Birth control and high blood pressure: Which methods are safe for you?

Three effective forms of birth control contain the hormone estrogen: the birth control patch, combined hormonal birth control pills, and a vaginal ring. Doctors have typically recommended that women avoid birth control with estrogen if they have high blood pressure, which current US guidelines define as 130 mm Hg systolic pressure and 80 mm Hg diastolic pressure, or higher. A recent clinical update in JAMA clarifies whether it’s safe for some women with high blood pressure to use these forms of birth control.

Why does blood pressure matter when choosing birth control?

Birth control containing estrogen can increase blood pressure. When women who have high blood pressure use these birth control methods, they have an increased risk of stroke and heart attack compared with women who do not have high blood pressure. However, their actual chances of having a stroke or a heart attack are still quite low.

When considering birth control options, it’s important to also weigh the possible risks of an unintended pregnancy. A woman who has a history of high blood pressure before she becomes pregnant is more likely to experience

• preeclampsia, a pregnancy complication that can affect liver and kidney function and can even lead to eclampsia, or seizures
• diabetes during pregnancy
• blood clots
• heart attack

She’s also at higher risk for problems with fetal growth and preterm birth.

Why are recommendations around blood pressure and birth control being updated?

When US blood pressure guidelines changed in 2017, many more people were diagnosed with high blood pressure. That happened because the new guidelines tightened standards, as follows:

• normal blood pressure is less than 120 (systolic)/80 (diastolic) mm Hg
• elevated blood pressure is between 120 and 129 mm Hg (systolic) and less than 80 mm Hg (diastolic)
• high blood pressure is 130 mm Hg (systolic) and 80 mm Hg (diastolic) or higher.

With these updated definitions, nearly half of American adults have high blood pressure. Black women are at particularly high risk: more than half of Black women over the age of 19 are diagnosed with high blood pressure.

If a woman has high blood pressure, the JAMA update recommends weighing three factors before starting an estrogen-containing birth control: a woman’s age, control of blood pressure, and any other risks for heart disease.

• Safe to use birth control containing estrogen: If women are 35 years old or younger, have well controlled blood pressure, and are healthy, estrogen-containing birth control can be used. Be sure to have a health professional check blood pressure within one month of starting this type of birth control. Additionally, routine blood pressure checks are recommended twice a year.
• Should avoid birth control containing estrogen: If women are older than 35, even if they have well controlled blood pressure, estrogen-containing birth control should be avoided. Similarly, women of any age who have multiple risk factors for heart disease or who have uncontrolled high blood pressure should not use birth control containing estrogen. These women also should not use the birth control shot (Depo-Provera) because it may increase cholesterol and lead to an increased risk of stroke, according to the review. (This medication contains a different hormone called progestin.)

The JAMA update reviewed evidence based on an older definition of high blood pressure in the context of birth control use. Further research is needed to better understand how different ranges of blood pressure might affect women using birth control that contains estrogen. However, it’s unlikely that these recommendations would change further based on the newer definition of high blood pressure.

Which birth control methods do not contain estrogen?

So, what can women who are unable to use birth control containing estrogen use to prevent pregnancy? The good news is that there are a variety of other birth control methods available, both hormonal and nonhormonal.

• The most reliable forms of birth control without estrogen are the copper intrauterine device (IUD), the hormonal IUD, the implant, and sterilization for women or men.
• Nonhormonal methods include the copper IUD, condoms for men or women, cervical cap, and diaphragm.
• Three progestin-only hormonal methods are safe to use: the minipill, the birth control implant, or the hormonal IUD. However, the birth control shot (Depo-Provera) is not recommended for women who have poorly controlled high blood pressure.

If you do have high blood pressure, exercise and dietary changes remain an important component of maintaining your heart health. Discuss with your doctor which birth control options might be best for you, so that you and your doctor can engage in shared decision-making about your preferences.

See the Harvard Health Birth Control Center for more information on options.

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Quarantine snacking fixer-upper

The “battle of the bulge” gained a new foe this year: quarantine snacking. Sales of snack foods like cookies and crackers shot up in the early days of lockdowns, and recent consumer surveys are finding that people have changed their eating habits and are snacking more.

We don’t yet have solid evidence that more snacking and consumption of ultra-processed food this year has led to weight gain. While memes of the “quarantine 15” trended on social media earlier this year, only a few small studies have suggested a link between COVID-19-related isolation and weight gain. But you don’t need scientific evidence to know if your waistband is tighter.

Snacking is not just a weight risk

Regular junk food snacking brings many risks. Processed foods are typically filled with loads of unhealthy saturated fats and high amounts of salt, calories, added sugar, and refined (unhealthy) grains.

Eating too much of these foods can lead to increased blood sugar (which raises the risk for diabetes), constipation, or an increased LDL cholesterol level (which boosts the risk for heart disease).

What you can do

If your snacking habits are off the rails, here are some tips to get back on track.

