Bellezamanana

The wait is finally over: after 40 weeks of medical appointments, nursery planning, and anticipation, your baby has finally arrived. She is perfect in your eyes, healthy and adorable. Yet over the next few weeks, your initial joy is replaced by all-consuming worries: Is she feeding enough? Why is she crying so often? Is something medically wrong with her? These worries are constant during the day and keep you up at night. You feel tense and irritable, your heart races, and you feel panicky. Your family members start to express their concern —not just about the baby, but about you. You wonder whether your anxiety is normal.

Baby blues, postpartum depression, or postpartum anxiety?

Chances are, you have heard about the baby blues or postpartum depression. You may have even filled out questionnaires about your mood during your postpartum doctor’s visit. The baby blues are a very common reaction to decreasing hormone levels after delivery, and may leave you feeling sad, weepy, and overwhelmed. However, these symptoms are mild and only last for a couple of weeks. When the symptoms persist and become debilitating, something else could be going on.

Many symptoms overlap between postpartum depression and postpartum anxiety (such as poor sleep, trouble relaxing, and irritability). Mothers experiencing postpartum depression commonly experience symptoms of anxiety, although not all mothers suffering from anxiety are depressed. Establishing the correct diagnosis is important, as women with postpartum anxiety may not respond as well to certain treatments for depression, such as interpersonal psychotherapy or medications such as bupropion (Wellbutrin).

Similar to postpartum depression, postpartum anxiety may spike due to hormonal changes in the postpartum period. It may also increase as a response to real stressors — whether it’s the health of the baby, finances, or in response to navigating new roles in your relationships. A history of pregnancy loss (miscarriage or stillbirth) also increases your risk for developing postpartum anxiety. If you have a history of anxiety before or during pregnancy, postpartum anxiety symptoms may also return after delivery. Anxiety and sadness may also appear after weaning from breastfeeding due to hormonal changes.

Some women experience panic attacks or symptoms of obsessive-compulsive disorder (OCD) in the postpartum period. Panic attacks are distinct episodes of intense anxiety accompanied by physical symptoms including a rapidly beating heart, feelings of doom, shortness of breath, and dizziness. Obsessions are intrusive, unwanted thoughts and may be accompanied by compulsions, or purposeful behaviors to relieve distress. These symptoms may be frightening to a new mother, especially when these thoughts involve harming the baby. Fortunately, when obsessions are due to an anxiety disorder, mothers are extremely unlikely to harm their babies.

What are the treatments for postpartum anxiety?

In general, postpartum anxiety is less studied than its cousin postpartum depression; however, it is estimated that at least one in five women has postpartum anxiety. We do know that therapies such as cognitive behavioral therapy (CBT) are excellent treatments for anxiety disorders, including OCD. For some women, medications can be helpful and are more effective when combined with therapy. Selective serotonin reuptake inhibitors (SSRIs) are generally the first-line medications (and the best studied medication class) for anxiety disorders, whereas benzodiazepines are rapidly acting anti-anxiety medications that are often used while waiting for an SSRI to take effect.

Should you take medications when breastfeeding?

Breastfeeding provides many benefits to the baby: it’s the perfect nutrition, it helps build a baby’s immune system, it may help prevent adulthood obesity, and it provides comfort and security. Breastfeeding also provides benefits for the mother: it releases prolactin and oxytocin (the love and cuddle hormones), which help a mother bond with her baby and provide a sense of relaxation. When considering whether to start a medication, it is important to be aware that all psychiatric medications are excreted into the breast milk. Your doctor can help you think through the risks and benefits of medications based on the severity of your illness, medication preference, and previous response, as well as factors unique to your baby, such as medical illness or prematurity.

What non-medication strategies are helpful in decreasing postpartum anxiety?

• Cuddle your baby (a lot). This releases oxytocin, which can lower anxiety levels.
• Try to maximize sleep. Although the baby may wake you every three hours (or 45 minutes) to feed, your partner should not. Sleeping in separate rooms or taking shifts caring for the baby may be necessary during the first few months. Aim for at least one uninterrupted four-hour stretch of sleep, and be mindful about caffeine intake.
• Spend time with other mothers. Although you may feel like you don’t have the time, connecting with other mothers (even online) can do wonders in lowering your fears and validating your emotions. Chances are you are not the only one worrying up a storm.
• Increase your physical activity. In spite of the physical toll that pregnancy, delivery, and milk production take on your body, physical activity is one of the most powerful anti-anxiety strategies. Activities that incorporate breathing exercises, such as yoga, may be particularly helpful.
• Wean gradually. If you are breastfeeding and make the decision to wean, try to do so gently (when possible) to minimize sudden hormonal changes.
• Ask for help. Caring for a baby often requires a village. If you are feeding the baby, ask someone else to help with household chores. There is an old saying “sleep when the baby sleeps.” You may prefer “do laundry when the baby does laundry.”

And finally, give yourself a break — after all, you just had a baby. Postpartum anxiety is common, and in many cases, it will pass with time.

About the Author

Stephanie Collier, MD, MPH, Contributor

Dr. Stephanie Collier is the director of education in the division of geriatric psychiatry at McLean Hospital; consulting psychiatrist for the population health management team at Newton-Wellesley Hospital; and instructor in psychiatry at Harvard Medical School. … See Full Bio View all posts by Stephanie Collier, MD, MPH

A positive outlook has been linked to better heart health and a longer life. But is that true for Black Americans, whose average lifespan is about 72 years, compared with an average lifespan of 77 years for all Americans?

