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  • Microplastics a growing challenge to health and the environment

    Microplastics a growing challenge to health and the environment


    Home / News / Microplastics a growing challenge to health and the environment
    Microplastics that cannot be recycled
    iStock/Svetlozar Hristov

    January 2, 2025 – Over the past few months, Harvard Chan faculty have been sharing evidence-based recommendations on urgent public health issues facing the next U.S. administration. Shruthi Mahalingaiah, an assistant professor of environmental, reproductive, and women’s health, offered her thoughts on the challenges posed by microplastics and the need for more public awareness about the surprising sources of a stealthy and growing hazard that demands multifaceted and creative solutions.

    Q: Why are microplastics a pressing public health issue?

    A: For a long time, oceanographers and marine biologists have focused on the threat to oceanic life for good reason. We have a floating garbage patch of plastic halfway between Hawaii and California that covers an area that is twice the size of Texas. And that is just the largest of five offshore plastic accumulation zones in the world’s oceans. The terrible impact on marine and wildlife species is clear.

    What people may not realize is that microplastics are also a pressing human health issue. These plastics are showing up everywhere, including throughout our bodies—and even within the human reproductive system, not only in placentas but also in testes and semen. What is worse, we don’t know what the accumulation of these plastics in our bodies might mean for us. Research points to potentially serious issues, including vascular disease, cancers, respiratory disorders, inflammatory bowel disease, as well as dizziness and neurological symptoms. We have much more to learn. We know microplastics and their impacts vary based on composition, size, and surface area. The smaller the particle, the deeper it can go into the body.

    There are many important questions to answer. For instance, in the human system, how do the chemical properties of the nanoparticles within the microplastics interact with nutrients and normal repair processes that prevent disease and slow aging? Is the way we produce and recycle plastic helping—or are these processes increasing unsafe exposures? It’s essential that we ask these types of questions and do the research to find out.

    Q: What are the biggest challenges facing the next administration around microplastics?

    A: It will be challenging to correct the deeply entrenched idea that consumer diligence in recycling plastics can or could ever solve the plastic waste and pollution crisis. The reality is that only about 9% of the world’s plastic is recycled—it’s often not economically or technically possible to recycle the rest and the vast majority of plastics end up in landfills or get incinerated or dumped into the environment.

    It is encouraging that the California attorney general has filed a lawsuit against ExxonMobil, the world’s largest producer of polymers, which are materials used to create single-use plastics, including plastic utensils, drink bottles, and packaging. The lawsuit alleges that the company for decades has used marketing campaigns to create a “myth” around the impact of recycling, leading consumers to buy more single-use plastic than people would if they knew most plastic never goes away.

    To make real impact, we need to be more strategic. In 2022, member states in the United Nations endorsed a resolution to end plastic pollution and forge an international legally binding agreement by 2024. It focuses on moving government and businesses away from single-use plastics. In late November, the fifth session of the negotiating committee to develop that treaty, which includes about 175 nations, met in South Korea. I hope a treaty will be adopted soon.

    It’s important that we expand both the public conversation as well as scientific research to investigate all sources of microplastics. For instance, a surprising source of microplastics is wear and tear on tires. When you drive your car, how fast you go and how often you accelerate and decelerate ultimately makes an impact. Research shows that tire wear-and-tear contributes up to 10% of the plastics that end up in our oceans and enter our food chain—an issue that requires both our awareness and creative action—including carpooling, using public transportation, increasing walking to close by areas, and so on.

    The challenges ahead are multifaceted. We have to understand all the sources and the complex ecosystem of microplastics for our mitigation efforts to work. We have to understand the full scope of the health impacts of microplastics. And as we work to address the problem, we have to take care not to introduce another threat, a different downstream effect created by substituting a microplastic with something that ultimately also poses health risks—so we can’t have blinders on, we must always look at the big picture in order to mitigate wisely.

    Q: What are your top two to three recommendations for policies to address microplastics?

    A: It’s important for relevant industries to consider the concept, “First, do no harm.” We need the wide range of industries that produce plastics as waste to take responsibility and develop creative solutions to shift away from the use of plastics.

    For instance, the medical-industrial complex uses a lot of single-use plastic. As a physician, I know that routine surgeries generate a bag or more of plastic trash and time-intensive surgeries yield up to six bags. And when harm is noted, as is the case with microplastics, we owe it to our patients, community, ecosystem, and to planetary health to move to ameliorate the impact. We need a wave of creative solutions across the medical-industrial complex. For example, we can create greener labs by adopting sustainable practices that minimize plastic use. All of us must start somewhere and act.

    And we must individually work to reduce microplastics in ways that extend far beyond recycling. We must be aware that microplastics are all around us, that tiny fragments of plastics exist in car tires, clothing, bedding, and all kinds of textiles, including the microplastics stripped off our clothing by friction and turbulence in the washing machine that end up in our wastewater. One solution to the latter example involves installing a filter on your washing machine to stop microfiber pollution.

    Q: What’s the evidence supporting these recommendations?

    A: There is a lot of evidence that single-use plastic is a problem and, as mentioned earlier, only 9% of plastic gets recycled.

    We know that people are consuming and breathing a lot of plastic. One analysis shows that Americans ingest and inhale up to 121,000 microplastic particles every year, and people who drink bottled water may be ingesting an additional 90,000 microplastics per year. Put another way, scientific research shows we probably ingest the weight of a plastic credit card every week without realizing it.

    I highly recommend a book by science journalist Matt Simon, A Poison Like No Other, which details a lot of the scientific research about the ubiquity of microplastics and their ability to penetrate into so many things, including our food chains and our bodies.

    Q: What do you hope could be accomplished in this field in the next four years?

    A: My big hope is that we get rid of single-use plastic. I want to see innovation in packaging, food storage, and especially in the medical sector where we should be rethinking single-use items and moving toward the use of sterilization of reusable equipment. Overall, I hope to see major systems across diverse sectors re-engineered in innovative ways, with the urgent reduction in microplastics a top priority.

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  • The Best Alternative to Knee Replacement for Osteoarthritis 

    The Best Alternative to Knee Replacement for Osteoarthritis 

    Is there a non-surgical alternative to knee replacement surgery that treats the cause and offers only beneficial side effects? 

    The largest study in history on the health effects of being overweight, analyzing data from more than 50 million people from nearly 200 countries, found that excess body weight accounts for the premature deaths of about four million people every year. Most of these deaths are from heart disease, but the researchers “found convincing or probable evidence” linking obesity to 20 different disorders—a veritable alphabet soup of potential health concerns.

    In the ABCs of the health consequences of obesity, A is for arthritis. Obesity can make rheumatoid arthritis worse and increase the risk of another inflammatory joint disease—gout, the so-called disease of kings. The most common joint disease in the world, though, is osteoarthritis, and obesity may be its “main modifiable risk factor.” 

    Osteoarthritis develops when the cartilage that lines and cushions our joints breaks down faster than our body can build it back up. Our knee is the most commonly affected joint, leading to the assumption that the association with obesity was simply due to the excess wear and tear from the added load on the joints. But non-weight-bearing joints, like our hands and wrists, can also be affected, suggesting the link isn’t “purely mechanical.” Obesity-related dyslipidemia may play a role, with elevations in the amounts of triglycerides, fat, and cholesterol in the blood aggravating inflammation in the joints, just like cholesterol can exacerbate the inflammation in our artery walls.

    Osteoarthritis sufferers not only have higher cholesterol levels in the blood, but they also have them within their joints, as you can see below and at 1:52 in my video The Best Knee Replacement Alternative for Osteoarthritis Treatment, in aspirated joint fluid and also found in the cartilage itself.

    When cholesterol is dripped onto human cartilage in a petri dish, the inflammatory degeneration worsens, which helps explain why the higher our cholesterol, the worse our disease, as shown below and at 2:05. 

    Cholesterol-lowering statin drugs may help prevent and also treat osteoarthritis, as can a cholesterol-lowering diet. In fact, a healthy enough plant-based diet may offer the best of both worlds, dropping cholesterol as much as a starting dose of a statin drug—within a single week—and having only good side effects, such as lowering blood pressure and facilitating weight loss. 

    Even losing only about a pound a year for a decade may decrease the odds of developing osteoarthritis by more than 50 percent. Weight reduction may even obviate the need for knee replacement surgery. Osteoarthritis sufferers with obesity who were randomized to lose weight improved their knee function as much as those undergoing surgery—and did so within just eight weeks. The researchers concluded that losing 20 pounds of fat “might be regarded as an alternative to knee replacement.”

    Isn’t it easier to get your knees replaced than lose 20 pounds, though? Rarely discussed is the fact that nearly 1 in 200 knee replacement patients lose their lives within 90 days of surgery. Given the extreme popularity of this surgery—about 700,000 are performed each year in the United States—an orthopedics journal editor suggested that “people considering this operation are inadequately attuned to the possibility that it may kill them.” Arguably, that’s the single most salient fact to share with a patient who is considering the operation. Responding to the question of whether patients should be told about the chance the operation may kill them, an orthopedic surgeon said: “To me, the real question is whether this knowledge will help the patient. Will it add to the anxiety of the already anxious patient, perhaps to the point of denying that patient a helpful operation? Or will this knowledge motivate a less-handicapped patient to stick to a diet and physical activity regime? Ultimately, then, the question boils down to the surgeon’s judgment.”

