Birth control and high blood pressure: Which methods are safe for you?

Three effective forms of birth control contain the hormone estrogen: the birth control patch, combined hormonal birth control pills, and a vaginal ring. Doctors have typically recommended that women avoid birth control with estrogen if they have high blood pressure, which current US guidelines define as 130 mm Hg systolic pressure and 80 mm Hg diastolic pressure, or higher. A recent clinical update in JAMA clarifies whether it’s safe for some women with high blood pressure to use these forms of birth control.

Why does blood pressure matter when choosing birth control?

Birth control containing estrogen can increase blood pressure. When women who have high blood pressure use these birth control methods, they have an increased risk of stroke and heart attack compared with women who do not have high blood pressure. However, their actual chances of having a stroke or a heart attack are still quite low.

When considering birth control options, it’s important to also weigh the possible risks of an unintended pregnancy. A woman who has a history of high blood pressure before she becomes pregnant is more likely to experience

• preeclampsia, a pregnancy complication that can affect liver and kidney function and can even lead to eclampsia, or seizures
• diabetes during pregnancy
• blood clots
• heart attack

She’s also at higher risk for problems with fetal growth and preterm birth.

Why are recommendations around blood pressure and birth control being updated?

When US blood pressure guidelines changed in 2017, many more people were diagnosed with high blood pressure. That happened because the new guidelines tightened standards, as follows:

• normal blood pressure is less than 120 (systolic)/80 (diastolic) mm Hg
• elevated blood pressure is between 120 and 129 mm Hg (systolic) and less than 80 mm Hg (diastolic)
• high blood pressure is 130 mm Hg (systolic) and 80 mm Hg (diastolic) or higher.

With these updated definitions, nearly half of American adults have high blood pressure. Black women are at particularly high risk: more than half of Black women over the age of 19 are diagnosed with high blood pressure.

If a woman has high blood pressure, the JAMA update recommends weighing three factors before starting an estrogen-containing birth control: a woman’s age, control of blood pressure, and any other risks for heart disease.

• Safe to use birth control containing estrogen: If women are 35 years old or younger, have well controlled blood pressure, and are healthy, estrogen-containing birth control can be used. Be sure to have a health professional check blood pressure within one month of starting this type of birth control. Additionally, routine blood pressure checks are recommended twice a year.
• Should avoid birth control containing estrogen: If women are older than 35, even if they have well controlled blood pressure, estrogen-containing birth control should be avoided. Similarly, women of any age who have multiple risk factors for heart disease or who have uncontrolled high blood pressure should not use birth control containing estrogen. These women also should not use the birth control shot (Depo-Provera) because it may increase cholesterol and lead to an increased risk of stroke, according to the review. (This medication contains a different hormone called progestin.)

The JAMA update reviewed evidence based on an older definition of high blood pressure in the context of birth control use. Further research is needed to better understand how different ranges of blood pressure might affect women using birth control that contains estrogen. However, it’s unlikely that these recommendations would change further based on the newer definition of high blood pressure.

Which birth control methods do not contain estrogen?

So, what can women who are unable to use birth control containing estrogen use to prevent pregnancy? The good news is that there are a variety of other birth control methods available, both hormonal and nonhormonal.

• The most reliable forms of birth control without estrogen are the copper intrauterine device (IUD), the hormonal IUD, the implant, and sterilization for women or men.
• Nonhormonal methods include the copper IUD, condoms for men or women, cervical cap, and diaphragm.
• Three progestin-only hormonal methods are safe to use: the minipill, the birth control implant, or the hormonal IUD. However, the birth control shot (Depo-Provera) is not recommended for women who have poorly controlled high blood pressure.

If you do have high blood pressure, exercise and dietary changes remain an important component of maintaining your heart health. Discuss with your doctor which birth control options might be best for you, so that you and your doctor can engage in shared decision-making about your preferences.

See the Harvard Health Birth Control Center for more information on options.

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Quarantine snacking fixer-upper

The “battle of the bulge” gained a new foe this year: quarantine snacking. Sales of snack foods like cookies and crackers shot up in the early days of lockdowns, and recent consumer surveys are finding that people have changed their eating habits and are snacking more.

We don’t yet have solid evidence that more snacking and consumption of ultra-processed food this year has led to weight gain. While memes of the “quarantine 15” trended on social media earlier this year, only a few small studies have suggested a link between COVID-19-related isolation and weight gain. But you don’t need scientific evidence to know if your waistband is tighter.

Snacking is not just a weight risk

Regular junk food snacking brings many risks. Processed foods are typically filled with loads of unhealthy saturated fats and high amounts of salt, calories, added sugar, and refined (unhealthy) grains.

Eating too much of these foods can lead to increased blood sugar (which raises the risk for diabetes), constipation, or an increased LDL cholesterol level (which boosts the risk for heart disease).

What you can do

If your snacking habits are off the rails, here are some tips to get back on track.

• Keep junk food out of the house. Without junk food lying around, you won’t be tempted to eat it.
• Plan healthy snacks. Stock your refrigerator and pantry with healthy snack foods such as fat-free Greek yogurt, berries, chopped vegetables, nuts (walnuts, almonds), hummus, or whole wheat crackers. Plan your daily snacks in advance, so you’ll be more likely to snack wisely.
• Zero in on hunger. Before snacking, ask yourself whether you’re hungry or just thirsty. A good way to tell: drink an eight-ounce glass of water and then wait 10 to 15 minutes. If you’re still hungry, have a healthy snack.
• Know your cravings. Are you hungry, or are you lonely, bored, or stressed? Food won’t fix the problem. Instead, go for a walk around the block, put on some music, or choose another activity that might distract you or boost your mood. If you still want food, eat only a small amount.
• Don’t skip meals. This can make you so hungry later in the day that you’re vulnerable to devouring mega-portions of snack food to supply your body with easily digested sugars.
• Don’t eat straight from the bag or carton. If you snack on an open bag of crackers or a tub of frozen yogurt, you may eat more than a single serving. Instead, portion out your serving in a dish.
• Eat mindfully. Turn off the TV, put down your phone, and pay attention to your snack. Savoring a piece of fine chocolate can be more satisfying than mindlessly gobbling down a whole chocolate bar.
• Prepare for snacks away from home. Plan ahead and keep a healthy snack in your bag or car. That way you won’t turn in desperation to calorie-laden cookies or vending machines.

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A new Alzheimer’s drug: From advisory panel to FDA — what’s at stake here?

It’s been more than 17 years since the FDA last approved an Alzheimer’s drug. Will Biogen’s drug, called aducanumab, end this drought? The FDA will decide by March 2021, based on its own analysis of clinical trial data and an advisory panel’s review of the evidence.

How does the drug work?

Aducanumab is a monoclonal antibody engineered in a laboratory to stick to the amyloid molecule that forms plaques in the brains of people with Alzheimer’s. Most researchers believe that the plaques form first and damage brain cells, causing tau tangles to form inside them, killing the cells. Once aducanumab has stuck to the plaque, your body’s immune system will come in and remove the plaque, thinking it’s a foreign invader. The hope and expectation is that, once the plaques are removed, the brain cells will stop dying, and thinking, memory, function, and behavior will stop deteriorating.

Will the FDA’s decision be important?

If aducanumab works, it would be the first drug that actually slows down the progression of Alzheimer’s. That means we could possibly turn Alzheimer’s from a fatal disease into one that people could live with for many years, in the same way that people are living with cancer, diabetes, and HIV/AIDS.

For researchers, it means that more than 20 years of scientific work, which suggests that removing amyloid from the brain can cure Alzheimer’s, may be correct. But many of us have begun to doubt this theory, because trial after trial has shown that amyloid could be cleared from the brain but clinical disease progression was not altered.

So, does the drug work?

I attended the day-long FDA hearing on November 6, 2020, and also independently reviewed all the publicly available data for aducanumab. There was one small (phase 2) clinical trial to assess efficacy and side effects, and two large (phase 3) clinical trials to assess effectiveness, side effects, safety, and how the drug might be used in clinical practice. The small phase 2 study and one of the large phase 3 studies were positive, meaning that the drug worked to slow down the decline of thinking, memory, and function that is usually impossible to stop in Alzheimer’s. The other large study was negative. Hmm… Is two out of three positive studies good enough? Biogen’s scientific team had many plausible explanations for why that one study was negative.

