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Screening tests, such as Pap smears or blood pressure checks, could save your life. They can detect a disease you have no reason to suspect is there. Early detection may allow treatment while a health condition is curable and before irreversible complications arise.

Some screening tests help prevent the disease they are designed to detect. For example, colonoscopies and Pap smears can identify precancerous abnormalities that can be addressed so they cannot continue to grow and become cancerous. And missed screening tests contribute to thousands of avoidable deaths each year in the US. Yet there’s a point of diminishing returns, as a new study on Pap smears illustrates. And many of us could benefit from a better understanding of the limits of screening, and how experts decide when people should stop routine screening tests.

Know the limits of screening tests

Even the best screening test has limitations. It can miss the disease it’s intended to detect (false-negative results). Or it can return abnormal results when no disease is present (false-positive results).

Equally important, as people grow older life expectancy declines and screening benefits tend to wane. Many conditions detected by routine screenings, such as prostate cancer or cervical cancer, typically take a while to cause trouble. A person in their 80s is more likely to die from another fatal condition before cervical cancer or prostate cancer would affect their health. Additionally, certain diseases, such as cervical cancer, become less common with advancing age.

As a result, many screening tests are not recommended forever: at some point in your life, your doctor may tell you that you no longer need to repeat a screening test, even one you finally got used to having.

Know when screening tests usually end

Expert guidelines for many common screening tests include an “end age” when people can reasonably stop having the test. For example:

• Pap smear: age 65
• mammogram: age 75
• colonoscopy: age 75
• chest CT scan (recommended for people with a significant smoking history): age 80.

There are exceptions, of course. For example, if a colonoscopy found abnormalities in an otherwise healthy 72-year-old, repeat testing after age 75 may be recommended.

Many women have Pap smears after guidelines suggest stopping

Pap smears screen for cervical cancer. In 1996, new guidelines recommended that women who received Pap smears at appropriate intervals before age 65 could safely stop.

Yet many women continue to have this screening after turning 65, according to a recent study published in JAMA Internal Medicine that looked at data from 15 to 16 million women per year between 1999 and 2019. Their average age was 76, most (82%) were white, and all were enrolled in Medicare.

The study found:

• In 1999, nearly three million women over age 65 (almost 19% of the study population) had Pap smears. By 2019, the number had fallen to 1.3 million (8.5%), a reduction of more than half.
• Among women older than age 80, about 3% had Pap smears.
• In 2019, the estimated cost related to Pap smears in these older women was $83.5 million.

Possibly, some women in this study had good reasons to continue having Pap smears. Perhaps they weren’t adequately screened when they were younger. Perhaps they had previous Pap smear abnormalities. Maybe their doctors recommended they continue having Pap smears despite their advanced age. We don’t know, because this study didn’t collect that information. Still, it’s quite likely that many (or even most) of these Pap smears represent overscreening: routine testing with little chance of benefit.

Why does overscreening matter?

Overscreening may cause

• discomfort that may be tolerable when there’s an expectation of benefit, but less acceptable when the test is unnecessary
• anxiety while awaiting the results of the test
• false-positive results that lead to additional testing and unnecessary treatment
• complications of testing, such as infection or bleeding after a Pap smear, or perforation or bleeding after a colonoscopy. (Fortunately, complications are rare.)
• unnecessary costs, including medical appointments and lab fees, time wasted, and taking health providers away from more valuable care.

The bottom line

Screening tests are typically performed for people without symptoms, signs, or a high suspicion of disease. In many cases, they’re looking for a condition that is probably not there. For most screening tests, we have guidelines developed by experts and backed by data suggesting when to start — and when to stop — screening.

But guidelines are only general recommendations, and individual preferences matter. If foregoing a screening test will cause you excessive anxiety, or if having a test will provide significant peace of mind, it may be reasonable to have a test even after the recommended end age. Be sure you understand potential downsides, such as additional tests and complications.

So, never hesitate to ask your doctor when your next screening tests are due — but don’t forget to also ask if they are no longer worth having.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

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

Climate change is an escalating threat to the health of people everywhere. As emergency medicine physicians practicing in Australia and the United States, we — and our colleagues around the world — already see the impacts of climate change on those we treat.

Will we be seeing you one day soon? Hopefully not. Yet an ever-growing number of us will face climate-related emergencies, such as flooding, fires, and extreme weather. And all of us can actively prepare to protect health when the need arises. Here’s what to know and do.

How is climate change affecting health?

As the planet warms, people are seeking emergency medical care for a range of climate-related health problems, such as heat exhaustion and heat stroke, asthma due to air pollution, and infectious diseases related to flooding and shifting biomes that prompt ticks, mosquitoes, and other pests to relocate. News headlines frequently spotlight physical and emotional trauma stemming from hurricanes, wildfires, tornadoes, and floods.

We care for people displaced from their homes and their communities by extreme weather events. Many suddenly lack access to their usual medical team members and pharmacies, sometimes for significant periods of time. The toll of extreme weather often lands hardest on people who are homeless, those with complex medical conditions, children, the elderly, people with disabilities, minoritized groups, and those who live in poorer communities.

