OK, boomer: You’re not the only one who needs testing for hepatitis C

It turns out that many more people than just boomers can benefit from testing for hepatitis C, a viral infection of the liver that often causes no symptoms. If you’re a member of the baby-boom generation (born between 1946 and 1964), your doctor may have already recommended the test. But those born before or after those years may not have known about the test unless they had a risk factor for hepatitis C, such as a history of intravenous drug use. A new guideline is changing this approach.

Why the different recommendations for baby boomers?

In 2012–2013, the CDC and the US Preventive Services Task Force (USPSTF) established guidelines that recommended all baby boomers be screened for hepatitis C. Boomers were singled out because this population had most of the undiagnosed infections.

Screening for hepatitis C is a big deal, because it’s a potentially serious and treatable infection affecting an estimated four million persons in the US and 100 million people worldwide. And, while it’s common to have it without knowing it, liver failure or liver cancer are known complications that could be prevented by screening and treatment.

Studies looking at the effectiveness of screening baby boomers have demonstrated success as well as limitations. In recent years it’s become clear that the fastest growing group of people newly infected with hepatitis C is young adults ages 20 to 39 who would be missed under previous guidelines.

Why not screen everyone?

That’s essentially what newly published guidelines recommend. They suggest that everyone ages 18 to 79 have a one-time screening blood test for the antibody to hepatitis C. This antibody indicates previous exposure to the virus and/or current infection.

All recommendations from the USPSTF are given grades based on how good the evidence is that it will be beneficial. These new guidelines were assigned a “B” grade, meaning that, based on the evidence, there was at least moderate certainty that the screening would provide significant benefit. This designation is important because it means health insurers are likely to cover its cost.

What happens after a screening test is done?

If your screening test for hepatitis C is positive, your doctor will perform a separate test to confirm the results, called polymerase chain reaction (or PCR). If that proves positive, the next steps will include:

• additional tests (such as blood tests and ultrasound) to find out if the liver has significant scarring
• eight to 12 weeks of treatment with an antiviral medication, such as ledipasvir/sofosbuvir (Harvoni), glecaprevir/pibrentasvir (Mavyret),‎‎ or sofosbuvir/velpatasvir (Epclusa), with regular monitoring of virus levels in the blood
• counseling about how to avoid infecting others, since hepatitis C can spread through blood and sexual contact
• regular follow-up to confirm a cure or to detect complications such as cirrhosis or liver cancer.

Liver health is not just about hepatitis C

A healthy liver is important because it performs so many essential functions: your liver removes toxins, produces bile that aids digestion, makes blood proteins that control clotting and fight infection, and stores sugar and iron.

Hepatitis C infection is only one cause of liver disease; there are many others. While keeping your liver healthy may not be something you think about every day, these measures are worth keeping in mind:

• Prevent other viral infections. While we have no vaccine yet for hepatitis C, hepatitis A and hepatitis B can be prevented by vaccination. Other ways to reduce the risk of these viral infections include avoiding contaminated food or water (a source of hepatitis A), and not using intravenous drugs or sharing needles (risk factors for hepatitis B).
• Moderate your alcohol intake.
• Maintain a healthy weight.
• Practice safe sex, and choose your tattoo or piercing parlor carefully.
• Because many medications can affect the liver, take medications only as prescribed and let your doctor know about everything you take, including over-the-counter drugs and supplements.

The bottom line

It’ll probably take a while before the new recommendations regarding screening for hepatitis C will be implemented by doctors, because they are just now hearing about them. In the meantime, if you’ve never been screened for this infection, ask your doctor about it. If you do have this virus, it’s better to know about it sooner rather than later, so you can avoid infecting others and keep your liver healthy.

Follow me on Twitter @RobShmerling

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Have a headache? The top 7 triggers

“Headaches aren’t welcome here” — that’s the sign you have hanging on your brain’s front door, but the pain is barging right in. You can chalk it up to stress from world events or something you ate or drank, and you might be right. But there are a number of common triggers for migraines, tension headaches, or cluster headaches. The faster you identify them, the quicker you can boot headache pain off the property.

What are the triggers for your headaches?

Take note of your circumstances when a headache starts. Keep a diary to track the day, time, symptoms, and circumstances surrounding the pain (what had you eaten? where did it happen?). Common causes of headaches include the following seven triggers.

1. Stress. Stress can cause tight muscles in the shoulders and neck. This often leads to a tension headache, which starts in the neck and back and works its way up to feel like a tight band around your head. “It’s believed to start in the muscles,” says Dr. Sait Ashina, a neurologist who specializes in headache treatment at Harvard-affiliated Beth Israel Deaconess Medical Center. “When tension headaches become frequent, the pain in shoulder and neck muscles is felt by the brain as pain in the head.” Stress is also a common trigger for a migraine headache, which begins on one side of the head, throbs or pounds, makes you sensitive to light and sound, and can last for hours or days.
2. Diet. Eating certain foods often triggers a migraine headache. Migraines may be started by just one type of food — like beans or nuts — or many foods, such as avocados, bananas, cheese, chocolate, citrus, herring, dairy products, and onions. “Processed foods with nitrites, nitrates, yellow food dyes, or monosodium glutamate can be especially problematic,” Dr. Ashina notes.
3. Alcohol intake. Alcohol is a common cause of a migraine headache or a cluster headache — a stabbing pain in the eye that may last hours, go away, and come back several times per day. For some people, a few ounces of red wine are all it takes to provoke a headache, although any kind of alcohol can be a trigger. It’s not clear if the alcohol itself is to blame, or if another component in the drink causes the problem.
4. Environment. “Cluster headaches seem to be seasonal and often happen in the spring or fall,” Dr. Ashina says. “It’s something in the environment, but we can’t tell exactly what it is yet.” Environmental factors such as bright light, smoke, humidity, intense scents, or cold weather are associated with migraine headaches.
5. Hormones. Changes in estrogen levels are associated with migraines in women, and women suffer from migraines more often than men. Menstrual cycles may be tied to migraine in younger women. Varying estrogen levels during perimenopause can sometimes start migraines in women who never experienced them before. Estrogen therapy may also be a migraine trigger. Menopause does seem to end migraines in most women.
6. Caffeine withdrawal. If you normally consume caffeine in coffee or tea, stopping intake abruptly may trigger a migraine. This may be because caffeine causes blood vessels to constrict; without caffeine, the blood vessels widen and bulge out with each heartbeat — a chief reason for the pounding pain of migraines.
7. Lack of sleep. A lack of sleep is associated with migraines and tension headaches. “We don’t know why, but we do know there’s a correlation and that sleep can lead to pain relief. Sometimes people feel better after taking a nap,” Dr. Ashina says.

Next steps to avoid headaches or ease headache pain

If you can associate your headache pain with particular triggers, you can try to avoid them. If that doesn’t help, talk to your doctor. There are many prescription medications, as well as pill-free treatments (acupuncture, meditation, biofeedback, relaxation therapy) that can help reduce headache frequency.

And you’ll need to go a step further: “Make sure you get enough sleep, exercise, eat a healthy diet, limit alcohol intake, and reduce stress,” Dr. Ashina says. “Headaches are a condition of hypersensitivity, so you need balance in your system to fight triggers.”

Finding that balance may be difficult right now, with the world in turmoil. But maintaining good health, and keeping a clear head that’s free of pain, will certainly give your more focus, and maybe even more strength to get through this challenging time.

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Thinning hair in women: Why it happens and what helps

Many people think of hair loss as a male problem, but it also affects at least a third of women. But unlike men, women typically experience thinning hair without going bald, and there can be a number of different underlying causes for the problem.

“Some are associated with inflammation in the body. Some are female-pattern hair loss,” says Dr. Deborah Scott, assistant professor of dermatology at Harvard Medical School and co-director of the Hair Loss Clinic at Brigham and Women’s Hospital. But the good news is that in many cases this hair loss can be stabilized with treatment, and it may be reversible. When it’s not, there are a number of new cosmetic approaches that can help.

Understanding hair loss

The first step in dealing with thinning hair is determining what’s happening inside your body that is causing those extra strands to cling to your shoulders and your brush. Some hair loss is normal. Everyone loses hair as part of the hair’s natural growth cycle, which occurs in three stages:

• The anagen stage refers to when a hair strand is actively growing. This stage can last anywhere from two to eight years.
• The catagen stage is a short transition phase that lasts up to three weeks. At this point the hair has stopped growing and is preparing to shed.
• The telogen stage is the part of the hair cycle when the hair is expelled from the follicle (the structure that produces and holds the hair). After the hair sheds, the follicle then stays dormant, typically for around three months, before a new hair starts to sprout.

