fitted mask can help prevent RSV and other respiratory illnesses. Talk to your doctor about cases of RSV — and COVID-19 — in your community, so that you can make the best decision for you and your family.

Follow me on Twitter @drClaire

Programs aim to support those at risk for psychosis or experiencing a first episode.

One of the many forms mental illness may take is psychosis. People experiencing it may have hallucinations (hearing voices, seeing visions, or feeling sensations that are not real) or delusions (firmly fixed beliefs that are not based on reality). And often, a first experience of psychosis occurs in the teenage or young adult years.

Could identifying early warning signs of psychosis and providing appropriate support change the course of the illness for the better? Experts believe that it can.

What should you know about psychotic disorders?

Psychosis affects three out of 100 people during their lifetimes. Just one in 100 people will be diagnosed with a psychotic disorder, such as schizophrenia, schizoaffective disorder, or bipolar disorder with psychotic features.

Along with hallucinations or delusions, people grappling with psychosis appear disorganized in the way they speak or behave. Their actions can be disturbing, especially if you’re a worried parent, family member, or friend of someone experiencing psychosis.

Years ago, mental health clinicians believed the possibility of recovery from a psychotic disorder was limited. Luckily, research on psychosis has taught us that this is not true. Outcomes vary significantly, and the three to five years after the first episode of psychosis are crucial in recovery.

Why is it important to identify psychosis early?

Research suggests that the longer a person has untreated psychosis, the more likely they are to have a high burden of symptoms, lower ability to function, and a poor quality of life. It’s best to seek help early by talking to a doctor if you have concerns.

A teen or young adult who is experiencing hallucinations, delusions, or other symptoms of a psychotic episode for the first time will usually respond well to antipsychotic medicines, such as risperidone or aripiprazole. Programs that support young people at risk for psychosis or experiencing their first episode are available, too.

What are the early warning signs to know?

Before having clear symptoms of psychosis, a teen or young adult often experiences distressing changes in thoughts and emotions. They might

• believe something odd is going on with them, or feel confused about what is real or imaginary
• feel singled out, watched, or not fully in control of their thoughts
• report changes in perception, such as their eyes or ears playing tricks, hearing jumbled, incomprehensible voices, or seeing shadows or figures in the corners of their eyes
• ask for help in trying to make sense of unsettling experiences like these.

Programs specializing in psychosis risk aim to reach out to these individuals.

How can psychosis-risk programs help?

These programs work with teens and young adults who have a mixture of mood and anxiety issues and a mild version of psychosis symptoms, but who haven’t been diagnosed with psychosis. They focus on treatments to ease distress and prevent a first episode of psychosis, when possible.

Combined data on people taking part in these programs suggests

• a third will have their symptoms resolve
• a third will be diagnosed with a psychotic disorder, such as schizophrenia, bipolar disorder with psychosis, or schizoaffective disorder
• a third will develop a nonpsychotic mental illness, such as depression, anxiety, or personality disorder.

A multidisciplinary team of psychiatrists, social workers, and psychologists provides care. Medication is often used to target co-occurring conditions such as depression and anxiety.

Individual therapy focuses on teaching coping skills, challenging distressing beliefs with cognitive behavioral therapy, and regulating intense emotions with dialectical behavioral therapy. Parent coaching and family therapy focuses on improving relationships. That’s important, because research shows that patients whose families express high negative emotions tend to have more symptoms.

Clinicians also support patients in sobriety, particularly those using cannabis, given that the risk of psychosis is five times greater in heavy cannabis users.

What programs can help during a first episode of psychosis?

Many psychosis-specialized early intervention programs in the US and around the world provide expert care. An analysis of 10 randomized controlled trials compared treatment at these centers with usual care for 2,176 young patients with first-episode psychosis over two years. Those who had access to an early intervention program were more engaged in treatment, had fewer hospitalizations, and were more involved in school or work compared to those who received usual care.

Early intervention services include a multidisciplinary team of mental health professionals with expertise in psychosis, such as psychiatrists, psychologists, and social workers. Teams coordinate treatment from within, rather than making referrals for outside providers. They frequently include peer mentors who are in recovery from diagnosed mental illness. Peers support patients by sharing their lived experience and journey in recovery. Vocational and occupational coaches help patients function better in society by supporting them as they return to school or work, or start volunteering.

The bottom line

Psychotic disorders are like many illnesses: while outcomes vary, people respond best when they receive early, appropriate treatment. Psychosis-risk programs aim at connecting with people who are at risk, and they offer psychotherapy, medication treatment, and a variety of supports.

Early intervention programs for psychosis are designed to meet the needs of patients who are recently diagnosed with a psychotic disorder. These programs offer specialized and highly coordinated care and family support. Recognizing early signs of illness and connecting young people with expert care can make a substantial difference.

Extraintestinal manifestations of IBD may be a clue toward diagnosis or treatment adjustment.

Inflammatory bowel disease (IBD) is a type of chronic inflammation of the gastrointestinal tract. Ulcerative colitis, marked by continuous inflammation of the large intestine, and Crohn’s disease, which causes patches of inflammation and can occur anywhere in the gastrointestinal tract, are both types of IBD. Patients with IBD can experience a variety of gastrointestinal symptoms such as abdominal pain, diarrhea, blood in their stool, bloating, and weight loss.