On a recent 110º Fahrenheit day, for example, a woman came to an emergency department in Adelaide, Australia complaining of a headache, fatigue, and nausea, all symptoms of heat exhaustion. She told medical staff that she had just walked for two hours in the sun to obtain groceries, as she had no car or access to public transportation. While health advisories in the media that day had advised her to stay inside in air conditioning, walking outside was only the only option she had to feed her family. For this woman and many others, well-intended public health warnings do little to reduce the risk of illness during extreme weather. Achieving safe, equitable health outcomes will require addressing access to shelter, access to transportation, and other societal factors that put people at risk of bad health outcomes.

Extreme weather contributes to large-scale health and safety issues

Increasingly, climate-related extreme weather is leading to interrupted access to medical care, contributing to later illness and death. Extreme weather can damage key infrastructure like the electrical grid, so that those relying on home medical equipment cannot use it. It may shut down health care facilities like a dialysis center or emergency room, or slow care in facilities that stay open.

People fleeing a fire or hurricane can be displaced into settings where they may have difficulty getting medical care or obtaining much-needed medicine, such as insulin, dialysis, high blood pressure treatments, and heart medicines. Such factors can worsen chronic conditions and may even cause death, particularly in people with existing medical conditions like heart failure, lung disease, and kidney disease.

How can you be ready to protect your health?

We all have a part to play in keeping ourselves and our communities well in the face of increasing dangers from climate change. Taking these steps will help.

If you or a loved one has health issues:

• Keep a printed summary handy listing all medical conditions, medications and dosages, and phone numbers for your health providers.
• If you have to leave your home, try to bring all medications with you — even bringing empty pill bottles will help a doctor trying to restart your medications.
• Store medicines in a waterproof bag in a place where you can easily find them. This will help if you need to evacuate quickly.

Think about what to do if you need to leave home quickly. Now is the time to figure out your basic emergency plan:

• Where will you go if you need to evacuate?
• How will you get there?
• How could you communicate with others if there is no electricity or phone service?
• Do you have written contact info for a few family members and friends, in case you lose your phone or the battery dies?

Finally, we all need to look out for others in our community. Check in on elderly neighbors and those around you who may be socially disconnected, and make sure that they are safe where they live and are able to access the medical care they may need when the weather turns hot, cold, smoky, fiery, snowy, wet, or windy.

Climate change is here. It is already having tangible and significant impacts on our communities and the health of people around the world. Moreover, the increased risk of climate-related extreme weather is here to stay for the foreseeable future, and we must prepare for the threats it poses to our health, both now and in decades to come. We all have a part to play — health professionals, communities, and individuals — in keeping ourselves and each other healthy and safe.

About the Authors

Kimberly Humphrey, MD, MPH, Contributor

Dr. Kimberly Humphrey is an emergency physician, a current Fellow in Climate Change and Human Health at Harvard C-CHANGE at Harvard's T.H. Chan School of Public Health, and a visiting scholar at the Harvard FXB Center. Her research focuses on the … See Full Bio View all posts by Kimberly Humphrey, MD, MPH

Caleb Dresser, MD, MPH, Contributor

Dr. Caleb Dresser is an emergency physician and assistant director of the Climate and Human Health Fellowship, cohosted by Beth Israel Deaconess Medical Center, the Harvard FXB Center, and Harvard C-CHANGE. His research focuses on understanding the health implications of climate-related … See Full Bio View all posts by Caleb Dresser, MD, MPH

A positive outlook has been linked to better heart health and a longer life. But is that true for Black Americans, whose average lifespan is about 72 years, compared with an average lifespan of 77 years for all Americans?

Recent findings from the nation’s largest and longest-running study of cardiovascular risk factors in Black Americans, the Jackson Heart Study, suggest that the answer is a qualified yes. Cardiovascular diseases, which give rise to heart attack and stroke, are the leading cause of death and disability worldwide. Perhaps not surprisingly, the association between optimism and longevity in Black Americans appears to be strongest among people with higher education or income levels, and those ages 55 and younger. It also proved stronger among men than among women.

Is optimism the only key to longevity in this study?

Probably not. There’s another possible explanation for the findings, says Dr. Rishi Wadhera, a cardiologist at Harvard-affiliated Beth Israel Deaconess Medical Center (BIDMC).

“Instead of optimism leading to better health, it’s possible that healthier individuals are simply more optimistic, or less healthy individuals are less optimistic,” he says. This so-called reverse causality — when cause and effect are the opposite of what one assumes — is always a possibility in observational studies, even when scientists take pains to control for possible confounding factors such as health conditions and behaviors, as they did in this study.

“Nonetheless, these findings contribute to a body of evidence that suggests that psychosocial resources, mood, and mental health are all associated with health,” says Dr. Wadhera, who is section head of health policy and equity research at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology at BIDMC.

Measuring optimism in the study

Led by researchers at the Harvard T.H. Chan School of Public Health, the study included 2,652 women and 1,444 men who were part of the Jackson Heart Study. Researchers measured optimism using the Life Orientation Test-Revised, which includes questions such as “In uncertain times, I usually expect the best.” Responses are scored on a scale of 0 (strongly disagree) to 4 (strongly agree). The researchers administered this test and others between 2000 and 2004, and tracked mortality among the study participants until 2018.

