Can appealing to teenagers’ vanity improve sun-protective behaviors?

As the summer warmth lures us outside, parents may be struggling to get their teenagers to follow sun protection guidelines. It can be challenging to catch the attention of younger people, for whom health concerns such as skin cancer feel like a lifetime away. One promising strategy for educating teens about sun-protective behavior is to appeal to their vanity and meet them where they are — on their smartphones.

Mobile app reveals possible effects of UV exposure

A recent study in JAMA Dermatology looked at the impact of using a face-aging mobile application on sun-protective behaviors in a group of Brazilian high school students. The face-aging mobile app used in the study, called Sunface, allows the user to take a selfie and shows what they might look like in five, 10, 15, 20, and 25 years, based on three levels of exposure the user selects: sun protection, no sun protection, and weekly tanning.

The face-aging mobile app modifies selfies by adding skin changes from chronic ultraviolet (UV) radiation exposure, such as from the sun or tanning beds. Signs of photoaging (premature aging of the skin from chronic sun exposure) include brown spots, increased facial wrinkles, uneven skin pigmentation, enlarged or broken blood vessels, and actinic keratoses (gritty rough spots that are precursors to skin cancer). While the accuracy of the face-aging app algorithm is unclear, it creates a reasonable facsimile of the effects of chronic sun exposure.

Study finds teens may be motivated by vanity

The JAMA Dermatology study authors divided the high school students into two categories. One group of students was shown the effects that UV exposure could have on their future faces via the app. The app also provided information about sun protection. The control group did not receive any intervention or sun protection education. At the start of the study, the researchers collected information from all study participants about their sunscreen application, tanning bed use, and performance of skin self-examinations. They then followed the students over six months to re-assess for changes in baseline behaviors. The study was led by the app developer.

In the face-aging app group, the percentage of students using sunscreen every day increased from 15% at the start of the study to 22.9% at the six-month follow up. There was no increase in sunscreen use in the control group. There was also an increase in the proportion of students in the face-aging app group who performed at least one skin self-examination during the six months of follow-up. There was no corresponding increase in the control group. Finally, while use of tanning beds had decreased in the mobile app group at the three-month follow up, tanning bed use returned to nearly baseline six months after students used the face-aging app. This is troubling, because indoor tanning increases the risk of skin cancers, including the deadliest form, melanoma.

The face-aging app had greater impact on high school girls, meaning boys were less likely to be motivated by appearance-based educational efforts. Over a lifetime, men are more likely than women to develop and die from melanoma, so other methods are needed to promote sun-safe behaviors in teenage boys.

One limitation of the study is that because students in the control group did not receive any basic sun protection education, it is not 100% clear whether the app’s face-aging simulation, the UV protection information provided by the app, or some combination of the two was responsible for the study findings.

Early sun-protective behaviors can have a lasting impact

Early sun-protective behaviors can have a lasting impact on the development and appearance of photoaging, and can reduce the risk of developing skin cancer. Beginning in infancy, children should be kept out of direct sunlight and covered with sun-protective clothing with an ultraviolet protective factor of 50+. Sunscreens are safe for infants starting at 6 months.

During adolescence and beyond, a tanned appearance is often associated with youthfulness and health. Instead of using a tanning bed, opt for a sunless tanning cream to achieve a similar effect — but be sure to apply a sunscreen, since tanning creams generally don’t contain sun-protective factor unless explicitly stated on the label. Another option is to apply a tinted sunscreen.

The following tips can help reduce photoaging and risk for skin cancer.

• Avoid peak hours of the sun’s intensity (generally between 10am and 2pm) and seek shade when outdoors.
• Wear sunscreen, even when it’s cloudy, raining, or snowing:
  • broad-spectrum UVA/UVB coverage
  • SPF 30+, which blocks 97% of the sun’s rays (no sunscreen blocks 100% of the rays)
  • water-resistant (be sure to reapply every two hours when outside or after getting wet or toweling off)
• Wear sun-protective clothing (UPF 50+) like broad-brimmed hats, long-sleeved shirts, and pants.

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I can’t tolerate CPAP, what can I do?

Continuous positive airway pressure, or CPAP, is the most common treatment prescribed for obstructive sleep apnea (OSA). CPAP involves wearing a mask that fits into the nostrils, underneath or over the nose, or over the nose and mouth, through which pressurized air is delivered via tubing from a machine to keep the upper airway open during sleep. CPAP is recommended by the American Academy of Sleep Medicine (AASM) as the initial treatment for moderate or severe OSA, and in mild cases of OSA when associated with insomnia, disrupted sleep, or excessive daytime sleepiness. When used consistently, and when treatment is effective, CPAP improves daytime sleepiness, quality of life, and it can have positive impacts on cardiac and metabolic health.

The effectiveness of CPAP depends on using the device correctly and consistently, since OSA is a chronic disease that requires long-term treatment. Most sleep doctors, myself included, recommend that patients with sleep apnea use their treatment whenever they sleep, in order to derive optimal benefit. While there are many patients who love their CPAP machines and report the treatment to be life-changing, and are unable to sleep without CPAP, there are others who learn to accept and tolerate CPAP because they appreciate either the functional benefits (such as better mood and less daytime sleepiness) or medical improvements they get from using the device. However, many patients struggle with CPAP.

CPAP is not easy and there are common complaints

Despite the many potential benefits, CPAP adherence estimates from clinical data and insurance groups suggest that about 50% of CPAP users either do not reach minimum adherence criteria or discontinue the treatment. Each patient is unique and may have individual struggles with CPAP; however, there tend to be similar themes among users. Some of the common complaints I hear from patients who have trouble tolerating CPAP include

• mask issues, including mask discomfort, skin irritation or marks, feelings of claustrophobia, or discomfort with the appearance of wearing a mask
• dryness, especially waking with a dry mouth
• removing the mask during sleep
• pressure intolerance, from either too much pressure or not enough pressure; trouble exhaling against the CPAP pressure; or swallowing air (aerophagia)
• breathing that feels out of sync
• noise from the machine bothering the patient or their bed partner.

Troubleshooting issues with CPAP tolerance

First and foremost, patients should partner with their doctor and healthcare team. OSA is a serious disease that warrants treatment. Before starting treatment, patients should be educated about OSA, learn about all treatment options and new technologies, and know what to expect with CPAP. Patients benefit from close clinical follow-up, including a review of data from their CPAP device (which may also be important for continued insurance coverage). Family and/or partner support is also important, as friends or family can help encourage and support CPAP use.

Other tips to improve adherence:

• Behavioral and medication interventions. Cognitive behavioral therapy or short-term use of sleep medications can help people adjust to CPAP.
• The right mask. If the mask does not fit, the treatment may not work well. There are many mask sizes and types, including nasal masks that fit over or under the nose, nasal pillows that fit in the nostrils, full face masks that cover the mouth and nose, hybrid masks that sit under the nose and cover the mouth, and even helmet masks that cover the face. A mask fitting is advised when patients start treatment, and several fittings may be needed.
• Mouth breathing is another mask-related factor to consider. When a patient sleeps with their mouth open, the pressure from the CPAP leaks out the mouth. This causes dryness, and also prevents CPAP from keeping the upper airway open. Mask leak can also result in noise and mask removals during sleep. A mask that covers the mouth will probably be needed, though sometimes adding a chinstrap can keep the jaw closed and prevent mouth breathing.
• The right pressure. Some people require vastly different pressure when on their back vs. on their side, or in one sleep stage vs. another. While a pressure range can be helpful, if the range is too wide, the machine cannot adjust rapidly enough to meet the pressure requirements. Weight changes may also impact pressure requirements. Following device data and/or evaluating with a treatment sleep study in a sleep lab can help identify the best pressure.
• Address coexisting conditions. Some people use CPAP consistently, tolerate it, but are still sleepy. CPAP is not a substitute for inadequate sleep. Sleep apnea can coexist with other sleep problems that might contribute to daytime sleepiness. Sometimes CPAP is not tolerated because sleep is poor, or fragmented due to other issues such as anxiety, PTSD, insomnia, poor sleep habits, or circadian disorders. These other problems need to be addressed.
• Consider alternative treatments. CPAP is the first-line treatment, but not the only treatment for OSA. Consider combining treatments or pursuing an alternative treatment if CPAP is not tolerated or is not desired.

