Coping with the loss of smell and taste

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As I cut a slice of lemon for my tea one morning last March, I found that I could not detect the familiar zing of citrus. Nor, it turned out, could I taste the peach jam on my toast. Overnight, my senses of smell and taste seemed to have disappeared. In the days prior to that I’d had body aches and chills, which I ascribed to a late-winter cold — nothing, I thought, an analgesic and some down time couldn’t take care of. But later that day I saw a newspaper article about the loss of smell and taste in patients with COVID-19, and I realized that I’d likely caught the virus. While I was fortunate enough to eventually recover from it without a trip to the hospital or worse, months after testing negative for COVID, my senses of both smell and taste are still not fully recovered.

In this, I know, I’m hardly alone. According to US News and World Report, 86% of patients with mild to moderate COVID-19 — over six million people, all told — reported problems with their sense of smell, while a similar percentage had changes in taste perception. (Taste and smell work together to create the perception of flavor.) This is in addition to the 13.3 million Americans diagnosed with anosmia — a medical term for the loss of smell — related to other respiratory viruses, head injuries, and other causes. For many of us, improvement has been slow.

Loss of smell affects our health and quality of life

Our senses — smell, vision, hearing, taste, and touch — are bridges that connect us to the world we live in, to life itself. Knock out two of the five bridges, and 40% of our sensory input is gone. Senses add richness and texture to everyday life; they are intricately tied in with our emotions. The loss of smell or taste might not seem as drastic as the shortness of breath or debilitating fatigue that many other people have experienced post-COVID, yet the impact can still be quite demoralizing. You can no longer smell the familiar scent of your loved ones, or taste your favorite dish. Author and poet Diane Ackerman describes these special tastes and smells as “the heady succulence of life” itself.

The loss of smell and taste can also affect our health, causing poor appetite and undesired weight loss. No longer able to enjoy food, patients with anosmia may no longer eat enough, or skip meals altogether. It can even pose an existential threat, by putting us at risk in detecting fires, gas leaks, or spoiled food.

All these impacts help explain why recent studies have linked post-COVID anosmia to depression and anxiety. The jury is still out on whether this has to do with the loss of smell or taste per se — or with the impact of the virus on the central nervous system. One thing we know for sure, however: mood and sense of smell are intricately related. The 5,000-plus members of the Facebook group for post-COVID anosmia sufferers can attest to that. Feelings expressed in their posts run the gamut from mere wistfulness to full-blown grief.

Recovering from the loss

The good news is that olfactory neurons are capable of regeneration. The bad news is that not everyone will return to his or her pre-COVID level of functioning. And, sadly, some of us might never regain our sense of smell or taste at all. According to some experts, patients with post-viral loss of smell have roughly a 60% to 80% chance of regaining some of their smell function within a year. Since the sense of smell usually diminishes due to age, the recovery could take longer and be less than complete for older adults.

Savor what you can experience and engage the mind

To reawaken the olfactory nerves, most specialists recommend smell training, a daily routine of sniffing essential oils such as lemon, eucalyptus, cloves, rose, and others. If you suffer from olfactory loss, don’t be discouraged if some of the essences smell different from what you expected: distortions associated with the loss of smell (troposmia) are not uncommon.

The principle of mindfulness plays an important role here. If you cannot smell the essence at all, try and remember the smell; in other words, engage your mind in evoking the sensation. When eating, if you cannot taste the full range of flavors of a dish, pay attention to the basic ones — sweet, bitter, sour, salty, or umami — as well as to the food’s texture and the sensation on your palate. This will help you focus on what you still can taste, rather than on what you cannot. When I eat dark chocolate, for example, I can taste only the bitter and the sweet; for the flavor of the cacao bean, I still have to rely on my memory.

The old adage, “What doesn’t kill me makes me stronger,” acquires a fresh meaning when applied to the losses associated with COVID-19. These losses challenge us to become more mindful and self-aware, and ultimately, more resilient. We must also learn to be patient and appreciate incremental bits of progress. The other day, for the first time in months, I caught a whiff of citrus in my tea. Lemon never smelled so sweet.

Tips and coping strategies

In my practice with patients with post-COVID losses, and in my own recovery, I have found the following coping strategies helpful.

• Acknowledge your feelings about the loss.
• Consult with an ear, nose, and throat specialist for guidance.
• Consider adjusting your cooking in favor of spicier foods.
• Maintain hope for recovery.
• Cultivate a sense of gratitude: you have survived a potentially lethal disease.
• For additional help, see a counselor or join a support group.

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Early, tight control of Crohn’s disease may have lasting benefits

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The gastrointestinal (GI) tract is a remarkable organ: it resides on the inside of our bodies, but is regularly in contact with the outside world by virtue of what we ingest. It is quite incredible that the immune cells of the GI tract are not activated more regularly by the many foreign products it encounters every day. Only when the GI tract encounters an intruder that risks causing disease do the immune cells of the GI tract spring into action.

That is, of course, under normal circumstances. In people with Crohn’s disease, the normally tolerant immune cells of the GI tract are activated without provocation, and this activation leads to chronic or relapsing — but ultimately uncontrolled — inflammation.

Crohn’s disease: A primer

First described by Dr. Burrill B. Crohn and colleagues in 1932, Crohn’s disease is a complex inflammatory disorder that results from the misguided activity of the immune system. It can involve any part of the GI tract from the mouth to the anus, but most commonly involves the end of the small intestine.

Depending on the precise location of GI inflammation, Crohn’s disease may cause any number of symptoms including abdominal pain, diarrhea, weight loss, fever, and sometimes blood in the stool.

Treatment options for Crohn’s disease have evolved dramatically since Dr. Crohn and colleagues first described the condition, but the basic principle has remained the same: reduce the uncontrolled inflammation. Early approaches to treatment involved nonspecific anti-inflammatory medications such as corticosteroids, which have many potentially serious side effects outside the intestines.

Today, a number of newer therapies exist that act more specifically on the immune system to target inflammatory pathways known to be active in Crohn’s disease. These newer drugs, termed biologics, are antibodies that block proteins involved in specific inflammatory pathways relevant to Crohn’s disease. Since we don’t fully understand which pathways are involved in which patients, however, choosing a medication for a given patient is as much an art as it is a science.

Evidence grows for early, aggressive treatment of Crohn’s disease

Early approaches to treatment of Crohn’s disease followed a step-up algorithm in which the newer medications would only be used if the patient did not benefit from established therapies. This sequential approach — termed step therapy — has more recently been called into question, as studies have repeatedly shown that the newer drugs for Crohn’s disease are more effective than the old standards, and have preferable side effect profiles. Research also indicates that early, aggressive intervention and treatment, targeting not just symptoms but objective evidence of inflammation (as assessed through blood work, stool tests, imaging, and endoscopy), lead to better health and quality of life, at least in the short term.

Researchers recently published a study in the journal Gastroenterology on the longer-term benefits of treating Crohn’s patients to reduce both symptoms and inflammation. Specifically, they analyzed follow-up data from patients enrolled in the CALM study — a multicenter trial that compared two approaches to the treatment of early, moderate to severe Crohn’s disease. In the first approach, the decision to escalate therapy was based on symptoms alone; in the other approach, the decision was based on both symptoms and objective evidence of inflammation (found in blood work or a stool test, for example). This second approach is called tight control. A patient under tight control might feel well, but therapy would be escalated if there was objective evidence of inflammation. The primary end point of the original CALM study was healing the inflamed lining of the intestines, and the data showed that the tight control approach to treatment was more effective at reaching this goal.

The Gastroenterology study took the results of the original CALM study one step further. The researchers looked at how the patients who achieved healing of their intestinal lining are doing several years later. To this end, the researchers looked at the rates of various adverse outcomes (including the need for surgery and hospitalization for Crohn’s disease) in the CALM study patients since the trial ended.

They found that patients who were both feeling well and had demonstrated healing of the intestinal lining (called deep remission) had a significantly decreased risk of Crohn’s disease progression. Healing of the intestinal lining without feeling well, and feeling well without healing of the intestinal lining, were also associated with a lower risk of disease progression when compared to patients with active symptoms and inflammation, but to a lesser extent.

Study findings may not generalize to many Crohn’s disease patients

The recent study lends strength to a growing body of evidence in support of a treatment approach that emphasizes early intervention aimed at healing the lining of the intestines and resolving symptoms. Can we generalize the findings to most patients with Crohn’s disease? Not necessarily.

