Legislators repeat myths about flu vaccines, get subtly corrected by a colleague who is a doctor; disease remains a threat in Ky.

By Melissa Patrick
Kentucky Health News

With all the people who come through the state Capitol, and all of the handshaking that goes on there, especially when the Kentucky General Assembly is in session, it's no wonder the House opened Monday's session with a call for members to keep in mind the many who were absent due to illness, or that the flu was mentioned several times in the Senate.

But some senators demonstrated how politics and public health don't always match up.

Sen. Dennis Parrett, a Democrat from Elizabethtown, said while recording votes that he missed while out with the flu, told his colleagues -- and everyone watching Kentucky Educational Television -- that the last two times he got a flu shot, he soon after got the flu, including this last time.

Parrett insinuated that the vaccine gave him the flu, but medical experts say that doesn't happen.

No one contradicted Parrett, and his remark prompted Senate President Robert Stivers, a Manchester Republican, to say from the dais, "I've never taken the flu shot, and I've never gotten the flu."

Several moments passed before Sen. Ralph Alvarado, R-Winchester, a physician, stood up and said, "I'd like to encourage everyone if they have not gotten their flu vaccination to get one."

He noted that the flu has been particularly virulent this year and stressed that flu is one of the most preventable diseases because of the vaccine. "So people who are watching at home, please go out and get your vaccination," he said.

And to laughter all around, Stivers uttered the line typically used when routine announcements are made: "Members, please take note."

Flu myths and misconceptions

On the surface, what Parrett and Stivers said about the flu is no big deal. But from a public-health perspective, their comments repeated several persistent myths about flu vaccines, which have long been proven to be the best defense against this often serious disease. So far, flu has killed 80 Kentuckians during this season, which runs through May.

The federal Centers for Disease Control and Prevention says that unequivocally that a flu shot cannot give you the disease. The vaccines are produced in two ways, with an "inactivated" or killed flu virus, or by using only part of a flu virus. In other words, there is nothing in a flu vaccine that can infect you.

And while nasal-spray flu vaccines do have live influenza viruses, the CDC says they are weakened, and will not cause a person to get the flu.

One reason for this persistent myth is because the flu virus is constantly changing – which creates confusion and distrust of the vaccine – and some years the vaccine doesn't cover the most prevalent strain of the virus.

Another reason for this persistent myth is because the flu shot does not offer protection immediately, and takes at least two weeks to kick in. So when someone says they got the flu right after having a shot, it means they were exposed to the virus before they developed immunity. Or, someone may have been exposed to a flu virus different from the viruses that the vaccine is designed to protect against.

That said, some people do report a mild reaction to flu vaccinations. The most common reactions are soreness, redness, tenderness or swelling where the shot was given, but some report low-grade fever, headache and muscle aches.

The bottom line: The vaccine is about reducing your risk, not eliminating it. And even if you get the flu after getting a shot, chances are that your symptoms will be less bothersome than if you didn't get it.

And while Stivers has never had the flu, despite never getting a shot, that doesn't mean he isn't at risk of getting it in the future. Also, it's possible to be infected with the flu virus but have no symptoms.

And its not about Stivers or any other individual. Adults need vaccination to provide "herd immunity" for those who can't be vaccinated: babies, older adults and those who are immuno-compromised.

The CDC notes that that the flu is highly contagious and can spread to people as much as six feet away, largely through the tiny droplets made when coughing, sneezing or even talking.

As Alvarado said, the best way to protect yourself from the flu is to get a yearly vaccine, and it's not too late, since the season usually runs through May. It is recommended that everyone over 6 months old get an annual flu vaccination.

Kentucky has a lot of room to improve its flu vaccination rates, especially among adults. The CDC reports that only 45 percent of Kentucky adults and 65% of the state's children got a flu shot last season.

Besides vaccination, there are other, simpler ways to protect yourself from the flu, a cold, or even the novel coronavirus.

Washing your hands properly is one of the most important ways you can keep from getting sick and spreading germs to others. It is recommended that you scrub your hands with soap and water for at least 20 seconds, or the length of time it takes to sing "Happy Birthday" twice.

Flu in Kentucky

For the last two months, Kentucky has seen about 2,000 new cases of flu a week, and the number of deaths from it continues to rise, with 14 more adults in the state reported to have died from the flu in the week that ended Feb. 22. That brought the state's total to 80 for the season. Four victims were under the age of 18, according to the state Department for Public Health.

The latest weekly report shows that in the week ending Feb. 22, Kentucky counted 1,943 new cases. During the flu season, 21,000 cases have been reported in Kentucky. The actual number of cases is higher, because not all flu cases are counted; flu does not have to be reported, and three counties did not contribute to the latest report. Here are the new cases recorded each week:

1,943 in week ended Feb. 22
1,854 in week ended Feb. 15
2,101 in week ended Feb. 8
1,815 in week ended Feb. 1
1,739 in week ended Jan. 25
1,544 in week ended Jan. 18
1,898 in week ended Jan. 11
2,213 in week ended Dec. 28
1,339 in week ended Dec. 21
814 in week ended Dec. 14
511 in week ended Dec. 7

Hotspots continue around the state, including: Barren County with 94 new cases, for a total of 1,147; Bullitt with 47, for at total of 842; Fayette with 53, for a total of 513; Floyd with 52, for a total of 248; Franklin with 49, for a total of 457; Greenup with 47, for a total of 296; Hardin with 44, for a total of 317; Jefferson with 679, for a total of 7,486; Knott with 52, for a total of 374; Oldham with 55, for a total of 508; Perry with 48, for a total of 1,056; Pike with 61, for a total of 1,111; and Warren with 55, for a total of 761.

MMWR = Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention

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House passes bill to loan money to struggling rural hospitals; funding is still in the works, but sponsor appears confident

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- Spurred to action when the hospital in his county said it was closing, state Rep. Danny Bentley filed a bill to create a loan program for financially distressed rural hospitals. It went from the House to the Senate without dissent Feb. 28, and Bentley voiced confidence that it will be funded.

Rep. Danny Bentley

House Bill 387 would allow the state Cabinet for Economic Development to provide loans to struggling hospitals for three purposes: to maintain or upgrade their facilities; to maintain or increase staff; or to provide health-care services not currently available.

Loans could run 20 years and would be available to hospitals in counties with fewer than 50,000 people.

Bentley, R-Russell, said more than 60 Kentucky hospitals would qualify for the loan, 13 of which are vulnerable to closure. One is already closing: Our Lady of Bellefonte Hospital in his home town, a Greenup County suburb of Ashland.

Most questions about the bill dealt with funding of the loans. Bentley told Kentucky Health News that it will be funded. The next day, he said that while funding details are still in the works, "It's too important not to be funded."

The bill has a powerful co-sponsor, House Speaker David Osborne, R-Prospect. He told The Associated Press that funding could come from state bonds.

“It's the goal to help turnarounds when turnarounds are possible," Osborne told reporters. “That doesn't mean that we can save every hospital that is failing, just like we can't save every business that's failing. But there are some, when given the opportunity, that can succeed, and that's our goal ... to help those that can."

Osborne told the AP that the idea stems from discussions about the state's proposed $35 million loan to the University of Louisville to help it buy Jewish Hospital and other KentuckyOne Health facilities that were at risk of closing. He said concerns were voiced about how the state could also help struggling rural hospitals. The House has passed HB 99, which would approve the loan.

On the House floor, Bentley pointed to the closing of the only hospital in his county as an example of how devastating the loss of a rural hospital can be. Our Lady of Bellefonte will close on April 30, according to a press release from the Catholic group that owns it.

Bentley said that will kill about 1,000 jobs and about $700,000 in annual tax revenue, and make care less accessible. He added, "If they close a rural hospital on us, they will never re-open them. So we've got to be concerned."

If passed and signed into law, HB 387 would take effect immediately. Many rural hospitals in Kentucky are struggling to keep their doors open.

Kentucky Health News reported in October that a Navigant Consulting Inc. study concluded that 16 of Kentucky's rural hospitals, or about one-fourth of the total, are at high risk of closing unless their finances improve. Another study at the University of North Carolina said eight rural Kentucky hospitals are at high risk of financial distress and 23 more are considered to have mid-high risk. The Kentucky Hospital Association, using 2017-18 data, concluded that 35 of the 70 hospitals it considers to be rural are in poor financial health, with 14 of them "very vulnerable." The numbers vary because the studies measure financial distress differently.

