Health Journal Online

Category: Nutrition

  • 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.”

    Last Updated

    Get the latest public health news

    Stay connected with Harvard Chan School

    Source link

  • Cannabis, Strokes, and Heart Attacks? 

    Cannabis, Strokes, and Heart Attacks? 

    The temporary quintupling of heart attack risk associated with cannabis smoking may be due to increased heart rate, blood pressure, and carbon monoxide levels.

    Does “the dark side of cannabis”—both “synthetic and non-synthetic marijuana”—include stroke?

    There have been case reports of artery damage due to the “vasoconstrictor effect of cannabis,” which has been well documented. One study found cannabis users had a hundred times greater odds of suffering from multifocal intracranial stenosis, where the arteries inside our brain clamp down at multiple points, as you can see below and at 0:39 in my video Does Marijuana Cause Strokes and Heart Attacks?, but that’s a rare condition. What about strokes? 

    “The paucity [lack] of high-level evidence regarding the adverse effects of marijuana usage on cerebrovascular [brain artery] health has permitted the false notion that recreational marijuana is safe.” So, researchers decided to put it to the test in a study of millions of cannabis users and found that “recreational marijuana use is independently associated with 17% increased likelihood of AIS hospitalization,” that is, being hospitalized with an acute ischemic stroke, but that may only be among those who use cannabis regularly, “weekly or more often.”

    The reason we think it’s cause-and-effect is that the majority of recorded strokes were “during or shortly after marijuana exposure,” and there are even cases in which strokes recurred after re-exposure to marijuana. So, when you put all of that together, it makes a convincing case. Though, to be sure, you’d need to randomize people to use cannabis or a placebo. 

    It’s like the heart disease story. A similar “temporal” relationship has been found between marijuana use and the development of heart attacks and sudden cardiac death, meaning they seemed to occur while individuals were using cannabis or right after usage. “However, careful evaluation of the cardiovascular effects of marijuana inhalation is complicated by the fact that it is often used in combination with other drugs, such as alcohol or cocaine.” So, you can’t just ask heart attack victims if they were smoking pot at the time of a cardiac event and make the connection; you have to ask about other substance use, too. Within an hour of using cocaine, for example, the risk of having a heart attack goes up more than 20-fold.

    That’s about four times more than after smoking pot. The hour after you smoke marijuana, your heart attack risk appears to nearly quintuple, but only for that hour. Then, your risk drops down to normal. So what does this mean? Even though heart disease is our number one killer, the risk of having a heart attack every hour is only about one in a million for any particular hour. So, even if you light up a joint, which may quintuple your risk, that would only bump up the risk to about 1 in 150,000 and only for that one hour. Even if you smoked every day, your annual risk might just go up by a few percentage points. But why the increased risk at all?

    Well, we’ve known since the 1970s that within an hour of smoking a joint, our pulse rate goes up about 35 percent, as you can see below and at 3:20 in my video. Smoking a single joint also increases blood pressure, as well as carbon monoxide levels in the blood of angina patients, and it cuts their ability to exercise nearly in half. Now is that just because they’re breathing in smoke of any kind? No, smoking a placebo joint—that is, a marijuana joint from which the THC has been removed—only cuts down exercise capacity by about 9 percent. In contrast, after smoking an actual cannabis joint, the time the study participants could exercise before experiencing chest pain was cut by 48 percent. So, it does seem to be a specific drug effect. Is it as bad as tobacco? We found that out a year later. 

    “Smoking 1 marihuana [sic] cigarette decreased the exercise time until angina more than smoking 1 high-nicotine [tobacco] cigarette,” which only cut exercise capacity by 23 percent, compared to 50 percent after the joint. This may be because smoking marijuana seems to put more demand on the heart, so it’s no surprise that it was worse than tobacco.

    It may also be carbon monoxide. Smoking marijuana leads to nearly five times more carbon monoxide in the bloodstream than smoking tobacco. This is in part because, compared to cigarette smokers, cannabis smokers inhale more deeply and then hold in the smoke for longer, allowing more carbon monoxide into their system. So, the increased heart rate and pressure, the “cardio acceleration,” may account for the accelerated chest pain in heart disease patients.

    Does cannabis have any chronic effects on the arteries? Users do seem to have relatively stiffer arteries for their age, suggesting “an acceleration of the aging process.” We are only as old as our arteries.

    Even second-hand marijuana smoke may be harmful, according to a recent study in the Journal of the American Heart Association entitled, “One Minute of Marijuana Secondhand Smoke Impairs Vascular Endothelial Function,” meaning artery function. So, there was a call to protect “vulnerable populations, including elderly and disabled [multi-unit housing] MUH residents, pregnant women, and children.” But, that one minute of exposure to second-hand marijuana smoke was in rats, so it’s not clear how applicable this is to us beyond, perhaps, not smoking around your pets.

    I have a slew of other videos on cannabis if you’re interested. Check out the related videos below. 

    I first released these videos in a webinar, and you can find them all in a digital download here. 



    Source link

  • Managing PTSD symptoms at work

    Managing PTSD symptoms at work

    Having post-traumatic stress disorder (PTSD) can affect people in the workplace, but there are coping strategies that can help, according to Harvard T.H. Chan School of Public Health’s  Karestan Koenen.

    In a Dec. 12 Forbes article, Koenen, professor of psychiatric epidemiology, said that having PTSD at work can lead people to re-experience trauma, become avoidant, and experience emotional dysregulation. “Avoidance can look like poor performance or not caring if it leads to missing meetings or obligations,” she said. “Emotion dysregulation can show up exactly how it sounds—losing your temper at work or exploding at a colleague over something small.”

    She recommended several grounding, distraction, and relaxation techniques. Grounding can include feeling your feet on the floor or holding something with a comforting texture. She added, “Have a go-to video or music or something to distract your mind while the flashback runs its course. Really mastering breathing techniques that induce relaxation by practicing them every day (twice a day) is helpful.”