Optimism — the general belief that good things will happen — may be partly inherited, although genetic factors are thought to explain only about 20% to 30% of this trait. Some research suggests that people can enhance their feelings of optimism either through cognitive behavioral therapy or writing exercises that focus on imagining their “best possible future self.”

Looking forward

Still, optimism is but one of many intertwined social factors that influence how long people live. A better understanding of biological pathways that could potentially explain the outcomes observed in this study may help, says Dr. Wadhera.

“But to meaningfully address the alarming and ubiquitous health inequities that exist in our country, we need to tackle the unacceptable gaps in care and resources that exist between different racial and ethnic groups,” he adds. This includes disparities in health insurance coverage, access to health care, neighborhood factors such as access to green space and healthy foods, and environmental stressors such as pollution exposure. “Doing so may help people and communities from all backgrounds live happier and longer lives,” Dr. Wadhera says.

 

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

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

When caught early through routine screening, cervical cancer is curable. In the US, roughly 92% of women with early-stage cervical cancer survive five years or longer, compared with only 17% of women with late-stage cervical cancer. So recent research that shows a steep rise in new cases of advanced cervical cancer among white Southern women, and underscores the disproportionate burden of advanced cases among Black Southern women, is worrisome.

What factors might be at play, and how can people best protect themselves? Two Harvard experts share their insights.

Human papilloma virus and cervical cancer: What to know

Human papilloma virus (HPV) causes nine out of 10 cervical cancers. In 2023, 13,960 women in the US will be diagnosed with cervical cancer and 4,310 will die from it, according to American Cancer Society estimates.

Pap test screening can detect this cancer early, when it’s easiest to treat. And testing for HPV has been approved as an additional screening test for cervical cancer. It can be used alone or with a Pap test.

What did the research focus on and learn?

The study was published online in International Journal of Gynecological Cancer. Researchers combed through cervical cancer data submitted to the United States Cancer Statistics program between 2001 and 2018, and national survey findings on Pap screening and HPV vaccination. During this period, nearly 30,000 women were diagnosed with late-stage cervical cancer, which has spread to other parts of the abdomen and body.

Early-stage cervical cancer cases have been dropping for most groups in the US in recent years. But advanced cervical cancer cases have not declined within any US racial, ethnic, or age group over the last 18 years.

New diagnoses of advanced disease rose 1.3% annually during the study period. Southern white women ages 40 to 44 saw an annual rise of 4.5% in advanced cases. Southern Black women ages 55 to 59 were diagnosed nearly twice as often as white women with early and advanced cases.

What else is important to understand?

The new study showed that women living in the South are less likely to be vaccinated against HPV or screened for cervical cancer. But lower screening rates likely don’t fully explain the rise in late-stage cases in that region, says Dr. Ursula Matulonis, chief of the Division of Gynecologic Oncology at Dana-Farber Cancer Institute.

“Most cervical cancer cases continue to be diagnosed early,” Dr. Matulonis says. “These new findings suggest that cases involving a more aggressive cell type called adenocarcinoma are also increasing. Often found higher up in the cervical canal, this is harder to detect with a Pap smear.”

Older women are especially vulnerable. Rates of late-stage cervical cancer are higher — and survival is worse — among women 65 and older than among younger women, according to a study in California. One possible reason? They may not have received the recommended number of screening tests with normal results before they stopped having Pap smears, says Dr. Sarah Feldman, a gynecologic oncologist at Brigham and Women’s Hospital.

HPV vaccine protects against cervical cancer

The HPV vaccine is FDA-approved for use in females ages 9 through 26. The first group of vaccinated adolescents, now in their 20s, have clearly benefited: invasive cervical cancer rates among women 20 to 24 dropped by 3% each year from 1998 through 2012.

“That’s pretty impressive,” Dr. Matulonis says. “And those decreases span race and ethnicity, which isn’t always the case in women’s cancers.”

What steps can you take to protect against cervical cancer?

Dr. Feldman offers this guidance around cervical cancer prevention and detection.

• HPV vaccination. All children should be vaccinated against HPV between ages 9 and 12, well before sexual activity begins. “The most important thing for future generations in cervical cancer prevention is vaccinating that generation,” Dr. Feldman says.
• Routine screening. Regardless of vaccination status or whether they’re sexually active, women should begin having screening tests for cervical cancer in their 20s and continue through age 65. Discuss the right intervals with your doctor. Current screening guidelines take into account when you start screening and whether results of tests are normal:
  • If you start at 21: Have a Pap test every three years until 30.
  • If you start at 25: Seek an HPV test first.
  • At age 30: If all screening tests so far have been normal, have HPV testing every five years. Continue this screening until age 65.
  • Don’t stop screening at 65 unless all test results are normal, including at least two results in the last 10 years and one in the last five years.
  • If any testing led to abnormal results, you may need to continue screening beyond age 65.

An HPV infection, rather than sexual activity alone, is the factor that places people at risk, Dr. Feldman says.

“A lot of older women may have a new sexual partner in their 50s. A new HPV infection raises risk for cervical cancer roughly 20 years later,” Dr. Feldman says. “If HPV test results are persistently negative through age 65, the risk of developing cervical cancer in your 70s is low.”