Recent findings from the nation’s largest and longest-running study of cardiovascular risk factors in Black Americans, the Jackson Heart Study, suggest that the answer is a qualified yes. Cardiovascular diseases, which give rise to heart attack and stroke, are the leading cause of death and disability worldwide. Perhaps not surprisingly, the association between optimism and longevity in Black Americans appears to be strongest among people with higher education or income levels, and those ages 55 and younger. It also proved stronger among men than among women.

Is optimism the only key to longevity in this study?

Probably not. There’s another possible explanation for the findings, says Dr. Rishi Wadhera, a cardiologist at Harvard-affiliated Beth Israel Deaconess Medical Center (BIDMC).

“Instead of optimism leading to better health, it’s possible that healthier individuals are simply more optimistic, or less healthy individuals are less optimistic,” he says. This so-called reverse causality — when cause and effect are the opposite of what one assumes — is always a possibility in observational studies, even when scientists take pains to control for possible confounding factors such as health conditions and behaviors, as they did in this study.

“Nonetheless, these findings contribute to a body of evidence that suggests that psychosocial resources, mood, and mental health are all associated with health,” says Dr. Wadhera, who is section head of health policy and equity research at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology at BIDMC.

Measuring optimism in the study

Led by researchers at the Harvard T.H. Chan School of Public Health, the study included 2,652 women and 1,444 men who were part of the Jackson Heart Study. Researchers measured optimism using the Life Orientation Test-Revised, which includes questions such as “In uncertain times, I usually expect the best.” Responses are scored on a scale of 0 (strongly disagree) to 4 (strongly agree). The researchers administered this test and others between 2000 and 2004, and tracked mortality among the study participants until 2018.

Optimism — the general belief that good things will happen — may be partly inherited, although genetic factors are thought to explain only about 20% to 30% of this trait. Some research suggests that people can enhance their feelings of optimism either through cognitive behavioral therapy or writing exercises that focus on imagining their “best possible future self.”

Looking forward

Still, optimism is but one of many intertwined social factors that influence how long people live. A better understanding of biological pathways that could potentially explain the outcomes observed in this study may help, says Dr. Wadhera.

“But to meaningfully address the alarming and ubiquitous health inequities that exist in our country, we need to tackle the unacceptable gaps in care and resources that exist between different racial and ethnic groups,” he adds. This includes disparities in health insurance coverage, access to health care, neighborhood factors such as access to green space and healthy foods, and environmental stressors such as pollution exposure. “Doing so may help people and communities from all backgrounds live happier and longer lives,” Dr. Wadhera says.

 

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

The decision to step down or stop taking a proton pump inhibitor is a complex decision you should discuss with your doctor.

Proton-pump inhibitors (PPIs) are a common type of anti-acid medication, and are available both by prescription and over the counter. Omeprazole and pantoprazole are examples of PPIs. They are the treatment of choice for several gastrointestinal disorders, such as peptic ulcer disease, esophagitis, gastroesophageal reflux disease, and H. pylori infection.

New guidelines by the American Gastroenterological Association have highlighted the need to address appropriate PPI usage, and they recommend that PPIs should be taken at the lowest dose and shortest duration for the condition being treated. However, PPIs are frequently overused, and may be taken for longer than necessary. This can happen unintentionally; for example, if the medication was started while the patient was hospitalized, or it was started as a trial to see if a patient’s symptoms would improve and then is continued beyond the needed timeframe.

Who should use PPIs in the short term?

There are a variety of reasons for short-term PPI usage. For instance, PPIs are prescribed typically for one to two weeks to treat H. pylori infection, in addition to antibiotics. A PPI course of four to 12 weeks may be prescribed for people with ulcers in their stomach or small intestine, or for inflammation in the esophagus.

People may also be prescribed a short course of PPIs for acid reflux or abdominal pain symptoms (dyspepsia), and for symptom relief while physicians perform tests to determine the cause of abdominal pain. People may be able to move to a lower dose of PPIs, or discontinue their medication altogether, if their symptoms get better or they have completed their treatment course.

Who should be on PPIs long-term?

Some patients with specific conditions may need to be on PPIs for the long term, and they should discuss their condition and unique treatment plan with their doctor. Some conditions that may require longer-term use of PPIs include:

• severe esophagitis, eosinophilic esophagitis, Barrett’s esophagus, esophageal strictures, or idiopathic pulmonary fibrosis
• acid reflux
• dyspepsia or upper airway symptoms that improve with PPI usage but worsen when stopping PPIs
• people with a history of upper gastrointestinal bleeding from gastric and duodenal peptic ulcers may need to be on PPIs long-term to prevent recurrence.

What are some side effects of PPIs?

Any medication can cause side effects. Fortunately, adverse effects from PPIs are generally rare. However, these medications have been associated with increased risk of certain infections (such as pneumonia and C. difficile). Previously, there had been concerns that PPI usage was linked to dementia, but newer studies have contradicted this association.

Additionally, while rare, PPIs may also cause drug interactions with other medications. For example, PPIs may affect the levels and potency of certain medications, such as clopidogrel (Plavix), warfarin (Coumadin), and some seizure and HIV medications, sometimes necessitating dosage adjustments of these drugs. Therefore, it is important to let the team of healthcare providers who manage your medications know when a new medication has been added to your list or if a medication has been discontinued.