Enrolled patients had never been treated with a newer biologic drug, or with a drug called an immunomodulator that affects the way the immune system functions, before enrolling in the CALM study. Immunomodulators have been used to treat inflammatory bowel disease (IBD) since the 1960s, and they are often one of the first drug classes used for treatment of IBD. As a result, these study results may not generalize to the many people who have had a Crohn’s diagnosis for long enough to have already been treated with an immunomodulator.

Furthermore, those who received escalation of therapy were treated with increasingly optimized doses of a single biologic, adalimumab (Humira). It remains to be seen whether we would see the same results in patients already exposed to a biologic or with the use of another biologic.

Doctor-patient collaboration is critical for successful Crohn’s treatment

In my practice, I regularly encourage using highly effective therapies early to pursue tight control. For some, the decision to follow this approach is easy. For others, the idea of escalating therapy, perhaps in the absence of symptoms, and to target something they may not feel, is more difficult to be convinced of. Concerns about side effects and the need for frequent monitoring are paramount among the roadblocks.

Collaborating with my patients so that they can make medical decisions that are in line with their values but still informed by evidence is critical for success, as is a commitment to regularly revisit and rethink the approach over time.

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The tragedy of the post-COVID “long haulers”

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Suppose you are suddenly are stricken with COVID-19. You become very ill for several weeks. On awakening every morning, you wonder if this day might be your last.

And then you begin to turn the corner. Every day your worst symptoms — the fever, the terrible cough, the breathlessness — get a little better. You are winning, beating a life-threatening disease, and you no longer wonder if each day might be your last. In another week or two, you’ll be your old self.

But weeks pass, and while the worst symptoms are gone, you’re not your old self — not even close. You can’t meet your responsibilities at home or at work: no energy. Even routine physical exertion, like vacuuming, leaves you feeling exhausted. You ache all over. You’re having trouble concentrating on anything, even watching TV; you’re unusually forgetful; you stumble over simple calculations. Your brain feels like it’s in a fog.

Your doctor congratulates you: the virus can no longer be detected in your body. That means you should be feeling fine. But you’re not feeling fine.

The doctor suggests that maybe the terrible experience of being ill with COVID-19 has left you a little depressed, or experiencing a little PTSD. Maybe some psychiatric treatment would help, since there’s nothing wrong with you physically. You try the treatment, and it doesn’t help.

How common are lingering COVID symptoms?

Tens of thousands of people in the United States have such a lingering illness following COVID-19. In the US, we call them post-COVID “long haulers.” In the United Kingdom, they are said to be suffering from “long COVID.”

Published studies (see here and here) and surveys conducted by patient groups indicate that 50% to 80% of patients continue to have bothersome symptoms three months after the onset of COVID-19 — even after tests no longer detect virus in their body.

Which lingering symptoms are common?

The most common symptoms are fatigue, body aches, shortness of breath, difficulty concentrating, inability to exercise, headache, and difficulty sleeping. Since COVID-19 is a new disease that began with an outbreak in China in December 2019, we have no information on long-term recovery rates.

Who is more likely to become a long hauler?

Currently, we can’t accurately predict who will become a long hauler. As a recent article in Science notes, people only mildly affected by COVID-19 still can have lingering symptoms, and people who were severely ill can be back to normal two months later. However, continued symptoms are more likely to occur in people over age 50, people with two or three chronic illnesses, and people who became very ill with COVID-19.

There is no formal definition of the term “post-COVID long haulers.” In my opinion, a reasonable definition would be anyone diagnosed with the coronavirus that causes COVID-19, or very likely to have been infected by it, who has not returned to their pre-COVID-19 level of health and function after six months.

Long-haulers include two groups of people affected by the virus:

• Those who experience some permanent damage to their lungs, heart, kidneys, or brain that may affect their ability to function.
• Those who continue to experience debilitating symptoms despite no detectable damage to these organs.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, has speculated that many in the second group will develop a condition called myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). ME/CFS can be triggered by other infectious illnesses — such as mononucleosis, Lyme disease, and severe acute respiratory syndrome (SARS), another coronavirus disease. The National Academy of Medicine estimates there are one million to two million people in the US with ME/CFS.

Dr. Tedros Ghebreyesus, director of the World Health Organization, also has expressed growing concern about the chronic illnesses that may follow in the wake of COVID-19, including ME/CFS.

What might cause the symptoms that plague long haulers?

Research is underway to test several theories. People with ME/CFS, and possibly the post-COVID long haulers, may have an ongoing low level of inflammation in the brain, or decreased blood flow to the brain, or an autoimmune condition in which the body makes antibodies that attack the brain, or several of these abnormalities.

The bottom line

How many people may become long haulers? We can only guess. Right now, more than seven million Americans have been infected by the virus. It’s not unthinkable that 50 million Americans will ultimately become infected. If just 5% develop lingering symptoms, and if most of those with symptoms have ME/CFS, we would double the number of Americans suffering from ME/CFS in the next two years. Most people who developed ME/CFS before COVID-19 remain ill for many decades. Only time will tell if this proves true for the post-COVID cases of ME/CFS.

For this and many other reasons, the strain on the American health care system and economy from the pandemic will not end soon, even if we develop and deploy a very effective vaccine by the end of 2021.

Virtually every health professional I know believes that the pandemic in the US could and should have been better controlled than it has been. Bad mistakes rarely lead to only temporary damage.

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Stopping osteoarthritis: Could recent heart research provide a clue?

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Here’s a recent headline that I found confusing: Could the first drug that slows arthritis be here?

It’s confusing because it depends on which of the more than 100 types of arthritis we’re discussing. We’ve had drugs that slow rheumatoid arthritis for decades. In fact, more than a dozen FDA-approved drugs can reduce, or even halt, joint damage in people with rheumatoid arthritis. We also have effective medications to slow or stop gout, another common type of arthritis.

But the headline refers to osteoarthritis, the most common type of arthritis. And currently, no medications can safely and reliably slow the pace of this worsening joint disease. That’s one reason so many knee and hip replacements are performed: more than 1.2 million each year in the US alone.

A drug that can slow down joint degeneration in osteoarthritis has long been the holy grail of arthritis treatments, because it could

• relieve pain and lessen suffering for millions of people
• help prevent the loss of function that accompanies osteoarthritis
• reduce the need for surgery, along with its attendant risks, expense, and time needed for recovery.

And, needless to say, such a drug would generate enormous profits for the pharmaceutical company that comes up with it first.

A study of heart disease might have identified a new treatment for osteoarthritis

According to new research published in Annals of Internal Medicine, it’s possible that such a treatment exists, and is already in use to treat other conditions. The researchers reanalyzed data on more than 10,000 people that originally looked at whether the drug canakinumab was beneficial for people with a previous heart attack — yes, heart attack, not arthritis.

Canakinumab inhibits interleukin-1, a substance closely involved with inflammation. And increasing evidence suggests that inflammation raises risk for cardiovascular disease, and may predict future cardiovascular trouble. All study participants had previously had a heart attack. Additionally, they had an elevated blood C-reactive protein (CRP) level, an indicator of inflammation in the body.

Every three months, each person received an injection of one of several doses of either canakinumab or a placebo. Canakinumab appeared to work for heart disease: those receiving the 150-mg dose of canakinumab had significantly fewer cardiovascular complications (repeat heart attack, stroke, or cardiovascular death) over about four years. Unfortunately, there was also a higher rate of fatal infections in the canakinumab-treated subjects.

Another look at this study of canakinumab

The reanalysis compares rates of hip or knee replacement due to osteoarthritis in those receiving canakinumab with rates among those who received a placebo. The study authors thought that since canakinumab reduces inflammation, it might help the inflammation found in the joints of people with osteoarthritis while also offering cardiovascular benefits.

Osteoarthritis has long been considered a wear-and-tear, age-related, and non-inflammatory form of joint disease. But over the last decade or so, research has demonstrated that some degree of inflammation occurs in osteoarthritis. So it’s not too much of a stretch to think a drug like canakinumab might be effective for osteoarthritis. This drug is already approved for a number of inflammatory conditions, including certain forms of pediatric arthritis.

