How to help your child get the sleep they need

This year, back-to-school plans are still a work in progress, and some (perhaps many) children will be learning from home because of the pandemic. As tempting as it might be to let the summer sleep schedules stay in place, it’s important that children have a regular routine — and that they are sleeping during the dark hours and awake during the light ones, as our bodies do best that way. So while a child whose trip to school is just a walk to the kitchen table might be able to sleep a bit later than one who has to catch an early bus, no child should be spending all morning in bed.

Sleep is crucial for all of us, and this is particularly true for children. Without enough quality sleep, children are more likely to have health and behavioral problems — and difficulty learning.

Here are a few simple things you can do to help your child get the sleep they need.

Have a regular schedule

Our bodies do best when we go to bed and wake up at roughly the same time every day.

• Children and teens need eight to 10 hours of sleep. Count back 10 hours from when your child needs to get up in the morning. That’s roughly the time they need to be getting ready for bed (for younger children, count back 11 hours).
• For example, if your teen needs to be up at 7, then they should be getting ready for bed by 9, and in bed by 10 (since most of us don’t fall asleep the moment our head hits the pillow). A younger child should start getting ready (bathing, etc.) by around 8.
• Understand that teens are biologically wired to fall asleep later and wake up later and will naturally have later bedtimes. Unfortunately, most school districts don’t accommodate to this, so you are often working against biology.
• While it’s okay to stay up a bit later on weekends, don’t let the bedtime vary by more than an hour or so.

Turn off the screens before bed

The blue light emitted by screens can keep us awake.

• It’s best if the screens can be off two hours before you want your child asleep. Use that time when they start getting ready for bed as the time that the screens go off.
• The only real way to achieve this is to get all devices out of the bedroom. (So true!)
• Teens will fight you on this. If you can, hold firm (and buy them an alarm clock if they say they need their phone for this). At the very least, be sure that the phone is on Do Not Disturb mode overnight.

Have an environment that encourages sleep

• Quiet things down. If you are watching TV, turn the volume down, and in general try to not make much noise after children go to bed.
• Consider a white noise machine, or a fan (or air conditioner if you live somewhere warm). There are also white noise apps for those teens who won’t give up their phones.
• Room-darkening curtains can make a difference for children who tend to wake up at the first light of dawn — or who can’t fall asleep if it’s not fully dark outside.

Know how other factors influence sleep

• Busy teens often have difficulty getting everything done in time to get enough sleep. Talk with your teen about their daily schedule and look for ways to help them get more shut-eye, such as getting homework done during the school day, or limiting video games or other activities that eat into homework time. Sleep needs to be the priority.
• Limit caffeine. It’s best not to have any, but certainly nothing from mid-afternoon on.
• Limit naps! For a tired older child naps may seem like a good idea, but they can interfere with nighttime sleep. Naptime is okay through preschool.
• Make sure your child gets exercise. It’s not only important for their health, it helps their sleep.
• Have calming routines before bed (not exercise!).

If your child is having trouble falling asleep, or is waking up at night, talk to your doctor. It’s also important to talk to your doctor if your child is snoring or having other breathing problems at night. Don’t ever ignore a sleep problem; always ask for help.

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Blown up in smoke: Young adults who vape at greater risk of COVID symptoms

COVID-19 has swept across the globe, infecting millions and resulting in hundreds of thousands of deaths. Substantial resources have been invested into understanding individual vulnerability in order to protect those at greatest risk. Age is the most often cited risk factor; 75% of US deaths have been in people over the age of 65, while younger people generally have milder symptoms. In addition to age, the Centers for Disease Control has delineated a list of health factors that increase vulnerability, most of which are chronic disorders that generally alter health status. The single most modifiable risk factor for severe COVID-19 infection is inhaled substance use through smoking or vaping.

Vaping and smoking increase young adults’ risk of COVID symptoms

A new study published in the Journal of Adolescent Health used national data to estimate the toll of smoking and vaping on COVID-19 risk for young adults. The team found that overall, nearly one in three young adults ages 18 to 25 in the US are at heightened risk, though that number falls to one in six among those who do not smoke or vape. In other words, smoking and vaping double the number of young adults in the at-risk category.

The at-risk categorization is more than a theoretical concern. Smoking and vaping both cause lung injury that threatens pulmonary reserve. Substance use can also weaken the immune system, resulting in reduced capacity to fight off infection. A recent study found that adolescents and young adults who smoke and vape were five times more likely to report COVID-19 symptoms and seven times more likely to have a diagnosis, compared to their peers. A combined analysis using data from multiple studies found that among people infected with COVID-19, those with history of smoking were twice as likely to have disease progression.

Risk-taking during adolescence could mean greater risk for COVID

During adolescence and young adulthood, developing brains are wired to seek large neurological rewards, resulting in the risk-taking that is associated with this stage of life. Most young adults enjoy good health and hearty physiologic reserve, allowing them to tolerate the insults of substance use without noticeable impact, until the cumulative effects accrue in middle adulthood — or at least that was generally assumed to be the case prior to the COVID-19 pandemic.

Unlike other risk factors for severe COVID-19 disease, smoking and vaping also inherently increase the risk of respiratory virus transmission. Smoking and vaping are often social activities for young adults. Both involve exhaling forcibly, which may propel droplets that carry viral particles further than at-rest breathing. The Canadian government recommends that people remain six feet apart and avoid sharing products, though people who get together to smoke or vape may not adhere to government guidelines. It goes without saying that both smoking and vaping are incompatible with wearing a mask. These factors combine to pose a real threat in places where young people gather — including colleges and universities. Schools would be smart to institute strict no-smoking and no-vaping rules and enforce them vigorously as part of a COVID-19 containment plan.

Younger people may be overconfident about health risks

Young people tend to overestimate their own ability to control a situation, and think of themselves as invincible; many are inclined to think that they will be able to quit smoking whenever they want to. A little extra confidence may be useful during the transition to adulthood, even if based on a faulty assessment of one’s own capabilities. But the same tendency can cause real problems in this pandemic. The idea that younger people are safe from COVID-19 is inaccurate; according to an early report from the CDC, one in five people ages 20 to 44 who become infected are hospitalized, and 2% to 4% require treatment in an intensive care unit. The best thing we can do for young people is to promote accurate information about their true risks. More than any other group, young adults who are able to quit smoking and vaping have the power to flatten their own personal risk curves.

Supporting young people who want to quit vaping and smoking

Parents and healthcare professionals have a role to play here, too. Many youth who use vaping products have seriously considered quitting, but quit attempts don’t always stick. Vaping is so new that specific treatments have not yet been rigorously tested, but there are effective treatments for nicotine use disorders. Healthcare professionals can prescribe medications that help relieve withdrawal symptoms and prevent cravings, and counselors can provide support during the process. Parents can help by encouraging their children to get help. For people who are trying to quit using nicotine, a little help can go a long way.

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Is it safe to reduce blood pressure medications for older adults?

“Doctor, can you take away any of my medications? I am taking too many pills.”

As physicians, we hear this request frequently. The population most affected by the issue of being prescribed multiple medications, known as polypharmacy, is the elderly. Trying to organize long lists of medications, and remembering to take them exactly as prescribed, can become a full-time job. In addition to the physical and emotional burden of organizing medications, older adults are at increased risk for certain types of side effects and potential worse outcomes due to polypharmacy.

A common source of prescriptions is high blood pressure, with older adults often finding themselves on multiple medications to lower their blood pressure. Data from the Framingham Heart Study show that over 90% of middle-aged people will eventually develop high blood pressure, and at least 60% will go on to take medications to lower blood pressure.

The OPTIMISE trial, recently published in JAMA, studied the effect of reducing the number of blood pressure medications, also known as deprescribing, in the elderly.

How low should blood pressure be in older adults?

Previous large studies, including the HYVET trial and the more recent SPRINT trial, have shown that treatment of high blood pressure in older adults remains important, and may reduce the risk of heart attack, heart failure, stroke, and cardiovascular death. Black adults made up 31% of the SPRINT trial study population; therefore, study results could be used to make recommendations for this population, which is at increased risk for high blood pressure. However, many groups of older people were excluded, including nursing home residents, those with dementia, diabetes, and other conditions common in more frail older adults.

