Midtermumbrella

In today’s fast-paced world, our waking hours are filled with decisions — often surrounding what to eat. After a long day, dinner could well be fast food or takeout. While you may worry about the toll food choices take on your waistline or blood pressure, as a liver specialist, I also want to put fatty liver disease on your radar.

One variant, officially called nonalcoholic fatty liver disease (NAFLD), now affects one in four adults globally. Sometimes it progresses to extensive scarring known as cirrhosis, liver failure, and higher risk for liver cancer. The good news? Fatty liver disease can be prevented or reversed.

What is fatty liver disease?

Fatty liver disease is a condition caused by irritation to the liver. Liver tissue accumulates abnormal amounts of fat in response to that injury. Viral hepatitis, certain medicines (like tamoxifen or steroids, for example), or ingesting too much alcohol can all cause fatty liver disease.

However, NAFLD has a different trigger for fat deposits in the liver: a group of metabolic risk factors. NAFLD is most common in people who have high blood pressure, high cholesterol, insulin resistance (prediabetes), or type 2 diabetes. It is also common among people who are overweight or obese, though it is possible to develop NAFLD even if your body mass index (BMI) is normal.

What helps prevent or reverse NAFLD?

Diet can play a huge role. Because NAFLD is so closely tied to metabolic health, eating more healthfully can help prevent or possibly even reverse it. A good example of a healthful eating pattern is the Mediterranean diet.

Overweight or obesity is a common cause of NAFLD. A weight loss program that includes activity and healthy eating can help control blood pressure, cholesterol, and blood sugar. Among the many healthful diet plans that help are the DASH diet and the Mediterranean diet. Talk to your doctor or a nutritionist if you need help choosing a plan.

To vigorously study any diet as a treatment for fatty liver disease, researchers must control many factors. Currently, no strong evidence supports one particular diet over another. However, the research below highlights choices to promote a healthy liver.

Avoid fast food

A recent study in Clinical Gastroenterology and Hepatology linked regular fast-food consumption (20% or more of total daily calories) with fatty liver disease — especially in people who had type 2 diabetes or obesity. Fast foods tend to be high in saturated fats, added sugar, and other ingredients that affect metabolic health.

Steer clear of soft drinks and added sugars

Soft drinks with high-fructose corn syrup, or other sugar-sweetened beverages, lead directly to large increases in liver fat deposits, independent of the total calories consumed. Read labels closely for added sugars, including corn syrup, dextrose, honey, and agave.

Instead of sugary drinks, sip plain water. Black coffee or with a splash of cream is also a good pick; research suggests coffee has the potential to decrease liver scarring.

Avoid alcohol

Alcohol directly damages the liver, lacks nutritional value, and may affect a healthy microbiome. If you have NAFLD, it’s best to avoid any extra cause for liver injury. We simply do not know what amount of alcohol is safe for those with fatty liver disease — even social drinking may be too much.

Eat mostly whole foods

Vegetables, berries, eggs, poultry, grass-fed meats, nuts, and whole grains all qualify, but cutting out red meat may be wise. An 18-month trial enrolled 294 people with abdominal obesity and lipid imbalances such as high triglycerides. Regular activity was encouraged, and participants were randomly assigned to one of three diets: standard healthy dietary guidelines, a traditional Mediterranean diet, or a green-Mediterranean diet. (The green-Med diet nixed red and processed meats and added green tea and a dinner replacement shake rich in antioxidants called polyphenols.)

All three groups lost some weight, although the Mediterranean diet groups lost more weight and kept it off for a longer period. Both Mediterranean diet groups also showed reduced liver fat at the end of 18 months, but liver fat decreased twice as much in the green-Med group as in the traditional Mediterranean diet group.

Healthy fats are part of a healthy diet

We all need fat. Dietary fats help your body absorb vitamins and are vital in the protection of nerves and cells. Fats also help you feel satisfied and full, so you’re less likely to overeat. Low-fat foods often substitute sugars and starches, which affect blood sugar regulation in our bodies. But all fat is not created equal.

