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HEALTHY-FOOD NATURAL-BEAUTY WORKOUT

Screening tests may save lives — so when is it time to stop?

Graphic of page-a-day calendar with a red cross icon and bright yellow background; concept is healthcare appointment

Screening tests, such as Pap smears or blood pressure checks, could save your life. They can detect a disease you have no reason to suspect is there. Early detection may allow treatment while a health condition is curable and before irreversible complications arise.

Some screening tests help prevent the disease they are designed to detect. For example, colonoscopies and Pap smears can identify precancerous abnormalities that can be addressed so they cannot continue to grow and become cancerous. And missed screening tests contribute to thousands of avoidable deaths each year in the US. Yet there’s a point of diminishing returns, as a new study on Pap smears illustrates. And many of us could benefit from a better understanding of the limits of screening, and how experts decide when people should stop routine screening tests.

Know the limits of screening tests

Even the best screening test has limitations. It can miss the disease it’s intended to detect (false-negative results). Or it can return abnormal results when no disease is present (false-positive results).

Equally important, as people grow older life expectancy declines and screening benefits tend to wane. Many conditions detected by routine screenings, such as prostate cancer or cervical cancer, typically take a while to cause trouble. A person in their 80s is more likely to die from another fatal condition before cervical cancer or prostate cancer would affect their health. Additionally, certain diseases, such as cervical cancer, become less common with advancing age.

As a result, many screening tests are not recommended forever: at some point in your life, your doctor may tell you that you no longer need to repeat a screening test, even one you finally got used to having.

Know when screening tests usually end

Expert guidelines for many common screening tests include an “end age” when people can reasonably stop having the test. For example:

  • Pap smear: age 65
  • mammogram: age 75
  • colonoscopy: age 75
  • chest CT scan (recommended for people with a significant smoking history): age 80.

There are exceptions, of course. For example, if a colonoscopy found abnormalities in an otherwise healthy 72-year-old, repeat testing after age 75 may be recommended.

Many women have Pap smears after guidelines suggest stopping

Pap smears screen for cervical cancer. In 1996, new guidelines recommended that women who received Pap smears at appropriate intervals before age 65 could safely stop.

Yet many women continue to have this screening after turning 65, according to a recent study published in JAMA Internal Medicine that looked at data from 15 to 16 million women per year between 1999 and 2019. Their average age was 76, most (82%) were white, and all were enrolled in Medicare.

The study found:

  • In 1999, nearly three million women over age 65 (almost 19% of the study population) had Pap smears. By 2019, the number had fallen to 1.3 million (8.5%), a reduction of more than half.
  • Among women older than age 80, about 3% had Pap smears.
  • In 2019, the estimated cost related to Pap smears in these older women was $83.5 million.

Possibly, some women in this study had good reasons to continue having Pap smears. Perhaps they weren’t adequately screened when they were younger. Perhaps they had previous Pap smear abnormalities. Maybe their doctors recommended they continue having Pap smears despite their advanced age. We don’t know, because this study didn’t collect that information. Still, it’s quite likely that many (or even most) of these Pap smears represent overscreening: routine testing with little chance of benefit.

Why does overscreening matter?

Overscreening may cause

  • discomfort that may be tolerable when there’s an expectation of benefit, but less acceptable when the test is unnecessary
  • anxiety while awaiting the results of the test
  • false-positive results that lead to additional testing and unnecessary treatment
  • complications of testing, such as infection or bleeding after a Pap smear, or perforation or bleeding after a colonoscopy. (Fortunately, complications are rare.)
  • unnecessary costs, including medical appointments and lab fees, time wasted, and taking health providers away from more valuable care.

The bottom line

Screening tests are typically performed for people without symptoms, signs, or a high suspicion of disease. In many cases, they’re looking for a condition that is probably not there. For most screening tests, we have guidelines developed by experts and backed by data suggesting when to start — and when to stop — screening.

But guidelines are only general recommendations, and individual preferences matter. If foregoing a screening test will cause you excessive anxiety, or if having a test will provide significant peace of mind, it may be reasonable to have a test even after the recommended end age. Be sure you understand potential downsides, such as additional tests and complications.

So, never hesitate to ask your doctor when your next screening tests are due — but don’t forget to also ask if they are no longer worth having.

About the Author

photo of Robert H. Shmerling, MD

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, 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

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HEALTHY-FOOD NATURAL-BEAUTY WORKOUT

Will miscarriage care remain available?

A abstract red heart breaking into many pieces against a dark blue background; concept is miscarriage during a pregnancy

When you first learned the facts about pregnancy — from a parent, perhaps, or a friend — you probably didn’t learn that up to one in three ends in a miscarriage.

What causes miscarriage? How is it treated? And why is appropriate health care for miscarriage under scrutiny — and in some parts of the US, getting harder to find?

What is miscarriage?

Many people who come to us for care are excited and hopeful about building their families. It’s devastating when a hoped-for pregnancy ends early.

Miscarriage is a catch-all term for a pregnancy loss before 20 weeks, counting from the first day of the last menstrual period. Miscarriage happens in as many as one in three pregnancies, although the risk gradually decreases as pregnancy progresses. By 20 weeks, it occurs in fewer than one in 100 pregnancies.

What causes miscarriage?