    Even among the vast majority who survive the surgery, approximately one in five knee replacement patients describe being unsatisfied with the outcome. Weight loss with a healthy diet, on the other hand, may offer a nonsurgical alternative that treats the cause and has only beneficial side effects.

    I continue the alphabet of obesity with the next few videos in the related posts below.

    You may be interested in my book on weight loss, How Not to Diet, and its companion, The How Not to Diet Cookbook, which is full of health-promoting, Green-Light recipes. Request them from your local library.

    For more on joint health, visit the topic page. 



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  • Alumni News: Winter 2024 | Harvard T.H. Chan School of Public Health

    Alumni News: Winter 2024 | Harvard T.H. Chan School of Public Health

    Marty Markay

    Harvard Chan alum Marty Makary chosen to lead FDA

    Martin “Marty” Makary, MPH ’98, will be nominated by President-elect Donald Trump to be commissioner of the Food and Drug Administration. If confirmed by the Senate, Makary would lead the agency responsible for regulating the nation’s food supply, vaccines, medicines and medical devices, cosmetics, tobacco, and biologics. Makary is a physician who specializes in surgical oncology and currently serves as chief of islet transplant surgery at the Johns Hopkins School of Medicine. He’s also a member of the National Academy of Medicine; a former leader of the World Health Organization Patient Safety Program; a medical and health policy researcher who has published more than 250 peer-reviewed articles; and an author who has written three New York Times best-selling books on health care. Read more

    Alumni win re-election to U.S., Iowa House seats

    Two alumni were re-elected to their seats in November: U.S. Rep. Raul Ruiz, MPH’07, of California’s District 25 and State Rep. Megan Srinivas, MPH ’15, of Iowa’s District 30.

    If you know of other alumni who ran in this election, please let us know.

    Epidemiology Alumni Q&A: Raymond Neutra
    Raymond Neutra, MPH ’69, DrPH ’74, has had a public health career in environmental medicine and epidemiology and has held leadership roles in academia and the public sector. Currently he is the president of the Neutra Institute for Survival Through Design, which promotes creative research and design that benefits people and the planet. He spoke with the Department of Epidemiology about his time as a graduate student and offered advice to current students.

    Disentangling complex medical outcomes

    Biostats alumna Linda Valeri, PhD ’13, was recently profiled  by Harvard Catalyst about the pilot funding that was critical to her research career. Valeri is an assistant professor in biostatistics at the Columbia University Mailman School of Public Health.

    Serving the community

    Deborah Cook Kaliel,SM ’06, recently spoke with The Amherst Student about her work with the U.S. Agency for International Development building sustainable HIV programs across the world.

    Alumni notes

    1980

    Jane Newburger, MPH, associate chair for academic affairs in the department of cardiology at Boston Children’s Hospital and Commonwealth Professor of Pediatrics at Harvard Medical School, received the 2024 Eugene Braunwald Academic Mentorship Award at the American Heart Association’s Scientific Sessions 2024 in November.

    1992

    Friday Okonofua, Takemi Fellow, was elected to the National Academy of Medicine in October. Okonofua is the leader of the Center of Excellence in Reproductive Health Innovation, University of Benin, in Nigeria. He has led research on maternal mortality prevention, with impact on policies and programming in African countries.

    1994

    Christine Sang, MPH, was named to the Clinical Advisory Board of Allay Therapeutics in October. She is associate professor of anesthesia at Harvard Medical School and the founding director of the Translational Pain Research program at Brigham and Women’s Hospital.

    1999

    Jessica Kahn, MPH, became the senior associate dean for clinical and translational research and director of the Block Institute for Clinical and Translational Research at Albert Einstein College of Medicine in October. She previously served as co-director of the Center for Clinical and Translational Science and Training and professor of pediatrics at the University of Cincinnati and as the founding associate chair of academic affairs and career development at Cincinnati Children’s.

    2002

    Lu Tian, SD, presented this year’s Lagakos Distinguished Alumni Award on “Adaptive Prediction Strategy with Individualized Variable Selection” in October. He is professor of biomedical data science at Harvard Medical School.

    2004

    Ashwin Vasan, SM, who led New York City through the COVID-19 pandemic as its 44th  Health Commissioner, was named the James McCune Smith Distinguished Fellow for the School of Global Health at Meharry Medical College in October.

    Kaja LeWinn, SM, SD ’07, professor of psychiatry and behavioral sciences at the University of California, San Francisco, received the Trinity College President’s Award for Science and Innovation in October. LeWinn’s research focuses on children’s neurodevelopment and mental health.

    2012

    Alisa Stephens-Shields,PhD, associate professor of biostatistics at the University of Pennsylvania Perelman School of Medicine, was the recipient of the 2024 Myrto Lefkopoulou Distinguished Lectureship in September. Stephens-Shields was recognized for her great capacity as both a methodologic and collaborative biostatistician and as a leader impacting health, statistical education, and inclusion in the field.

    2017

    Huda Zoghbi, SD, was invested as a member of the American Academy of Sciences and Letters in October. She is distinguished service professor at Baylor College of Medicine, an investigator with the Howard Hughes Medical Institute, and founding director of the Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital. 

    2021

    Irina Degtiar, PhD, received both the 2024 ASA Outstanding Statistical Application Award and the Manning Memorial Award for the Best Research in Health Econometrics for her dissertation paper. She currently is a statistician at Mathematica Research.

    2024

    Esias Bedingar, was selected to join WHO’s Global Action for Measurement of Adolescent Health (GAMA) Advisory Group. As a part of this 20-member group, he will help advise WHO and UN partners on research priorities and strategies to improve adolescent health measurement.

    Wedding

    Anup Kanodia, MPH ’08,married Rupal Ramesh Shah in June 2023 in Columbus, Ohio. Several Harvard Chan School classmates attended the ceremony, which incorporated America, Indian, and African traditions. Kanodia runs a medical practice in the Columbus area. See a photo feature on the wedding that ran in the Columbus Dispatch.

    In memoriam

    Evelyn Benson, MPH ’55, died on October 20 at 100. She was a rural public health nurse in Ohio and a community gerontological nurse in Chester, Penn. She later taught at Widener College and Temple University and was assistant dean of the School of Nursing at LaSalle University when she retired in 1994. She co-authored the textbook Community Health and Nursing Practice and wrote dozens of articles on public health nursing, international nursing, and nursing history. Read her obituary.

    Ralph Hoover, MPH ’62, died June 9 at 92. He was a physician and public health officer in Waterloo, Iowa, and in retirement went back to school to become a lawyer. He founded a law firm specializing in health care law. Read his obituary.

    David Wheeler, MPH ’09, died June 29 at 51. He was an internationally recognized biostatistician with a focus on spatial, cancer, and environmental epidemiology. He joined the Biostatistics Department at the School of Medicine at Virginia Commonwealth University in 2011 and was promoted to a full professorship in 2023. Read his obituary.

    DrPH alumni news

    Read alumni news from the DrPH program.

    Harvard Chan School alumni in action

    Tell us about your life since Harvard Chan School.

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  • Does Fasting Help Autoimmune Diseases? 

    Does Fasting Help Autoimmune Diseases? 

    Various fasting regimens have been attempted for inflammatory autoimmune diseases, such as lupus, ankylosing spondylitis, chronic urticaria, mixed connective-tissue disease, glomerulonephritis, and multiple sclerosis, as well as osteoarthritis and fibromyalgia.

    The strongest evidence of the benefits of fasting surrounds the treatment of rheumatoid arthritis, an autoimmune joint disease, as I detailed in my previous blog post. A German study suggested benefits for osteoarthritis, too, and reported improvements in pain and joint function, but we’d really need randomized controlled studies to know for sure. The researchers despaired they only had 30 patients, but that’s 30 times more than many reports on fasting in the medical literature, which may detail only single cases.

    One woman, for example, with a rare autoimmune disease known as mixed connective-tissue disease, which can cause all sorts of painful and distressing symptoms, was treated with steroids in an attempt to suppress her immune system. After 21 days of fasting, and off her medications, “she had no further complaints.” More importantly, her symptoms seemed to stay away, and “she remained free of medication.” So, does fasting work for mixed connective tissue disease? All we can say is that it worked at least once.

    A similar success story was reported with fibromyalgia. A woman with pain throughout her body, who couldn’t sustain activity and was on a lot of drugs, became “symptom-free” after a 24-day fast and remained that way at her “follow-up visit 1 month later.” However, when a modified fasting regimen was tried on dozens of individuals, the benefits seen at week 2 largely disappeared by week 12, as shown below and at 1:32 in my video Fasting for Autoimmune Diseases. 