New CPAP innovations can help

A variety of technological advances may improve CPAP comfort and adherence. Some of these include

• heated humidification, a comfort intervention that can help with nasal congestion and dryness
• ramp-up features that allow the machine to start off at a low or minimal pressure as the patient adjusts and falls asleep
• expiratory pressure relief, where the pressure from the machine decreases slightly during exhalation, which is especially helpful when a higher pressure setting is needed to keep the airway open
• auto-titrating CPAP machines, which allow for a range of pressures to be set; the machine self-adjusts the pressure when it senses that more or less pressure is needed to keep the airway open. This is helpful for those who require higher pressures in one body position (back vs. side) or sleep stage (dream/REM sleep vs. nondream/NREM).
• modems that allow the machine to transmit data (either cellular or by wi-fi), so both the patient and their doctor can determine the effectiveness of the treatment.

The bottom line

CPAP is an effective treatment for OSA. If you are struggling with CPAP tolerance, do not give up, but rather talk to your clinician. Proper education, support, personalized troubleshooting, new technologies, and close clinical follow-up can improve adherence and optimize treatment outcomes.

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Avoiding COVID-19 when following the guidelines seems impossible

By now, we all know the drill: Maintain physical distance. Wear a mask. Wash your hands. Avoid people who are sick and stay away from others if you are sick. While these measures may seem simple enough, they are not easy to keep up month after month. Yet they are likely to be with us for a while.

But what about those who cannot comply? Certain conditions can make the standard measures to stay safe during the pandemic seem impossible. At the same time, some of those likely to have the most trouble following the guidelines — such as older people with dementia — are at higher risk for illness and death if they do become ill. And the risk for spreading infection to others by not wearing face coverings, washing hands regularly, and observing physical distancing remains very real.

Mitigation efforts are harder for some than others

People who may have the most trouble complying with pandemic-related restrictions include those with

• Dementia. Without constant supervision and reminders, people with cognitive problems may take off their masks or wear them incorrectly, and fail to maintain distance from others.
• Breathing problems. Although for healthy people there is no evidence that commonly worn cloth masks lower your oxygen levels or raise your carbon dioxide levels, those who have lung disease (such as asthma, emphysema, or cystic fibrosis) may find it particularly uncomfortable trying to breathe through a mask.
• Claustrophobia. Wearing a mask may make people with claustrophobia feel panicky or smothered. And this not a rare problem: claustrophobia is the most common phobia, affecting 5% to 10% of the population.
• Depression and anxiety. For people who struggle with mood or excessive worry, concerns about one’s health and the health of loved ones, and the limitations placed on social interactions, may make these conditions worse. According to recent National Center for Health Statistics data, symptoms of anxiety or depression have more than tripled since this time last year.
• Autism spectrum disorder. Difficulties with social skills, a need for routine, and a reliance on support services such as behavior or speech therapy are everyday challenges for many people with autism spectrum disorder. The pandemic has made these challenges even greater. A heightened sensitivity to touch and difficulty with nonverbal communication can make wearing a mask especially problematic.

Even the experts urging us all to wear face coverings to lower rates of illness and deaths recognize that some cannot comply. Still, there are steps that folks in these situations can take to reduce the risk of becoming infected with the virus that causes COVID-19 and spreading it to others.

What can be done?

There are no easy answers here. I know of at least one memory care center that has largely given up on requiring mask wearing for some of its residents (though staff are still required to wear them). While not ideal, it’s the most practical option. And other measures are still followed: every resident is surveyed about symptoms and has temperature checks daily, chairs and activities are set up to encourage physical distancing, and the number of people in a room is limited. Gentle and frequent reminders and redirection to prevent crowding, increase handwashing, and encourage mask wearing (if possible) are now part of the routine in most nursing homes and long-term care facilities.

The Alzheimer’s Association also recommends extra reminders to wear a mask and wash hands for people living at home with dementia. Visual cues around the home can help. Try tacking up images of people in masks — including their favorite actors or even superheroes — and written reminders in several spots explaining the rationale for all the handwashing and face masks. If possible, try to increase social support (while maintaining physical distance) for those with dementia living at home. For example, if someone living in a memory care center usually talks to family members on the phone once or twice a week, perhaps three or four times a week would be a good idea while social distancing restrictions are in place.

Those with breathing problems may be able to tolerate wearing a mask for short periods. If a particular mask seems too uncomfortable or restrictive, try another type. There are masks of many shapes, sizes, and fabrics out there, and it’s worth trying more than one type of mask before giving up on them. If wearing a mask still seems impossible, conscientious physical distancing and frequent handwashing may make face coverings less necessary. For anyone whose respiratory condition is so severe that wearing a mask is impossible, experts suggest that the safest course of action is to avoid public places rather than relying on “mask exemptions.”

People with depression or anxiety may need to consult more often with their mental health providers during the pandemic. Adjustments in behavioral therapies or medications may help. Claustrophobic people may find that wearing a mask at home for short periods, and gradually increasing the amount of time, may make it easier to consistently wear one in public.

Experts working with people who have autism spectrum disorder recommend a number of ways to help with mask wearing, including education about the rationale for wearing them, demonstrating the use of a mask on a favorite object or person, allowing the person to choose among different types of masks, and wearing the mask for only short periods of time to start. Transparent face masks that make the mouth or face of the speaker visible may be a good option.

The bottom line

While we should not have an expectation that people with certain medical or psychological conditions will be able to follow the guidelines perfectly, that’s one more reason we should maintain high expectations for everyone else.

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

Follow me on Twitter @RobShmerling

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The lowdown on the low-FODMAP diet

Irritable bowel syndrome (IBS) is a common intestinal disorder that produces distressing symptoms like abdominal pain, significant bloating, and altered bowel movements that can shuttle between diarrhea and constipation.

While changing what you eat won’t cure you, an evidence-based approach called the low-FODMAP diet is the most frequently prescribed food plan to help relieve IBS symptoms. Studies show it can reduce symptoms for the majority of patients. However, because of certain challenges and risks associated with the low-FODMAP diet, it’s worth talking to an expert before you try it.

FODMAP basics

 The low-FODMAP diet addresses four types of fermentable carbohydrates: oligosaccharides, disaccharides, monosaccharides, and polyols (collectively referred to as FODMAPs). While the names sound somewhat abstract, the foods found within these groups are often too familiar to those with digestive woes.

Oligosaccharides are present in foods like wheat, beans, garlic, and onions, while the disaccharide lactose is prevalent in dairy products like ice cream and milk. Monosaccharides refer to foods with excess fructose, and are found in items like apples, mangos, and honey. The final group, sugar alcohols, are found in some artificially sweetened products like chewing gum, and are naturally present in foods like avocados and mushrooms.

Though the FODMAP carbohydrates can trigger digestive discomfort for anyone when consumed in large amounts, much smaller portions can worsen symptoms for those with IBS.

A multiphase approach to a low-FODMAP diet

The low-FODMAP diet is meant to be undertaken in three phases. In the first phase, all high-FODMAP foods are eliminated from the diet for an extended period of time, often four to six weeks. In phase two, you systematically reintroduce restricted foods, noting how well you tolerate increasing quantities of the foods you’re reintroducing. Phase three is the personalization phase, in which you only avoid foods in quantities that cause symptoms.

This multiphase process can be complex and confusing, and requires substantial food knowledge. For instance, most varieties of soymilk are high-FODMAP. Extra-firm tofu, on the other hand, while also made from soybeans, is low-FODMAP. Guidance from a dietitian can be helpful for navigating this diet, but insurance coverage and medical referrals can be barriers to scheduling an appointment. As a result, some patients simply receive a list of low- and high-FODMAP foods.

Risks associated with not reintroducing some high-FODMAP foods

While avoiding high-FODMAP foods can be difficult, adding the carbohydrate groups back systematically to test tolerance can be even more challenging. Some people become hesitant to reintroduce items, especially if they have experienced significant symptom relief during the elimination phase. This increases the potential for nutritional risks. For example, it’s common for people avoiding dairy to have inadequate calcium intake.

Other lesser-known nutrients, like magnesium, are also a concern. Some of the best dietary sources of magnesium come from beans and nuts like almonds and cashews, which are usually restricted during the initial phase of the diet. In addition, people with IBS may already be at increased risk of magnesium deficiency due to digestive symptoms like diarrhea.

There is also concern that long-term restriction of high-FODMAP foods changes the makeup of bacterial colonies in the gut, which may negatively impact intestinal health and possibly worsen digestive issues over time. Oligosaccharides, in particular, are an important energy source for beneficial bacteria. This is particularly worrisome for individuals with IBS, who have been shown to have lower levels of protective intestinal bacteria and higher levels of potentially harmful inflammatory microbes. Probiotics have been suggested to restore such bacterial imbalances, but this remains contentious, and the American Gastroenterological Association recently published guidelines that recommend their use in IBS only when participating in a research study.

