METFORMIN—the first-line treatment for Type 2 diabetes— is getting new attention with the launch of the Targeting Aging with Metformin (TAME) study. The six-year study will assess the drug’s effects against three age-related diseases – dementia, heart disease and cancer—for which early research has shown some good results.
And metformin prescribed for weight loss made the pounds “fall away,” according to DC lawyer and writer D.P. In a few weeks, D.P. lost 14 pounds “without feeling hungry.” She also has “metabolic” conditions, such as high blood pressure and high cholesterol, that put her at risk for heart disease.
(Prescriptions of metformin for weight loss have been “off-label” since the FDA gave approval only for Type 2 diabetes in 1994. And because aging does not fall under the category of disease, the FDA is unlikely to grant approval for anti-aging effects of an already-licensed drug or even for a new drug.)
Long-time champion of the life-lengthening powers of metformin, Albert Einstein College of Medicine endocrinologist Nir Barzilai has been taking the drug since 2015 after a diagnosis of pre-diabetes. As scientific director of the American Federation for Aging Research (AFAR), Barzilai is leading the TAME trial.
Preventing Frailty
The goal is greater resilience, especially against severe disease, said Barzilai, who believes, “Death is inevitable, but aging is not.” In past studies, diabetics who took metformin lived longer than non-diabetics who did not. Other research will assess the use of metformin to prevent the onset of frailty, which often has serious health consequences.
But metformin works differently in each patient, making its exact mechanisms of action unclear, cautioned Alan Garber, endocrinologist at Baylor College of Medicine, in 2017. “A quarter of the patient population does extremely well. Half the population does rather well, and a quarter…doesn’t do well at all.”
What Type 2 diabetes, age-related conditions and weight loss have in common is chronic inflammation, which can damage cells, tissues and organs throughout the body. Chronic inflammation, as well as the body’s poor use of insulin, appear to play a role in frailty.
For diseases of aging, metformin seems to help control the body’s energy demands—mimicking the effects of a low-calorie diet in studies showing that dramatically reducing calorie intake may extend life. “The goal is not to help people live forever, but help them stay healthy longer,” according to aging researcher Steven Austad at the University of Alabama at Birmingham. “But the fringe benefit is that you live longer.”
Metformin facilitates the work of insulin to convert glucose into energy —by increasing sensitivity to insulin and decreasing insulin resistance—and reduces the production of glucose by the liver. Improved insulin sensitivity can keep blood sugar at a stable level, preventing the cravings that come with spikes and drops.
The Biggest Loser
And reducing the liver’s production of glucose decreases the chance that excess sugar will be stored as fat tissue in the body, explains Massachusetts General Hospital obesity specialist Fatima Cody Stanford, who often prescribes the medication to overweight or obese people without diabetes.
For those who struggle with weight loss, the battle is unsuccessful in many cases because of resting metabolism, which determines how many calories a person burns when at rest. On the TV show “The Biggest Loser,” most of the extremely overweight contestants who lost weight regained much if not all—and some ended up even heavier.
In subsequent research, contestants’ metabolisms not only did not recover, but some became even slower. “It is frightening and amazing,” said metabolism specialist Kevin Hall at the National Institutes of Diabetes and Digestive and Kidney Disease. One contestant regained more than 100 pounds, his metabolism slowing to the point that he must now eat 800 calories a day less than a typical man his size to avoid putting on additional pounds.
Metformin, however, is not a good option for everyone. In addition to decreased appetite, side effects include nausea, stomach upset and diarrhea. Some doctors require frequent blood-sugar testing for patients on metformin, though others believe the drug keeps sugar levels stable enough that testing is unnecessary. Finally, some people who lose weight on metformin must stay on the drug to avoid future weight gain.
Getting a Prescription
Because metformin affects blood sugar and weight, some people interested in its anti-aging possibilities may have trouble obtaining a prescription if these issues are not a problem. The diagnosis of Type 2 diabetes requires blood levels of hemoglobin A1c (or AIC) at 6.4% or higher. While some physicians want to start treatment for “pre-diabetes” —AIC levels between 5.7% and 6.4%—others contend that “pre-” disease, including others like osteopenia, means no disease at all.
In addition, most physicians don’t want to prescribe any drug for pre-diabetes in those over age 60 because blood sugar levels in the majority of these patients will either remain stable or revert to lower “normal” levels, according to research from Sweden and elsewhere.
Metformin is also available online after a “consultation.” And once the TAME trial begins, volunteers could receive the drug. A concurrent trial, TAME BIO, will search for indicators or biomarkers of aging — to provide diagnostic grounds for future metformin prescriptions.
Florida lawyer L. M., who is thin, in good shape and has a healthy diet, asked her doctor to prescribe metformin for dementia (about which she worries but has no symptoms); she does have a familial risk for diabetes, as well as high total cholesterol levels. But concern about side effects as well as L.M.’s insufficiently high blood-sugar levels led her doctor to prescribe instead only a statin for the cholesterol.
Despite worries about GI side effects, I would take metformin if my doctor were willing to prescribe it but am reluctant to go the online route. And if given the chance, I will volunteer for the TAME trial—for the value of being carefully followed during the aging process, with the added hope of obtaining metformin’s benefits.
Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
LATELY, views about Covid-19 are diverging generally into three camps: In the first, the future looks rosy and bright; for the second, emerging Covid variants threaten to pose serious risks; and the third camp believes there is too little information, though they have lingering concerns.
Many who are fully vaccinated consider the most worrisome risk, even if very unlikely, is Covid’s “long-haul symptoms” —most often intense fatigue, which can last more than six months and affect all ages, including the youngest and healthiest.
Meanwhile, officials continue to advocate caution: the CDC discourages long-distance travel and large gatherings; and President Biden said Americans need to continue wearing masks until “the vast majority” of Americans have been vaccinated—which by the end of last week was 12% of the population.
First, the yay-sayers—with conservatives leading the pack. “Republicans consistently underestimate risks, while Democrats consistently overestimate them,” according to a Gallup/Franklin Templeton survey of 35,000 Americans. More than one-third of Republican voters incorrectly stated that people without Covid symptoms could not spread the virus and that Covid killed fewer people than seasonal flu; while a large share of Democratic voters put the hospitalization rate due to Covid, which is close to 1%, at around 20%.
“Once most adults are immune—following natural infection or vaccination —the virus will be no more of a threat than the common cold,” writes Apoorva Mandavilli, quoting a study in the journal Science. It will become endemic—a pathogen circulating at low levels “that only rarely causes serious illness”—like the four endemic common cold coronaviruses circulating currently.
“Ending the Covid crisis should take only a few months,” writes Eric Levitz in New York magazine. Levitz makes the important distinction between the goals of herd immunity and “eradicating” the novel coronavirus versus Covid following the path of earlier coronaviruses and becoming “an endemic common cold.”
The possibility that emergent “hypervirulent” Covid variants might prove resistant to existing vaccines appears “far-fetched,” according to Levitz. Against both the British and South African variants, the full two-dose regimen of the Pfizer vaccine produced neutralizing antibodies in 90% of participants in an Oxford University study—and “insulated subjects from the threat of even mild illness, no matter the strain.”
The vaccine “dramatically reduced viral load in those infected with the virus”—reducing both its rate of transmission and its lethality—in studies in England and Israel. This coronavirus should become endemic, writes Levitz, even if the ongoing emergence of new variants makes it impossible to achieve herd immunity—“the point at which such a high percentage of the population is incapable of transmitting the virus, it gradually dies away.”
Levitz concedes, however, that “It is possible that the darkest days of America’s winter are still to come…The ongoing spread of hypercontagious variants, pervasive flouting of public-health guidelines and logistical headaches afflicting the vaccine rollout could coalesce into a perfect epidemiological storm.”
It is exactly those “hypercontagious variants”—with higher rates of both transmission and lethality—that are causing new spikes in Covid cases and hospitalizations in Michigan, and rising case numbers in Maryland, Minnesota and New Jersey.
The main culprit in these states, the B.1.1.7. variant, carries a 61% higher risk of death than earlier strains, according to a London School of Hygiene and Tropical Medicine study. University of Minnesota public health specialist Michael Osterholm warns that the spread of B.1.1.7. in Britain began with small outbreaks “that snowballed even though most of the country was shut down.”
“European countries hit hard by the variant did not experience rising case numbers until the variant accounted for more than half of all circulating strains—a milestone the United States could hit in the coming week,” Osterholm noted.
Alongside the threat from variants, “breakthrough infections with lesser amounts of virus” can occur even in those who are fully vaccinated —as long as a high percentage of the population remains unvaccinated and levels of virus are high, according to CDC Director Rochelle Walensky. Fully vaccinated people who are exposed to the virus in crowded settings like group homes still need to quarantine for 14 days and get tested.
High on the watch list for the too-little-information group is the comparison of Covid’s future to that of seasonal flu or the common cold. Said Harvard Public Health epidemiologist Marc Lipsitch, “I don’t think it’s absolutely guaranteed.”
This third group is also paying attention to the variants. “Let’s wait and see what we know about the variants. Fingers crossed,” a woman recently responded to her 80-year old mother, who had been eager to make travel plans.
Exacerbating the unknowns, different states have different rules about quarantines, while different doctors have different opinions about what is safe. Driving the CDC’s advice March 8 against long-distance travel is that, according to Walensky, “Every time there is a surge in travel, we have a surge in cases in this country.”
In D.C. and most surrounding counties, Covid numbers remain “very high”—the second highest category in the New York Times ranking, meaning more than 10 new cases/100,000 population/day. For those in the “very high” category, indoor activities are “very dangerous”—with the accompanying advice to avoid nonessential travel and events with more than a handful of people.
Meanwhile, “long-haul” symptoms continue to make front-page news—afflicting as many as 30% of Covid patients, of all ages, among cases ranging from serious to asymptomatic. The 177 Seattle-based patients followed in a University of Washington study were “relatively young and healthy,” said infectious disease specialist Kristin Englund at the Cleveland Clinic.
In studies from England, Canada, China and the U.S., Covid “long-haul” symptoms have included debilitating brain fog and fatigue, often relapsing and remitting over three months and longer, as well as loss of smell and taste, heart problems and the potential for new cases of diabetes.
After a bout of Lyme disease, I was exhausted for months—with little energy for more than a minimal amount of work and low-level family caretaking—followed by years of difficulties with sleep and peripheral neuropathy. As a result, I waver between groups two and three—slightly worried but lacking sufficient information— trying to take precautions when possible.
For meals inside restaurants, I’m not sure when I will be enthusiastic. Even indoor dining at friends’ houses now sounds slightly claustrophobic after so many months of outdoor get-togethers. Because we did these in very cold weather, the prospect now of spending time in the warmth of sunshine or on balmy summer nights seems almost irresistible.
‘TISA disease which attacks not only the Breast…It sometimes assumes different names; when it comes on the Legs, ‘tis called the Wolf, because if left to itself, ‘twill not quite them ‘till it has devoured them —1707 description of cancer by French surgeon Pierre Dionis.
