Month: January 2023

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

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

Why eat small fish?

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

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

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

Small fish in the Mediterranean diet

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

Sardines packed in water or olive oil can be

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

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

Bivalve benefits

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

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

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

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

Aquatic plant foods

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

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

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

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

About the Reviewer

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

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

Many people know the form of dementia called Alzheimer’s disease. But what is frontotemporal dementia (FTD)? Damage to nerves in certain parts of the brain causes a group of frontotemporal disorders, affecting behavior and language as I’ll describe below.

Early signs of frontotemporal dementia

Have you noticed someone behaving differently? Is your coworker doing odd things, such as slapping each door as they walk down the hall? Or has your previously kind and caring spouse lost their capacity for empathy, such that when you told them about your cancer diagnosis, they complained that your treatment schedule would interfere with their golf game? If so, they might be showing early signs of the behavioral variant of FTD.

Maybe there’s a problem with language, rather than behavior. Perhaps it started with difficulty finding words (like any older adult), but is your sibling now having trouble with grammar and getting out an intelligible sentence? Or does your friend not know the meaning of some ordinary words, like pizza, lemonade, wood, or metal? If so, they might be showing signs of primary progressive aphasia, which may also be due to FTD.

A common pathology inside the brain

What’s the connection between these behavior and language problems? Why are they both part of FTD?

Both have the same underlying causes: a family of abnormal proteins that can be seen under the microscope. In fact, more than a dozen different pathologies can cause FTD. Each of them can lead to either behavioral variant frontotemporal dementia or the language difficulties of primary progressive aphasia.

Location, location, location

How can the same pathology — the same abnormal protein — lead to either behavior problems or language problems, or sometimes both? The answer is, it depends on where the pathology is.

The frontal lobes of your brain, behind your forehead, regulate and guide your personality, judgement, and behavior. So, if the frontotemporal pathology is in this region, it will cause changes in personality, judgement, and behavior.

The left temporal lobe (near your left ear and temple) and a part of the left frontal lobe just above it are the critical brain regions for language. When these areas are affected by frontotemporal pathology, language problems develop.

How does frontotemporal dementia compare with Alzheimer’s disease?

Frontotemporal dementia affects people in middle age, usually between ages 45 and 65, although one-quarter of individuals are diagnosed after age 65. Alzheimer’s usually affects people over 65.

In terms of symptoms, people with frontotemporal dementia experience either language or behavior problems, whereas people with Alzheimer’s disease — the most common cause of dementia — usually have memory problems.

Because more than 12 different abnormal proteins can cause frontotemporal dementia, it has a very variable time course. From the time of diagnosis, people with frontotemporal dementia need nursing home–level care in two to 20 years. The typical range with Alzheimer’s disease is four to 12 years.

Who is at risk for FTD?

Up to 40% of cases of frontotemporal dementia run in families, but that means at least 60% of cases do not. Unfortunately, everyone is at risk for frontotemporal dementia as they approach middle age.

What are common signs of the behavioral variant?

There are six common signs of behavioral variant frontotemporal dementia, and most people with the disorder have at least three of them. They are:

• loss of self-control
• apathy or inertia (not wanting to do anything)
• loss of sympathy or empathy
• repetitive or compulsive, ritualistic behavior
• uncontrolled or unusual eating
• difficulty doing complicated tasks.

One individual I cared for with this disorder would walk up to strangers, stand closer than would be comfortable, and say loudly, “You’re handsome!” Another would eat almost anything left out in the kitchen. One woman I treated with this disorder tried to pick up men from a restaurant — while her husband was sitting at the next table. A previously kind and shy grandfather with frontotemporal dementia began to ask his daughter-in-law for sexual favors.

What are common signs of the language variants?

Two variants of primary progressive aphasia are part of the frontotemporal dementia family of diseases. Common signs are:

• difficulty getting words and sentences out, although the meaning of words is preserved (nonfluent or agrammatic variant). People become frustrated because they know what they want to say but find it difficult or impossible to do so.
• losing the meaning of words (semantic variant). I had one patient who did not know the meaning of the words shoe, pants, foot, knee, elbow, and many other words related to clothing and parts of the body.

Can frontotemporal dementia be treated?

Currently, there is no cure or way to slow these disorders down, so treatment is supportive. SSRI medications (selective serotonin reuptake inhibitors) can help with some disinhibited behaviors.

Speech therapy can be helpful, at least initially, with primary progressive aphasia, but thus far no medications are effective.

What can I do if I suspect that someone has frontotemporal dementia?

FTD is difficult to diagnose. Because it affects people in middle age, dementia is usually not suspected. Early in the disease, people are often thought to be having a midlife crisis, depression, or perhaps a drug or alcohol problem. Many marriages end prior to the diagnosis because the spouse with the disorder has grown self-absorbed and inconsiderate over several years.

If you do suspect the disorder, start by simply asking the person if there is anything that you can help with. You may find out that it is another problem entirely. But if it is becoming clear that this or another form of dementia may be involved, encourage them and their family to discuss this possibility with their doctor.