How do I work with my doctor to step down from taking PPIs?

Some patients are prescribed PPIs twice a day in an acute situation, such as to prevent rebleeding from stomach ulcers or if a patient has severe acid reflux symptoms. If there no longer remains a reason to take PPIs twice a day, you may be stepped down to once a day. To discontinue a PPI, your doctor may decide to taper the medication — for example, by decreasing the dose by 50% each week until discontinued.

What might I experience if my doctor suggests I stop taking a PPI?

Studies have shown that for patients with long-term PPI use, there can be rebound secretion of stomach acid and an increase in upper gastrointestinal symptoms when discontinuing PPIs. However, a different type of anti-acid medication (such as an H2 antagonist like famotidine or a contact antacid medication containing calcium carbonate like TUMS) can be used for relief temporarily. If a patient experiences more than two months of severe persistent symptoms after discontinuing a PPI, this may be a reason to resume PPI therapy.

What steps should I take next?

It is important to routinely discuss your medication list and concerns with your primary care doctor. The decision to step down or discontinue a PPI is complex, and for your safety you should verify with your doctor before adjusting your PPI dosing. Ultimately, the goal is to make sure you are only taking medications that are necessary in order to maximize the benefit and minimize side effects.

About the Authors

Nisa Desai, MD, Contributor

Dr. Nisa Desai is a practicing hospitalist physician at Beth Israel Deaconess Medical Center, and an instructor in medicine at Harvard Medical School. She completed undergraduate education at Northwestern University, followed by medical school at the … See Full Bio View all posts by Nisa Desai, MD

Loren Rabinowitz, MD, Contributor

Dr. Loren Rabinowitz is an instructor in medicine Beth Israel Deaconess Medical Center and Harvard Medical School, and an attending physician in the Inflammatory Bowel Disease Center at BIDMC. Her clinical research is focused on the … See Full Bio View all posts by Loren Rabinowitz, MD

Pregnancy is often painted as a time of elation and joy, emotions many people may indeed feel. As doctors, though, it’s hard to ignore the health risks and the fears that can arise in the wake of a positive pregnancy test for some of our most vulnerable patients.

Simply being pregnant poses significant short-term and long-term risks to health, particularly in the US. We have the highest rate of serious pregnancy-related complications among developed nations, resulting in about 700 deaths a year nationally. This health burden is unequally distributed, falling hardest on women of color and low-income women — in fact, Black women are three times as likely to die as white women from pregnancy-related complications.

What makes pregnancy challenging from a health standpoint?

Pregnancy acts as an ongoing stress test that taxes body systems and generates unique health risks. It changes how the heart, lungs, and kidneys function. It also alters the immune system, and changes metabolism through effects on various organs. It increases blood flow throughout the body. The impact is greater for anyone who already has high blood pressure, diabetes, or other health conditions. Additionally, pregnancy can also deepen existing mental health disorders such as depression and anxiety, often exacerbating symptoms.

Two health issues unique to pregnancy are:

• Preeclampsia. This causes high blood pressure and possible damage to other organs, such as the kidneys, liver, and brain. Pregnancy alone places extra stress on the heart and blood vessels. Having a pregnancy affected by preeclampsia more than triples one’s lifetime risk of cardiovascular disease such as stroke or heart attack, according to the Preeclampsia Foundation. The biggest risk factors for developing preeclampsia are being younger than 18 or older than 40, autoimmune disease (such as lupus), existing high blood pressure, or preeclampsia in a prior pregnancy.
• Excess bleeding after birth (postpartum hemorrhage). While certain factors put people at higher risk, hemorrhage may occur with any birth, even those that follow uncomplicated pregnancies.

Most often, pregnancy can be safely navigated even when a person has health conditions. Yet having an existing condition like heart disease or diabetes does raise risk for complications and death. Now that pregnancies at later ages are more common, existing heart disease is complicating more pregnancies. Once rarely needed, large multidisciplinary teams of health professionals are now often required to care for pregnant people with complex cardiac needs or other health conditions.

Many pregnancies are unintended

Nearly half of all pregnancies in the United States are unintended. In some cases that means a pregnancy is wanted at a future time; in others that a pregnancy is not desired.

Why do so many unintended pregnancies occur? Nine in 10 sexually active women who are not trying to get pregnant report using some form of birth control. Of course, not all types of birth control are highly effective. In a year of use, 13 out of 100 people relying on condoms alone — and up to 23 out of 100 relying on fertility awareness methods — will become pregnant.

Unintended pregnancies occur even when people use very effective contraceptives. With perfect use (which is very hard to achieve), fewer than one in 100 women taking birth control pills for a year will become pregnant. With typical use, seven in 100 will become pregnant. More than 13 million US women use surgical sterilization, such as tubal ligation, as a permanent form of birth control. Given the failure rate of nearly one in 100, research suggests more than more than 65,000 unintended pregnancies may occur annually after these procedures.

Health factors in, too. Certain medical conditions or medications, such as medicines used to treat epilepsy, may also increase the risk of contraceptive failure. Health conditions also dictate whether people can use some of the more effective forms of birth control.

A narrowing of health care choices and life choices

Pregnancy, childbirth, and parenting alter the trajectory of many lives — parents, siblings, and wider family — even when people choose this path. Since June 2022, when the Dobbs Supreme Court decision overturned a national constitutional right to abortion, at least 14 states have banned or severely restricted the ability to make choices once pregnant. Even before Dobbs, nearly 10% of people seeking abortion care in the US had to travel out of state.