The most recent guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA), published in 2017, define optimal blood pressure as less than 120/80 for most people, including older adults age 65 or above. They recommend a target of 130/80 for blood pressure that is treated with medication. The 2018 guidelines from the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) recommend a more relaxed goal of less than 140/90.

The US and European populations differ in their risk for cardiovascular disease, with the US population generally considered at higher risk for strokes, heart failure, and heart attacks, so it might be appropriate to have different blood pressure goals for these two groups. Regardless, both groups acknowledge that factors such as frailty, limited life expectancy, dementia, and other medical issues should be considered when developing individualized goals for patients.

What happened to older patients whose blood pressure medications were reduced?

 The OPTIMISE trial provided preliminary evidence that some older adults may be able to reduce the number of blood pressure medications they take, without causing a large increase in blood pressure. For the trial, researchers randomized 569 patients age 80 or older, with systolic blood pressure lower than 150 mm Hg, to either remain on their current blood pressure medications, or to remove at least one blood pressure medication according to a prespecified protocol. The study subjects were followed for 12 weeks to assess blood pressure response.

Researchers found that both the people who remained on their previous blood pressure medications and those who reduced the number of medications had similar control of blood pressure at the end of the study. While the mean increase in systolic blood pressure for the group that reduced medications was 3.4 mm Hg higher than the control group, the number of patients who had systolic blood pressure below the goal of 150 mm Hg at the end of the study was not significantly different between groups. Approximately two-thirds of patients were able to remain off the medication at the end of the study.

It is important to note that OPTIMISE is relatively a small study, and the investigators did not examine long-term outcomes such as heart attack, heart failure, or stroke for this study (as the HYVET and SPRINT trials did), so we don’t know what the long-term effect of deprescribing would be.

More research needed to examine long-term effects of deprescribing

While the OPTIMISE trial was promising, larger and longer-duration trials looking at outcomes beyond blood pressures alone are necessary to really know whether deprescribing is safe in the long term. Additionally, these researchers used a target systolic blood pressure of less than 150 mm Hg, which is higher than the most recent ACC/AHA and ESC/ESH recommendations.

An interesting aspect of this study design is that the primary care physician had to feel that the patient would be a good candidate for deprescribing. This left room for physicians, who may know patients well, to individualize their decisions regarding deprescribing.

The bottom line

This trial gives doctors and other prescribers some support when considering a trial of deprescribing a blood pressure medication for select older patients, with a goal to improve quality of life. These patients must be closely followed to monitor their responses.

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5 ways to ease pain using the mind-body connection

I smashed my elbow a few weeks ago. There was no bone break — just a bad bruise after slipping in the kitchen and landing on my arm — but at times the pain has been excruciating. So I’ve been following doctor’s orders: babying my elbow, icing it, and taking an occasional over-the-counter painkiller. (PS: I wear sneakers in the kitchen now.)

Something else has helped, too: mind-body therapies. These approaches aim to change our awareness of pain and retrain the way we respond to it. The therapies can help us control pain — such as long-lasting back pain — or live with it better. While these techniques won’t erase pain, they can help change perception of pain intensity through distraction, relaxation, and reframing our thoughts.

Five mind-body therapies to consider for pain relief

Cognitive behavioral therapy (CBT). This talk therapy teaches people to redirect their thoughts, feelings, and behaviors in response to chronic pain. For example, when a pain flare-up strikes, instead of bracing yourself and thinking, “Oh no, here it comes again,” tell yourself you’ve handled this before, and focus instead on your favorite place in the world: picture it in your mind, and feel how happy or relaxed you are when you’re there. A therapist trained in CBT can train you to hone your skills.

Deep breathing. We typically take short little breaths without noticing our breathing, especially when we’re in pain. Focusing on breathing and taking deep breaths quiets the mind and induces the relaxation response, a well-studied physiologic response that counteracts the stress response, and may lessen chronic pain severity. To practice deep breathing:

• Breathe in slowly through your nose, allowing your chest and lower belly to rise as you fill your lungs completely.
• Now exhale slowly through your mouth or nose.
• Practice deep breathing for several minutes.

Meditation. Like deep breathing, meditating triggers the relaxation response and may reduce the perception of pain. You can use many methods to meditate, such as transcendental meditation (repeating a word, phrase, or sound to quiet your thoughts); yoga (a series of strengthening and stretching postures combined with breathing techniques); or mindfulness meditation (focusing objectively on negative thoughts as they move through your mind, so you can achieve a state of calm).

One simple way to meditate:

• Sit quietly, close your eyes, and focus on your breathing.
• Say a word such as “peace” or “one” each time you exhale.
• Don’t worry about thoughts that come to mind; you can come back to them later. Continue to repeat your word and focus on breathing.

Mindfulness-based stress reduction (MBSR). This approach combines mindfulness meditation and yoga to build awareness and acceptance of moment-to-moment experiences, including pain. A 2019 study published in the journal Evidence-Based Mental Health found MBSR was just as effective as CBT at reducing pain and depression, and improving physical functioning, compared with usual care or no care. You’ll find MBSR programs at hospitals, universities, and meditation centers, and online videos.

Relaxation. Relaxation techniques, such as progressive muscle relaxation, may also help reduce the perception of pain. To try progressive muscle relaxation, start with your facial muscles and work your way down the body. Tighten each muscle or muscle group for 20 seconds before slowly releasing the contraction. As the muscle relaxes, concentrate on the release of tension and the sensation of relaxation.

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Worried about sleep apnea? Home-based testing is now the norm

If your bed partner complains about your loud snoring, it might be a disruptive nuisance — or something more serious. High-volume snoring punctuated by snorts, gasps, and brief pauses in breathing is the hallmark of obstructive sleep apnea.

Although this condition occurs most often in men over 40 who are overweight or obese, it can affect people of all ages and sizes. The resulting daytime sleepiness — a direct result of not getting enough high-quality sleep — can leave people moody and forgetful. Even more worrisome: car accidents are two to three times more common in people with sleep apnea. Sleep apnea also can boost blood pressure and may increase the risk of clogged heart arteries, heart rhythm disorders, heart failure, and stroke.

What is the STOPBANG test for sleep apnea?

The easy-to-remember acronym STOPBANG can help you decide whether it’s wise to talk to a doctor about having a sleep study to determine whether you have sleep apnea. It helps to have input from someone who sees you sleep.

A “yes” answer to three or more of these questions suggests possible sleep apnea. Ask your doctor if you should have a sleep study.
S	Snore: Have you been told that you snore?
T	Tired: Do you often feel tired during the day?
O	Obstruction: Do you know if you briefly stop breathing while asleep, or has anyone witnessed you do this?
P	Pressure: Do you have high blood pressure or take medication for high blood pressure?
B	Body mass index (BMI): Is your BMI 30 or above? (For a calculator, see www.health.harvard.edu/bmi.)
A	Age: Are you 50 or older?
N	Neck: Is your neck circumference more than 16 inches (women) or 17 inches (men)?
G	Gender: Are you male?

Sleep monitoring can be done at home

Diagnosing sleep apnea is less complicated that many people realize. In the past, diagnosing this condition always required an overnight stay in a sleep lab. “Today, about 60% to 70% of sleep studies for suspected sleep apnea are done using home-based tests,” says Dr. Sogol Javaheri, a sleep specialist at Harvard-affiliated Brigham and Women’s Hospital. If your symptoms suggest moderate to severe sleep apnea and you don’t have any other significant medical problems, home sleep monitoring is almost as accurate for detecting apnea as a night in a sleep lab, she says.

So, if you suspect you have sleep apnea, ask your doctor for an evaluation. Or if your health insurance allows you to see a specialist without a referral, you can start there instead. “Sleep specialists are better versed in insurance-related barriers, and they know how to order testing to avoid problems and delays in care,” says Dr. Javaheri.

For the test, you’ll get a small, lightweight monitor, a belt you slip around your midsection, a small finger clip that monitors your oxygen, and an airflow sensor to place under your nose. These sensors and devices measure your oxygen saturation, heart rate, and airflow, as well as the movements of your chest and abdomen and your position while you sleep.