    Read the Forbes article: How To Deal With PTSD Symptoms At Work

    Last Updated

    Get the latest public health news

    Stay connected with Harvard Chan School

    Source link

  • Harvard Chan School faculty recognized among world’s most influential researchers

    Harvard Chan School faculty recognized among world’s most influential researchers


    Home / News / Harvard Chan School faculty recognized among world’s most influential researchers
    Exterior of Harvard T.H. Chan School of Public Health's Kresge building
    Harvard T.H. Chan School of Public Health’s Kresge building / Photo: Anna Webster

    More than 30 faculty members or researchers affiliated with Harvard T.H. Chan School of Public Health were named to Clarivate Analytic’s 2024 list of Highly Cited Researchers. The annual list includes researchers from around the world whose papers have been cited most often by their peers—in the top 1% of citations for a chosen field or fields.

    Worldwide, 6,886 researchers were named to the 2024 “highly cited” list. Those affiliated with Harvard Chan School are listed below. Thirteen Harvard Chan School faculty were identified as having exceptional performance across several fields. Their names are marked with an asterisk.

    They include: Rifat Atun*, Andrea Baccarelli*, David Bates*, Francesca Dominici*, Sarah Fortune*, Wendy Garrett, Edward Giovannucci, Christopher Golden*, William Hanage*, Miguel Hernan, Frank Hu, Curtis Huttenhower, Rafael Irizarry*, Ichiro Kawachi*, Karestan Koenen, Nancy Krieger, I-Min Lee, Marc Lipsitch*, Vasanti Malik*, Brendan Manning, JoAnn Manson, Vikram Patel, Alkes Price, Eric Rimm*, Shekhar Saxena, Meir Stampfer*, S.V. Subramanian, Elsie Sunderland, Tyler VanderWeele, Walter Willett, David Williams.

    Krieger was featured in a Q&A on the site as one of seven researchers whose work contributes to societal impact. She said, “As someone whose scientific work for health justice is not part of the mainstream research that dominates the public health and medical literature, I find it encouraging, from the standpoint of health equity, that my work is cited frequently enough to merit my being named a Highly Cited Researcher. It is an affirmation that my work is of use to others.”

    Last Updated

    Featured in this article

    Nancy Krieger

    Professor of Social Epidemiology

    Get the latest public health news

    Stay connected with Harvard Chan School

    Source link

  • STRIPED 2024 Newsletter: Advancing eating disorder prevention through advocacy, research, and youth voices

    STRIPED 2024 Newsletter: Advancing eating disorder prevention through advocacy, research, and youth voices

    Decorative image showing the word Newsletter alongside STRIPED's logo

    Discover the latest updates from the Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED) in our 2024 Annual Newsletter. This edition spotlights the inspiring work of youth advocates featured in the new documentary Generation Flex, the restoration of critical disordered eating questions into the CDC’s Youth Risk Behavior Surveillance System, and efforts to protect youth from harmful diet pills and muscle-building supplements. Through policy change, research, and youth-driven advocacy, STRIPED continues to push for meaningful progress in eating disorder prevention.

    Explore More:

    Join the Conversation:

    • Follow Us: Stay connected through our social media channels for real-time updates and community engagement.
    • Contact Us: For inquiries or to get involved, email us at STRIPED@hsph.harvard.edu.

    Last Updated

    Get the latest public health news

    Stay connected with Harvard Chan School

    Source link

  • Bone Fractures, Lung Cancer, and Vitamin B12 Supplements? 

    Bone Fractures, Lung Cancer, and Vitamin B12 Supplements? 

    What do randomized controlled trials of high-dose daily vitamin B12 supplementation show about its effects on cancer risk, death, and longevity? 

    In 2019, “Association of High Intakes of Vitamins B6 and B12 from Food and Supplements with Risk of Hip Fracture Among Postmenopausal Women in the [Harvard] Nurses’ Health Study” was published. Note, though, that only the combined high intake of vitamins B6 (≥35 mg/day) and B12 (≥20 mcg/day) was associated with an increased hip fracture risk. We know that treatment with high doses of vitamin B6 may increase hip fracture risk on its own. After a decade or so, those who had been taking high-dose (40 mg) B6 supplements had about a 40 percent higher hip fracture risk, but not those taking B12, as you can see below and at 0:35 in my video Do Vitamin B12 Supplements Cause Bone Fractures and Lung Cancer?.  

    That’s what the Harvard study found, too. High intake of vitamin B12 alone was not associated with increased risk. In fact, some observational studies suggest a slightly lower fracture risk at high B12 blood levels. What we care about most, though, are interventional studies, where people are randomized to B12 so we can see what happens, and when we look at those, we find there is no increased fracture risk among those given B12. In conclusion, based on randomized controlled trials, high doses of vitamin B12 have not been shown to be associated with the risk of fractures.

    Okay, but what about this? In 2017, a study found that men taking vitamin B12 supplements appeared to have increased lung cancer risk. Now, the researchers didn’t find any such association in women, and the increased risk was mostly among men who smoked. Could it be that B12 was feeding budding tumors? It’s hard enough imagining a vitamin being carcinogenic on its own, especially if it somehow only affects men and not also women. “Replication of these findings in additional prospective studies with careful measurement of B vitamin supplement use is warranted.” And, indeed, when you put together all the observational studies, there is no significant correlation between lung cancer and levels of B12 in the blood, whether you’ve smoked or not. If anything, most studies seemed to trend towards higher B12 levels being protective, as you can see below and at 2:03 in my video. 

    Then, in 2018, a new study found an association between overall lung cancer risk and higher circulating levels of B12, again appearing to be more of a concern with smokers, as seen here and at 2:16 in my video. 

    Now, this was another observational study. Those with higher B12 levels were just observed to have higher cancer levels. Those of you who have been following my work know the drill: There are two potential issues that arise in observational studies that prevent us from ascribing cause-and-effect: confounding factors, also known as “lurker variables,” and reverse causation.

    What might be a lurker variable in this case? What might be a third factor associated with both higher B12 levels and cancer that may be the true cause? Well, who has higher levels of B12 circulating in their blood? Those who eat a lot of meat and dairy, which are, in fact, “the most important contributors to serum vitamin B-12,” that is, B12 in our blood. And those who eat more meat do tend to have more lung cancer: “Dose-response analysis showed that consumption of red meat for 120 g per day might increase the risk of lung cancer by 35%, and consumption of processed meat for 50 g per day might increase the risk of lung cancer by 20%.” So, we’re generally talking about 35 percent more risk for every quarter-pound burger eaten each day and about 20 percent increased risk for every breakfast sausage link. It’s no wonder those with higher B12 levels in their blood could have more lung cancer. The B12 could just be a marker for meat intake.