It’s clear that Mediterranean-style diets can help decrease liver fat, thus helping to prevent or possibly reverse NAFLD. These diets are high in healthful fats, such as monounsaturated fats found in olive oil and avocados and omega-3 fats found in walnuts and oily fish like salmon and sardines.

With so many choices, it’s hard to know where to start in the healthy eating journey. Let’s strive to eat whole foods in their natural state. Our livers will thank us for it.

About the Author

Kathleen Viveiros, MD, Contributor

Dr. Kathleen Viveiros is a clinical hepatologist at Brigham and Women’s Hospital who sees patients in Boston and in Foxborough and Westwood, MA. She is an instructor in medicine at Harvard Medical School. Her professional interests … See Full Bio View all posts by Kathleen Viveiros, MD

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

What is collagen?

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

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

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

What does the science say about collagen drinks and supplements?

Research on skin includes:

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

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

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

Should you try collagen supplements or drinks?

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

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

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

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

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

The bottom line

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

It will also help to:

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

Follow Payal Patel on Twitter @PayalPatelMD

Follow Maryanne Makredes Senna on Twitter @HairWithDrMare

About the Authors

Payal Patel, MD, Contributor

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

Maryanne Makredes Senna, MD, Contributor

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

Be honest: just how much television are you watching? One study has estimated that half of American adults spend two to three hours each day watching television, with some watching as much as eight hours per day.

Is time spent on TV a good thing or a bad thing? Let's look at some of the data in relation to your risks for cognitive decline and dementia.

Physical activity does more to sharpen the mind than sitting

First, the more time you sit and watch television, the less time you have available for physical activity. Getting sufficient physical activity decreases your risk of cognitive impairment and dementia. Not surprisingly, if you spend a lot of time sitting and doing other sedentary behaviors, your risk of cognitive impairment and dementia will be higher than someone who spends less time sitting.

Is television actually bad for your brain?

Okay, so it's better to exercise than to sit in front of the television. You knew that already, right?

But if you're getting regular exercise, is watching television still bad for you? The first study suggesting that, yes, television is still bad for your brain was published in 2005. After controlling for year of birth, gender, income, and education, the researchers found that each additional hour of television viewing in middle age increased risk for developing Alzheimer's disease 1.3 times. Moreover, participating in intellectually stimulating activities and social activities reduced the risk of developing Alzheimer's.

Although this study had fewer than 500 participants, its findings had never been refuted. But would these results hold up when a larger sample was examined?

Television viewing and cognitive decline

In 2018, the UK Biobank study began to follow approximately 500,000 individuals in the United Kingdom who were 37 to 73 years old when first recruited between 2006 and 2010. The demographic information reported was somewhat sparse: 88% of the sample was described as white and 11% as other; 54% were women.

The researchers examined baseline participant performance on several different cognitive tests, including those measuring

• prospective memory (remembering to do an errand on your way home)
• visual-spatial memory (remembering a route that you took)
• fluid intelligence (important for problem solving)
• short-term numeric memory (keeping track of numbers in your head).

Five years later, many participants repeated certain tests. Depending on the test, the number of participants evaluated ranged from 12,091 to 114,373. The results of this study were clear. First, at baseline, more television viewing time was linked with worse cognitive function across all cognitive tests.

More importantly, television viewing time was also linked with a decline in cognitive function five years later for all cognitive tests. Although this type of study cannot prove that television viewing caused the cognitive decline, it suggests that it does.

Further, the type of sedentary activity chosen mattered. Both driving and television were linked to worse cognitive function. But computer use was actually associated with better cognitive function at baseline, and a lower likelihood of cognitive decline over the five-year study.

Television viewing and dementia

In 2022, researchers analyzed this same UK Biobank sample with another question in mind: Would time spent watching television versus using a computer result in different risks of developing dementia over time?

Their analyses included 146,651 people from the UK Biobank, ages 60 and older. At the start of the study, none had been diagnosed with dementia.