Usually, there is no obvious or single cause for miscarriage. Some factors raise risk, such as:

  • Pregnancy at older ages. Chromosome abnormalities are a common cause of pregnancy loss. As people age, this risk rises.
  • Autoimmune disorders. While many pregnant people with autoimmune disorders like lupus or Sjogren’s syndrome have successful pregnancies, their risk for pregnancy loss is higher.
  • Certain illnesses. Diabetes or thyroid disease, if poorly controlled, can raise risk.
  • Certain conditions in the uterus. Uterine fibroids, polyps, or malformations may contribute to miscarriage.
  • Previous miscarriages. Having a miscarriage slightly increases risk for miscarriage in the next pregnancy. For instance, if a pregnant person’s risk of miscarriage is one in 10, it may increase to 1.5 in 10 after their first miscarriage, and four in 10 after having three miscarriages.
  • Certain medicines. A developing pregnancy may be harmed by certain medicines. It’s safest to plan pregnancy and receive pre-pregnancy counseling if you have a chronic illness or condition.

How is miscarriage diagnosed?

Before ultrasounds in early pregnancy became widely available, many miscarriages were diagnosed based on symptoms like bleeding and cramping. Now, people may be diagnosed with a miscarriage or early pregnancy loss on a routine ultrasound before they notice any symptoms.

How is miscarriage treated?

Being able to choose the next step in treatment may help emotionally. When there are no complications and the miscarriage occurs during the first trimester (up to 13 weeks of pregnancy), the options are:

Take no action. Passing blood and pregnancy tissue often occurs at home naturally, without need for medications or a procedure. Within a week, 25% to 50% will pass pregnancy tissue; more than 80% of those who experience bleeding as a sign of miscarriage will pass the pregnancy tissue within two weeks.

What to know: This can be a safe option for some people, but not all. For example, heavy bleeding would not be safe for a person who has anemia (lower than normal red blood cell counts).

Take medication. The most effective option uses two medicines: mifepristone is taken first, followed by misoprostol. Using only misoprostol is a less effective option. The two-step combination is 90% successful in helping the body pass pregnancy tissue; taking misoprostol alone is 70% to 80% successful in doing so.

What to know: Bleeding and cramping typically start a few hours after taking misoprostol. If bleeding does not start, or there is pregnancy tissue still left in the uterus, a surgical procedure may be necessary: this happens in about one in 10 people using both medicines and one in four people who use only misoprostol.

Use a procedure. During dilation and curettage (D&C), the cervix is dilated (widened) so that instruments can be inserted into the uterus to remove the pregnancy tissue. This procedure is nearly 99% successful.

What to know: If someone is having life-threatening bleeding or has signs of infection, this is the safest option. This procedure is typically done in an operating room or surgery center. In some instances, it is offered in a doctor’s office.

If you have a miscarriage during the second trimester of pregnancy (after 13 weeks), discuss the safest and best plan with your doctor. Generally, second trimester miscarriages will require a procedure and cannot be managed at home.

Red flags: When to ask for help during a miscarriage

During the first 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

  • heavy bleeding combined with dizziness, lightheadedness, or feeling faint
  • fever above 100.4° F
  • severe abdominal pain not relieved by over-the-counter pain medicine, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). Please note: ibuprofen is not recommended during pregnancy, but is safe to take if a miscarriage has been diagnosed.

After 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

  • any symptoms listed above
  • leakage of fluid (possibly your water may have broken)
  • severe abdominal or back pain (similar to contractions).

How is care for miscarriages changing?

Unfortunately, political interference has had significant impact on safe, effective miscarriage care:

  • Some states have banned a procedure used to treat second trimester miscarriage. Called dilation and evacuation (D&E), this removes pregnancy tissue through the cervix without making any incisions. A D&E can be lifesaving in instances when heavy bleeding or infection is complicating a miscarriage.
  • Federal and state lawsuits, or laws banning or seeking to ban mifepristone for abortion care, directly limit access to a safe, effective drug approved for miscarriage care. This could affect miscarriage care nationwide.
  • Many laws and lawsuits that interfere with miscarriage care offer an exception to save the life of a pregnant patient. However, miscarriage complications may develop unexpectedly and worsen quickly, making it hard to ensure that people will receive prompt care in life-threatening situations.
  • States that ban or restrict abortion are less likely to have doctors trained to perform a full range of miscarriage care procedures. What’s more, clinicians in training, such as resident physicians and medical students, may never learn how to perform a potentially lifesaving procedure.

Ultimately, legislation or court rulings that ban or restrict abortion care will decrease the ability of doctors and nurses to provide the highest quality miscarriage care. We can help by asking our lawmakers not to pass laws that prevent people from being able to get reproductive health care, such as restricting medications and procedures for abortion and miscarriage care.

About the Authors

photo of Sara Neill, MD, MPH

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 photo of Scott Shainker, DO, MS

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

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HEALTHY-FOOD NATURAL-BEAUTY WORKOUT

Healthier planet, healthier people

A crystal globe with countries etched on, circled by stethoscope with red heart; Earth health and our health connect

Everything is connected. You’ve probably heard that before, but it bears repeating. Below are five ways to boost both your individual health and the health of our planet — a combination that environmentalists call co-benefits.

How your health and planetary health intersect

Back in 1970, Earth Day was founded as a day of awareness about environmental issues. Never has awareness of our environment seemed more important than now. The impacts of climate change on Earth — fires, storms, floods, droughts, heat waves, rising sea levels, species extinction, and more — directly or indirectly threaten our well-being, especially for those most vulnerable. For example, air pollution from fossil fuels and fires contributes to lung problems and hospitalizations. Geographic and seasonal boundaries for ticks and mosquitoes, which are carriers of infectious diseases, expand as regions warm.

The concept of planetary health acknowledges that the ecosystem and our health are inextricably intertwined. Actions and events have complex downstream effects: some are expected, others are surprising, and many are likely unrecognized. While individual efforts may seem small, collectively they can move the needle — even ever so slightly — in the right direction.

Five ways to improve personal and planetary health

Adopt plant-forward eating.