    And, if you remember, reverse causation is when X may not lead to Y, but, instead, Y may lead to X. So, instead of high B12 blood levels leading to cancer, maybe cancer leads to high blood levels of B12. And, indeed, nearly 75 percent of patients diagnosed with cancer exhibit elevated B12 levels. So, elevated B12 levels may simply be a marker for cancer. Besides taking extra B12, there are all sorts of reasons your levels can rise, such as liver problems, kidney problems, bone marrow problems, and cancer, as you can see below and at 3:50 in my video. So, high B12 levels may just be a marker of brewing, but not yet diagnosed, cancer. 

    What about observational studies specifically linking B12 supplement use to lung cancer, though? Those could also be reverse causation: “The consequence of being at risk for cancer is that patients will engage in healthier behaviors, including taking multivitamins (reverse causality). The well-established causes, such as smoking, chronic obstructive pulmonary disease, and previous cancers, are the real lung cancer risks.” So, we’re left with this “chicken or the egg causality dilemma,” which is why, ideally, we need randomized controlled trials to see if there’s any cause and effect.

    This became even more urgent with genetic evidence suggesting that those born with higher lifelong levels may be at increased risk. Thankfully, as you can see below and at 4:47 in my video, we do have randomized controlled trials—more than a dozen randomized controlled trials randomizing thousands of people up to 2,000 micrograms of B12 every single day for years, in fact. 

    The findings? “Vitamin B supplementation does not have an effect on cancer incidence, death due to cancer, or total mortality.” And this includes specifically looking at lung cancer, as seen below and at 5:02 in my video. In fact, if anything, vitamin B supplements may actually lower the risk of the most dangerous form of skin cancer. 

    If you missed my previous video, check out Do Vitamin B12 Supplements Cause Acne?.

    For my other B12 updates, see related posts below. All of these videos can be found in one digital download: Latest Vitamin B12 Recommendations.

    I’ve also explored vitamin B12’s role in stroke risk. See the related posts below. That series is available for digital download, too: Why Do Vegetarians Have Higher Stroke Risk?.



    Source link

  • Managing Mental and Emotional Health

    Managing Mental and Emotional Health

    Reviewed by Brian St. Pierre, MS, RD and Helen Kollias, PhD

    It’s like my thoughts were under a pile of garbage.

    On a Friday night, as my husband and I tried to figure out where to eat, a typical conversation would go like this:

    Me: Do you want to go to that restaurant?

    Him: What restaurant?

    Me: I can’t think of the name. We’ve eaten there before. It’s that place with the peanut shells on the floor? It’s next to… You know… It’s on that road where we used to take the dog to the vet. Do you know the one I’m talking about??

    It was as if certain details got lost in a pile of sludge in the deep recesses of my brain. Then, hours later, the details would escape, and I’d shout into an empty room…

    “Texas Roadhouse!”

    Sludginess with proper nouns is typical for people who are middle-aged and beyond.

    However, what seemed to be happening to me, increasingly in my late 40s and early 50s, felt far from typical.

    Not only could I never seem to spit out the names of various restaurants or people or books or movies or so many other things, but my brain was also pooping out during the workday.

    I’d sit in front of my computer screen, stare at a document, and will myself to do something constructive with my fingertips. Everything seemed hazy, like those first few moments in the morning when you’re awake enough to turn off the alarm but too sleepy to do basic math.

    I had my good moments, usually in the morning, when I attempted to pack eight hours of writing into the two or three hours I possessed mental clarity.

    On my worst days, however, I awoke with a haze I never managed to shake. Work was a non-starter. Nor did I have enough bandwidth to read, or do much of anything, really.

    I sought medical advice.

    Three healthcare professionals recommended antidepressants. I tried one, and felt even worse. I tried another. I tried yet another at a higher dose. Still, I felt like a zombie. Another professional gave me a sleeping pill. It left me feeling even more drugged.

    Someone tested my thyroid. There was nothing wrong with it. Nor was I anemic. I tried supplements, mushroom coffee, and just about any product with the word “think” somewhere on its label.

    Finally, after nearly two years of seeing a revolving door of doctors, I made an appointment with a gynecologist for my yearly exam. I mentioned vaginal dryness. That information triggered her to ask a string of questions that had nothing to do with my undercarriage. How was my sleep? Mood? Energy levels? Was I experiencing hot flashes? How about brain fog?

    “Funny you should mention brain fog,” I said in my usual hazy monotone. “I feel like I’m barely alive.”

    By the end of the visit, I understood that I’d likely never had depression.

    What I “had” was menopause.

    My gynecologist sent me home with prescriptions for estradiol and progesterone.

    Within days, it was as if someone had flipped a switch.

    I could think again. I could type words again. I could follow conversations. I could work past noon.

    And, for the first time in years, I could sleep more than two hours without waking.



    Over 150,000 health & fitness professionals certified

    Save up to 37% on the industry’s top nutrition certification

    Help people improve their health and fitness—while making a great full-time or part-time living doing what you love.

    Now, menopause isn’t a medical condition.

    Nor is it a disease.

    Instead, like puberty, it’s a life stage—a transitional moment to be precise.

    Once you’ve gone 12 consecutive months without a period, you’ve reached menopause. And from that moment onwards, you’re officially “postmenopausal.”

    As women approach this transitional moment, hormone levels fluctuate and fall, triggering dozens of symptoms. Weight gain and reduced sex drive get a lot of attention.

    However, during and after menopause, roughly 40 percent of women report increased irritability, mood swings, anxiety, fatigue, and trouble concentrating, according to the American College of Obstetricians and Gynecologists.1 2 As the following image shows, it’s also one of the most vulnerable times in a woman’s life to develop depression,3 particularly if they’ve struggled in the past with it before.

    Graph shows men and women's risk of depression across the lifespan. While men's risk remains relatively stable across adulthood (and also lower than women's risk overall), women's risk peaks around the perimenopausal years, before declining around age 50.

    Before starting hormones, I often found myself sobbing for no reason. Other times, the world’s stimuli felt too… stimulating.

    Normal everyday sounds—like the buzz of traffic or people at the mall—literally hurt. I was jumpy and irritable and felt anxious about situations that had never bothered me in the past, such as driving over bridges or through construction.

