Summer camp: What parents need to know this year

It’s time to make summer plans, and for many families, those plans include summer camp. After the year we’ve had, the idea of getting out of the house, being active, and seeing other children sounds very appealing.

While there is reason to hope that this summer will be better than 2020, the reality is that COVID-19 will still be with us. The vaccines will make a difference, but they aren’t available yet for campers under the age of 16 — and the youth and young adults who make up most of the staff will likely not all have been vaccinated either. So as families make plans, they need to think about COVID-19.

Start here: Consider risk factors

Before even thinking about camp, families should take into account their particular risk factors. Hopefully, any high-risk adults in the family will have received a COVID-19 vaccine by the time kids head to camp. If they haven’t been vaccinated yet, now is the time to work on getting the vaccine.

If children have health problems like asthma or congenital heart disease that put them at higher risk of complications of COVID-19, parents should talk with their child’s doctor before sending them to camp. For some children at high risk, it might be better to stay home one more summer.

It’s also important to make sure that children are up to date on childhood vaccinations. Many children have gotten behind because of the pandemic.

Find out about risks at camp — and plans to lower risk

There is no way to make any camp risk-free. But there are lots of ways that camps, and parents, can lessen the risk. Here are some things for parents to think and ask about:

Where are campers and staff from? A local day camp with children and staff mostly from a town with low numbers of COVID cases is going to be lower risk than one that draws from many different communities, including some with higher numbers. The New York Times has an interactive map of the US that can help you check how low or high COVID-19 case counts are in states and counties.

How are the campers organized? Are they divided into small groups that don’t mix (which is preferable)? Or are they in larger groups — or not divided into groups at all? The more mixing, the more chance of exposure and spread.

Are activities mostly indoors or mostly outdoors? The more outdoors, the better. Indoor activities should be in well-ventilated spaces.

How much physical distancing is planned or possible? While distancing may not be possible all day, the camp should be set up in a way that limits crowding and gives children three to six feet of space whenever feasible. Parents should ask specifically about typical days and activities at the camp, including how meals will be managed, to get a sense of how close to each other the children will be.

How much shared equipment will there be? The less, the better — and any shared equipment or surfaces should be regularly cleaned. This is particularly important for sports camps. (If your child or teen has had COVID-19, see my previous blog post about returning to sports and physical activity afterward.)

How is the camp screening for symptoms or exposures, and what protocols do they have in place? There should be daily screening for symptoms (and exposures outside of camp) for campers and staff, with appropriate plans for staying home, testing, and quarantine based on the results of those screenings. Sleep-away camps should have designated quarantine space, and access to testing. Ask about testing requirements, as well.

Will the campers and staff be wearing masks? There may be some situations (like swimming) when wearing masks may be difficult, but as much as possible, campers and staff should be wearing masks to keep everyone safe.

What are the camp’s plans for hand washing? Regular hand washing with soap and water or hand sanitizer is important to limit the spread of germs, including the virus that causes COVID-19. Parents should ask how often campers will be washing their hands, and about the availability of hand sanitizer.

What is the plan for meals? It’s best if children bring their own food, and sit at a distance from each other when they eat. If food is being served, it should be pre-packaged in bags or boxes, with no shared utensils.

What kind of training and supervision will staff have regarding COVID-19? Staff should be trained in recognizing and preventing COVID-19. Further, they should be supervised and held accountable. There should be written protocols that parents should be able to see.

Are there additional considerations for overnight camps? Yes. Overnight camps need to take additional precautions. Examples include having everyone sleep head-to-toe, and using physical barriers between beds and bathroom sinks.

Talk to your children about how they feel about camp — and about the worries they may have about being around other people, especially if they have mostly been isolated at home. Talk specifically about how the days will work, and be ready to answer any questions.

It sounds like a lot to do, but it’s important. For at least one more summer, we need to stay safe — for our health, and the health of everyone around us.

For more information about overnight camps and on recommendations for all camps, check out the information about camp safety during COVID-19 on the website of the Centers for Disease Control and Prevention.

Follow me on Twitter @drClaire

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Harvard Health Ad Watch: Mitochondria do a lot for you — what can you do for them?

Ever see an ad for a product that sounds awesome and wondered if it was really that good? That happened to me recently. “How are you taking care of your mitochondria?” an announcer asked. Well, there’s a question I’m not asked every day. And it’s one for which I had no answer.

Your cells are aging: Can supplements keep them young?

This ad and an accompanying website describe their products this way:

• “a breakthrough range of nutritional solutions”
• supplements that “work in harmony with your body’s natural processes to rewrite the rules of cell aging”
• “helps activate the renewal of mitochondria in muscles”
• “targets age-related changes occurring inside cells”
• “renews cells’ natural ability to produce daily energy”
• “features cellular nutrients studied in more than 20 clinical trials in humans”

And just what is this miracle product? It’s food! Just kidding. These statements come from ads for Celltrient supplements made by Nestlé Health Science. Yes, from the makers of famed candy bars come supplements to improve your health and slow aging!

The buzz about mitochondria and cell health

The claims focus on two main areas of health that have been the subject of extensive research at the cellular level in recent years: aging and energy production.

You may remember from high school biology that nearly all human cells have a nucleus that contains our genetic blueprint (DNA). But do you remember much about the mitochondria? These so-called power stations of the cell convert nutrients into energy. They’re essential to the health of each cell — and to the health of the tissues and organs of the person in whom those cells reside.

When mitochondria aren’t working normally, debilitating, sometimes life-threatening conditions may occur, such as mitochondrial myopathies and a number of eye diseases.

An enormous amount of research in recent years suggests that mitochondria

• play a key role in the aging process and most age-related diseases
• are vital to cell health, including by regulating how nutrients get into individual cells
• contain DNA that is easily damaged with age, is prone to mutation, and has limited ability to repair
• play a key role in immune function.

These findings have led to speculation that treatments to maintain or improve mitochondrial and cellular health could lead to ways to slow aging.

What the ads gets right — and the rest of the story

It’s true, as noted above, that mitochondria are essential for the vital process of cellular energy production. And an increasing body of evidence suggests mitochondria are key players in aging and the development of chronic disease.

But the rest of the claims made by the makers of Celltrient should be taken with a hefty dose of skepticism. The evidence behind them is scant. Like all over-the-counter, unproven supplements and remedies, Celltrient carries this FDA-required disclaimer: “These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure or prevent any disease.”

What about the 20 human studies mentioned? Well, this refers to research on one or more of the ingredients found in these products, but not the products themselves. These studies can’t demonstrate that the claims made in the ad are true in humans.

For example, one study shows that one ingredient in Celltrient — niacin, a form of vitamin B₃ — gets absorbed into the bloodstream. Also, it increases blood levels of a substance that mitochondria need to function properly, called nicotinamide adenine dinucleotide (NAD).

Sound impressive? Keep in mind that taking a specific vitamin supplement may be useless if you already have enough of that vitamin in your body. So it’s not clear from the study that Celltrient actually “renewed” or “replenished” mitochondria in the cells of study participants. More importantly, there’s no proof that these supplements make people healthier or feel better, slow aging, or provide any other specific health benefit.

Considerable cost and key information lacking

The promotions also don’t mention cost. Prices on the product website range from about $60 to $130 per month. And there’s no mention of possible side effects, interactions with other drugs, or whether certain people are more likely to benefit from them than others.

Finally, these ads don’t tell you what your other options are for mitochondrial heath, assuming you’re concerned about this. For example, regular exercise may be the best treatment for mitochondrial aging.

The bottom line

Ads like the ones for Celltrient products are rampant. You’ll see supplements promoted for heart health, joint pain, memory loss, and a host of other conditions. Some have more scientific support than others. But beware of ads for drugs or supplements that promise vague and sweeping health benefits without actual proof that the product works. A statement that it’s “backed by science” — without explanation — is not enough.

For cell and mitochondrial health, you could accept the unproven claims in these ads and spend thousands of dollars each year on Celltrient products. Perhaps future studies will even prove these supplements work. Or you could take a chance on a more conventional source of nutrients needed by mitochondria: food. I guess I wasn’t kidding after all.

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Simple, low-cost, low-tech brain training

We’re all looking for ways to boost our brain power. And fortunately, there are plenty of simple, low-cost, low-tech ways to help sharpen cognition.