This means increasing plant-based foods in your diet while minimizing meat. Making these types of choices lowers the risks of heart disease, stroke, obesity, high blood pressure, type 2 diabetes, and many cancers. Compared to meat-based meals, plant-based meals also have many beneficial effects for the planet. For example, for the same amount of protein, plant-based meals have a lower carbon footprint and use fewer natural resources like land and water.

Remember, not all plants are equal.

Plant foods also vary greatly, both in terms of their nutritional content and in their environmental impact. Learning to read labels can help you determine the nutritional value of foods. It’s a bit harder to learn about the environmental impact of specific foods, since there are regional factors. But to get a general sense, Our World in Data has a collection of eye-opening interactive graphs about various environmental impacts of different foods.

Favor active transportation.

Choose an alternative to driving such as walking, biking, or using public transportation when possible. Current health recommendations encourage adults to get 150 minutes each week of moderate-intensity physical activity, and two sessions of muscle strengthening activity. Regular physical activity improves mental health, bone health, and weight management. It also reduces risks of heart disease, some cancers, and falls in older adults. Fewer miles driven in gas-powered vehicles means cleaner air, decreased carbon emissions contributing to climate change, and less air pollution (known to cause asthma exacerbations and many other diseases).

Start where you are and work up to your level of discomfort.

Changes that work for one person may not work for another. Maybe you will pledge to eat one vegan meal each week, or maybe you will pledge to limit beef to once a week. Maybe you will try out taking the bus to work, or maybe you will bike to work when it’s not winter. Set goals for yourself that are achievable but are also a challenge.

Talk about it.

It might feel as though these actions are small, and it might feel daunting for any one individual trying to make a difference. Sharing your thoughts about what matters to you and about what you are doing might make you feel less isolated and help build community. Building community contributes to well-being and resilience.

Plus, if you share your pledges and aims with one person, and that person does the same, then your actions are amplified. Who knows, maybe one of those folks along the way might be the employee who decides what our children eat from school menus, or a city planner for pedestrian walkways and bike lanes!

About the Author

photo of Wynne Armand, MD

Wynne Armand, MD, Contributor

Dr. Wynne Armand is a physician at Massachusetts General Hospital (MGH), where she provides primary care; an assistant professor in medicine at Harvard Medical School; and associate director of the MGH Center for the Environment and … See Full Bio View all posts by Wynne Armand, MD

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HEALTHY-FOOD NATURAL-BEAUTY WORKOUT

Easy ways to shop for healthful, cost-conscious foods

A dark background with brightly colored foods, such as tomato, orange, mushroom, cheese, eggs, celery, watermelon, salmon

Three months into the year is a good time to recalculate if you’ve been slacking on your resolution to eat healthy. And if you’ll be leaving home base or school soon and foraging for yourself (plus or minus roommates), it’s a great time to learn about healthy, low-cost choices for your grocery list.

The basics: A weekly shop

A healthy diet is rich in vegetables, fruits, legumes (beans or lentils), whole grains, nuts, seeds, lean proteins, and low-fat dairy products. Trying to fill your cart with all of those goodies can feel overwhelming. But just think in terms of twos.

“Get two fruits and two vegetables of different colors, and two types of lean protein — such as fresh, frozen, or canned fish, chicken or lean ground turkey, or plant-based options,” suggests Nancy Oliveira, a registered dietitian and manager of the Nutrition and Wellness Service at Harvard-affiliated Brigham and Women’s Hospital.

Oliveira also recommends getting two foods in each of these categories on your weekly shopping trip:

  • plant proteins, such as canned or dried beans, tofu, tempeh, veggie burgers, or unsalted nuts or seeds
  • whole grains, such as whole-grain bread, whole-grain pasta, brown or black rice, quinoa, or farro
  • dairy or nondairy milk items, such as nonfat Greek yogurt or cheese.

Go ahead and add one or two healthy treats or snacks, such hummus or dried apricots.

Do you need to choose organic foods?

Organic produce is grown without synthetic fertilizers and pesticides, which are linked to many health problems. While US scientists debate whether foods grown with organic fertilizers (such as animal waste) are safer for your health, other countries, including European Union nations, have banned or phased out synthetic pesticides still used in the United States.

That doesn’t mean that everything you buy must be organic. But try to stay away from conventionally grown produce with thin skins, such as strawberries, spinach, kale, peaches, and grapes. They tend to absorb more chemicals compared to produce with thick skins, such as avocados or pineapples.

The Environmental Working Group creates an annual list to help shoppers avoid high-pesticide produce, and another one that highlights the least contaminated produce.

Buying cost-conscious fresh food and staples

Healthy food, especially organic produce, has a reputation for being expensive. But it doesn’t have to be. Just do a little comparison shopping, and follow Oliveira’s tips to save money on a grocery run:

  • Shop in a smaller store with fewer choices.
  • Never enter a store hungry, since you might buy more than you normally would.
  • Carry a shopping list and stick to it.
  • Go directly to the aisles you need. Avoid browsing elsewhere, which may lead to extra purchases.
  • Be flexible, have several options within your food categories, and go with sale items.
  • Always check the day-old produce cart that offers perfectly edible fresh produce at 50% to 75% off regular prices.
  • Buy unseasoned canned or frozen whole foods such as vegetables, chicken, or fish (salmon, sardines, tuna), which are often cheaper than fresh versions.
  • Wait for sales of healthy nonperishable staples like quinoa, brown rice, whole-grain pasta, and high-fiber cereals.
  • Use coupons and coupon apps.

