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As the new year rolls on, sports fans rejoice! You’ve had the excitement of the college football bowl games and the national championship game, the NFL playoff games are winnowing teams down to the Super Bowl contestants, and basketball and hockey seasons are in full swing. Spring training for the upcoming Major League Baseball season is around the corner.

But hold these thoughts a moment. Watching sports — not just playing them — can be hazardous to your health. I’ve seen it firsthand while working in a walk-in clinic near Fenway Park, where people would show up bleeding from cuts that needed stitches (from trips and falls at the stadium), broken bones (from trying to catch a foul ball or an altercation with another fan), and dehydration.

Most of these injuries weren’t life-threatening. But there’s evidence that the health impact of sports spectatorship can be far more serious for some of us — and, perhaps, underappreciated.

What are the health risks of watching live sports?

When you’re watching games in person, some risks are related to the weather and other fans. For example:

• Watching a baseball game in the summer for hours may lead to heat stroke or dehydration.
• Live winter football games may raise the risk of hypothermia, frostbite, or other cold-related problems.
• Stampedes, riots, and brawls between rival fans watching soccer matches are not rare and may actually be on the rise.
• And, as mentioned, spectators of live sports can be injured by balls hit into the stands or other flying objects such as bats, pucks, or golf balls.

How could watching sports on TV boost health risks?

Doctors and nurses often describe how quiet things get in the emergency room during a World Series game or the Super Bowl. But once the game ends, it tends to get much busier. One theory is that people with chest pain, trouble breathing, or other symptoms of a potentially serious problem who ordinarily would have reported to the emergency room right away may delay seeking care until after the game.

Of course, there’s another possibility: the game itself — especially if a game is close and particularly exciting — might cause enough stress on the body that heart attacks, strokes, or other dangerous conditions develop.

Research supporting the idea that watching sports can negatively affect your health includes:

• Older studies have linked hospital admissions for heart failure and cardiac arrest with watching sporting events.
• A 2017 study found that spectators of Montreal Canadiens hockey games experienced a doubling of their heart rate during games. The effect was more pronounced for live games than televised games, but even the latter experience led to faster heart rates similar to the effect of moderate exercise.
• A 2022 study found that hospital admissions for cardiovascular problems jumped 15% during and just after World Cup soccer games.

Together, these studies suggest that watching sports can be stressful enough to trigger dangerous cardiovascular events.

It’s worth emphasizing that most people watching sports enjoy it and do not experience any health problems related to the game. But these studies suggest that spectating may carry some small risk, similar to what might accompany moderate or vigorous exercise. This may be most relevant for people who are older or who already have cardiovascular disease.

What’s a sports fan to do?

One common recommendation is to remember that it’s only a game. Of course, if you care a lot about sports or a particular team, that advice is unlikely to help. A second is to get regular exercise. Staying physically active strengthens the heart and lowers blood pressure, which could help ward off some of the health risks described above.

Five additional game-day precautions are:

• Avoid overeating, especially salty junk food. For some, overindulging in food, drink, and salt can stress the heart or trigger heart failure.
• Be prepared for the weather. Check the forecast. If you’re planning to watch a game in the cold, dress in layers, use hand warmers, and drink warm fluids. If you’re going to be out in the sun, use sunscreen liberally, wear a hat, and hydrate well.
• If you have cardiovascular disease, don’t forget to take your medications, especially if there’s a big game coming up. And if you develop worrisome symptoms, such as chest pain or trouble breathing, seek medical attention right away. Don’t wait till the game ends!
• Stay hydrated and moderate your alcohol intake. Stay well-hydrated by drinking water, especially if you’re out in the heat for hours. Although beer is a liquid, it’s also a diuretic, meaning it can make you urinate more and lose more fluids than other beverages.
• Stay alert at live events. Give yourself a fighting chance of getting out of the way of a line-drive foul ball or an errant bat that’s slipped out of the batter’s hands during a swing.

The bottom line

I can attest to many upsides of watching sports: the excitement of competition and the bonding and camaraderie with likeminded friends, family, and other fans. And perhaps watching sports might improve your health if sports spectatorship sparks sports participation.

While watching sports has been linked to certain health risks, the overall risk is likely low for most people. And you can take steps to reduce this. The health risks of spectatorship only rarely require giving up watching a favorite team. So, put on your team jersey, cheer your team on to victory, and stay healthy while you’re at it. Oh, and watch out for outraged fans or flying bats.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

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

If you suffer from the throbbing, intense pain set off by migraine headaches, you may well wonder which medicines are most likely to offer relief. A recent study suggests a class of drugs called triptans are the most helpful option, with one particular drug rising to the top.