Five rural Kentucky hospitals have closed since 2009, four of them since 2014, according to a UNC report.

Bentley said one reason rural hospitals struggle to make ends meet is because most of their patients are on Medicare or Medicaid, which pay less than the full cost of care.

But that's just part of the problem. The Navigant report pointed to other issues, including: a shift from inpatient to outpatient care, which has left hospitals overstaffed and underused; shrinking populations that tend to be older and poorer, meaning that there are more Medicaid and Medicare patients; and not enough money in their budgets to invest in updated, innovative technology.

The hospital association also says changes in federal reimbursement policies have also hurt Kentucky hospitals. It supports Bentley's bill.

KHA President Nancy Galvagni said in an e-mail. "We do not expect HB 387 to be a panacea for the challenges facing some rural hospitals, but it will be an important support for both the hospitals and for our rural communities." She added, "Kentucky’s hospitals are not just buildings where people seek health care; they are also crucial economic players in our communities across the commonwealth."

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State House passes 25% tax on electronic cigarettes

By Melissa Patrick

Kentucky Health News

FRANKFORT, Ky. -- A bill aimed at reducing teen use of electronic cigarettes by increasing their price passed the state House 75-17 and went to the Senate Feb. 26. The bill would place a 25 percent wholesale tax on the products.

State Rep. Jerry Miller

The bill's sponsor, Rep. Jerry Miler, R-Louisville, told the House that youth use of e-cigarettes is "creating a crisis" and "The most effective way to attack underage use is through raising the price."

The Kentucky Incentives Prevention Survey found that from 2016 to 2018, Kentucky teenagers nearly doubled their e-cigarette use, with more than one in four high-school seniors and one in seven eighth-graders reporting use in 2018.

House Bill 32 would also raise the wholesale tax for "other tobacco products," such as cigars, to 25% from the current 15%, and add e-cigarettes to that list. It would also double the per-unit tax on chewable and non-smokable products, but does not increase the tax on traditional cigarettes.

Gov. Andy Beshear proposed a 10-cent-per-pack hike in the cigarette tax, estimated to raise nearly $40 million for the next two-year state budget.

Miller said his bill is projected to bring in nearly $50 million. He said the amounts were increases "that a large manufacturer" said it could live with without opposing the bill.

The original bill called for a 27.5% wholesale tax on e-cigarettes, which are the only tobacco products in Kentucky that does not have an excise tax. That would be equivalent to the current tax in cigarettes.

Terry Brooks, executive director of Kentucky Youth Advocates, applauded the bill's passage, but asked that the Senate go to 27.5%, "to make a real impact for young people." 

"E-cigarettes put our young people at risk of nicotine addiction, serious lung injury or disease, and other harmful outcomes," Brooks said in a prepared statement. "A tax on e-cigarettes equivalent to that on cigarettes is a proven way to prevent usage among youth and can reduce future healthcare costs and provide additional revenue for the state budget."

Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, said the 25% tax was close enough to the cigarette tax to reduce youth use of the products. Chandler noted that after the state raised the cigarette tax 50 cents a pack, to $1.10, in 2018, annual sales dropped 36 million packs.

Miller is also the sponsor of House Bill 69, which would add a long list of regulations to e-cigarettes. It passed out of committee on Feb. 12, but has not yet been called up for a House vote.

Representatives from the Kentucky Smoke Free Association, which represents about 400 independent vape shops statewide, told lawmakers at the bill's committee hearing that while they support the added regulations in HB 69 because they address teen-access issues, they did not support the tax because it would hurt their businesses and would discourage adults from using their products as a smoking cessation device.

A recent U.S. Department of Health and Human Services report says more research is needed before it can be concluded that e-cigarettes help people stop smoking.

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Study: rural women with ovarian cancer more likely to be diagnosed at stage IV, but not because of distance to doctor

Rural women who have ovarian cancer are more likely to find out about it when it's already at stage IV than women who live in metropolitan areas, according to a newly published study in The Journal of Rural Health. That matters because detecting cancer earlier makes for a higher survival rate. From 2000-2015, the five-year survival rate of stage IV ovarian cancer was only 29 percent. The American Cancer Society estimates that 23,000 were diagnosed with ovarian cancer in 2019, and about 14,000 died or will die from it. That includes 280 new cases in Kentucky, and 190 deaths.

Researchers from the University of Iowa and the Centers for Disease Control and Prevention studied a sample of about 1,000 women in Iowa, Kansas and Missouri who had been diagnosed with ovarian cancer in 2011-2012. Rurality was based on the National Center for Health Statistics' definition. At diagnosis, 111 women had stage IV cancer and 889 had stages I-III. The stage IV patients were more likely to be older, rural, and have other health problems.

It is tempting to attribute that difference to poverty or difficulty in accessing health care, but the study controlled for those factors. Rural women were more likely to be diagnosed with late-stage ovarian cancer regardless of their census tract's socioeconomic status or the distance to their primary care provider.

The diagnosis-stage disparity also isn't likely related to lifestyle factors such as smoking, obesity, or lack of physical activity; though such factors are more prevalent in rural areas, they aren't prominent risk factors for ovarian cancer. And though it's possible those lifestyle factors could create a higher incidence of cancer, they aren't likely to create geographic survival or diagnostic disparities.

Rural cancer patients overall have poorer outcomes than non-rural patients, including a lower survival rate. That's true of rural ovarian cancer patients too, probably because of lower access to specialty care and treatment after diagnosis.

The researchers suggest that better access to gynecological specialists in urban areas could make a difference, since those doctors are highly trained and may be able to recognize the symptoms of ovarian cancer sooner than other health care providers.

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The role of our minds in the avoidance of falls

A few years ago, my grandmother suffered a fall and broke her hip. She has never fully recovered and is now constantly fearful of falling, and has significantly limited her activities to prevent a fall from ever happening again. As a scientist focused on translational research in mobility and falls in older adults, of course I asked her how she fell. She stated that she was standing in the kitchen and reading a recipe when the phone rang. When she turned and started to walk over to the phone, her feet “weren’t in the right spot.” She fell sideways and unfortunately, her hip was unable to absorb the impact without breaking.

For older adults, falls are a leading cause of hip and wrist fractures, concussions, mobility disability, loss of independence, and even death. As it turns out, the circumstances leading up to my grandmother’s fall were typical. In fact, the majority of falls occur when an individual is “dual-tasking;” that is, standing or walking while at the same time performing a separate cognitive task (such as reading), a motor task (carrying groceries), or both (walking while talking and carrying a cup of coffee).

Why does dual-tasking (or multitasking) often lead to falls in older adults?

It turns out that the seemingly simple acts of standing upright, or walking down an empty, well-lit hallway, are quite complex. To complete these tasks, we must continuously stabilize our body’s center of mass — a point located just behind our sternum — over the relatively small base of support that we create by positioning our feet on the ground. This control requires quick reflexes, as well as strong muscles of the trunk, hips, legs, ankles, and toes. However, to avoid falling we also need to pay attention to our body and environment, predict and perceive unsafe movements of our body, and adjust accordingly. Our brains need to quickly make sense of information coming from our eyes, ears, and bodies to produce patterns of muscle activity that appropriately adjust our body’s position within the environment.

Therefore, tasks of standing and walking are in fact cognitive tasks, and these tasks require more and more cognitive effort as we grow older and our senses and muscles no longer work as well as they once did. For my grandmother and many others, dual-tasking led to a fall because it diverted shared cognitive resources away from the critical job of controlling her body’s center of mass over her feet on the ground.

The role of our minds in the avoidance of falls is striking

Older adults who are cognitively impaired are more than two times as likely to fall compared to those who are cognitively intact. A recent study by researchers at the Albert Einstein College of Medicine has shown that even subtle differences in the brain’s ability to dual-task when walking are predictive of future falls in healthy older adults. Specifically, the researchers asked their volunteers to walk while completing a word-generation task in their laboratory, and used a technology called functional near-infrared spectroscopy to measure brain activity. Those volunteers who required more brain activity (mental effort) to complete these tasks were more likely to fall during a four-year follow-up period.