Research shows that women who seek an abortion but are denied abortion care are more likely to have health problems during their pregnancy and to experience financial difficulties or live in poverty years later. State bans on abortion care will have a disproportionate impact on Black and low-income women, who already are at higher risk for complications or death related to childbirth. Ultimately, legislation that restricts or bans comprehensive health care that includes abortion care puts all people capable of pregnancy at risk — medically, economically, and socially.

Like pregnancy itself, the decision to remain pregnant is deeply personal. And as with all health care, patients and physicians should be able to freely consider all medical options to help guide decisions, including ending a pregnancy. Although abortion care is more restricted today than it has been since 1973, options are available and remain a critical part of maternal health care.

Selected resource

Contraceptive Technology, 21st edition, Managing Contraception LLC. More information is available on the Managing Contraception website.

About the Authors

Sara Neill, MD, MPH,

Contributor

Dr. Sara Neill is a physician-researcher in the department of obstetrics & gynecology at Beth Israel Deaconess Medical Center and Harvard Medical School. She completed a fellowship in complex family planning at Brigham and Women's Hospital, and … See Full Bio View all posts by Sara Neill, MD, MPH

Scott Shainker, DO, MS, Contributor

Scott Shainker, D.O, M.S., is a maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center (BIDMC). He is also a member of the faculty in the Department of Obstetrics, … See Full Bio View all posts by Scott Shainker, DO, MS

5 takeaways from the 2023 diabetes guidelines.

At nearly 300 pages long, the recently released 2023 American Diabetes Association Standards of Medical Care are quite comprehensive. And given the strong link between obesity and diabetes, one major theme is weight loss. For the estimated 37 million Americans currently living with diabetes, what other changes are worth noting?

Collaborating on lifestyle change is key

There aren’t any dramatic shifts in this update, says Harvard Medical School professor Dr. David M. Nathan, who co-authored and chaired earlier versions of some of the guidelines, which have been published annually for more than three decades. “Most of the standard lifestyle advice for managing diabetes are the same common-sense things your grandmother told you: eat your vegetables, go outside and exercise, and get enough sleep.”

One subtle shift in the association’s advice over the past five to 10 years, however, is an overarching effort to make care for people with diabetes more person-centered, says Dr. Nathan, who directs the Diabetes Center and the Clinical Research Center at Massachusetts General Hospital. “That means collaborating with your physician to figure out a lifestyle and medication plan that works for you,” he says. “Doctors don’t stand by your dinner table or bedside telling you what to do. They can help you make plans and informed decisions to better manage your diabetes, but you have to play an active role.”

Five takeaways for a diabetes tune-up

According to Dr. Nathan, here are five key takeaways from the guidelines that people with the most common form of the disease, type 2 diabetes, should know. (Several of these tips also apply to people with type 1 diabetes, but those people should check with their own doctors for targeted advice).

Strive for sound, uninterrupted sleep. Experts have long recognized a link between poor sleep and obesity. Mounting evidence suggests that sleep problems are also associated with diabetes risk. “Altered sleep patterns can affect blood sugar control,” Dr. Nathan says. Obstructive sleep apnea, a serious disorder that causes repeated, brief pauses in breathing throughout the night, is a frequent cause of disrupted sleep. Because it’s more common in people with diabetes (especially those who have obesity), anyone with the hallmark symptoms — loud snoring, snorts and gasps during sleep, and daytime sleepiness despite a full night’s sleep — should be evaluated. Ask your doctor about a home-based test for sleep apnea.

Don’t “diet.” Many popular fad diets — keto, paleo, intermittent fasting, and others — can help people lose weight. But most people regain any lost weight once they stop following the diet. Instead, it’s much more effective to gradually move toward a healthy dietary pattern that you can stick with over the long haul, says Dr. Nathan. Good choices include the Mediterranean eating pattern and the closely related DASH diet. For people with diabetes, it’s especially important to avoid sodas and other sugary drinks. You should also reduce how often you have desserts, sweets, and fatty foods, and eat more high-fiber carbohydrates, such as whole-wheat bread and brown rice.

Exercise safely. Walking is ideal exercise for most people, provided you start slow and ramp up your distance and speed gradually if you haven’t been physically active. People with diabetes need to pay special attention to choosing a well-fitting pair of shoes and check their feet regularly for redness, blisters, or sores. That’s because diabetes can cause neuropathy (numbness due to nerve damage), which can leave you unable to sense minor trauma and injuries to the toes and feet. These can result in more severe foot problems and lead to amputations.

Work toward a healthier weight. The three tips above can help people lose weight, but many people with obesity need medications to lose significant amounts of weight. Metformin, the most commonly prescribed drug to lower blood sugar, may help people lose about five pounds on average. And while that modest weight loss improves diabetes and its complications, larger losses are even more beneficial.

Two relatively new diabetes drugs, semaglutide (Ozempic) and tirzepatide (Mounjaro) can help people shed up to 15 to 20 pounds, respectively. They also lower hemoglobin A1c levels by as much as two percentage points. (A1c is a three-month average measure of blood sugar.)

“These drugs, which are given by a once-weekly injection, are quite exciting, and should be in the running as a first choice to add to metformin for people with diabetes and obesity,” says Dr. Nathan. But because they’re very expensive (around $1,000 per month before insurance) and must be taken indefinitely, they aren’t realistic for everyone, he adds. In contrast, metformin costs only $4 per month.