“Low-tech, mentally stimulating activities, especially ones that are challenging, help our brains create new connections. The more connections we have, the more paths our brain has to get information to where it needs to go. This can help with improving cognition overall or in specific areas, depending on the activity,” says Dr. Joel Salinas, a behavioral neurologist and faculty member of the Harvard Center for Population and Development Studies.

Low-tech brain training activities to try

Mentally stimulating activities make you do a little cognitive light lifting: they require some work to process or produce information. These kinds of activities can include any of the following.

• Learning a language. Bilingual people have greater mental flexibility and agility, and may have some protection from the risk of developing dementia, compared to people who speak one language. Learning a second language later in life may even delay cognitive decline. To get started, listen to language recordings, take an online class, or download an app such as Babbel or Duolingo.
• Listening to or making music. Music can activate almost all regions of the brain, including those involved with emotion, memory, and physical movement. Get in on this benefit by listening to new kinds of music, or by learning how to play an instrument. Check out playlists from other countries, or start learning to play an instrument by watching free videos on YouTube.
• Playing card and board games. Games strengthen your ability to retrieve memories (if you play Trivial Pursuit, for example) or think strategically (if you play games like Monopoly or checkers). Playing card games is helpful because it requires you to use a number of mental skills at once: memory, visualization, and sequencing.
• Traveling. Visiting a new place exposes you to sights and sounds that enhance brain plasticity, forming new connections in your brain. You might not be able to travel far during the pandemic, but simply exploring areas nearby may produce brain changes. Consider driving to a town you’ve never visited before, or going to an outdoor park with unfamiliar terrain (perhaps mountains or thick forests) to gain new perspectives.
• Watching plays, films, concerts, or museum tours. Cultural activities stimulate the brain in many ways. While you may not be able to enjoy these activities indoors right now, it might be possible to see them outside or online. Choose something that requires a little effort to understand it, for example a Shakespearean play or a foreign film (try to figure out what the characters are saying without reading the subtitles). If you’re watching a concert, choose one with complex classical compositions. If you’re looking at an online museum exhibit, try to pick up on the details the artist used to convey a message.
• Word puzzles. Working on word puzzles (such as a crossword, Jumble, or Sudoku) has been shown to help people improve their scores on tests of attention, reasoning, and memory. Try a different kind of puzzle each day (for example, a Sudoku one day, a Jumble the next), and increase the level of difficulty as puzzles get easier.

Maximizing benefits of brain training

Don’t limit yourself to one mentally stimulating activity: some evidence suggests that the more of these activities you do, the more your risk for mild cognitive impairment will decrease.

And combining mentally stimulating activities with exercise, learning, or socializing may have an even more potent effect on cognition. For example:

• Get physical and dance while you listen to new music.
• Learn something by watching a video lecture about an artist before checking out an exhibit of the person’s work.
• Socialize by playing a board game online with friends during a video call.

One thing you shouldn’t do: think of these activities as brain training chores. Just enjoy them because they’re fun. They’ll enhance your life, and they may wind up sharpening your cognition to boot.

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School reopening? What parents need to know and can do

It’s amazing how something as ordinary as going to school can become frightening and overwhelming during a pandemic.

While some children have been attending school throughout the pandemic, most have been learning remotely, or in a hybrid model of some remote and some in person. As we pass the one-year mark, it has become increasingly clear that children need to get back into their pre-pandemic school routines. It’s not just education that has suffered; being isolated at home is bad for the mental and physical health of children too.

The problem is, the pandemic isn’t over yet. While vaccines are giving us hope, children under 16 can’t yet be vaccinated, and access to vaccines for teachers is uneven. Understandably, many people would prefer not to make any changes just yet. Instead, they’d like to wait until the next school year, when more adults will be vaccinated and high school students may be eligible for vaccines.

Waiting could do more harm

But so much has been lost already, and many students and families are in crisis. Even for those who aren’t in crisis, getting away from computer screens, back to in-person teaching and seeing friends, not to mention some physical activity — could make a big difference for many students, even if it is just for a few weeks.

Most school districts do and will continue to provide a remote option — and for children and families with high medical risk who are not yet vaccinated, that may be the best option. But if there isn’t anyone at high risk in the family, and if community numbers are low, school is likely safe. It’s also the better educational option.

Learn about school district plans for safety

It’s important to know what your school’s plans are for

• Distancing: What is feasible? What will classrooms and lunchrooms look like?
• Masks: Wearing well-fitted masks lowers the risk for spreading the virus that causes COVID-19. Staff and students should wear them — even if staff have had the vaccine.
• Handwashing: There should be regular opportunities for staff and students to wash their hands, and hand sanitizer should be available.
• Screening for symptoms and exposure: There should be daily screening for any symptoms of COVID-19, or any exposure to someone with the illness — and clear protocols for isolating and testing before coming back to school.
• Contact tracing: If a staff member or student is found to have COVID-19, there should be a clear system for identifying and notifying all possible contacts, with a clear plan for quarantine and testing.
• Ventilation: The more air can circulate, the better. This is more feasible in some buildings than others.
• Cleaning: Shared surfaces should be regularly cleaned.
• Meals: Students should be safely spaced while eating, and any meals served should be pre-packaged.

How can parents help children prepare to go back to school?

Some students haven’t been in a school building for a year. Parents may need to do some preparation, such as

• Practicing wearing masks: It’s not easy to wear one for hours at a time, and families may want to practice.
• Getting used to keeping distance: If students have only been with family members or others in their pod, they may not be used to the idea of staying three to six feet apart. Families will need to talk about this, and may want to practice this too.
• Planning for hand-washing: Get in the habit of doing it regularly at home so it will be easier to remember at school.
• Changing schedules: After a year of rolling out of bed (or not) and starting school on a computer, it may be a hard change to get up earlier, get dressed, and commute to school. It may also require an earlier bedtime. It could be helpful to adjust to those schedules a few days ahead of time.
• Have conversations about what it will be like to be in class again: While children learning online have had to follow the rules of a remote class, they may have forgotten about the rules of an in-person class. Talk about how it will be different.
• Meal planning: Meals look different at schools these days, and packing a lunch may be the best bet. Doing some planning and shopping (for foods that are simple to prepare, and a lunchbox and water bottle) may be helpful.

Be prepared for some bumps in the transition, and set aside time every day to talk with your child about their feelings and experiences. It could be a “high/low” open question at dinner, or some other screen-free time when your child can have your full attention. Keep questions open-ended and ask them in the most supportive way you can.

If you have questions about your child’s particular situation, talk to your doctor.

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Fully vaccinated against COVID-19? So, what can you safely do?

Congrats on getting your COVID-19 vaccine! You qualify as fully vaccinated two weeks after your second dose of the Moderna or Pfizer/BioNTech vaccine, or two weeks after your single dose of the Johnson & Johnson vaccine, according to the US Centers for Disease Control and Prevention (CDC).

Maybe you’re wondering what you can safely do now that you’re fully vaccinated. As an infectious disease specialist, I’ve provided answers to some common questions. Please keep in mind that information about COVID-19 and vaccines is evolving, and recommendations may change as we learn more.

Can I gather with people outside my household who also are fully vaccinated?

Yes, if you and your friends or family are fully vaccinated, gathering in small groups without masks is considered low-risk. Although it’s possible that people who are fully vaccinated could still spread the virus, the vaccines are excellent at protecting you from severe illness, hospitalization, and death due to COVID-19.

Hopefully, we can start to view COVID-19 like influenza: the flu vaccine reduces flu severity and decreases your chances of going to the hospital for pneumonia, but does not completely eliminate the virus.

Regardless of your vaccination status, if you experience COVID-19 symptoms, you should avoid close interactions with others. If you have tested positive for COVID-19 in the prior 10 days before a planned visit, you should refrain from visiting others.

Can I see family and friends who don’t yet have the vaccine, and socialize without my mask if I am fully vaccinated?

The risk that you’ll develop COVID-19 is low if you are vaccinated and attend a gathering indoors with others who are not vaccinated. However, please be aware that you can potentially spread the virus to others. Vaccination does not completely shield you from becoming infected with the virus; it just lessens symptoms and severity of disease. So, it’s possible that you could have no symptoms or only very mild symptoms, and still pass the virus to your family and friends who are not yet vaccinated.

The new recommendations below are based on the vaccination status of yourself and your family members or friends. As we learn more, these recommendations may change.

If you are fully vaccinated and visiting fully vaccinated family or friends:

• Indoor visits without masks are okay and likely low-risk.