Low-FODMAP is not for everyone

The low-FODMAP diet is not intended for individuals without IBS, nor is it appropriate for everyone with the condition. It should be avoided by anyone with an eating disorder, as it may worsen food fears and diet restrictions. This is particularly notable because those with gastrointestinal issues appear to have a higher prevalence of disordered eating compared to the general population. In addition, people with already restricted diets, such as vegans or those with food allergies, may be unable to meet their nutritional needs on the diet. Those who are already malnourished or underweight are poor candidates, as well. The diet is not as well researched for other gastrointestinal conditions, so it’s generally best to avoid the diet if you don’t have IBS, unless otherwise advised by a doctor or dietitian.

Finding an alternative approach

 If the low-FODMAP diet is not a good option for you, simply cutting back on high-FODMAP foods in your diet, without entirely eliminating any food groups, may be an alternative. If your diet contains many common offenders like garlic, onions, beans, apples, milk, mushrooms, and wheat, a simple reduction may help decrease symptoms.

To find a list of registered dietitians who can help you to safely make changes, click here. Or contact a nutrition practice to ask if they have someone knowledgeable about the low-FODMAP diet.

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Youth sports during COVID-19: What parents need to know and do

It’s become clear that the COVID-19 pandemic isn’t going to end anytime soon. This means that we are going to have to figure out how to live, and raise our children, when seemingly every action we take carries some risk.

Youth sports can bring great benefits to children. Team sports offer opportunities for exercise, which is crucial for health, and also for socialization and learning how to be part of a community. Children need these opportunities, which are particularly lacking during the pandemic. It would be great if we could find a way for children to engage in sports during the pandemic. But as with every trip to the store or even the mailbox, there are risks involved.

To help parents understand and navigate these risks, the Centers for Disease Control and Prevention (CDC) has released some information and considerations about youth sports during COVID-19.

First, which sport?

The first thing for parents to think about is the sport itself. Some sports are just more risky than others. Questions to consider include:

• Does the sport require that people be close to each other? Think about wrestling vs. baseball.
• Is there a lot of shared equipment and/or gear? The less gear, obviously, the better.
• What about the players who aren’t playing? For example, while social distancing is relatively easy for swimmers during a race, they are often packed together on a pool deck between races.

Other considerations when thinking about a sport or team include:

• The age and maturity of the players: Can they realistically be trusted to follow all safety rules?
• The size of the team: Big teams are harder to manage and keep safe. Smaller groups, especially cohorts of children that stay the same (as opposed to mixing it up), are best.
• The coaching staff: Are there enough to manage the team, but not so many to create more risk? Are they educated about COVID-19, and do they have support for getting and doing what is needed to keep players safe?
• The nonplayers: Spectators, volunteers and other people increase the risk. How is the team/league managing this?
• The physical setup for practices and competitions: Do they maximize social distancing whenever possible? This also includes start and end times, which should be staggered so that people have time to leave before new people arrive.
• Is there a plan/policy to manage possible exposures? This should be in place before anything starts, and everyone should be aware of it.
• Travel competition plans: This is particularly an issue if one team is from an area with more cases of COVID-19. Local competition is likely better.
• Are there at-risk players on the team, such as children with health problems? This could change everything about the risks a team can safely take.

Lowering risk, but not erasing it

The only way to have zero risk of catching or spreading COVID-19 from youth sports is not to play them. Some families will likely end up making that choice, such as families with vulnerable children or other vulnerable people living with them, or families whose living or work situations put them at ongoing risk of catching the illness, which could end up spreading it to the team. For these families, it will be just one of the many difficult and sad decisions they have to make during this crisis.

For those who decide to give it a try, after thinking carefully about the sport and team, there are ways to decrease risk. They include:

• Staying home if you are sick or have a known or possible exposure. This cannot be said often or clearly enough. We have a great responsibility to each other right now. There is no practice or competition worth risking someone else’s health or life. Check with your doctor or local health department as to when it would be safe to return.
• Frequent hand washing. Hand sanitizer should be readily available at practices and competitions, and everyone should use it all the time.
• Wearing a mask. I know it can be hard to wear one during vigorous exercise, but it can literally save lives. Do some experimenting to find the mask that works best, and remember that it needs to cover both the nose and mouth. Masks are most important when social distancing isn’t possible; if players need to take theirs off briefly, they should get more than six feet away from anyone.
• Be outdoors as much as possible. This works better for some sports than others, obviously.
• Wipe down any shared equipment or surfaces frequently. Cleaning supplies should be as available as hand sanitizer, and should be used just as often.

Finally, as much as players and spectators may want to shout encouragement, it’s best to keep quiet, as shouting can propel the virus further.

Team sports won’t be the same, of course — and for many children and families this will be very disappointing. But if we can find a way to do something, to be active and be together, it could help us get through this extraordinary, scary, terrible time.

Follow me on Twitter @drClaire

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Does air pollution cause Alzheimer’s disease?

Have you ever spent the day in a city with such bad air pollution that when you blew your nose the mucus had a black tinge? Have you ever coughed as you breathed in diesel fumes from a passing bus and thought to yourself, “Well, that’s a year gone from my life”? Could it actually be true — that air pollution leads to an early death? The answer, in fact, is an unqualified yes.

Air pollution causes heart disease, lung disease, and early death

It has been known for some time that air pollution causes lung cancer, chronic obstructive pulmonary disease, emphysema, asthma, heart disease, and stroke. One recent study in China estimated that for those ages 75 and older, there are 1,166 early deaths for every 100,000 people — that’s more than 1%. But if it doesn’t kill you outright, can air pollution impair your memory, and cause dementia in general and Alzheimer’s disease (one cause of dementia) in particular?

Studies from several countries link air pollution to cognitive impairment

Three studies from three different parts of the world suggest that air pollution might cause cognitive impairment, dementia, and Alzheimer’s disease. In the first study, researchers from China and the US teamed up to analyze data from China. They found that long-term exposure to air pollution is related to poor performance on both verbal and math tests. Moreover, the poor performance on the verbal tests was more pronounced for older individuals, especially for men and those less educated.

In the second study, researchers in England studied 130,978 adults ages 50 to 79 from 75 medical practices in greater London. They found that from 2005 to 2013, 2,181 older adults from this sample were diagnosed with dementia: 39% with Alzheimer’s disease, 29% with vascular dementia, and 32% without a specific dementia diagnosis. Adults living with the highest annual concentration of air pollution had the highest risk of dementia — 1.4 times the risk of those with the lowest annual concentration. They also found that these associations were more consistent for those given an Alzheimer’s disease diagnosis.

In the third study, published earlier this year, researchers from the United States, including the University of Southern California and Harvard Medical School, studied data from 998 women ages 73 to 87 who had both cognitive tests and MRI scans. They found that those women who were exposed to higher concentrations of air pollution in the preceding three years showed two differences compared to those who were exposed to less air pollution. Cognitively, those exposed to more air pollution showed greater declines in learning a list of words. Anatomically, they showed more atrophy (shrinkage) in those areas of the brain that typically shrink due to Alzheimer’s disease.

Importantly, in all three studies, the researchers controlled for every possible other factor that they thought might make a difference. For example, in this third study they controlled for: sociodemographic factors (age, geographic region, race/ethnicity, education, income); lifestyle (smoking, alcohol, physical activity); employment status; clinical characteristics (diabetes, high cholesterol, hypertension, cardiovascular diseases, hormone therapy); and MRI-measured cerebrovascular disease.

Air pollution is associated with a greater risk of Alzheimer’s disease, but it may not be the cause of the cognitive decline

The first thing to say is that I believe this correlation is real. The fact that three different groups analyzed data from three different continents and came to similar conclusions cannot be due to chance alone. Thus, I firmly believe that the following statement is true: Higher levels of air pollution are associated with a greater risk of cognitive decline, dementia in general, and Alzheimer’s disease in particular.

However, that is not the same thing as saying that high levels of air pollution cause cognitive decline, dementia, and Alzheimer’s disease. Air pollution could cause Alzheimer’s disease, and many researchers provided possible mechanisms as to how that might happen.