The results of this new study surprised me: over about four years, those receiving canakinumab were at least 40% less likely to have a hip or knee replacement than those receiving placebo.

Warning: These results are preliminary

Before declaring victory over osteoarthritis with canakinumab treatment, it’s important to acknowledge that this trial doesn’t prove it actually works. That’s because the trial

• was not a treatment trial of people with osteoarthritis. More than 80% of participants had no history of osteoarthritis.
• did not compare x-rays or other imaging tests before and after treatment to confirm the diagnosis of osteoarthritis, or demonstrate that treatment slowed its progression
• did not assess whether joint pain was present before treatment or improved after treatment. It’s possible that the reason there were fewer joint replacements among people taking canakinumab is that the medication reduced pain, rather than slowing joint damage. Perhaps the medication can delay the need for joint replacement by reducing symptoms without slowing progression of joint damage.
• lasted about four years. The results could have been different if it had lasted longer.
• only included people who had prior heart attack and an elevated CRP. The results may not apply to people who have no history of cardiovascular problems or a normal CRP.

To learn whether canakinumab actually can slow osteoarthritis, we need a proper trial that enrolls people with osteoarthritis, and compares symptoms and x-rays after treatment with canakinumab or placebo.

Canakinumab is expensive, nearly $70,000/year (though discounts, insurance coverage, and copays vary), and only available by injection. It’s not clear how many people with osteoarthritis would accept such treatment. If it is proven highly effective at preventing the need for joint replacement surgery, its high cost might be easier to accept.

The bottom line

We need definitive information about the potential of canakinumab or related drugs to treat osteoarthritis and slow its progression. Until then, it’s unlikely to become a common option.

If you have osteoarthritis of the knees or hips, talk to your doctor about your options, including maintaining a heathy weight, staying active, and taking pain relievers as needed. Some people improve with walking aids (such as a cane) or knee braces (for knee arthritis). Joint replacement surgery can be considered as a last resort.

As for new treatments that can slow the progression of osteoarthritis, we should be hopeful. But we’re not there yet.

Follow me on Twitter @RobShmerling

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Stress and the heart: Lessons from the pandemic

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The effects of COVID-19 have been extensive, with more than seven million confirmed cases and more than 200,000 deaths in the US alone. COVID-19 has caused additional impacts on healthcare; for example, patients have delayed seeking care for serious symptoms over fears of exposure to COVID-19. But the consequences of COVID-19 have reached beyond healthcare alone, with daily impacts on our financial, social, and emotional well-being.

As we attempt to cope and settle into this new normal, we will learn about the long-term effects of these hardships. Doctors have already begun to study the effects of COVID-related stress and anxiety on people around the world.

Physical effects of stress

Stress can have real physical effects on the body, and it has been linked to a wide range of health issues. Stress directly activates our sympathetic nervous system, initiating a fight-or-flight response that can elevate blood pressure and blood sugar. Though potentially useful in the short term from an evolutionary standpoint, stress can worsen hypertension and diabetes when it occurs chronically. Stress can disrupt our sleep, and can lead us to make unhealthy food choices, as we seek comfort foods or abandon portion control.

A recent study suggests that stress due to the pandemic may already be affecting our heart health.

The link between stress and heart health

Stress cardiomyopathy, also called Takotsubo cardiomyopathy and broken-heart syndrome, is a cardiac disorder characterized by a sudden onset of chest pain and heart dysfunction that mimics a heart attack. But, in contrast with what is seen during a heart attack, doctors are unable to find evidence of a blood clot or abnormalities with cardiac blood flow.

Typical stress cardiomyopathy patients are postmenopausal women experiencing sudden onset of chest pain and shortness of breath. The link between stress and stress cardiomyopathy is well documented; patients with stress cardiomyopathy often experience emotional or physical stress in the week preceding their illness. The exact mechanism of this reaction is not clearly understood, but researchers have found changes in blood flow to the brain and in signaling of stress-related hormones.

Emotional triggers of stress cardiomyopathy include death of a spouse or family member, divorce or interpersonal conflict, and natural disasters such as earthquakes and floods. It stands to reason that living with the chronic stress of a global pandemic could also trigger this syndrome.

Pandemic-related stress is already affecting heart health

A recent study published in JAMA Network Open attempted to measure the effect of COVID-19-related stress on our health by looking at the prevalence of stress cardiomyopathy during the pandemic. The researchers compared the incidence of stress cardiomyopathy during the COVID-19 pandemic (March 1 to April 30, 2020) to the incidence of stress cardiomyopathy during three prior periods (in 2018, 2019, and earlier in 2020). Importantly, all patients included in the study tested negative for COVID-19.

Researchers found that there was a significant rise in stress cardiomyopathy during the COVID-19 period, with stress cardiomyopathy occurring more than four times as often as usual during March and April 2020.

Fortunately, heart function typically recovers over one to two weeks in people with stress cardiomyopathy, and prognosis is generally good. However, affected patients do have an increased risk of recurrence.

Take steps to manage stress

This study is a cautionary tale regarding the impact of stress. It serves as a good reminder that we should all strive to minimize stress, even in these trying times, and improve how we handle it. Some practical tips for managing stress including choosing healthy foods, exercising regularly, getting enough sleep, and staying connected with friends and family.

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Why is music good for the brain?

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Can music really affect your well-being, learning, cognitive function, quality of life, and even happiness? A recent survey on music and brain health conducted by AARP revealed some interesting findings about the impact of music on cognitive and emotional well-being:

• Music listeners had higher scores for mental well-being and slightly reduced levels of anxiety and depression compared to people overall.
• Of survey respondents who currently go to musical performances, 69% rated their brain health as “excellent” or “very good,” compared to 58% for those who went in the past and 52% for those who never attended.
• Of those who reported often being exposed to music as a child, 68% rated their ability to learn new things as “excellent” or “very good,” compared to 50% of those who were not exposed to music.
• Active musical engagement, including those over age 50, was associated with higher rates of happiness and good cognitive function.
• Adults with no early music exposure but who currently engage in some music appreciation show above average mental well-being scores.

Let’s take a closer look at this study

Those are pretty impressive results, to be sure. However, this 20-minute online survey has some limitations. For one, it included 3,185 US adults ages 18 and older; that is a small number if you are extrapolating to 328 million people across the country. For another, it is really a survey of people’s opinions. For example, although people might report their brain health as “excellent,” there was no objective measure of brain health such as an MRI scan, or even a test to measure their cognition.

Lastly, even if the ratings were true, the findings are only correlations. They do not prove that, for example, it was the exposure to music as a child that led to one’s improved ability to learn new things. It may be equally likely that those children brought up in more affluent households were both more likely to be exposed to music and to be given a good education that led to their being able to easily learn new things later in life.

But let’s assume that the results of the AARP survey are indeed true. How can music have such impressive brain effects? Although we don’t know the answers for sure, developments in cognitive neuroscience over the last few years have allowed us to speculate on some possible mechanisms.

Music activates just about all of the brain

Music has been shown to activate some of the broadest and most diverse networks of the brain. Of course, music activates the auditory cortex in the temporal lobes close to your ears, but that’s just the beginning. The parts of the brain involved in emotion are not only activated during emotional music, they are also synchronized. Music also activates a variety of memory regions. And, interestingly, music activates the motor system. In fact, it has been theorized that it is the activation of the brain’s motor system that allows us to pick out the beat of the music even before we start tapping our foot to it!

Use it or lose it

Okay, so music activates just about all of the brain. Why is that so important? Well, have you ever heard the expression, “If you don’t use it, you’ll lose it”? It turns out this is actually true in the brain. Brain pathways — and even whole networks — are strengthened when they are used and are weakened when they are not used. The reason is that the brain is efficient; it isn’t going to bother keeping a brain pathway strong when it hasn’t been used in many years. The brain will use the neurons in that pathway for something else. These types of changes should be intuitively obvious to you — that’s why it is harder to speak that foreign language if you haven’t used it in 20 years; many of the old pathways have degraded and the neurons are being used for other purposes.

Music keeps your brain networks strong

So just how does music promote well-being, enhance learning, stimulate cognitive function, improve quality of life, and even induce happiness? The answer is, because music can activate almost all brain regions and networks, it can help to keep a myriad of brain pathways and networks strong, including those networks that are involved in well-being, learning, cognitive function, quality of life, and happiness. In fact, there is only one other situation in which you can activate so many brain networks all at once, and that is when you participate in social activities.