Easy healthy snacks to reach for

Move on from easy grab-n-go snacks, which are typically processed foods. They often contain unhealthy ingredients and promote overeating. Instead, Oliveira suggests keeping healthy snacks on hand, such as:

  • unsalted mixed nuts
  • string cheese
  • grapes and berries (rinse before eating)
  • clementines, bananas, or other fruits that don’t need washing
  • a rice cake with nut butter or hummus
  • fat-free Greek yogurt
  • a peeled hard-boiled egg.

“To save money, buy certain foods in larger amounts when possible, such as an 8-ounce bar of cheese that you slice into small cubes and store in a sealed container in the fridge,” Oliveira says.

Crowdsource shopping tips and savings

Don’t be shy about asking for shopping tips from friends and family members who’ve already developed shortcuts, and grocery store staffers who can offer insider advice.

You can also turn to apps for help. Oliveira recommends two faves:

  • Mealime is a meal-planning app with simple, healthy plant-based recipes that automatically create grocery lists for the ingredients.
  • List Ease creates lists for grocery runs. You can search for items to add or scan barcodes to add to lists.

“And if you prefer not to use apps, just jot down notes after a quick pantry or fridge inventory, or text yourself every time you remember something you need,” Oliveira advises. “With a little practice, you’ll quickly work out the best system for you.”

About the Author

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Heidi Godman, Executive Editor, Harvard Health Letter

Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman

About the Reviewer

photo of Howard E. LeWine, MD

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

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HEALTHY-FOOD NATURAL-BEAUTY WORKOUT

Does running cause arthritis?

A middle-aged man wearing a blue zip top and lighter blue track pants running alongside a blurred cityscape

When I took up running in college, a friend of mine scoffed at the idea. He hated running and was convinced runners were “wearing out” their joints. He liked to say he was saving his knees for his old age.

So, was he onto something? Does running really ruin your joints, as many people believe?

Runners can get arthritis, but is running the cause?

You may think the answer is obvious. Surely, years of running (pounding pavements, or even softer surfaces) could wear out your joints, much like tires wear out after you put enough miles on them. And osteoarthritis, the most common type of arthritis, usually affects older adults. In fact, it’s often described as age-related and degenerative. That sounds like a wear-and-tear sort of situation, right?

Maybe not. Sure, it’s easy to blame running when a person who runs regularly develops arthritis. But that blame may be misguided. The questions to ask are:

  • Does running damage the joints and lead to arthritis?
  • Does arthritis develop first and become more noticeable while running?
  • Is the connection more complicated? Perhaps there’s no connection between running and arthritis for most people. But maybe those destined to develop arthritis (due to their genes, for example) get it sooner if they take up running.

Extensive research over the last several decades has investigated these questions. While the answers are still not entirely clear, we’re moving closer.

What is the relationship between running and arthritis?

Mounting evidence suggests that that running does not cause osteoarthritis, or any other joint disease.

  • A study published in 2017 found that recreational runners had lower rates of hip and knee osteoarthritis (3.5%) compared with competitive runners (13.3%) and nonrunners (10.2%).
  • According to a 2018 study, the rate of hip or knee arthritis among 675 marathon runners was half the rate expected within the US population.
  • A 2022 analysis of 24 studies found no evidence of significant harm to the cartilage lining the knee joints on MRIs taken just after running.

These are just a few of the published medical studies on the subject. Overall, research suggests that running is an unlikely cause of arthritis — and might even be protective.

Why is it hard to study running and arthritis?

  • Osteoarthritis takes many years to develop. Convincing research would require a long time, perhaps a decade or more.
  • It’s impossible to perform an ideal study. The most powerful type of research study is a double-blind, randomized, controlled trial. Participants in these studies are assigned to a treatment group (perhaps taking a new drug) or a control group (often taking a placebo). Double-blind means neither researchers nor participants know which people are in the treatment group and which people are getting a placebo. When the treatment being studied is running, there’s no way to conduct this kind of trial.
  • Beware the confounders. A confounder is a factor or variable you can’t account for in a study. There may be important differences between people who run and those who don’t that have nothing to do with running. For example, runners may follow a healthier diet, maintain a healthier weight, or smoke less than nonrunners. They may differ with respect to how their joints are aligned, the strength of their ligaments, or genes that direct development of the musculoskeletal system. These factors could affect the risk of arthritis and make study results hard to interpret clearly. In fact, they may explain why some studies find that running is protective.
  • The effect of running may vary between people. For example, it’s possible, though not proven, that people with obesity who run regularly are at increased risk of arthritis due to the stress of excess weight on the joints.

The bottom line

Trends in recent research suggest that running does not wear out your joints. That should be reassuring for those of us who enjoy running. And if you don’t like to run, that’s fine: try to find forms of exercise that you enjoy more. Just don’t base your decision — or excuse — for not running on the idea that it will ruin your joints.

About the Author

photo of Robert H. Shmerling, MD

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, 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

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HEALTHY-FOOD NATURAL-BEAUTY WORKOUT

Why eat lower on the seafood chain?

A white plate with fresh silvery sardines with sliced lemon, parsley, garlic cloves, and olive at the ready to cook

Many health-conscious consumers have already cut back on hamburgers, steaks, and deli meats, often by swapping in poultry or seafood. Those protein sources are better than beef, and not just because they’re linked to a lower risk of heart disease, diabetes, and cancer. Chicken and fish are also better for the environment, as their production uses less land and other resources and generates fewer greenhouse gas emissions.

And choosing seafood that’s lower on the food chain — namely, small fish such as herring and sardines and bivalves such as clams and oysters — can amp up those benefits. “It’s much better for your health and the environment when you replace terrestrial food sources — especially red meat — with aquatic food sources,” says Christopher Golden, assistant professor of nutrition and planetary health at the Harvard T.H. Chan School of Public Health. But instead of popular seafood choices such as farmed salmon or canned tuna, consider mackerel or sardines, he suggests.

