Is Guinness really ‘good for you’? | CNN

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CNN
— 

Guinness, like other Irish stouts, enjoys a seasonal popularity every St. Patrick’s Day. It has also been touted as being “good for you,” at least by its own advertising posters decades ago.

But can this creamy, rich and filling beer really be added to a list of healthy beverages? Or is its reputation just good marketing? We researched the beer’s history and talked to brewing experts and break out the good, the not-so-great and the ingenuity of Guinness.

The original Guinness is a type of ale known as stout. It’s made from a grist (grain) that includes a large amount of roasted barley, which gives it its intense burnt flavor and very dark color. And though you wouldn’t rank it as healthful as a vegetable, the stouts in general, as well as other beers, may be justified in at least some of their nutritional bragging rights.

According to Charlie Bamforth, distinguished professor emeritus of brewing sciences at the University of California, Davis, most beers contain significant amounts of antioxidants, B vitamins, the mineral silicon (which may help protect against osteoporosis), soluble fiber and prebiotics, which promote the growth of “good” bacteria in your gut.

And Guinness may have a slight edge compared with other brews, even over other stouts.

“We showed that Guinness contained the most folate of the imported beers we analyzed,” Bamforth said. Folate is a B vitamin that our bodies need to make DNA and other genetic material. It’s also necessary for cells to divide. According to his research, stouts on average contain 12.8 micrograms of folate, or 3.2% of the recommended daily allowance.

Because Guinness contains a lot of unmalted barley, which contains more fiber than malted grain, it is also one of the beers with the highest levels of fiber, according to Bamforth. (Note: Though the US Department of Agriculture lists beer as containing zero grams of fiber, Bamforth said his research shows otherwise.)

Bamforth has researched and coauthored studies published in the Journal of the Institute of Brewing and the Journal of the American Society of Brewing Chemists.

Here’s more potentially good news about Guinness: Despite its rich flavor and creamy consistency, it’s not the highest in calories compared with other beers. A 12-ounce serving of Guinness Draught has 125 calories. By comparison, the same size serving of Budweiser has 145 calories, Heineken has 142 calories, and Samuel Adams Cream Stout has 189 calories. In the United States, Guinness Extra Stout, by the way, has 149 calories.

This makes sense when you consider that alcohol is the main source of calories in beers. Guinness Draught has a lower alcohol content, at 4.2% alcohol by volume, compared with 5% for Budweiser and Heineken, and 4.9% for the Samuel Adams Cream Stout.

In general, moderate alcohol consumption – defined by the USDA’s dietary guidelines for Americans as no more than two drinks per day for men or one drink per day for women – may protect against heart disease. So you can check off another box.

Guinness is still alcohol, and consuming too much can impair judgment and contribute to weight gain. Heavy drinking (considered more than 14 drinks a week for men or more than seven drinks a week for women) and binge drinking (five or more drinks for men, and four or more for women, in about a two-hour period) are also associated with many health problems, including liver disease, pancreatitis and high blood pressure.

According to the National Council on Alcoholism and Drug Dependence, “alcohol is the most commonly used addictive substance in the United States: 17.6 million people, or one in every 12 adults, suffer from alcohol abuse or dependence along with several million more who engage in risky, binge drinking patterns that could lead to alcohol problems.”

And while moderate consumption of alcohol may have heart benefits for some, consumption of alcohol can also increase a woman’s risk of breast cancer for each drink consumed daily.

Many decades ago, in Ireland, it would not have been uncommon for a doctor to advise pregnant and nursing women to drink Guinness. But today, experts (particularly in the United States) caution of the dangers associated with consuming any alcohol while pregnant.

“Alcohol is a teratogen, which is something that causes birth defects. It can cause damage to the fetal brain and other organ systems,” said Dr. Erin Tracy, an OB/GYN at Massachusetts General Hospital and Harvard Medical School associate professor of obstetrics, gynecology and reproductive gynecology. “We don’t know of any safe dose of alcohol in pregnancy. Hence we recommend abstaining entirely during this brief period of time in a woman’s life.”

What about beer for breastfeeding? “In Britain, they have it in the culture that drinking Guinness is good for nursing mothers,” said Karl Siebert, professor emeritus of the food science department and previous director of the brewing program at Cornell University.

Beer in general has been regarded as a galactagogue, or stimulant of lactation, for much of history. In fact, according to irishtimes.com, breastfeeding women in Ireland were once given a bottle of Guinness a day in maternity hospitals.

According to Domhnall Marnell, the Guinness ambassador, Guinness Original (also known as Guinness Extra Stout, depending on where it was sold) debuted in 1821, and for a time, it contained live yeast, which had a high iron content, so it was given to anemic individuals or nursing mothers then, before the effects of alcohol were fully understood.

Some studies have showed evidence that ingredients in beer can increase prolactin, a hormone necessary for milk production; others have showed the opposite. Regardless of the conclusions, the alcohol in beer also appears to counter the benefits associated with increased prolactin secretion.

“The problem is that alcohol temporarily inhibits the milk ejection reflex and overall milk supply, especially when ingested in large amounts, and chronic alcohol use lowers milk supply permanently,” said Diana West, coauthor of “The Breastfeeding Mother’s Guide to Making More Milk.”

“Barley can be eaten directly, or even made from commercial barley drinks, which would be less problematic than drinking beer,” West said.

If you’re still not convinced that beer is detrimental to breastfeeding, consider this fact: A nursing mother drinking any type of alcohol puts her baby in potential danger. “The fetal brain is still developing after birth – and since alcohol passes into breast milk, the baby is still at risk,” Tracy said.

“This is something we would not advocate today,” Marnell agreed. “We would not recommend to anyone who is pregnant or breastfeeding to be enjoying our products during this time in their life.”

Regarding the old wives’ tale about beer’s effects on breastfeeding, Marnell added, “It’s not something that Guinness has perpetuated … and if (people are still saying it), I’d like to say once and for all, it’s not something we support or recommend.”

Assuming you are healthy and have the green light to drink beer, you might wonder why Guinness feels like you’ve consumed a meal, despite its lower calorie and alcohol content.

It has to do with the sophistication that goes into producing and pouring Guinness. According to Bamforth, for more than half a century, Guinness has put nitrogen gas into its beer at the packaging stage, which gives smaller, more stable bubbles and delivers a more luscious mouthfeel. It also tempers the harsh burnt character coming from the roasted barley. Guinness cans, containing a widget to control the pour, also have some nitrogen.

Guinness is also dispensed through a special tap that uses a mixture of carbon dioxide and nitrogen. “In Ireland, Guinness had a long history of hiring the best and brightest university graduates regardless of what they were trained in,” Siebert said. “And they put them to work on things they needed. One was a special tap for dispensing Guinness, which has 11 different nozzles in it, that helps to form the fine-bubbled foam.”

The foam is remarkably long-lasting. “After you get a freshly poured Guinness, you can make a face in the foam, and by the time you finish drinking it, the face is still there,” Siebert said.

The famous advertising Guinness slogans – including “It’s a good day for a Guinness” – started through word of mouth, said Marnell. “In 1929, when we were about to do our first ad, we asked (ourselves), ‘What stance should we take?’ So we sent around a group of marketers (in Ireland and the UK) to ask Guinness drinkers why they chose Guinness, and nine out of 10 said their belief was that the beer was healthy for them. We already had this reputation in the bars before we uttered a word about the beer.

“That led to the Gilroy ads that were posted,” Marnell explained, referring to the artist John Gilroy, responsible for the Guinness ads from 1928 to the 1960s. “You’ll see the characters representing the Guinness brand – the toucan, the pelican – and slogans like ‘Guinness is good for you’ or ‘Guinness for Strength.’ But those were from the 1920s, ’30s and ‘40s.”