The study drew on real-world data gleaned from more than three million entries on My Migraine Buddy, a free smartphone app. The app lets users track their migraine attacks and rate the helpfulness of any medications they take.

Dr. Elizabeth Loder, professor of neurology at Harvard Medical School and chief of the Division of Headache at Brigham and Women’s Hospital, helped break down what the researchers looked at and learned that could benefit anyone with migraines.

What did the migraine study look at?

Published in the journal Neurology, the study included self-reported data from about 278,000 people (mostly women) over a six-year period that ended in July 2020. Using the app, participants rated migraine treatments they used as “helpful,” “somewhat helpful,” or “unhelpful.”

The researchers looked at 25 medications from seven drug classes to see which were most helpful for easing migraines. After triptans, the next most helpful drug classes were ergots such as dihydroergotamine (Migranal, Trudhesa) and anti-emetics such as promethazine (Phenergan). The latter help ease nausea, another common migraine symptom.

“I’m always happy to see studies conducted in a real-world setting, and this one is very clever,” says Dr. Loder. The results validate current guideline recommendations for treating migraines, which rank triptans as a first-line choice. “If you had asked me to sit down and make a list of the most helpful migraine medications, it would be very similar to what this study found,” she says.

What else did the study show about migraine pain relievers?

Ibuprofen, an over-the-counter pain reliever sold as Advil and Motrin, was the most frequently used medication in the study. But participants rated it “helpful” only 42% of the time. Only acetaminophen (Tylenol) was less helpful, helping just 37% of the time. A common combination medication containing aspirin, acetaminophen, and caffeine (sold under the brand name Excedrin) worked only slightly better than ibuprofen, or about half the time.

When researchers compared helpfulness of other drugs to ibuprofen, they found:

• Triptans scored five to six times more helpful than ibuprofen. The highest ranked drug, eletriptan, helped 78% of the time. Other triptans, including zolmitriptan (Zomig) and sumatriptan (Imitrex), were helpful 74% and 72% of the time, respectively. In practice, notes Dr. Loder, eletriptan seems to be just a tad better than the other triptans.
• Ergots were rated as three times more helpful than ibuprofen.
• Anti-emetics were 2.5 times as helpful as ibuprofen.

Do people take more than one medicine to ease migraine symptoms?

In this study, two-thirds of migraine attacks were treated with just one drug. About a quarter of the study participants used two drugs, and a smaller number used three or more drugs.

However, researchers weren’t able to tease out the sequence of when people took the drugs. And with anti-nausea drugs, it’s not clear if people were rating their helpfulness on nausea rather than headache, Dr. Loder points out. But it’s a good reminder that for many people who have migraines, nausea and vomiting are a big problem. When that’s the case, different drug formulations can help.

Are pills the only option for migraine relief?

No. For the headache, people can use a nasal spray or injectable version of a triptan rather than pills. Pre-filled syringes, which are injected into the thigh, stomach, or upper arm, are underused among people who have very rapid-onset migraines, says Dr. Loder. “For these people, injectable triptans are a game changer because pills don’t work as fast and might not stay down,” she says.

For nausea, the anti-emetic ondansetron (Zofran) is very effective, but one of the side effects is headache. You’re better off using promethazine or prochlorperazine (Compazine), both of which treat nausea but also help ease headache pain, says Dr. Loder.

Additionally, many anti-nausea drugs are available as rectal suppositories. This is especially helpful for people who have “crash” migraines, which often cause people to wake up vomiting with a migraine, she adds.

What are the limitations of this migraine study?

The data didn’t include information about the timing, sequence, formulation, or dosage of the medications. It also omitted two classes of newer migraine medications — known as gepants and ditans — because there was only limited data on them at the time of the study. These options include

• atogepant (Qulipta) and rimegepant (Nurtec)
• lasmiditan (Reyvow).

“But based on my clinical experience, I don’t think that any of these drugs would do a lot better than the triptans,” says Dr. Loder.

Another shortcoming is the study population: a selected group of people who are able and motivated to use a migraine smartphone app. That suggests their headaches are probably worse than the average person, but that’s exactly the population for whom this information is needed, says Dr. Loder.

“Migraines are most common in young, healthy people who are trying to work and raise children,” she says. It’s good to know that people using this app rate triptans highly, because from a medical point of view, these drugs are well tolerated and have few side effects, she adds.

Are there other helpful takeaways?

Yes. In the study, nearly half the participants said their pain wasn’t adequately treated. A third reported using more than one medicine to manage their migraines.