    It’s not completely clear what drives these cognitive and emotional symptoms.

    Fluctuating hormone levels likely play a role, as do typical age-related changes in the brain.

    In addition, during this stage of life, women often deal with several issues that siphon cognitive capacity faster than a thirsty vampire drains a carotid.

    During their 40s and 50s, for example, many women have reached the peak of their careers, with responsibilities that follow them home and keep them up at night. They may also be parenting angst-filled teens, caring for aging parents, adjusting to an empty nest, questioning their marriage, or trying to wrap their bank account around the latest statement from the college bursar or hospital billing department.

    However, one of the lesser-known and talked about triggers for cognitive discontent has nothing to do with aging or life stress and everything to do with that hallmark menopausal symptom: the hot flash.

    Anatomy of a hot flash

    Hot flashes, which happen during the day, and night sweats, which occur at night, fall under the category of vasomotor symptoms. (The word “vasomotor” refers to the constriction or dilation of blood vessels which, in turn, can influence everything from blood pressure to sweating.)

    During a hot flash or night sweat, norepinephrine and cortisol levels rise. Blood vessels dilate in an attempt to shed heat. Blood pressure and heart rate increase.

    Depending on the severity of the hot flash, your skin might redden as sensations of warmth spread through your face, neck, and chest.

    You might sweat, experience heart palpitations, or feel anxious, tired, or faint.4

    It’s not entirely clear why hot flashes crop up around menopause.

    According to one theory, falling estrogen levels affect the hypothalamus, the area of the brain involved in temperature regulation. The brain’s internal thermostat gets wonky and occasionally thinks your body is too hot or cold (when it’s not).

    How vasomotor symptoms change the brain

    For many years, experts thought of vasomotor symptoms as mere inconveniences or sources of embarrassment.

    (To be honest, so did I. During all of those fruitless visits to various healthcare professionals, it never occurred to me to mention them.)

    However, an increasing body of research has revealed that hot flashes may do more than make us uncomfortable or force us to change our sheets in the middle of the night.

    They may also affect our blood vessels and brains—and not for the better.5 For this reason, an increasing number of experts now consider vasomotor symptoms to be a treatable medical condition.6 7 8

    Hot flashes and brain lesions

    In one study, researchers asked 226 women to wear monitors that tracked when they were experiencing a hot flash. The women also underwent magnetic resonance imaging (MRI), filled out sleep diaries, and wore smartwatches that recorded how often they woke at night.9

    As researchers looked at the brain images obtained from women who experienced the most hot flashes, they noticed an abundance of patchy areas called whole-brain white matter intensities.

    These lesions were once thought of as a typical consequence of aging. However, neuroscientists now believe that the presence of whole-brain white matter intensities is predictive of future cognitive decline.

    People with an abundance of these brain lesions are twice as likely to get diagnosed with dementia and three times as likely to have a future stroke.10

    The blood vessel connection

    It’s thought that the increased presence of whole-brain white matter intensities may stem, in part, from changes taking place in the blood vessels that feed the brain.

    A three-year study of 492 women supports that theory. It determined that women who experienced frequent hot flashes also tended to experience unhealthy changes in their blood vessels, such as an inability to dilate to accommodate increased blood flow.11

    Other research has linked frequent hot flashes with increases in the following:

    • Thickening in the carotid arteries that supply blood to the brain, face, and neck12
    • Body fat
    • Total and LDL cholesterol
    • Insulin resistance13 14 15 16

    The sleep connection

    In addition to directly affecting the blood vessels, frequent hot flashes may also affect the brain by disturbing sleep.17

    Interestingly, many women don’t necessarily know that hot flashes are disturbing their sleep.

    They may instead—as I did—assume they have insomnia or sleep apnea.

    That’s because night sweats aren’t always sweaty.

    By the time a surge in cortisol and norepinephrine jolts a woman awake, the hotness of the flash may have dissipated. So, it can feel as if she’s repeatedly waking, over and over and over again, for no discernable reason.

    These frequent awakenings may interfere with the brain’s ability to consolidate memories, metabolize toxins, and store all the names, dates, and facts one encounters daily.

    It can also lead to lost connectivity in the hippocampus, a part of the brain that’s important for learning and memory.

    Sleep loss also means the amygdala, a part of the brain involved in emotion, becomes more reactive, causing people to feel more easily stressed, anxious, irritable, frustrated, or enraged.18 19

    All of these brain changes can set in after just days to a week of lost sleep. So, imagine what happens when you’ve been waking over and over again—for years.

    Why it can be hard to get help

    To diagnose depression, healthcare professionals use a tool called the Patient Health Questionnaire (PHQ-9) depression scale. If you check off four of the nine symptoms on the scale, you’re considered depressed.

    However, four of the symptoms on the checklist also overlap with the symptoms of menopause-related sleep deprivation:

    • Little interest or pleasure in doing things
    • Trouble falling or staying asleep
    • Feeling tired or having little energy
    • Trouble concentrating on things, such as reading the newspaper or watching television

    Check off those four items, and you might be diagnosed with depression, even if what’s really ailing you is the battle with sleep you’ve been waging since you turned 47.

    A lack of menopause-specific training

    Another problem: On surveys, 80 percent of medical residents admit they feel “barely comfortable” talking about menopause.20 In addition, few residency programs—including ob-gyn residency programs—offer training in it.21

    Given the above, it’s no wonder so many healthcare professionals never think to ask about hot flashes or sleep disturbances when people like me show up complaining of fatigue, lack of gumption, and an inability to focus.

    In addition, even when it’s clear that vasomotor symptoms are leading to cognitive and emotional symptoms, many healthcare professionals still shy away from prescribing menopausal hormone therapy (also called hormone replacement therapy, or HRT), often telling women that supplemental hormones are “not safe” or “too risky.”

    These professionals are practicing what Michigan-based menopause-trained gynecologist Jerrold H. Weinberg, MD, calls “defensive medicine.”

    “It’s one of the first reflexes doctors have when they recommend a treatment,” says Dr. Weinberg. “They worry they’re going to get sued.”