If you are fully vaccinated and visiting healthy but not yet vaccinated people ages 64 or younger living in a single household:

• Indoor visits without masks are okay and likely low-risk. Although spreading the virus is still possible, the risk of healthy — and particularly younger — individuals developing severe COVID-19 is low.
• Be aware that if older people do get COVID-19, their risk for hospitalization and death is much higher than the risk for younger people. A 60-year-old has a higher risk than a 50-year-old, and a 50-year-old is at higher risk than a 40-year-old. Learn more on this CDC page explaining risks by age group.

If you are fully vaccinated and visiting a single household of family or friends who are not yet vaccinated, and are at risk for severe COVID-19 due to age (65 or older) or health conditions, such as cancer, diabetes, heart disease, sickle cell disease, or other specific conditions:

• All of you should wear well-fitted masks and stay six feet away from each other when indoors. If possible, hold the visit outdoors or in a well-ventilated space to reduce risk.

Mixing two or more households that have people who aren’t yet vaccinated raises the risk for getting the virus that causes COVID-19 for anyone who isn’t vaccinated.

Generally, the more closely people interact and the longer they spend with others, the higher the risk of getting or spreading the virus, according to the CDC.

When possible, everyone gathering for a visit can lower risk further by avoiding contact with people outside their household for 14 days before a visit, and/or by getting tested for the virus.

What if my partner or people in my household aren’t vaccinated?

You can do your part to help keep your partner or household members who have not yet been vaccinated safe. Although it may not be feasible to wear a mask or stay at a distance within the house, you can maintain these strict measures outside of the home. This will help to reduce your chance of exposure to the virus, and thus decrease the risk of passing the virus to your partner or household members. Your unvaccinated partner or housemates should abide by the same guidelines: wear a well-fitted mask, wash hands frequently, maintain physical distance, and avoid crowds in places outside of the home.

Can I travel for leisure or pleasure?

At this time you should avoid unnecessary travel, and only visit people nearby because cases of COVID-19 are still high. Traveling by air, bus, or train puts you in contact with many people and increases risk of transmission. The vaccines do not offer 100% protection. We must maintain caution, especially as we learn more about variants of concern and how much the vaccine protects against these strains.

And as stated before, you also can put others at risk and spread the virus, even if you are protected yourself.

What precautions should I continue taking? Is it true that people need to continue wearing masks in public?

Many more people need to be vaccinated before we achieve sufficient community immunity. Until that happens, you still can pass the virus to others, even if you are fully vaccinated. Therefore, to keep others safe and reduce the overall spread of the virus, you can do your part by wearing a well-fitted mask in public spaces, maintaining physical distance, washing hands frequently, and avoiding large crowds.

When can I go to a restaurant, concert, or sports event?

As noted, the larger the event or gathering, the more risk you take in exposing yourself to the virus and/or spreading the virus to others. Indoor dining at restaurants is lower-risk for vaccinated individuals, compared with attending a large indoor concert. Regardless of risk level, in any public setting, you can do your part by wearing a well-fitted mask, observing distancing, washing your hands, and avoiding crowds.

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Omega-3 fatty acids and the heart: New evidence, more questions

My patients commonly ask me whether they should try one supplement or another. Often my answer is equivocal, because for most supplements we just don’t have enough evidence to give a definite answer. This doesn’t mean that a particular patient couldn’t benefit from a specific supplement; it just means I don’t have standardized research to guide my recommendations. Sadly, this remains true of omega-3 fatty acid supplements. The results of studies looking at omega-3 supplements have been inconsistent, and have left both physicians and patients wondering what to do.

Omega-3 fatty acids show benefit in REDUCE-IT trial and win FDA approval

Two main omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are found mainly in fish and fish oil. Omega-3s from fish and fish oil have been recommended by the American Heart Association (AHA) for the past 20 years to reduce cardiovascular events, like heart attack or stroke, in people who already have cardiovascular disease (CVD). I have written about and been a strong advocate of getting omega-3s through diet, and sometimes through the use of supplements.

Over the past year I have prescribed an omega-3, sold under the brand name Vascepa, to my patients who are at high risk for CVD, based on evidence of cardiovascular benefits. Vascepa contains purified EPA, and its use is based on good clinical data from the REDUCE-IT trial. This study enrolled over 8,000 patients with elevated cardiovascular risk and high blood triglyceride levels. They assigned half of the study participants to receive 2 grams of Vascepa twice a day, and assigned the other participants a placebo (a pill filled with mineral oil). The results showed a significant benefit of Vascepa over the placebo. Vascepa reduced blood triglyceride levels, but more importantly, it reduced the number of heart attacks and strokes, the need for a heart stenting procedure to open clogged arteries, and death.

A subsequent meta-analysis, which included data from over 10 studies, found fish oil omega‐3 supplements lowered risk for heart attack and death from coronary heart disease.

In December 2020, the FDA approved the use of Vascepa to reduce the risk of cardiovascular events in certain patients with, or at high risk for, CVD.

STRENGTH trial casts some doubt on omega-3 benefits

But a recent study has raised some questions. The STRENGTH trial, published in JAMA, looked at a different formulation of omega-3 fish oil — a combination of EPA and DHA — to see if it would also reduce cardiovascular risk. This study enrolled over 13,000 patients who were randomized to receive either the EPA/DHA combination pill or the placebo (a pill filled with corn oil). The trial was terminated early due to an interim analysis revealing no difference between the two treatment groups.

We don’t know for certain why the REDUCE-IT trial showed a benefit from omega-3s while the STRENGTH trial did not. One possibility is that the different results are due to the different drugs studied. REDUCE-IT studied a purified formulation of high-dose EPA, which resulted in higher EPA levels. This was similar to the results of another trial, which also found that pure EPA reduced the risk of cardiac events. The STRENGTH trial tested a combination of EPA and DHA. No large study has ever evaluated the effects on cardiovascular outcomes of purified DHA alone, leaving us to wonder whether DHA might counteract the benefits of EPA.

Where do we stand?

Back to my patients who want to know if they should be taking an omega-3 supplement. With the availability of today’s data, I would recommend a pure EPA supplement, or one that contains more EPA than DHA. But don’t stop there. Eat a heart-healthy diet, get regular exercise, and pursue other lifestyle changes that have proven benefits for cardiovascular health. In the meantime, my colleagues and I wait for more definitive data on the utility of omega-3 fish oil, and who might benefit the most.

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Beyond CBD: Here come the other cannabinoids, but where’s the evidence?

In the span of a few years, the component of cannabis called CBD (cannabidiol) went from being a relatively obscure molecule to a healthcare fad that has swept the world, spawning billions in sales, millions of users, CBD workout clothing, pillowcases, hamburgers, ice cream — you name it. The concerns of such a rapid adoption are that enthusiasm might be soaring high above the actual science, and that there are safety issues, such as drug interactions, that are given short shrift in the enthusiasm to treat chronic pain, insomnia, anxiety, and many of the other conditions that CBD is believed to help alleviate.

Cannabis, however, consists of about 600 different molecules, some 140 of which are called cannabinoids because they work on our body’s endocannabinoid system — a vast system of chemical messengers and receptors that help control many of our most critical bodily systems such as appetite, inflammation, temperature, emotional processing, memory, and learning. It was only a matter of time until new cannabinoids were discovered and commercialized.

What are some of these newer cannabinoids, and what is the evidence they may help us?

Unfortunately, much of the data for these newly discovered compounds comes from animal studies, so it is going to take some time — and high-quality research — to determine if the benefits that have been found in animals will apply to humans.

CBG

CBG, or cannabigerol, is a nonintoxicating cannabinoid that is being marketed for the alleviation of anxiety, pain, infection, inflammation, nausea, and even the treatment of cancer. It has a wide variety of potential medical uses, but virtually all of the studies that have been done on it have been done in animals, so it is difficult to fully extrapolate to humans. Experiments in mice have shown that it can decrease inflammation associated with inflammatory bowel disease, and that it can slow the growth of colorectal cancer. In cells, it inhibits glioblastoma multiforme cells (the type of brain cancer that Senator John McCain suffered from).

CBG has also been shown to act as an antimicrobial against many different agents, including the difficult-to-treat MRSA bug that causes so many hospital-acquired infections. Additionally, CBG is an appetite stimulant, and it may help treat bladder contractions. Currently, one main danger in its use lies in the lack of regulation and standardization that accompanies the entire supplement industry in this country, so it isn’t always guaranteed that you are getting what you think you are getting — and this is true for all of the substances discussed in this post.