If you experience these problems, consult a health care provider who can help you find a more effective therapy. “If you’re using over-the-counter drugs, consider trying a prescription triptan,” Dr. Loder says. If nausea and vomiting are a problem for you, be sure to have an anti-nausea drug on hand.

She also recommends using the Migraine Buddy app or the Canadian Migraine Tracker app (both are free), which many of her patients find helpful for tracking their headaches and triggers.

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

Dr. Howard LeWine 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

When we think about radiation therapy, we typically picture treatments directed at tumors by a machine located outside the body. Now imagine a different scenario — one in which radioactive particles injected into the bloodstream find and destroy individual cancer cells, while leaving healthy cells unscathed.

The drug

One such “radioligand” is already available for certain patients with prostate cancer. Called Lu-PSMA-617 (trade name Pluvicto), it carries a lethal payload of radioactive atoms. The drug binds with a cell protein known as prostate-specific membrane antigen (PSMA), which is abundant on most prostate cancer cells but absent on most normal cells. After sticking to that protein, Lu-PSMA-617 delivers its radioactive cargo, and then the targeted cell dies.

As it currently stands, Lu-PSMA-617 is approved only for very a specific circumstance: eligible patients must have been treated already with chemotherapy for metastatic castration-resistant prostate cancer (mCRPC). During this advanced stage of the disease, prostate-specific antigen (PSA) levels rise despite treatments that block testosterone, a hormone that fuels prostate cancer growth (rising PSA indicates the cancer is progressing).

Doctors will often respond by switching to second-line hormonal treatments that block testosterone in other ways. If those drugs don’t work or become ineffective, then chemotherapy is typically the next option.

But could men with mCRPC bypass chemotherapy — along with its challenging side effects — and start on Lu-PSMA-617 right away? Investigators evaluated that potential strategy during a newly-completed clinical trial.

The study

The PSMAfore phase 3 trial enrolled 468 men with mCRPC. All the men had PSMA-positive tumors, and each of them had been treated already with a second-line testosterone blocker. For most men, that drug was abiraterone; the rest had been treated with a drug called enzalutamide. None of the men had yet been given chemotherapy.

The investigators randomized all the enrolled men into two groups. Men in the treatment group were given infusions of Lu-PSMA-617, while men in the control group were switched to a second testosterone-blocker that they hadn’t yet received.

The findings

After nearly a year and a half of follow-up, Lu-PSMA-617 treatment generated promising results. Crucially, the treated men avoided further cancer progression for a year on average, which was six months longer than progression was avoided in the control group.

Lu-PSMA-617 also produced significant drops in PSA: in 58% of the Lu-PSMA-617-treated men, PSA levels declined by half or more. Just 20% of men in the control group experienced comparable PSA declines. Lu-PSMA-617 was also well tolerated. The most common side effects were dry mouth and minor gastrointestinal symptoms, and treated men also reported less pain and better quality of life.

Commentary

Researchers still need to show that using Lu-PSMA-617 before chemotherapy actually lengthens survival before the FDA will approve this new indication. The enrolled subjects are still being followed, and “hopefully with further follow up, this sequence of treatments may become more widely available,” says Dr. Marc B. Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center.

Added Dr. Garnick, “This study marks another advance in our emerging treatment options for men with advanced prostate cancer, and underscores the methodical progression of pharmaceutical development. When new therapies are introduced, they are studied in patients in whom the treatment options are limited. Fortunately, Lu-PSMA-617 showed excellent results in this population, and the study outlined here suggests that it may be able to move this therapy to even earlier forms of advanced prostate cancer. We anxiously await longer-term follow-up of this important research.”

About the Author

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

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

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

Early in the new year, promises to reboot your health typically focus on diet, exercise, and weight loss. And by now you may have begun making changes — or at least plans — to reach those goals. But consider going beyond the big three.

Below are 10 often-overlooked, simple ideas to step up personal health and safety. And most won’t make you break a sweat.

Review your health portals

Your medical information is kept in electronic records. You have access to them through the patient portal associated with your doctor’s office. Set aside time to update portal passwords and peruse recent records of appointments, test results, and notes your doctor took during your visits.

“Many studies have shown that when patients review the notes, they remember far better what went on during interactions with their clinicians, take their medicines more effectively, and pick up on errors — whether it’s an appointment they forgot to make or something their doctor, nurse, or therapist got wrong in documenting an encounter,” says Dr. Tom Delbanco, the John F. Keane & Family Professor of Medicine at Harvard Medical School and cofounder of the OpenNotes initiative, which led shared clinician notes to become the new standard of care.