The Wolf in Cancer, and Wolf is one of many entirely unfamiliar terms on a 1632 “Diseases and Casualties” list—sometimes printed on the backside of “Bills of Mortality.” Other names are familiar but surprising causes of death, like piles; familiar but with generally unknown definitions, like dropsie; and familiar with definitions that are surmisable, like flux.
Some terms are still in use but with different definitions or grouped differently, such as meagrom with apoplex; and some are still used but as euphemisms, like French Pox. By 1665, the most common cause of death in London was bubonic plague—killing about one-fourth of the city’s population.
“Nasty, poor, brutish and short” was how Thomas Hobbes described life in 17th-century England. But in the American colonies, even more “horrifying mortality rates” led England to send shiploads—in one, of approximately 1,500 kidnapped children to the Virginia colony; and in others, of “unemployed, vagrants, and other undesirable multitudes.”
Among unfathomable “Diseases and Casualties,” Planet (or plannet) was “likely a shorthand for “planet-struck [because] Many medical practitioners believed the planets influenced health and sanity.” The label applied to any sudden illness or death, such as a heart attack or aneurysm, according to “15 Historic Diseases that Competed with Bubonic Plague.”
Likewise, King’s Evil came from a belief, in this case that the touch of a king would bring a cure—for scrofula, a tuberculosis infection of the neck glands. Another label that embodied more than medicine was Impostume—a swelling, cyst or abscess, usually filled with pus, but with the “metaphorical meaning of an egotistical or corrupt person ‘swollen’ with pride.”
A popular listing, Rising of the Lights referred to “literally coughing your lungs up,” because lights was a familiar name for lungs, considered lightweight organs when referring to edible organ meats, in this case haggis. The diagnosis covered croup, pneumonia and any illness characterized by a hoarse cough or choking sensation.
Livergrown indicated an enlarged (failing) liver, diagnosed by symptoms such as jaundice and abdominal pain. And Cut of the Stone described death during surgery for bladder or kidney stones. Tissick came from the now-obsolete phthisis, wheezing and coughing associated with asthma or possibly tuberculosis.
Besides Piles (hemorrhoids), terms that are still familiar but surprising as causes of death include Winde,Sciatica and Falling sickness. Also, Surfet, or overeating—which may have referred to death from eating too much of a food that becomes poisonous in large quantities, as with King Henry I and lampreys; but may also have included death due to untreated diabetes and other causes of overweight, or to excessive drinking.
Among terms that remain familiar, Dropsie (dropsy) refers to swelling of soft tissues—though today’s diagnosis would specify cause, as in edema due to congestive heart failure. And flux, appeared on the list as Bloody flux, scowring, and flux, with each term referring to dysentery.
Quinsie, from the Latin word meaning choke, described an abscess that can arise behind the throat as a complication of tonsilitis. Tympany referred to swelling or bloating in the digestive tract that produced a hollow sound when tapped and could be fatal if caused by kidney disease.
Pox, still used as a generic description, appeared on the list as Flocks, and small pox,Swine Pox and French Pox—all originally diagnoses of venereal disease, usually advanced syphilis, but the latter term endures as a British euphemistic slur for French licentiousness.
Among antiquated groupings, Apoplex, and Meagrom combined various kinds of severe head pain that resulted in death—with apoplex signaling stroke and paralysis resulting from stroke; and meagrom, all other head injury and pain. In the modern version, apoplexy refers to unconsciousness or incapacity from the same original causes but can also refer to speechlessness due to extreme anger; and migraine indicates specific kinds of headaches.
Another grouping, Colick, Stone, and Strangury, refers to severe abdominal pain, usually causing death without a more specific diagnosis—but which could also indicate bladder/kidney stones or ruptured appendix. Strangury alone meant—and continues in Chinese medicine to mean—painful, frequent urination, in which “drops’ of urine are ‘squeezed out.’”
For Purples, and spotted Feaver, in the combination spotted fever referred loosely to any typhus or fever accompanied by reddish skin eruptions. Purples alone indicated bruising, especially when widespread; or to broken blood vessels caused by underlying illness, including scurvy or a circulation disorder.
Viewed from today, some old names seem more direct than current labels, such as Made away themselves — now, committed suicide, or the increasingly used suicided. And Suddenly suggests the jolting emotional effect on others of sudden unexplained death—compared to today’s term, cause of death unknown.
While Consumption was the most frequent reason for adult death (1797) on this list, almost 2,500 deaths to infants occurred from the combined causes of Childbed;Over-laid, and starved at nurse; and Chrisomes, and Infants—the latter referring to deaths that occurred in the first month of life, around the time of baptism using white cloths called chrisomes.
“The infant mortality rate would fluctuate sharply, according to the weather, the harvest…severe times, a majority of infants would die within one year,” according to “The First Measured Century” on PBS. While life expectancy by the mid-Victorian era barely exceeded age 40, “dramatic declines” in infant mortality in the 20th century led to “equally stunning” increases in life expectancy.
—Mary Carpenter
Mary Carpenter usually reports on current medical and health issues.
“Our clothing was insufficient to protect us from the severe cold: we had no boots, the snow got into our shoes and melted there: our ungloved hands became numbed and covered with chilblains, as were our feet…” at Lowood, the charity school for orphans in Jane Eyre.
WHEN PHILADELPHIA Charlotte Bronté aficionado L.N. noticed purple spots on the tips of two toes that had been hurting, her first reaction was embarrassment at having the“antique ailment” chilblains, which occur primarily on the hands and feet. The purplish or bluish-red color distinguishes chilblains, also called pernio, from other reactions to cold.
Also described as a “pernio-like reaction, “Covid toes” most often appear in young adults and children—while the most common skin sign of Covid-19 infection is a measles-like rash. Like chilblains, the purplish bumps of Covid toes can arise without any sensation or can cause itching, blisters or pain.
Chilblains—occurring when tiny blood vessels in the fingers and toes swell or leak blood—happen in weather that is cold but not freezing; in temperatures as high as 60 degrees F.; most often in damp cold and regions with high humidity; and usually after repeated exposure. Chilblains most often last two to three weeks, although in England’s damp, cold winters, chilblains are common and can last for several months.
By contrast, frostbite occurs in below-freezing temperatures and freezes the skin and tissues beneath the skin. Along with Raynaud’s disease, frostbite causes skin to look pale or bluish; while cold urticaria and cellulitis make the skin turn abnormally red. Itching and red patches can accompany all of these conditions.
(How cold air feels on your skin and how much heat is lost from the body depend on the so-called “feels-like” temperature—feels-like 25 degrees can cause frostbite even when air temperature is above 32, which takes into account both humidity and the wind speed at around five feet. At lower temperatures, wind speed is more important because it strips the thin layer of warm air above the skin; while at higher temperatures, humidity has the greater impact because it impedes perspiration that helps release body heat.)
“No one knows exactly what causes chilblains,” according to the Mayo Clinic. The tiny blood vessels may swell and become inflamed in response to the cold. Alternatively, rewarming causes the “small vessels to expand more quickly than nearby larger blood vessels can handle…results in a bottleneck effect and blood leaking into nearby tissues.”
In rewarming too quickly—with strenuous rubbing or hot water or air—blood vessels that have narrowed with cold can’t handle the sudden increased blood flow that accompanies warmth. Reheating should instead occur gradually “with warm (not hot) water and without rubbing or slapping.”
The swelling that results when blood leaks into tissue can irritate the nerves and cause pain, which “may represent an allergic reaction or hypersensitivity to the cold.” Additional causes of chilblains include circulatory or cardiovascular diseases, genetic factors, hormonal changes and autoimmune diseases, such as lupus. Perniosis occurs more often in females, and more often in women who are very thin.
For some, perniosis is a seasonal inflammatory disorder but can last for years if untreated and exposure to damp cold persists. Lotions and moisturizers ease most symptoms, and steroid creams help with itching and swelling. Blisters caused by chilblains will heal faster when kept clean, warm and dry, but any sign of infection requires a doctor’s visit.
Tight-fitting clothing may increase susceptibility to chilblains in cold weather by restricting blood flow, which causes a decrease in skin temperature in those areas. Perniosis of the thighs “more commonly affects young females who wear tight-fitting pants,” according to the National Organization for Rare Disorders. “It is characterized by red or bluish patches on the…upper hip region and on the outside of the thighs.”
For those with persistent swelling in the lower limbs, compression socks or stockings can help reduce extra fluid, which will in turn improve the skin’s ability to receive optimal amounts of oxygen. Compression can be especially important for wound healing—but is not advised in cases of impaired sensitivity in the feet and legs.
Keeping skin healthy to avoid adverse reactions to the cold can involve maintaining pH levels just below 5, because skin is “weakly acidic”—while most adults average closer to 5.7. Keeping pH low can also help with dry skin, and acidic cleansers can help combat acne.
Healthy skin may also benefit from bathing less often, according to Atlantic staff writer and Yale School of Public Health lecturer James Hamblin. Says Hamblin, “Bathing disrupts our skin’s microbiome, which has particular importance as our initial defense against pathogens. Maintaining microbiome health can help prevent outbreaks of acne, eczema and psoriasis—which can involve “an interplay between your immune system and the microbes on your skin.”
Hamblin believes that overcleansing may also interfere with skin signals of underlying health problems. As of September, 2020, Hamblin had gone five years without a shower—described in his book Clean: The New Science of Skin. Although he maintains hygiene by frequent hand-washing, people have called him “gross.”
Skin health care may be especially important for feet, which benefit from regular inspection and moisturizing. I have tried to do this more vigilantly since getting advice from my ex-mother-in-law, though I ignored it at first. With age, feet need better care.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
IN A SEMI-VACCINATED WORLD, vaccinated people may get together with each other. For most everyone else, falling case numbers along with rising vaccination rates and new vaccines in the pipeline are raising hopes for making future plans —for next month, next summer, next year.
The many unknowns, meanwhile, create ongoing worries—that vaccinated people might still be able to spread the virus; that vaccine protection could last as little as three months; and that new variants may be able to evade current vaccines—although in each case, new research counters some of the worst possibilities.
One year into the pandemic, one theme prevails, notes local public health expert Lauren Greenberger: “I think there is still a lot that could change as more data becomes available—especially longitudinally.”
Those who have been vaccinated should be safe with each other, according to George Washington University health policy professor and former Baltimore health commissioner Leana Wen. “A couple who want to get together with another fully vaccinated couple are probably fine to do so, including to hug and see one another indoors, without masks. They should probably still avoid large gatherings.”
For the near future, “vaccines might never bring us to herd immunity but they can help end the pandemic,” writes Sarah Zhang in the Atlantic. Zhang notes that the definition of “herd immunity” is very precise: “a population reaches herd immunity when the average number of people infected by a single sick person falls below one. Patient zero might infect another person, but that second person can’t infect a third.”