Normal hair loss is highly individual. Most people have a sense of how much hair is normal for them to lose. If you suddenly notice more hair than usual falling out, you’re shedding clumps of hair, or your hair seems to be visibly thinning, it may be a sign that something is amiss, says Dr. Scott.

Underlying causes for hair loss

Numerous problems can trigger female hair loss. Some are external, such as taking certain medications, frequently wearing hairstyles that pull the hair too tight, or even a stressful event such as surgery. In other cases, thinning hair is triggered by something going on inside the body — for instance, a thyroid problem, a shift in hormones, a recent pregnancy, or an inflammatory condition.

Hair loss may also be genetic. The most common genetic condition is known as female-pattern hair loss, or androgenic alopecia. Women with this condition might notice a widening of the part at the top of the head, often beginning when a woman is in her 40s or 50s. You might experience this if you inherit certain genes from one or both parents. Hormonal shifts that occur during menopause may also spur it.

Another trigger for hair loss in women is an inflammatory condition affecting the scalp. That might be eczema, psoriasis, or a condition called frontal fibrosing alopecia, which typically causes scarring and hair loss — sometimes permanent — at the front of the scalp above the forehead.

Other common causes of hair loss include overuse of damaging hair products, or tools such as dryers and other devices that heat the hair. Underlying illness, autoimmune conditions such as lupus, nutritional deficiencies, or hormonal imbalances may also cause hair to shed.

Medications to treat hair loss

Treatment depends on the underlying cause, says Dr. Scott. Sometimes simply addressing a medical condition prompting hair loss will be enough for the hair to regrow. In other instances, a woman might consider a medication like minoxidil (Rogaine), which helps with certain types of hair loss, or another treatment to replace or regrow lost hair.

A newer option being used to treat hair loss is platelet-rich plasma (PRP) injections. For this treatment, the doctor draws your blood, divides it into its separate components, recombines the blood fluid (plasma) with a high concentration of platelets (structures in the blood that help with clotting, among other functions), and introduces the resulting preparation back into the scalp.

“The science on this isn’t totally worked out. We still don’t completely understand the mechanism behind PRP, but growth factors contained in platelets can stimulate regeneration of hair follicles and other tissues as well,” says Dr. Scott.

In addition, low-level LED laser lights have been found to be helpful in regrowing hair in some cases. It’s likely that even more treatments will be developed in the near future.

Cosmetic options for hair loss

When medical treatments fall short, women can also consider cosmetic options to make up for lost hair, such as wearing a wig. At the other end of the spectrum is hair transplantation, a surgical procedure that moves active follicles from the back of the scalp to areas where the hair is thinning. Once transplanted, the hair grows normally.

Hair transplantation is typically performed as an outpatient surgical procedure. In appropriate patients, it can be extremely successful, but it won’t work for everyone, says Dr. Scott. One drawback is the expense: it can cost thousands of dollars and is not covered by insurance. The procedure also requires recovery time. And it may not be appropriate for women who have diffuse thinning across the whole scalp. It’s more effective in treating smaller, more defined areas of balding.

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Strategies to promote better sleep in these uncertain times

These are unprecedented times. Given the real and tangible threat of the coronavirus pandemic on personal, community, and societal levels, it is normal to experience anxiety and sleep problems. Sleep is a reversible state marked by a loss of consciousness to our surroundings, and as members of the animal kingdom, our brains have evolved to respond to dangers by increasing vigilance and attention — in other words, our brains are protecting us, and by doing so it’s harder for us to ignore our surroundings.

Despite the threat of the coronavirus and its rapid and pervasive disruption to our daily lives, many of us are an in a position to control our behaviors and dampen the impact of the emerging pandemic on our sleep. Cultivating healthy sleep is important; better sleep enables us to navigate stressful times better in the short term, lowers our chance of developing persistent sleep problems in the longer term, and gives our immune system a boost.

Daytime tips to help with sleep

• Keep a consistent routine. Get up at the same time every day of the week. A regular wake time helps to set your body’s natural clock (circadian rhythm, one of the main ways our bodies regulate sleep). In addition to sleep, stick to a regular schedule for meals, exercise, and other activities. This may be a different schedule than you are used to, and that is okay. Pay attention to your body’s cues and find a rhythm that works for you and that you can maintain during this “new normal.”  Make this a priority for all members of your household.
• Get morning light. Get up, get out of bed, and get some light. Light is the main controller of the natural body clock, and regular exposure to light in the morning helps to set the body’s clock each day. Natural sunlight is best, as even cloudy days provide over double the light intensity of indoor lighting. If you are living in an area with shelter-in-place, try to expose yourself to natural light by stepping outside, at a distance from others, for at least 20 minutes.
• Exercise during the day helps improve your sleep quality at night, reduces stress, and improves mood. Fit in exercise as best as you can. If you need to go outside for exercise, maintain proper social distancing at least six feet away from others. Avoid any group exercise activities, especially contact sports. Many gyms and yoga studios are now “at home” and offering virtual programs at low or no cost.
• Don’t use your bed as an escape. While the gravity of the pandemic certainly makes us all tired, try not to spend too much time in bed during the day, especially if you are having trouble sleeping at night. If you must take a nap, try to keep it short — less than 30 minutes.
• Avoid caffeine late in the day.
• Helping others may help with feelings of uncertainty or unease. Even if you do not work in an “essential” industry, your role in maintaining physical distance is critical in our fight against coronavirus. If you would like to be more actively involved in helping people, seek out ways to contribute your skills, donate money, or leverage your social capacity locally, such as providing virtual social connection to your loved ones by checking in on elderly family members or a friend, or providing in-kind donations. Doing altruistic acts may provide a sense of purpose, reduce helplessness, and alleviate some of the uncertainty contributing to sleep problems.

Nighttime tips to help with sleep

• Prepare for bedtime by having a news and electronic device blackout. Avoid the news and ALL electronics at least one hour before bedtime. Avoid the news and ALL electronics at least one hour before bedtime. (Yes, it’s so important, I am saying this twice!) The nonstop news cycle seldom provides new information in the evening hours that you can’t wait until morning to hear, and will likely stimulate your mind or incite fear, making it harder to fall and stay asleep. Remind yourself by setting a timer or putting your television on the sleep setting. Make a pact with your family members to respect these parameters.
• Cell phones, tablets, and all electronic devices make it harder for your brain to turn off, and the light (even dim light) from devices may delay the release of the hormone melatonin, interfering with your body clock. If you need something to watch to help you unwind, watching something that you find relaxing on TV from far away and outside the bedroom is likely okay for a limited time. You can also curl up with a book or listen to music.
• Minimize alcohol intake. While alcohol can help people fall asleep, it leads to more sleep problems at night.
• Set a regular bedtime. There are certain times at night that your body will be able to sleep better than others. If you feel sleepy but your brain is busy thinking, it can’t shut off and go to sleep. It may be helpful to sit down with a pen and paper in the evening and write down the things that worry you; you can review this list in the morning and attend to any important concerns. If you have a bed partner, enlist their support to helping you stick to your schedule.
• Reduce stress. The evening and bedtime hours are also a good time to perform some relaxation techniques, such as slow breathing or yoga. There are many free resources available for bedtime meditation.
• Create a comfortable sleep environment, a place that is cool, dark, and quiet.
• Don’t spend too much time in bed during the night (or the daytime). Minimize spending time in bed in which you are not sleeping. If you are having trouble going to sleep or staying asleep, don’t stay in bed for more than 20 minutes. Get out of bed and do a quiet activity — read a book, journal, or fold some laundry.

What if I am doing all these things and I still can’t sleep?

This may be a sign that you have a clinical sleep problem, such as insomnia disorder or sleep apnea. If you are doing all the right things, and still have trouble falling or staying asleep, you should discuss your sleep problems with your doctor.

What if I have been diagnosed with a sleep disorder?

If you have a history of insomnia and take sleep medications and can’t sleep, contact your doctor for medical advice, including questions about making changes in your medication. Many doctors are doing virtual visits now and they can review your current sleep problems and changes to management. You can also consider online programs for insomnia, such as Sleepio.