One main advantage of home-based testing is the cost, which runs between $150 and $500, compared to testing done in a sleep laboratory, which usually tops $1,000. But the best part about home sleep test is the convenience. You sleep in your own bed, not an unfamiliar hospital bed, and you do the test based on your schedule. However, you’ll need to borrow the monitor from a hospital sleep lab, and you may have to wait a few weeks to get it. Later, if you are diagnosed with sleep apnea, home-based tests also provide an easy way for a physician to check how well your treatment is working.

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Hormonal treatments for prostate cancer are often given late

Men with advanced prostate cancer are typically treated with drugs that cause testosterone levels to plummet. Testosterone is a hormone that fuels growing prostate tumors, so ideally this type of treatment, which is called androgen deprivation therapy (ADT), or hormonal therapy, will stall the disease in its tracks.

For that to happen, ADT has to be administered correctly. But according to a new study, men frequently don’t get ADT at the proper dosing intervals. Too many of them get the treatments later then they should, causing testosterone levels to rise unacceptably. “Rapid increases in testosterone following delays in dosing could have implications for cancer progression,” cautions Dr. David Crawford, a urologist at the University of California San Diego, who led the study.

What the researchers did

Dr. Crawford’s team reviewed clinical data from nearly 23,000 men who were given ADT injections between 2007 and 2016. Each man’s treatment varied by how their ADT was formulated. Some types of ADT are given once a month, and others are given at three-, four-, or six-month intervals. The researchers wanted to know how many men were late on their ADT treatments, and how that would affect the amounts of testosterone in their blood.

During this research, the investigators defined “month” in two ways: either as one lasting 28 days, which is how months were defined during the clinical trials that set dosing schedules for ADT, or as a calendar month lasting 31 days. ADT was deemed late if it was given after day 28 by the first definition or after day 32 by the second definition.

What was learned

According to results, 84% of treatments were late by the first definition, meaning that subsequent treatments were given more than 28 days after the preceding ones. Of those treatments, 60% were more than a week late and 29% were late by more than two weeks.

Results obtained with the extended definition of a month followed a similar trend: 27% of injections were given more than 32 days after the preceding treatments, and of those, 13% were tardy by more than a week, and 9% were more than two weeks late.

Men who got late injections were twice as likely to have high testosterone levels as men who got the treatments on time. ADT is supposed to knock testosterone down to below 20 nanograms per deciliter of blood (ng/dL) for the set duration of therapy. The authors stressed that keeping testosterone below 20 ng/dL correlates with better survival, so clinicians should give ADT within approved dosing instructions, and monitor the hormone accordingly.

But among nearly half the men who got late injections, testosterone levels climbed over the therapeutic target. Depending on how months were defined, the levels ranged from nearly four times higher (for the 28-day month) to five times higher (for the extended month), on average, when the injections were given two weeks late.

The authors cited a number of reasons for why ADT is given late so often. Insurance companies sometimes resist financial coverage if the dosing intervals don’t correspond to a calendar month. Scheduling and transportation challenges create logistical problems for patients, and clinicians and patients alike may be unaware of how even short delays in dosing affect testosterone, since it’s rarely measured during the course of therapy.

“This is an important contribution that may explain why some men do not experience the optimal response to hormonal therapies,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. “It also underscores the need for continued testosterone monitoring. Finally, as we indicate, a one-month dose should be repeatedly given every 28 days, and a three-month dose repeatedly given at 12 weeks. On a personal preference level, my general practice is to use the four-week treatments as opposed to longer-acting formulations, which are associated with more frequent departures from optimal testosterone levels.”

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Does diet really matter when it comes to adult acne?

When I was a teenager, the advice I got about acne was clear and consistent:

• Avoid oily foods and chocolate because they trigger breakouts and make existing acne worse
• Wash your face often
• Try a topical, over-the-counter remedy such as those containing benzoyl peroxide (Clearasil) or salicylic acid (Stridex).

By the time I got to medical school, the message had changed. I learned that the diet-acne connection was considered a myth, and that what we eat has little to do with making acne better or worse.

But a new study has once again turned the tables. It suggests that diet might contribute to acne — at least in adults.

Why does acne develop?

For many — including me — thinking about teenage acne is a painful exercise. But it’s worth understanding why acne develops in the first place.

Acne is thought to develop because of a combination of factors: the production of too much oil in the skin, clogged skin pores, bacteria in the skin, and inflammation. Hormonal changes — which occur during puberty, or with a condition called polycystic ovary syndrome — and the menstrual cycle can have a big impact on acne, because they affect oil production in the skin. Some medications can cause acne (especially steroids and lithium), and hair products, makeup, and other products we put on our skin can contribute to clogged pores. Genetic factors, pollution, smoking, and stress have also been suggested as causes or contributors to acne.

And then there remains the possibility that diet matters. Certain foods can promote inflammation throughout the body, and it’s possible this triggers acne outbreaks. In addition, diet can affect hormones that, in turn, could make acne worse. For example, milk and foods with a high sugar content can cause a rise in insulin levels, altering other hormones that can affect the skin. Some research has linked milk and whey protein with acne.

Despite these possible connections between diet and acne, there is no consensus that changing your diet is an effective way to deal with acne.

Adult acne: This just in

A new study, published in the medical journal JAMA Dermatology, compared the results of 24-hour dietary surveys of more than 24,000 adults (average age 57) who reported having acne currently, having it in the past but not currently, or never having had it. The researchers found a correlation between the chances of having current acne and consumption of

• high-fat foods (including milk and meat)
• sugary foods and beverages
• a diet high in the combination of high-fat and high-sugar foods. Compared with those who never had acne, respondents with current acne were 54% more likely to consume this type of diet.

Higher intake of high-fat, high-sugar foods was associated with a higher incidence of current acne. For example, compared with those with no history of acne, those with acne at the time of the survey were 76% more likely to report drinking at least five glasses of milk in the previous day, more than twice as likely to report consuming at least five servings of high-sugar drinks in the previous day, and eight times more likely to report consuming “a complete meal of fatty and sugary products” in the previous day.

Fast foods and snack foods were linked with past (rather than current) acne. And chocolate? Neither dark nor milk chocolate were associated with past or current acne.

There are reasons to interpret these results cautiously. Dietary records can be faulty. For example, a person with acne who strongly believes that diet affects their skin health may be more likely than others to recall and report certain elements of their diet (such as fatty or sugary foods) than those who are more skeptical about a connection. Such recall bias can affect the results of a study like this. And many of those who reported having adult acne were self-diagnosed; it’s possible that some of these diagnoses were not accurate. Other factors — so-called confounders — might be at play and lead to misleading conclusions. For example, maybe people who drink more milk also happen (just by chance) to live in more polluted areas, and it’s the pollution, not the milk, that explains the findings.

Finally, studies like this can only detect an association, not causation. That means that while those with adult acne tended to consume more fatty and sugary foods, the study cannot prove that their diet actually caused adult acne. It also could not determine whether a change in diet would reduce the incidence or severity of acne.

The bottom line

As our understanding of acne continues to evolve, we may eventually have clearer guidelines about the best diets to prevent or treat it. For now, whether you’re a teenager or an adult, it’s likely that there is no single diet that will guarantee clear skin. So enjoy your favorite foods in moderation. And if you find that some of them make your skin worse, you’ll have to decide if they’re worth it.

Follow me on Twitter @RobShmerling

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Food insecurity, COVID-19, and eating disorders

Every human in the United States can attest that COVID-19 has changed our way of life. In addition to shining a light on the prevalence of racial and ethnic disparities, socioeconomic status, and weight status on outcomes in COVID-19, the pandemic is driving food insecurity to an all-time high.

So, what is food insecurity?

Food insecurity is a disruption in food intake or eating patterns because of lack of money and other resources. The United States Department of Agriculture (USDA) divides food insecurity into two categories:

• Low food security: Quality, variety, or desired foods are being reduced by necessity. However, low food security is linked to little or no paring back in food intake.
• Very low food security: Multiple indicators of disrupted eating patterns — such as having no food in the fridge — and reduced food intake due to not having access to food.