Dance the night away

How do you incorporate music into your life? It’s easy to do. Although the AARP survey found that those who actively listened to music showed the strongest brain benefits, even those who primarily listened to background music showed benefits, so you can turn that music on right now. Music can lift your mood, so put on a happy tune if you are feeling blue. Uptempo music can give you energy. And if you combine music with an aerobic and social activity, you can receive the maximum health benefit from it. Participate in a Zumba class. Do jazz aerobics. Jump to the rhythms of rock & roll. Or, better yet, go dancing. (And yes, in a pandemic, you can still benefit by doing these activities virtually.)

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As family well-being declines, so does children’s behavior

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The COVID-19 pandemic is bad not only for our physical health, but our mental health as well. It has killed thousands of people and disrupted our lives in terrible ways. So it’s not surprising that a recent survey finds that parents in the US are having a hard time.

Researchers did a national survey in June of 2020 of more than 1,000 parents with children under the age of 18, asking questions about mental health, insurance coverage, food security, child care, and use of health care. They found that compared to before March of 2020,

• 27% reported worsening mental health for themselves
• 17% reported worsening behavioral health for their children
• Moderate to severe food insecurity rose by a third, going from 6% to 8%
• Employee-sponsored health care went down only slightly, from 63% to 60%
• 24% reported loss of child care; however, among families with children 5 or younger, it was closer to 50%. Among those who lost childcare, the majority (74%) reported that a parent was watching the child instead. Obviously, this has implications for that parent’s ability to work.
• 40% reported cancellations or delays in their child’s health care, most commonly well-child care but also specialty and behavioral health care.

Connections to mental and behavioral health

One in 10 families reported worsening mental health for themselves as well as worsening behavioral health for their children. Among those who reported that both were happening, 48% reported loss of regular child care, 16% reported a change in health insurance status, and 11% had worsening food security. Clearly, these families have been hard-hit by the economic effects of the pandemic.

Interestingly, rates of mental health problems were similar across parents of different races and incomes. However, two groups of parents had worse declines in their mental health: female and unmarried parents; and families with younger children.

This survey was done before parents had to manage the implications of a new school year, which is going to bring new stress, especially as it appears that many if not most school systems will be providing at least some of their instruction remotely. Parents again are going to have to juggle working with not just caring for their child, but being sure that they are doing — and understanding — their remote schoolwork. For many families, this is essentially impossible.

It’s also important to remember that compared to families without children, families with children are more likely to be poor — and with job losses continuing and a predicted epidemic of evictions, poor families are going to have even bigger difficulties with basic needs such as food and housing.

The implications of this are staggering. It’s not just short-term homelessness and hunger we have to worry about — it’s the long-term educational, psychological, and health effects on children. This pandemic could quite literally change the course of millions of lives for the worse.

Responding to growing needs

So what can we do? Clearly, as a country we need to devote real financial resources to helping families with children, especially single-parent families and families with young children. That’s the biggest and most immediate need, and will require action from not just government but every possible source of funding.

We also need to devote resources to mental health support, making sure that anyone who needs it can get it. This won’t be cheap either, but the cost will be higher in so many ways if we don’t.

We need to find ways to look out for each other. At this moment when we need to be physically distant to prevent spread of the virus, we also need to be connected. We need to find safe ways to check in with members of our communities. That might be regular phone calls or socially distant check-ins with at-risk families, contributing to food pantries and clothing drives, volunteering to do online tutoring, donating to organizations that are helping families, and anything else that can make a difference.

Part of looking out for each other is doing everything we can to stop the spread of the virus. Along with lots of hand washing, that means that everyone over the age of 2 should wear a mask when they can’t physically distance — and that we must take physical distancing truly seriously. If we let our guard — or our mask — down, we will prolong the pandemic, with everything that means.

We need each other, more than ever.

Follow me on Twitter @drClaire

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How to cope when a loved one is depressed, suicidal, or manic

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If you aren’t sure how to cope when a loved one is depressed, suicidal, or manic, it may be time to learn.

The number of people reporting depression symptoms shot up when the pandemic began, with a recent study suggesting depression tripled among Americans this past spring. The greater burden fell on people with fewer resources, socially and economically, and more exposure to stressful situations, such as job loss. Ongoing surveys are finding that 25% of respondents still report feeling depressed every day.

These kinds of struggles are heart-wrenching to witness. The following suggestions can help you both.

Ways to help care for a loved one in distress

• Encourage your loved one to get treatment and stick with it. Ask if you can help arrange an in-person or telehealth appointment with a therapist. Gently remind your loved one about taking medication or keeping therapy appointments.
• Don’t ignore comments about suicide. If you believe your loved one is suicidal, call the person’s doctor or therapist. Mental health professionals can’t divulge patient information without permission, but it is not a violation of confidentiality for the professional to listen to you. In urgent situations, bring your loved one to a local ER or call a local or national crisis hotline for advice. You can also try a suicide prevention text hotline. For example, you can contact the hotline provided by the National Alliance on Mental Illness by texting “NAMI” to 741741.
• Offer emotional support. Your patience and love can make a huge difference. Ask questions and listen carefully to the answers. Try not to brush off or judge the other person’s feelings, but do offer hope. Suggest activities that you can do together, and keep in mind that it takes time to get better. Don’t worry if you don’t know what to say — it takes a great deal of training (such as that received by therapists) to advise people in emotional distress.
• Recognize that depression may manifest as irritability or anger, which is often directed toward family and other loved ones. Remind yourself that a disease is causing your loved one to act differently. Try not to blame the person who is struggling — after all, you wouldn’t place blame if a physical illness was causing the person to change.
• If a loved one has bipolar disorder, try to prevent reckless acts during manic episodes. It’s common for a person to make poor decisions when manic, so it’s a good idea to try to prevent this problem by limiting access to cars, credit cards, and bank accounts. Watch for signs that a manic episode is emerging. Disruption of sleep patterns can trigger an episode, so support your loved one in keeping a regular sleep schedule. Consistent patterns for other activities such as eating, exercising, and socializing may also help.

Take good care of yourself

Finally, remember to pay attention to your own well-being. Consider therapy for yourself, or join a support group. This is a crucial step to lessen your own risk for depression, because caregivers have high rates of depression and anxiety. Other forms of self-care can be very helpful, too.

Numerous mental health organizations sponsor such groups and can also provide you with information on the illness, the latest treatments, and coping tips. With encouragement, knowledge, and support, you’ll feel stronger and more empowered to help shepherd your loved one through this difficult illness.

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Treating mild hypothyroidism: Benefits still uncertain

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Your thyroid, a tiny, butterfly-shaped gland located in front of your windpipe (trachea) and below your voice box (larynx) can have a profound impact on your health and well-being. Throughout life, your thyroid is constantly producing hormones that influence your metabolism. These hormones affect your mood, energy, body temperature, weight, heart, and more.

A brief overview of hypothyroidism

Your thyroid produces two kinds of thyroid hormones: T4, or thyroxine, and T3, or triiodothyronine. These hormones influence every cell, tissue, and organ in your body, from your muscles, bones, and skin to your digestive tract, brain, and heart, by controlling how fast and efficiently cells convert nutrients into energy — a chemical activity known as metabolism.

The thyroid gland is under the influence of the pituitary gland. No larger than a pea and located at the base of the brain, the pituitary gland controls your thyroid’s production of thyroid hormone by releasing thyroid stimulating hormone (TSH).

TSH levels in your bloodstream rise or fall depending on whether there is enough thyroid hormone made to meet your body’s needs. Higher levels of TSH prompt the thyroid to produce more thyroid hormone, while lower levels signal the thyroid to produce less.

Hypothyroidism occurs when the thyroid fails to produce enough thyroid hormone to meet the body’s needs, thereby slowing metabolism. In someone with overt hypothyroidism, thyroid hormone levels are below normal and TSH levels are well above the normal range.

What is mild hypothyroidism?

Subclinical, or mild, hypothyroidism doesn’t meet the standard definition of hypothyroidism. In mild hypothyroidism, you may or may not have symptoms and your levels of T4 and T3 are normal, but your TSH levels are slightly elevated. Mild hypothyroidism is diagnosed by a blood test.

More than 10 million adults in the US have hypothyroidism, the vast majority of which is subclinical.

