Birds Can See Earth’s Magnetic Fields, And We Finally Know How That’s Possible

The mystery behind how birds navigate might finally be solved: it’s not the iron in their beaks providing a magnetic compass, but a newly discovered protein in their eyes that lets them “see” Earth’s magnetic fields.

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These findings come courtesy of two new papers – one studying robins, the other zebra finches.

The fancy eye protein is called Cry4, and it’s part of a class of proteins called cryptochromes – photoreceptors sensitive to blue light, found in both plants and animals. These proteins play a role in regulating circadian rhythms.

There’s also been evidence in recent years that, in birds, the cryptochromes in their eyes are responsible for their ability to orient themselves by detecting magnetic fields, a sense called magnetoreception.

We know that birds can only sense magnetic fields if certain wavelengths of light are available – specifically, studies have shown that avian magnetoreception seems dependent on blue light.

This seems to confirm that the mechanism is a visual one, based in the cryptochromes, which may be able to detect the fields because of quantum coherence.

To find more clues on these cryptochromes, two teams of biologists set to work. Researchers from Lund University in Sweden studied zebra finches, and researchers from the Carl von Ossietzky University Oldenburg in Germany studied European robins.

The Lund team measured gene expression of three cryptochromes, Cry1, Cry2 and Cry4, in the brains, muscles and eyes of zebra finches. Their hypothesis was that the cryptochromes associated with magnetoreception should maintain constant reception over the circadian day.

They found that, as expected for circadian clock genes, Cry1 and Cry2 fluctuated daily – but Cry4 expressed at constant levels, making it the most likely candidate for magnetoreception.

This finding was supported by the robin study, which found the same thing.

“We also found that Cry1a, Cry1b, and Cry2 mRNA display robust circadian oscillation patterns, whereas Cry4 shows only a weak circadian oscillation,” the researchers wrote.

But they made a couple of other interesting findings, too. The first is that Cry4 is clustered in a region of the retina that receives a lot of light – which makes sense for light-dependent magnetoreception.

The other is that European robins have increased Cry4 expression during the migratory season, compared to non-migratory chickens.

Both sets of researchers caution that more research is needed before Cry4 can be declared the protein responsible for magnetoreception.

The evidence is strong, but it’s not definitive, and both Cry1 and Cry2 have also been implicated in magnetoreception, the former in garden warblers and the latter in fruit flies.

Observing birds with non-functioning Cry4 could help confirm the role it seems to play, while other studies will be needed to figure Cry1’s role.

bird visionThis is how a bird might see magnetic fields. (Theoretical and Computational Biophysics/UofI)

So what does a bird actually see? Well, we can’t ever know what the world looks like through another species’ eyes, but we can take a very strong guess.

According to researchers at the Theoretical and Computational Biophysics group at the University of Illinois at Urbana-Champaign, whose researcher Klaus Schulten first predicted magnetoreceptive cryptochromes in 1978, they could provide a magnetic field “filter” over the bird’s field of view – like in the picture above.

The zebra finch study was published in the Journal of the Royal Society Interface, and the robin study was published in Current Biology.

If We Can See the Outcome, We Can Change the Outcome

Tom Lee: This is Tom Lee, and I’m pleased to be chatting with Roy Rosin, a very interesting and effective Chief Innovation Officer at Penn Medicine. A bunch of organizations have chief innovation officers these days. I think Penn’s program is among the most robust in the country, and they’ve got one of the most interesting leaders. Roy, you came from outside health care to be a chief leader of innovation at Penn. What were you doing before, and why did you make this move?

Roy Rosin: It’s great to talk to you, Tom. It was fun to have an opportunity to do something like it in health care when I did. I had spent many years at Intuit, which a lot of people know as the maker of TurboTax or Quicken or QuickBooks, and it’s just a fantastic company out in Silicon Valley. I had been there quite a long time, had built some of the software businesses like Quicken, but back in 2003 — my wife is from Philadelphia and wanted to move home to be near family, so I made that transition with her. I sometimes say I never really left Intuit, I just wanted to stay married, and I needed to go back and rethink what I wanted to do.

Intuit was fabulous. They gave me an opportunity to stay with the company. In fact, I stayed for another 9 years working remotely, and in those 9 years what I was able to do was think about enterprise, scale, innovation. How do you get new things going and turn ideas into actions and outcomes, and how do you get a lot of new things off the ground that actually have some impact? So we did that. We built these programs over the course of 9 years. I could do it remotely because we had new businesses starting all over the place, and we learned a tremendous amount.

Intuit was a learning organization, and after 9 years it was a lot of travel. I had kids, going back and forth, and I had started talking with Kevin Volpp who I know you know well. He’s an old friend of mine from college, and Kevin had started an innovation center at Penn that also was doing just fascinating work in behavior changes applied to health care.

Some of what we had done at Intuit was . . . thinking about, how do you get people to make different and better decisions? A lot of what we did was for profit at Intuit, but some of it worked so well that you start to wonder, well, gee, how can I do this for purely a social mission to provide some meaningful difference in the world? So talking to Kevin got me fascinated. And then seeing about what was happening in health care, [in terms of] moving toward value-based plans and into value-based care, all of a sudden I realized this was a fascinating time to be going after social missions that I could be part of as a nonclinical person. That’s what led to my leaning into it and coming over and starting to work with Penn.

Lee: I’ve been following along and in just a few years, if memory serves me, you guys have launched like 90 or so projects. That’s a lot. It’s an overwhelming number. How is it going? Is 90 too many? Is 90 not enough? How are you thinking about the overall scale of what you’re doing?

Rosin: Yeah. It is a lot of projects. Now, to be fair, some of them are very light-touch. Sometimes we’re just advising or just consulting on a project and we meet with somebody a couple of times a month and it doesn’t take up a tremendous amount of time. [But] some of the projects we’re leading in a much deeper dive, so it’s a little bit hard to get a picture. But we’ve done 90 over about 5 years. And it’s going really well.

One of the things that I absolutely love to see are outcomes, measurable outcomes, where we’re defining, what is the needle we want to move. We want to move 30-day readmissions or an infection rate or something that is important and that we’re able to do so. And we find that we can. Those projects were across a lot of different areas. They cross new care models, models about how do you get people with uncontrolled hypertension to be normotensive, new models around how do you treat women who have had a miscarriage so they don’t end up in the ER or the OR, even models like IMPaCT, just a wonderful program that has to do with how do you treat vulnerable populations where the normal care design isn’t working well and they end up being what’s often called superutilizers in the wrong setting of care and the wrong cost and not being treated well. And from those new models to technology interventions to — Kevin and David [Asch] spent a lot of time developing connected health interventions, so seeing and knowing things we never saw or knew before, things that are going on in the home or in different settings that could determine the health outcomes, and as we start see those, we can change the outcome — to all kinds of technology interventions. It’s a broad, broad range of work that we’ve been able to do, and overall I’m happy with the way it’s been going.

Lee: When I’ve spoken with you, you told me that everywhere you look you see low-hanging fruit and I’m sure it’s true, but with so much opportunity to improve, how do you prioritize, how do you choose what to do and what not to do?

Rosin: It’s a blend. We try to stay aware of what the system’s priorities are. David Asch — he’s my co-conspirator — and I, we’ll often go on listening tours and spend time with the CEOs of the entities and the chief medical officers and chief nursing officers. We will try to plug into some of the operating mechanisms where the senior leadership is talking about system priorities. Of course, we’re aware of big changes in our environment like when an area becomes bundles and all of a sudden you’re responsible in a different way than you have been before. [For example,] we just signed a fairly public big deal with Independence Blue Cross where we’re now responsible for all 30-day readmissions and not being paid for 30-day readmissions, so those certainly set some of our priorities, but I think what’s an important insight is that the way innovation works is that you have to find passion. You have to find people who really want to make a change. Innovation doesn’t work well as an assignment where you go and say hey, I want you to work on this and please go do it.