Thankfully, these startling studies have a silver lining: they suggest that cognitive function is a promising — and largely untapped — target for the prevention and rehabilitation of falls. In fact, there are several large-scale clinical trials currently underway that are testing the effects of computer-based cognitive training on balance, mobility, and falls in older adults (see here and here). There is also strong evidence that a physical therapy program that asks patients to balance while completing cognitive tasks like counting backwards significantly reduces the incidence of falls in stroke survivors.

It seems like only a matter of time before cognitive and dual-task training become mainstays of fall prevention programming in older adults. In the meantime, if you are worried about falling, or feel like your balance is slipping, you might consider the following:

• Be aware of your surroundings. Try to minimize distractions if and when you find yourself standing in a crowded room, walking down an uneven sidewalk, or in a hurry to get to an appointment. In these situations, avoid answering your cellphone, keep conversations light, and prioritize your balance above all else.
• Keep your mind sharp. Cognitive decline is not an unavoidable consequence of aging. There are evidence-based tips for maximizing your mental abilities into older age.
• Consider joining a group activity class focused on tai chi, yoga, or dance. These safe mind-body exercises have proven effective for improving balance and even reducing falls in numerous populations of older adults.
• Remember that falls rarely occur due to a single factor, like poor muscle strength, fatigue, or reduced vision. Instead, they usually occur when multiple factors combine to cause an irrecoverable loss of balance. Multifactorial strategies therefore appear to be the best “medicine” for the avoidance of falls over time.

The post The role of our minds in the avoidance of falls appeared first on Harvard Health Blog.

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Bill to help people with addictions get medication-assisted treatments moves; advocates say insurers killed the last one

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- A bill to help people with opioid and alcohol addictions to get prescription drugs to treat their substance-use disorders -- the recognized standard of drug treatment -- passed unanimously out of committee Thursday and now heads to the full House.

Kimi Banta, Rep. Kim Moser, Dr. Shawn Ryan

House Bill 389, sponsored by Rep. Kim Moser, R-Taylor Mill, would ban the requirement of "prior authorization" for any prescription drug that is used in the treatment of alcoholism or opioid-use disorder and contains methadone, buprenorphine or naltrexone, which are the recommended first courses of treatment for most patients.

Under prior authorization, insurance companies require health-care providers to get the insurer's approval for certain drugs and procedures before they can be administered.

"Your treatment could be delayed anywhere from several hours to several weeks because of the prior authorization rules that insurance companies have in place," Moser told the House Banking and Insurance Committee. "Ultimately, your health-care provider knows what is best for you . . . but unfortunately, they are not always the ones to make the final decision."

Starting Jan. 1, a law passed during the last legislative session gave insurers five days or less to give or deny approval of a drug, allowing some maintenance drugs used to treat chronic conditions to be approved for up to a year.

Moser, whose main job between 2014 and 2018 was Northern Kentucky director of the state Office of Drug Control Policy, talked about the dangers such delays have for people with addictions, often resulting in relapse or death from overdose.

She also said immediate access to these "life-saving treatments" is imperative because the window for when a person is ready and willing to seek treatment for addiction is often very short.

"The evidence is clear, treatment works," she said. "It helps keep people out of jail, it helps them stay in jobs, it helps them be productive members of society and family members, but most importantly, it saves lives."

This claim is well supported. Most recently, a study published Feb. 5 in JAMA Network Open compared six treatment plans for nearly 41,000 adults with opioid-use disorder between 2015 and 2017 and found that patients who were treated with buprenorphine or methadone were 76 percent less likely to overdose within three months and 59% less likely in 12 months, compared to those who did not get these drugs but participated in other types of treatment.

The same patients were 32% less likely to go to the emergency room or be admitted to the hospital in three months, and 26% less likely in 12 months.

Only 12.5% of the patients in the study were prescribed buprenorphine or methadone, citing a lack of access to doctors who can prescribe those drugs; high co-payments; prior-authorization requirements; "and other restrictions on use," the study said.

Kimi Banta of Louisville told the committee that as an alcohol and an addict in recovery, "Medically assisted treatment has saved my life."

She said "after years and years of failed attempts to stop my drug use," she was prescribed Suboxone, which is a combination of buprenorphine and naloxone, a drug that reverses an opioid overdose, and that has allowed her to stay sober for two years and rebuild her life.

"I am a changed person and Suboxone bought me the time to do it all," she said. "More Kentuckians deserve this opportunity and should not have to jump through hoops to get medication that can change their life and their families life. This bill will save lives."

Moser, who chairs the House health committee, said the bill is supported by American Medical Association, the Kentucky Medical Association, the American Society of Addiction Medicine, the Kentucky Society of Addiction Medicine and treatment providers everywhere.

KMA President Dr. Brent Wright said in a news release, "This legislation will remove a critical barrier to ending Kentucky’s ongoing overdose and death epidemic. We support this bill because it will save lives."

A similar measure passed the House 97-0 last year, but was not given a hearing in a Senate committee. The joint  KMA and AMA news release says last year's bill "was ultimately defeated by opposition from health-insurance companies."

Kentucky's Medicaid program and some insurance companies have voluntarily lifted prior authorization for some medication-assisted treatments. Moser said her bill would codify this requirement for all three drugs in the Medicaid system and with private insurers.

Moser told Kentucky Health News, "There are patients who when they are ready for treatment for their addiction, they need these medications right away so that they don't go back out and use and overdose and die -- and we are seeing that. That's why [this bill] is so critical."

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What’s new with the Nutrition Facts label?

The Nutrition Labeling and Education Act of 1990 (NLEA) mandated nutrition labeling on most packaged foods. These include canned and frozen foods, breads, cereals, desserts, snacks, beverages, and a variety of other foods that line the aisles of grocery stores. Food labels — officially called Nutrition Facts labels — are intended to help consumers choose healthy foods. It is the FDA’s responsibility to make sure that foods are properly labeled.

Over the years there have been many changes to the initial law, and to the label. The newest version of the food label rolled out on January 1, 2020 for larger food manufacturers; smaller manufacturers have until January 1, 2021 to introduce the new labels.

Here’s a rundown of features you’ll encounter on the new food labels.

Serving size

The new food label shows “servings per container” and “serving size” in a larger font size and a bolder type. Per the NLEA, serving sizes must be based on the Reference Amounts Customarily Consumed (RACCs) — that is, the amounts that people are actually eating, not what recommendations suggest they should be eating. The amounts that people eat and drink have changed since 1993, when the previous serving size requirements were published. For example, in 1993 the reference amount used for a serving of soda was 8 ounces; it will now be 12 ounces. A serving of ice cream has also increased, from 1/2 cup to 2/3 cup.

For packages that are between one and two servings, such as a 15-ounce can of soup, the label will now treat the package as a single serving, since people usually consume it at one time.

Certain foods and beverages that are larger than a single serving but could be eaten in one sitting will now display two columns: one showing calories and other nutrients per serving, the other showing the same information for the entire package.

Calories

Calories will now be displayed much more prominently on the label. But you’ll no longer see “calories from fat” on the food label, since research has shown that the type of fat in a food is more important than the amount of fat.

Added sugars

One of the biggest changes is that the new food labels will specify the amount of added sugar — sugars that are added during food processing. Added sugars are a bigger concern than natural sugars, which occur naturally in all foods that contain carbohydrates, including fruits and vegetables, grains, and dairy products.

Research shows that it is difficult to meet nutritional needs while staying within calorie limits if you consume more than 10% of your total daily calories from added sugar (added sugars will appear on the label in both grams and percent daily value). Too much added sugar can also lead to weight gain and other health problems, including diabetes and heart disease.

Dietary fiber

The FDA definition of fiber, which is used as a guideline for what appears on food labels, includes both naturally occurring fibers and fibers added to foods that show a physiological health benefit. Fiber is naturally present in vegetables, whole grains, fruits, cereal bran, flaked cereal, and flours. In addition, some nondigestible carbohydrates that are added to food also meet the FDA’s definition of dietary fiber, and are accounted for in the dietary fiber value on the new food label.