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

About the Reviewer

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

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

Want your child to grow up healthy, happy, smart, capable, and resilient? Play with them. Infants and toddlers thrive on playful games that change as they grow.

Why does play matter during the first few years of life?

More than a million new nerve connections are made in the brain in the first few years of life. And pruning of these neural connections makes them more efficient. These processes literally build the brain and help guide how it functions for the rest of that child’s life. While biology — particularly genetics — affects this, so does a child’s environment and experiences.

Babies and children thrive with responsive caregiving. Serve and return, a term used by the Harvard Center on the Developing Child, describes this well: back-and-forth interactions, in which the child and caregiver react to and interact with each other in a loving, nurturing way, are the building blocks of a healthy brain and a happy child, who will have a better chance of growing into a healthy, happy, competent, and successful adult.

Play is one of the best ways to do responsive caregiving. To maximize the benefits of play:

• Bring your full attention. Put the phone down, don’t multitask.
• Be reciprocal. That’s the “serve and return” part. Even little babies can interact with their caregivers, and that’s what you want to encourage. It doesn’t have to be reciprocal in an equal way — you might be talking in sentences while your baby is just smiling or cooing — but the idea is to build responsiveness into the play.
• Be attuned to developmental stages. That way your child can fully engage — and you can encourage their development as well.

Great games to play with infants: 6 to 9 months

The Center for the Developing Child has some great ideas and handouts for parents about specific games to play with their children at different ages.

6-month-olds and 9-month-olds are learning imitation and other building blocks of language. They are also starting to learn movement and explore the world around them.

Here are some play ideas for this age group:

• Play peek-a-boo or patty-cake.
• Play games of hiding toys under a blanket or another toy, and then “find” them, or let the baby find them.
• Have back-and-forth conversations. The baby’s contribution might just be a “ma” or “ba” sound. You can make the same sound back, or pretend that your baby is saying something (“You don’t say! Really? Tell me more!”).
• Play imitation games: if your baby sticks out their tongue, you do it too, for example. Older babies will start to be able to imitate things like clapping or banging, and love when grownups do that with them.
• Sing songs that involve movement, like “Itsy Bitsy Spider” or “Trot, Trot to Boston” with words and motions.
• Play simple games with objects, like putting toys into a bucket and taking them out, or dropping them and saying “boom!”

Great games to play with toddlers

Between 12 months and 18 months, young toddlers are gaining more language and movement skills, and love to imitate. You can:

• Play with blocks, building simple things and knocking them down together.
• Do imaginative play with dolls or stuffed animals, or pretend phone calls.
• Use pillows and blankets to build little forts and places to climb and play.
• Play some rudimentary hide-and-seek, like hiding yourself under a blanket next to the baby.
• Continue singing songs that involve movement and interaction, like “If You’re Happy And You Know It.”
• Go on outings and explore the world together. Even just going to the grocery store can be an adventure for a baby. Narrate everything. Don’t worry about using words your baby doesn’t understand; eventually they will, and hearing lots of different words is good for them.

Older toddlers, who are 2 or 3 years old, are able to do more complicated versions of these games. They can do matching, sorting, and counting games, as well as imitation and movement games like “follow the leader” (you can get quite creative and silly with that one).

As much as you can, give yourself over to play and have fun. Work and chores can wait, or you can actually involve young children in chores, making that more fun for both of you. Checking social media can definitely wait.

Playing with your child is an investment in your child’s future — and a great way to build your relationship and make both of you happy.

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

The decision to step down or stop taking a proton pump inhibitor is a complex decision you should discuss with your doctor.

Proton-pump inhibitors (PPIs) are a common type of anti-acid medication, and are available both by prescription and over the counter. Omeprazole and pantoprazole are examples of PPIs. They are the treatment of choice for several gastrointestinal disorders, such as peptic ulcer disease, esophagitis, gastroesophageal reflux disease, and H. pylori infection.

New guidelines by the American Gastroenterological Association have highlighted the need to address appropriate PPI usage, and they recommend that PPIs should be taken at the lowest dose and shortest duration for the condition being treated. However, PPIs are frequently overused, and may be taken for longer than necessary. This can happen unintentionally; for example, if the medication was started while the patient was hospitalized, or it was started as a trial to see if a patient’s symptoms would improve and then is continued beyond the needed timeframe.

Who should use PPIs in the short term?

There are a variety of reasons for short-term PPI usage. For instance, PPIs are prescribed typically for one to two weeks to treat H. pylori infection, in addition to antibiotics. A PPI course of four to 12 weeks may be prescribed for people with ulcers in their stomach or small intestine, or for inflammation in the esophagus.

People may also be prescribed a short course of PPIs for acid reflux or abdominal pain symptoms (dyspepsia), and for symptom relief while physicians perform tests to determine the cause of abdominal pain. People may be able to move to a lower dose of PPIs, or discontinue their medication altogether, if their symptoms get better or they have completed their treatment course.

Who should be on PPIs long-term?