Why eat small fish?

Anchovies, herring, mackerel, and sardines are all excellent sources of protein, micronutrients like iron, zinc, and vitamin B12, and heart-healthy omega-3 fatty acids, which may help ease inflammation within the body and promote a better balance of blood lipids. And because you often eat the entire fish (including the tiny bones), small fish are also rich in calcium and vitamin D, says Golden. (Mackerel is an exception: cooked mackerel bones are too sharp or tough to eat, although canned mackerel bones are fine to eat).

Small fish are also less likely to contain contaminants such as mercury and polychlorinated biphenyls (PCBs) compared with large species like tuna and swordfish. Those and other large fish feed on smaller fish, which concentrates the toxins.

It's also more environmentally friendly to eat small fish directly instead of using them to make fish meal, which is often fed to farmed salmon, pork, and poultry. Feed for those animals also includes grains that require land, water, pesticides, and energy to produce, just as grain fed to cattle does, Golden points out. The good news is that increasingly, salmon farming has begun using less fish meal, and some companies have created highly nutritious feeds that don’t require fish meal at all.

Small fish in the Mediterranean diet

The traditional Mediterranean diet, widely considered the best diet for heart health, highlights small fish such as fresh sardines and anchovies, says Golden. Canned versions of these species, which are widely available and less expensive than fresh, are a good option. However, most canned anchovies are salt-cured and therefore high in sodium, which can raise blood pressure.

Sardines packed in water or olive oil can be

  • served on crackers or crusty, toasted bread with a squeeze of lemon
  • prepared like tuna salad for a sandwich filling
  • added to a Greek salad
  • tossed with pasta, either added to tomato sauce or with lemon, capers, and red pepper flakes.

Golden is particularly fond of pickled herring, which you can often find in jars in supermarkets, or even make yourself; here’s his favorite recipe.

Bivalve benefits

Bivalves are two-shelled aquatic creatures that include clams, oysters, mussels, and scallops. Also known as mollusks, they’re good sources of protein but are quite low in fat, so they aren’t as rich in omega-3’s as small, fatty fish. However, bivalves contain several micronutrients, especially zinc and vitamin B12. Zinc contributes to a healthy immune system, and vitamin B12 helps form red blood cells that carry oxygen and keep nerves throughout the body healthy. While most Americans get enough B12, some may not.

And from a planetary health perspective, bivalves are among the best sources of animal-based protein. “Bivalves can be ‘nature positive’ because they don’t require feed and they filter and clean up water,” says Golden.

Be aware, however, that bivalves can become contaminated from runoff, bacteria, viruses, or chemicals in the water. So be sure to follow FDA advice about buying and preparing seafood safely.

Although we tend to think of coastal cities as the best places to find seafood, it’s available throughout the United States. For less-common varieties, try larger Asian markets, which often carry a wide variety of fish and bivalves, Golden suggests.

Aquatic plant foods

You can even go one step further down the aquatic food chain by eating aquatic plant foods such as seaweed and kelp. If you like sushi, you’ve probably had nori, the flat sheets of seaweed used to make sushi rolls. You can also find seaweed snacks in Asian and many mainstream grocery stores. The truly adventurous may want to try kelp jerky or a kelp burger, both sold online.

Nutrients in seaweed vary quite a bit, depending on species (kelp is one type of brown seaweed; there are also numerous green and red species). But seaweed is low in calories, is a good source of fiber, and also contains iodine, a mineral required to make thyroid hormones. Similar to terrestrial vegetables, seaweeds contain a range of other minerals and vitamins. For now, aquatic plant foods remain fringe products here in the United States, but they may become more mainstream in the future, according to Golden.

About the Author

photo of Julie Corliss

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

photo of Howard E. LeWine, MD

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

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Prostate cancer in transgender women

close-up photo of a vial of blood marked PSA test alongside a pen; both are resting on a document showing the PSA test results

The transgender population is steadily increasing. Last year, investigators reported that 1.3% of people between the ages of 18 and 24 in the United States identify as transgender, compared to 0.55% of the country’s older adults. This trend has implications for public health, and one issue in particular concerns the risk of prostate cancer in transgender women.

Because removing the prostate can lead to urinary incontinence and other complications, doctors leave the gland in place when initiating hormonal treatments to induce female sex characteristics in transitioning people. This process, which is called feminizing or gender-affirming hormonal therapy (GAHT), relies on medications and surgery to block testosterone, a male sex hormone. Prostate cancer is fueled by testosterone, and therefore GAHT lowers overall risks for the disease. But transgender women can still develop prostate cancer in ways that remain poorly understood, according to the authors of a new paper.

“More individuals are openly identifying as transgender, particularly as advances are made in reducing the discrimination and marginalization that this group has faced,” says Dr. Farnoosh Nik-Ahd, a urologist at the University of California, San Francisco, and the paper’s first author. “Thus, it’s important to understand their health outcomes and how best to care for this population.”

Dr. Nik-Ahd and her colleagues wanted better insights into prostate cancer incidence and screening rates among transgender women, so they performed a comprehensive review of the literature that generated some notable findings. One is that that the prevalence of GAHT in the transgender population is still unknown. Some studies put the figure at roughly one in every 12,000 to 13,000 people who identify as transgender. But this is likely an underestimate, the authors claim, and it’s not broken out by sex.

Questions over GAHT

Similarly, little is known about the impact of GAHT on the likelihood of developing prostate cancer, the team reported. Prostate cancer rates do appear to be lower among transgender women than they are among cisgender men (men whose gender identify matches their sex at birth). For instance, one study found just a single case of prostate cancer among 2,306 transgender women receiving routine health care at a clinic in Amsterdam, Holland, between 1975 and 2006. Another study, also from Holland, detected six cases of prostate cancer among 2,281 transgender women over 17 years, which again is less than the comparable rate among cisgender men.