    What about lupus? A 45-year-old woman who had remained in pain despite taking immunosuppressive drugs was pain-free by day four of fasting and remained symptom-free for one year when her symptoms began to recur, but she wiped them out again with a second seven-day fast, “after which she had no symptoms.” Note, though, that she didn’t only fast. She water-only fasted, then followed it with a plant-based diet in an attempt to solidify the gains. On its own, a strictly plant-based diet without any animal protein has been shown to control symptoms in at least some cases.

    The same with sacroiliitis, a common manifestation of ankylosing spondylitis, an autoimmune arthritis that primarily affects the spine, causing back pain that can last for years. In the case of a 33-year-old man, all sorts of conventional therapies and drugs were tried, but the pain wouldn’t go away. So, the complete avoidance of animal foods was recommended, and “the complaints improved distinctly and persistently” within days—until the patient ate meat again. Once again, back on plant-based nutrition, he was off most of his drugs and almost completely free of symptoms. So, at least in this case, inflammatory pain refractory to other treatments was abolished by eating more healthfully. At least it’s worth a try!

    Autoimmune glomerulonephritis, where your body attacks your own kidneys, is a common manifestation of lupus. In a case series, 29 patients were fasted for 60 hours, then had only fruits and vegetables until they got better. They described such remarkable recoveries that fasting, in their opinion, “should be an essential part of treatment.”

    What about multiple sclerosis, an autoimmune nerve disease? Individuals with MS were randomized to a “fasting-mimicking diet”—in this case, a modified fast that started out with an 800-calorie-a-day diet of fruit, rice, or potatoes, followed by a week sipping a few hundred calories of flaxseed oil and vegetable broth, then transitioning to a plant-based Mediterranean diet. Over the next three months, they experienced a significant improvement in overall quality of life. They also tried a ketogenic diet, but that failed to offer clinically or statistically significant overall benefit, as you can see below and at 3:34 in my video. 

    And, finally, let’s look at chronic urticaria (hives), where you get a rash of itchy weals and welts, as seen here and at 3:40 in my video. Individuals started to improve on day 3 of the fast, and their hives completely disappeared by day 11. This is consistent with studies from Germany and Japan that evidently showed around 75 percent effectiveness for such patients with what looks like some sort of tea with sugar diet. It’s certainly worth giving fasting therapy a try, but, of course, fasting should only be done under trained medical supervision. Otherwise, you’d never know if you have some hidden underlying kidney issue that could land you in a coma, then maybe in the morgue. You have to have your kidney function and electrolytes monitored to make sure your body is up for the challenge. 

    “Despite the possible good outcomes, water-only fasting is not a cure or treatment in the traditional sense; it is simply intended to promote the body’s self-healing mechanisms.” Since fasting is unsustainable, by definition, “to maintain the results obtained by water-only fasting, it is necessary to adhere to a health-promoting lifestyle that includes a diet of minimally processed plant foods, adequate sleep, and robust physical exercise.”

    If you haven’t seen it yet, check out my related video Fasting for Rheumatoid Arthritis.

    I’ve held three webinars on fasting. All of the videos are available for free on NutritionFacts.org, but you can also get them in a digital download—as a bundle or separately. See: 

    To see all of the fasting videos currently on the site, please visit our fasting topic page.

    Interested in more on using diet to prevent and treat autoimmune diseases? Check out the related posts below.



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  • Student Perspective: My lessons in vulnerability

    Student Perspective: My lessons in vulnerability


    Home / News / Student Perspective: My lessons in vulnerability
    Tina Purnat in 1991
    Tina Purnat in 1991. / Photo: Courtesy of Tina Purnat

    In July 1991, I found myself sitting in the back seat of our family car, heart pounding with a mix of excitement and apprehension.

    The 10-day war for Slovenian independence from Yugoslavia had just ended, and while the armed conflict was officially over, the atmosphere was still thick with uncertainty. The weeks prior had been marked by listening to press conferences of the national war cabinet and evacuating hurriedly to bomb shelters. I remember the fear that gripped me as both my parents left for work each day—my mother to care for patients at the regional hospital, and my father, a first responder, on site to protect a key factory from potential bombings that could lead to deadly chemical spills.

    It was against this backdrop that my parents were now driving me to Villach, Austria, where I was to attend a four-week immersive German language course. This was something I had been looking forward to all year—a chance to brush up on my German before entering my freshman year of secondary school where I’d study it as the second foreign language.

    But as we crossed the border, the thrill of the upcoming adventure was tinged with a new, deeper sense of fear.

    When we arrived in Villach, my parents helped me settle in, and then it was time for them to leave. As we stood outside the small dormitory where I would be staying, my mother turned to me with a seriousness I hadn’t seen in her before. “If the war breaks out again,” she said, her voice steady but her eyes betraying a deep worry, “don’t try to come back to Slovenia. Stay here in Austria and find a way to your uncle in Sweden.” I nodded, the gravity of her words sinking in. Suddenly, the world seemed much larger, and far less certain, than it had just moments before. Despite the bombing scares and evacuations I had endured during the brief war, it was in that moment, hearing my mother’s words, that I felt the most afraid. I realized that if conflict erupted again, I would be on my own as a 14-year-old girl in a foreign country.

    For the next four weeks, I was surrounded by other teenagers from Slovenia and various other parts of Europe. We spent our days conjugating verbs, practicing vocabulary, swimming, hiking and navigating the cultural quirks of our peers. But in the back of my mind, my mother’s words lingered. What would happen if the conflict reignited? How would I make my way to Sweden on my own? How would I even find my uncle there? The thought of being stranded in a foreign country, unable to return home, was terrifying. It was my first real encounter with the vulnerability that so many people around the world experience daily—the fear of being uprooted, of losing the safety of home.

    Thankfully, the weeks passed without incident. No more armed conflict erupted in Slovenia, and my parents returned to pick me up as planned. But I was not the same person who had arrived in Villach just four weeks earlier. The experience had left an indelible mark on me, a heightened awareness of the fragility of safety and the ever-present possibility of displacement.

    Tina Purnat
    Tina Purnat today / Photo: Courtesy of Tina Purnat

    Back in Slovenia, I couldn’t shake the thoughts of what might have been. I imagined what it would be like to be forced to flee my home, to live in a place where I didn’t speak the language, surrounded by people who didn’t understand my culture. These thoughts only grew stronger in the following weeks and months as the war in Croatia and Bosnia and Herzegovina intensified. Refugees were fleeing their homes, seeking safety wherever they could find it, and often first in Slovenia before moving on to other countries. Many of them were children, just like me, whose lives had been upended overnight.

    Later on, I decided to volunteer as a companion and homework tutor for kids my own age at the refugee center. It wasn’t just about helping them with English homework and math; it was about being there for them, offering some semblance of normalcy in their otherwise chaotic lives.

    I remember a brother and sister, both in their early teens, who never left each other’s side. I remember thinking: we grew up in the same federation of Yugoslavia, just in different parts of it, and just because of where we were born, I had a home but they lost it. Despite their reserved demeanor, I made it my goal to connect with them. I would bring bubble gum and comic books to our meetups, hoping to break the ice. At first, our interactions were limited to simple exchanges—sharing a piece of gum, pointing out a favorite comic strip. But over time, these small gestures began to build a bond between us.

    We never talked about the war or their experiences—those topics remained unspoken, heavy in the background. But through our shared love of comic books and the simple pleasure of chewing gum, we found a way to connect. They would smile, sometimes even laugh, and in those moments, I knew I was making a difference, however small. We communicated in the language of teen friendship, where words were less important than the shared experiences that brought us a bit of lightheartedness in a difficult time.

    Then, one day, they were gone—moved on to Germany for asylum. I never got to say goodbye, but I like to think that our time together left a positive mark on their lives, just as it did on mine. I often wonder where they ended up—Canada? The U.S.? New Zealand? Sweden? Maybe they ended up settling in Germany? Wherever they are, I hope they remember those afternoons spent laughing over comic books and enjoying the small pleasures of pink bubble gum.

    These experiences shaped my understanding of vulnerability in profound ways. They led me to the profession of public health because public health, at its core, prioritizes the needs of the most vulnerable and at-risk populations. It emphasizes the values I learned from my parents and wider family—the importance of empathy, service, and resilience. My time with those refugee kids taught me that vulnerability is not just about addressing immediate needs but also about the layers of crises people experience and endure, often silently. Public health approaches cannot solve all their problems, but working in this field gives me a tangible way to address some of the critical needs of people who, like those refugee kids, experience and navigate multiple crises. It’s about creating systems, structures and solutions that support their resilience, help them find stability, and, ultimately, help them to rebuild their lives and thrive.

    Thirty-five years later, I’ve built a career in public health. The responsibility to serve and protect the most vulnerable remains at the forefront of everything I do. Whether I’m working with health information and evidence, implementing digital health solutions, combating health misinformation, pointing out deceptive marketing of vapes to youth, or responding to outbreaks, it’s never just about the policy, tools, data or the technology. It’s always about the people—the children, the families, the communities—who need health systems and public health efforts to better serve them and meet their needs.