Some patients with specific conditions may need to be on PPIs for the long term, and they should discuss their condition and unique treatment plan with their doctor. Some conditions that may require longer-term use of PPIs include:

• severe esophagitis, eosinophilic esophagitis, Barrett’s esophagus, esophageal strictures, or idiopathic pulmonary fibrosis
• acid reflux
• dyspepsia or upper airway symptoms that improve with PPI usage but worsen when stopping PPIs
• people with a history of upper gastrointestinal bleeding from gastric and duodenal peptic ulcers may need to be on PPIs long-term to prevent recurrence.

What are some side effects of PPIs?

Any medication can cause side effects. Fortunately, adverse effects from PPIs are generally rare. However, these medications have been associated with increased risk of certain infections (such as pneumonia and C. difficile). Previously, there had been concerns that PPI usage was linked to dementia, but newer studies have contradicted this association.

Additionally, while rare, PPIs may also cause drug interactions with other medications. For example, PPIs may affect the levels and potency of certain medications, such as clopidogrel (Plavix), warfarin (Coumadin), and some seizure and HIV medications, sometimes necessitating dosage adjustments of these drugs. Therefore, it is important to let the team of healthcare providers who manage your medications know when a new medication has been added to your list or if a medication has been discontinued.

How do I work with my doctor to step down from taking PPIs?

Some patients are prescribed PPIs twice a day in an acute situation, such as to prevent rebleeding from stomach ulcers or if a patient has severe acid reflux symptoms. If there no longer remains a reason to take PPIs twice a day, you may be stepped down to once a day. To discontinue a PPI, your doctor may decide to taper the medication — for example, by decreasing the dose by 50% each week until discontinued.

What might I experience if my doctor suggests I stop taking a PPI?

Studies have shown that for patients with long-term PPI use, there can be rebound secretion of stomach acid and an increase in upper gastrointestinal symptoms when discontinuing PPIs. However, a different type of anti-acid medication (such as an H2 antagonist like famotidine or a contact antacid medication containing calcium carbonate like TUMS) can be used for relief temporarily. If a patient experiences more than two months of severe persistent symptoms after discontinuing a PPI, this may be a reason to resume PPI therapy.

What steps should I take next?

It is important to routinely discuss your medication list and concerns with your primary care doctor. The decision to step down or discontinue a PPI is complex, and for your safety you should verify with your doctor before adjusting your PPI dosing. Ultimately, the goal is to make sure you are only taking medications that are necessary in order to maximize the benefit and minimize side effects.

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

Feeling rooted in community and socializing with neighbors may strongly contribute to better cardiovascular health by improving diet, exercise habits, and weight control, new research among Black adults in Georgia suggests. And better cardiovascular health may add up to fewer heart attacks and strokes, two leading causes of disability and death.

“There’s a range of interactions within the community that can improve one’s cardiovascular health, not to mention the effect on mental health — the sense of belonging, of being seen — which is tightly related to cardiovascular outcomes in the long run,” says Dr. Dhruv Kazi, director of the cardiac critical care unit at Beth Israel Deaconess Medical Center (BIDMC) and associate director of the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology.

“Another way to put it is that these unique sources of resilience in communities may directly affect diet, exercise, weight, and mental well-being, all of which lead to improved cardiovascular health,” he adds.

A positive perspective on health within Black communities

The new analysis is part of the ongoing Morehouse-Emory Cardiovascular Center for Health Equity (MECA) study in Atlanta. MECA builds on prior research indicating that living in disadvantaged areas is associated with higher rates of having heart disease or dying from it. But unlike much of that research — which focused on negative aspects of Black neighborhoods that may contribute to poor cardiovascular health — the new study fills a gap. It zeroes in on positive neighborhood features, especially social interactions, that can promote ideal cardiovascular health despite higher risks related to race or socioeconomic status.

“Typically, researchers are identifying factors that result in health disparities on the negative side, such as deaths or co-existing diseases, or that cause increased rates of a particular disease,” explains Dr. Fidencio Saldana, dean for students at Harvard Medical School and an attending physician in medicine and cardiology at Brigham and Women’s Hospital (BWH), whose research interests include racial disparities and outcomes in cardiovascular disease. “It’s quite unique to be able to look for solutions, or to look at these positive attributes of communities and think about how to replicate them.”

Measuring social environment and heart health

The study included 392 Black men and women between the ages of 30 and 70 living in the Atlanta area. None had existing cardiovascular disease. About four in 10 participants were men.

Social environment includes perceptions of neighbors and any support system, as well as how often neighbors interact. Participants answered questions about seven neighborhood features: aesthetics, walking environment, availability of healthy foods, safety, social cohesion, activity with neighbors, and violence.

Heart health was measured using Life’s Simple 7 (LS7) scores, developed by the American Heart Association to determine ideal cardiovascular health. LS7 calculates seven elements that influence cardiovascular health: self-reported exercise, diet, and smoking history, as well as measured blood pressure, sugar level, cholesterol level, and body mass index (BMI). Researchers also gathered information about annual income, education, and marital and employment status, and physical exams that included blood tests.

What did the researchers learn?

After controlling for factors that could skew results, researchers found participants who reported more social connection and activity with neighbors were about twice as likely to record ideal LS7 scores. The association was even stronger among Black women than men.