Over 12 years, on average, 3,507 participants (2.4%) were diagnosed with dementia. Importantly, after controlling for participant physical activity:

• time spent watching television increased the risk of dementia
• time spent using the computer decreased the risk of dementia.

These changes in risk were not small. Those who watched the most television daily — more than four hours — were 24% more likely to develop dementia. Those who used computers interactively (not passively streaming) more than one hour daily as a leisure activity were 15% less likely to develop dementia.

Studies like these can only note links between behaviors and outcomes. It's always possible that the causation works the other way around. In other words, it's possible that people who were beginning to develop dementia started to watch television more and use the computer less. The only way to know for sure would be to randomly assign people to watch specific numbers of hours of television each day while keeping the amount of exercise everyone did the same. That study is unlikely to happen.

The bottom line

If you watch more than one hour of TV daily, my recommendation is to turn it off and do activities that we know are good for your brain. Try physical exercise, using the computer, doing crossword puzzles, dancing and listening to music, and participating in social and other cognitively stimulating activities.

About the Author

Andrew E. Budson, MD, Contributor; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Andrew E. Budson is chief of cognitive & behavioral neurology at the Veterans Affairs Boston Healthcare System, lecturer in neurology at Harvard Medical School, and chair of the Science of Learning Innovation Group at the … See Full Bio View all posts by Andrew E. Budson, MD

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

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

Why eat small fish?

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

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

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

Small fish in the Mediterranean diet

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

Sardines packed in water or olive oil can be

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

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

Bivalve benefits

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

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

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

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

Aquatic plant foods

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

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

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

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

About the Reviewer

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

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

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

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

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

Survey reports on who uses cannabis, why, and how

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

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

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

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

How might cannabis help menopause symptoms?

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

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

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

No research yet on long-term effects

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

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

About the Author

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

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

Should a woman consider having her fallopian tubes removed to lower her risk for developing ovarian cancer? Recent recommendations from the Ovarian Cancer Research Alliance (OCRA), endorsed by the Society for Gynecologic Oncology, encourage this strategy, if women are finished having children and would be undergoing gynecologic surgery anyway for other reasons.

Why is this new guidance being offered?

Ovarian cancer claims about 13,000 lives each year, according to the American Cancer Society. The new guidance builds on established advice for women with high-risk genetic mutations or a strong family history of ovarian cancer.

This idea isn’t new for women at average risk for ovarian cancer, either: in 2019, the American College of Obstetricians and Gynecologists (ACOG) floated this strategy in a committee opinion.

A Harvard expert agrees the approach is sound, considering established evidence that many cases of aggressive ovarian cancers arise from cells in the fallopian tubes.

“We’ve known for a long time that many hereditary cases of ovarian cancer likely originate in lesions in the fallopian tubes,” says Dr. Katharine Esselen, a gynecologic oncologist at Beth Israel Deaconess Medical Center. “Although we group all of these cancers together and call them ovarian cancer, a lot actually start in the fallopian tubes.”

Can ovarian cancer be detected early through symptoms or screening?

No — which helps fuel these recommendations.

Ovarian cancer is notoriously difficult to detect. Symptoms tend to be vague and could be related to many other health problems. Signs include bloating, pelvic pain or discomfort, changes in bowel or bladder habits, feeling full earlier when eating, fatigue, unusual discharge or bleeding, and pain during sex.

Disappointing results from a large 2021 study in the United Kingdom reported in The Lancet show that lowering the risks of a late-stage diagnosis isn’t easy. The trial tracked more than 200,000 women for an average of 16 years. It found that screening average-risk women with ultrasound and a CA-125 blood test doesn’t reduce deaths from the disease. By itself, the CA-125 blood test isn’t considered reliable for screening because it’s not accurate or sensitive enough to detect ovarian cancer.

Only 10% to 20% of patients are diagnosed at early stages of ovarian cancer, before a tumor spreads, Dr. Esselen notes. “There’s never been a combination of screenings that has reliably identified the majority of these cancers early, when they’re more treatable,” she says.