What you’re looking for are clinical champions and care teams who are engaged, who want to work on the problem, and I always say they’re pulling instead of us pushing, so we are a blended tops-down and bottoms-up model. We also will do bottoms-up work that may involve a fascinating idea, or a new idea from a clinical or administrative leader or somebody on the front lines, that doesn’t necessarily seem fully aligned with some of the system priorities just because there’s a lot of energy and passion, and it might be off our radar, and those are exciting, too. We do have a blend, and it’s a portfolio of projects that we pay attention to. We stay mostly aligned with the top priorities in the health system.

Lee: Is the goal making money for Penn, or making money for innovators, or is the top priority changing Penn’s health care?

Rosin: We have a fairly lucky position, I’d say, in that we do get to spend time [doing] what I call “de-risking” more future models. We see the world moving toward more risk-bearing contracts. We see an increasing focus on value-based care. And we have a tremendous number of colleagues across Penn who are innovating, frankly, who are changing the way we work and doing good work. We’re certainly not the only people who are innovating care, and in many cases what we try to do is enable and create infrastructure where every team can go faster and do better work.

But our work has often stayed focused on where things become a little bit more risk-bearing and the future where we expect to be pretty soon. Now, we will certainly do operations projects so we’re looking for economic wins, we’re looking for places that our work can have a measurable economic impact on what Penn is doing, but we’re also in some areas that don’t.

A good example might be [that] when we started off we did work on some benefit redesign. We have 30,000 employees and they’re self-insured, so the cost of health care just makes bottom line. Doing work there that made our own employees better off and healthier saved a tremendous amount of money and it bought us the right to work on things like hypertension, where David had a strong desire to look at our folks who had uncontrolled hypertension to try to get it normal blood pressure.

If you’re perfect there, you don’t save or make any money in the near term, but it’s, as you know, a critically important area of health. We try to keep our eye out to a balance of both long and short term as well as things that are system priorities, tops-down and bottoms-up.

Lee: It sounds like you’re amassing political capital and using it as well as financial capital. But now, have you had disappointments that bug you? Things that you think should’ve worked and they fell short, they couldn’t move any needle, at least so far for reasons that you hadn’t anticipated or you haven’t figured out how to surmount yet?

Rosin: The ones I put in that bucket haven’t not worked, they’re maybe what I call stalled. When we do our work, we often will do small pilots with a small sample size because we are trying to get things ready before we scale them. That’s one of the big changes in an innovation approach — that you don’t scale until you figure out what works and you can validate a lot of the hypotheses that you may have about a new intervention or a new care model. We had a long list of successes at the pilot stage, but to the extent that I feel frustrated is how quickly some of those moved into a scaled model. Real wins and real success for us are scale of impact, things that help lots and lots of people, millions or an entire population.

And what we love is when we do work that gets taken even beyond Penn’s walls and applied in other locations. So the pace of getting from a successful pilot to a scaled win is probably the thing that’s been frustrating. It’s a solvable problem.

We have a new CEO at the Hospital of the University of Pennsylvania, a woman named Regina Cunningham who came up as a nurse and a chief nursing officer, and we had a great meeting with Regina the other day where we had a couple of important successful pilots. One was around people who are discharged on IV antibiotics — a  high-risk, high–readmission rate population — and another was the liver population, cirrhosis and liver transplant.

In both cases the teams had done extraordinarily good work cutting that readmission rate, and in the case of liver, dramatically reducing the cost of the intervention from $1,000 a person down to $50 a person, so cutting 95% of the cost out. And even with those kind of results sometimes the pilot would stay sort of in this middle ground of no man’s land.

We were always smart enough not to throw it over the wall. We know that us doing pilots and then going to find a champion doesn’t work. We have certainly done a pretty good job of engaging operations and moving them upstream and trying to stay in tight contact with the operational leaders of the system and have good partnerships, but I love what Regina did. In this meeting she said, “Look, here’s what we have to do. You guys have to do a better job of thinking of the budget cycles and getting in front of my leadership team. Here’s the setting I’m providing to you, here is the timing [for how] we’re going to do it. Here’s the story that you need to sell and the analysis that we need to have.”

And so, making sure we’re absolutely clear on who will operationalize and how good is good enough, what is that economic argument that we need, and making sure we have the audience set up early before it’s time to do a handoff. We’re getting better at that, and that’s what is getting me around some of the things that I might otherwise call disappointments. With hindsight, I think about an intervention very early [on] that turned into a success but wasn’t for a long time. It was the early days of connected health, and you already saw this at Partners with Joe Kvedar, and Kevin and David were already doing a wonderful job talking about automated hovering and talking about we need to stay connected once people leave the hospital. We have done a version of that in the CHF population, and working with one of our physicians we ended up with zero preventable readmissions, which was probably better than anyone expected. Again, a fairly small sample size.

Everyone saw this, and the analysis was done that it was successful and financially important. We decided to scale it. And a whole year went by, I mean a full year passed without forward motion, and what we realized is that organizationally, there wasn’t anybody who owned at that time — this was many years ago now — who owned the job of preventing readmissions, of keeping someone healthy and out of the hospital. The executive team created a structure called, basically our service line, so now you were not just focused on inpatient and separately on outpatient, but more focused on patient populations, and it was remarkable what happened after the organizational change.

All of a sudden, now somebody had this job and was accountable for keeping people healthy and out of the hospital, and then they were looking for a tool that essentially did what we had figured out how to do — all of a sudden it was adopted. The problem wasn’t a technology problem or a, say, can you come up with some kind of service model that works — it was actually, gosh, I need an organizational approach that embraces and wants it. That was interesting to see that when the org[anization] changed the innovation became successful, became adopted, and became scaled.

Lee: Let me close by asking a question that may be impossible because we can’t ask someone which child you love the most, but is there any particular innovation that you bring up as one that as among those that you love the most?

Rosin: It is hard to say your favorite child. I certainly love Shreya Kangovi’s IMPaCT program because of how completely she rethought the use of community health workers and how they’re hired and identified, trained, deployed, and get out the extraordinarily difficult problems of social determinants. [That] would be one. And she’s seeing a few dollar return for every dollar invested, which I think is phenomenal.

If I could tell a single story right now, it might be a program we call Heart Safe Motherhood. Heart Safe Motherhood is a neat program. It grows out of that same connected health approach of seeing and knowing about things we never used to see and know about.

In this case it was postpartum preeclampsia and that was the number one driver of both 7-day readmissions and morbidity in the maternal population. And the team had done a whole bunch of work, good work, and yet it wasn’t moving the needle. There were free walk-in clinics. We called people and tried to follow up. They weren’t answering the phone or returning our calls and [were] not showing up to the free walk-in clinic.

And what the team did was led by two doctors . . . and at first they realized that the preferred modality was texting, because in many cases this population . . . they didn’t want to talk to us maybe ever, certainly not at any particular point in time, and we would send the women home with a blood pressure cuff. One of the interesting insights early on was that it wasn’t high-tech. It wasn’t one of these wireless cuffs that would automatically broadcast. It was actually a low-tech off-the-shelf at a Walmart or CVS because they could just text us the number and that addressed connectivity and wireless issues. They started to iterate and play with the texting, can I get these blood pressure values.

Around the same time, ACOG, the American College of OB-GYN, created a standard that said, look, to keep this population safe you need two blood pressure values, that first week after discharge, one around 3 days, one around 7 days. And in all of the top systems, including Penn, we had that for nobody. We were at 0%, and by sending women home with these blood pressure cuffs and beginning the texting protocol, that team ended up going from 0% to 82% of coverage, where we have the information, the blood pressure information we needed to keep the women safe.

But why I like the program so much is [that] it wasn’t just about this automated hovering, it wasn’t just about having that information. The real outcome you’re trying to change is could you avoid the morbidity and the readmissions and the bad outcomes, bad outcomes both for the patient and for the health system. And they were able to do that. The numbers are growing, and they moved a couple hundred patients through the system now and it has zero readmissions.

