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A new study suggests that a daily multivitamin might improve memory in older adults.

Millions of people take a multivitamin each day. Some believe it’s a sort of insurance in case their diet is missing some essential nutrient. Others believe it will ward off disease by boosting immunity, improving brain health, or regulating metabolism. It’s easy to see where these ideas come from: ads tout wide-ranging health benefits, even though most offer little or no evidence to back up the claims.

But research on the health benefits of multivitamins has been mixed at best. This year, for example, the US Preventive Services Task Force, a leading authority on preventive healthcare, reviewed 90 of the best available studies on supplements and vitamins, concluding the products didn’t protect healthy adults lacking nutritional deficits against cardiovascular disease, cancer, or death from all causes.

Might research on different doses, supplement combinations, or populations prompt a different conclusion? Well, yes — in fact, that may have already happened, according to a new study that focused on memory and brain function.

Can a daily multivitamin improve brain function in older adults?

Our current options for improving brain health are limited. For example, regular exercise, optimal weight, and a heart-healthy diet can improve cardiovascular health and lower the chances of certain types of dementia, such as dementia due to strokes. Beyond such common-sense measures, no available medicines, supplements, or treatments reliably improve brain function over the long term, despite advertisements claiming otherwise.

That’s why researchers continue to explore whether certain foods or supplements could prove effective. In a recent study published in Alzheimer’s and Dementia, more than 2,200 volunteers ages 65 and older were randomly assigned to receive cocoa or a placebo, a multivitamin or a placebo, or both cocoa and a multivitamin for three years. The multivitamin chosen for this study was Centrum Silver, which contains 27 vitamins, minerals, and other nutrients in various amounts.

When tests of cognition were analyzed at the end of the trial, those receiving cocoa did not demonstrate any improvement. But those assigned to take a multivitamin had improved scores on tests of

• overall brain function (especially in people with cardiovascular disease)
• memory
• executive function (tasks such as planning ahead or remembering instructions).

Based on these findings, the researchers estimated that three years of multivitamin use could slow age-related decline in brain function by as much as 60%.

Notably, study participants were mostly white (89%), had an average age of 73, and more than half were female (60%). They were followed for only three years. However, it was a randomized, double-blind trial, which is considered the most powerful study design.

Should we all be taking multivitamins?

This study alone isn’t enough to suggest routine use of multivitamins for people of all ages. It may turn out that the benefits for older adults seen in this study were due to deficiencies in certain nutrients among some of the study participants. We don’t know if this is true because it wasn’t part of the study.

Or we might learn that the benefits reported here are too small to make much difference in real life, or wane over time, or have no effect on preventing common types of dementia. And it’s hard to ignore an earlier randomized, placebo-controlled trial that was actually larger and longer-term: it found no improvement in brain function among male physicians ages 65 and older taking multivitamins.

But it does mean that more study is warranted. We need to understand who is most likely to benefit from multivitamin use, what dose is optimal, and what parts of the multivitamin are most important. We also need trials that are larger, last longer, and include a more diverse group of participants. And certainly, there’s a difference between improving cognitive function and preventing dementia. We still need to know if conditions like Alzheimer’s disease can be prevented by multivitamin use or other supplements.

The bottom line

Claims that certain supplements can improve brain health are everywhere you look. But sound scientific evidence backing up those claims is much rarer. That’s one reason this new study is important: if confirmed, it means that a safe, widely available, and inexpensive vitamin supplement could improve quality of life for many millions of aging people.

In the past, claims made by the makers of various supplements and vitamins have gotten far ahead of the science. Studies like this one should help science catch up and sort out which claims are valid.

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

Recommendations from the CDC emphasize safe, effective, and individualized options for pain relief.

Six years ago, the Centers for Disease Control and Prevention (CDC) created guidelines for prescribing opioids to help reduce the staggering number of lives lost from overdoses — a goal that unfortunately remains out of reach. As an unintended consequence, some people who were taking these medicines had trouble getting them prescribed, or getting a dosage sufficient to reduce their level of pain or avoid uncomfortable withdrawal symptoms.

Now, newly revised opioid guidelines from the CDC aim to reduce unnecessary barriers and build on best practices for prescribing and using opioids for pain. If you need relief for a chronic condition that causes you significant pain (such as disabling back problems, neuropathy pain, fibromyalgia, or osteoarthritis), here are several important takeaways from the guidelines.

Are best practices for opioid use in the new guidelines?

Yes. Many of these practices were carried forward from the 2016 guidelines. A few key recommendations are:

• Other strategies for pain relief should always be tried first before opioids are prescribed. Opioids should not be first-line pain medicines.
• Anyone prescribing opioids (such as oxycodone, hydrocodone, and hydromorphone) has a duty to carefully explain the possible benefits and risks, including the risk for addiction and overdose. Your doctor or medical team should help you consider whether benefits outweigh risks in your situation and continue to monitor this regularly over time. You should also discuss how to discontinue opioids if risks begin to outweigh benefits, or if these medicines don’t improve your ability to carry out your daily activities.
• Though useful for some people, opioids are highly addictive. So are medicines known as benzodiazepines (such as lorazepam, diazepam, and alprazolam), which are used for anxiety. If combined with opioids, benzodiazepines make the risk of overdose even higher. Whenever possible, opioids and benzodiazepines should not be prescribed together.

Are opioids the best solution for many types of pain?