What does it mean to be at higher risk for ovarian cancer?

Family history is the top risk factor for the disease, which is diagnosed in nearly 20,000 American women annually. A woman is considered at higher risk of ovarian cancer if her mother, sister, grandmother, aunt, or daughter has had the disease.

Additionally, inherited mutations in the BRCA1 or BRCA2 gene raise risk considerably, according to the National Cancer Institute. (These mutations are more common among certain groups, including people of Ashkenazi Jewish heritage.) While about 1.2% of women overall will develop ovarian cancer in their lifetime, up to 17% of those with a BRCA2 mutation and up to 44% with a BRCA1 mutation will do so by ages 70 to 80.

How much can surgery lower the odds of ovarian cancer?

It’s not clear that all women — even those not scheduled for surgery — should undergo removal of their fallopian tubes to reduce this risk once they finish having children, Dr. Esselen says. This surgery can’t totally eliminate the possibility of ovarian cancer — and surgery carries its own risks. She recommends discussing options with your doctor depending on your level of risk for this disease:

For those at average risk for ovarian cancer: Available data seem to support the idea of removing the fallopian tubes. Studies of women who underwent tubal ligation (“tying the tubes”) or removal to avoid future pregnancies indicate their future risks of ovarian cancer dropped by 25% to 65% compared to their peers. And if a woman is already undergoing gynecologic surgery, such as a hysterectomy, the potential benefits likely outweigh the risks.

Before menopause, removing the fallopian tubes while leaving the ovaries in place is preferable to removing both. That’s because estrogen produced by the ovaries can help protect against health problems such as cardiovascular disease and osteoporosis. Leaving the ovaries also prevents suddenly experiencing symptoms of menopause.

“The fallopian tubes don’t produce any hormones and aren’t really needed for anything other than transporting the egg,” she says. “So there’s little downside to removing them at the time of another gynecologic procedure if a woman is no longer interested in fertility.”

For those at high risk for ovarian cancer: “In a world where we don’t have good screening tools for ovarian cancer, it makes sense to do something as dramatic as surgery to remove both ovaries and fallopian tubes when a woman is known to be at higher risk because of a strong family history or a BRCA gene mutations,” Dr. Esselen says.

Currently, preliminary evidence suggests it may be safe to proactively remove the fallopian tubes while delaying removal of the ovaries to closer to the time of menopause to avoid an early menopause. However, it’s unclear how much this procedure lowers the odds of developing ovarian cancer.

“Generally, the findings so far have focused on the safety of the surgery itself and women’s quality of life,” Dr. Esselen says. “Long-term data in high-risk women takes a great number of years to accumulate. We need this data to know whether removing the fallopian tubes alone is equally effective in preventing ovarian cancer as removing the tubes and ovaries.”

Discussing your options is key

Ultimately, Dr. Esselen says that she advocates OCRA’s new recommendations. “For anyone who’s completed childbearing, if I’m doing surgery that wouldn’t necessarily include routinely removing their fallopian tubes, I’m offering it,” she says. “A woman and her doctor should always discuss this at the time she’s having gynecologic surgery.”

About the Author

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

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

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

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

What is miscarriage?

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

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

What causes miscarriage?

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

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

How is miscarriage diagnosed?

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

How is miscarriage treated?

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

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

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

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

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

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

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

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

Red flags: When to ask for help during a miscarriage

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

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

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

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

How is care for miscarriages changing?

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

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

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

About the Authors

Sara Neill, MD, MPH, Contributor

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

Scott Shainker, DO, MS, Contributor

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

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

The basics: A weekly shop

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

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

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

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

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

Do you need to choose organic foods?

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

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

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

Buying cost-conscious fresh food and staples

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

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

Easy healthy snacks to reach for

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

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

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

Crowdsource shopping tips and savings

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

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

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

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

About the Author

Heidi Godman, Executive Editor, Harvard Health Letter

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

About the Reviewer

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

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

Low energy, brain fog, and lung problems are a few of the lingering aftereffects reported by some people who have had COVID-19. Could gut troubles also fall among the constellation of chronic symptoms that people with long-haul COVID experience? And if so, what do experts suggest to help ease this?