If you have obstructive sleep apnea you can check out the American Academy of Sleep Medicine guidelines for COVID-19 related questions.

Remember, don’t stress out about sleep

Disrupted sleep is a normal response to stress, and it is okay to have a few nights of poor sleep as you adjust to new routines and big changes to your work and personal life. But with some simple measures you can preserve your sleep and improve your well-being during these uncertain times. We can’t control what’s happening in the world right now, but we can control our behaviors and dampen the impact of the emerging pandemic on our sleep

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Coping with the coronavirus pandemic for people with anxiety disorders

These days, we all have to accept the anxiety inherent in living in the time of the coronavirus pandemic and COVID-19. If there was a way to dispel all anxious feelings, I’d tell you, but there isn’t. The one exception might be someone who could summon such a degree of denial that they carry on as if everything was normal. And that, as I’m sure you can see, would prove to be very, very unwise.

Anxiety helps us prepare to respond in a more adaptive and healthy way. Some people find it possible to tolerate some degree of discomfort and can manage their anxiety in a healthy manner. Often that’s because some people have done well under this kind of challenge already, albeit in very different contexts. Life has a way of requiring this. Yet other people — particularly people who have anxiety disorders — may understandably be having a great deal of trouble coping.

How can I cope with the coronavirus outbreak if I have a pre-existing anxiety disorder?

Anxiety disorders take many forms and affect many people. So, what happens now if you’re someone who has suffered way too much already with a pre-existing anxiety disorder? For example, perhaps you have been, or could be, diagnosed with panic disorder, post-traumatic stress disorder (PTSD), or obsessive-compulsive disorder (OCD). Hopefully, you may find that the tips below will help you cope more successfully with what we are all facing together in these unprecedented times.

Seek support from a mental health professional

Talking to a mental health professional can bolster your ability to address present concerns, and help you clarify where your feelings are coming from, as explained below. When you’re feeling extra worried or overwhelmed, it could be that some of your feelings are from the present challenge and some are from challenges you have faced in the past.

Many psychotherapists and health plans are offering telehealth visits during this time. Ask your therapist or insurance plan if this is an option. More therapists than ever before are moving their practices online. If you search for therapists in your area, their websites may tell you whether they participate in telehealth. Additionally, some national telehealth apps offer therapy via video or audio chat.

Work toward separating out where your feelings are coming from

Doing this work can allow you to take a breath and divvy up the different emotional contributions that feed how you’re feeling.

• Try saying this, for example: “Of course, I’m more concerned than (my roommate/my friend/my family), because I’m practiced at feeling anxious or helpless.”
• The next step is to recognize that the percentage of feelings that stem from the past do not have to govern how you necessarily feel in the present. Try saying this out loud: “Well that was then, this is now.” A simple statement like this can actually open the door to some significant relief.
• Gently remind yourself of this crucial separation, cleaving the past from the present. And kindly and reassuringly remind yourself that you have the resources — both internal and external — to manage your feelings and reactions in the now. This is crucially important.

Keep providing yourself with guidance

As often as you need to hear it, tell yourself the following: “I can manage. I can practice what I know to be helpful, and I know that in managing my feelings and reactions I can seek support from a few close friends. Further, I can seek the support of a mental health professional when needed. By combining these strategies, I will be able to settle my nerves in order to be able to make healthy choices.”

This kind of mantra bears repeating over and over. This is not “fake it till you make it.” This is believing in yourself and believing in a course of action that you can set in motion. Try to believe that, together with supportive others, this self-guidance and this plan will work for you. Know that in many instances, people who have known tremendous adversity and even trauma are able to demonstrate a strength forged from those circumstances. This is entirely consistent with human abilities.

Drawing on what you’ve learned can help you cope

We are wired for fight or flight. But as a colleague of mine noted, the present situation does not require either of these. If you’re a human who’s been challenged, or somewhat disabled, by anxiety in the past, I encourage you now to draw upon what you’ve learned in terms of how you can manage successfully.

Separating out feelings from the past, reminding yourself that you have the strength and ability in the present to prevail, seeing a path forward for yourself and setting yourself upon that path is the way forward. If along that way you should stumble and fall, picture yourself as able to pick yourself back up and carry on. Reassure yourself that the basic provisions for your safety and well-being are within your power to meet. In my book, every day that you are able to do so, counts as a very good day indeed.

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Why follow a vaccine schedule?

Right now, many people are hoping for a vaccine to protect against the new coronavirus. While that’s still on the horizon, new research suggests that families who do vaccinate their children may not be following the recommended schedule.

Vaccines are given on a schedule for a reason: to protect children from vaccine-preventable disease. Experts designed the schedule so that children get protection when they need it — and the doses are timed so the vaccine itself can have the best effect. When parents don’t follow the schedule, their children may not be protected.

And yet, many parents do not follow the schedule.

A third of families change vaccine schedule

In a study recently published in the journal Pediatrics, researchers looked at data from the National Immunization Survey from 2014 and found that only 63% of families followed the recommended vaccination schedule for their children. The majority of those who didn’t followed an alternate schedule, spacing vaccines out, skipping some, or doing a combination of both.

The study did not include the influenza vaccine, one that many parents choose not to give. The vaccines in this study were routine vaccines, given to all children and required for many schools and daycare programs.

Not surprisingly, children whose parents used an alternate vaccine schedule were four times as likely to be behind in their immunizations or missing vaccines entirely. This can be very dangerous.

In the first two years of life, vaccines protect babies and toddlers against:

• pneumococcus and Haemophilus Influenzae, bacteria that can cause serious infections
• pertussis (whooping cough), which can be fatal in infants
• polio, which can cause a paralysis that can be fatal
• diphtheria, a serious respiratory illness
• rotavirus, a diarrhea that can lead to serious dehydration in young infants
• measles, which can cause pneumonia and neurological problems
• mumps, which causes swollen glands in the neck and can sometimes lead to complications
• rubella, or German measles. If women catch it during pregnancy, it can lead to miscarriage or birth defects.
• varicella (chicken pox). While most infections are mild, the rash caused by chicken pox can get infected and the virus itself can affect the lungs or brain.
• hepatitis B and hepatitis A, both infections of the liver. Hepatitis B infections can be chronic and lead to liver damage.

Having vaccines on schedule protects babies and children vulnerable to disease

Parents sometimes worry about giving several vaccines at once, something that the schedule calls for, especially at the 2, 4, and 6-month visits. Not only is it safe, but when parents spread out the schedule it takes longer before the child is protected, leaving babies vulnerable to these diseases. It also means more visits to the doctor: the study found that babies whose parents used an alternate schedule had three more vaccination visits than babies whose parents followed the recommended schedule.

Parents also worry about side effects of vaccines, and other risks, often fueled by information they get on social media. Not every person who gets these infections has a serious case or complications. But the risk of a complication of the disease is always higher than the risk of the vaccine, an important fact that sometimes gets lost in the vaccine discussion.

Another important fact is that when children get behind on vaccines, it can put others at risk as well. When enough of the community is vaccinated, it makes disease less likely to spread. This is particularly important for those who aren’t fully vaccinated, such as newborns, and those who can’t be vaccinated, such as children who are taking medications that suppress the immune system. Parents often forget that the decisions they make about immunization affect more people than just their child.

It’s normal for parents to have questions and worry about medical treatments given to their children. After all, it’s a parent’s job to worry. But as parents question and worry, it’s really important that they get reliable medical information from expert sources. The Centers for Disease Control and Prevention, as well as immunize.org and the American Academy of Pediatrics, have lots of accurate and useful information, and parents should always talk to their child’s doctor if they have concerns.

The bottom line for parents

Think long and hard, and get information from reliable sources, before you change your child’s vaccine schedule. The schedule is there to protect your child — and everyone around your child.

Follow me on Twitter @drClaire

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Apps to keep us connected in a time of social distancing

If you’re wondering how to stay in touch during this time of social distancing, take heart: thanks to technology, chatting with and even seeing others has never been easier — and frankly, it’s never been more important. “Isolation cuts against our natural impulses that have evolved to make us fitter, healthier, and safer. That is probably why it can be so uncomfortable to be isolated for extended periods of time,” says Dr. Michael Craig Miller, assistant professor of psychiatry at Harvard Medical School.

