Can controlling blood pressure later in life reduce risk of dementia?

Everyone talks about the importance of treating high blood pressure, the “silent killer.” And everybody knows that untreated high blood pressure can lead to heart attacks and strokes. But can treating high blood pressure reduce your risk of cognitive impairment and dementia?

High blood pressure is a risk factor for cognitive impairment and dementia

Cognition encompasses thinking, memory, language, attention, and other mental abilities. Researchers have known for many years that if you have high blood pressure, you have a higher risk of developing cognitive impairment and dementia. However, just because high blood pressure is a risk factor, it does not necessarily mean that lowering high blood pressure will lower your risk. Many things in health and science correlate without one causing the other (my favorite is the correlation between the drop in birth rate and the decline in the stork population). Thus, randomized, double-blind, controlled studies are needed to answer this question.

Prior studies have not provided clear answers

There have, in fact, been a lot of these studies. The most recent relevant study is the SPRINT-MIND study, designed to measure the effects of lowering high blood pressure on dementia and/or mild cognitive impairment. This study was so successful at reducing the risk of mild cognitive impairment by lowering high blood pressure that it ended early, because the data and safety monitoring board felt that it was unethical to continue the control group. However, the dementia endpoint had not yet reached statistical significance — likely because of this early termination. Thus, while the study succeeded in one sense, it ultimately concluded that treating systolic blood pressure to below 120 mmHg (versus lower than 140 mmHg) did not reduce risk of dementia.

A new analysis of many studies

Because SPRINT-MIND and many other prior studies have not clearly shown whether lowering our high blood pressure can reduce our risk of cognitive impairment and dementia, meta-analyses are needed to answer this question. Researchers in Ireland looked at data from 14 studies comprising almost 100,000 participants, followed over an average of more than four years. They found that older individuals (average age 69) who lowered their blood pressure are slightly less likely to develop dementia or cognitive impairment (7.0% versus 7.5%). Thus, the answer is: Yes! Lowering high blood pressure will lower our risk of dementia and cognitive impairment.

The relationship between high blood pressure and dementia

So, how does lowering high blood pressure reduce our risk of cognitive impairment and dementia? Most people who have dementia don’t have just a single cause. Two or even three different problems in the brain cause their cognitive impairment and lead to their decline in function. One study estimates that the fraction of dementia risk attributable to cerebrovascular disease — that is, strokes — was nearly 25% in people who developed significant memory loss late in life. These researchers also found that the dementia risk attributable to Alzheimer’s disease was considerably higher, nearly 40%.

My reading of the literature is that lowering blood pressure reduces dementia risk because it reduces the risk of stroke. It’s the strokes — not high blood pressure by itself — that cause cognitive impairment. Note, however, that the strokes may be so tiny that one doesn’t even know that they have them. But developing a lot of these tiny strokes (or a few big ones) will greatly increase our risk of dementia.

Optimal blood pressure for optimal brain health

Okay, but what’s considered a healthy blood pressure from the perspective of the brain? The SPRINT-MIND study answers that question: people are less likely to develop mild cognitive impairment if their systolic blood pressure is lower than 120 mm Hg compared to the control condition of between 120 and 140 mm Hg. Thus, for optimal brain health, it’s best to keep your systolic blood pressure below 120 mm Hg — at least according to the SPRINT-MIND study.

The bottom line

The take-home message is clear: You can reduce your risk of cognitive impairment and dementia by lowering your systolic blood pressure to less than 120 mm Hg, preferably with aerobic exercise, a Mediterranean diet, and a healthy weight, and by adding medications if those lifestyle changes alone are not sufficient.

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Brain plasticity in drug addiction: Burden and benefit

The human brain is the most complex organ in our body, and is characterized by a unique ability called neuroplasticity. Neuroplasticity refers to our brain’s ability to change and adapt in its structural and functional levels in response to experience. Neuroplasticity makes it possible for us to learn new languages, solve complex mathematical problems, acquire technical skills, and perform challenging athletic skills, which are all positive and advantageous for us. However, neuroplasticity is not beneficial if we develop non-advantageous learned behaviors. One example of non-advantageous learning is habitual drug misuse that can lead to addiction.

Our brain learns to respond to drugs of abuse

Our first decision to use a drug may be triggered by curiosity, circumstances, personality, and stressful life events. This first drug exposure increases the release of a molecule (neurotransmitter) called dopamine, which conveys the feeling of reward. The increased changes in dopamine levels in the brain reward system can lead to further neuroplasticity following repeated exposure to drugs of abuse; these neuroplasticity changes are also fundamental characteristics of learning. Experience-dependent learning, including repeated drug use, might increase or decrease the transmission of signals between neurons. Neuroplasticity in the brain’s reward system following repeated drug use leads to more habitual and (in vulnerable people) more compulsive drug use, where people ignore the negative consequences. Thus, repeated exposure to drugs of abuse creates experience-dependent learning and related brain changes, which can lead to maladaptive patterns of drug use.

Views on addiction: Learning and disease

A recent learning model proposed by Dr. Marc Lewis in New England Journal of Medicine highlights the evidence of brain changes in drug addiction, and explains those changes as normal, habitual learning without referring to pathology or disease. This learning model accepts that drug addiction is disadvantageous, but believes it is a natural and context-sensitive response to challenging environmental circumstances. Dr. Nora Volkow, director of the National Institute on Drug Abuse (NIDA), and many addiction researchers and clinicians, view addiction as a brain disease triggered by many genetic, environmental, and social factors. NIDA uses the term “addiction” to describe the most severe and chronic form of substance use disorder that is characterized by changes in the brain’s reward, stress, and self-control systems. Importantly, both learning and brain disease models accept that addiction is treatable, as our brain is plastic.

We can adapt to new learned behaviors

Our brain’s plastic nature suggests that we can change our behaviors throughout our lives by learning new skills and habits. Learning models support that overcoming addiction can be facilitated by adopting new cognitive modifications. Learning models suggest pursing counseling or psychotherapy, including approaches such as cognitive behavioral therapy (CBT), which can help a person modify their habits. NIDA suggests that, for some people, medications (also called medication-assisted treatment or MAT) can help people manage symptoms to a level that helps them pursue recovery via strategies such as counseling and behavioral therapies, including CBT. Many people use a combination approach of medications, behavioral therapies, and support groups to maintain recovery from addition.

Neuroplasticity can help us modify behaviors relevant to addiction

CBT is an example of a learning-based therapeutic intervention; thus, it utilizes neuroplasticity. Scientific evidence suggests that CBT, alone or in combination with other treatment strategies, can be effective intervention for substance use disorders. CBT teaches a person to recognize, avoid, and learn to handle situations when they would be likely to use drugs. Another example of evidence-based behavioral therapy that has been shown to be effective for substance use disorders is contingency management. Contingency management provides a reward (such as vouchers redeemable for goods or movie passes) to individuals undergoing addiction treatment, to reinforce positive behaviors such as abstinence. This approach is based on operant conditioning theory, a form of learning, where a behavior that is positively reinforced tends to be repeated. Overall, multiple evidence-based approaches are used for the treatment of substance use disorders that require learning and utilize neuroplasticity.

The bottom line

Our brain is plastic, and this trait helps us learn new skills and retrain our brain. As the brain can change in a negative way as observed in drug addiction, the brain can also change in a positive way when we adopt skills learned in therapy and form new, healthier habits.

References

Targeting Behavioral Therapies to Enhance Naltrexone Treatment of Opioid Dependence: Efficacy of Contingency Management and Significant Other Involvement. Archives of General Psychiatry, August 2001.

Efficacy of Disulfiram and Cognitive Behavior Therapy in Cocaine-Dependent Outpatients: A Randomized Placebo-Controlled Trial. Archives of General Psychiatry, March 2004.

Cognitive Behavioral Therapy and the Nicotine Transdermal Patch for Dual Nicotine and Cannabis Dependence: A Pilot Study. American Journal on Addictions, May-June 2013.

Brain Change in Addiction as Learning, Not Disease. New England Journal of Medicine, October 18, 2018.

Cognitive Behavioral Therapy for Substance Use Disorders. The Psychiatric Clinics of North America, September 2010.

Neurobiologic Advances from the Brain Disease Model of Addiction. New England Journal of Medicine, January 28, 2016.

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How risky is a hug right now?

“Can I get a hug?”

It’s a simple question for a simple act that’s been especially missed because of COVID-19 distancing. “Human beings need social contact,” says Dr. Eugene Beresin, executive director of The Clay Center for Young Healthy Minds at Massachusetts General Hospital, and professor of psychiatry at Harvard Medical School. “We are not hermits. We are not solo pilots. We are pack animals.” Not that it needs more promotion, but along with feeling connected, a hug has been shown to help fight off a cold and help your mood when dealing with conflict.