Frequently, the answer is no. Nonopioid pain medicines (such as ibuprofen, acetaminophen, naproxen, or topical pain relievers applied to skin) and nondrug therapies are preferred for pain that lasts up to one month (acute pain). They’re also preferred for pain lasting one to three months (subacute pain) or longer than three months (chronic pain).

Research shows these medicines are at least as effective as opioids for many painful conditions. Opioids may be prescribed to help relieve severe acute pain, like after surgery or dental procedures. However, it’s safest to take them for the shortest possible time needed to get through the worst pain — typically just a few days — and switch over to nonopioid medicines as soon as possible.

Nondrug therapies (such as physical therapy, cognitive behavioral therapy, mindfulness techniques, massage, acupuncture, and chiropractic adjustments) also may effectively relieve pain when tailored for specific conditions and situations.

Often, when a person is dealing with chronic pain, combining these strategies can help them tackle essential tasks and improve their comfort and quality of life. Talk to your medical team about the best solutions for you. This interactive tool describing options and resources for people living with chronic pain may be helpful, too.

What are some changes in the new guidelines?

Laws passed by many states in the wake of the original guidelines and the snowballing opioid crisis further restricted the ability of prescribing clinicians to treat individual patients with opioid medicines. For example, helping people taper from a higher dose of opioids to a lower one is the right choice from a health perspective for many, but not for everyone. And tapering will take some people longer than others to manage safely. Removing flexibility in how prescribing clinicians could work with their patients may have been harmful to some people.

The new guidelines

• explain the complex nature of pain.
• emphasize the importance of flexibility and nuance in treating individuals suffering from chronic pain.
• recommend starting with the lowest effective dose of opioids for the shortest possible time. Risk for addiction and other side effects rises as dosage becomes higher and with the length of time opioid medicine is taken. It’s important to avoid diminishing returns in the balance of benefit and risk.
• allow clinicians and patients to judge what treatment is best, rather than setting strict limits on dosage.
• encourage clinicians to offer or arrange effective treatment for people with opioid use disorder, to minimize risks for withdrawal symptoms, relapse to drug use, and overdose, which is sometimes fatal.

It’s important to note that the new guidelines for opioids are not intended for pain related to cancer, pain crises in sickle cell disease, palliative care, or end-of-life care, because less restrictive use of opioids may be appropriate in such cases.

The bottom line

If you have problems with pain, talk to your doctor about the most effective combination of pain relief strategies for your situation. For many people opioids are not necessary or helpful, though some people do benefit from these medicines despite their risks. The new CDC guidelines can help patients and prescribers find this delicate balance.

About the Author

Scott Weiner, MD, Contributor

Scott G. Weiner, MD, MPH, FACEP, FAAEM, an attending emergency physician and assistant clinical director in the department of emergency medicine at Brigham and Women’s Hospital in Boston. He is the director of B-CORE: The Brigham … See Full Bio View all posts by Scott Weiner, MD

What the new hearing aid options mean for your ears and wallet.

A change in FDA regulations has cleared the way for over-the-counter (OTC) hearing aids. What does this mean for you if you’re among the approximately 48 million Americans with some degree of hearing loss? We asked Dr. James Naples, assistant professor of otolaryngology/head and neck surgery at Harvard-affiliated Beth Israel Deaconess Medical Center, to help explain potential pros and cons.

The basics: Hearing aids versus amplification products

There are various types of hearing aids that largely work in the same way. Whether the style is behind the ear or in the ear canal, they amplify sounds to make them louder. They also help filter out certain types of noise. “All hearing aids use a combination of signal processing and directional microphones to filter out some unwanted noise and to improve our ability to hear sounds,” says Dr. Naples.

Don’t confuse prescription or OTC hearing aids with personal sound amplification products (PSAPs) sold at most drug stores. Such products merely amplify nearby sounds. They’re not tailored to an individual’s hearing loss, and aren’t regulated by the FDA or intended to treat hearing loss.

“PSAPs are a great alternative for people who only experience difficulties in specific situations, like listening to the TV, says Dr. Naples.”

Will I need a hearing test to get an OTC hearing aid?

Traditionally, people have their hearing tested by a certified audiologist trained to configure hearing aids based on a person’s specific hearing loss. The process is similar to getting prescription glasses.

Hearing tests measure how loud a sound needs to be for you to hear it clearly. People with normal hearing can identify sounds less than 25 decibels (dB). Mild to moderate hearing loss is in the 26 dB to 55 dB range. A person with mild hearing loss may hear certain speech sounds, but find softer sounds hard to hear. Someone with moderate hearing loss may have difficulty hearing speech when another person talks at a normal level. Hearing loss related to age or other conditions may affect one or both ears.

OTC hearing aids don’t require a hearing test by an audiologist. However, these devices can only treat mild to moderate hearing loss. “If you have severe or profound hearing loss, you still need to see an audiologist for a full exam,” says Dr. Naples.

Will costs for hearing aids be lower?

Most likely yes, though savings will vary. While Medicare doesn’t cover any hearing aids, some Medicare Advantage plans and other commercial health insurance plans do.

The new FDA regulations mean many people with mild to moderate hearing loss needn’t pay for a hearing exam and fitting. But the most significant savings will be the cost of hearing aids. While costs for brands and types of hearing aids vary, a single prescription hearing aid averages about $2,000 — that’s $4,000 if you need one for each ear, as many people do.

For the US market, a handful of companies produce most prescription hearing aids. Lack of competition contributes to high prices.