But the interpretation of these rates is limited by the fact that transgender women often experience barriers to care. Nearly a third of them live in poverty, and many avoid the health system for fear of mistreatment. Some scientists suspect that estrogen given during GAHT may somehow contribute to prostate cancer development when given over long durations. However, more confirmatory evidence is needed. Worryingly, one study found that survival among transgender women with prostate cancer is worse than it is in cisgender men with the disease, yet that research lacked data on GAHT use.

Interpreting PSA values for specific populations

Dr. Nik-Ahd’s team was especially concerned about the lack of guideline recommendations for prostate-specific antigen (PSA) screening in the transgender population. None of the available guidelines worldwide mention transgender women, and the PSA cutoff of 4 nanograms per milliliter (ng/mL) of blood — which raises suspicions for prostate cancer — is specific to cisgender men. PSA levels ordinarily plummet in people taking GAHT, so the limit for what’s considered normal in transgender women should be capped at 1.0 ng/mL, the researchers propose. In the absence of more specific guidance, they also recommend that people meeting age criteria for PSA screening get tested before starting on GAHT, in order to obtain a baseline value.

Many doctors are already familiar with other common drugs that alter PSA values — in this case with screening implications for cisgender men, points out Dr. Heidi Rayala, a urologist affiliated with Beth Israel Deaconess Medical Center in Boston, and a member of the Harvard Medical School Annual Report on Prostate Diseases editorial board. For instance, PSA values drop by half in men taking finasteride or dutasteride for hair loss (or to shrink an enlarged prostate). “Doctors take extra care when interpreting PSA in cisgender men who take these drugs,” she says. “The same care needs to be taken in interpreting PSA values in transgender women. And there needs to be broader education on this topic for both primary care doctors as well as the transgender community.

Dr. Nik-Ahd agrees. “Future research should aim to understand baseline PSA values for those on gender-affirming hormones, and to understand how to navigate some of the psychosocial barriers around PSA screening so as to not stigmatize transgender patients,” she says.

About the Author

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Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

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Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

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HEALTHY-FOOD NATURAL-BEAUTY WORKOUT

Considering collagen drinks and supplements?

A red-colored drink being poured from a bottle into a glass with ice; concept is collagen drinks

A tremendous buzz surrounds collagen drinks and supplements, as celebrities and influencers tout miraculous benefits for skin, hair, and nails. Since the collagen in our bodies provides crucial support for these tissues, it seems plausible that consuming collagen might lead to lush locks and a youthful glow. But what does the science say?

What is collagen?

Collagen is a major structural protein in our tissues. It’s found in skin, hair, nails, tendons, cartilage, and bones. Collagen works with other substances, such as hyaluronic acid and elastin, to maintain skin elasticity, volume, and moisture. It also helps make up proteins such as keratin that form skin, hair, and nails.

Our bodies naturally produce collagen using the amino acids from protein-rich or collagen-rich foods like bone broth, meat, and fish. But aging, sun damage, smoking, and alcohol consumption all decrease collagen production.

Collagen drinks and supplements often contain collagen from many different sources, such as fish, cattle, pigs, or chicken. Typically, they contain peptides, short chains of amino acids that help make up essential proteins in the body, including collagen itself and keratin.

What does the science say about collagen drinks and supplements?

Research on skin includes:

  • A review and analysis of 19 studies, published in the International Journal of Dermatology, that had a total of 1,125 participants. Those who used collagen supplements saw an improvement in the firmness, suppleness, and moisture content of the skin, with wrinkles appearing less noticeable. That sounds promising, but it’s unclear if these skin improvements were actually due to collagen. Most of the trials used commercially available supplements that contained more than collagen: vitamins, minerals, antioxidants, coenzyme Q10, hyaluronic acid, and chondroitin sulfate were among the additional ingredients.
  • A few randomized, controlled trials (see here and here) show that drinking collagen supplements with high amounts of the peptides prolylhydroxyproline and hydroxyprolylglycine can improve skin moisture, elasticity, wrinkles, and roughness. But large, high-quality studies are needed to learn whether commercially available products are helpful and safe to use long-term.

Hardly any evidence supports the use of collagen to enhance hair and nails. One small 2017 study of 25 people with brittle nails found that taking 2.5 grams of collagen daily for 24 weeks improved brittleness and nail growth. However, this small study had no control group taking a placebo to compare with the group receiving collagen supplements.

There haven’t been any studies in humans examining the benefits of collagen supplementation for hair. Currently, no medical evidence supports marketing claims that collagen supplements or drinks can improve hair growth, shine, volume, and thickness.

Should you try collagen supplements or drinks?

At this time, there isn’t enough proof that taking collagen pills or consuming collagen drinks will make a difference in skin, hair, or nails. Our bodies cannot absorb collagen in its whole form. To enter the bloodstream, it must be broken down into peptides so it can be absorbed through the gut.

These peptides may be broken down further into the building blocks that make proteins like keratin that help form skin, hair, and nails. Or the peptides may form collagen that gets deposited in other parts of the body, such as cartilage, bone, muscles, or tendons. Thus far, no human studies have clearly proven that collagen you take orally will end up in your skin, hair, or nails.

If your goal is to improve skin texture and elasticity and minimize wrinkles, you’re better off focusing on sun protection and using topical retinoids. Extensive research has already demonstrated that these measures are effective.

If you choose to try collagen supplements or drinks, review the list of ingredients and the protein profile. Avoid supplements with too many additives or fillers. Products containing high quantities of prolylhydroxyproline and hydroxyprolylglycine are better at reducing wrinkles and improving the moisture content of skin.

