Slowing down racing thoughts

Two black heads outlined against a yellow background; one showing white loops of tangles and the other showing neat white coils to indicate upsetting thoughts and calmer thoughts Everyone has moments when their brain suddenly goes haywire. They repeatedly fixate on the same thought, like being stuck on a hamster wheel. Or their thoughts aimlessly bounce from one random topic to the next like a pinball.

People often refer to these thought patterns as racing thoughts, and the most common cause is anxiety, says Fairlee Fabrett, PhD, a psychologist at Harvard-affiliated McLean Hospital.

“People who struggle with racing thoughts are constantly worried about what needs to be done, what hasn’t been done, and what is next,” says Fabrett. “Or they obsess about past, present, or future situations.” For example, you replay a conversation with different versions of dialogue, ruminate about an upcoming meeting with your boss or medical appointment, or worry about an unlikely doomsday scenario.

“When racing thoughts take over your mind you can’t stay focused, and you feel trapped, which makes you even more anxious and stressed, and the cycle continues,” says Fabrett.

Breaking the cycle of anxiety and racing thoughts

How can you break this cycle and keep racing thoughts from controlling you? Here are five strategies to try.

Give yourself permission. Racing thoughts are often made worse by the anxiety over having racing thoughts. To escape this, give yourself permission to experience them. “Acknowledge that racing thoughts are just noise, it is what our minds sometimes do, and that’s okay,” says Fabrett. “This gives you a sense of control so you don’t feel helpless. When you put racing thoughts in their proper context, they feel less threatening and easier to manage.”

Get mindful. Practicing mindfulness can help change your thought patterns. For instance, try counting your breaths. Close your eyes and count to yourself as you take slow, steady breaths: count one on the inhale, two on the exhale, etc. When you reach 10, start over and repeat the process until you calm down. “This is also a great remedy before sleep when most people’s minds begin to ruminate,” says Fabrett. Also, practice this breath work at times when your thoughts are not racing, so you will have the skill when you need it.

Distract yourself. You can sometimes break the cycle by distracting your mind. “As soon as you notice yourself worrying again or thinking about things over and over, make an internal comment to yourself, like ‘here I go again, with my list of thoughts that never ends,” says Fabrett. Then make a conscious decision to do something else, like reading, listening to music, or calling a friend.

Get moving. It sounds like token health advice — exercise more — but movement is helpful for defusing anxiety. For instance, when an episode of racing thoughts strikes, do a set of push-ups, 10 jumping jacks, take a five-minute walk, or do household chores. “These not only help break the cycle of racing thoughts but give your mind something else to focus on,” says Fabrett. Also, try to build regular exercise into your life as well as these short bursts of activity. That can help relieve anxiety and stress.

Schedule worry time. Sometimes it’s best to let racing thoughts run their course; otherwise, they may linger indefinitely. To do this, schedule worry time. When anxious racing thoughts occur, recognize them, but tell yourself that now is not worry time and you will deal with them later. Then at a fixed time of your choosing, do nothing but explore those thoughts and work through them. For example, write down the thoughts that come to mind without editing, including all the worst-case scenarios you can think of.

“You can also talk about them aloud and ask what makes you nervous and why,” says Fabrett. “This allows you to confront your anxiety head-on, but on your schedule without taking away from other activities,” says Fabrett. Set a limit to worry time, like 10 to 20 minutes. When the time is up, you move on.

If racing thoughts regularly affect your life or interfere with sleep, talk to your doctor or a mental health professional. “Frequent racing thoughts may be related to anxiety disorders, attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), trauma, or other mental health issues that need exploring,” says Fabrett.

About the Author

photo of Matthew Solan

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

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

About the Reviewer

photo of Howard E. LeWine, MD

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


Which skin creams are most effective for eczema?

Woman with dark hair and a blue shirt itching her extended arm; background is yellow

Quelling the discomfort of atopic dermatitis, the most common form of eczema, can be a daily quest. This inflamed, itchy skin condition can interfere with sleeping, socializing, and many other activities.

If home remedies such as gentle cleansing and regular moisturizing don’t provide relief, your doctor might recommend a prescription treatment to apply to your skin. Which prescription cream is most effective? A new study boils it down to a few overall winners.

What is atopic dermatitis and the itch-scratch cycle?

Atopic dermatitis is a chronic inflammatory skin disease. The areas commonly affected include the face, hands, feet, or the skin folds of the elbows or behind the knees.

We don’t know exactly what causes atopic dermatitis. Genes, the environment, and an overactive immune system all seem to play a role in creating inflammation, which feels itchy. Scratching the itch creates more irritation and inflammation, which causes more itching.

As the itch-scratch cycle continues, the rash gets worse. The skin might tear, ooze, and crust over, which can be painful.

Which skin treatments were more effective in the study?

Some prescription topical skin treatments for atopic dermatitis are more effective than others, according to a 2023 study published online by The Journal of Allergy and Clinical Immunology.

Scientists evaluated more than 200 randomized trials involving more than 43,000 people with atopic dermatitis (average age 18). The researchers compared almost 70 different prescription creams or ointments, which are broadly called topical treatments and are designed to be applied to affected areas of skin.