The new OTC hearing devices should increase competition among manufacturers and lower average prices over time. Some early estimates suggest the average price could drop to about $1,600 or lower.

Will OTC hearing aids be the same quality as prescription hearing aids?

OTC hearing aids will be regulated by the FDA for product quality, just like prescription hearing aids. Appearance, styles, and features may differ.

Are OTC hearing aids right for me?

Hearing aids are not one-size-fits all. “While OTC devices may help many people with mild or moderate hearing loss, they might not be appropriate for all types of hearing loss,” says Dr. Naples.

Think of drugstore readers, the magnifying glasses useful for reading up close. “Those are designed to correct a specific type of vision problem. Depending on your eyesight, they may only help so much,” says Dr. Naples. “OTC hearing aids may have similar limitations.”

A prescription hearing aid can be individually fine-tuned and fitted; people choosing OTC aids must rely on generic sizes that can’t be altered. And unlike prescription hearing aids, you may not be able to return OTC devices. Right now, it’s unclear how repairs, warranties, and replacements will work.

What else to consider

Self-prescribing an OTC hearing device might result in some people not getting a proper diagnosis of their hearing loss.

“Their hearing loss could be a symptom of an underlying condition that requires evaluation. A number of different conditions can cause hearing loss, and often people cannot differentiate the cause without an evaluation,” says Dr. Naples. “So, even if you benefit from an OTC device, you should see your doctor if you have symptoms like ear pain, dizziness, vertigo, hearing loss in only one ear, or ringing in the ear, which could represent a condition other than just simple hearing loss.”

It’s also important to have realistic expectations about what hearing aids can do. “The safest bet is to get a hearing test to confirm your type of hearing loss, to ensure that OTC hearing aids are an option for you,” he says.

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

It may not happen overnight, but parents can help preschoolers start out and stay in their own beds.

“Sleep is still most perfect… when it is shared with a beloved,” wrote D.H. Lawrence, and most young children would agree. But sometimes those beloved — that is, parents — would rather have some privacy and not be woken by a kicking child all night.

So what can you do?

Sleep-alone campaign step one: Understanding

Before you do anything, be sure you understand why your child wants to sleep with you. It’s most likely simply because they love you and feel most secure snuggled next to you, but before you work to change the habit, be sure that your child is ready for — and can handle — the change. If your child has been more clingy or irritable than usual, or is having difficult behaviors in any way, touch base with your doctor.

Sleep-alone campaign step two: Changing habits

Changing where your child sleeps is changing a habit. When it comes to changing habits, it helps to be practical and — this is really important — consistent. Here are some tips:

• Make an appealing sleep space for your child. Not that anything can really take the place of you, but it is certainly easier to get them to stay in their own room or space if they like it there. Work with them to set up and decorate in a way they like.
• As you create the space, keep in mind what keeps your child awake. If it’s light, use room-darkening curtains. If it’s darkness, think night lights and flashlights. If it’s noise, think about getting a white-noise machine. Set your child up for success. Please: no TVs or devices in the bedroom. They get in the way of healthy sleep.
• Have a consistent bedtime. Try not to let your child stay up late — or sleep late — on weekends. This way your child is more likely to be tired when you want them to be tired.
• Have a consistent, calming, and nurturing bedtime routine. Try to lower the energy level, perhaps with a bath and then some snuggling and reading stories. You want to help them wind down, and also be sure they end the day feeling loved.
• If your child has a hard time going to bed alone, it’s okay to sit in the room and ease yourself out bit by bit after lights are out (you can literally move closer and closer to the door). Try to gradually shorten the time you are in the room.
• If your child gets out of bed, bring them back to their bed. This is the hard part: your child won’t like it, and it can be exhausting for you if they keep creeping out of their bed and into yours. But if you give in and let them stay in your room, they will stay in your room. Every night.
• Use incentives. Make sure your child gets major kudos for any progress at all — and maybe earns something extra for staying in their own bed all night. Try to steer away from things, if possible, and think more about quality time (an extra story, a fun outing).

If nothing is working, or your child is really upset, talk to your doctor. There may be more going on, and the two of you can work together to figure things out and help your child. Both of you deserve a restful night’s sleep.

Follow me on Twitter @drClaire

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

Expert consensus focuses on individual planning to bring down elevated LDL.

Recently I met with Nancy, a 72-year-old woman with coronary artery disease, to review her latest cholesterol results. Despite taking a statin, following a healthy diet, and exercising regularly, her low-density lipoprotein (LDL) cholesterol remained above our target. “What else can I do?” she asked. “When I increase my statin dose I get terrible leg pains. But I don’t want to have another heart attack!”

When elevated, LDL contributes to cardiovascular disease, which can cause a heart attack or stroke. Taking statin drugs can drop LDL levels in most people by about 30%, substantially lowering this risk. Usually, these commonly prescribed drugs work effectively with tolerable side effects. But what if a person’s LDL level remains too high on their maximally tolerated dose? An expert consensus report issued by the American College of Cardiology lays out a clear path for next steps.

What is a healthy target for LDL cholesterol?

Target LDL depends on many factors, including your age, family history, and personal history of cardiovascular disease. For people at intermediate risk, LDL should be lowered by 30% to 50%. For those who have already had a heart attack, target LDL is no more than 70 mg/dl (note: automatic download).

Which non-statin therapies are recommended first?

Five non-statin therapies described in this post aim to help people achieve target LDL goals while minimizing side effects. They may be combined with a statin or given instead of statins.