    What the research actually says about hormone therapy

    These worries are based on research done several decades ago that linked the use of certain types of hormones with a slightly increased risk of developing breast cancer or stroke.22

    However, according to more recent research, that small increased risk seems to depend on several other factors, such as age, dose, the type of hormonal preparation, and the duration of hormone use.23 24

    As long as you’re younger than 60 and have been postmenopausal for fewer than 10 years, many experts now say the benefits outweigh the risks for women with moderate to severe menopausal symptoms.25

    It’s also counterbalanced by health benefits such as reduced risk of developing Alzheimer’s disease or osteoporosis, says Dr. Weinberg, who confirms the health benefits of menopause hormone therapy far outweigh the risks for most women.

    Because some antidepressants can lift mood, improve sleep, and reduce hot flashes, some healthcare professionals turn to them instead of menopause hormone therapy. As with any medicine, antidepressants have their own list of side effects. However, for someone practicing defensive medicine, they often seem like a safer bet, says Dr. Weinberg.26 27 28

    How to advocate for your health

    If you or your client are on what seems like a never-ending quest to find a healthcare professional who understands menopause, use the following advice from Dr. Weinberg and Helen Kollias, PhD, an expert on physiology and molecular biology and science advisor at Precision Nutrition and Girls Gone Strong.

    ▶ Seek care from a menopause-trained health professional.

    Usually, these professionals list this training and interest in their bio. For example, they might list “menopause” as an area of focus.

    You can also search this database for practitioners who have earned a certification from the Menopause Society.

    ▶ Document your symptoms.

    Write them down. That way, if you feel foggy or nervous during your appointment, you can lean on your notes.

    This information can also help you judge whether MHT or another medicine is working. Based on your symptom data, you and your healthcare professional may decide to switch to a different medicine or change your dose.

    Consider tracking:

    • How often you get hot flashes
    • The number of hours in a typical day you find yourself battling brain fog
    • How often you experience fatigue, anxiety, rage, or some other symptom
    • How often you wake up at night

    ▶ Be as specific as you can during your appointment.

    Saying something like “I don’t sleep well,” is less likely to get you the right kind of help than saying, “During the past seven days, I’ve only gotten four uninterrupted hours once. I wake, on average, five times a night. On a typical night, my longest stretch of sleep is three hours.”

    If you use a smartwatch, come ready to fire up your health app, so your healthcare professional can see the data.

    ▶ Talk about the pros and cons of treatment.

    There’s a concept in medicine known as “shared decision-making.” Part of that process involves frank discussions about the benefits and risks of a given treatment. Then, patients and clinicians work together to make decisions based on those benefits and risks.

    Many healthcare networks encourage clinicians to use shared decision-making, as it seems to reduce patient complaints as well as malpractice lawsuits.29 30

    For this reason, shared decision-making can help shift a healthcare professional out of the “defensive medicine” mindset.

    You might ask questions like:

    • “I’m interested in seeing if menopausal hormone therapy might be helpful. Could we discuss if I’m a good candidate?”
    • “I’ve read that menopausal hormone therapy could slightly increase my risk of breast cancer. Could you help me understand my personal breast cancer risk based on my family history, age, body weight, and lifestyle?”
    • “Osteoporosis runs in my family, as does dementia. I’ve heard that menopausal hormone therapy might help to reduce the risk for both, in addition to helping me sleep. Could you help me weigh the pros and cons?”

    How to improve mental and emotional health during menopause: 9 lifestyle strategies

    The lifestyle habits that improve mental and emotional health during menopause aren’t terribly different from the lifestyle habits that improve overall health—for any person, at any stage of life.

    Other than avoiding caffeine, alcohol, and spicy or hot foods, there’s no special diet for people with vasomotor symptoms. (And by the way, tofu and other soy products don’t seem to help with vasomotor symptoms as much as once thought30—though they’re still nutritious.)

    Strategy #1: Lean into fundamental health strategies.

    Healthy behaviors don’t necessarily change during middle age.

    Nutrition, physical activity, stress management, sleep, social connectedness, and a sense of purpose matter just as much during the menopausal transition as they do when we’re younger. However, these fundamentals are even more important to dial in as life progresses.

    So consider:

    • Are you setting aside enough time for sleep and rest?
    • Are you physically active?
    • Are you eating a diet that’s mostly minimally processed and full of brightly colored produce, healthy fats, lean protein, fibrous vegetables, and legumes?
    • Do you regularly connect with other humans in ways that help you buffer stress and feel supported?
    • Do you find ways to experience awe, joy, curiosity, peace, and purpose?

    If you answered “no” to some or all of those questions, consider why that is. What’s stopping you? How might you remove barriers or shore up support to make those fundamentals easier?

    Strategy #2: Experiment with creatine.

    In addition to helping to blunt age- and hormone-related losses in muscle and bone mass, creatine may also help bolster mood and brain function while reducing mental fatigue.

    It also seems to counter some of the negative effects of sleep deprivation. 32 33 Research shows a daily dose of 5 to 7 grams of creatine monohydrate is effective.

    Strategy #3: Get regular about light exposure.

    In addition to helping you feel alert, sunlight helps to set the internal clock in your brain that makes you sleepy at night and spunky in the morning. Morning and late afternoon light exposure seem particularly potent.

    In a study of 103 people, exposure to morning sunlight predicted better sleep quality the following night. When people spent time outdoors in the mornings, they fell asleep more quickly, slept longer, and experienced fewer awakenings the following evening.34

    Sunlight may also improve mood and concentration.35

    Strategy #4: Go easier at the gym.

    If you’re already worn out, long, intense exercise sessions will likely make you feel worse.

    For one, injuries crop up much more easily at middle age than during our 20s and 30s. In addition, it takes longer to recover between sessions.36

    String too many overly zealous workouts too close together, and you’ll not only likely start to feel achy but also more irritable, tense, and tired.

    However, much like a cold shower, short bursts of exercise may help you to feel alert during the day.

    If you’re falling asleep at your desk, encourage yourself to take short movement breaks such as a 5- or 10-minute walk outdoors or a quick set of pushups or squats.

    In addition, you may find gentle exercise—such as yoga or stretching—helps you relax before bed. Just don’t make it too intense, or you’ll trigger a release of adrenaline.

    Whenever you exercise, tune into how your body feels, especially after a particularly bad night of sleep.

    We’re not saying you should never exercise vigorously or try to beat your lifting PRs. However, depending on your sleep and recovery, you might want to pare things back, especially if you’ve traditionally hit the gym hard.