• Keep junk food out of the house. Without junk food lying around, you won’t be tempted to eat it.
• Plan healthy snacks. Stock your refrigerator and pantry with healthy snack foods such as fat-free Greek yogurt, berries, chopped vegetables, nuts (walnuts, almonds), hummus, or whole wheat crackers. Plan your daily snacks in advance, so you’ll be more likely to snack wisely.
• Zero in on hunger. Before snacking, ask yourself whether you’re hungry or just thirsty. A good way to tell: drink an eight-ounce glass of water and then wait 10 to 15 minutes. If you’re still hungry, have a healthy snack.
• Know your cravings. Are you hungry, or are you lonely, bored, or stressed? Food won’t fix the problem. Instead, go for a walk around the block, put on some music, or choose another activity that might distract you or boost your mood. If you still want food, eat only a small amount.
• Don’t skip meals. This can make you so hungry later in the day that you’re vulnerable to devouring mega-portions of snack food to supply your body with easily digested sugars.
• Don’t eat straight from the bag or carton. If you snack on an open bag of crackers or a tub of frozen yogurt, you may eat more than a single serving. Instead, portion out your serving in a dish.
• Eat mindfully. Turn off the TV, put down your phone, and pay attention to your snack. Savoring a piece of fine chocolate can be more satisfying than mindlessly gobbling down a whole chocolate bar.
• Prepare for snacks away from home. Plan ahead and keep a healthy snack in your bag or car. That way you won’t turn in desperation to calorie-laden cookies or vending machines.

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A new Alzheimer’s drug: From advisory panel to FDA — what’s at stake here?

It’s been more than 17 years since the FDA last approved an Alzheimer’s drug. Will Biogen’s drug, called aducanumab, end this drought? The FDA will decide by March 2021, based on its own analysis of clinical trial data and an advisory panel’s review of the evidence.

How does the drug work?

Aducanumab is a monoclonal antibody engineered in a laboratory to stick to the amyloid molecule that forms plaques in the brains of people with Alzheimer’s. Most researchers believe that the plaques form first and damage brain cells, causing tau tangles to form inside them, killing the cells. Once aducanumab has stuck to the plaque, your body’s immune system will come in and remove the plaque, thinking it’s a foreign invader. The hope and expectation is that, once the plaques are removed, the brain cells will stop dying, and thinking, memory, function, and behavior will stop deteriorating.

Will the FDA’s decision be important?

If aducanumab works, it would be the first drug that actually slows down the progression of Alzheimer’s. That means we could possibly turn Alzheimer’s from a fatal disease into one that people could live with for many years, in the same way that people are living with cancer, diabetes, and HIV/AIDS.

For researchers, it means that more than 20 years of scientific work, which suggests that removing amyloid from the brain can cure Alzheimer’s, may be correct. But many of us have begun to doubt this theory, because trial after trial has shown that amyloid could be cleared from the brain but clinical disease progression was not altered.

So, does the drug work?

I attended the day-long FDA hearing on November 6, 2020, and also independently reviewed all the publicly available data for aducanumab. There was one small (phase 2) clinical trial to assess efficacy and side effects, and two large (phase 3) clinical trials to assess effectiveness, side effects, safety, and how the drug might be used in clinical practice. The small phase 2 study and one of the large phase 3 studies were positive, meaning that the drug worked to slow down the decline of thinking, memory, and function that is usually impossible to stop in Alzheimer’s. The other large study was negative. Hmm… Is two out of three positive studies good enough? Biogen’s scientific team had many plausible explanations for why that one study was negative.

The advisory panel, however, was not convinced. They pointed out that phase 2 studies are always positive, because otherwise you wouldn’t move on to phase 3, so that study doesn’t count. They also pointed out that, although you can think of the positive phase 3 study as the “true” one, and try to understand why the negative one failed (which is what Biogen did), you could equally think of the negative study as the true one, and try to understand why the other one showed positive results.

The advisory council was concerned that there was “functional unblinding” in both studies, because large numbers of participants in the treatment group needed additional MRI scans and physical exams to deal with side effects, which did not occur in the placebo group. Hence, if you were asked to come in for an extra MRI scan, you knew that you were on the real drug. This knowledge may have influenced the responses subjects and their family members gave regarding how they were doing, which were the primary outcomes of the study.

Should the FDA approve it?

To determine if a drug should be approved, many factors need to be considered. First is whether it works and, as discussed above, there are questions regarding its efficacy. You also have to consider side effects and other burdens on patients, families, and society.

You first need an amyloid PET scan to be sure you have the amyloid plaques of Alzheimer’s. Then to take the drug, you need an intravenous infusion every four weeks — forever. Thirty percent of those who took the drug had a reversible swelling of the brain, and more than 10% had tiny brain bleeds. These side effects need to be watched closely by an expert neurology/radiology team who understand how to monitor for these events, and know when to pause or stop the drug.

Another factor to consider is the size of the benefit. Here, it was fairly small. Looking at the two objective measures, in the positive trial, the high dose made a 0.6-point change on the 30-point Mini-Mental State Examination (MMSE). On the 85-point Alzheimer’s Disease Assessment Scale–Cognitive Subscale-13 (ADAS-Cog-13), the high dose made a 1.4-point change. In the negative trial, the analogous results were -0.1 (worsening) for the MMSE and 0.6 for the ADAS-Cog-13.

Cost also needs to be considered; for aducanumab, this is estimated at $50,000 per year per patient. There are more than two million people with Alzheimer’s in the mild cognitive impairment and mild dementia stages. If one-quarter of those decide to take the drug, that’s $25 billion each year — not including the cost of the PET scans and the neurology/radiology teams to monitor side effects. Since most people with Alzheimer’s disease have Medicare, we will all share this cost.

Moreover, Dr. Joel Perlmutter, a neurologist at Washington University in St. Louis and member of the FDA’s advisory committee, argued that if the FDA approves aducanumab, fewer people would want to participate in a trial of a novel medication — and that would likely delay the approval of better medicines.

If it’s not approved, what other treatments are out there?