What are the risks of leaving mild hypothyroidism untreated?

Whether or not to treat mild hypothyroidism is a subject that has been studied and debated for years. What worries doctors most about mild hypothyroidism is the potential link between untreated mild hypothyroidism and coronary artery disease. Results of research on whether subclinical thyroid disease causes heart problems have been conflicting. The condition has been associated with heart and blood vessel abnormalities, and studies indicate that treating mild hypothyroidism can improve various markers of heart structure and function.

However, a recent study published in the Journal of the American Medical Association may give doctors pause. The researchers studied people with mild hypothyroidism who had also had a heart attack. They treated one group of these patients for their mild hypothyroidism, and left the condition untreated in the other group. The study showed that those treated for mild hypothyroidism did not have better heart function than those who were not treated.

What are the downsides of treating mild hypothyroidism?

When mild hypothyroidism is treated, levothyroxine (T4) is the treatment of choice.

A 2017 trial published in The New England Journal of Medicine found that treating people ages 65 and older for mild hypothyroidism doesn’t have much of a benefit. The authors found no real differences in symptoms between participants who received levothyroxine and those who got a placebo. The authors say many older adults revert to normal thyroid function on their own, without treatment. A follow-up study recently published in the Annals of Internal Medicine analyzed data from patients enrolled in the 2017 NEJM study, and determined that even those with the greatest number of symptoms did not benefit.

In addition to the possibility that the treatment may not offer any benefit, there are other reasons for caution. Overtreatment — prescribing thyroid medication to someone with subclinical disease who may not need treatment, or giving excessive thyroid medication — comes with serious risks, particularly thyrotoxicosis, the presence of too much thyroid hormone in the body. This happens frequently; estimates suggest 20% or more of those treated with thyroid hormone experience thyrotoxicosis. Long-term complications of even mild thyrotoxicosis can include heart problems and bone loss.

Considering the risks and benefits of treatment

If you are weighing the pros and cons of treatment for hypothyroidism, discuss the following questions with your doctor:

• How might I benefit from treatment? Could it treat my symptoms? Prevent heart disease? Help me conceive?
• What are the risks of treatment?
• How will we know if treatment is working, and how long will it take to determine this?
• For how long will I need to continue treatment?

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Managing the new normal: Actively help your family weather the pandemic

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When the pandemic first began earlier this year, it seemed like if we could just hunker down until perhaps summer, things would get better and we’d be able to get back to life as usual (or at least something similar to life as usual). We were in survival mode: we cut corners and made do, broke some parenting rules, and otherwise made choices we would never usually make. Because that’s what you do when you are in survival mode.

It’s now very clear that the pandemic is here for at least this school year, and survival mode is taking on a whole new meaning. It’s time to make new habits and routines specifically for the pandemic. It’s time to make better and more durable choices that can help keep us healthier — and happier.

Some things obviously aren’t about choices. If you have lost loved ones, are struggling financially, are living in a dangerous situation, or if you or anyone in your family is having thoughts of self-harm, please reach out for help. Your doctor may be able to direct you to resources in your community.

What I am talking about is practical, daily life choices that we can make in a different way that may help us feel and live better. Be proactive — and do it as a group activity with your partner and family, so that everyone feels heard and invested.

Identify the pain points and tackle those first

Think about the past few months, and literally make a list of everything that was particularly hard. Lack of structure? Too much screen time for everyone? Problems getting kids to do their remote work? Problems getting your own remote work done? Feeling isolated from friends and family?

Work together to come up with ideas to tackle these pain points. They might include:

• Clear daily routines (use something like a white board so that all are on the same page). Along with those routines, have rules about screen time limits.
• For those doing remote work or remote school, create spaces they can use that approximate school or work spaces (no school from bed, for example).
• Come up with some non-screen activities for all of you. Books with pages, for example. Blocks for kids, arts and crafts, dollhouses, and other things that spur imagination.
• Set up regular remote contact with friends and family that you haven’t seen. Consider widening your “bubble” to include some select friends and family that you trust to be safe and take precautions.
• If you have a partner, work out the division of labor in a way that feels fair to both of you.

Identify activities that make you happy, and build them in too

We really need this now; it is crucial, not optional. We need to be deliberate in this. Identify both things that people can do alone, and things that you can do together, and make them part of your routines. Maybe it’s some alone time for each of the adults, a date night (light some candles at a table after the kids go to sleep and put your phones aside), a family game night, some daily silliness… whatever makes you smile, build it in.

Identify ways to become healthier, both physically and mentally

This too is crucial; it’s not something we can put aside anymore. For example:

• Be sure everyone is getting enough sleep (at night, not during the day, unless someone works a night shift).
• Eat healthy foods. I know, pandemics seem to justify comfort food. But too much cookies, ice cream, and chips catch up with you eventually, and start to make you feel bad instead of good.
• Get exercise. Every day is best, but do it at least five times a week — and make sure everyone in the family does it. It could literally be dancing in the kitchen, or a YouTube exercise video. If you can get outside, even for a short walk, all the better — we need to be places that don’t have ceilings sometimes.
• Be mindful of your alcohol and other substance use. That little bit to “take the edge off” can be a slippery slope.
• Build in time for communication with each other. It could be as simple as device-free family dinner and at least one device-free check-in with your partner.
• Reach out to your doctor if you or anyone in your family is feeling particularly sad or anxious. There are many resources available. Lots of counselors offer virtual sessions. Don’t wait, hoping things will get better. They may only get worse, and at the very least will get better with help.

We will make it through this. The choices we make today will make all the difference in who and how we are when we emerge — so let’s make them proactively, wisely, and with kindness.

Follow me on Twitter @drClaire

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Lifestyle medicine for all: Healthy food comes first

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“Lifestyle medicine is only for rich people, right?” a colleague asked me several years ago, questioning my involvement in this relatively new field of medicine that guides people toward healthy habits. This has been a common misperception, for sure.

But across the US, a revitalized brand of health activism is intent on bringing lifestyle medicine to a broader range of people. This is backed by a new effort from the American College of Lifestyle Medicine to engage communities most affected by chronic disease.

The first pillar of healthy lifestyle: Food is medicine

Lifestyle medicine is an evidence-based practice of helping people adopt and sustain healthy behaviors like improving diet, increasing activity, managing stress, sleeping well, moderating alcohol consumption, and quitting tobacco. Large studies show such habits can extend our lives by well over a decade. What’s more, these habits can even keep these extra years free of diseases like diabetes, heart disease, strokes, and cancer.

Eating a plant-based diet — meaning a diet rich in vegetables, fruits, beans and legumes, nuts and seeds, and whole grains — can lower inflammation, as well as the risk of many chronic diseases such as diabetes, heart disease, strokes, and cancer. Simply put, food is medicine. Some doctors are providing this information to patients as part of their regular medical care.

But many people do not have easy access to healthy plant foods. Especially now, they may be suffering from significant financial limitations, unemployment, and unstable housing. Or they may live in a “food desert,” where grocery options are severely limited, or worse, a “food swamp,” an area where fast food and junk food are more available than anything else. Living in a food swamp puts people at a higher risk of becoming overweight or obese.

Ways to help change the equation

Helping patients access healthy plant foods is critically important. And some doctors and academic medical centers are taking action to bring healthy foods to underserved communities.

Food pantries. Dr. Jacob Mirsky is a physician at Massachusetts General Hospital and co-director of the department of medicine’s Healthy Lifestyle Program. He works in an underserved community north of Boston, where he directs his clinic’s new plant-based food pantry. When he prescribes a plant-predominant diet to his patients, he also is able to provide the plants. He views this work as activism and a potent way to address inequalities while also taking care of his patients.

Plant-based food pantries and food prescription programs have been positively received by communities. One such program in a rural, low-income area of Texas provided 30 pounds of fresh produce to households identified as food-insecure — meaning they did not have enough food to eat — every two weeks for six months. Participants described the program as critical for helping them feed their families, and 99% reported that they consumed all or almost all of the food they received.

Education and support. Dr. Michelle McMacken is an assistant professor of medicine at New York University’s Grossman School of Medicine, and director of the Plant-Based Lifestyle Medicine Program at NYC Health and Bellevue Hospital. She is working to make lifestyle medicine services available to as many patients as possible, regardless of socioeconomic status.