    Returning to that summer in Villach, I realize now that it was a turning point in my life. The uncertainty I faced then is minute compared to the struggles of those who live in conflict zones or walk thousands of miles in search of a safer home, but it gave me a window into their experience. It taught me that the safety and stability I had always taken for granted could be lost in an instant, and that those who are forced to flee their homes or are displaced within their own country or even within their own city need more than just shelter and services—they need understanding, compassion, and a sense of belonging.

    As I continue my work in public health, I carry these lessons with me. My mother’s words, spoken with such quiet urgency, have stayed with me, reminding me of the responsibility we all share to protect the vulnerable.

    And every time I meet someone who has been displaced, I think back to that 14-year-old girl in Villach, standing alone in a foreign country, and I know that I am doing what I am meant to be doing—helping to build a world where no one has to face that kind of uncertainty alone.

    —Tina Purnat is a DrPH student and Prajna Leadership Fellow.

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  • Page Not Found – Precision Nutrition

    Page Not Found – Precision Nutrition

    It seems the page you’re looking for has disappeared. But we do have some other cool stuff to share.
    Just scroll down to check out our products and services, free starter kits,
    and free nutrition and fitness articles. You can also search for what you need below.

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  • No evidence that cell phone radiation causes cancer, says expert

    No evidence that cell phone radiation causes cancer, says expert

    Under the Donald Trump administration, the Department of Health and Human Services (HHS) may re-evaluate policies related to the potential health risks of cell phone radiation and wireless signals, such as cancer—but research has not demonstrated such risks, according to Harvard T.H. Chan School of Public Health’s Timothy Rebbeck.

    Robert F. Kennedy Jr.—the nominee for HHS secretary—has previously expressed concerns about cell phone safety, and it’s possible that, if confirmed, he would push for tighter regulations. But in a Dec. 10 Undark article, Rebbeck, Vincent L. Gregory, Jr. Professor of Cancer Prevention, said that studies have not found a connection between cell phone radiation and health issues. He explained that the types of radiation known to cause cancer—such as gamma rays and x-rays—have shorter wavelengths than those produced by cell phones.

    “The best evidence is all pretty clear around cell phones right now, and I would make sure that the policy recommendations are not only based in science, but also don’t cause issues that are unnecessary,” he said.

    Read the Undark article: In the Trump Administration Crosshairs: Cell Phone Radiation

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    Cell phones don’t cause brain cancer: study (Harvard Chan School news)

    No link found between brain cancer and cell phone use, experts say (Harvard Chan School news)

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  • How to stop tracking macros and trust yourself around food

    How to stop tracking macros and trust yourself around food

    “I worried that if I stopped tracking macros, I would lose my physique.”

    After years of careful macro tracking, Dr. Fundaro finally admitted to herself that the method no longer worked for her. Yet she was afraid to give it up.

    If anyone should feel confident in their food choices, it would be Dr. Gabrielle Fundaro. After all, Dr. Fundaro has a PhD in Human Nutrition, a decade-plus of nutrition coaching experience, and six powerlifting competitions under her belt.

    Yet, when she was really honest with herself, Dr. Fundaro realized that she felt far from confident around food. For years, she’d used macro counting as a way to stay “on track” with her eating.

    And it worked… until it didn’t.

    After years of macro tracking, Dr. Fundaro was tired of the whole thing. She was tired of making sure her macros were perfectly in balance. She was sick of not being able to just pick whatever she wanted off a menu and enjoy the meal, trusting that her health and physique wouldn’t go sideways as a result.

    Yet the idea of not tracking freaked her out. Every time she quit tracking, she worried:

    “What if I don’t eat enough protein, and lose all my muscle?”

    “What if I overeat and gain fat?”

    “What if I have no idea how to fuel myself without tracking macros? And what does that say about me as an expert in the field of nutrition?”

    The more Dr. Fundaro wrestled with macro tracking, the more she wanted to find an alternative.

    Something that would support her nutritional goals while also giving her a sense of freedom and peace around food.

    Calorie counting wouldn’t do it. That was just as restrictive as counting macros—maybe more.

    Intuitive eating didn’t seem like a good fit either. Intuitive eating relies heavily on a person’s ability to tune into internal hunger and fullness cues to guide food choices and amounts. After years of relying on external cues (like her macro targets), Dr. Fundaro didn’t feel trusting enough of her own instincts; she wanted more structure.

    Meanwhile, at the gym, Dr. Fundaro began lifting based on the Rate of Perceived Exertion (RPE) scale—a framework that helps individuals quantify the amount of effort they’re putting into a given movement or activity. It’s considered a valuable tool to help people train safely and effectively according to their ability and goals. (More on that soon.)

    While using the RPE scale in her training, Dr. Fundaro found she was both getting stronger and recovering better. There was something to this combination of structure and intuition that just worked.

    And then, it dawned on Dr. Fundaro like the apple hit Sir Isaac Newton on the head:

    If Rate of Perceived Exertion could help her train better, couldn’t a similar framework help her eat better?

    With that, the RPE-Eating Scale was born.

    Dr. Fundaro has since used this alternative method to help herself and her clients regain confidence and self-trust around food; improve nutritional awareness and competence; and free themselves from food tracking.

    (Yup, Dr. Fundaro finally trusts her eating choices—no macro tracker in sight.)

    In this article, you’ll learn how she did it, plus:

    • What the RPE-Eating scale is
    • How to practice RPE-Eating
    • How to use RPE-Eating for weight loss or gain
    • Whether RPE-Eating is right for you or your clients
    • What to keep in mind if you’re skeptical of the concept

    What is RPE-Eating?

    Invented by Gunnar Borg in the 1960’s, Rate of Perceived Exertion (RPE) is a scale that’s used to measure an individual’s perceived level of effort or exertion during exercise.

    Though Borg’s RPE uses a scale that goes from 6 to 20, many modern scales use a 0 to 10 range (which is the range that Dr. Fundaro adapted for her RPE-Eating scale).

    Here’s the RPE scale used in fitness.

    Rating Perceived Exertion Level
    0 No exertion, at rest
    1 Very light
    2-3 Light
    4-5 Moderate, somewhat hard
    6-7 High, vigorous
    8-9 Very hard
    10 Maximum effort, highest possible

    Originally used in physiotherapy settings, the scale is now frequently used in fitness training.

    For example, powerlifters might use it to choose how heavy they want to go during a training session. Or, pregnant women might use it to ensure they aren’t over-exerting themselves during a fitness class or strength training session.

    Because human experience is highly subjective and individual, the scale allows the exerciser to judge how hard they’re working for themselves. A coach can provide a general guideline, such as “aim for a 7/10 this set,” but it’s up to the client to determine exactly what that means for them.

    Dr. Fundaro had used the scale many times with herself, and clients. She always appreciated the sense of autonomy it gave her clients, while still providing some structure.

    So, she decided to take the same 1-10 scale and its principles, and apply it to eating.

    Here’s what the RPE-Eating Scale looks like:

    Table shows a hunger scale that goes from 1 to 10. 1 represents feeling painfully hungry, dizzy or sick; 2 represents feeling “hangry,” with uncomfortable hunger and stomach growling; 3 represents feeling like hunger is noticeable and stomach is rumbling; 4 represents feeling mild hunger a snack would satisfy; 5 represents feeling no hunger or fullness, just sated; 6 represents feeling a noticeable fullness, but comfortable; 7 represents feeling a little too full for comfort; 8 represents feeling an uncomfortable fullness; 9 represents feeling very uncomfortable or “stuffed”; and 10 represents feeling overly full to the point of feeling sick.

    The goal with RPE-Eating is similar to RPE when training: Develop the skills to determine what is sufficient for you, without having to rely on other external metrics (such as apps or trackers).

    How to practice RPE-Eating

    If you’ve ever practiced RPE-training, you’ll know it takes some time to get used to. RPE-Eating is the same.

    Don’t expect to be in lockstep with all of your body’s internal cues at first, especially if you’ve been ignoring them for a long time.

    With this in mind, apply the steps below to practice the RPE-Eating process.

    Step #1: Get clear on your goals.

    RPE-Eating is not just another diet.

    “It’s not about aiming to change your body,” Dr. Fundaro explains. “It’s not about feeling more control over your diet. Nor is it about feeling like you’re eating the ‘optimal’ diet.”

    If your priority is maintaining a specific physique (such as staying ultra lean) or changing your body (building muscle or losing fat), this method can be adapted for that, though it isn’t the most efficient one to use.

    Instead, RPE-Eating is about sensing into what your body needs and giving yourself appropriate nourishment—while building inner trust and confidence along the way.

    “You have to trust that you’ll be able to nourish your body, and that you’ll be okay even though things may change in your body,” says Dr. Fundaro.

    Admittedly, this can be challenging to do. It can also be difficult to let go of the expectation that you’ll hit the “right” macros at every meal—which RPE-Eating isn’t specifically designed to do.