There are many other treatments for Alzheimer’s that are also being developed. Drugs that remove tau — the tangles of Alzheimer’s — are being tested. Treatments using flashing lights to induce specific brain rhythms may protect the brain. Other treatments change the microbiome of the gut or other parts of the body. Drugs are being developed which alter nitric oxide — a gas that has critical functions in brain health. Lastly, in my laboratory, we are developing strategies to help individuals with mild Alzheimer’s and mild cognitive impairment to remember things better, because, at the end of the day, that’s what matters most.

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Does lupus or arthritis affect your prognosis if you get COVID-19?

Soon after the coronavirus pandemic began, we learned that older adults and people with certain chronic conditions, such as high blood pressure or diabetes, are at increased risk for severe COVID-19. One condition on that list is an immunocompromised state (a weakened immune system). This can be due to a number of conditions, including having had an organ transplant, having HIV, or taking medications that suppress the immune system.

If you have an autoimmune condition such as rheumatoid arthritis or lupus (also called systemic lupus erythematosus), you may wonder how this affects your risk. It’s thought that these conditions occur because the immune system misfires and attacks organs in the body. And many people with these disorders are treated with medications that suppress the immune system.

Two newly published studies examine this. While the results are not definitive, they do provide some reassurance. Most people recovered from COVID-19, and most of their prior treatments did not seem to worsen their infections.

Lupus and COVID-19

In the first study, researchers enrolled 226 people with lupus. After comparing those who had COVID-19 with those who did not, they found that

• nearly 60% of those with COVID-19 and lupus became sick enough to be hospitalized, and 10% were admitted to the intensive care unit.
• about 10% died.
• risk factors for hospitalization were similar to those reported in people outside of this study who did not have lupus. For example, race (more hospital admissions among those who were Hispanic or nonwhite), other chronic diseases (including kidney failure, lung disease, and hypertension), and being overweight or obese were more common among those needing hospital admission.
• steroid treatment for lupus was nearly two times higher among hospitalized patients (54%) compared with those who were not hospitalized (29%). However, this difference was not statistically significant.
• treatment with other immune-suppressing medications taken for lupus (such as azathioprine or mycophenolate) was similar in both groups.

Inflammatory arthritis and COVID-19

The second study included 103 people with inflammatory arthritis (which includes rheumatoid arthritis and related conditions) who were also diagnosed with COVID-19. Some were hospitalized with severe disease, while others were treated as outpatients. Here’s what the study found.

• 26% of study subjects were hospitalized.
• About 4% died.
• Risk factors for hospital admission included being 65 or older, high blood pressure, and lung disease.
• Steroid treatment for inflammatory arthritis was more common among those hospitalized (37%) than those treated as outpatients (about 4%).
• Biologic therapy (such as etanercept or infliximab) did not appear to increase the risk of severe COVID-19. One other type of treatment — JAK inhibitors, which include tofacitinib (Xeljanz) — was more common among those requiring hospital admission. However, few patients were taking this medication.

Why these studies aren’t the last word

These studies only included patients with COVID-19 and either SLE or inflammatory arthritis. It wasn’t possible to rigorously compare the study participants to people without lupus or arthritis. Also, these studies did not include large numbers of people with lupus or arthritis who tested positive for the virus, yet did not have symptoms of COVID-19 (asymptomatic infection). Nor did they confirm the diagnosis of COVID-19 in every suspected case. So, while this research offers some new information, the true impact of lupus or arthritis on people who develop COVID-19 hasn’t yet been determined.

Finally, the lupus study was small: only 41 subjects had confirmed COVID-19. Although the findings on steroid treatment weren’t statistically significant, that might not have been true if the differences observed persisted in a larger study.

The bottom line

Public health experts often include people with autoimmune disease on the list of those who are more likely to have a bad outcome if they develop COVID-19. The relatively high rate of hospital admission for lupus patients with COVID-19 confirms an increased risk for severe disease. Other standard risk factors (such as high blood pressure or lung disease) apply, but steroid therapy may increase risk even further. Other studies have come to similar conclusions (see here and here).

There was some good news to emphasize in these trials: the survival rate among patients with lupus or inflammatory arthritis who develop COVID-19 was relatively high. Also, biologic therapy did not appear to worsen prognosis for the arthritis patients. And other immune suppressants did not worsen prognosis for those with lupus. And, the hospitalization rate for COVID-19 among patients with inflammatory arthritis was similar to what has been reported for people without arthritis.

These findings add to what we are learning about COVID-19. Clearly, we need to learn more. For example, is there a dose of steroids to treat chronic illness that is so low that it does not increase the risk of a worse prognosis with COVID-19? Do certain medications (such as biologics) actually reduce the risk of severe COVID-19? Until we do know more, it remains particularly important for people with lupus and inflammatory arthritis — especially those taking steroids — to be especially vigilant about measures to avoid COVID-19.

Follow me on Twitter @RobShmerling

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Defusing the “Benadryl challenge”: Discussing danger with teens

Let’s start with the bottom line: Parents of teens need to help them understand that just because they have been “challenged” to do something doesn’t mean it’s a good idea. But as simple as that sounds to us, it’s tough for many teens to grasp.

The latest challenge in the news is the “Benadryl challenge” that appeared on TikTok, a popular social media video platform. The idea was to take a whole lot of Benadryl (diphenhydramine, a common antihistamine) in order to cause a high, with hallucinations. While it’s true that diphenhydramine can make you high and make you hallucinate, when you take too much of it you can also have seizures, pass out, have heart problems, or even die. And indeed, emergency rooms across the country have treated overdoses of diphenhydramine, and at least one death has been attributed to the challenge.