What conditions can occur outside the GI tract in people with IBD?

IBD symptoms can occur both inside and outside the gastrointestinal tract. The latter are known as extraintestinal manifestations (EIMs) of IBD. These conditions occur in nearly half of all people with IBD, and can be present before and/or after someone’s IBD is diagnosed. EIMs are more frequent in people who receive their diagnosis at an earlier age, and generally also occur earlier in the course of IBD. In fact, approximately 24% of EIM symptoms are present prior to receiving a diagnosis of IBD. The causes of EIMs are poorly understood but, similar to IBD, may be due to a combination of genetic risk factors, immune reactions, and lifestyle factors such as cigarette smoking.

What are some examples of extraintestinal manifestations of IBD?

Patients may have multiple EIMs at the same time, with varying severity. EIMs may not be easy to detect, and almost any organ system can be affected. Sometimes the severity of EIM symptoms mirrors that of the gut symptoms, but in certain conditions the EIMs behave independently. Below are some common examples of extraintestinal manifestations.

Musculoskeletal: Musculoskeletal manifestations of IBD are the most common, occurring in up to 46% of IBD patients. They may present as inflammatory back pain (ankylosing spondylitis), inflammation of tendons or ligaments, arthritis, joint pain without arthritis, or swelling of fingers or toes (dactylitis). Arthritis can occur both within the axial skeleton (hips, lower back, spine) or peripherally (fingers, wrists, elbows, knees, ankles).

Mucocutaneous: IBD can cause changes in the skin and mucosa (the moist lining covering certain organs and cavities in the body). Oral aphthous ulcers (seen with Crohn’s disease), erythema nodosum (raised purple nodules typically on the front of the legs, which can occur in 10% to 15% of patients), and pyoderma gangrenosum (painful skin ulcers) are some examples of how IBD can impact the skin. Sweet syndrome, which involves tender lumps under the skin and is also associated with increased white blood cell count, fevers, arthritis, and eye symptoms, is a rare EIM.

Ocular: Inflammation in parts of the eye (episcleritis, scleritis, or anterior uveitis) affects 2% to 7% of IBD patients. If patients experience eye pain, redness, sensitivity, or visual changes, urgent evaluation by an ophthalmologist may be necessary, due to the risk of blindness from uncontrolled inflammation.

Vascular: Patients with IBD are at up to three times greater risk of developing blood clots compared to patients without IBD. Sometimes these clots can travel to the lungs and are called pulmonary embolisms. Symptoms of blood clots may be leg swelling or shortness of breath. Poorly controlled inflammation in the GI tract is thought to be the cause of increased clotting risk.

Gastrointestinal: While not common, patients can develop liver diseases related to IBD, including primary sclerosis cholangitis (inflammation and scarring of the bile ducts) and autoimmune hepatitis (when the immune system attacks the liver cells, causing liver inflammation). Autoimmune pancreatitis has also been reported. These conditions can be diagnosed by symptoms, blood tests, or imaging findings (sometimes using MRI).

How are EIMs treated?

It is important to effectively treat bowel inflammation, as this may reduce activity of extraintestinal manifestations. Sometimes, EIMs may require additional specific treatments. For example, corticosteroids, sulfasalazine (anti-inflammatory medication), or specific biologic therapies may be considered for arthritis treatment. Skin and eye manifestations of IBD may be treated with topical or systemic corticosteroids, immunosuppressants, or specific biologic therapies. Vascular manifestations such as blood clots may be treated with anticoagulation medications. Treatment of EIMs is complex, and frequently requires a collaborative approach to care with several healthcare providers.

What should I do if I am experiencing symptoms?

EIMs are important to recognize, as they can significantly affect your quality of life and may also impact your doctors’ approach to IBD treatment and monitoring over time.

Whether or not you have been diagnosed with IBD, it is important to see your primary care doctor or gastroenterologist (if you have one) to discuss any symptoms you may be experiencing. Your doctor(s) will discuss your medical and family history to determine your risk for IBD or other medical conditions.

For patients with a diagnosis of IBD or at risk for IBD, EIMs may be the first clue toward diagnosis or the need for treatment review and adjustment. It is important to communicate both your gastrointestinal and non-gastrointestinal symptoms with your gastroenterologist in order to promptly be started on the appropriate treatment and connected to specialists for the affected organ system. Lifestyle modifications such as smoking cessation may also reduce the risk of EIMs.

With targeted treatment and the appropriate health care team in place, management of both IBD and EIMs can be achieved to improve patients’ quality of life.

We are in the midst of a pediatric mental health crisis — and parents need to take action.

Over the past couple of years, the pandemic has not only killed hundreds of thousands; it has also shut us inside, cut off social contacts, taken parents out of work and children out of school. The consequences have been tremendous. And one of those consequences is that we are seeing alarming amounts of anxiety and depression in our children and teens.

A national emergency among children and teens

In the fall of 2021, the American Academy of Pediatrics along with the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association declared a national emergency in child and adolescent mental health. They called for increased funding for mental health resources, as well as other actions, including more integration of mental health care into schools and primary care, more community-based systems to connect people to mental health programs, strategies to increase the number of mental health providers, and ensuring that there is insurance coverage of mental health care.