The advisory panel, however, was not convinced. They pointed out that phase 2 studies are always positive, because otherwise you wouldn’t move on to phase 3, so that study doesn’t count. They also pointed out that, although you can think of the positive phase 3 study as the “true” one, and try to understand why the negative one failed (which is what Biogen did), you could equally think of the negative study as the true one, and try to understand why the other one showed positive results.

The advisory council was concerned that there was “functional unblinding” in both studies, because large numbers of participants in the treatment group needed additional MRI scans and physical exams to deal with side effects, which did not occur in the placebo group. Hence, if you were asked to come in for an extra MRI scan, you knew that you were on the real drug. This knowledge may have influenced the responses subjects and their family members gave regarding how they were doing, which were the primary outcomes of the study.

Should the FDA approve it?

To determine if a drug should be approved, many factors need to be considered. First is whether it works and, as discussed above, there are questions regarding its efficacy. You also have to consider side effects and other burdens on patients, families, and society.

You first need an amyloid PET scan to be sure you have the amyloid plaques of Alzheimer’s. Then to take the drug, you need an intravenous infusion every four weeks — forever. Thirty percent of those who took the drug had a reversible swelling of the brain, and more than 10% had tiny brain bleeds. These side effects need to be watched closely by an expert neurology/radiology team who understand how to monitor for these events, and know when to pause or stop the drug.

Another factor to consider is the size of the benefit. Here, it was fairly small. Looking at the two objective measures, in the positive trial, the high dose made a 0.6-point change on the 30-point Mini-Mental State Examination (MMSE). On the 85-point Alzheimer’s Disease Assessment Scale–Cognitive Subscale-13 (ADAS-Cog-13), the high dose made a 1.4-point change. In the negative trial, the analogous results were -0.1 (worsening) for the MMSE and 0.6 for the ADAS-Cog-13.

Cost also needs to be considered; for aducanumab, this is estimated at $50,000 per year per patient. There are more than two million people with Alzheimer’s in the mild cognitive impairment and mild dementia stages. If one-quarter of those decide to take the drug, that’s $25 billion each year — not including the cost of the PET scans and the neurology/radiology teams to monitor side effects. Since most people with Alzheimer’s disease have Medicare, we will all share this cost.

Moreover, Dr. Joel Perlmutter, a neurologist at Washington University in St. Louis and member of the FDA’s advisory committee, argued that if the FDA approves aducanumab, fewer people would want to participate in a trial of a novel medication — and that would likely delay the approval of better medicines.

If it’s not approved, what other treatments are out there?

There are many other treatments for Alzheimer’s that are also being developed. Drugs that remove tau — the tangles of Alzheimer’s — are being tested. Treatments using flashing lights to induce specific brain rhythms may protect the brain. Other treatments change the microbiome of the gut or other parts of the body. Drugs are being developed which alter nitric oxide — a gas that has critical functions in brain health. Lastly, in my laboratory, we are developing strategies to help individuals with mild Alzheimer’s and mild cognitive impairment to remember things better, because, at the end of the day, that’s what matters most.

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Drugstore skincare: Science-backed anti-aging ingredients that don’t break the bank

With a sharp increase in working from home during the COVID-19 pandemic, more people are noticing age-related skin changes up close on their videoconference calls.

The good news? You don’t need to rush to the dermatologist for your anti-aging needs. The best skincare regimens to combat the cardinal signs of aging, which include uneven skin tone, fine lines, roughness, and dryness, can start from the comfort of your own home. You don’t need a prescription, time to get to a dermatologist, or deep pockets to score quality products.

Here are a few science-backed, dermatologist-favorite ingredients that can help to slow, or even reverse, signs of aging. All of the ingredients listed below can be found over the counter (OTC) and are available in preparations that cost under $30.

The problem? Uneven skin tone. The solution: Topical niacinamide

Niacinamide, or vitamin B₃, helps to block extra pigment formation by inhibiting the transfer of melanin (the major pigment in the skin) between skin cells. Applying topical niacinamide (5% concentration) twice a day was shown in a randomized and controlled, split-face trial to reduce freckles and sun spots in as soon as four weeks. The results were maintained throughout the eight-week treatment period. Another clinical study showed improvement of skin redness and sallowness (yellowing of the skin that occurs with age) in people who used topical niacinamide, resulting in a more even complexion. Niacinamide may also improve acne and fine lines.

Topical niacinamide appears to be well tolerated, with no serious side effects.

The problem? Fine lines. The solution: Topical retinoids

Aging can contribute to gradual loss of vitamin A, a retinol, which naturally occurs in the skin. This can be replenished by vitamin A derivatives, known as topical retinoids. Topical retinoids, such as retinol and adapalene, are available over the counter. They have been shown to significantly improve fine wrinkles, likely due to increased skin collagen thickness with prolonged use. Other benefits of retinoids include improvement of dark spots and reduction of atypical skin cells that could lead to skin cancer.

If you have acne or clogged pores, you may want to opt for adapalene, which appears to have more uptake in the follicles where acne starts, and also has anti-inflammatory effects. Both of these factors are important in acne formation. Adapalene may also be less irritating than some other retinoids.

The most common side effects of topical retinoids are dryness, redness, and irritation. This can be mitigated by gradually increasing use (from every third night, to every other night, to nightly), or by avoiding use with other potentially irritating or abrasive products.

Avoid topical retinoids if you are trying to get pregnant, or are currently pregnant or breastfeeding. Also make sure to use an SPF 30+ sunscreen on your face daily, due to increased sun sensitivity with this product.

The problem? Rough or dull skin. The solution: Alpha-hydroxy acids

The very top layers of skin, known as the stratum corneum, may increase in thickness with age, possibly because older cells are less able to renew and turn over. This can lead to skin roughness and can interfere with skin “glow” or luminosity. Alpha-hydroxy acids, such as glycolic acid or lactic acid, are naturally occurring substances that help to break down the bonds between cells in this top layer of skin, which results in smoother skin in as little as 24 hours. Over time, regular use may also improve fine lines, skin yellowing, blotchiness, and dark spots.

Glycolic acid at concentrations of 30% or more is used in the dermatologist’s office as a peel. But there is evidence that OTC preparations at concentrations of around 10% can give you real results and are safe to use at home.

Alpha-hydroxy acids such as lactic acid can also be found in OTC body lotions. They help to smooth the skin from the neck down.

The most common side effect is excess redness, and this can be made worse by using several new, irritating products at once.

The problem? Dry skin. The solution: Hyaluronic acid

An important (but often overlooked) sign of aging skin is dryness. As we age, our skin naturally loses its ability to retain moisture. This is due to decreasing stores of hyaluronic acid, an important component of healthy skin that has the ability to suck in water. Replacing hyaluronic acid through topical serums or moisturizers may help to boost overall skin hydration. Hyaluronic acid can also improve the appearance of wrinkles and skin firmness.

A few parting words

Start slow. If you are new to skincare, you don’t want to start using all of these ingredients at once (this is especially true of using a retinoid and an alpha-hydroxy acid together). Begin in a stepwise fashion, and increase frequency or add additional products only as tolerated. Remember that improvements in skin appearance with any skincare regimen may be subtle and can take time.

Once your skin has become accustomed to these ingredients, consider combination products that combine two or more of the ingredients you’re looking for. Finally, no skincare regimen is complete without good sun protection, so limit sun exposure, wear broad-brimmed hats and sunglasses when outside, and apply daily sunscreen.)

For treatment of deep wrinkles or sagging skin, or for medical skin concerns, seek care from a board-certified dermatologist.

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How to recognize a ministroke or stroke — and what to do

If you suddenly experience a strange but fleeting symptom — your arm or face suddenly feels weak or numb — you might be tempted to brush it off, especially if it’s short-lived.

But if those odd, unexplained symptoms last more than a few seconds, they could signal a transient ischemic attack, or TIA. Commonly referred to as a ministroke, a TIA is caused by a temporary lack of blood in part of the brain. Most of the time a blood clot is to blame, and the symptoms resolve quickly because your body’s natural clot-dissolving action restores blood flow. But according to the American Stroke Association (ASA), these events should be called warning strokes rather than ministrokes.