Dangerous challenges appeal to teens

To TikTok’s credit, they say that they have taken down the videos and are monitoring for any new ones. When I searched the site myself, nothing came up when I searched “Benadryl.” But it’s not like it’s the only challenge out there on social media. We’ve had the cinnamon challenge, the nutmeg challenge, and others like the “Kiki challenge” where people get out of their slow-moving cars and dance alongside them, or the “skull-breaker challenge” which, well, speaks for itself. Getting rid of all challenges is not really possible; it’s a game of whack-a-mole.

The reason teens do this stuff is actually rooted in evolutionary biology. The adolescent and young adult brain is growing and changing rapidly to meet the needs of their particular moment in life. As teens enter adulthood and become independent, they need to be able to learn a lot of information quickly. Their brains are set up to help them do that.

Entering adulthood and becoming independent also requires being brave and taking risks. There is so much that is new and scary as you enter adulthood, which is why many of us are glad we are past that part of life. The development of the adolescent brain takes that into account, too: the last part of the brain to develop is the prefrontal cortex, the part that helps us control our impulses and avoid risk. By the mid-20s or so, the process is complete.

Working with the teen brain

This doesn’t mean that parents, teachers, and others should just throw up their hands and quit trying to talk to teens about making safer decisions. We absolutely need to keep trying, day after day. But it does mean that we have to understand why these challenges may have so much appeal, and why teens may not fully appreciate the risks. It means that our efforts need to be not just ongoing, but understanding. We need to work with the teen brain, not against it.

There’s no easy way to do that. But here are some ideas:

• Listen as much as you talk. Ask questions. The more you understand about their behavior, the better chance you will have of finding strategies that work.
• Don’t jump to judgment. Besides the fact that they are wired to make impulsive and sometimes dangerous decisions, if teens feel judged they are less likely to listen to anything you have to say.
• Try to engage your teen in coming up with ideas to keep him or her safe. Not only do they know themselves and their peers better than you do, they may be more invested in an idea they come up with themselves.
• Ask for help. Teens don’t always listen to parents, but they may listen to other adults in their lives. And definitely, if you feel like your child is doing things that are dangerous and you can’t stop them, talk to your doctor.

Follow me on Twitter @drClaire

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Intermittent fasting: Does a new study show downsides — or not?

Intermittent fasting (IF) is an approach to eating based on timing. The idea is that fasting for long enough allows insulin levels to fall low enough that our body will use fat for fuel. Growing evidence in animals and humans shows that this approach leads to significant weight loss. When combined with a nutritious, plant-based diet and regular physical activity, IF can be part of a healthy weight loss or maintenance plan, as I described in an earlier blog post.

Now, a randomized controlled trial published in JAMA claims that IF has no significant weight loss benefit and a substantial negative effect on muscle mass. News outlets picked up the story and ran headlines like A Potential Downside of Intermittent Fasting and An Unintended Side Effect of Intermittent Fasting.

But what did this study actually look at and find?

In the study, 141 patients were randomly assigned to 12 weeks of either a time-restricted eating plan (TRE) that involved fasting for 16 hours and eating only during an eight-hour window of the day, or a consistent meal timing (CMT) eating plan, with three structured meals a day plus snacks.

Neither group received any nutrition education or behavioral counseling, nor was physical activity recommended. There was no true control group (meaning a group that did not receive any instructions about meal timing).

Interestingly, both groups lost weight. Given the headlines, I had to read and reread the results several times, because they show that the IF group lost a statistically significant amount of weight from beginning to end — which wasn’t true in the CMT group. The researchers reported: “There was a significant decrease in weight in the TRE group (−0.94 kg; 95% CI, −1.68 kg to −0.20 kg; P = .01) and a nonsignificant decrease in weight in the CMT group (−0.68 kg; 95% CI, −1.41 kg to 0.05 kg; P = .07).”

Translated into plain English, the IF group lost more weight than could be due to chance: between half a pound and 4 pounds, or an average of 2 pounds. The structured meals group also lost some weight, although the amounts lost could have been due to chance: between 0.1 and 3 pounds, or an average of 1.5 pounds. The upshot was that there wasn’t a significant difference in weight change between the two groups. And the researchers saw a loss of muscle mass in the IF group that didn’t occur in the CMT group.

Diving deeper into the study

By the way, all of these folks may have been eating fried or fast foods, and sugary sodas and candy — we don’t know. The study doesn’t mention quality of diet or physical activity. This isn’t how IF is supposed to be done! And yet the IF folks still lost between half a pound and 4 pounds.

Importantly, the structured meals group also lost weight. While not significant enough to prove it was due to this intervention, for some participants it was enough to make structured meal weight loss differ little from IF weight loss. But think about it: structured meals are an intervention. After all, some people eat more than three times a day, consuming multiple small meals throughout the day. Telling people to limit their eating to three mealtimes plus snacks may actually be helping some to eat less.

The authors very well could have concluded that IF was indeed successful. They might also call for a follow-up study with a true no-intervention control group, as well as behavioral counseling, guidance on a healthy diet, and recommended activity levels for IF and CMT groups.

Does additional support make a difference?

Prior studies of IF that have provided behavioral counseling, and guidance on nutrition and activity, have definitely shown positive results. For example, in a previous blog post I described a 2020 American Journal of Clinical Nutrition study in which 250 overweight or obese adults followed one of three diets for 12 months:

• IF on the 5:2 protocol, which means drastically reducing food intake for any two of five days of the week (down to 500 calories for women and 700 calories for men)
• Mediterranean, which emphasized fruits and vegetables, legumes, nuts, seeds, whole grains, and olive oil with moderate fish, chicken, eggs, and dairy, and with an allowance of one glass of wine per day for women and two per day for men
• Paleo, which emphasized fruits and vegetables, animal proteins, coconut products, butter, and olive oil, along with some nuts, seeds, and legumes.
• And this is key: all participants were provided education on behavioral strategies for weight loss, stress management, sleep, and exercise.