About the Author

Andrew E. Budson, MD,

Contributor; Editorial Advisory Board Member, Harvard Health Publishing

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

Many people and their families associate the term palliative care with the end of life. Some may think that palliative care and hospice care are one and the same. So it’s worth explaining that palliative care is a medical specialty able to help people during many different stages of health, not just during a terminal illness. Importantly, the services offered could help you or someone you love enjoy a better quality of life, ease uncomfortable symptoms, and avoid unnecessary hospitalizations.

Asmedical oncologists (cancer doctors), we’ve witnessed how helpful this care can be when people experience cancer or another serious illness. Yet we find that not enough people who could benefit from this care receive it. By addressing misconceptions about what palliative care is and who it can help, we hope more people will ask for the full range of care they deserve, and inquire about whether a referral to palliative care is right for them.

What is palliative care?

Palliative care looks holistically at ways to improve quality of life for people and caregivers by

• helping people manage pain, nausea, fatigue, and other troubling symptoms associated with illness or treatment, to optimize their comfort and ability to function
• providing support for depression, anxiety, or stressors such as finances or relationships that may be affected by a serious illness
• improving care coordination by communicating with other health care providers to make sure everyone is on the same page regarding needs and preferences
• if appropriate, explaining and providing options for end-of-life care (this form of palliative care is part of hospice care).

In many health care settings, palliative care is handled by one or a few health care providers, such as a physician, physician assistant, or nurse practitioner. In others, palliative care may be provided by a team of clinicians and social workers, spiritual counselors, and case managers.

People sometimes think of palliative care as a last resort; you might have heard this, or even thought this way yourself. It may help to know that the type of care we’re describing is now recognized as essential to treatment, even during the early stages of serious illnesses like cancer, emphysema, heart failure, and kidney disease. People can and should receive palliative care while also receiving curative or life-prolonging treatments.

Who can palliative care help?

Palliative care can help any person experiencing a serious medical problem causing physical or emotional distress.

Typically, this refers to people with life-threatening or chronic illnesses such as cancer, heart disease, lung disease, neurologic impairment, or kidney failure. It can also refer to people who have experienced an injury resulting in physical ailments, emotional distress, or both. So in a sense, these services can be offered to anyone based on their symptoms rather than their specific diagnosis. Palliative care services are also available to support families and caregivers.

Why is my doctor talking to me about palliative care?

You might feel alarmed if your doctor recommends palliative care. However, it’s important to understand that the benefits of palliative care are greatest when introduced early after a new diagnosis of a serious illness, pain syndrome, or physical trauma. In our practice, we tend to explain the concept of palliative care soon after a cancer diagnosis for people who may benefit from additional support.

Our goal is to offer information on the resources available to support well-being, not to take away hope or scare people. The better you feel, the better you’ll do. Experiencing less pain, nausea, fatigue, or depression makes medical treatments and surgeries easier to tolerate, which may expand both quality and quantity of life.

We’ve answered frequently asked questions below.

Why is my doctor talking about palliative care?

To enhance support for people experiencing tough times and serious illnesses, not when “there’s nothing left to do.”

Am I dying?

A referral to palliative care does not mean that you are dying — it just means that you and your family may need more support to help you live as long and as well as possible.

Are you still my doctor?

Yes! Palliative care providers are consultants who team up with your doctors, including your primary care doctor and other specialists involved in your care.

If I have a question, who do I call?

If your question is related to a symptom or medicine managed by your palliative care team, then it is appropriate to reach out to them. However, you can never go wrong by calling the primary doctor directing your care, such as your oncologist if you have cancer. They can field your question and send you to the right person.

What medicines will be available to me?

Any medicines to help you feel better or live longer, including cancer treatments, are available if deemed helpful by you and your doctors.

Do I have to continue seeing my palliative care provider or team?

Just like any other doctor, they are available if you find you benefit from their services. If you no longer feel that you have needs that they can address, then you do not have to continue receiving their care.

Will my family benefit from palliative care?

Yes, definitely! One of the main goals of palliative care is to improve quality of life for people and their families or caregivers through counseling, information, and helping to coordinate doctor visits and medical tests.

About the Authors

Emily Stern Gatof, MD, Guest Contributor

Dr. Emily Stern Gatof is a hematology/oncology fellow at Beth Israel Deaconess Medical Center (BIDMC). She is pursuing a career as a breast oncologist and has a special interest in hereditary cancer syndromes. After attending the … See Full Bio View all posts by Emily Stern Gatof, MD

David J. Einstein, MD, Contributor

Dr. David J. Einstein is a genitourinary medical oncologist at Beth Israel Deaconess Medical Center, and an assistant professor of medicine at Harvard Medical School. In addition to patient care, he leads clinical/translational research in immunotherapy … See Full Bio View all posts by David J. Einstein, MD

Driving along the freeway recently, a billboard caught my eye. In bold letters it proclaimed:

Milk hydrates better than water.