Nutrients and daily values

The list of nutrients that appear on the food label has been updated. Vitamin D and potassium will now be required; vitamins A and C will no longer be required, since deficiencies of these vitamins are rare today. Calcium and iron will continue to be required. Manufacturers must declare the actual amount, in addition to percent daily value, of vitamin D, calcium, iron, and potassium. In the old food label, manufacturers only needed to include percent daily value of these nutrients.

Daily values are reference amount of nutrients to consume or not to exceed, and are used to calculate the daily value percentages on the label. This can help the consumer use the nutrition information in the context of a total daily diet. They are based on 2,000 calories, which is a reference number of calories for general advice. Individuals may need less or more than 2,000 calories per day depending upon their specific needs.

The daily values for nutrients like fiber, sodium, vitamin D, and potassium have all been updated based on the most recent research from the Institute of Medicine, and the 2015 Dietary Guidelines Advisory Committee Report used in the development of the 2015–2020 Dietary Guidelines for Americans.

With its more realistic measure of serving size and emphasis on calories and added sugars, the new food label has the potential to help consumers make healthier food choices.

Source: FDA

The post What’s new with the Nutrition Facts label? appeared first on Harvard Health Blog.

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As coronavirus spreads, many questions and some answers

The rapid spread of COVID-19 has sparked alarm worldwide. The World Health Organization (WHO) has declared a global health emergency, and many countries are grappling with a rise in confirmed cases. In the US, the Centers for Disease Control and Prevention (CDC) is advising people to be prepared for disruptions to daily life that will be necessary if the virus spreads within communities.

Below, we’re responding to a number of questions about COVID-19 raised by Harvard Health Blog readers. We hope to add further questions and update answers as reliable information becomes available.

Does the virus spread person-to-person?

What is the incubation period for the virus?

What are the symptoms?

Can people who are asymptomatic spread the virus?

Can the virus live on fabric, carpet, and other soft surfaces? What about hard surfaces?

Should I wear a face mask? Should my children?

Should someone who is immunocompromised wear a face mask?

Should I accept packages from China?

an I catch the virus by eating food prepared by others?

Should I travel on a plane with my children?

Is there a vaccine available?

Is there a treatment available?

How is this virus confirmed?

How deadly is COVID-19?

What should people do if they think they have the virus or their child does? Go to an urgent care clinic? Go to the ER?

Can people who recover from the virus still be carriers and therefore spread it?

Does the virus spread person-to-person?

Yes, the virus can spread from one person to another, most likely through droplets of saliva or mucus carried in the air for up to six feet or so when an infected person coughs or sneezes, or through viral particles transferred when shaking hands or sharing a drink with someone who has the virus.

Often it’s obvious if a person is ill, but there have been some cases where people who did not yet feel sick had the virus and could spread it.

Basic steps for avoiding flu and other infections—including steps for handwashing shown in this video—are likely to help stop the spread of this virus. The CDC has a helpful list of preventive steps.

Quarantines and travel restrictions now in place in many counties, including the US, are also intended to help break the chain of transmission. Public health authorities like the CDC may recommend other approaches for people who may have been exposed to the virus, including isolation at home and symptom monitoring for a period of time (usually 14 days), depending on level of risk for exposure. The CDC has guidelines for people who have the virus to help with recovery and prevent others from getting sick.

What is the incubation period for the virus?

An incubation period is the time between catching an illness and showing symptoms of the illness. Current estimates suggest that symptoms of COVID-19 usually appear within around five days or less in most cases, but the range could be between one and 14 days.

What are the symptoms?

Fever, dry cough, trouble breathing, and sometimes pneumonia are the common symptoms of COVID-19. There have been some reports of gastrointestinal symptoms (nausea, vomiting, or diarrhea) before respiratory symptoms occur, but this is largely a respiratory virus.

Those who have the virus may have no obvious symptoms (be asymptomatic) or symptoms ranging from mild to severe. In some cases, the virus is life-threatening or fatal.

Currently, it seems that most people who get sick will recover from COVID-19. Recovery time varies and, for people who are not severely ill, may be similar to the aftermath of a flulike illness. People with mild symptoms may recover within a few days. People who have pneumonia may take longer to recover (days to weeks). In cases of severe, life-threatening illness, it may take months for a person to recover, or the person may die.

Can people who are asymptomatic spread the virus?

A person who is asymptomatic may be shedding the virus and could make others ill. How often asymptomatic transmission is occurring is unclear.

Can the virus live on fabric, carpet, and other soft surfaces? What about hard surfaces?

Currently, there’s no evidence that the virus can be transmitted from soft surfaces like fabric or carpet to humans.

It’s possible that the virus could be on frequently-touched surfaces, such as a doorknob, although early information suggests viral particles would be likely to survive for just a few hours, according to the WHO. This also assumes that someone who is sick with the virus has touched a surface after sneezing or coughing into their hand or rubbing their eye. That’s why personal preventive steps like frequently washing hands with soap and water or an alcohol-based hand sanitizer, and wiping down often-touched surfaces with disinfectants or a household cleaning spray, are a good idea.

Should I wear a face mask? Should my children?

Follow public health recommendations where you live. Currently, face masks are not recommended for the general public in the US. Your risk of catching the virus in the US is likely to be low, since there is little evidence of community transmission at this time. At this writing, only one confirmed case in the US is unrelated to travel to China or close contact with travelers from China.  Even though there are some confirmed cases of COVID-19 in the US, you’re much more likely to catch and spread influenza (the flu). (So far this season, there have been nearly 30 million cases of flu and 17,000 deaths.)

Some health facilities require people to wear a mask under certain circumstances, such as if they have traveled from the city of Wuhan, China or surrounding Hubei Province, or have been in contact with people who did or with people who have confirmed coronavirus.

If you have respiratory symptoms like coughing or sneezing, experts recommend wearing a mask to protect others. This may help contain droplets containing any type of virus, including the flu, and protect close contacts (anyone within three to six feet of the infected person).

The CDC offers more information about masks. The WHO offers videos and illustrations on when and how to use a mask.

Should someone who is immunocompromised wear a mask?

If you are immunocompromised because of an illness or treatment, talk to your doctor about whether wearing a mask is helpful for you in some situations. We are currently in the middle of a flu epidemic in the US. By contrast, we have limited cases of COVID-19 and no evidence of sustained person-to-person transmission in our communities. At this time, it wouldn’t make sense for someone who is immunocompromised to wear a mask when in public to decrease risk for catching COVID-19. However, if your healthcare provider advises you to wear a mask when in public areas because you have a particularly vulnerable immune system, follow that advice. But if masking has not been recommended to you to protect against the flu and numerous other respiratory viruses, then it doesn’t make sense to me to advise wearing a mask to protect against COVID-19 at this time.

Should I accept packages from China?

There is no reason to suspect that packages from China harbor COVID-19. Remember, this is a respiratory virus similar to the flu. We don’t stop receiving packages from China during their flu season. We should follow that same logic for this novel pathogen.

Can I catch the virus by eating food prepared by others?

We are still learning about transmission of COVID-19. It’s not clear if this is possible, but if so it would be more likely to be the exception than the rule. That said, COVID-19 and other coronaviruses have been detected in the stool of certain patients, so we currently cannot rule out the possibility of occasional transmission from infected food handlers. The virus would likely be killed by cooking the food.

Should I travel on a plane with my children?

Keep abreast of travel advisories from regulatory agencies and understand that this is a rapidly changing situation. At this writing, most travel throughout the world is unrestricted (exceptions include China and now South Korea). I recently flew with my son and his friend and did not bring any type of masks.

Of course, if anyone has a fever and respiratory symptoms, that person should not fly if at all possible, but anyone who has a fever and respiratory symptoms and flies anyway should wear a mask on an airplane.

Is there a vaccine available?

No vaccine is available, although scientists are working on vaccines. In 2003, scientists tried to develop a vaccine to prevent SARS but the epidemic ended before the vaccine could enter clinical trials.

Is there a treatment available?

Currently there is no specific antiviral treatment for COVID-19. Treatment is therefore supportive, which means giving fluids, medicine to reduce fever, and, in severe cases, supplemental oxygen. People who become critically ill from COVID-19 may need a respirator to help them breathe. Bacterial infection can complicate this viral infection. Patients may require antibiotics in cases of bacterial pneumonia as well as COVID-19.