Everyone lost weight. The IF group lost more than anyone with an average of 8.8 pounds, Mediterranean next at 6.2 pounds, and Paleo last at 4 pounds. Adherence was better with the Mediterranean diet (57%) and IF (54%) than with the Paleo diet (35%), and better adherence resulted in one to three pounds more weight loss. The Mediterranean and IF groups also saw significant drops in blood pressure, another good result.

What about the loss in muscle mass that occurred in the IF group in the JAMA study? While this needs to be studied further, it’s important to note that other research on IF that included guidance on physical activity did not show any loss of muscle mass.

The bottom line

What’s the takeaway here? A high-quality diet and plenty of physical activity — including resistance training — are critical for our good health, and nothing replaces these recommendations. IF is merely a tool, an approach that can be quite effective for weight loss for some folks. While this one negative study adds to the body of literature on IF, it doesn’t reverse it. We simply need more high-quality studies in order to have a better understanding of how to most effectively incorporate IF into a healthy lifestyle.

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Talking to your doctor about an abusive relationship

When Jayden called our clinic to talk about worsening migraines, a medication change was one potential outcome. But moments into our telehealth visit, it was clear that a cure for her problems couldn’t be found in a pill. “He’s out of control again,” she whispered, lips pressed to the phone speaker, “What can I do?”

Unfortunately, abusive relationships like Jayden’s are incredibly common. Intimate partner violence (IPV) harms one in four women and one in 10 men in the United States. People sometimes think that abusive relationships only happen between men and women. But this type of violence can occur between people of any gender and sexual orientation.

Experiencing abuse can be extremely isolating, and can make you feel hopeless. But it is possible to live a life free from violence. Support and resources are available to guide you towards safety — and your doctor or health professional may be able to help in ways described below.

What is intimate partner violence?

Intimate partner violence (IPV) isn’t just physical abuse like kicking or choking, though it can include physical harm. IPV is any emotional, psychological, sexual, or physical way your partner may hurt and/or control you. This can include sexual harassment, threats to harm you, stalking, or controlling behaviors such as restricting access to bank accounts, children, friends, or family.

If this sounds like your relationship, consider talking to your doctor or health care professional, or contact the National Domestic Violence Hotline at 800-799-SAFE.

What does a healthy relationship look like?

Media images show us uniformly blissful relationships, but perfect relationships are a myth. This culture can make it difficult for us to recognize unhealthy characteristics in our own relationships. Respect, trust, open communication, and shared decisions are part of a healthy relationship. You should be able to freely participate in leisure activities or see friends without fear of your partner’s reaction. You should be able to share your opinions or make decisions without fear of retaliation or abuse. Sexual and physical intimacy should include consent — meaning that no one uses force or guilt to compel you to do things that hurt you or make you feel uncomfortable.

How can a health professional help me?

Health professionals like doctors or nurses can take a history and assess how the abuse may be affecting your health, well-being, and safety. Trauma from IPV can cause visible symptoms, like bruises or scars, as well as more subtle symptoms, like abdominal pain, headaches, trouble sleeping, or symptoms of traumatic brain injury. Health professionals can also provide referrals to see specialists, if needed.

With your consent, health professionals can take a detailed history, examine you, and document the exam findings in your confidential medical record. Let them know if you are concerned that your partner will view your medical record, so measures can be taken to keep it confidential. This documentation can help to strengthen a court case if you decide to pursue legal action in the future.

Additionally, you may be at risk for pregnancy or certain sexually transmitted infections (STIs). A health professional can perform tests for STIs or pregnancy and offer birth control options. Some forms of birth control are less easily detected by your partner, like an IUD, or a contraceptive implant or injection.

Health professionals can help you develop a safety plan if you feel unsafe. They can also help connect you with social services, legal services, and specially trained advocates. If you would like, health professionals can also connect you with law enforcement to file a report.

What is a sexual assault exam?

If you have experienced sexual assault within 120 hours (five days), you may be offered a sexual assault medical examination. This exam is voluntary. It is performed by a trained health professional and may include a full body exam, including your vagina, penis, or anus. It may also include taking blood, urine, or body surface samples and/or photographs that could be used during an investigation or legal action. You may be prescribed medication that could prevent infections or a pregnancy. You can click here to learn more about the sexual assault exam.

What can I expect if I talk to a health care professional about IPV?

Health professionals should listen to you supportively and without judgement. While not all health professionals are trained in trauma-informed care, it is your right to be treated with respect and empathy to help you feel safe and empowered. You should not be pressured to do anything you don’t want to do. And this shouldn’t change the care you receive. You have the right to decline any care you are not comfortable with. You get to decide how you want to proceed after you share information with your healthcare professional, whether that means seeking out legal support, making a safety plan to leave the relationship, or choosing to stay in the relationship and be connected to ongoing support. And you can choose not to share information about abuse at all.

Will the conversation be private and confidential?

These discussions should occur with you and your health professional in a private space. If your abusive partner accompanies you to your appointment, your health professional may ask them to leave the examination room for a period of time so that you have the privacy to talk openly. You can also ask to speak with the health professional alone.