It went from the highest, 7 day readmissions, to so far no readmissions, which [is] the real impact that we’re looking for, and then you get scale, because this program is now being adopted not only in other settings across Penn, but even in other cities and in other places. When we can get that kind of endorsement and support from, for example, the National Preeclampsia Foundation and others, and see the stuff start to scale and go to other places to have a population effect, I get really happy. That’s probably it.

Lee: That is a great story, Roy. It’s a lovely one and it also shows that innovation really has to occur at that disease level. It can’t happen across the board for all readmissions. But you have a lot to be proud of and I know a lot more great work’s going to come out. The approaches you’re using I think will be instructive for all the other folks out there listening. I want to thank you for taking the time to share your insights with the NEJM Catalyst audience today.

Shared Decision-Making for Good Clinical Care: Better, but Not Easier

The practice of medicine is changing. An expanding array of approaches is available to address patients’ health situations, and patients are increasingly encouraged to collaborate with their clinicians to figure out which is best for them. Patients are considered autonomous, and, in their work of being a patient, they are expected to take responsibility over their health, to be informed about their care, and to be actively involved in managing their care.

Particularly, they are expected to actively take part in the medical decision-making by preparing for clinical encounters: by reviewing booklets, videos, or decision tools, and then using this information to develop preferences to discuss with their clinicians. Clinicians, in turn, are expected to provide patients with the required information about their health and (possible) care, to apply (inter-)national and regional guidelines, and at the same time, to provide patient-centered care that fits the wishes and needs of their “client”: the patient. In this way, shared decision-making — patients and clinicians working together to figure out what is best — is like a business transaction.

It is questionable, however, whether all patients can, should, and want to be actively involved in making decisions about their care. Assuming — or imposing — patient autonomy could lead to “an underestimation of patients’ vulnerability and an overestimation of patients’ abilities to make such decisions.” Realizing that there are options, and that the outcomes of care are uncertain, can feed the fear of making the wrong decision and be enormously burdensome to patients. However, we must also stay alert for the opposite: when patients are considered vulnerable and helpless, clinicians may engage in paternalism, underestimating patients’ ability and wish to be involved in deciding what is best. Ultimately, this could lead to patients receiving care that is unnecessary, unwanted, unreasonable, or harmful.

Shared decision-making refers to more than just making decisions about care. It is a process, a conversation between the clinician and the patient, a way to craft care. The shared decision-making process can be broken down into different elements, including creating choice awareness, discussing reasonable approaches and their respective desirable and undesirable characteristics, discussing patients’ values and deliberating to form preferences about the options, and making a final decision. Shared decision-making is thus more than just offering patients information or choice and asking them to be autonomous in making decisions about their care.

Shared decision-making is not a transaction in which clinicians claim to be “patient centered” but in fact abandon our patients to uncertainty and fear. It is irrelevant who makes the final medical decision, as long as the chosen approach makes the most sense to each patient and his or her life. If patients are not able or willing to be autonomous, clinicians could make decisions about care based on whatever imperfect information they may have about each patient’s informed preferences, with the utmost respect for what the patient values in life and health.

Although there is some evidence — unfortunately much weaker than usually acknowledged — that shared decision-making can lead to improved patient outcomes, the primary goal of shared decision-making is simply to ensure that patients receive good care. It is a way to fundamentally care for this patient, not just for people like this patient. This approach to care can be difficult, both for patients and clinicians. Clinicians must be up to date on the available approaches (treatment strategies, for example) and be able to conduct clear, unhurried conversations with each patient about these approaches and what each one would mean for them in their situation.

This is not a sinecure. But who has ever claimed that clinical care should be easy? Indeed, in this way, shared decision-making is a challenging practice, one that clinicians and the systems that support their work must master on behalf of patients. Done well, it draws a stronger connection between clinicians and patients, and rewards clinicians with meaning within care routines. While not easier, shared decision-making can make care better.

Time to Start Using Evidence-Based Approaches to Patient Engagement

Seasoned clinicians have vast experience in patient interactions, through which they have learned many helpful techniques. But in this era of evidence-based medicine, we should be more discerning. Would you trust a surgeon who told you, “I haven’t had any formal training for this procedure, observed any experts, nor received feedback on my skills, BUT over the course of time, through trial and error, I think I’ve found what works for me”? That is essentially how physicians were “trained” in communication skills for decades. Even though most of us know that it is the right thing to communicate effectively, humanistically, and compassionately, fewer of us know that over the past quarter-century or so, patient-clinician communication has become a prominent field of scientific research. Important findings from these data affect almost every patient interaction we have.

Overall, effective communication leads to increased patient and clinician satisfaction, increased trust with the clinician, and functional and psychological well-being. Effective communication also leads to improved outcomes in specific diseases, including a small but significant absolute risk reduction of mortality from coronary artery disease, improved control of diabetes and hyperlipidemia, better adherence to antihypertensives, bereavement adjustment in caregivers of cancer patients, and higher self-efficacy of adherence to HIV medications. Patients with medically unexplained physical symptoms (the kind that lack easily identified biomedical diagnoses) report significantly higher levels of satisfaction when their clinicians use effective communication skills. A recent review found that a strong patient-clinician relationship has a beneficial effect on overall health care outcomes with an effect size approximately equal to taking a daily aspirin for 5 years to prevent myocardial infarction. What’s more, unlike aspirin, good patient-provider relationships do not cause GI bleeding.

Data also show that clinicians do not communicate as effectively as they think. There are certainly systemic factors that interfere with the way that most clinicians would like to practice optimally. Even so, there is still a gap between what we think we’re doing and what we’re actually doing. We do not elicit the full spectrum of patient concerns so as we prepare to leave, we need to wrestle with “doorknob” questions that make us less efficient. We redirect patients after 18–23 seconds and rarely allow them to return to their thoughts. We unreliably seek patients’ perspectives of their illnesses and inadequately address their emotions, which further wastes time in medical encounters. We incompletely attend to cultural differences. We use incomprehensible jargon and don’t confirm that our patients understand their diagnosis and treatment plans.

The negative outcomes of our ineffective communication are measurable: Outpatients do not return to clinicians with poor communication skills, and readmission rates for inpatients are higher. What’s more, perceived failures in communication, or patient experiences of humiliation by poor communication from clinicians, are associated with more malpractice claims.

There is good news. Clinicians who elicited the patient’s full list of concerns and prioritized the agenda for the encounter reported an increased sense of control and enjoyment. Explicitly addressing patients’ emotional cues appears to save time. Participants completing a mindful communication program had higher well-being and attitudes toward patient care. Clinicians who underwent a daylong communication skills course showed higher patient experience scores, increased empathy scores, and lower burnout scores when compared with those who did not.

It’s tempting to search for a “quick fix” to help clinicians with low patient experience scores. But as chief medical officers and patient experience staff have begun to discover, one can’t acquire proficiency by attending a 30- or 60-minute lecture. There is a dramatic difference between learning a concept and learning skills. Whether you were on a soccer team or in an orchestra, you know that skill improvement and achieving mastery requires deliberate practice and feedback. No one would ever expect a proceduralist to attend an hour-long didactic and then immediately perform a new procedure with complete proficiency. For communication skills expertise, we must note the complex needs, desires, histories, approaches, stories, assumptions, and psychology that every individual patient brings to a relationship. Data on effective communication skills programs show that they are typically full-day trainings, start with learners’ goals and needs, and focus on application of learnings to clinical practice.

Skills-based exercises, including role-play, in small groups or through individualized coaching, are more effective than isolated didactic presentations; specific feedback on communication skills is the most important element that contributes to heightened patient experiences of care. Specifically, at the Academy of Communication in Healthcare, we teach an educational framework and rationale for communication skills, followed by a demonstration of how the skills apply to a typical clinical case. Then, in small group skills sessions, rather than using canned patient scenarios, we invite participants to volunteer their own clinical cases to adapt these skills to their particular practices.