These are all necessary, and efforts to ensure them are ongoing. But while we work to build mental health care systems, there are things that parents can do to help their children through this crisis.

Mental health is just as important as physical health

First and foremost, we must understand that. If a child has a fever or a persistent cough, parents react — they pay attention and reach out for help. But if a child seems sad or irritable, or less interested in activities they used to enjoy, they tend to think of it as a phase, or teen angst, or something else that can be ignored. The mental health of our children is crucial. Not only does mental health affect physical health, but untreated mental health problems interfere with learning, socialization, self-esteem, and other important aspects of child development that can have lifelong repercussions. And for some children, untreated mental health problems lead to suicide.

So pay attention, and take what you see seriously. If your child is showing signs of anxiety or depression, call your doctor. Don’t put it off. If your child talks about harming themself or others, get help immediately, such as by going to your local emergency room. In this situation, it’s better to overreact than underreact.

Create rituals of communication and safe spaces to talk

It’s easy to lose connection with our children, especially our teens. Whether it’s family dinner, family game night, talking on the ride to school, or a nightly check-in before bed, having regular times to ask open-ended questions and to listen to your children is important.

Make sure your child has downtime

We all need this, and children particularly need it. Be sure they aren’t overscheduled; make sure that there is time for them to do things they enjoy.

Encourage healthy media habits

One of the things kids enjoy these days is being on their devices, which can be fun and connect them to friends, but can also contribute to problems with mental health. Talk to your child about how they use media. Common Sense Media has a wealth of useful information.

Make sure your child is getting enough sleep — and some exercise

Both are very important for mental health as well as physical health. Here are tips to help your child get the sleep they need. And even short bursts of exercise can lessen anxiety.

Keep in touch with teachers, coaches, and other adults in your child’s life

Not only may they have information about your child that you need, but they can also play an important supportive role. Open lines of communication with them can make a difference — and help to create community, which we all need, especially now.

Try to make your home a judgement-free safe haven

This doesn’t mean you can’t and shouldn’t have expectations about behavior or grades. But you can have expectations without judgment; you can and should let your child know that you love them no matter what, that they can say what they feel, and that you will always help them. Do your best to listen more than you talk; be empathetic and forgiving. To be genuine about that, you will need to be empathetic and forgiving toward everyone, including yourself.

Pay attention to your own mental health

Children pay more attention to what parents do than what they say. If you are clearly struggling with anxiety or depression, and aren’t doing anything about it, that sends the wrong message to your children. It also makes it hard to be a good parent.

If we take care of each other and ourselves, we can weather this storm.

Follow me on Twitter @drClaire

Cost, safety, comfort, and environmental impact can help guide personal choices.

On any given day, over 300 million people around the world are having their period. Yet the high costs of period products continue to be a problem for many. Those costs are not just financial (though period equity is a serious problem that is largely unaddressed in the US); there are also environmental, health, and safety costs to consider.

While single-use disposable period products like pads and tampons make up the majority of the multibillion-dollar global market, reusable products like cups (inserted into the vagina to collect the blood) and period panties (absorbent underwear) are beginning to gain more traction. Recently, my team took an eye-opening look at product data with respect to cost, health and safety, comfort and satisfaction, and environmental impacts in the United States.

How much do period products cost?

Scotland is the first country to offer free period products to all who need them. In the US, the upfront cost is cheapest for pads, followed by tampons — though the prices for these products increased by almost 10% in the last year. Reusable period cups and period panties are more expensive to start. Cups begin to offer cost savings by around a year.

Some factors to consider with reusables:

• You might need to try more than one period cup to find your fit, or may want to have more than one on hand. Savings go up the longer your period cup lasts, which may be from two to 10 years with good care.
• Period panties have varying absorbency, so you might choose to mix and match products depending on period flow. For example, you might use period panties on light days, or in combination with tampons or cups on heavier days. Also, they might be helpful for other reasons, like discharge or mild urinary incontinence.

Your mileage may vary, as they say, but see the chart below for a rough cost comparison of period products.

Product	Cost per year	Cost per item	Cost over four years
Disposable pads	$40 (assuming people use 20 pads per cycle)		$160
Disposable tampons	$60 (assuming people use 20 tampons per cycle)		$240
Reusable period cup		$20 to $40 per cup, adding up to $60 to $120 (assuming people buy three cups to rotate)	$60 to $120 (more if a cup doesn’t last the full four years)
Reusable period panty		$10 to $35 per panty	Not clear, because number of panties needed and how long they last depend on how you choose to use them.

Health and safety of period products

Long-term exposure to high levels of toxic contaminants called dioxins can cause cancers and other health problems. Dioxins can form when bleach is used on pulp and paper products that go into pads and tampons. Most people are not exposed to high enough levels to cause health harms.

Over the years, manufacturers have modified the bleaching process to minimize dioxins in these products. Dioxin levels in tampons are much lower than FDA limits, and even lower than from exposure through food. Period cups do not contain dioxins, as they are usually made of medical grade silicone; neither do period panties (but do check that these are free of chemicals known as PFAS).

The other risk of some period products is toxic shock syndrome (TSS), a life-threatening illness related to a toxin made by certain bacteria. TSS occurs in roughly 1 in 100,000 menstruating people in the US. Reports of TSS with period cup use are even more rare. It is mostly linked with high-absorbency tampon use.

