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Experiencing discrimination in the workplace — where many adults spend one-third of their time, on average — may be harmful to your heart health.

A 2023 study in the Journal of the American Heart Association found that people who reported high levels of discrimination on the job were more likely to develop high blood pressure than those who reported low levels of workplace discrimination.

Workplace discrimination refers to unfair conditions or unpleasant treatment because of personal characteristics — particularly race, sex, or age.

How can discrimination affect our health?

“The daily hassles and indignities people experience from discrimination are a specific type of stress that is not always included in traditional measures of stress and adversity,” says sociologist David R. Williams, professor of public health at the Harvard T.H. Chan School of Public Health.

Yet multiple studies have documented that experiencing discrimination increases risk for developing a broad range of factors linked to heart disease. Along with high blood pressure, this can also include chronic low-grade inflammation, obesity, and type 2 diabetes.

More than 25 years ago, Williams created the Everyday Discrimination Scale. This is the most widely used measure of discrimination’s effects on health.

Who participated in the study of workplace discrimination?

The study followed a nationwide sample of 1,246 adults across a broad range of occupations and education levels, with roughly equal numbers of men and women.

Most were middle-aged, white, and married. They were mostly nonsmokers, drank low to moderate amounts of alcohol, and did moderate to high levels of exercise. None had high blood pressure at the baseline measurements.

How was discrimination measured and what did the study find?

The study is the first to show that discrimination in the workplace can raise blood pressure.

To measure discrimination levels, researchers used a test that included these six questions:

• How often do you think you are unfairly given tasks that no one else wanted to do?
• How often are you watched more closely than other workers?
• How often does your supervisor or boss use ethnic, racial, or sexual slurs or jokes?
• How often do your coworkers use ethnic, racial, or sexual slurs or jokes?
• How often do you feel that you are ignored or not taken seriously by your boss?
• How often has a coworker with less experience and qualifications gotten promoted before you?

Based on the responses, researchers calculated discrimination scores and divided participants into groups with low, intermediate, and high scores.

• After a follow-up of roughly eight years, about 26% of all participants reported developing high blood pressure.
• Compared to people who scored low on workplace discrimination at the start of the study, those with intermediate or high scores were 22% and 54% more likely, respectively, to report high blood pressure during the follow-up.

How could discrimination affect blood pressure?

Discrimination can cause emotional stress, which activates the body’s fight-or-flight response. The resulting surge of hormones makes the heart beat faster and blood vessels narrow, which causes blood pressure to rise temporarily. But if the stress response is triggered repeatedly, blood pressure may remain consistently high.

Discrimination may arise from unfair treatment based on a range of factors, including race, gender, religious affiliation, or sexual orientation. The specific attribution doesn’t seem to matter, says Williams. “Broadly speaking, the effects of discrimination on health are similar, regardless of the attribution,” he says, noting that the Everyday Discrimination Scale was specifically designed to capture a range of different forms of discrimination.

What are the limitations of this study?

One limitation of this recent study is that only 6% of the participants were nonwhite, and these individuals were less likely to take part in the follow-up session of the study. As a result, the study may not have fully or accurately captured workplace discrimination among people from different racial groups. In addition, blood pressure was self-reported, which may be less reliable than measurements directly documented by medical professionals.

What may limit the health impact of workplace discrimination?

At the organizational level, no studies have directly addressed this issue. Preliminary evidence suggests that improving working conditions, such as decreasing job demands and increasing job control, may help lower blood pressure, according to the study authors. In addition, the American Heart Association recently released a report, Driving Health Equity in the Workplace, that aims to address drivers of health inequities in the workplace.

Encouraging greater awareness of implicit bias may be one way to help reduce discrimination in the workplace. Implicit bias refers to the unconscious assumptions and prejudgments people have about groups of people that may underlie some discriminatory behaviors. You can explore implicit biases with these tests, which were developed at Harvard and other universities.

On an individual level, stress management training can reduce blood pressure. A range of stress-relieving strategies may offer similar benefits. Regularly practicing relaxation techniques or brief mindfulness reflections, learning ways to cope with negative thoughts, and getting sufficient exercise can help.

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

Dr. Howard LeWine 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

What happens when a widely used medicine is no longer available at pharmacies across the US? Until recently, Flovent (fluticasone) inhalers were frequently prescribed to help control asthma. If you or your child relied on these products, you may be scrambling to find medicines that will help you stay healthy without breaking the bank.

What’s essential to know, and what questions should you ask your health care provider? We checked in with Dr. William B. Feldman, a physician in the Division of Pulmonary and Critical Care Medicine at Harvard-affiliated Brigham and Women’s Hospital to get answers.

Which medicines are discontinued?

In January, GlaxoSmithKline stopped producing Flovent, which was available as a prescription metered-dose inhaler (Flovent HFA) and a dry powder inhaler (Flovent Diskus).

Both contain fluticasone, a steroid. Fluticasone reduces inflammation and swelling in the airways. Both types of inhalers are FDA-approved to help prevent asthma attacks.

However, children under age 5 and adults with particularly poor lung function may not be able to use a dry powder inhaler. They may lack the lung power necessary to breathe in deeply enough to pull the medicine into their airways, Dr. Feldman explains. A metered-dose inhaler could be the best choice for them.

Now that Flovent is discontinued, is a generic product available?

Yes, the drug manufacturer has licensed an authorized generic of both Flovent products: the metered-dose inhaler and the dry powder inhaler.