Today, he said, the company would not claim any health benefits for its beer. “If anyone is under the impression that there are health benefits to drinking Guinness, then unfortunately, I’m the bearer of bad news. Guinness is not going to build muscle or cure you of influenza.”

In fact, Guinness’ parent company, Diageo, spends a lot of effort supporting responsible drinking initiatives and educating consumers about alcohol’s effects. Its DrinkIQ page offers information such as calories in alcohol, how your body processes it and when alcohol can be dangerous, including during pregnancy.

“One of the main things we focus on … is that while we would love people to enjoy our beer, we want to make sure they do so as responsibly as possible,” Marnell said. “We would never recommend that anyone drink to excess, and (we want to make people) aware of how alcohol effects the body.”

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  • And again: Most health providers in the US would advise forgoing all alcohol if you are pregnant, nursing or have other health or medical issues where alcohol consumption is not advised.

    So responsibly celebrate St. Patrick this year a little wiser about the health benefits and risks with one of its signature potables.

    This story originally published in 2017.



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    Sleep like a pro with these 6 expert tips | CNN

    Editor’s Note: Dana Santas, known as the “Mobility Maker,” is a certified strength and conditioning specialist and mind-body coach in professional sports, and is the author of the book “Practical Solutions for Back Pain Relief.”



    CNN
    — 

    How you sleep each night plays a vital role in how you perform in your daily life. So, it’s no wonder that professional sports teams tap the expertise of sleep doctors to ensure their elite athletes get the quality sleep they need to perform at the highest levels.

    As a mobility coach who works in Major League Baseball, I can attest that during spring training, when every day starts early, players and coaches alike dread losing an hour of sleep when we “spring forward” for Daylight Saving Time.

    It’s not just professional baseball players who struggle. A 2022 study found that more than 30% of adults have reported an hour of sleep debt — when you sleep less than your body needs — while nearly 1 in 10 adults had a sleep debt of two hours or more.

    Adults need at least seven hours of solid sleep at night, according to the US Centers of Disease Control and Prevention. Sleep debt and irregular sleep duration are linked to an increased risk of heart disease, dementia, obesity and mood disorders such as depression and anxiety.

    I asked two of my favorite MLB sleep experts to share some of the same tips they provide to professional baseball players, so that anyone can learn to sleep like a pro.

    It’s important to get the recommended seven-plus hours of sleep nightly.

    Sticking with a regularly scheduled bedtime and wake time helps, according to Dr. Cheri D. Mah, a sleep physician specializing in the sleep and performance of elite athletes. “Our bodies like regularity and will anticipate sleep with a regular sleep schedule,” Mah said. “As a reminder, set a daily alarm on your phone to go off 30 minutes before you want to start your wind-down routine.”

    Pay attention to what your body and brain are telling you about your sleep schedule, suggested Dr. Chris Winter, a neurologist and host of the “Sleep Unplugged” podcast. “If you go to bed at 9 p.m. but it always takes you two hours to fall asleep, why not try going to bed later?”

    If you want to sleep better, you need an environment conducive to sleep. “Make your room like a cave,” Mah said, “You want it to be really dark, quiet and cool — as well as comfortable.”

    She recommends getting comfortable bedding, using blackout curtains or eye masks, wearing earplugs and setting the room temperature at 60 to 67 degrees Fahrenheit (about 16 to 19 degrees Celsius).

    Do you judge how well you slept based on how fast you fell asleep?

    The amount of time it takes you to fall asleep, called the speed of sleep latency, is an inaccurate gauge for sleep quality, according to Winter. How long it takes to fall asleep varies from person to person. The consensus of most sleep experts, including Winter, is that the average sleep latency is five to 20 minutes.

    “Someone who is asleep ‘before their head hits the pillow’ is not a champion sleeper any more than an individual who can eat their entire dinner in three minutes is a highly nutritious eater,” Winter said. “That can often be a red flag and not a sign of great sleep.”

    Many people jump right into bed with a racing mind, Mah said, which results in difficulty sleeping. She suggests that her clients create a 20- to 30-minute wind-down routine to help them transition to sleep. Activities could include gentle yoga, breathing exercises and reading, “just not on a tablet or phone that emits sleep-disturbing blue light frequencies,” she said.

    Doing activities such as gentle yoga shortly before bedtime can help to ease a racing mind.

    Both Mah and Winter report that getting people to refrain from technology use the hour before bedtime presents the biggest challenge for their clients. “It’s hard to convince people to change a behavior that doesn’t cause immediate pain,” Winter added.

    Despite the popularity of “night cap” cocktails, Mah and Winter agree that alcohol is an impediment to sleep. They suggest that it be avoided entirely or at least not enjoyed in the hours before bed. They also recommend limiting caffeine intake later in the day. “Caffeine has a half-life of about six hours, so it’s best to cut it out in the late afternoon and early evening,” Mah added.

    Along with all the other health benefits of regular exercise, research shows a strong link with better quality sleep, which Winter frequently points out to his clients. “If you are complaining about your sleep and not exercising, you better have a good reason for not doing it,” he said. “From a research perspective, it is far more effective at deepening sleep and improving its quality than any fad tech gadget in existence today … and it’s free!”

    There is one caveat: Because some research has shown that the benefits of exercise are mitigated and can even hurt sleep quality when performed later at night, avoid vigorous exercise at least one hour before bed.

    Sleep debt is the difference between your needed amount of sleep and the sleep you actually get, accumulating over time, if not paid back.

    Many clients come to Mah without any knowledge of the concept of sleep debt and the need to repay it. More so, she said they are surprised to find that “it often takes longer than one night or one weekend to significantly pay back accumulated sleep debt.”

    If you’ve built up sleep debt, try going to sleep an hour earlier or sleeping an hour later over a few days — or however long it takes for you to feel adequately rested.

    Catching up on sleep can increase your daily alertness and help ward off inflammation.

    Catching up on your sleep isn’t just good for increasing daily alertness — a 2020 study found that adults who caught up on sleep were less likely to show elevated inflammation levels, which contribute to chronic disease.

    At the same time, it’s important not to stress about sleep, Winter said. Too much emphasis on things such as “falling asleep faster” or the notion that people “can’t sleep,” creates a sense of fear that he deems “highly problematic.”

    “It’s physiologically impossible to not sleep at all, so nature has you covered,” he said. “Control the variables you can control, like schedule, environment, etc., and put it out of your mind.”

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    Senator John Fetterman’s hospitalization for depression has raised awareness of the condition. Our medical analyst explains what it is and how it’s treated | CNN

    Editor’s Note: If you or someone you know is struggling with suicidal thoughts or mental health matters, please call the 988 Suicide and Crisis Lifeline, or visit the hotline’s website.



    CNN
    — 

    Sen. John Fetterman of Pennsylvania is continuing to receive treatment for depression at Walter Reed Medical Center in Bethesda, Maryland, after checking himself into the hospital on February 15. His office has said he has experienced depression “off and on” during his life, but that his condition “only became severe in recent weeks,” necessitating inpatient care.

    Fetterman’s disclosure, widely praised by mental health advocates, has prompted many people to ask questions about the often misunderstood illness: What is depression and what are the symptoms? What are its risk factors? How can one distinguish clinical depression from feeling sad? How common is major depressive disorder? What treatments are available and when is hospitalization needed? And how can someone who needs help find assistance?

    To guide us through these questions, I spoke with CNN Medical Analyst Dr. Leana Wen, an emergency physician and professor of health policy and management at the George Washington University Milken Institute School of Public Health. She is also chair of the advisory board for Behavioral Health Group, a network of outpatient opioid treatment and recovery centers around the United States. Previously, she served as Baltimore’s health commissioner and chaired the board of Behavioral Health System Baltimore, a nonprofit organization that oversaw mental health services in the city.

    CNN: What is depression, and what are its symptoms?