“A TIA can be a harbinger of a much more serious stroke,” says Dr. Christopher Anderson, director of acute stroke services at Harvard-affiliated Massachusetts General Hospital. If a blood clot blocking a brain artery doesn’t dissolve and remains in place for more than a few minutes, it can destroy brain cells by depriving them of oxygen and nutrients. Known as an ischemic stroke, these account for 87% of all strokes. As many as 17% of people who have a TIA will suffer a full-blown ischemic stroke within the next 90 days, with the greatest risk in the first week.

What should you understand about TIAs?

A recent study found that women with short-lived sensory or visual symptoms were less likely to be diagnosed with TIA compared with men. One reason could be that migraines are more common in women. As a result, both women and doctors may be less likely to suspect a TIA in women with sensory or vision changes, which may occur with or without a migraine headache. “But it’s important to consider a TIA in all people with those symptoms, regardless of their gender,” says Dr. Anderson.

Other short-lived TIA symptoms may be easy to dismiss, says Dr. Anderson. “Sometimes, people will say, ‘That’s funny, I can’t feel one side of my face,’ and garble their words for a short time,” he says. People may repeatedly drop objects (a cooking utensil, for example) but then be able to function normally after a few minutes. Another classic TIA symptom is seeing what’s often described as a dark curtain dropping over one eye from top to bottom. This symptom is called amaurosis fugax (from the Greek amaurosis, meaning dark, and the Latin fugax, meaning fleeting).

BE-FAST when recognizing a stroke or TIA

The ASA coined the mnemonic FAST to help people recognize stroke symptoms. The first three letters, which stand for Face drooping, Arm weakness, and Speech difficulties) account for about 75% of the symptoms people experience during a stroke. (The T stands for Time to call 911.)

But some neurologists suggest adding two additional letters: B for balance and E for eyes. Balance is a tricky one, because balance problems can occur due to a range of problems other than a stroke, especially in older people, says Dr. Anderson. With a stroke, balance problems rarely appear in isolation; they usually occur in tandem with other symptoms such as leg weakness or vision problems, he explains. Vision problems during a TIA or stroke can include reduced, blurry, or double vision.

The simpler FAST makes sense for a public health campaign. But if you’re at risk, knowing BE-FAST may be the most helpful, as it may help you recognize even more potential TIAs and strokes. High blood pressure is the leading cause of stroke. Other risk factors to be aware of include smoking, diabetes, physical activity, and obesity. People with heart disease (such as coronary artery disease, atrial fibrillation, and heart failure) face a higher-than-normal risk of stroke. Talk to your doctor about your risks for stroke or TIA, and healthy steps you can take to lessen your chance of having either one.

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Does lupus or arthritis affect your prognosis if you get COVID-19?

Soon after the coronavirus pandemic began, we learned that older adults and people with certain chronic conditions, such as high blood pressure or diabetes, are at increased risk for severe COVID-19. One condition on that list is an immunocompromised state (a weakened immune system). This can be due to a number of conditions, including having had an organ transplant, having HIV, or taking medications that suppress the immune system.

If you have an autoimmune condition such as rheumatoid arthritis or lupus (also called systemic lupus erythematosus), you may wonder how this affects your risk. It’s thought that these conditions occur because the immune system misfires and attacks organs in the body. And many people with these disorders are treated with medications that suppress the immune system.

Two newly published studies examine this. While the results are not definitive, they do provide some reassurance. Most people recovered from COVID-19, and most of their prior treatments did not seem to worsen their infections.

Lupus and COVID-19

In the first study, researchers enrolled 226 people with lupus. After comparing those who had COVID-19 with those who did not, they found that

• nearly 60% of those with COVID-19 and lupus became sick enough to be hospitalized, and 10% were admitted to the intensive care unit.
• about 10% died.
• risk factors for hospitalization were similar to those reported in people outside of this study who did not have lupus. For example, race (more hospital admissions among those who were Hispanic or nonwhite), other chronic diseases (including kidney failure, lung disease, and hypertension), and being overweight or obese were more common among those needing hospital admission.
• steroid treatment for lupus was nearly two times higher among hospitalized patients (54%) compared with those who were not hospitalized (29%). However, this difference was not statistically significant.
• treatment with other immune-suppressing medications taken for lupus (such as azathioprine or mycophenolate) was similar in both groups.

Inflammatory arthritis and COVID-19

The second study included 103 people with inflammatory arthritis (which includes rheumatoid arthritis and related conditions) who were also diagnosed with COVID-19. Some were hospitalized with severe disease, while others were treated as outpatients. Here’s what the study found.

• 26% of study subjects were hospitalized.
• About 4% died.
• Risk factors for hospital admission included being 65 or older, high blood pressure, and lung disease.
• Steroid treatment for inflammatory arthritis was more common among those hospitalized (37%) than those treated as outpatients (about 4%).
• Biologic therapy (such as etanercept or infliximab) did not appear to increase the risk of severe COVID-19. One other type of treatment — JAK inhibitors, which include tofacitinib (Xeljanz) — was more common among those requiring hospital admission. However, few patients were taking this medication.

Why these studies aren’t the last word

These studies only included patients with COVID-19 and either SLE or inflammatory arthritis. It wasn’t possible to rigorously compare the study participants to people without lupus or arthritis. Also, these studies did not include large numbers of people with lupus or arthritis who tested positive for the virus, yet did not have symptoms of COVID-19 (asymptomatic infection). Nor did they confirm the diagnosis of COVID-19 in every suspected case. So, while this research offers some new information, the true impact of lupus or arthritis on people who develop COVID-19 hasn’t yet been determined.

Finally, the lupus study was small: only 41 subjects had confirmed COVID-19. Although the findings on steroid treatment weren’t statistically significant, that might not have been true if the differences observed persisted in a larger study.

The bottom line

Public health experts often include people with autoimmune disease on the list of those who are more likely to have a bad outcome if they develop COVID-19. The relatively high rate of hospital admission for lupus patients with COVID-19 confirms an increased risk for severe disease. Other standard risk factors (such as high blood pressure or lung disease) apply, but steroid therapy may increase risk even further. Other studies have come to similar conclusions (see here and here).

There was some good news to emphasize in these trials: the survival rate among patients with lupus or inflammatory arthritis who develop COVID-19 was relatively high. Also, biologic therapy did not appear to worsen prognosis for the arthritis patients. And other immune suppressants did not worsen prognosis for those with lupus. And, the hospitalization rate for COVID-19 among patients with inflammatory arthritis was similar to what has been reported for people without arthritis.

These findings add to what we are learning about COVID-19. Clearly, we need to learn more. For example, is there a dose of steroids to treat chronic illness that is so low that it does not increase the risk of a worse prognosis with COVID-19? Do certain medications (such as biologics) actually reduce the risk of severe COVID-19? Until we do know more, it remains particularly important for people with lupus and inflammatory arthritis — especially those taking steroids — to be especially vigilant about measures to avoid COVID-19.

Follow me on Twitter @RobShmerling

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Early birds may be more active, but night owls can catch up

Being an early bird has long been associated with a go-getter attitude. Early birds, or those who tend to wake early and go to bed early, are people who naturally feel sleepy earlier in the evening and naturally wake early in the morning. For an early bird type, a 9 pm bedtime may be the norm, and rising at 5 am without an alarm clock feels relatively effortless.

Our internal clock controls more than sleep patterns

Being an early bird, or the opposite night owl, is usually not something that is thought of as being highly under our control. Some people seem to be hardwired to sleep early, while others get a second wind and tend to sleep late. This internal clock is called our circadian rhythm, each person’s unique internal timekeeper and the body’s own master controller of many functions. Most obvious is our sleep patterns; however, our internal clock also plays a role in our hunger and eating patterns, hormone levels, and maybe even our mood.

Does being an early bird or night owl affect our health?

A growing body of research shows that we may want to pay more attention to circadian rhythm, also called our chronotype. Identifying if we’re more of an early bird or night owl may help predict our risk of potential health problems.

A recent study from the Scandinavian Journal of Medicine and Science in Sports looked at whether the body clock is related to levels of physical activity. Using a wrist-based device that measures movement, over 5,000 participants’ activity levels were collected for two weeks. Researchers also identified whether each person was more of an early bird or night owl, based on a well-studied questionnaire. After considering some factors that may explain differences, such as education or background health conditions, they found that being a night owl was linked to lower physical activity. Night owls, as compared to morning types, had up to 60 to 90 fewer minutes per day of activity.

Why might your body’s clock and your activity level be linked?