Increasing the pace of vaccination to three million shots/day could make “total immunity” possible by May and “vaccine immunity” by July, according to the PHICOR public health research group—although both deadlines could change with the relaxation of social distancing and the spread of more contagious variants. “Total immunity” includes both the vaccinated and the previously infected, but it depends on estimates of those with infection-produced immunity; whereas “vaccine immunity” is based on real numbers and may be easier to predict, but it can change depending on the length of a vaccine’s effectiveness.
Instead of a herd-immunity goal, many experts focus on transforming Covid-19 from a much-feared cause of hospitalization and death into something closer to the seasonal flu via a combination of expanding vaccinations, improving treatments and maintaining social restrictions. The only caveat: Even mild Covid infection can cause debilitating, long-lasting symptoms.
Consorting with others, meanwhile, means observing the most conservative measures desired by the most worried person: Among those who have been vaccinated, although the risk of becoming infected is low, some worry about that small percentage of risk and ask others to wear masks and keep their distance.
A vaccinated visitor to an unvaccinated “pod” may be asked to stay somewhere safer than a hotel, like an Airbnb; to wear one or more masks when venturing into public spaces; and to take a Covid test following domestic air travel—even with the knowledge that those results will reflect, not post-flight infection status, but that of several days earlier, because that’s the rule of the pod.
Still unknown is what happens in the case of a sneeze from a vaccinated person who may have been recently exposed to infection. Injections into arm muscles create immunity in the body but may have no effect on viral particles that can reside in the nose and throat for five days or longer—and whether that amount of virus, or viral load, is sufficient to transmit the infection remains under study.
Using “viral load” as a proxy for infectiousness, the small number of people in one study who became infected two to four weeks after receiving the Pfizer vaccine had a “significant drop” in viral load compared to those who became infected during the first two weeks.
Also, the Pfizer vaccine showed 85% effectiveness in blocking not just symptomatic but also asymptomatic infection, according to new, unpublished research—providing “the first evidence that Pfizer’s vaccine might block transmission,” according to Nature.
Another troublesome data void is the length of immunity conferred by the vaccine. The most recent CDC recommendations stick to the three month limit: “vaccinated persons…are not required to quarantine if they…are within 3 months following receipt of the last dose in the series.”
Ever-mutating variants may become capable of evading immunity created by either vaccines or infection. Variants discovered recently in New York and California may increase the need for surveillance of travelers within the U.S., not to mention those going back and forth to Europe. Meanwhile, vaccine creators are working hard to find ways to adjust current products as well as to create boosters—to deal both with expiring immunity as well as mutations in variants.
For vaccinated travelers, Wen says, the risk is “already pretty low [and] can be reduced further by vaccinated visitors avoiding other social gatherings before travel.”
Reagan and Dulles airports expect to offer Covid-19 testing to travelers, both rapid tests and the more reliable PCR tests, within the next month, but offerings can differ by airline and may be more cumbersome and more expensive than visiting a free testing site after arrival.
The coronavirus continues to be devastating in sickness and lives lost, as well as in unemployment, poverty and many related ills. At the same time, the virus is creating better understanding of the interconnectedness of our world and our communities, and of how to take better care of each other—as well as of viruses themselves, which usually attack but can also contribute to our bodies’ health.
Eloquently exploring many unusual facets of viruses, Carl Zimmer addresses one basic question, whether they are dead or alive—quoting a 1930s New York Times article: “Enough is known about matter, organized and unorganized, to assure us that there may be things ‘twixt heaven and earth which are not so alive as an eel or so dead as a rock…”
FOR THOSE with diabetes who contract Covid-19 infections, an impaired immune response leads to higher risk of hospitalization and death (though not of contagion). And poorly controlled diabetic symptoms cause more devastating effects of Covid-19— especially for people living in minority, immigrant and low-income communities with limited access to healthy food and medical care.
In addition, the possibility that Covid-19 infection might itself cause new cases of diabetes sheds light on problems linked to undiagnosed diabetes, which affects more than eight million people in the U.S.—and to “pre-diabetes,” high blood sugar levels that could be an early sign of diabetes. Of one in three adults with pre-diabetes, nine out of ten are unaware of it— but they may suffer more serious consequences of a Covid infection.
(Pre-disease—as in pre-diabetes or osteopenia—is a questionable diagnosis because measurable levels of blood sugar or bone loss are insufficient to confirm the presence of disease. But abnormal levels can motivate people to take beneficial, preventive measures—perhaps especially important in the time of Covid.)
In both Type 1 and Type 2 diabetes, though for different reasons, insulin is no longer doing its job of processing glucose, which then circulates at high levels in the bloodstream. Persistent hyperglycemia can impair the body’s ability to fight off infections–putting diabetics at higher risk for tuberculosis, pneumonia, and infections in the urinary tract, skin and elsewhere.
Circulating high blood sugar impairs “the ability of white blood cells to come to the site of an infection, stay in the infected area, and kill microorganisms,” according to the University of Michigan Health Library. In addition, damage to the blood vessels and buildup of plaque related to high blood sugar may diminish the blood supply and thus the transport of immune cells to infected areas.
While high circulating levels of glucose damages blood vessels over time, so too does the low-level inflammation that is continuously harming pancreatic insulin-producing beta cells and increasing insulin resistance. Inflammation, in turn, worsens with the immune response to high blood glucose levels and with increased inflammatory mediators produced in fat tissue.
In addition, the “stress hormone” cortisol raises blood sugar levels to deal with crises like the pandemic; while chronic stress—worry about contagion, anxiety about jobs and health—causes chronically elevated cortisol and the resulting high blood-sugar levels, even with a healthy diet and regular exercise. Lack of sleep can also provoke a response similar to insulin resistance.
The healthy diet crucial for diabetic control is often out of reach for those on limited budgets and living in low-income areas—with few grocery stores and even fewer options for fresh fruit and vegetables. Healthcare insurers such as Humana have begun supplementing food options for diabetics in the second half of each month—when diabetes patients make more ER visits, linked to the period when government food program money runs low.
Controlling blood sugar levels is also more challenging in communities with a high “social vulnerability index” (SVI) score—created by government agencies to determine the level of extra support communities need in the case of hazardous events, including extreme weather and disease outbreaks. The SVI puts more than a dozen variables into four categories: socioeconomic status; household composition/disability; minority status; and housing/transportation—which includes “No vehicle” as a key measure of restricted access to food and healthcare.
On the other hand, it may be too soon to tell if people with the new diagnoses will have permanent diabetes, according to Columbia University endocrinologist Dominico Accili. Confirmation of a “separate entity of post-Covid-19 diabetes” depends on lasting damage in the pancreatic beta cells that produce insulin—which requires long-term followup, because many other facets of diabetes, such as hyperglycemia, can arise independently along with a Covid-19 infection, writes Accili.
“Stress hyperglycemia” can occur in patients without clear evidence of pre-existing diabetes—as can ketoacidosis (high levels of circulating acid caused by diminished production of insulin), which occurs in unusually high prevalence among patients who have both Covid-19 and diabetes, according to Accili. Rather than Covid-19 causing permanent beta-cell damage, however, it may be that uncontrolled hyperglycemia stuns the b-cells and impairs insulin secretion—but only for the duration of the Covid infection.
For people worried about the diet-diabetes link, new wearable 24-hour glucose monitors can keep track non-invasively of which foods elevate their blood sugar levels, writes the New York Times’s Anahad O’Connor. Responses to different foods can vary widely among individuals—with bread and butter or chocolate causing “substantial blood sugar spikes” in some but not in others. O’Connor himself gave up balsamic vinegar after discovering how much it raised his blood sugar level.
Such monitors are useful, however, only for those willing to alter their diets accordingly. I see no reason to completely forgo sugary tea and ice cream—and especially my favorite white balsamic vinegar—as long as I do not have pre-diabetes, let alone confirmation of disease.
—Mary Carpenter
Well-Being Editor Mary Carpenter keeps us updated on Covid-19 and its effects. To read more of her posts, click here.
ADVICE to combat possible flu-like side effects of the SARS-Cov-2 vaccine has focused on “hydrating with electrolytes”—starting the day before the vaccine appointment. That has raised the following questions—what are electrolytes, what can hydration do and why include these together?
Drinking extra fluids—waters, juices, herbal teas—can help boost blood circulation and the body’s general health to prepare for the vaccine’s jolt to the immune system. A specific reason is to counter mild fever that can be a common reaction to the vaccine—taking acetaminophen post-vaccination is also suggested. (Other post-vaccine side effects—in addition to local pain at the injection site: fatigue, chills, nausea, joint pain and headache.)
Supplemental electrolytes—potassium and magnesium but most of all sodium—help the body retain rather than excrete excess liquid, which is especially helpful following strenuous exercise and in humid, hot weather. Drinking too much plain water can result in hyponatremia—insufficient salt in the blood—as can dehydration; and both can trigger muscle cramping and fainting. Medical rehydration formulas—usually salt and carbohydrates, or simple sugar —work by improving the body’s absorption of replacement liquids.
Electrolytes—calcium, phosphorus, chloride and bicarbonate, along with the first three—are minerals with an electrical charge that regulate cell function, help produce energy and stimulate nerve signaling and muscle contraction. Sodium in particular facilitates the contraction of heart muscles—aided by potassium, which is also credited for lowering blood pressure and decreasing risk of stroke, and is notable for reducing the risk of muscle cramps.
The concentration of electrolytes in bodily fluids like blood can vary only within a tight range without creating serious health problems. In addition to exercise and hot weather, illness accompanied by diarrhea or vomiting can disrupt the fine balance.
In research on pre-exercise hydration, salty chicken noodle soup produced the greatest retention of fluids, followed by a “carbohydrate-electrolyte beverage,” with water alone the least effective. And the desired goal of plasma osmolality (the amount of water retained in the blood) increased the most successfully after ingestion of the soup and “remained elevated throughout exercise,” as did proportionally reduced urinary water loss—compared with ingestion of the two alternatives.
Among commercial electrolyte-replacement options, the best-known are sports drinks like Gatorade and Powerade, although most contain either high sugar levels or sugar replacements that can cause gas and bloating.
In recent years, ever-increasing choices include chewable tablets and the more common powders and capsules to be mixed with water. For the latter, “best-of” lists include “best overall,” “best organic,” “best for keto and one “best for runners” selection that adds caffeine for an extra boost —though caffeine also shows up in many electrolyte supplements.
“Best budget” on this list and others is Pedialyte, a liquid originally prescribed for rehydration following illness, although one Amazon commenter complains that the unflavored option “tastes so bad I would rather drink from the Gulf of Mexico after the BP oil spill.”
A confusing entry on some lists is Essentia Water, described as “supercharged alkaline water infused with trace amounts of electrolytes,” although the ingredients list notes “Per serving: 0 mg sodium, 0 mg potassium, 0 mg magnesium.”