These treatments fall into five categories. If you have eczema, their generic names may or may not be familiar to you, but your medical team is likely to know them well:

  • topical corticosteroids, divided into seven classes ranging from the most to the least potent, decrease the release of an inflammatory chemical called phospholipase A2
  • topical Janus kinase (JAK) inhibitors interrupt inflammatory signals as they enter cells
  • topical PDE4 inhibitors raise the production of a chemical called phosphodiesterase-4, or PDE4, and lower the body’s inflammatory response
  • topical calcineurin inhibitors help suppress the production of chemical messengers that tell the body to ramp up its defenses
  • other topical treatments, including antibiotics and prescription moisturizers.

Researchers looked at which medications had outcomes important to patients, including which

  • were best at improving quality of life
  • were best at reducing eczema-related severity, itch, sleep disturbances, or flare-ups
  • caused the fewest serious side effects
  • were discontinued least often due to serious side effects.

Which atopic dermatitis medications proved to be most effective?

The study yielded some predictable results and a surprise. The overall winners were

  • two calcineurin inhibitors: pimecrolimus (Elidel) and tacrolimus (Protopic)
  • moderate-potency topical corticosteroids, a large group that includes fluocinolone acetonide (Synalar cream 0.025%) and triamcinolone acetonide (Kenalog cream/ointment 0.1%).

What did these medications improve?

  • Pimecrolimus improved six of seven outcomes, and was among the best at reducing sleep disturbances and eczema flares.
  • High-dose tacrolimus (0.1%) improved five outcomes, and was among the best at reducing itch and eczema flares.
  • Moderate-potency steroids improved four to six of the seven outcomes, and were best at reducing eczema itch, flares, and serious side effects.

“That’s in line with what we often prescribe,” says Dr. Connie Shi, a dermatologist who often treats people with eczema at Harvard-affiliated Brigham and Women’s Hospital. “The strongest topical steroids appeared to be the most effective at reducing eczema severity in the study. However, for longer-term maintenance we may consider switching to a moderate-potency steroid, or one of the nonsteroid options, to minimize the risk of thinning the skin, which can occur with long-term use of topical steroids.”

The surprise finding: the study found little to no effectiveness from using a topical cream twice daily versus just once daily. “The traditional advice is twice daily,” Dr. Shi says. “Once a day would make it more convenient to use, and it may help people stay on their medication regimen without decreasing effectiveness.”

Which treatments were less effective in this study? The researchers found that topical antibiotics were among the least effective treatments for eczema.

Should you change your treatment?

“While the study included more than 40,000 people, what worked for participants may not always work for you, as different people may respond differently to the same treatment,” Dr. Shi explains. “There are many factors to consider when prescribing a treatment, including your age, the areas on your skin that are affected, the severity of the eczema, and potential side effects.”

The bottom line? “If a treatment regimen is working for you, then continue it, as long as you don’t have any serious side effects,” she says. “If your current regimen isn’t working well, talk with your doctor or a dermatologist to see if there’s another prescription cream or ointment that you may want to try.”

About the Author

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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

photo of Howard E. LeWine, MD

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


Wondering what your lymph nodes have done for you lately?

3D illustration of the upper body of a man with arms outstretched and a green network of immune system lymph nodes connected through lymph channels; dark blue background

Here’s a question you may not have been asked lately: what do you know about lymph nodes?

If your answer is “not much,” you’re not alone. But even as our lymph nodes maintain a low profile, they’re working around the clock to deal with potential health problems ranging from common viruses to deadly bacteria and even cancer.

Read on to learn more about these workhorses of the immune system as they stand guard against outside invaders and rogue elements within our bodies.

What are lymph nodes?

Your lymph nodes are one part of the immune system that helps defend the body against health threats. These bean-shaped, pea-sized mounds of tissue form a network of clusters throughout the body. They filter lymphatic fluid (lymph), a white-yellow fluid that originates in the bloodstream.

The human body has hundreds of lymph nodes. They’re most plentiful — and most noticeable — in the neck, armpits, and groin. They’re also abundant in the chest and abdomen, where they’re observable by imaging tests such as CT or MRI scans.

Sometimes, lymph nodes are called glands (as in: “when I had mono, I had swollen glands in my neck”), but that’s not really accurate. Glands such as the thyroid gland produce hormones or other chemicals that have effects elsewhere in the body. That’s not what lymph nodes do.

How does lymph reach our lymph nodes?

Lymph is created when plasma, the liquid part of blood, seeps out of tiny blood vessels and flows into connecting channels that link lymph nodes throughout the body. These connecting channels are known as the lymphatic drainage system.

After lymph passes through lymph nodes, it eventually returns to the bloodstream through lymphatic channels.

What do lymph nodes do?

Our lymph nodes scour lymphatic fluid for infection or other potential triggers of illness. If threats are found, white cells called lymphocytes, and other immune cells within the lymph nodes, identify and try to eliminate them.

The main functions of your lymph nodes are:

  • detecting and eliminating infectious organisms
  • removing abnormal cells, including cancer cells and precancerous cells
  • eliminating damaged cells or cell products that might cause illness.

Is it normal for lymph nodes to swell and become painful?

It’s normal for lymph nodes to enlarge and become tender when they’re doing their job, especially when reacting to an infection. These reactive lymph nodes can become as large as grapes and painful to touch. But that’s only temporary: they should return to normal promptly when the infection resolves.

For local infections such as a skin infection or sore throat, the lymph node enlargement is limited to the part of the body near the infection. However, for bodywide infections such as HIV or mononucleosis, lymph node enlargement may be more widespread.

