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Weight stigma, as defined in a recent BioMed Central article, is the “social rejection and devaluation that accrues to those who do not comply with prevailing social norms of adequate body weight and shape.” Put simply, weight stigma is a form of discrimination based on a person’s body weight.

The authors of this article assert that weight stigma can trigger changes in the body, such as increased cortisol levels, that lead to poor metabolic health and increased weight gain. In addition, those with higher body weight may cope with weight stigma by increasing alcohol and substance use, overeating to deal with negative emotions, and avoiding health care settings or social encounters. The subsequent negative health outcomes are a result of what they call chronic social stress, and studies have found the harmful effects of weight discrimination resulted in a 60% increased risk of death, even when body mass index (BMI) was controlled for.

What can be done to combat weight stigma?

There are many ways to address weight stigma. The first is to acknowledge that it exists, since we cannot combat something if we do not first acknowledge it.

Another step we can take is to make changes in the way we think and speak about people who have excess weight. One important way to do this is to remove the word “obese” from our vocabularies. When referring to someone who has excess weight, we should aim to keep in mind that they are a person with a disease, and strive to identify them as a person instead of as the disease they have. For example, the phrase “person with obesity” should be used instead of “obese person.” This way of speaking is called using person-first language.

Addressing weight stigma in health care settings

The health care setting is one in which weight stigma is particularly rampant, leading to significant health consequences for people with overweight or obesity. Studies have shown that physicians show strong anti-fat bias in health care situations. This bias results in reduced quality of care, and is yet another way in which weight stigma contributes to poor health in people with overweight and obesity.

Just as in everyday situations, there are many ways to address stigma in health care settings. Clinicians should of course follow the same recommendations as above, to acknowledge the existence of weight stigma and strive to use person-first language in their speech and medical documentation.

In addition, dispensing with the standard cookie-cutter advice to eat less and exercise more to lose weight would be of great benefit to patients. This type of advice doesn’t take into account the many environmental, genetic, and physiologic causes of obesity, and puts blame on the patient as the sole cause and contributor of their obesity.

Clinicians should also take care not to assume a patient with obesity is automatically engaging in overeating behaviors, and should believe their patients’ reports of dietary intake and physical activity. The clinical visit should be focused on information gathering and understanding of a patient's particular situation. Referral to an obesity specialist may be warranted if the clinician is not comfortable with discussing or prescribing different treatment options.

It is of utmost importance for patients with obesity to seek care from compassionate and knowledgeable health care providers, to optimize the quality of their care and reduce the negative effects of weight bias.

Where to go for more information and resources

The following organizations have plenty of information and resources for both patients and health care providers to learn more about obesity as a disease and how to combat weight stigma.

The Obesity Action Coalition is an organization that works to help individuals with obesity improve their health through education, advocacy, awareness, and support.

The Obesity Medicine Association has a search tool to find a clinician who is board-certified in obesity medicine within a specific geographic area.

The American Society for Metabolic and Bariatric Surgery has information for those with severe obesity, or with milder obesity and other medical complications, who are interested in bariatric surgery.

About the Author

Chika Anekwe, MD, MPH, Contributor

Chika V. Anekwe, MD, MPH is an obesity medicine physician at Massachusetts General Hospital (MGH) Weight Center and Instructor in Medicine at Harvard Medical School (HMS). Her professional interests are in the areas of clinical nutrition, … See Full Bio View all posts by Chika Anekwe, MD, MPH

Prostate cancer can progress over long durations, and if a man’s tumor has features that predict slow growth, he can opt for active surveillance instead of immediate treatment. Men on active surveillance get routine PSA blood tests and prostate biopsies, and are treated only if the cancer advances or shows evidence of increasing activity. But when the time comes for treatment, up to a third of men still decide against it. Now, a new study finds that for some of these men, treatment can be safely delayed.

Researchers from the University of California, San Francisco identified 531 men whose cancers progressed while they were on active surveillance. All the men were diagnosed initially with Grade Group 1 prostate cancer, which is the bottom rung on a classification scheme that ranks cancers from low to high risk of aggressive spread. Within 25 months, on average, the men’s biopsy samples showed they had progressed to higher-risk grade groups that are typically treated.

In all, 192 men wound up having surgery to remove the prostate within six months of their tumor upgrade. But 125 men waited up to five years before having the operation, and 214 men decided against being treated at all.

Outcomes and observations

When the researchers compared long-term outcomes among the men who got surgery within six months and those who waited longer for their operation, they found little difference between them. Forty-five men from both groups combined had their cancer return within three years after surgery. But the percentage who avoided a cancer recurrence was similar in both groups: 80% of the men in the early-surgery group were still cancer-free three years later, compared to 87% of the men who put the surgery off for up to five years.

Furthermore, prostate tissues observed by a pathologist immediately after surgery showed similar rates of adverse biological features that predict worse outcomes later. Tumors from about half the men from either group had this type of adverse pathology. Based on these results, the authors concluded that “a subset of patients with biopsy progression can safely continue on active surveillance.”

The trick is to predict who those patients are in advance. Unfortunately, genetic testing provided few insights into which men might progress faster than others. The authors emphasized that further studies are needed to determine how genetic tests might help with making treatment decisions for men on active surveillance. In an editorial comment, Dr. Christopher Morash from the University of Ottawa cautioned that the three-year follow-up is not very long, and that differences between the early- and late-surgery groups may emerge in the coming years.