In most cases, discussing your experiences with your health professional is confidential under HIPAA. All states have laws that protect children, elders and people with disabilities from abuse of any kind. Your health professional is obligated in certain circumstances to report abuse, such as violence against a minor or vulnerable adult. However, only a few states require health professionals to report intimate partner abuse.

Where can I find more resources on IPV?

Want to learn more about IPV and how to seek help?

If you or someone you know you is at risk, call the National Domestic Violence Hotline at 800-799-SAFE (7233) or 800-787-3224. This hotline is for anyone, regardless of race, sex, ethnicity, gender identity, sexual orientation, religion, or ability.

If you are unable to speak safely, you can visit thehotline.org or text LOVEIS to 22522. They are available 24/7 by phone or with a live chat, and can work with you to find help in your area.

• RAINN (national resource for sexual assault and violence)
• Love Is Respect (national resource for dating violence)
• WomensLaw.org (legal information for women experiencing domestic violence)
• LGBT National Help Center (LGBTQ+ resources, including chat and peer counseling).

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Making special education work for your child during COVID-19

Even in normal times, parents wrestle with decisions about how best to support their children’s development. Now, however, parents are faced with nearly-unprecedented choices, and problems with no clear solutions: What if in-person schooling is better for emotional health, but remote schooling is better for physical health? How can children foster social skills without typical social interactions? How can parents select among learning environments when all the options have clear downsides?

These concerns and choices are even more difficult for parents of children with disabilities, who are among the most vulnerable students and who are at increased risk of regression during school disruptions.

Special education: One size does not fit all

Of course, students who receive special education are not a uniform group. They range in age from 3 to 22, attending preschool through post-secondary placements. They include students with a wide variety of mild to severe cognitive, physical, social, emotional, and behavioral disabilities.

But students with disabilities share a need for special services, accommodations, or both, in order to fully access the school curriculum, and to make meaningful progress appropriate to their ability. At a time when schools are scrambling to deliver regular education in a novel and frightening new context, parents and educators must also work together to select and design appropriate programs for students with special needs.

Remote learning

Remote learning has two obvious benefits. First, it is the safest choice from a physical health perspective; it may indeed be the only choice for students who are medically fragile. Second, remote learning is less likely to be disrupted or changed over the course of the school year. Students who struggle with transitions or anxiety may benefit from the relatively predictable course of remote learning.

But remote learning also carries risks, some of which are particularly acute for students with disabilities. When children are at home, educators may not be able to deliver some services or accommodations. It may be more difficult, or even impossible, to work toward some goals, especially those that require proximity to or interaction with others, such as independently toileting, or purchasing lunch in the school cafeteria without adult support.

Remote learning also requires flexibility in parents’ schedules, and intensive parental participation. Even with parental involvement, students vary in how effectively they can engage with remote learning. And students who struggle with attention, intellectual functioning, language, self-regulation, or a combination of these challenges may have great difficulty learning efficiently from a remote platform. The lack of peer models may lead some children to regress behaviorally or academically.

In-person learning

In-person or hybrid (a combination of remote and in-person learning) models offer most of the benefits that remote options lack. These include a social environment with peers, and access to services and accommodations in as normal an environment as possible. Students who require intensive support, hands-on services, or who are working on skills specific to the school or vocational environment may require in-person learning opportunities in order to fully access the curriculum.

However, in-person models carry one major and obvious risk: the potential of increased exposure to COVID-19. All parents must be wary of this dangerous disease, and parents of medically complex children may deem such a risk unacceptable, despite potential academic or social benefits.

In-person models are also likely to evolve as the pandemic progresses. As a result, students will require greater flexibility in order to be successful at a physical school.

What should parents do?

Parents and educators will need to approach this challenge with creativity, flexibility, and collaboration. Parents should request to meet with their child’s educational team as soon as possible, and should plan to meet regularly thereafter to monitor their child’s progress, and to update the educational program as needed. When parents meet with their team, they should consider each goal and service with an open mind, discussing multiple options for how a goal could be met, and how a service or accommodation could be delivered.

Some adaptations are easy: for example, large print, screen-reading software, and speech-to-text are all immediately available in a remote context. Other adaptations pose challenges, but not necessarily insurmountable ones. A behavior analyst could offer coaching through a video call, for example. Or a teacher certified in intensive special education could deliver discrete trials instruction remotely by positioning two tablets in the child’s home, one for the child to use, and one as a screen to watch the child’s responses. An aide or behavioral support could join a child’s virtual classroom, and chat with or break out with the child as needed to offer support.

Now is the time for innovation, and many schools and families are discovering great new ways to deliver special education instruction safely and effectively.

Put schooling in perspective

While it can seem like there are no great options for school, parents should try to take comfort in accepting that this year, “good enough” is truly enough.

We should also strive to prioritize the things that children require even more than schooling: physical and emotional safety, a responsive adult, and unconditional love and acceptance. Children who feel safe and loved will emerge from this pandemic resilient, and ready to overcome other challenges in their future — and they may even have learned a thing or two along the way.

 

Resources

Autism Speaks COVID Resources

Child Trends (includes multiple excellent articles about supporting children through COVID-19)

Harvard’s Center for the Developing Child Guide to COVID-19 and Early Child Development

Helping Traumatized Children Learn, a collaborative work of MA Advocates for Children and Harvard Law School

Learning Policy Institute Resources and Examples

PTA Resources

US Department of Education resources for schools, students and families

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Communities of color devastated by COVID-19: Shifting the narrative

Editor’s note: First in a series on the impact of COVID-19 on communities of color and responses aimed at improving health equity.