Can disease begin in lymph nodes?

Though they usually function as a helpful part of the immune system, diseases sometimes start in lymph nodes.

Lymphoma is a type of cancer that begins in the lymph nodes or in lymphatic tissue elsewhere in the body (including bone marrow, the spleen, or the intestinal tract). Rare inflammatory conditions can also involve lymph nodes; two examples are Castleman disease and Kikuchi disease.

Infections can affect the lymphatic system. Lymphatic filariasis, a parasitic disease spread by mosquitoes, is a good example.

Imagining a world without lymph nodes

Because they play an important role in the body’s immune defense, having no lymph nodes would likely mean having more and longer-lasting infections. In addition, an infection that might ordinarily be confined to one part of the body might spread more easily.

Considering all the ways in which lymph nodes help us stay healthy, it may seem surprising how commonly they’re removed. One or more lymph nodes may be removed to determine if they are cancerous, or if a newly diagnosed cancer (such as breast cancer) has spread to the lymph nodes. But since we have hundreds of lymph nodes, this sort of lymph node removal is unlikely to cause problems with immune function.

Sometimes lymph node surgery impairs lymphatic drainage. When this occurs, fluid can accumulate in nearby tissues. Chronic swelling called lymphedema can be a complication.

The bottom line

While there are many steps you can take to maintain a healthy immune system and good health — choosing a healthy diet, exercising regularly, not smoking, and more — you can’t do for yourself what your lymph nodes do for you.

So, even though the humble lymph node is easy to overlook, we should all be glad we have them.

About the Author

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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


Considering collagen drinks and supplements?

A red-colored drink being poured from a bottle into a glass with ice; concept is collagen drinks

A tremendous buzz surrounds collagen drinks and supplements, as celebrities and influencers tout miraculous benefits for skin, hair, and nails. Since the collagen in our bodies provides crucial support for these tissues, it seems plausible that consuming collagen might lead to lush locks and a youthful glow. But what does the science say?

What is collagen?

Collagen is a major structural protein in our tissues. It’s found in skin, hair, nails, tendons, cartilage, and bones. Collagen works with other substances, such as hyaluronic acid and elastin, to maintain skin elasticity, volume, and moisture. It also helps make up proteins such as keratin that form skin, hair, and nails.

Our bodies naturally produce collagen using the amino acids from protein-rich or collagen-rich foods like bone broth, meat, and fish. But aging, sun damage, smoking, and alcohol consumption all decrease collagen production.

Collagen drinks and supplements often contain collagen from many different sources, such as fish, cattle, pigs, or chicken. Typically, they contain peptides, short chains of amino acids that help make up essential proteins in the body, including collagen itself and keratin.

What does the science say about collagen drinks and supplements?

Research on skin includes:

  • A review and analysis of 19 studies, published in the International Journal of Dermatology, that had a total of 1,125 participants. Those who used collagen supplements saw an improvement in the firmness, suppleness, and moisture content of the skin, with wrinkles appearing less noticeable. That sounds promising, but it’s unclear if these skin improvements were actually due to collagen. Most of the trials used commercially available supplements that contained more than collagen: vitamins, minerals, antioxidants, coenzyme Q10, hyaluronic acid, and chondroitin sulfate were among the additional ingredients.
  • A few randomized, controlled trials (see here and here) show that drinking collagen supplements with high amounts of the peptides prolylhydroxyproline and hydroxyprolylglycine can improve skin moisture, elasticity, wrinkles, and roughness. But large, high-quality studies are needed to learn whether commercially available products are helpful and safe to use long-term.

Hardly any evidence supports the use of collagen to enhance hair and nails. One small 2017 study of 25 people with brittle nails found that taking 2.5 grams of collagen daily for 24 weeks improved brittleness and nail growth. However, this small study had no control group taking a placebo to compare with the group receiving collagen supplements.

There haven’t been any studies in humans examining the benefits of collagen supplementation for hair. Currently, no medical evidence supports marketing claims that collagen supplements or drinks can improve hair growth, shine, volume, and thickness.

Should you try collagen supplements or drinks?

At this time, there isn’t enough proof that taking collagen pills or consuming collagen drinks will make a difference in skin, hair, or nails. Our bodies cannot absorb collagen in its whole form. To enter the bloodstream, it must be broken down into peptides so it can be absorbed through the gut.

These peptides may be broken down further into the building blocks that make proteins like keratin that help form skin, hair, and nails. Or the peptides may form collagen that gets deposited in other parts of the body, such as cartilage, bone, muscles, or tendons. Thus far, no human studies have clearly proven that collagen you take orally will end up in your skin, hair, or nails.

If your goal is to improve skin texture and elasticity and minimize wrinkles, you’re better off focusing on sun protection and using topical retinoids. Extensive research has already demonstrated that these measures are effective.

If you choose to try collagen supplements or drinks, review the list of ingredients and the protein profile. Avoid supplements with too many additives or fillers. Products containing high quantities of prolylhydroxyproline and hydroxyprolylglycine are better at reducing wrinkles and improving the moisture content of skin.

Consult your doctor before starting any new supplements. People who are prone to gout or have other medical conditions that require them to limit protein should not use collagen supplements or drinks.