Where to start in getting connected

There are lots of tools to connect with others via smartphone, computer, or tablet. They work anywhere in the world where internet or cellular service is available, although some countries may ban certain apps.

Using an app is simply a matter of downloading it to your device and inviting your contacts to do the same. (If you’re not sure how to do this, you can search online for a quick video tutorial — just specify whether you’re downloading the app to your phone, or a tablet or computer.)

Follow instructions on the app to find people you know. On some apps, names of your acquaintances will pop up in a window if you allow the app to gain access to your contacts. Otherwise, you’ll need to enter the contact’s phone number or user name. Once the contact information is in place, messaging or calling is just a matter of clicking on a name.

Most of these apps are free, but they use data quickly. So, if you rely on cellular service to connect to the internet, but don’t have a plan on your smartphone or tablet for unlimited data, you may rack up hefty overage fees.

Which apps should I use?

Not sure which app meets your needs? Consider the following ways to connect with others.

WhatsApp (www.whatsapp.com). This popular platform allows you to send text messages and make phone calls (with or without video). The app also enables you to send and receive videos, documents, and voice messages.

Snapchat (www.snapchat.com) offers a way to send fun messages and short videos. The app features filters that augment images by adding silly hats, eyes, noses, voices, and stickers. You can take a number of “snaps” and send them in chronological order for a “story” that you share with others. Another feature: messages are automatically deleted after a brief time. You can also use Snapchat to send standard text messages and make video phone calls.

Google Duo. This app (duo.google.com) is a video conferencing platform. You can make video calls to just one person or with up to eight people. You can also leave video messages for people you call — a nice feature that others can play again and again if they’re missing you.

FaceTime (www.apple.com) is an app that comes preloaded onto any Apple device, including smartphones, desktop computers, and tablets. The app allows you to call people around the world — just one person or as many as 32 people at a time (although you might not see them all at once). If you don’t have an internet connection, this app also works on cellular connections alone. You’ll need your contacts’ phone numbers to contact them. A caveat: this app works only with other Apple devices.

Note: Android phones also come with built-in apps that enable video calls, although the particular app can vary by phone. Changing from an audio-only call to a video call, no matter which type of Android phone you have, is typically a matter of pressing the video icon on your keypad.

Videoconferencing platforms. Two popular platforms include Zoom (www.zoom.com) and Skype (www.skype.com). Zoom is typically used by schools and businesses because the app can host up to 1,000 people in a video meeting. The app is free with limitations. For example, Zoom is free for calls between two people for 24 hours, and free for up to 100 people for 40 minutes; but there are charges to add additional participants or meeting minutes. Some restrictions and fees are being suspended during the coronavirus crisis. Skype can host up to 50 people at a time, and you can use it with or without video.

Netflix Party (www.netflixparty.com). This new app is an extension of Google Chrome that encourages watching movies and TV shows together, even when you’re far apart. The app allows you to watch a program on the Netflix video streaming service at the exact same time as other users, and chat about it in real time.

Which app is best for you?

While nothing substitutes for being with someone in person, Dr. Miller says you probably will get a lot of benefit from being able to see another person’s face while speaking via computer or smartphone. Any contact, he notes, will ease the pain of social distancing and keep you connected during this difficult time. “Humans are social creatures by nature, so use the tools you have to see a loved one’s face, to share stories, to let them know you’re thinking of them,” he says. “It’s corny, but share the love you have for another person. Odds are, you’ll both feel better.”

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Harvard Health Ad Watch: What’s being cleansed in a detox cleanse?

Lately, I’ve been hearing a lot from patients and friends who are enthusiastically pursuing a “whole body cleanse” or “colon cleanse,” or a “detoxification cleanse.” And I’ve seen ads about these cleanses promising a number of health benefits, based on the general principle that every so often it’s a good idea to rid yourself of toxins that are undoubtedly accumulating within you.

Spring cleaning for your body? The idea goes back centuries. And sure, cleansing — or cleaning — is clear enough for bathing or mopping a floor. But how does a cleanse work in the human body? Do cleanses really deliver on their claims?

Let’s start with the name

Cleanses go by many names and descriptions, including:

• Colon cleansing, also called a “colonic” or “colonic irrigation.” Large amounts of water and other substances, such as coffee or herbs, are flushed through the colon via a tube placed into the rectum.
• Detoxification (or detox) diets with names like “Super Cleanse,” “Full Body Cleanse Express,” and “Antioxidant Cleanse.” These are specific, often restrictive diets that last a few days to a month and consist largely of liquified vegetables, fruit juices, and spices.
• Periodic fasting to take a break from your usual (and potentially harmful) diet, which is presumed to include an array of toxins, synthetic chemicals, and other poisons. Fasting is often a part of detox diets.

Does it make sense?

If you’ve seen the ads I’ve seen, it doesn’t just make sense — it seems like something we should all be doing regularly! Cleansing means cleaning and who doesn’t like clean?

But it’s not that simple. The normal intestinal tract is teeming with bacteria. While dietary changes, medications, and even exposure to other people (and pets!) can change your intestinal flora, scientific reality dictates that you can’t “cleanse” your body through diet or “detoxify” your colon. It’s not even clear what toxin or toxins a cleanse is supposed to remove, or whether this actually happens.

Advocates of cleanses would argue it makes intuitive sense. You’ll find plenty of testimonials from people who report feeling better in a number of ways (see below) after completing a cleanse. Predictably, the answer to whether a cleanse is a good idea depends on who you ask.

What the ads say

Claims vary by product, but ads often promise a cleanse will

• increase your energy level, focus, and sense of well-being
• help you lose weight
• improve circulation
• reduce inflammation (and as a result, relieve arthritis pain and suppress autoimmune disease)
• remove toxins from urine, stool, and sweat.

Some ads promise specifics, such as “strengthening the liver, blood, and colon.” What? There are claims about increased sex drive, better mood, and fewer cravings for junk food. According to the ads, the number of ways a cleanse can help seems endless.

What the evidence says

There’s a stark contrast between powerful claims made by those promoting various cleanses and the scant evidence that they do anything good for your health. Searching the medical literature for “detox diets” or “cleanse diets” yields almost no relevant, high-quality medical evidence demonstrating health benefits. For example:

• A lemon detox diet is often cited as evidence supporting detox diets to improve health. A single study found that overweight women following a very-low-calorie diet with “organic maple and palm syrups and lemon juice” reduced body fat and insulin resistance, and had lower levels of inflammation. However, the study was small, lasted only 11 days, and most of the positive changes were also observed among subjects on a similarly calorie-restricted diet without lemon juice.
• A review of detox diets for weight control and toxin elimination stated that “Although the detox industry is booming, there is very little clinical evidence to support the use of these diets.”
• A review of colonic cleanses concluded that “The practice of colonic cleansing to improve or promote general health is not supported in the published literature and cannot be recommended…”

Remember, health claims for cleanses have not been evaluated by the FDA. Read the product disclaimers before you buy and use these products!

Could a cleanse be potentially harmful?

Just as there is limited evidence of benefit associated with detox or cleanse programs, there is limited evidence of harm. However, there are reports of side effects and complications. Examples include:

• kidney failure linked to the use of a juice cleanse diet, including a green smoothie cleanse
• irritability
• fatigue
• vitamin and mineral deficiencies
• dehydration, abdominal cramping, and nausea (with colonic cleanses)
• diarrhea (especially since some cleanse diets include laxatives).

And there’s also cost to consider; product costs are not covered by most health insurance. I found ads for detox diet programs charging $15 to more than $250. Some recommended repeating the program periodically, so the cost can be considerable.

The bottom line

I know there are many people who find intermittent detox diets or cleanses useful, and firmly believe they improve health. And the ads for these programs are filled with glowing testimonials. “It has been an awakening for me!” “I’ve never had this much energy! “Toxins were leaving my body through my pores and digestive system… better sleep, increased energy levels, and I lost weight.“ This one seemed directed at me: “I don’t care who says what about this detox, this stuff works!!! Day 12, no exercise, down 19 pounds!”

Still, given the lack of evidence supporting their use, the risks associated with their use (even if small), and their lack of regulation, it’s hard for me to be enthusiastic about the use of detox diets or cleanses. If you’re concerned about toxins in your body, I say choose a healthy diet and avoid pollution, pesticides, and other harmful substances as best you can. Leave the detoxification to the professionals: your kidneys, liver, and other self-cleaning organs of your body.