Due to changes in how tampons are made, instances of TSS have declined. Reduce your risk of TSS by not leaving in tampons for longer than eight hours or period cups for longer than 12 hours. Depending on your flow, you may need to change sooner to avoid leakage.

Comfort and satisfaction with period products

Most people are able to use tampons or cups regardless of virginity. Some people do not want to insert anything in the vagina, in which case pads or period panties would be preferred. There are plenty of choices now for period panties varying in color, cut, absorbency, and ranging in style from thong to athletic shorts. They can be purchased online or at many department stores.

Period cups might take some getting used to. A small, randomized study found that overall satisfaction was lower after the first month of cup use as compared to tampon use, but then comparatively higher after months two and three.

Environmental impacts of period products

The environmental impact of a product can be estimated through a life cycle assessment. This considers its footprint from natural resource use to greenhouse gas emissions — the major contributor to global warming and climate change. The environmental impact of disposable pads and tampons is much higher than that of reusable menstrual cups due to raw materials, manufacturing processes, and landfill waste.

Ultimately, which period products you choose may depend on several factors, and on what makes the most sense for you. The Center for Young Women’s Health offers more information on disposable tampons and pads, and eco-friendly options.

Multiple supportive connections in community settings can help people lose weight.

Attaining and maintaining a healthy weight is a major health issue, not only in the United States but in many countries throughout the world. Governments are looking to identify the most effective services to support people to lose weight and improve overall health. A recent systematic review and meta-analysis (a larger study of studies) examined the effectiveness of weight management interventions delivered in primary care settings, and included data from the United States, the United Kingdom, and Spain.

Looking at weight loss support in primary care

Researchers evaluated 34 studies with adults who had a body mass index greater than 25 (overweight). They looked at people who received weight loss interventions within primary care settings. The interventions included instruction on weight management behaviors such as low-calorie diets, increased exercise, use of food diaries, and/or behavioral self-management approaches with support by clinic staff to set weight-related goals, solve problems, and increase self-efficacy.

Weight loss interventions were conducted by telephone, the internet, email, or face-to-face, and included group-based and/or individual connections. The research compared these types of interventions to no weight loss treatment, minimal intervention (use of printed or electronic education about weight loss), or instruction in attention control to resist urges or behaviors, but not focusing specifically on weight loss behavior.

Programs delivered in primary care did produce meaningful weight loss

The interventions were delivered by a variety of medical professionals (nurses, dietitians, and general practitioners) and nonmedical practitioners such as health coaches. The interventions lasted between one session (with patients following the program unassisted for three months) and several sessions over three years, with a median of 12 months.

Results showed that the mean difference between the intervention and comparison (no specific weight loss intervention) groups at one year was a weight loss of 5.1 pounds, and at two years it was 4 pounds for those that received weight loss interventions in primary care. There was also a mean difference in waist circumference of -2.5 cm, in favor of the intervention at one year.

Importantly, since this was a systematic review of 34 trials with a wide range of interventions, the authors were not able to specifically identify which interventions produced the result.

Even small weight loss impacts health

The authors noted that although a 5-pound greater weight loss in the intervention group may seem small, research has shown that a 2% to 5% weight loss is associated with health benefits, including lower systolic blood pressure along with reduced triglyceride and glucose levels, which may impact cardiac health.

Do personal check-ins and support impact weight loss?

The study recognized that the comparison groups had fewer person-to-person contacts than the intervention groups, and this may have played a critical role in the findings. A greater number of contacts between patients and providers led to more weight loss. The research suggests that programs should be developed to include at least 12 contacts (face-to-face, telephone, or a combination).

Although the study did not determine the costs of the programs, it is likely that interventions delivered by nonmedical personnel, with supervision and support from primary care health professionals, would be less expensive. It may be that a combination of practitioners would be most effective, since physicians and general practitioners most likely will not have the time for 12 consultations to support a weight management program.

Prior research supports community-based behavioral interventions for weight loss

A study prepared for the US Preventive Services Task Force and published in 2018 found similar results. This review reported a reduction of 5.3 pounds in participants who received weight management interventions in a variety of settings, including universities, primary care, and the community. Compared with controls, participants in behavior-based interventions had greater mean weight loss at 12 to 18 months and less weight regain.

In the two largest trials (of the 124 identified), there was a decreased probability of developing type 2 diabetes compared with those who did not receive the weight management interventions. There was an absolute risk reduction of approximately 14.5% in both trials over three to nine years, meaning those who received weight loss management intervention had a 14.5% reduced chance of developing diabetes compared to a control group.

What’s the takeaway?

Weight management interventions delivered in primary care settings are an effective way to deliver services. Primary care practices offer good reach into the community, and oftentimes are the first point of contact for people to the healthcare system. With our growing obesity epidemic, every effort should be considered to connect with patients struggling with their weight and offer viable, effective interventions.

What can you do?

• Ask your PCP if their practice or clinic offers programs to support weight management.
• Contact your health insurance and inquire about programs they have in their system to help reduce risk factors and manage weight. Ask if they are free or discounted as part of your plan.
• Check in your area if there are any community-based programs such as the YMCA, a school-based program, or a senior center focused on wellness and weight management.