Among more natural solutions, “coconut water”—usually unadulterated, direct from the inside of coconuts—is popular both for its electrolytes that include sodium, potassium, calcium and magnesium, and for having few calories and little sugar. Cow’s milk is “somewhat of an unsung hero…. with a rich supply of electrolytes,” according to Healthline—as are other dairy products as well as those made from soy.
Fruit juices— notably “watermelon water” but also orange and tart cherry juices—provide good amounts of electrolytes but have the drawback of little to no sodium plus high levels of sugar. Foods high in potassium include fruits like bananas, vegetables like sweet potatoes and spinach; and many nuts.
After several bouts of dehydration following summer exercise—resulting in muscle cramps, dizziness and nausea—I looked for electrolyte options that did not involve commercial drinks or fizzy-flavored mixes from tablets and powders. In hot weather, large quantities of lemonade filled with ice and diluted with water has worked quickly and well.
Year-round, before and after some exercise, I eat lemon-flavored chewable electrolyte tablets called SaltStick Fastchews, which also come in orange, watermelon and peach. To prepare for coronavirus vaccination, besides chewing a few of these, I hope to plan a pre-vaccine day of favorite electrolyte-rich foods: an avocado and an orange; chicken soup; yogurt and milk—and maybe ice cream.
AFTER FEELING a sharp pain, Prague-based journalist C.M. saw that one of her eyes appeared full of bright red blood. C.M. wondered about blood pressure—although hers is moderate to low—or coughing as possible causes. Only for a medical emergency would she be willing to leave her apartment mid-pandemic for crowded streets and few people wearing masks.
Not just red, but also pink, yellow and orange are possible colors that can appear when tiny blood vessels in the eye swell, leak or burst to cause a subconjunctival hemorrhage, which may look alarming but is usually nothing to worry about.
Coughing, along with sneezing, vomiting or just bending over are common causes—as is strenuous exercise or weight-training, especially if holding the breath or not breathing continuously. In the morning-after bloodshot eye, alcohol dilates the tiny blood vessels: the more alcohol, the more visible and red these vessels can appear against the whites of the eyes.
The bloody or bloodshot eye is like a bruise—in this case, with blood trapped under the conjunctiva, the thin membrane on the eye’s surface. The best treatment is time, as long as three weeks, for the eye to absorb trapped blood and slowly turn white again.
What might require a complete physical exam is more than one hemorrhage or if blood appears inside the iris; also if hemorrhages recur—some experts say in the span of a few months, but others say more than two of these in a year. Frequent hemorrhages can be warning signs of hypertension, diabetes or disorders of the blood, including leukemia.
If itching “like crazy” accompanies eye redness, the diagnosis may be pinkeye, or conjunctivitis, which can be the result of allergies or something small in the eye like a stray eyelash. But if the cause is bacteria or a virus, pinkeye requires frequent hand-washing to prevent spreading—and a doctor’s visit for diagnosis and sometimes antibiotic treatment.
Lack of sleep can cause eye redness, because keeping the eyes opened for too long dries out the cornea. But if the cause is sleep apnea—for which eye redness can be a sign—that may indicate increased risk of glaucoma.
Seeing an eye doctor might be important when eye symptoms accompanying the bloodshot look include pain, light sensitivity, discharge, vision problems such as seeing bright circles or halos around lights, headache and nausea. Halos and nausea along with a very red and painful eye can signal acute glaucoma —caused by rapid increase of blood pressure in the eye, as well as when pupils in certain kinds of eyes are enlarged due to stress or being in dark places like movie theaters.
Acute glaucoma requires immediate medical attention—as does what looks like a black curtain descending over one eye, which can indicate a torn retina or one beginning to tear.
For relief of bloodshot or otherwise red eyes, cold water or a cold compress can help shrink blood vessels and, in the case of the blood-filled eyes, may help reduce the startling appearance. Eyedrops labeled “artificial tears” can also help slow swelling or hemorrhage—but “anti-redness” drops can cause redness-rebound if used excessively or for too long.
Likewise, to prevent eye hemorrhages and redness, avoid hot water and excess heat or hot air on the face—from hair dryers, car heaters and even fireplaces. The advice also applies to redness due to dry eye syndrome (DES)—which occurs twice as often in women over 50 and is the most frequent eye complaint related to air pollution.
The eyes’ tiny blood vessels, in addition to showing signs of sleep apnea and glaucoma, under photographic examination can reveal risk of stroke —because leakage, ballooning or narrowing of the vessels in the back of the eye may be markers of blood vessel damage elsewhere in the body. In the same way, malfunction in these vessels can indicate poor control in other systemic conditions like diabetes.
While the eyes may not always be windows to the soul, they can offer insights into whole body health—and good reasons to keep regular check-ups on both body and eyes and to take most symptoms seriously—although the scariest-looking bloody eye may require nothing more than time.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine
“IT’S THE first time I’ve been concerned,” said Harvard immunologist Barry Bloom, in response to recent reports of the new coronavirus variants. “I’m now quite worried about them.”
Experts are wavering on earlier contentions that this coronavirus couldn’t mutate fast enough to evade existing vaccines and treatment drugs. Perhaps most indicative of new concerns, the manufacturers of the two vaccines available in the U.S., Moderna and Pfizer/BioNTech, have begun researching booster shots as well as ways to modify their vaccines.
The result is a race against time between a mutating virus—which is becoming both more infectious and more lethal—and the combined efforts of widespread vaccinations and public policy mitigation, like mask wearing. The resulting suspense is compounding already-high stress levels of the pandemic.
On mask wearing, the increased contagiousness of virus variants has led experts in the U.S. and elsewhere to recommend or require more protective options. U.S. infectious disease expert Anthony Fauci calls for double-masking—the more layers, the better, with the first layer being the most protective, such as N95 or KN95. Germany requires medical-grade (N95 or other surgical) masks in public.
[The threat from variants is] “what makes this moment dangerous,” writes Ezra Klein. The B.1.1.7 variant of coronavirus, first seen in Britain and now spreading throughout Europe, appears to be 30 to 70 percent more contagious, and it may be more lethal, too. It hit Britain like a truck, sending daily confirmed deaths per million people from about six per million in early December to more than 18 per million today.”
This yo-yo of hope and fear increases pressure to tolerate what’s known as cognitive dissonance—simultaneously keeping track of two conflicting ideas. As F. Scott Fitzgerald wrote in his 1936 essay “The Crack-Up,” according to Quartz: “the test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.”
“Furious urgency” is what public health expert Ashish Jha at Brown University says is needed for the vaccination effort to stay ahead of the mutations, writes New York Times columnist Michelle Goldberg, who urges that the U.S. raise its vaccine goal to two million/day versus the current 1.5 million/day. By the middle of last week (January 27), only seven percent of the U.S. population had received both doses.
Meanwhile, the U.S. is “43 in the world” in its ability to monitor genetic variants, according to recently appointed Covid-response coordinator Jeffrey Zients. While creating a nationwide genetic monitoring system could cost millions of dollars now, future savings could be high both in costs of caring for sick people and in preventing untold numbers of deaths. Having the world’s worst outbreak makes the U.S. the world’s largest breeding ground for mutations. As the virus copies itself millions of times in each infected person, mistakes can happen—meaning that higher numbers of infections create more opportunities for the circulating virus to pick up more mutations more quickly.
The coronavirus genome is “a twisted strand of nearly 30,000 ‘letters’ of RNA… genetic instructions [that] force infected cells to assemble up to 29 kinds of proteins that help the coronavirus multiply and spread,” write Jonathan Corum and Carl Zimmer in the New York Times.
Mutations in the new variants can make the virus more easily transmissible by keeping protective antibodies from binding to it—or by making the virus “stickier” as it attaches to our cells.
Any mutation that allows the virus to infect more cells can make the infection more dangerous. British epidemiologist Neil Ferguson of Imperial College said there was a “realistic possibility” that the British variant could be 30% more lethal than the original version of the coronavirus—although in the absence of good data, that risk could be anywhere from zero to 65%.
Meanwhile, the South African variant B.1.351, which has been slow to reach the U.S., has appeared more adept at dodging antibodies created by the Moderna vaccine—resulting in a six-fold reduction in the antibodies’ effectiveness—as well as at reducing effectiveness of the soon-to-be-available Johnson & Johnson vaccine. As of last week, infections from the Brazil variant had just appeared in the U.S.
(Although the Johnson & Johnson vaccine appears to provide lower protection than the two currently in use in the U.S., its 66% effectiveness may be more a reflection of the strengthening of the variants because tests for this vaccine took place in areas of the world where the virus was already changing, as with the still-experimental Novavax vaccine, which had 89% effectiveness in Britain but less than 50% in South Africa.
Most recently in the U.S., a new homegrown variant, CAL.20C, is burgeoning in California and is likely responsible for the surge of cases in L.A. county. It has since appeared in New York and the DC area, as well as in Oceania. While much remains unknown about this variant such as its lethality or whether current vaccines will be effective against it, scientists suspect it is more contagious than existing strains.
Finally, coronavirus variants may pose problems for the new monoclonal antibody drugs, delivered intravenously, because the precise design that makes them so effective against the original virus could be exactly what makes them a poor match against the variants.
Also on the good-news side, vaccines cause a “cushion effect,” a powerful immune response that remains protective even when the antibodies they created have diminished power against the new variants, according to Fauci. In addition to neutralizing antibodies, that immune response involves T cells, memory B cells and a host of other so-called “effectors.”
—Mary Carpenter
Well-Being Editor Mary Carpenter keeps us updated on Covid-19. To read more of her posts, click here.
STRENGTHENING muscles was never of much interest to DC-based writer WZ so long as she could do the daily aerobic exercise she enjoyed, especially swimming—until she had pulmonary testing to investigate mild shortness of breath—dyspnea. When results of lung testing—many rounds of spirometry (blowing out strenuously into a tube)—were good, two other possible explanations did not apply: she was not obese, and her heart was fine.
That, according to the pulmonologist, left the muscles. As lung function and capacity can decline with age, muscles like the diaphragm get weaker, and oxygen capacity decreases. Conversely, optimal breathing capacity correlates with lung volume as well as with upper extremity strength —and expiratory muscle strength training has led to improved breathing ability. Sarcopenia, first used in 1989 to describe progressive loss of skeletal muscle mass (SMM) with advancing age, now more commonly refers to impaired muscle strength for any reason —which can include chronic conditions like diabetes. And while it most often occurs with age, sarcopenia may worsen with inflammation, such as that occurring with osteoarthritis.
Skeletal muscle mass—important for mobility, balance and strength—differs from “lean body mass,” which includes bones, connective tissue and bodily fluids in addition to muscle mass. To combat diminished SMM, resistance weight training and upping protein consumption are the most common recommendations, as are breathing exercises if weakened diaphragm muscles restrict activity or cause other problems.
One reason for assessing SMM: when added to decreases in bone density, sarcopenia may double the risk of osteoporosis and the corresponding likelihood of bone fracture in women—and may also contribute to insulin resistance and the risk of diabetes.