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Can telehealth help flatten the curve of COVID-19?

Telehealth, the virtual care platforms that allow health care professionals and patients to meet by phone or video chat, seems tailor-made for this moment in time. Also known as telemedicine or digital health, it’s often touted as a convenience for patients who are busy or far away, or when travel isn’t feasible due to severe weather or an urgent condition like a stroke. The current crisis makes virtual care solutions like telehealth an indispensable tool as COVID-19 spreads across US communities. As director of the Center for TeleHealth at Massachusetts General Hospital and vice president of virtual care for Partners Healthcare, I believe it can help flatten the curve of infections and help us to deploy medical staff and lifesaving equipment wisely.

How can telehealth help during the COVID-19 outbreak?

While it’s likely many people will become infected with the coronavirus that causes COVID-19, most will not get seriously ill. Those at greatest risk are over 60, or have underlying health conditions or a compromised immune system. The number one job for all of us is to avoid becoming a carrier and distributor of the virus. By using virtual care for much regular, necessary medical care, and deferring elective procedures or annual checkups, we free up medical staff and equipment needed for those who become seriously ill from COVID-19. Additionally, by not congregating in small spaces like waiting rooms, we thwart the ability of the virus to hop from one person to another. Keeping people apart is called “social distancing.” Keeping healthcare providers apart from patients and other providers is “medical distancing.” Telehealth is one strategy to help us accomplish this.

How can medical staff use telehealth to decide who should come to the hospital?

We think that patients with minor symptoms of COVID-19, such as cough and body aches, can rest at home, drinking fluids and treating this like any flulike illness. Test kits are in short supply and currently being used mainly for certain groups: for example, patients who are high-risk or seriously ill, and medical staff who have symptoms or have been exposed to COVID-19, to help prevent further spread of illness. Telehealth uses video chat, or even a simple phone call, to allow medical staff to ask specific questions and gather information to find out whether care is urgently needed, or if a person can continue to self-monitor symptoms at home while recovering. It can also be used for regular check-ins during recovery, as needed.

How can you make the best use of a clinician’s time on the call?

In the US, health care providers are following guidance provided by the Centers for Disease Control and Prevention (CDC), state and local health departments, and hospital infectious disease experts. The screening questions a clinician asks during the call help establish if a person is in a low-, medium-, or high-risk group, and if they have mild, moderate, or severe symptoms of upper respiratory infection that could be due to COVID-19.

By quickly and consistently gathering key information, the clinician you speak with can help determine if you need to see a doctor or go to the hospital for care, or if you are better off staying at home while recovering.

• Before you call write down your symptoms, whether you have a fever, and whether you’ve taken any medicine.
• Be ready to answer a few questions that might seem tedious or irrelevant, such as where you have traveled recently. As the infection becomes more widespread, travel questions will be less necessary, since it becomes more likely that you caught it within your own community.
• Try to resist the urge to ask reasonable but nonmedical questions that are time-consuming: “Should I cancel our family summer vacation?” or “Can I catch this from petting my neighbor’s dog?” Many calls to triage hotlines go unanswered because call volumes are high. Keeping calls short allows clinicians to help more people. If you have questions about the coronavirus or COVID-19, visit reliable websites, such as the CDC or World Health Organization, to get answers. The CDC website offers information on how to protect yourself and what to do if you’re sick.

What telehealth services are available to me?

If you have health insurance, find out if your plan has an option for telehealth services. If not, several well-known national companies provide services for a fixed fee. Your doctor may be able to suggest a specific service, or you can search for “online urgent care” or “telehealth companies in US” or “telemedicine companies in US.”

Medicare and many health plans are currently reimbursing many types of health care providers for telehealth visits.

How can we help one another?

These are challenging times. Let us look to each other for support, kindness, and compassion. We must protect and care for each other, and lend a hand where we can, all while keeping a safe distance. There is nothing we cannot endure if we keep our humanity front and center, and carefully steward our shared resources. We have enough key health care workers — including but not limited to doctors; nurses; physical, occupational, speech, and respiratory therapists; and social workers — to care for the sick if we can slow the pace at which infection is spreading. We need your help to manage this. It’s well past opening night and we all have a part to play.

For more information about coronavirus and COVID-19, see the Harvard Health Publishing Coronavirus Resource Center.

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Opportunities for growth: Transitions for youth with autism spectrum disorder

Autism spectrum disorder (ASD) is a lifelong condition that affects a person’s social and communication skills. People with ASD can have repetitive behaviors, a narrow range of interests, a strong preference for sameness, and sensory processing differences. The number of children diagnosed with ASD has increased dramatically over the past several decades. Because of this, growing numbers of youth with ASD are now making the developmental transition from adolescence to adulthood. This transition is marked by changes in many areas of life, including new healthcare providers, educational or occupational settings, and living arrangements.

What makes the transition to adulthood particularly challenging for youth with ASD?

There are several features of ASD that add challenges to the transitions of adulthood, including a strong preference for sameness and a difficulty tolerating change. Communication difficulties can also complicate expressing distress or asking for help. Young adults with ASD may also find it difficult to participate in more complex social relationships. Finally, many people with ASD are very detail-focused but have difficulty taking into consideration the larger context, which can affect planning and organizing.

What are some ASD-specific transitional needs?

Youth with ASD also have some specific transitional needs in terms of healthcare, education, employment, and independent living. They are more likely to have active medical needs and require a healthcare team that is familiar with ASD. Unfortunately, many adult healthcare providers receive very little ASD-specific training regarding common medical and psychiatric comorbidities, as well as the pragmatics of working with adults with ASD.

Helpful strategies for healthcare providers include adjusting the lighting in the examination room, being flexible as to where the patient sits, scheduling “practice visits,” minimizing wait times, and booking patients with ASD for either the first or last appointment of the day. Also, many young adults with ASD transition from their parents’ private health insurance plan to a public insurance plan, which can limit access to certain providers. Finally, many youth with ASD feel anxious about managing their own medical conditions. Parents also express concern about whether their adult child is capable of making their own medical decisions, and in some cases seek guardianship (a court-ordered arrangement in which a person is given authority to make decisions on behalf of another person), particularly when there is significant comorbid intellectual disability.

The transition to adulthood also marks an important change in the educational setting. The Individuals with Disabilities Education Act (IDEA) mandates that public education be available from ages 3 to 21. When an adult with ASD turns 22, he or she is expected to transition out of the school environment. This may result in loss of services, since many of these supports, including speech, behavioral, and occupational therapy, are provided through school. Leaving school can also result in loss of established social connections. Furthermore, young adults can have difficulty finding and accessing appropriate vocational or post-secondary educational environments that provide sufficient supports while also allowing the young adult to develop new skills.

How can caregivers and healthcare providers ease the transitions?

Although the transition to adulthood can seem daunting, there are several strategies that can be helpful. First, it is important to have a clear sense of a young person’s strengths, challenges, skills, and interests in order to develop realistic long-term goals and seek out educational and vocational settings that are a good fit. The person with ASD should be as involved in this process as possible. Smaller, intermediate goals can be developed with the long-term goal in mind. Progress should be assessed regularly, and the development of long-term goals can be a flexible and iterative process.

Second, since the transition to adulthood is complex, early preparation and a series of conversations is needed. Healthcare providers should initiate these conversations several years in advance to allow patients and families to prepare and seek additional resources. Caregivers may want to seek additional information about funding and services from their local state and federal agencies, including the state’s department of developmental services, the state’s vocational rehabilitation program, and the Social Security Administration. In some cases, legal counsel regarding guardianship may also be helpful. Further information on the transition to adulthood can be accessed through the Autism Speaks Resources Guide. Healthcare providers can also help ease the transition from pediatric to adult healthcare providers by creating written medical summaries, developing lists of adult healthcare providers familiar with ASD, and scheduling transition-specific appointments.

Finally, since independent living requires a range of self-care skills including personal hygiene, dressing, meal preparation, household chores, money management, self-advocacy, and community safety, it is important for caregivers and healthcare providers to gradually teach and assess acquisition of independent living skills throughout childhood, rather than waiting until an adolescent is on the cusp of adulthood. These skills can be developed through education, therapeutic supports such as occupational therapy, and positive reinforcement.