The bottom line

Large-scale trials evaluating the benefits of oral collagen supplements for skin and hair health are not available. If you’re concerned about thinning or lackluster hair, brittle nails, or keeping skin smooth and healthy, talk to your doctor or a dermatologist for advice on the range of options.

It will also help to:

  • Follow a healthy lifestyle and eat a balanced diet that includes protein-rich foods.
  • If you smoke, quit.
  • Limit alcohol to two drinks or less in a day for men or one drink or less in a day for women.
  • Apply sunscreen daily and remember to reapply every two hours.
  • Wear wide-brimmed or UV-protective hats and clothing when you’re spending a lot of time in the sun.

Follow Payal Patel on Twitter @PayalPatelMD

Follow Maryanne Makredes Senna on Twitter @HairWithDrMare

About the Authors

photo of Payal Patel, MD

Payal Patel, MD, Contributor

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

Maryanne Makredes Senna, MD, Contributor

Dr. Maryanne Makredes Senna is a board-certified dermatologist at at Beth Israel Lahey Health, and assistant professor of dermatology at Harvard Medical School. Dr. Senna founded and directs the Lahey Hair Loss Center of Excellence and … See Full Bio View all posts by Maryanne Makredes Senna, MD


Navigating middle school is tough: How parents can help

Groups of middle school students standing near lockers and walking through school corridor

Middle school can be challenging for many students. It’s tougher academically than elementary school, with more work and higher expectations. Even just changing classes — which for most students starts in middle school — can be stressful. It can be challenging socially, as students try to find friends and community amidst what can be very tough peer pressure. It’s also when some students start to experiment with sexuality and substance use, which can be overwhelming — even when glimpsed secondhand through the experiences of friends.

So what can parents do? Here are some suggestions for helping your middle schooler navigate these new waters.

Support schoolwork and socializing

Help them stay organized and on task. Keeping assignments and tests straight with multiple classes is an adjustment. Encourage your child to use a daily or weekly planner (paper or online). Help them work out a schedule that makes sure they get their homework done while also still having time for exercise and other activities. Fight the urge to micromanage; the idea is to help your child gain skills — and any true gaining of skills involves making some mistakes.

Be mindful of the effects of screen time — and social media. Screen time has a way of eating into things like homework, sleep, and other important uses of time. And social media can not only be distracting but a source of anxiety for middle schoolers. Everything and everyone looks perfect on social media, whether or not they are. It’s easy to feel less than or left out. Have ground rules about device use, such as no use during meals or homework, and charging the phone outside of the bedroom at night.

Get to know their teachers and school culture. Go to the fall open house. Sign up for any conferences or other resources offered to parents. Join the PTO or look for chances to volunteer, to the extent that you can around your own responsibilities. It can give you useful context and connect you with other parents.

Support healthy habits

Keep healthy habits in mind. A healthy diet, regular exercise, and getting a good night’s sleep are crucial. If life is particularly busy, think about making some healthy snacks, lunches, or dinners ahead of time on the weekend. Exercise can be as simple as a walk — maybe even to school or with the dog.

Encourage your child to get involved — but not overscheduled. Joining a club, sport, or other school-sponsored activity is a great way to make friends and grow as a person. At the same time, all of us need downtime. Make sure that downtime gets scheduled along with any extracurricular activities. Some of that downtime should be fun family time, like a game or movie night, or going out for ice cream, or whatever your child enjoys.

Strengthen bonds — yours and theirs

Keep the lines of communication open. Eat meals together, make sure to carve out time to be together and talk — or rather, listen. It’s always a good idea to listen more than one talks, and this is particularly true in middle school. Ask open-ended questions. Make it clear that you won’t judge. Be supportive and positive. Try to validate strong emotions, which can help defuse them.

Remember that the point isn’t to give advice but to help them feel comfortable talking to you, something that won’t be true for long if the conversation turns to your opinions. Sometimes it’s easier to talk when it’s less intense, like while watching a movie or sitting in the car — using media can also be a useful way to start conversations about tricky things like relationships.

Keep your expectations reasonable and fair. Your child does not need to get straight As in middle school to get into a good college. Nor do they need to be the lead in the school play or the best on their sports team. Have some ground rules about homework, healthy habits, and follow-through on commitments (and agreed-upon chores), but keep the emphasis on quality of life rather than achievement. This is a time of finding their way; let them do that.

Ask for help if you need it. If your child is struggling in some way, there is always someone who can help — such as a teacher, guidance counselor, a friend or family member, or your pediatrician. Adolescence is tough for both the child and the parent; we all do better when we do tough things together rather than alone.

About the Author

photo of Claire McCarthy, MD

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

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


Is online gambling harming you?

Multicolored neon signs with "Big Bet," "Online Betting," "Free Bet," plus gambling and sports icons like dice, baseketball and football

Online gambling — all those websites and apps that offer casino games, sports betting, poker, fantasy sports, and lotteries — can be exciting and entertaining. It’s an estimated $9.5 billion per year business, and growing. But for millions of Americans, what starts as occasional fun can lead to devastating gambling-related problems.

“You can experience harm from gambling, including addiction, just like you can with alcohol or other drugs,” says Debi LaPlante, director of the Division on Addiction at Harvard-affiliated Cambridge Health Alliance.

Who is being harmed?

In fact, the American Psychiatric Association’s classification of mental health disorders places gambling disorder in the section defining substance-related and addictive disorders, along with problems like opioid use disorder and alcohol use disorder.