However, it is also possible that air pollution could be linked to some as-of-yet unidentified factor that explains the association. For example, it has already been fairly well established that some viral illnesses are associated with Alzheimer’s disease. It has also been well established that viral illnesses are more likely to be transmitted when people are gathered together indoors versus outdoors. So, it may simply be that where there is greater pollution, people are more likely to gather together inside, shut the windows, and trade viruses with each other. The new virus they acquire may be the real cause of the increased risk of Alzheimer’s disease. Now, that’s just speculation — just an example of how a real association is not the same thing as evidence of causation.

What can you do if you want to reduce air pollution to lower your risk of Alzheimer’s disease?

Directly or indirectly, we are all responsible for the air pollution in our cities, our country, and our planet. We should each work to do what we can to reduce our carbon footprint. We can work to reuse and recycle materials so that factories don’t need to produce as much. We can buy local foods that don’t need to be trucked across the country and shipped around the world. We can walk and bike instead of driving our cars (and, once we’re done with COVID, carpool and take public transportation). Lastly, we can elect public officials who will advocate for local, national, and international policy to reduce pollution. And those are just some of the things that we can do to clear the air.

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Healthy headphone use: How loud and how long?

As our society and culture become more connected through technology, the use of headphones has increased. Headphones allow people to enjoy music and have conversations from anywhere at any time. The ease of headphone use and the mobility that they afford cannot be overstated. This is particularly true currently, as our society spends more time with virtual meetings and headphones during the COVID-19 pandemic. Despite the convenience of headphones and the increased utility, questions about safety of use have been raised. There is such a thing as healthy headphone use; you just need to know about safe sound levels and when to take a break from headphones.

How does sound cause hearing loss?

Isn’t sound supposed to provide a tool for communication and awareness of our environment? Yes, sound is an essential mode of communication that also orients us to our environment; however, the inner ear is very sensitive to the balance of sound that it perceives. There are thousands of cells in the ears, some of which have little hairlike structures called hair cells that are responsible for transmitting sound from the ears back to the brain, where it is further processed. Excess sound can cause permanent damage to these cells, which interrupts the mechanism of sound transmission. Damage may also happen via the connection between the hair cells and nerve cells, which can be interrupted by excess sound, even if the hair cells remain normal. In short, one thing is clear: sound that is too loud is harmful.

How loud is too loud?

The CDC has detailed information on various daily experiences and the volume, or decibel (dB) level, associated with them. One of the important things to note when considering headphone use is that personal listening devices are tuned to a maximum volume of around 105 to 110 dB. For reference, exposure to sound levels above 85 dB (equal to a lawnmower or leaf blower) can cause possible ear damage with exposure of more than two hours, while exposure to sound of 105 to 110 dB can cause damage in five minutes. Sound less than 70 dB is unlikely to cause any significant damage to the ears. This is important to know, because the maximum volume of personal listening devices is above the threshold at which damage occurs (in both children and adults)! It is important that as a listener, you are aware that most devices can, in fact, be used in a way that is harmful. Ultimately, personal listening devices should be comfortable to the listener.

How long is too long?

In addition to volume, the duration of sound exposure is an important factor that contributes to possible ear damage. Simply stated, louder sounds have potential for more damage with less exposure. The Occupational Safety and Health Administration (OSHA) mandates that employers offer hearing protection for employees with averaged exposure of 85 dB for greater than eight hours. While this sounds like a long time, headphone use at only slightly higher sound levels can cause damage in less than one hour, and it is easy to imagine listening to music with headphones for an hour or longer. Importantly, listening at a comfortable level should be safe for an unlimited amount of time, though it is essential to balance duration of use with loudness of exposure.

Suggestions for safe listening

Our ears can be damaged by excess sound, and the combination of excess level of sound and duration of exposure contributes to potential hearing problems. Here are some suggestions for healthy listening habits.

• Be aware of how long you have been listening and how loud the sound is.
• Take breaks after prolonged listening sessions, and be sure to listen at a comfortable level.
• Be prepared. If you are going to attend an event where there is likely to be prolonged loud noise (such as a concert or sporting event), bring earplugs or headphones. There is a range of devices available that offer protection from a potentially damaging situation, from simple foam earbuds, to headphones with noise cancelling properties, to customizable ear molds made by an audiologist.
• Finally, don’t hesitate to talk with an audiologist or otolaryngologist about any questions you have around headphone use or safe sound levels. Hearing health is important and complex, and we can help you take steps to protect your ears while using headphones.

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Vaccines for COVID-19 moving closer

As the world reels from illnesses and deaths due to COVID-19, the race is on for a safe, effective, long-lasting vaccine to help the body block the novel coronavirus SARS-CoV-2. The three vaccine approaches discussed here are among the first to be tested clinically in the United States.

How vaccines induce immunity: The starting line

In 1796, in a pastoral corner of England, and during a far more feudal and ethically less enlightened time, Edward Jenner, an English country surgeon, inoculated James Phipps, his gardener’s eight-year-old son, with cowpox pustules obtained from the arm of a milkmaid. It was widely believed at the time that once milkmaids became ill with cowpox, a relatively mild disease, they were no longer susceptible to smallpox. The young boy became quite ill, but recovered in about a week. Jenner then injected James with material from a smallpox pustule and observed that nothing untoward happened. A new scientific approach to disease prevention was born.

A century later, it became clear that vaccination — a term Jenner coined from the Latin name for cowpox, Vaccinae variolae — worked because vaccines induce protective immune responses. We now know that vaccines can generate neutralizing antibodies by activating immune cells called B lymphocytes that secrete those molecules. Antibodies specifically recognize a shape on a virus or a toxin and bind to it, much like a key that tightly fits into a lock. They can then block the virus or toxin from binding to our own cells, effectively disarming it.

However, in order for these antibodies to bind strongly to viruses or bacteria and to last a very long time, the body has to be tricked into believing it is responding to an infection. When that happens, immune cells called T lymphocytes are activated and can help B lymphocytes make better, long-lived antibodies.

Seeking long-lasting immunity: Fragments and targets

Many weakened (attenuated) live viruses have been used as vaccines. These tend to provide long-lasting immunity even after a single dose. The yellow fever vaccine, for instance, generates immunity that can last a lifetime. Other examples include measles, mumps, and rubella combined (MMR), rotavirus, smallpox, and chickenpox vaccines.

Some vaccines are just killed versions of the whole virus. Immunity in response to such vaccines is not that long-lasting, and several booster shots are needed to enhance immune memory and prolong protection. The injected flu vaccine — a combination of strains of influenza most likely to circulate in a given year — is an example of a killed virus vaccine. Given as a single injection, it only offers protection for about three months. Other killed virus vaccines include those for rabies and the injected polio vaccine; both induce long-lasting immunity only when multiple doses are administered.

Many vaccines are made up of a piece, or a modified version, of the target virus or bacteria. Their effectiveness can vary, and booster shots are generally necessary to achieve relatively long-lasting immunity. For instance, the modified versions of the toxins released by the bacteria that cause tetanus and diphtheria given in the Td vaccine can generate protection for about 10 years. One current vaccine for pneumonia offers protection for four or five years.

Creating vaccines for COVID-19: mRNA and hybrid approaches

Unfortunately, research shows not all COVID-19 patients make natural antibodies against the novel coronavirus. Even in those who do, antibody amounts tend to decline about two months after the initial diagnosis. Therefore, natural infection is unlikely to create herd immunity (the slowing of the spread of a pathogen when a large proportion of a community acquires immunity against it). So, effective vaccines are desperately needed.

There are over 100 different COVID-19 vaccines in various stages of testing and development: preclinical work using animal models, followed by Phase 1 (safety), Phase 2 (optimal dose, schedule, and proof of concept), and Phase 3 (effectiveness, side effects) trials in humans.

Three promising vaccines (there are many others) are discussed below, because they will be the earliest to be tested in the United States through clinical trials:

• A vaccine created by Moderna in Cambridge, Massachusetts, uses a type of molecule called messenger RNA (mRNA) that can be mass-manufactured very rapidly. In this vaccine, mRNA induces human cells to make a molecule called the spike protein, which studs the surface of the coronavirus and enables it to enter human cells. The vaccine then triggers the immune system to make antibodies against the spike protein. Phase 1 human trials were started in March 2020 by the NIH. Initial results have shown the vaccine is safe and generates high levels of neutralizing antibodies. The vaccine is expected to enter Phase 3 clinical trials in July 2020.
• A hybrid vaccine uses a modified, harmless form of a chimpanzee common-cold adenovirus as a capsule, or vector, to deliver the coronavirus spike protein into the body and to stimulate immune response. This platform was developed at the Jenner Institute at Oxford University in collaboration with AstraZeneca. Already in clinical trials in many parts of the world, this vaccine is expected to enter clinical trials in the United States in August 2020.
• Another hybrid vaccine uses a human common-cold adenovirus to deliver the coronavirus spike protein into the body. That platform was developed by Harvard Medical School scientists in collaboration with Johnson and Johnson. This vaccine is expected to enter Phase 1 clinical trials in September 2020.