Seeking solutions to a public health issue via advocacy for people with ASD

The transition to adulthood can be challenging for adolescents with ASD, because of the nature of their condition and because of the many gaps in systems of care, limited public funds, and the need to coordinate among multiple agencies. These challenges are increasingly recognized as a major public health issue, and both patient advocates and medical providers who specialize in ASD are working to find solutions to these issues, by preparing people entering the healthcare field to become aware of the needs of people with ASD through life’s transitions. Successful navigation of the transition to adulthood can help set the stage for a young person with ASD to be able to tolerate, navigate, and seek support during future periods of change throughout adulthood.

References

Examining Primary Care Health Encounters for Adults With Autism Spectrum Disorder. The American Journal of Occupational Therapy, September-October 2019.

The Massachusetts General Hospital Guide to Medical Care in Patients with Autism Spectrum Disorder (Eric P. Hazen and Christopher J. McDougle, editors).

Autism Speaks Resource Guide

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What one study from China tells us about COVID-19 and children

As we try to predict what will happen here in the US with COVID-19, it’s natural to look at the experience in China, where the epidemic began. In a study published in the journal Pediatrics, we learn about how the pandemic affected children.

What this study tells us

The study looked at information about 2,143 children with COVID-19 infections that were reported to China’s Centers for Disease Control from January 16 to February 8 of this year. Of the infections, about a third were confirmed with a laboratory test for COVID-19. The others were diagnosed based on symptoms and the results of other tests, such as x-rays.

The best news in this study is that 90% of the children had illness that was asymptomatic, mild, or moderate — as opposed to severe or critical. While 4.4% were reported as asymptomatic, given that only a third had laboratory testing, it’s very likely that the actual number of asymptomatic infections in children during that time period was higher. Only one child died.

In adults, it appears that more like 80% have mild to moderate infections. We don’t know why children appear to have milder disease overall. It’s likely a combination of factors related to body chemistry, immune function, and even social factors such as how children are cared for and spend their days. But whatever the reason, it’s good news.

What else is important to know

However, there is a part of the study we need to pay attention to: younger children are at higher risk of running into trouble. Among children less than a year old, 10.6% had severe or critical disease. For children ages 1 to 5, that number was still high at 7.3%. It dropped to 4.2% for 6-to-10-year-olds, 4.1% for 11-to-15-year-olds, and 3% for those 16 and older. Interestingly, the only child who died was 14 years old.

It’s not really surprising that the youngest children, especially infants, are more vulnerable. In most epidemics, such as influenza, it’s the very young and the very old that have the highest risk.

How can this information help us?

How can we use this information? Aside from all the advice already given to parents about hand washing, social distancing, and maintaining healthy habits, parents of young children should take extra care.

Be especially careful about who has contact with your young children

• Choose caregivers carefully. Limit the number overall, and choose those who have limited contact with other people and who can be trusted to practice social distancing, wash their hands frequently, and stay away if they feel at all sick.
• Limit the number of people who have contact with or hold young children.
• To the extent that it is possible, keep young children at home. If you take them out, keep them inside strollers or otherwise limit what they touch.
• Wash their hands even more often. They just can’t stop themselves from touching things and touching their face.

Be particularly watchful should young children get sick

Call your doctor for advice rather than bringing your child in for mild or moderate illness (there’s nothing your doctor can do at the office, and you are just adding the risk of more exposures). However, you should absolutely seek medical care if your child has

• any trouble breathing — rapid or forceful breathing, a pale or blue color to skin, trouble feeding or talking, or doing usual activities because of breathing problems
• a high fever you can’t get down (while it’s not certain, there have been some concerns raised about using ibuprofen with COVID-19 — out of an abundance of caution, best to use acetaminophen instead)
• unusual sleepiness
• pain or irritability you can’t soothe
• trouble drinking or refusal to drink, and is making less urine.

Follow me on Twitter @drClaireMD

For more information on coronavirus and COVID-19, see the Harvard Health Publishing Coronavirus Resource Center.

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Skin tag removal: Optional but effective

Skin tags are common, benign skin growths that hang from the surface of the skin on a thin piece of tissue called a stalk. They are made up of many components, including fat, collagen fibers, and sometimes nerve cells and small blood vessels. It’s possible that these collagen fibers and blood vessels become wrapped up inside a layer of skin, leading to the formation of a skin tag. The medical term for a skin tag is acrochordon, and they can also be referred to as soft fibromas or fibroepithelial polyps.

Skin tags are frequently found in areas of friction on the skin, such as the neck, underarms , under the breasts, eyelids, and other skin folds. They start as small, often flesh-colored bumps. They may stay that size and go largely unnoticed, enlarge and continue to be painless, or enlarge and become irritated due to friction or pressure.

It’s not entirely clear what causes skin tags, and there are no proven ways to prevent them. Some studies have shown that skin tags are more common in people who have diabetes or are overweight. Pregnancy may also lead to increased numbers of skin tags, most likely due to hormonal changes in the body.

Many methods are available for skin tag removal

Skin tags do not have to be removed. They are not harmful, and will not become so over time. However, some people find them unsightly and choose to have to have them removed. Skin tag removal can be accomplished via a number of different methods. One commonly used method is cryotherapy, in which a physician, usually a dermatologist, freezes off the skin tag using liquid nitrogen. Another option is electrocautery, in which an electric probe or needle is used to burn off the skin tag. Snipping or excision, either with scissors or a scalpel, may be a better option for larger skin tags. Because skin tag removal is considered cosmetic, these procedures are usually not covered by insurance.

Home remedies for skin tag removal are largely unproven

While home remedies are available, their efficacy is largely anecdotal and not supported by significant data. Some commercial kits contain ligation bands that can be placed around the base of skin tags, thereby cutting off their circulation and causing them to fall off. Home “freezing” kits are also available, but typically require multiple applications. Tea tree oil and apple cider vinegar have also reportedly been used to treat skin tags; however, there is little research data to support their effectiveness. Furthermore, these substances often cause skin irritation. Tea tree oil, in particular, is known to cause allergic skin reactions in some people.

Keep an eye out for atypical features

Sometimes, what may look like a skin tag could actually be a different type of skin growth. If you notice a fleshy growth that has features that are not typical of skin tags, such as variations in color, sudden changes in size, or areas of bleeding or pain.

Follow me on Twitter @KristinaLiuMD

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Grandparenting in the time of COVID-19

Baby boomers are used to embracing grandparenting head on. Some of us have moved across the country to be with our grandchildren; others regularly bridge distances via FaceTime and Skype; many take pride in kayaking, rock climbing, jumping on trampolines, and doing yoga with our grandkids. Before the new coronavirus and COVID-19 came along, many grandparents were confident we could do it all. The threats posed by this new virus are humbling and present new conundrums. As schools and daycares temporarily close, many grandparents are wrestling with questions surrounding whether they can safely spend time with their grandchildren, and possibly help their adult children with childcare.

Is it safe to spend time with my grandchildren right now?

COVID-19 affects older people more severely than younger people — and children are notorious for spreading germs, notes Claire McCarthy, MD, a pediatrician at Boston Children’s Hospital and faculty editor for Harvard Health Publishing.

“To be safe, grandparents really shouldn’t be doing childcare,” says Dr. McCarthy. “Even if the child is a baby who doesn’t go out into the world much at all, it’s impossible to be sure that the baby’s parents won’t bring anything home. As sad as it is, older adults are the ones who really need to isolate themselves. In a time of crisis, it’s natural to want to be with family and help them, but in this particular crisis families need to think differently — and keep grandparents safe.”

(See the Coronavirus Resource Center for information on how the virus spreads, how to protect yourself, and who is at highest risk for serious illness.)

Staying connected and helping families

Given current public health recommendations to practice social distancing — even with beloved grandchildren — many grandparents are grappling with two questions. What can I do to stay connected with my grandchildren? How can I help their parents, who may be working from home and trying to cope with their children being home from school?

Ways to stay connected to your grandchildren

Long-distance grandparents often become incredibly skilled and creative with FaceTime, Skype, and other ways of connecting face-to-face. Those who haven’t yet developed these skills can begin building them now. Guided by the age of your grandchildren, their interests, and the nature of your relationship, you can establish a daily meet-up online to read books, play games, or do activities.