In the US, about 1% of adults (two million) are estimated to have a severe gambling problem, and 2% to 3% (four to six million) are thought have a mild or moderate problem.

How can you recognize a possible gambling problem?

The Brief Biosocial Gambling Screen from the Cambridge Health Alliance’s Division on Addiction tests for gambling disorder risk by asking three questions:

  • During the past 12 months, have you become restless, irritable, or anxious when trying to stop and/or cut down on gambling?
  • During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?
  • During the past 12 months, did you have such financial trouble due to gambling that you had to get help with living expenses from family, friends, or welfare?

“If you answer yes to any of these questions, you should evaluate your gambling and how it fits into your life, and seek out further assessment,” says LaPlante.

How do you know if you’re engaging in harmless or harmful gambling?

A gambling addiction often occurs gradually. The line between harmless and harmful is often blurred, so people don’t always recognize they have a problem until it becomes severe. Here is what is considered the threshold of low-risk gambling:

  • You gamble no more than 1% of household income.
  • You gamble no more than four days per month.
  • You don’t gamble at more than two types of games.

What does gambling disorder share with other forms of addiction?

Gambling disorder shares certain risk factors with other types of addiction:

  • genetics
  • faulty thought patterns
  • impulse control disorders
  • availability in one’s community
  • poverty.

Like other types of addiction, gambling-related problems can lead to disrupted romantic, social, and work relationships. Feelings of withdrawal when someone tries to cut back are similar, too.

Does online gambling affect the brain?

Gambling games can affect people at the neurobiological level. Many games have features that trick the brain into thinking a loss is actually a win. For example, a slot machine displays celebratory music, sounds, and lights for a $3 return on a $5 bet.

“Research has found that our sympathetic nervous system responds to losses celebrated as wins the same way it responds to actual wins,” says LaPlante. “This is a powerful reinforcer, and just one example of games affecting brains.”

How can you find help for problem gambling?

Finding help for gambling can be challenging because, unlike for other types of addiction, the number of professionals who treat gambling addiction is limited, according to LaPlante. “Also, because of shame and stigma, people are less likely to acknowledge that gambling can become a problem,” she says.

Still, resources such as Gamblers Anonymous, local and national crisis helplines like 1-800-GAMBLER, self-help books such as Your First Step to Change, and local departments of public health are available to connect people to help.

Addiction treatment is not an exact science, and success varies from person to person. Some treatments have shown promise for gambling disorders, such as cognitive behavioral therapy (CBT) and motivational interviewing.

With CBT, people work with a therapist to help identify faulty thoughts and behaviors, such as the feeling one is “due to win” after a string of losses, and then learn tools to reframe those harmful thought patterns and respond to them more appropriately. During motivational interviewing, a person works with a counselor to enhance their motivation to change by together examining their ambivalence about change.

“If the gambling addiction is a symptom of another mental or physical health problem, addressing those issues is essential,” says LaPlante.

What does recovery from a gambling problem look like?

Different people have different ideas about what it means to be recovered from gambling addiction. For some, this means completely cutting gambling out of their life; for others, it means cutting back.

“Ideally, the treatment experience will include plans to prevent lapses that take people away from maintaining their own goals,” says LaPlante.

About the Author

photo of Matthew Solan

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

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

About the Reviewer

photo of Howard E. LeWine, MD

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


Preventable liver disease is rising: What you eat — and avoid — counts

A word cloud on fatty liver disease; risk factors, such as alcohol and high fat diet, appear in different colors

In today’s fast-paced world, our waking hours are filled with decisions — often surrounding what to eat. After a long day, dinner could well be fast food or takeout. While you may worry about the toll food choices take on your waistline or blood pressure, as a liver specialist, I also want to put fatty liver disease on your radar.

One variant, officially called nonalcoholic fatty liver disease (NAFLD), now affects one in four adults globally. Sometimes it progresses to extensive scarring known as cirrhosis, liver failure, and higher risk for liver cancer. The good news? Fatty liver disease can be prevented or reversed.

What is fatty liver disease?

Fatty liver disease is a condition caused by irritation to the liver. Liver tissue accumulates abnormal amounts of fat in response to that injury. Viral hepatitis, certain medicines (like tamoxifen or steroids, for example), or ingesting too much alcohol can all cause fatty liver disease.

However, NAFLD has a different trigger for fat deposits in the liver: a group of metabolic risk factors. NAFLD is most common in people who have high blood pressure, high cholesterol, insulin resistance (prediabetes), or type 2 diabetes. It is also common among people who are overweight or obese, though it is possible to develop NAFLD even if your body mass index (BMI) is normal.

What helps prevent or reverse NAFLD?

Diet can play a huge role. Because NAFLD is so closely tied to metabolic health, eating more healthfully can help prevent or possibly even reverse it. A good example of a healthful eating pattern is the Mediterranean diet.

Overweight or obesity is a common cause of NAFLD. A weight loss program that includes activity and healthy eating can help control blood pressure, cholesterol, and blood sugar. Among the many healthful diet plans that help are the DASH diet and the Mediterranean diet. Talk to your doctor or a nutritionist if you need help choosing a plan.

To vigorously study any diet as a treatment for fatty liver disease, researchers must control many factors. Currently, no strong evidence supports one particular diet over another. However, the research below highlights choices to promote a healthy liver.