“I believe everyone deserves access to lifestyle medicine, especially the highest-risk, most vulnerable patients who potentially stand to benefit the most,” she says. “The majority of my patients — including those facing significant socioeconomic challenges — want to learn what they can do to become healthier. We collaborate to figure out how they can leverage lifestyle medicine within their own situation.”

Despite challenging circumstances, she has seen patients achieve health transformations, including weight loss and improved cholesterol and blood sugar levels.

Programs that educate people about the power of plant foods can have a big impact. A study of 32 Latinx people with type 2 diabetes living in a medically underserved area of California offered a five-week program introducing participants to the power of plant foods. Declines in blood sugar continued even six months after that program had ended.

Connecting people and food. The Family Van is a longtime mobile health program supported by Harvard Medical School that provides free education, resources, and some clinical services to anyone, regardless of insured status. A large part of what they do is help people access nutritional support through SNAP (Supplemental Nutrition Assistance Program) and locate low-cost produce sources like The Fresh Truck and The Daily Table. They also will provide grocery gift cards along with their healthy diet counseling. The Family Van has been collecting data such as body mass index, blood pressure, blood sugars, and ore for over a decade, and has published several papers showing that such interventions work.

Programs like these are essential and wonderful, but there is a lot more work to be done. In our Healthy Lifestyle Program at Massachusetts General Hospital, we hope to establish the practice of healthy lifestyle as the standard of care for preventing and treating chronic disease for all of our patients. To do this, we are developing practical, accurate methods to assess clinically important diet and lifestyle factors at every patient’s physical exam. At the same time, we’re studying evidence-based approaches to help people eat and live healthier, including our plant-based food pantry, health coaching, and web-based group education classes. We hope that in the future, every one of our patients will have access to the quality information, resources, and support that they need to live their healthiest life.

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Shorter dream-stage sleep may be related to earlier death

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Time and time again, adequate sleep has been shown to be critical to daily functioning and long-term health. Sleep serves numerous roles: recovering energy for the brain, clearing waste products, and forming memories. Prior studies have clearly linked shortened sleep times to heart disease, obesity, reduced cognitive performance, worsened mood, and even a shorter life. There is now new research that suggests that lack of a certain type of sleep (the dream stage of sleep) may be related to an earlier death in middle-aged and older people.

What is REM sleep?

Normal sleep is broken down into two sleep types: rapid eye movement (REM) and non-rapid eye movement (NREM). NREM is further classified by depth of sleep; N1 and N2 are lighter sleep stages, and N3 is deep sleep, which is most restorative. (REM is the stage where vivid dreaming occurs.) Brainwave activity during this time appears similar to the brain’s activity while awake. REM periods generally occur every 90 minutes, and are longest during the second half of the night. REM sleep normally makes up 20% to 25% of sleep time.

How does sleep change with age?

Sleep time and sleep stages naturally change as we age. Total sleep time decreases by 10 minutes every decade until age 60, when it stops decreasing. Time in N3 sleep, the deepest sleep stage, also shortens with age; time in N1 and N2 tends to increase. As a result, people wake more easily from sleep as they age. The percentage of REM sleep also naturally decreases; thus, reduced time spent in REM may be a marker of aging.

The circadian rhythm is a 24-hour internal clock that governs numerous body functions including body temperature, release of hormones, and sleep time. The internal clock “advances” with age, so older adults tend to fall asleep earlier and wake earlier. Adapting to jet lag and shift work becomes more difficult. Daytime napping also increases as the strength of the circadian rhythm and the drive to sleep at night decrease.

Studies have also shown that older adults who are healthy may not perceive problems with sleep when it is actually impaired, or may assume that certain disruptions are part of aging when they have treatable conditions.

Why would less sleep increase my risk of death?

In the short term, sleep deprivation increases cortisol levels, causes increased blood pressure, decreases glucose tolerance, and increases the activity of the body’s fight-or-flight system, all of which are linked to increased risk of diabetes, heart attacks, and strokes. Daytime cognitive performance is also reduced, resulting in more accidents. Twenty-four hours of sustained wakefulness impairs driving ability to the same degree as a blood alcohol concentration of 0.10%, which is above the legal limit.

In the long term, both short and long sleep (less than five hours or more than nine hours) have been associated with earlier death. People who sleep less than four hours dramatically increase their risk of dying early, possibly through heart disease, diabetes, high blood pressure, chronic stress, lower immunity, and overall more rapid aging.

Less dream-stage sleep makes a difference

We know that short sleep is associated with increased mortality, but until now it has been unclear if shorter sleep in a particular sleep stage makes a difference in the health risks associated with sleep deprivation. A new study published in JAMA Neurology looked at the relationship between REM sleep and earlier death in two large study groups, one consisting of 2,675 older men and the other of 1,386 middle-aged men and women. They followed both groups over time and looked at the relationship between sleep stages and causes of death.

Both groups showed increased mortality rates related to a decrease in REM sleep, with a 13% higher mortality rate for every 5% reduction in REM sleep. REM sleep was the most important sleep stage for predicting survival.

Putting new research into context: What does this mean for me?

This study showed an association between reduced REM and increased mortality, but it did not demonstrate the cause of the association. REM deprivation could independently contribute to the development of numerous other diseases. The results apply more clearly to older adults, given that the age groups studied averaged in the 50s and 70s. Short REM may also be a marker of a sick or aging brain; less REM sleep has already been tied to a greater risk of dementia. Overall, ensuring adequate REM sleep is important to protecting your long-term health.

Getting better sleep in middle age and beyond

Maintaining good sleep should remain a priority throughout your life. Everyone can make healthy choices to maximize restorative sleep. Dr. Suzanne Bertisch has written previously about recommendations for improving sleep hygiene, and even more suggestions are available in the Harvard Health Publishing Special Health Report Improving Sleep: Getting a Good Night’s Rest.

Some fundamental steps to improve your sleep and health include:

• Get at least seven hours of sleep each night. If you still feel tired, sleep a little more; some people need eight or nine hours of sleep to feel rested.
• Keep a consistent bedtime and wake time. This will make falling asleep easier, and will keep your circadian rhythm aligned with your sleep and wake time.
• Try to sleep when your body naturally wants to fall asleep and wake up. This can differ from sleep and wake times required for work schedules, which also has negative consequences. A sleep doctor can help you realign your circadian clock with your schedule.
• Depression or other mood disorders can cause disrupted sleep. Talk to your doctor if you are feeling low, no longer enjoy your hobbies, or are struggling with anxiety or sadness.
• If you can’t fall asleep, stay asleep, or feel sleepy all the time, you may need evaluation from a doctor for a sleep disorder such as sleep apnea or insomnia. Treating these disorders can make a major difference in overall sleep quality and health.

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Harvard Health Ad Watch: A feel-good message about a diabetes drug

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This 60-second advertisement for Trulicity, a medication for diabetes, is one of the most feel-good medication commercials I’ve ever seen. The narrator never uses the scare tactic of so many other ads, listing the terrible things that could happen if you don’t take the treatment. Instead, from start to finish, music, images, and spoken words deliver empowering, encouraging messages focused on helping your body to do what it’s supposed to be doing despite having diabetes.

There’s a lot of good information here, but as in most direct-to-consumer health marketing there’s also some that’s missing. Let’s go through it, shall we?

Three actors, three positive messages

The ad opens with uplifting music and statements by three people with type 2 diabetes (though all are actors, as noted in text at the bottom of the screen). A woman faces the camera to declare

“My body is truly powerful.”

So far so good! Then a man wearing a hard hat and holding blueprints at a construction site states

“I have the power to lower my blood sugar and A1C.”

More good news! By the way, he’s referring to hemoglobin A1C (HbA1C), a molecule in the circulatory system that serves as a standard test of average blood sugar over the previous two to three months. A normal or nearly normal HbA1C suggests good diabetic control, while higher results indicate elevated blood sugar and poorer control of diabetes.

We then meet a third woman wearing scrubs, who works in the physical therapy department of a hospital. She says

“…because I can still make my own insulin and Trulicity activates my body to release it, like it’s supposed to.”

Well, that sounds good, too, right? Presented this way, Trulicity seems more natural, because it encourages the release of your body’s insulin rather than relying on injected insulin.

What is Trulicity anyway?