    Dr. Leana Wen: Major depressive disorder, colloquially referred to as depression or clinical depression, is a common illness. It is a serious mental health condition characterized by a persistently low or depressed mood and a loss of interest in activities that previously brought a person joy. Other symptoms include a lack of energy, feelings of guilt or worthlessness, an inability to concentrate, appetite changes, sleep disturbances or suicidal thoughts. These symptoms often affect someone’s ability to function at work, at home, and in social interactions.

    CNN: How can one distinguish clinical depression from feeling sad? How is a diagnosis made?

    Wen: It’s very common to feel down from time to time; many people experience periods of sadness, especially when facing challenging life situations. But this is different from major depressive disorder, for which there are specific diagnostic criteria including depressed mood or lack of interest in normal activities causing social or occupational impairment, and other specified symptoms such as problems with sleep, eating, concentration, energy or self-worth. These symptoms must persist for at least two weeks for a diagnosis of major depressive disorder to be made.

    Screening for major depressive disorder generally begins with a physical examination by a health care provider. Often, laboratory tests are done to rule out other ailments, such as hypothyroidism and vitamin deficiency. There are questionnaires that can help screen for depression and aid your physician or other provider with the diagnosis.

    CNN: How common is major depressive disorder?

    Wen: An estimated 21 million adults in the United States had at least one major depressive disorder episode lasting at least two weeks in 2020, according to the US Substance Abuse and Mental Health Services Administration. This is about 8.4% of all US adults. The prevalence is higher among girls and women compared to boys and men (10.5% compared to 6.2%). The age group with the highest prevalence is young adults 18-25 years old (17%).

    The lifetime prevalence of major depressive disorder is even higher; some studies estimate it affects on average 12% of people in the US, but that it could be as high as 17%. That’s 1 in every 6 people.

    CNN: What are risk factors for depression?

    Wen: There are several different types of risk factors. One is a recent change in life circumstances. The death of a loved one, getting a divorce, losing a home or a job and other major upheavals can increase risk. Other behavioral health conditions, such as anxiety and substance use disorders, are also associated with depression.

    A recent illness can increase the risk of major depressive disorder, too. Serious chronic conditions such as heart disease, cancer, multiple sclerosis and dementia are associated with higher rates of depression.

    Senator John Fetterman on Capitol Hill in Washington, D.C., on February 14, 2023.

    There is a link, too, between stroke and depression; about a third of people who have had a stroke suffer some depressive symptoms.

    Senator Fetterman suffered a stroke in May 2022, during his Senate campaign. That could have increased his risk for a depressive episode, especially as, according to his office, he has had episodes of depression in the past.

    CNN: What treatments are available, and when is hospitalization needed?

    Wen: It’s very important to note that effective treatments are available for major depressive disorder. Initial treatment includes anti-depressant medications and psychotherapy. Sometimes, lifestyle modifications and social supports can also help.

    Most patients can be managed effectively with outpatient treatment, meaning that they do not need to be hospitalized. But there are circumstances under which someone may need inpatient treatment in the hospital. A patient could have worsening symptoms and may be suicidal, for instance. They could also have several other medical conditions and may need medication adjustments that are best provided in a hospital setting.

    (These refer generally to patients who require hospitalization for major depressive disorder, and not specifically to Senator Fetterman, for whom such detailed medical information is not known and should not be presumed.)

    Other individuals can be treated well on an outpatient basis and still from time to time, require inpatient care. This is not dissimilar to how we manage other medical conditions. Patients with diabetes, for example, may be doing well with oral medication then need to switch to insulin. Sometimes, they may have complications that require hospitalization. I think it’s important for us to think about major depressive disorder and other mental health conditions the same as we would physical health conditions.

    CNN: How can someone who needs help find assistance?

    Wen: For those with a trusted health care provider, a good place to start is to speak with that person. Your physician or other provider can help with the initial assessment, often can make the diagnosis and either begin treatment or refer to someone else who can.

    If your primary care provider is delayed in making a referral to a mental health specialist or treating you themselves, you should follow up and emphasize the importance of getting care. Many workplaces and universities offer resources, and there are online telehealth services that could provide some care while you are pursuing referrals through your physician. Local and state health departments often provide some treatment options as well.

    In addition, the federal government last year launched the 988 hotline that provides 24/7, free and confidential support for people experiencing emotional distress. The 988 hotline is a network of local and regional hotlines that can refer people and help them get information about where to seek treatment in their area. People can — and should — call or text this number if they are experiencing a mental health crisis.

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    Ozempic prescriptions can be easy to get online. Its popularity for weight loss is hurting those who need it most | CNN



    CNN
    — 

    Telehealth and social media are playing a significant role in driving demand for Ozempic, a prescription drug that treats Type 2 diabetes, experts told CNN. The current drug shortage has limited access for patients with diabetes who rely on it to control their blood sugar.

    Digital health companies make medications like Ozempic easier to get by providing prescriptions online. Many advertise quick and easy — sometimes same-day — access.

    “Anecdotally, it’s almost easier to get medication [via digital health companies],” said Dr. Disha Narang, endocrinologist and director of obesity medicine at Northwestern Medicine, Lake Forest Hospital. “But not always the safest.” People who put in average weights on the online intake forms were still offered the antidiabetic drug, Narang told CNN.

    In part because of Ozempic’s popularity, the prescription weight loss drug market has grown significantly, according to MarketData Enterprises, an independent market research and consulting firm. The market surpassed forecasters’ expectations for 2022 and is expected to become a nearly $2 billion industry in 2023.

    WeightWatchers is also tapping into the telehealth prescription drug space. Last week, the company bought telehealth subscription service Sequence, which helps connect patients to doctors who can prescribe weight loss and diabetes drugs.

    “At the start of 2022, these companies weren’t marketing this stuff,” Narang said, noting advertising around Ozempic took off in 2022. “I think we really need to start questioning our ethics around this.”

    There are few across-the-board requirements when it comes to digital health companies’ intake processes, Dr. Bree Holtz, an associate professor at Michigan State University studying telemedicine, told CNN. Once a patient fills out the required forms online, information gets transferred to an in-state provider who can write the prescription. Some companies require that the patient hop on a video or phone call with the provider — others don’t require either.

    “It’s a little scary that you can just wake up and get these appointments in — or these pharmaceuticals — and you’re not being cared for,” said Holtz.

    Telehealth has been a game changer in providing access to health care, particularly during the pandemic. And especially for people living in places where high-quality primary care is not available, direct to consumer telehealth services can help fill a gap, said Dr. Laurie Buis, associate professor in the Department of Family Medicine at the University of Michigan, whose research focuses on digital health.

    When patients begin to seek selective treatment from selective providers, however, Buis says it opens the door to problems like fragmented care or abuse. Telehealth providers may not have access to a patient’s full medical history and may be less able to provide holistic care that a primary care physician otherwise could.

    “I have no doubt that some of these services are doing a good job,” said Buis. “There are also services that don’t take it quite as seriously. And that’s of concern.”

    The US Food and Drug Administration first announced that Ozempic was in shortage last August. Supply will likely be strained through mid-March, according to the FDA drug shortages database.

    Ozempic prescriptions in the US reached an all-time high in the last week of February, with over 373,000 prescriptions filled, according to a J.P. Morgan analysis of IQVIA data shared with CNN. That’s an increase of 111%, compared with the same week in 2022.

    Of these, more than half were new prescriptions, according to a CNN review of J.P. Morgan’s analysis.​​

    With many patients relying on Ozempic for diabetes treatment, providers like Narang are scrambling to figure out what alternatives to put their patients on.

    “We’re getting messages daily about patients not being able to get their own medication,” Narang said. “It’s been tough for patients and providers alike.”

    Ozempic currently holds more than 40% of the US market share of glucagon-like peptide 1 (GLP-1) agonists — a class of drugs that mimic an appetite-regulating hormone — according to analysis from J.P. Morgan. These drugs work by stimulating the release of insulin, which helps lower blood sugar. They also slow the passage of food through the gut.