    You can still do intense sessions—just balance them out with more moderate sessions, as well as proportionate recovery.

    Depending on how you feel, you might decide to go all out, as usual.

    However, you might also decide to do a zone 2 training session instead of an intense run. Or, if you’re resistance training, you might still do your planned session, but reduce the number of sets, reps, or volume lifted.

    Strategy #5: Investigate Cognitive Behavior Therapy for Insomnia (CBT-I).

    This research-based therapy for insomnia can help you develop skills and mental reframes that encourage sound sleep.

    For example, a CBT-I therapist will help you develop the skill of getting up at the same time every day, regardless of how badly you slept (or didn’t sleep) the night before.

    (Read more: Three CBT-I skills that can transform how you sleep.)

    Strategy #6: Get real about stress.

    You may not have the energy (or desire) to do everything you did when you were younger. (When you were 36, your daily checklist defied time and space.)

    As a result, you might benefit from looking critically at your current responsibilities to see which ones you can shrink or downsize. For several days, track how you spend your time and bandwidth. Then, analyze your data.

    Ask yourself:

    • Is this how you truly want to spend your time and energy?
    • Does your current schedule allow you to rest, recover, and tend to your own needs? Or, do you spend nearly all of your time and energy caring for and providing for others?
    • What changes could you make to prioritize rest and recovery?

    If you’re a coach, use the Wheel of Stress Assessment to help clients identify different dimensions of their life that might be draining their mental and emotional capacity. (When you know specifically where your stress is coming from, you have a better chance of resolving it.)

    If it’s demands from other people that prevent you from prioritizing self-care and recovery, you might like to read: How saying “no” can seriously change your life.

    Strategy #7: Experiment with cooling technology.

    You might find you sleep better and experience fewer night sweats if you sleep in a cooler environment.

    Try turning down the thermostat a couple of degrees, using a fan, or investing in an electric cooling mattress pad.

    Strategy #8: Take frequent breaks.

    When you feel the fog take over your brain, it’s not likely you’ll be doing “your best work” anyway.

    So, for a block of time—say, 20 minutes—permit yourself to do nothing. You might:

    • Relax with a cold beverage
    • Cuddle with a pet
    • Gaze out a window
    • Sit outdoors while listening to the birds
    • Call a friend

    If you need a quick “refresh,” you can also try a 5-minute mind-body scan.

    Get your body into a comfortable position. For example, you might use the yoga “legs up the wall” pose or lie down and place a pillow under your knees.

    Then, close your eyes and bring your attention to physical sensations in your body. Start at your head, and work your way down to your toes.

    Don’t judge or rush to change anything. Just observe, like a scientist. You can also scan your mind, for example, by noticing thoughts.

    When you’ve completed the scan, consider:

    • What are you feeling physically?
    • What are you feeling emotionally?
    • What are you thinking?

    You don’t have to “do” anything with the information you uncover, just notice.

    Strategy #9: Follow a diet that promotes healthy circulation.

    The foods that protect the blood vessels around your heart can also protect the blood vessels in your brain.

    For example, both the MIND and Mediterranean diets are associated with a reduced risk of Alzheimer’s disease and depression.37 38 These eating patterns are rich in vegetables, fruit, whole grains, olives, beans, fish, and other minimally-processed whole foods.

    In addition, nitrate-rich foods like beets and dark, leafy greens may help to dilate blood vessels, temporarily improving memory by helping more blood to reach the brain.39 40

    (For more on how our diet can support brain function and emotional regulation, read: Nutrition and mental health: What (and how) to eat)

    The upside of menopause

    It’s frustrating when you feel like you can’t do it all.

    Believe me. I know.

    However, this stage of life presents a hidden opportunity, forcing you to re-evaluate what’s most important.

    Before going on hormones, as my ability to type coherent words and phrases diminished, I was forced to ask an important question:

    Do I really need to be doing this?

    It was more of an existential question than a career-related one, and it allowed me to reassess how I wanted to spend my limited mental resources.

    Given that I was self-employed, I didn’t actually need to be working eight hours a day. That was a gift, wasn’t it?

    Maybe I also didn’t need to cook dinner six nights out of seven. Maybe the recipes I chose could be simplified, too.

    Finally, maybe saying “no” a lot more often and without regret would allow me to continue to say yes to the things that mattered most.

    Things like visiting my aging parents.

    And picking up the phone whenever my kid called from college.

    Or meeting a friend for a meandering walk around town.

    Thanks to the hormones and life tweaks, I now have energy again. I’m also clear-headed most of the time. However, I still tend to end my work day around 3 p.m.

    Why?

    Because I can, and I want to.

    References

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

    Source link

  • Study opens door to a rethink of colonoscopy guidelines — Harvard Gazette

    Study opens door to a rethink of colonoscopy guidelines — Harvard Gazette


    A new analysis of nearly 200,000 adults shows that those with a clean result on their first colonoscopy may not need another for longer — perhaps significantly longer — than the current recommendation of 10 years.

    The result is a bit of good news about a cancer whose increasing rates in younger patients has worried experts, including the Harvard Chan School’s Mingyang Song, for several years. Colorectal cancer is the nation’s second-deadliest after lung cancer, killing an estimated 52,550 in 2023. While rates among older patients have been declining, younger patients — those 40 to 49 — have seen cases rise 15 percent between 2000 and 2026. Experts aren’t sure of the cause, but in 2021, the U.S. Preventive Services Task Force lowered the recommended age of first screening to 45 from 50. They also recommend that those with average risk get screened 10 years afterward.

    Song, an associate professor of clinical epidemiology and nutrition at the Chan School, said that the increase in screenings has also increased appointment wait times.

    “Especially with the lowered age, the clinic is overwhelmed,” said Song, also an associate professor at Harvard Medical School. “It was overwhelmed before, now it’s even worse.”

    In the work, published last month in JAMA Oncology, Song and colleagues examined colorectal cancer screening results and colorectal cancer incidence among 195,453 participants in three long-running studies: the Nurses’ Health Study, Nurses’ Health Study II, and the Health Professionals Followup Study. They compared incidence between two groups: those who received negative results in their initial colorectal cancer screening — meaning no polyps or cancer — and those who had not yet been screened.