Avoid fast food

A recent study in Clinical Gastroenterology and Hepatology linked regular fast-food consumption (20% or more of total daily calories) with fatty liver disease — especially in people who had type 2 diabetes or obesity. Fast foods tend to be high in saturated fats, added sugar, and other ingredients that affect metabolic health.

Steer clear of soft drinks and added sugars

Soft drinks with high-fructose corn syrup, or other sugar-sweetened beverages, lead directly to large increases in liver fat deposits, independent of the total calories consumed. Read labels closely for added sugars, including corn syrup, dextrose, honey, and agave.

Instead of sugary drinks, sip plain water. Black coffee or with a splash of cream is also a good pick; research suggests coffee has the potential to decrease liver scarring.

Avoid alcohol

Alcohol directly damages the liver, lacks nutritional value, and may affect a healthy microbiome. If you have NAFLD, it’s best to avoid any extra cause for liver injury. We simply do not know what amount of alcohol is safe for those with fatty liver disease — even social drinking may be too much.

Eat mostly whole foods

Vegetables, berries, eggs, poultry, grass-fed meats, nuts, and whole grains all qualify, but cutting out red meat may be wise. An 18-month trial enrolled 294 people with abdominal obesity and lipid imbalances such as high triglycerides. Regular activity was encouraged, and participants were randomly assigned to one of three diets: standard healthy dietary guidelines, a traditional Mediterranean diet, or a green-Mediterranean diet. (The green-Med diet nixed red and processed meats and added green tea and a dinner replacement shake rich in antioxidants called polyphenols.)

All three groups lost some weight, although the Mediterranean diet groups lost more weight and kept it off for a longer period. Both Mediterranean diet groups also showed reduced liver fat at the end of 18 months, but liver fat decreased twice as much in the green-Med group as in the traditional Mediterranean diet group.

Healthy fats are part of a healthy diet

We all need fat. Dietary fats help your body absorb vitamins and are vital in the protection of nerves and cells. Fats also help you feel satisfied and full, so you’re less likely to overeat. Low-fat foods often substitute sugars and starches, which affect blood sugar regulation in our bodies. But all fat is not created equal.

It’s clear that Mediterranean-style diets can help decrease liver fat, thus helping to prevent or possibly reverse NAFLD. These diets are high in healthful fats, such as monounsaturated fats found in olive oil and avocados and omega-3 fats found in walnuts and oily fish like salmon and sardines.

With so many choices, it’s hard to know where to start in the healthy eating journey. Let’s strive to eat whole foods in their natural state. Our livers will thank us for it.

About the Author

photo of Kathleen Viveiros, MD

Kathleen Viveiros, MD, Contributor

Dr. Kathleen Viveiros is a clinical hepatologist at Brigham and Women’s Hospital who sees patients in Boston and in Foxborough and Westwood, MA. She is an instructor in medicine at Harvard Medical School. Her professional interests … See Full Bio View all posts by Kathleen Viveiros, MD


Fall shots: Who’s most vulnerable to RSV, COVID, and the flu?

Yellow, red, and greenish autumn leaves with a vaccine syringe and vial posed against a white background; concept is fall vaccines

The fall calendar doesn’t just warn us of impending cold temperatures: It also points toward seasonal upticks in cases of RSV (respiratory syncytial virus), COVID, and influenza. These respiratory viruses were dubbed a “tripledemic” last year. After they collided to overload health care systems across the country, hospitalizations rose in tandem for all three illnesses over the fall and winter months.

Warding off severe cases — which may lead to hospitalization or death — should be top of mind, especially for those who are most vulnerable, a Harvard expert says. And updated versions of all three vaccines are now available to help protect us.

Why do cases of flu, RSV, and COVID typically rise in fall?

“This is typically the time of year we start to see viral infections increase, which has a lot to do with kids going back to school,” says Dr. John Ross, an assistant professor of medicine at Harvard Medical School who is board-certified in infectious diseases.

“Also, we’re starting now to have weather that’s more favorable for viral transmission, particularly lower humidity. Viruses survive better in dry air. And drier air also affects our airways and makes them more vulnerable to being infected.”

Who is eligible for each shot?

Eligibility recommendations vary by age and vulnerability to serious illnesses. Additionally, some shots are designed to help protect specific groups against serious illness.

The CDC recommends these shots for the following groups.


  • Babies under 8 months and older infants at risk of severe RSV: A new shot, nirsevimab (Beyfortus), provides antibodies that protect against RSV for about five months.
  • If you’re pregnant: One vaccine (Abrysvo) is approved at 32 weeks to 36 weeks of pregnancy. Having this shot during pregnancy protects infants during the first six months of life.
  • If you’re over 60: Two vaccines (Arexvy and Abrysvo) are approved. Ask your health provider if you should consider getting one.


  • Everyone 6 months and older should consider getting one of the updated COVID boosters, which were approved and authorized for emergency use by the FDA in early September. 
  • Age 5 and older: Regardless of prior vaccination, children and adults are eligible for one dose of an updated mRNA vaccine if it’s been at least two months since their last COVID vaccine, the FDA says.


  • Everyone 6 months and older should receive a flu vaccine.
  • Different vaccines are approved for different age groups and for people with certain health issues or allergies. Most protect against four strains of flu virus (quadrivalent vaccines) expected to circulate this season.
  • Three vaccines could potentially be more effective for people over 65: Fluzone High-Dose Quadrivalent vaccine; Flublok Quadrivalent Recombinant vaccine; and Fluad Quadrivalent adjuvanted flu vaccine. If these are not available, it’s fine to get any other flu shot approved for your age and health issues or allergies.