But even as restrictions have started to loosen, there are no clear-cut answers on personal interactions between adults. Dr. Todd Ellerin is director of infectious diseases and vice chairman of the department of medicine at South Shore Hospital in Weymouth, Massachusetts, and an instructor in medicine at Harvard Medical School. He doesn’t recommend against giving a hug, but he’s also not giving it the green light.

The reality, he says, is there are no safety guarantees, just as it’s not, “You hug, you get the virus — it’s not that simple.” Like with all coronavirus issues, it’s about individuals making their own assessments about risk.

With a hug, it’s not the act itself that’s worrisome, but everything that comes with it. “It’s where you are and how close you’ll be standing. It’s what you’ll be doing before and after. The hug is not an isolated event.” Ellerin offers three factors to consider in order to determine whether it’s a safe choice for you.

People. Who’s involved? The more people who you’re going to hug, the higher the risk. The health of you and the others involved also matters. It’s not only whether someone has coronavirus symptoms, but anything that would compromise the immune system, like cancer, obesity, heart disease. And age is still a factor. People over 60 years old, even if healthy, are more vulnerable.

Place. Where would it happen? Outside is preferable, and lower risk than indoors.

Space. How close will you be after the hug? The six-foot zone — the approximate distance a droplet travels before it falls — is still a good prescription. And proximity can be an overlooked factor, since there’s the tendency to remain close and talk, and hugs often come with kissing. You’re certainly able to exchange words when you have a mask on. You just shouldn’t. Masks work, but they’re not perfect, so, in order to minimize the risk if you choose to hug, when you’re in close, you shouldn’t talk.

So what’s the ideal hug?

Ellerin says that it needs to mutual, discussed, and pretty much planned. This is not the time for surprise or spontaneous shows of affection. You need to start at six feet away; if you’ve already been talking close to each other, you’ve increased the risk. You need to be masked and looking in opposite directions, so there’s no breathing or chance of coughing or sneezing on each other. Once the hug is over, you both back away to at least six feet without saying anything. If the hug makes someone cry, you don’t wipe away another person’s tears. And even though you should not have hand-to-hand contact, you want to wash your hands afterwards in order to maintain the habit. If you want to add an extra layer of protection, you can also wear a face shield.

The easier decision might be to say it’s not worth chancing, but in extreme cases, such as when a person is dying, the benefits might outweigh the consequences, Beresin says. These kinds of considerations reflect how COVID-19 has turned instinctive acts into calculations. “You need to be scientific about this, but it’s hard to be scientific about people you love. We’re not robots,” Ellerin says.

Maybe there’s another option

Beresin adds that rather than attempt to script a quick hug and still worry about the dangers, this is an opportunity to be creative, while being masked and at least six feet apart. You can listen to music. You can meditate with guided imagery. You can sit, maybe by a fire, and talk, maybe sharing a reminiscence about a great family vacation or a disastrous Thanksgiving that ended in laughs.

Recollecting, along with making eye contact and saying kind words, are ways to feel close and to be a reminder of how you got through something together. None of these alternatives are as immediate or physical as a hug, “but it does the same kinds of things. We can touch and embrace each other in many different ways,” Beresin says. “And in some respects, it could be better, because it lasts longer than 10 seconds.”

But with the hug, it goes back to the fact that the decision is up to each person. Ellerin says that until a widespread vaccine and treatments are available, “as individuals, we have to learn how to manage risks. It’s not an exact formula.”

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

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Autoimmune lung disease: Early recognition and treatment helps

A man who was diagnosed with rheumatoid arthritis (RA) five years ago sees his rheumatologist for a follow-up visit. Fortunately, his arthritis is well controlled through medication. He can walk and do all his daily activities without pain. But over the past six months, he’s been feeling short of breath when climbing stairs. He has an annoying dry cough, too. COVID-19? That’s ruled out quickly. But a CT scan of his chest reveals early fibrosis (scarring) of the lungs, most likely related to rheumatoid arthritis. “I can finally walk normally, and now I can’t breathe when I walk!” says the frustrated patient, whose next step is a full evaluation by a pulmonologist.

What is autoimmune lung disease?

This man’s experience offers one example of an uncommon but potentially life-altering complication associated with rheumatic or autoimmune diseases, including:

• rheumatic arthritis, an inflammatory disease that primarily affects the joints
• systemic sclerosis (scleroderma), a fibrosing disorder that typically affects the skin
• dermatomyositis, which results in inflammation in muscles and skin
• systemic lupus erythematosus (SLE or lupus), an inflammatory condition that can affect many parts of the body, including joints, kidneys, and skin.

There are various terms for this complication: autoimmune lung disease, interstitial lung disease, and interstitial fibrosis. Characterized by lung inflammation and/or scarring, it is one of many potential complications affecting different organs in people who have an underlying autoimmune or rheumatic disease.

What is autoimmunity?

Our immune system normally wards off infection and guards against cancer. The term autoimmunity implies that a person’s own immune system sometimes sees its own body tissue as foreign. When this happens, the body generates an immune response against itself. Most people with rheumatoid arthritis experience its effects on joints. But about 10% will also develop symptomatic lung disease like the patient described above.

Why is it important to identify autoimmune lung disease as early as possible?

Studies have shown that this complication is one of the leading causes of illness and death among people with autoimmune diseases. Early disease that is more inflammatory in nature often responds to anti-inflammatory therapies (corticosteroids, for example). But people with mostly fibrotic disease may be more difficult to treat and have poorer outcomes, including disability or a need for oxygen — and in some cases even a lung transplant. However, how quickly or slowly this complication progresses varies. Some people find it progresses more quickly, whereas others may have little or no progression. For that reason, careful surveillance by a pulmonologist who can monitor lung function during regular check-ups is essential.

What triggers this complication and who is most at risk?

While definitive studies have not been done, population studies have identified risk profiles (see here and here). Being male, having a history of cigarette smoking, or having certain antibodies and genetic markers raises risk for autoimmune lung disease. Environmental factors, occupational exposure, and air pollutants also may play a role in developing autoimmunity that affects the lungs (see here and here). Other potential causes include medications that may cause lung injury, or an esophageal dysfunction leading to silent aspiration into the lungs, a common finding in many autoimmune diseases.

Are there treatments for autoimmune lung disease?

Yes, although effectiveness varies. When inflammatory disease is caught early before extensive scarring develops, anti-inflammatory agents, such as corticosteroids, often help. Additionally, catching and treating inflammation early usually leads to a better prognosis.

Recently, the FDA approved pirfenidone (Esbriet) and nintedanib (Ofev) to treat a different fibrotic lung disease called idiopathic pulmonary fibrosis (IPF). Nintedanib is now approved for use in patients with autoimmune lung disease. Both agents can slow, but do not appear to reverse, the presence of fibrosis in the lung. Longer-term studies investigating whether these treatments offer better quality of life and meaningful benefits in terms of illness and death are needed.

If I have a rheumatic or autoimmune disease, what can I do to stay as healthy as possible?

The most important first step is to eliminate any known risks that may cause or exacerbate lung disease. Work with your doctor to stop smoking, if necessary. Ask if you can eliminate any occupational exposures or medications that may contribute to or worsen lung disease. Since early detection of lung inflammation is a goal, rheumatologists often screen people for lung disease at the time of their diagnosis if they are deemed at higher risk, using CT scanning and pulmonary function testing. Increasingly, careful surveillance over time is becoming a normal practice among rheumatologists.

If you do develop signs or symptoms that suggest autoimmune lung disease, such as dry cough and shortness of breath, talk to your doctor. The next step may be a referral to a pulmonologist, or to a multidisciplinary center comprised of pulmonologists, rheumatologists, pathologists, and radiologists, who work as a team to diagnose this complication and develop a treatment plan to reverse or slow the progress of lung disease.

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Daily decisions about risk: What to do when there’s no right answer

Let’s face it: there’s still a deadly virus out there and it’s not going away anytime soon. And that means we all must make a lot of decisions that involve personal risk. And for many of these daily decisions, there’s no single right answer: no Centers for Disease Control (CDC) guidelines, World Health Organization recommendations, or expert advice exist. And as more places lift restrictions keeping people at home, more questions arise:

• Is it safe to go to the grocery store? And, how often is okay?
• How safe is it to fly on a commercial airline? Get a haircut? Go out to dinner?
• Should I avoid a friend whose daughter works someplace where someone tested positive?

A new CDC guideline on venturing out shares ways to lessen risk for certain activities: frequent handwashing, wearing a mask, keeping your distance, and other familiar protective measures feature prominently. While helpful, the guideline won’t tell you whether it’s okay to visit your cousin, drive cross-country, or get a massage.