    However, if your goal is to build more self-trust, RPE-Eating can be a great tool to help you do that.

    Step #2: Practice identifying your hunger cues

    Before we explore this step, let’s distinguish between two motivators for eating.

    First, there’s hunger. Hunger occurs when physical cues in your body (like a general sense of emptiness or rumbling in your stomach, or lightheadedness) tells you that you require energy—known to us mortals as food.

    Then, there’s appetite. Appetite is our desire or interest in eating. It can stay peaked even after hunger is quelled, especially if something looks or tastes especially delicious—like a warm, gooey cookie offered after dinner that you feel you have to try, even though you’re technically full.

    While it’s normal to eat for both hunger and appetite drives, the two can become mixed up. Especially if we have a history of dieting and tracking food.

    The RPE-Eating scale helps you tap back into those true physical hunger cues, and learn the difference between hunger and appetite.

    To put this in practice, try this before your next meal:

    ▶ Using the RPE-Eating scale mentioned above, identify your current level of hunger. Record the number on paper or the notes app on your phone.

    ▶ Then, eat your meal with as much presence as possible. (Note: This in itself takes practice. It can help to limit distractions, such as eating at the table rather than in front of the TV, and focusing on the flavors and textures of the food you’re eating, and how you feel eating it.)

    ▶ About halfway through the meal, check in again. Based on the scale, how hungry are you now? As before, record the number.

    ▶ If you’re still hungry, finish your meal. When you’re finished, repeat the same process, writing down where you are on the scale.

    ▶ Once you’re done, take a minute and tune into what your body feels like. What does it feel like to be full? “Download” that feeling into your mind and internalize it in your body, as if you’re updating your phone with the latest software.

    Repeat this for as many meals as you can. Aim to do it for one meal a day for a week or so, or for as long as feels good to you. Don’t worry if you forget: simply repeat the practice when you can.

    The more you practice this, the better you’ll become at being attuned with your actual hunger cues. With time, you’ll likely find you develop more trust in your internal compass than what the latest diet tracker says for your needs.

    (For more on fully-tuned-in, mindful eating, read: The benefits of slow eating.)

    Step #3: Get to know your non-hunger triggers

    Have you ever come home after a super stressful day and you’ve basically thrown yourself onto a bag of chips or a carton of ice cream?

    We might like to imagine ourselves eating every meal mindfully, using the RPE- Eating system to a tee, but life rarely works like that.

    Chances are, there are certain situations that trigger you to eat more quickly, mindlessly, and beyond the point of hunger.

    That’s okay.

    Dr. Fundaro’s suggestion? Aim to become more aware of the situations that cause you to overeat in the first place.

    To do this, you can practice something we use in PN Coaching: Notice and name.

    When you find yourself scarfing down food faster than you can blink, simply try to notice what’s going on.

    Can you name a feeling—such as anxiety, or sadness?

    Can you identify a situation or moment that happened before you started eating—say, an argument with your teenager, or a nasty email from your boss?

    Once you’ve identified the feeling, event, or person that’s triggered you to eat compulsively, see if you can also identify what you might really be needing or desiring.

    Eating for comfort is normal. However, if it’s the only coping method we have, it can cause more problems than it solves in the long run.

    When you find yourself with an urge to eat mindlessly, consider what non-food coping mechanisms might help you feel better. That could be 10 minutes away from your computer to close your eyes and breathe, a walk outside, or a quick call to a friend to rant—or just talk about something completely unrelated.

    Getting to know your non-hunger eating triggers—plus widening your repertoire of self-soothing methods—is just as valuable as getting to know your hunger cues. Over time, this awareness will allow you to eat with more intention.

    Step #4: Eat for satiety AND satisfaction

    Even when you’re “adequately fueled” from a physical perspective, you might still feel unsatisfied from an emotional perspective.

    That’s because, according to the RPE-Eating framework, eating should fulfill two criteria:

    ▶ Satiety describes the physical sensation of being full; your calorie or fuel needs are met.

    ▶ Satisfaction describes a more holistic feeling of being nourished; your calorie needs are met, but your meal also felt pleasurable.

    If you ate to satiety only, your calorie needs might be met and your physical hunger quelled, but you might still feel unsatisfied—maybe because chocolate is on your “don’t” list, and even though you’ve eaten everything else in your kitchen that isn’t chocolate, nothing quite “hit the spot.”

    In other words, you can eat to satiety at every meal, yet still be “restricting” foods.

    You may not be restricting calories per se, but you may have banned entire food groups—baked goods, pizza, or whatever else curls your toes. This can lead to a feeling of constantly needing to police yourself, and doesn’t leave much room for the flexibility and spontaneity that real-life (enjoyable) eating requires.

    (Plus, avoiding particular foods tends to work like a pendulum: restrict now; binge later. If you want to learn how to stop those wild swings, read: How to eat junk food: A guide for conflicted humans)

    Satisfaction is a key part of eating.

    After all, humans don’t just eat for adequate nutrients and energy. We eat for other reasons too: pleasure, novelty, tradition, community, enjoyment.

    So, to take your RPE-Eating to the next level, Dr. Fundaro recommends trying it with meals and foods you genuinely enjoy.

    If any foods or meals have been “off-limits,” try eating them using the RPE technique. (Macaroni and cheese, anyone?)

    Practice using the scale with a variety of meals (including those you may have restricted previously), and notice how you feel over time.

    With experience, you’ll get to know what it feels like to adequately fuel yourself with a variety of foods—including those you genuinely enjoy.

    How do I know if RPE-Eating is right for me or my clients?

    RPE-Eating isn’t for everyone, but might be a good fit for you (or your clients) if:

    ✅ You feel dependent on food tracking, but you don’t want to be.

    ✅ Every time you stop tracking, the loss of perceived control freaks you out and drives you right back to tracking.

    ✅ You want to stop tracking, but you want to have some type of system or guidance in place.

    ✅ You’re currently tracking (or considering tracking) your food intake, and you have elevated risk factors for developing an eating disorder such as high body dissatisfaction; a history of yo-yo dieting; a history of disordered eating patterns; and/or participation in weight class sports.

    If you’re a coach looking to use this tool with a client, check out Dr. Fundaro’s resources. Remember this tool may not be for everyone, and how you apply it needs to be flexible.

    Note: If you or your client struggles with disordered eating, this tool does not replace working with a health professional who specializes in eating disorders, such as a therapist, doctor, or registered dietician.

    How to use RPE- Eating for weight loss or weight gain

    According to Dr. Fundaro, the best way to use RPE-Eating is in a weight-neutral setting.

    While it could be used for weight modification, she doesn’t recommend treating it as another way to hit your macros or “goal weight.”

    “I’m not anti-weight modification,” Dr. Fundaro explains. “I’m pro safe weight modification. I compare weight loss to contact sports. There are inherent risks but they can be mitigated through best practices.”

    Dr. Fundaro elaborates: “Since RPE-Eating removes macro-tracking, which can increase risk of disordered eating in some people, and relies on biofeedback and non-hunger triggers, RPE-Eating provides a safety net that macro-tracking alone doesn’t provide.”

    But if you do want to use RPE-Eating for intentional weight change, what should you do?

    Dr. Fundaro recommends aiming to hover around the ranges that support your goal.

    (As a reminder, a 1 to 3 on the RPE-Eating scale is categorized as “inadequate fuel; a 4 to 7 is categorized as “adequate fuel”; and a 8 to 10 is categorized as “excess fuel.”)

    ▶ If the goal is weight gain, you’ll likely aim to eat within the 7 to 8 range for most of your meals.

    ▶ If the goal is weight loss, you’ll likely aim to eat within the 4 to 5 range for most of your meals.

    A key thing to remember is that you would never use RPE-Eating for extreme weight-modification such as for a bodybuilding competition. “That would be like using physio exercises to prepare for a powerlifting competition.” In other words, it’s not the right tool for the job.

    Hold up, bro: Isn’t this just feelings over facts?

    If you’re skeptical and think this is just eating “based on your feelings,” keep in mind that RPE was once laughed at by lifters, too.

    These days, RPE and autoregulation are widely accepted in gym culture and have been studied as a valid method for managing and guiding your training. 1

    RPE isn’t perfect, but it’s pretty accurate and incredibly convenient. A lot more convenient than, say, using a velocity loss tracker for every set. 2 3

    And while it might seem like it’s all feelings-based, the RPE scale is actually built around practicing the skill of interoceptive awareness—the awareness of internal sensations in your body.

    The better you get at the skill of interoceptive awareness, the more you’ll be able to use that awareness to make informed decisions about your training.

    RPE-Eating is similar: It builds the skill of sensing into your own body, and lets your internal sensations guide your decisions.

    Similar to how the bar slowing down on a squat would indicate you’re getting closer to failure, experiencing the absence of hunger at the end of your meal would indicate you’re closer to being full.