“Our health is more closely related to these social networks than we appreciate,” Dr. Kazi says, noting that individual efforts to combat obesity and smoking, for instance, are more likely to gain steam “when shared by neighbors.”

“The more we’re able to engage with our neighbors and the communities we live in, the better it probably is for our cardiovascular health,” he says.

The study was observational, so it cannot prove cause and effect. It’s also possible that those who are already healthier are more likely to engage with their neighbors, Dr. Kazi notes. Other limitations are the location of all participants in a single metropolitan area, and the self-reported nature of neighborhood characteristics. Another key area that went unexamined, Dr. Kazi says, involves a “missing piece” in LS7 scores: mental health.

“Living in a community where you feel safe and know your neighbors — where you feel part of the social fabric — is critically important to mental health, and therefore cardiovascular health,” he explains. “If anything, this study underestimates the health benefits of feeling part of a cohesive neighborhood.”

What are a few takeaways from this study?

Social environment and feeling rooted within a community matter to health, and may even help counter negative risk factors. However, long-term lack of investment and the effects of gentrification threaten many Black neighborhoods in cities throughout the US.

“When a neighborhood gets gentrified and longstanding residents are forced to leave, the community is gone forever,” Dr. Kazi adds. “Simply offering the departing residents housing elsewhere doesn’t make up for what is lost. Going forward, we need to be cognizant of the value of community, and invest in our neighborhoods that allow people to safely engage in physical and community activities.”

Dr. Saldana agrees. “Our system is not set up for some communities to have those advantages. It’s important to look to the positive aspects of our communities, and as a system encourage those positive traits in other communities.”

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

Pregnancy is often painted as a time of elation and joy, emotions many people may indeed feel. As doctors, though, it’s hard to ignore the health risks and the fears that can arise in the wake of a positive pregnancy test for some of our most vulnerable patients.

Simply being pregnant poses significant short-term and long-term risks to health, particularly in the US. We have the highest rate of serious pregnancy-related complications among developed nations, resulting in about 700 deaths a year nationally. This health burden is unequally distributed, falling hardest on women of color and low-income women — in fact, Black women are three times as likely to die as white women from pregnancy-related complications.

What makes pregnancy challenging from a health standpoint?

Pregnancy acts as an ongoing stress test that taxes body systems and generates unique health risks. It changes how the heart, lungs, and kidneys function. It also alters the immune system, and changes metabolism through effects on various organs. It increases blood flow throughout the body. The impact is greater for anyone who already has high blood pressure, diabetes, or other health conditions. Additionally, pregnancy can also deepen existing mental health disorders such as depression and anxiety, often exacerbating symptoms.

Two health issues unique to pregnancy are:

• Preeclampsia. This causes high blood pressure and possible damage to other organs, such as the kidneys, liver, and brain. Pregnancy alone places extra stress on the heart and blood vessels. Having a pregnancy affected by preeclampsia more than triples one’s lifetime risk of cardiovascular disease such as stroke or heart attack, according to the Preeclampsia Foundation. The biggest risk factors for developing preeclampsia are being younger than 18 or older than 40, autoimmune disease (such as lupus), existing high blood pressure, or preeclampsia in a prior pregnancy.
• Excess bleeding after birth (postpartum hemorrhage). While certain factors put people at higher risk, hemorrhage may occur with any birth, even those that follow uncomplicated pregnancies.

Most often, pregnancy can be safely navigated even when a person has health conditions. Yet having an existing condition like heart disease or diabetes does raise risk for complications and death. Now that pregnancies at later ages are more common, existing heart disease is complicating more pregnancies. Once rarely needed, large multidisciplinary teams of health professionals are now often required to care for pregnant people with complex cardiac needs or other health conditions.

Many pregnancies are unintended

Nearly half of all pregnancies in the United States are unintended. In some cases that means a pregnancy is wanted at a future time; in others that a pregnancy is not desired.

Why do so many unintended pregnancies occur? Nine in 10 sexually active women who are not trying to get pregnant report using some form of birth control. Of course, not all types of birth control are highly effective. In a year of use, 13 out of 100 people relying on condoms alone — and up to 23 out of 100 relying on fertility awareness methods — will become pregnant.

Unintended pregnancies occur even when people use very effective contraceptives. With perfect use (which is very hard to achieve), fewer than one in 100 women taking birth control pills for a year will become pregnant. With typical use, seven in 100 will become pregnant. More than 13 million US women use surgical sterilization, such as tubal ligation, as a permanent form of birth control. Given the failure rate of nearly one in 100, research suggests more than more than 65,000 unintended pregnancies may occur annually after these procedures.

Health factors in, too. Certain medical conditions or medications, such as medicines used to treat epilepsy, may also increase the risk of contraceptive failure. Health conditions also dictate whether people can use some of the more effective forms of birth control.

A narrowing of health care choices and life choices

Pregnancy, childbirth, and parenting alter the trajectory of many lives — parents, siblings, and wider family — even when people choose this path. Since June 2022, when the Dobbs Supreme Court decision overturned a national constitutional right to abortion, at least 14 states have banned or severely restricted the ability to make choices once pregnant. Even before Dobbs, nearly 10% of people seeking abortion care in the US had to travel out of state.