If you’re in your 80s or 70s and you’ve noticed that you’re having some memory loss, it might be reasonable to be concerned that you could be developing Alzheimer’s disease or another form of dementia. But what if you’re in your 60s, 50s, or 40s… surely those ages would be too young for Alzheimer’s disease or dementia, right?

About 10% of Alzheimer’s disease is young onset, starting before age 65

Not necessarily. Of the more that 55 million people living with dementia worldwide, approximately 60% to 70% of them have Alzheimer’s disease. And of those 33 to 38.5 million people with Alzheimer’s disease, memory loss or other symptoms began before age 65 in 10% of them. Alzheimer’s is, in fact, the most common cause of young onset dementia. A recent study from the Netherlands found that of those with a known classification of their young onset dementia, 55% had Alzheimer’s disease, 11% vascular dementia, 3% frontotemporal dementia, 3% Parkinson’s disease dementia, 2% dementia with Lewy bodies, and 2% primary progressive aphasia.

Young onset dementia is uncommon

To be clear, young onset dementia (by definition starting prior to age 65, and sometimes called early onset dementia) is uncommon. One study in Norway found that young onset dementia occurred in 163 out of every 100,000 individuals; that’s in less than 0.5% of the population. So, if you’re younger than 65 and you’ve noticed some trouble with your memory, you have a 99.5% chance of there being a cause other than dementia. (Whew!)

There are a few exceptions to this statement. Because they have an extra copy of the chromosome that carries the gene for the amyloid found in Alzheimer’s plaques, more than half of people with Down syndrome develop Alzheimer’s disease, typically in their 40s and 50s. Other genetic abnormalities that run in families can also cause Alzheimer’s disease to start in people’s 50s, 40s, or even 30s — but you would know if you are at risk because one of your parents would have had young onset Alzheimer’s disease.

How does young onset Alzheimer’s disease differ from late onset disease?

The first thing that should be clearly stated is that, just as no two people are the same, no two individuals with Alzheimer’s disease show the same symptoms, even if the disease started at the same age. Nevertheless, there are some differences between young onset and late onset Alzheimer’s disease.

People with typical, late onset Alzheimer’s disease starting at age 65 or older show the combination of changes in thinking and memory due to Alzheimer’s disease plus those changes that are part of normal aging. The parts of the brain that change the most in normal aging are the frontal lobes. The frontal lobes are responsible for many different cognitive functions, including working memory — the ability to keep information in one’s head and manipulate it — and insight into the problems that one is having.

This means that, in relation to cognitive function, people with young onset Alzheimer’s disease may show relatively isolated problems with their episodic memory — the ability to form new memories to remember the recent episodes of their lives. People with late onset Alzheimer’s disease show problems with episodic memory, working memory, and insight. So, you would imagine that life is tougher for those with late onset Alzheimer’s disease, right?

Depression and anxiety are more common in young onset Alzheimer’s disease

People with late onset Alzheimer’s disease do show more impairment, on average, in their cognition and daily function than those with young onset Alzheimer’s disease, at least when the disease starts. However, because their insight is also impaired, those with late onset disease don’t notice these difficulties that much. Most of my patients with late onset Alzheimer’s disease will tell me either that their memory problems are quite mild, or that they don’t have any memory problems at all!

By contrast, because they have more insight, patients with young onset Alzheimer’s disease are often depressed about their situation and anxious about the future, a finding that was recently confirmed by a group of researchers in Canada. And as if having Alzheimer’s disease at a young age wasn’t enough to cause depression and anxiety, recent evidence suggests that in those with young onset Alzheimer’s disease, the pathology progresses more quickly.

Another tragic aspect of young onset Alzheimer’s disease is that, by affecting individuals in the prime of life, it tends to disrupt families more than late onset disease. Teenage and young adult children are no longer able to look to their parent for guidance. Individuals who may be caring for children in the home now need to care for their spouse as well — perhaps in addition to caring for an aging parent and working a full-time job.

What should you do if you’re younger than 65 and having memory problems?

As I’ve discussed, if you’re younger than 65 and you’re having memory problems, it’s very unlikely to be Alzheimer’s disease. But if it is, there are resources available from the National Institute on Aging that can help.

What else could be causing memory problems at a young age? The most common cause of memory problems below age 65 is poor sleep. Other causes of young onset memory problems include perimenopause, medication side effects, depression, anxiety, illegal drugs, alcohol, cannabis, head injuries, vitamin deficiencies, thyroid disorders, chemotherapy, strokes, and other neurological disorders.

Here are some things that everyone at any age can do to improve their memory and reduce their risk of dementia:

All of us can lower the odds of unintentional shootings.

Guns hurt and kill; it’s a simple fact. And while most gun injuries and deaths are the result of an assault or suicide, unintentional injuries happen all the time, including to children and between them. In the six-year span between January 1, 2015, and December 31, 2020, there were at least 2,070 unintentional shootings by children under 18 years old, resulting in 765 deaths and 1,366 injuries, according to Everytown Research and Policy.

If you’re a parent — or even if you’re not — you can help reduce the odds of an accidental shooting in several ways.

Why is it important to talk about gun safety with children?

Children are naturally curious, and guns are ubiquitous in the media and video games that children see all the time. Many don’t really understand how dangerous guns can be, and most don’t know how to tell if a gun is loaded.