Doing this can help you become more engaged in your care. “We know from numerous studies that engaged patients who share decisions with those caring for them have better outcomes,” he adds.

Ask about health insurance freebies

Your insurance plan may offer perks that can lead to better health, such as:

• weight loss cessation programs
• quit-smoking programs
• free or reduced gym memberships.

Some insurers even offer breastfeeding counseling and equipment. Call your insurance company or take a close look at their website to find out if there’s anything that would help you.

Get rid of expired medications

Scour your cabinets for expired or unneeded drugs, which pose dangers for you and others. Look for prescription and over-the-counter medications (pills, potions, creams, lotions, droppers, or aerosol cans) as well as supplements (vitamins, minerals, herbs).

Bring your finds to a drug take-back site, such as a drugstore or law enforcement office, or a medical waste collection site such as the local landfill.

As a last resort, toss medications into the trash, but only after mixing them with unappealing substances (such as cat litter or used coffee grounds) and placing the mixture in a sealable plastic bag or container.

Invest in new sneakers

The wrong equipment can sabotage any exercise routine, and for many people the culprit is a worn pair of sneakers. Inspect yours for holes, flattened arch support, and worn treads. New sneakers could motivate you to jazz up your walking or running routine.

For example, if it’s in the budget, buy a new pair of walking shoes with a wide toe box, cushy insoles, good arch support, a sturdy heel counter (the part that goes around your heel), stretchy uppers, and the right length — at least half an inch longer than your longest toe.

Cue up a new health app

There are more than 350,000 health apps geared toward consumer health. They can help you with everything from managing your medications or chronic disease to providing instruction and prompts for improving diet, sleep, or exercise routines, enhancing mental health, easing stress, practicing mindfulness, and more.

Hunt for apps that are free or offer a free trial period for a test drive. Look for good reviews, strong privacy guardrails, apps that don’t collect too much information from you, and those that are popular — with hundreds of thousands or millions of downloads.

Make a schedule for health screenings and visits

Is it time for a colonoscopy, mammogram, hearing test, prostate check, or comprehensive eye exam? Has it been a while since you had a dermatologist examine the skin on your whole body? Should you have a cholesterol test or other blood work — and when is a bone density test helpful?

If you’re not sure, call your primary care provider or any specialists on your health team to get answers.

Four more simple healthy steps

The list of steps you can take this year to benefit your health can be as long as you’d like it to be. Jot down goals any time you think of them.

Here are four solid steps to start you off:

• Take some deep breaths each day. A few minutes of daily slow, deep breathing can help lower your blood pressure and ease stress.
• Get a new pair of sunglasses if your old ones have worn lenses. Make sure the new pair has UV protection (a special coating) to block the sun’s ultraviolet (UV) light, which can cause eye damage and lead to permanent vision loss.
• Make a few lunch dates or phone dates with friends you haven’t seen in a while. Being socially connected wards off loneliness and isolation, which can help lower certain health risks.
• Do a deep cleaning on one room in your home per week. Dust and mold can trigger allergies, asthma, and even illness.

You don’t have to do all of these activities at once. Just put them on your to-do list, along with the larger resolutions you’re working on. Now you’ll have a curated list of goals of varying sizes. The more goals you reach, the better you’ll feel. And that will make for a very healthy year, indeed.

About the Author

Heidi Godman, Executive Editor, Harvard Health Letter

Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman

About the Reviewer

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

Dr. Howard LeWine 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

By midwinter, our urge to hibernate can start to feel constricting instead of cozy. What better antidote to being cooped up indoors than a bracing hike in the crisp air outdoors?

Winter backdrops are stark, serene, and often stunning. With fewer people on the trail, you may spot more creatures out and about. And it’s a prime opportunity to engage with the seasons and our living planet around us, says Dr. Stuart Harris, chief of the Division of Wilderness Medicine at Massachusetts General Hospital. But a multi-mile trek through rough, frosty terrain is far different than warm-weather hiking, requiring consideration of health and safety, he notes. Here’s what to know before you go.

Winter hiking: Safety first

“The challenge of hiking when environmental conditions are a little more demanding requires a very different approach on a winter’s day as opposed to a summer’s day,” Dr. Harris says. “But it gives us a chance to be immersed in the living world around us. It’s our ancient heritage.”

A safety-first attitude is especially important if you’re hiking with others of different ages and abilities — say, with older relatives or small children. It’s crucial to have both the right gear and the right mindset to make it enjoyable and safe for all involved.