Research shows that women who seek an abortion but are denied abortion care are more likely to have health problems during their pregnancy and to experience financial difficulties or live in poverty years later. State bans on abortion care will have a disproportionate impact on Black and low-income women, who already are at higher risk for complications or death related to childbirth. Ultimately, legislation that restricts or bans comprehensive health care that includes abortion care puts all people capable of pregnancy at risk — medically, economically, and socially.

Like pregnancy itself, the decision to remain pregnant is deeply personal. And as with all health care, patients and physicians should be able to freely consider all medical options to help guide decisions, including ending a pregnancy. Although abortion care is more restricted today than it has been since 1973, options are available and remain a critical part of maternal health care.

Selected resource

Contraceptive Technology, 21st edition, Managing Contraception LLC. More information is available on the Managing Contraception website.

About the Authors

Sara Neill, MD, MPH,

Contributor

Dr. Sara Neill is a physician-researcher in the department of obstetrics & gynecology at Beth Israel Deaconess Medical Center and Harvard Medical School. She completed a fellowship in complex family planning at Brigham and Women's Hospital, and … See Full Bio View all posts by Sara Neill, MD, MPH

Scott Shainker, DO, MS, Contributor

Scott Shainker, D.O, M.S., is a maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center (BIDMC). He is also a member of the faculty in the Department of Obstetrics, … See Full Bio View all posts by Scott Shainker, DO, MS

How well are you protecting yourself against heart disease, the nation’s leading cause of death? A check of five important numbers can give you a good idea: blood pressure, blood sugar, LDL cholesterol and triglyceride levels, and waist circumference. Those values provide a picture of a person’s overall health and, more specifically, what factors they may need to address to lower their chance of a heart attack or stroke.

Below are the ideal values for each measurement, along with why they’re important and targeted advice for improving them. Universal suggestions for improving all five measurements appear at the very end.

How do your heart health numbers stack up?

While the ideal values are good goals for most people, your doctor may recommend different targets based on your age or other health conditions.

Blood pressure

Less than 120/80 mm Hg

Blood pressure readings tell you the force of blood pushing against your arteries when your heart contracts (systolic blood pressure, the first number) and relaxes (diastolic blood pressure, the second number). Your blood pressure reflects how hard your heart is working (when you’re resting or exercising, for example) and the condition of your blood vessels. Narrowed, inflexible arteries cause blood pressure to rise.

Why it matters to heart health: High blood pressure accelerates damage to blood vessels, encouraging a buildup of fatty plaque (atherosclerosis). This sets the stage for a heart attack. High blood pressure forces the heart’s main pumping chamber to enlarge, which can lead to heart failure. Finally, high blood pressure raises the risk of strokes due to a blocked or burst blood vessel in the brain.

What helps: A diet rich in potassium (found in many vegetables, fruits, and beans) and low in sodium (found in excess in many processed and restaurant foods); minimizing alcohol.

LDL cholesterol

Less than 70 mg/dL

A cholesterol test (or lipid profile) shows many numbers. Doctors are usually most concerned about low-density lipoprotein (LDL) cholesterol, particles that makes up about two-thirds of the cholesterol in the blood.

Why it matters to heart health: Excess LDL particles lodge inside artery walls. Once there, they are engulfed by white blood cells, forming fat-laden foam cells that make up atherosclerosis.

What helps: Limiting saturated fat (found in meat, dairy, and eggs) and replacing those lost calories with unsaturated fat (found in nuts, seeds, and vegetable oils).

Triglycerides

Less than 150 mg/dL

Perhaps less well-known than cholesterol, triglycerides are the most common form of fat in the bloodstream. Derived from food, these molecules provide energy for your body. But excess calories, alcohol, and sugar the body can’t use are turned into triglycerides and stored in fat cells.

Why it matters to heart health: Like high LDL cholesterol, elevated triglyceride values have been linked to a higher risk of heart attack and stroke.

What helps: Limiting foods that are high in unhealthy fats, sugar, or both; eating foods rich in omega-3 fatty acids (such as fish); avoiding alcohol.

Blood sugar

Less than 100 mg/dL (fasting)

High blood sugar defines the diagnosis of diabetes. Type 2 diabetes is most common. It occurs when the body develops insulin resistance (insulin enables cells to take in sugar) and does not produce enough insulin to overcome the resistance.

Why it matters to heart health: High blood sugar levels damage blood vessel walls and cause sugar (glucose) to attach to LDL. This makes LDL more likely to oxidize — another factor that promotes atherosclerosis. Excess sugar in the blood also makes cell fragments called platelets stickier so they’re more likely to form clots, which can trigger a heart attack or stroke.

What helps: Avoiding sugary beverages and foods high in sugar; eating whole, unprocessed grains instead of foods made with refined grains (white flour, white rice).

Waist circumference

Whichever number is lower:

Less than half your height in inches

OR

Women: Less than 35 inches

Men: Less than 40 inches

Measure your waist around your bare abdomen just above your navel (belly button). A big belly — what doctors call abdominal or visceral obesity — usually means fat surrounding internal organs.

Why it matters to heart health: Visceral fat secretes hormones and other factors that encourage inflammation, which triggers the release of white blood cells involved in atherosclerosis.