    Ozempic has grown quickly in popularity since it was first put on the market in 2018. The drug has safely and successfully been used to help diabetics improve blood sugar levels and put diabetes into remission, Narang told CNN. Ozempic is the most potent of all the GLP-1 medications, she said.

    Behind the brand name Ozempic is the medication semaglutide. While Ozempic is used primarily to treat Type 2 diabetes, another drug by the name Wegovy — also semaglutide — is approved specifically for chronic weight management.

    Although approved by the FDA in 2021, Wegovy was not readily available through most of last year, according to Narang, so people turned to Ozempic. According to the FDA drug shortages database, Wegovy was undersupplied starting at the end of last March but came back in stock earlier this year.

    Social media buzz around the two drugs took off at the start of 2023. Celebrities shared their testimonies about how semaglutide helped them shed unwanted pounds. Elon Musk, for example, publicly credited Ozempic and Wegovy in part for his weight loss.

    #Ozempic and #Wegovy have been “extremely popular” over the last few months on TikTok, according to company analytics.

    The use of Ozempic and Wegovy for short-term weight loss has resulted in real consequences for patients who need the drugs most for diabetes treatment and chronic weight management, said Narang. For example, some insurance companies in the past have reportedly refused to cover Wegovy, one calling it a “vanity drug.”

    Both drugs are intended for long-term use, not for short-term weight loss. Their appetite-regulating effects wear off quickly after you stop taking them.

    “This is not meant to be a medication to take off your last five or 10 pounds to get ready for an event or something like that. It’s not for use of three or four weeks,” Narang said. “When we think about weight management, we’re thinking about the next 25 years of someone’s life.”



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    Chronic pain patients struggle to get opioid prescriptions filled, even as CDC eases guidelines | CNN



    KHN
    — 

    Jessica Layman estimates she has called more than 150 doctors in the past few years in her search for someone to prescribe opioids for her chronic pain.

    “A lot of them are straight-up insulting,” said the 40-year-old, who lives in Dallas. “They say things like ‘We don’t treat drug addicts.’”

    Layman has tried a host of non-opioid treatments to help with the intense daily pain caused by double scoliosis, a collapsed spinal disc, and facet joint arthritis. But she said nothing worked as well as methadone, an opioid she has taken since 2013.

    The latest phone calls came late last year, after her previous doctor shuttered his pain medicine practice, she said. She hopes her current doctor won’t do the same. “If something should happen to him, there’s nowhere for me to go,” she said.

    Layman is one of the millions in the U.S. living with chronic pain. Many have struggled to get opioid prescriptions written and filled since 2016 guidelines from the Centers for Disease Control and Prevention inspired laws cracking down on doctor and pharmacy practices. The CDC recently updated those recommendations to try to ease their impact, but doctors, patients, researchers, and advocates say the damage is done.

    “We had a massive opioid problem that needed to be rectified,” said Antonio Ciaccia, president of 3 Axis Advisors, a consulting firm that analyzes prescription drug pricing. “But the federal crackdowns and guidelines have created collateral damage: patients left high and dry.”

    Born of an effort to fight the nation’s overdose crisis, the guidance led to legal restrictions on doctors’ ability to prescribe painkillers. The recommendations left many patients grappling with the mental and physical health consequences of rapid dose tapering or abruptly stopping medication they’d been taking for years, which carries risks of withdrawal, depression, anxiety, and even suicide.

    In November, the agency released new guidelines, encouraging physicians to focus on the individual needs of patients. While the guidelines still say opioids should not be the go-to option for pain, they ease recommendations about dose limits, which were widely viewed as hard rules in the CDC’s 2016 guidance. The new standards also warn doctors about risks associated with rapid dose changes after long-term use.

    But some doctors worry the new recommendations will take a long time to make a meaningful change — and may be too little, too late for some patients. The reasons include a lack of coordination from other federal agencies, fear of legal consequences among providers, state policymakers hesitant to tweak laws, and widespread stigma surrounding opioid medication.

    The 2016 guidelines for prescribing opioids to people with chronic pain filled a vacuum for state officials searching for solutions to the overdose crisis, said Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School.

    The dozens of laws that states passed limiting how providers prescribe or dispense those medications, she said, had an effect: a decline in opioid prescriptions even as overdoses continued to climb.

    The first CDC guidelines “put everybody on notice,” said Dr. Bobby Mukkamala, chair of the American Medical Association’s Substance Use and Pain Care Task Force. Physicians reduced the number of opioid pills they prescribe after surgeries, he said. The 2022 revisions are “a dramatic change,” he said.

    The human toll of the opioid crisis is hard to overstate. Opioid overdose deaths have risen steadily in the U.S. in the past two decades, with a spike early in the covid-19 pandemic. The CDC says illicit fentanyl has fueled a recent surge in overdose deaths.

    Taking into account the perspective of chronic pain patients, the latest recommendations try to scale back some of the harms to people who had benefited from opioids but were cut off, said Dr. Jeanmarie Perrone, director of the Penn Medicine Center for Addiction Medicine and Policy.

    “I hope we just continue to spread caution without spreading too much fear about never using opioids,” said Perrone, who helped craft the CDC’s latest recommendations.

    Christopher Jones, director of the CDC’s National Center for Injury Prevention and Control, said the updated recommendations are not a regulatory mandate but only a tool to help doctors “make informed, person-centered decisions related to pain care.”

    Multiple studies question whether opioids are the most effective way to treat chronic pain in the long term. But drug tapering is associated with deaths from overdose and suicide, with risk increasing the longer a person had been taking opioids, according to research by Dr. Stefan Kertesz, a professor of medicine at the University of Alabama-Birmingham.

    He said the new CDC guidance reflects “an extraordinary amount of input” from chronic pain patients and their doctors but doubts it will have much of an impact if the FDA and the Drug Enforcement Administration don’t change how they enforce federal laws.

    The FDA approves new drugs and their reformulations, but the guidance it provides for how to start or wean patients could urge clinicians to do so with caution, Kertesz said. The DEA, which investigates physicians suspected of illegally prescribing opioids, declined to comment.

    The DEA’s pursuit of doctors put Danny Elliott of Warner Robins, Georgia, in a horrible predicament, said his brother, Jim.

    In 1991, Danny, a pharmaceutical company rep, suffered an electric shock. He took pain medicine for the resulting brain injury for years until his doctor faced federal charges of illegally dispensing prescription opioids, Jim said.

    Danny turned to doctors out of state — first in Texas and then in California. But Danny’s latest physician had his license suspended by the DEA last year, and he couldn’t find a new doctor who would prescribe those medications, Jim said.

    Danny, 61, and his wife, Gretchen, 59, died by suicide in November. “I’m really frustrated and angry about pain patients being cut off,” Jim said.

    Danny became an advocate against forced drug tapering before he died. Chronic pain patients who spoke with KHN pointed to his plight in calling for more access to opioid medications.

    Even for people with prescriptions, it’s not always easy to get the drugs they need.

    Pharmacy chains and drug wholesalers have settled lawsuits for billions of dollars over their alleged role in the opioid crisis. Some pharmacies have seen their opioid allocations limited or cut off, noted Ciaccia, with 3 Axis Advisors.

    Rheba Smith, 61, of Atlanta, said that in December her pharmacy stopped filling her prescriptions for Percocet and MS Contin. She had taken those opioid medications for years to manage chronic pain after her iliac nerve was mistakenly cut during surgery, she said.

    Smith said she visited nearly two dozen pharmacies in early January but could not find one that would fill her prescriptions. She finally found a local mail-order pharmacy that filled a one-month supply of Percocet. But now that drug and MS Contin are not available, the pharmacy told her.

    “It has been a horrible three months. I have been in terrible pain,” Smith said.

    Many patients fear a future of constant pain. Layman thinks about the lengths she’d go to in order to get medication.