Based on duration of exposure, setting, and “dose” (the amount of virus to which you’re exposed), we do know that some activities are riskier than others. Spending 15 minutes or more in a small room with someone who is coughing while neither of you wears a mask is considered high-risk. Going for a walk outdoors, well away from others, is low-risk.

But each of us must make our own decisions about all of the things in the middle — including activities now allowed in many places — without much guidance.

We already calculate risks every day

We already have to make daily decisions about what is safe or less safe, and how much risk we’re willing to accept. Each time we decide to drive, fly, or go skiing, we make judgements about our safety without precise data, specific guidelines, or expert advice for our particular situation.

Of course, there is an important difference when we’re talking about COVID-19. Here, the threat to safety is catching, and possibly spreading, an unpredictable, potentially deadly infection. So, my behavior affects not only my health but may affect the health of others. And the behavior of others can affect me.

Sometimes you have to improvise

Strong opinions aside, no one actually knows what’s best for many everyday decisions. There’s a lot of making it up on the fly and rationalizing: a friend recently “expanded his social circle” for a birthday party with the plan to quarantine himself afterward. But the 14-day quarantine was “just too long,” so he decided six days was enough. When I asked him where the six-day figure came from, I got the look that means “don’t judge me, it’s my personal decision.” In fact, he’d chosen six days because that’s when he had to return to work.

How can you make decisions around personal risk?

If you’re considering relaxing restrictions in your work or social life, consider these three important steps:

• Think about your risk factors for developing a severe case of COVID-19; do the same for others with whom you’ll have contact.
• Find out if community spread is common where you live.
• Gauge how risky the activity is.

And then what? Weigh the five Ps to round out your reckoning of risks and benefits:

• Personal risk tolerance. Is your mantra “better safe than sorry”? Or is it closer to “you only live once”?
• Personality. If you’re an extrovert, you may be willing to dial down your restrictions (and accept more risk) because the alternative feels like torture. For introverts, limiting social interactions may not seem so bad.
• Priorities. If you put a high priority on dining out, getting your hair done, or getting a tattoo, it’s a bigger sacrifice to put these off than it is for someone who doesn’t care about these things.
• Pocketbook. Although the pandemic affects everyone, it does not affect everyone equally: some can weather the economic impact better than others. As a result, keeping one’s business closed or staying home from work are less appealing for some than others.
• Politics. One’s preferred sources of information and political affiliation have a dramatic effect on views about restrictions related to the pandemic.

The bottom line

We all will have to continue to make challenging decisions each day about how to behave in this pandemic, until far more people are immune due to infection or a vaccine, or until we have effective treatments. And that could be many months or even years away.

So, listen to the experts and their recommendations, especially when they change in response to new information about the virus. Spread out your risk if you can: if you go to the grocery store today, put off your haircut to another day — in this way, the “virus dose” may be lower than if you’re out doing multiple errands among other people over a few hours.

Think about your decisions and how they may affect you and others. Try to be reasonable, consistent, but flexible in considering new information. Avoid the temptation to “COVID-shame” those who have chosen a different approach; if their decisions put you at risk, do your best to avoid them.

Talk about your plans with those with whom you’re sharing space. When there’s no right answer and our decisions may affect each other, it’s especially important to understand others’ perspectives.

Follow me on Twitter @RobShmerling

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Probiotics — even inactive ones — may relieve IBS symptoms

Irritable bowel syndrome (IBS) is a chronic gut-brain disorder that can cause a variety of uncomfortable gastrointestinal symptoms including abdominal pain and diarrhea, constipation, or a mix of the two. IBS can reduce quality of life, often results in missed school or work, and can have a substantial economic impact.

Physicians diagnose IBS by identifying symptoms laid out in the Rome Criteria, a set of diagnostic measures developed by a group of more than 100 international experts. Limited diagnostic testing is also done, to help exclude other conditions that could present with similar symptoms.

Although the precise cause of IBS remains unknown, recent research suggests that an imbalance in intestinal microbiota (the microorganisms living in your digestive tract) and a dysfunctional intestinal barrier (which, when working properly, helps keep potentially harmful contents in the intestine while allowing nutrients to be absorbed into the bloodstream) may be involved in the development of IBS in some people. Because of this, methods to restore the microbiota have been explored as treatment for this condition.

Balance of bacteria is important for gut health

Many digestive processes rely on a balance of various bacteria, which are found naturally in the gastrointestinal tract. If these bacteria fall out of balance, gastrointestinal disorders may occur, possibly including IBS.

Probiotics, which are bacteria or yeast that are associated with health benefits, may help restore this balance. Most probiotics used in IBS treatment fall under two main groups: Lactobacillus and Bifidobacterium. These probiotics are thought to assist the digestive system. Among other functions, they may strengthen the intestinal barrier, assist the immune system in removing harmful bacteria, and break down nutrients.

Probiotics may relieve symptoms of IBS

The American College of Gastroenterology conducted a meta-analysis of more than 30 studies, which found that probiotics may improve overall symptoms, as well as bloating and flatulence, in people with IBS. However, the overall quality of evidence of studies included in the meta-analysis was low, and specific recommendations regarding use of probiotics for IBS remained unclear.

The probiotic strain Bifidobacterium bifidum MIMBb75 has been reported to adhere particularly well to intestinal cells, and therefore may have an advantage in altering the intestinal microbiota and increasing the intestinal barrier.

In a clinical trial published in Alimentary Pharmacology & Therapeutics, once-daily Bifidobacterium bifidum MIMBb75 significantly improved overall IBS symptoms, as well as individual IBS symptoms including abdominal pain, bloating, and fecal urgency.

Recent study finds inactive probiotics relieve IBS symptoms

More recently, Bifidobacterium bifidum MIMBb75 has been shown to improve symptoms of IBS, even in its inactivated form. For the eight-week, double-blind, placebo-controlled clinical trial published in Lancet Gastroenterology, researchers studied whether the heat-inactivated form of Bifidobacterium bifidum MIMBb75 could alleviate IBS symptoms. (The heat-inactivated Bifidobacterium bifidum bacteria were nonviable, but retained their shape as well as their ability to adhere to intestinal cells.)

Overall, 443 patients (average age 41, 70% women) were randomized to receive heat-inactivated Bifidobacterium bifidum MIMBb75 or placebo once daily. A total of 377 patients (190 probiotic and 187 placebo) completed the trial. The primary endpoint was defined as a 30% or greater improvement of abdominal pain and at least “somewhat relieved” overall IBS symptoms for four or more weeks of the eight-week study duration. Significantly more patients receiving the Bifidobacterium probiotic met the primary endpoint compared to patients receiving placebo (34% versus 19%). In addition, a significantly greater percentage of patients receiving the probiotic also reported adequate relief of symptoms compared to placebo. Finally, individual symptoms including bloating, bowel movement satisfaction, and quality of life were also significantly improved with Bifidobacterium bifidum MIMBb75 compared to placebo.

Advantages of inactive probiotics

Previously, general consensus held that only active, living bacteria may have beneficial effects. But these results suggest that heat-inactivated Bifidobacterium can play a significant role in relieving symptoms of IBS, a syndrome with typically limited options for relief.

This is important because inactive probiotics have several potential advantages over active probiotics. For example, they are more likely to be stable, particularly if exposed to excessive heat. Inactive probiotics are also easier to standardize than active probiotics. Active probiotics also raise concerns for patients who may be susceptible to infection; inactive probiotics should relieve these concerns. Whether other strains of heat-inactivated probiotics will also improve IBS symptoms remains unknown.

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The plight of nursing home residents in a pandemic

For anyone living in a nursing home or other long-term or assisted-living facility, these are particularly difficult times. I’ve heard more than one resident complain bitterly about feeling trapped in their rooms, having meals left outside their door (rather than gathering in the dining room with friends), and not being allowed to participate in their routine activities or have visitors. “They’re treating me like a prisoner,” said one resident I know. Yes, for many, it’s feeling more like a prison than the place they knew as home before the pandemic.

And yet there are good reasons for all the restrictions. A recent analysis shows that residents of nursing homes and assisted living facilities account for 42% of all COVID-19 deaths in the US. In more than a dozen states, over half of deaths were among nursing home residents. West Virginia (80%), Minnesota (80%), and Rhode Island (73%) had the highest rates.

Unfortunately, nursing homes and other long-term care facilities offer the perfect breeding grounds for viral infections like the novel coronavirus: many people living indoors in close quarters and in close contact — in fact, regularly dining and socializing together.