THCV

THCV, or tetrahydrocannabivarin, is potentially exciting because it may support efforts to treat our obesity and diabetes epidemics. There is robust animal data that it lowers fasting insulin levels, facilitates weight loss, and improves glycemic control. In a 2016 study published in Diabetes Care, THCV was shown to significantly improve fasting glucose, pancreatic beta cell function (the cells that make insulin and that ultimately fail in diabetes), as well as several other hormones associated with diabetes. In both animals and humans, it has been well tolerated without significant side effects. In places like Israel, where the study of cannabinoids is far more advanced than the United States, strains with high levels of cannabinoids such as THCV (and low levels of THC) are being cultivated so that they can be studied.

CBN

The cannabinoid CBN, or cannabinol, is present in trace amounts in the cannabis plant, but is mainly a byproduct of the degradation of THC. Marijuana that has been sitting around for too long has a reputation for becoming “sleepy old marijuana” — purportedly because of higher CBN concentrations in it, though there are other plausible explanations for this phenomenon. CBN is widely marketed for its sedative and sleep-inducing qualities, but if you review the literature, it is interesting to note that there is virtually no scientific evidence that CBN makes you sleepy, except for one study of rats that were already on barbiturates, and who slept longer when CBN was added. This isn’t to say that CBN doesn’t make people sleepy — as many people claim — just that it hasn’t been scientifically established yet.

Usually with claims about cannabinoids, there is some evidence, at least in animal studies, to back them. CBN does, however, have potential (though only in animal studies so far) to act as an appetite stimulant and an anti-inflammatory agent — both extremely important medical uses, if they pan out in humans. One recent study from Israel in humans demonstrated that strains of cannabis higher in CBN were associated with better symptom control of ADHD. We need more human studies before marketing claims about the benefits of CBN are supported by science.

Delta-8-THC

Delta-8-THC is found in trace quantities in cannabis, but can be distilled and synthesized from hemp. It is increasingly being marketed as medical marijuana with less of the high and less of the anxiety that can come with this high. Unlike the other compounds discussed here, Delta-8-THC is an intoxicating cannabinoid, but it has only a fraction of the high that THC causes — and much less of the accompanying anxiety and paranoia. It can alleviate many of the same symptoms that cannabis can, making it a potentially attractive medicine for people who want little to do with the high of cannabis. It is thought to be especially helpful for nausea and appetite stimulation. There is some evidence (albeit from a very small study of 10 children) that suggests delta-8-THC may be an effective option to prevent vomiting during chemotherapy treatments for cancer. While the claims for delta-8 are intriguing, there is a lack of good human studies to substantiate its efficacy or safety, so we need to take the marketing claims with a grain of salt.

There is renewed interest in cannabis research

As acceptance of medical cannabis is growing — currently, 94% of Americans support legal access to medical cannabis — the one thing that virtually everyone agrees on is the need for further research into cannabis and cannabinoids: their benefits, their harms, and the ways we can develop and safely use them to improve human health. We are in the midst of an incredibly exciting time, with new discoveries occurring daily in cannabinoid science, and I am eager to see what the future holds. However, just as we’ve learned from our experiences with CBD, we need to be patient and filter our enthusiasm through the calm lens of science. Most of all, we need to be smart consumers who can find the true benefits amidst the complexity of political agendas and marketing claims that seem to accompany all things related to cannabis.

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Zero weight loss from zero calorie drinks? Say it ain’t so

Are you trying to cut back on calories by making the switch from regular soda to diet soda? Do you prefer carbonated water with a bit of flavor, such as Hint or LaCroix? Or maybe you’ve purchased a carbonating device like SodaStream or Drinkmate?

Research suggests that none of these choices may actually help with weight loss. Worse, they might even lead to weight gain! The reason might surprise you. It sure surprised me.

The problem with regular sodas isn’t just the calories

If you’re drinking two 12-ounce cans of regular Coke each day, you could eliminate 280 “empty” (non-nutritive) calories by switching to a zero-calorie alternative. Over a month, that’s 8,400 fewer calories, enough to lose almost two and a half pounds. So, what’s the catch?

One worry is that artificially sweetened diet sodas may create a craving for sweet, high-calorie foods. So, even as calorie counts drops from zero-calorie sodas, consumption of other foods and drinks might add back even more. In rodent studies, at least one artificial sweetener (aspartame) has been found to damage a part of the brain that tells the animal when to stop eating.

And a number of studies in humans (such as this one and this one) have actually found a tendency toward weight gain among people drinking artificially sweetened beverages. But research has been mixed: other studies have found that artificially sweetened low-calorie beverages can help with weight loss.

One factor complicating the study of zero-calorie beverages and weight loss is called “reverse causation.” People at risk for obesity tend to choose these beverages, making it appear that these drinks are to blame.

Of course, there are other health concerns associated with artificial sweeteners, including a possible increase in the risk of certain cancers, cardiovascular disease, and kidney problems. The evidence for this isn’t strong enough to be sure, though.

Surely carbonated water with no artificial sweeteners is fine?

Drinks that contain carbonated water and no artificial sweeteners have long been considered safe bets when it comes to breaking the regular soda habit. With none of the sugar, calories, or artificial sweeteners, how can you go wrong?

But a 2017 study of humans and rats casts doubt on this approach, too.

First, the rats: For more than a year, male rats were given one of four drinks: water, a regular carbonated drink, a regular carbonated drink that had been allowed to go flat, or a diet carbonated drink. The regular carbonated beverages had sweetener that wasn’t artificial.

Here’s what the researchers found:

• The rats drinking a carbonated beverage (regular or diet) ate more food than rats drinking water or flat soda
• The rats drinking a carbonated beverage (regular or diet) gained weight faster than rats drinking water or flat soda
• The amount of ghrelin in the stomach tissue was higher after exposure to carbonated beverages compared with non-carbonated drinks. Ghrelin is a hormone that controls hunger.

And now, the humans: 20 male students drank five drinks, one at each sitting during a one-month period. The drinks included water, regular soda, regular soda that had gone flat, diet soda, or carbonated water. Soon after, their blood ghrelin levels were measured.

When students drank any carbonated beverage (regular soda, diet soda, or carbonated water), their ghrelin levels rose to higher levels than when they drank water or flat soda.

Although this study did not assess the students’ food intake or weight changes after drinking different types of beverages, the increased ghrelin levels after carbonated beverage consumption make it plausible that these drinks might lead to hunger, increased food consumption, and weight gain. And that’s cause for concern.

Why would drinking carbonated beverages encourage your body to release more ghrelin? The study authors speculate that cells in the stomach that are sensitive to pressure respond to the carbon dioxide in carbonated beverages by increasing ghrelin production.

What’s left to drink?

The short answer is easy: water. Unsweetened tea or fruit-infused water are also good alternatives.

It’s worth emphasizing that drinking an occasional regular soda or other carbonated beverage is not hazardous. The question is, what’s your default drink of choice — and what are its possible consequences?

The bottom line

While plain water might be best healthwise, for many it’s not the most appealing choice. If you prefer to drink soda every day, it makes sense to switch from regular to a zero-calorie alternative. A low-calorie carbonated beverage may still be a reasonable choice, as long as you keep an eye on the rest of your diet and your weight.

There’s a real possibility that carbonated beverages may have underappreciated negative effects on appetite and weight. Still, it would be premature to say that we should all give up carbonated beverages lest the obesity epidemic worsen.

Stay tuned for future research assessing the health effects of a range of low-calorie beverages. While it’s good to have choices, it’s also good to know the pros and cons of each one.

Follow me on Twitter @RobShmerling

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Returning to sports and physical activity after COVID-19: What parents need to know

While most children and teens who have COVID-19 recover completely, sometimes the virus can have lasting effects. One of those effects can be damage to the muscle of the heart — and if a damaged heart is stressed by exercise, it can lead to arrhythmias, heart failure, or even sudden death.

This appears to be rare. But given that we are literally learning as we go when it comes to COVID-19, it’s hard for us to know how rare — and just how risky exercise after testing positive for COVID-19 might be. To help doctors, coaches, gym teachers, parents, and caregivers make safe decisions, the American Academy of Pediatrics has published some guidance on returning to sports and physical activity after having COVID-19.