Planning and preparation for winter hikes

Prepare well beforehand, especially if you’re mixing participants with vastly different fitness levels. Plan your route carefully, rather than just winging it.

People at the extremes of age — the very old or very young — are most vulnerable to frigid temperatures, and cold-weather hiking can be more taxing on the body. “Winter conditions can be more demanding on the heart than a perfectly-temperatured day,” Harris says. “Be mindful of the physical capabilities of everyone in your group, letting this define where you go. It’s supposed to be fun, not a punishing activity.”

Before setting out:

• Know how far, high, and remote you’re going to go, Dr. Harris advises, and check the forecast for the area where you’ll be hiking, taking wind chill and speed into account. Particularly at higher altitudes, weather can change from hour to hour, so keep abreast of expectations for temperature levels and any precipitation.
• Know if you’ll have access to emergency cell coverage if anything goes wrong.
• Always share plans with someone not on your hike, including expected route and time you’ll return. Fill out trailhead registers so park rangers will also know you’re on the trail in case of emergency.

What to wear for winter hikes

Prepare for extremes of cold, wind, snow, and even rain to avoid frostbite or hypothermia, when body temperature drops dangerously low.

• Dress in layers. Several thin layers of clothing are better than one thick one. Peel off a layer when you’re feeling warm in high sun and add it back when in shadow. Ideally, wear a base layer made from wicking fabric that can draw sweat away from the skin, followed by layers that insulate and protect from wind and moisture. “As they say, there’s no bad weather, just inappropriate clothing,” Dr. Harris says. “Take a day pack or rucksack and throw a couple of extra thermal layers in. I never head out for any hike without some ability to change as the weather changes.”
• Protect head, hands, and feet. Wear a wool hat, a thick pair of gloves or mittens, and two pairs of socks. Bring dry spares. Your boots should be waterproof and have a rugged, grippy sole.
• Wear sunscreen. You can still get a sunburn in winter, especially in places where the sun’s glare reflects off the snow.

Carry essentials to help ensure safety

• Extra food and water. Hiking in the cold takes serious energy, burning many more calories than the same activity done in summer temperatures. Pack nutrient-dense snacks such as trail mix and granola bars, which often combine nuts, dried fruit, and oats to provide needed protein, fat, and calories. It’s also key to stay hydrated to keep your core temperature normal. Bonus points for bringing a warm drink in a thermos to warm your core if you’re chilled.
• First aid kit. Bandages for slips or scrapes on the trail and heat-reflecting blankets to cover someone showing signs of hypothermia are wise. Even in above-freezing temperatures, hypothermia is possible. Watch for signs such as shivering, confusion, exhaustion, or slurring words, and seek immediate help.
• Light source. Time your hike so you’re not on the trail in darkness. But bring a light source in case you get stuck. “A flashlight or headlamp is pretty darn useful if you’re hiking anywhere near the edges of daylight,” Harris says.
• Phone, map, compass, or GPS device plus extra batteries. Don’t rely on your phone for GPS tracking, but fully charge it in case you need to reach someone quickly. “Make sure that you have the technology and skill set to be able to navigate on- or off-trail,” Harris says, “and that you have a means of outside communication, especially if you’re in a large, mixed group.”

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

Feeling sad, anxious, or angry at times is a normal part of the human experience. But do you — or someone you’re close to — seem to experience these and similar emotions more quickly, more frequently, and more intensely than most people?

This problem, known as emotional dysregulation, is a hallmark of many mental health conditions, but especially borderline personality disorder. The most effective treatment for borderline personality disorder is dialectical behavior therapy (DBT), which has also been shown to help people experiencing other issues. What is DBT, who might benefit from this form of therapy, and how is it applied?

What is DBT?

DBT focuses on teaching people skills to manage intense emotions, cope with challenging situations, and improve their relationships. It encourages people to learn and use mindfulness training in practical ways.

During individual and group sessions, therapists encourage a nonjudgmental attitude and emphasize acceptance, compassion, and other aspects of mindfulness.

Who may benefit from DBT?

DBT has a proven track record for addressing the most debilitating symptoms of borderline personality disorder: self-injury and suicide threats or attempts. It is now also used to treat depression, post-traumatic stress disorder, eating disorders, and substance use disorders.

In fact, the cornerstone of DBT — the skills training — can help anyone navigate emotionally charged situations with more ease.

How can mindfulness change how people experience strong emotions?