For example, Dr. Hospitalist might invoke a case of an inpatient admitted for pneumonia, whom another group member will portray. In a skills session using the framework of agenda-setting, we will carefully set up the scenario so that Dr. Hospitalist will succeed in eliciting the patient’s full list of topics to discuss. Once the short scenario is completed (typically in less than 5 minutes), we will ask Dr. Hospitalist to reflect on how effectively she used the skills, and then we will ask other group members for feedback. In a diverse group of providers, cases can range broadly, including those that involve inpatient and outpatient circumstances, medical and surgical procedures, and general, specialty, and subspecialty-based professionals. Our experience in using this learner-centered method is that the vast majority of clinicians find the skills helpful in their everyday practices and feel renewed dedication and energy in their careers.

While communication skills training is not a health care panacea, it can reliably improve quality of care, patient outcomes, and patient and provider experience. In some instances, the data have existed for well more than a decade, yet only recently have market forces, such as value-based purchasing and emphasis on patient experience, started to exert influence on these most interactive — and human — of provider behaviors. Though there are some glimmers of hope at places that have adopted provider communication training — such as Mayo, the Cleveland Clinic, and several other health systems across the country — we still have a long way to go. As recent technological advances drive people toward interacting with devices rather than directly with others, in the health care setting, interpersonal communication skills have never been more important. In the high-stakes setting of health, well-being, and wellness, a trustful, caring relationship between patient and clinician leads to better outcomes for both.

The Top Cause of Disability Is Usually Mistreated

Story at-a-glance

  • Up to 80 percent of Americans experience low back pain at some time in their life, many of whom are prescribed opioid painkillers and given instruction to rest
  • A global study demonstrates this treatment often extends your disability and increases your risk of addiction to opioids and heroin, while remaining active and off painkillers or over-the-counter drugs shortens your rehabilitation
  • Mistreating lower back pain contributes to rising opioid addiction, now claiming top spot as the leading cause of death in people under 50 in the U.S.
  • Remaining active as able, correcting posture problems and walking mechanics, developing a strong core, increasing flexibility and treating pain without drugs help to improve your symptoms and reduce your chances of experiencing low back pain again

By Dr. Mercola

Up to 80 percent of adults will experience low back pain at some time in their life.1 Multiple studies have demonstrated complaints of lower back pain have risen dramatically over the past decades. Ranking 12th as a cause of disability in 1990,2 it has risen to the leading cause of disability in nearly all high income countries in the Global Burden of Disease study from 2017.3,4

Central Europe, Eastern Europe, North Africa and the Middle East experience the same level of back pain disability. Estimates suggest 1 million years of productive life are lost each year in the U.K. due to low back pain, 3 million years are lost every year in the U.S. and 300,000 productive years are lost every year in Australia.5

Unfortunately, while the problem is fairly common worldwide, so is the mistreatment of the condition.6 A series of papers published in The Lancet7 has highlighted the extent to which this treatment is contributing to further pain and, potentially, to the rising opioid epidemic.

Commenting on findings that nearly 37 percent of Americans struggling with back pain avoid seeking professional help for pain relief, Mary Ann Wilmarth, spokesperson for the American Physical Therapy Association (APTA) and chief of physical therapy at Harvard University, said,8 “Most people experience low back pain at some point in their lives, but many people don’t realize they can prevent or treat the condition with the help of a physical therapist.” Indeed, there are many ways to address back pain beside taking dangerous narcotics.

Why Might You Suffer Low Back Pain?

As with all illnesses and injuries, it’s important to understand the trigger before diving into treatment. Otherwise, you may be treating the symptom and not the condition, opening yourself up to further injury or illness down the road. There are a number of bones and discs in your back whose abnormality may trigger lower back pain.

However, a majority who experience lower back pain do not suffer from these conditions: Back pain is more commonly triggered by a mechanical issue unrelated to structural change. In other words, you’re more likely to have a muscle problem than a bone problem. According to the National Institute of Neurological Disorders and Stroke,9 sprains and strains account for the majority of acute back pain, triggering painful back spasms.

Overuse and misuse of the muscles supporting your spine, poor muscle strength and inappropriate posture while sitting, standing and walking are also reasons why you may suffer from lower back pain. These also indicate changes you might need to make to reduce your risk of debilitating back spasms.

Unfortunately, suffering from lower back pain may make it difficult to perform everyday activities. Your lower back, also called the lumbar region, is a complex structure consisting of vertebra, spinal cord, discs, nerves, ligaments and muscles. Each of these work in concert to achieve pain-free mobility. When there is an imbalance in any of the musculature supporting your lower back, hips, legs or upper back, it may cause an imbalance in the remainder of the interacting muscles.

For instance, when walking with your toes pointed outward, the muscles in your hips and lower back tighten, increasing your risk for lower back pain. Sitting with your shoulders hunched over a computer screen, stretches muscles in your upper back and places added stress on your lower back, increasing your risk for lower back pain.

It also increases your risk for upper back pain. As your head is the single heaviest part of your body impacting your posture, when you walk with your head down, it has repercussions on the rest of your back and hips.10

The structures of your core, from your abdominal muscles to your back muscles, are all related and helped to support your spine. Therefore, an imbalance in these interactions, which may be triggered by poor posture while sitting or walking, may cause tension or tight muscles in other areas. This can lead to spasms in muscles not designed to carry the weight of supporting your spinal column.

Mistreatment Fuels an Epidemic and Fails to Address the Core Challenge

According to the recent international study published in The Lancet, people in the U.S. experience more of the wrong treatment for lower back pain than any of the other countries studied.11 Despite guidelines, recommendations and studies, physicians still tend to prescribe pain pills instead of movement, physical therapy and exercise, all of which work better.

In the U.S., more than 60 percent of people who see their physician for lower back pain are prescribed opioid painkillers. Guidelines from the American College of Physicians state individuals with lower back pain should first try heat wraps and exercise, and prescription drugs should only be used as a last resort.12

Rachelle Buchbinder, Ph.D., director of the Monash department of clinical epidemiology and professor in the Monash University department of epidemiology and preventive medicine, has spent decades working to educate physicians to stop making back pain worse. Author of the call to action in the low back pain series,13 Buchbinder commented on the current treatment of back pain:14

“One of the big problems is that patients aren’t always being given the right advice. Rather than evidence-based advice to stay active and exercise, much care for low back pain is of low value and is making the problem worse. There are a lot of misconceptions about back pain. Many people, including clinicians, think that people with back pain should rest in bed, yet we know that resting in bed and not remaining active delays recovery.

The best advice is therefore to keep trying to move normally, remain active and at work. Another misconception is that imaging is needed to identify the cause of back pain and to guide treatment. But even with the most sensitive scans that are available today, we still can’t usually identify a specific cause in most people.”

Many go to their doctor asking for pain medication after being taught by pharmaceutical advertising campaigns to ask for the latest pill to reduce symptoms. Physicians, often pressured to see as many patients as possible,15 may find it easier to prescribe a painkiller and an imaging scan, and send you to a specialist, than to educate your lower back pain and how to get relief.

Results from the papers in the Lancet support the assertion that strong drugs, injections and surgery are generally overkill and there’s limited evidence that they help patients.16

One of the authors of the The Lancet papers, Dr. Martin Underwood from Warwick University, commented on the results,17 “Our current treatment approaches are failing to reduce the burden of back pain disability.” Instead, with the addition of opioid painkillers to treatment, many are becoming addicted and fueling the opioid and heroin epidemic.

Activity Is the Treatment of Choice

Doug Gross, Ph.D, professor in the faculty of rehabilitation medicine at the New University of Alberta and coauthor of the global study on lower back pain, believes the spine needs movement. “Historically, we tended to medicalize back pain,” he says.18 Patients and physicians have been conditioned to believe pain is serious, needing rest, immobilization, surgery or opioid painkillers. However, each of these have significant adverse effects. Gross adds:19

“There is no evidence that routine back imaging improves outcomes. It could actually provide misleading information from age-related changes that are common even in people without pain. X-rays or MRI may be required in cases of trauma or accident, or when back pain comes with other symptoms like radiating pain. Otherwise they should be avoided.”