However, insurance coverage may not pay for the authorized generic because it may cost an insurer more than some other branded medicines. So, you may need to switch to another brand to stay healthy. Call your insurance company to check.

What are your alternatives?

This is a good chance for you and your doctor to review your asthma treatment plan. It may be a good time to make changes.

If you had been using Flovent daily for symptom control, your doctor may recommend:

• Trying an inhaled steroid similar to Flovent. Many types of steroids will work, including beclomethasone (Qvar RediHaler), budesonide (Pulmicort Flexhaler), ciclesonide (Alvesco), and mometasone (Asmanex Twisthaler, Asmanex HFA). “These products use different molecules to do the same job as fluticasone,” says Dr. Feldman.
• Switching to a combination inhaler. New studies suggest this approach may help many people who use Flovent daily for symptom control and only use a short-acting medicine to open airways when an asthma flare occurs (see here and here). If you have intermittent asthma symptoms, talk with your provider about whether you could use a combination inhaler when you start to wheeze or have shortness of breath. This combines a medicine called formoterol with a steroid. Symbicort provides this combination in one inhaler. Although not yet approved by the FDA for this specific use, it is approved in many other countries.

What else do asthma specialists advise people to do?

If your insurance covers the authorized generic, this may be a good choice because you already know how to use the product. But what if insurance won’t cover this?

“Any other inhaled steroid should work for most — but not all — people,” says Dr. Feldman. “There are brand-name metered-dose and dry powder inhalers available, such as those mentioned above.”

Here’s what else to know and do

• Discuss whether it’s safe to switch medicines or type of device. For many people, the answer will be yes. But if your health care provider believes that a metered-dose inhaler is the best choice due to age or poor lung function, ask your insurance company for a formulary exception to cover the authorized generic fluticasone or another metered-dose inhaler. Ask your provider to make the same request.
• If you have a child under 5, you and your doctor should also ask your insurance company for a formulary exception to cover a metered-dose inhaler with a steroid.
• For anyone who needs to switch brands, your new inhaler may look and feel different and may require a new technique when you use it to get the full benefit of the medicine. “When folks switch from one type of inhaler to another, it’s very important to get proper education, ideally from their prescriber. But you can also do this online to understand how to properly use this new product,” says Dr. Feldman.

If you do switch, ask your health care provider to show you how to use the new inhaler in an in-person or virtual visit. If that’s not possible, check your technique by watching these videos created by National Jewish Health, a leading US hospital for respiratory care.

What if you’re not feeling as good on a new asthma medicine?

If you’ve switched and notice worsening symptoms or more asthma attacks, contact your health care provider, Dr. Feldman advises. “They should make sure this isn’t due to improper technique with the new device. It may not be, but it’s important to check and to keep your doctor aware of changes like these.”

Is there a difference between an authorized generic and independent generic medicines?

“With an authorized generic, the brand-name company produces the generic or licenses another company to do that. It’s the exact same medicine as the original brand-name drug. It just doesn’t have the label,” says Dr. Feldman.

Independent generics encourage price competition if several companies make them. “With authorized generics, you don’t see those price decreases to the same extent, because you typically just have one product and it’s totally controlled by the branded company,” he adds.

What if you don’t have insurance, or insurance won’t cover a medicine you need?

“These inhalers have extraordinarily high list prices — $200, $300, $400 per month for the product,” notes Dr. Feldman. Manufacturers negotiate rebates with insurers that may substantially lower the price for an insurance plan.

If you don’t have insurance, you won’t get that lower price. So, it’s worth checking prices for all options: you may find the authorized generic will cost you less than other brand-name inhalers.

About the Author

Francesca Coltrera, Editor, Harvard Health Blog

Francesca Coltrera is editor of the Harvard Health Blog, and a senior content writer and editor for Harvard Health Publishing. She is an award-winning medical writer and co-author of Living Through Breast Cancer and The Breast … See Full Bio View all posts by Francesca Coltrera

About the Reviewer

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

Dr. Howard LeWine 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

If you've been cocooning due to winter’s cold, who can blame you? But a lack of activity isn't good for body or mind during any season. And whether you're deep in the grip of winter or fortunate to be basking in signs of spring, today is a good day to start exercising. If you’re not sure where to start — or why you should — we’ve shared tips and answers below.

Moving more: What’s in it for all of us?

We’re all supposed to strengthen our muscles at least twice a week and get a total at least 150 minutes of weekly aerobic activity (the kind that gets your heart and lungs working). But fewer than 18% of U.S. adults meet those weekly recommendations, according to the CDC.

How can choosing to become more active help? A brighter mood is one benefit: physical activity helps ease depression and anxiety, for example. And being sufficiently active — whether in short or longer chunks of time — also lowers your risk for health problems like

• heart disease
• stroke
• diabetes
• cancer
• brain shrinkage
• muscle loss
• weight gain
• poor posture
• poor balance
• back pain
• and even premature death.

What are your exercise obstacles?

Even when we understand these benefits, a range of obstacles may keep us on the couch.

Don’t like the cold? Have trouble standing, walking, or moving around easily? Just don’t like exercise? Don’t let obstacles like these stop you anymore. Try some workarounds.

• If it’s cold outside: It’s generally safe to exercise when the mercury is above 32° F and the ground is dry. The right gear for cold doesn’t need to be fancy. A warm jacket, a hat, gloves, heavy socks, and nonslip shoes are a great start. Layers of athletic clothing that wick away moisture while keeping you warm can help, too. Consider going for a brisk walk or hike, taking part in an orienteering event, or working out with battle ropes ($25 and up) that you attach to a tree.
• If you have mobility issues: Most workouts can be modified. For example, it might be easier to do an aerobics or weights workout in a pool, where buoyancy makes it easier to move and there’s little fear of falling. Or try a seated workout at home, such as chair yoga, tai chi, Pilates, or strength training. You’ll find an endless array of free seated workout videos on YouTube, but look for those created by a reliable source such as Silver Sneakers, or a physical therapist, certified personal trainer, or certified exercise instructor. Another option is an adaptive sports program in your community, such as adaptive basketball.
• If you can’t stand formal exercise: Skip a structured workout and just be more active throughout the day. Do some vigorous housework (like scrubbing a bathtub or vacuuming) or yard work, climb stairs, jog to the mailbox, jog from the parking lot to the grocery store, or do any activity that gets your heart and lungs working. Track your activity minutes with a smartphone (most devices come with built-in fitness apps) or wearable fitness tracker ($20 and up).
• If you’re stuck indoors: The pandemic showed us there are lots of indoor exercise options. If you’re looking for free options, do a body-weight workout, with exercises like planks and squats; follow a free exercise video online; practice yoga or tai chi; turn on music and dance; stretch; or do a resistance band workout. Or if it’s in the budget, get a treadmill, take an online exercise class, or work online with a personal trainer. The American Council on Exercise has a tool on its website to locate certified trainers in your area.

Is it hard to find time to exercise?

The good news is that any amount of physical activity is great for health. For example, a 2022 study found that racking up 15 to 20 minutes of weekly vigorous exercise (less than three minutes per day) was tied to lower risks of heart disease, cancer, and early death.

"We don't quite understand how it works, but we do know the body's metabolic machinery that imparts health benefits can be turned on by short bouts of movement spread across days or weeks," says Dr. Aaron Baggish, founder of Harvard-affiliated Massachusetts General Hospital's Cardiovascular Performance Program and an associate professor of medicine at Harvard Medical School.

And the more you exercise, Dr. Baggish says, the more benefits you accrue, such as better mood, better balance, and reduced risks of diabetes, high blood pressure, high cholesterol, and cognitive decline.

What’s the next step to take?

For most people, increasing activity is doable. If you have a heart condition, poor balance, muscle weakness, or you’re easily winded, talk to your doctor or get an evaluation from a physical therapist.

And no matter which activity you select, ease into it. When you’ve been inactive for a while, your muscles are vulnerable to injury if you do too much too soon.

“Your muscles may be sore initially if they are being asked to do more,” says Dr. Sarah Eby, a sports medicine specialist at Harvard-affiliated Spaulding Rehabilitation Hospital. “That’s normal. Just be sure to start low, and slowly increase your duration and intensity over time. Pick activities you enjoy and set small, measurable, and attainable goals, even if it’s as simple as walking five minutes every day this week.”

Remember: the aim is simply exercising more than you have been. And the more you move, the better.

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

Dr. Howard LeWine 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

Snuff is a smokeless tobacco similar to chewing tobacco. It rarely makes headlines. But it certainly did when the FDA authorized a brand of snuff to market its products as having a major health advantage over cigarettes. Could this be true? Is it safe to use snuff?

What did the FDA authorize as a health claim?

Here’s the approved language for Copenhagen Classic Snuff:

If you smoke, consider this: switching completely to this product from cigarettes reduces risk of lung cancer.

While the statement is true, this FDA action — and the marketing that’s likely to follow — might suggest snuff is a safe product. It’s not. Let’s talk about the rest of the story.

What is snuff, anyway?

Snuff is a form of tobacco that’s finely ground. There are two types:

• Moist snuff. Users place a pinch or a pouch of tobacco behind their upper or lower lips or between their cheek and gum. They must repeatedly spit out or swallow the tobacco juice that accumulates. After a few minutes, they remove or spit out the tobacco as well. This recent FDA action applies to a brand of moist snuff.
• Dry snuff. This type is snorted (inhaled through the nose) and is less common in the US.

Both types are available in an array of scents and flavors. Users absorb nicotine and other chemicals into the bloodstream through the lining of the mouth. Blood levels of nicotine are similar between smokers and snuff users. But nicotine stays in the blood for a longer time with snuff users.

Why is snuff popular?

According to CDC statistics, 5.7 million adults in the US regularly use smokeless tobacco products — that’s about 2% of the adult population. A similar percentage (1.6%) of high school students use it as well. That’s despite restrictions on youth marketing and sales.

What accounts for its popularity?

• Snuff may be allowed in places that prohibit smoking.
• It tends to cost less than cigarettes: $300 to $1,000 a year versus several thousand dollars a year paid by some smokers.
• It doesn’t require inhaling smoke into the lungs, or exposing others to secondhand smoke.
• Snuff is safer than cigarettes in at least one way — it is less likely to cause lung cancer.
• It may help some cigarette smokers quit.

The serious health risks of snuff

While the risk of lung cancer is lower compared with cigarettes, snuff has plenty of other health risks, including

• higher risk of cancers of the mouth (such as the tongue, gums, and cheek), esophagus, and pancreas
• higher risk of heart disease and stroke
• harm to the developing teenage brain
• dental problems, such as discoloration of teeth, gum disease, tooth damage, bone loss around the teeth, tooth loosening or loss
• higher risk of premature birth and stillbirth among pregnant users.

And because nicotine is addictive, using any tobacco product can quickly become a habit that’s hard to break.

There are also the “ick” factors: bad breath and having to repeatedly spit out tobacco juice.

Could this new marketing message about snuff save lives?

Perhaps, if many smokers switch to snuff and give up smoking. That could reduce the number of people who develop smoking-related lung cancer. It might even reduce harms related to secondhand smoke.

But it’s also possible the new marketing message will attract nonsmokers, including teens, who weren’t previously using snuff. A bigger market for snuff products might boost health risks for many people, rather than lowering them.

The new FDA action is approved for a five-year period, and the company must monitor its impact. Is snuff an effective way to help smokers quit? Is a lower rate of lung cancer canceled out by a rise in other health risks? We don’t know yet. If the new evidence shows more overall health risks than benefits for snuff users compared with smokers, this new marketing authorization may be reversed.

The bottom line

If you smoke, concerns you have about lung cancer or other smoking-related health problems are justified. But snuff should not be the first choice to help break the smoking habit. Commit to quit using safer options that don’t involve tobacco, such as nicotine gum or patches, counseling, and medications.

While the FDA’s decision generated news headlines that framed snuff as safer than smoking, it’s important to note that the FDA did not endorse the use of snuff — or even suggest that snuff is a safe product. Whether smoked or smokeless, tobacco creates enormous health burdens and suffering. Clearly, it’s best not to use any tobacco product.

Until we have a better understanding of its impact, I think any new marketing of this sort should also make clear that using snuff comes with other important health risks — even if lung cancer isn’t the biggest one.

Follow me on Twitter @RobShmerling

About the Author

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

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

If you suffer from the throbbing, intense pain set off by migraine headaches, you may well wonder which medicines are most likely to offer relief. A recent study suggests a class of drugs called triptans are the most helpful option, with one particular drug rising to the top.

The study drew on real-world data gleaned from more than three million entries on My Migraine Buddy, a free smartphone app. The app lets users track their migraine attacks and rate the helpfulness of any medications they take.

Dr. Elizabeth Loder, professor of neurology at Harvard Medical School and chief of the Division of Headache at Brigham and Women’s Hospital, helped break down what the researchers looked at and learned that could benefit anyone with migraines.

What did the migraine study look at?

Published in the journal Neurology, the study included self-reported data from about 278,000 people (mostly women) over a six-year period that ended in July 2020. Using the app, participants rated migraine treatments they used as “helpful,” “somewhat helpful,” or “unhelpful.”

The researchers looked at 25 medications from seven drug classes to see which were most helpful for easing migraines. After triptans, the next most helpful drug classes were ergots such as dihydroergotamine (Migranal, Trudhesa) and anti-emetics such as promethazine (Phenergan). The latter help ease nausea, another common migraine symptom.

“I’m always happy to see studies conducted in a real-world setting, and this one is very clever,” says Dr. Loder. The results validate current guideline recommendations for treating migraines, which rank triptans as a first-line choice. “If you had asked me to sit down and make a list of the most helpful migraine medications, it would be very similar to what this study found,” she says.

What else did the study show about migraine pain relievers?

Ibuprofen, an over-the-counter pain reliever sold as Advil and Motrin, was the most frequently used medication in the study. But participants rated it “helpful” only 42% of the time. Only acetaminophen (Tylenol) was less helpful, helping just 37% of the time. A common combination medication containing aspirin, acetaminophen, and caffeine (sold under the brand name Excedrin) worked only slightly better than ibuprofen, or about half the time.

When researchers compared helpfulness of other drugs to ibuprofen, they found:

• Triptans scored five to six times more helpful than ibuprofen. The highest ranked drug, eletriptan, helped 78% of the time. Other triptans, including zolmitriptan (Zomig) and sumatriptan (Imitrex), were helpful 74% and 72% of the time, respectively. In practice, notes Dr. Loder, eletriptan seems to be just a tad better than the other triptans.
• Ergots were rated as three times more helpful than ibuprofen.
• Anti-emetics were 2.5 times as helpful as ibuprofen.

Do people take more than one medicine to ease migraine symptoms?

In this study, two-thirds of migraine attacks were treated with just one drug. About a quarter of the study participants used two drugs, and a smaller number used three or more drugs.

However, researchers weren’t able to tease out the sequence of when people took the drugs. And with anti-nausea drugs, it’s not clear if people were rating their helpfulness on nausea rather than headache, Dr. Loder points out. But it’s a good reminder that for many people who have migraines, nausea and vomiting are a big problem. When that’s the case, different drug formulations can help.

Are pills the only option for migraine relief?

No. For the headache, people can use a nasal spray or injectable version of a triptan rather than pills. Pre-filled syringes, which are injected into the thigh, stomach, or upper arm, are underused among people who have very rapid-onset migraines, says Dr. Loder. “For these people, injectable triptans are a game changer because pills don’t work as fast and might not stay down,” she says.

For nausea, the anti-emetic ondansetron (Zofran) is very effective, but one of the side effects is headache. You’re better off using promethazine or prochlorperazine (Compazine), both of which treat nausea but also help ease headache pain, says Dr. Loder.

Additionally, many anti-nausea drugs are available as rectal suppositories. This is especially helpful for people who have “crash” migraines, which often cause people to wake up vomiting with a migraine, she adds.

What are the limitations of this migraine study?

The data didn’t include information about the timing, sequence, formulation, or dosage of the medications. It also omitted two classes of newer migraine medications — known as gepants and ditans — because there was only limited data on them at the time of the study. These options include

• atogepant (Qulipta) and rimegepant (Nurtec)
• lasmiditan (Reyvow).

“But based on my clinical experience, I don’t think that any of these drugs would do a lot better than the triptans,” says Dr. Loder.

Another shortcoming is the study population: a selected group of people who are able and motivated to use a migraine smartphone app. That suggests their headaches are probably worse than the average person, but that’s exactly the population for whom this information is needed, says Dr. Loder.

“Migraines are most common in young, healthy people who are trying to work and raise children,” she says. It’s good to know that people using this app rate triptans highly, because from a medical point of view, these drugs are well tolerated and have few side effects, she adds.

Are there other helpful takeaways?

Yes. In the study, nearly half the participants said their pain wasn’t adequately treated. A third reported using more than one medicine to manage their migraines.

If you experience these problems, consult a health care provider who can help you find a more effective therapy. “If you’re using over-the-counter drugs, consider trying a prescription triptan,” Dr. Loder says. If nausea and vomiting are a problem for you, be sure to have an anti-nausea drug on hand.

She also recommends using the Migraine Buddy app or the Canadian Migraine Tracker app (both are free), which many of her patients find helpful for tracking their headaches and triggers.

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

Dr. Howard LeWine 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

Infections after a prostate biopsy are rare, but they do occur. Now research shows that fewer than 2% of men develop confirmed infections after prostate biopsy, regardless of the technique used.

In the United States, doctors usually thread a biopsy needle through the rectum and then into the prostate gland while watching their progress on an ultrasound machine. This is called a transrectal ultrasound-guided biopsy (TRUS). Since the biopsy needle passes through the rectum, there's a chance that fecal bacteria will be introduced into the prostate or escape into the bloodstream. For that reason, doctors typically treat a patient with antibiotics before initiating the procedure.

Alternatively, the biopsy needle can be passed through the peritoneum, which is a patch of skin between the anus and the base of the scrotum. These transperitoneal prostate (TP) biopsies, as they are called, are also performed with ultrasound guidance, and since they bypass the rectum, antibiotics typically aren't required. In that way, TP biopsies help to keep antibiotic resistance at bay, and European medical guidelines strongly favor this approach, citing a lower risk of infection.

Study goals and methodology

TP biopsies aren't widely adopted in the United States, in part because doctors lack familiarity with the method and need further training to perform it. The technology is steadily improving, and TP biopsies are increasingly being conducted in office settings around the country. But questions remain about how TRUS and TP biopsies compare in terms of their infectious complications.

To investigate, researchers at Albany Medical Center in New York conducted the first-ever randomized clinical trial comparing infection risks associated with either method. The results were published in February in the Journal of Urology.

The Albany team randomized 718 men to either a TRUS or TP biopsy. Nearly all the men who got a TRUS biopsy (and with few exceptions, none of the TP-treated men) first received a single-day course of antibiotics. All the biopsies were administered between 2019 and 2022 by three urologists working at the Medical Center's affiliated and nonaffiliated hospitals.

The men were then monitored for fever, genitourinary infections, antibiotic prescriptions for suspected or confirmed infections, sepsis, and infection-related contacts with caregivers. Researchers collected data during a visit conducted two weeks after a biopsy procedure, and then by phone over an additional 30-day period following this initial meeting.

What the researchers found

According to the results, 1.1% of men in the TRUS group and 1.4% of men in the transperineal group wound up with confirmed infections. The difference was not statistically significant. If "possible" infections were counted (for example, antibiotic prescriptions for fever), then the rates increased to 2.6% and 2.7% of men in the TRUS and TP groups, respectively.

Fever was the most frequent complication, reported by six participants in each group. One participant from each group also developed noninfectious urinary retention, requiring the temporary use of a catheter. None of the men developed sepsis or required post-biopsy treatments for bleeding.

The study had some limitations: Nearly all the participants were white, and so the results may not be applicable to men from other racial and ethnic groups. Furthermore, since all the men were biopsied by a single institution, it's unclear if the findings are generalizable in other settings. Still, the study provides reassuring evidence that both types of biopsies "appear safe and viable options for clinical practice," the authors concluded.

Commentary from experts

"The paper provides needed evidence that TP biopsies without antibiotics are about as safe and efficacious as TRUS biopsies with antibiotics," said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center. The findings also help to dispel a growing view that transperineal biopsies are superior, Dr. Garnick pointed out.

"Recent years have witnessed a marked interest and surge in the transperineal approach, primarily driven by early studies suggesting a lower risk of infectious complications compared with transrectal biopsy," said Dr. Boris Gershman, a urologist at Harvard-affiliated Beth Israel Deaconess Medical Center in Boston, and a member of Harvard Health Publishing's Annual Report on Prostate Diseases advisory board.

"Interestingly, the investigators find no difference in infectious complications, and it will be important to see if other ongoing studies report similar results," Dr. Gershman continued. "In addition to safety, we also need to confirm whether there are any meaningful differences between the two approaches with respect to cancer detection rates."

About the Author

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

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

About the Reviewer

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

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

All of us have an internal clock that regulates our circadian rhythms, including when we sleep and when we are awake. And light is the single most important factor that helps establish when we should feel wakeful (generally during the day) and when we should feel sleepy (typically at night).