What happens to the gut during a COVID infection?

As we head into the fourth year since COVID-19 became a global health emergency, hundreds of millions of people around the globe have been infected with the virus that causes it. Since 2020, we’ve known that the virus particles that cause lung illness also infect the gastrointestinal (GI) tract: the esophagus, stomach, small intestines, and colon. This can trigger abdominal pain and diarrhea, which often — but not always — clear up as people recover.

We know chronic gut problems such as irritable bowel syndrome (IBS) sometimes occur even after illness caused by microorganisms like Campylobacter and Salmonella are cured. Could this happen with COVID-19?

What is long COVID?

While most people who get COVID-19 will survive, medical science is becoming aware of a group of people suffering from lasting declines in health. Well-reported long COVID aftereffects include tiredness, breathing difficulty, heart rhythm changes, and muscle pain. But few people, even in the medical field, are aware that long COVID symptoms may include chronic diarrhea and abdominal pain.

Why might the gut be involved in long COVID?

It is not clear why chronic gut symptoms might occur after a COVID-19 infection. One possible insight is a well-known syndrome called post-infectious irritable bowel syndrome (IBS) that may occur after a stomach flu (gastroenteritis).

Long after the bug causing the illness is gone, a change in gut-brain signaling may occur. A complex network of nerves connects the gut and the brain, and controls communication between different parts of the gut. These nerves tell body organs to produce digestive juices, alert you to the need to go to the bathroom, or prevent you from having another serving of stuffing at the Thanksgiving table.

The nerve network of the gut is so complicated that it is sometimes called the second brain. When the nerves are working well, you won’t notice a thing: you eat without pain, you move your bowels with ease, you have no GI worries. But what if the nerves are not working well? Then, even if the process of digestion remains normal, you may frequently have symptoms like pain or a distressing change in your bowel movements, such as diarrhea or constipation.

Once known as functional GI disorders, these health problems are now called disordered gut-brain interactions (DGBIs). When viruses and bacteria infect the gut, experts believe they may prompt a change in gut-brain signaling that can cause a DGBI like IBS to develop.

What to do if you’re noticing long-lasting gut problems after COVID-19 infection

We still do not know conclusively if COVID-19 can cause a long-term change in gut-brain messaging that leads to IBS or other disordered gut-brain interactions. But increasing evidence suggests that GI distress lasting six months or longer might be a symptom of long COVID. While we wait for more evidence, some GI specialists, including myself, recommend trying approaches that help relieve irritable bowel syndrome and other DGBIs.

If you are suffering from chronic abdominal pain and a change in your bowel movements after having had COVID-19, talk to your primary care doctor. Many health conditions have similar symptoms, including viral or bacterial infections, inflammation, or even cancers. A thorough exam can help to rule out certain conditions.

If the problem persists, do not suffer alone or feel embarrassed to act! Seek help if severe pain or changes in bowel movements are harming your quality of life or affecting daily activities. Talk with your doctor about the possibility that your chronic gut symptoms might be a form of long COVID. Find out if they can recommend helpful treatments or suggest a referral to a GI specialist. As research continues, new information may be available.

About the Author

Christopher D. Vélez, MD, Contributor

Dr. Christopher Vélez is an attending gastroenterologist in the Center for Neurointestinal Health of Massachusetts General Hospital's division of gastroenterology and the MGH department of medicine. He focuses on neurogastroenterology and motility disorders of the esophagus, … See Full Bio View all posts by Christopher D. Vélez, MD

Making friends and finding social opportunities can sometimes be difficult, particularly for children with neurodevelopmental disabilities, such as autism spectrum disorder, attention deficit hyperactivity disorder, or an intellectual disability. Here’s what parents can do to help.