A voiceover tells us Trulicity is not insulin, it’s taken once weekly, and it starts acting from the first dose. Tiny print notes the generic name (dulaglutide) and the fact that it’s an injection “to improve blood sugar in adults with type 2 diabetes when used with diet and exercise.” Then we hear who should not take Trulicity, a list including children, people with Type 1 diabetes, and women who are pregnant. Possible side effects are described, such as nausea, low blood sugar, stomach problems, and allergic reactions (see full list here). The FDA requires this in all direct-to-consumer ads.

As the camera pans up to sun shining through leaves and a band plays in the background, we see the physical therapist again — having changed out of scrubs into regular clothes — at a picnic with her family. We hear a few more warnings about side effects and the risk of lowering blood sugar too much when taking Trulicity with other diabetes medications.

Standing in a beautiful park, the woman faces the camera and says

“I have it within me to lower my A1C.”

Finally, the voiceover makes the usual suggestion

“Ask your doctor about Trulicity.”

What this ad gets right

The description of dulaglutide as a non-insulin medication that stimulates the release of insulin is accurate. The text and spoken information about the medication, including who should and should not take it and the possible side effects, reflect the FDA-approved prescribing information. And the unspoken message — that people with diabetes can be active, working, social individuals — is also true (and, perhaps, underappreciated).

What’s missing from this ad

Some important information provided only in text is easy to miss. It appears only for a few seconds, and some of the print is quite small — they don’t call it fine print for nothing! For example, you could easily miss the fact that Trulicity is available only by injection. Similarly, you could overlook the text explaining that Trulicity is not a first choice for the treatment of type 2 diabetes, and that diet and exercise are important in managing this condition.

Other missing information includes

• the meaning and relevance of HbA1C
• whether Trulicity reduces complications of diabetes, such as kidney disease, nerve damage, or visual problems, or improves quality of life or longevity; in fact, there is evidence it can reduce cardiovascular complications and death in high-risk individuals
• whether Trulicity is better than other treatments for diabetes, including other injectable treatments that work in a similar way, oral medications, or insulin
• the high cost of Trulicity: the “list price” is nearly $10,000/year, although health insurance or assistance programs may lower the out-of-pocket cost.

One other potentially misleading feature of the ad is the choice of actors. Excess weight is a major risk factor for type 2 diabetes. Yet, two of the three actors portraying patients, including the physical therapist who makes multiple appearances, appear close to normal weight. The third appears only modestly overweight.

The bottom line

Advertisements can provide a lot of useful information, but they can also be misleading. While there are regulations around what can and cannot be included in ads for prescription medications like Trulicity, these regulations do not require commercials to paint a full picture.

If you or a loved one has type 2 diabetes, there are better ways to learn about the options for treatment than a drug ad. Yes, talk to your doctor. But don’t limit your conversation to something you heard or read about in a feel-good drug ad.

The post Harvard Health Ad Watch: A feel-good message about a diabetes drug appeared first on Harvard Health Blog.

6 all-natural sex tips for men

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If you believe those upbeat, seductive advertisements, men only need to pop a pill to awaken their dormant sex life. Whether the problem is erectile dysfunction (ED) — the inability to maintain an erection for sex — or low libido, ED medications appear to be the quickest and easiest solution.

While these drugs work for most men, they are not right for everyone. ED drugs are relatively safe, but can cause possible side effects such as headaches, indigestion, and back pain. Plus, some men may not want their sex life dependent on regular medication, or simply can’t take them because of high or low blood pressure, or other health conditions.

Fortunately, there are some proven natural ways for men to manage their ED and increase vitality. Bonus: these strategies also can enhance your overall health and quality of life, both in and out of the bedroom.

Six ways to boost your sex life without medications

1. Get moving. Research has shown that regular exercise is one of the best medicines for ED. One study of almost 32,000 men ages 53 to 90 found that frequent vigorous exercise equal to running at least three hours per week or playing tennis five hours per week was associated with a 30% lower risk of ED compared with little or no exercise. It doesn’t really matter how you move — even walking is great — as long as you keep moving.
2. Eat right. Go bullish on fruit, vegetables, whole grains, and fish, while downplaying red and processed meat and refined grains. This type of diet lessened the likelihood of ED in the Massachusetts Male Aging Study. Another tip: chronic deficiencies in vitamin B₁₂ — found in clams, salmon, trout, beef, fortified cereals, and yogurt — may harm the spinal cord, potentially short-circuiting nerves responsible for sensation, as well as for relaying messages to arteries in the penis. Multivitamins and fortified foods are the best bets for those who absorb B₁₂ poorly, including many older adults and anyone with atrophic gastritis, a condition that may affect nearly one in three people ages 50 and older. Also, make sure you get enough vitamin D, which is found in fortified milk or yogurt, eggs, cheese, and canned tuna. A study in the journal Atherosclerosis found that men with vitamin D deficiency have a 30% greater risk for ED.
3. Check your vascular health. Signs that put you on the road to poor vascular health include soaring blood pressure, blood sugar, LDL (bad) cholesterol, triglycerides; low HDL (good) cholesterol; and a widening waist. Check with your doctor to determine whether your vascular system — and thus your heart, brain, and penis — is in good shape, or needs a tune-up through lifestyle changes and, if necessary, medications.
4. Measure up. A trim waistline is one good defense — a man with a 42-inch waist is 50% more likely to have ED than one with a 32-inch waist.
5. Slim down. Tip the scales at a healthy weight. Obesity raises risks for vascular disease and diabetes, two major causes of ED. And excess fat tinkers with several hormones that may feed into the problem, too. Need more reasons? Slimming down helps with tips 3 and 4.
6. See your dentist. A study in The Journal of Sexual Medicine found an association between gum disease and risk for ED. Gum disease causes chronic inflammation, which is believed to damage the endothelial cells that line blood vessels, including those in your penis.

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Learning to live well with a persistent illness

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When we get an acute illness like the flu or a cold, we feel sick for a week or two and then get back to our usual lives. This is how illness is “supposed” to go. But what happens when illness doesn’t fit this bill? What do patients with chronic conditions like diabetes or multiple sclerosis, or with persistent symptoms of Lyme disease or long-haul COVID-19, do when they can’t go back to their normal lives? Having suffered from the latter two — tick-borne illnesses that have plagued me for two decades, and a case of COVID-19 that took four months to shake — I’ve learned a few lessons about living with persistent illness.

Reframe your mindset

The most important — and hardest — lesson I’ve learned is that with debilitating, persistent conditions, there is no going back. I got sick at age 25. I had been working full-time, living an incredibly active lifestyle, burning the candle at both ends. Suddenly, the candle was gone. Bedridden through years of intense treatment, all I could talk about was getting back on track. I even threw a big “back to life” party when I finally achieved remission. Then I went right back to the high-functioning lifestyle I’d always known.

Three months later, I relapsed completely. It took another couple of years of treatment to get well enough to attend graduate school, socialize, exercise, and work. The journey wasn’t linear. I had to pace myself to have more good days than bad. I realized I couldn’t just wipe my hands of my illnesses. These persistent infections were coming with me, and not only did I have to accept them, I had to learn to move forward with them in a way that honored my needs but didn’t let them run my life.

Recognize your needs

Our bodies are good at telling us what they need: food, sleep, down time. We’re not always good at listening to these messages, however, because we live busy lives and sometimes can’t or don’t want to make time to take care of ourselves. When you have a persistent illness, ignoring your body’s needs becomes harder, if not impossible, and the consequences are more severe.

I’ve learned that I have to pace myself physically and neurologically, stopping activity before I get tired so my symptoms don’t flare. I have to rest in the early afternoon. I must stick to a particular diet, stay on low-dose medications, and do regular adjunct therapies in order to maintain my health. Now, after recovering from COVID-19, I also need to be conscious of residual lung inflammation.

At first, I saw these needs as limitations. They take up time and energy and prevent me from living a normal life. But when I reframed my thinking, I realized that I’ve simply created a new normal that works in the context of my illnesses. Everyone, sick or healthy, has needs. Acknowledging and respecting them can be frustrating in the short term, but allows us to live better in the long term.

Think outside the box

Once you figure out how to best meet your needs, you can plan other parts of your life accordingly. Your health must come first, but it isn’t the only important aspect of your life, even when you have a persistent, debilitating illness.