    Instead of tracking your glucose levels to validate your perceived hunger, you use internal cues that correlate with lowered blood sugar and coincide with hunger.

    And, let’s be real: Being mindful of stomach grumbling or general hunger pangs is much more convenient and accessible than tracking glucose readings.

    This process will not be perfect. You may undereat or overeat at first. But over time, with practice, you’ll build the core skills of RPE-Eating.

    Are there downsides to RPE-Eating?

    While this tool can be helpful, it’s just a tool. A screwdriver is great, but it isn’t useful when you need a hammer.

    RPE-Eating can be great for helping you become more aware of your internal hunger cues and build a better relationship with food along the way.

    It can also be more laborious. It requires paying real attention to your feelings (physical and emotional), and reflecting on them.

    This can be difficult for anyone—but especially people who aren’t able to sit at the table and have a leisurely meal, like parents with small kids, or people with work schedules that require eating on-the-go.

    If this is you, just use RPE-Eating when it does work for you—or simply pick and choose specific steps to use in isolation. For example, maybe you try RPE-Eating on the occasional quiet lunch break. Or, maybe you focus solely on developing your awareness of hunger and fullness cues, without trying to change anything else.

    If you’ve been tracking macros for a long time, it can be hard to stop.

    Tracking macros isn’t inherently bad. It can actually be a helpful tool to teach you more about nutrition. But it’s also not something most people want to do for the rest of their lives.

    The problem is, if you’ve depended on tracking your food intake, stopping can feel scary.

    In these cases, RPE-Eating can be used as a kind of off-ramp to help transition away from rigid and restrictive macro tracking.

    (It can also help loosen the compulsion to “always finish your plate.” Though macros tracking and habitual plate-cleaning may sound different, they’re actually similar: both rely on external cues—such as macro targets or what’s served on your plate—to determine when you’re “done.”)

    RPE-Eating won’t take away all the scary feelings that may come with changing ingrained ways of eating.

    However, it can provide some structure and language to help you, or your clients, eat with less fear, less stress, and a bit more confidence.

    “The goal,” says Dr. Fundaro, “is to know that you’re nourishing yourself—and you don’t need a food tracker to do that.”

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    References

    Click here to view the information sources referenced in this article.

    1. Helms, Eric R., Kedric Kwan, Colby A. Sousa, John B. Cronin, Adam G. Storey, and Michael C. Zourdos. 2020. Methods for Regulating and Monitoring Resistance Training. Journal of Human Kinetics 74 (1): 23–42.

    2. Hackett, Daniel A., Nathan A. Johnson, Mark Halaki, and Chin-Moi Chow. 2012. A Novel Scale to Assess Resistance-Exercise Effort. Journal of Sports Sciences 30 (13): 1405–13.

    3. Zourdos, Michael C., Alex Klemp, Chad Dolan, Justin M. Quiles, Kyle A. Schau, Edward Jo, Eric Helms, et al. 2016. Novel Resistance Training-Specific Rating of Perceived Exertion Scale Measuring Repetitions in Reserve. Journal of Strength and Conditioning Research 30 (1): 267–75.

    The post How to stop tracking macros and trust yourself around food appeared first on Precision Nutrition.

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  • Does Fasting Help Rheumatoid Arthritis? 

    Does Fasting Help Rheumatoid Arthritis? 

    Fasting, followed by a plant-based diet, is put to the test for autoimmune inflammatory joint disease. 

    Alan Goldhamer is the founder of the TrueNorth Health Center in Santa Rosa, California, where 10,000 individuals have fasted for “a variety of conditions from diabetes and cardiovascular disease to autoimmune diseases.” He noted that “conditions that seemed to be tied to dietary excess tended to respond predictably to the use of fasting followed by a health-promoting diet,” which he describes as one that is “low salt, vegan, high fiber, low fat, low protein, and low sugar.”

    “This approach offers people an option to make lifestyle changes, eliminate the cause of the problem, and stabilize their conditions, to the point where the medication is no longer needed.” It’s in contrast to “conventional medicine, which is more about the suppression of the symptoms associated with the disease, rather than removing the underlying mechanisms by which they are caused.”

    Said Dr. Goldhamer: “If you treat high blood pressure medically, they tell you, ‘You must take these drugs the rest of your life.’ If you have diabetes, they’ll tell you, ‘You’ll be on these medications the rest of your life.’ If you have autoimmune disease, like lupus, rheumatoid arthritis, ulcerative colitis, ankylosing spondylitis, psoriasis, or eczema, you will be told, ‘You must be on medications the rest of your life,’ because medicine guarantees you will never recover. They promise you, if you follow their advice explicitly, you will be sick the rest of your life.”

    Preliminary data suggest that fasting may benefit “metabolic diseases, pain syndromes, hypertension [high blood pressure], chronic inflammatory diseases, atopic [allergic] diseases, and psychosomatic disorders,” but the highest level of evidence we have for the benefits of fasting are in regard to rheumatic diseases—autoimmune inflammatory joint diseases, like rheumatoid arthritis.

    Nearly a century ago, it was written that “diet treatment is not generally recognized by the medical profession…as one of the weapons with which to attack rheumatic conditions.” This attitude persisted until relatively recently, but a systematic review of controlled trials has since shown “a statistically and clinically significant beneficial long-term effect.”

    Rheumatoid arthritis has a well-known genetic component, but the concordance rate—that is, the chance that a pair of identical twins both get it when one has it—is probably less than 30 percent, despite the twins having the same genes. That leaves 70 percent to be explained by nongenetic factors.

    Even if we don’t know exactly what those factors are, “fasting is very similar to rebooting the hard drive in a computer. Sometimes, the computer gets corrupted and you do not know exactly where the problem is. But if you just turn it off and reboot it, a lot of times, that corruption gets cleared out.”

    The evidence base started with case reports of water-only fasting followed by a plant-based diet. There were remarkable reports of years of pain and stiffness that were not only gone within a week but, more importantly, stayed gone on the healthier diet. One after another, just like that. But case reports are merely glorified anecdotes. There have been studies going back decades suggesting that “fasting may represent the most rapid and most available way of inducing relief of arthritic pain and swelling for patients who have RA,” rheumatoid arthritis, but they often failed to control for the placebo effect, which is “particularly important whenever self-reporting systems are used (reports on general well-being, pain, stiffness, tiredness, and the like)”—that is, subjective symptoms. There are objective measures, however, including lab tests of inflammation that don’t appear to be affected by placebos. As shown below and at 3:22 in my video Fasting for Rheumatoid Arthritis is what can be seen in controlled trials, starting immediately and staying down for at least a year. 

    Ten different measures of inflammation decreased significantly after the fasting and subsequent meat- and egg-free diet, whereas none of the parameters budged in those individuals with rheumatoid arthritis who continued to eat their regular diets. What’s more, this squelching of inflammation translated into a significant reduction in pain, morning stiffness, loss of grip strength, and the number of tender and swollen joints, as you can see below and at 3:43 in my video. 

    Even a year after the trial had ended, those who benefited from the diet continued to benefit in terms of less pain, stiffness, and tender and swollen joints, presumably because they stuck with it, as shown here and at 4:00 in my video. 

    “There is little doubt that during the period of fasting both inflammation and pain are reduced in RA patients,” individuals with rheumatoid arthritis. “However, after the normal diet is resumed, inflammation returns unless the fasting period is followed by a vegetarian diet…” Why might that be? It could be due to changes in the microbiome. The improvement in symptoms coincided with a “significant alteration in the intestinal flora” when patients switched from an omnivorous diet. “A diet can change intestinal flora and this may somehow be beneficial in RA,” perhaps by strengthening the gut barrier. We know fasting can decrease the leakiness of the gut in individuals with rheumatoid arthritis, but we don’t yet know what role, if any, this plays in the disease process.

    It could be as simple as eicosanoids, the mediators of inflammation that are formed from arachidonic acid. Arachidonic acid is a long-chain, inflammatory, omega-6 fatty acid found in animal fats. As seen below and at 5:04 in my video, the biggest contributors are chicken and eggs, which together contribute nearly half the intake of Americans. That’s also been suggested as an explanation for why those eating more plant-based appear to have better mental health; they aren’t suffering the “cascade of neuroinflammation” caused by arachidonic acid. It’s also why removing eggs, chicken, and other meats was shown to improve mood in a randomized controlled trial, suggesting the arachidonic acid “may negatively impact mood state.” It may also help explain the impact of more plant-based diets on inflammatory diseases like rheumatoid arthritis. 

    So, all of this may help explain why “maintaining a nutrient-dense, vegan diet of unrefined plant foods”—a plant-based diet—“appears to be necessary after the fast to prevent the recurrence of symptoms and inflammatory activity,” or as one popular press article put it, fasting may just be a tool to get you to radically kickstart a change in the way you eat. 

    For more on fasting, see related posts below.

    This video was originally part of my Fasting for Disease Reversal webinar. If you want to see all of the videos in one place, check them out here.

    Stay tuned for Fasting for Autoimmune Diseases, coming up next.