In animal models, all three vaccines provide protective immunity against SARS-CoV-2. Upcoming trials will help establish their long-term effectiveness and potential side effects. A central question will be how long protection might last. Based on information from trials for other diseases, it’s likely that hybrid adenovirus vector vaccines will protect individuals for at least one or two years, and probably longer.

Many are wondering when a vaccine will be available. If all goes well for at least one of these vaccine candidates, it may be as soon as the first quarter of 2021. Much hinges on results from the larger trials ramping up this summer.

Join @MassCPR researchers and physician-scientists for an update on the state of COVID-19 vaccine development, with a focus on vaccine trials in humans underway and others expected to launch soon. To register for this event click here.

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

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How can I know if my penicillin allergy is real?

People with a penicillin allergy on their medical record are not given penicillins (or often their relatives the cephalosporins) when they have infections. Instead, the antibiotics prescribed may be broader-spectrum, less effective, and/or more toxic.

Penicillin alternatives may be less effective or more toxic

One recent national study from more than 100 US hospitals with almost 11,000 patients demonstrated that if you have a reported penicillin allergy, you are five times more likely to be prescribed clindamycin than if you do not have that label. Clindamycin is an antibiotic that is highly associated with the potentially life-threatening Clostridioides difficile (C. diff) gastrointestinal infection. A study using comprehensive United Kingdom data recently confirmed that people with a documented penicillin allergy have a 69% increased risk of C. diff.

When patients undergo surgery, a penicillin relative (cefazolin) is often used to prevent an infection at the surgical site. However, according to this study, in patients labeled with a penicillin allergy, cefazolin is routinely avoided in place of a less effective substitute, resulting in a 50% higher risk of surgical site infections for people with a documented penicillin allergy.

Confirming or ruling out a penicillin allergy through penicillin allergy testing could justify the risks of avoiding beta-lactams (the drug class that includes penicillins and cephalosporins), or potentially avert them by allowing doctors to prescribe beta-lactams when they are needed. Even some patients with severe penicillin allergy histories are able to take penicillins safely again, because penicillin allergy often does not persist for life. In all, about 95% of people tested for penicillin allergy in the US are found not to be allergic.

What does penicillin allergy testing entail?

Penicillin allergy testing often begins with an allergy history. In order to know if testing is appropriate, the clinician needs to know some details about the reaction, such as: When did it happen? What were the symptoms? How were you treated?

If appropriate, the next step may be the penicillin skin test. This test involves pricking the skin and introducing a small amount of allergen. Anyone with a positive skin test to penicillin — there’s usually itching, redness, and swelling at the site of the test — is allergic and should avoid penicillin.

People who have no reaction to the skin test can undergo the amoxicillin challenge. In this test, the clinician gives the person amoxicillin (a type of penicillin), and observes for signs and symptoms of an allergic reaction for at least one hour.

Allergists routinely perform penicillin allergy testing. Other types of doctors, nurses, nurse practitioners, and even pharmacists can be trained to perform penicillin allergy skin testing in the US. The amoxicillin challenge test can also be done by a variety of healthcare providers, as long as they are comfortable diagnosing and treating allergic reactions.

New clinical tools may help evaluate likelihood of a true penicillin allergy

There are increasing numbers of clinical tools that can help your primary care doctor, or other nonallergist healthcare provider, assess whether you have a true penicillin allergy.

The first tool is a risk stratification scheme, published in JAMA and endorsed by multiple professional associations. The review encourages an amoxicillin challenge be prescribed for low-risk patients. Patients are classified as low-risk if their reactions occurred more than 10 years ago, and: were isolated and unlikely allergic (gastrointestinal symptoms, headaches); featured itching without rash; and did not include allergic symptoms such as hives, swelling, wheezing, shortness of breath, or chest tightness. The JAMA review recommends that medium-risk and high-risk patients, including those who did experience one or more allergic symptoms or an anaphylactic reaction, undergo a skin test before completing an amoxicillin challenge.

Another recently developed tool, called PEN-FAST, can be used by all types of medical providers to help decide if it is safe to give you penicillin, and potentially remove your allergy label (“delabel” you). The tool uses your allergy history to determine risk similar to the JAMA expert guideline.

PEN-FAST
PEN	PENicillin allergy reported by the patient
F	Five years of less since the reaction	2 points
A	Anaphylaxis or Angioedema or Severe cutaneous adverse reaction	2 points
S
T	Treatment required for the reaction	1 point
TOTAL POINTS

PEN-FAST stands for PENicillin allergy reported by the patient, Five years or less since the reaction, Anaphylaxis or Angioedema, Severe cutaneous adverse reaction, Treatment required for the reaction. You receive a score based on your responses to these four criteria, which reflects the likelihood that you have a true penicillin allergy.

Although you are likely to know the “F” and “T” parts of FAST — when it happened and whether you were treated — the “A” and “S” reaction assessments should be discussed with your doctor. Anaphylaxis is a bodywide allergic reaction, and angioedema is severe swelling under the skin. Along with the severe skin-related adverse reactions, these are severe and potentially life-threatening reactions.

Patients who are able to say “no” to the four PEN-FAST criteria (0 points) have a very low risk of true penicillin allergy. A total score of less than 3 indicates a low risk of penicillin allergy. Both of these patient groups would be likely to tolerate an amoxicillin challenge. Of course, you and your doctor must be prepared for an allergic reaction prior to ingesting any medication to which there is a possible allergy.

Follow me on Twitter @KimberlyBlumen1

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Metabolic syndrome is on the rise: What it is and why it matters

Metabolic syndrome may be the most common and serious condition you’ve never heard of. (At least that’s what I found out when I asked friends and relatives about it.) Worse, a study published recently in JAMA shows that it’s on the rise.

Let’s start with the name, according to Merriam-Webster:

Metabolic: Relating to the chemical changes in living cells by which energy is provided for vital processes and activities and new material is assimilated

Syndrome: A group of signs and symptoms that occur together and characterize a particular abnormality or condition.

So now you know what metabolic syndrome is, right? Perhaps not. Just knowing what the words in its name mean doesn’t help much in this case.

Metabolic syndrome defined

According to the most widely accepted definition, a person has metabolic syndrome when at least three of the following are present:

• Obesity: A body mass index (BMI) of 30 or above, or a large waistline (greater than 40 inches in men or 35 inches in women)
• Elevated blood triglycerides (a type of fat in the blood): Above 150 mg/dL
• Low HDL (good) cholesterol: Below 40 mg/dL in men or 50 mg/dL in women
• High blood pressure: 130 mmHg or above (systolic pressure), or 85 mmHg or above (diastolic pressure), or previously diagnosed hypertension that requires medication
• Elevated blood sugar: A fasting plasma glucose level of 100 mg/dL or above, or taking diabetes medications.

Why having metabolic syndrome matters

While each component of metabolic syndrome can cause health problems on its own, a combination of them powerfully increases the risk of having

• cardiovascular disease (including heart attacks and stroke)
• diabetes
• liver and kidney disease
• sleep apnea

And this only a partial list. It’s likely we’ll learn about other health risks associated with metabolic syndrome in the future.

Metabolic syndrome is on the rise

A new study explores how common metabolic syndrome is and who is getting it. Researchers analyzed survey data from more than 17,000 people who were representative of the US population in gender, race, and ethnicity. While the overall prevalence of metabolic syndrome increased slightly between 2011 and 2016 — going from 32.5% to 36.9% — it increased significantly among

• women (from 31.7% to 36.6%)
• adults ages 20 to 39 (from 16.2% to 21.3%)
• Asian (from 19.9% to 26.2%) and Hispanic (from 32.9% to 40.4%) adults.

Rates of metabolic syndrome were similar among men and women, but increased with age (from about one in five in young adults to nearly half of all people over 60). Among Hispanic adults 60 and over, nearly 60% had metabolic syndrome.

Perhaps these findings should not be surprising given the connection between obesity and metabolic syndrome, and the well-documented epidemic of obesity in this country. Still, it is particularly worrisome that metabolic syndrome is rising so fast among certain ethnic groups and young adults, and there is currently little reason to think these trends won’t continue in the near future.