    “Would you be willing to buy drugs off the street? Would you be willing to go to an addiction clinic and try to get pain treatment there? What are you willing to do to stay alive?” she said. “That is what it comes down to.”

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    US maternal death rate rose sharply in 2021, CDC data shows, and experts worry the problem is getting worse | CNN



    CNN
    — 

    As women continue to die due to pregnancy or childbirth each year in the United States, new federal data shows that the nation’s maternal death rate rose significantly yet again in 2021, with the rates among Black women more than twice as high as those of White women.

    Experts said the United States’ ongoing maternal mortality crisis was compounded by Covid-19, which led to a “dramatic” increase in deaths.

    The number of women who died of maternal causes in the United States rose to 1,205 in 2021, according to a report from the National Center for Health Statistics, released Thursday by the US Centers for Disease Control and Prevention. That’s a sharp increase from years earlier: 658 in 2018, 754 in 2019 and 861 in 2020.

    That means the US maternal death rate for 2021 – the year for which the most recent data is available – was 32.9 deaths per 100,000 live births, compared with rates of 20.1 in 2019 and 23.8 in 2020.

    The new report also notes significant racial disparities in the nation’s maternal death rate. In 2021, the rate for Black women was 69.9 deaths per 100,000 live births, which is 2.6 times the rate for White women, at 26.6 per 100,000.

    The data showed that rates increased with the mother’s age. In 2021, the maternal death rate was 20.4 deaths per 100,000 live births for women under 25 and 31.3 for those 25 to 39, but it was 138.5 for those 40 and older. That means the rate for women 40 and older was 6.8 times higher than the rate for women under age 25, according to the report.

    The maternal death rate in the United States has been steadily climbing over the past three decades, and these increases continued through the Covid-19 pandemic.

    Questions remain about how the pandemic may have affected maternal mortality in the United States, according to Dr. Elizabeth Cherot, chief medical and health officer for the infant and maternal health nonprofit March of Dimes, who was not involved in the new report.

    “What happened in 2020 and 2021 compared with 2019 is Covid,” Cherot said. “This is sort of my reflection on this time period, Covid-19 and pregnancy. Women were at increased risk for morbidity and mortality from Covid. And that actually has been well-proven in some studies, showing increased risks of death, but also being ventilated in the intensive care unit, preeclampsia and blood clots, all of those things increasing a risk of morbidity and mortality.”

    The American College of Obstetricians and Gynecologists previously expressed “great concern” that the pandemic would worsen the US maternal mortality crisis, ACOG President Dr. Iffath Abbasi Hoskins said in a statement Thursday.

    “Provisional data released in late 2022 in a U.S. Government Accountability Office report indicated that maternal death rates in 2021 had spiked—in large part due to COVID-19. Still, confirmation of a roughly 40% increase in preventable deaths compared to a year prior is stunning new,” Hoskins said.

    “The new data from the NCHS also show a nearly 60% percent increase in maternal mortality rates in 2021 from 2019, just before the start of the pandemic. The COVID-19 pandemic had a dramatic and tragic effect on maternal death rates, but we cannot let that fact obscure that there was—and still is—already a maternal mortality crisis to compound.”

    Health officials stress that people who are pregnant should get vaccinated against Covid-19 and that doing so offers protection for both the mother and the baby.

    During the early days of the pandemic, in 2020, there was limited information about the vaccine’s risks and benefits during pregnancy, prompting some women to hold off on getting vaccinated. But now, there is mounting evidence of the importance of getting vaccinated for protection against serious illness and the risks of Covid-19 during pregnancy.

    The Covid-19 pandemic also may have exacerbated existing racial disparities in the maternal death rate among Black women compared with White women, said Dr. Chasity Jennings-Nuñez, a California-based site director with Ob Hospitalist Group and chair of the perinatal/gynecology department at Adventist Health-Glendale, who was not involved in the new report.

    “In terms of maternal mortality, it continues to highlight those structural and systemic problems that we saw so clearly during the Covid-19 pandemic,” Jennings-Nuñez said.

    “So in terms of issues of racial health inequities, of structural racism and bias, of access to health care, all of those factors that we know have played a role in terms of maternal mortality in the past continue to play a role in maternal mortality,” she said. “Until we begin to address those issues, even without a pandemic, we’re going to continue to see numbers go in the wrong direction.”

    Some policies have been introduced to tackle the United States’ maternal health crisis, including the Black Maternal “Momnibus” Act of 2021, a sweeping bipartisan package of bills that aim to provide pre- and post-natal support for Black mothers, including extending eligibility for certain benefits postpartum.

    As part of the Momnibus, President Biden signed the bipartisan Protecting Moms Who Served Act in 2021, and other provisions have passed in the House.

    In the United States, about 6.9 million women have little or no access to maternal health care, according to March of Dimes, which has been advocating in support of the Momnibus.

    The US has the highest maternal death rate of any developed nation, according to the Commonwealth Fund and the latest data from the World Health Organization. While maternal death rates have been either stable or rising across the United States, they are declining in most countries.

    “A high rate of cesarean sections, inadequate prenatal care, and elevated rates of chronic illnesses like obesity, diabetes, and heart disease may be factors contributing to the high U.S. maternal mortality rate. Many maternal deaths result from missed or delayed opportunities for treatment,” researchers from the Commonwealth Fund wrote in a report last year.

    The ongoing rise in maternal deaths in the United States is “disappointing,” said Dr. Elizabeth Langen, a high-risk maternal-fetal medicine physician at the University of Michigan Health Von Voigtlander Women’s Hospital. She was not involved in the latest report but cares for people who have had serious complications during pregnancy or childbirth.

    “Those of us who work in the maternity care space have known that this is a problem in our country for quite a long time. And each time the new statistics come out, we’re hopeful that some of the efforts that have been going on are going to shift the direction of this trend. It’s really disappointing to see that the trend is not going in the right direction but, at some level, is going in the worst direction and at a little bit of a faster rate,” Langen said.

    “In the health care system, we need to accept ultimate responsibility for the women who die in our care,” she added. “But as a nation, we also need to accept some responsibility. We need to think about: How do we provide appropriate maternity care for people? How do we let people have time off of work to see their midwife or physician so that they get the care that they need? How do all of us make it possible to live a healthy life while you’re pregnant so that you have the opportunity to have the best possible outcome?”

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    How to reduce PFAS in your drinking water, according to experts | CNN

    Editor’s Note: Get inspired by a weekly roundup on living well, made simple. Sign up for CNN’s Life, But Better newsletter for information and tools designed to improve your well-being.



    CNN
    — 

    In the next three years, drinking water in the United States may be a bit safer from potentially toxic chemicals that have been detected in the blood of 98% of Americans.

    Perfluoroalkyl and polyfluoroalkyl substances or PFAS are a family of thousands of man-made chemicals that do not break down easily in the environment. A number of PFAS have been linked to serious health problems, including cancer, fertility issues, high cholesterol, hormone disruption, liver damage, obesity and thyroid disease.

    The US Environmental Protection Agency proposed on Tuesday stringent new limits on levels of six PFAS chemicals in public water systems. Under the proposed rule, public systems that provide water to at least 15 service connections or 25 people will have three years to implement testing procedures, begin notifying the public about PFAS levels, and reduce levels if above the new standard, the EPA said.

    Two of the most well-studied and potentially toxic chemicals, PFOA and PFOS, cannot exceed 4 parts per trillion in drinking water, compared with a previous health advisory of 70 parts per trillion, the EPA said.

    Another four chemicals — PFNA, PFHxS, PFBS and GenX — will be subject to a hazard index calculation to determine whether the levels of these PFAS pose a potential risk. The calculation is “a tool the EPA uses to address the cumulative risks from all four of those chemicals,” said Melanie Benesh, vice president of government affairs for the Environmental Working Group, a consumer organization that monitors exposure to PFAS and other chemicals.