Know your treatment targets. As in the past, most people with diabetes should aim for an A1c of 7% or less. Even if you don’t lose weight, reaching that goal reduces your risk for serious diabetes complications like vision and kidney problems and neuropathy, says Dr. Nathan.

Diabetes also raises your risk of heart disease. Target blood pressure is less than 130/80 mm Hg. Target LDL cholesterol is at least a 50% reduction (or reaching 70 mg/dL or lower). If you already have heart disease, the guidelines suggest an even lower LDL target of 55 mg/dL. “Many of the people I treat take cholesterol-lowering statins, and I often increase their doses to help them reach a lower goal,” says Dr. Nathan. In some instances, a combination of cholesterol-lowering medicines can help lower stubbornly high LDL.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

While studies sometimes reach faulty conclusions, researchers can help correct the record.

When it comes to clinical research, the most powerful type of study is a randomized, double-blind, placebo-controlled trial.

But even a well-designed trial can arrive at questionable conclusions. Recent follow-up on a 2019 cardiovascular study dubbed REDUCE-IT is one example that offers a great lesson. While innovative treatments are the focus of many clinical trials like this one, the choice of placebo is critical as well.

What made this a powerful study?

In this type of study, subjects are randomly assigned to two groups: one group receives the treatment being evaluated (such as a new drug) while the other group gets a fake treatment called a placebo.

Neither study subjects nor researchers know who is receiving active treatment and who is receiving placebo. That is, they are both blind to group assignment — that’s why it’s called double-blind. Treatment assignment is coded and kept secret until the end of the study, or decoded at earlier, planned intervals to monitor effectiveness or safety.

This reduces the chance that expectations of the researchers or participants will bias study outcomes. That means any differences in health or side effects can reasonably be attributed to the treatment — or lack of it.

What to know about placebo treatment

Ideally, study participants and researchers cannot tell who is getting an active treatment and who is getting a placebo. But sometimes, participants might be able to tell what they received. For example, the active treatment might have a bitter taste, or a noticeable side effect such as diarrhea.

If that happens, the study is no longer double-blind. This means expectations could affect outcomes. Studies can assess this by asking participants during or after the trial whether they thought they were taking an active treatment or a placebo. If the answers seem random or the subjects answer “I don’t know,” blinding was successful.

While a placebo treatment should have no effect, that’s not always true:

• The well-known placebo effect is a positive effect related to an expectation of benefit: if you tell someone a pill can relieve pain, some people will experience pain relief, even if that pill was a placebo.
• A negative side effect due to a placebo is called the nocebo effect: if you tell someone they might develop diarrhea from the placebo pill they’re taking, the expectation may cause some people to experience this. (The very same placebo used in another study may trigger headaches, if that’s the side effect the study subject is warned about.)

Finally, a placebo should not have any direct, biological impact on the person taking it. And that seems to be where REDUCE-IT went wrong.

REDUCE-IT demonstrates the importance of choosing a placebo carefully

The full name of REDUCE-IT is the Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial). It was designed to determine whether the drug icosapent ethyl could lower triglyceride levels as a way to reduce cardiovascular disease, such as heart attack or stroke.

Triglycerides are a type of fat in the blood. High levels may increase cardiovascular risk, but experts aren’t sure whether treatments to lower triglyceride levels result in fewer heart attacks or strokes.

Among participants who received the active drug, triglyceride levels fell. Rates of cardiovascular problems, including heart attack or stroke, were a whopping 25% lower compared with rates in those assigned to take a placebo. There was even a 20% reduction in cardiovascular deaths in the treatment group.

Based on these findings, the FDA approved a drug label claiming that icosapent ethyl benefitted certain people at high risk for cardiovascular disease.

But questions arose soon after the study was published in 2019. True, the treatment group fared better than the placebo group. Yet a careful reading of the results suggested that this may have been because those in the placebo group had more heart attacks and strokes over time, not because the treatment group had fewer.

A follow-up study shows a different result

Responding to these questions, the study’s authors performed additional analyses. This time they looked at substances in the blood called biomarkers associated with cardiovascular risk. They found little change in the biomarker results among participants receiving the active drug. But biomarkers worsened in the placebo group, suggesting that the apparent benefit conferred by the drug may have been due to the negative effects of the placebo!

How can a placebo worsen cardiovascular risk? One possibility is that the mineral oil placebo used in this trial may have reduced absorption of statin drugs participants were taking to lower their cholesterol, which also affect heart and blood vessel health. Regardless, this new analysis suggests that the skepticism about the dramatic results of the original study was appropriate, and additional study is warranted.

The bottom line

For me, this story has three take-home points:

• There are many ways for research to come to faulty conclusions; an unfortunate placebo choice is an unusual one, but appears to be true here.
• For medical research to be trusted, researchers must be willing to accept criticism, re-assess findings, and perform additional analyses if necessary.
• It appears that in the case of REDUCE-IT, this self-correction process worked.

After the initial study in 2019, enthusiasm was high for the drug icosapent ethyl. In the wake of this latest analysis, however, that excitement is likely to wane. But one thing should be clear: this is not science being unable to make up its mind, as is sometimes said. Reassessment and correction, when warranted, is how science is supposed to work.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

Climate change is an escalating threat to the health of people everywhere. As emergency medicine physicians practicing in Australia and the United States, we — and our colleagues around the world — already see the impacts of climate change on those we treat.