Other contributors include:

• Advanced age is a risk factor for more severe illness with COVID-19.
• Chronic medical conditions. Hypertension, heart, lung, and kidney disease, and diabetes are common among nursing home residents.
• Inadequate testing and access to personal protective equipment.
• Ability to follow preventive measures. Those with dementia may not remember to wear a mask or maintain a social distance.
• Family adherence to preventive measures. Family members may try to bypass restrictions established by long-term care facilities because they feel the risks of COVID-19 are lower than the risks of keeping their loved one socially distanced, or they may be skeptical about the seriousness of COVID-19.
• Care needs. For people who need help dressing, bathing, and eating, it is impossible for staff to maintain social distance. Staff may lack necessary protective equipment, or find nearly constant mask-wearing and frequent disinfecting and hand sanitizing hard to maintain.
• Shared spaces. In many places, residents share bathrooms, bedrooms, dining rooms, and activity areas. Modifying how and where residents spend their days is challenging, especially for smaller facilities with tight budgets and little flexibility in the physical layout.
• Vulnerable staff. COVID-19 tends to be more severe among people who are poorer and members of minority groups (especially African Americans). Many employees in long-term care facilities are members of these higher-risk groups. Many cannot afford to miss work, and may work at more than one facility. So, if a staff member becomes ill, they may spread infection before they know they have it. Or, they may feel they need to keep working if their symptoms are mild.
• Understaffing, low pay, and high staff turnover are particularly common in this industry, and may also be important contributors.

What happens when a resident develops COVID-19?

Once someone develops COVID-19 in a nursing home, they’re isolated from others and receive necessary medical care. But, then what? If they are recovering but not sick enough to be in a hospital, where can they go? Many long-term care facilities have set aside separate areas (and separate staff) to look after them. But not every place can do this. Even with the best efforts, any infected individual can trigger an outbreak in a facility. And of course, there has to be a plan in place to end the isolation of infected residents — yet it may not be clear when isolation can end without risking spread of the virus.

Keeping residents safe from COVID-19

Some care facilities have been spared an outbreak of the virus so far. Enacting protective measures right away and training staff and residents about how to avoid the virus may have played a role. Some facilities tested staff and residents early in the outbreak and repeatedly, so that anyone infected could be separated from everyone else.

Other factors in their success might include low rates of community spread, a lower number of residents, and halting new admissions (or requiring a two-week quarantine of any new residents). Some credit having staff agree to work in only one facility and providing pay raises to make this possible.

Guidelines from the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) recommended certain restrictions: limiting visits, no communal dining or group activities, daily screening for symptoms or fever, requiring staff to wear masks. Possibly, facilities that conscientiously followed these guidelines were more successful at avoiding outbreaks. In many states, outdoor visits are recommended because the risk of spreading the virus is lower outside.

Some nursing homes are relaxing visitor restrictions

Recently, CMS released new recommendations about relaxing visitation restrictions that include

• testing all staff every week. Residents should have a baseline test and repeat testing if any other resident or staff member tests positive or has symptoms suggesting COVID-19.
• no new cases for at least a month
• adequate personal protective equipment and cleaning supplies
• adequate staffing
• adequate hospital and ICU beds nearby to take care of residents needing this care.

In many places, these ambitious goals will not be met for weeks or even months from now. Yet it’s clear that nursing homes cannot remain closed to visitors indefinitely. The impact of isolation on residents is just too great. So hopefully, protective measures and community containment of the virus will safely allow visits to resume soon.

The cost of isolation

Even if those living in long-term facilities manage to avoid the virus that causes COVID-19, it’s important to recognize that the mitigation efforts may take a terrible toll. Social interactions matter at every age. Extensive research on older adults links a strong social network to better psychological well-being and physical health.

The impact may be particularly profound on people who are elderly, already have dementia, disability, and psychological problems: these are precisely the people for whom social connectedness, routine, and structure are most important. The pandemic has taken a lot of this away from them.

The way forward

Measures to help residents avoid getting COVID-19 are essential. But so are strategies to help counter isolation, such as:

• re-introducing activities that allow distancing (such as book clubs, art classes, or bingo)
• encouraging outdoor activities, including ones that used to be held indoors (such as art or music classes)
• frequent video or telephone contact with family, which staff may be helpful in setting up. Some nursing homes purchased iPads for residents to allow them to have virtual visits, take virtual walks, or watch a movie with family.
• frequent “window visits” and bringing in favorite meals if allowed
• establishing “bubbles” of residents who have quarantined and can socialize
• sending some people home if there’s adequate support there; this may require major improvements in the availability and capabilities of home care (which will require funding).

While much has been done to contain COVID-19 outbreaks in long-term care facilities, the toll has been substantial, and many residents still feel imprisoned. Balancing the risks of infection with the risks of mitigation efforts will continue to present an enormous challenge to nursing homes and long-term care facilities until the pandemic is under control, or we have effective treatments or a vaccine. Talk to the management of your loved one’s facility to find out what more you can do.

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Olive oil or coconut oil: Which is worthy of kitchen-staple status?

Coconut oil has developed a cultlike following in recent years, with proponents touting benefits ranging from body fat reduction to heart disease prevention. Sadly for devotees, the evidence to support these assertions remains rather sparse.

But there is plenty of research to suggest that other plant-based oils have advantages over their animal-derived counterparts, particularly when it comes to heart health. So which is best? While no specific type should be hyped as a panacea, one variety isn’t getting the press it deserves: olive oil.

The case for olive oil continues to grow

Olive oil is a staple fat in the Mediterranean diet, and its previously publicized benefits have largely relied on examining its use by European populations. This information is useful, but looking at olive oil within the context of American diets provides us with stronger data to guide dietary choices here at home.

A recent study published in the Journal of the American College of Cardiology looked at adults in the United States and found that replacing margarine, butter, or mayonnaise with olive oil was associated with reduced cardiovascular disease (CVD) risk. This is particularly notable because Americans tend to consume less olive oil than our European counterparts. In the US, high consumers averaged a little less than one tablespoon of olive oil a day, whereas daily intake in studies examining Mediterranean populations has been as high as three tablespoons.

After taking demographic and lifestyle factors into consideration, those consuming more than half a tablespoon per day had a reduced risk of developing CVD compared to those using olive oil infrequently (less than once per month). Consuming more olive oil was also associated with a decreased likelihood of dying from CVD. Even slight increases in olive oil consumption, like replacing roughly a teaspoon of margarine or butter each day with a similar amount of olive oil, had advantages.

Olive oil was also correlated with a reduction in inflammatory compounds that may contribute to the progression of CVD. Olives contain plant chemicals called polyphenols that may help reduce inflammation. Using virgin olive oil, which is extracted through mechanical rather than chemical means, is thought to offer higher levels of protective plant compounds than refined olive oils. Extra virgin olive oil (EVOO) is a product of the preferred, mechanical processing.

Though we need more research, these polyphenols may also extend benefits to other areas of the body, like the brain. For instance, along with other healthy diet habits like eating leafy greens, primarily using olive oil when cooking has been associated with combating the decline in brain function that happens as we age.

How does coconut oil compare?

Proponents of coconut oil cite the medium-chain fatty acids it contains as a benefit because of the unique way these fats are digested. It’s claimed these fats offer advantages related to weight loss and cholesterol, though these assertions remain controversial. Regardless, lauric acid, the primary fat found in coconut oil, is thought to behave differently from other medium-chain fats, and may not deliver as promised.

In a recently published study in the journal Circulation, which compiled data from a variety of trials, coconut oil did not show benefits related to waist circumference or body fat compared to other plant-based fats. Coconut oil, a tropical plant oil, also did not fare as well as nontropical plant oils, like olive oil, with respect to reducing other cardiac risk factors. In fact, coconut oil increased low-density lipoprotein (LDL) cholesterol, the kind associated with an increased risk of heart disease.

Coconut has been an important fat in a variety of traditional diets in Asia, and is touted to impart health benefits within these communities, including fewer cardiac complications and premature deaths. However, these diets often feature minimally processed coconut products, like coconut flesh, which are also higher in nutrients like fiber. Lifestyle habits in these Asian communities also typically include eating more fruits, vegetables, and fish than in many American diets.

That said, extra virgin coconut oil, which can be purchased in the United States, is arguably less processed, and often refined in a manner similar to EVOO. A recent trial published in BMJ Open looking at extra virgin coconut oil did not show an increase in LDL cholesterol when compared to EVOO during a four-week period. (Both oils performed better than butter.) Unfortunately, there are not enough human studies involving extra virgin coconut oil to support its use as a primary fat in our diets. Nor do we have information about its long-term effects here in the US.