Consult your doctor before starting any new supplements. People who are prone to gout or have other medical conditions that require them to limit protein should not use collagen supplements or drinks.

The bottom line

Large-scale trials evaluating the benefits of oral collagen supplements for skin and hair health are not available. If you’re concerned about thinning or lackluster hair, brittle nails, or keeping skin smooth and healthy, talk to your doctor or a dermatologist for advice on the range of options.

It will also help to:

  • Follow a healthy lifestyle and eat a balanced diet that includes protein-rich foods.
  • If you smoke, quit.
  • Limit alcohol to two drinks or less in a day for men or one drink or less in a day for women.
  • Apply sunscreen daily and remember to reapply every two hours.
  • Wear wide-brimmed or UV-protective hats and clothing when you’re spending a lot of time in the sun.

Follow Payal Patel on Twitter @PayalPatelMD

Follow Maryanne Makredes Senna on Twitter @HairWithDrMare

About the Authors

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Payal Patel, MD, Contributor

Dr. Payal Patel is a dermatology research fellow at Massachusetts General Hospital. Her clinical and research interests include autoimmune disease and procedural dermatology. She is part of the Cutaneous Biology Research Center, where she investigates medical … See Full Bio View all posts by Payal Patel, MD photo of Maryanne Makredes Senna, MD

Maryanne Makredes Senna, MD, Contributor

Dr. Maryanne Makredes Senna is a board-certified dermatologist at at Beth Israel Lahey Health, and assistant professor of dermatology at Harvard Medical School. Dr. Senna founded and directs the Lahey Hair Loss Center of Excellence and … See Full Bio View all posts by Maryanne Makredes Senna, MD

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HEALTHY-FOOD NATURAL-BEAUTY WORKOUT

Dementia: Coping with common, sometimes distressing behaviors

Confused older father with dementia seated on bed, adult son kneeling, holding his hands and talking to himDementia poses many challenges, both for people struggling with it and for those close to them. It can be hard to witness and cope with common behaviors that arise from illnesses like Alzheimer’s disease, vascular dementia, or frontotemporal dementia.

Caring for a person who has dementia may be frustrating, confusing, or upsetting at times. Understanding why certain behaviors occur and learning ways to handle a variety of situations can help smooth the path ahead.

What behaviors are common when a person has dementia?

People with dementia often exhibit a combination of unusual behaviors, such as:

  • Making odd statements or using the wrong words for certain items.
  • Not realizing they need to bathe or forgetting how to maintain good hygiene.
  • Repeating themselves or asking the same question over and over.
  • Misplacing objects or taking others’ belongings.
  • Not recognizing you or remembering who they are.
  • Being convinced that a deceased loved one is still alive.
  • Hoarding objects, such as mail or even garbage.
  • Exhibiting paranoid behavior.
  • Becoming easily confused or agitated.
  • Leaving the house without telling you, and getting lost.

Why do these behaviors occur?

Inside the brain of a loved one with dementia, picture a wildfire shifting course, damaging or destroying brain cells (neurons) and neural networks that regulate our behavior.

What drives this damage depends on the underlying cause, or causes, of dementia. For example, while the exact cause of Alzheimer’s disease is not known, it is strongly linked to proteins that are either gunking up or strangling brain cells. Someone with vascular dementia has experienced periodic insufficient blood flow to certain areas of the brain, causing neurons to die.

“As dementia progresses, the person loses brain cells associated with memory, planning, judgment, and controlling mood. You lose your filters,” says Dr. Stephanie Collier, a psychiatrist at Harvard-affiliated McLean Hospital.

Six strategies for coping with dementia-related behaviors

Dealing with distressing or puzzling dementia-related behavior can require the type of tack you’d take with a youngster. “Due to declines, older adults with dementia can seem like children. But people are generally more patient with children. You should consider using that approach with older adults,” suggests Lydia Cho, a McLean Hospital neuropsychologist.

  • Don’t point out inaccurate or strange statements. “It can make people with dementia feel foolish or belittled. They may not remember details but hold onto those emotions, feel isolated, and withdraw. Instead, put them at ease. Just go with what they’re saying. Keep things light,” Cho says.
  • Don’t try to reason with the person. Dementia has damaged your loved one’s comprehension. Attempting to reason might be frustrating for both of you.
  • Use distraction. This helps when the person makes unreasonable requests or is moderately agitated. “Acknowledge what the person is saying, and change the activity. You could say, ‘I see that you’re upset. Let’s go over here for a minute.’ And then do an activity that engages the senses and relaxes them, such as sitting outside together, listening to music, folding socks, or eating a piece of fruit,” Dr. Collier says.
  • Keep unsafe items out of sight. Put away or lock up belongings the loved one shouldn’t have — especially potentially dangerous items like car keys or cleaning fluids. Consider installing cabinet locks.
  • Supervise hygiene routines. The person with dementia might need a reminder to bathe, or might need to have the day’s clothes laid out on the bed. Or you might need to assist with bathing, shaving, brushing teeth, or dressing.
  • Spend time together. You don’t have to convince your loved one of your identity or engage in fascinating conversation. Just listen to music or do some simple activities together. It will help keep the person from withdrawing further.

Safety is essential when a person has dementia

Sometimes simple strategies aren’t enough when a loved one has dementia.

For example, if the person frequently tries to leave home, you might need to add child-proof covers to doorknobs, install additional door locks or a security system in your home, or get the person a GPS tracker bracelet.