This is “interim guidance” — our current best guess about what to do, based on what we know so far. Unfortunately, there is much we don’t know, and can’t know until we have had more time to study the virus and watch what happens to patients as they recover over weeks, months, and years.

What’s important to know about returning to sports and physical activity?

Teens and young adults who play competitive sports are at highest risk for a heart problem. This is both because younger children appear to be less affected by COVID-19, and because older teens and young adults have harder workouts that are more likely to stress the muscle of the heart. Of course, nobody can say for certain that running around an elementary school playground is completely risk-free for a child who has had COVID-19.

The guidance for returning to physical activity depends on whether the case of COVID-19 was considered mild (including asymptomatic), moderate, or severe.

• Mild: fewer than four days of fever greater than 100.4, and less than one week of muscle aches, chills, or fatigue (this would include those with asymptomatic cases)
• Moderate: four or more days of fever greater than 100.4; a week or more of muscle aches, chills, or fatigue; or a hospital stay (not in the ICU) with no evidence of MIS-C. (MIS-C is the multisystem inflammatory syndrome that sometimes occurs with COVID-19.)
• Severe: any ICU stay and/or intubation, or evidence of MIS-C. During intubation, a tube is placed through the mouth into the airway and connected to a machine to help a child breathe.

What screening might be done after a child recovers from an asymptomatic to mild case of COVID-19?

It’s toughest to offer guidance for youths who have had mild or asymptomatic cases, as we truly have limited data on this group when it comes to the health of their hearts.

For these children, experts recommend that parents check in with the child’s primary care provider. Wait until the child has recovered from their illness (or at least 10 days after a positive test if a child is asymptomatic). They should be screened for any symptoms of heart problems, with the most worrisome being

• chest pain
• shortness of breath that is more than you’d expect after a bad cold
• palpitations that they have never had before
• dizziness or fainting.

A simple phone call to the doctor’s office may be sufficient following very mild or asymptomatic cases in children who aren’t serious athletes.

An in-person examination is a good idea for those whose cases were more borderline, or if there are any concerns at all, or if the child is a serious athlete.

If there are any worries based on the answers to questions or the physical examination, then an EKG and a referral to a cardiologist make sense.

If there aren’t any worries, then children can return to recreational physical activity as they feel able. Returning to competitive sports should be done gradually, watching for symptoms along the way. See the AAP guidance linked above for suggestions on how to do this.

What screening might be done after a child recovers from a moderate or severe case of COVID-19?

Any child who had a moderate illness should see their primary care provider to be screened for symptoms and examined. Schedule the visit at least 10 days after the child had a positive test for the virus, and has had no symptoms for at least 24 hours without taking any acetaminophen or ibuprofen.

If there are any questions or worries at all about symptoms or a finding on the physical examination, referral to a cardiologist for clearance and guidance about returning to physical activity is a good idea.

Children who have had severe illness absolutely need to see a cardiologist, and should be restricted from activity for a minimum of three to six months, only returning when a cardiologist says it’s okay.

Again, this is interim guidance that will evolve as we learn more about COVID-19 and its short- and long-term effects. If you have questions, talk to your doctor.

Follow me on Twitter @drClaire

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Numb from the news? Understanding why and what to do may help

In the spring of 2020, the pandemic catapulted many of us into shock and fear — our lives upended, our routines unmoored. Great uncertainty at the onset evolved into hope that, a year later, a semblance of normalcy might return. Yet not only do people continue to face uncertainty, but many of us have also reached a plateau of fatigue, resignation, and grief.

We are living through a time of widespread illness, social and political unrest, economic fractures, and broken safety nets. Whether each of us experiences the ravages of this time close to home or as part of a larger circle, the symptoms of collective trauma are widespread. Many of these symptoms — feeling overwhelmed, anxious, fatigued — may be familiar. One deserves special mention: numbness. As a psychiatrist who has considerable experience treating refugees suffering from trauma, and an author and teacher who works with collective trauma, we have learned a great deal about how numbness affects us all.

Newsfeeds: Friend or foe?

Compounding our challenges are our news viewing habits. During times of uncertainty, we are each, in our own way, experiencing vulnerability. Fears that had lain dormant for years may be activated, causing low-grade stress or full-blown anxiety. These fears are exacerbated by what might be called the “toxic trauma story” churned out by mainstream news channels.

The formula is simple: brutal facts associated with high emotion attract viewers. As the old adage says, “If it bleeds, it leads.” Negative news around vaccine reactions or political unrest provides the ultimate sensational content for viewers. But for most Americans, this daily onslaught of negativity exerts a toll on mind, body, and emotions.

Numbness is one possible response to trauma

When a situation is overwhelming, your body protects itself by entering a “fight, flight, or freeze” mode. Our responses to the pandemic and continuous uncertainty, fueled by doomscrolling and newsfeeds, range from hyperactivation (fight or flight) to numbness (freeze). While the three Fs refer to the body’s stress response in the moment, these reactions can continue long after exposure to trauma.

In medical terms, numbness occurs when nerves are damaged, leading to partial or total loss of sensation in the body. We can also describe numbness related to our psychological well-being: a lack of enthusiasm and interest in life, a sense of apathy and indifference. The spectrum ranges from mild apathy to disassociation to a heavy, weighty lethargy, which is often a symptom of severe depression. “Freeze” refers to a paralyzed or frozen state associated with post-traumatic stress disorder (PTSD) and major depression. We have each worked with thousands of people — some refugees, some not — who have experienced this level of trauma.

The numbness many people are experiencing and describing these days didn’t necessarily begin with the pandemic, nor is a toxic stream of trauma stories the only source feeding it. It may have been there for many years, only to be triggered by recent personal and societal challenges.

This numbness is not just a lack of feeling; its symptoms vary. You might feel a low level of anxiety operating in the background, much like an operating system running our computers silently. You may feel no emotion or a sense of frozenness during the day, followed at night by insomnia or nightmares. Some people who are refugees cannot watch the daily news, since it is a terrifying trigger that floods them with memories of their past traumas.

How does numbness affect us collectively?

Millions of people turn to their phones and devices for daily notifications of traumatic news. These instantaneous alerts offer little space for digestion and reflection. That harmful combination of speed and trauma can strike at our nervous systems, overwhelming us until we are too numb to comprehend the complex range of experiences flooding in over the last days, weeks, and years. What happens to us as a culture, grappling with this cumulative phenomenon?

Where collective trauma now exists, we need to seek ways to facilitate dialogue and restoration. The numbness following traumatization reduces our capacity to witness suffering. We lose our reflective capacity to be self-aware, which reduces empathy and compassion. Indifference and disconnection can contribute to further atrocities, fueling a feedback loop that makes new traumas more likely to occur.

Collective numbness can surface as epidemic substance misuse; food, sex, or entertainment addiction; media overuse; or in other ways. It reveals itself as a collective shutting-down to crisis, which can derail healing.

How can you counter numbness and feeling overwhelmed?

As individuals, we can spend more time practicing self-care, as outlined in the Harvard Program in Refugee Trauma toolkit. For example, take time to reflect on the resources and sources of support you have in your life. Spend quality time with family, and if possible, in nature. Set boundaries on news devices to give your nervous system a chance to relax. Turn off your notifications, leave your phone far from your bedroom at night, and consider periodic news fasts to give your system a full recharge.

Developing a mindfulness practice can help reduce stress, allowing people to digest and integrate hidden emotions or experiences buried under numbness. One option is a practice called 3-sync: imagine a journey of witnessing yourself, moving deliberately as you notice the state of your body first, then your mind, and finally, your emotions. Following this during meditation can help you become aware of imbalances within yourself, as well as areas of strength and vitality. Another practice, global social witnessing, is a conscious process of witnessing the news, and digesting it with our minds, bodies, and emotions fully present.

By working together to be with whatever is present, acknowledging and feeling our discomfort, resistance, and pain, we may move closer to integration and a sense of healing during this time of upheaval.

Follow us on Twitter @ThomasHuebl and @hprtcambridge

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Racial disparities and early-onset colorectal cancer: A call to action

Colorectal cancer (CRC) is the second leading cause of death from cancer in both men and women in the US. Thanks in large part to increased screening of those over age 50 in last decade, overall CRC rates have been falling among the general population. However, the incidence of CRC among younger individuals in the US is rising at an alarming rate. Over the past 20 years, the rate of CRC has increased by 2.2% per year in people under age 50. Hidden within these statistics are the significant disparities in CRC incidence and outcomes that exist for African Americans.