The same DEXA (dual-energy X-ray absorptiometry) scans that assess bone density may also provide the best measurements of muscle mass, although other scans like CT and MRI also work well. But most physicians consider scans for muscle mass scans insufficiently useful to justify the radiation involved —thus reserving them for suspected muscle degeneration diseases, like muscular dystrophy, or malnutrition, WZ’s internist explained.
Methods for assessing muscle mass that do not involve radiation, on the other hand, are less accurate because they rely on estimates from standard prediction equations rather than making direct measurements, and in many cases use prediction formulas that are inaccurate.
The “gold standard” assessment of the past, underwater weighing, measured displacement—with subjects required to “expel as much air as possible from their lungs and sit completely submerged in a tank of water, a process that may be repeated several times.”
More recently, bioelectrical impedance analysis (BIA)—used, for example, by “body fat scales”—sends a weak electrical impulse through the body that encounters varying levels of resistance (impedance) to detect fat, which creates more resistance than muscle or water. Although some BIA assessments have correlated well with those made by DEXA scans, readings in a 2016 evaluation of six body-fat scales by Consumer Reports were off by anywhere from 21% to 34%.
The device against which Consumer Reports made its comparisons, the Bod Pod, is another “displacement” method like underwater weighing, but its sensors detect air pressure changes that reflect the volume of air displaced by body. Despite sharing a high margin of error—because these also use formula-based estimates instead of direct measurement—both the scales and the Bod Pod can help keep track of losses or gains in muscle mass over time.
For combating decreased muscle mass, many turn to protein supplements—based on evidence that adults over 50 benefit from eating as much as twice the RDA. In one study, the group who consumed 25% of calories from protein had lower blood pressure and harmful LDL cholesterol levels; in another, those who doubled their protein RDA built more muscle than they were losing.
Another popular supplement to counter low muscle mass is creatine—produced by several organs and stored in muscles throughout the body—which plays an important role in physical performance and muscle growth. On the other hand, both supplements have had mixed results, “despite a huge amount of research.”
Some research has also linked regular doses of anti-inflammatories to improved muscle mass, but there are many caveats and downsides to the ongoing use of these.
And although aerobic exercise can help support muscle growth and slow its loss, those exercises that specifically target increasing muscle mass for improved breathing include: bodyweight exercises like pushups and planks; resistance-band exercises; free weights; and Pilates.
Focused solely on breathing, the most commonly recommended exercises work best with modifications that involve gentle breath and movements, according to Rebecca Carli, whose DC area Rolfing-based body-work practice has helped WZ over decades and who recommended Carola Speads’s book Ways to Better Breathing.
For “pursed-lip breathing,” sit upright in a chair; inhale; then exhale briefly before bringing a drinking straw to the mouth, between pursed lips, without bending forward; and continue exhaling. To be sure all air is passing through the straw, use a nose clip during the first few exhales; leave a little breath at the end for a final, unforced exhale; and after each exhalation through the straw, take time out to allow the breath to respond freely.
“Belly breathing,” also called “diaphragmatic breathing,” starts with lying flat and exhaling. Then, instead of the common advice of placing one hand on the lower abdomen to feel the in-breath expand there, focus instead on allowing the breath to fill the lower back or sacral area. At first, do each exercise for five minutes—and slowly add on as breathing becomes easier.
Reluctant to add muscle mass to WZ’s next DEXA scan prescription, her internist had a different suggestion—addressing the shortness of breath with “some pulmonary rehabilitation, once the Covid situation is improved.”
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
WITH EFFORTS underway across the country to expand access to Covid-19 vaccines, new questions have arisen about what happens if the supply is insufficient for everyone to get a second dose: about how long protection might last after just one dose or how long a delay might be possible before getting the second dose without risking Covid-19 infection.
As January 15 marks one year since the first confirmed U.S. case of Covid-19, numbers of cases and deaths continue to increase, and more contagious variants of the vaccines continue to spread.
Because drug companies did not study what happens to people if the second dose is delayed—past 21 days for the Pfizer vaccine, and 28 for the Moderna—some experts say that’s a reason any delay is too risky, while others point to the same lack of evidence as support for their position that delay could pose little or no risk.
In the U.S.—along with increasing access to the vaccine for younger ages and different health groups—the current administration has promised second doses to everyone who has the first one. But having a sufficient supply of vaccines to provide second doses on the prescribed schedules would require an exponential expansion in production and delivery, which seems unlikely given ongoing supply-chain bottlenecks.
Of 300 million doses promised by Operation Warp Speed by January, only about 1/10th of those vaccines were available; and Pfizer recently announced lower production targets for its vaccine. On the other hand, delays in providing second doses could buy extra time to ramp up production, which in turn could provide enough doses in enough time to avoid compromising immunity.
Also, the long-awaited Johnson and Johnson vaccine—which requires only one shot and less extreme refrigeration, and is thus less expensive—could win approval by late March, although manufacturing difficulties have already delayed the company’s delivery schedule by about two months.
The AstraZeneca vaccine, available in the U.K., also faces at least a two-month delay in the U.S., with approval held up by questions about efficacy—for one, among elderly people, which is “effectively unknown,” according to Operation Warp Speed head Moncef Slaoui. In addition, while combined results from different trials add up to 70% efficacy, the AstraZeneca vaccine showed 90% effectiveness in one group that mistakenly received a half dose in the first shot.
“We need a clear and concrete number more than a number that is accumulated by adding together different trials with different schedules and different materials,” Slaoui told Politico. On the question of delaying second doses, Slaoui stands firmly on the need-more-research side of the debate, saying, “It’s important, I think, to use the vaccine based on how you studied it.”
All Covid-19 vaccines approved to date require two doses—similar to many current vaccines, such as those for tetanus, hepatitis B, measles, polio and HPV, as well as the newer shingles vaccine. After the first dose, immunity builds slowly, creates significant protection in anywhere from one to two weeks and may peak at around four weeks. After that, for Covid-19 vaccines, researchers have no data.
The WHO currently recommends that the interval between doses for the Pfizer vaccine might be extended up to six weeks “on the basis of currently available clinical trial data.”
And testing of the vaccines’ efficacy done by both Pfizer and Moderna throughout the trials showed “robust immune response four weeks after the first shot, and most experts believe it is extremely unlikely immunity would somehow plummet by week eight or even week 12 following a single shot,” write UCSF Department of Medicine Chair Robert Wachter and Brown School of Public Health Dean Ashish Jha in a Washington Post Op-ed.
Giving a single shot that is 80 to 90% effective to 100 million people will save “far more lives than giving 50 million people two shots that are 95% effective,” write Wachter and Jha. In people who have suffered the coronavirus infection, immunity also declines over time—to below 85% in one recent British study of more than 20,000 healthcare workers.
Another concern with a second-dose delay is the risk that, in those with weakening immunity, the virus might develop resistance —leading to the spread of vaccine-resistant virus variants through the population.
On the other hand, if single doses of the vaccine reduce natural infection, they might cut the risk of resistance evolving, according to University of Chicago virologist Sarah Cobey, who told Nature: “It’s a very serious thing to be sacrificing people now because you’re afraid that you won’t be able to handle a strain in the future…If I were to place a bet I would be doing what the UK is doing.”
Conducting large studies that compare the efficacy of one dose alone versus two could help answer the questions and, if started now, could produce preliminary data by March, suggests Memorial Sloan Kettering’s Peter Bach on STAT.
Another possibility: Although numbers are unavailable, a few participants in the original trials who didn’t receive a second dose—usually because they didn’t show up—“were generally only followed for a short period of time,” according to an FDA statement. Now some are wondering about tracking these patients down.
Finally, according to Moncef Slaoui, the administration is considering allowing half-doses of the Moderna vaccine—despite lack of research on this option, although missing data is exactly the reason that Slaoui firmly resists altering current vaccine dose schedules.
—Mary Carpenter
Well-Being Editor Mary Carpenter keeps us updated on Covid-19. To read more of her posts, click here.
PSILOCYBIN-assisted treatments—for depression, cancer pain, addiction—may not appeal to everyone, but the film Fantastic Fungi has been raising curiosity about these and other mushrooms that are non-hallucinogenic and potentially health-enhancing.
In small studies in the U.S. and many in East Asia, lion’s mane mushrooms have spurred nerve growth and helped patients with mild memory loss; while turkey tail and reishi mushrooms have shown immune-boosting effects in cancer patients. And more than 100 species of so-called “magic” psychedelic mushrooms exist—although most research participants receive synthetic psilocybin for better control of variables, such as strength.
(Neither plant nor animal, mushrooms belong to the Kingdom of Fungi, which includes other members like yeasts, rusts and slime mold. What is visible and edible is the organism’s fruit, while the mushroom body is a wide mass of traveling tendrils called the mycelium that is usually unseen, often underground and can cover many acres.)
“Rapid and large reductions in depressive symptoms” was the finding in a Johns Hopkins study of 24 participants that made the news in November, with “most patients showing improvement and half of study participants achieving remission through the four-week follow-up,” according to the Hopkins report.
“The magnitude of the effect we saw was about four times larger than what clinical trials have shown for traditional anti-depressants on the market,” according to Hopkins psychiatry professor Alan Davis. Those drugs can take weeks or months to work, often have side effects, and for about half the patients result in “some improvement,” while the psilocybin experience resulted in “remissions:” that is, those patients were no longer depressed.
While questions arise about the Fantastic Fungi film’s objective accuracy on health benefits of mushrooms, reviewer Matt Fagerholm notes that, “What is inarguable are the motivations of those in power when attempting to censor the medical and spiritual breakthroughs produced by fungi.” Fagerholm points to psilocybin as “a far less costly option to Prozac.”
Most research on the 270 or so mushroom varieties thought to have medicinal properties comes from Japan, China and Korea. In a Japanese study, lion’s mane “significantly improved” mild cognitive impairment and mental functioning. In mice, it has reduced symptoms of memory loss; and in laboratory studies, stimulated the production of nerve growth factor, which promotes the growth and differentiation of neurons that normally slow with age.
About the effects of various varieties of mushrooms in cancer patients, the U.S. site Cancer.gov repeats the notice, “The FDA does not approve dietary supplements as safe or effective.” For turkey tail mushrooms, the site mentions that Japanese researchers have used the active ingredient PSK “as an adjuvant therapy in thousands of cancer patients since the mid-1970s”—including those with gastric, breast, colorectal and lung cancer.
And for reishi mushrooms, research in both Japan and China suggests they bolster the immune system in patients with lung cancer. For colon cancer, these mushrooms decreased the size and numbers of tumors, and stopped benign colorectal tumors from forming.
In the report on reishi from Memorial Sloan Kettering, “laboratory studies suggest that these mushrooms may stimulate some cells of the immune system. A small clinical trial showed that reishi can enhance immune response in advanced-stage cancer patients. More studies are needed.”
In the U.S. the economics of fungi pose the biggest obstacle to explorations of their medicinal effects, mostly because such preparations are unlikely to return a profit on the costs of research and development—but also because they could cut deeply into ongoing profits from current medications, notably Prozac.