Each helps lower LDL cholesterol when diet and statins are not sufficient, such as when there is a family history of high cholesterol (familial hypercholesterolemia). But so far, only two options are proven to reduce cardiovascular risk — the risk for heart attack, stroke, heart failure, and other issues affecting the heart and blood vessels.

Ezetimibe (Zetia)

What it does: Lowers LDL and cardiovascular risk by reducing cholesterol absorption.

How it’s given: A daily pill

Relatively inexpensive and often given with statins.

PCSK9 inhibitors, alirocumab (Praluent) and evolocumab (Repatha)

What it does: A protein called PCSK9 controls the number of LDL receptors on cells. These medicines are monoclonal antibodies against PCSK9 that increase LDL receptors on the liver, helping to clear circulating LDL from the bloodstream.

How it’s given: A shot every two to four weeks

Highly effective for lowering LDL, but expensive and may not be covered by insurance.

Three newer non-statin therapies

Three newer, FDA-approved non-statin therapies are highly effective for lowering LDL cholesterol. Whether these lessen cardiovascular risk is not yet known.

Bempedoic acid (Nexletol)

What it does: Like statins, bempedoic acid tells the liver to make less cholesterol.

How it’s given: A daily pill

Bempedoic acid is activated only in the liver, whereas statins are activated in liver and muscle tissue. Experts hope that this difference will translate to a similar LDL lowering effect, but without the muscle aches that some people who take statins report. Indeed, early trials show this medication lowers LDL cholesterol by about 20% to 25% compared to placebo.

Potential downsides include high cost and a possible increase in the risk of tendon rupture, gout, and a heart arrythmia called atrial fibrillation. Results of larger trials are expected in late 2022.

Evinacumab (Evkeeza)

What it does: Rare individuals born without a cholesterol-processing protein called ANGPTL3 have extremely low LDL and triglyceride levels, which lowers their risk for coronary heart disease by about 40%. Taking a cue from nature, scientists developed evinacumab, a monoclonal antibody that turns off ANGPTL3, mimicking this rare condition and resulting in dramatic LDL lowering of almost 50% in one trial.

How it’s given: Monthly intravenous infusion

Currently, the FDA has only approved evinacumab for people with familial hypercholesterolemia. Evinacumab appears safe in early trials, but is very expensive and can only be given in a doctor’s office.

Inclirisan (Leqvio)

What it does: Inclirisan blocks PCSK9. However, unlike alirocumab and evolocumab, which inactivate PCSK9 after it is produced, inclirisan inhibits production of PCSK9 in the liver. Inhibition of PCSK9 leads to an increase in the number of LDL receptors on the surface of the liver, speeding clearance of LDL from the bloodstream and dropping LDL by about 50% (see here and here).

How it’s given: A shot every six months

Potential downsides include increased rate of urinary tract infection, joint and muscle pain, diarrhea, and shortness of breath. This medicine is expensive and insurance may not cover it.

What does the report recommend?

It reinforces the importance of personalizing a plan to lower LDL by accounting for individual risk, cost of medication, and genetic factors. A combination of lifestyle changes and medicine can help people achieve better control of LDL. So, if you have elevated LDL cholesterol, try to follow healthy eating patterns, exercise regularly, avoid smoking and vaping, and maintain a healthy weight.

• Statin drugs are the first choice to treat anyone who has elevated cholesterol and cardiovascular risk factors, such as diabetes and high blood pressure.
• If statins aren’t sufficient to help you reach your LDL target, or if side effects aren’t tolerable, ezetimibe should be added next. PSCK9 inhibitors are then considered for those who remain at increased risk after adding ezetimibe.
• If LDL targets still cannot be achieved in people with cardiovascular disease, bempedoic acid and inclirisan are considered.
• For those with familial hypercholesterolemia, evinacumab may be appropriate.

Cardiologists eagerly await the results of studies looking at whether the three new LDL-lowering medications also lower risk for heart attack, stroke, and other poor cardiovascular outcomes. Until then, their use is likely to be limited to people at high risk for whom proven, less costly drugs cannot achieve LDL goals.

About the Author

Dara K. Lee Lewis, MD, Contributor

Dara Lee Lewis, MD, is a full-time cardiologist, director of imaging, and co-director of the Women’s Program at the Lown Cardiovascular Center. Her clinical interests include cardiac physiology, echocardiography, and heart disease in women. She is … See Full Bio View all posts by Dara K. Lee Lewis, MD

Adults who take the ADHD drug Adderall may be looking for options due to short supply in some locales.

Adderall, a drug commonly prescribed to treat attention deficit hyperactivity disorder (ADHD), has been in short supply for months. Generic versions known as mixed amphetamine salts are available, but not in sufficient quantities to meet nationwide demand. How widespread is this problem? And what are the consequences, and possible solutions, for adults who rely on this medication to manage ADHD, a brain disorder characterized by inattention, being easily distracted, and impulsive behavior?

“Currently, there isn’t reliable information about how many people are affected by the shortage,” says Dr. Craig Surman, associate professor of psychiatry at Harvard Medical School, scientific coordinator for the Adult ADHD Research Program at Massachusetts General Hospital, and coauthor of Fast Minds: How to Thrive If You Have ADHD (or Think You Might). But if you’re concerned about a shortage of ADHD medicine — or experiencing one — here’s what to know.

Why is this shortage in the news?