"This is an important study that continues to provide support for active surveillance not only in men with Grade Group 1 cancers, but also for those who over time progress to Grade Group 2, which in the past has been an impetus to initiate treatment," says Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org. "New findings emerging from the field of biomarkers and genomics should hopefully continue to add to our knowledge about even more precision in selecting men who can and cannot safely defer=”defer” treatments, even in the face of progression."

About the Author

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

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

As a cisgender woman with long hair and a closet full of dresses, I can count on one hand the number of times I’ve been misgendered by being called “he” or “sir.” Cisgender means I was assigned female at birth and identify as a woman. For people who are transgender and/or nonbinary (TNB), with a different gender identity than their assigned sex at birth, being misgendered may be a daily occurrence.

Why does misgendering matter?

Imagine a scenario in which you are called the wrong pronoun or honorific — for example Mr., Ms., or Mrs. — multiple times a day. It might happen in person, over the phone, or via email. Each time it happens, you must decide whether it is worth it to correct that person or easier to let it go. Imagine that you are repeatedly confronted with this experience and the decision of whether or not to correct it throughout the day — every day. As we know from research, and as I’ve also heard from the TNB people I know, this is both exhausting and demoralizing. When people are misgendered, they feel invalidated and unseen. When this happens daily, it becomes a burden that can negatively impact their mental health and their ability to function in the world.

If you are a cisgender person, you can lighten this burden for TNB people by using the right names, pronouns, and honorifics to refer to them, apologizing when you misgender someone, and correcting other people when they misgender someone.

How do you use the correct name, pronouns, and honorifics?

It’s simple: follow the person’s lead, or ask them. The name, pronouns, and honorifics that a person chooses to use for themselves communicate to others how they want to be seen and acknowledged. Using the correct terms for someone is a sign of respect and recognition that you see them as they see themselves.

If you knew someone previously as one gender and now they use a different name, pronouns, or honorifics, it can be hard to remember to use the right terms, especially if the person is gender-fluid and changes their pronouns more often. It can also be challenging to adjust to using gender-neutral pronouns like they and them, neopronouns like ze and zir, and unfamiliar honorifics, such as Mx (pronounced “mix”). But using the right terms is critically important for supporting and respecting TNB people.

A few tips and tools

• Try not to make assumptions about a person’s name, pronouns, or honorifics based on how they look. The only way to know for sure what terms a person uses is to ask them in private (“What pronouns do you use?”). Asking someone in front of other people may unintentionally put them on the spot to disclose their identity to new people. You can ask anyone — cisgender or TNB — their name, pronouns, or honorifics.
• Once you know what terms a person uses, the best way to make sure that you use the correct ones is to practice (this tool can help). Practice when they are in the room and when they are not in the room. Practice before you know you will see someone. Practice with others in your life: your cisgender friends, your spouse, your pet, your child. In our household, my wife and I try to use gender-neutral pronouns to refer to our preschooler’s toys and dolls so that we can practice using them ourselves. We even change the pronouns of characters in books that we read as another way to practice.
• Another tip for remembering to use the correct name, pronouns, and honorifics is to pause before you speak. When we are stressed or busy, we are more likely to misgender people. Try to pause for a beat before you speak to make sure you are using the right terms to refer to someone. Similarly, reread emails before you send them to make sure you are not misgendering someone.
• Be patient as you learn to use new terms and pronouns. It gets easier with practice and may become second nature over time.

How to apologize for misgendering someone

Misgendering will happen. What’s most important is how you handle it when it does. The best way to handle misgendering someone who is present is to apologize and try harder next time (“I’m sorry, I meant [correct name/pronoun/honorific]”). Keep your apology brief so that it doesn’t become about you and your mistake.

If you are corrected by someone else, try not to be defensive. Instead, simply respond with a thank you and a correction (“Oh, thank you — I’ll email [correct name/pronoun] about that”). This is an important step, even if the misgendered person is not present, so you can practice and so others can learn from your example. Any time you misgender someone, practice so you can do better next time.

How to correct misgendering when you hear or see it

As a cisgender colleague and supervisor to numerous TNB people, many of whom are nonbinary and use they/them pronouns, I often find myself in situations where I need to correct misgendering. I might say something like “I noticed you used she to refer to that person. Just to let you know, they use they/them pronouns.” Or I might write a note in a Zoom chat or in an email, “Just a friendly reminder that this person uses they/them pronouns.” Stepping forward this way lessens the burden of correcting misgendering for TNB people. It also models to others that a correction can be done in a friendly way, and is important for respecting and including TNB people.

How to use gender-neutral language and normalize pronouns

One way to avoid misgendering is to use gender neutral language. Here are some examples:

• Instead of “boys and girls” or “ladies and gentlemen,” say “everyone.”
• Instead of “fireman” or “policeman,” say “firefighter” or “police officer.”
• Instead of “hey guys,” say “hey everyone” or “hey all.”

Try to pay attention to your language and find ways to switch to gender-neutral terms.

You can be mindful of your own pronouns and help other people be mindful by normalizing displays of pronouns. Here are some ways that I make my own pronouns (she/her) visible to others:

• I list my pronouns in my email signature, in my Zoom name, and on the title page of presentations.
• I wear a pronoun pin at work.
• I introduce myself with my pronouns.

These actions signal to others that I am thinking about pronouns,  and am aware that people may use different pronouns than might be expected from their appearance.

You may still make mistakes, but it’s important to keep practicing and trying to use the right terms! By using the correct names, pronouns, and honorifics to refer to people, apologizing when you misgender someone, and correcting other people when they misgender, you can support and respect the TNB people around you. This helps create a more inclusive world for everyone.

About the Author

Sabra L. Katz-Wise, PhD, Contributor

Sabra L. Katz-Wise, PhD (she/her) is an assistant professor in adolescent/young adult medicine at Boston Children’s Hospital, in pediatrics at Harvard Medical School, and in social and behavioral sciences at the Harvard T.H. Chan School of … See Full Bio View all posts by Sabra L. Katz-Wise, PhD

Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States, and rates are rising, particularly in adults ages 20 to 49. Unfortunately, approximately 30% of eligible people in the US still have not been screened for CRC.

Colon cancer may be prevented with screening tests that look for cancer or precancerous growths called colon polyps.

When should you start screening?

The United States Preventative Services Task Force recommends starting screening for CRC at age 45 for average-risk patients. These guidelines reflect the most up-to-date research on when risk for colon cancer begins to increase.

Average-risk patients are those with no personal or family history of colon cancer or a genetic condition that increases the risk of developing CRC. For this reason, it is important for patients to share their family history, including all cancer diagnoses in blood relatives, with their primary care doctor, who can help decide the right time to begin colon cancer screening.

High-risk patients are advised to begin screening before age 45. A primary care physician can help determine when and how a patient who is concerned about their risk level should be screened for CRC. Patients who have a history of CRC or polyps; a first-degree family member with CRC or advanced polyps (those that would have gone on to become CRC if they had not been removed); a family history of certain genetic syndromes; or a history of inflammatory bowel disease (like Crohn’s disease or ulcerative colitis) are some examples of high-risk factors.

What are the options for CRC screening?

Colonoscopy: Colonoscopy is the gold standard of screening tests, and identifies approximately 95% of CRC. It is also the only method that allows a gastroenterologist to both detect and remove potentially precancerous colon polyps. Colonoscopies are considered low-risk procedures, but they do have a small risk of bleeding and perforation that increases in older age groups.

Patients need to clean out their colon prior to the procedure by drinking a colonoscopy prep, which washes stool out of the colon so that it can be properly assessed during the procedure. The prescription instructions for the prep are provided by the gastroenterologist’s office.

In most cases, the procedure will be performed under sedation to ensure the patient is as comfortable as possible. It is important to note that patients are not placed under general anesthesia, but most remain sleepy and comfortable throughout their colonoscopy.

During the colonoscopy, a gastroenterologist will insert a flexible tube with a camera at the end, called a colonoscope, into the rectum. The entire colon is then carefully examined. If no polyps are detected and the preparation (cleanout) of the colon is adequate, a repeat a colonoscopy is suggested in 10 years. If polyps are detected, or the patient’s risk level or symptoms change, this interval will be shorter.

FIT testing: The fecal immunochemical test (FIT) is a lab test that looks for hidden blood in the stool. Patients use a kit to collect their stool and then use a probe to scrape the stool, which is then placed into a tube and mailed to the lab. FIT testing is repeated every year. A drawback of FIT testing is that it has a false positive rate of approximately 5%. It can effectively rule out CRC with 79% accuracy. FIT testing is noninvasive, convenient, and cost-effective, making it an acceptable alternative to a colonoscopy for many people. If a stool test is positive, a colonoscopy is needed to evaluate the reason for the positive test.

Flexible sigmoidoscopy: A flexible tube with a camera is used to look at the rectum and the lower part of the colon. The advantages of this procedure are that it is faster than a colonoscopy (only 5 to 15 minutes) and requires less aggressive laxative medications. Typically, patients receive a flexible sigmoidoscopy every five years if no polyps are detected. As this test does not examine the whole colon, it cannot detect cancers or polyps in the unexamined portion. At best, it can detect 70% of cancers and polyps. If an abnormality is detected, a follow-up colonoscopy is needed to look at the entire colon.

CT colonography: A CT scan is used to visualize your rectum and entire colon. Just like with a colonoscopy, patients need to take laxative medications the night before to empty the colon. A small tube is placed in the rectum to expand the colon to get clear pictures. This test may be useful for patients who cannot tolerate anesthesia or have other medical conditions that prevent them from having a colonoscopy. A drawback of CT colonography is radiation exposure, and finding unrelated abnormalities outside the colon that can lead to unnecessary tests. While CT colonography is about 88.7% accurate at finding certain polyps, it is less accurate than colonoscopy overall. If the CT colonography result is abnormal, a colonoscopy is required for full evaluation of the colon.

Cologuard: This is a test where patients collect their stool, scrape it with a probe, insert it into a container with preservative, and mail it to the lab. This test looks for atypical DNA, or traces of blood in the collected stool that may be suggestive of precancerous polyps or CRC. Typically, patients repeat the test every three years. If the Cologuard test is positive, a colonoscopy is necessary for further evaluation. However, Cologuard’s accuracy is still limited; 13% of the time the test indicates the patient may have cancer when they do not. In 2019, a study showed that annual FIT testing or colonoscopy may be more effective and less costly than Cologuard. Further research is ongoing to evaluate how accurate (and thus how useful) this test is at detecting CRC.

Which screening option should you choose?

The most important part of colon cancer screening is to have a screening test performed. For most patients, colonoscopy or FIT testing are the most common ways to screen for colon cancer. However, there are other options to consider if you are unable to undergo or are uncomfortable with colonoscopy or FIT testing. Ultimately, this is an important and personalized decision, and a discussion for a patient to have with their healthcare provider, so that the right test can be done at the right time.

About the Authors

Nisa Desai, MD, Contributor

Dr. Nisa Desai is a practicing hospitalist physician at Beth Israel Deaconess Medical Center, and an instructor in medicine at Harvard Medical School. She completed undergraduate education at Northwestern University, followed by medical school at the … See Full Bio View all posts by Nisa Desai, MD

Loren Rabinowitz, MD, Contributor

Dr. Loren Rabinowitz is an instructor in medicine Beth Israel Deaconess Medical Center and Harvard Medical School, and an attending physician in the Inflammatory Bowel Disease Center at BIDMC. Her clinical research is focused on the … See Full Bio View all posts by Loren Rabinowitz, MD

In the spring of 2020, the pandemic catapulted many of us into shock and fear — our lives upended, our routines unmoored. Great uncertainty at the onset evolved into hope that, a year later, a semblance of normalcy might return. Yet not only do people continue to face uncertainty, but many of us have also reached a plateau of fatigue, resignation, and grief.

We are living through a time of widespread illness, social and political unrest, economic fractures, and broken safety nets. Whether each of us experiences the ravages of this time close to home or as part of a larger circle, the symptoms of collective trauma are widespread. Many of these symptoms — feeling overwhelmed, anxious, fatigued — may be familiar. One deserves special mention: numbness. As a psychiatrist who has considerable experience treating refugees suffering from trauma, and an author and teacher who works with collective trauma, we have learned a great deal about how numbness affects us all.

Newsfeeds: Friend or foe?

Compounding our challenges are our news viewing habits. During times of uncertainty, we are each, in our own way, experiencing vulnerability. Fears that had lain dormant for years may be activated, causing low-grade stress or full-blown anxiety. These fears are exacerbated by what might be called the “toxic trauma story” churned out by mainstream news channels.

The formula is simple: brutal facts associated with high emotion attract viewers. As the old adage says, “If it bleeds, it leads.” Negative news around vaccine reactions or political unrest provides the ultimate sensational content for viewers. But for most Americans, this daily onslaught of negativity exerts a toll on mind, body, and emotions.

Numbness is one possible response to trauma

When a situation is overwhelming, your body protects itself by entering a “fight, flight, or freeze” mode. Our responses to the pandemic and continuous uncertainty, fueled by doomscrolling and newsfeeds, range from hyperactivation (fight or flight) to numbness (freeze). While the three Fs refer to the body’s stress response in the moment, these reactions can continue long after exposure to trauma.

In medical terms, numbness occurs when nerves are damaged, leading to partial or total loss of sensation in the body. We can also describe numbness related to our psychological well-being: a lack of enthusiasm and interest in life, a sense of apathy and indifference. The spectrum ranges from mild apathy to disassociation to a heavy, weighty lethargy, which is often a symptom of severe depression. “Freeze” refers to a paralyzed or frozen state associated with post-traumatic stress disorder (PTSD) and major depression. We have each worked with thousands of people — some refugees, some not — who have experienced this level of trauma.

The numbness many people are experiencing and describing these days didn’t necessarily begin with the pandemic, nor is a toxic stream of trauma stories the only source feeding it. It may have been there for many years, only to be triggered by recent personal and societal challenges.

This numbness is not just a lack of feeling; its symptoms vary. You might feel a low level of anxiety operating in the background, much like an operating system running our computers silently. You may feel no emotion or a sense of frozenness during the day, followed at night by insomnia or nightmares. Some people who are refugees cannot watch the daily news, since it is a terrifying trigger that floods them with memories of their past traumas.

How does numbness affect us collectively?

Millions of people turn to their phones and devices for daily notifications of traumatic news. These instantaneous alerts offer little space for digestion and reflection. That harmful combination of speed and trauma can strike at our nervous systems, overwhelming us until we are too numb to comprehend the complex range of experiences flooding in over the last days, weeks, and years. What happens to us as a culture, grappling with this cumulative phenomenon?

Where collective trauma now exists, we need to seek ways to facilitate dialogue and restoration. The numbness following traumatization reduces our capacity to witness suffering. We lose our reflective capacity to be self-aware, which reduces empathy and compassion. Indifference and disconnection can contribute to further atrocities, fueling a feedback loop that makes new traumas more likely to occur.

Collective numbness can surface as epidemic substance misuse; food, sex, or entertainment addiction; media overuse; or in other ways. It reveals itself as a collective shutting-down to crisis, which can derail healing.

How can you counter numbness and feeling overwhelmed?

As individuals, we can spend more time practicing self-care, as outlined in the Harvard Program in Refugee Trauma toolkit. For example, take time to reflect on the resources and sources of support you have in your life. Spend quality time with family, and if possible, in nature. Set boundaries on news devices to give your nervous system a chance to relax. Turn off your notifications, leave your phone far from your bedroom at night, and consider periodic news fasts to give your system a full recharge.

Developing a mindfulness practice can help reduce stress, allowing people to digest and integrate hidden emotions or experiences buried under numbness. One option is a practice called 3-sync: imagine a journey of witnessing yourself, moving deliberately as you notice the state of your body first, then your mind, and finally, your emotions. Following this during meditation can help you become aware of imbalances within yourself, as well as areas of strength and vitality. Another practice, global social witnessing, is a conscious process of witnessing the news, and digesting it with our minds, bodies, and emotions fully present.

By working together to be with whatever is present, acknowledging and feeling our discomfort, resistance, and pain, we may move closer to integration and a sense of healing during this time of upheaval.

About the Authors

Richard F. Mollica, MD, Contributor

Dr. Richard F. Mollica is a professor of psychiatry at Harvard Medical School, and director of the Harvard Program in Refugee Trauma (HPRT) at Massachusetts General Hospital. A pioneer in international research on refugee trauma, he … See Full Bio View all posts by Richard F. Mollica, MD

Thomas Hübl, Guest Contributor

Thomas Hübl is a renowned teacher, and author of Healing Collective Trauma: A Process for Integrating Our Intergenerational and Cultural Wounds. Since 2002, he has led dialogue and restoration processes around collective trauma with more than … See Full Bio View all posts by Thomas Hübl

This spring, many parts of United States experienced historic heat waves. Now summer is officially underway, and experts are predicting hotter than normal temperatures across most of the country.

Extreme temperatures increase health risks for people with chronic conditions, including heart problems. If you do have a heart condition, here’s how to keep cool and protect yourself when temperatures rise.

How does hot weather affect the heart?

Not only does exposure to high heat increase the risk for heat exhaustion and heat stroke, but it can also place a particular burden on heart health. It stresses the cardiovascular system and makes the heart work harder. This can increase the chance of heart attacks, heart arrhythmias (irregular heartbeat), and heart failure.

According to the Environmental Protection Agency, the interaction of high heat and cardiovascular disease contributes to about a quarter of heat-related deaths.

And the higher the temperature, the greater the threat. A recent study in the journal Circulation looked at cardiovascular death rates over seven years in Kuwait, where daytime temperatures can reach triple digits in the hottest months. The researchers found a link between rising temperatures and the risk of cardiovascular deaths, with most occurring between temperatures of 95° F to 109° F.

“Climate change is giving us more, and unprecedented, heat that can be deadly, especially for people with heart disease,” says Dr. Aaron Bernstein, interim director of the Center for Climate, Health, and the Global Environment at Harvard T.H. Chan School of Public Health.

How does the body shed heat?

Your body is designed to shed extra heat in two major ways, each of which may affect the heart:

Radiation. When the air around you is cooler than your body, you radiate extra heat into the air. This process requires rerouting blood flow so that more of it goes to the skin.

Evaporation. Evaporating sweat helps cool you down by pulling heat away from your skin. When the air is dry, this works well. But when it’s hot and humid, sweat just sits on the skin as your body temperature rises.

When air temperature approaches or exceeds body temperature, especially in high humidity, the heart has to beat faster and pump harder to help your body shed heat. On a hot and humid day, your heart may circulate two to four times as much blood each minute compared with a cool day.

Some medicines meant to help the heart can add to problems on hot days. For example, beta blockers slow the heartbeat and hinder the heart’s ability to circulate blood fast enough for effective heat exchange. Diuretics (water pills) increase urine output and raise the risk of dehydration.

How can you protect yourself and your heart when temperatures rise?

While exposure to high heat and heat waves affects everyone, having existing heart problems raises your risk for heat-related illness and hospitalization. So it’s especially important to try to follow basic strategies for staying cool, including these:

• Monitor weather forecasts for heat advisories and stay inside on those days. If home is too hot, check with your town or city health department for cooling centers and other options to help you stay cool. If you venture outside, evening and early morning are often the coolest times. Rest in the shade whenever possible.
• When outside, try to drink 8 ounces of water every 20 minutes. Set a timer to remind you. “Never wait until you’re thirsty to drink,” says Dr. Bernstein. If you have heart failure, ask your doctor how much fluid you should drink daily, since fluids can build up and cause swelling. If you take diuretics, ask how much you should drink during hot weather.
• Avoid soda or fruit juice and limit alcohol. Soda and fruit juice may slow the passage of water from the digestive system to the bloodstream. While research is limited, some studies have found that excessive alcohol intake may raise risk for heat stroke during scorching weather.
• Protect your skin. Sunburn affects your body’s ability to cool down and increases dehydration. Wear a wide-brimmed hat, wraparound sunglasses, and lightweight, light-colored, loose-fitting clothing. Also, apply plenty of broad-spectrum or UVA/UVB protection sunscreen with SPF 30 or higher to all exposed skin 30 minutes before going out. Reapply every hour.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

A forest fire in northern California and a mile-long glacier breaking apart appear in your news feed. The stark reminders of climate change are constant, and may cause additional stress to your daily tasks. For example, in surveying your shopping cart filled with wipes, sandwich bags, and packets of baby food, you may question your choices, knowing that the plastic in those items will never break down completely. You may feel guilty about driving the short distance to the store, or you may struggle to stop worrying about how your actions will affect future generations.

What is climate anxiety?

Climate anxiety, or eco-anxiety, is distress related to worries about the effects of climate change. It is not a mental illness. Rather, it is anxiety rooted in uncertainty about the future and alerting us to the dangers of a changing climate. Climate change is a real threat, and therefore it's normal to experience worry and fear about the consequences. Anxiety about the climate is often accompanied by feelings of grief, anger, guilt, and shame, which in turn can affect mood, behavior, and thinking.

How common is climate anxiety?

According to a survey by the American Psychological Association, more than two-thirds of Americans experience some climate anxiety. A study published by The Lancet found that 84% of children and young adults ages 16 to 25 are at least moderately worried about climate change, and 59% are very or extremely worried. This makes sense, as children and young adults will disproportionately suffer the consequences of environmental changes. A 2021 UNICEF report estimates that one billion children will be at "extremely high risk" as a result of climate change. Children and young adults are also particularly vulnerable to the effects of chronic stress, and climate anxiety may affect their risk of developing depression, anxiety, and substance use disorders.

How does climate change affect mental health?

In addition to existential worries and fears about the future, climate change can affect mental health directly (such as through natural disasters or heat) and indirectly (through displacement, migration, and food insecurity). Rising temperatures have been associated with increases in emergency department visits for psychiatric reasons, and may impair cognitive development in children and adolescents. Furthermore, food insecurity is associated with depression, anxiety, and behavioral problems.

How can you manage climate anxiety?

As uncertainty and a loss of control characterize climate anxiety, the best treatment is to take action. On an individual level, it’s therapeutic to share your worries and fears with trusted friends, a therapist, or by joining a support group. You can also make changes to your lifestyle consistent with your values. This may include deciding to take fewer flights, joining a protest, or increasing public awareness about climate change through advocacy. Joining an organization like The Good Grief Network can help you process feelings related to climate anxiety and connect with others to take meaningful action.

How can you help a younger person?

Climate anxiety disproportionately affects children and youth. To be an ally for a child, adolescent, or younger adult with climate anxiety, you can consider showing your support in the following ways:

• Validate their concerns. “I hear you, and it makes sense that you are worried (or angry) about this issue.”
• Help direct their efforts to advocacy groups. Spend time together researching organizations that they can get involved with.
• Educate yourselves on steps you both can take to minimize your impact on the environment.
• Support your loved one’s decisions to make changes to their lifestyle, especially changes they can witness at home.
• Spend time in nature with your family, or consider planting flowers or trees.

The bottom line

Climate anxiety is rife with uncertainty, but taking action may help you feel in control. Talk with others, join forces, and make lifestyle changes based on your values.

About the Author

Stephanie Collier, MD, MPH, Contributor

Dr. Stephanie Collier is the director of education in the division of geriatric psychiatry at McLean Hospital; consulting psychiatrist for the population health management team at Newton-Wellesley Hospital; and instructor in psychiatry at Harvard Medical School. … See Full Bio View all posts by Stephanie Collier, MD, MPH

If you’re in your 80s or 70s and you’ve noticed that you’re having some memory loss, it might be reasonable to be concerned that you could be developing Alzheimer’s disease or another form of dementia. But what if you’re in your 60s, 50s, or 40s… surely those ages would be too young for Alzheimer’s disease or dementia, right?

About 10% of Alzheimer’s disease is young onset, starting before age 65

Not necessarily. Of the more that 55 million people living with dementia worldwide, approximately 60% to 70% of them have Alzheimer’s disease. And of those 33 to 38.5 million people with Alzheimer’s disease, memory loss or other symptoms began before age 65 in 10% of them. Alzheimer’s is, in fact, the most common cause of young onset dementia. A recent study from the Netherlands found that of those with a known classification of their young onset dementia, 55% had Alzheimer’s disease, 11% vascular dementia, 3% frontotemporal dementia, 3% Parkinson’s disease dementia, 2% dementia with Lewy bodies, and 2% primary progressive aphasia.

Young onset dementia is uncommon

To be clear, young onset dementia (by definition starting prior to age 65, and sometimes called early onset dementia) is uncommon. One study in Norway found that young onset dementia occurred in 163 out of every 100,000 individuals; that’s in less than 0.5% of the population. So, if you’re younger than 65 and you’ve noticed some trouble with your memory, you have a 99.5% chance of there being a cause other than dementia. (Whew!)

There are a few exceptions to this statement. Because they have an extra copy of the chromosome that carries the gene for the amyloid found in Alzheimer’s plaques, more than half of people with Down syndrome develop Alzheimer’s disease, typically in their 40s and 50s. Other genetic abnormalities that run in families can also cause Alzheimer’s disease to start in people’s 50s, 40s, or even 30s — but you would know if you are at risk because one of your parents would have had young onset Alzheimer’s disease.

How does young onset Alzheimer’s disease differ from late onset disease?

The first thing that should be clearly stated is that, just as no two people are the same, no two individuals with Alzheimer’s disease show the same symptoms, even if the disease started at the same age. Nevertheless, there are some differences between young onset and late onset Alzheimer’s disease.

People with typical, late onset Alzheimer’s disease starting at age 65 or older show the combination of changes in thinking and memory due to Alzheimer’s disease plus those changes that are part of normal aging. The parts of the brain that change the most in normal aging are the frontal lobes. The frontal lobes are responsible for many different cognitive functions, including working memory — the ability to keep information in one’s head and manipulate it — and insight into the problems that one is having.

This means that, in relation to cognitive function, people with young onset Alzheimer’s disease may show relatively isolated problems with their episodic memory — the ability to form new memories to remember the recent episodes of their lives. People with late onset Alzheimer’s disease show problems with episodic memory, working memory, and insight. So, you would imagine that life is tougher for those with late onset Alzheimer’s disease, right?

Depression and anxiety are more common in young onset Alzheimer’s disease

People with late onset Alzheimer’s disease do show more impairment, on average, in their cognition and daily function than those with young onset Alzheimer’s disease, at least when the disease starts. However, because their insight is also impaired, those with late onset disease don’t notice these difficulties that much. Most of my patients with late onset Alzheimer’s disease will tell me either that their memory problems are quite mild, or that they don’t have any memory problems at all!

By contrast, because they have more insight, patients with young onset Alzheimer’s disease are often depressed about their situation and anxious about the future, a finding that was recently confirmed by a group of researchers in Canada. And as if having Alzheimer’s disease at a young age wasn’t enough to cause depression and anxiety, recent evidence suggests that in those with young onset Alzheimer’s disease, the pathology progresses more quickly.

Another tragic aspect of young onset Alzheimer’s disease is that, by affecting individuals in the prime of life, it tends to disrupt families more than late onset disease. Teenage and young adult children are no longer able to look to their parent for guidance. Individuals who may be caring for children in the home now need to care for their spouse as well — perhaps in addition to caring for an aging parent and working a full-time job.

What should you do if you’re younger than 65 and having memory problems?

As I’ve discussed, if you’re younger than 65 and you’re having memory problems, it’s very unlikely to be Alzheimer’s disease. But if it is, there are resources available from the National Institute on Aging that can help.

What else could be causing memory problems at a young age? The most common cause of memory problems below age 65 is poor sleep. Other causes of young onset memory problems include perimenopause, medication side effects, depression, anxiety, illegal drugs, alcohol, cannabis, head injuries, vitamin deficiencies, thyroid disorders, chemotherapy, strokes, and other neurological disorders.

Here are some things that everyone at any age can do to improve their memory and reduce their risk of dementia:

• Perform aerobic exercise.
• Eat Mediterranean-style meals.
• Avoid alcohol, cannabis, and drugs.
• Sleep well.
• Participate in social activities.
• Pursue novel, cognitively stimulating activities, listen to music, practice mindfulness, and keep a positive mental attitude.

About the Author

Andrew E. Budson, MD, Contributor

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

Editor’s note: in honor of Pride Month, we’re re-publishing a 2019 post by Dr. Cecil Webster.

Generally speaking, discussing what happens in our bedrooms outside of the bedroom can be anxiety-provoking. Let’s try to make your doctor’s office an exception. Why is this important? People in the LGBTQ+ community contend not only with a full range of health needs, but also with environments that may lead to unique mental and physical health challenges. Whether or not you have come out in general, doing so with your doctor may prove critical in managing your health. Sexual experiences, with their impact on identity, varied emotional significance, and disease risk, are a keystone for helping your doctor understand how to personalize your healthcare.

Admittedly, talking about your intimate sexual experiences or your gender identity may feel uncomfortable. Many LGBTQ+ patients worry that their clinicians may not be knowledgeable about their needs, or that they’ll to have to educate them. Finding a LGBTQ+ adept doctor, preparing ahead of time for your next appointment, and courageously asking tough questions can give you and your health the best shot.

Finding a skilled clinician who is LGBTQ+ adept

Many large cities have healthcare institutions whose mission centers on care for LGBTQ+ peoples. However, these organizations may prove inaccessible to many for a variety of reasons. Regardless of your location, asking friends, family, or others to recommend a clinician may be a game changer. If your trans friend had a relatively painless experience visiting an area gynecologist, perhaps your Pap smear may go smoothly there as well. If your coworker has a psychiatrist who regularly asks him about his Grindr use, perhaps it may be easier to navigate your gay relationship questions with her.

Word of mouth is often an undervalued method of finding someone skilled and attentive to the needs of LGBTQ+ individuals. Online, many clinicians offer a short bio with their areas of expertise, and there are provider directories featuring trusted clinicians. Further, some doctors regularly write articles and give talks that may offer clues about desired knowledge. A simple Google search of your provider may yield a bounty.

Next, give your doctor or healthcare organization a call. Don’t be shy about requesting someone whose practice matches your specific needs. Your health information is protected, and generally, physicians hold your clinical privacy dear. Keep in mind that not all clinics will know or share whether or not your doctor is, for example, also a lesbian, but they may pair you with someone well suited to your request or point you in the right direction.

Preparing for your appointment

Let’s say you are nervous about coming out to your doctor. A little preparation may ease this burden. Here are some quick tips:

• Let them know you’re nervous at the start of the conversation.
• Be as bold as you can tolerate.
• Write down what you are excited about, nervous about, and/or curious about.
• Go in with a few goals and start with what’s most important.
• Maximize your comfort. If your partner is calming, bring them. If Beyoncé soothes what ails you, bring her along too.
• Lightly correct or update your clinician if they get something wrong.

Ask tough questions, give clear answers

As a psychiatrist who works with kids and adults, I often hear questions like, “I don’t know really how to say this, but I started experimenting with other guys. Does this mean I’m gay?” I may start by asking if you’ve enjoyed it. My colleagues in health care might begin with the same question.

Pleasurable experiences come in all sorts of constellations, and healthy exploration is part of being human. Additionally, clinicians need to assess and address your safety. Many LGBTQ+ people are at higher risk of intimate partner violence. We may ask about your use of condoms, how many partners you’ve had recently, your use of substances during sex, and how these experiences may shift how you see yourself. Give clear answers if possible, but don’t fret if you’re uncertain. Your doctor will not likely provide a label or pry unnecessarily. They may offer constructive information on the use of condoms, reasons to consider using PrEP (which can effectively prevent HIV), and places you can go for more guidance. Physicians enjoy giving personalized information so that you may make informed healthcare decisions.

There is no end to what is on people’s minds. Be bold. Will tucking reduce my sperm count? Maybe. Does binding my breasts come with risk? Likely. Was Shangela robbed of her RuPaul’s Drag Race: All Stars 3 crown? Utterly, but let’s get back to your cholesterol, shall we?

Remember that it is often impossible to squeeze everything into one appointment. Afterward, take time to catch your breath, reflect on what you’ve learned, and come up with more questions for next time. We’re here for that.

About the Author

Cecil R. Webster, Jr., MD, Contributor

Dr. Cecil R. Webster, Jr. is a child, adolescent, and adult psychiatrist in Boston. He is a lecturer in psychiatry at McLean Hospital and Harvard Medical School, and consultant for diversity health outreach programs at the … See Full Bio View all posts by Cecil R. Webster, Jr., MD

Acne can be frustrating, especially when it does not go away after your teenage years. Believe it or not, acne can continue to affect adults beyond adolescence, or develop for the very first time in adulthood. This may be particularly distressing for adult women, who are more likely to get acne after the age of 20 compared to men.

What is adult female acne?

Adult female acne can look very similar to teenage acne. While adult acne is commonly thought to affect the jawline and chin, it can appear on any part of the face or trunk. Adult women can have clogged pores, inflamed pus-filled bumps, or deep-seated cysts. Unfortunately, treatment options that worked well in the teenage years may not work as well in adult females with acne, due to triggering factors such as hormonal imbalance, stress, and diet.

There are many reasons adult females can get acne. Hormonal disturbances caused by pregnancy, menstrual cycle, menopause, and oral contraceptives can contribute to acne by modifying the production of certain hormones. These hormones stimulate oil production within the skin, promoting the growth of acne-causing bacteria. Stress can increase the production of substances that activate oil glands within the skin of acne patients. Consumption of dairy and high-glycemic foods is also linked to acne. Certain hair or skin products can clog pores and cause comedonal acne (blackheads and whiteheads). A board-certified dermatologist can help determine the appropriate treatment for the type of acne you have.

Consequences of adult acne and scarring

The extent to which acne causes emotional distress varies, and is not related to the severity of the acne or acne scars. Some women with acne may experience disruption in their personal and professional lives as they fear stigmatization in relationships and employment. Adult females may also be more likely to seek treatment for active acne when acne bumps and scarring persist.

Acne scarring can be disfiguring. Permanent changes in skin texture in the form of pits or raised scars may not be easily concealed with makeup. Raised scars may also lead to skin picking and worsening skin texture and pigment.

Acne can also heal with red or dark spots that may not resolve for weeks to months. The dark spots may persist even longer without proper sun protection, especially on darker skin. Having both acne and dark spots may negatively impact one’s quality of life and self-perception.

The emotional toll associated with acne may include an elevated risk of developing depression compared to patients who do not have acne. Clinical studies show that having severe acne can negatively affect quality of life on par with long-term diseases such as arthritis, diabetes, back pain, and asthma. If you have acne, extensive scarring, or dark spots of any severity that are affecting your mental health, you may benefit from earlier intervention with oral medications.

What are options for treatment and support?

Acne is a medical condition, but it only needs to be treated if the acne or marks left behind from it are bothersome to you. Please see a board-certified dermatologist (in person or virtually) for the best available options if you wish to seek treatment.

Your dermatologist may prescribe a combination of topical (skin) and oral treatments. Some of these medications may not be appropriate if you are pregnant or breastfeeding, or carry risks. Ask your dermatologist about hair and skin products that may be irritating, clogging pores, or promoting oil production in the skin, making your acne worse. Also, avoid skin picking to prevent scarring, and try to minimize emotional and physical stressors.

For individuals with dark spots or scarring, consult a board-certified dermatologist to get a personalized treatment geared to your skin concerns. Use a broad-spectrum, tinted sunscreen daily and reapply it every two hours to help prevent acne marks from worsening. If your acne is causing you significant mental distress, ask your doctor about mental health resources. Additionally, seeking treatment for your acne may help you feel better. Consider joining online or in-person support groups in your area.

For more information, visit the American Academy of Dermatology Acne Resource Center.

Follow Dr. Nathan on Twitter @NeeraNathanMD
Follow Dr. Patel on Twitter @PayalPatelMD

About the Authors

Neera Nathan, MD, MSHS, Contributor

Dr. Neera Nathan is a dermatologist and researcher at Massachusetts General Hospital and Lahey Hospital and Medical Center. Her clinical and research interests include dermatologic surgery, cosmetic dermatology, and laser medicine. She is part of the … See Full Bio View all posts by Neera Nathan, MD, MSHS

Payal Patel, MD, Contributor

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