    “The EPA action is a really important and historic step forward,” Benesh said. “While the proposed regulations only address a few PFAS, they are important marker chemicals. I think requiring water systems to test and treat for these six will actually do a lot to address other PFAS that are in the water as well.”

    For people who are concerned about PFAS exposure, three years or so is a long time. What can consumers do now to limit the levels of PFAS in their drinking water?

    First, look up levels of PFAS in your local public water system, suggested David Andrews, a senior scientist at the Environmental Working Group. The advocacy nonprofit has created a national tap water database searchable by zip code that lists PFAS and other concerning chemicals, as well as a national map that illustrates where PFAS has been detected in the US.

    However, not all water utilities currently test for pollutants, and many rural residents rely on wells for water. Anyone who wants to personally test their water can purchase a test online or from a certified lab, Andrews said.

    “The most important thing is to ensure the testing method can detect down to at least four parts per trillion or lower of PFAS,” he said. “There are a large number of labs across the country certified to test to that level, so there are a lot of options available.”

    If levels are concerning, consumers can purchase a water filter for their tap. NSF, formerly the National Sanitation Foundation, has a list of recommended filters.

    “The water filters that are most effective for PFAS are reverse osmosis filters, which are more expensive, about in the $200 range,” Andrews said. Reverse osmosis filters can remove a wide range of contaminants, including dissolved solids, by forcing water through various filters.

    “Granular activated carbon filters are more common and less expensive but not quite as effective or consistent for PFAS,” he said, “although they too can remove a large number of other contaminants.”

    Reverse osmosis systems use both carbon-based filters and reverse osmosis membranes, Andrews explained. Water passes through the carbon filter before entering the membrane.

    “The important part is that you have to keep changing those filters,” he said. “If you don’t change that filter, and it becomes saturated, the levels of PFAS in the filtered water can actually be above the levels in the tap water.”

    Carbon filters are typically replaced every six months, “while the reverse osmosis filter is replaced on a five-year time frame,” he added. “The cost is relatively comparable over their lifetime.”

    Another positive: Many of the filters that work for PFAS also filter other contaminants in water, Andrews said.

    Drinking water is not the only way PFAS enters the bloodstream. Thousands of varieties of PFAS are used in many of the products we purchase, including nonstick cookware, infection-resistant surgical gowns and drapes, mobile phones, semiconductors, commercial aircraft, and low-emissions vehicles.

    The chemicals are also used to make carpeting, clothing, furniture, and food packaging resistant to stains, water and grease damage. Once treated, the report said, textiles emit PFAS over the course of their lifetimes, escaping into the air and groundwater in homes and communities.

    Made from a chain of linked carbon and fluorine atoms that do not readily degrade in the environment, PFAS are known as “forever chemicals.” Due to their long half life in the human body, it can take some PFAS years to completely leave the body, according to a 2022 report by the prestigious National Academies of Sciences, Engineering, and Medicine.

    “Some of these chemicals have half-lives in the range of five years,” National Academies committee member Jane Hoppin, an environmental epidemiologist and director of the Center for Human Health and the Environment at North Carolina State University in Raleigh, told CNN previously.

    “Let’s say you have 10 nanograms of PFAS in your body right now. Even with no additional exposure, five years from now you would still have 5 nanograms.

    “Five years later, you would have 2.5 and then five years after that, you’d have one 1.25 nanograms,” she continued. “It would be about 25 years before all the PFAS leave your body.”

    The 2022 National Academies report set “nanogram” levels of concern and encouraged clinicians to conduct blood tests on patients who are worried about exposure or who are at high risk. (A nanogram is equivalent to one-billionth of a gram.)

    People in “vulnerable life stages” — such as during fetal development in pregnancy, early childhood and old age — are at high risk, the report said. So are firefighters, workers in fluorochemical manufacturing plants, and those who live near commercial airports, military bases, landfills, incinerators, wastewater treatment plants and farms where contaminated sewage sludge is used.

    The PFAS-REACH (Research, Education, and Action for Community Health) project, funded by the National Institute of Environmental Health Sciences, gives the following advice on how to avoid PFAS at home and in products:

    • Stay away from stain-resistant carpets and upholstery, and don’t use waterproofing sprays.
    • Look for the ingredient polytetrafluoroethylene, or PTFE, or other “fluoro” ingredients on product labels.
    • Avoid nonstick cookware. Instead use cast-iron, stainless steel, glass or enamel products.
    • Boycott takeout containers and other food packaging. Instead cook at home and eat more fresh foods.
    • Don’t eat microwave popcorn or greasy foods wrapped in paper.
    • Choose uncoated nylon or silk dental floss or one that is coated in natural wax.

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    ‘Am I dreaming?’: Double lung transplants save two people with late-stage cancer | CNN



    CNN
    — 

    Two people with stage IV lung cancer who had been told that they had only weeks or months to live are breathing freely after receiving double lung transplants, Northwestern Medicine in Chicago said Wednesday.

    Lung cancer is the leading cause of cancer-related deaths in the United States. The American Cancer Society estimates that over 127,000 Americans will die from the disease this year.

    It is considered stage IV once additional tumors have developed in the lungs, aside from the primary tumor, or the cancer has spread to more organs.

    Someone diagnosed with stage IV lung cancer has limited treatment options, Northwestern Medicine says. A double lung transplantation offers a potentially lifesaving option for some people with a poor prognosis, but doctors say there are specific criteria a lung cancer patient must meet, including that the cancer is contained within the lungs and the person has tried all other treatment options.

    In 2020, 54-year-old Albert Khoury of Chicago received a devastating lung cancer diagnosis.

    Khoury, a cement finisher for the Chicago Department of Transportation, began to have back pain, sneezing and chills, along with coughing up blood, according to Northwestern Medicine. It was near the start of the Covid-19 pandemic, so at first, he thought he had coronavirus-related symptoms.

    He was diagnosed with stage I lung cancer soon after.

    Because of the pandemic, Khoury did not begin treatment until July 2020. At that point, the cancer had progressed to stage II and was continuing to grow, eventually reaching stage IV. He was told to consider hospice, special care for people near the end of their lives that focuses on comfort and support.

    “I had a couple weeks to live,” Khoury said in a video released by the hospital. “Not that much time.”

    His sister suggested that he reach out to Northwestern Medicine about the possibility of a double lung transplant.

    “I need new lungs. That is the only hope to live,” Khoury said he told his doctor.

    He met with an oncologist at Northwestern Medicine, who told him he should try additional treatments first. But not too long after, he was admitted to the intensive care unit with pneumonia and sepsis.

    As his health declined, the oncologists began considering the rarely used procedure.

    “His lungs were filled with cancer cells, and day by day, his oxygen was dropping,” said Dr. Young Chae, a medical oncologist at Northwestern Medicine who helped treat Khoury.

    Transplant is typically considered for people with some form of lung cancer that has not spread to other parts of the body and for those who have tried all other treatment options and have limited time to live, according to Dr. Ankit Bharat, chief of thoracic surgery at the Northwestern Medicine Canning Thoracic Institute, who helped treat Khoury.

    William Dahut, chief scientific officer at the American Cancer Society, also noted the importance of ensuring that cancer has not spread to other parts of the body before doing a transplant.

    “There would need to be as much certainty as possible that the cancer is limited to the lungs, so whatever sort of extensive screening tests should be done … to ensure that there are no cancer cells outside of the lungs,” said Dahut, who was not involved in the care of either Northwestern patient.

    The oncologists decided Khoury was eligible for the procedure. In September 2021, he spent about seven hours in surgery.

    “Surgeons had to be extremely meticulous to not let trillions of cancer cells from the old lungs spill out into Khoury’s chest cavity or into his blood stream,” Northwestern Medicine noted in a news release.