    They found that the risk of developing colorectal cancer was significantly lower among those who had received a negative cancer screening than those who had not yet been screened. The research team, led by first author Markus Knudsen, a postdoctoral fellow in Song’s lab, then divided the negative screening result group according to lifestyle risk factors for colorectal cancer. The work was supported in part by the National Institutes of Health.

    The results showed that it took 16 years for those with a negative screening result and an intermediate-risk lifestyle to have the same colorectal cancer incidence of the unscreened group at 10 years. Those with negative screening and a low-risk lifestyle — including a healthy diet and exercise — didn’t reach the 10-year cancer incidence of the unscreened group until 25 years from their negative screening.

    The results, Song said, show that cancer screening should be individualized and discussed between patient and physician. While it is likely that additional evidence will be needed before national screening guidelines are changed, those with a negative screening result may be able to safely extend the screening interval beyond the recommended 10 years and, for those also living a low-risk lifestyle, perhaps as long as 20 years.

    What this more tailored approach would do, Song said, is spare those who might get little benefit from a colonoscopy while focusing increasingly scarce resources where they’re most needed: on people who’ve never been screened — only about 70 percent of eligible U.S. adults have been screened — on disadvantaged groups with historically lower screen rates, and on those whose lifestyle or family history puts them at increased risk.  

    “What we have seen generally is that the more advantaged groups of individuals are more likely to receive colonoscopy, whereas those who are disadvantaged and who actually have a higher risk of developing colon cancer are less likely to receive colonoscopy,” Song said. “We’ve tried to correct this mismatch and improve colonoscopy delivery at the population scale.”


    Source link
  • Acne and Vitamin B12 

    Acne and Vitamin B12 

    Acne can be triggered in one in ten people who get vitamin B12 injections.

    “Acne is a disease unique to humans.” Why do we even get it? Well, think about the distribution of those greasy sebaceous glands. They’re “on the face, chest and back; these are exactly the same structures that pose the greatest obstruction during childbirth…Having extra lubrication at these sites would help make the baby more slippery for birth conferring a selective advantage to successful delivery.” Perhaps, but what triggers them to become inflamed into pimples later in life?

    “In westernized societies, acne vulgaris is a nearly universal skin disease afflicting 79% to 95%” of teens. Not even a single case could be found in some populations where more “traditional” diets are eaten (i.e., minimally processed, high-carb, low-fat diets). “Nutrition counseling” has been suggested “as a first-line or adjunctive therapy…for individuals with mild to moderate acne.” It looks like high glycemic foods and dairy products are “exacerbating factors,” so we’re talking about sugar, soda, refined junky carbohydrates, white flour, breakfast cereal, and dairy products, like milk, cheese, yogurt, and whey, as well as saturated and trans fats, which are concentrated in meat, dairy, junk, and fast food. You can see a table detailing this below and at 1:21 in my video Do Vitamin B12 Supplements Cause Acne?.

    “Acne patients should be encouraged to discontinue any whey protein supplements they might be taking,” for example. “The relationship between milk and acne severity may be explained by the presence in dairy of normal reproductive [sex] steroid hormones or the enhanced production of polypeptide [growth] hormones such as IGF-1…” What if you gave up dairy a month ago and there’s still no change? “It should be noted that changes in acne due to any pharmaceutical treatment or dietary changes are likely to take at least 10 to 12 weeks,” so you have to stick with it.

    “Acne patients,” not surprisingly, “were more than twice as likely to have a non-vegan diet compared with controls,” but the difference did not reach statistical significance. Were the vegans eating a lot of vegan junk? Maybe, but what about the paper entitled, “Vitamin B-12 Induced Acne”? Mammalian herbivores, including nonhuman primates like gorillas, and our fellow great apes, get all the B12 they need by practicing coprophagy, the eating of feces, but my preference would be to take B12 supplements. And you don’t have to worry about getting too much because it’s been reported that “there are no reports of adverse effects associated with excess B12 intake”—but that’s not true. First described back in the 1950s, acne erupts in about one in ten people within days or even hours of getting an injection of vitamin B12, which then disappears rapidly when injection “treatment is discontinued.”

    At the time, we had no idea what the mechanism might be, and the problem remained unsolved until just a few years ago when we finally figured it out: Vitamin B12 modulates the gene expression of the skin bacteria that cause acne. Researchers swabbed the skin of ten people before and after being injected with vitamin B12. As you can see below and at 3:20 in my video, it turns out that the level of B12 on our skin is proportional to the level in our blood, so, after a B12 injection, the bacteria on our skin have to make less of their own B12. As a result, the acne bacteria could concentrate instead on using their cellular machinery to churn out more compounds to attack our face and “induce inflammation in acne.” 

    Indeed, as you can see here and at 3:53 in my video, without excess B12 on the skin (with B12 shown in green), the bacteria have to make most of it on their own at the expense of porphyrins (shown in red), which can trigger acne inflammation. When there is a lot of B12 floating around, the bacteria don’t have to waste resources and, instead, can focus on trying to pimple you up. 

    So, what do you do? We know that individuals on plant-based diets have to take supplemental B12, but we don’t have to get injections. Vitamin B12-related acne tends to occur only “in dosages in excess of 5 to 10 mg per week.” That’s 5,000 to 10,000 micrograms a week, which is well in excess of the 50 micrograms a day or, alternately, the 2,000-microgram single weekly dose that I recommend. The only time you should be taking 5,000 to 10,000 micrograms a week is if you are treating B12 deficiency. If you remember from my previous video, B12 deficiency is treated with 1,000 micrograms a day for a month or more, as shown below and at 4:35 in my video, and that could potentially trigger acne. 

    For example, a vegan woman who hadn’t been taking B12 developed a deficiency and had to be treated with such high doses of the vitamin that her face erupted in acne, as you can see at 4:49 in my video. All the more reason not to become B12-deficient in the first place. But, even if you do get B12 injections, the likelihood of it triggering acne may only be about one in ten.

    For background and my updated recommendations, see my extended look at vitamin B12 in the related posts below. All of these videos can be found in one digital download. Check out Latest Vitamin B12 Recommendations.

    I previously explored vitamin B12’s role in stroke risk, which you can also see in the related posts below. That series is available for digital download, too: Why Do Vegetarians Have Higher Stroke Risk?.

    Up next is Do Vitamin B12 Supplements Cause Bone Fractures and Lung Cancer?.