By now we’ve read headlines like these all too often: “Communities of Color Devastated by COVID-19.” Way back in March, available data started to show that vulnerable, minority communities were experiencing much higher rates of infection and hospitalization from COVID-19 than their white counterparts. New York City, New Orleans, Chicago, Detroit, Milwaukee, and Boston, where I live and work, all became ground zeros in our nation’s early battle with the pandemic. The numbers were astounding: Blacks and Latinos were four to nine times more likely to be infected by COVID than whites, even in our nation’s top hot spots. Was I surprised? Absolutely not.

A long view on health disparities

I’m originally from Puerto Rico, and grew up in a bilingual, bicultural home where I had a ringside seat to witness how the issues of race, ethnicity, culture, and language barriers intersected with all aspects of society. Currently, I’m a practicing internist at Massachusetts General Hospital (MGH), where I founded the MGH Disparities Solutions Center in 2005, which I led until becoming the Chief Equity and Inclusion Officer for the hospital last year. I’ve studied and developed interventions to address disparities in health and health care for more than two decades. My career has connected me to more than 100 hospitals in 33 states that are actively engaged in efforts to improve quality, eliminate racial and ethnic disparities in care, and achieve health equity. So, addressing disparities in care isn’t just a job for me; it’s my profession and my passion.

History teaches us that disasters — natural or man-made — always disproportionately harm vulnerable and minority populations. Think of Hurricane Katrina in New Orleans. Those with lower socioeconomic status, who were predominately Black, lived in lower-lying areas with limited protections against flooding, including levees that hadn’t been upgraded or reinforced. Multiple factors converged during and after the storm to rain down unprecedented damage and destruction on these communities, compared with white communities with higher socioeconomic status.

A shifting, yet familiar story of health disparities unspools

Fast-forward to the early months of this devastating pandemic. Working alongside many talented colleagues, I led the combined Mass General Brigham and Equity COVID Response efforts at MGH. Hospitals around the country quickly learned that people with chronic conditions such as diabetes, lung disease, and heart disease, and those of advanced age, had a poorer prognosis once infected with COVID-19.

In the United States, these chronic conditions disproportionately affect minority populations. So, minorities entered the pandemic with a long history of health disparities that put them at a disadvantage. Structural racism, discrimination, and the negative impact of the social determinants of health — including lower socioeconomic status, less access to education, hazardous environments — continuously undermine the health and well-being of these communities. This is compounded by minorities having less access to health care, and, when they are able to see a health care provider, often engaging with significant mistrust, or language barriers, that make it difficult to obtain high-quality care.

We quickly saw the importance of effective public health messaging, delivered by trusted messengers. However, in minority communities, where mistrust prevails due to historic racism, and limited English proficiency is common, these messages, and the appropriate messengers, weren’t available.

Multicultural media tried its best. But a lack of physicians of color to deliver key messages, and a lot of messages being delivered in English, created a vacuum in good information. Not surprisingly, this was filled by misinformation. So, many communities didn’t get important information early, shared by someone they could trust and easily understand, and presented in their language. Time lost led to lives lost.

Physical structures of systemic inequities helped drive illnesses and deaths

COVID-19 is a respiratory virus that is easily spread from person to person through droplets, and aerosols produced when people breathe, talk, cough, or even sing. This means proximity increases risk, thus the push to social distance, and more recent mandates about wearing masks. To make matters more complicated, a person can have COVID-19 for 10 to 14 days and be asymptomatic, spreading the virus easily and unknowingly to friends, family, coworkers, and those who stood close by on public transportation.

So, what have we learned since last spring about who is at highest risk for COVID-19? It’s those who live in densely populated areas; those who have multiple and multigenerational households in small living spaces; those deemed essential workers — health care support services, food services, and more — who don’t have the luxury to work from home, have groceries delivered, or socially isolate themselves; and those who depend on public transportation to get to work, and thus can’t travel safely in their car, or afford parking when they get to work.

Minorities aren’t more genetically susceptible to COVID-19. Instead, all of the factors described here are the social conditions in which minorities and vulnerable communities are more likely to live and move around in this world every day. Only by building from this understanding can we hope to shift the narrative, and change the headlines before cases surge this winter.

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Treating mild hypothyroidism: Benefits still uncertain

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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Discrimination, high blood pressure, and health disparities in African Americans

Over the past few months, we have all seen the results of significant disruption to daily life due to the COVID-19 pandemic, high levels of unemployment, and civil unrest driven by chronic racial injustice. These overlapping waves of societal insult have begun to bring necessary attention to the importance of health care disparities in the United States.

Direct links between stress, discrimination, racial injustice, and health outcomes occurring over one’s lifespan have not been well studied. But a recently published article in the journal Hypertension has looked at the connection between discrimination and increased risk of hypertension (high blood pressure) in African Americans.

Study links discrimination and hypertension in African Americans

It has been well established that African Americans have a higher risk of hypertension compared with other racial or ethnic groups in the United States. The authors of the Hypertension study hypothesized that a possible explanation for this disparity is discrimination.

The researchers reviewed data on 1,845 African Americans, ages 21 to 85, enrolled in the Jackson Heart Study, an ongoing longitudinal study of cardiovascular disease risk factors among African Americans in Jackson, Mississippi. Participants in the Hypertension analysis did not have hypertension during their first study visits in 2000 through 2004. Their blood pressure was checked, and they were asked about blood pressure medications, during two follow-up study visits from 2005 to 2008 and from 2009 to 2013. They also self-reported their discrimination experiences through in-home interviews, questionnaires, and in-clinic examinations.