In short, more research in this area is needed to know for sure. Most studies on this topic look at patterns; there seem to be trends emerging that certain body clock patterns and health conditions run together. What we don’t know, though, is whether being a night owl or early bird is the cause. But when trying to understand why, there are a number of potential factors that come into play.

For those with a more of a night owl or an “eveningness” type, it may be more of a challenge to incorporate activity into their day. For many night owls, jobs or other demands on time may mean that a morning alarm is sounding well before their natural wake time. As a result, a night owl type may be starting the day relatively “jet lagged” — feeling out of sync with their body due to being awake when the body would prefer to be asleep. They also may be sleep deprived if they had to get up significantly earlier than desired. These may contribute to less activity on a regular basis.

On days off, catching up on sleep may become a priority given too little sleep during the week. Sleep patterns, such as how much or when people are sleeping, are potentially the key here, but this information wasn’t captured in this study. Other health conditions or behaviors that interfere with sleep, such as mood disorders, may be found more often among night owls.

If I’m a night owl, what can I do?

We should emphasize that this study does not tell us that being a night owl is the cause for lower physical activity. (This is true for much research around our body clock, as previously mentioned.) It simply shows an association between being an early bird or night owl and certain conditions. In addition, the factors at play — sleep patterns and activity — are factors we have some control over. Though we may be hardwired to lean toward being a night owl or morning bird, most people fall somewhere in the middle. Sleep patterns and activity are modifiable, and even small changes can have a big impact over days, weeks, months, and years.

Reflecting on your sleep patterns is one way to take advantage of the best times of the day for more activity. Are you someone who feels ready and alert first thing in the morning? That may be the best time to get those steps in. More energy in the evening? Then scheduling that walk for after dinner may be best. Using your body clock to your advantage may help optimize the best time to be active.

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Type 2 diabetes: Which medication is best for me?

If you are living with type 2 diabetes, you certainly are not alone. One in 10 people in the US has diabetes, according to the CDC. However, despite considerable progress in diabetes treatment over the past 20 years, fewer than half of those with diabetes actually reach their target blood sugar goal.

In part, this may be because doctors can be slow to make changes to a patient’s treatment plan, even when a patient’s treatment goals are not being met. One reason for this may be the overwhelming number of medications currently available. And yet, waiting too long to adjust treatment for type 2 diabetes can have long-lasting negative effects on the body that may raise the risk of heart and kidney disease and other complications.

What is type 2 diabetes?

Type 2 diabetes is a chronic disease where the body’s ability to use glucose or sugar as fuel is impaired. Our bodies produce a hormone called insulin which enables sugar from carbohydrates in food we eat to reach the cells and be used as energy. In type 2 diabetes, insulin’s ability to do its job is compromised, and over time the body actually produces less of it. This means less sugar in the cells for fuel, and more sugar in the blood where it can’t be used. Having high levels of blood sugar over time can cause damage to vital organs like the heart, kidneys, nerves, and eyes.

Some risk factors that predispose people to developing type 2 diabetes, such as genetics and age, are not modifiable. Other risk factors, such as being overweight or having obesity, can be altered. This is why losing 5% to 10% of one’s baseline weight by healthful eating and physical activity remains the backbone of type 2 diabetes management.

Most diabetes medications effectively lower blood sugar

The blood sugar goal for most adults with diabetes is an A1C of below 7%. (A1C is a measure of a person’s average blood sugar over a period of about three months.) In many people, diet and exercise are not enough to reach this goal, and one or more medications may be needed. Metformin is a tried and tested medicine that has been used for many decades to treat type 2 diabetes, and is recommended by most experts as first-line therapy. It is affordable, safe, effective, and well tolerated by most people.

When metformin does not adequately control blood sugar, another medication must be added. It is at this point that doctors and patients must choose among the many drugs and drugs classes available to treat type 2 diabetes. In general, for people who are at low risk of heart disease or have no history of diabetic kidney disease, most diabetes medications that are added to metformin effectively reduce blood sugars and can lower A1C to under 7%.

So, how to choose a medication? Each person with diabetes has their own goals, needs, and preferences. Before choosing a medicine, it is important to ask some relevant questions: Is my blood sugar at goal? Is this medicine affordable? Do I have heart or kidney disease? What are the side effects? Is it a pill or injection, and how often is it taken?

Regardless of which treatment is selected, the American Diabetes Association Standards of Care recommends reassessment of diabetes control every three to six months, followed by modifications to treatment if needed.

Newer diabetes medications: Weighing benefits and risks

Lately, newer treatment options for type 2 diabetes — glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter-2 (SGLT2) inhibitors — have been heavily advertised. These newer drug classes lower blood sugar and also have cardiovascular and kidney benefits.

GLP-1 receptor agonists are drugs that lower blood sugar after eating by helping your body’s insulin work more efficiently. All drugs in this group except one are self-injected under the skin, either daily or weekly. Several of them, such as liraglutide (Victoza), semaglutide (Ozempic), and dulaglutide (Trulicity), have been shown to lower the risk of cardiovascular disease in people who are at high risk for it, or who have pre-existing heart disease. They also promote weight loss. Some people who take GLP-1 receptor agonists may have side effects such as nausea and vomiting, and in very rare cases pancreatitis.

SGLT2 inhibitors like empagliflozin (Jardiance), canagliflozin (Invokana), dapagliflozin (Farxiga), and ertugliflozin (Steglatro) are also a newer class of medications that work by blocking your kidneys from reabsorbing sugar back into your body. They also have cardiovascular benefits, especially in those who have heart failure, and have been shown to slow the progression of diabetic kidney disease. Other benefits include lowering blood pressure and promoting weight loss. Use of these medications may increase the risk of genital yeast infections, especially in women. A rare but serious consequence of SGLT2 inhibitors is diabetic ketoacidosis, which is a medical emergency that can be avoided by stopping these medications in consultation with your doctor before major surgeries, or if you are ill or fasting.

While these diabetes medications certainly have more to offer than just improvements in blood sugar, they remain costly and inaccessible to many individuals. This is why it is essential to have an open and honest conversation with your doctor about what is most important to you and what aligns with your goals and preferences. Management of a complex disease like diabetes takes an entire team, with you being the key team member.

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It’s still true: Not all the news about COVID-19 is bad

I thought the pandemic would be over by now. And I’m not alone; there were sophisticated models predicting a dramatic drop in the number of infections by the summer. And while there was understandable worry about the second wave, re-infection, and the coming flu season, there was good reason to believe we’d have the worst of the first wave well behind us.

Now, that all seems like wishful thinking. Here we are, over nine months into the pandemic, with more than 224,000 deaths, and more than 70,000 new cases and 800 deaths every day in this country as of late October. There are new hot spots popping up in the US and all over the world. Herd immunity, whether due to infection or vaccination, is still many months or even years away — if it happens at all. Despite these challenges, we do have some good news.

Good news about COVID-19: my top 5 list

It’s easy to miss some positive developments about how the fight against this pandemic is going, given all the gloomy news. Here’s my perspective on five important ones.

1. Soon after its appearance, researchers identified the viral cause of COVID-19, mapped its genome, and tracked its spread.

For a virus that was unknown less than a year ago, all of these things happened quickly because of the dedication and cooperation of scientists and public health officials around the world. Imagine how things would be right now if we still did not know the cause of this terrible disease, and had no idea where it was spreading.

2. We now have good evidence that face coverings and physical distancing work.

Although recommendations to wear masks or other face coverings and to maintain physical distance were first made many months ago, a compelling scientific case to support these recommendations has been published only recently. Studies of the effectiveness of these measures (such as this, this, and this) make it difficult to justify not following these recommendations.

3. There is increasing evidence that testing and contact tracing work.

Recognizing that there are formidable challenges and barriers to widespread implementation of these measures, we’ve seen better containment in places where testing and contact tracing are routine (such as New Zealand, South Korea, Singapore). And it seems likely that at some point we’ll have new and better tests with improved accuracy, more widespread availability (including home testing), and faster turnaround times.

4. The care of patients with COVID-19 has improved from the early days of the pandemic.

This may account for reports of lower rates of death among the sickest people with COVID-19. Increased testing, detection of more asymptomatic cases, and more patients in younger age groups may also be contributing to improving numbers. Still, supportive care (such as “proning” patients), certain medications (such as dexamethasone and the recently approved remdesivir), and more experience with this infection have likely improved outcomes overall. Importantly, we have also identified ineffective treatments (such as hydroxychloroquine — see here, here, and here for studies), so that we can avoid those that are unnecessary and potentially harmful.