In the case of psychedelic-assisted therapy, money may also create a different problem—in the transition from research to widespread use—because of the large number of therapist hours involved, which can add up to treatment costs of $10,000 or more per patient not covered by insurance.
Early studies at Johns Hopkins on psilocybin for smoking cessation—chosen because of easily quantifiable outcomes, compared with mood problems like depression—offered participants three sessions or “trips.” In addition, each participant had several weeks of cognitive-behavioral therapy, which can help change patterns of addictive thinking. The result: 67% of subjects remained abstinent 12 months after their quit date—compared to about a 35% success rate for other smoking-cessation methods.
For the depression study, each of 24 patients had two five-hour psilocybin sessions —with a therapist sitting at their side for support and guidance—in addition to therapists’ assessments beforehand and therapy sessions afterwards.
For psychedelic therapy, too, other issues arise such as the possibility of a “bad trip”—although “safe environments and trusted companions may decrease the risk of negative experiences,” according to the extensive and continuously updated “Ultimate Psychedelic Research Review” from MAPS (Multidisciplinary Association for Psychedelic Studies).
“From ‘life-alteringly positive’ to ‘nighmarish,’ depending on the individual in question,” is the MAPS description of psychedelic trips. Those individuals who appear “more susceptible to experiencing anxiety during psilocybin dosing” are those who score high, among the “Big Five” personality traits, in neuroticism, according to the MAPS summary.
But “deeper-level changes in the Big Five personality trait of Openness…which commonly typifies people with active imaginations, creative or artistic tendencies and curious mindsets” can be the flip side of such experiences, making for an ultimately positive outcome.
Psychedelic drugs appear to enhance the ability of neurons to interact with each other—by releasing neurotransmitters like serotonin—while mood disorders appear to impair this ability. According to the MAPS summary, psychedelics could be improving “communication between the brain’s cerebral ‘thinking’ and more emotional ‘well-being’ regions.”
(To clarify, within the larger category of hallucinogens, psychedelics such as psilocybin appear to work by altering the brain’s serotonergic pathways; while “non-psychedelic” hallucinogens like ketamine and MDMA affect other parts of the brain.)
Also a major obstacle to widespread use, the classification of psychedelic mushrooms as a Schedule 1 drug—high potential for abuse or no recognized medical use—makes them illegal, while other mushrooms like lion’s mane and reishi are widely available. Although a handful of U.S. cities have decriminalized plant-based psychedelics, and D.C. voted yes on a recent ballot initiative, local status still requires approval from the DC Council and then from Congress—currently considered unlikely.
Meanwhile, most people’s psilocybin psychedelic trips take place “in the wild” (outside of therapeutic settings), although there’s always the Jamaica vacation, with “mushroom tea” for sale to the public on various beaches, as well as group experiences such as that offered by MycoMeditations.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
Editor’s Note: This post initiates a new series on films and books relevant to well-being.
SLEEPING WELL may help prevent Covid-19 infection as well as stave off its worst symptoms and outcomes—with similar advantages seen in people who take the hormone melatonin. While melatonin plays a role in many operations of the body—such as helping calibrate the immune system–current benefits may come more for its role as a sleep aid in the heightened stress and disruptions of the pandemic, as well as for those exposed to and suffering infection with Covid-19.
“It is highly probably that sleep is involved in the pathological process of Covid-19,” according to a recent report from China’s National Science Foundation.
The effects of melatonin first showed up in a review by Cleveland Clinic data analyst Feixiong Cheng: people taking the supplement had “significantly lower odds of developing Covid-19, much less dying of it,” writes James Hamblin, Atlantic columnist and lecturer at The Yale School of Public Health.
“Few other treatments [for Covid-19] are receiving so much research attention,” according to Hamblin, who cites eight ongoing trials. In a Columbia University study of intubated patients, those taking melatonin had a lower risk of dying; and melatonin was on President Trump’s medication list at Walter Reed.
But melatonin may not deserve as much credit as “the function it most famously controls: sleep,” Cheng warns. Inadequate sleep may not only worsen symptoms during active Covid-19 infection but is often a lasting problem following recovery from the infection and notable in so-called “long-haulers.”
More evidence for the sleep-infection connection comes from studies of those receiving vaccines for seasonal flu —who appear to have a stronger, more effective reactions if they have slept well in the previous several days.
What links the two may be inflammation—associated with increased risk of “everything from diabetes to heart disease to Alzheimer’s disease (AD),” according to the EarlyBird blog. Among other health benefits, sleep helps clear the brain of toxins, including the amyloid-beta proteins that are linked to Alzheimer’s disease.
The best measure of inflammation in the body is the cytokines—also called C-reactive proteins. In the Chinese research, “sleep exerted roles in modulation of…numerous cytokines, including detrimental interleukin-6 and tumor necrosis factor, both of which were closely related with cytokine storm.”
Although cytokines signal the body’s immune system to send “repairing blood” to infected cells, overactive cytokines can drown the lungs, blocking transportation of oxygen into the body. Cytokines also make blood vessels more permeable to facilitate passage of immune cells from the blood to attack the virus, but too much permeability stimulates the clotting system, which can cause stroke as well as heart or kidney failure.
Determining optimal amounts of sleep as well as dosages for sleep aids like melatonin can be tricky. Besides age, individual sleep requirements depend on genetics—which can affect needed sleep time as well as individual proclivities for waking early or staying up late: “larks” vs. “owls.”
While the average adult sleeps anywhere from seven to nine hours, the advice for assessing individual need is to go to bed without setting an alarm clock around the same time every night for a period of several days when schedules can be relaxed enough to allow for catching-up and rebalancing.
Getting too much sleep can be just as unhealthy as getting too little. Arizona State University professor Shawn Youngstedt told the Wall Street Journal: “The lowest mortality and morbidity is with seven hours [of sleep].” In the Nurses’ Health Study of more than 70,000 women—which started in 1976 and, by 2011, all participants were age 65 and older—those who slept more than nine hours a night were 38% more likely to have heart disease; while other studies have linked excessive sleep to stroke. Those who slept more than nine hours a night were 38% more likely to have heart disease; while other studies have linked excessive sleep to stroke.
“If you regularly need more than eight or nine hours of sleep per night to feel rested, it might be a sign of an underlying problem,” says Johns Hopkins sleep expert Vsevolod Polotsky. That problem could be poor-quality sleep due to sleep apnea, bruxism (teeth grinding or clenching) or other causes.
Or it could be insufficient sleep due to conditions such as “delayed sleep phase syndrome,” in which an individual’s circadian rhythm keeps them up at night. For those with DSPS—and for many other people—sleeping into the morning hours allows for the completion of final sleep cycle of the night to provide the best, deepest sleep.
For melatonin dosages, University of Texas at San Antonio Cell Biology Professor Russell Reiter, who has studied the hormone’s potential health benefits since the 1960s, takes 70 milligrams each evening, while typical recommended doses range from 1 to 10 mg.
But according to the “majority of sleep scientists,” healthy habits should be the main focus for optimal sleep, writes Hamblin. Baylor College of Medicine Psychiatry and Behavioral Sciences Professor Asim Shah believes the “key to healthy pandemic sleep is to deliberately build routines,” including spending time in sunlight early in the day, reducing blue light for an hour before bed, waking and sleeping at the same time every day and taking scheduled walks.
The amino acid tryptophan, a building block of melatonin, is present in higher quantities in some food (notably dairy products and turkey) but has the best chance of enhancing sleep when consumed in combination with complex carbohydrates. For optimal sleep, the Mediterranean diet is high in such carbohydrates as whole grains, legumes and nuts.
For those affected by the heightened stress of the pandemic, with disrupted daily and nightly schedules and changes in diet and exercise, online videos offer training in meditation and self-hypnosis, which can help slow the rapid firing of nerves and eventually train the brain to fall asleep.
None of the above, however, applies to people who seem able to sleep anywhere for endless amounts of time for whom the no-alarm-clock test merely wreaks havoc with daily schedules. And for those suffering Covid-19 symptoms, the advice for sleeping is to stay off your back—better to lie on your stomach, or at least your side —and every two hours or so, get up and walk around.
Mary Carpenter
Well-Being Editor Mary Carpenter keeps us updated on the effects of Covid-19. To read more of her posts, click here
PERVASIVE good news about the O positive blood group—along with other possible genetic markers of health and disease—usually turns out to be a mixed bag. But recent studies on Covid-19 patients that link blood types and genetic markers to the risk of serious disease are helping explain why some people get sicker than others—and may ultimately contribute to using better drugs to fight the illness.
For Covid-19, type O blood reduced susceptibility to the infection but did not correlate with lower rates of hospitalization or death following infection—in a Danish study that compared blood from over 473,000 people infected with Covid-19 to that from more than two million in the general population.
A “slightly increased infection prevalence among non-O types” was the finding in a different study at the New York Presbyterian hospital system on 14,112 individuals who tested positive for Covid-19 infection. Importantly, in that study, Rh-negative blood type had a “protective effect” for all risks — of infection, intubation and death.
(Compared to those with O type blood, risk of intubation decreased for those with A type, and increased among AB and B types in this study. And risk of death increased for type AB and decreased for types A and B. In another study, those with type A were at higher risk of severe infection.)
Blood type is vital information for people needing transfusions; the wrong type is likely to trigger rejection, followed by severe reaction and even death. Each person’s blood type depends on the kinds of antigens or protein molecules on the surface of red blood cells—with four types in the “ABO system,” A, B, AB and O—which are involved in detecting unwanted or foreign cells.
The other system, referred to as Rh, indicates the presence or absence of a different molecule on the red blood cells called the Rhesus factor, which makes an individual’s blood type either positive or negative. The most prevalent blood type is O positive —found in 37% of the population, followed by A positive in 34%, down to the least common type, AB negative.
With the first SARS coronavirus, decreased susceptibility to infection may have occurred in patients with types O and B blood—with the possible explanation that anti-A antibodies blocked interaction between the virus and receptors in the cell, thus preventing transmission.
Among blood-type risk factors linked to Covid-19, venous thromboembolism (obstruction of a blood vessel by a clot) is more common among those with non-O blood types, as is coagulopathy (impaired ability of the blood to clot). But the latter may also be a downside following severe trauma: in a recent Japanese study, those with type O blood appeared to be at higher risk for death, perhaps due to reduced levels of blood clotting factors.
Those with non-O type blood are at higher risk for high blood pressure, high cholesterol and stroke due to disrupted blood flow to the brain. Coronary artery disease also occurs more often in these groups who have the ABO gene (sometimes confusingly referred to as ABO type blood) responsible for blood types A, B or AB. “If you have the ABO gene and you live in an area of high pollution, you may be at greater risk of heart attack,” explained New Jersey oncologist Douglas Guggenheim.