I had to shift my thinking from feeling anxious and embarrassed by what I couldn’t do, to optimizing what I can. I can’t work a traditional 9-to-5 job anymore, but I can write and teach on a more flexible schedule. I can’t go for an all-day hike (and might not want to anyway, due to ticks!), but I can enjoy a morning of kayaking. What skills do you have to offer, and what innovative opportunities might put them to good use? What activities do you miss, and how can you do them in an adaptive way? If that’s not possible, what’s a new activity you could explore?

Hope for the future, but live in the present

Learning to live well with a persistent illness does not mean resigning yourself to it. I’m able to do more each year, even though I sometimes have short setbacks. I change medications. I try new therapies. I manage my illnesses as they are now, but I haven’t given up hope for a cure, and am always striving to find ways to make my life even better. I can’t control what my illnesses do, but I can control how I handle them. And that makes life a little brighter.

Follow me on Twitter @writerjcrystal.

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5 takeaways for returning to school

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School districts in the United States are in a period of profound uncertainty, which will likely persist throughout the 2020–2021 school year. Many agree that remote teaching in spring 2020 was piecemeal and sub-optimal. Now, despite a stated universal commitment to full-time, in-person, high-caliber education, many states have rising rates of COVID-19, and teachers and parents share deep health concerns. Already we have witnessed a rapid and seismic transition from the beginning of this summer — in June, many schools planned to open full-time for in-person learning — to near-universal adoption of hybrid or remote teaching models. In fact, as of August 26th, 24 of the 25 largest school districts in the US will start their school year providing remote-only education.

Seeking perspective on a safe return to school

I began the summer thinking that I could contribute in some small way to fusing together basic public health and educational principles toward a safe return to school. I teach a course at the Harvard T.H. Chan School of Public Health on big public health campaigns. My daughter, an urban education scholar, lectures in my class on the value of parent-teacher collaboration. As a grandparent of three little boys ages 7, 4, and 3, and as a parent and father-in-law of two children and their spouses facing extraordinarily difficult decisions concerning school and day care, I am personally invested.

A colleague from a large social service agency shared a story of parents working in the hospitality industry. They face having to leave children, ages 6 and 8, home alone during the day trying to learn remotely. My own story — working years ago as a day care worker and unionized steelworker — affords me a sense of kinship with teachers. And during the past three months, while writing guidelines for school superintendents in Massachusetts and nationally, I’ve talked with parents of school-age children, school nurses, and superintendents navigating the raging debate over a safe return to school. The view differs depending on where you stand, but I have distilled some lessons.

Five takeaways: Steps and missteps in return to school

Sleepless nights, anxiety, and collaboration. In all of my conversations, whether it was with a school leader, a parent, a grandparent, or a school nurse, people shared the same stories of a succession of sleepless nights, coupled with the most difficult decision they have made in their personal and professional lives. Parents, in particular, speak of their anxiety, panic, exhaustion, powerlessness, and lack of support in trying to come up with a reasonable strategy for their children. At the same time, the potential for collaboration abounds. Parents and teachers are natural allies. They can jointly advocate for federal and state resources to ensure that our nation’s children can ultimately return to safe schools.

Lack of metrics. School superintendents, for whom I have come to have immense respect, have received little guidance on metrics to use as they decide to open schools now or close them later. They will need data on the number of cases in their community, trends over time, and the positive test rates for their areas and the areas closest to their districts. Parents are also looking for complete transparency as districts review community metrics to make closing or reopening decisions. There will be successful school openings and challenging ones. All interested parties need a forum to share their stories with one another.

Tutors, mentors, and collective space. Providing computers and hotspots is important to children and families who need them, although we also need to keep in mind that some families clearly have no internet access. Many families will need tutors, mentors, facilitators, and collective space to be skillfully educated in a remote setting. Low-income communities should be funded to promote and create community learning hubs that will be required for the millions of children who will not be educated in classrooms.

Masks and fabric face coverings. Mask wearing, dubbed the “interim vaccine,” must be the cornerstone of a national plan to reduce transmission in school settings and collective spaces. How can we reinforce mask wearing? For parents, teachers, and day care providers alike, the clock starts now as we vigilantly practice mask wearing before and after in-person schooling starts, then maintain this practice through the school year. School leaders, parents, and teachers can work together on crafting signage that reinforces the social norm of mask wearing in schools and on school buses, and incentivizing children for doing so.

Openness to evolving science and wisdom beyond our borders. Most importantly, we should all be humble about the limits of knowledge in the early stages of a pandemic, and expect changes as scientific understanding evolves. Initially, many experts believed that children did not get and did not transmit the virus. There was little basis to say this, as nearly every school in the US had shut down by no later than March 17th. We can look elsewhere for models, but schools in Europe started outdoors and never had more than 15 kids per class. If it were not for the surge that hit a large swath of the country in late June, we may have careened tragically toward full, in-person reopenings, with 25 children in a class and 66 children on a school bus. Recently, as schools opened in the US and abroad, we have been inundated with reports of cases diagnosed among students and teachers. However, basic public health principles of social distancing, mask wearing, and handwashing can prevail if consistently applied.

Schools cannot open safely if there are high rates of community transmission. School reopenings must take precedence over the opening of bars, indoor restaurants, and large indoor social gatherings. We all have a collective responsibility and social compact with one another to strive for a healthy and full return to school for our nation’s students and teachers.

For further discussion of return-to-school issues, listen to our “Living Better, Living Longer” podcast with Alan Geller, “Back to School: It’s Never Been More Complicated.”

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Getting the best treatment for your fibromyalgia

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Imagine being in pain and having your doctor tell you it’s all in your head. Unfortunately, this is not an uncommon experience for many of the six million Americans living with fibromyalgia, a chronic, painful condition.

People with fibromyalgia experience widespread pain, aches, and stiffness in muscles and joints throughout the body, as well as unusual tiredness. No one knows what causes this condition, and no apparent physical cause has been identified thus far. The most likely culprit is a brain malfunction that amplifies normal nerve responses, causing people with fibromyalgia to experience pain or other symptoms when nothing seemingly triggers them.

For those seeking relief, finding help can sometimes be a challenge. The best way to find a successful treatment strategy is to seek out a doctor who understands fibromyalgia, knows how to treat it, and can help you understand and cope with this condition. There are ways that you can improve your chances of finding the right match.

Understand your condition

The first step in this process is to arm yourself with the facts.

• Fibromyalgia is a real disorder. The American College of Rheumatology has created criteria that doctors can use to diagnose it (see this link for a patient-friendly version). It is recognized by national and international health agencies, including the World Health Organization.
• Fibromyalgia often coexists with mental health conditions such as anxiety and depression, but it is not caused by a mental illness.
• Fibromyalgia is not “in your head,” but it is related to brain activity. Differences in how the brain processes pain can be seen on functional MRI scans of people with fibromyalgia.
• The FDA has approved three drugs specifically for treating fibromyalgia: pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran (Savella). These drugs are effective against nerve pain, and are used for other conditions as well.

Seek referrals to providers who understand fibromyalgia

To find the right healthcare provider, it may help to go to those who already have experience in this area. Support groups provide a natural starting point. The National Fibromyalgia Association website lists support groups in each state that can help you find these initial connections. The organization can also provide a list of “fibro friendly” doctors in your state.

You can also look to your primary care doctor to help steer you in the right direction. Many doctors will be able to recommend a specialist who can help you manage your condition.

Once you settle on a prospective provider, make sure she or he is the right fit. Ask the office staff whether the doctor frequently sees patients with fibromyalgia and treats them on an ongoing basis. Also ask what treatments the doctor typically prescribes. Find out what type of services they provide; for example, do they offer telemedicine appointments? What services will they provide remotely, and which ones will require an office visit? If the answers aren’t what you’re looking for, or the office doesn’t seem receptive to your concerns, don’t be afraid to look elsewhere.

Connect your medical team

Once you do find the right provider, make certain that she or he is willing to communicate with your other providers. Many people with fibromyalgia need multiple doctors to manage their symptoms. Seeing multiple specialists can increase the risk of medication errors or harmful interactions of drugs prescribed by different doctors. In addition, your doctors may duplicate laboratory tests or other services. This can unnecessarily increase the cost of your care.

Finding the right doctor for your needs may not always be easy, but it’s worth the extra effort to increase your chances of successfully managing your condition.

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