Recent news stories have featured anecdotal reports of people calling multiple pharmacies to fill their prescriptions, sometimes in vain. However, problems like this have long been par for the course, says Dr. Surman, noting that similar shortages have occurred in the past. In addition, stimulants such as Adderall have a high potential for misuse, so prescriptions and refills are controlled.

For people with ADHD who take Adderall and related medications as prescribed, the drugs can make a huge difference, both mentally and physically. “The simple health benefits can even include things like getting enough sleep because they got their work done earlier in the day and don’t have to stay up late to finish, and they go to the gym because they remember to bring their shoes,” Dr. Surman says.

How do Adderall and related medicines work?

Prescription stimulants for ADHD include mixed amphetamine salts (Adderall) and methylphenidate (Concerta, Ritalin). They raise brain levels of dopamine and norepinephrine, two neurotransmitters that play important roles in the prefrontal cortex, a brain region that helps regulate thoughts, actions, and emotions.

Stimulants have a range of effects, increasing alertness and energy, and (in the case of 70% of people with ADHD) improving ability to focus. They also can have less desirable physical effects, such as appetite suppression and increased heart rate and blood pressure, and should only be used as prescribed by a physician.

Newer nonstimulant medications, such as atomoxetine (Strattera) and viloxazine (Quelbree), are approved by the FDA to treat ADHD in adults, while guanfacine (Intuniv) is also approved for children. These medicines all increase availability of norepinephrine. Side effects for nonstimulant ADHD drugs vary, and can be similar to those of stimulants.

People often respond better to one of these ADHD medications than another, so unless a person already knows what works best, a shortage could be a time to try another treatment. Adderall also comes in different dosages and formulations, and speaking to a pharmacist might clarify if another form may be more available. But often, the supply problem can be resolved by asking if your regular prescription is available within the same pharmacy chain at a different location, says Dr. Surman.

Rollercoaster dosing can cause problems

Sometimes, people intentionally skip stimulant doses — for example, on weekends — to stretch out their prescriptions. However, this can create withdrawal symptoms like fatigue unless people taper off. In other people, amphetamines have less effect over time. Some prescribers recommend taking breaks to rejuvenate the effectiveness of the medicine, says Dr. Surman.

So-called rollercoaster dosing may have downsides. To be diagnosed with ADHD, you must have symptoms in at least two settings, such as work and home. If you only take the medication sometimes (such as on the days you work), you may miss out on its benefits for managing other aspects of your life, such as relationship and self-care commitments.

“My patients tell me that when they’re off their medication, they have to work harder to manage their daily lives,” says Dr. Surman. Something has to slide, and it’s usually self-care, such as doing things like preparing their schedule ahead of time, so they have time to eat healthfully and exercise.

What about coping strategies for ADHD?

Other ADHD treatments include coping strategies that improve organization and minimize the sense of feeling overwhelmed. These techniques aren’t a replacement for medication. Still, because life circumstances can change, it can be helpful to periodically revisit your need for medication.

“A medication shortage may give you a chance to ask, what is the medicine actually doing for me?” says Dr. Surman. If you can adjust your environment in ways that reduce unrealistic demands, you might be able to manage well without medication.

Some people outgrow symptoms, or learn to manage them so well that the disorder is no longer a factor in their everyday lives. And still others with ADHD enjoy long stretches in which their symptoms are not noticeable or problematic. But others rely on medications, coaching, and therapy into old age. “If someone has ADHD challenges that only can be managed with stimulants, they may need to be more strategic until some of these shortages are straightened out,” says Dr. Surman.

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

Pulse oximeters and other devices to monitor aspects of our health may work better for some than for others.

In recent years, there’s been a veritable explosion in the number and type of health monitoring devices available in smartphones and fitness apps.

Your smartphone is likely tracking the number of steps you take, how far and fast you walk, and how many flights of stairs you climb each day. Some phones log sleep, heart rate, how much energy you’re burning, and even “gait health” (how often are both feet on the ground? how even are your steps?). And, of course, nonphone wearables and fitness gadgets are available, such as devices to measure your heart rhythm, blood pressure, or oxygen levels. The accuracy of these devices varies — and, in some instances, your skin tone may make a difference.

Generally, how accurate are health monitors?

I know from my experience with hospital monitoring devices that they aren’t always accurate. False alarms from EKG monitors often send medical staff scurrying into patient rooms, only to find the patient feeling fine and surprised about the commotion. A particularly common false alarm is a dangerous and unstable heart rhythm on a continuous heart monitor, which can be due to the motion from a patient brushing their teeth.

High-stakes devices with monitoring capability, such as defibrillators and pacemakers, are extensively tested by their makers and vetted by the FDA, so their accuracy and reliability are generally quite good.

But what about home health monitoring devices intended for consumer use that are not extensively tested by the FDA? Ever count your steps for a few minutes just to see if your phone’s tally agrees? Or climb a couple of flights of stairs to see if you are getting full credit for not taking the elevator?

The accuracy of consumer devices depends in part on what is being monitored. For example, one study assessed the accuracy of heart rate monitors and energy expenditure calculators in phones and health apps. Accuracy was quite high for heart rate (often in the range of 95%), but much less accurate for energy expenditure. Accuracy can also vary depending on who is being monitored.

Device bias: What it is and why it occurs

While no health gadget is perfect, some users get more reliable results than others. For example, if you’re wearing nail polish, a pulse oximeter — a device that clips onto the fingertip to measure blood oxygen through the skin — may not work well, because the polish interferes with proper function of the light sensor. In that situation, there’s a simple solution: remove the polish.