How does food insecurity drive eating disorders?

One of the first studies to address the full spectrum of eating disorders in people living with food insecurity was published in the International Journal of Eating Disorders in 2017. In this study, participants with the highest level of food insecurity experienced:

• higher levels of binge eating (uncontrollable eating)
• a higher likelihood of having any type of eating disorder, such as anorexia or bulimia
• dietary restraint for any reason, for example, avoiding a food group, such as carbohydrates, or types of foods, such as desserts
• weight self-stigma, assessed through responses to a questionnaire that measured self-devaluation and fear of experiencing stigma (sample statement: “I would never have any problems with weight if I were stronger”)
• high levels of worry, also measured through responses to a questionnaire (sample statement: “My worries overwhelm me”).

A 2020 study in Eating Disorders points to high levels of dietary restraint in racially and ethnically diverse, low-income urban populations. The primary reasons people reported holding back on eating were:

• minimizing the effect of hunger on children and other family members
• stretching food by eating less to make it last longer
• prioritizing medical expenses over food.

Stretching the limits of food banks

Unfortunately, in the wake of COVID-19, unemployment rates are higher than those at the peak of the Great Depression. With this rise in unemployment, consistent access to nutritious food is elusive for many people. Food banks throughout the country are seeing higher rates of attendance than ever before.

As a woman who was raised serving as a worker in the food bank at my home church in Atlanta, I am encouraged by my parents’ consistent service as the leads of this food bank. They show up every week to make sure the hundreds of families that need food receive food, despite their fears of the COVID-19 pandemic, which has disproportionately impacted the Black community — especially those over the age of 65 like themselves. They show up because they care, but they realize that their efforts will likely fall short of solving food insecurity in their community. Only a coordinated multi-sector approach can solve this issue.

Impact on health and well-being

One public sector approach is the current HEROES bill, which has provisions to address food insecurity, as discussed in a recent blog post. But whether or not a fully-funded HEROES bill becomes law, we must address the role of food insecurity in eating disorders. The research is clear: food insecurity is linked to eating disorders that undermine health. Food insecurity has intensified in the middle of the most significant pandemic of our lifetime, COVID-19. Racial and ethnic minorities continue to face the brunt of the compounded issues of food insecurity, COVID-19, disordered eating, and excess weight. Indeed, food insecurity has increased since 1999 to affect about 20% of the US adult population. We must remain vigilant in efforts to address the intersectionality of these major issues, which have a tremendous impact on the health and well-being of our communities.

Follow me on Twitter and Instagram @fstanfordmd

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Should we screen all adolescent girls and women for anxiety?

Anxiety disorders are the most common mental illnesses, affecting up to 40% of women and 20% of men in the course of their lifetimes. Women and adolescent girls are at particularly high risk for the development of anxiety disorders, due to differences in their brain chemistry, psychosocial contributors such as childhood sexual abuse, as well as the hormonal effects of estrogen and progesterone. Since anxiety disorders are so common among women and girls, could early detection lead to improved outcomes?

The US expert recommendations

In a recent clinical guideline, the Women’s Preventive Service Initiative (WPSI) recommends screening all women and adolescent girls ages 13 and older for anxiety disorders, including pregnant and postpartum women. The WPSI is a national coalition of 21 health professional organizations and patient representatives that researches and disseminates evidence-based recommendations for women’s preventive health care services. Their universal screening recommendations are based on a systematic review that demonstrates moderate to high accuracy of screening tools, but clearly acknowledges that no studies have evaluated the effectiveness or harms of screening. While these new guidelines recommend a wider net for screening, as a practicing psychiatrist I believe we should not recommend further screening until the potential harms have been evaluated.

Why are the recommendations changing?

Although the US Preventive Services Task Force (USPSTF) recommends routine screening for depression in adolescents and adults, no recommendations for the screening of anxiety disorders have previously been made. The WPSI’s recommendations are based on studies demonstrating the accuracy of screening instruments, as well as confirmation of the benefits of treatment of anxiety disorders with cognitive behavioral therapy and medications.

Are anxiety disorders on the rise?

According to the media, it seems that anxiety disorders have been increasing in recent years, attributed to various causes: the COVID-19 pandemic, greater performance stress at school or work, social media use, etc. However, we do not have robust epidemiologic data suggesting that the prevalence rate for anxiety disorders has truly increased, due to the imprecision of data collected before the introduction of psychiatric classification systems. Studies conducted with the same population and same methodology over time, such as the National Comorbidity Survey and data from the European Union, have not demonstrated an increase in anxiety disorders. We do know, however, that more individuals are seeking treatment for anxiety, and that more people are willing to speak about their anxiety. We also know that prevalence rates in different countries and cultures are more likely to be due to differences in how the data were collected, rather than due to cultural differences.

Risks of screening

As with all other screening tools in medicine, screening tools for anxiety have limitations in diverse populations. Non-Western populations are not represented in the studies used to build screening tools, which results in decreased accuracy in populations in which their use has not been validated. Among people living within the United States, anxiety symptoms also present differently based on ethnic, racial, and cultural contexts; for example, anxiety may present as physical or spiritual complaints. Among immigrants in particular, the effects of migration, legal status, and experiences of discrimination may result in psychological distress and anxiety that are not accurately reflected in anxiety screening tools. The risks of screening for anxiety in populations in whom the screening tools have not been validated include errors in diagnosis and inappropriate treatment (or lack of treatment).

Even among populations in whom anxiety screening tools have been validated, universal anxiety screening for women and adolescent girls poses the following concerns:

• redirecting resources away from the treatment of people with known anxiety disorders, who already receive less than adequate treatment
• the high cost of identifying people with mild anxiety who may not benefit from treatment
• inappropriate treatment of people based on a false diagnosis as a result of a positive anxiety screen
• overprescription of medications, with an increased number of people suffering from medication side effects
• consequences of carrying an improper diagnosis.

Both the Canadian Task Force on Preventive Health Care and the United Kingdom National Screening Committee do not endorse questionnaire-based screening for mental illnesses, given concerns about potential harms and resource use.

The take-home message

The new WPSI guidelines recommend screening all adolescent girls and women for anxiety disorders. Anxiety disorders are particularly common among women, but they are often unrecognized and undertreated. Universal screening for anxiety in this population may help to identify those suffering from anxiety disorders, resulting in earlier evaluation and treatment. However, future research is needed to evaluate the effectiveness of such screening and to assess for potential harms.

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An emerging link between the urinary microbiome and urinary incontinence

Most people know that microorganisms live on our skin, and in other places in the body such as the digestive tract. However, traditional thinking and medical teaching was that there was no such microbiome in the urinary tract. Many people may still believe that urine is sterile.

Advanced detection methods such as enhanced urine cultures and DNA sequencing have shown that this is not true. These newer technologies have enabled identification of low levels of microorganisms that were not previously detected using conventional methods. This has revolutionized how we think about the urinary tract when it is both healthy and unwell, and has led to a paradigm shift as we recognize that the bladder, like other parts of the human body, is widely colonized by microorganisms.

Gaining insight into the urinary microbiome

The urinary microbiome has quickly become a hot topic of investigation, leading to a burgeoning collection of scientific literature in this area. Multiple scientific investigations have studied which microorganisms make up the urinary microbiome, and how changes in the microbiome may result in or be a result of disease.

Lactobacillus is the most common species of bacteria in the female urinary microbiome, but other bacteria including Streptococcus, Staphylococcus, Aerococcus, Gardnerella, and Bifidobacterium are also present. There’s evidence that the urinary microbiome changes with age. In addition, previous studies have shown that women with various urologic conditions, including overactive bladder and interstitial cystitis/bladder pain syndrome, have an altered urinary microbiome.

Study links urinary microbiome and urinary incontinence

In a recent publication in the American Journal of Obstetrics and Gynecology, researchers found that women with urinary incontinence — urine loss beyond one’s control — had different urinary microbiomes compared with continent women. The microbiomes differed not only in terms of the types of bacteria present, but also in terms of the diversity of species present. Furthermore, women who had stress urinary incontinence (urine loss with physical activity) had different urinary microbiomes compared to women who had urgency urinary incontinence (urine loss with a sudden desire to urinate).