The study supports past evidence the treatment of choice for lower back pain is maintaining activity.20 The study also showed over-the-counter pain medication has limited value and is not the first line of treatment. Although the capacity for exercise is different for everyone, it is important to stay as active as possible in your recovery.

If the pain is severe, you may have to ease up on your usual activities, but continuing some activity is necessary. Studies have demonstrated bed rest may actually extend your disability by promoting muscle stiffness and spasms.21 In reality, many are treated in emergency rooms and encouraged to rest and stop work,22 when the more successful treatment modalities include light exercise, better posture, core strengthening and improved flexibility.

Opioid Overdoses Leading Cause of Death in People Under 50

Despite the high risk of addiction, opioids and other potentially hazardous drugs are prescribed to many who present with low back pain. In 1960, 80 percent who entered treatment for opioid addiction had started with heroin. In 2000, 75 percent report their addiction began with a prescription drug.23 Unneeded and excessive prescriptions of opioid painkillers has contributed greatly to the crisis of addiction and overdose deaths affecting America.24

Unfortunately, less than one-third of people in an NPR health poll25 questioned or refused their doctor’s prescription for opioids. According to the U.S. Centers for Disease Control and Prevention (CDC), nearly 2 million Americans abused or were dependent on opioids in 2014, and more than 1,000 land in emergency rooms every day as the result of abusing or misusing prescription painkillers.26 The CDC also reports deaths involving prescription opioids were five times higher in 2016 than in 1999.

In keeping with the higher rate of abuse and misuse, sales of these prescription drugs have also quadrupled between 1999 and 2016. The drugs most commonly involved in opioid overdose deaths include oxycodone and hydrocodone, both prescribed for muscle and back pain.27 Deborah Taylor, senior vice president and executive director of Phoenix House Mid-Atlantic, a nonprofit drug and alcohol rehabilitation organization operating in 10 U.S. states, notes:28

“The progression of addiction and the behavior that comes with it is pretty standard regardless of where you’re born, how much money you have, how old you are and your race or nationality. You can be the smartest person in the world — and the minute that chemical hits your bloodstream, you lose control of what it does in your body. You can’t control it. Nobody can control it. I don’t care who you are. It’s not controllable.”

According to data compiled by The New York Times,29 deaths attributed to opioid overdoses top 59,000, 19 percent more than the year before. The medical examiner for Cuyahoga County, Ohio, commented the number of young people dying in the U.S. from opioid overdose is the same as the number of casualties in the entire Vietnam conflict,30 raising opioid overdoses to the leading cause of death in Americans under age 50.

Signs You May Have More Than Muscle Tenderness or Spasms

Although back pain is definitely serious, as it affects your everyday life and can suck the joy out of your days for a week or more, it is often not dangerous. In other words, the severity of your pain does not indicate your condition is medically dangerous.

However, there are some signs and symptoms that might suggest the pain you’re experiencing is not common low back pain from a muscle strain or sprain, but might be something more serious requiring physical assessment and treatment. These signs include:31,32,33,34

Fever Difficulty passing urine Previous high risk of fracture
Loss of bladder or bowel control Feeling like you need to pass urine but there is none Loss of muscle strength or sensation in the legs
Night back pain not relieved by adjusting in bed or starting only at night Impaired sexual function, such as loss of sensation, numbness or tingling in the genitals or buttocks Pain in your upper or lower back not tied to a specific joint or muscle may signal a heart attack

At Home Back Pain Relief

You may be able to prevent and treat lower back pain using drug-free strategies to remain active, improve core strength, use correct posture and reduce inflammation. For example, consider addressing your:

Strength and flexibility

Preventing or treating lower back pain does not require hours of work in the gym. Discover how a strong and flexible core allows your muscles to work together to support your spine and provide you with a full range of motion without pain or discomfort by incorporating techniques from my previous articles, “A Review of Four Core Routines and Their Effectiveness for Preventing or Treating Back Pain” and “Yoga: A Secret Weapon Against Back Pain.”


Using correct posture will prevent further damage to your lower back and help to relieve the symptoms of muscle pain and spasms triggered by an imbalance in the use of your upper, middle and lower back muscles. Follow these 3 simple steps to perk up your posture.

Walking mechanics

Much of the damage to your back may be avoided by using good body mechanics while walking. In this short video, Dr. Brian McMaster demonstrates backward walking that may bring you relief throughout the day while helping retrain your posture for long-term relief.

Researchers have found walking backward reduces stress on your hamstrings, and thus your lower back, and strengthens your core. Steer clear of walking backward on a treadmill to reduce your risk of further injury. Instead, find a long hall or clear sidewalk to walk five to 10 steps each hour.

Drug-free pain reduction

While waiting for your back to heal you may get pain relief using several different drug-free strategies outlined in my previous article, “Treating Pain Without Drugs.”

Why Do 90 Percent of People Eat Garbage?

Story at-a-glance

  • A recent report from the CDC reveals nearly 90 percent of people surveyed did not eat adequate amounts of fruits and vegetables to support optimal health
  • The food industry has used research and advertising to build an extensive consumer base; the Partnership for Healthier America is fighting back with a fruit and vegetable campaign designed to tempt more people to eat healthy foods
  • To improve your eating habits, consider shopping along the perimeter of the store; choose a variety of foods and learn techniques to deal with stress that may drive some of your cravings for sugar and unhealthy fats

By Dr. Mercola

Junk food is a multibillion-dollar industry. In his book, “Fast Food Nation,” Eric Schlosser, investigative journalist and best-selling author, describes how nearly 90 percent of America’s budget is spent on junk food.1 What is more appalling is that nearly 60 percent of food eaten in America are ultra-processed,2 convenience foods that can be purchased at your local gas station. These processed foods also account for nearly 90 percent of the consumption of added sugar in the U.S.

The industry doesn’t depend upon fate to drive sales. They use several tricks to paint their products in a better light. Since people eventually start questioning the decision to eat foods based solely on taste, especially with the increasing attention on healthy eating, the industry funds research to justify your cravings for their products.

Thus, when a study revealed that children who ate candy bars were 22 percent less likely to be overweight,3 it came as no surprise the research was funded by a trade association representing some of the country’s top candy makers. Marion Nestle, Ph.D., professor of nutrition at New York University, acknowledges that “The only thing that moves sales is health claims.”4

Nestle formerly served as nutrition policy adviser in the U.S. Department of Health and Human Services and editor of the Surgeon General’s Report on Nutrition and Health.5

Reliance on these ultra-processed foods is undoubtedly one of the primary factors driving skyrocketing rates of obesity and disease. Consumers may “know better,” but it is difficult to steer clear of foods that may be more addictive than cocaine for some.6 A recent report from the U.S. Centers for Disease Control and Prevention (CDC) reveals only 10 percent of Americans are getting enough fruit and vegetables in their daily diet.7

CDC Finds 90 Percent of Americans Don’t Eat Enough Real Food

Researchers used data from a 2015 government survey of a nationally representative sample of over 319,000 Americans. The survey asked the participants how many times in the past 30 days they had consumed 100 percent fruit juice, dried beans, whole fruit or green, orange or other vegetables.8 The researchers found those who consumed five each day lowered their risk of developing cancer, cardiovascular disease, Type 2 diabetes and obesity.

Researchers also found that consumption was even lower among adults and young adults living below the poverty line.9 The report from the CDC attributed the reduced intake to lack of access, cost and the perceived need for cooking and preparation that may get in the way of people consuming enough fruit and vegetables each day.

Depending upon the individual’s age and gender, federal guidelines recommend eating between 1.5 and two servings of fruit and two to three servings of vegetables a day.10 Seven of the top 10 leading causes of death are the result of chronic disease that researchers believe could be avoided with better nutrition. Seung Hee Lee-Kwan, Ph.D., of the CDC’s division of nutrition, physical activity and obesity, commented on the results of the report, saying:

“This report highlights that very few Americans eat the recommended amount of fruits and vegetables every day, putting them at risk for chronic diseases like diabetes and heart disease. As a result, we’re missing out on the essential vitamins, minerals, and fiber that fruits and vegetables provide.”