    The surgery is not without risk, Bharat said. In people with late-stage cancers, there is always a chance of it returning after the procedure.

    “There is certainly the risk of potentially being in a worse off situation than they were,” he said. “So you go through a big surgery, and then you could very quickly have the cancer come back.”

    Another risk is the treatment needed after a transplant, Dahut said.

    All lung transplant recipients have to take medications to weaken their immune systems, which helps reduce the possibility of their body rejecting the organ – but also decreases its ability to fight off infection, according to the National Cancer Institute.

    “Drugs that actually suppress your immune system put you at risk for infection afterwards but could even potentially put you at risk for second cancers afterwards,” Dahut said.

    However, 18 months later, Khoury has not had any complications and is back to work.

    His doctor showed him an X-ray of his chest with no signs of cancer. “When I saw that X-ray, I believed him,” Khoury said. “My body is in my hands now.”

    The procedure was put to the test again last year, this time in a 64-year-old Minnesota woman.

    Tannaz Ameli, a retired nurse from Minneapolis, had a persistent cough for several months. Her doctors did a chest X-ray and diagnosed her with pneumonia.

    The illness lingered until she was told she had stage IV lung cancer in January 2022.

    “There was no hope for my life at that point. They gave me … three months,” Ameli said in a video released by Northwestern Medicine.

    She went through unsuccessful chemotherapy treatments and was told to consider hospice.

    “I had no hope. I was ready for my life to end,” she said.

    But her husband reached out to Northwestern Medicine about the option of a transplant. The oncologists found that Ameli fit their criteria, and she received a double lung transplant in July.

    When she was told the procedure had made her cancer-free, she wondered, ” ‘Am I dreaming, sitting here? Can it happen?’ And it did happen.”

    Ameli hasn’t had any complications, and she said the procedure has given her a new perspective on life.

    “Every morning when I open my eyes, I just can’t believe it,” Ameli said. “Life has a different meaning now.”

    Double lung transplants for cancer are rare due to the concern that the cancer may come back, Bharat said.

    Historically, the surgery required sequential transplantations, but they are looking to alter the approach to lower the risk of recurrence, he said.

    “Typically, what happens in a double lung transplant procedure is, we take one lung out, put the new one in, then take the second lung out and put the second lung in,” he said. “The concern is that when you take one lung out and put a new lung, the other lung is still attached, and they could cross-contaminate. … You could inadvertently have the cancer cells spread into the bloodstream.”

    If cancer cells cross-contaminate or enter the bloodstream, there is a higher risk of cancer coming back.

    Bharat and his team took a different approach with Khoury and Ameli: They opened the chest cavity and did a full heart and lung bypass.

    “Essentially, what that means is, we don’t let any blood go through the heart and the lungs and bypass all of that,” Bharat said. “That allows us to then stop the blood flow to the lungs, which will prevent any cancer cells from going from the lung into the bloodstream.”

    The surgeons gave Khoury and Ameli lung-shaped friendship necklaces Wednesday to mark their success.

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    Most men with prostate cancer can avoid or delay harsh treatments, long-term study confirms | CNN



    CNN
    — 

    Most men who are diagnosed with prostate cancer can delay or avoid harsh treatments without harming their chances of survival, according to new results from a long-running study in the United Kingdom.

    Men in the study who partnered with their doctors to keep a close eye on their low- to intermediate-risk prostate tumors – a strategy called surveillance or active monitoring – slashed their risk of the life-altering complications such as incontinence and erectile dysfunction that can follow aggressive treatment for the disease, but they were no more likely to die of their cancers than men who had surgery to remove their prostate or who were treated with hormone blockers and radiation.

    “The good news is that if you’re diagnosed with prostate cancer, don’t panic, and take your time to make a decision” about how to proceed, said lead study author Dr. Freddie Hamdy, professor of surgery and urology at the University of Oxford.

    Other experts who were not involved in the research agreed that the study was reassuring for men who are diagnosed with prostate cancer and their doctors.

    “When men are carefully evaluated and their risk assessed, you can delay or avoid treatment without missing the chance to cure in a large fraction of patients,” said Dr. Bruce Trock, a professor of urology, epidemiology and oncology at Johns Hopkins University.

    The findings do not apply to men who have prostate cancers that are scored through testing to be high-risk and high-grade. These aggressive cancers, which account for about 15% of all prostate cancer diagnoses, still need prompt treatment, Hamdy said.

    For others, however, the study adds to a growing body of evidence showing that surveillance of prostate cancers is often the right thing to do.

    “What I take away from this is the safety of doing active monitoring in patients,” said Dr. Samuel Haywood, a urologic oncologist at the Cleveland Clinic in Ohio, who reviewed the study, but was not involved in the research.

    Results from the study were presented on Saturday at the European Association of Urology annual conference in Milan, Italy. Two studies on the data were also published in the New England Journal of Medicine and a companion journal, NEJM Evidence.

    Prostate cancer is the second most common cancer in men in the United States, behind non-melanoma skin cancers. About 11% – or 1 in 9 – American men will be diagnosed with prostate cancer in their lifetime, and overall, about 2.5% – or 1 in 41 – will die from it, according to the National Cancer Institute. About $10 billion is spent treating prostate cancer in the US each year.

    Most prostate cancers grow very slowly. It typically takes at least 10 years for a tumor confined to the prostate to cause significant symptoms.

    The study, which has been running for more than two decades, confirms what many doctors and researchers have come to realize in the interim: The majority of prostate cancers picked up by blood tests that measure levels of a protein called prostate-specific antigen, or PSA, will not harm men during their lifetimes and don’t require treatment.

    Dr. Oliver Sartor, medical director of the Tulane Cancer Center, said men should understand that a lot has changed over time, and doctors have refined their approach to diagnosis since the study began in 1999.

    “I wanted to make clear that the way these patients are screened and biopsied and randomized is very, very different than how these same patients might be screened, biopsied and randomized today,” said Sartor, who wrote an editorial on the study but was not involved in the research.

    He says the men included in the study were in the earliest stages of their cancer and were mostly low-risk.

    Now, he says, doctors have more tools, including MRI imaging and genetic tests that can help guide treatment and minimize overdiagnosis.

    The study authors say that to assuage concerns that their results might not be relevant to people today, they re-evaluated their patients using modern methods for grading prostate cancers. By those standards, about one-third of their patients would have intermediate or high-risk disease, something that didn’t change the conclusions.

    When the study began in 1999, routine PSA screening for men was the norm. Many doctors encouraged annual PSA tests for their male patients over age 50.

    PSA tests are sensitive but not specific. Cancer can raise PSA levels, but so can things like infections, sexual activity and even riding a bicycle. Elevated PSA tests require more evaluation, which can include imaging and biopsies to determine the cause. Most of the time, all that followup just isn’t worth it.

    “It is generally thought that only about 30% of the individuals with an elevated PSA will actually have cancer, and of those that do have cancer, the majority don’t need to be treated,” Sartor said.

    Over the years, studies and modeling have shown that using regular PSA tests to screen for prostate cancer can do more harm than good.

    By some estimates, as many as 84% of men with prostate cancer identified through routine screening do not benefit from having their cancers detected because their cancer would not be fatal before they died of other causes.

    Other studies have estimated about 1 to 2 in every five men diagnosed with prostate cancer is overtreated. The harms of overtreatment for prostate cancer are well-documented and include incontinence, erectile dysfunction and loss of sexual potency, as well as anxiety and depression.

    In 2012, the influential US Preventive Services Task Force advised healthy men not to get PSA tests as part of their regular checkups, saying the harms of screening outweighed its benefits.

    Now, the task force opts for a more individualized approach, saying men between the ages of 55 and 69 should make the decision to undergo periodic PSA testing after carefully weighing the risks and benefits with their doctor. They recommend against PSA-based screening for men over the age of 70.