Those with the ABO gene are also more likely to develop Type 2 diabetes, compared to those with type O blood. An 18-year study of more than 82,000 female French teachers found 3,553 women diagnosed with Type 2 diabetes. Compared to those with blood type O, those with type A were 10% more likely to develop the disease and those with type B, 21% more likely.
Among other diseases, malaria infections are less likely to cause symptoms in people with type O blood. But those with type O tend to have higher levels of stomach acid and may be more prone to infections with the bacterium that causes stomach ulcers, Helicobacter pylori.
(The latter was one explanation in once-popular theories about a “blood-type diet” for why those with type O blood do better eating high levels of animal proteins. But skeptics have pointed to the lack of supporting research for these diets and trace any benefits to the universal recommendation to avoid processed food—making all of the diets based on blood type healthier than what most people eat.)
For Covid-19, additional genetic links include several sites on chromosome 3 associated with respiratory failure in critically ill patients. Recent studies also found genetic variants located close to genes involved in the interferon immune response, suspected to play a role in life-threatening Covid-19 infections.
But only a “chunk of the answer is in our genes,” said University of Edinburgh Covid-19 researcher Sara Clohisey. The likely combination of factors involved includes age, obesity and gender—though in men, who are more likely to die of Covid-19 than women, genetic variants related to sex have not yet shown up in these studies.
A recent example of the limited role of genetic inheritance in Covid-19 infections was a pair of identical twins, who contracted the infection from the same individual at the same time, exhibited the same symptoms and had similar vital signs and lab test results. But soon after admission to the same hospital, one twin went home while the other ended up in the ICU, needed a respirator, developed septic shock and took another month to recover.
Rather than genetic inheritance, the best explanation for different responses in monozygotic twins (who develop from one fertilized egg divided in two) is gene expression—epigenetic differences. In another case of twins, one developed a malignancy and the other did not, despite carrying a gene that put them both at risk.
(Epigenetics may also be the explanation for physiological differences observed in astronaut Scott Kelly—compared with his identical twin brother Arizona Senator Mark Kelly—after spending time on the International Space Station. As for whether blood type itself can change, the only possible explanation is a bone marrow transplant.)
And those with AB+—also rare, making up less than 4% of the population—are universal recipients, able to receive blood of every type. People with any Rh-negative blood type can donate to someone who is Rh-negative or positive; but a person who is Rh-positive can donate only to someone who also has Rh-positive blood.
—Mary Carpenter
Well-Being Editor Mary Carpenter keeps us updated on Covid-19. To read more of her posts, click here.
WORKUPS over the years for problems with fatigue led doctors treating Polly R., a now-retired political aide, to focus on an underactive thyroid, or hypothyroidism. On their advice, Polly took the supplemental thyroid hormone levothyroxine (first the brand Synthroid, then Tirosint), ate carefully, exercised diligently and, most challenging, gave up coffee.
But switching doctors at age 71, Polly got a pleasant surprise: the new recommendation that, as she put it, “at this point in my life one cup of coffee would do little harm and much good.” Her new doc also explained that, with age, most people need lower levels of thyroid medication—and “normal” measurements may no longer apply.
Another difference in impaired thyroid activity in those 65 and older can be a single symptom—such as memory loss or decreased cognitive function—compared to the long list of possible symptoms in younger adults.
Because thyroid hormones affect so many functions of metabolism, insufficient levels often cause fatigue and insomnia, as well as dry skin, hair loss, constipation and joint pain. Depression can be a symptom of hypothyroidism—or both can be the result of excessive stress.
Depression, sleep problems and stress are all on the rise during the coronavirus pandemic. Disrupted daily routines, Stanford University sleep specialist Donn Posner told in the Harvard’s T.H. Chan School of Public Health “Coronavirus Update” series, help create a “perfect storm of sleep problems.”
The primary measure of thyroid health is the level of thyroid-stimulating hormone (TSH), which is created by the pituitary gland and in turn prods the thyroid gland to produce the hormones T3 and T4. When these hormones are low, the cause is most often autoimmunity—when the body’s immune system in overdrive damages the thyroid gland. Of more than 90% of low-thyroid cases traced to Hashimoto’s thyroiditis, the risk increases for women, for those over 60 and for those with a family history.
In addition, prominent among environmental triggers for thyroid disorders is chronic stress—when increased levels of stress hormones, such as cortisol, cause lower blood levels of thyroid hormones and slow the metabolism—one reason underactive thyroid can lead to insulin resistance and weight gain.
Because many people with low-thyroid symptoms have TSH levels measuring in the normal range—and are thus not candidates for supplemental thyroid—some specialists prefer to use a narrower “optimal” TSH range —between 1.0 and 2.5 mIU/L (milli-international units per liter) of blood, versus the traditional wider normal of 0.5 to 4.5.
Such optimal levels may also be a better goal for combating hypothyroid issues, such as weight gain and hair loss. While hair loss can occur with both under- and over-active thyroid (hyperthyroidism), the blame most often falls on low-circulating TSH levels or insufficient dosage of supplemental thyroid hormones.
Practitioners of “functional medicine” often rely on the optimal thyroid levels, along with other measures of poorly performing thyroid hormones. Rather than prescribing supplemental thyroid, however, they focus instead on stress as both the cause of low hormone levels and as the best target to “modulate the expression of autoimmunity,” according to functional medicine thyroid expert Datis Kharrazian, author of Why Do I Still Have Thyroid Symptoms? When My Lab Tests are Normal.
Also challenging to treat is “mild hypothyroidism,” more prevalent in adults 65 and over, which causes no symptoms, and circulating thyroid hormones are normal—but elevated TSH levels indicate the thyroid gland may be working too hard, according to Harvard Health.
A possible explanation for the condition is that “normal” changes with age—with some research showing increased TSH levels in those 70 and older may have no negative health effects. A European study of more than 700 adults, average age 75, with mild hypothyroidism, found that treatment with thyroid medication failed to improve either symptoms or quality of life.
Overtreatment with synthetic thyroid hormones can cause jittery feelings and insomnia, as well as long-term loss of bone density. On the other hand, physicians worry about the risks of elevated cholesterol levels and damage to coronary artery health with untreated subclinical hypothyroidism.
For Polly, avoiding morning coffee had the goal of assessing her fatigue, before and with thyroid supplements, without the artificial boost. But after a few months on the new regimen, she reported, “It is such a pleasure to get that boost, now rediscovered, I will do almost anything to keep coffee in my life.”
Mary Carpenter regularly reports on topical issues in health and medicine.
“WHEN I’M vaccinated and everyone around me is”—was the response to the question “When would you personally feel comfortable returning to the office?” from New York Times coronavirus reporter Donald G. McNeil Jr. in a daily New York Times email.
At this point, most predictions place widespread availability of the coronavirus vaccine around May or June—depending on the smooth rollout of approval, production and distribution.
On the other hand, “social gatherings will again be common and largely safe by the summer,” Johns Hopkins epidemiologist Caitlin Rivers predicted in another New York Times email. After the first batch of vaccines has gone to high-risk healthcare workers and others, according to a rollout timeline created by a panel of scientific advisors to the CDC, February and March are the target dates for “people over the age of 65 (and especially those over 75),” along with several other groups.
The order of distribution is up to individual states—with healthcare workers at the top of most lists, although definitions of these includes anything from ICU and emergency health services workers to those employed in long-term care facilities. Also near the top in most locales are the three million or so residents of these facilities, which have accounted for almost 40% of deaths caused by the coronavirus to date.
Other high-priority groups with varying definitions are “essential workers” and/or those whose jobs cannot be done from home—usually emergency transportation workers and often those in the food industry. In Colorado, these include “ski industry” workers who live in congregate housing.
Local rankings are important because the distribution of doses will occur in waves of limited allotments. In DC, the currently assigned initial batch of 6,800 doses (with each vaccine requiring require two doses) will cover 3,400 people—about 10% of the District’s healthcare workers. With these workers numbering close to 85,000—of whom about 75% reside in Maryland or Virginia—District health officials are requesting more doses.
“Vaccines don’t save lives,” Yale public health professor David Paltiel told the New York Times. “Vaccine programs save lives.” Worrying that the U.S. has not built adequate infrastructure to distribute the vaccines, Paltiel described models assessing the effects of vaccination on infections, hospitalizations and deaths, which concluded that deployment mattered as much as the vaccines’ efficacy.
The first two vaccines from Pfizer and Moderna are products of new mRNA (messenger RNA) technology that has never before produced a marketable vaccine. With the intention of offering a range of vaccine types, others should win approval soon.
The more conventional vaccine from AstraZeneca and Oxford University, created by modifying an adenovirus to contain the disease-causing gene from the SARs-CoV-2 virus, is less expensive and does not require the extreme frozen storage conditions as the other two. But testing of this ADZ vaccine produced a puzzling result: while half of the study participants received two full doses, the other group received a reduced initial dose due to a lab error— a protocol that unexpectedly resulted in greater efficacy.
Because the research to date is limited to comparing each vaccine against a placebo, it remains unclear whether one company’s vaccine might work better for different groups. In the case of flu, for example, specific vaccines recommended for ages 65 and older are either high-dose or bolstered by an adjuvant.
Also unknown about these vaccines is whether, while creating immunity in a vaccinated individual, they will also prevent that individual from spreading the virus. The trials assessed the severity of disease in vaccinated versus placebo groups, but did not account for asymptomatic cases, which are considered major spreaders of this virus.
All three front-runner vaccines have shown impressive rates of efficacy. However, that refers to results obtained under conditions of clinical trials, with certain people more likely to sign up than others. Effectiveness, by contrast, indicates how well vaccines work in the real world; and impact, how well they slow the spread of a virus and protect society as a whole —both of which can emerge only after the vaccination of much larger numbers of people.
When asked how to respond to people desperate to see friends and families over the holidays, McNeil suggests a comparison to American soldiers and Red Cross workers in Europe during World War II, who “missed the holidays. Life went on. There were happier years later.”
McNeil, along with other journalists covering the pandemic, also contributed to a three-step guide for reducing risk: Eliminate time spent in a confined space outside your household where anyone is unmasked; minimize time spent in indoor spaces even with universal masking; and relax during activities that are less risky, including errands (wearing a mask, staying distant from others) and outdoor exercise. For the latter, says McNeil, “I consider keeping six feet distant outdoors more important than wearing a mask.”
To give individuals an idea of their place in line for the vaccine, The New York Times created a quiz. With my answers—age (70), county (DC) and other factors (not an essential worker; no Covid-related health risks)—my place in the DC lineup will follow 237,200 others (in a total population of 705,000). To make sure I understand the magnitude of these numbers, an accompanying drawing shows one person for each of the categories ahead of and behind me—in what looks like a very long, winding line.
—Mary Carpenter
Well-Being Editor Mary Carpenter keeps us updated on Covid-19. To read more of her posts, click here
NOT MUCH news has emerged about CBD from the research community to better document its effects since a recent MyLittleBird Well-Being post in Spring, 2019. But with 64 million Americans trying the purportedly non-psychoactive cannabinoid in a recent 24-month period — of whom 22% said it helped them—clarifications may be in order.