Many people in therapy have very strong emotions that lead to negative thoughts, says Dr. Blaise Aguirre, a psychiatrist who founded the 3 East Dialectic Behavior Therapy Continuum at Harvard-affiliated McLean Hospital. “They say things like, ‘I’m stupid,’ or ‘I can’t control my anger,’ or ‘No one will ever love me,'” he says.

The mindfulness aspect of DBT teaches people to pay careful attention to the nature, quality, and volume of their thoughts. The idea is to observe these thoughts as separate from yourself without identifying with their meaning. This is the first step to addressing the impact of those thoughts, Dr. Aguirre explains.

How does DBT differ from cognitive behavioral therapy?

DBT is derived from cognitive behavioral therapy (CBT). CBT assumes that certain negative thoughts (cognitions) are distortions, and if you learn how to swap those distorted thoughts with more productive ones, you’ll be less depressed or anxious.

“But for someone with very deep emotions and convictions, telling them that their thoughts and feelings are somehow ‘wrong’ feels very invalidating,” says Dr. Aguirre. A DBT-trained therapist would instead acknowledge that the person’s thoughts make sense, given who they are and their experiences. This practice, known as validation, is a central tenet of DBT. It’s key to know that you can validate a person’s thoughts even if you don’t agree with them.

That concept touches on the core of DBT — the dialectical part. It refers to the idea that two opposite things can be true at the same time. Rather than viewing things in extremes of black and white, DBT encourages people to recognize there’s more than one way to view a situation and to try to “walk the middle path.” A classic DBT mantra is “I’m doing the best that I can in this moment, and I want to and can do better.”

What other skills does DBT rely on?

In addition to mindfulness, DBT teaches three other main skills:

• Distress tolerance is the ability to manage emotional distress in the moment, using techniques such as distraction.
• Emotion regulation involves recognizing, accepting, and managing intense emotions.
• Interpersonal effectiveness focuses on improving communication with other people to strengthen relationships and improve your self-esteem.

What does DBT entail?

Ideally, DBT includes one-on-one sessions with a therapist (who is also available between sessions for phone or text coaching). The one-on-one sessions are combined with weekly group sessions led by a therapist who teaches the specific, interconnected skills and gives homework that helps to reinforce the skills. Participants are encouraged to keep a daily diary to track their emotions, behaviors, reactions, and examples of how they’re practicing their skills.

DBT has been shown to be effective for people ranging from adolescents to older adults with a range of mental health conditions. It appears to be especially useful for adolescents, perhaps for the same reason that it’s easier to learn a language or how to play an instrument when you’re younger rather than older, says Dr. Aguirre.

Are there different options for gaining access to DBT?

Accessing the full DBT experience can be challenging for many people. The skills groups meet for one to two hours weekly for six to 12 months, which is in addition to weekly, hour-long sessions with an individual therapist. Individual therapy may cost as much as $250 to $300 per hour, and the groups are often around $100 per hour. Not all DBT providers accept insurance.

“We’re starting to recognize that the majority of people can improve just doing the skills groups and don’t need the full DBT,” says Dr. Aguirre.

But for teens who are suicidal or harming themselves, intensive DBT can help keep them out of the hospital and potentially save their lives. “If your child had cancer, you wouldn’t think twice about taking them in for chemotherapy infusions twice a week,” says Dr. Aguirre.

Another problem is that there aren’t many DBT-trained providers in less populated parts of the country. Online DBT therapy may be an option, although its effectiveness hasn’t been studied.

Is there one simple DBT tool I can try?

If a family member struggles with very strong emotions, Dr. Aguirre offers this mini-DBT lesson about validation. Situations that trigger intense emotions are often rooted in a perception of abandonment, neglect, or rejection, he says. For example, if a person believes that someone at work is avoiding them, or a romantic partner doesn’t show up on time, it can trigger a rapid rise in emotional distress.

Here’s what to avoid saying:

“You have to calm down.”

“You are making a big deal over nothing.”

“When I am upset, I make myself a nice cup of tea and that should help you, too.”

Here’s what you can say instead:

“You seem really upset. Do you want to talk about it, or do you want some time by yourself?’

“You seem very sad. I am around if you want to talk.”

“Is there anything that I can do to help?”

“These types of statements validate the person’s feelings and convey that you’re listening and open to helping, if that’s what they want,” says Dr. Aguirre.

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

Dr. Howard LeWine 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

If your fingers or toes ever turn pale (or even ghostly white) and go numb when exposed to cold, you might assume you just have poor circulation. That’s what I used to think when I first started noticing this problem with my own hands many years ago.