    Source link

  • Eating to Reverse Heart Failure 

    Eating to Reverse Heart Failure 

    An entire issue of a cardiology journal dedicated to plant-based nutrition explores the role an evidence-based diet can play in the reversal of congestive heart failure.

    It is a hopeful sign of the times when an entire issue of a cardiology journal is not just dedicated to nutrition, but to a plant-based diet in particular. Dr. Kim Williams, past president of the American College of Cardiology, starts his editorial with a quote attributed to the philosopher Arthur Schopenhauer: “All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” He goes on to write that “the truth (i.e., evidence) for the benefits of plant-based nutrition continues to mount.” We’ve got the evidence. The problem is the “inertia, culture, habit, and widespread marketing of unhealthy foods. Our goal must be to get the data out to the medical community and the public where it can actually change lives—creating healthier and longer ones.” That’s essentially my life’s mission in four words: Get the data out. Based on what we already know in the existing medical literature, “plant-based nutrition…clearly represents the single most important yet underutilized opportunity to reverse the pending obesity and diabetes-induced epidemic of morbidity and mortality,” meaning disease and death.

    As I discuss in my video How to Reverse Heart Failure with Diet, the issue featured your typical heart disease reversal cases, including a 77-year-old woman with such bad heart disease that she couldn’t walk more than half a block or go up a single flight of stairs. She had severe blockages in all three of her main arteries and was referred to open-heart surgery for a bypass. However, instead of surgery, “she chose to adopt a whole-food plant-based diet, which included all vegetables, fruits, whole grains, potatoes, beans, legumes and nuts.” Even though “she described her previous diet as a ‘healthy’ Western one,” within a single month of going plant-based, “her symptoms had nearly resolved”—and forgot about walking a block. “She was able to walk on a treadmill for up to 50 min without chest discomfort or dyspnea,” becoming out of breath. Her cholesterol dropped about a hundred points from around 220 mg/dL (5.7 mmol/L) down to 120 mg/dL (3.2 mmol/L), with an LDL under 60 mg/dL (1.5 mmol/L). Then, four to five months later, she must have started missing her “chicken, fish, low-fat dairy and other animal products” and “returned to her prior eating habits.” Within a few weeks, with no change in her medications or anything else, her chest pain returned and she went on to have her chest sawed in half after all. After the surgery, she continued to eat the same diet that had contributed to causing her disease in the first place, then went on to have further disease progression.

    Another case featured in the journal has a happier ending. It started out similarly: A 60-year-old man with severe chest pain after walking just half a block decided to take control of his health destiny and switched to a whole food, plant-based diet. “He described his prior diet as a ‘healthy’ diet of skinless chicken, fish, and low-fat dairy with some vegetables, fruits, and nuts”—a diet that had been choking off his heart. Within a few weeks, he experienced the same amazing transformation—from not being able to exercise at all to walking a mile, then being able to jog more than four miles (6.4 km), completely asymptomatic, off all drugs, without any surgery, and off to live happily ever after.

    Now, of course, case reports are just glorified anecdotes. What we need is a randomized controlled trial to prove that heart disease can be reversed with lifestyle changes alone. Guess what? There was one published three decades ago, proving angiographic reversal of heart disease in 82 percent of the patients. Their arteries opened up without drugs and without surgery. So, these case reports are just to remind us that hundreds of thousands of individuals continue to needlessly die every year from what was proven to be a reversible condition decades ago.

    The conventional use of case reports, though, is to present novel results in the hopes of inspiring trials to put them to the test. For example, consider this case report on a plant-based diet for congestive heart failure—not simply coronary artery disease. In this case, the heart muscle itself was so weakened that it couldn’t efficiently pump blood. It was only able to eject about 35 percent of the blood in the main heart chamber with every beat, whereas, normally, the heart can pump out at least 50 percent. And that’s exactly what the patient’s heart was able to do just six weeks after switching to a whole food, plant-based diet, which he chose to do instead of getting his chest cracked open. The researchers wrote: “To our knowledge, this is the first report of an improvement in heart failure symptoms and left ventricular ejection fraction following adoption of a plant-based diet.” It may be the first, but it isn’t the last.

    Another case: A 54-year-old woman, obese and diagnosed with type 2 diabetes, presented with swelling ankles due to her heart failure. She switched from her regular diet of chicken and fish to whole plant foods. She started eating more healthfully, lost 50 pounds, and reversed her diabetes—meaning she had normal blood sugars on a normal diet without the use of diabetes medications. Her heart function normalized, too, going from an abysmal ejection fraction of just 25 percent up to normal, as you can see below and at 5:00 in my video. Since it wasn’t a randomized controlled trial, all we can say is that her improvements coincided with her adoption of a whole food, plant-based diet. But, “given the burden of heart failure [as a leading cause of death], its adverse prognosis,” meaning it usually worsens progressively, “and the overall evidence to date, a plant-based diet should be considered as part of a multifaceted approach to heart failure care.” We already know it can reverse coronary artery disease, so any heart failure benefits would just be a bonus.

    Now, we just need good strategies for healthcare “practitioners to support patients in plant-based eating.” Shown below and at 5:42 in my video are some excellent suggestions to pause and reflect on. 

    Doctors, for example, can “use the Plant Rx pads produced by the Plantrician Project” and prescribe a good website or two, like NutritionFacts.org, as seen below and at 5:50 in my video. 

    “While it is certainly true that many people would be resistant to fundamental dietary changes, it is equally true that millions of intelligent people motivated to preserve their health are now taking half-way measures that may provide only modest benefit—choosing leaner cuts of meat, using reduced-fat dairy products….Most of these people have neither the time nor the training to evaluate the biomedical literature themselves. Don’t they deserve honest, forthright advice when their lives are at stake? Those who wish to ignore this advice, or implement it only partially, are at liberty to do so.”

    Do you want to go smoke cigarettes? Bungee jump? It’s your body, your choice. It’s up to each of us to make our own decisions as to what to eat and how to live, but we should make these choices consciously, educating ourselves about the predictable consequences of our actions.

    Did I say reverse coronary heart disease? As in reverse the number one killer of men and women? I’ve got a lot of videos on the topic, and How Not to Die from Heart Disease is a good place to start.

    Check out the Plantrician Project at plantricianproject.org. I am a proud supporter. 



    Source link