Antiviral treatments used for HIV and other compounds are being investigated.

There’s no evidence that supplements, such as vitamin C, or probiotics will help speed recovery.

How is this virus confirmed?

A specialized test must be done to confirm that a person has COVID-19. Most testing in the US has been performed at the CDC. However, the goal is to send test kits to state laboratories so testing can be performed locally.

How deadly is COVID-19?

We don’t yet know. However, signs suggest that many people may have had mild cases of the virus and recovered without special treatment.

Very early in this epidemic, it looked like about 20% of cases were severe. People developed acute respiratory distress syndrome (ARDS), which causes tiny air sacs in the lungs to fill with fluid, crowding out air so that not enough oxygen can reach the bloodstream.

As of February 25, 2020, the reported confirmed cases and deaths in China suggest the mortality rate is roughly 3%. It is important to remember that early on in an epidemic there is a “tip of the iceberg” phenomenon where we overestimate more severe cases and mild or asymptomatic cases go unrecognized, so the mortality seems higher than the reality. That may be happening when we speak of up to 3% mortality. By contrast, SARS had a mortality rate of around 10%; the MERS mortality rate is closer to 30% to 40%. There appear to be many more COVID-19 cases confirmed than there were with SARS and MERS.

What should people do if they think they have the virus or their child does? Go to an urgent care clinic? Go to the ER?

If you have a health care provider or pediatrician, call them first for advice. If you live in the US, it’s far more likely to be the flu or another viral illness.

If you do not have a doctor and you are concerned that you or your child may have COVID-19, contact your local board of health. They can direct you to the best place for evaluation and treatment in your area.

Only people with symptoms of severe respiratory illness should seek medical care in the ER. Severe symptoms are rapid heart rate, low blood pressure, high or very low temperatures, confusion, trouble breathing, severe dehydration. Call ahead to tell the ER that you are coming so they can be prepared for your arrival.

Can people who recover from the virus still be carriers and therefore spread it?

People who get COVID-19 need to work with providers and public health authorities to determine when they are no longer contagious.

Reliable resources:

• WHO coronavirus web site and answers to frequently asked questions
• WHO coronavirus mythbusters page
• CDC coronavirus web site and answers to frequently asked questions

Also, read our earlier blog posts on coronavirus:

• The new coronavirus: What we do — and don’t — know
• Be careful where you get your news about coronavirus
• Coronavirus: What parents should know and do

The post As coronavirus spreads, many questions and some answers appeared first on Harvard Health Blog.

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New study compares long-term side effects from different prostate cancer treatments

Prostate cancer therapies are improving over time. But how do the long-term side effects from the various options available today compare? Results from a newly published study are providing some valuable insights.

Investigators at Vanderbilt University and the University of Texas MD Anderson Cancer Center spent five years tracking the sexual, bowel, urinary, and hormonal status of nearly 2,000 men after they had been treated for prostate cancer, or monitored with active surveillance (which entails checking the tumor periodically and treating it only if it begins to grow). Cancers in all the men were still confined to the prostate when diagnosed.

Dr. Karen Hoffman, a radiation oncologist at MD Anderson and the study’s first author, said the intent was to provide information that could help men choose from among the various therapeutic options. “Surgical and radiation techniques have changed significantly in the last few decades, and at the same time, active surveillance has become an increasingly acceptable strategy,” she said. “We wanted to understand the adverse events associated with contemporary approaches from the patient’s perspective.”

Roughly two-thirds of the men enrolled in the study had “favorable risk” cancer, which is nonaggressive and slow-growing. A quarter of these men chose active surveillance, and the rest were treated with one of three different methods:

• nerve-sparing prostatectomy (an operation to remove the prostate with the intent of sparing the nerves required for erections)
• external beam radiation therapy (EBRT)
• low-dose rate brachytherapy, which is a method for destroying cancerous tissues with tiny radioactive beads implanted inside the prostate gland.

Men with favorable risk cancer who chose EBRT or active surveillance tended to be older than men who choose surgery, likely because increasing age and illness make prostatectomy harder to tolerate.

The rest of the men in the study were diagnosed with “unfavorable risk” tumors that were more likely to spread. These men were treated either with prostatectomy, or with EBRT combined with drugs that block testosterone (a hormone that fuels growing prostate tumors).

What the results showed

After five years, there were no significant differences in survival associated with any of the selected treatments. Just one man in the favorable risk category died from prostate cancer during the study, and there were eight deaths from the disease in the unfavorable risk group.

Many men in the study had initial problems with sexual, bowel, urinary, and hormonal functioning. Brachytherapy caused more irritative urinary problems during the initial six months than the other treatments, but then those symptoms steadily improved. Brachytherapy and EBRT were associated with minor bowel symptoms such as urgency, bleeding, frequency, and pain that resolved within a year in men from both risk groups.

After five years, differences in side effects between the treatment options had disappeared, with a notable exception: about half the surgically treated men in both the favorable and unfavorable risk groups still had difficulty achieving erections sufficient for intercourse, and between 10% and 13% of them reported ongoing problems with urinary leakage and incontinence. “However, I don’t want anyone to walk away from this analysis thinking they should not get a prostatectomy,” Dr. Hoffman emphasized. “Side effects will differ from person to person.” Furthermore, radiation side effects may still develop even after five years, “and this is something we’re continuing to monitor,” she said. “Our hope is that doctors will use this information to counsel men on expected side effects so they can make an informed choice that is right for them.”

Dr. Marc Garnick, Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, agreed the study provides a valuable resource that adds to existing information. Yet he cautioned against brachytherapy, warning that this particular treatment in some cases has long-term urinary side effects that can significantly alter a patient’s quality of life. “I do not routinely recommend brachytherapy,” Garnick said. “This is especially true in patients with a pre-existing history of urinary tract infections or prostatitis.”

The post New study compares long-term side effects from different prostate cancer treatments appeared first on Harvard Health Blog.

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If you're worried about coronavirus, you should be more worried about the flu, and take the same precautions, including a flu shot

Worried about the novel coronavirus spreading in the United States? Take the same precautions that you would against influenza, which is twice as bad as it was in Kentucky last year and is a much bigger threat, having killed 66 Kentuckians.

That's the advice from the Kentucky Medical Association, its foundation and a statewide health foundation, in the wake of the Feb. 25 warning from the federal Centers for Disease Control and Prevention that coronavirus outbreaks are expected in the United States.  

"While novel coronavirus presents a low risk currently to the majority of populations within the U.S., we do know that the virus can spread rapidly and is transmitted primarily through tiny air droplets and close contact with an infected person," said Dr. Brent Wright, president of KMA and board chair of the Foundation for a Healthy Kentucky.

"The good news is we already know how to prevent the spread of such a virus, since protocols for it are nearly identical to those for the flu, which remains a much greater threat to public health currently. . . . While coronavirus is scary, we can be confident that we are doing everything we can to prevent it by treating the threat of the virus the same manner we do the flu."

The flu vaccine won't work against the novel coronavirus, but having the flu weakens the immune system, leaving unvaccinated people more susceptible to contracting other illnesses, including coronavirus. "It isn't too late to get a flu shot, even if you've already had a bout of flu this season," the foundation said in a press release with the KMA and its foundation, the Kentucky Foundation for Medical Care. Flu season usually runs into May.

"Symptoms of coronavirus also closely resemble influenza, so patients are encouraged to consult with their doctor if they are experiencing fever, cough and shortness of breath," the release says. "Health officials have also emphasized that proper hand washing is the most effective way to prevent the spread of both novel coronavirus and influenza."

"Washing your hands with warm soap and water, for at least 20 seconds, as frequently as possible, helps prevent the spread of germs more than anything else," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky. "Covering your mouth when you sneeze or cough and staying away from others when you are sick are also common-sense practices we should be utilizing during all seasons, but particularly to prevent respiratory illnesses like the flu and coronavirus."

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Bill would let health professionals refuse treatment that violates their conscience; critics say it would put discrimination into law

A bill to allow health-care professionals to refuse to provide treatment that violates their conscience is nearing a floor vote in the state Senate. 