And the winner is… olive oil

The benefits of using nontropical plant-based oils remain very promising, making olive oil a natural choice in the kitchen. Try oil and vinegar on a fresh summer salad, or in place of mayo in potato or tuna salad. Consider a drizzle of olive oil instead of a pat of butter or margarine when cooking vegetables. And keep coconut fat to occasional use, say, to enhance the flavor of a vegetable curry, or as a substitute for butter in baked desserts.

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Summer’s here, teens and parents — now what?

Summer is upon us, and for many teens in this country, school’s already out. Now what? Typical and cherished summer activities like jobs, internships, and camps may be on hold. There is a general sense of uncertainty about what the coming months will bring, and higher levels of worry in cities and states that struggled with many cases of COVID-19. This is going to be a very different summer than usual for many teenagers and their families. As the weather heats up, here are four tips to guide parents in helping their teens plan for the months ahead.

Validate your teen’s reaction to current circumstances

Teens may be feeling disappointed, anxious, and/or sad about cancelled activities and events. They may have a sense of uncertainty about what is to come. They may also be missing friends and feeling socially isolated. While it can be tempting as a parent to jump into problem-solving mode when you see your teen in distress, first take some time to listen to their concerns. Express their worries back to them, letting them know that you hear what they are saying through your words, tone, and expression. It’s more important to help your teen feel heard and understood than to try to fix the problem in that moment.

Enlist your teen’s help in mapping out a daily structure

This could mean agreeing on rough times for meals, wake-up and bedtime, and incorporating physical activity into each day. (Accept that most teens like going to bed later and sleeping later than they did when they were younger.) Next, brainstorm together about how to fill the remaining time. Strike a balance between structure and down time, incorporating expectations for screens into the plan. Having a voice in these decisions and the opportunity to make adjustments as time goes by matter to teens. As you map out a plan together, keep in mind that boredom is not the enemy. While we, as a culture, have become less accustomed to down time and boredom in our daily lives, there are benefits to both.

Ask your teen which goals or hobbies they want to master or develop

Help teens decide on appropriate goals or hobbies to pursue over the course of the summer. Are they interested in learning to drive a car? Cook meals? Walk dogs or pet-sit? Maybe learn a language or take a course? Family resources need to factor into what’s possible, of course. Once they decide what they want to accomplish, help them sketch out a roadmap and action steps toward these goals. Determine how you, as a parent, can provide some scaffolding during this process while also supporting and celebrating your teen’s autonomy.

Set clear guidelines around socializing

The coronavirus hasn’t disappeared, so try to stay aware of how it’s affecting your community. Decide on guidelines and expectations for your family members in terms of social distancing and preventive measures, such as washing hands often and wearing face masks when distancing isn’t possible. Families may differ in their approaches, depending on how vulnerable family members might be to illness as well as other factors.

Talk to your teen about what these decisions will mean for various social interactions. Take stock of how secure or leaky your family bubble has been, in terms of the interactions you have had with people outside of the family over the past few months, and discuss any changes for the summer. Be explicit. What will this mean for your teen’s interactions with friends and extended family members? What about wearing masks, trips to stores, and joining in various indoor and outdoor activities? Be clear about which rules and expectations are non-negotiable and which are negotiable based on your family’s risk factors, state guidelines, and your own threshold for safety. Your teen will likely face challenges and obstacles in following these plans, so it can be helpful to anticipate these in advance and recruit your teen in problem-solving how to manage them.

It all boils down to listening to your teen and empowering them to take an active role in planning. While this likely isn’t going to be the summer they’d planned on, with luck it will still hold joyful moments and opportunities to develop resilience and a sense of autonomy.

For more information on coronavirus and COVID-19, see the Harvard Health Publishing Coronavirus Resource Center and our “Parenting in a Pandemic” webcast.

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4 parenting tips to break the negativity loop

“It’s a beautiful day outside,” you say, smiling. Your son replies, “It’s supposed to rain later.” You share, “That game was fun!” Your daughter adds, “I messed up one of my turns.”

If you find that your child tends to channel Eeyore from Winnie-the-Pooh and has difficulty seeing some of the bright moments in a day, below are some ways to help them interrupt a negativity loop. The first tip works well for all ages. Choose the other tools depending on whether your children are younger or older.

Start by validating emotions

Parents have a lot of wisdom to share with their children, and their advice often is filled with a lot of logic. Unfortunately, that logic tends to backfire when shared with someone experiencing an unhappy emotion, and can make the emotion even stronger. Both children and adults need to feel heard before their ears can open up and hear what else you have to say, so try to validate first before you try to help children appreciate positive aspects of a situation.

Validation allows us all to feel heard. You are not agreeing or disagreeing with the emotion; you’re showing that you see it. For example, if your daughter comes home sulking after scoring two goals in soccer and missing the final one, you might have the urge to say, “Why are you so sad? You scored two goals and looked like you were having so much fun while playing!” Your intention is kind, yet does not match your daughter’s experience. Instead, try reflecting how she is feeling by saying, “You’re disappointed that you didn’t make that final shot.” This acknowledges that your daughter is disappointed without agreeing or disagreeing with her.

Sometimes, it’s enough to leave it at that. When you think it’s important to have your daughter see another side of a situation, remember to use the conjunction “and” instead of “but” so you don’t negate or erase your validation. In this example, you could say, “You’re disappointed that you didn’t make that final shot, and I am really proud of you for trying your best for the whole game.”

Alternatively, you could add a question to help your daughter discover positive aspects of the experience herself. In this case, you could say, “You’re disappointed that you didn’t make that final shot, and I wonder if there were any parts of the game that you enjoyed?”

A few more tips:

• Say, “You’re [insert emotion here] because…” Some examples of emotion words include sad, angry, worried, disappointed, embarrassed, disgusted, jealous, guilty, and surprised. Try to be as specific as possible. For example, “Upset,” could be a mixture of emotions, so identify which ones, such as sadness and/or anger, might be at play.
• Try to avoid, “I understand that you’re feeling…” or “I know that you’re feeling…” As children get older, it will be developmentally on target for them to think that you could not possibly know what their experiences are like, and make you feel like you’ve entered a land mine by trying to relate to them.
• Instead, offer a validation tentatively, “You seem…” or “I wonder if you were…”

Reflect on positive events

• Younger children (under 8) may enjoy the High-Low Game, which helps them balance out negative experience reflections with positive ones. You can use the start of dinner time each night to have each family member share one high or positive experience in the day and one low or negative experience in the day. You even can have your son start off by sharing the low before the high, so that he ends on a high note. This is a way to hear about everyone’s day and see how your son views his daily experiences.
• Older children (8 and up) may prefer a positive events diary. If your son walks around in life as though wearing those sunglasses from the ‘80s that look like window blinds and only seem to let in the negative events of each day, try having him write down three positive experiences he had at the end of each day. Not only can this help him realize that his day was not all bad, it also can help him improve his mood.

Foster gratitude

• Younger children (under 8) may like playing this game during dinner. Have everyone practice identifying something for which they’re grateful that day. Practicing gratitude in this way can create a more positive tone at meals, and maybe — just maybe — you might even hear that your son is grateful for the meal you just prepared!
• Older children (8 and up) could try a daily gratitude log, and you can set the tone for doing this by writing in your journal each day, too. It can be a slippery slope once someone starts focusing on all the things going wrong that day. Fostering gratitude, an appreciation of experiences, people, or things that are at least partially outside of oneself or one’s own doing, can help your daughter form a different and more positive relationship with aspects of her day, and research has shown that gratitude can help improve one’s mood. Have your daughter take a step back and remind herself of a few things for which she’s grateful each day. She can use prompts, such as “Someone/Something I was grateful for today was…” to get her started.

The takeaways

When you are concerned that your child reacts more like Eeyore than like Tigger, remember that your child needs to feel heard before he can see another perspective. Validate first, and then you can help your child consider all aspects, both positive and negative ones.

If you find that your child remains stuck in a negativity loop and starts to show signs of depression, ask your child’s pediatrician for a referral for therapy, such as cognitive behavioral therapy, so that just like Eeyore, your child can learn tools to look for sunshine.

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Global mental health in the time of COVID-19

Just months ago, who could have imagined that the world would be looking down the barrel of a spiralling health crisis and economic recession unlike any witnessed in our lifetime? Now, in a world gripped by the fear of a marauding virus, mental health is emerging as a key concern.

Diverse pathways to poorer mental health

The reaction of the media and governments to the epidemic served to fuel anxiety. The dramatic way the term “pandemic” was announced by the WHO after weeks of watching the epidemic unfolding around the world was a hair-raising moment. Apocalyptic messaging about millions of dead bodies littering our cities followed, even though experts had identified vulnerable populations — people who are elderly or chronically ill, and those who live in group facilities like nursing homes — early on.