Who is likely to benefit most?

Getting the right vaccines can help people avoid missed work or school days and running the risk of making others sick. And the protection offered by these shots is especially important for certain groups.

For all three viruses, the people most vulnerable to severe illness are similar, Dr. Ross says, including

  • adults 65 and older
  • those with compromised immune systems or underlying lung conditions such as COPD and asthma
  • those who are pregnant.

“Certainly with COVID and flu, pregnancy outcomes are worse with those infections,” Dr. Ross says. “I’m not saying that RSV isn’t a risk for pregnant mothers, but there’s not much data. The reason pregnant women are offered RSV vaccination is so the maternal antibodies they produce protect the newborns, because they’re at very high risk for RSV with very bad outcomes.”

Additionally, an even wider range of people are more prone to complications from the flu, according to the CDC. This includes

  • infants under 2
  • people with heart disease, neurologic conditions, blood disorders, endocrine disorders such as diabetes, obesity, kidney disease, liver or metabolic disorders
  • people who have had a stroke.

What else should you know about flu, COVID, and RSV shots?

Beyond broad guidance determining who’s eligible for each type of vaccine, Dr. Ross offers other useful insight that may guide your choices.

When is the best time to get a flu shot?

The CDC recommends getting a flu shot in September or October, and Dr. Ross agrees. “These are usually the months the flu vaccine becomes available and vaccine clinics are easiest to find,” he says. “My personal approach is just to get the vaccine when it’s available, so you don’t forget.”

Will the updated COVID vaccines protect against newer strains of the virus?

The latest mRNA shots by drugmakers Pfizer and Moderna are monovalent, meaning they protect against one variant — XBB.1.5, the most recent to descend from Omicron earlier in 2023. Though that strain is no longer dominant, the boosters should still guard against closely related subvariants that are now circulating, Dr. Ross says. “People can feel comfortable about their protection regardless,” he says.

What else should I know about RSV shots?

The version meant for infants, Beyfortus, isn’t a vaccine at all. It’s a monoclonal antibody product that directly delivers antibodies that protect babies for the duration of a single fall-winter RSV season. These antibodies can prevent RSV or lessen its severity.

Dr. Ross says adults over 60 considering RSV vaccination should be aware of the potential for two rare but potentially serious side effects of the nervous system: the autoimmune conditions Guillain-Barre syndrome and acute disseminated encephalomyelitis, or ADEM. Guillain-Barre can lead to bodywide paralysis, while ADEM can cause weakness and seizures. The risk of these side effects after RSV vaccination in adults is about one in 7,000 — far higher than occurs after flu vaccination, Dr. Ross notes.

“If you’re a totally healthy 60-year-old, I’m not sure it makes sense to get the RSV vaccine,” he says. “It’s a conversation you should have with your doctor.”

How should I schedule shots if I’m getting several vaccines?

Research suggests that it’s safe to get both flu and COVID vaccines at the same time. Reactions (such as muscle aches, fatigue, and headache) are slightly higher when flu vaccine and an mRNA COVID vaccine are combined, according to one study, though these reactions usually are mild and disappear quickly.

“Because RSV vaccines are newer, I don’t think we know much about combining these shots with other vaccines,” says Dr. Ross. Scheduling this vaccine separately is a good idea, although you should talk to your doctor about potential risks and benefits for your situation.

About the Author

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

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

About the Reviewer

photo of Howard E. LeWine, MD

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


Got immunity? Thank your thymus

A a 3-D illustration of the chest in shades of blue shows the human thymus gland in orange between the top of the lungs

Quick, point to your thymus gland.

If you pointed to the front of your upper chest, well done! The thymus gland sits just behind the upper part of the breastbone, between the tops of the lungs and in front of and above the heart. In newborns, the thymus gland may be 2.5 inches long and weigh 1 ounce, but it shrinks over time beginning in the first year of life.

If you pointed elsewhere or had no idea, don’t feel bad. For most people, the thymus is unfamiliar and so is its whereabouts. And, for good reason: in most adults, the thymus gland is a tiny gland that’s been largely replaced by fat. But it wasn’t always that way.

How does the thymus gland help the immune system?

During fetal development, infancy, and early childhood, the thymus gland is quite important for the developing immune system. That’s when the thymus produces a special type of immune cells called T-cells (named for the thymus gland).

T-cells are essential to healthy immune function because they can kill cells infected by bacteria or viruses. They also attack tumor cells and help regulate other parts of the immune system.

Do you actually need your thymus gland?

The answer to this question depends on whether you are a developing fetus, young child, or adult. For the fetus and young child it’s quite essential, as noted above.

But there’s been uncertainty regarding the role of the thymus gland among adults. One reason is that over time it becomes a shrunken vestige of its former self, weighing in at a fraction of an ounce and shrinking to just one inch.

In addition, adults seem to do just fine without a thymus gland if it needs to be removed as a treatment for certain diseases, such as cancerous or benign tumors. Along with medications, thymus removal (thymectomy) may be part of treatment for myasthenia gravis, an autoimmune disease that causes muscle weakness, droopy eyelids, and double vision. The thymus gland seems to be the source of abnormal immune cells that cause this disease.