In a sense, these findings are not surprising given that stress and urgency urinary incontinence have different underlying causes. Stress urinary incontinence is thought to be more of an anatomic problem (having to do with the structure of body parts), while urgency urinary incontinence is thought to be more of a physiologic one (how body parts function).

These study findings raise the question of whether differences in the urinary microbiome play a role in causing urinary incontinence, or are a consequence of these conditions — not unlike the chicken-and-egg conundrum. Further research is needed to better understand the connection.

A role for probiotics in treating urologic conditions?

These study findings may also prompt questions about whether probiotics have a role in managing urinary incontinence. However, most urinary microbiome studies to date are descriptive in nature, and have not looked into probiotic use for the treatment of most urologic conditions. However, there are some studies (like this one and this one) that suggest Lactobacillus-based probiotics may be effective in preventing urinary tract infections.

Emerging research about the urinary microbiome represents an important next step in our quest to increase the treatment options available to women with urinary incontinence and other urologic conditions.

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Which test is best for COVID-19?

Now that we’re several months into the COVID-19 pandemic, steps we need to take to effectively control the outbreak have become clear: conscientious prevention measures like handwashing and distancing, widespread testing with quick turnaround times, and contact tracing. None of these is easy to maintain over a prolonged period. But combined, they are our best bets while awaiting better treatments and an effective vaccine.

So, which tests to use?

The many types of tests available are sowing considerable confusion. Unfortunately, because this novel coronavirus is indeed novel, and COVID-19 is a new disease, information about these tests is incomplete and the options for testing keep changing. But here’s what we know now about tests designed to diagnose a current infection, and those that show whether you previously had the virus.

Diagnostic tests for current infection

If you want to know if you are currently infected with the COVID-19 virus, there are two types of tests: molecular tests and antigen testing.

Molecular tests (also called PCR tests, viral RNA tests, nucleic acid tests)

How is it done? Nasal swabs, throat swabs, and tests of saliva or other bodily fluids.

Where can you get this test? At a hospital, in a medical office, in your car, or even at home.

What does the test look for? Molecular tests look for genetic material that comes only from the virus.

How long does it take to get results? It depends on lab capacity. Results may be ready the same day, but usually take at least a day or two. Throughout the pandemic, especially lately, delayed turnaround times of up to a week or two have been reported in many places.

What about accuracy? False negatives — that is, a test that says you don’t have the virus when you actually do have the virus — may occur. The reported rate of false negatives is as low as 2% and as high as 37%. The reported rate of false positives — that is, a test that says you have the virus when you actually do not — is 5% or lower.

A molecular test using a deep nasal swab is usually the best option, because it will have fewer false negative results than other diagnostic tests or samples from throat swabs or saliva. People who are in the hospital, though, may have other types of samples taken.

You may have heard about pooled testing, in which multiple samples are combined and a molecular test is performed on them. This could speed up the testing of large numbers of people and reduce the number of tests needed.

If a pooled test is negative, the people whose samples were combined are told they have a negative test and individual testing is unnecessary. But if the pooled sample tests positive, each of the individual samples that were taken will then be tested to see which person(s) is responsible for the positive pooled result.

This approach may be particularly helpful in settings where the number of infections is low and declining, and most test results are expected to be negative. For example, in a community where the infection seems to be under control and reopenings of schools and businesses are planned, pooled testing of employees and students could be an effective strategy.

Antigen tests

How is it done? A nasal or throat swab.

Where can you get these tests? At a hospital or doctor’s office (though it is likely home testing will soon be available).

What does the test look for? This test identifies protein fragments (antigens) from the virus.

How long does it take to get results? The technology involved is similar to a pregnancy test or a rapid strep test, with results available in minutes.

What about accuracy?: The reported rate of false negative results is as high as 50%, which is why antigen tests are not favored by the FDA as a single test for active infection. However, because antigen testing is quicker, less expensive, and requires less complex technology to perform than molecular testing, some experts recommend repeated antigen testing as a reasonable strategy. According to one test manufacturer, the false positive rate of antigen testing is near zero. So, the recent experience of Ohio Governor Mike DeWine, who apparently had a false-positive result from an antigen test, is rare.

Tests for past infection

Antibody tests (also called serologic testing)

How is it done? A sample of blood is taken.

Where can you get these tests? At a doctor’s office, blood testing lab, or hospital.

What does the test look for? These blood tests identify antibodies that the body’s immune system has produced in response to the infection. While a serologic test cannot tell you if you have an infection now, it can accurately identify past infection.

How long does it take to get results? Results are usually available within a few days.

What about accuracy? Having an antibody test too early can lead to false negative results. That’s because it takes a week or two after infection for your immune system to produce antibodies. The reported rate of false negatives is 20%. However, the range of false negatives is from 0% to 30% depending on the study and when in the course of infection the test is performed.

Research suggests antibody levels may wane over just a few months. And while a positive antibody test proves you’ve been exposed to the virus, it’s not yet known whether such results indicate a lack of contagiousness or long-lasting, protective immunity.

The true accuracy of tests for COVID-19 is uncertain

Unfortunately, it’s not clear exactly how accurate any of these tests are. There are several reasons for this:

• We don’t have precise measures of accuracy for these tests — just some commonly quoted figures for false negatives or false positives, such as those reported above. False negative tests provide false reassurance, and could lead to delayed treatment and relaxed restrictions despite being contagious. False positives, which are much less likely, can cause unwarranted anxiety and require people to quarantine unnecessarily.
• How carefully a specimen is collected and stored may affect accuracy.
• None of these tests is officially approved by the FDA. They are available because the FDA has granted their makers emergency use authorization. And that means the usual rigorous testing and vetting has not happened, and accuracy results have not been widely published.
• A large and growing number of laboratories and companies offer these tests, so accuracy may vary. At the date of this posting, more than 160 molecular tests, two antigen tests, and 37 antibody tests are available.
• All of these tests are new because the virus is new. Without a long track record, assessments of accuracy can only be approximate.
• We don’t have a definitive “gold standard” test with which to compare them.

The bottom line

Unfortunately, getting a test for COVID-19 can be confusing, because the options are rapidly changing and tests from many companies are being marketed. Despite the current limitations of testing, we’re lucky to have reasonably accurate tests available so early in the course of a newly identified virus. Imagine where we’d be if that was not the case.

Still, we need better tests and better access to them. And all tests should undergo rigorous vetting by the FDA as soon as possible. Lastly, widely available tests and short turnaround times for results are essential for effective contact tracing and getting this virus under control.

Follow me on Twitter @RobShmerling

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

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Be vigilant about bug spray

Ticks and mosquitoes don’t care about COVID-19 safety protocols. They don’t care that people are trying to squeeze out the last moments of this restrictive summer by getting outdoors, hiking, or just sitting on their decks at night and feeling something that’s close to normal.

COVID-19 has commanded our attention and caused people to adapt their behaviors to prevent one major health concern, but it doesn’t mean others have been eliminated. “Masks and social distancing will do nothing to protect you from what ticks and mosquitoes potentially carry,” 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.

Ellerin adds another reason to remain vigilant: tick-borne illnesses and COVID-19 share symptoms, such as fevers, achiness, fatigue, sore throats, rashes, headaches, low white blood cell counts, and elevated liver functions. One illness can be confused for the other, and health care resources are used up in the process. “It adds another level of diagnostic confusion,” he says. It means taking the necessary precautions becomes more important now, but the upside is one repellent is effective for both insects.

What are some common tick- and mosquito-borne illnesses?

This list isn’t exhaustive, but common viruses associated with ticks include Lyme disease, anaplasmosis, and babesiosis. They all can occur nationwide, but the highest concentrations are in the northeast and Midwest. Borrelia miyamotoi is relatively new and rare, according to the Centers for Disease Control and Prevention, so questions about where it’s most prevalent are still being explored. And with Rocky Mountain spotted fever, over 50% of cases come from five states in the southeast and Midwest.