The breathless questions mounted. When, if ever, would life return to a semblance of what we used to experience? Within the torrent of mixed messages about the science, what was real or fake? What might the post-lockdown scenario for containing the virus look like? All of this played on an endless daily newsreel, rounded out by rising figures on illnesses, hospitalizations, and deaths around the world and close to home.

Not surprisingly, experiences of anxiety, fearfulness, sleep problems, irritability, and feelings of hopelessness are widespread. These are mostly the rational responses of our minds to the extraordinary realities that we are facing. But economic recession, widening inequalities, continuing uncertainty about waves of the epidemic still to come, and the emotional impact of physical distancing policies will continue to bite deeper into our mental health. A rise in clinically significant mental illnesses and suicides may well follow.

Unemployment, acute poverty, and indebtedness are strongly associated with poor mental health. A recent report documents “deaths of despair,” mostly through suicide and substance use, as the cause for increased mortality and reduced life expectancy in working-age Americans following the 2008 economic recession. The profound inequality in the US, coupled with its weak social security net, deeply polarized society, and fragmented health care system, are a toxic recipe for a similar surge of deaths of despair on this occasion.

Emerging evidence suggests that the lockdowns and the pivot of health care services to this one virus has seriously disrupted mental health care in many parts of the world. Access to mental health care — including vital continuing care — has not been available for many people experiencing new-onset episodes of depression and anxiety, or exacerbations of pre-existing mental health problems.

Transforming mental health globally

Fortunately, we know what needs to be done and how to achieve it. Further, we know the resources invested are excellent value-for-money. The pandemic presents a historic opportunity to reimagine mental health care.

The GlobalMentalHealth@Harvard initiative was launched in 2017 to marshal the rich, inter-disciplinary expertise within the university and to scale up this knowledge with a worldwide network of partners. In response to the pandemic, the initiative is prioritizing actions to transform and build resilient mental health care systems globally, using three strategies:

• EMPOWER deploys a range of digital tools to build a mental health workforce. It enables front-line providers, such as community health workers and nurses, to learn, master, and deliver evidence-based brief psychosocial therapies. Two examples are behavioral activation for depression and psychological first-aid for acute mental health crises.
• CHAMPIONS builds on time-tested executive leadership training, twinning it with hands-on mentoring by experienced faculty. It aims to build leadership capacity to scale up evidence-based mental health care. CHAMPIONS will create a global peer group of mental health leaders across the US and the world to take forward the critical work of building back — and improving — mental health services.
• COUNTDOWN is developing a set of common core metrics, such as availability of skilled providers and quality of care, to evaluate the performance of these mental health care systems and make them more accountable. COUNTDOWN can perform many roles in the context of the pandemic. A few examples are tracking population-level mental health across and within countries, identifying where the unmet need for services is greatest, and evaluating the impact of investments.

Together, these three essential, interwoven strategies can achieve the transformation of mental health care systems that the global community so urgently needs.

Only with significant resources can we realize such ambitious projects. But here we need to anticipate the pandemic’s biggest threat to mental health: pushing back, once again, mental health from the global health agenda.

Back in the 1990s, it appeared that the world’s leading development agencies would finally recognize mental health as a priority. Yet the Millenium Development Goals of 2000 left it off the table. Fifteen years later, mental health found its rightful place in the Sustainable Development Goals. Now, once again, all funding and health care action is pivoting toward one disease, as mental health risks are being shoved back into the shadows.

Investing in mental health enables each individual to regain hope for the future. It will also contribute to making societies healthier, economically productive, and socially cohesive. There cannot be a more important investment in the face of the most serious crisis to test the global population in a century. Let’s work together to realize our shared mission.

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New drugs approved for advanced BRCA-positive prostate cancer

Defective BRCA genes are well known for their ability to cause breast and ovarian cancers in women. But these same gene defects are also strong risk factors for aggressive prostate cancer in men. About 10% of men with metastatic prostate cancer — meaning cancer that is spreading away from the prostate — test positive for genetic mutations in BRCA genes. Fortunately, these cancers can be treated with new types of personalized therapies.

In May, the FDA approved two new drugs specifically for men with BRCA-positive metastatic prostate cancer that has stopped responding to other treatments. One of the drugs, called rucaparib, was approved on May 15. The other one, olaparib, was approved on May 19.

Both drugs work by shutting down the cancer cell’s ability to fix its DNA. Like all cells in the body, cancer cells are bombarded every day by free radicals, low-level radiation, and other stressors that cause DNA damage. BRCA genes ordinarily fix that damage so that cells can function normally and survive. But if the genes are defective, then the damage piles up. BRCA-positive tumors get around that problem by deploying an alternate DNA repair gene called PARP. Rucaparib and olaparib both inhibit PARP, leaving cancer cells without any way to fix their increasingly mangled DNA; eventually the cells die.

The drugs had each been approved already for other BRCA-positive cancers, and prior to their approval were given “off-label” to men with prostate cancer as well. The approvals “should ease some of the previously existing insurance barriers for coverage, enabling more patients to benefit,” says Dr. Marc Garnick, Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org.

What the studies showed

Clinical trial results showed the drugs were well-tolerated, with side effects similar to mild chemotherapy. Rucaparib was tested in a single-arm clinical trial (meaning there was no control group), enrolling nearly 400 men with BRCA-positive metastatic prostate cancer who were no longer responding to other treatments. Results showed that tumors shrank in 44% of the enrolled subjects, in some cases for up to two years. Olaparib was tested in a similar population and delayed disease progression by an average of 7.4 months, which was just over two times longer than a type of hormonal therapy used in the control arm of that study.

Both drugs have their shortcomings. As personalized therapies, they work only for men with BRCA-positive prostate cancer, and just half the treated men will benefit. Furthermore, the experience with PARP-inhibitors so far is that tumors become resistant to therapy within six to 12 months. Whether PARP-inhibitors actually lengthen survival for men with metastatic prostate cancer is still being investigated. And many other questions remain about how to use the drugs most effectively to maximize their benefits.

Still, Dr. Garnick describes the approvals as a major advance for prostate cancer therapies developed for specific subgroups in the population. “Genetic testing, which is required to determine a patient’s eligibility for receiving these drugs, has shown that mutations are much more common than previously thought,” he says. “In addition, other mutations in men with advanced prostate cancer are being uncovered, and many of them can be successfully treated with targeted drugs that can slow the progression of their disease.”

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Treating mild sleep apnea: Should you consider a CPAP device?

Obstructive sleep apnea (OSA) is a disorder characterized by repeated episodes of partial or total upper airway obstruction that result in arousals from sleep, and changes in oxygen levels during sleep. OSA is one of the most common conditions I see as a sleep medicine specialist. This is not surprising, considering that OSA is estimated to affect about 20% of the general population, and is even more prevalent in patients who are obese, or who have heart or metabolic conditions like diabetes.

When untreated, OSA can negatively impact cardiac and metabolic health, quality of life, and result in excessive daytime sleepiness, insomnia, problems with thinking, and depression or anxiety. OSA impacts people of all ages, backgrounds, shapes, and sizes, and while both patients and doctors have become increasingly aware about OSA and its effects over recent years, about 80% of patients with OSA still go undiagnosed.

How is OSA diagnosed?

The severity of OSA is based on the number of respiratory sleep disruptions per hour of sleep during a sleep study, also called the apnea-hypopnea index (AHI). Basically, the higher the AHI, the more severe the sleep apnea. Most population studies suggest that about 60% of people with OSA fall into the mild category. In general, many studies demonstrate a linear relationship between the AHI and adverse health outcomes, lending strong support for treatment of moderate and severe OSA, but with less clear-cut support for clinical and/or cost-effective benefits for treating mild OSA.

Scores for OSA don’t always correlate with symptoms

Regardless of the criteria for categorizing OSA as mild, moderate, or severe, the severity of disease does not always correlate with the extent of symptoms. In other words, some people with very mild disease (based on their AHI) can be extremely symptomatic, with excessive sleepiness or severe insomnia, while others with severe disease have subjectively good sleep quality and do not have significant daytime impairment.

Sleep disorders also tend to overlap, and patients with OSA may suffer from comorbid insomnia, circadian (internal body clock) disorders, sleep movement disorders (like restless legs syndrome), and/or conditions of hypersomnia (such as narcolepsy). To truly improve a patient’s sleep and daytime functioning, a detailed sleep related history is needed, and sleep issues must be addressed via a comprehensive, multidimensional, and individualized approach.

Treatment approaches depend on the severity of your OSA

When sleep apnea is moderate or severe, continuous positive airway pressure (CPAP) is considered the first-line treatment, and is the recommended treatment by the American Academy of Sleep Medicine (AASM). CPAP, by eliminating snoring, breathing disturbances, and drops in oxygen saturation, can essentially normalize breathing during sleep. However, to be most beneficial, CPAP should be worn consistently throughout sleep. Unfortunately, many studies of OSA set a relatively low bar for treatment adherence (many use a four-hour-per-night threshold), and do not necessarily take into account treatment efficacy (whether sleep apnea and related daytime symptoms persist despite treatment).