But in other cases, the solution isn’t simple. Increasingly, we’re recognizing that certain medical devices are less accurate depending on a person’s skin color, a phenomenon called device bias.

• Pulse oximeters. Although generally considered highly accurate and commonly relied upon in healthcare settings, their accuracy tends to be lower in people of color. That’s because the device relies on shining light through the skin to detect the color of blood, which varies by oxygen level. The amount of pigment in the skin may alter the way light behaves as it travels to blood vessels, leading to inaccurate results.
• Bilirubin measurement in newborns. Bilirubin is a breakdown product of red blood cells. Newborns are screened for high levels because this can cause permanent brain damage. When detected, phototherapy (light treatments) can help the baby get rid of the excess bilirubin, preventing brain damage. The screening involves examining a newborn’s skin and eyes for jaundice (a yellowing due to elevated bilirubin), and a light meter test to detect high bilirubin levels. But the accuracy of this test is lower in Black newborns. This is particularly important because jaundice is more difficult to detect in infants with darker skin, and dangerously high bilirubin levels are more common in this population.
• Heart rate monitors in smartphones. According to at least one study, smartphone apps may also be less accurate in people of color. Again, this is because the more skin pigment present, the more trouble light sensors have detecting pulsations in blood flow that reflect heartbeats.

Why device bias matters

Sometimes an error in measurement has no immediate health consequences. A 5% to 10% error rate when measuring heart rate may be of little consequence. (In fact, one could ask why anyone needs a device to monitor heart rate when you could just count your pulse for 15 seconds and multiply by 4!)

But pulse oximeter readings are used to help decide whether a person needs to be hospitalized, who requires admission to the intensive care unit, and who requires additional testing. If the oxygen level is consistently overestimated in people of color, they may be more likely to be undertreated compared with others whose readings are more accurate. And that may worsen previously existing healthcare disparities.

These examples add to the growing list of bias imbedded within healthcare, and other instances where failing to include diverse individuals has serious consequences. When you use a health device, it’s reasonable to wonder if it’s been tested on people like you. It’s also reasonable to expect people who develop medical and consumer health devices to widen the demographics of test subjects, to make sure results are reliable for all users before putting them on the market.

Sometimes a change in technology, such as using a different type of light sensor, can make health-related devices work more accurately for a wider range of people.

Or there may be no easy fix, and user characteristics will need to be incorporated into proper interpretation of the results. For example, a device could offer the user a choice of skin tones to match skin color. Then based on extensive data from prior testing of people with different skin colors, the device could adjust results appropriately.

The bottom line

The push to monitor our bodies, our health, and our life experiences continues to gain momentum. So we need to thoroughly test and validate health-related devices to be sure they work for diverse individuals before declaring them fit for the general public.  An expert panel at the FDA has advocated for better regulation and testing of pulse oximeters to ensure they are accurate for all.

With even the best testing, device bias may not disappear: bodies vary, and technology has its limits. The key is to know it exists, fix what can be fixed, and interpret the results accordingly.

Follow me on Twitter @RobShmerling

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

Reframing common negative patterns can help you feel more balanced.

You’ve just been laid off, and doomsday thoughts ricochet through your brain in a chaotic rush: You’re an idiot who can’t hold a job. You’ll never be hired again. You’re going to end up on the street with no means of supporting yourself.

This all-or-nothing way of thinking is a typical example of a pattern known as automatic negative thought (ANT). Comprising about a dozen categories (many overlapping), thoughts like these compel people to interpret distressing situations in unbalanced ways without examining the actual evidence at hand. That can sap happiness unless people learn to recognize and disarm these cognitive distortions.

Who is affected by automatic negative thoughts?

The focus of decades of research and refinement, ANTs tend to strike when we’re anxious or depressed. While most of us succumb to cognitive distortions like these at least occasionally, it only becomes a problem when done chronically or to extremes, says Jacqueline Samson, a psychologist at Harvard-affiliated McLean Hospital.

“They’re extremely common, and all of them can lead to a certain amount of misery,” she says. “When people get into a negative state of mind, it’s really easy to remember all the bad things someone said or did to you, and hard to remember your successes.”

Feeling stuck in extremes of thinking

The all-or-nothing ANT above leaves us stuck in good or bad, success or failure, with no middle ground between the two extremes. If you’ve fallen short, it’s because you’re completely incompetent — or so the thinking goes.

Two other common ANTs to watch:

“Should” statements: You “should’ be perfect, because mistakes are unacceptable. Things “should” or “shouldn’t” be the way they actually are. You feel guilty when you’ve done something you “shouldn’t,” and angry and resentful of others who break the invisible “should.”

Let’s say your grandchildren didn’t send thank-you notes for their holiday gifts. How dare they? You went to a lot of work to choose their presents. How rude! They’re never getting another gift from you! But your response is based on an ingrained belief that people “should” send thank-you cards. “Most of the time, these types of ‘shoulds’ are assumptions,” says Samson. “The intensity of response can be enormous.” It can even drive a wedge into relationships.

Discounting the positive: Maybe you dismiss any happy development as unimportant or due to chance. Positive experiences don’t count for one reason or another.

For example, your daughter calls to say she can’t make Sunday dinner as you asked, but instead will visit on Saturday night. You ignore the fact that she’s coming on Saturday and focus only on the thought that she’s not coming when you wanted. “You’re not noticing the ways your daughter is showing she cares about you,” Samson explains.

Why do you fall into ANT traps?