Compared to whites, African Americans have a 20% higher incidence of CRC. They are more likely to develop CRC at younger ages, be diagnosed further along in their illness, and are more likely to die of their disease. African Americans have the lowest five-year survival rate for CRC of any racial group in the US. Absolute rates of early-onset CRC, generally defined as CRC diagnosed before age 50 to 55, are higher among African Americans compared to whites. The recent deaths of Chadwick Boseman at age 43 and Natalie Desselle-Reid at age of 53 serve as tragic examples of the disproportionate impact of early-onset CRC among the African American community.

Inequities contribute to many factors that may increase risk for early-onset CRC

The reasons for this racial disparity in early-onset CRC are unclear. This is not surprising, given our overall lack of understanding of the factors driving the increased incidence of early-onset CRC across all races.

Some factors that have been linked with early-onset CRC include obesity, physical inactivity, and unhealthy dietary patterns. According to data from a National Institutes of Health/AARP survey, each of these risk factors may be more prevalent in African American communities, particularly those of low socioeconomic status. African Americans are also less likely to have access to health care. As a result, they may not be able to promptly seek medical care for symptoms associated with colorectal polyps or cancer. This, in turn, could delay detection of tumors, which could be cured by removal through colonoscopy or surgery if detected early enough. Finally, for reasons that are not entirely clear, once diagnosed, African Americans are less likely to receive chemotherapy or surgery compared to white patients.

Underlying these potential explanations are pervasive inequities based on socioeconomic status and systemic racism.

Biological features associated with disparities

African Americans are also more likely to be diagnosed with a CRC that originated in the right colon, rather than in the left colon or the rectum. As I noted in an earlier blog post, right-side colon cancers may be more difficult to detect, and they have a worse prognosis compared with left-side CRCs.

Recent studies suggest that differences in the epigenome of the right colon relative to the left colon among African Americans, compared with the pattern seen among whites, could explain racial differences in the site at which CRCs originate. (An epigenome consists of chemical compounds that attach to a person’s DNA and influence its expression.) Some data suggest that there may be variation in the molecular profile of tumors that develop in African Americans compared to whites, which may indicate that the pathways that initiate or encourage progression of cancers may differ by race. Differences in the gut microbiome have been increasingly implicated in the rising incidence of early-onset CRC, and may also contribute to higher CRC incidence in African Americans.

Updated screening guidelines may leave African Americans behind

Until recently, most expert bodies have not generally recommended CRC screening of average-risk individuals younger than age 50, with only the American College of Gastroenterology and American Society for Gastrointestinal Endoscopy recommending earlier screening among African Americans. However, in 2018 the American Cancer Society (ACS) modified their guidelines to recommend beginning screening at age 45 for individuals of all races. In October 2020, the US Preventive Services Task Force released draft recommendations that were aligned with the ACS guidelines.

These newer guidelines are expected to have an impact in reducing early-onset CRC incidence. However, significant concerns remain about persistent disparities between African Americans and whites in access to, and participation in, CRC screening. Furthermore, rates of early-onset CRC have risen sharply among individuals between the ages of 20 and 45; the revised guidelines will not apply to people in this age group.

Improvements in racial inequities and systemic racism needed, along with medical advances, to close gaps in early-onset CRC

Given the increasing attention on early-onset CRC, and the longstanding problem of racial disparities in CRC incidence and outcomes, there will hopefully be significant progress in the coming years in addressing these converging public health priorities. This should include continued research into the causes of early-onset CRC, improving early detection through screening and prevention, and ensuring access to effective treatment. However, because the root cause of many CRC disparities lies in socioeconomic and racial inequities, there remains a high unmet need for the medical and public health communities to address these broader issues.

Follow me on Twitter @AndyChanMD.

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4 essential nutrients — are you getting enough?

The newest dietary guidelines for Americans say that many Americans don’t get enough of four vital nutrients. Over time, a shortfall of these nutrients may affect different aspects of your health, from teeth and bones to your heart, gut, muscles, blood pressure, weight, and more.

What is a nutritional shortfall?

Nutritional advice can be confusing. Eat more of this, less of that. Make sure you get enough — but not too much. It’s no wonder many people have so-called nutritional shortfalls, where their diet lacks sufficient essential nutrients.

So, which nutrients do you really need and how much? And what key nutrients do most people lack?

The Dietary Guidelines for Americans 2020–2025 offers some insight. Updated every five years by the US Department of Health and Human Services and the USDA, the report found many Americans are lacking in four vital nutrients: calcium, potassium, dietary fiber, and vitamin D.

According to the guidelines, these four are “considered dietary components of public health concern for the general US population.” That’s government talk for: these nutrients help you stay healthy, and you probably should eat more of them.

Four nutrients you need — and where to find them

Here is a closer look at these four nutrients, how much you need, and some of the best sources, per the recent guidelines.

The specific daily amounts of each nutrient are based on the recommended daily calorie intake for adult men and women who don’t need to lose or gain weight. For example:

• Women ages 19 to 50 should aim for 1,800 to 2,000 daily calories, and women ages 51 and older 1,600 calories
• Men ages 19 to 50 should aim for 2,200 to 2,400 calories, and those ages 51 and older 2,000 calories.

Of course, specific calorie needs depend on the individual, but these figures offer a reasonable estimate.

Food is always the preferred source, as it gives you other essential vitamins and minerals needed for optimal health. However, if you have trouble eating the suggested foods, check with your doctor about whether supplements are an option.

Keep in mind that the listed portions for these foods are not recommended serving sizes. But they should help you get more of the fab four in your daily diet. (See this DGA resource page for a more detailed list of foods containing these nutrients.)

Calcium

How much: women: 1,000 to 1,200 milligrams (mg); men: 1,000 mg

Where to find it? 8 ounces of plain, nonfat yogurt: 488 mg; 1 cup low-fat or soy milk: 301 to 305 mg; 1 cup cooked spinach: 245 mg; 1/2 cup tofu: 434 mg.

Potassium

How much: women: 2,600 mg; men: 3,400 mg

Where to find it? 1 cup cooked lima beans: 969 mg; 1 medium baked potato with skin: 926 mg; 1 cup cooked acorn squash: 896 mg; 1 medium banana: 451 mg; 3 ounces skipjack tuna: 444 mg.

Dietary fiber

How much? women 22 to 28 mg; men: 28 to 34 mg

Where to find it? 1 cup shredded wheat cereal: 6.2 mg; 3 cups popcorn: 5.8 mg; 1/2 cup navy or white cooked beans: 9.3 to 9.6 mg; 1 cup berries (raspberries, blackberries, blueberries): 6.2 mg to 8 mg.

Vitamin D

How much? women and men: 600 international units (IU)

Where to find it? 3 ounces salmon: 383 to 570 IU; 3 ounces canned light tuna: 231 IU; 1 cup unsweetened soy milk: 119 IU; 1 cup 1% milk: 117 IU; 8 ounces nonfat plain yogurt: 116 IU; 1 cup 100% fortified orange juice: 100 IU.

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Agoraphobia: Has COVID fueled this anxiety disorder?

The past year has been hard on most of us. Who hasn’t felt anxious? Who hasn’t wanted to retreat from the world at times? Staying home when possible as COVID-19 rates climbed felt safer — and in many places was required by lockdown rules. Yet, could growing accustomed to feeling less safe in public spaces seed, or feed, the anxiety disorder known as agoraphobia? If you’re wondering whether the discomfort you experience is normal or has crossed a line, read on.

What is agoraphobia?

People with agoraphobia become anxious in places where they feel helpless, out of control, stuck, or judged. Someone who has agoraphobia might avoid places where they might be trapped (such as an office meeting) or put on the spot and judged — perhaps during a conversation at a party. They also may avoid situations or places that feel out of control, such as a trip with other people where they don’t control the schedule and timing, or an open, public space like a park. As a result, people who have agoraphobia often fear leaving their homes.

In the US, about 2% of adults and teens have agoraphobia, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Roughly a third to half of people with agoraphobia have had panic attacks prior to diagnosis.

What are the symptoms of agoraphobia?

A feared situation — or even the thought of such a situation — triggers panic or panic attacks, often when a person is outside of their home. A panic attack is an intense bout of anxiety that is experienced physically through a racing heart, shortness of breath, chest pain, sweating, and dizziness. Worrying about having another panic attack, especially in front of other people, makes agoraphobia even worse.