    For more on rheumatoid arthritis, see Turmeric Curcumin and Rheumatoid Arthritis, Why Do Plant-Based Diets Help Rheumatoid Arthritis?, and Friday Favorites: Fasting for Rheumatoid Arthritis and Autoimmune Diseases.



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  • Private equity’s appetite for hospitals may put patients at risk

    Private equity’s appetite for hospitals may put patients at risk


    Home / News / Private equity’s appetite for hospitals may put patients at risk
    Illustration: A female healthcare practitioner, left, and a businessman, right, face off in an illustration describing relationship between fall care and rising costs.
    Illustration: Traci Daberko

    In the wake of the Steward Health Care crisis, corporate and private equity ownership of health care has come under new scrutiny. Here, Harvard health policy experts weigh in on the growing corporatization of the U.S. health care system and what it means for patients, practitioners, and public health.

    Throughout 2024, eye-opening news headlines from around the country trained a spotlight on the collapse of Steward Health Care:

    As Steward hospitals teeter, CEO’s $40 million yacht is docked in the Galapagos Islands

    Sick patients collapsed waiting for care in overwhelmed Steward hospital’s emergency department

    Steward Health Care files for Chapter 11 bankruptcy

    Steward owned more than 30 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, and Texas. Its volatility and eventual crash jeopardized access to health care for millions of patients.

    How did Steward, at one point the largest private for-profit health system in the U.S., go belly up?

    The long and short: In 2010, private equity firm Cerberus Capital Management purchased Caritas Christi Health Care, a struggling eastern Massachusetts hospital system, from the Archdiocese of Boston, converting it from non-profit to for-profit and rebranding it as Steward Health Care. In 2016, after years of continued financial instability, Steward signed a sale-leaseback agreement with Medical Properties Trust (MPT), selling the land and buildings occupied by its hospitals to the real estate investment trust then leasing them back. Steward made $1.25 billion from the agreement—enough to steady its financial footing, pay off Cerberus, and fund a growth spree. The next year, the company purchased 26 more hospitals across the country. But with the agreement came what many viewed as inflated rents.

    By 2020, Cerberus, having made $800 million in profit on its initial investment, decided to sell Steward hospitals to a group of its physicians, essentially transferring ownership back to Steward’s management team, led by CEO Ralph de la Torre. Over the next several years, concerns about patient care and safety at Steward hospitals mounted as the company opted to cut costs and neglect bills in order to keep up with its rent payments to MPT. In January 2024, MPT announced that Steward was $50 million behind on those payments. By May, the company filed for bankruptcy. Financial documents made clear that the company had paid hundreds of millions to investors and leadership, including de la Torre, who enjoyed a lavish lifestyle while patients at Steward hospitals faced increasingly unsafe conditions. De la Torre was subpoenaed by Congress in July; he failed to appear.

    After months of tense negotiations between state governments, Steward, MPT, and potential buyers, by November, most Steward hospitals had found new owners, a mix of non- and for-profit hospital systems and private equity firms. But two hospitals didn’t survive: Carney Hospital, which served Boston’s low-income, majority Black and Hispanic southern neighborhoods, and Nashoba Valley Medical Center, which served 17 suburban and rural communities across central Massachusetts. Thousands of patients and hundreds of staff have been left to find health care and jobs with new providers farther away.

    The Steward meltdown has captured the attention of the public and policymakers not as an outlier, but as an object lesson. Its story shines a light on the growing role of private equity in the U.S. health system, helps explain rising discontent among patients and clinicians, and lays bare the dangers of prioritizing profits over people in health care.

    A ‘core contradiction’

    John McDonough, professor of the practice of public health at Harvard Chan School, calls private equity “the sharp end of capitalism.”

    “It’s otherwise often described as ‘capitalism on steroids,’” McDonough said. “It’s for-profit business in its most aggressive form. [Private equity firms] seek returns on their investment as high as possible as quickly as possible, then rush to sell off that investment and go on to their next conquest.”

    After decades establishing a presence everywhere from manufacturing, to telecommunications, to grocery stores, in the mid 2000s private equity firms began targeting health care. It was a natural next step: The industry is worth nearly $5 trillion in the U.S., offering significant, dependable cash flow. Firms saw the potential for profits and began buying up physician practices and health facilities, from hospitals to nursing homes to fertility clinics, looking to at least double their initial investment and then sell within a short time, often three to seven years.

    Private equity’s foothold in health care has continued to grow. In 2021, according to researchers at UC Berkeley, 5,779 physician practices, specializing in everything from primary care to oncology, were owned by private equity firms—up from 816 in 2012. Nonprofit watchdog the Private Equity Stakeholder Project (PESP) reported that, as of February 2024, nearly 460 U.S. hospitals were owned by private equity firms. These hospitals—which include non-specialty acute care hospitals, rehabilitation hospitals, psychiatric facilities, and long-term acute care facilities—represent 8% of all private (not owned by the government) hospitals and 22% of for-profit hospitals.

    5,779

    physician practices were owned by private equity in 2021—up from 816 in 2012

    22%

    of for-profit hospitals—460 in total—are currently owned by private equity

    80%

    of physicians are employed by a hospital system or corporation—up from 60% in 2019

    But ownership by private equity is just the latest version of capitalism’s creep into health care. Its way was paved by corporations entering the industry in the 1980s as an era of free market fundamentalism emerged and the “maximizing shareholder value” movement began to boom. Publicly traded companies began buying up hospitals and health facilities, as well as physicians and physician practices, to establish their own health systems. Today, nearly a quarter of U.S. hospitals are run by for-profit entities that promise to bring business smarts and a flow of capital to health care delivery.

    “The pitch is that corporations can raise capital and invest in improving the business—quality of care, operations, professional management—in a way non-profits can’t,” said Meredith Rosenthal, C. Boyden Gray Professor of Health Economics and Policy. “But the challenge is that because health care is so important, the public expects these corporations to prioritize public interest over profits. And that’s not what they’re built to do.”

    Because health care is so important, the public expects corporations to prioritize public interest over profits. And that’s not what they’re built to do.

    Meredith Rosenthal, C. Boyden Gray Professor of Health Economics and Policy

    “Medical care has always had a for-profit element. Physicians were mostly small businesspeople,” McDonough said. “But there’s a difference between a sole proprietor or small business and a mega-corporation that believes its only purpose in the world is return on equity to shareholders. Hold that belief up against a medical provider’s belief that patients come first, and right away there’s conflict. It’s this core contradiction that I think American society has never sufficiently grappled with.”

    Non-profits like profits, too

    It’s not just corporate health care providers producing this dilemma. Non-profits, which remain the majority of U.S. hospitals and health care facilities, sometimes prioritize profits over their social missions—and community benefit requirement cementing their tax-exempt status—in order to grow, and even just survive, in a tight economy and increasingly competitive health care market.

    “Economists have studied whether non-profits behave differently than for-profits. Do they provide more charity care [free or discounted medical services for poor patients]? Do they invest more in community well-being? The answer generally has been no,” Rosenthal said.

    One study, conducted in 2020 by Joseph Bruch, PhD ‘21 and David Bellamy, PhD ’23, indeed found no significant difference between what non-profit and for-profit hospitals spend on charity care as a percent of their total expenses.

    “It’s getting harder and harder to tell the difference between a non-profit and for-profit board of directors,” McDonough said. “It’s this for-profit ethos that has swarmed and swamped the U.S. medical space. Many people think the system can prioritize patients and profits at the same time and that it will be okay. But then we look at calamities like Steward, and we think to ourselves, maybe it can’t. And maybe it won’t be okay.”

    Consequences of cost-cutting

    For Steward patients, it wasn’t okay. Reports of poor-quality care and compromised patient safety ran the gamut: from understaffed emergency rooms and ill-equipped maternity wards, to stairwells infested with bats, to cancelled surgeries and suspended trash service due to unpaid invoices. These extreme examples represent what a growing body of research suggests: Health care quality declines when private equity and its extreme for-profit approach take over.

    A 2023 study found that Medicare patients at private equity-owned hospitals suffered a 25% increase in hospital-acquired complications compared to Medicare patients at hospitals not owned by private equity. These complications included a 38% increase in bloodstream infections from central lines—longer-term, surgically inserted ports through which patients can intravenously receive fluids, medications, and blood—despite 16% fewer central lines placed. Similarly, the rate of surgical site infections doubled at private equity-owned hospitals while those at the control hospitals decreased. And while falls at hospitals not owned by private equity have been trending downward—a product of a nationwide, decades-long hospital safety movement—falls at private equity-owned hospitals have remained steady, amounting to a 27% relative increase.

    “We believe [these findings are] largely explained by staffing cuts,” said the study’s senior author Zirui Song, PhD ’12, associate professor at Harvard Medical School and Massachusetts General Hospital. “The unique financial pressures private equity-owned hospitals face, such as new debt placed on them from the acquisition and expectations of profitability in the short run, may lead to cutting the costs of delivering care—such as through reducing staffing. But while you may be able to substitute people with machines in other industries, health care remains human-labor intensive, especially inpatient care. Cutting staff can have salient consequences for quality of care and patient outcomes.”