To process information quickly, we tend to filter it into categories and impressions based on what we already know. When we’re stressed, Samson says, it’s easier to lump our interpretations into distortions. We don’t think out of the box or consider less-threatening alternatives.

These patterns of thinking might have started in childhood, based on behavior modeled by family members or the ways we processed stressful situations without an adult’s input. “We squirrel these schemas away as how we think about the world and ourselves,” she says. “If you find automatic, distorted thoughts coming up again and again, they probably have their origins in other things.”

How can you escape from cognitive distortions?

The first step to disarming ANTs is to take a mental step back and view your thoughts as understandable but ultimately unhelpful. Beyond that, Samson offers this advice to escape from ANTs:

• Catch the thought. Notice how you frame what happens to you. “Anytime you use a word that’s absolute, thinking something is ‘totally’ this or that, remind yourself that it can’t be,” she says.
• Write it down. Sometimes seeing your thoughts on paper — which engages a different part of your brain — can spur you to evaluate them more effectively, she says.
• Examine the evidence for and against your thoughts. If you’ve been laid off, are you really an idiot who can’t hold a job? The facts might state differently: you have a college degree and have held several jobs long-term. “Realizing this, it’s still disappointing to be laid off, but without the same downward cascade that ‘it’s over’ and things will never change,” Samson says.

 It can take time to reverse long-held ANTs, Samson says. Be patient. “It depends on how pervasive they are and how often you catch your thoughts and restructure them,” she adds. “Many would say it’s a matter of practice, and if you’re diligent, you’ll pick up on it quicker. You get to a point where you notice when you’re falling into those traps.”

And that’s the first step toward climbing out — or sidestepping the trap entirely.

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

A survey offers a glimpse into cannabis and CBD use among women in midlife.

Hot flashes and sleep or mood changes are well-known, troublesome symptoms that may occur during perimenopause and menopause. Now, one survey suggests nearly 80% of midlife women use cannabis to ease certain symptoms, such as mood issues and trouble sleeping.

Mounting numbers of US states have legalized marijuana for medical or recreational use in recent years. This wave of acceptance runs alongside skepticism in some quarters concerning FDA-approved menopause treatment options, including hormone therapy. But a lack of long-term research data surrounding cannabis use has led one Harvard expert to question how safe it may be, even while acknowledging its likely effectiveness for certain menopause woes.

"More and more patients tell me every year that they’ve tried cannabis or CBD (cannabidiol, an active ingredient in cannabis), particularly for sleep or anxiety," says Dr. Heather Hirsch, head of the Menopause and Midlife Clinic at Harvard-affiliated Brigham and Women’s Hospital. "Adding to its appeal is that cannabis is now legal in so many places and works acutely for a couple of hours. You don’t need a doctor’s prescription. Socially, it may be easier to justify than using a medication. But why is there a movement toward saying okay to something that has unknown long-term effects, more than something that’s been studied and proven safe?" she asks.

Survey reports on who uses cannabis, why, and how

The new Harvard-led survey, published in the journal Menopause, looked at patterns of cannabis use in 131 women in perimenopause — the often years-long stretch before periods cease — along with 127 women who had passed through menopause. Participants were recruited through online postings on social media sites and an online recruitment platform. Nearly all survey respondents were white and most were middle-class, according to income reporting.

The vast majority (86%) were current cannabis users. Participants were split on whether they used cannabis for medical reasons, recreational purposes, or both. Nearly 79% endorsed it to alleviate menopause-related symptoms. Of those, 67% said cannabis helps with sleep disturbance, while 46% reported it helps improve mood and anxiety.

Perimenopausal women reported worse menopausal symptoms than their postmenopausal peers, as well as greater cannabis use to address their symptoms. More than 84% of participants reported smoking cannabis, while 78% consumed marijuana edibles, and nearly 53% used vaping oils.

One glaring limitation of the analysis is its self-selected group of participants, which lacked diversity and might skew results. But Dr. Hirsch wasn’t surprised by the high proportion reporting regular cannabis use. "I wouldn’t be surprised if those numbers reflect the broader population," she says.

How might cannabis help menopause symptoms?

It makes sense that midlife women reported cannabis improves anxiety, mood, and sleep, Dr. Hirsch says. The drug likely helps all of these symptoms by "dimming the prefrontal cortex, the decision-making part of our brain."

For many women, anxiety spikes during perimenopause, she notes. Common stressors during that time, such as aging parents or an emptying nest, add to the effects of dipping hormones. "It’s that feeling of, ‘I can’t turn my brain off.’ It’s really disturbing because they get in bed and can’t fall asleep, so they’re more tired, moody, and cranky the next day," she explains. Dimming the prefrontal cortex enables people to calm down.

Hot flashes, often cited as the most common menopause symptom, did not improve as much from cannabis use, according to survey respondents. That too makes sense, Dr. Hirsch says, because the hypothalamus — the brain region considered the body’s thermostat — isn’t believed to be significantly affected by the drug.

No research yet on long-term effects

Given a lack of clinical trials objectively testing the effectiveness and safety of cannabis to manage menopause symptoms, more research is clearly needed.

"If people are finding relief from cannabis, great. But is it safe? We think so, but we don’t know," she says. "There are no studies of middle-aged women using cannabis for 10 years, for as long as menopause symptoms often last. Are there going to be long-term effects on memory? On lung function? We don’t know."

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

With many options available, it's important to work with your doctor to try new treatments.