5. A number of vaccines have been developed, and large-scale trials are on track to determine which are safe and effective.

Again, this has happened at unprecedented speed. Multiple companies are working on different vaccine candidates. Manufacturing of some leading candidates is already happening, and officials are making plans to distribute millions of vaccine doses in the coming months. While there is no guarantee that any of the vaccines in the pipeline will be successful, these developments increase the chances that we’ll have an effective vaccine sooner than later.

It’s worth emphasizing that there are major concerns about the safety of moving so fast, a lack of transparency about trial data, and the possibility of politics influencing the process, all of which could promote a reluctance to be vaccinated. Still, it seems better that this effort is under way, rather than having to wait years for a potential vaccine to be approved.

The bottom line

Plenty about how our country has responded to the pandemic could — and should — have gone better. But things would be even worse if not for the items on this list.

If we all do our part in the fight against COVID-19, good news should become easier to find. Maybe that’s already happening: some places have been able to contain or nearly eliminate COVID-19, at least temporarily. And toilet paper is back on the store shelves.

Follow me on Twitter @RobShmerling

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

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Coping With IBS

Irritable bowel syndrome (IBS) can be painful, annoying, and embarrassing. There is currently no cure for this complex condition, and managing its symptoms and flare-ups is tricky. So, coping mechanisms are a constant need.

What are the symptoms of IBS?

IBS is a gastrointestinal disorder in which your gut becomes more sensitive, and the muscles of your digestive system have abnormal contractions. People with IBS usually have abdominal pain along with frequent changes in bowel habits (diarrhea, constipation, or alternating between both). Other common symptoms include

• bloating and gas
• urge to move the bowels, but being unable to do so
• incomplete bowel movements
• urgent need to move the bowels.

Because no one knows what causes IBS, it is impossible to prevent it. Once you have been diagnosed, the goal is to focus on managing the condition. You can do this by identifying specific triggers of your IBS symptoms and then adopting strategies to make them less severe and frequent.

The most common approaches are dietary changes — eliminating or reducing problem foods — and stress management techniques, such as yoga, meditation, acupuncture, and cognitive behavioral therapy. Certain supplements and over-the-counter and prescription medications also can help. Your doctor can help you implement these strategies and advise what medications to take.

Coping with IBS day-to-day

People often need additional assistance, especially when it comes to coping with the awkwardness and emotional turmoil of living with IBS. Here are some ways to get the extra support you may require.

Join a support group. Talking with others who are dealing with IBS can help you cope with your disorder’s stress and anxiety. The online community Irritable Bowel Syndrome Self Help and Support Group offers moral support and information, including news about recent studies on IBS.

Prepare for public outings. Don’t let IBS keep you from enjoying an active social life. Being mindful about your IBS can help you avoid potential problems. For example, always note the nearest bathroom and try to sit close to it. When eating out, try to review the menu in advance. If there are no agreeable meals, you can eat beforehand. Also, don’t be afraid to call it an early night if your IBS is acting up. People will understand if you say you are simply not feeling well.

Share with someone. Not everyone needs to know about your IBS, but tell a few friends and coworkers so they can cover for you when symptoms appear.

Have an emergency kit on hand. Always keep spare underwear, clothing, toilet paper, wet wipes, and a large plastic bag on hand just in case.

Don’t rush bowel movements. This can help reduce the stress of having to use the bathroom all the time. Set aside a regular time or times each day to have a bowel movement. Give yourself the time you need so you can relax. When you push, be sure to avoid excessive straining. It can help to elevate your feet using a footstool.

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Defusing the “Benadryl challenge”: Discussing danger with teens

Let’s start with the bottom line: Parents of teens need to help them understand that just because they have been “challenged” to do something doesn’t mean it’s a good idea. But as simple as that sounds to us, it’s tough for many teens to grasp.

The latest challenge in the news is the “Benadryl challenge” that appeared on TikTok, a popular social media video platform. The idea was to take a whole lot of Benadryl (diphenhydramine, a common antihistamine) in order to cause a high, with hallucinations. While it’s true that diphenhydramine can make you high and make you hallucinate, when you take too much of it you can also have seizures, pass out, have heart problems, or even die. And indeed, emergency rooms across the country have treated overdoses of diphenhydramine, and at least one death has been attributed to the challenge.

Dangerous challenges appeal to teens

To TikTok’s credit, they say that they have taken down the videos and are monitoring for any new ones. When I searched the site myself, nothing came up when I searched “Benadryl.” But it’s not like it’s the only challenge out there on social media. We’ve had the cinnamon challenge, the nutmeg challenge, and others like the “Kiki challenge” where people get out of their slow-moving cars and dance alongside them, or the “skull-breaker challenge” which, well, speaks for itself. Getting rid of all challenges is not really possible; it’s a game of whack-a-mole.

The reason teens do this stuff is actually rooted in evolutionary biology. The adolescent and young adult brain is growing and changing rapidly to meet the needs of their particular moment in life. As teens enter adulthood and become independent, they need to be able to learn a lot of information quickly. Their brains are set up to help them do that.

Entering adulthood and becoming independent also requires being brave and taking risks. There is so much that is new and scary as you enter adulthood, which is why many of us are glad we are past that part of life. The development of the adolescent brain takes that into account, too: the last part of the brain to develop is the prefrontal cortex, the part that helps us control our impulses and avoid risk. By the mid-20s or so, the process is complete.

Working with the teen brain

This doesn’t mean that parents, teachers, and others should just throw up their hands and quit trying to talk to teens about making safer decisions. We absolutely need to keep trying, day after day. But it does mean that we have to understand why these challenges may have so much appeal, and why teens may not fully appreciate the risks. It means that our efforts need to be not just ongoing, but understanding. We need to work with the teen brain, not against it.

There’s no easy way to do that. But here are some ideas:

• Listen as much as you talk. Ask questions. The more you understand about their behavior, the better chance you will have of finding strategies that work.
• Don’t jump to judgment. Besides the fact that they are wired to make impulsive and sometimes dangerous decisions, if teens feel judged they are less likely to listen to anything you have to say.
• Try to engage your teen in coming up with ideas to keep him or her safe. Not only do they know themselves and their peers better than you do, they may be more invested in an idea they come up with themselves.
• Ask for help. Teens don’t always listen to parents, but they may listen to other adults in their lives. And definitely, if you feel like your child is doing things that are dangerous and you can’t stop them, talk to your doctor.

Follow me on Twitter @drClaire

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Intermittent fasting: Does a new study show downsides — or not?

Intermittent fasting (IF) is an approach to eating based on timing. The idea is that fasting for long enough allows insulin levels to fall low enough that our body will use fat for fuel. Growing evidence in animals and humans shows that this approach leads to significant weight loss. When combined with a nutritious, plant-based diet and regular physical activity, IF can be part of a healthy weight loss or maintenance plan, as I described in an earlier blog post.

Now, a randomized controlled trial published in JAMA claims that IF has no significant weight loss benefit and a substantial negative effect on muscle mass. News outlets picked up the story and ran headlines like A Potential Downside of Intermittent Fasting and An Unintended Side Effect of Intermittent Fasting.

But what did this study actually look at and find?

In the study, 141 patients were randomly assigned to 12 weeks of either a time-restricted eating plan (TRE) that involved fasting for 16 hours and eating only during an eight-hour window of the day, or a consistent meal timing (CMT) eating plan, with three structured meals a day plus snacks.

Neither group received any nutrition education or behavioral counseling, nor was physical activity recommended. There was no true control group (meaning a group that did not receive any instructions about meal timing).

Interestingly, both groups lost weight. Given the headlines, I had to read and reread the results several times, because they show that the IF group lost a statistically significant amount of weight from beginning to end — which wasn’t true in the CMT group. The researchers reported: “There was a significant decrease in weight in the TRE group (−0.94 kg; 95% CI, −1.68 kg to −0.20 kg; P = .01) and a nonsignificant decrease in weight in the CMT group (−0.68 kg; 95% CI, −1.41 kg to 0.05 kg; P = .07).”

Translated into plain English, the IF group lost more weight than could be due to chance: between half a pound and 4 pounds, or an average of 2 pounds. The structured meals group also lost some weight, although the amounts lost could have been due to chance: between 0.1 and 3 pounds, or an average of 1.5 pounds. The upshot was that there wasn’t a significant difference in weight change between the two groups. And the researchers saw a loss of muscle mass in the IF group that didn’t occur in the CMT group.

Diving deeper into the study

By the way, all of these folks may have been eating fried or fast foods, and sugary sodas and candy — we don’t know. The study doesn’t mention quality of diet or physical activity. This isn’t how IF is supposed to be done! And yet the IF folks still lost between half a pound and 4 pounds.

Importantly, the structured meals group also lost weight. While not significant enough to prove it was due to this intervention, for some participants it was enough to make structured meal weight loss differ little from IF weight loss. But think about it: structured meals are an intervention. After all, some people eat more than three times a day, consuming multiple small meals throughout the day. Telling people to limit their eating to three mealtimes plus snacks may actually be helping some to eat less.

The authors very well could have concluded that IF was indeed successful. They might also call for a follow-up study with a true no-intervention control group, as well as behavioral counseling, guidance on a healthy diet, and recommended activity levels for IF and CMT groups.

Does additional support make a difference?

Prior studies of IF that have provided behavioral counseling, and guidance on nutrition and activity, have definitely shown positive results. For example, in a previous blog post I described a 2020 American Journal of Clinical Nutrition study in which 250 overweight or obese adults followed one of three diets for 12 months:

• IF on the 5:2 protocol, which means drastically reducing food intake for any two of five days of the week (down to 500 calories for women and 700 calories for men)
• Mediterranean, which emphasized fruits and vegetables, legumes, nuts, seeds, whole grains, and olive oil with moderate fish, chicken, eggs, and dairy, and with an allowance of one glass of wine per day for women and two per day for men
• Paleo, which emphasized fruits and vegetables, animal proteins, coconut products, butter, and olive oil, along with some nuts, seeds, and legumes.
• And this is key: all participants were provided education on behavioral strategies for weight loss, stress management, sleep, and exercise.

Everyone lost weight. The IF group lost more than anyone with an average of 8.8 pounds, Mediterranean next at 6.2 pounds, and Paleo last at 4 pounds. Adherence was better with the Mediterranean diet (57%) and IF (54%) than with the Paleo diet (35%), and better adherence resulted in one to three pounds more weight loss. The Mediterranean and IF groups also saw significant drops in blood pressure, another good result.

What about the loss in muscle mass that occurred in the IF group in the JAMA study? While this needs to be studied further, it’s important to note that other research on IF that included guidance on physical activity did not show any loss of muscle mass.

The bottom line

What’s the takeaway here? A high-quality diet and plenty of physical activity — including resistance training — are critical for our good health, and nothing replaces these recommendations. IF is merely a tool, an approach that can be quite effective for weight loss for some folks. While this one negative study adds to the body of literature on IF, it doesn’t reverse it. We simply need more high-quality studies in order to have a better understanding of how to most effectively incorporate IF into a healthy lifestyle.

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Keeping your family safe this Thanksgiving

So much is different and hard during this pandemic — including planning for the holidays.

It’s understandable to want to gather with friends and family. We are all so worn out by the COVID-19 pandemic, and need some cheering up. And most of us have friends and family that we haven’t been able to really spend time with — or haven’t seen at all — for months.

But gathering with friends and family can bring real risks during the pandemic, especially with cases rising all over the country. All it takes is one sick person — who may not even realize that they are sick — to infect others and spread the virus even more.

The best thing to do, honestly, is to celebrate the holiday with just the people you live with, and to skip in-person sporting (or other) events, or in-person Black Friday shopping. That’s truly the best way to keep everyone safe. Just hunker down, check in virtually, and make plans for next year, when things will hopefully be much better.

Still planning to gather for Thanksgiving?

While experts advise skipping gatherings this Thanksgiving, here are some recommendations to help limit risks for people who plan to celebrate the holiday with others.

Plans to make beforehand

• Travel safely if you are traveling. The safest way is by car with just the people you live with, but if that requires an overnight stay somewhere, a direct flight is likely safer. If you do fly, look for flights that space people apart, wear a mask, and bring hand sanitizer and wipes.
• Keep the numbers low. This is just not the year for a big family gathering.
• Keep the party short. This is not the year for a long family gathering either.
• Agree on “no symptoms” and “no exposure.” Make sure that everyone understands that anyone who has any symptoms of COVID-19, or has been exposed to someone with the virus, cannot come. That needs to be non-negotiable.
• Agree to socialize outside if possible. If you have to be inside, do everything you can to improve ventilation, like opening windows (but understand that this is not as safe as being outside).

Seating and food

• Arrange seating so that there is at least six feet between family members who don’t live together.
• Be mindful of risks as you plan the meal:
  • Ideally, everyone should bring their own food and not share.
  • If some people will be cooking, ask them to wear gloves and masks. And limit the people involved in preparing shared food.
  • No buffets this year. Think pre-served plates of food that people can grab and bring to their seat.
  • If you are serving food, have one person wearing a mask and gloves do all the serving.
  • Try to use single servings of condiments (like packets of salt and pepper) so that people are not all touching the same container.
• Use disposable plates, cutlery, and cooking ware, when possible.
• Use touchless garbage cans or pails.

Masks, physical contact, and sanitizing hands and surfaces

• Wear masks when you aren’t eating and when you cannot be six feet apart. I know this feels weird and hard at a family gathering, but it’s crucial.
• No hugs or other physical contact between people who don’t live together. Even elbow bumps are not a good idea. Not this year.
• Everyone should wash their hands often. Have hand sanitizer available.
• Wipe down surfaces regularly (keep wipes in the bathroom, for example).

Finally, don’t go to any crowded sporting events or shopping venues. Again: not the year for that. It’s just not worth the risk.

For more information on keeping your family safe this holiday season, visit the website of the Centers for Disease Control and Prevention or the Harvard Health Publishing Coronavirus Resource Center.

Follow me on Twitter @drClaire

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Talking to your doctor about an abusive relationship

When Jayden called our clinic to talk about worsening migraines, a medication change was one potential outcome. But moments into our telehealth visit, it was clear that a cure for her problems couldn’t be found in a pill. “He’s out of control again,” she whispered, lips pressed to the phone speaker, “What can I do?”

Unfortunately, abusive relationships like Jayden’s are incredibly common. Intimate partner violence (IPV) harms one in four women and one in 10 men in the United States. People sometimes think that abusive relationships only happen between men and women. But this type of violence can occur between people of any gender and sexual orientation.

Experiencing abuse can be extremely isolating, and can make you feel hopeless. But it is possible to live a life free from violence. Support and resources are available to guide you toward safety — and your doctor or health professional may be able to help in ways described below.

What is intimate partner violence?

Intimate partner violence (IPV) isn’t just physical abuse like kicking or choking, though it can include physical harm. IPV is any emotional, psychological, sexual, or physical way your partner may hurt and/or control you. This can include sexual harassment, threats to harm you, stalking, or controlling behaviors such as restricting access to bank accounts, children, friends, or family.

If this sounds like your relationship, consider talking to your doctor or health care professional, or contact the National Domestic Violence Hotline at 800-799-SAFE.

What does a healthy relationship look like?

Media images show us uniformly blissful relationships, but perfect relationships are a myth. This culture can make it difficult for us to recognize unhealthy characteristics in our own relationships. Respect, trust, open communication, and shared decisions are part of a healthy relationship. You should be able to freely participate in leisure activities or see friends without fear of your partner’s reaction. You should be able to share your opinions or make decisions without fear of retaliation or abuse. Sexual and physical intimacy should include consent — meaning that no one uses force or guilt to compel you to do things that hurt you or make you feel uncomfortable.

How can a health professional help me?

Health professionals like doctors or nurses can take a history and assess how the abuse may be affecting your health, well-being, and safety. Trauma from IPV can cause visible symptoms, like bruises or scars, as well as more subtle symptoms, like abdominal pain, headaches, trouble sleeping, or symptoms of traumatic brain injury. Health professionals can also provide referrals to see specialists, if needed.

With your consent, health professionals can take a detailed history, examine you, and document the exam findings in your confidential medical record. Let them know if you are concerned that your partner will view your medical record, so measures can be taken to keep it confidential. This documentation can help to strengthen a court case if you decide to pursue legal action in the future.

Additionally, you may be at risk for pregnancy or certain sexually transmitted infections (STIs). A health professional can perform tests for STIs or pregnancy and offer birth control options. Some forms of birth control are less easily detected by your partner, like an IUD, or a contraceptive implant or injection.

Health professionals can help you develop a safety plan if you feel unsafe. They can also help connect you with social services, legal services, and specially trained advocates. If you would like, health professionals can also connect you with law enforcement to file a report.

What is a sexual assault exam?

If you have experienced sexual assault within 120 hours (five days), you may be offered a sexual assault medical examination. This exam is voluntary. It is performed by a trained health professional and may include a full body exam, including your vagina, penis, or anus. It may also include taking blood, urine, or body surface samples and/or photographs that could be used during an investigation or legal action. You may be prescribed medication that could prevent infections or a pregnancy. You can click here to learn more about the sexual assault exam.

What can I expect if I talk to a health care professional about IPV?

Health professionals should listen to you supportively and without judgement. While not all health professionals are trained in trauma-informed care, it is your right to be treated with respect and empathy to help you feel safe and empowered. You should not be pressured to do anything you don’t want to do. And this shouldn’t change the care you receive. You have the right to decline any care you are not comfortable with. You get to decide how you want to proceed after you share information with your healthcare professional, whether that means seeking out legal support, making a safety plan to leave the relationship, or choosing to stay in the relationship and be connected to ongoing support. And you can choose not to share information about abuse at all.

Will the conversation be private and confidential?

These discussions should occur with you and your health professional in a private space. If your abusive partner accompanies you to your appointment, your health professional may ask them to leave the examination room for a period of time so that you have the privacy to talk openly. You can also ask to speak with the health professional alone.

In most cases, discussing your experiences with your health professional is confidential under HIPAA. All states have laws that protect children, elders and people with disabilities from abuse of any kind. Your health professional is obligated in certain circumstances to report abuse, such as violence against a minor or vulnerable adult. However, only a few states require health professionals to report intimate partner abuse.

Where can I find more resources on IPV?

Want to learn more about IPV and how to seek help?

If you or someone you know you is at risk, call the National Domestic Violence Hotline at 800-799-SAFE (7233) or 800-787-3224. This hotline is for anyone, regardless of race, sex, ethnicity, gender identity, sexual orientation, religion, or ability.

If you are unable to speak safely, you can visit thehotline.org or text LOVEIS to 22522. They are available 24/7 by phone or with a live chat, and can work with you to find help in your area.

• RAINN (national resource for sexual assault and violence)
• Love Is Respect (national resource for dating violence)
• WomensLaw.org (legal information for women experiencing domestic violence)
• LGBT National Help Center (LGBTQ+ resources, including chat and peer counseling).

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Mind-body medicine in addiction recovery

As someone who struggled with a miserable opiate addiction for 10 years, and who has treated hundreds of people for various addictions, I am increasingly impressed with the ways in which mind-body medicine can be a critical component of recovery from addiction. Mind-body medicine is the use of behavioral and lifestyle interventions, such as meditation, relaxation, yoga, acupuncture, and mindfulness, to holistically address medical problems. Mind-body treatments can be integrated with traditional medical treatments, or used as standalone treatments for certain conditions. Mind-body medicine is now being studied by the National Institutes of Health and effectively used in the treatment of addiction, and it will likely play a role in addiction recovery programs in the future.

Mind-body principles are not new to the recovery movement

Mind-body principles have been around since the start of the recovery movement in 1937, and they are a big part of Alcoholics Anonymous. The 12 Steps of AA feature concepts such as surrender, meditation, gratitude, and letting go — all critical components of mind-body medicine. Most 12-step meetings end with the Serenity Prayer: “God, grand me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” Mutual help groups play a role in recovery for many people, and the principles of mindfulness that are part of these programs — in addition to the social support — shouldn’t be overlooked.

My experience with mind-body therapies for addiction

When I was sent to rehab for 90 days by the medical board due to my addiction, we participated in a lot of activities that seemed to be meant to approximate mind-body medicine, but they were haphazard and not particularly scientific, and I don’t believe they had the intended effect or were at all therapeutic. For example, we did shrubbery mazes (I’d get lost); we sat meditatively in silence (everyone around me chain-smoked, triggering my asthma); we had repeated lectures about “letting go and letting God” (I still have no idea what this means); we’d spend 30 minutes staring at a red square projected onto a screen (this gave me a migraine); and we went to a local acupuncture place where they hooked up extra electric current to the needles to give us extra “chi” (I felt like I was being cooked for dinner). Given that rehab is a $50 billion industry, I felt this was a lost opportunity to utilize mind-body medicine in a way that wasn’t superficial or trivial.

Formal mind-body therapies for addiction are being rigorously studied

Fortunately, there are now several scientifically-based mind-body medicine options for people in recovery. Mindfulness-Based Relapse Prevention (MBRP) is a technique that uses meditation as well as cognitive approaches to prevent relapse. It aims to cultivate awareness of cues and triggers so that one doesn’t instinctively turn to using drugs. It also helps people get comfortable sitting with unpleasant emotions and thoughts —their distress tolerance, a person’s ability to tolerate emotional discomfort — without automatically escaping by taking a drug. Improving distress tolerance is a common theme to many, if not all, approaches to addiction recovery, as a large part of the appeal of drug use is replacing a bad emotion with a good emotion — for example, by using a drug.

Mindfulness-Oriented Recovery Enhancement (MORE) is another technique to address addiction in recovery. MORE attempts to use both mindfulness and positive psychology to address the underlying distress that caused the addiction in the first place. There are three main pillars of MORE: it has been proven to help with distress tolerance; cue reactivity (the way people with addiction respond to cues, such as seeing a bottle of prescription drugs, which often trigger cravings); and attentional bias (the way an addicted brain will pay extra, selective attention to certain things, such as a pack of cigarettes when one is quitting smoking).

Mindfulness-Based Addiction Therapy (MBAT) is a technique that uses mindfulness to teach clients how to notice current emotions and sensations, and how to detach themselves from the urge to use drugs. This is called “urge surfing,” and we practiced it extensively in rehab. The aim is to break the automatic link between feeling uncomfortable, craving drugs, and, without thought or reflection, taking a drug to alleviate that discomfort.

Is there good evidence for mind-body medicine approaches to recovery?

While there is promising research that mind-body treatments for addiction are effective, some of the research is contradictory. According to a meta-analysis in the Journal of Substance Abuse Treatment, mindfulness is a positive intervention for substance use disorders, it has a significant but small effect on reducing substance misuse, a substantial effect on reducing cravings, and, importantly, it is a treatment that has a large effect on reducing levels of stress.

However, not all studies of mind-body medicine for addiction have shown overwhelmingly positive results. Some studies showed that the treatment gains diminish over time. Some randomized controlled trials did not show that mind-body medicine was better than cognitive behavioral therapy in decreasing alcohol and cocaine use, or in abstaining from cigarette use.

The National Center for Complementary and Integrative Health did a thorough review of much of the current literature surrounding mind-body medicine as it applies to addiction treatment, and summarized the impact of certain mind-body treatments as follows:

• Acupuncture is generally safe, and may help with withdrawal, cravings, and anxiety, but there is little evidence that it directly impacts actual substance use.
• There was some evidence that hypnotherapy my improve smoking cessation.
• Mindfulness-based interventions can reduce the use of substances including alcohol, cocaine, marijuana, cigarettes, opiates, and amphetamines greater than control therapies do, and are also associated with a reduction in cravings and risk of relapse. But the data in several studies are not strong.

At this time, we need more and better evidence, and more definitive conclusions, about how helpful, ultimately, mind-body medicine will be in helping to treat addiction in different treatment settings. But a takeaway message is that mindfulness-based treatments are certainly quite effective as adjunct treatments for addiction, in that they can help people with their anxiety, distress tolerance, and cravings, and quite plausibly will turn out to help people put down the drink or the drug, and to avoid relapsing, once they have managed to get themselves into recovery.