Ultra-Processed Is Ultra-Garbage

Any foods that aren’t whole foods, directly from the vine, ground, bush or tree, is considered processed. If it’s been altered in any way, it is processed, such as bread, pasta, canned or frozen foods. Depending on the amount of change the food undergoes, processing may be minimal or significant. For instance, frozen fruit is usually minimally processed, while pizza, soda, chips and microwave meals are ultra-processed foods.

The difference in the amount of sugar between foods that are ultra-processed and minimally processed is dramatic. Research has demonstrated that nearly 2 percent of calories in processed foods comes from sugar, while unprocessed foods contains no refined or added sugar.

In a cross-sectional study using data from the National Health and Nutrition Examination Survey of over 9,000 participants, researchers concluded,11 “Decreasing the consumption of ultra-processed foods could be an effective way of reducing the excessive intake of added sugars in the USA.”

Despite what industry-funded studies, industry expert advice and advertising campaigns would like you to believe, junk food is still bad for you. In a short five-day-long study using 12 college age nonobese men, researchers discovered eating a junk food diet of macaroni and cheese, lunchmeat, sausage biscuits and microwavable meals, participants’ muscles lost the ability to oxidize glucose after a meal, which can lead to insulin resistance.12

Eating junk food is also associated with depression,13 low academic performance14 and behavioral problems by age 7.15 In my view, eating a diet consisting of 90 percent real food and only 10 percent or less processed foods is a doable goal for most and could make a significant difference in your weight and overall health.

I realize for many this is a challenge, but I know it can be done. Unless I’m traveling, my diet is very close to 100 percent real food, much of it grown on my property. You just need to make the commitment and place a high priority on it.

Garbage In — Garbage Out

The dangers of eating a diet high in sugar are well-documented and are even officially recognized by the government, as the 2015-2020 U.S. Dietary Guidelines16 recommend you limit sugar intake to no more than 10 percent of your total daily calories.17 Increased consumption of sugar is linked to obesity, Type 2 diabetes, insulin resistance and poor outcomes with other chronic diseases.

Research has demonstrated that as much as 40 percent of the health care budget in the U.S. is spent on chronic diseases directly related to the overconsumption of sugar.18 According to a report on global cancer, obesity is responsible for 500,000 cancer cases worldwide every year.19 Different mechanisms have been proposed for the development of disease associated with obesity, including oxidative stress, inflammation, obesity-induced hypoxia and the functional impairment of the immune system.20

Eating junk food has even further effects on your body, cognitive performance and your health. Many junk foods contain trans fat, associated with chronic inflammation, oxidative stress and a rising risk of cardiovascular disease.21 Trans fat also damages the inner lining, endothelium, of your blood vessels, increasing dysfunction and contributing to coronary artery disease.22 Results from the Nurses’ Health Study link trans fat to an increased risk of breast cancer after menopause.23

University of Wisconsin health system recommends their athletes steer clear of heavily processed foods to improve their sports performance.24 Instead, they recommend as much whole foods as possible, advising athletes to pack snacks when they participate in a full day of activities so they aren’t tempted to eat at the concession stands.

Harvard Business Review recommends you eat a well-balanced diet, full of whole foods, skimping on processed foods, to increase your productivity and creativity.25 They point out that poor lunch choices may derail your afternoon business decisions, stressing that fruits and vegetables aren’t just good for your body but they also help improve your cognitive performance. They cite a study from the University of Otago that found evidence eating fruits and vegetables is related to improved feelings of well-being and curiosity.26

Science Creates Cravings

Working with scientists, food manufacturers exert a lot of effort to create foods that have an addictive quality and make the experience of eating foods pleasurable.27 In his book, “Why Humans Like Junk Food,” scientist Steven Witherly, Ph.D., states there are two factors that make the experience of eating enjoyable.28 The first is sensation, which is composed of taste, aroma and the sensation you experience when food is in your mouth, known as orosensation.

The second factor is the caloric stimulation from macronutrients that make up the product: proteins, carbohydrates and fats. Food companies spend millions of dollars to achieve a level of satisfaction with their product that will drive the consumer to purchase their food over and over again.

The food industry looks for dynamic contrast within one product, such as a crunchy outer shell, followed by something soft or creamy. The more a food causes you to salivate, the greater coverage over your taste buds and the better taste response it receives. Witherly also lists “vanishing caloric density” as a means to an end of increasing your intake of a food product, leading to an increased risk of obesity. He explains:29

“Now, few foods qualify (meringues, diet soda, cotton candy and pretzels), but popcorn is perhaps the best example. Buttered, salted popcorn is very tasty, and you can eat a lot of it, repeat oral stimulation, since it isn’t that filling. In fact, I’ve seen some people actually accelerate their eating rate due to the absence of gastric satiety. Eating a whole bowl of popcorn for dinner is not a rare occurrence.

Foods that exhibit this rapid (oral) meltdown response may actually signal the brain that the food being ingested is lower in calories than it really is.

The reduced satiety response to high dynamic contrast foods (ice cream, chocolate and french fries) may partially explain Dr. Drewnowski’s observation that energy dense foods that melt down rapidly in the mouth, often lack satiety. Hence, foods that quickly “vanish” in the mouth are more rewarding, reduce gastric satiety and encourage over ingestion.”

Half of Cancer Deaths Related to Three Choices

A recently published study from the American Cancer Society used data gathered in 2014 and found that 45 percent of all deaths from cancer could be attributed to what the authors called “modifiable risk factors.”30 In other words, lifestyle choices that increase your risk of developing cancer. The risk behaviors researchers analyzed were:31

Cigarette smoking Secondhand smoke Excess body weight
Alcohol intake Consuming red and processed meat Low consumption of fruit, vegetables, dietary fiber and dietary calcium
Physical inactivity Ultraviolet light Six cancer-associated infections

However, the researchers also concluded:32

“These results, however, may underestimate the overall proportion of cancers attributable to modifiable factors, because the impact of all established risk factors could not be quantified, and many likely modifiable risk factors are not yet firmly established as causal.”

In other words, while the data indicated almost 50 percent of cancer could have been prevented from modifiable factors, not all factors have been identified and environmental risk factors, such as exposure to toxins, were not considered.

Give Your Vegetables a Makeover

You may find adding vegetables to your diet challenging if you aren’t sure how to integrate them into your everyday choices, and you wouldn’t be the only one. In an effort to increase consumption of vegetables and fruit, Partnership for a Healthier America (PHA) has started a fruits and vegetable (FNV) campaign33 to improve public perception. This short video is a preview of the advertisements that are as enticing as those junk food manufacturers produce, and they seem to be working.

Consumption of fruits and vegetables appear to have been trending downward, which is a significant cause for concern for the coming generation of children who are not eating these foundational foods rich in nutrients and antioxidants in their formative years. The ads are using adults whom children and young adults recognize, demonstrating how delicious and tempting fruits and vegetables can be. The campaign is supported by several food companies, universities and insurance companies.34

According to the PHA, the new campaign has already changed some behavior.  Materials provided to Forbes by Toni Carey, senior manager, communications and marketing for PHA, state: “Eighty percent of people bought or consumed more fruits and veggies after seeing FNV advertising” and “over 90 percent have a favorable impression of FNV and would engage with the brand in some way.”35 Here are several more suggestions that may make the process go smoothly at home:

Advertising works

As demonstrated by junk food manufacturers, advertising works to increase your interest in foods. Expose yourself and your family to the new ad campaign by PHA to help make eating fruits and vegetables more exciting and appetizing.