    Another study by Song and colleagues found that private equity-owned hospitals earned 27% more income after acquisition than hospitals not owned by private equity. That financial gain was fueled by increasing charges—the asking prices for hospital services—by between 7% and 16%, depending on the department, as well as by issuing more charges per day and seeing fewer patients enrolled in Medicare, which provides lower reimbursements than commercial insurers.

    A white and magenta yard sign reads
    A “Save Our Hospital” sign is displayed outside the former Nashoba Valley Medical Center, which was part of the bankrupt Steward Health Care company and closed on Aug. 31, 2024. (Charles Krupa / AP Photo)

    Exacerbating disparities

    What type of hospitals does private equity tend to target?

    New evidence from Song and colleagues suggests that firms typically set their sights on financially healthier—rather than struggling—hospitals, compared to similar peer hospitals that were not acquired. That’s because private equity firms tend to place new debt onto acquired hospitals, and those on stronger financial footing are better able to take on that debt.

    There are examples, however, of hospitals serving mostly uninsured or publicly insured patients being taken over by private equity firms. These takeovers may exacerbate health disparities, as many of these disadvantaged patients belong to racial or ethnic minorities and already suffer worse health outcomes, said Song. When discontinuation of hospital services—or total closure—occurs, it has an outsize impact in communities where access to health care is already limited. Carney Hospital is one such example; in an op-ed, Harvard Chan School’s Alecia McGregor, assistant professor of health policy and politics, called its closure “a matter of life and death” that threatens to deepen Boston’s already extreme racial disparities in health.

    “I don’t think there is enough evidence to definitively say that private equity targets hospitals that mostly serve people of color. But in some cases, these financially vulnerable facilities may fit their business model,” McGregor said. “And when private equity backed acquisitions lead to closures, this is when marginalized communities often hurt the most. Take Hahnemann University Hospital, for instance—a historic facility serving mostly low-income Black and Hispanic Philadelphians that was closed by its private equity owner after less than two years. Many viewed the closure as a maneuver for the hospital’s prime city real estate.”

    PESP also reports that a quarter of private equity-owned hospitals serve rural populations, whose health care alternatives are sparse if they’re unsatisfied with quality or costs and whose outcomes are jeopardized if the only hospital in town closes. Since Nashoba Valley Medical Center was closed, first responders travel around 15 miles to transport patients to emergency care, according to a local fire chief. They used to travel three.

    Policy potential

    “Theoretically, there could be benefits to private equity investments in health care. They could provide facilities and clinicians with an infusion of capital, but also with managerial know-how and business acumen that might improve health care, such as through making care more ‘efficient,’” Song said. “Unfortunately, however, the current evidence base does not support that. Rather, evidence seems to suggest that by cutting the human labor and other inputs that make care delivery possible—also seen in private equity acquisitions of physician practices and nursing homes—the care might just become less safe.”

    Song published a series of policy recommendations for officials looking to reduce corporate influence, specifically that of private equity, over health care delivery and outcomes. His recommendations for state policy included reviving or enforcing corporate practice of medicine laws, which, in their aim to protect physicians as independent practitioners, can go as far as prohibiting corporations from hiring physicians or influencing medical decisions. His recommendations for federal policy included:

    • Strengthening fraud and abuse protections
    • Improving Federal Trade Commission staffing and bandwidth, in order to improve oversight over health care acquisitions and mergers
    • Discouraging risk-taking behavior by corporate owners (sometimes referred to as moral hazard), through measures like legally affiliating private equity firms with their rolled-up set of acquired entities, limiting the percent debt a firm can use to make an acquisition, and reforming the tax benefit that allows private equity proceeds to be taxed at 20% (rather than the regular corporate business rate, which is higher)
    • Regulating health care prices and prohibiting surprise billing
    • Increasing public transparency into private equity acquisitions

    Some policymakers have already begun efforts to enact these recommendations. In June, Massachusetts senators Elizabeth Warren and Edward Markey introduced the Corporate Crimes Against Health Care Act, which would penalize private equity firms if a health facility they own closes or has poor finances resulting in injury or death to a patient. A month later, Markey proposed another bill, the Health Over Wealth Act, which would require greater transparency for private equity firms and for-profit companies that own health care entities.

    Meanwhile, in the last year, several congressional committees—including the Senate Budget Committee, the Senate Committee on Homeland Security and Governmental Affairs, and the House Committee on Ways & Means—have launched investigations into and held hearings on the role of private equity in health care. On a state level, legislation to regulate private equity in health care is pending in Massachusetts, New Jersey, New York, and Pennsylvania. California, Indiana, Minnesota, New Mexico, and Oregon already have programs that do so. (In September, California Governor Gavin Newsom vetoed a bill that would further intensify regulations.)

    A group of protestors in front of the Masscushetts state house. They hold signs that read
    Protesters gather in front of the Massachusetts State House to advocate for keeping Nashoba Valley Medical Center and Carney Hospital open. (Steve LeBlanc / AP Photo)

    Deeper changes

    These regulations—if passed—could help protect physicians as well as patients. One of the significant changes from the corporatization of health care is that, increasingly, physicians are no longer working for themselves. In the 1980s, most doctors owned their own small clinics. Today, nearly 80% are employed by a hospital system or corporation—up from just over 60% in 2019, according to Avalere Health.

    “If you’re a physician working in a hospital, chances are you don’t work for the hospital. You work for a corporation,” McDonough said. “And when you sign on with the corporation, you sign a non-compete clause. You can’t criticize anybody or raise your voice even as your workload keeps growing, even when you’re the only physician in the emergency department with multiple traumas, even when you’re seeing patients being put at risk and your colleagues being exploited.”

    As this hypothetical proves reality for more and more physicians, many are banding together to advocate for some of the policies Song recommends. A physician advocacy group called Take Medicine Back, for instance, is working to garner support for corporate practice of medicine laws.

    Burnt out, frustrated—and organizing

    In November, primary care physicians employed by Massachusetts’ largest health system, non-profit Mass General Brigham, cited the “corporatization of medicine” among their reasons for pushing to unionize. Across the country, a small number of doctors—around 70,000, representing 8% of the profession—already belong to a union. But that number has been growing steadily, and will likely continue to do so with the arrival of a new generation of physicians. Currently, 20% of medical residents—more than 32,000—belong to a union, a number that has doubled since 2019.

    But tighter regulations on private equity and corporations in health care can only achieve so much. Many experts believe deeper changes to health policy and investments in public health are equally needed. Examples include:

    • Higher reimbursements for public insurance, so that, in McGregor’s words, “small community hospitals that serve populations largely on Medicare or Medicaid can better meet their costs and remain in business without the private sector filling in”
    • Simplified health insurance systems, like those in the Netherlands and Switzerland, that use private insurance plans that are streamlined, with fewer choices, making them more transparent and easier to understand and regulate
    • Funding for non-medical social care, such as housing and food—in Rosenthal’s words, “social supports that make a big difference in people’s lives and that, when underinvested in, drive up our health care costs”

    ‘One of the biggest lies we’ve ever been told’

    These additional policy levers could help diminish for-profit health care’s influence, but by how much is a matter for debate.

    “At the end of the day, I think we’re always going to have this kind of mixed public and private system,” Rosenthal said. “Politically, it would be very challenging for us to go in a more government-focused direction. There’s just a lot of distrust. And the one big thing that’s quite different about our country is that we don’t consider health a right. It’s not in our constitution like it is for many of our peers.”

    But significant change may be on the horizon, driven by public discontent around health care and growing visibility, brought by cases like Steward, into the consequences of a system where profits can come at the expense of patient care.

    When health care follows the money, we get sicker and sicker.

    Alecia McGregor, assistant professor of health policy and politics

    “As a country, we’ve become desensitized to this notion that health care is the same as any ordinary commodity, and that the provision of health care can be run like any other business,” McGregor said. “I think this is one of the biggest lies we’ve ever been told, because we’ve seen health care costs skyrocket in a way that’s different from any of our wealthy country counterparts, yet our outcomes—life expectancy, maternal health, infant mortality—are abysmal. When health care follows the money, we get sicker and sicker.”

    “Surrendering our health care system to the for-profit marketplace was a fundamental error that we’re paying the debts of right now,” McDonough added. “But I see people working on it, reassessing the role and value of for-profits and asking what a post-neoliberal health care system might look like.”

    In the meantime, the story of Steward, now under new ownership and a new name, continues to unfold. Its physician network, made up of 5,000 doctors, was recently purchased by Rural Healthcare Group and rebranded as Revere Medical. Rural Healthcare Group is owned Kinderhook Industries, a private equity firm.

    For concerned patients, Rosenthal offered some concrete advice. “Find a provider you trust and be skeptical. Always ask about the benefits of an intervention. Because more services, more tests, more treatments are not always beneficial—but they’re always profitable.”

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