Common mosquito viruses include malaria, Zika, West Nile, and Eastern equine encephalitis (EEE). The CDC calls EEE rare, but Ellerin says that last year there was a spike. Massachusetts, for example, had 12 cases after reporting none from 2014 to 2018. The concern with EEE is that the virus usually runs in two-to-three-year cycles, and approximately 30% of people who become infected will die from it; that’s why mosquitoes shouldn’t be ignored. “Globally, mosquitoes actually are the most dangerous animal, causing the most deaths,” says Ellerin.

Bug spray is a safe and effective prevention strategy

Taken all together, the risks of contracting a serious illness from a tick or mosquito can seem overwhelming. However, it may be reassuring to know that over-the-counter bug sprays work well to repel ticks and mosquitoes through one of three common active ingredients: oil of lemon-eucalyptus, picaridin, or diethyltoluamide, better known as DEET. Permethrin is another one, but it’s an insecticide and is designed to be used on clothing, not skin. Ellerin says that whichever bug spray ingredients you choose, they’re safe and effective when used according to their labels.

Find the repellent that’s right for you

The choice may just come down to preference or need. DEET is the most well-known, but it can cause irritation, says Dr. Abigail Waldman, clinical director of the Mohs and Dermatologic Surgery Center at Brigham and Women’s Hospital, and assistant professor at Harvard Medical School. If that’s the case, picaridin is best for sensitive skin. Some people may prefer not to use a chemical, so oil of lemon-eucalyptus is a good option. There are two caveats, she says. It’s not recommended for children under 3 years old, and a botanical can still cause a rash; for that, after you wash with soap and water, apply an emollient, such as Vaseline or Aquaphor.

No matter what type of bug spray you choose, the concentration of the active ingredient that repels ticks and mosquitoes is important. Waldman says with DEET, you want at least 20%, but no more than 50%. With picaridin, it’s 5% to 20%. And with oil of lemon-eucalyptus, a 10% to 30% concentration is most effective.

How to safely use it

Pay attention to how you apply bug spray. Cover all exposed skin; don’t forget your head, Waldman says. For your face, spray it onto your hands first and then apply. Ellerin adds to spray your ankles and tops of shoes for low-lying ticks. And as a further means of prevention, it helps to walk on clear paths, avoiding tall grass where ticks like to reside. Wear clothes that cover your extremities and tuck pant legs into your socks. At home, mow your lawn frequently, clear away brush, and keep play areas away from shrubs, bushes, and wooded areas.

Waldman says that each parent knows the abilities of their kids, but young children shouldn’t handle bug spray on their own. The concern is that it would go into eyes, noses, ears, or mouths, and that young children tend to put their fingers in their mouths. At high exposure it can be toxic, so it’s good to avoid ingesting it at any level, and it’s a good idea for everyone to wash their hands after putting on repellent, she says.

If you’re planning to be in the sun, apply sunscreen first since it needs to sink in, then bug spray, and reapply sunscreen every 60 to 90 minutes since the repellent reduces effectiveness. As for the repellent, it usually lasts six to eight hours. If it hasn’t worn off by bedtime, you’ll want to wash it off with soap and water, as it can be irritating if left on overnight. Unless you are camping overnight in an area with ticks or mosquitoes, you don’t want it sitting on your skin if insects aren’t a concern. “If you don’t need it on, get it off,” Waldman says.

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Children, teens, and the safety of psychotropic medicines

Medicines prescribed for attention deficit/hyperactivity disorder (ADHD), depression, anxiety, and other mood disorders — known as psychotropic drugs — have largely been studied in adults. This concerns many parents whose children take these drugs regularly. Studies have most often looked at the effectiveness of these medicines in teens and children. Now a recent systematic review of multiple studies done in children and adolescents offers new guidance on safety for commonly used medicines.

What did the study look at?

The aim of this study was to comprehensively synthesize current evidence on the safety of four major classes of psychotropic drugs given to children and adolescents. This helps clinicians make decisions when prescribing, and assists in developing well-grounded guidelines. It also helps identify areas needing further research.

What are the take-home messages for parents?

The researchers focused on adverse events, such as side effects or other problems, linked to 80 medicines in four categories: antidepressants, antipsychotics, anti-ADHD medications, and mood stabilizers. Altogether, the studies considered data from 337,686 children and teens. Most study participants were taking either anti-ADHD medicines or antidepressants (roughly 149,000 and 121,000, respectively). Smaller numbers took antipsychotics or mood stabilizers (roughly 67,000 and 1,600).

The study looked at safety profiles and common side effects, which were available in the scientific literature for some, but not all of the medicines: 18 antidepressant medicines; 15 antipsychotic medicines; seven anti-ADHD medicines; and six mood stabilizers. While side effects were modest overall, the researchers found the following:

• Antidepressants. Common issues were nausea, vomiting, and stopping a drug due to side effects. Escitalopram (Lexapro) and fluoxetine (Prozac) were less likely than others to cause adverse effects.
• Antipsychotic medicines. Common issues were drowsiness, abnormal muscle movements, and weight gain. Lurasidone (Latuda) was less likely than others to cause adverse effects.
• Anti-ADHD medicines. Common issues were loss of appetite and insomnia. Methylphenidate (Ritalin, Concerta) was less likely than others to cause adverse effects.
• Mood stabilizers. Common issues were drowsiness and weight gain. Lithium was less likely to cause adverse effects, although its long-term effects, such as possible harm to the kidneys, might be underrepresented.

What are the limitations of this study?

The authors acknowledge that there were limited data about adverse events for many of these medications. Therefore, a more comprehensive reporting of adverse events is necessary in future research on the use of psychotropic medications in children and adolescents. Additionally, long-term and rare side effects are likely underrepresented here, due to the limited availability of longer-term data.

What should I ask if a doctor says my child may need a psychotropic medication?

• What is this medication for? Surprisingly, I’ve talked to a number of parents who aren’t sure why their child is being treated with medication. Make sure you clearly understand several points: what is the diagnosis that requires treatment, and what behavioral symptoms might the medicine help with? Ask if this treatment is approved by the FDA for this diagnosis, or if the doctor is recommending it for off-label use. If you find the discussion confusing, don’t hesitate to ask your doctor to break down or repeat some of the explanations. You may also ask for additional resources, such as educational handouts or websites related to your child’s condition.
• Is this the only medication option available? As described in this study, each psychotropic medication has a unique profile for side effects and effectiveness. This can differ even within the same medication category. Typically, a variety of treatment options are available, either as single drugs or combined with other drugs. Ask about the rationale behind choosing each option, as well as its potential benefits and risks.
• What are the potential side effects? Going over every single possible side effect of each prescribed medication may not be practical, because the list may be long and could create unnecessary anxiety. Instead focus on common and important potential side effects, such as FDA black box warnings. Many teens find it hard to take medications regularly, so ask if there are any important withdrawal effects (in case your child ends up skipping medications).
• How long should my child stay on this medication? This is probably one of the most popular questions that comes up, especially when a youth starts psychotropic medications for the first time. Nobody wants their children to stay on medications indefinitely. Ask your doctor about the recommended duration of treatment. Although none of us can predict the future, it’s a good idea to discuss proposed treatment plans.
• What else should you understand? Some psychotropic medications require specific monitoring protocols to ensure safety. Examples might involve checking blood pressure, tracking body weight and body mass index (BMI), or having blood tests at specific times. Also ask your doctor if you need to be aware of any restrictions, such as avoiding certain foods or other medications.

Medicine is one tool in the toolbox

While medication is one of the stronger treatment tools in mental health care, it’s not the only one. Especially for children and teens, it is essential to approach behaviors holistically by considering biology, psychology, and social and environmental factors. Frequently, medication is combined with other approaches, such as individual therapy, family therapy, and multidisciplinary, system-based approaches like developing an IEP (individualized education program) for school. A comprehensive assessment can guide the care team in making appropriate plans aimed at an optimal outcome.

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Rising temperatures: How to avoid heat-related illnesses and deaths

In Boston, we believe warmer is better. Our cravings for warmth are formed in the cold, dark winter nights when the prospect of summer seems impossibly remote. But with July temperatures reaching near 100° F, our winter dreams are becoming a summertime nightmare. Dangerous heat exposures in Boston and other cities across the US aren’t felt equally. Urban areas with less green space and more pavement can be up to 15 degrees hotter than other, greener places. These urban heat islands are much more likely to be poor, minority neighborhoods, and their origins can be traced straight back to redlining that began in the 1930s.