So, where does the pandemic come in?

Agoraphobia is an anxiety disorder that makes people fear and avoid situations where they feel embarrassed, helpless, or threatened. Their fear of a situation is out of proportion to its true level of risk. Yet fearing public spaces as COVID-19 continues to spread is a normal response to such a threatening event.

According to an American Psychological Association (APA) report, Americans are experiencing a nationwide mental health crisis that could have repercussions for years to come. Their survey shows upticks in mental health issues like stress and anxiety since the pandemic began. However, it is unclear how this relates to agoraphobia. Because crowded spaces are potentially dangerous right now, avoiding them is a natural response, rather than a sign of a disorder. It’s normal to have some fear of public spaces now, because the threat of danger is real.

When do anxious feelings move beyond normal?

If you worry that you may be struggling with agoraphobia or another anxiety disorder, ask yourself these questions:

• Is my response in line with the potential threat of danger?
• Are my loved ones concerned about my level of worry and avoidance?
• Am I following the CDC guidelines to avoid getting or spreading COVID, such as practicing social distancing with people outside of my household, wearing a mask, and handwashing? Or am I avoiding more people and situations than necessary?

If you are concerned about your anxiety, consult with a mental health professional. You can schedule a telemedicine visit to get help assessing whether your fear and avoidance is healthy or problematic. Contact your health plan and ask for a list of behavioral health clinicians.

How is agoraphobia typically treated?

Agoraphobia is often treated with cognitive behavioral therapy (CBT), which helps people understand connections between thoughts, feelings, and actions. Typically, a mental health or behavioral health specialist helps you

• understand the triggers of anxiety and agoraphobia
• understand your internal thoughts about the situation that is creating the fear
• build skills to better tolerate anxiety
• begin to slowly and safely face the situation that creates anxiety and subsequent avoidance. This is generally done by practicing facing the feared situation in a controlled environment.

Medicine, like antidepressants and anti-anxiety medications, is sometimes used along with CBT.

How to get help

Getting over agoraphobia without treatment is difficult (only 10% of people are successful).

The SAMHSA National Helpline (800-662-4357) or website may be able to refer you to mental health clinicians in your state who treat anxiety. Some may accept Medicare or Medicaid, or charge lower fees depending on your income. The National Alliance on Mental Illness also offers helpful resources on their website and through their volunteer HelpLine (800-950-NAMI (6264), or info@nami.org).

Agoraphobia is an anxiety disorder that can seriously limit quality of life, because those who struggle with it avoid many events and social situations. Although it usually will not go away on its own, therapy and appropriate medications can help people address the anxiety and live life fully.

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But I don’t feel like exercising…

Not long after the first fitness magazine was published, a list probably followed soon after, ranking the best fitness equipment. This tradition has continued, with the implicit message: use this and exercise will be yours.

And that’s part of the problem, says Dr. Daniel E. Lieberman, a professor of biological sciences and human evolutionary biology at Harvard University. There isn’t one “best” anything to achieve fitness. Besides, people already know. They’ve heard the federal recommendation of 150 minutes of moderate exercise a week. They understand that exercise is good for them.

Knowledge about exercise still doesn’t motivate

Before you can answer why, it helps to look at history. Before the Industrial Revolution, people fetched water and walked up stairs because they had to. But then technology, like elevators and cars, made life and work easier. Exercise has become something that people have to carve out time for and want to do. Not surprisingly, they usually don’t. “It’s a fundamental instinct to avoid physical activity when it’s neither necessary nor rewarding,” he says.

It would seem like being healthy would qualify as necessary, but a doctor’s prescription to exercise “can make it like taking cod liver oil,” Lieberman says. “Sometimes it works, but more often than not, it doesn’t.” And it’s still coming across as an order, usually tied to losing weight or avoiding disease, and “not having a heart attack in five years is not an immediate reward,” says Dr. Beth Frates, assistant professor of physical medicine and rehabilitation at Harvard Medical School.

Frates adds that people might not want to exercise because it’s never been enjoyable. Most of us probably have memories of gym class, not being picked for a team, or being in a fitness center that’s filled with in-shape people. As she says, “The majority don’t feel excited. However, coaching people in an empowering and motivating way can work much better than ordering someone to exercise. Helping people experience and enjoy the release of endorphins and the increase in dopamine as well as serotonin that accompany exercise is key,”

An overarching obstacle is that exercise tends to get packaged as only counting if it includes certain clothes, gadgets, trainers, or even a gym. Those can help, but they’re not required, and, if you’re older or don’t have access to or the money for such things, people can feel that exercise isn’t for them.

But it can be. Lieberman and Frates say it starts with an expanded definition of what counts as exercise, and an injection of what’s rarely used to describe exercise, but is certainly allowed: namely, fun.

Crafting your plan

There’s no single way to exercise, but these steps can help you figure out what works for you.

Make it personal. Some people need the gym because it offers programs and defines “their workout,” but the essential component of exercise is elevating your heart rate, and to accomplish that there are almost limitless options. “It’s not gym or jog,” Frates says.

She adds that if you’re stumped, it helps to think about what you’ve enjoyed in the past, even as a kid. It might lead you to getting a Hula Hoop — a solid workout and good laugh — but it also could make you realize that the possibilities are closer than you imagined. People never refer to dancing, playing soccer, or going for a walk with friends as exercise, but they all can qualify, Lieberman says.

Start small. Time is a common excuse, and 150 minutes a week feels like a big number. Breaking it down to 21 minutes a day makes it less so, but if you do too much too soon you risk injury, and that’s a further negative connotation and disincentive. While you’ll want to get clearance from your primary care physician, especially if you’ve been inactive, it’s reasonable to begin at five minutes, twice a day, three days a week, and slowly ramp up. “The goal is to sit less and move more,” Frates says. “Some is better than none.”

Remove the hurdles. Sometimes inertia is hard to overcome because you don’t know of a good walking route in your neighborhood, or you don’t have sneakers suitable for walking. Your first “workouts” can be getting what you need, and after that you don’t have to leave home. It might be sitting on a stability ball as your office desk chair, or using a portable pedaler while you sit and watch television or read. It’s all about forward momentum. “Start where you’re ready to start,” Frates says.

Increase the chatter. Lieberman says that exercising with others is key. “We’re social creatures,” he says. “It’s more fun to go to the movies with other people.” When you’re part of a group or even with one other person, there’s a tacit contract and subtle peer pressure: I’ll show up because you’re showing up, and we can referee each other. More than that, you can talk. If it’s walking, no one is thinking about the time or distance. If it’s dancing, there’s also music and you can do it over Zoom. Whatever you choose, you’re more likely to stick with it. “It’s making the process joyful,” Frates says. “Fear is not a substantial motivator, but laughter, fun, and love are.”

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You got the COVID-19 vaccine? I have vaccine envy

I admit it: I have vaccine envy. It’s that feeling of jealousy, disappointment, or resentment you feel when someone else gets the vaccine for COVID-19 — and you can’t.

I’m not proud of it. We should all be celebrating the astounding speed with which multiple effective and safe COVID-19 vaccines were developed. Millions of people are receiving them daily, bringing the increasingly real possibility of herd immunity closer day by day.

So, I should just be patient, right? It’s not easy.

Vaccine envy is inevitable

Current evidence suggests vaccination could save your life and those around you while helping daily life achieve a semblance of normalcy. And while we can reduce the risk of becoming infected without the vaccine (for example, through physical distancing and face coverings), there are plenty of reports of people “doing everything right” and still getting infected. So, it’s good to know people are getting vaccinated.

But it can be tough to see your friends, family, or coworkers beaming up at you in emails or social media posts, holding a vaccination card or flaunting a band-aid on their upper arm.

The vaccine rollout is testing our patience

It’s hard enough to tolerate the way this pandemic has upended our lives. Every week, thousands of people continue to become sick and die. But it’s harder still to know there are highly effective vaccines that only some of us can get. For those who want a vaccine, yet aren’t eligible or cannot get a rare appointment, each passing day is another day facing unseen and uncertain risk. So it’s understandable that many people are running out of patience.

The vaccine rollout is testing our sense of fairness

When the first vaccines were approved for emergency use, there were too few doses available for the entire US population. So, the CDC created detailed recommendations to set priorities for who should get the vaccinations first, by considering groups most at risk for illness and death. Healthcare workers and residents of long-term facilities topped the list. Frontline essential workers and the elderly were next, followed by those with conditions linked to more severe COVID-19. Farther down the list is everyone else.