Building inclusive communities

Friendships and social connections are an important aspect of our lives. They provide a sense of belonging and allow people to be included in their communities.

People with neurodevelopmental disabilities may communicate, learn, and behave differently. Sometimes these differences make it harder than usual to develop friendships and participate in social activities.

But parents and others can help create more inclusive communities and opportunities to build social relationships, especially for people with neurodiverse abilities.

Below are some tips and strategies to help children learn and develop the social and emotional skills they need to make friends.

Practice at home: Tips for common social situations

Navigating social settings and making friends involve many skills you can practice with children at home.

• Greetings and questions. Make a habit of practicing greetings throughout the day. Model good listening for your child, and take turns asking and answering conversation starters like, “How are you?”
• Calm body movements. Sometimes it can be hard for children with neurodevelopmental disabilities to keep a calm body. Have your child practice giving their body enough room and keeping personal space between themselves and others by using an arm’s-length distance.
• Appropriate level of voice. Encourage your child to listen and match the level of your voice. Imagine your voice has a volume dial and practice turning the volume up and down.
• Eye contact. Looking directly into someone’s eyes can be difficult, so help your child instead look at different parts of your face or practice looking at their own eyes in the mirror.
• Reading and responding to social signals. People regularly communicate using more than just words. Social signals are the variety of ways in which we communicate through body language and facial expressions. Often this can be tricky to detect for children who are neurodiverse. Help your child recognize common social signals by asking what someone’s body or face might be saying.

Rerouting challenging behaviors to help children build friendships

Challenging behaviors may get in the way of making and keeping friends. It is important to address challenging behaviors like impulsivity and aggression through therapies and programming. Additionally, practicing the following fundamental skills can help reduce challenging behaviors.

• Patience. Learning how to wait for a turn to play or a time to speak in a conversation is an important social skill. Practice waiting with a timer, gradually building up from 10 seconds, to one minute, to five minutes.
• Flexibility. Help your child make compromises using first/then statements, such as, “First we play your way, then my way.” Model flexible play and redirect with new toys to show how play can evolve.
• Communicating strong emotions.Handling strong feelings can be difficult sometimes. Practice communicating these feelings effectively either by asking for help, using an emotions board, or taking a break.

How to throw a wide net socially

Encouraging social opportunities is an important part of supporting friendships and social relationships for children with neurodevelopmental disabilities. Social spaces offer chances for children who are neurodiverse to find activities they enjoy. They are able to practice the social and emotional skills they are learning and even meet other children practicing these same skills.

• Structure and organize play dates. Set up the environment before a play date by making a list of activities to do with a friend, then picking out of a hat which activities to do and in what order.
• Make a list of things that are fun to do and invite others to join. Look for free or low-cost programs or events out in the community.
• Connect with other parents of children with disabilities. Set up an activity for your children like an ice cream date, going on a walk, or a game night with adults and kids together. These encounters can give rise to repeat, planned social interactions.
• Check out organizations in the community for children with disabilities, like Special Olympics, or recreational programs that foster inclusive environments through Unified Sports.
• Look into facilitated recreational activities like a Lego club or pizza parties with teachers. Plan to bring a support person if needed.

Your child’s doctor or teacher may be able to suggest additional community or web-based resources designed to help families support friendships for children with neurodiverse abilities.

About the Authors

Sydney Reynders, ScB, Contributor

Sydney Reynders, ScB, is a clinical research coordinator in the Boston Children’s Hospital Down Syndrome Program. She assists in research investigating educational, behavioral, and medical interventions in Down syndrome and other neurodevelopmental disorders. She received her … See Full Bio View all posts by Sydney Reynders, ScB

Nicole Baumer, MD, MEd, Contributor

Nicole Baumer, MD, MEd is a child neurologist/neurodevelopmental disabilities specialist at Boston Children's Hospital, and an instructor in neurology at Harvard Medical School. Dr. Baumer is director of the Boston Children's Hospital Down Syndrome Program. She … See Full Bio View all posts by Nicole Baumer, MD, MEd