Health disparities in metabolic syndrome

The finding that metabolic syndrome is more common among certain ethnic groups reveals significant health disparities. These disparities are important not only in the context of long-term health consequences, but also because of the current pandemic. Some components of metabolic syndrome, such as obesity and hypertension, are associated with more severe COVID-19. Separately, research shows higher rates of infection, hospitalization, and deaths from COVID-19 among some racial and ethnic groups.

For example, hospitalization rates for COVID-19 among Blacks and Hispanics are four to five times higher than for non-Hispanic white people. Health disparities associated with COVID-19 may reflect a complex combination of elements — not just age and chronic medical conditions, but also genetic, social, environmental, and occupational factors. Similar factors probably play a role in why metabolic syndrome affects, and is rising in, some groups more than others. This is an area of active (and much needed) research.

What’s to be done about metabolic syndrome?

The biggest priority now regarding metabolic syndrome is prevention. Healthy habits can have a big impact on maintaining a healthy weight and normal blood sugar, lipid levels, and blood pressure. Once present, metabolic syndrome can be treated with loss of excess weight, improved diet (such as the Mediterranean diet or the DASH diet), and, when necessary, with medications (including those that can improve blood lipids, or lower blood pressure or blood sugar).

The bottom line

Metabolic syndrome is an important risk factor for some of the most common and deadly conditions, including cardiovascular disease and diabetes. We need to figure out how to more effectively prevent and treat it, particularly because it appears to be on the rise. A good starting point is to pay more attention to risk factors such as excess weight, lack of exercise, and an unhealthy diet.

Now you know what metabolic syndrome is. Considering that about one in three people in the US has this condition, it’s likely someone close to you has it. Talk to your doctor about whether that “someone” is you.

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Gender differences in cardiovascular disease: Women are less likely to be prescribed certain heart medications

Cardiovascular disease (CVD) is the leading killer of both women and men in the US. Despite the significant impact CVD has on women, awareness and education for women’s heart disease has historically been low. A recent study, based on data from over two million patients, suggests that women were less likely to be prescribed aspirin, statins, and certain blood pressure medications compared to men.

CVD is a group of diseases involving the heart or blood vessels. It includes high blood pressure (hypertension), coronary artery disease, heart attacks, heart failure, heart valve problems, and abnormal heart rhythms. CVD can look different in men and women, potentially requiring different approaches to diagnosis and treatment and leading to differences in outcomes.

Gender differences in CVD

A general lack of awareness of women’s heart disease may lead to doctors or patients missing heart attacks in women or delaying their diagnosis. For example, while the frequency of CVD tends to be lower in women before menopause than in men, the frequency dramatically increases after menopause, when it accounts for approximately one out of every three deaths in women.

In addition, many of the “classic” signs and symptoms of CVD are based on medical research largely performed in men. For example, many think of chest pain as a typical symptom of a heart attack. But while both men and women can experience chest pain, women are more likely to experience atypical symptoms such as nausea or vomiting, shortness of breath, dizziness, or no symptoms at all. What’s more, 64% of women who die suddenly of coronary heart disease had no previous symptoms.

Underlying physiological differences in CVD in men and women may also result in less aggressive diagnosis and treatment in women. Men more commonly develop blockages of the major heart arteries, whereas women more commonly have disease of the small heart arteries (microvascular dysfunction), which can make treatment more challenging. And studies (like this one and this one) suggest that women get lifesaving procedures, such as heart catheterizations, less frequently, and later during the course of a heart attack, than men.

Treatments to control and prevent CVD

Many medications are commonly used to both prevent CVD before it occurs and to prevent existing disease from getting worse.

• Statins: a family of cholesterol-lowering medications
• Aspirin: one baby aspirin (81 mg) per day is widely recommended for people with established coronary artery disease or those who have had a heart attack
• Blood pressure medications: several classes of blood pressure medications exist, including ACE inhibitors, diuretics, beta blockers, and calcium-channel blockers.

Other medications are used to treat specific types of CVD, such as atrial fibrillation and heart failure.

Are there gender differences in how CVD medications are prescribed?

A recent study published in Journal of the American Heart Association studied whether common CVD medications were prescribed differently in men and women. The study — which was a meta-analysis, or an examination of data from previously published studies — looked specifically at prescriptions placed by primary care providers for aspirin, statins, and blood pressure medications. The authors examined 43 studies that included over two million patients. They found that women were significantly less likely to be prescribed aspirin, statins, and ACE inhibitors (a type of blood pressure medicine) compared to men.

Though the authors applied careful statistical analysis to data from a large sample of patients, there are important limitations to this study. First, the analysis did not account for differences in individual cardiovascular diagnoses between women and men in order to determine the appropriateness of medication prescriptions. Second, the study did not look at other common medications used to treat atrial fibrillation or heart failure. Finally, the study only looked at prescriptions from primary care providers, and did not account for medications that may have been prescribed by cardiologists.

Overall, this study adds to a growing body of literature that women are less likely to be prescribed guideline-recommended heart medications. More research is needed in order to understand why these differences exist, but it is likely related, at least in part, to the underlying gender differences in CVD discussed above.

What do people need to know to ensure they are receiving the best cardiovascular care?

Everyone, regardless of age and medical history, should routinely visit their primary care doctor and stay up to date on recommended CVD screenings, specifically cholesterol, diabetes, and blood pressure checks. During these visits, ask your doctor about your individual risk for CVD, and discuss the risks and benefits to you of cardiovascular medications. Finally, everyone — but women especially — should be aware of the signs and symptoms of CVD.

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Envisioning food security: Steps we take now can help

Before the start of the COVID-19 pandemic, food insecurity (lack of reliable access to nutritious food) was a considerable problem, affecting 11% of the country, with higher rates among low-income and racial and ethnic minorities. The shutdown of businesses to slow the spread of COVID-19 has led to historically high levels of unemployment, most recently reported at 11% in June. That translates to more than 40 million people losing their jobs. Like food insecurity, jobless claims also disproportionately harm Black and Hispanic populations. However, it is possible to envision different paths, and even a path that leads to food security for many more adults and children across the US.

How are people faring now?

Food insecurity is a major public health concern linked to common, costly, and preventable chronic conditions like obesity, diabetes, heart disease, and poor mental health. It results in an estimated $78 billion in additional health care costs annually.

To get a handle on how American households are faring during the COVID-19 pandemic, the Census Bureau and other government agencies launched a weekly Household Pulse Survey in late April 2020. The survey includes questions about food insufficiency, a narrower definition of food insecurity. It captures data about food consumption and affordability, but not lack of resources, the inability to acquire enough nutritious food, anxiety about being able to get food, or attempts to stretch available food. Census questions likely underestimate food insecurity, and are difficult to directly compare to pre-pandemic levels. Still, the results are instructive.

Using recent census data from week eight (June 18–23), we see very large disparities in food insufficiency by race and ethnicity. While about 7% of white households report sometimes or often not having enough to eat, this rate is almost triple (about 19%) among Black households, and double (about 14%) among Hispanic households. Affordability was the most common reason for not having enough food. This is not surprising, given that food prices have increased during this pandemic. Other estimates suggest that in the next year, one in four children will experience food insecurity.

What can we do to move toward food security?

We have proven policy approaches that meaningfully address the problem of food insecurity. Key among them is leveraging the Supplemental Nutrition Assistance Program (SNAP). Formerly known as food stamps, SNAP is by far the largest federal nutrition assistance program. Prior to COVID-19, SNAP helped 38 million people — nearly half of whom are children — afford food each month. Enrollment in SNAP has increased substantially during COVID-19 due to massive unemployment. During a crisis, SNAP is one of the easiest and fastest ways to get money into the hands of low-income Americans. These benefits can be adjusted easily because recipients receive them on a debit card.

Through the recent stimulus bills responding to COVID-19, Congress has appropriated $15.8 billion for expanded SNAP enrollment and made some key changes to SNAP, which are surely helping with food insecurity. Temporarily, the expanded benefits for people receiving SNAP provide

• two months of emergency benefits up to a maximum (this varies — it’s $646 for a family of four)
• a pandemic EBT of about $114 per child per month
• a temporary suspension of work requirements for able-bodied adults without dependents
• state waivers, to allow for re-enrollment flexibilities.

Is the SNAP benefit adequate?

Notably, none of these changes increase the overall size of the monthly SNAP benefit. The benefit is widely recognized as inadequate, because it unrealistically assumes that households have certain types of ingredients, time, equipment, and knowledge to prepare food from scratch. The average SNAP household receives a monthly benefit of about $1.40 per person per meal, which does not cover the cost of a meal in 99% of US counties.