The study found that higher stress from lifetime discrimination was associated with higher risk of hypertension, but the association was weaker when hypertension risk factors such as body mass index, smoking, alcohol, diet, and physical activity were taken into consideration. The study authors concluded that lifetime discrimination may increase the risk of hypertension in African Americans.

Discrimination may impact hypertension directly and indirectly

Discrimination is a chronic stressor that has been proposed to contribute to adverse health outcomes, including hypertension. Discriminatory acts may directly impact hypertension via the stress pathway, triggering a rise in hormones that cause blood vessels to narrow, the heart to beat faster, and blood pressure to rise. Discrimination may also contribute to the development of hypertension through unhealthy behaviors, such as unhealthy eating or sedentary lifestyles. People may even avoid seeking medical care due to concern that they will experience discrimination in a medical setting.

Two other longitudinal studies (a type of study that follows participants over time) have examined discrimination and hypertension. A 2019 study published in Annals of Behavioral Medicine found that everyday discrimination may be associated with elevated hypertension risk among a sample of white, African American, Latino, and Asian middle-aged women. Another 2019 study in the International Journal of Environmental Research and Public Health found association between chronic discrimination and hypertension in a large sample of African American women.

Disparities are evident across health indicators

Racial and ethnic health disparities are reflected in a number of national health indicators. For example, in 2002, non-Hispanic Blacks trailed non-Hispanic whites in the following areas:

• people younger than 65 with health insurance (81% of non-Hispanic blacks versus 87% of non-Hispanic whites)
• adults 65 or older vaccinated against influenza (50% versus 69%) and pneumococcal disease (37% versus 60%)
• women receiving prenatal care in the first trimester of pregnancy (75% versus 89%)
• adults 18 and older who participated in regular moderate physical activity (25% versus 35%).

In addition, non-Hispanic Blacks had substantially higher proportions of deaths from homicide, and children and adults who were overweight or obese, compared to non-Hispanic whites.

Many factors contribute to health inequities

For African Americans in the United States, health disparities can mean earlier deaths related to development of chronic disease such as diabetes, hypertension, stroke, heart disease, decreased quality of life, loss of economic opportunities, and perceptions of injustice. In our society, these disparities translate into less than optimal productivity, higher health care costs, and social inequity.

It is clear that multiple factors contribute to racial and ethnic health disparities. These include socioeconomic factors such as education, employment, and income; lifestyle factors like physical activity and alcohol intake; social and environment factors, including educational and economic opportunities, racial/ethnic discrimination, and neighborhood and work conditions; and access to preventive health care services such as cancer screening and vaccination.

The solution to health disparities for African Americans is certainly within our societal grasp. It requires leadership at a state and national level, appropriate resource allocation, and larger and more focused clinical investigation.

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Shorter dream-stage sleep may be related to earlier death

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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Learning to live well with a persistent illness

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

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

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.

The post Getting the best treatment for your fibromyalgia appeared first on Harvard Health Blog.

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Hormonal treatments for prostate cancer may prevent or limit COVID-19 symptoms

Men have roughly twice the risk of developing severe disease and dying from COVID-19 than women. Scientists say this is in part because women mount stronger immune reactions to the disease’s microbial cause: the infamous coronavirus called SARS-CoV-2.

Now research with prostate cancer patients points to another possible explanation, which is that the male sex hormone testosterone helps SARS-Cov-2 get into and infect human cells.

SARS-CoV-2 initiates infections by first latching onto its human cell receptor. But it can only pass into a cell with the aid of a second protein called TMPRSS2. Testosterone regulates TMPRSS2, such that levels of the hormone and the protein rise and fall together in tandem. If testosterone levels are depressed, scientists speculate, then TMPRSS2 levels might also be so low that the novel coronavirus is blocked at the gates.

At least five clinical trials are now investigating if drugs acting on testosterone and its own receptor “could either prevent or cure COVID-19 symptoms,” said Dr. Andrea Alimonti from the University of Lugano in Bellanzona, Switzerland.

Positive results from one study

During a recent study, Alimonti’s team reviewed data from 42,434 men who were being treated for prostate cancer in the Veneto region of Italy. Among them, 5,273 were getting androgen deprivation therapies (ADT) that suppress testosterone. (The hormone fuels prostate tumors, so ADT is for some men a mainstay of treatment.) According to that investigation, coronavirus infection rates in the ADT-treated men were four times lower than they were in men who were not getting ADT. The researchers acknowledged the need for more study, but proposed that ADT “could be used transiently in men affected by SARS-CoV-2.”

And negative results from another

Other scientists are skeptical. Dr. Eric Klein, a urologist at the Cleveland Clinic Lerner College of Medicine, argues that testosterone may not regulate TMPRSS2 in the lungs as it does in the prostate. Suppressing the hormone, he says, might therefore have little consequence for preventing SARS-CoV-2 respiratory symptoms. In a recent study of 1,779 men with prostate cancer, Klein and his colleagues generated evidence showing that ADT did not protect from COVID-19. The paper is currently in press at the Journal of Urology and has not yet been published.

Still, Klein stopped short of dismissing the possibility that ADT could be therapeutically useful in treating COVID-19. “Definitive answers will only come from the results of ongoing clinical trials using various forms of ADT in COVID-19 patients,” he said.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, agrees. “These studies — some positive and some negative — add to the complexities of fully understanding what affects coronavirus infectivity,” he says. “It is likely to be multi-factorial, and in some patients, testosterone levels may play a role. Pending results from large-scale clinical studies, however, no definitive recommendations about altering testosterone levels for COVID-19 treatment can be made.”

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