What helps: Consuming fewer calories, especially those from highly processed foods full of sugar, salt, and unhealthy types of fat.

Universal advice to improve all five measures of heart health

If one or more of your numbers is above ideal levels, you’re far from alone. Most Americans are overweight or obese and have bigger-than-healthy bellies. Excess weight and waist circumference affect blood pressure, LDL cholesterol, triglycerides, and blood sugar. Eating a healthy, plant-based diet can help. Regular exercise also helps: aim for at least 30 minutes of moderate-intensity exercise like brisk walking most days. Other lifestyle habits that can lower your heart disease risk include getting seven to eight hours of sleep nightly and managing your stress level.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

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

About the Reviewer

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

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

While studies sometimes reach faulty conclusions, researchers can help correct the record.

When it comes to clinical research, the most powerful type of study is a randomized, double-blind, placebo-controlled trial.

But even a well-designed trial can arrive at questionable conclusions. Recent follow-up on a 2019 cardiovascular study dubbed REDUCE-IT is one example that offers a great lesson. While innovative treatments are the focus of many clinical trials like this one, the choice of placebo is critical as well.

What made this a powerful study?

In this type of study, subjects are randomly assigned to two groups: one group receives the treatment being evaluated (such as a new drug) while the other group gets a fake treatment called a placebo.

Neither study subjects nor researchers know who is receiving active treatment and who is receiving placebo. That is, they are both blind to group assignment — that’s why it’s called double-blind. Treatment assignment is coded and kept secret until the end of the study, or decoded at earlier, planned intervals to monitor effectiveness or safety.

This reduces the chance that expectations of the researchers or participants will bias study outcomes. That means any differences in health or side effects can reasonably be attributed to the treatment — or lack of it.

What to know about placebo treatment

Ideally, study participants and researchers cannot tell who is getting an active treatment and who is getting a placebo. But sometimes, participants might be able to tell what they received. For example, the active treatment might have a bitter taste, or a noticeable side effect such as diarrhea.

If that happens, the study is no longer double-blind. This means expectations could affect outcomes. Studies can assess this by asking participants during or after the trial whether they thought they were taking an active treatment or a placebo. If the answers seem random or the subjects answer “I don’t know,” blinding was successful.

While a placebo treatment should have no effect, that’s not always true:

• The well-known placebo effect is a positive effect related to an expectation of benefit: if you tell someone a pill can relieve pain, some people will experience pain relief, even if that pill was a placebo.
• A negative side effect due to a placebo is called the nocebo effect: if you tell someone they might develop diarrhea from the placebo pill they’re taking, the expectation may cause some people to experience this. (The very same placebo used in another study may trigger headaches, if that’s the side effect the study subject is warned about.)

Finally, a placebo should not have any direct, biological impact on the person taking it. And that seems to be where REDUCE-IT went wrong.

REDUCE-IT demonstrates the importance of choosing a placebo carefully

The full name of REDUCE-IT is the Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial). It was designed to determine whether the drug icosapent ethyl could lower triglyceride levels as a way to reduce cardiovascular disease, such as heart attack or stroke.

Triglycerides are a type of fat in the blood. High levels may increase cardiovascular risk, but experts aren’t sure whether treatments to lower triglyceride levels result in fewer heart attacks or strokes.

Among participants who received the active drug, triglyceride levels fell. Rates of cardiovascular problems, including heart attack or stroke, were a whopping 25% lower compared with rates in those assigned to take a placebo. There was even a 20% reduction in cardiovascular deaths in the treatment group.

Based on these findings, the FDA approved a drug label claiming that icosapent ethyl benefitted certain people at high risk for cardiovascular disease.

But questions arose soon after the study was published in 2019. True, the treatment group fared better than the placebo group. Yet a careful reading of the results suggested that this may have been because those in the placebo group had more heart attacks and strokes over time, not because the treatment group had fewer.

A follow-up study shows a different result

Responding to these questions, the study’s authors performed additional analyses. This time they looked at substances in the blood called biomarkers associated with cardiovascular risk. They found little change in the biomarker results among participants receiving the active drug. But biomarkers worsened in the placebo group, suggesting that the apparent benefit conferred by the drug may have been due to the negative effects of the placebo!

How can a placebo worsen cardiovascular risk? One possibility is that the mineral oil placebo used in this trial may have reduced absorption of statin drugs participants were taking to lower their cholesterol, which also affect heart and blood vessel health. Regardless, this new analysis suggests that the skepticism about the dramatic results of the original study was appropriate, and additional study is warranted.

The bottom line

For me, this story has three take-home points:

• There are many ways for research to come to faulty conclusions; an unfortunate placebo choice is an unusual one, but appears to be true here.
• For medical research to be trusted, researchers must be willing to accept criticism, re-assess findings, and perform additional analyses if necessary.
• It appears that in the case of REDUCE-IT, this self-correction process worked.

After the initial study in 2019, enthusiasm was high for the drug icosapent ethyl. In the wake of this latest analysis, however, that excitement is likely to wane. But one thing should be clear: this is not science being unable to make up its mind, as is sometimes said. Reassessment and correction, when warranted, is how science is supposed to work.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

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