Above all, any CBD product purchased outside a medical marijuana pharmacy should contain less than .3% THC — the cannabis ingredient responsible for the “high” and other psychotropic effects. But because they are “supplements,” CBD products are unregulated and unreliable.
In a Penn Medicine survey that found 70% of products mislabeled, some contained no CBD at all while others contained THC above the legal limit. In another survey of CBD products purchased in the Miami area, one-third contained no CBD.
Among CBD products, the topicals—creams, lotions and ointments—rarely have side effects, while oral/ingestible formulations cause adverse health issues in about one-third of users. The most popular CBD products are ingestible “sublingual” tinctures—drops placed under the tongue—which enter the bloodstream, can stimulate the immune system and can produce brain-based results, such as reducing anxiety and insomnia.
On the other hand, even topical CBD can cause systemic effects. Producing topical formulations that penetrate the skin deeply enough to produce some benefit yet not so deep as to reach the bloodstream is tricky, University of Michigan chronic pain researcher Kevin Boehnke told SELF magazine. Whatever depth is reached by a product, questions remain about how much CBD gets there and how much is needed for an effect.
Sleepiness, sedation and lethargy are common side effects of oral CBD products, according to Miami internist Michael Hall. Other serious side effects include elevated liver enzymes, diarrhea, insomnia and possible interaction with prescription medicines. Among side effects considered “non-serious” are dry mouth, nausea, irritability, euphoria, hunger, irritated eyes and fatigue.
Current FDA warnings focus on unsubstantiated health benefits of ingestible CBD: “It is currently illegal to market CBD by adding it to a food or labeling it as a dietary supplement; the FDA has seen only limited data about CBD safety and these data point to real risks that need to be considered before taking CBD for any reason; and some CBD products are being marketed with unproven medical claims and are of unknown quality.
Endocannabinoid receptors in the body, which interact with cannabinoids (CB) that are produced internally, congregate on the skin and throughout the body in different concentrations for each individual. In addition, the amount of cannabinoids produced naturally by each person varies widely. As a result, huge differences in clinical effects of CBD among individuals make it extremely difficult to do well-controlled studies.
In addition, many of CBD’s effects may occur via receptors other than those for cannabinoids, for example, serotonin receptors and those affected by caffeine or associated with taste. “It’s a very promiscuous compound,” said Boehnke, who also believes that credit for at least some of CBD’s pain-reducing effects may belong to additional ingredients in the formulations, such as arnica.
One of the few studies on humans was actually a Phase 2 clinical trial on a CBD transdermal gel—applied to the skin and designed to penetrate into the bloodstream—on 320 patients with knee osteoarthritis. After 12 weeks, the reports of pain from participants using the CBD products didn’t differ significantly from those who got the placebo—although those receiving the gel reported “some reductions in pain and improvements in physical function,” said Boehnke.
The most common uses of CBD are for pain relief (64%), anxiety (49%) and insomnia (42%). In one study, the 15 men who took 300 mg of CBD before a stressful public speaking event became calmer, compared to those who received either a higher or lower dose —while commercially available CBD doses hover around 10-20 mg.
To counter both pain and inflammation, topical CBD products can work directly on specific areas of the body, says Baylor immunologist Matthew Halpert. In a study of 3,000 people at the University of New Mexico, cannabis products with higher THC levels were associated with greater symptom relief, while CBD products with no THC were not.
In animal models, CBD applied on the skin reduced measurable pain and inflammation caused by osteoarthritis. Other studies showed CBD inhibiting inflammatory and neuropathic pain—two of the most challenging types of chronic pain to treat, but which also come and go unpredictably and are thus hard to study.
CBD topicals have also shown good results with skin disorders, including psoriasis, atopic dermatitis and scars, with 20 patients in one small study reporting improved signs and symptoms. Some dermatologists say the most promising role for cannabinoids is in the treatment of itch.
Among CBD products, those labeled “isolate” contain only CBD and require higher doses to create a beneficial effect —compared to “full-spectrum” products that contain a wide range of different cannabinoids, including THC at levels below .3%. (“Broad-spectrum” products contain all active compounds in cannabis except for THC.)
Topicals that are highly rated for pain relief include Lazarus Naturals CBD Massage oil; Moon Mother Massage oil; and Papa and Barkley Releaf Body Oil. Customers report the best effects from topical CBD products when applied every four to six hours.
Among THC-free transdermal patches—with the advantage of dispensing CBD over long periods—the best rated are Green Garden Gold CBD Patch, which lasts for 48 hours; and CBD Living “Reservoir” Patch, for 96 hours.
While older people may experience more pain from arthritis and other causes of inflammation, the ages most likely to use CBD consistently are 18 to 29, at 20% (with 16% for 30-49; 11% for 50-64; and 8% of those age 65 and older). The states with the highest CBD sales in 2019 were California, Florida and New York.
In the burgeoning market of CBD products, nearly half of consumers prefer oils/tinctures, lotions/balms and gummies, while those interested in CBD-infused food such as chocolate is growing, now at 17%. One product, Vital Leaf’s Body CBD Balm, combines the two: a topical ointment that exudes odors of chocolate.
First-time CBD experimenters should be cautious because it acts so differently on each individual depending on so many variables—different individual responses, different formulations different doses. Maybe most important is the variable of timing—especially with edibles, though even topical products might enter the bloodstream. Because cannabis products can take up to several hours to produce an effect, start with a low dose. Then wait before increasing.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
WORRIED WAITING has moved up on everyone’s list of serious stressors. The wait for upcoming election results has become a wait for the January 20 inauguration. The wait for vaccine development has become one for approval and availability—with the latter projected for anywhere from six weeks to ten months from now.
And for anyone with symptoms or who has been in contact with possible cases, there’s the wait to get a test, an increasingly long wait for results and the wait of 14 days in total quarantine.
Meanwhile, last week’s head-snapping coronavirus news veered between terrific—vaccine makers publicizing hopeful study results—and terrible: the nation’s hospitals overrun; Covid cases up more than 70%; and deaths up more than 50%, with someone dying every hour, at least.
For anyone unpersuaded by Covid’s myriad threats of infection, chronic illness or death, the stress of worried waiting caused by random encounters that risk contagion should convince them and everyone else to maintain the strictest precautions possible—not only wearing masks but hand-washing and social-distancing as well.
(In a recent Danish study, even those wearing masks got sick. Although the study failed to account for many variables, such as what kind of mask and how well participants wore them, the few infections among mask wearers indicated the crucial need to employ every protective measure available.)
On skyrocketing stress, the 2020 rates are impressive. A CDC report in August found anxiety symptoms had tripled and depression quadrupled among more than 5,000 adults compared with a 2019 sample. In addition, two surveys by researchers at Boston University and Johns Hopkins conducted in April found anxiety symptoms had tripled from 2018 measurements.
Even compared to “other large-scale traumas like September 11, Hurricane Katrina and the Hong Kong unrest,” the rates found this past April were higher, Boston University Public Health researcher Catherine Ettman told Scientific American’s Claudia Wallis.
Increased engagement with media coverage—especially exposure to conflicting information—was a major cause of anxiety, according to UC Irvine psychologist Roxane Cohen Silver, who studied the aftermath of the 2013 Boston Marathon bombing as well as of 9/11. Said Silver, “If people are engaged with a great deal of media, they are more likely to exhibit and report distress, but that distress seems to draw them further into the media.”
Maintaining social contacts, a common recommendation for minimizing stress during times of trauma, has been difficult during the pandemic. Said University of Texas at Austin psychologist James Pennebaker, “Unlike any other disaster that I’ve studied, people are actively less close to friends and community.”
Among quick-break strategies to counter stress, “self-interruption” can take just a few minutes—of jumping jacks, wall push-ups, dancing—anything that involves changing position and moving. “Any time you move your muscles and get your heart rate up, you’ll get a boost in dopamine and sense yourself as alive and engaged,” Stanford University health psychologist Kelly McGonigal told the New York Times.
McGonigal also suggested finding ways to “imagine a positive future,” which can include getting rid of clutter, making a scrapbook, hanging artwork and choosing a new comforter. In fact shopping for anything (these days online) can offer not just a break from stress but a symbol of hope and planning for the future—even when no purchase is made.
For longer breaks, lavender baths can lower levels of the stress hormone cortisol. “Even antidepressants work better when combined with lavender,” writes Tara Parker-Pope, noting research that suggests “lavender reaches odor-sensitive neurons in the nose that send signals to the parts of the brain related to wakefulness and awareness.”
Activating the senses can change the biological and chemical response, which reduces intense emotions, in the experience of New York City psychotherapist Alyssa Mairanz who recommends baths that are “very hot.” Among sensory stimuli, she suggests splashing cold water on your face, eating something very salty or sour, or clenching various parts of your body, like your fist, for a few seconds and then release.
Self-compassion can also help. Place your hand over your heart or stomach, or cup your face; acknowledge the stressful situation by saying “this is a moment of suffering;” say something soothing like, “may I be peaceful” are suggestions from “self-compassion” researcher and University of Texas, Austin psychologist Kristin Neff.
Finally, “one good way to deal with anxiety-ridden waiting” is the awe experience, according to research from the UC Riverside “Life Events” lab. In studies on 729 undergraduates, psychologist Katharine Sweeny said: “All it took was a high-definition sunset set to an instrumental score.” Compared to meditation, which helped law students manage anxiety in an earlier study by Sweeny, she said, “awe helps cloak it.”
But stress reducers can be very personal: while lavender soothes some, others can’t bear the smell; and the knitting that helps some makes others grind their teeth. While some relax by playing competitive Text-Twist, others prefer walking in the park with a friend. And some people do better on a strict routine interspersed with treats, while others can both relax and get more accomplished by doing various tasks only when they feel up to them.
My own fallback de-stressors failed to provide relief when someone with whom I’d had brief, masked contact developed short-lived, mild symptoms, and my doctor’s office said I must quarantine and get tested—and scheduling the test took days.
What worked well for relaxing then was a Zoom class in Feldenkrais—movement therapy that requires focusing on different body parts: if your attention wavers, you get behind, finding yourself on your back while everyone else has turned over. That motivated me to keep my mind from wandering back to worries—better than my usual MBSR attention on following the breath in and out—for which I had now become too easily distracted.
In search of awe, I took an unusual midday break outdoors in the sunshine; and, for later, moved a film about Antarctica to the top of my Netflix list. For distraction, Casey Cep’s book Furious Hours created a true-crime anthropological foray into 1970s Alabama, a world that now seemed more aberrant than 2020.
For self-interrupters, salty pretzels worked well, along with sugary afternoon quarant-tea—while others do better with the cocktail-hour quaran-tini. But for frequent breaks, the best for me is cold water on the face, the icier the better.
—Mary Carpenter
Well-Being Editor Mary Carpenter keeps us updated on Covid-19. To read more of her posts, click here.