Sen. Stephen Meredith

Senate Bill 90, sponsored by Sen. Stephen Meredith, R-Leitchfield, would also exempt providers from liability for exercising their rights and allow individuals to sue if they have been injured through disciplinary action, such as being fired or demoted over a refusal to provide a health-care service.

"Meredith said it is aimed solely at providing protection for health-care workers under pressure to provide certain treatments or medication they oppose in a rapidly changing climate of medical advances," reports Deborah Yetter of the Louisville Courier Journal..

 "This is not intended to deny health care to anyone," Meredith, a retired hospital CEO, told the Senate Judiciary Committee on Feb. 20.

Opponents, including the Kentucky Mental Health Coalition, the Kentucky Association of Sexual Assault Programs, Planned Parenthood and the state Fairness Campaign, argued it could curtail care for health services ranging from abortion and psychological counseling to treatment for rape victims, Yetter reports.

"It's going to put discrimination into the statutes," said Sheila Schuster, a psychologist and executive director of the mental-health coalition.

Several health providers spoke in favor of the bill in committee, including Dr. Steven House, a Glasgow physician who said doctors "should not be forced to participate in treatments that conflict with their morals, religion or their beliefs."

The bill would allow individuals to base their objections on "religious, moral, ethical or philosophical beliefs or principles." It also includes students, such as medical residents or those studying nursing or psychology.

"Critics said the bill is so broadly written that anyone at any health care facility, including the receptionist at the front desk or the janitor cleaning the building, could object to allowing services for someone," Yetter reports.

As approved by the committee, the bill would give insurance companies and self-funded health plans the same rights as health-care providers, but Meredith filed a floor amendment Feb. 24 to take them out of the bill. As of Feb. 25, the bill had still not been posted for a floor vote.

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Dopamine fasting: Misunderstanding science spawns a maladaptive fad

The dopamine fast, created by California psychiatrist Dr. Cameron Sepah, has very little to do with either fasting or dopamine. As Sepah told the New York Times, “Dopamine is just a mechanism that explains how addictions can become reinforced, and makes for a catchy title. The title’s not to be taken literally.” Unfortunately, with such a snazzy name, who could resist? This is where the misconceptions begin.

What’s the thinking behind a dopamine fast?

What Sepah intended with his dopamine fast was a method, based on cognitive behavioral therapy, by which we can become less dominated by the unhealthy stimuli — the texts, the notifications, the beeps, the rings — that accompany living in a modern, technology-centric society. Instead of automatically responding to these reward-inducing cues, which provide us with an immediate but short-lived charge, we ought to allow our brains to take breaks and reset from this potentially addictive bombardment. The idea is that by allowing ourselves to feel lonely or bored, or to find pleasures in doing simpler and more natural activities, we will regain control over our lives and be better able to address compulsive behaviors that may be interfering with our happiness.

The six compulsive behaviors he cites as behaviors that may respond to a dopamine fast are: emotional eating, excessive internet usage and gaming, gambling and shopping, porn and masturbation, thrill and novelty seeking, and recreational drugs. But he emphasizes that dopamine fasting can be used to help control any behaviors that are causing you distress or negatively affecting your life.

You can’t “fast” from a naturally occurring brain chemical

Dopamine is one of the body’s neurotransmitters, and is involved in our body’s system for reward, motivation, learning, and pleasure. While dopamine does rise in response to rewards or pleasurable activities, it doesn’t actually decrease when you avoid overstimulating activities, so a dopamine “fast” doesn’t actually lower your dopamine levels.

Unfortunately, legions of people have misinterpreted the science, as well as the entire concept of a dopamine fast. People are viewing dopamine as if it was heroin or cocaine, and are fasting in the sense of giving themselves a “tolerance break” so that the pleasures of whatever they are depriving themselves of — food, sex, human contact — will be more intense or vivid when consumed again, believing that depleted dopamine stores will have replenished themselves. Sadly, it doesn’t work that way at all.

Fasting may simply be a technique to reduce stress and engage in mindfulness-based practices

Sepah recommends that we start a fast in a way that is minimally disruptive to our lifestyles. For example, we could practice dopamine fasting from one to four hours at the end of the day (depending on work and family demands), for one weekend day (spend it outside on a Saturday or Sunday), one weekend per quarter (go on a local trip), and one week per year (go on vacation).

This all sounds sensible, if not necessarily new or groundbreaking. In fact, it sounds a lot like many mindfulness practices and good sleep hygiene, in the suggestion of no screen time before bed.

However, people are adopting ever more extreme, ascetic, and unhealthy versions of this fasting, based on misconceptions about how dopamine works in our brains. They are not eating, exercising, listening to music, socializing, talking more than necessary, and not allowing themselves to be photographed if there’s a flash (not sure if this applies to selfies).

Misunderstanding science can create maladaptive behaviors

When you think that none of this is actually lowering dopamine, it’s kind of funny! Especially since avoiding interacting with people, looking at people, and communicating with people was never part of Sepah’s original idea. Human interaction (unless it is somehow compulsive and destructive) is in the category of healthy activities that are supposed to supplant the unhealthy ones, such as surfing social media for hours each day. In essence, the dopamine fasters are depriving themselves of healthy things, for no reason, based on faulty science and a misinterpretation of a catchy title.

Taking time out for mental rejuvenation is never a bad thing, but it’s nothing new

The original intent behind the dopamine fast was to provide a rationale and suggestions for disconnecting from days of technology-driven frenzy and substituting more simple activities to help us reconnect us with ourselves and others. This idea is noble, healthy, and worthwhile, but it’s certainly not a new concept. Most religions also suggest a rest day (for example, the Jewish Sabbath) or holidays without technological distractions, so that you can reflect and reconnect with family and community, Thousands of years of meditation also suggests that a mindful approach to living reaps many health benefits.

Unfortunately, the modern wellness industry has become so lucrative that people are creating snappy titles for age-old concepts. Perhaps that is how to best categorize this fad, if only we can get its proponents to look at us or speak to us, without disturbing their dopamine levels, in order to explain this to them.

The post Dopamine fasting: Misunderstanding science spawns a maladaptive fad appeared first on Harvard Health Blog.

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Co-parent adoption: A critical protection for LGBTQ+ families

Every child deserves to be part of a loving family, and establishing a secure legal relationship known as parentage between parents and their children is critical to the well-being of all families. This provides stability and security for children and allows parents to care for their children, including making important medical decisions. For LGBTQ+ families, co-parent adoption ensures that parents have a secure legal relationship to their child.

What is co-parent adoption?

Co-parent adoption (also called “second parent adoption”) is the legal process of adopting a partner’s biological or legal child, when a person is not biologically or legally related to the child. This may be the case if the parents used donated sperm or eggs to create their family, or if one partner had children prior to the relationship, either through adoption or biological means. Co-parent adoption can be used to establish a legal relationship in any of these cases. (This post focuses on families created with donated sperm or eggs.)

Why is co-parent adoption important?

Because adoption decrees must be honored in all US states and jurisdictions, they are the best way to ensure that the legal status of both parents is recognized. Birth certificates are not considered as legally strong as adoption decrees. If a co-parent is on a state birth certificate due to marriage, but hasn’t legally adopted their child, the co-parent might not be treated as a legal parent outside of the state where the child was born. This may be critical in certain situations, such as when a child needs emergency health care.

Why is co-parent adoption especially important for families with same-gender parents?

Because of outdated assumptions about parents and families, the parental rights of same-gender parents may be questioned more often than those of a family with a mother and father — even when one parent is not genetically related to the child.

Consider the following scenario: A married same-gender female couple has a baby using sperm from a donor. Both mothers are listed as parents on their child’s birth certificate because they are married to one another. When the child is 5 years old, the family is traveling in another US state and there is a car accident. The gestational mother and child are both hurt. While the gestational mother is in surgery and unable to give consent, time-sensitive medical decisions must be made about their child. In the state the family is visiting, the nongestational mother’s legal relationship to her child is questioned, because she did not give birth to the child and that state does not honor a birth certificate with two mothers listed as the parents. Because the hospital questions the nongestational mother’s right to consent for her child’s treatment, the doctors decide the course of treatment.

All states must honor an adoption decree, so the nongestational mother in this scenario would be able to make medical decisions for her child if she had adopted the child through co-parent adoption.