If the person is frequently upset or even violent, you’ll need to call the doctor. It could be that a new medical problem (such as a urinary tract infection) is causing agitation. “If the agitated behavior isn’t due to a new health problem and is predictable and severe, we might prescribe a medication to help regulate mood, such as an antidepressant or an antipsychotic in cases of extreme agitation or hostility,” Dr. Collier says.

As dementia changes, seek the help and support you need

No one expects you to know how to interact with someone who has dementia. There’s a learning curve for all of us, and it continues even after you get a feel for the situation. “The process keeps changing,” Cho says. “What works today may not work next week or the week after that for your loved one. So keep trying different strategies.”

And get support for yourself, such as group therapy for caregivers and their families. You can also find information at the Alzheimer’s Association or Family Caregiver Alliance.

About the Author

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Heidi Godman, Executive Editor, Harvard Health Letter

Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman

About the Reviewer

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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

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HEALTHY-FOOD NATURAL-BEAUTY WORKOUT

When replenishing fluids, does milk beat water?

6 colorful or black panels with a brightly colored or black jug on each

Driving along the freeway recently, a billboard caught my eye. In bold letters it proclaimed:

Milk hydrates better than water.

Wait, could this be true? And if so, should I be rehydrating with milk after a workout? And should we all have milk, rather than water, in our water bottles?

What’s behind the claim?

Unsurprisingly, the ad is sponsored by the milk industry. And while I’d never heard this claim before, the studies behind the idea aren’t particularly new or compelling. The website supporting this ad cites three small studies dating back more than a decade:

  • A 2007 study enrolled 11 volunteers (five men, six women) who exercised until they were markedly dehydrated on several occasions. Each time they rehydrated with a different drink, and their urine output was measured over the following five hours. After drinking milk, the study volunteers produced less urine (and therefore retained more fluid) than with water or a sports drink (Powerade). Therefore, milk was considered to provide better hydration.
  • A study published in 2016 described seven men with marked dehydration following exercise who drank fat-free milk, water, or Powerade. The results were similar.
  • A 2016 study enrolled 72 healthy, well-hydrated men who drank various fluids and then had their urine production measured over the next four hours. The drinks used in this study were water, whole milk, skim milk, beer, Dioralyte (an oral rehydration solution used after fluid loss from diarrhea), tea, coffee, diet cola, regular cola, orange juice, and Powerade. The researchers found that fluid retention was best after drinking either type of milk or the oral rehydration solution; results for the other drinks were similar to water.

Sounds like milk is a winner, right? Maybe. But there are other things to consider.

The study details matter

The findings of these studies aren’t definitive. As with all research, there are important limitations. For example:

  • The small number of participants in these studies means that just a few people could have an outsized impact on the results.
  • Two of the three studies involved significant dehydration by intensely exercising in a warm environment, leading to several pounds of fluid loss. Therefore, the results may not apply to people engaged in more typical daily activities or workouts. In addition, the studies equated better hydration with less urine production in the hours after drinking various fluids. This is only one way to define hydration, and not clearly the best one.
  • The advantage of milk reported in these studies may be too small or too temporary to matter much. For example, in the study of 72 people, milk drinkers produced about 37 ounces of urine over four hours while water drinkers produced 47 ounces. Does the 10-ounce difference have a meaningful health impact? If the study participants had been monitored for a longer period, would this difference disappear?
  • The amount of milk consumed in the study of seven men would contain more than 1,000 calories. That may be acceptable for an elite athlete after hours of intensive exercise in the heat, but counterproductive and costly for someone working out for 30 minutes to help maintain or lose weight. Tap water is free and has no calories!

Hyping hydration: Many claims, little evidence

The billboard promoting milk reflects our relatively recent focus on hydration for health. This is promoted — or perhaps created — by advertisers selling sports drinks, energy drinks and, yes, water bottles. But does drinking “plenty of water” translate to weight loss, athletic performance, and glowing appearance? Does monitoring urine color (darker could indicate dehydration) and downing the oft-recommended eight glasses of water daily make a difference in our health? On the strength of evidence offered so far, I’m not convinced.

But wait, there’s more! Emotional support water bottles, a trend popularized recently in Australia, offer one part public expression of your commitment to health and one part security blanket. (Yes, it’s a thing: #emotionalsupportwaterbottle has more than 80 million views on TikTok.) And then there’s intravenous hydration on demand for healthy (and often wealthy) people convinced that intravenous fluids will improve their looks, relieve their hangovers, help with jet lag, or remedy and prevent an assortment of other ailments.

Is this focus on hydration actually helpful?

Before water bottles were everywhere and monitoring fluid intake became commonplace, medically important dehydration wasn’t a problem for most healthy people who were not rapidly losing fluids due to heat, intense exercise, diarrhea, or the like.

The fact is, drinking when thirsty is a sound strategy for most of us. And while there are important exceptions noted below, you probably don’t need fluids at hand at all times or to closely monitor daily fluid intake to be healthy. There are far more important health concerns than whether you drink eight glasses of water each day.

When is dehydration a serious problem?

Weather, exercise, or illness can make dehydration a major problem. Particularly susceptible are people who work or exercise outside in hot and humid environments, those at the extremes of age, people experiencing significant fluid loss (as with a diarrheal illness), and those without reliable access to fluids. If significant dehydration occurs, replacing lost fluids is critically important, and may even require a medical setting where intravenous fluids can be provided quickly.

The bottom line

Despite the claims of milk ads and the iffy studies justifying them, the idea of replacing water with milk for rehydration may not convince everyone: the taste, consistency, and extra calories of milk may be hard to get past.

As for me, until there’s more convincing evidence of an actual health advantage of milk over water for routine hydration, I’ll stick with water. But I’ll forego the water bottle.

Follow me on Twitter @RobShmerling

About the Author

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Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, 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