Will we be seeing you one day soon? Hopefully not. Yet an ever-growing number of us will face climate-related emergencies, such as flooding, fires, and extreme weather. And all of us can actively prepare to protect health when the need arises. Here’s what to know and do.

How is climate change affecting health?

As the planet warms, people are seeking emergency medical care for a range of climate-related health problems, such as heat exhaustion and heat stroke, asthma due to air pollution, and infectious diseases related to flooding and shifting biomes that prompt ticks, mosquitoes, and other pests to relocate. News headlines frequently spotlight physical and emotional trauma stemming from hurricanes, wildfires, tornadoes, and floods.

We care for people displaced from their homes and their communities by extreme weather events. Many suddenly lack access to their usual medical team members and pharmacies, sometimes for significant periods of time. The toll of extreme weather often lands hardest on people who are homeless, those with complex medical conditions, children, the elderly, people with disabilities, minoritized groups, and those who live in poorer communities.

On a recent 110º Fahrenheit day, for example, a woman came to an emergency department in Adelaide, Australia complaining of a headache, fatigue, and nausea, all symptoms of heat exhaustion. She told medical staff that she had just walked for two hours in the sun to obtain groceries, as she had no car or access to public transportation. While health advisories in the media that day had advised her to stay inside in air conditioning, walking outside was only the only option she had to feed her family. For this woman and many others, well-intended public health warnings do little to reduce the risk of illness during extreme weather. Achieving safe, equitable health outcomes will require addressing access to shelter, access to transportation, and other societal factors that put people at risk of bad health outcomes.

Extreme weather contributes to large-scale health and safety issues

Increasingly, climate-related extreme weather is leading to interrupted access to medical care, contributing to later illness and death. Extreme weather can damage key infrastructure like the electrical grid, so that those relying on home medical equipment cannot use it. It may shut down health care facilities like a dialysis center or emergency room, or slow care in facilities that stay open.

People fleeing a fire or hurricane can be displaced into settings where they may have difficulty getting medical care or obtaining much-needed medicine, such as insulin, dialysis, high blood pressure treatments, and heart medicines. Such factors can worsen chronic conditions and may even cause death, particularly in people with existing medical conditions like heart failure, lung disease, and kidney disease.

How can you be ready to protect your health?

We all have a part to play in keeping ourselves and our communities well in the face of increasing dangers from climate change. Taking these steps will help.

If you or a loved one has health issues:

• Keep a printed summary handy listing all medical conditions, medications and dosages, and phone numbers for your health providers.
• If you have to leave your home, try to bring all medications with you — even bringing empty pill bottles will help a doctor trying to restart your medications.
• Store medicines in a waterproof bag in a place where you can easily find them. This will help if you need to evacuate quickly.

Think about what to do if you need to leave home quickly. Now is the time to figure out your basic emergency plan:

• Where will you go if you need to evacuate?
• How will you get there?
• How could you communicate with others if there is no electricity or phone service?
• Do you have written contact info for a few family members and friends, in case you lose your phone or the battery dies?

Finally, we all need to look out for others in our community. Check in on elderly neighbors and those around you who may be socially disconnected, and make sure that they are safe where they live and are able to access the medical care they may need when the weather turns hot, cold, smoky, fiery, snowy, wet, or windy.

Climate change is here. It is already having tangible and significant impacts on our communities and the health of people around the world. Moreover, the increased risk of climate-related extreme weather is here to stay for the foreseeable future, and we must prepare for the threats it poses to our health, both now and in decades to come. We all have a part to play — health professionals, communities, and individuals — in keeping ourselves and each other healthy and safe.

About the Authors

Kimberly Humphrey, MD, MPH, Contributor

Dr. Kimberly Humphrey is an emergency physician, a current Fellow in Climate Change and Human Health at Harvard C-CHANGE at Harvard's T.H. Chan School of Public Health, and a visiting scholar at the Harvard FXB Center. Her research focuses on the … See Full Bio View all posts by Kimberly Humphrey, MD, MPH

Caleb Dresser, MD, MPH, Contributor

Dr. Caleb Dresser is an emergency physician and assistant director of the Climate and Human Health Fellowship, cohosted by Beth Israel Deaconess Medical Center, the Harvard FXB Center, and Harvard C-CHANGE. His research focuses on understanding the health implications of climate-related … See Full Bio View all posts by Caleb Dresser, MD, MPH

Obesity is a complex health issue that affects a staggering percentage of US children and teens. Hovering around 5% in 1963 to 1965, rates of obesity had more than tripled to 19% by 2017 to 2019. Early data suggest childhood obesity rates continued climbing during the pandemic. If these trends continue, 57% of children currently ages 2 to 19 will have obesity as adults in 2050.

In a nutshell, this puts more than half of children now alive in the US at greater risk for high blood pressure, heart disease, diabetes, liver disease, and the other health complications of obesity. Stress, depression, and poor self-esteem are often linked to stigma surrounding obesity. For these reasons and more, the American Academy of Pediatrics recently updated clinical practice guidelines for evaluating and treating children and teens with obesity.

A complex interplay contributes to childhood obesity

Obesity has long been stigmatized as simply a problem of personal choice: if people just ate less and exercised more, they would not be obese, experts once believed. But the medical evidence is far more complicated than that. Genetic, physiologic, socioeconomic, and environmental factors contribute to obesity in children.