Give them the backstory

Talk with your family about how whole foods are grown, from seedlings to harvest to your table. When they know the process, the foods become more interesting. Talk about the benefits of the individual foods, such as tomatoes are high in lycopene that is a powerful antioxidant that protects your eyesight and fights aging.36

Shop along the perimeter

You can avoid eating processed foods if you don’t have them in the house. Shop around the perimeter of the grocery store where most of the whole foods reside, such as meat, fruits, vegetables, eggs and cheese. Not everything around the perimeter is healthy, but you’ll avoid many of the ultra-processed foods this way.

Include a variety of foods

Your brain enjoys a variety of textures and tastes. Vary the whole foods you purchase and the way you eat them. For instance, carrots and peppers are tasty dipped in hummus. You get the crunch of the vegetable and smooth texture of the hummus to satisfy your taste, your brain and your physical health.

Recognize and address with stress

Stress creates a physical craving for fats and sugar that may drive your addictive, stress-eating behavior. If you can recognize when you’re getting stressed and find another means of relieving the emotion, your eating habits will likely improve.

Preventing stress-related illnesses, including those created by poor eating habits, is easier to prevent than it is to recover from it. To read more about managing stress, see my previous article, “Documentary Investigates the Cause and Ramifications of Stress-Related Burnout.”

Start with fruits and vegetables that taste better than junk foods

There are fruits and vegetables that do taste better and help you feel better than junk foods. Starting with these may give you an advantage as you continue your journey to increasing your daily intake. Discover “13 Health Foods That Taste Better Than Junk Foods,” in this previous article.

Try the Emotional Freedom Techniques

Stress and anxiety have similar effects on your brain function and can lead to physical health problems. Anytime you change habits, or attempt to include something new in your daily routine, it may trigger a stress response.

The Emotional Freedom Techniques (EFT) can help reduce your perceived stress, change your eating habits around stress, and help you create new, healthier eating habits that support your long-term health. To discover more about EFT, how to do it and how it may help reduce your stress and develop new habits, see my previous article, “EFT is an Effective Tool for Anxiety.”

Vitamin D Can Significantly Lower Your Risk of Metabolic Syndrome

The Role of Vitamin D in Disease Prevention

A growing body of evidence shows that vitamin D plays a crucial role in disease prevention and maintaining optimal health. There are about 30,000 genes in your body, and vitamin D affects nearly 3,000 of them, as well as vitamin D receptors located throughout your body.

According to one large-scale study, optimal Vitamin D levels can slash your risk of cancer by as much as 60 percent. Keeping your levels optimized can help prevent at least 16 different types of cancer, including pancreatic, lung, ovarian, prostate and skin cancers.

How Vitamin D Performance Testing Can Help Optimize Your Health

Is it any wonder then that no matter what disease or condition is investigated, vitamin D appears to play a crucial role? This is why I am so excited about the D*Action Project by GrassrootsHealth. Dr. Robert Heaney is the research director of GrassrootsHealth and is part of the design of the D*action Project as well as analysis of the research findings.

GrassrootsHealth shows how you can take action today on known science with a consensus of experts without waiting for institutional lethargy. It has shown how by combining the science of measurement (of vitamin D levels) with the personal choice of taking action and, the value of education about individual measures that one can truly be in charge of their own health.

In order to spread this health movement to more communities, the project needs your involvement. To participate, simply purchase the D*Action Measurement Kit and follow the registration instructions included. (Please note that 100 percent of the proceeds from the kits go to fund the research project. I do not charge a single dime as a distributor of the test kits.)

As a participant, you agree to test your vitamin D levels twice a year during a five-year study, and share your health status to demonstrate the public health impact of this nutrient. There is a $65 fee every six months for your sponsorship of this research project, which includes a test kit to be used at home, and electronic reports on your ongoing progress. You will get a follow up email every six months reminding you “it’s time for your next test and health survey.”

Fasting Reduces Your Cardiovascular Risk

Intermittent energy restriction diets such as the 5:2 diet clears fat from the blood quicker after eating meals compared with daily calorie restriction diets, reducing an important risk factor for cardiovascular disease, a new study in the British Journal of Nutrition reports.

Intermittent fasting allows the body to use fat as it’s primary source of energy instead of sugar and there are five huge benefits.

In the first study of its kind, researchers from the University of Surrey examined the impact of the 5:2 diet on the body’s ability to metabolise and clear fat and glucose after a meal and compared it to the effects of weight-loss achieved via a more conventional daily calorie restriction diet. Previous studies in this field have predominantly focused on blood risk markers taken in the fasted state, which only tend to be, in for the minority of the time, overnight.

The simplicity of the diet and the fact you can eat pretty much what you like five days a week, are key to its popularity. Dieters are recommended to consume a ‘normal’ number of calories five days a week and then, for two, non-consecutive days, eat just 25% of their usual calorie total – 500 calories for women and 600 for men.

There are no restrictions on the types of food you can eat and it is suggested that women can expect to lose about a 1lb a week on the diet with men losing about the same if not a little more.

During the study, overweight participants were assigned to either the 5:2 diet or a daily calorie restriction diet and were required to lose five per cent of their weight. Those on the 5:2 diet ate normally for five days and for their two fasting days consumed 600 calories, using LighterLife Fast Foodpacks, whilst those on the daily diet were advised to eat 600 calories less per day than their estimated requirements for weight maintenance (in the study women ate approx. 1400 calories, men ate approx. 1900 calories/day).

Under the expert guidance of the team, those on the 5:2 diet achieved 5 per cent weight-loss in 59 days compared to those on the daily calorie restriction diet who took in 73 days. 27 participants completed the study, with approximately 20 per cent of participants in both groups dropped out because they either could not tolerate the diet or were unable to attain their 5 per cent weight-loss target.

Researchers found that following weight-loss, participants who followed the 5:2 diet cleared the fat (triglyceride) from a meal given to them more efficiently than the participants undertaking the daily diet. Although there were no differences in post meal glucose handling, researchers were surprised to find differences between the diets in c-peptide (a marker of insulin secretion from the pancreas) following the meal, the significance of which will need further investigation.

The study also found a greater reduction in systolic blood pressure (the pressure in your blood vessels when your heart beats) in participants on the 5:2 diet. Systolic blood pressure was reduced by 9% of following the 5:2, compared to a small 2% increase among those on the daily diet. A reduction in systolic blood pressure reduces pressure on arteries, potentially lessening incidences of heart attacks and strokes.

Dr Rona Antoni, Research Fellow in Nutritional Metabolism at the University of Surrey, said:

“As seen in this study, some of our participants struggled to tolerate the 5:2 diet, which suggests that this approach is not suited to everybody; ultimately the key to dieting success is finding an approach you can sustain long term.

“But for those who do well and are able stick to the 5:2 diet, it could potentially have a beneficial impact on some important risk markers for cardiovascular disease, in some cases more so than daily dieting. However, we need further studies to confirm our findings, to understand the underlying mechanisms and to improve the tolerability of the 5:2 diet.”

Equal Options

Two treatments and a placebo yield similar relief for postmenopausal vaginal discomfort


A clinical trial comparing two common treatments for postmenopausal vaginal discomfort to placebo treatment found that both low-dose vaginal estrogen and a vaginal moisturizer produced symptom improvements similar to those associated with placebo after 12 weeks of treatment.

The authors note that better understanding of the causes of postmenopausal symptoms could lead to more effective treatment options for this bothersome problem.

The results were published online in JAMA Internal Medicine.

“The fact that all three treatments—vaginal estradiol tablets, a vaginal moisturizer and the lubricating gel we used as a placebo—were able to reduce symptoms is great news for women, since it means that regular use of any of these treatments is likely to have benefit, whether the cost is $20 or $200,” said corresponding author Caroline Mitchell, HMS assistant professor of obstetrics, gynecology and reproductive biology at Massachusetts General Hospital.

“The significant impact of vaginal discomfort on the lives of women is reflected by how quickly we were able to enroll more than 300 participants in less than a year. Women are desperate for some kind of intervention for these symptoms,” Mitchell said.