So, let me ask you a personal question: just how dark is your bedroom? To find out why that matters — and whether sleeping in an eye mask is worthwhile — read on.

How is light related to sleep?

Our circadian system evolved well before the advent of artificial light. As anyone who has been to Times Square can confirm, just a few watts of power can trick the brain into believing that it is daytime at any time of night. So, what’s keeping your bedroom alight?

• A tablet used in bed at night to watch a movie is more than 100 times brighter than being outside when there is a full moon.
• Working on or watching a computer screen at night is about 10 times brighter than standing in a well-lit parking lot.

Light exposure at night affects the natural processes that help prepare the body for sleep. Specifically, your pineal gland produces melatonin in response to darkness. This hormone is integral for the circadian regulation of sleep.

What happens when we are exposed to light at night?

Being exposed to light at night suppresses melatonin production, changing our sleep patterns. Compared to sleeping without a night light, adults who slept next to a night light had shallower sleep and more frequent arousals. Even outdoor artificial light at night, such as street lamps, has been linked with getting less sleep.

But the impact of light at night is not limited to just sleep. It’s also associated with increased risk of developing depressive symptoms, obesity, diabetes, and high blood pressure. Light exposure misaligned with our circadian rhythms — that is, dark during the day and light at night — is one reason scientists believe that shift work puts people at higher risk for serious health problems.

Could sleeping with an eye mask help?

Researchers from Cardiff University in the United Kingdom conducted a series of experiments to see if wearing an eye mask while sleeping at night could improve certain measures of learning and alertness.

Roughly 90 healthy young adults, 18 to 35 years of age, alternated between sleeping while wearing an eye mask or being exposed to light at night. They recorded their sleep patterns in a sleep diary.

In the first part of the study, participants wore an intact eye mask for a week. Then during the next week, they wore an eye mask with a hole exposing each eye so that the mask didn't block the light.

After sleeping with no light exposure (wearing the intact eye mask) and with minimal light exposure (the eye mask with the holes), participants completed three cognitive tasks on days six and seven of each week:

• First was a paired-associate learning task. This helps show how effectively a person can learn new associations. Here the task was learning related word pairs. Participants performed better after wearing an intact eye mask during sleep in the days leading up to the test than after being exposed to light at night.
• Second, the researchers administered a psychomotor vigilance test, which assesses alertness. Blocking light at night also improved reaction times on this task.
• Finally, a motor skill learning test was given, which involved tapping a five-digit sequence in the correct order. For this task, there was no difference in performance whether participants had worn an intact eye mask or been exposed to light at night.

What else did the researchers learn?

No research study is ever perfect, so it is important to take the conclusions above with a grain of salt.

According to sleep diary data, there was no difference in the amount of sleep, nor in their perceptions of sleep quality, regardless of whether people wore an eye mask or not.

Further, in a second experiment with about 30 participants, the researchers tracked sleep objectively using a monitoring device called the Dreem headband. They found no changes to the structure of sleep — for example, how much time participants spent in REM sleep — when wearing an eye mask.

Should I rush out to buy an eye mask before an important meeting or exam?

If you decide to try using an eye mask, you probably don’t need to pay extra for overnight shipping. Instead, follow a chronobiologist’s rule of thumb: “bright days, dark nights.”

• During the daytime, get as much natural daylight as you possibly can: go out to pick up your morning bagel from a local bakery, take a short walk during your afternoon lull at work.
• In the evening, reduce your exposure to electronic devices such as your cell phone, and use the night-dimming modes on these devices. Make sure that you turn off all unnecessary lights. Finally, try to make your bedroom as dark as possible when you go to bed. This could mean turning the alarm clock next to your bed away from you or covering up the light on a humidifier.

Of course, you might decide a well-fitted, comfortable eye mask is a useful addition to your light hygiene toolkit. Most cost $10 to $20, so you may find yourself snoozing better and improving cognitive performance for the price of a few cups of coffee.

About the Author

Eric Zhou, PhD, Contributor

Eric Zhou, PhD, is an assistant professor at Harvard Medical School. His research focuses on how we can better understand and treat sleep disorders in both pediatric and adult populations, including those with chronic illnesses. Dr. … See Full Bio View all posts by Eric Zhou, PhD

The tongue is secured to the front of the mouth partly by a band of tissue called the lingual frenulum. If the frenulum is short, it can restrict the movement of the tongue. This is commonly called a tongue-tie.

Children with a tongue-tie can’t stick their tongue out past their lower lip, or touch their tongue to the top of their upper teeth when their mouth is open. When they stick out their tongue, it looks notched or heart-shaped. Since babies don’t routinely stick out their tongues, a baby’s tongue may be tied if you can’t get a finger underneath the tongue.

How common are tongue-ties?

Tongue-ties are common. It’s hard to say exactly how common, as people define this condition differently. About 8% of babies under age one may have at least a mild tongue-tie.

Is it a problem if the tongue is tied?

This is really important: tongue-ties are not necessarily a problem. Many babies, children, and adults have tongue-ties that cause them no difficulties whatsoever.

There are two main ways that tongue-ties can cause problems:

• They can cause problems with breastfeeding by making it hard for some babies to latch on well to the mother’s nipple. This causes difficulty with feeding for the baby and sore nipples for the mother. It doesn’t happen to all babies with a tongue-tie; many of them can breastfeed successfully. Tongue-ties are not to blame for gassiness or fussiness in a breastfed baby who is gaining weight well. Babies with tongue-ties do not have problems with bottle-feeding.
• They can cause problems with speech. Some children with tongue-ties may have difficulty pronouncing certain sounds, such as t, d, z, s, th, n, and l. Tongue-ties do not cause speech delay.