• Calories and foods. It is true that excess calories and eating unhealthy foods play a significant role in the development of obesity. But many families don’t have easy access to healthy foods like fresh foods and vegetables. For many children, the only foods available to them are heavily processed foods, fast foods, and other unhealthy foods, which may be all their families can afford or find — and not all schools offer healthy foods either. Even when families do have resources, they are often stressed in ways that make putting time and energy into healthy eating hard.
• Exercise. While it is also true that regular exercise helps keep children at a healthy weight, many children live in places where there aren’t safe places to play outside, and their parents either cannot afford to sign them up for activities or do not have the time to bring them to those activities — or both.
• Other factors influencing obesity. Prenatal factors, such as maternal weight gain or gestational diabetes, increase risk before a child is even born. We are just beginning to understand genetic factors, many of which can be further affected by the child’s environment. There are ways that systemic racism and deeply embedded socioeconomic factors play a role. Simply put, obesity is complicated.

Work with your child’s doctor on a plan for better health

The new guidelines recommend that your doctor should:

• Screen regularly for obesity, using body mass index (BMI) as a measure. This calculation uses a child’s height and weight and is given as a percentage based on age (unlike in adults, where the number alone is used). It’s not a perfect measure, but it is the best we have. A BMI higher than the 95th percentile for age is considered obese.
• Look at the whole picture when a child is gaining too much weight for their age or is at an unhealthy weight. Where does your family live? What is your socioeconomic status? What can you share about beliefs, daily life, school, ethnic background, and community connections? Willingness and ability to make lifestyle changes? All of this, along with family medical history, matters when it comes to understanding and helping develop a good plan.
• Explain options for treatment. The best evidence-based treatment is called intensive health behavior lifestyle treatment, or IHBLT. This involves face-to-face, family-based, multidisciplinary counseling on nutrition and physical activity, preferably based in your community and connected to community resources. To make a difference, it should involve at least 26 hours over at least three to 12 months. These programs, unfortunately, are not easily available to most families.

What if the comprehensive program called IHBLT is not available?

When a comprehensive program is not available, the new guidelines recommend that pediatricians:

• Try to see children with obesity regularly, do their best to understand and manage all the contributing circumstances, and encourage strategies endorsed by professional organizations, including:
  • drinking fewer sugar-sweetened beverages
  • using recommendations and recipes at myplate.gov
  • getting kids engaged in 60 minutes a day of moderate to vigorous physical activity
  • finding ways to avoid inactivity (sedentary behavior) generally, such as limiting screen time and encouraging active games.
• Consider medications. A number of weight-loss medicines have been approved for children. Benefits are modest for all of them and don’t take the place of lifestyle changes.
• Consider surgery. Bariatric surgery may offer the greatest long-term benefits, especially for children or teens who have severe obesity (a BMI in the 120th percentile for age). We tend to think of this more as an option for adults, but growing evidence suggests surgery can and should be considered earlier.

What can families do together?

The Centers for Disease Control and Prevention suggests four actions families can take:

• Try to model healthy eating patterns. 
• Find ways to help children move more, such as through athletics, dancing, games, and active chores.
• Help children and teens get sufficient sleep.
• Consider ways to replace screen time.

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

Lifestyle changes like regular exercise, a healthy diet, and sufficient sleep are cornerstones of self-care for people with type 2 diabetes.

But what about mind-body practices? Can they also help people manage or even treat type 2 diabetes? An analysis of multiple studies, published in the Journal of Integrative and Complementary Medicine, suggests they might.

Which mindfulness practices did the study look at?

Researchers analyzed 28 studies that explored the effect of mind-body practices on people with type 2 diabetes. Those participating in the studies did not need insulin to control their diabetes, or have certain health conditions such as heart or kidney disease. The mind-body activities used in the research were:

• yoga
• qigong, a slow-moving martial art similar to tai chi
• mindfulness-based stress reduction, a training program designed to help people manage stress and anxiety
• meditation
• guided imagery, visualizing positive images to relax the mind.

How often and over what time period people engaged in the activities varied, ranging from daily to several times a week, and from four weeks to six months.

What did the study find about people with diabetes who practiced mindfulness?

Those who participated in any of the mind-body activities for any length of time lowered their levels of hemoglobin A1C, a key marker for diabetes. On average, A1C levels dropped by 0.84%. This is similar to the effect of taking metformin (Glucophage), a first-line medication for treating type 2 diabetes, according to the researchers.

A1C levels are determined by a blood test that shows a person’s average blood sugar levels over the past two to three months. Levels below 5.7% are deemed normal, levels from 5.7% to less than 6.5% are considered prediabetes, and levels 6.5% and higher are in the diabetes range.

How can mind-body practices help control blood sugar?

Their ability to reduce stress may play a big part. “Yoga and other mindfulness practices elicit a relaxation response — the opposite of the stress response,” says Dr. Shalu Ramchandani, a health coach and internist at the Harvard-affiliated Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital. “A relaxation response can lower levels of the stress hormone cortisol. This improves insulin resistance and keeps blood sugar levels in check, thus lowering A1C levels.”

A relaxation response can help people with diabetes in other ways, such as by improving blood flow and lowering blood pressure, which protects against heart attacks and strokes.

What else should you know about this study?