Mind-body interventions to prevent addiction

If mind-body medicine can significantly reduce stress, then one must ask if it can also help us prevent addiction by helping our society deal with the chronic, overwhelming stress that it is facing. Addiction is in large part considered to be a “disease of despair.” Important contributors to addiction are untreated anxiety and depression, unresolved childhood trauma, social isolation, and poor distress tolerance. If all of us can learn, or be trained, to be more mindful, grateful, present, and connected, perhaps the need, and eventually the habit, of fulfilling our most basic needs with the false promise of a chemical that merely wears off — and leaves us worse off — will become less of a problem in our society.

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What your skin should expect when you’re expecting

Are you pregnant or thinking of becoming pregnant? You’re probably prepared for morning sickness, weight gain, and an expanding belly. But did you know your skin can also undergo a variety of changes when you’re expecting? These changes are due to normal alterations in hormones that occur during pregnancy. Rest assured, most skin conditions that develop or worsen during pregnancy are benign, and tend to improve following delivery.

Darkening of the skin

A large majority of women experience darkening of their skin due to hormone shifts that occur during pregnancy. You may notice that the areas around your thighs, genitals, neck, armpits, and nipples darken. Many women also develop linea nigra, a dark line extending between the belly button and pubic bone. It is also not uncommon for women to experience darkening of their pre-existing moles and freckles. (If you are concerned that a spot on your body is growing or changing more than you’d expect, see a dermatologist for further evaluation.) However, most pigmentary changes tend to return to normal following childbirth, but may take many months to do so.

Melasma, the “mask of pregnancy”

Perhaps the most cosmetically distressing pigmentary change to occur in pregnancy is melasma, also known as the “mask of pregnancy.” Melasma, which can appear as dark patches on the forehead, cheeks, and upper lip, develops in approximately 70% of pregnant women. Melasma is exacerbated by exposure to sunlight. To help prevent it, consistently use sunscreens with sun protection factor (SPF) greater than 50, wear sun-protective clothing and hats when spending time outdoors, and avoid too much direct sunlight.

Melasma can sometimes persist after delivery, though it tends to improve after childbirth. If you wish to treat melasma after delivery, there are many treatments that can be prescribed or performed by a dermatologist, including skin lightening agents, chemical peels, and certain types of lasers. Hydroquinone, which is one of the most commonly used lightening agents on the market, is not safe to use during pregnancy or while breastfeeding. If you want to use a cream that has brightening properties while pregnant, look for glycolic acid or azelaic acid in the ingredient list.

Stretch marks

Stretch marks, also called striae gravidarum, are pink or white streaks of thin skin that develop in up to 90% of pregnant women. They occur due to expansion and stretching of skin during pregnancy, and they are most frequently seen on the abdomen, breasts, buttocks and hips. Stretch marks tend to develop in the late second and third trimester.

Many treatments, including vitamin E-containing oils, olive oil, and cocoa butter, have been used for prevention and treatment of striae, but unfortunately there is limited data to suggest the that any of these products are truly effective. These pink or red marks tend to fade to skin color following delivery, although they rarely disappear entirely. Evidence suggests that topical hyaluronic acid, tretinoin, and trofolastin can be used, with varying degrees of success, after delivery. If topicals are not effective, research has shown that several laser treatments, energy-based devices, and microneedling can lead to visible improvement in striae by increasing production of collagen (a structural component of skin) and decreasing blood flow to the lesions.

Acne… again?!

Many women experience breakouts during their pregnancies, especially those who had acne prior to pregnancy. This typically occurs in the first trimester and is related to the surge of estrogen causing overproduction in oil glands. Guidelines for the treatment of acne during pregnancy are scarce due to the lack of safety data. Dermatologists often recommend a combination of topical azelaic acid and/or benzoyl peroxide. If these treatments are not effective, topical antibiotics such as erythromycin or clindamycin can be added in some cases. Oral antibiotics, including erythromycin, azithromycin, and cephalexin, may be used for persistent cases. Oral and topical retinoids, normally a mainstay of treatment for moderate to severe acne, can result in birth defects and should be avoided during pregnancy.

If you develop any skin eruptions during pregnancy that cause concern, you should be evaluated by a dermatologist prior to starting any medications.

Follow me on Twitter @KristinaLiuMD

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Making special education work for your child during COVID-19

Even in normal times, parents wrestle with decisions about how best to support their children’s development. Now, however, parents are faced with nearly-unprecedented choices, and problems with no clear solutions: What if in-person schooling is better for emotional health, but remote schooling is better for physical health? How can children foster social skills without typical social interactions? How can parents select among learning environments when all the options have clear downsides?

These concerns and choices are even more difficult for parents of children with disabilities, who are among the most vulnerable students and who are at increased risk of regression during school disruptions.

Special education: One size does not fit all

Of course, students who receive special education are not a uniform group. They range in age from 3 to 22, attending preschool through post-secondary placements. They include students with a wide variety of mild to severe cognitive, physical, social, emotional, and behavioral disabilities.

But students with disabilities share a need for special services, accommodations, or both, in order to fully access the school curriculum, and to make meaningful progress appropriate to their ability. At a time when schools are scrambling to deliver regular education in a novel and frightening new context, parents and educators must also work together to select and design appropriate programs for students with special needs.

Remote learning

Remote learning has two obvious benefits. First, it is the safest choice from a physical health perspective; it may indeed be the only choice for students who are medically fragile. Second, remote learning is less likely to be disrupted or changed over the course of the school year. Students who struggle with transitions or anxiety may benefit from the relatively predictable course of remote learning.

But remote learning also carries risks, some of which are particularly acute for students with disabilities. When children are at home, educators may not be able to deliver some services or accommodations. It may be more difficult, or even impossible, to work toward some goals, especially those that require proximity to or interaction with others, such as independently toileting, or purchasing lunch in the school cafeteria without adult support.

Remote learning also requires flexibility in parents’ schedules, and intensive parental participation. Even with parental involvement, students vary in how effectively they can engage with remote learning. And students who struggle with attention, intellectual functioning, language, self-regulation, or a combination of these challenges may have great difficulty learning efficiently from a remote platform. The lack of peer models may lead some children to regress behaviorally or academically.

In-person learning

In-person or hybrid (a combination of remote and in-person learning) models offer most of the benefits that remote options lack. These include a social environment with peers, and access to services and accommodations in as normal an environment as possible. Students who require intensive support, hands-on services, or who are working on skills specific to the school or vocational environment may require in-person learning opportunities in order to fully access the curriculum.

However, in-person models carry one major and obvious risk: the potential of increased exposure to COVID-19. All parents must be wary of this dangerous disease, and parents of medically complex children may deem such a risk unacceptable, despite potential academic or social benefits.

In-person models are also likely to evolve as the pandemic progresses. As a result, students will require greater flexibility in order to be successful at a physical school.

What should parents do?

Parents and educators will need to approach this challenge with creativity, flexibility, and collaboration. Parents should request to meet with their child’s educational team as soon as possible, and should plan to meet regularly thereafter to monitor their child’s progress, and to update the educational program as needed. When parents meet with their team, they should consider each goal and service with an open mind, discussing multiple options for how a goal could be met, and how a service or accommodation could be delivered.

Some adaptations are easy: for example, large print, screen-reading software, and speech-to-text are all immediately available in a remote context. Other adaptations pose challenges, but not necessarily insurmountable ones. A behavior analyst could offer coaching through a video call, for example. Or a teacher certified in intensive special education could deliver discrete trials instruction remotely by positioning two tablets in the child’s home, one for the child to use, and one as a screen to watch the child’s responses. An aide or behavioral support could join a child’s virtual classroom, and chat with or break out with the child as needed to offer support.

Now is the time for innovation, and many schools and families are discovering great new ways to deliver special education instruction safely and effectively.

Put schooling in perspective

While it can seem like there are no great options for school, parents should try to take comfort in accepting that this year, “good enough” is truly enough.

We should also strive to prioritize the things that children require even more than schooling: physical and emotional safety, a responsive adult, and unconditional love and acceptance. Children who feel safe and loved will emerge from this pandemic resilient, and ready to overcome other challenges in their future — and they may even have learned a thing or two along the way.

 

Resources

Autism Speaks COVID Resources

Child Trends (includes multiple excellent articles about supporting children through COVID-19)

Harvard’s Center for the Developing Child Guide to COVID-19 and Early Child Development

Helping Traumatized Children Learn, a collaborative work of MA Advocates for Children and Harvard Law School

Learning Policy Institute Resources and Examples

PTA Resources

US Department of Education resources for schools, students and families

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