What should you do if think your baby or child has a tongue-tie?

If you think that your newborn is not latching well because of a tongue-tie, talk to your doctor. There are many, many reasons why a baby might not latch onto the breast well. Your doctor should take a careful history of what has been going on, and do a careful examination of your baby to better understand the situation.

You should also have a visit with a lactation specialist to get help with breastfeeding — both because there are lots of reasons why babies have trouble with latching on, and also because many babies with a tongue-tie can nurse successfully with the right techniques and support.

Talk to your doctor if you think that a tongue-tie could be causing problems with how your child pronounces words. Many children just take some time to learn to pronounce certain sounds. It is also a good idea to have an evaluation by a speech therapist before concluding that a tongue-tie is the problem.

What can be done about a tongue-tie?

When necessary, a doctor can release a tongue-tie using a procedure called a frenotomy. A frenotomy can be done by simply snipping the frenulum, or it can be done with a laser.

However, nothing should be done about a tongue-tie that isn’t causing problems. While a frenotomy is a relatively minor procedure, complications such as bleeding, infection, or feeding difficulty sometimes occur. So it’s never a good idea to do it just to prevent problems in the future. The procedure should only be considered if the tongue-tie is clearly causing trouble.

It’s also important to know that clipping a tongue-tie doesn’t always solve the problem, especially with breastfeeding. Studies do not show a clear benefit for all babies or mothers. That’s why it’s important to work with a lactation expert before even considering a frenotomy.

If a newborn with a tongue-tie isn’t latching well despite strong support from a lactation expert, then a frenotomy should be considered, especially if the baby is not gaining weight. If it is done, it should be done early on and by someone with training and experience in the procedure.

What else should parents know about tongue-tie procedures?

Despite the fact that the evidence for the benefits of frenotomy is murky, many providers are quick to recommend them. If one is being recommended for your child, ask questions:

• Make sure you know exactly why it is being recommended.
• Ask whether there are any other options, including waiting.
• Talk to other health care providers on your child’s care team, or get a second opinion.

About the Author

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

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

Are online gambling and sports betting new to your area? Are gambling advertisements catching your eye? Have you noticed sports and news shows covering the spread? Recent changes in laws have made gambling widely accessible, and its popularity has soared.

Occasional bets are rarely an issue. But uncontrolled gambling can lead to financial, psychological, physical, and social consequences, some of which are extreme. Understanding whether gambling is becoming a problem in your life can help you head off the worst of these issues and refocus on having more meaning, happiness, and psychological richness in your life. Gambling screening is a good first step.

Can you screen yourself for problem gambling?

Yes. Screening yourself is easy. The Brief Biosocial Gambling Screen (note: automatic download) is a validated way to screen for gambling disorder. It has three yes-or-no questions. Ask yourself:

• During the past 12 months, have you become restless, irritable, or anxious when trying to stop/cut down on gambling?
• During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?
• During the past 12 months, did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends, or welfare?

What do your answers mean?

Answering yes to any one of these questions suggests that you are at higher risk for experiencing gambling disorder. Put simply, this is an addiction to gambling. Like other expressions of addiction, for gambling this includes loss of control, craving, and continuing despite bad consequences. Unique to gambling, it also often means chasing your losses.

A yes doesn’t mean that you are definitely experiencing a problem with gambling. But it might be valuable for you to seek a more in-depth assessment of your gambling behavior. To find an organization or person qualified to help, ask a health care provider, your local department of public health, or an advocacy group like the National Council on Problem Gambling.

Are you ready for change?

Your readiness to change a behavior matters when deciding the best first steps for making a change. If someone asks you whether you want to change your gambling, what would you say?

Depending on your answer, you might seek out different solutions. What’s most important initially is choosing a solution that feels like the right fit for you.

What if you don’t feel ready to change? If you haven’t thought about your gambling or only occasionally think about changing your gambling, you might explore lower intensity actions. For example, you could

• read more about how gambling could create a problem for you
• listen to stories of those who have lived experience with gambling disorder.

If you are committed to making a change or are already trying to change, you might seek out more engaging resources and strategies to support those decisions, like attending self-help groups or participating in treatment.

Read on for more details on choices you might make.

What options for change are available if you want to continue gambling?

If you want to keep gambling in some way, you might want to stick to lower-risk gambling guidelines:

• gamble no more than 1% of household income
• gamble no more than four days per month
• avoid regularly gambling at more than two types of games, such as playing the lottery and betting on sports.

Other ways to reduce your risk of gambling harm include:

• Plan ahead and set your own personal limits.
• Keep your entertainment budget in mind if you decide to gamble.
• Consider leaving credit cards and debit cards at home and use cash instead.
• Schedule other activities directly after your gambling to create a time limit.
• Limit your use of alcohol and other drugs if you decide to gamble.

What are easy first steps toward reducing or stopping gambling?

If you’re just starting to think about change, consider learning more about gambling, problem gambling, and ways to change from

• blogs, like The BASIS
• books like Change Your Gambling, Change Your Life
• podcasts like After Gambling, All-In, and Fall In, which offer expert interviews, personal recovery stories, and more.