• Simply calling to chat will get old quickly. Right now the children are home from school or daycare, and missing so much of their daily routines and activities. So, step in with “Nana Academy” or “Granpa Games.” You may begin to teach a young child to recognize the letters of the alphabet, or create interesting history lessons for an older child. Show off dance steps or favorite songs from your youth and have them share theirs. Again, be guided initially by your grandchild’s interests and your own. Start with small, sure-fire activities and expand when you can. Once you get started, you are likely to discover a vast number of possibilities.
• If you have grandchildren living in more than one family, try creating a daily or weekly “cousins’ time.” Depending on ages, you can read all of them a story, or encourage the older ones, already readers, to read to younger siblings and cousins. Cousins’ time could also be an opportunity for you to share stories, perhaps from their parents’ childhoods. Or you might tell stories about it was like to live in a time before Velcro and microwaves, let alone iPhones and FaceTime.
• Break bread together. One woman I know cooks for her adult daughter, drops the food off at a safe distance outside, then goes home to get online for a virtual meal with her daughter and grandchildren.
• Ask children what they do and don’t like about their new routines, and talk together about what each person might like to look forward to. Life may not return to normal for children soon, and not knowing how long this difficult stretch will last is part of the hardship. But hopefully one day, many important aspects of our lives will resume.

How can I help my children?

Many adult children are struggling to balance work and homeschooling. Others may need a break from 24/7 childrearing. You could help by:

• Freeing up time for parents. You may decide to video chat regularly with your grandchildren, so that you can remain connected with them, but remember that your efforts will also be helping their parents. Spending a half-hour or more engaging with them daily will free up some time for the parents, and reassure them that responsibility for their children’s education and well-being during this time is not all on their shoulders.
• Considering financial help. This crisis will cost all of us financially, but will hurt some more than others. To the extent you can help and to the extent your adult kids could use your financial help, this is a way you can be there for them. It may come in the form of large cash gifts, although most of us cannot make that sort of contribution. Offering to pay for an activity or send a grandchild to camp for a week or two (assuming this becomes possible) gives the child something to look forward to, grandparent and grandchild something to anticipate together, and eases finances a bit for the parents.
• Inviting grandchildren to plan virtual celebrations and holidays with you. If a birthday is approaching, you and your grandchild might go online to find something special that can be delivered to the child’s home and opened “together.” And with Easter and Passover on the horizon, you may be able to dye Easter eggs together, and you can surely talk about the 10 — now 11 — plagues in a very real way.

We grandparents take a lot of pride in the energy, youthfulness, creativity, and love that we offer our grandchildren. COVID-19 may temporarily alter the format of our relationships with our grandchildren. This is humbling but it need not be crippling. Whether via FaceTime or Zoom or even old-fashioned telephone, there remain all sorts of meaningful and joyful ways that we can be with our grandchildren despite any distance between us.

For more information on coronavirus and COVID-19, see the Harvard Health Publishing Coronavirus Resource Center.

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Harvard Health Ad Watch: Are nutritional drinks actually good for you?

I first heard of nutritional drinks in the 1980s, early in my medical training. They were recommended for people struggling to maintain a healthy weight, often due to loss of appetite, cancer, or swallowing problems.

Since then, nutritional supplement drinks like Boost and Ensure have gone mainstream. Their widespread, primetime advertising aimed at a much broader audience has proven highly effective. The market for nutritional drinks is now worth many billions of dollars. In 2019, Ensure sales alone totaled nearly $400 million.

When you watch ads for nutritional drinks, do you wonder if you should start drinking them? Will it improve your health or fend off future health problems, as the ads suggest? Are there any downsides? Read on.

What the ads say

Right now, two ads in heavy rotation are for Boost and Ensure.

One 30-second ad for Boost shows a well-appearing older woman holding a camera (a real, two-handed, professional photographer’s camera, not a cell phone). As she takes photos of a young, hipster musical group, she tells the viewer, “I don’t keep track of regrets. And I don’t add up the years. But what I do count on is staying happy and healthy. So I add protein, vitamins, and minerals to my diet — with Boost.”

As she happily sips her chocolate drink, a voiceover tells you more. “Boost high-protein nutritional drink has 20 grams of protein, along with 26 essential vitamins and minerals your body needs.” A graphic of a human body with a list of eight of these vitamins and minerals is displayed: calcium, vitamin D, magnesium, vitamin C, B vitamins, iron, zinc, and potassium.

Then comes the big finish and trademarked tagline: “All with guaranteed great taste. And now try peaches & cream natural flavor. With 27 vitamins and minerals and 10 grams of protein. Boost — be up for life.”

Ensure’s 15-second ad takes a very different tack. Here we have animated food characters — an egg, a pear, a carrot, and some broccoli — hanging out together in the fridge. So adorable! An egg looks off camera and exclaims, “Wow!” A bottle of Ensure Original explains what the egg is admiring: “That’s Ensure Max Protein with high protein and 1 gram of sugar.” Shift to a towering bottle of Ensure Max, complete with bulging biceps, sounding like a drill sergeant shouting orders at the banana: “It’s a sit-up, banana, bend at the waist.”

“I’m trying!” says the banana, as it rocks back and forth on its back. “Keep it up, you’ll get there,” Ensure Max barks. Two bottles of Ensure high-five each other. Meanwhile, the banana falls backwards, failing to complete even a single sit-up.

A voiceover breaks in: “30 grams of protein, and 1 gram of sugar. Ensure Max Protein.”

What the ads suggest

The suggestion is clear: to be healthy, you need to be drinking these supplements. A healthy diet won’t suffice.

Product names deliver their own message. You can “boost” your health and “ensure” you’re getting all the nutrition you need by consuming these drinks. The Boost commercial seems to target older people, implying that downing bottles of Boost regularly can help you keep up with the young folks and maintain an active, healthy, and working life well into advanced age. The Ensure commercial, meanwhile, suggests that while exercise might be a chore, at least your nutrition will be covered by this high-protein supplement drink.

What the ads don’t say

The information provided in these ads and on their websites is generally accurate. People who don’t get enough calories, protein, or certain minerals or vitamins could make up for what’s missing by consuming these drinks. In addition, there are different versions of these products for people with diabetes or other health problems.

But these ads are missing important information. For example:

• Who benefits? Some people are far more likely than others to benefit from Ensure, Boost, or similar products. The vast majority of people can get all the nutrition they need from their diet. There’s absolutely no evidence that these supplements improve health or prevent disease in people who have no specific nutritional problems, as my colleague Suzanne Salamon, MD, notes. However, if you’re losing weight involuntarily and don’t carry excess weight in the first place, or if you can’t take in adequate nutrition, you might benefit from nutritional supplements.
• Should supplements replace meals or be added to them? The ads don’t say. In fact, the advice would vary depending on the person’s overall heath and diet.
• Significant calories. Regular Boost has 240 calories; Ensure Max Protein has 150 calories; original Ensure has 220 calories.
• Sugar and artificial sweetener. Regular Boost has 20 grams of added sugar. While Ensure Max Protein has only 1 gram of sugar (along with an artificial sweetener, sucralose), original Ensure has 14 grams of added sugar.
• Cost adds up. I found these products for sale online for around $2 per bottle. Depending on how many you drink each day, the cost can be significant, especially over the long term. You can get similar amounts of protein, vitamins, and minerals at far lower cost from high-protein foods (such as milk or yogurt) and a multivitamin. And, you may not need that multivitamin.
• High protein isn’t for everyone. Some people should avoid high-protein diets, and therefore should not consume high-protein nutritional supplements. People with significant kidney disease are a good example.

The bottom line

The value of Boost, Ensure, or their competitors to the general population is questionable. The best way to decide if you should consume these products is to discuss your health, medical problems, and diet with your doctor. He or she may recommend that you consult with a nutritionist.

I’ll leave you with some questions I find perplexing. Why would a nutritional supplement yell at a banana to do a sit-up? How can the banana bend at the waist when it has no waist? And why is the banana the only food being asked to work out? If you ask me, the pear and egg look a bit big around the middle. Perhaps the failure of the banana to do a sit-up is a metaphor for our own inability to do the work of exercise ourselves — and so we need help from a nutritional drink. I’m probably overthinking this; it’s likely just an eye-catching way of promoting a product. But if you understand this commercial better than I do, please let me know.

In the meantime, my advice is to choose a healthy diet (like the Mediterranean diet), get regular exercise, and don’t count on nutritional drinks — or the physical fitness of your fruit — to keep you healthy.

Follow me on Twitter @RobShmerling

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Is there any good news about the coronavirus pandemic?

In the midst of the fear, worry, and uncertainty surrounding the coronavirus pandemic, each day seems to bring news that’s worse than the day before.

The cause for concern is justified. But, as in most major disasters, tragedies, and public health threats, there are reasons for hope, and even optimism. They may be hard to see, even if you’re a “cup-half-full” or “it could always be worse” type of person. But they are there. Here are a few.

The good news about the coronavirus pandemic

• Most people with COVID-19 recover. Estimates now suggest that 99% of people infected with the virus that causes COVID-19 will recover. Some people have no symptoms at all. And while thousands of people have died, the overall death rate is about 1% (or perhaps even lower), far less than MERS (about 34%), SARS (about 11%), or Ebola (90%), though higher than the average seasonal flu (0.1%).
  The loss of life related to this illness is terrible and far more cases are expected, but based on the fatality rates alone, it could be far worse.
• Children seem to be infected less often and have milder disease. According to the CDC, the vast majority of infections so far have afflicted adults. And when kids are infected, they tend to have milder disease. For kids and their parents, that’s good news. However, it’s important to note that children can develop infection. A recent study from China early in the outbreak demonstrated that a small number of kids, especially infants and toddlers, can develop serious infection. As is true generally, it’s likely that kids can spread infection in the absence of symptoms, though how often this happens is unclear. It’s perplexing, though fortunate, that this new coronavirus does not behave the way so many other illnesses do, in which the elderly and the young are particularly vulnerable.
• The number of new cases is falling where the outbreak began. During his speech declaring the new coronavirus outbreak a pandemic, the director-general of the WHO pointed out that “China and the Republic of Korea have significantly declining epidemics.” In fact, Wuhan province (site of the very first cases) has just reported no new local cases for the first time since the outbreak began. The only new cases were “imported” from travelers arriving there. While actual numbers are hard to verify, and the methods these countries used to contain infection, such as aggressive diagnostic testing and strict isolation measures, are unlikely to be practical or acceptable everywhere, if the number of new cases in China is truly declining, that’s a good thing and suggests that efforts to contain the spread of this infection can be successful.
• The internet exists. We currently have ways to practice social distancing that preserve at least some social and medical connections. People in isolation or quarantine can ask for help, visit friends, “see” family and doctors virtually, and provide updates on their condition.
• Our response to future pandemics should improve. The COVID-19 pandemic has exposed shortcomings in healthcare systems throughout the world that provide an opportunity to improve them. For example, a faster global response, better and quicker distribution of testing kits, and more coordinated and coherent public messaging should be expected the next time around. (No guarantees, of course.)
• Many people and organizations have stepped up to improve the situation. In the US, for example:
  • Some major health insurers have promised to cover care and testing related to COVID-19.
  • A number of celebrities and professional athletes have donated significant resources to help those taking a financial hit by the pandemic, such as the workers at the stadiums where athletes play.
  • Newly approved legislation provides paid sick leave and paid family and medical leave for some American workers, free testing for people without insurance, and added funding to states for Medicaid.
  • There are innumerable stories of people helping each other out — here’s one I particularly like.

The bottom line

Make no mistake: the new coronavirus epidemic is a big problem that’s expected to become bigger in the weeks and months to come. For those who are infected as well as those trying to avoid infection, these are trying times. But amid all the doom and gloom, there are some positive stories, positive messages and reasons to remain hopeful.

At a time when the citizenry of this country is so politically divided, we can also hope that this threat brings us together in ways that help us to better recognize commonalities: we’re all human, we get sick, and we worry about loved ones. As social creatures, we try to help one another when bad things happen. If that happens, it would be good news that could not have been foreseen before the pandemic.

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Acoustic neuroma: A slow-growing tumor that requires specialized care

An acoustic neuroma, also known as a vestibular schwannoma, is a tumor of the hearing and balance nerve complex in the brain. They are rare, and account for less than 10% of all brain tumors. The tumor involves an area of the brain and ear called the lateral skull base; an acoustic neuroma can range in size, and it can cause a variety of troublesome symptoms related to hearing and balance.

It is important to note that although the diagnosis of a brain tumor can cause significant anxiety, acoustic neuromas are noncancerous and grow very slowly. This means that immediate treatment is rarely necessary.

What are the most common symptoms?

Acoustic neuromas can cause you to experience a variety of symptoms. In general, the first thing you may notice is hearing loss in one ear greater than the other, ringing in the ears (tinnitus), and/or dizziness or imbalance (acute or chronic). These symptoms can range from mild to very distressing and bothersome. It is important to note that these symptoms are not related to the size of the tumor. Some people can have a very small tumor with significant hearing loss and imbalance, while other people can have very large tumors with few symptoms. If you are experiencing any or all of these symptoms, you should seek the attention of your physician.

How are acoustic neuromas diagnosed?

If symptoms of hearing loss, tinnitus, or imbalance are present, you will likely be referred to an ear, nose, and throat specialist (ENT) for evaluation. Commonly, with these symptoms you will be asked to undergo a hearing test. If you are dizzy, additional balance testing may be performed. If there are any abnormalities on either of these tests that demonstrate unequal function (asymmetrical hearing loss), you may undergo imaging of the inner ears and head with an MRI to check for an acoustic neuroma. An MRI can help accurately diagnose an acoustic neuroma because the characteristics of these tumors look particularly unique compared to other brain tumors.

What if the MRI doesn’t show an acoustic neuroma?

Because acoustic neuromas are rare, MRI scans are often normal in patients with symptoms of hearing loss, tinnitus, and dizziness, and it is very unlikely that you have an acoustic neuroma with a normal MRI. However, this does not mean that you do not have the symptoms, and additional testing of these symptoms may be necessary. Talking to your doctor about symptom management is important, no matter what the MRI scan reveals.

What is the next step if I am diagnosed with an acoustic neuroma?

If you are diagnosed with an acoustic neuroma, the amount of information you receive can seem overwhelming. It is important to know that decisions for treatment rarely need to be made immediately. After diagnosis, your next step may involve referral to a specialist.

You should expect a team of specialist doctors to be involved in your care, including ENTs with specialty training (neuro-otologists), neurosurgeons, and/or a radiation oncologist and a physical therapist.

The team of physicians and clinicians involved in the care of acoustic neuromas will often work together to coordinate a plan that optimizes your needs.

Treatment options

Before your visit with the specialist, you should take time to prepare and ask about the various treatment options. The treatment approach will be individualized based on your specific tumor and your personal health situation; however, there are three main options for treatment:

• Observation of these tumors without intervention is possible because of their slow-growing, benign nature. If you decide to observe your acoustic neuroma, repeat MRIs will be necessary to monitor for tumor growth.
• Surgery or microsurgery has various indications, and there are a variety of surgical approaches. The goal with surgery is to remove the tumor and preserve important structures near it. If you elect to have surgery for your acoustic neuroma, the approach should be a joint decision between you and your surgeon.
• Radiation therapy is also an option for acoustic neuromas. With this treatment approach, your tumor will not be removed; rather, the goal is to stop the growth of the tumor. Treatment courses are variable and may include a single treatment or multiple treatments over the course of weeks.

There are a few factors that physicians use when deciding on your treatment approach: your age, the size of your tumor, and your hearing status. While each of these factors will be considered for your specific tumor, there are no specific treatment guidelines, and there is no right answer or single treatment approach that is best. In general, in younger patients and larger tumors surgery may be favored, while in older patients or patients in poor health, nonsurgical options may be offered.

Regardless of the treatment option you elect to pursue, hearing rarely improves, although preservation of existing hearing is possible in some cases. If you choose to observe your tumor, changes in your hearing may still occur, as it is difficult to predict what factors lead to hearing changes in this setting. Similarly, it is important to know that after treatment your balance will temporarily be worse, and physical therapy may be necessary to regain balance.

Take-home message

Acoustic neuromas are rare brain tumors that often have a range of symptoms from mild to bothersome. The treatment options are very complex and require specialized care. If you are diagnosed with an acoustic neuroma, the most important thing to know is that there is often time to make an informed decision, and your treatment team can help you manage your symptoms and personalize your care.

Additional resources can be found at the Acoustic Neuroma Association.

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