It usually happened near the end of a long hike on a spring or fall afternoon, when the temperature dropped and I didn’t have any gloves handy. My pinkie, third, and middle fingers would turn white, and the fingernails took on a bluish tinge. As I soon discovered, I have Raynaud’s phenomenon, an exaggeration of normal blood vessel constriction.

Raynaud’s phenomenon: Beyond poor circulation

When you’re exposed to a cold environment, your body reacts by trying to preserve your core temperature. Blood vessels near the surface of your skin constrict, redirecting blood flow deeper into the body. If you have Raynaud’s phenomenon, this process is more extreme.

Is wintry weather the only trigger for Raynaud’s phenomenon?

“Cold weather is the classic trigger for Raynaud’s phenomenon," says rheumatologist Dr. Robert H. Shmerling, senior faculty editor at Harvard Medical School's Harvard Health Publishing.

"But it can occur any time of year — for example, when you come out of a heated pool, walk into an air-conditioned building, or reach into the freezer section at the supermarket. Even slight changes in air temperature can trigger an episode.”

What happens when an episode occurs?

During an episode, the small arteries supplying the fingers and toes contract spasmodically, hampering the flow of oxygen-rich blood to the skin. Some of these vessels even temporarily collapse, and the skin becomes pale and cool, sometimes blanching to a stark white color.

In addition to the hands, Raynaud’s can also affect the feet. Less often, the nose, lips, and ears.

Is Raynaud’s phenomenon a circulation problem?

Technically, Raynaud’s phenomenon is a circulation problem, but it’s very different than what doctors typically mean by poor circulation, says Dr. Shmerling. Limited or poor circulation usually affects older people whose arteries are narrowed with fatty plaque (known as atherosclerosis). This condition is often caused by high cholesterol, high blood pressure, and smoking.

In contrast, Raynaud’s usually affects younger people (mostly women) without those issues. And the circulation glitch is generally temporary and completely reversible, he adds.

How can you prevent episodes?

As I can attest, the best treatment for this condition is to prevent episodes in the first place, mainly by avoiding sudden or unprotected exposure to cold temperatures. I’ve always bundled up in the winter before heading outside, but now I bring extra layers and gloves even when the temperature might dip even slightly, or the weather may turn rainy or windy. Preheating the car in winter before getting in, and wearing gloves in chilly grocery store aisles, can also help.

Generally, it’s best to avoid behavior and medicines that cause blood vessels to constrict. This includes not smoking and not taking certain medications, such as cold and allergy formulas that contain pseudoephedrine and migraine drugs that contain ergotamine. Emotional stress may also provoke an episode of Raynaud’s, so consider tools and techniques that can help you ease stress, such as mindfulness techniques.

If necessary, your doctor may prescribe a medication that relaxes the blood vessels, usually a calcium-channel blocker such as nifedipine (Adalat, Procardia). If that’s not effective, drugs to treat erectile dysfunction such as sildenafil (Viagra) may help somewhat. Other treatment options include losartan (Cozaar), fluoxetine (Prozac), and topical nitroglycerin. You may only need to use these medications during the cold season, when Raynaud’s tends to be worse.

What steps may help during an episode?

Once an episode starts, it’s important to warm up the affected extremities as quickly as possible. For me, placing my hands under warm running water does the trick.

When that’s not possible, you can put them under your armpits or next to another warm part of your body. When the blood vessels finally relax and blood flow resumes, the skin becomes warm and flushed — and very red. The fingers or toes may throb or tingle.

Is Raynaud’s phenomenon linked to other health problems?

Some people with Raynaud’s phenomenon have other health problems, usually connective tissue disorders such as lupus or scleroderma. Your doctor can determine this by reviewing your symptoms, performing a physical exam, and taking a few blood tests. But most of the time, there is no underlying medical problem.

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

Dr. Howard LeWine 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

Dementia usually develops in people ages 65 years and older. So-called young-onset dementia, occurring in those younger than age 65, is uncommon. Now, a new study published in December 2023 in JAMA Neurology has identified 15 factors linked to a higher risk of young-onset dementia.

Let’s see what they found, and — most importantly — what you can do to reduce your own risks.

Are early dementia and young-onset dementia the same?

No. Experts think of early dementia as the first stage in dementia. Mild cognitive impairment and mild dementia are forms of early dementia. So, someone age 50, 65, or 88 could have early dementia.

Young-onset dementia refers to the age at which dementia is diagnosed. A person has young-onset dementia if symptoms and diagnosis occur before age 65.

What has previous research shown?

A previous study of men in Sweden identified some risk factors for young-onset dementia, including high blood pressure, stroke, depression, alcohol use disorder, vitamin D deficiency, drug use disorder, and overall cognitive function.