Some YouTube clips demystify gambling, such as how slot machines work, the limits of skill and knowledge in gambling, and how gambling can become an addiction. These sources might help you think about your own gambling in new ways, potentially identifying behaviors that you need to change.

What are some slightly more active steps toward change?

If you’re looking for a slightly more active approach, you can consider engaging in traditional self-help experiences such as helplines and chatlines or Gamblers Anonymous.

Another option is self-help workbooks. Your First Step to Change is a popular workbook that provides information about problem gambling, self-screening exercises for gambling and related conditions like anxiety and depression, and change exercises to get started. A clinical trial of this resource suggested that users were more likely than others to report having recently abstained from gambling.

Watch out for gambling misinformation

As you investigate options, keep in mind that the quality of information available can vary and may even include misinformation. Misinformation is incorrect or misleading information. Research suggests that some common types of gambling misinformation might reinforce harmful beliefs or risky behaviors.

For example, some gambling books, websites, and other resources exaggerate your likelihood of winning, highlight win and loss streaks as important (especially for chance-based games like slots), and suggest ways to change your luck to gain an edge. These misleading ideas can help you to believe you’re more likely to win than you actually are, and set you up for failure.

The bottom line

Taking a simple self-screening test can start you on a journey toward better gambling-related health. Keep in mind that change can take time and won’t necessarily be a straight path.

If you take a step toward change and then a step back, nothing is stopping you from taking a step forward again. Talking with a care provider and getting a comprehensive assessment can help you understand whether formal treatment for gambling is a promising option for you.

About the Author

Debi LaPlante, PhD, Contributor

Dr. Debi LaPlante is director of the division on addiction at the Cambridge Health Alliance, and an associate professor of psychiatry at Harvard Medical School. She joined the division in 2001 and is involved with its … See Full Bio View all posts by Debi LaPlante, PhD

If you’ve ever tried to lose excess weight, you’ve probably gotten this advice: drink more water. Or perhaps it was more specific: drink a full glass of water before each meal.

The second suggestion seems like a reasonable idea, right? If you fill your stomach with water before eating, you’ll feel fuller and stop eating sooner. But did that work for you? Would drinking more water throughout the day work? Why do people say drinking water can help with weight loss — and what does the evidence show?

Stretching nerves, burning calories, and thirst versus hunger

Three top theories are:

Feel full, eat less. As noted, filling up on water before meals has intuitive appeal. Your stomach has nerves that sense stretch and send signals to the brain that it’s time to stop eating. Presumably, drinking before a meal could send similar signals.

• The evidence: Some small, short-term studies support this idea. For example, older study subjects who drank a full glass of water before meals tended to eat less than those who didn’t. Another study found that people following a low-calorie diet who drank extra water before meals had less appetite and more weight loss over 12 weeks than those on a similar diet without the extra water. But neither study assessed the impact of drinking extra water on long-term weight loss.

Burning off calories. The water we drink must be heated up to body temperature, a process requiring the body to expend energy. The energy spent on this — called thermogenesis — could offset calories from meals.

• The evidence: Though older studies provided some support for this explanation, more recent studies found no evidence that drinking water burned off many calories. That calls the thermogenesis explanation for water-induced weight loss into question.

You’re not hungry, you’re thirsty. This explanation suggests that sometimes we head to the kitchen for something to eat when we’re actually thirsty rather than hungry. If that’s the case, drinking calorie-free water can save us from consuming unnecessary calories — and that could promote weight loss.

• The evidence: The regulation of thirst and hunger is complex and varies over a person’s lifespan. For example, thirst may be dulled in older adults. But I could find no convincing studies in humans supporting the notion that people who are thirsty misinterpret the sensation for hunger, or that this is why drinking water might help with weight loss.

Exercise booster, no-cal substitution, and burning fat demands water

Being well-hydrated improves exercise capacity and thus weight loss. Muscle fatigue, cramping, and heat exhaustion can all be brought on by dehydration. That’s why extra hydration before exercise may be recommended, especially for elite athletes exercising in warm environments.

• The evidence: For most people, hydrating before exercises seems unnecessary, and I could find no studies specifically examining the role of hydration to exercise-related weight loss.

Swapping out high calorie drinks with water. Yes, if you usually drink high-calorie beverages (such as sweetened sodas, fruit juice, or alcohol), consistently replacing them with water can aid weight loss over time.

• The evidence: A dramatic reduction in calorie intake by substituting water for higher-calorie beverages could certainly lead to long-term weight loss. While it’s hard to design a study to prove this, indirect evidence suggests a link between substituting water for high-cal beverages and weight loss. Even so, just as calorie-restricting diets are hard to stick with over the long term, following a water-only plan may be easier said than done.

Burning fat requires water. Dehydration impairs the body’s ability to break down fat for fuel. So, perhaps drinking more water will encourage fat breakdown and, eventually, weight loss.

• The evidence: Though some animal studies support the idea, I could find no compelling evidence from human studies that drinking extra water helps burn fat as a means to lose excess weight.

The bottom line

So, should you bump up hydration by drinking water before or during meals, or even at other times during the day?

Some evidence does suggest this might aid weight loss, at least for some people. But those studies are mostly small or short-term, or based on animal data. Even positive studies only found modest benefits.

That said, if you think it’s working for you, there’s little downside to drinking a bit more water, other than the challenge of trying to drink if you aren’t particularly thirsty. My take? Though plenty of people recommend this approach, it seems based on a theory that doesn’t hold water.

About the Author

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

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