What about mild sleep apnea?

There have not always been consistent outcomes data or consensus about treatment recommendations for people with mild sleep apnea. Nonetheless, there are several studies that have demonstrated quality of life benefits in treating mild OSA, including a recent study published in The Lancet, where researchers from 11 centers throughout the United Kingdom recruited and randomized 301 patients with mild OSA to receive CPAP plus standard of care (sleep hygiene counselling) vs. standard of care alone, and followed them over three months. The results found that in patients with mild OSA, treatment with CPAP improved their quality of life, based on a validated questionnaire.

This study supports a comprehensive approach to evaluation and treatment of mild OSA. While all people with mild OSA may not need to be treated with CPAP, there are patients who can greatly benefit from it.

Treatments may be trial and error until you and your doctor get it right

When sleep apnea is mild, treatment recommendations are less clear-cut, and should be determined based on the severity of your symptoms, your preferences, and other co-occurring health problems. Working in conjunction with your doctor, you can try a stepwise approach — if one treatment doesn’t work, you can stop that and try an alternative. Managing mild sleep apnea involves shared decision-making between you and your doctor, and you should consider just how bothered you are by sleep apnea symptoms, as well as other components of your health that could be made worse by untreated sleep apnea.

Take home suggestions

Conservative approaches for mild OSA:

• Maximize a side sleeping position; try not to sleep on your back.
• Optimize weight if overweight or obese; even a 5-to-10-pound weight loss can make a difference in mild OSA.
• Treat nasal allergies/congestion.
• Avoid alcohol or respiratory depressant medications close to bedtime.
• Make sure that you get an adequate amount of sleep, and keep fairly regular sleep and wake times across the week.

If you have bothersome symptoms related to OSA — such as loud, disruptive snoring, long pauses in breathing, repeated nighttime awakenings, unrefreshing sleep, insomnia, trouble thinking, or excessive daytime sleepiness — or significant health problems that might be exacerbated by OSA (even mild) — such as arrhythmia, high blood pressure requiring multiple medications to control, stroke, or a severe mood disorder — medical treatment(s) for OSA should be considered.

The medical treatments for mild OSA:

• continuous positive airway pressure device (CPAP)
• a dental appliance to treat sleep apnea
• an evaluation with an ear, nose, and throat specialist (ENT), to see if there is an anatomic issue (like severe nasal septal deviation) that may be causing OSA, or making it worse.

If you are concerned you might have OSA, talk to your doctor

Based on your symptoms, exam, and risk factors, your doctor may recommend a sleep study, or you might be referred to see a sleep medicine specialist. A comprehensive sleep assessment is needed to accurately evaluate sleep complaints, since sleep disorders tend to overlap. Treatment for mild OSA may improve sleep-related symptoms and your quality of life. However, there is no one-size-fits-all approach when it comes to sleep disorders, but rather a multidimensional and individualized approach to find what works for you.

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How to stock a plant-based pantry (and fridge) on a budget

Given the current pandemic and related economic stressors, many of us are trying to maintain healthy habits while watching our expenses. One of the areas where we can support our immune system is through our food choices. We all have to eat, and eat several times a day, and selecting foods that support our health and our planet — while also saving money — is now a priority for many.

People are going meatless for many reasons

About a quarter of the US is now vegetarian, especially people ages 25 to 34. A survey from 2017 studied US attitudes toward animal farming, and found that 54% of Americans were trying to purchase less meat, dairy, and eggs, and buying more plant-based foods. A plant-based diet has been linked with a lower risk of type 2 diabetes, heart disease, and overall mortality. Studies have also shown an improved mood with a diet rich in fruits and vegetables.

In additional to health reasons for eating less meat, many people are embracing a plant-based diet with fewer meats, or even starting with one meatless day per week, in order to save money. Meat is becoming expensive, and even scarce, as some supermarkets are setting limits on the number of packages of beef or poultry a person can purchase per shopping trip. Also, more people are at home, and with schools and summer camps being canceled there are more meals to make each day within a tighter food budget. Additionally, many people have reduced incomes and may be using food pantries, or may need to be very limited in their grocery shopping choices.

Focus on wholesome ingredients, even with a limited food budget

Our food choices truly do make a difference to our physical and mental health, and with a little planning, we can make good foods go further. While many processed carbs are cheap, you can get much more nutrient-dense food without spending much more. One example: a large family-sized bag of potato chips costs about the same price as a bag of dried beans, or several cans of beans. A box of sugary, processed breakfast cereal may last less than a week compared to a large box of fiber-filled oatmeal, which is not only a healthier choice, but one that will last longer and be more filling.

Shopping to stock a mostly plant-based pantry and fridge

Setting up or adjusting your panty and fridge to include more plant-based options can help your budget and your health. Your focus should be on whole foods such as fresh (or frozen) vegetables and fruit, protein sources that include legumes (lentils, peas, and beans), whole grains, nuts, and seeds.

Long-lasting pantry staples include a variety of beans, chickpeas, spinach, coconut milk, tomatoes, olives, and corn. Some nondairy nut milks are shelf-stable, and can be great options for many recipes. Other shelf-stable options include whole-grain pastas (look for the Whole Grains Council stamp on the box), buckwheat noodles (which are gluten free), rice, and pad Thai noodles. Canned tomatoes, tomato paste, and tomato sauce (look for low-sugar brands) are great options for pasta sauces, lasagna, hearty stews, or vegetarian chili. Dry spices last a long time, and can help you add new flavors to your meals and change up leftovers to extend your budget even further. As an example, adding Mexican seasonings and a side of salsa to last night’s roast chicken can be today’s tacos!

Spend time in the foods section and stock up on lower-cost frozen vegetables and fruit. Adding vegetables to meals will make them more filling due to the fiber content. Adding frozen berries to breakfast oatmeal or whole-grain pancakes is more cost effective than buying fresh berries. Many Asian-inspired dishes such as pad Thai, noodle soups, or salads can be bulked up by adding vegetables, and these dishes will add variety to your menu. Some low-cost fresh vegetable options for soups and grain bowls include shredded carrots, peas, scallions, spinach, and bean sprouts.

Try homemade instead of canned soups

Rather than purchase a canned soup, why not buy dried lentils or legumes and fresh veggies and make your own? Lentils are low in sodium and saturated fat but high in potassium, fiber, folate, and antioxidants. They are also a great prebiotic for your gut microbiome. You’ll also know exactly what’s in your soup, and you’re cutting down on the excessive sodium and preservatives in most commercial soups. When you make a large quantity of soup, it’s less money per serving than a single can of soup, and you can freeze leftovers.

Plant-based can be protein-rich

If you are concerned about not getting enough protein through a plant-based diet, you should know that 8 ounces (1 cup) of cooked lentils provides about 18 grams of protein, and it has little to no saturated fat or sodium. Compare this to 4 ounces of ground beef, which provides 14 grams of protein, no fiber, and 11 grams of saturated fat.

In addition, plant-based options are great sources of folate, soluble and insoluble fiber, iron, phosphorus, polyunsaturated and monounsaturated fatty acids. Many plant-based options are neutral in flavor, lending themselves to creative cooking, from soups and stews to bean and lentil salads, stir-fry dishes, vegetable burgers, hummus, and bean dips.

Plant-based foods	Grams of protein
1 cup cooked/boiled lentils	18 g
1/2 cup dry red beans	21 g
1/2 cup chia seeds	18 g
1/2 cup flax seeds	18 g
1/2 cup dry black beans	24 g

General tips for healthy, budget-friendly shopping

A helpful guideline at the supermarket is that fresh produce is on the outer perimeter of the store. Start there, see what is on sale that week, and stock up. Remember, you can freeze fruits and vegetables for later use by properly chopping and storing them in the freezer. The shelf-stable items and more processed foods are in the supermarket aisles. Again, stock up on sale items such as canned low-sodium beans, chickpeas, corn, dry lentils, or beans. Planning a plant-based diet on a budget is possible, and has several positive effects: you’ll benefit physically and mentally from a diet with less meat, and you may see savings at the checkout.