Inflammatory bowel disease (IBD), which includes Crohn’s disease (CD) and ulcerative colitis (UC), is a condition that involves inflammation of the digestive tract. In recent years, treatment options for IBD have rapidly expanded. The goal of these newer treatments is to improve control of inflammation in the gut, which can greatly improve patients’ quality of life.

Medication options for IBD

5-aminosalicylates: This class of drugs contain 5-aminosalicylic acid, which works to reduce inflammation in the intestine. Sulfasalazine and mesalamine (available in oral and rectal forms) are often prescribed for patients with mild UC or CD of the colon, but are especially helpful in patients with inflammation limited to the rectum and sigmoid colon. Aminosalicylates are generally well tolerated, but it is important for blood tests (including those for kidney function) to be monitored closely every few months while taking the medication.

Biologics: These medications target specific proteins and pathways to reduce inflammation in IBD. Biologics, which historically were reserved for severe cases, are now often a first-line approach for patients with CD and UC. This class of medications is a rapidly developing area of research, with several ongoing clinical trials and newly-approved agents.

• Anti-TNF alpha therapies: These medications block a protein called tumor necrosis factor (TNF) to reduce inflammation, and are used in both CD and UC patients. Infliximab and adalimumab are some examples of anti-TNF drugs. With anti-TNF alpha therapies, you will require frequent blood tests to follow your response to treatment. Additionally, an approach called therapeutic drug monitoring, where drug concentrations in the blood are measured, can be used to tailor the dosage of medication to an individual patient’s needs.
• Anti-IL-12/23: These therapies reduce intestinal inflammation by inhibiting specific pro-inflammatory proteins called interleukin-12 and interleukin-23. Ustekinumab is FDA-approved to treat both UC and CD. Risankizumab was FDA-approved in June 2022 to treat moderate to severe CD; clinical trials to assess its utility in UC are ongoing.
• Anti-Integrin: These medications block white blood cells that cause inflammation from entering the GI tract. Vedolizumab has been shown to be an effective treatment that is tolerated well in IBD patients. Natalizumab has been approved to treat moderate to severe CD, but is less commonly used due to its side effect profile.

Small molecules: This newer class of medications uses molecules that are small enough to easily enter cells in order to modify different inflammatory pathways in the body. One advantage to these treatments is that they are orally administered, and therefore may be more convenient for patients.

• JAK inhibitors: These therapies interfere with the activity of Janus kinases (JAK), which normally work to stimulate the body’s inflammatory response. Tofacitinib has been approved for the treatment of moderate to severe UC, and is being investigated in CD. Upadacitinib was shown to have high clinical remission rate in UC, and was FDA-approved in March of 2022.
• S1P receptor modulators: This class of medication blocks the receptor of a signaling fat molecule called S1P, in order to reduce inflammation and the immune response. Ozanimod was approved in May of 2021 for the treatment of moderate to severe UC.

Corticosteroids: The use of oral corticosteroids such as prednisone was once a mainstay of IBD treatment, but now is typically reserved for short-term usage for patients with active flare symptoms. These medications are associated with increased risk of infection, blood clots, bone thinning, and hyperglycemia, among other unfavorable side effects. One specific type of oral corticosteroid called budesonide is primarily released in the gastrointestinal tract, and is associated with fewer adverse effects.

Immunomodulators: These medications reduce inflammation in the gastrointestinal tract by suppressing the immune system, and can be effective in treating both CD and UC. Azathioprine, methotrexate, 6-mercaptopurine, tacrolimus, and cyclosporin are some examples. However, their usage as a primary treatment is declining due to adverse side effects such as bone marrow suppression, increased risk for certain blood cancers, liver injury, and gastrointestinal intolerance.

Sometimes, these medications are used in lower doses in combination with biologic medications in order to optimize the effectiveness of treatment and prevent the development of antidrug antibodies to biologics. Patients on these medications require regular blood tests for monitoring.

Which treatment is right for me?

IBD treatment plans are complex, and are personalized for each patient. Your past medical history, disease severity and location, type of IBD, and response to past treatments are some of the many factors in deciding which medication is right for you.

To assess your treatment, your doctor will continue to use a combination of your symptoms, blood work, stool tests, imaging, and endoscopy (upper endoscopy and/or colonoscopy) to determine if your treatment is working or needs adjustments. Sometimes this means changing the dosage or frequency of your current medication, adding a second medication, or starting you on a different type of treatment. The goal is to find the right medications for you for the long term, and to achieve clinical remission.

What happens if I cannot afford my recommended treatment?

There are several options to reduce the cost of IBD treatments. Your doctor can work with you to see if the drug manufacturer offers patient financial assistance programs that provide medication at a discounted cost. Additionally, your doctor may work with your insurance company to prescribe more affordable biosimilars (medicines with similar structure, function, and clinical efficacy as standard biologic drugs).

In some cases, missing doses of medication may lead to the development of antidrug antibodies, which can make a patient vulnerable to serious allergic reactions when the medication is restarted. Additionally, medication gaps can make patients with IBD more susceptible to flares and complications, including surgery and hospitalization. For these reasons, it is important to work with your doctor, insurance company, and the manufacturer of any medication you are on to minimize gaps in medication dosing.

Crohn’s and ulcerative colitis are lifelong, chronic conditions. However, when remission is achieved, most people have an excellent quality of life. Additionally, every patient’s symptom course is unique. If you are concerned about medication costs or safety, or are considering stopping your medications, reach out to your doctor to discuss a personalized solution for you.

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