This summer, the disparate heat risk these communities face has piled onto the outsized harm that COVID-19 has already wrought upon them. The good news is that we can take actions that protect our most vulnerable urban neighbors and ourselves from COVID-19 and extreme heat.

What is heat-related illness?

Our ability to cool off has limits. When the heat is too strong, our bodies overheat. When that happens, we can get headaches and muscle cramps, and vomit. Severe overheating, when body temperature reaches 104° F or higher, can lead to heatstroke that can damage kidneys, brains, and muscles.

Even for people who are healthy, heat can be dangerous and cause heat-related illness. Outdoor workers, athletes (especially football players and young athletes), and women who are pregnant should be especially careful when it’s hot outside.

Who is at greater risk from high temperatures?

Heat can be a risk for those who are healthy, but it’s particularly risky for people who have existing health problems. It can even be lethal. Decades of research show that people die during heat waves, and that these deaths are not occurring among people who were likely to die soon anyway.

Many of us probably know someone who is at greater risk from too much heat. The elderly — particularly those with heart failure, kidney disease, and chronic lung disease — and the homeless are at high risk when temperatures soar. Less well known are the others who need to be vigilant when extreme heat hits, including parents of children with asthma and people with diabetes. Anyone taking medicines, such as diuretics, that can affect their body’s ability to sweat or hold onto water may also be more vulnerable.

How can you keep yourself and others safe during heat waves?

More than half the people in the US may have received some form of warning during our most recent heat wave. But research on these mass alerts shows they may not be as effective as we’d like. And now, with COVID-19, many people may understandably be less interested in going to cooling centers, which are often a mainstay of heat wave response plans. This makes actions you can take all the more important. You can keep yourself and others safe by taking these steps:

• Think about whether your health, or the health of your neighbors or loved ones, is at risk from heat. If so, make sure everyone — including you — understands how to stay safe during heatwaves.
• Check up on your neighbors and friends. Call or text first, and knock on a door if you have to. You can do this while wearing a mask and practicing physical distancing.
• Sign up for heat alerts. Many city or town governments have a website where you can sign up to receive text messages to alert you of dangerous heat conditions. Free services, such as iAlert, also can send you alerts. Be aware, though, that the alert may go out at temperatures above what is known to be risky for health.
• Find out where the cooling centers are in your city, and whether they are still open during the pandemic. Many may be implementing new social distancing guidelines or limiting their capacity. Tell others who might be at risk about them. During heat waves, many cities offer free transportation to these centers. Many cities have websites that can help you find the cooling center nearest you. Or a citywide number to call or text, such as 311 for the city of Boston, may connect you to many different services like these.
• Drink plenty of water during heat waves. Avoid too much caffeine and alcohol, which can promote dehydration.
• Cover windows with curtains, shades, paper, or any material that will keep the sun from shining in.
• Eat food that can be served cold, so you don’t have to use your oven or range.
• If and when the temperature falls below 70, which in many places happens early in the morning and at night after the sun has gone down, open windows and use a fan to circulate air.

What other steps can you take?

It’s right to focus our immediate actions on protecting people most at risk. But we also need to consider recent heat waves a sign of things to come. We know climate change has already led to more severe heat waves throughout the United States. Curbing carbon pollution by taking these actions and others can help prevent more frequent and dangerous heat waves.

We can make our cities greener. The difference in temperature between the hottest and coolest parts of cities can be 20° F or more, because of how much the urban landscape absorbs heat. Planting trees and other plants can make a big difference toward reducing heat in cities. Green space doesn’t just keep us cool, it also keeps us healthy. Trees remove air pollutants that can further harm people who are at risk from heat. Vegetation prevents water runoff. In Boston, runoff from heavy spring rains last year led to pollution levels in the Charles River that forced cancellation of all summer swimming events. Climate change has increased heavy downpours in New England and around the country. Trees can help make our cities more resilient to climate change.

We can work to reduce traffic congestion. This is a growing problem in cities all over the country, although the pandemic has cut down on commuting traffic in many places. Use public transit or carpool when possible, given the need to protect yourself and others from COVID-19. If you buy a car, remember that greater fuel efficiency reduces carbon pollution and other pollutants that damage lungs, hearts, and brains — and lowers monthly costs. Improvements to make public transit accessible, affordable, and reliable help everyone. Find out what’s going on in your community about transit, bike lanes, and pedestrian ways. Advocate by speaking out at community meetings (many of which have moved online), and by voting for improvements through local and state referendums.

We can conserve energy at home. If you are redoing your roof, consider getting a green roof, or at least choose light-colored roofing material. Many cities and states offer free home energy audits, plus incentives to improve a home’s insulation and replace old appliances with newer, more energy-efficient models.

Follow me on Twitter @DrAriBernstein

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School, camp, daycare, and sports physicals: What to do in the time of COVID-19

As some youth sports teams get started again, some summer camps and daycares are opening up, and we begin to think about school (or some form of it) in the fall, many parents are wondering: what do I do about getting that physical form I need for my child?

Understandably, many families do not want to go to the doctor right now. They are worried about going anywhere, and especially worried about going to a medical office, where they are concerned they may end up around sick people.

I want to say up front that most medical facilities are very aware of the risk, and take measures to make sure that patients can safely get the medical care they need. But when it comes to forms for physicals, in some cases families may not need to leave their homes at all — or if they do, they may be able to do it in a limited way.

What questions should parents ask about forms for sports, daycare, or school?

Do I even need a form?

• In many school districts, forms are not required every year but rather at certain times, such as kindergarten or middle school entry. Parents should check and find out; it may not be an issue at all.
• Some activities and facilities that the child has attended in the past may be willing to use a previously submitted form. It’s worth asking.
• Because of the pandemic, there may be some wiggle room or a grace period allowed for forms. Again, parents should check.

Would my child’s last appointment suffice for the form?

• Very often, what is required is documentation of a check-up within the past one to two years. If your child had a check-up within that time frame, you may be able to just get a form sent to you, no visit needed.

Would a telehealth visit be possible — and accepted?

• Many practices, mine included, are providing well-child care via telehealth for children who do not need to be seen in person — and providing forms based on those visits. (It’s helpful if you can get your child’s height and weight before the visit.). Parents should call their doctor to find out if this is an option, and also check to be sure a form based on a telehealth visit would be accepted.

Does my child need immunizations or something else that requires an in-person visit?

• It’s very important that children stay up to date on immunizations. Because of the pandemic, many children are falling behind. This may lead to outbreaks of measles and other vaccine-preventable diseases, many of which could be more dangerous to children than COVID-19.
• There are some conditions that require in-person monitoring, like anemia or high blood pressure. While many practices are finding remote ways to manage these and other chronic health problems, not everything can be done remotely. Parents should check with their doctor.

If my child needs to go in person, what can be done to keep us safe?

I strongly encourage families to call their doctor’s office to find out what they are doing to minimize risk; they will likely be pleasantly surprised. For instance:

• In my practice, we have cut down on the number of patients we are seeing, and spread out the appointments so that patients go directly into rooms and don’t wait in a waiting room. We also do lots of screening before and at the visit, everyone wears a mask, and we have made physical changes to our office as well as changes in our routines that make spread of the virus less likely.
• Sometimes, the visit can be streamlined by having a phone call or virtual visit ahead of time to collect information. Then when the child comes in, it’s for a quick exam and any shots or other in-person care they need, minimizing the time in the office. Parents should see if this is an option.

As a pediatrician, the most important thing to me is that children get the medical care they need. I worry that many children won’t because their families are afraid of COVID-19. Please, call your doctor and talk about what your child needs — and how they can get it safely. Trust me, we are just as invested in your child’s health and safety as you are.