And even though some states now allow unmarried parents to sign a Voluntary Acknowledgment of Parentage so they can both be on their child’s birth certificate, most unmarried parents also need to complete a co-parent adoption to ensure that the nongestational parent has a legal relationship to their child.

Is co-parent adoption an option for same-gender parents in every state?

Fewer than 20 US states and territories currently permit co-parent adoptions for same-gender parents. In those states, the process varies widely. In Massachusetts, the paperwork is simple enough that parents can file it themselves without the help of a lawyer. In Rhode Island, a family lawyer must file the paperwork, and the nongestational parent must complete numerous steps before the whole family goes to court. Required steps might include: a physical exam; submission of tax returns; fingerprinting for a criminal background check; character letters; a lengthy questionnaire about the parent’s own childhood and parenting beliefs; an advertisement posted in a newspaper to find the donor; and a visit from a social worker to assess the safety of the family’s home.

The co-parent adoption process creates numerous barriers for LGBTQ+ families. Co-parent adoptions may not be financially feasible for some families. The process may also be psychologically difficult, especially if a nongestational parent has planned for the birth of their child and cared for them since birth. To have to prove their commitment to their child may feel unnecessary and invasive. Having a social worker visit the family’s home may make both parents feel vulnerable.

Improving co-parent adoption laws

GLBTQ Legal Advocates & Defenders and others are working to legalize co-parent adoptions in states where it is not yet available, and simplify the process in states where it is available. As one example, a group of parents in Rhode Island is currently working to simplify the co-parent adoption process to make it more attainable for families. You can help these efforts by

• educating yourself about laws on parentage and co-parent adoption in your state
• writing letters to state legislators or testifying at the statehouse when co-parent adoption laws are being considered
• sharing your story if you have gone through the co-parent adoption process, or faced barriers to securing a legal relationship to your child
• providing emotional or financial support to families going through the co-parent adoption process.

For more information

National Center for Lesbian Rights

Family Equality Council

Academy of Adoption & Assisted Reproduction Attorneys can help with finding a qualified adoption lawyer

The post Co-parent adoption: A critical protection for LGBTQ+ families appeared first on Harvard Health Blog.

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Puffing away sadness

Ask a smoker what they get out of cigarettes and they are likely to talk about pleasure, contentment, and an overall good feeling. Nicotine, the active ingredient in cigarettes, is a stimulant. Used in low doses like those delivered by combustible cigarettes, stimulants activate the nervous system, resulting in enhanced arousal and alertness. Nicotine binding in the limbic system — the part of the brain that houses the pleasure and reward center — releases dopamine, resulting in feelings of euphoria. These effects combine to give smokers a boost in their mood.

In this context, new research from a team at Harvard University, that found that when smokers feel sad they reach for cigarettes and inhale longer and deeper, is not surprising. Cigarettes are a “solution” to the “problem” of sadness that smokers seem to learn to use effectively. This new research is the first to show that sadness elicits nicotine use much more than other negative emotions, and that sad feelings are not only associated with smoking, but can actually cause it.

Smoking may blunt an adaptive and necessary emotion

Sadness is a basic emotion, typically felt in response to loss. The experience of sadness and the underlying neurobiology is universal. Sadness that is too intense or too prolonged — i.e., depression — is a disorder that results in dysfunction. But normal sadness has an adaptive function: people experiencing sadness focus their attention internally and become better problem solvers.

The expression of sadness is physiologically determined. Humans can reliably read sadness on each other’s faces independent from cultural cues, and these signals provoke empathy from others — another benefit to the individual who is sad. In this regard sadness, while unpleasant, has its upsides; its universality is an indication of its survival advantage.

While smokers get immediate relief from sadness with a cigarette, that may come at a cost if they also lose these adaptive benefits. “Treatment” of sad emotional states with nicotine over time may also impair innate restorative responses, just as treatment of chronic pain with opioids results in many patients experiencing hyperalgesia, a pathologically heightened response to painful stimuli. Indeed, this may help to explain the association between smoking and depression.

Part of maturing is learning to manage emotions

Compared with adults, adolescents experience emotions more strongly; with maturity they transition from the emotional reactivity typical of this age group to the more tempered presentation of adults. When it comes to sadness, reactivity and response are age-dependent: the triggering content of sadness is less tightly coupled with physiologic responses in the young compared to mature adults. Experience appears to be a crucial component of the maturational process.

What happens when adolescents use nicotine to blunt their sadness?

Does smoking interrupt emotional maturation, making young smokers susceptible to depression? Does disruption in emotional maturity make adolescent smokers more likely to use other drugs? The short answer to all of these questions is that we do not know, but there is reason to be concerned, because we do know that smoking is associated with increased risk of depression, marijuana use, binge drinking, and use of other drugs including opioids. Since most smokers start using cigarettes during their teen years, these questions have real salience.

After 20 years of dramatic decline in the rates of smoking among high school students, and a more gradual decline among adults, e-cigarettes and vaping devices have begun to reverse these trends. The new findings demonstrating the linkage between sadness and smoking should give us all pause. While the health impacts of smoking have been well documented over the past 50 years, we are still learning about the impacts of nicotine.

The post Puffing away sadness appeared first on Harvard Health Blog.

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House passes public-assistance bill with plan for temporary health coverage for people who earn too much to stay on Medicaid

By Melissa Patrick
Kentucky Health News

A bill aimed at moving Kentuckians off public assistance includes several health-related provisions, including a new coverage plan for people who lose their Medicaid benefits if their income rises above the limit for the program.

House Speaker Pro Tem David Meade
presents House Bill 1. (LRC photo)

A heavily revised version of House Bill 1 passed the House Feb. 21 by a vote of 58-32. It was along party lines, except one Democrat who voted for it: Rep. John Sims of Flemingsburg.

Other Democrats said the bill was rushed, but Speaker Pro Tem David Meade, R-Stanford, its lead sponsor, said "We are trying to find a good balance between compassion to help those folks in those situation who truly need care and help in these public assistance programs, but also a balance of accountability."

Most of the bill is aimed at cracking down on fraud, but a major part of it would provide a temporary state health-insurance option for Kentuckians who stop being eligible for Medicaid because their income exceeds 138 percent of the federal poverty level, $17,609 for a single person. It would be available for those earning up to 200% of the poverty line, $25,520 for an individual.

This provision addresses the "benefit cliff," the term for the loss of public benefits by people whose earnings exceed limits for programs but who are unlikely to have jobs with health insurance or the money to afford it. Republicans said they had heard stories of people who ask employers not to give them raises so they can keep their Medicaid benefits.

This health insurance program would require premiums and cost sharing to rise 25% for every 15% in income above 138% of the poverty line. Participants could stay in the program for a year after exiting Medicaid, with a possibility of extension on a case-by-case basis. The plan would also extend for five months their benefits under the Supplemental Nutrition Assistance Program, formerly food stamps.

SNAP is a major focus of the bill, as is Temporary Assistance for Needy Families. It would remove form the programs individuals who fraudulently misuse their benefits card, or are completely able-bodied adults with no dependents who choose not to participate in a community engagement program, including work, school or volunteering. It would expand many benefits, with task groups formed to explore further expansions.

Democratic objections

Some Democrats said they agreed with the goals of the bill, but said it was rushed. They questioned its enforcement costs and said it would lead to lawsuits.

"Although there are good elements in this piece of legislation that I'm glad to see move forward, they are really stamped and trampled on by the bad parts of this legislation," said Rep. Charles Booker, D-Louisville.

Meade said, "What you're hearing today is, we like the expansion of benefits, we want to continue to give people more but we don't want to hold anyone accountable," Meade said.

The House adopted two amendments from Rep. Kim Moser, R-Taylor Mill, one of which had to do with health. It would require the state to apply for a waiver of the rules to allow Medicaid to pay for substance-use disorder treatment for people who are incarcerated.

The bill would ban from Medicaid and other programs people who violate the rules.

For example, those who are convicted of a drug-related felony who are released from incarceration and fail to sign up for substance-use treatment within 90 days of release would be banned from getting Medicaid, but the bill makes provisions for regaining coverage.