The fourth stimulus bill, the HEROES Act, passed the House in May. It has a provision to increase monthly SNAP benefits by 15% ($100 per month for a family of four) for two months. If this bill passes the Senate, it could provide a critical and much-needed boost for low-income households, perhaps helping to attenuate the longstanding inequities in food insecurity. It would also help to stabilize the economy, because increased SNAP spending creates a multiplier effect by generating income for food production, distribution, marketing, and sales.

How else could Congress act with food security in mind?

The House HEROES bill includes promising additional policy options to address food insecurity. For example:

• extending pandemic EBT benefits
• keeping the SNAP work requirement suspension for able-bodied adults without dependents; these requirements decrease participation among groups at higher risk for food insecurity
• increasing school meal reimbursements for schools scrambling to feed children while also grappling with the costs of measures to help prevent the spread of COVID-19.

The bill is awaiting a vote in the Senate and the president’s final approval. Senators return from the two-week July 4th recess on July 20th, and will have three weeks to act before the traditional August recess. Interested readers can contact their senators and urge action.

Food insecurity is entirely preventable. We have proven policy tools to address this problem. We just need the political will to deploy them, and the recognition that food insecurity is not an individual problem, but a reflection of systemic inequality.

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How risky is using a public bathroom during the pandemic?

Given the choice between using a public bathroom and doing anything else, some people will always choose the latter. Regardless of the urgency or however pristine it’s reported to be, the space comes with an ick factor, says Dr. John Ross, who practices hospital medicine at Brigham and Women’s Hospital in Boston and is board-certified in infectious diseases.

That image is hard to shake even in normal times, but COVID-19 has done nothing to make public bathrooms more appealing, as they come with high-touch surfaces and often lidless toilets. Ross says that it’s easy to see them as hotbeds of infection and avoid them in the name of safety. But not using them has caused people to reorganize their days, figuring out how many errands can be done in one trip, when to stop drinking water, and preventing the possibility of socially-distant visits with friends and relatives.

Weighing the risks compared to other indoor activities

There’s no clear-cut answer. The coronavirus requires each person to asses each situation, says Dr. Todd Ellerin, 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.

Ross says that as an indoor space, a public bathroom is not necessarily a safe environment, but it’s also on par with other indoor spaces. In some ways, it’s a lower-level risk in comparison, but it comes down to the components. One area of concern is the air. A flush creates an aerosol spray (the toilet plume), and the virus exists in feces. Taken together, and since the virus enters the body through mucus membranes, that would seem worrisome, but Ross and Ellerin say the research suggests otherwise.

A recent study of two hospitals in Wuhan, China, found that the highest aerosol concentration was in a bathroom, although it noted that it was a temporary, single-toilet room with no ventilation. The study also found that sanitization and ventilation effectively limited the virus’s concentration in aerosols. Another recent study that analyzed samples from patients hospitalized with COVID-19 found that attempts to isolate the virus from stool samples were never successful, and that existing fragments were not infectious.

Ross adds that the flush is a one-time event, and any direct plume is from a person’s own feces; if the virus was present, that person would already be infected. “Our own fecal plume poses no risk to us,” he says. If someone else in the bathroom happens to flush, there are barriers blocking direct contact. “The risk of bathroom exposure is largely theoretical — possible, but not proven,” he says.

There are other elements in play that make the bathroom less risky than it might seem. Your exposure time is a factor with transmission. Ellerin says that if an unmasked interaction within six feet lasts under 15 minutes and doesn’t include coughing or sneezing, the transmission risk is still low. Since most bathroom visits will probably be shorter, “time is on your side,” he says. “Save the long visits for your home.”

The number of people you’ll be around is another factor. Ross says that more than the plume, being coughed on is a bigger concern. Wearing a mask provides a needed layer to anything in the air. The barriers in the bathroom also keep people separate, making less chance for face-to-face contact. “That’s also in your favor,” Ellerin says.

Ross says that other indoor activities, which are more socially acceptable, can offer a greater risk, such going to bars, weddings, religious services, and indoor parties. They all can be tightly packed. Music might be playing, causing people to lean in and speak to each other. Alcohol can make people relax and forget about distancing, and when there’s singing, breaths are forcibly ejected into the air. In many of these settings, masks might not be required and might not be worn, further encouraging the spread.

So what’s the best way use a public bathroom?

The fundamental steps are: Put a mask on before you enter. Wash your hands immediately after. You can also wear glasses to protect your eyes. There are a number of high-touch surfaces, and the virus, along with bacteria, can exist on them. It’s good to minimize contact by using your foot or toilet paper when lifting, turning, or pulling anything, Ross says.

Contact before going to the bathroom isn’t as important, since you’ll be washing your hands, but even if you touch a surface, Ross says that the virus won’t go through your skin. The main thing is to not touch your face, specifically your mouth, nose, or eyes, before washing. And before you leave, use your foot, elbow (if possible), or a paper towel to open the door, and once outside, spray your hands with a sanitizer.

Ellerin says don’t overlook cleaning your glasses and cell phone. “Is your iPhone a major risk? Probably not, but it could be a potential source for some individuals,” he says. “That’s the thing with COVID-19. We don’t know, so it’s good to disinfect high-touch areas. Some people will take their own extra steps with cleaning, because it provides a greater sense of psychological confidence, since there’s still much uncertainty.”

But doing what’s known, such as washing hands, wearing a mask, and minimizing close contact, while it doesn’t guarantee safety, can help people consider options and re-engage with lost activities. “When it comes to the bathroom,” Ellerin says, “follow the basic hygiene, get in and out, and you’re probably in a low-risk group.”

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

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A new hormonal therapy for prostate cancer is under expedited FDA review

In June, the US Food and Drug Administration (FDA) launched an accelerated review of a promising new drug for advanced prostate cancer. Called relugolix, it suppresses testosterone and other hormones that speed the cancer’s growth. If approved, this new type of hormonal therapy is expected to set a new standard of care for the disease.

Doctors give hormonal therapies when a man’s tumor is metastasizing (spreading beyond the prostate), or if his PSA levels start rising after surgery or radiation. The most commonly used hormonal therapies, called LHRH agonists, will eventually lower testosterone levels in blood. But that decline happens only after testosterone flares up to high levels as an initial response to treatment. This short-term flare-up, which lasts about a month, can cause bone pain, urinary obstruction, and other symptoms. So, doctors will ordinarily give LHRH agonists together with other drugs that prevent testosterone from interacting with cells in the body.

Alternatively, men can be treated with a different class of hormonal therapies that lower testosterone levels without the initial flare. These drugs are known as GnRH antagonists, and only one is currently available in the United States. Called degarelix, it’s given once a month by injections that can in some instances cause pain, redness, and swelling. (A different injectable GnRH antagonist, called abarelix, was withdrawn from US markets in 2005 after it caused a higher-than-expected increase in allergic reactions.)

Needle-free

Here is where relugolix enters the picture: it’s also a GnRH antagonist, but rather than being given by monthly injections, it’s taken as a daily pill.

The FDA was prompted to speed the drug’s review based on its superior performance during a late-stage clinical trial. The study investigators enrolled 934 men from 155 hospitals in the United States and Japan. Half the men had elevated PSA levels after having been treated already for prostate cancer. The rest had newly diagnosed metastatic cancer, or more localized prostate tumors that weren’t suitable for surgery. A total of 622 were treated with relugolix, and 305 men were given an LHRH agonist called leuprolide. All the men were treated for 48 weeks.

By all measures, relugolix came out ahead. The drug lowered testosterone to acceptable therapeutic levels within four days, whereas in the leuprolide-treated men, testosterone initially surged to an average of more than ten times the target concentration before dropping below it 29 days later. Furthermore, normal testosterone levels were restored within 90 days after relugolix treatment was discontinued. By contrast, just 3% of the leuprolide-treated men achieved normal testosterone levels within that same duration after treatment. That testosterone levels go back to normal after hormonal therapy is important for quality of life, including among men who receive the treatment intermittently.

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, points out that relugolix also had a better safety profile for measures of heart health. It’s long been known that hormonal therapy in general can have cardiac toxicities, especially among men with pre-existing risk factors such as diabetes, hypertension, or a prior heart attack. But during this clinical trial, fewer men in the relugolix group experienced significant cardiac side effects after 48 weeks of treatment.