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Paprika Roasted Cauliflower Florets

Set the oven the 400° F

Use a sheet pan or baking dish (a cookie sheet will work too)

1 bag of frozen cauliflower florets

1 teaspoon paprika

1/2 teaspoon garlic powder

1 teaspoon kosher salt

2 tablespoons olive oil

Squeeze of fresh lemon

Add the dry spices to the olive oil

Toss the frozen cauliflower in the olive oil

Spread cauliflower on the sheet pan in a single layer

Oven roast for 25 to 30 minutes

Add a squeeze of fresh lemon before serving

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Driving across the country in a pandemic

Thinking about traveling during the pandemic? Before heading out, there’s a lot to think about, including:

• Do you have risk factors for severe COVID-19, such as advanced age or chronic medical conditions?
• What about your co-travelers’ health and risk factors? Are your co-travelers part of your household or tight social circle?
• Is the virus spreading in the places you’re going?
• Who are you going to see along the way, and what’s their health risk profile?
• If you get sick while traveling, will healthcare be available? And do you have the supports you need in case you have to quarantine for two weeks when you return home — or in a state you’ll be staying in?

Depending on your answers, you might decide it’s better to stay home! Or you may decide the risks are acceptable given some preparation and precautions, as we recently did.

Fly or drive?

“Please be careful when you drive out of the airport today, as you begin the most dangerous part of your trip.” Ever hear a flight attendant say that when your plane lands? It suggests that driving is riskier than the flight you just took. And the statistics support that.

But this may not be true during a pandemic. Tight seating and exposure to lots of people whose behavior you can’t control might be riskier than driving between cities. For many, driving may be safer than flying precisely because you have more control over potentially risky exposures.

We just drove from Denver to Boston. We chose to drive rather than fly because we’d be traveling with our large dog. Yes, he could have traveled in the cargo hold, but let’s just say that option was vetoed. Having just made the reverse trip from Boston to Denver in January, right before the pandemic began, it’s fair to say the return trip was quite different.

Preparing for the trip

We carefully planned our route, choosing stopping points that had open hotels (some were reserved for healthcare workers and first responders) and making reservations at a chain that had a reputation for being particularly conscientious about COVID-19 safety. Fortunately, many hotels are taking a number of steps to keep their lodgers safe during the pandemic, as a recent article in Forbes notes.

Then we loaded the car up with

• hand sanitizer, disinfectant wipes, paper towels, and spray disinfectant
• food and water, so we could avoid stopping at restaurants
• supplies to allow bathroom breaks in the woods, in case we could not find suitable public restrooms
• masks
• the dog (of course), along with his food, toys, and bed.

Heading out into the world

As we left Denver, we knew some potentially risky situations would be hard to avoid. We’d have to stop for gas, walking the dog, walking me (I needed to stretch often), and of course bathroom breaks.

Friends told us to “just go in the woods,” but there are no woods along much of I-70 in Kansas! We were pleased to find plenty of truck stops, rest areas, and gas station restrooms that were clean and easy to use without touching nearly anything (though we took disinfectant wipes in case a door handle or soap dispenser had to be touched). I also used disinfectant wipes to touch gas pumps. Once back in the car, we used lots of hand sanitizer before resuming the trip.

We did notice masks were worn more in some areas than in others. One mask-free man saw our masks and asked us, “Do you really think there’s something to this virus thing?” I said yes, I thought there was something to it indeed! Clearly, there are a range of perspectives on the seriousness of the pandemic.

The hotels we stayed at seemed safe as well. Lots of wipes and sanitizer in the lobby, a protective shield at the front desk, masks on all the employees, and a two-person limit in the elevators. Once in the room, we wiped everything down: lamp switches, surfaces, door handles, bathroom, and of course, the TV remote. The hotel gave us the option of having no one enter the room (such as for maid service) during our stay, and we accepted.

It was easy to socially distance: there was almost no one in the hotel or in nearby streets, so going for a walk seemed safe.

Seeing family

Halfway home, we visited family at an independent living facility. Waving and talking through a glass door and wearing masks, our hugless greeting was far different from normal but much better than nothing. At another gathering of six people, we sat outside six feet apart and wondered if beer could kill viruses. (It can’t.)

The bottom line

After five days on the road, we arrived home weary but, hopefully, uninfected. We appreciated that most of our fellow travelers and all of our hosts took the pandemic seriously. While nothing is risk-free, our efforts and those of people we encountered made the trip feel like a low-risk undertaking. If you’re healthy, symptom-free, and need to drive a long way, I think there are ways to do it safely, even during a pandemic.

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Better heart health in eight weeks? Double down on fruits and veggies

Two decades ago, the DASH (Dietary Approaches to Stop Hypertension) study tested the effects of three different diets on almost 500 participants over eight weeks. The first diet was a typical American diet, relatively low in fruits and vegetables (3.5 servings daily) and high in junk foods and sweets. The second offered more fruits and vegetables (8.5 servings daily) as well as seeds, nuts, and beans, and not many sweets. The third was the very healthy DASH diet, rich in fruits and vegetables (9.5 servings daily), beans, nuts, seeds, and whole grains, and barely any sweets. Participants truly stuck to each diet plan: All meals were provided by the researchers, with one meal per day eaten at the study center and the rest provided in coolers for take-home. All diets had the same amount of sodium (salt) and calories.

What did the original DASH study find?

After only two weeks, both the more-fruits-and-vegetables diet and the DASH diet significantly lowered blood pressure! This healthy blood pressure effect lasted for the whole eight-week study. Most importantly, it didn’t occur due to any differences in sodium intake or weight loss among the participants in all three diet groups.

Further, the study highlighted a remarkable effect on participants following the DASH diet. Among those with a diagnosis of high blood pressure, systolic blood pressure (the top number) dropped by 11.4 points, and diastolic blood pressure (the lower number) by 5.5 points. Basically, the DASH diet was more effective than a lot of blood pressure medications. Who wants to take a pill when you can simply eat healthier, which will provide plenty of other benefits? For example, diets higher in fruits and vegetables are associated with lower risk for all sorts of cardiovascular disease, like heart attacks and strokes.

What does the new data tell us about heart benefits?

Researchers eager to learn more about the heart benefits recently took a second look at data collected in the original study. Using blood samples from the original study participants in all three diet groups, they ran newer tests that can detect levels of heart strain, heart muscle injury, and total body inflammation. They found that both the more-fruits-and-vegetables diet and the DASH diet significantly lowered levels of heart strain and heart muscle injury, after just eight weeks. Total body inflammation levels were not significantly different, but scientists hypothesize that inflammation — which is linked to weight — would decrease with ongoing healthy eating and the inevitable weight loss that follows. This has been shown in many other studies.

The takeaway

The benefits of eating even slightly more fruits and vegetables can be seen in as little as two to eight weeks: significantly lower blood pressure, a measurably lower strain on the heart, and decreased heart muscle damage. Here is an important point: You can’t see these changes with your eyes. Blood pressure measurements and blood tests that find markers of heart strain and damage can show invisible changes critically important to our health, that can later lead to a heart attack, aortic aneurysm, stroke, peripheral artery disease, even dementia. A healthy cardiovascular system, the network of arteries connected to our hearts, keeps our bodies functioning well.

What it is not about: The numbers on the scale. The overall goal of a healthy diet should not be only about weight loss. If it is, then all of the other benefits are missed. A healthy diet and lifestyle will lead to healthy weight loss, which is great, but if that’s the only goal, then folks end up disappointed and disillusioned. Focus instead on eating healthy to be healthy, and take the focus off of the scale.

So how do we eat more like the DASH diet? You can find more information at the American Heart Association and the Harvard T.H. Chan School of Public Health Nutrition Source. But basically, it’s about working in more fruits, veggies, beans and legumes, nuts, seeds, and whole grains, and avoiding processed foods, red meats, snacks, and sweets.

Tips from a pro

• Health-ify breakfast. Instead of a bowl of cereal or a bagel for breakfast (which are processed foods), have plain low-fat yogurt and a big serving of thawed berries with a sprinkling of nuts. It’s my favorite healthy breakfast! Do you prefer not to eat dairy? Feel like you need some whole grains in your breakfast? Great, try my no-added-sugar vegan granola. Need eggs for breakfast? Check out these other breakfast ideas, including a veggie-heavy frittata. You do you. Make your healthy breakfast out of foods you enjoy eating that are available to you and that also happen to be good for you. There are lots of options.
• Always have a fruit or a vegetable with your snack. Hangry in the late afternoons? Have a handful of nuts and a banana, or a tablespoon of peanut butter and an apple, or a cup of hummus and a bunch of carrots, or even one of my faves, a couple of squares of very dark chocolate and an orange. Every snack will be healthier (and more filling) if it includes fiber-rich fruits and veggies.
• Sneak more veggies into your main meals. Have frozen chopped spinach or kale handy to add to soups and stews, adding fiber and plant nutrients to your usual recipe. Add another veggie side to your barbecue, like sweet onions and colorful peppers sliced thin and sautéed in a grill pan on your grill.

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