Dustin Pugel, policy analyst for the Kentucky Center for Economic Policy, wrote that "a similar ban in SNAP in Kentucky has led to thousands losing food assistance and likely more who never applied due to a past conviction." Further, he writes that "Medicaid law doesn't allow bans contingent on recovery status or for people with a drug-related felony conviction."

If passed, Gov. Andy Beshear's administration would be required to implement the measures within 120 days. Beshear said Friday, "I want to continue to see where they're going, but I don't believe in a system that pushes people off of benefits." Mark Vanderhoff reports for WLKY-TV.

Beshear added, "I believe in a system that encourages people and gives them the tools to get jobs with higher wages where you naturally move off of them. I believe in providing people opportunity -- not consequences."

Medicaid work requirements?

Reflecting Republicans' concern about the cost of the 2014 Medicaid expansion, the bill says that if the state General Fund appropriation for this population reaches half of General Fund spending on Medicaid overall, those who have been on the expansion for a year would have to participate in at least 80 hours a month of "qualifying activities," presumably work, school or volunteering.

That seems unlikely; the Kentucky Center for Economic Policy reports that it is currently only 10.7% of the budget. Such requirements were an integral part of former Gov. Matt Bevin's plan to overhaul the state's Medicaid program. It and a similar plan in Arkansas were blocked twice by a federal judge, and Beshear rescinded the plan soon after taking office in December.

Several lawmakers predicted that this part of the bill would be challenged in court, noting that a federal appeals court recently upheld the rulings against Arkansas's plan. The Supreme Court may or may not hear an appeal.

Meade said it is "well worth the risk" of a legal challenge to these community engagement requirements for able-bodied workers because they have been shown to move people off public assistance and increase their income in other states.

Concerns about fraud

Mich of the debate was around the issue of fraud in public assistance programs, an issue that Rep. Nima Kulkarni, D-Louisville, said likely has to do more with perception than reality.

The U.S. Department of Agriculture reports that public-assistance fraud is 1%, and it was mentioned during the debate that it's reported at 2% in Kentucky.

"My concern here is that we are ignoring actual facts, actual numbers . . . and going with opinions and potential numbers that are not in existence, that we have not heard about in this body," Kulkarni said. "In our zeal to counteract the tiny fraction of fraud that may be occurring in Kentucky, we are potentially impacting millions of lives that are using these programs to simply lift their families out of poverty, to put food on the table at night. I really urge the body to think long and hard about the unintended consequences of this bill to those individuals that are properly using the benefits that they so desperately need."

Early in the two-and-a-half-hour debate, Meade corrected a statement he made Feb. 20 that there were studies showing upwards of 40% of fraud in public assistance programs. He corrected that to say that a group had told him that with its current detection systems, Kentucky was likely only catching 30 to 40% of the fraud in the system. When asked who that group was, he declined to answer. But he said he thinks it is higher than 2% because people are very creative when they commit fraud. "To say that we only have a 2 percent fraud rate, that we feel we are catching it all, is just not imaginable in my mind."

But House Minority Leader Joni Jenkins, D-Louisville, said, "I think what we have here is an attempt to go after a gnat, and when you go after a gnat with a sledgehammer, you tend to destroy the whole darn thing."

The bill also includes a provision for Medicaid work and community engagement requirements for some if state funding requirements increase; and a provision to ban some from Medicaid if they break the rules.

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Bill to stop 'shenanigans' of Medicaid drug middlemen moves unanimously to House; sponsor says bill is first of its kind in U.S.

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- A bill to address payment issues between middlemen known as pharmacy benefit managers and pharmacists who fill drugs for Kentuckians on Medicaid passed the Senate unanimously Feb. 20.

Sen. Max Wise presents Senate Bill 50
Photo by LRC Public Information 

PBMs act as middlemen between insurance and drug companies; they determine what drugs are offered, how much someone pays for the drug, and the payments to pharmacists.

Currently, each of the state's five Medicaid managed-care firms contracts with a PBM to manage the state's $1.7 billion-a-year prescription drug business. A revised version of Senate Bill 50, sponsored by Sen. Max Wise, R-Campbellsville, would require the state to hire a single PBM.

Kentucky lawmakers have been working on the PBMs' "shenanigans," as Wise called them, for years, with little headway.

This bill furthers those efforts with measures to combat billing practices that Kentucky pharmacists have long said are so unfair that they are putting some of the state's pharmacies out of business.

Wise said one such pharmacy was Sacramento Pharmacy in McLean County, noting that Gregg Henry, a pharmacist and the store's owner, had reached out to him many times over the past year about this issue.

Henry told Renee Beasley Jones of the Owensboro Messenger-Inquirer that he was closing his store after seven years because of the low reimbursements paid by the PBMs, which started in 2017. He said he lost $5,000 in January alone because of recent cuts.

"This little bitty pharmacy in this little bitty community stood up," Henry told Jones in reference to at least two years of fighting against the PBMs. "I hope the Sacramento Pharmacy is able to put a face on SB 50. And I hope our martyrdom creates a wake-up call about the absolute necessity for the passage of this legislation."

SB 50 addresses several PBM practices that have hurt Kentucky pharmacies.

For example, it would prohibit the state PBM from requiring Medicaid recipients to get specialty drugs from a pharmacy that is owned or operated by the PBM; require the PBM to pay the managed-care firm the actual discounted pharmacy price negotiated with the pharmacy network, or "pass-through pricing;" prohibit spread pricing, in which a PBM keeps the difference between what it bills Medicaid for medications and what it pays the pharmacy to dispense the drug; and prohibit a whole list of fees.

"This doesn't just fix the problem. This fixes a social injustice that has been cast upon pharmacists throughout the state," Sen. Stephen Meredith, R-Leitchfield, told the Senate.

Wise's original bill called for a complete carve-out of pharmacy from the Medicaid program, which would have gotten rid of the PBMs in Medicaid managed care altogether.

That brought a backlash from the Kentucky Hospital Association, the Kentucky Association of Health Plans and the Kentucky Primary Care Association, which includes federally qualified health centers; all said a carve-out would hurt a federal drug-discount program known as 340B -- the savings from which allows safety-net hospitals and community health centers to expand health programs to the communities they serve.

Sen. Stan Humphries, R-Cadiz, told the Senate that in southwestern Kentucky, "The loss of the 340B drug program would be detrimental to the point of closing doors for some rural hospitals."

After much negotiation and collaboration with stakeholders, including the Cabinet for Health and Family Services, Wise said the bill protects both pharmacies and the 340B program, and is supported by the lobbying groups.

The bill also establishes a single preferred drug list, or formulary, to be used by each managed-care firm, instead of each one having its own separate list; and puts the state Department for Medicaid Services in charge of the reimbursement methodologies, including dispensing fees. An emergency clause would cause it to take effect immediately, so the state PBM will be in place when the new managed-care contracts begin on Jan. 1, 2021.

"We're going to be the first state in the country that is going to do something like this," Wise told Kentucky Health News. "There are going to be a lot of eyes on Kentucky."

Rosemary Smith of the Kentucky Independent Pharmacist Alliance, which represents 500 independent pharmacists, told Kentucky Health News that it supports the bill.

"We are very much in favor of this compromise," she said. "It's not perfect, but it's a step in the right direction and we know we're going to get to where we need to be. . . . This bill will allow us to stay open."

Smith said she and her husband have been forced to close two of their drug stores because of PBMs' low reimbursement rates. They own Jordan Drug pharmacies in Eastern Kentucky.

The Kentucky Pharmacists Association "supports the intent of Senate Bill 50 as amended and is glad the focus can now return to PBMs’ bad actions," it said in a statement. "We thank Sen. Max Wise for his steadfast efforts to hold PBMs accountable and protect community pharmacies and their patients across the commonwealth."

CVS Health, an affiliate of the drugstore chain, which holds most of the state's current PBM business in contracts with manged-care firms, criticized the bill, Deborah Yetter reports for the Louisville Courier-Journal.

"The latest version of SB 50 would be a step backwards for Kentucky’s most vulnerable citizens by fragmenting care coordination and adding additional administrative and financial burden on the commonwealth," a spokesman told Yetter. "Access to high-value, clinically-appropriate care for Kentuckians is a key priority for CVS Health — and we look forward to working with legislators to ensure it’s delivered sustainably.”

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