The results of studies like this suggest a link between various mind-body practices and lower A1C levels, but do not offer firm proof of it. Levels of participation varied widely. But because all mindfulness practices studied had a modest positive effect, the researchers suggested that these types of activities could become part of diabetes therapy along with standard lifestyle treatments.

Could mind-body practices protect people against developing type 2 diabetes, especially for those at high risk? While this study wasn’t designed to look at this, Dr. Ramchandani again points to the long-range benefits of the relaxation response.

“Reducing and managing stress leads to improved moods, and greater self-awareness and self-regulation,” she says. “This can lead to more mindful eating, such as fighting cravings for unhealthy foods, adhering to a good diet, and committing to regular exercise, all of which can help reduce one’s risk for type 2 diabetes.”

Trying mind-body practices

There are many ways to adopt mind-body practices that can create relaxation responses. Here are some suggestions from Dr. Ramchandani:

• Do a daily 10-minute or longer meditation using an app like Insight Timer, Calm, or Headspace.
• Attend a gentle yoga, qigong, or tai chi class at a local yoga studio or community center.
• Try videos and exercises to help reduce stress and initiate relaxation responses.
• Practice slow controlled breathing. Lie on your back with one or both of your hands on your abdomen. Inhale slowly and deeply, drawing air into the lowest part of your lungs so your hand rises. Your belly should expand and rise as you inhale, then contract and lower as you exhale. Repeat for several minutes.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Howard LeWine, M.D., is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

Love isn’t the only reason your heart may skip a beat. While abnormal heartbeats can be alarming, they’re usually harmless. They occur for different reasons. Which types are common — and when should you be concerned?

Palpitations

Your heartbeat normally keeps a predictable pace: speeding up when you’re active and slowing down when you rest. But many people notice odd heart sensations called palpitations at least once in a while. People usually say it feels as though their heart has skipped a beat, or is racing or pounding.

“One common scenario is a person who feels their heart is racing, but if you look at their electrocardiogram (ECG), It’s totally normal,” says cardiologist Alfred E. Buxton, professor of medicine at Harvard Medical School.

A heightened awareness of normal heart rhythms may occur more in people who wear smartwatches with heart rate monitors, he adds. “People with a resting heart rate of 60 beats per minute are concerned when their heart rate goes up to 90, but that’s still in the normal range,” he says.

Ectopic beats

The sensation that your heart has skipped a beat also occurs when the heart’s upper chambers (atria) or lower chambers (ventricles) contract slightly earlier than normal.

During the next beat, the atria pause a bit longer to get back into a normal rhythm. The heart’s lower chambers (ventricles) then squeeze forcefully to clear out the excess blood that accumulates during that pause. They also can contract earlier than usual, which may make you feel like your heart has briefly stopped and restarted.

Known as ectopic beats, both types of these premature contractions may cause a brief pounding sensation. However, this is nothing to worry about. “I often tell my patients that the fact they feel these beats is usually a sign that their heart is healthy. A weak, sick heart can’t exert a forceful beat,” says Dr. Buxton.

AV block and bundle branch block

Electrical impulses tell your heart to pump. They travel through the right and left sides of your heart. But sometimes the impulses travel more slowly than normal or irregularly, causing a condition called AV block. There are various degrees of AV block, some benign, others associated with extremely slow heart rates that may be dangerous.

Another electrical conduction irregularity is a bundle branch block. This results from an abnormal activation pattern of the ventricles that squeeze blood out of the heart to the rest of the body. The most common is right bundle branch block, which usually doesn’t cause obvious symptoms. It may be spotted during an ECG, and can simply reflect the gradual aging of the heart’s conduction system. However, sometimes a right bundle branch block is caused by underlying damage from a heart attack, heart inflammation or infection, or high pressure in the pulmonary arteries.

A left bundle branch block may occur as an isolated phenomenon, or may be caused by a variety of underlying conditions. In some cases, left bundle branch block may lead to abnormal function of the left ventricle, a condition that is sometimes corrected by special pacemakers.

Atrial fibrillation

An electrical misfire in the atria can cause atrial fibrillation, an uncoordinated quivering of the atria that raises the risk for stroke. Commonly known as afib, this heart rhythm problem can come and go, lasting only a few minutes or sometimes for days or even longer. And while some people report a fluttering sensation in their chest or a rapid, irregular heartbeat during an episode of afib, other people don’t have any symptoms.

Certain smartwatches that can record a brief ECG may be able to detect afib. But Dr. Buxton says they’re not sensitive or specific enough to reliably diagnose the problem. “Sometimes the watch tells you that you have afib when you don’t, or vice versa,” he says.

The heart rate monitoring feature may be helpful, however. In people younger than 65, the heart rate can soar to 170 beats per minute or higher during a bout of afib. But for those in their 70s and 80s, who are more likely to have afib, the heart rate usually doesn’t get that high.

When should you be concerned about irregular heartbeats?

An irregular heartbeat, such as racing, fluttering, or skipping a beat, is usually harmless. Even in cases when palpitations are frequent and bothersome (which occurs rarely), reassurance may be the only treatment needed.

But you should contact your doctor if you notice other symptoms accompanying an unusual heartbeat, such as feeling

• chest pain
• dizzy
• lightheaded
• tired
• breathless
• as though you’re going to faint.

People who have been told they have a bundle branch block may need periodic ECGs to monitor their condition. They should also be alert to symptoms such as dizziness or fainting, which can happen if the blockage worsens or occurs on both sides and causes a low heart rate.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

About the Reviewer

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD