New Advisory Brings the Alcohol-Cancer Connection to the Forefront

Alcohol and Cancer Risk

Our year was off to a sobering start with the advisory on alcohol and cancer risk issued by the Surgeon General in January. The key points, which were concerning, and for at least half of Americans, seemingly unknown until now, included:

• A direct link was reported between alcohol consumption and higher risk for cancers of the breast, colorectum, esophagus, liver, mouth, throat (pharynx), and voice box (larynx).
• Four pathways were posited: 1) As it metabolizes, alcohol breaks down into acetaldehyde, a chemical which damages DNA in multiple ways. This can cause a cell to begin growing uncontrollably and create a cancerous tumor. 2) Alcohol induces oxidative stress, damaging DNA, proteins, and cells, and increasing inflammation. 3) Alcohol may alter hormone levels, which can play a role in development of breast cancer. 4) Carcinogens from other sources, especially particles of tobacco smoke, can dissolve in alcohol, making it easier to be absorbed into the body, and increasing risk for mouth and throat cancers.
• Citing a 2019 survey showing that just 45% of Americans recognize alcohol as a risk factor for cancer, a strong recommendation was made to raise awareness by updating the current warning label on alcoholic beverages.

There is no doubt that the Surgeon General can greatly influence recognition of a health issue, as evidenced by the landmark 1964 report on the risks of tobacco, laying the groundwork for public regulations in the decades to follow. Then, 42% of Americans smoked, now just 11% do. The impact of the current alcohol advisory may not be as profound, but it is significant for several reasons.

While the science behind the advisory is not new, as alcohol-related cancer risk has been noted previously by many healthcare organizations, it has grown increasingly stronger over the years. Particularly for women who drink, recent studies have added to the mounting evidence of their higher risk of developing breast cancer, as well as increased susceptibility to liver disease, cardiovascular disease, and neurotoxicity compared to males. A more widespread public campaign with prominent warnings on alcohol-containing products will help underscore these findings.

The advisory may also add impetus to the cultural shift around alcohol use that’s been occurring over the last decade. As noted, the percentage of Americans who agreed that 1-2 drinks per day is bad for one’s health is low at 45% in the most recent Gallup poll but still reflects a marked improvement compared to 26% in 2016. Most promisingly, the younger generation is leading the charge, with 65% of adults aged 18 to 34 agreeing that alcohol consumption negatively affects health vs. 38% on average of their elders.

Highlighting the risk of disease associated with alcohol requires a more nuanced approach than tobacco, where no consumption is considered safe. Instead, alcohol consumption is viewed along a continuum where risk for most people remains relatively low at 2 standard drinks or less per week, and moderately low at 3 to 6 standard drinks per week – yet fully acknowledging that individual risk is determined by a complex interaction of biological and environmental factors. As long-time researchers wrote in the Harvard Public Health Journal, while heavy drinking is indisputably harmful at every age, the data may not justify sweeping statements about the effects of moderate alcohol consumption. They point to research with mixed results e.g. studies showing decreased mortality, lower risk of cardiovascular disease in moderate drinkers, and a widely cited UK study of one million women that reported higher rates of breast cancer among drinkers but lower rates of thyroid cancer, non-Hodgkin lymphoma, and renal cell carcinoma. Recognizing that a gold-standard randomized control study would be well-nigh impossible to conduct, the most reasonable approach is to equip people with information that allows them to understand why less alcohol is better, and zero risk is only possible at zero consumption.

Our recommendations:

If you don’t drink, don’t start, as benefits are unproven, and the downsides are clear. Avoid alcohol completely if you are pregnant or trying, have a personal or family history of alcohol use disorder (AUD), have a medical condition that alcohol can aggravate (e.g., liver disease, precancerous conditions of the digestive tract), use medication that can cause interactions, or operate potentially dangerous machinery. However, if you are debating whether you can enjoy an occasional glass of chardonnay, please talk to us. We’ll help you make an informed decision based on multiple factors, including age, gender, medical history, diet, fitness, and lifestyle.

Symptoms of Alcohol Use Disorder (AUD)

What defines a heavy drinker, or a person with AUD? If you’ve experienced two or more of these symptoms in the past year, you may benefit from professional guidance to help you decrease or stop alcohol consumption:

1. Had times when you ended up drinking more, or longer, than you intended?
2. More than once wanted to cut down or stop drinking, or tried to, but couldn’t?
3. Spent a lot of time being sick from drinking, or getting over other aftereffects?
4. Wanted a drink so badly you couldn’t think of anything else?
5. Found that drinking—or being sick from drinking—often interfered with taking care of your home or family, or caused job troubles?
6. Continued to drink even though it was causing trouble with your family or friends?
7. Given up or cut back on activities important to you to drink?
8. Gotten into unsafe situations while or after drinking e.g., driving, walking in a dangerous area?
9. Continued to drink even though it was making you feel depressed/anxious or after an alcohol-related memory blackout?
10. Found that your usual number of drinks had much less effect than before?
11. Experienced withdrawal symptoms when the effects of alcohol were wearing off e.g., trouble sleeping, shakiness, restlessness, nausea, sweating?

Sources: Harvard Public Health, Journal of Internal Medicine, Journal of the National Cancer Institute, Surgeon General’s Advisory on Alcohol and Cancer Risk, UptoDate, Rethinking Drinking, National Institutes of Health

Heart Health Update: All Roads Lead to Prevention

Whether you’re a healthy 40-something with a family history of premature cardiac events, a 50-year-old mother who experienced a complicated pregnancy decades ago, or a 65-year-old man whose statin treatment has failed to lower high cholesterol levels, take heart in the growing arsenal of tests and therapies aimed at preventing disease. A long-time advocate for proactive, preventive cardiac care, Dara Lee Lewis, MD, a cardiologist at Boston’s Lown Cardiology Group and Assistant Professor at Harvard Medical School, shares insightful updates in the Q&A below.

Q: What do you see as some of the most promising recent developments in preventive heart care?

A: As a cardiologist, I’m trained to help patients live well with chronic conditions like coronary atherosclerosis, heart failure and atrial fibrillation. But let’s face it – by the time patients are referred to me, their cardiac disease is already established. Wouldn’t it be better to prevent these diseases from developing in the first place? While we can do an excellent job minimizing symptoms and stabilizing disease, I’m just treating the tip of the iceberg.  We know that atherosclerosis, or hardening of the arteries, takes decades to develop. The time for intervention is in the iceberg itself, before that first heart attack, when someone may feel fine but under the surface, disease is brewing. That’s where risk factors such as inflammation, pre-diabetes, high cholesterol levels, and unhealthy behaviors are putting the patient at risk. We have the opportunity to make a huge impact by working with our primary care colleagues to identify high-risk patients at the earliest stages and reduce the chance of having a cardiovascular event in the first place.

Q: In addition to the well-documented factors that can signal a person at high risk for heart disease – unhealthy cholesterol levels, hypertension, diabetes, metabolic syndrome, smoking, lack of physical activity, age, family history – have others been identified?

A: Yes, we’re beginning to better understand the key role inflammation plays in the development of coronary artery disease, and now consider chronic inflammatory conditions such as gingivitis, rheumatoid arthritis and certain autoimmune disorders to be risk factors. Women who experienced a complicated pregnancy history, premature menopause or certain cancer treatments are also at a higher risk of heart disease and require close monitoring and screening throughout their lifetime.  Most notably, elevated levels of lipoprotein (a), known as Lp(a) (a subtype of LDL cholesterol), have been identified as an independent risk factor.

Q: Why is Lp(a) so significant?

 A:   An elevated Lp(a), greater than 30-50 mg/dl, is often present in otherwise healthy people. It is a genetically determined risk factor for heart disease, peripheral artery disease, and ischemic stroke. What makes this challenging is that traditional strategies for lowering cholesterol such as statins or exercise and diet modifications have little to no effect on Lp(a); however, PCSK9 inhibitors (non-statin therapy for lowering cholesterol), hormone replacement therapy and Tamoxifen can work for certain individuals. There are also some promising newer medications currently being studied.

Q: Sometimes statins (e.g. Lipitor, Crestor) don’t work to lower LDL or ‘bad’ cholesterol either…are other options available?

A: A number of non-statin therapies can be prescribed, including:

• Ezetimibe (Zetia), a relatively inexpensive pill that can be used alone or given with statins to reduce cholesterol absorption.
• PCSK9 inhibitors (e.g. Praluent, Repatha), monoclonal antibodies given as a shot every two to four weeks. These inactivate the protein PCSK9 to promote more LDL receptors and help clear LDL from the bloodstream.
• Bempedoic acid (Nexletol), a daily pill that causes the liver to make less cholesterol, but with fewer of the muscle aches experienced by some who take statins.
• Inclirisan (Leqvio), given as a shot twice yearly, blocks production of PCSK9.
• Evinacumab (Evkeeza), a monthly infusion approved only for people with a family history of hypercholesterolemia.

Q: Are there any new tools for calculating an individual’s risk of heart disease?

A: I’ve found the American Heart Association’s new PREVENT calculator to be a convenient resource to assess an individual’s risk of heart attack, stroke or heart failure over the next 10 and 30 years. It’s more comprehensive than earlier versions, as it includes measures of kidney function and metabolic health and can be used to predict risk in patients as young as age 30, which is extremely valuable in terms of early detection.

Truth or Dare: Staying Informed in an Age of Misinformation

“A lie can travel halfway around the world while the truth is still putting its boots on.” *

It’s not easy to cut through the clutter in our world of often viral misinformation and find irrefutable facts. Healthcare is especially prone to misinterpretation because the scientific method—developing, testing, experimenting and refining hypotheses—can seem imperfect but is fundamental to reaching a solid conclusion. As the evidence evolves, previous findings may be corroborated, but may also be contradicted. Importantly, even some widely publicized studies may be unreliable or not based on a solid foundation. All of which proves frustrating to people seeking unequivocal advice on issues ranging from nutrition (is a low fat diet healthier than a high protein one?) to exercise (are 10,000 daily steps necessary or will 5,000 do?) to longevity (can a healthy lifestyle overcome challenging genetics?). No definitive answers just yet, but as new research reports continue to flow in, we offer this short guide to help you identify the characteristics of a good, credible scientific study.

• Randomized design, where participants are divided into control and test groups in a random manner to minimize the chance of bias. This is the gold standard of research, ensuring findings are causal and not confounded by other factors.
• Double-blinded, where neither participants or researchers are aware of whether the participant is in the control or test group.
• Observational, where the effects of a risk factor or treatment are studied over time without changing who is or isn’t exposed to them; used to develop the Surgeon General’s advisory on alcohol and cancer risk.
• A large enough sample size to have statistically significant findings, and allow for a range of individual differences.
• Has been replicated by other researchers.
• Results published in a peer-reviewed, respected professional journal, with no conflicts of interest reported by the researchers.

*Has been erroneously attributed to Mark Twain; but actually appeared in the 1859 book Spurgeon’s Gems by Rev. CH Spurgeon.

Set Your Sites

Start with any of these 18 websites for trustworthy health information:

1. 1. Mayoclinic.org – Mayo Clinic guide to diseases and conditions
   2. HopkinsMedicine.org – Johns Hopkins Medicine
   3. Health.Harvard.edu – Harvard Health Publishing – Harvard Medical School
   4. MerckManuals.com – Consumer version of medical reference book used by physicians since 1899
   5. EatRight.org – American Academy of Nutrition & Dietetics
   6. Heart.org — American Heart Association
   7. Diabetes.org —  American Diabetes Association
   8. FamilyDoctor.org – American Academy of Family Physicians
   9. HealthChildren.org – American Academy of Pediatrics
   10. Sexetc.org – Teen sexual health information, sponsored by Rutgers University
   11. Meopause.org – National Menopause Society
   12. HealthinAging.org – American Geriatrics Society
   13. TheConversationProject.org – Advanced care planning
   14. NCCN.org – National Comprehensive Cancer Network
   15. NAMI.org – National Alliance on Mental Illness (NAMI)
   16. Rarediseases.org – National Organization for Rare Diseases
   17. VeryWellFit.com – Very Well Fit
   18. ACEFitness.org – American Council on Exercise

The New Holiday Plate: Healthy, Wholesome, and Welcoming For All

As dietary restrictions become more commonplace (an estimated 10% of Americans have a food allergy, another 5% are vegetarian or vegan), serving a holiday meal that satisfies a diversity of diners may seem intimidating. Below we show some easy ways to deconstruct or reconstruct your dishes to give everyone – whether they’re heart-healthy, diabetic, gluten-sensitive, lactose-intolerant, nut-free or plant-forward – a prime seat at the table.

Keep it fresh

Opt for meats or poultry that haven’t been pre-seasoned or injected with a brine that adds sodium and sugar. Offer a small tofurky as an alternative option for committed vegetarians and adventurous eaters.

Keep it traditional with a twist

Prepare a rice-based stuffing or quinoa-centric pilaf with time-honored holiday seasonings like celery, sage and thyme. Swap out canned cranberry sauce, high in preservatives and sugar, for a tasty new recipe of fresh cranberries boiled and simmered with fruit juice, applesauce and orange zest.

Keep it versatile

Small adjustments can make a big difference. Use olive oil instead of butter, vegetable stock instead of chicken or beef broth, or a plant-based milk instead of regular.

Keep it neutral

Serve sauces and gravies on the side so everyone can enjoy the main dish without concerns about hidden allergenic ingredients.

Keep it simple

Place nuts, croutons, cheese, dried fruits and dressings adjacent to the greens, and let guests build a salad according to their individual preferences.

Keep it seasonal

Pile a colorful selection of winter’s best, from sweet potatoes and beets to broccoli and Brussels sprouts, in a single layer on a baking sheet, spray lightly with olive oil, season with black pepper and herbs, and roast at 425 degrees for about 45 minutes. The heat will coax out the exquisite natural flavors in the veggies for a dish that’s suited to any type of diet.

Keep it light

Substitute apple sauce for oil when baking to cut down on fat and sugar.

Keep it non-alcoholic

Stir up an appealing selection of ‘mocktails’ for all who choose not to imbibe.

Allergens: Off the Plate

Be aware of these ingredients, which account for more than 90% of all food allergies:

1. Fish
2. Milk
3. Peanuts
4. Crustacean shellfish
5. Soybeans
6. Tree nuts
7. Wheat
8. Eggs
9. Sesame (added in 2021)

Sources:

• Academy of Nutrition and Dietetics
• Food Revolution Network

The Gratitude Attitude

If your parents repeatedly exhorted you to count your blessings, it may well prove to be one of the best pieces of medical advice they shared. In this season of giving and thankfulness, we share a brief synopsis of how gratitude – defined as appreciation of what is valuable and meaningful to oneself – is associated with a host of beneficial health effects.

Mental Health

A grateful outlook may contribute to lower rates of depression, stress and anxiety, greater emotional functioning, stronger social relationships, higher life satisfaction, and help reduce the impact of stress on negative health outcomes.

Physical Health

Studies suggest that an attitude of gratitude may help lower blood pressure and glucose, improve immune function, promote more efficient sleep, boost pain tolerance, and lead to better cardiovascular health. Specifically, research has pointed to how practicing gratitude may help decrease hemoglobin A1c levels and contribute to reducing biomarkers of inflammation. A recent observational Harvard study of more than 49,000 registered nurses found that those scoring in the highest level of gratitude had a 15% lower risk of death from cardiovascular disease. Other reports have found that grateful individuals tend to be more health-conscious, avoiding smoking and drinking alcohol. For instance, a recent experimental study showed that evoking feelings of gratitude in people who smoke reduced their urge to do so and increased the likelihood of their enrollment in smoking cessation programs.

The Gratitude and Health Connection

Taken together, research suggests that interventions targeted at increasing gratitude may be an effective resource for health promotion and maintenance. Or as Dr. Robert Emmons, a long-time leader in the field of gratitude research and professor emeritus of psychology at UC-Davis, more eloquently explains:

“Gratitude heals, energizes and changes lives. Studies have shown that gratitude is often deepened and strengthened in trying times, as they lead us to not take things for granted. Gratitude is not simply a switch that we turn on when life is going well, but also shines a light in the darkness.”

Interested in trying this out? Visit UC Berkley’s Thnx4.org site, which offers free 10- or 21-day group or solo journaling challenges.

Unpacking the Mysteries of the Microbiome

In the past decade it has become well recognized that the millions of bacteria in the gut, collectively known as the microbiome, can influence the health of the brain, lung, heart, metabolism and the immune system. Thousands of studies have been conducted since the term was first introduced in 2001, with research shifting from an early focus on cataloging microorganisms in the human microbiome to pathogen identification and now to understanding their functional roles and how they interact with the host. Following are some of the key learnings to date, including a conversation with a leading microbiome researcher on behalf of our Well Read Patient readers. Please keep in mind that microbiome research is still in its infancy, and probiotic/prebiotic treatments are not the standard of care at this time.

What exactly is the microbiome?

Scientists define it as the sum of the microorganisms (bacteria, viruses, fungi, etc. that live in the body in healthy conditions), their genetic information, and their ecological niches. The microbiome is spread across different organs and tissues of the human body, but the most important and best studied is the gut microbiome. Studies show that under normal conditions, formation of the adult gut microbiome occurs over the first 3 years of life and is affected by events such as birth method, cessation of breastfeeding and starting solid food. Over time, it is thought that diet, drugs, age, smoking, exercise and host genetics affect the composition of the gut microbiome, and that some of these changes may contribute to metabolic, neurological, and immune disorders.

A high fiber, low animal fat diet may have beneficial effects on the gut microbiome.  With this in mind, the principle of “You are what you eat” is further clarified as “You are what your gut microbes do with what you eat,” according to the European Society of Neurogastroenterology & Motility. This is precisely the area that has long fascinated Christopher Damman, MD, a gastroenterologist who has studied the microbiome’s role in health and disease for the past two decades.

“While there are many ways to consider the role microbes play in our health, most essentially they activate or transform components of food that the body can’t process by itself,” he explains. “The microbiome converts polyphenol, the colorful compounds that occur naturally in plants, and fiber, a carbohydrate prebiotic that resists host digestion, to metabolites, which are molecular byproducts of digestion. These in turn influence the mitochondria, our cells’ metabolic powerhouses, that generate most of the energy needed for the cell to function.”

Metabolites also underly the gut’s natural production of hormones GLP and GLP-1, best known for its use in weight loss and type 2 diabetes drugs like Wegovy and Ozempic. Together, with another lower gut hormone called PYY, they help coordinate the body’s response to food by regulating appetite and blood sugar.

The traditional focus has been on therapeutic use of live microbes to repopulate the gut; for some, however, says Dr. Damman, there may be more power in postbiotics. “It can be very difficult to repopulate the microbiome of individuals whose guts may resemble a bleached coral reef as opposed to a vibrant aquarium, by just increasing intake of prebiotics through whole foods. The next best approach may be to therapeutically provide the metabolites naturally produced by a healthy gut microbiome,” he says.

While the gut responds to everything in your environment, from exercise to stress levels, food appears to be disproportionately important, asserts Dr. Damman. “The key to fostering a healthy microbiome may focus on four nutrients: fiber, phenols, bioactive fats, and ferments.” To that end, he has created a tool to help guide people to microbiome-friendly choices by assigning a Nutrient Consume Score (NCS) from one to 100 for a wide range of foods. Based on an algorithm that promotes increased fiber, phytonutrients, bioactive fats and potassium, and decreased amounts of simple carbs, additives, saturated fats and sodium, NCS is available as a prototype online at Dr. Damman’s website gutbites.org.  An app is in development that will enable easier use, such as scanning UPC codes at the grocery store. “I believe this is the first microbiome-focused nutrient calculator, and my intent is to have it validated scientifically and clinically before a beta release, possibly by early next year,” he says.

The takeaway from all this is deceptively simple. “We have gone on these really interesting, complex journeys intellectually, but at the end of the day, we return to our original understanding of healthy eating,” muses Dr. Damman. “As Michael Pollan (influential best-selling author and fellow at the Radcliffe Institute for Advanced Study at Harvard) says, eating mostly plant-based food, and not too much, is the way to go. All the research on the microbiome, metabolites, mitochondria, bioactives, etc. points in screaming ways right back at something we’ve known all along. We’ve evolved over centuries in concert with our microbiome and healthy whole foods that naturally regulate our appetites.”

In terms of preventing obesity, diabetes and metabolic disease, Dr. Damman maintains: “There’s no substitute for a healthy diet complemented by mindfulness, movement, and adequate sleep.”

New Tools, New Strategies for Gut Microbioma Therapy

Initially, gut microbiome therapies ranged from probiotics and prebiotics to fermented foods and fecal transplants.

But these are still early days, and new approaches are continually under the microscope, including:

• According to research from Nature Aging, in healthy individuals the microbiome can continue to change after age 50, in contrast with a static microbiome composition seen in people who are less healthy and die earlier. Of particular note is the finding that each person’s microbiome becomes more distinct as they age, emphasizing the ineffectiveness of a ‘one size fits all’ approach and influencing the need for personalized health therapies.
• Mayo Clinic’s recently announced Gut Microbiome Wellness Index 2, a tool designed for healthcare practitioners to identify adverse changes in their patients’ gut health before serious symptoms arise. By screening a gut microbiome sample, the tool can predict with 80% accuracy or greater whether a person’s gut is healthy or trending toward a diseased state. The ability to detect shifts in gut health was tested in various clinical scenarios, including people who had undergone fecal microbiota transplantation, or had made changes in dietary fiber intake, or who had antibiotic exposure. Additional testing is in progress.
• New technologies that allow physicians to more easily examine the small intestine and upper part of the colon are sure to shine a bright light on these often neglected areas of microbiome research, according to Dr. Damman. Most exciting is the recent launch of swallowable devices with compartments that open up when certain acidity levels are reached to sample the small intestine. “This could be a real breakthrough for exploring how to best help those with small intestinal bacterial overgrowth (SIBO), Crohn’s, irritable bowel syndrome (IBS) and other conditions who frequently experience significant gastrointestinal symptoms from macro nutrient-rich diets.” Future possibilities may include partnering small intestine bacteria with their preferred prebiotics and personalized combinations of prebiotics.

Sources:

• Mayo Clinic Gut Microbiome Laboratory
• World Journal of Methodology
• Gutbites
• Nature
• Nature Aging

Ageism, the Last Unacceptable Bias  

“I’m having a senior moment.

I’m too old to try that.

I look good for my age.

It’s time to put her/him out to pasture.

These are just aches and pains from old age.

Sweetie, you don’t look a day over 29.

Ok boomer.

There will be a tsunami of aging dependents in the coming decade.”

These oft-used phrases may sound inoffensive but they’re actually examples of ageism, perhaps the only stereotype in America yet to be banished, or even fully recognized. Raising awareness of ageist beliefs as inaccurate at best, and physically and psychologically harmful at worst, is the work of a lifetime for a diverse group of medical and scientific advocates. Why is changing the narrative so important?

Research shows that ageism can influence health through three pathways: psychological, behavioral and physiological. Negative age stereotypes can increase biological markers of stress and may predict detrimental brain changes decades later, while also spurring worse health behavior, such as noncompliance with prescribed medications.  A national poll on healthy aging showed those who regularly experienced three or more forms of ageism were less likely to rate their mental health as excellent or very good (61% vs. 80%) and more likely to report symptoms of depression (49% vs. 22%) than those who did not. Additionally, ageism can lead to inequities in healthcare, with age-based exclusions common in clinical trials, and older adults more apt to be left out of screenings, investigations and treatment for mental health issues.

Ageism: A Mental and Physical Toll

What may be most important to appreciate is how the internalizing of age stereotypes by older adults themselves can be an important determinant of health and well-being. Experts have found that negative self-perceptions of aging are associated with a higher prevalence for many of the most frequently seen health conditions among Americans, including heart disease, lung disease, diabetes, musculoskeletal disorders, and injuries, and tend to show more shrinkage of hippocampal volume in the brain. They may also show poorer memory performance and start to walk slower, reinforcing the negative loop around their aging process.

The Power of Positive Aging

Flipping the narrative, however, can result in dramatically improved outcomes. As reported in the Gerontologist, those who have more positive age beliefs live on average 7.5 years longer than those who harbor negative age beliefs. As the researchers noted: “If there were a pill that gave people an extra seven years of life in relatively good health, we would encounter very long lines at the pharmacy.”

The reasons for optimism around aging are based on science, not magical thinking. Consider that steep declines in physical and cognitive abilities are not inevitable parts of aging. According to the Administration on Aging, 80% of adults over 65 are not experiencing a physical or cognitive  disability such as hearing impairment or memory loss that impacts their function, and 60% report only moderate or small impairments in their mobility.  Procedural memory (e.g. how to ride a bike) is maintained in normal aging, and there is evidence suggesting abstract thinking and metacognition improve.

Challenging the Aging Myth

Despite the stereotype of people becoming more curmudgeonly with age, Manfred Diehl, PhD, a lifespan developmental psychologist, reports the opposite: “The conclusion from several meta-analyses is that in the personality area, we see quite a bit of positive development in terms of becoming socially more mature, with improved coping strategies and more regulation of emotions. Conscientiousness tends to increase at least until the mid-60s, possibly early 70s.”

Most remarkably, ongoing research at the Yale School of Public School by epidemiologist Dr. Becca Levy pointed to the conclusion that beliefs about aging rather than aging itself help explain why some older adults thrive while others do not. Her studies found that adults briefly primed with pos­itive statements about aging showed improvements in their memory, gait speed, and balance that were measurable months later, and further generated increasing confidence in their abilities that endured over years. Additional studies suggest that positive beliefs about aging may protect against dementia, even among those with a high-risk gene.

Changing the Conversation Around Aging

How can we help shift the conversation? Start by increasing awareness of the culture of ageism around us and recognize how it can impact health rather than the actual aging process, encourages Levy.

You may also want to explore how to get involved in organizations that focus on bringing generations together, including:

Generations Over Dinner – A free global initiative to create meaningful experiences and conversations by hosting in-person or virtual multi-generational dinner events.

Generations United– A nonprofit network with a comprehensive database of intergenerational programs across the country.

CoGenerate –A nonprofit organization aiming to bridge generational divides and foster intergenerational collaboration.

When to seek help for mental health

Remember: it is not normal for older adults to be unhappy as they age. Seek help for these treatable medical conditions:

Anxiety

• Panic disorder: Panic attacks or sudden feelings of terror that strike repeatedly
• Obsessive-compulsive disorder: Repetitive, unwanted thoughts or rituals
• Post-traumatic stress disorder (PTSD): Nightmares, depression after a traumatic event
• Phobias: Extreme fear of something that poses little real danger
• Generalized anxiety disorder: Chronic worry about everyday activities

Depression

Feelings of intense sadness that last for weeks or months. Symptoms include:

• No pleasure in everyday activities
• Poor sleep
• Rapid weight gain or loss
• Low energy
• Unable to focus

While grieving a loss may look similar to depression, there are differences. A mix of good and bad days is common when grieving. With depression, feelings of emptiness are constant and don’t improve over time.

Sources:Aging Research Reviews; Breaking the Age Code; Contemporary Clinical Trials, NCOA, Helpguide.org

Testosterone Therapy for Midlife Males: More Questions Than Answers

At around the same time as females enter menopause in their late 40s or early 50s, males are experiencing their own hormonal decline, called andropause. As part of the normal aging process, a man’s testosterone levels decrease by about 1% a year after age 40.

Low testosterone by itself is not concerning, but with symptoms, may indicate a more serious issue called male hypogonadism. Men may notice changes in body such as decreased muscle bulk, increased body fat, and fatigue; in mind, including depression, difficulty concentrating and disturbed sleep; and reduced libido.

When Should Men Consider Testosterone Therapy

For men diagnosed with hypogonadism, testosterone replacement therapy can help improve libido, energy, muscle mass and bone density. However, for those with low testosterone (low “T”) and symptoms due to aging, if or when testosterone therapy should be recommended is not clear, because:

• Mental health symptoms may be due to other conditions, and there is no evidence to date of improvement from therapy.
• Risks can include acne, sleep disturbances, and blood clots.
• More research is needed: earlier studies pointed to a potentially higher risk of prostate cancer or cardiovascular disease while later ones seemed to allay those concerns but are not yet conclusive.

The best course to pursue? First, consult with our office about your concerns, and we will discuss your individual risks and benefits. Second, be aware that current medical guidelines do not recommend testosterone therapy for men with age-related low testosterone to improve energy, vitality, physical function, or cognition. Third, avoid over-the-counter supplements for boosting testosterone as evidence is lacking regarding their efficacy. Finally, consider natural ways to boost testosterone, such as losing excess weight, increasing muscle mass through resistance exercise, getting quality sleep, and eating a healthy diet.

Sources: Mayo Clinic, Harvard Health Letter

A New Look at Moving through Menopause

Defined simply as the final menstrual period, when it is no longer possible for a woman to get pregnant, the current approach to menopause has become increasingly nuanced, recognizing that each individual’s experience varies widely. Many women transition into this stage smoothly with minimal discomfort, but others experience severe vasomotor symptoms such as hot flashes, night sweats, sleep disruption, vaginal dryness, and possibly, “brain fog” and poorer mental health.

The Popularity of Hormone Therapy for Menopause

While hormone therapy (HT) was once routinely prescribed to relieve the symptoms of menopause, this stopped as a result of a large Women’s Health Initiative (WHI) study in 2002 which showed an increased risk of heart attacks, breast cancer, blood clots, and strokes for older postmenopausal females using the estrogen-progestin combination.

However, the pendulum may now be swinging back as subsequent trials that addressed the limitations of the WHI study found hormone therapy – consisting of estrogen for symptom relief and progesterone to protect the uterine lining – may be safer than previously thought. For women under 60 who are less than 10 years out from the start of menopause, an estradiol oral pill or transdermal patch can eliminate symptoms that impact sleep and mood and may decrease the risk for heart disease, diabetes and fractures due to osteoporosis. Progesterone can be taken as a pill, patch or IUD.

Further studies have shown that HT needn’t be routinely discontinued after 10 years for women at low risk for breast cancer and cardiac disease who continue to be challenged by persistent menopause symptoms.

Depression and Menopause

Additionally, new research suggests that despite a long-held association of depression with menopause, women are not universally at risk of depressive symptoms over the transition. For those more vulnerable to depression because of severe sleep disruptions, a long transition through menopause, stressful life events, or a previous history of clinical depression, a combination of psychological interventions and medication is advised. Other studies found estrogen treatment, sometimes with an antidepressant, effective in managing mood-related symptoms.

A Healthy Lifestyle to Mitigate Menopause Symptoms

The renewed acceptance of HT has spurred a reconsideration of our entire approach to menopause with practitioners asking: Can a healthy lifestyle play a key role in mitigating menopause symptoms? Can this passage be navigated successfully with informed, individualized decision-making and social and medical support? In 2024, all signs point to yes.

Midlife Crisis or Midlife Reassessment?

Like so many popular 20^th century concepts, the image of a man in an existential crisis at age 50 who trades in his long-time wife and car for newer models is on the wane – and may never have been correct. Psychoanalyst Elliott Jaques coined the term in 1965 to describe his midlife client’s sudden change in lifestyle and productivity, but the breakthrough “Midlife Development in the U.S. (MIDUS)” studies conducted over three decades beginning in 1995, proved otherwise. Only an estimated 10% of adults actually experienced a midlife crisis while the majority considered it a period of great satisfaction, redefining it as a time of deepened connections and continuity, peak earning power, career advancement, and greater emotional intelligence. In fact, asserts study author Margie Lachman, PhD, adults reach the apex of their competence and expertise in middle age, with time to chart a healthy course for the future.

Midlife Challenges and Stressors

Still, midlife does pose its share of challenges in terms of concurrently balancing as many as eight roles, including spouse, parent, grandparent, adult child, sibling, friend, co-worker, and caregiver. Partially a result of an ongoing cultural shift encouraging openness around mental health, today’s midlife adults are more frequently diagnosed and seek help with issues such as depression and anxiety – from 31% in 2019 to 45% in 2023 among ages 35 to 44; and from 26% to 36% among ages 45 to 64, as reported in the American Psychological Association’s annual “Stress in America” survey.

Work is the primary stressor for many midlife patients of concierge psychologist Dr. Rebecca Osei. “Their self-worth is intertwined with career achievement,” she says. “If they haven’t yet reached the goals they set for themselves, there can be issues with depression and how to move forward from this point.”

High achievers face their own set of problems, according to psychiatrist Brook Choulet, MD, who works with CEOs and elite athletes contending with mental health concerns despite the outward appearance of great success. “I often start by asking how they would feel if I sent them on a two-week vacation right now,” she says. “Their answer can help reveal whether they’re headed toward burnout (removing the stress factor of work improves their mood) or struggling with clinical depression or an anxiety disorder.”

Strategies for High Achievers to Overcome Stress and Anxiety

Top performers are driven to constantly keep chasing the next goal, rather than taking the time to appreciate their achievements, says Choulet. “Many also have perfectionist tendencies, leading to stress and fear of failure if everything is not done flawlessly.” She helps them overcome their challenges with strategies that include:

• Establishing good boundaries between personal and professional life.
• Adopting a growth mindset focused on progress rather than perfection.
• Developing stress management and self-care techniques. “Prioritize your own mental health in order to lead effectively.”
• Taking a pulse on what brings you joy. “This is particularly important as you near retirement and can’t imagine life without work. Lean into your network of friends and family and learn how to step away and enjoy what you really love,” says Choulet.