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Wondering about goosebumps? Of course you are

They go by different names: goosebumps, goose pimples, goose flesh, and my personal favorite, goose bumples. The medical term is cutis anserine (cutis means skin and anser means goose). I guess the similarity in texture is just too close to goose skin to ignore. Other medical terms for goosebumps are horripilation, piloerection, or the pilomotor reflex.

Each of these terms describes a temporary change in the skin from smooth to bumpy, most commonly developing after exposure to cold.

Many people associate goosebumps with fear, or perhaps more accurately, with horror. Perhaps that’s why a popular series of children’s horror stories by R.L. Stine published in the 1990s was called Goosebumps.

Ever wonder why you get them? Do they serve a purpose? Why do they develop when we’re frightened?

What are goosebumps?

Goosebumps are the result of tiny muscles flexing in the skin, making hair follicles rise up a bit. This causes hairs to stand up. Goosebumps are an involuntary reaction: nerves from the sympathetic nervous system — the nerves that control the fight or flight response — control these skin muscles.

In the animal kingdom, a threatened animal has a similar reaction, causing fur to be puffed out a bit. This makes the animal appear bigger and more dangerous. Perhaps the most dramatic example is the porcupine, which puffs out its quills when sensing danger. This can make a threatening adversary think twice before attacking. That may explain why the sympathetic nervous system controls goosebumps — the reflex is tied into the fight or flight response.

This just in

Researchers studying mice recently linked goosebumps to the regeneration of hair and hair follicles. It seems that the nerves connected to the tiny muscles responsible for goosebumps also connect to hair follicle stem cells, which are the cells responsible for hair growth. So, in response to cold, the nerve tells the tiny muscles in the skin to contract (causing goosebumps) and the same nerve activates hair follicle stem cells for new hair growth.

What purpose do goosebumps serve?

Goosebumps may help you conserve heat when you’re exposed to cold. They may do this in several ways.

• As with larger muscles, contraction of the muscles in the skin (called arrectores pilorum) generates heat.
• The raised hair follicles cause skin pores to close.
• Hairs standing up trap a layer of air near the skin, holding onto body heat.

Each of these might be more important for furry animals than for humans. In fact, it’s not clear how important goosebumps are in humans. For example, if you couldn’t form goosebumps at all, it wouldn’t necessarily mean that you’d have problems with temperature control. Goosebumps may be one of those leftovers from our evolutionary ancestors (like the coccyx, or tailbone) that serve no important purpose.

The new discovery linking goosebumps with hair follicle stem cells might be explained as a longer-term response to cold, at least for animals with fur: they get goosebumps (or the animal equivalent) in the short run to conserve heat, and thicker fur to keep warmer in the long term.

Goosebumps: More than just being cold

Most people associate goosebumps with unpleasant situations, such as feeling particularly cold or feeling afraid. Yet there is more to it than that. The arrectores pilorum are hooked up to the sympathetic nervous system, and the sympathetic nervous system has input from many parts of the brain, including those involved with motivation, arousal, and emotion. So other stimuli may cause goosebumps, for instance:

• hearing music or seeing art that is particularly moving or completely engrosses you (which is why you might say “it gave me chills”)
• awe
• pride
• excitement
• fear.

Goosebumps and disease

Though rare, goosebumps can be a sign of a seizure disorder called temporal lobe epilepsy, a disorder of the sympathetic nervous system, or other brain disorders. They are also common during heroin or other opiate withdrawal. In fact, one explanation for the origin of the expression “quitting cold turkey” is that goose bumps that develop during withdrawal from heroin mimic cold turkey flesh.

The bottom line

You’ll see goosebumps most often when you’re cold. But don’t be surprised (or afraid or awed) if they appear at other times. They are a universal but poorly understood phenomenon, but our understanding is improving. And the recent discovery linking goosebumps with hair follicle regeneration could lead to more than just a better understanding of goosebumps; it could lead to new ways to fight baldness or improve tissue healing.

In humans, it’s possible that goosebumps will gradually disappear over the coming centuries as with other remnants of evolution, like the tailbone or wisdom teeth. Or they may serve a more important role than we currently understand and continue to puzzle us for years to come.

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Lifestyle changes are important for managing atrial fibrillation

Atrial fibrillation (afib) is a common heart rhythm disorder in which the upper chambers of the heart (the atria) beat fast and irregularly. Afib commonly causes recurrent symptoms, usually palpitations and shortness of breath, and can negatively affect quality of life. Afib also substantially increases the risk of stroke, and is also associated with heart failure, high blood pressure, and diabetes. People with afib routinely require lifelong treatment with blood thinners, to prevent blood clots that can lead to strokes.

Doctors are only recently understanding the importance of lifestyle factors in treating afib. Modifiable lifestyle factors are so important and under-recognized that the American Heart Association (AHA) recently released a scientific statement summarizing the latest research on this topic. The AHA wants both doctors and patients to understand the relationship between lifestyle and afib, and to work as a team to put these lifestyle factors into practice. Following is a discussion of important lifestyle factors, how they may impact afib, and what you can do.

Obesity

One of the strongest factors associated with afib is body weight. Obesity (defined as body mass index [BMI] > 30) has been shown in multiple studies to be linked to the development of afib. Obesity is associated with changes to electrical signaling within the atria, as well as structural changes to the heart’s upper chambers. Overeating can also cause inflammation via changes in hormone and cell-signaling pathways in the atria. Several studies have shown that as we gain weight, fat is deposited in the heart (as well as other places throughout the body), and this can trigger arrhythmias, most commonly afib.

Obesity can also be a cause of new or worsening hypertension (high blood pressure), which promotes further structural changes in the heart. Obesity also can cause obstructive sleep apnea and diabetes, both of which independently increase risk of afib.

The good news is that for people who are overweight or obese, just a 10% reduction in weight seems to improve symptoms related to afib.

Exercise

For decades cardiologists have encouraged people to exercise, because exercise reduces the risk of dying from cardiovascular causes. Not only is exercise good, but physical inactivity is actually detrimental; a sedentary lifestyle contributes to afib and may actually be an independent predictor of this condition. The AHA recommends 150 minutes per week of moderate-intensity aerobic exercise, or 75 minutes per week of vigorous-intensity aerobic exercise, to improve cardiovascular health. Regular exercise helps to prevent atrial fibrillation and, if you already have afib, reduces symptoms and improves afib-related quality of life.

If you are not already exercising, talk to your physician about starting a low-intensity exercise program. Brisk walking is a great form of moderate exercise and allows for physical distancing. Start with 20 minutes a day and gradually increase your pace and duration to achieve at least 150 minutes per week of moderate-intensity activity.

Sleep disorders

Obstructive sleep apnea (OSA) is a sleep disorder in which people stop breathing for short periods while they are sleeping. It is the most common form of sleep-disordered breathing and is strongly associated with cardiovascular disease. There is also a very high prevalence of OSA in people with afib, and recurrence of afib symptoms is higher in people with more severe OSA.

Cardiologists now routinely screen people with recurrent afib symptoms for OSA. Treating OSA with continuous positive airway pressure (CPAP) appears to improve afib symptoms.

If you experience afib symptoms, ask your doctors if you should have a sleep study to check for OSA.

Alcohol

Alcohol is a known risk factor for atrial fibrillation, and there is mounting evidence that the old adage “less is more” may be true for drinking if you have afib. A recent study in the New England Journal of Medicine found less afib when patients decreased or abstained from alcohol.

If you have afib, try cutting back on alcohol, or even not drinking at all. Talk to your doctor if you are having trouble reducing your alcohol consumption.

Diabetes

The risk of afib is higher in patients with type 2 diabetes. While the mechanism is not well understood, it’s likely that elevated blood sugars directly damage the heart and promote structural, electrical, and autonomic changes within the heart tissue.

The good news is that better blood sugar control improves both the severity and frequency of afib symptoms. Lifestyle changes that promote exercise and limit inactivity can also help with weight loss and blood sugar control.

Diet

Dietary changes can translate into weight loss, and also help to control blood sugar if you have diabetes. Changing your diet can be challenging, but eating less processed foods and more fresh vegetables and fruit is a good starting place. Target bad habits, like snacking or eating out of boredom. And consider transitioning to a Mediterranean diet, which helps control weight, blood sugar, and blood pressure.

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