“This is an important study, as it demonstrates the ability of a GnRH antagonist to be administered as an oral drug,” Garnick said. “The continued development of GnRH antagonists has many advantages compared to drugs that require an obligatory increase in testosterone before achieving their desired effects. The oral availability of relugolix may also lessen some of the local skin reactions that are common with degarelix, or some of the allergic reactions that occurred with abarelix.”

The FDA is expected to make a decision on the drug’s approval by December 20, 2020.

Disclosure: Dr. Garnick has been named as a scientific advisor to Myovant Sciences (the developer of relugolix) and is a shareholder in the company. He was also a developer of abarelix and previously served as an advisor to Ferring Pharmaceuticals, the developer of degarelix.

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Tinted sunscreens: Benefits beyond an attractive glow

Tinted sunscreens are having a moment. These mineral-based sunscreen formulations have an added color base that can help even out skin tone while protecting your skin. And thanks to their ability to block visible light, they may help certain skin conditions. Could the days of unsightly sunscreen residue be in your past?

What is visible light, and how can it affect your skin?

Ultraviolet (UV) radiation and visible light are both part of the electromagnetic spectrum. UV radiation is composed of three different wavelengths: UVA, UVB, and UVC. UVC is mostly absorbed by the ozone layer, so UVA and UVB are the primary wavelengths that penetrate the skin’s surface. The harmful effects of UV light on the skin have been well documented. UVA is primarily responsible for premature skin aging, and UVB has been implicated in sunburns and skin cancer. The primary source of UV radiation is sunlight.

Visible light is also emitted by the sun. It is the portion of the electromagnetic spectrum that can be perceived by the human eye. Visible light may also come from artificial sources, including medical devices, screens, and light bulbs. Visible light has several skin-related therapeutic uses at specific wavelengths, including treatment of superficial blood vessels, removing unwanted hair, and treating acne and precancerous skin lesions.

Visible light penetrates much deeper into the skin than UV radiation, and can also have negative consequences for your skin. For example, visible light has been implicated in exacerbating disorders of excess skin pigmentation, including melasma and post-inflammatory hyperpigmentation (dark spots). One study showed that visible light caused more noticeable, persistent hyperpigmentation that UVA alone, especially in people with deep skin tones. This may be especially true for blue light (the kind emitted by device screens), which seems to promote pigment production more than other wavelengths of the visible light spectrum.

Components of tinted sunscreens

Broad-spectrum, non-tinted sunscreens contain filters that block UVA and UVB, but these preparations are not designed to block visible light. To block visible light, a sunscreen must be visible on skin. The problem? The particles in broad-spectrum, non-tinted sunscreens are “nanosized” (made smaller) to help reduce the white appearance of sunscreen. Thus, non-tinted sunscreens are formulated to be invisible on skin, and therefore cannot block visible light.

Tinted sunscreens combine broad-spectrum mineral UV filters, like zinc oxide and titanium dioxide, with added pigments — pigmentary titanium dioxides and iron oxides — that create the visible, skin-tone color that can reflect away visible light. The colored base of tinted sunscreens is created by mixing different amounts of black, red, and yellow iron oxides with pigmentary titanium dioxide, resulting in a tinted sunscreen that can be matched to any skin tone.

While these pigments are considered inactive, there have been two reports of allergic reactions to iron oxides contained in mascara products. Otherwise, these ingredients appear to be well tolerated.

Tinted sunscreens may help certain skin conditions

Tinted sunscreens can provide anyone an instant, skin-evening glow, while simultaneously helping to protect your skin from both sunlight and artificial light.

Growing evidence suggests that tinted sunscreens may be particularly important for people who are prone to hyperpigmentation or melasma. That’s due to their ability to block visible light, which is known to exacerbate these conditions. Tinted sunscreens have been found to reduce relapses of melasma more than non-tinted, broad-spectrum sunscreens. Tinted sunscreens have also been shown to reduce hyperpigmentation, both on the skin surface and under a microscope. Iron oxide, in particular, appears to be particularly effective at blocking blue light.

What should I look for in a tinted sunscreen?

Choosing a broad-spectrum, tinted sunscreen may help prevent age-related skin damage (thanks to UVA filters), may help to prevent cancer-inducing skin changes (thanks to UVB filters), and may help protect against excess pigmentation (thanks to the color base that blocks visible light).

Tinted sunscreens are now widely available to purchase online or in retail stores. If you are prone to hyperpigmentation or melasma, choose a tinted sunscreen that contains iron oxide (you’ll see it on the ingredient list).

Follow me on Twitter @NeeraNathanMD.

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Can a daily pill lighten heavy menstrual bleeding caused by fibroids?

Fibroids are generally benign (not cancerous) tumors that form within the tissues of the uterus. They are very common in reproductive-age women: studies report that up to 70% of white women and 80% of Black women may develop fibroids by age 50. And research suggests Black women are more likely to experience severe or very severe symptoms related to fibroids, such as heavy and sometimes prolonged monthly periods.

In some cases, women seek medical care due to menstrual bleeding so heavy that they develop anemia and require iron supplements or, much more rarely, blood transfusions. Now, a new medicine taken as a daily pill may help some women reduce heavy bleeding caused by fibroids.

Surgery and injections help some women

Until recently, the treatment options for heavy bleeding due to fibroids were limited to surgical procedures or an injection of a medication called leuprolide, which is given monthly or every three months to help shrink fibroids and lighten bleeding. While these treatments are effective for some women, each has risks and disadvantages:

• Any surgical procedure comes with a risk of infection. Additionally, excess bleeding requiring transfusion, hysterectomy (removal of the uterus), injury to other pelvic or abdominal organs, and recurrence of the fibroids are possible. In some cases, fertility is affected as well.
• Regular injections of leuprolide have significant side effects, as this medication essentially puts women into medically induced menopause. Therefore, it is typically used only as a bridge to surgery.

What does research tell us about a new approach to fibroid-related heavy menstrual bleeding?

The new medicine approved by the FDA to treat heavy menstrual bleeding due to fibroids is Oriahnn. It’s a daily pill that combines two hormones (a form of estrogen called estradiol, plus norethindrone acetate) with a medication called elagolix. Elagolix helps inhibit a hormone that causes a woman’s body to release estrogen and progesterone during her monthly menstrual cycle.

A recently published trial demonstrated that elagolix effectively decreases blood loss during menses, and causes high rates of amenorrhea (no bleeding at all). The trial was performed in conjunction with AbbVie, the company that produces and markets Oriahnn. It studied 433 women who had fibroids and heavy menstrual bleeding for 12 months per woman over a period of 2.5 years.

One strength of the study is that 67% of the women who participated were Black. Black women have higher rates of uterine fibroids, so their inclusion in this study is particularly important.

The study compared two groups of women for one year: one group received just elagolix, and the other received elagolix with estradiol and norethindrone acetate (“add-back therapy”). Because elagolix suppresses hormonal release of estrogen and progesterone, it may cause hot flashes, night sweats, and decreased bone mineral density (a marker indicating bone loss) that can predispose women to bone fractures. In theory, the add-back therapy might decrease the risk of hot flashes, night sweats, and bone loss.

For women taking elagolix with add-back therapy, the researchers found that by the end of 12 months:

• Nearly 90% of women had less blood loss during their period; compared with their blood loss before starting the medicine, these women experienced at least a 50% reduction in blood loss.
• 64% of women on elagolix with add-back therapy did not get a period at all.
• Among women who were anemic at the beginning of the study period, nearly 73% showed a statistically significant improvement in their blood count.
• The size of the uterus also decreased, although the size of the fibroids did not.

The most common side effects in both groups were hot flashes and headaches. Severe side effects were rare. However, compared with women taking only elagolix, women on elagolix with add-back therapy had fewer and less severe hot flashes and night sweats, and experienced much less loss of bone mineral density (although both groups demonstrated bone loss).

Based on a questionnaire given to both groups, women taking elagolix with add-back therapy reported a better quality of life.

Who might find this new option helpful?

This new FDA-approved medication could potentially be an excellent option for women who would like to avoid surgery and try medical management of their fibroids instead. The caveat is that the trial studied this drug for 12 months. The FDA has not approved its use for more than 24 months, so this may not be a lifelong solution for patients.

However, elagolix with add-back therapy could be an excellent option for women who are perimenopausal, will likely go through menopause in one to two years, and want to avoid a hysterectomy. It would also be an excellent option for women who are interested in conceiving in one to two years, and would like to decrease menstrual bleeding without resorting to surgery.

Women seeking long-lasting relief from heavy menstrual bleeding due to fibroids have long been told that their best option is a hysterectomy. This new data may have the potential to change that advice.

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