The authors, from seven research centers across the country, note that symptoms such as vaginal dryness, itching and pain during sexual intercourse affect around half of postmenopausal women and can have negative quality-of-life effects similar to those of chronic conditions like arthritis or irritable bowel syndrome.

But more than half of affected women use no medical treatments. Available nonprescription products, such as vaginal lubricants and moisturizers, can be messy; and prescription hormonal treatments in the form of creams, vaginal tablets and oral pills can be expensive and may raise concerns about safety.

The current trial was designed to assess the effectiveness of the two most commonly recommended treatments—low-dose estrogen vaginal tablets and a nonhormonal vaginal moisturizer.

The study enrolled 302 women, most between the ages of 55 and 64, who reported moderate to severe symptoms of vaginal itching, dryness, irritation or pain with sexual activity.

Participants were randomly divided into three groups, one receiving a low-dose vaginal estrogen tablet and a placebo vaginal gel, one receiving a placebo vaginal tablet and a nonprescription vaginal moisturizer and one receiving both placebo tablets and placebo gel.

Participants were instructed to administer the vaginal tablet once a day for 2 weeks and then twice a week for the remaining 10 weeks of the study period. The moisturizing gels were to be applied every three days throughout the study period. Neither participants nor study staff knew to which group individual participants were assigned.

At the end of the study period all three groups had similar decreases in the severity of their most bothersome symptom. A similar proportion of women in each group had at least a 50 percent decrease in overall symptom severity.

Improvement in sexual function and overall treatment satisfaction were also similar across all three groups. There was a significantly higher positive response to the question, “Did you have a meaningful benefit from the treatment?” among those receiving the vaginal estrogen tablet than among those receiving placebos.

Mitchell notes that, while most studies of treatments for vaginal discomfort show a significant placebo effect, the size of the response to placebo treatments in this trial was surprising.

“It’s hard to say whether the properties of the placebo gel itself, which is an excellent lubricant, are responsible, but our results suggest that regular use of any one of these products may be helpful,” she said.

“During the 12 weeks of the trial, more than 90 percent of women used the medication regularly, but prior studies suggest that many women do not continue use of this type of treatment beyond six months. A remaining question is whether women find the benefits of the treatment worthwhile enough to continue regular use,” Mitchell said.

Co-author Susan Reed, of the University of Washington, added, “It was notable that the overwhelming majority of women in our study were bothered by pain with sexual activity and earnestly wanted to help find a treatment for the many women bothered by this problem. More couples are remaining sexually intimate despite aging, and better therapies for vaginal discomfort need to be developed.”

Butterflies of the Soul

New study sheds light on the developmental origins of interneurons

Drawing of the cells of the chick cerebellum by Santiago Ramón y Cajal, from “Estructura de los centros nerviosos de las aves,” Madrid, circa 1905.

Modern neuroscience, for all its complexity, can trace its roots directly to a series of pen-and-paper sketches rendered by Nobel laureate Santiago Ramón y Cajal in the late 19th and early 20th centuries.

His observations and drawings exposed the previously hidden composition of the brain, revealing neuronal cell bodies and delicate projections that connect individual neurons together into intricate networks.

As he explored the nervous systems of various organisms under his microscope, a natural question arose: What makes a human brain different from the brain of any other species?

At least part of the answer, Ramón y Cajal hypothesized, lay in a specific class of neuron—one found in a dazzling variety of shapes and patterns of connectivity, and present in higher proportions in the human brain than in the brains of other species. He dubbed them the “butterflies of the soul.”

Known as interneurons, these cells play critical roles in transmitting information between sensory and motor neurons, and, when defective, have been linked to diseases such as schizophrenia, autism and intellectual disability.

Despite more than a century of study, however, it remains unclear why interneurons are so diverse and what specific functions the different subtypes carry out.

Now, in a study published in the March 22 issue of Nature, researchers from Harvard Medical School, New York Genome Center, New York University and the Broad Institute of MIT and Harvard have detailed for the first time how interneurons emerge and diversify in the brain.

Using single-cell analysis—a technology that allows scientists to track cellular behavior one cell at a time—the team traced the lineage of interneurons from their earliest precursor states to their mature forms in mice. The researchers identified key genetic programs that determine the fate of developing interneurons, as well as when these programs are switched on or off.

The findings serve as a guide for efforts to shed light on interneuron function and may help inform new treatment strategies for disorders involving their dysfunction, the authors said.

“We knew more than 100 years ago that this huge diversity of morphologically interesting cells existed in the brain, but their specific individual roles in brain function are still largely unclear,” said co-senior author Gordon Fishell, HMS professor of neurobiology and a faculty member at the Stanley Center for Psychiatric Research at the Broad.

“Our study provides a road map for understanding how and when distinct interneuron subtypes develop, giving us unprecedented insight into the biology of these cells,” he said. “We can now investigate interneuron properties as they emerge, unlock how these important cells function and perhaps even intervene when they fail to develop correctly in neuropsychiatric disease.”

A hippocampal interneuron. Image: Biosciences Imaging Gp, Soton, Wellcome Trust via Creative CommonsA hippocampal interneuron. Image: Biosciences Imaging Gp, Soton, Wellcome Trust via Creative Commons

Origins and Fates

In collaboration with co-senior author Rahul Satija, core faculty member of the New York Genome Center, Fishell and colleagues analyzed brain regions in developing mice known to contain precursor cells that give rise to interneurons.

Using Drop-seq, a single-cell sequencing technique created by researchers at HMS and the Broad, the team profiled gene expression in thousands of individual cells at multiple time points.

This approach overcomes a major limitation in past research, which could analyze only the average activity of mixtures of many different cells.

In the current study, the team found that the precursor state of all interneurons had similar gene expression patterns despite originating in three separate brain regions and giving rise to 14 or more interneuron subtypes alone—a number still under debate as researchers learn more about these cells.

“Mature interneuron subtypes exhibit incredible diversity. Their morphology and patterns of connectivity and activity are so different from each other, but our results show that the first steps in their maturation are remarkably similar,” said Satija, who is also an assistant professor of biology at New York University.

“They share a common developmental trajectory at the earliest stages, but the seeds of what will cause them to diverge later—a handful of genes—are present from the beginning,” Satija said.

As they profiled cells at later stages in development, the team observed the initial emergence of four interneuron “cardinal” classes, which give rise to distinct fates. Cells were committed to these fates even in the early embryo. By developing a novel computational strategy to link precursors with adult subtypes, the researchers identified individual genes that were switched on and off when cells began to diversify.

For example, they found that the gene Mef2c—mutations of which are linked to Alzheimer’s disease, schizophrenia and neurodevelopmental disorders in humans—is an early embryonic marker for a specific interneuron subtype known as Pvalb neurons. When they deleted Mef2c in animal models, Pvalb neurons failed to develop.

These early genes likely orchestrate the execution of subsequent genetic subroutines, such as ones that guide interneuron subtypes as they migrate to different locations in the brain and ones that help form unique connection patterns with other neural cell types, the authors said.

The identification of these genes and their temporal activity now provide researchers with specific targets to investigate the precise functions of interneurons, as well as how neurons diversify in general, according to the authors.

“One of the goals of this project was to address an incredibly fascinating developmental biology question, which is how individual progenitor cells decide between different neuronal fates,” Satija said. “In addition to these early markers of interneuron divergence, we found numerous additional genes that increase in expression, many dramatically, at later time points.”

The association of some of these genes with neuropsychiatric diseases promises to provide a better understanding of these disorders and the development of therapeutic strategies to treat them, a particularly important notion given the paucity of new treatments, the authors said.

Over the past 50 years, there have been no fundamentally new classes of neuropsychiatric drugs, only newer versions of old drugs, the researchers pointed out.

“Our repertoire is no better than it was in the 1970s,” Fishell said.

“Neuropsychiatric diseases likely reflect the dysfunction of very specific cell types. Our study puts forward a clear picture of what cells to look at as we work to shed light on the mechanisms that underlie these disorders,” Fishell said. “What we will find remains to be seen, but we have new, strong hypotheses that we can now test.”