According to the Pew Research Center, three in 10 in Americans own a gun, and four in 10 live in a household with one. So it’s not surprising that 34% of children in the US live in a home with at least one firearm. While it is recommended that guns be stored locked, with ammunition locked separately, less than half of US families with both children and guns actually do this.

What steps can parents take around gun safety?

If you have a gun and you have a child in your home, please lock up the gun, and lock up the ammunition separately. And make sure that your child doesn’t know how to unlock either or both. Children know more than most adults realize.

If your child plays at the homes of other children, you need to think — and ask — about gun safety. Many people feel uncomfortable asking; they worry that asking could be seen as an invasion of privacy, or as being judgmental. But it’s not either one. It’s simple safety.

The best way to do it is to make it routine, and make it part of other questions you should ask before sending your child to someone else’s home. You might say: “Hey, I have some questions I always ask before sending my child somewhere, just being safe.” Then, you could ask things like:

• “Who will be home with them, and how do you handle supervision?”
• “Do you have a pool?” (If yes, more questions about safety and supervision are important.)
• “Does anybody smoke?” (This is particularly important if your child has asthma or other breathing issues.)
• “Do you have pets?” (This is important for allergies, if your child is afraid of animals, and to find out if there are any animals that might be aggressive.)
• “Does anyone have allergies?” (So that your child doesn’t bring any foods that might cause problems.)

There may be other questions you ask based on your situation. As for guns, the question you should ask is:

• “Do you have an unlocked gun in your home?”

If the answer is yes, you have options. You can either ask them to please lock it up (and ask more questions about supervision), or if you’re not sure the family can or will lock it up, say, “I am so sorry, but I won’t be able to send my child to your home.” Be matter-of-fact and pleasant. If it’s a playdate, you can offer to have it at your home, or to take the children somewhere else like a local park.

They may be surprised or offended, sure. But that’s a risk worth taking to protect your child’s safety, and maybe even their life.

An ad for a new eczema drug leaves some questions unanswered.

Dry, itchy, reddened skin is the hallmark of eczema. If you have eczema and have seen this ad, you may be wondering about Dupixent (dupilumab). Does this new medicine work as well as it seems to in the ad? Where does the ad hit the mark, and where could it do better?

The medicine only treats one type of eczema

While the ad uses “eczema” and “atopic dermatitis” interchangeably, these conditions aren’t exactly the same. Eczema is an umbrella term that includes:

• atopic dermatitis, which develops in people prone to asthma and environmental allergies, such as hay fever
• contact dermatitis, which is an allergic reaction to a substance touching the skin, such as soaps, scented products, or poison ivy
• skin inflammation that accompanies leg swelling.

Atopic dermatitis is the only skin condition for which Dupixent is approved.

The pitch

Every ad is a sales pitch, whether it uses real people or paid actors. Here we see real people banging on drums in a band, playing piano or trombone, and baking in the kitchen. A voiceover says “With less eczema, you can show more skin. So, roll up those sleeves and help heal your skin from within with Dupixent.” The pitch? People with eczema may be embarrassed by it and try to hide it — and effective treatment means you need not keep your skin covered.

We next hear this is “the first treatment of its kind that continuously treats moderate to severe eczema, or atopic dermatitis, even between flare-ups.” The viewer sees an outstretched arm with a red rash that clears up over a second or two. Of course, that’s not what happens in real life; it can take weeks to see improvement.

More perplexingly, the voiceover tells us that the drug “…is a biologic, and not a cream or steroid.” Perhaps you’re wondering what a “biologic” medicine is. Hold that question for further explanation below. “Many people taking Dupixent saw clear or almost clear skin and had significantly less itch. That’s a difference you can feel.“

Side effects, warnings, and a tagline

The warnings may raise eyebrows. “Don’t use if you’re allergic to Dupixent. Serious allergic reactions can occur, including anaphylaxis, which is severe. Tell your doctor about new or worsening eye problems such as eye pain or vision changes, or parasitic infection. If you take asthma medicines, don’t change or stop them without talking to your doctor.“

Quickly, though, the ad moves on to a glowing tagline: “So help heal your skin from within” and recommends talking to “your eczema specialist” about Dupixent. That may be difficult: most people with eczema see their primary care physician for it, not a dermatologist.

What the ad gets right

It’s true that people with eczema may try to hide it and that effective therapy may be liberating, allowing them to worry less about others seeing their skin. Dupixent is, indeed, neither a cream nor a steroid, which are older, common treatments for eczema. And, yes, Dupixent is the first treatment of its kind for eczema. It blocks a chemical called interleukin 4 (IL-4), which is thought to play an important role in this skin disease.

What else should you consider if you have atopic dermatitis?