Unfortunately, the subsequent rollout of the COVID-19 vaccines was confusing, unpredictable, and in many cases unfair. For example:

• Eligibility varies widely from state to state because each state created its own priority lists. For example, some states prioritized people who received cancer treatment within 30 days; others prioritized anyone with a cancer diagnosis, even if it was years ago and now in remission. In some states, teachers could receive vaccines in January; in others, they’ve just become eligible.
• Some health issues that could increase COVID-19-related risk, such as certain neurologic or autoimmune diseases, do not count as a “comorbid condition” that moves up vaccine eligibility.
• Scheduling vaccinations has been difficult in many states. Navigating online appointment systems has been impossible for some older adults, people lacking time or resources, and others.
• Vaccine shipments reaching vaccination centers have fluctuated, making it impossible to predict whether there would be enough to provide to eligible recipients.
• Verification of age or health conditions varies widely. Some states rely on the honor system while others require documentation.

So, even within similar groups of people, these factors mean that some already have the vaccine and some are still waiting. That doesn’t just seem unfair — it is unfair.

Who gets the leftovers?

“Leftover” doses of vaccine allow some people to get vaccinated before they are eligible. Once an mRNA vaccine thaws to room temperature, it must be administered within a few hours or thrown out. Because each vial holds multiple doses, any left over may be offered to anyone, even those not yet on the priority list, to avoid wasting them. This has led to swarms of people — called “vaccine chasers” — flocking to wherever there are reports of leftover vaccines.

Social media has helped enable this. Connections matter, too. Ideally, those in charge of vaccine administration would keep a backup list of eligible recipients who could come on short notice to receive leftover vaccines. But such systems require upkeep and resources that aren’t widely available.

The fact that people can jump the line raises questions of fairness.

The vaccine rollout is testing our ethics

More questionable than accepting leftover vaccine doses that might otherwise be wasted are efforts to game the vaccine eligibility system. For example, there have been reports of

• people traveling to a place where the vaccine eligibility rules are more favorable. Known as vaccine tourism, this behavior ignores the fact that the number of doses allotted to each location is based on and intended for its population. Even vaccine centers specifically established in underserved communities note that people are traveling there from more affluent neighborhoods.
• people taking advantage of the honor system. Some have even falsely stated that they were healthcare workers.
• wealthy donors receiving early access to vaccinations at a Florida nursing home
• people in California sharing information that allegedly allowed hundreds who work in Hollywood or for the media to secure appointments intended for essential workers holding certain jobs.

Ethically questionable acts like these may worsen existing health disparities suffered by minority groups who are already disproportionately affected by the pandemic. The economically disadvantaged are less likely to have the time, resources, or connections to get around the eligibility rules, compared with those with more privilege.

The bottom line

The COVID-19 vaccination eligibility rules have put many of us in a difficult spot: hoping to get a vaccine as soon as possible, but having to wait as others get it much sooner while grinding our teeth over people who seem to be cutting in line. But instead of jumping the line as well, we should speak out against rules that seem unfair, try hard to be patient and understanding until our turn comes, and continue to take measure to reduce our risk — including wearing masks (which is no longer required in some states).

Within a few months, everyone who wants a vaccination may be eligible to get one. Meanwhile, if you’re experiencing vaccine envy, welcome to the club.

Postscript: Soon after writing this blog post, I became eligible for the COVID-19 vaccine and have received my first dose. I hope widespread vaccination soon eliminates vaccine envy for everyone.

Follow me on Twitter @RobShmerling

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Glaucoma: What’s new and what do I need to know?

Glaucoma is the leading cause of permanent blindness worldwide, and the second leading cause of permanent blindness in the United States. An estimated three million people in the United States have glaucoma, a number that is expected to increase to 6.3 million in the next 30 years. Although glaucoma is more common in adults older than 60, it can develop at any age. While there is currently no cure for glaucoma, vision loss can be slowed or stopped if the disease is diagnosed and treated early.

What is glaucoma?

Glaucoma is a group of disorders that damage the optic nerve of the eye, which carries visual signals from the retina to the brain, allowing us to see. In glaucoma, the optic nerve is slowly damaged, leading to gradual loss of vision and permanent blindness. Because the damage occurs slowly, it is often without symptoms and goes unnoticed until it is too late. As it progresses, glaucoma can lead to poor quality of life, increased risk of falls, decreased mobility, and difficulty with driving.

Glaucoma is often associated with increased pressure inside the eye. Healthy eyes produce fluid known as the aqueous, which flows through and exits the eye. In glaucoma, this process does not work properly, resulting in increased eye pressure and damage to the optic nerve. The two main types of glaucoma — open-angle glaucoma and angle-closure glaucoma — are determined by the structure of the drainage pathway in the front of the eye (known as the angle), through which aqueous fluid flows.

In open-angle glaucoma, the angle appears open, but a number of factors — including drainage problems — result in poor pressure regulation. This form of glaucoma can occur at both high and normal eye pressures (normal-tension glaucoma). Both subtypes can lead to vision loss and damage to the optic nerve.

In angle-closure glaucoma the angle is narrow, and the resulting structural problems can lead to an abrupt closure of the drainage pathway, leading to a sudden increase in eye pressure. This condition is known as acute angle closure. Although relatively rare, acute angle-closure glaucoma is an ophthalmological emergency, and requires immediate treatment with medication, laser, or surgery, as it can lead to rapid and irreversible blindness. Angle-closure glaucoma also exists in a chronic form where the increase in eye pressure occurs more slowly, often without symptoms, but still requires evaluation and treatment.

Who is at risk for developing glaucoma?

Glaucoma is a complex disease, and while many associated genes have been identified, the underlying causes are still unclear.

However, a number of important risk factors have been identified, which include

• age older than 60 (40 for African Americans)
• a first-degree relative with glaucoma
• African American or Hispanic descent
• East and Southeast Asian descent (for angle-closure glaucoma)
• history of eye trauma or multiple eye surgeries
• chronic eye conditions, such as diabetic eye disease
• highly near-sighted or far-sighted
• use of steroid medications.

What are the symptoms of glaucoma?

Most people with glaucoma, particularly those with open-angle glaucoma or normal-tension glaucoma, may have no or very minimal symptoms for years. It is probably not surprising that an estimated 50% of glaucoma cases are undiagnosed, emphasizing the need for regular eye examinations, beginning at age 40. An eye care professional will be able to detect signs of glaucoma before you can, and timely intervention is key to preventing disease progression and vision loss.

Early signs of glaucoma include difficulty with low contrast, and some loss of peripheral vision. In more advanced stages, patients develop loss of their visual field, or blind spots, that ultimately progress to central vision loss.

Acute angle-closure glaucoma causes symptoms of pain, blurred vision, and nausea, and is a medical emergency.

What treatment options are available?

Although there is currently no cure for glaucoma, prompt treatment can help slow or stop the progression of vision loss. Depending on many factors, including your age and the type and severity of your glaucoma, treatment may include medications and/or surgery directed at lowering eye pressure.

Medications include pressure-lowering eye drops that work to increase fluid drainage or decrease fluid production. Laser is sometimes used to increase drainage (in the angle) or to make an opening in the iris, or colored part of the eye, in the case of angle-closure glaucoma. Various surgical techniques may be used to create an alternate fluid drainage pathway in the eye, so-called filtering surgery and tube-shunt surgery. Recent surgical innovations called minimally invasive glaucoma surgery, or MIGS, increase fluid drainage using implantable microscopic-sized stents and shunts.

The future of glaucoma care

Research in glaucoma continues to improve our understanding of the causes of disease and develop more targeted and personalized treatments. There are subtypes of glaucoma, beyond the main categories described here, that many believe will benefit from different treatments. In the future, genetic testing may play a role in estimating individual risk for developing glaucoma over time. Additionally, treatments to stop loss of nerve cells (of the retina and optic nerve), called neuroprotection, show promise. Researchers are studying new drugs, drug delivery systems, and innovations to make surgery more safe and effective.

Early detection is key

If you are worried about glaucoma, and especially if you have a family history, the best approach is to visit your eye doctor regularly. Every adult should have a baseline eye exam at age 40, even if your vision is normal. Vision loss from glaucoma can be minimized with treatment, so early detection is key.

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