What to know about the new study

In the new study, a research team in the Netherlands and the United Kingdom looked at data from the UK Biobank. The biobank follows about half a million individuals in the United Kingdom who were 37 to 73 years old when they first joined the project between 2006 and 2010. Most participants identified as white (89%), and the remaining 11% were described only as “other.” Slightly more than half of the participants (54%) were women.

The researchers excluded anyone age 65 or older and people who already had dementia at the start of the study, leaving 356,052 participants for the analyses. Over roughly a decade, 485 participants developed young-onset dementia. The researchers compared participants who did and did not develop young-onset dementia to identify possible risk factors.

What did the researchers learn about risks for young-onset dementia?

In reviewing the results, I think it is helpful to group the risk factors into several categories, and then to examine each of them. These risks may act on the brain directly or indirectly.

Eight factors that we know or strongly suspect cause dementia:

• Genes: Carrying two apolipoprotein E (APOE) ε4 alleles is a major genetic risk factor for Alzheimer’s disease. The risk is thought to be caused by the APOE ε4 protein not clearing amyloid efficiently from the brain. This allows amyloid to accumulate and cause plaques, which starts the cascade to cell death and Alzheimer’s disease.
• Being diagnosed with alcohol use disorder (AUD) has been associated with damage to several parts of the brain, including the frontal lobes, which leads to trouble with executive function and working memory. When combined with poor nutrition, AUD also harms small regions connected to the hippocampus that are critical for forming new memories.
• Being socially isolated is a major risk factor for dementia. Although the exact mechanism is unknown, it may be because our brains evolved, in large part, for social interactions. Individuals with fewer social contacts have fewer social interactions, and simply don’t use their brains enough to keep them healthy.
• Not getting enough vitamin D can lead to more viral infections. A number of studies suggest that certain viral infections increase your risk of dementia.
• Not hearing well increases your risk for dementia, as I discussed in a prior post. This is likely because of reduced brain stimulation and reduced social interactions. Using hearing aids lessens that risk.
• Previously having had a stroke is a risk factor because strokes damage the brain directly, which can lead to vascular dementia.
• Having heart disease is a major risk factor for strokes, which can then lead to vascular dementia.
• Having diabetes if you’re a man can lead to dementia in many different ways. Why only if you’re a man? The researchers suggest that it is because middle-aged men are more likely to have a diabetes-related ministrokes than middle-aged women, which can, again, lead to vascular dementia.

Two factors that reduce cognitive reserve

Cognitive reserve can be described as our capacity to think, improvise, and problem-solve even as our brains change with age. These two risk factors make it more likely that dementia symptoms will show up at a younger age.

• Having less formal education may affect your familiarity with the items on the pencil-and-paper cognitive tests that are used to diagnose dementia.
• Having lower socioeconomic status may be related to lower-quality education.

Is every factor identified in the study a clear risk?

No, and here’s why not: Sometimes research turns up apparent risk factors that might be due to reverse causation. It’s possible, for example, that symptoms of impending dementia appear to be risk factors because they become noticeable before obvious dementia is diagnosed.

• Lower handgrip strength is a sign of frailty, which is often associated with dementia.
• No alcohol use is a risk factor because people may stop drinking when they develop memory loss (also known as the “healthy drinker effect” in dementia).
• Depression is a risk factor because many people get sad when they have trouble remembering or when they are worried about having dementia.

Lastly, there are risk factors that could be either a contributing cause or a result of the impending dementia.

• High C-reactive protein is a sign of inflammation.
• Orthostatic hypotension is an abnormal drop in blood pressure when a person stands up after lying down or sitting. While this condition can lead to brain damage and dementia, it can also be a result of some types of dementia, such as Parkinson’s disease dementia and dementia with Lewy bodies.

What can you do to prevent young-onset dementia?

Taking these five steps can reduce your risk for developing dementia before age 65:

• Don’t drink alcohol in excess.
• Seek opportunities to socialize with others regularly.
• Make sure that you’re getting enough vitamin D. You can make your own vitamin D if your skin (without sunblock) is exposed to sunlight. But in northern climates you might need to take a supplement, especially in the winter. Because vitamin D can interact with other medications, ask your doctor about this option.
• Make sure you are hearing well and use hearing aids if you are not.
• Exercise regularly, eat a healthy diet, maintain a healthy body weight, and work with your doctor to reduce your risk of strokes, heart disease, and diabetes.

About the Author

Andrew E. Budson, MD, Contributor; Editorial Advisory Board Member, Harvard Health Publishing

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