• How is it usually treated? Mild cases of atopic dermatitis may respond to skin moisturizers or medicated creams, gels, or ointments, some of which contain steroids. But this may not be effective for more severe eczema.
• What’s a biologic? These medicines are made in a living system such as a microorganism, human or animal cells, or plant cells. They are often antibodies that block a substance in the body thought to cause or contribute to a disease. Because biologics are usually large molecules that would be destroyed during digestion if taken in pill form, they are generally available only by injection. Dupixent is injected every two weeks.
• Why are eye problems, parasites, and asthma mentioned in the warnings? Eye inflammation was a side effect of the medicine in studies leading to approval. IL-4 is considered a key part of our immune defense against parasitic infections, and a few study participants developed parasitic infections. As for asthma, Dupixent is an approved asthma treatment when combined with other medicines. So, if you had asthma and it improved while you treated your atopic dermatitis, you might be tempted to cut back on your other medicines — but that’s not safe without medical supervision.
• What about cost? Biologics are expensive. This yearly price tag for this medicine is about $40,000 a year. Even when covered by health insurance, copays and deductibles can make it a costly treatment.
• Does it work? Text appearing on the screen says 37% of adults and 24% of teenagers saw major improvement after four months of treatment, compared with less than 10% of people not taking Dupixent. That may seem great if you’re in the minority of people who dramatically improved. Or it might seem like modest success for a systemic treatment with significant risk of side effects and a large price tag.

The bottom line

Drug ads exist to sell a product. They should never be your primary source of health and treatment information. For that, look to your own health care providers and other reliable sources of information like the FDA or NIH. Their primary interest is providing accurate information and promoting public health and medication safety, not convincing you to use a particular drug.

Busy people may find it hard to take heart-healthy steps. These simple swaps can help.

Busy days make it hard to put heart health on the front burner. It just feels like you don’t have time for habits that keep the ticker in top shape — like exercising regularly, getting enough sleep, and eating a healthy diet. So maybe you take the stairs when you can, or you park farther away from a store to rack up a few extra steps each day. But what else can you do? Here are three things that might fit in your schedule.

Swap electronic communication for an in-person meeting

It’s fine if texting, emailing, social media, or Zoom calls are your primary means of communicating with others. But it’s not okay if those methods leave you feeling lonely or isolated — two problems linked to higher risks for heart disease, heart attack, or stroke, according to a scientific statement from the American Heart Association in the Journal of the American Heart Association.

To combat loneliness and isolation, try to replace some of your electronic back-and-forth with people with in-person meetings. Maybe you can find room in your schedule for a quick walk, cup of coffee, or brief lunch with a friend or colleague.

“Time spent face-to-face helps connect you to others and may make you feel less isolated,” explains Matthew Lee, a sociologist and research associate at Harvard University’s Human Flourishing Program. “Being physically co-present can help you feel more engaged with others, more valued, and more likely to feel a sense of shared identity — all things that may help ease loneliness. This is why some doctors are starting to engage in ‘social prescribing,’ including suggesting that people get involved in volunteering and other activities that build in-person social relationships.”

A recent study published in the International Journal of Public Health by Lee and a team of Harvard-led researchers suggests that better social connectedness may reduce the risk of being diagnosed with depression or anxiety. Both are associated with heart disease or making existing heart conditions worse.

Swap an unhealthy breakfast for a healthier one

Is your typical breakfast something quick and full of refined (not whole) grains, processed meat, saturated fat, or added sugar? Eating that kind of food regularly may drive up calories, weight, blood sugar, or cholesterol levels — and that’s not good for your heart.

Instead, chose breakfast foods rich in fiber, a type of carbohydrate that either passes through the body undigested (insoluble fiber) or dissolves into a gel (soluble fiber) that coats the gut.

Not only does fiber help digestion, it also

• traps, mops up, and lowers bad [LDL] cholesterol that can lead to clogged arteries
• controls blood sugar and lowers the risk for diabetes, which is strongly associated with heart attacks and strokes
• may help fight chronic inflammation, which plays a role in clogging arteries and causing heart attacks.

Fruits, nuts, seeds, whole grains (oats, barley, quinoa) and many other foods are rich in fiber. Try these fiber-rich breakfast ideas:

• microwaved oatmeal (heat a 1/2 cup of oatmeal with almost a cup of low-fat milk for about two minutes)
• a serving of cooked quinoa (cold, if you have it in your fridge) with a dollop of nonfat Greek yogurt, berries, and granola
• whole-grain cereal with milk (go for cereals with the highest amounts of whole grains and lowest amounts of added sugars)
• a slice of whole-grain toast with two tablespoons of nut butter (like almond or peanut butter)
• one or two handfuls of homemade trail mix (use your favorite unsalted nuts, sunflower seeds, and dried fruit such as raisins or apricots).

Swap a few minutes of scroll time for meditation time

If you ever take a break from your busy day to scroll through news on your phone or computer, chances are you can also find a little time to meditate, which is important for heart health. Research indicates that people who meditate have lower rates of high cholesterol, diabetes, high blood pressure, stroke, and coronary artery disease compared with people who don’t meditate.

What’s the connection? Meditating triggers the body’s relaxation response, a well-studied physiological change that appears to help lower your blood pressure, heart rate, breathing rate, oxygen consumption, adrenaline levels, and levels of the stress hormone cortisol.

The great news: it doesn’t take much time to reap the heart-healthy benefits of meditating — just about 10 to 20 minutes per day.

Ideas for quick ways to meditate in a busy day include sitting quietly, closing your eyes, and

• focusing on your breathing, without judging sounds you hear or thoughts that pop into your head
• listening to a guided meditation, which uses mental images to help you relax
• listening to a recording of calming sounds such as waves, a bubbling brook, or gentle rain.

Just try to calm your brain for a few minutes a day. Soon, you may find you’ve become better at meditating and better at practicing other heart-healthy habits, no matter how busy you are.