    The American Cancer Society endorses much the same approach, recommending that men at average risk have a conversation with their doctor about the risks and benefits beginning at age 50.

    The trial has been following more than 1,600 men who were diagnosed with prostate cancer in the UK between 1999 and 2009. All the men had cancers that had not metastasized, or spread to other parts of their bodies.

    When they joined, the men were randomly assigned to one of three groups: active monitoring or using regular blood tests to keep an eye on their PSA levels; radiotherapy, which used hormone-blockers and radiation to shrink tumors; and prostatectomy, or surgery to remove the prostate.

    Men who were assigned monitoring could change groups during the study if their cancers progressed to the point that they needed more aggressive treatment.

    Most of the men have been followed for around 15 years now, and for the most recent data analysis, researchers were able get follow-up information on 98% of the participants.

    By 2020, 45 men – about 3% of the participants – had died of prostate cancer. There were no significant differences in prostate cancer deaths between the three groups.

    Men in the active monitoring group were more likely to have their cancer progress and more likely to have it spread compared with the other groups. About 9% of men in the active monitoring group saw their cancer metastasize, compared with 5% in the two other groups.

    Trock points out that even though it didn’t affect their overall survival, a spreading cancer isn’t an insignificant outcome. It can be painful and may require aggressive treatments to manage at that stage.

    Active surveillance did have important benefits over surgery or radiation.

    As they followed the men over 12 years, the researchers found that 1 in 4 to 1 in 5 of those who had prostate surgery needed to wear at least one pad a day to guard against urine leaks. That rate was twice as high as the other groups, said Dr. Jenny Donovan of the University of Bristol, who led the study on patient-reported outcomes after treatment.

    Sexual function was affected, too. It’s natural for sexual function to decline in men with age, so by the end of the study, nearly all the men reported low sexual function, but their patterns of decline were different depending on their prostate cancer treatment, she said.

    “The men who have surgery have low sexual function early on, and that continues. The men in the radiotherapy group see their sexual function drop, then have some recovery, but then their sexual function declines, and the active monitoring group declines slowly over time,” Donovan said.

    Donovan said that when she presents her data to doctors, they point out how much has changed since the study started.

    “Some people would say, ‘OK, yeah, but we’ve got all these new technologies now, new treatments,’ ” she said, such as intensity-modulated radiation therapy, brachytherapy and robot-assisted prostate surgeries, “but actually, other studies have shown that the effects on these functional outcomes are very similar to the effects that we see our study,” she said.

    Both Donovan and Hamby feel the study’s conclusions still merit careful consideration by men and their doctors as they weigh treatment decisions.

    “What we hope that clinicians will do is use these figures that we’ve produced in these papers and share them with the men so that newly diagnosed men with localized prostate cancer can really assess those tradeoffs,” Donovan said.

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    Insurance requirements for prior authorization may prompt ‘devastating’ delays | CNN

    When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.

    As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.

    But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn’t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut’s health insurer deemed the MRI medically unnecessary and would not authorize the visit.

    “On at least four or five occasions, she called me up, hysterical,” Roux said.

    Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.

    Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”

    Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.

    Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.

    Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.

    So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.

    “The prior authorization system should be completely done away with in physicians’ offices,” said Dr. Shikha Jain, a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”

    In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment through March 13.

    Although groups like AHIP, an industry trade group formerly called America’s Health Insurance Plans, and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes, some doctors feel they don’t go far enough.

    “Seven days is still way too long,” said Dr. Julie Kanter, a hematologist in Birmingham, Alabama, whose sickle cell patients can’t delay care when they arrive at the hospital showing signs of stroke. “We need to move very quickly. We have to make decisions.”

    Meanwhile, some states have passed their own laws governing the process. In Oregon, for example, health insurers must respond to nonemergency prior authorization requests within two business days. In Michigan, insurers must report annual prior authorization data, including the number of requests denied and appeals received. Other states have adopted or are considering similar legislation, while in many places insurers regularly take four to six weeks for non-urgent appeals.

    Waiting for health insurers to authorize care comes with consequences for patients, various studies show. It has led to delays in cancer care in Pennsylvania, meant sick children in Colorado were more likely to be hospitalized, and blocked low-income patients across the country from getting treatment for opioid addiction.

    In some cases, care has been denied and never obtained. In others, prior authorization proved a potent but indirect deterrent, as few patients have the fortitude, time, or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up, because fighting denials often requires patients to spend hours on the phone and computer to submit multiple forms.

    Erin Conlisk, a social science researcher for the University of California-Riverside, estimated she spent dozens of hours last summer trying to obtain prior authorization for a 6-mile round-trip ambulance ride to get her mother to a clinic in San Diego.

    Her 81-year-old mother has rheumatoid arthritis and has had trouble sitting up, walking, or standing without help after she damaged a tendon in her pelvis last year.

    Conlisk thought her mom’s case was clear-cut, especially since they had successfully scheduled an ambulance transport a few weeks earlier to the same clinic. But the ambulance didn’t show on the day Conlisk was told it would. No one notified them the ride hadn’t been pre-authorized.

    The time it takes to juggle a prior authorization request can also perpetuate racial disparities and disproportionately affect those with lower-paying, hourly jobs, said Dr. Kathleen McManus, a physician-scientist at the University of Virginia.

    “When people ask for an example of structural racism in medicine, this is one that I give them,” McManus said. “It’s baked into the system.”

    Research that McManus and her colleagues published in 2020 found that federal Affordable Care Act marketplace insurance plans in the South were 16 times more likely to require prior authorization for HIV prevention drugs than those in the Northeast. The reason for these regional disparities is unknown. But she said that because more than half the nation’s Black population lives in the South, they’d be the patients more likely to face this barrier.

    Many of the denied claims are reversed if a patient appeals, according to the federal government. New data specific to Medicare Advantage plans found 82% of appeals resulted in fully or partially overturning the initial prior authorization denial, according to KFF.

    It’s not just patients who are confused and frustrated by the process. Doctors said they find the system convoluted and time-consuming, and feel as if their expertise is being challenged.

    “I lose hours of time that I really don’t have to argue … with someone who doesn’t even really know what I’m talking about,” said Kanter, the hematologist in Birmingham. “The people who are making these decisions are rarely in your field of medicine.”

    Occasionally, she said, it’s more efficient to send patients to the emergency room than it is to negotiate with their insurance plan to pre-authorize imaging or tests. But emergency care costs both the insurer and the patient more.

    “It’s a terrible system,” she said.

    A KFF analysis of 2021 claims data found that 9% of all in-network denials by Affordable Care Act plans on the federal exchange, healthcare.gov, were attributed to lack of prior authorization or referrals, but some companies are more likely to deny a claim for these reasons than others. In Texas, for example, the analysis found 22% of all denials made by Blue Cross and Blue Shield of Texas and 24% of all denials made by Celtic Insurance Co. were based on lack of prior authorization.

    Facing scrutiny, some insurers are revising their prior authorization policies. UnitedHealthcare has cut the number of prior authorizations in half in recent years by eliminating the need for patients to obtain permission for some diagnostic procedures, like MRIs and CT scans, said company spokesperson Heather Soules. Health insurers have also adopted artificial intelligence technology to speed up prior authorization decisions.

    Meanwhile, most patients have no means of avoiding the burdensome process that has become a defining feature of American health care. But even those who have the time and energy to fight back may not get the outcome they hoped for.

    When the ambulance never showed in July, Conlisk and her mother’s caregiver decided to drive the patient to the clinic in the caregiver’s car.

    “She almost fell outside the office,” said Conlisk, who needed the assistance of five bystanders to move her mother safely into the clinic.

    When her mother needed an ambulance for another appointment in September, Conlisk vowed to spend only one hour a day, for two weeks leading up to the clinic visit, working to get prior authorization. Her efforts were unsuccessful. Once again, her mother’s caregiver drove her to the clinic himself.

    KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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