Wait, could this be true? And if so, should I be rehydrating with milk after a workout? And should we all have milk, rather than water, in our water bottles?

What’s behind the claim?

Unsurprisingly, the ad is sponsored by the milk industry. And while I’d never heard this claim before, the studies behind the idea aren’t particularly new or compelling. The website supporting this ad cites three small studies dating back more than a decade:

• A 2007 study enrolled 11 volunteers (five men, six women) who exercised until they were markedly dehydrated on several occasions. Each time they rehydrated with a different drink, and their urine output was measured over the following five hours. After drinking milk, the study volunteers produced less urine (and therefore retained more fluid) than with water or a sports drink (Powerade). Therefore, milk was considered to provide better hydration.
• A study published in 2016 described seven men with marked dehydration following exercise who drank fat-free milk, water, or Powerade. The results were similar.
• A 2016 study enrolled 72 healthy, well-hydrated men who drank various fluids and then had their urine production measured over the next four hours. The drinks used in this study were water, whole milk, skim milk, beer, Dioralyte (an oral rehydration solution used after fluid loss from diarrhea), tea, coffee, diet cola, regular cola, orange juice, and Powerade. The researchers found that fluid retention was best after drinking either type of milk or the oral rehydration solution; results for the other drinks were similar to water.

Sounds like milk is a winner, right? Maybe. But there are other things to consider.

The study details matter

The findings of these studies aren’t definitive. As with all research, there are important limitations. For example:

• The small number of participants in these studies means that just a few people could have an outsized impact on the results.
• Two of the three studies involved significant dehydration by intensely exercising in a warm environment, leading to several pounds of fluid loss. Therefore, the results may not apply to people engaged in more typical daily activities or workouts. In addition, the studies equated better hydration with less urine production in the hours after drinking various fluids. This is only one way to define hydration, and not clearly the best one.
• The advantage of milk reported in these studies may be too small or too temporary to matter much. For example, in the study of 72 people, milk drinkers produced about 37 ounces of urine over four hours while water drinkers produced 47 ounces. Does the 10-ounce difference have a meaningful health impact? If the study participants had been monitored for a longer period, would this difference disappear?
• The amount of milk consumed in the study of seven men would contain more than 1,000 calories. That may be acceptable for an elite athlete after hours of intensive exercise in the heat, but counterproductive and costly for someone working out for 30 minutes to help maintain or lose weight. Tap water is free and has no calories!

Hyping hydration: Many claims, little evidence

The billboard promoting milk reflects our relatively recent focus on hydration for health. This is promoted — or perhaps created — by advertisers selling sports drinks, energy drinks and, yes, water bottles. But does drinking “plenty of water” translate to weight loss, athletic performance, and glowing appearance? Does monitoring urine color (darker could indicate dehydration) and downing the oft-recommended eight glasses of water daily make a difference in our health? On the strength of evidence offered so far, I’m not convinced.

But wait, there’s more! Emotional support water bottles, a trend popularized recently in Australia, offer one part public expression of your commitment to health and one part security blanket. (Yes, it’s a thing: #emotionalsupportwaterbottle has more than 80 million views on TikTok.) And then there’s intravenous hydration on demand for healthy (and often wealthy) people convinced that intravenous fluids will improve their looks, relieve their hangovers, help with jet lag, or remedy and prevent an assortment of other ailments.

Is this focus on hydration actually helpful?

Before water bottles were everywhere and monitoring fluid intake became commonplace, medically important dehydration wasn’t a problem for most healthy people who were not rapidly losing fluids due to heat, intense exercise, diarrhea, or the like.

The fact is, drinking when thirsty is a sound strategy for most of us. And while there are important exceptions noted below, you probably don’t need fluids at hand at all times or to closely monitor daily fluid intake to be healthy. There are far more important health concerns than whether you drink eight glasses of water each day.

When is dehydration a serious problem?

Weather, exercise, or illness can make dehydration a major problem. Particularly susceptible are people who work or exercise outside in hot and humid environments, those at the extremes of age, people experiencing significant fluid loss (as with a diarrheal illness), and those without reliable access to fluids. If significant dehydration occurs, replacing lost fluids is critically important, and may even require a medical setting where intravenous fluids can be provided quickly.

The bottom line

Despite the claims of milk ads and the iffy studies justifying them, the idea of replacing water with milk for rehydration may not convince everyone: the taste, consistency, and extra calories of milk may be hard to get past.

As for me, until there’s more convincing evidence of an actual health advantage of milk over water for routine hydration, I’ll stick with water. But I’ll forego the water bottle.

Follow me on Twitter @RobShmerling

About the Author

Robert H. Shmerling, MD,

Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

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

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

What happens to the gut during a COVID infection?

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

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

What is long COVID?

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

Why might the gut be involved in long COVID?

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

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

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

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

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

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

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

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

About the Author

Christopher D. Vélez, MD, Contributor

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