Burnout is causing physicians to leave the profession.

Reading the book The Doctor Stories by William Carlos Williams seared into my mind the ways in which a primary care physician (PCP) can transform the lives of patients with a nuanced blend of careful listening, emotional connection, and medical skill. This book inspired me to become a PCP.

According to a 2021 report by the National Academy of Sciences, Engineering, and Medicine, an increased supply of PCPs is associated with better population health and more equitable outcomes. With our country’s fraying healthcare system, it is essential to have a PCP who knows you, because it is almost impossible to access any type of coherent medical care without the coordination of a PCP.

The most common question I get asked as a doctor — by friends, acquaintances, relatives, families of patients, colleagues — is “Can you help me find a PCP?” I can’t. None of us can. Why is it so difficult to find a PCP nowadays?

Unfavorable demographics and PCPs leaving the profession

While the COVID pandemic certainly pushed a large subset of already burned-out PCPs over the brink into semi- or full retirement, or into less stressful jobs, the current primary care crisis has been brewing for much longer. The US is expected to face a shortage of primary care physicians ranging from 21,000 to 55,000 by the year 2033.

Both patients and doctors are getting older. As patients age, they tend to need more care from their PCPs to address the proliferation of medical problems and medications that inevitably comes with aging. At the same time, the Association of American Medical Colleges reports more than 40% of active physicians in the United States will be 65 or older within the next decade. The American Medical Association notes that 29% of physicians retire between the ages of 60 and 65, and 12% retire before the age of 60.

These numbers have daunting implications for the future supply of seasoned doctors. Further, one-fifth of doctors say they will likely leave their current practice within the next two years, and one-third of doctors are intending to reduce their work hours within the next 12 months.

PCPs have higher burnout and lower pay than many specialties

Primary care is getting hit harder than most specialties, due to having lower salaries, higher ratings of burnout, and a growing feeling that their job is generally impossible and thankless on all fronts. According to a 2019 physician survey, the burnout scores among PCPs were up to 79%. Many hospitals are happy to replace PCPs with even lower-paid NPs and PAs, who do a good job with routine care but aren’t trained in subtleties and complexities, which come into play if you develop a challenging or rare medical condition, or if you have multiple medical comorbidities.

Multiple causes of primary care dissatisfaction

Many PCPs are facing requirements by their hospitals to see a greater number of patients, who get sicker and whose care gets more complicated every year, in the face of significant salary and benefit cuts and with dwindling administrative and clinical support. PCPs have more to do at each visit, as new requirements and treatments come up, but none of the work aimed toward preventive health seems to disappear, such as managing blood pressure and cholesterol, as well as discussing and providing hospital scheduling requests for health screenings like mammograms and colonoscopies.

Further, when patients are finally able to get in to see us in person, they have many more unaddressed problems and concerns because they often haven’t seen us for a year or two. This creates a vicious feedback cycle, with PCPs having ever-growing issues to address under a time pressure and patients having increasingly unmet medical symptoms and needs.

Time devoted to electronic medical records is further impacting burnout

It is estimated that for each hour a PCP spends with a patient, up to two hours of work are generated, which includes writing summary notes and treatment plans in a patient’s electronic medical record (EMR) and communicating test results or other important information to patients and their caregivers. Many PCPs that I know go home at the end of crushingly stressful days, spend an hour or two with their families, and then stay up late to finish all the computerized documentation that their day in clinic has generated. Many also have second jobs or side gigs to pay off their medical school debts.

What we are managing in today’s clinics is increasingly complicated and out of our control. As our entire health care system struggles, it is more difficult to get patients into the emergency department, into the hospital, and scheduled to see medical specialists. PCPs are left managing many things in the absence of the support that we are ordinarily used to.

We are also managing greater mental health needs and dealing with the brunt of our patients’ problems, such as lack of housing and employment, unaffordable medications, and widespread financial problems. The fact that we are unable to care for our patients nearly as well as we previously could is considered to be a “moral injury” that many of us are suffering. And there is research that when your doctor is struggling like this, the quality of your health care can suffer.

What can patients do to find a PCP?

If your current PCP quits or retires, ask the practice to assign you to someone new. In theory, practices aren’t supposed to leave patients stranded and abandoned, even if they, like many places, don’t truly have enough experienced physicians to take adequate care of patients. If that doesn’t work, or if you don’t feel that your new doctor is a good match for you, you can call your health insurance and see which doctors are accepting new primary care patients.

If you happen to have a friend who is a doctor or a nurse, perhaps they can advocate for you by asking a colleague to accept you into their practice. Our system shouldn’t work this way, but it often does. Most practices have waiting lists, so if you are without a PCP, put your name down, as late is better than never.

What might reverse the primary care crisis?

We need to train and financially support more PCPs by encouraging trainees to go into primary care, and to eliminate the pay gap between PCPs and specialists. We need to buttress those doctors who are currently trying to stick it out as primary care doctors, so they don’t cut down hours or quit. These doctors urgently need emotional, financial, logistical, and psychological support.

Finally, we need to cultivate in new doctors the magic of primary care, so eloquently spelled out by William Carlos Williams, so that people can, in fact, access the care that will enable them to live and enjoy the long and healthy lives they deserve.