Rethinking the importance of the thymus gland in adulthood

Growing evidence suggests the thymus gland might play a role in the health of the immune system, and overall health in adults, for much longer than previously thought. For example:

  • The thymus gland continues to produce T-cells well into adulthood, though at a slower pace. In addition, newer scanning technology suggests less shrinkage of the organ than had been reported in the past. 
  • Even though the thymus gland’s function declines over time, it may help adults fight off infections, such as HIV and COVID-19.
  • A 2023 study concluded that people who had their thymus removed during adulthood had higher rates of cancer, autoimmune disease, and death than people who had other types of surgery.

Along with other research, this suggests that we may have underestimated this gland’s function and importance in adults.

The bottom line

There is much we don’t know about the thymus gland, but one thing seems certain: most people are unaware of its major contributions to immune function and overall health.

Future research may change how we think about the importance of this gland, especially its role among aging adults. But well before that happens, I think the thymus gland deserves more recognition and respect. Without the thymus gland, we’d be prone to childhood infections and shorter lifespans. By the time we’re old enough to appreciate it, this amazing gland has already helped create a well-functioning immune system that protects us from health threats we face throughout our lives.

It’s truly amazing what a small, shrunken gland can do — or has already done — for you.

About the Author

photo of Robert H. Shmerling, MD

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


Easy ways to shop for healthful, cost-conscious foods

A dark background with brightly colored foods, such as tomato, orange, mushroom, cheese, eggs, celery, watermelon, salmon

Three months into the year is a good time to recalculate if you’ve been slacking on your resolution to eat healthy. And if you’ll be leaving home base or school soon and foraging for yourself (plus or minus roommates), it’s a great time to learn about healthy, low-cost choices for your grocery list.

The basics: A weekly shop

A healthy diet is rich in vegetables, fruits, legumes (beans or lentils), whole grains, nuts, seeds, lean proteins, and low-fat dairy products. Trying to fill your cart with all of those goodies can feel overwhelming. But just think in terms of twos.

“Get two fruits and two vegetables of different colors, and two types of lean protein — such as fresh, frozen, or canned fish, chicken or lean ground turkey, or plant-based options,” suggests Nancy Oliveira, a registered dietitian and manager of the Nutrition and Wellness Service at Harvard-affiliated Brigham and Women’s Hospital.

Oliveira also recommends getting two foods in each of these categories on your weekly shopping trip:

  • plant proteins, such as canned or dried beans, tofu, tempeh, veggie burgers, or unsalted nuts or seeds
  • whole grains, such as whole-grain bread, whole-grain pasta, brown or black rice, quinoa, or farro
  • dairy or nondairy milk items, such as nonfat Greek yogurt or cheese.

Go ahead and add one or two healthy treats or snacks, such hummus or dried apricots.

Do you need to choose organic foods?

Organic produce is grown without synthetic fertilizers and pesticides, which are linked to many health problems. While US scientists debate whether foods grown with organic fertilizers (such as animal waste) are safer for your health, other countries, including European Union nations, have banned or phased out synthetic pesticides still used in the United States.

That doesn’t mean that everything you buy must be organic. But try to stay away from conventionally grown produce with thin skins, such as strawberries, spinach, kale, peaches, and grapes. They tend to absorb more chemicals compared to produce with thick skins, such as avocados or pineapples.

The Environmental Working Group creates an annual list to help shoppers avoid high-pesticide produce, and another one that highlights the least contaminated produce.

Buying cost-conscious fresh food and staples

Healthy food, especially organic produce, has a reputation for being expensive. But it doesn’t have to be. Just do a little comparison shopping, and follow Oliveira’s tips to save money on a grocery run:

  • Shop in a smaller store with fewer choices.
  • Never enter a store hungry, since you might buy more than you normally would.
  • Carry a shopping list and stick to it.
  • Go directly to the aisles you need. Avoid browsing elsewhere, which may lead to extra purchases.
  • Be flexible, have several options within your food categories, and go with sale items.
  • Always check the day-old produce cart that offers perfectly edible fresh produce at 50% to 75% off regular prices.
  • Buy unseasoned canned or frozen whole foods such as vegetables, chicken, or fish (salmon, sardines, tuna), which are often cheaper than fresh versions.
  • Wait for sales of healthy nonperishable staples like quinoa, brown rice, whole-grain pasta, and high-fiber cereals.
  • Use coupons and coupon apps.

Easy healthy snacks to reach for

Move on from easy grab-n-go snacks, which are typically processed foods. They often contain unhealthy ingredients and promote overeating. Instead, Oliveira suggests keeping healthy snacks on hand, such as:

  • unsalted mixed nuts
  • string cheese
  • grapes and berries (rinse before eating)
  • clementines, bananas, or other fruits that don’t need washing
  • a rice cake with nut butter or hummus
  • fat-free Greek yogurt
  • a peeled hard-boiled egg.

“To save money, buy certain foods in larger amounts when possible, such as an 8-ounce bar of cheese that you slice into small cubes and store in a sealed container in the fridge,” Oliveira says.

Crowdsource shopping tips and savings

Don’t be shy about asking for shopping tips from friends and family members who’ve already developed shortcuts, and grocery store staffers who can offer insider advice.

You can also turn to apps for help. Oliveira recommends two faves:

  • Mealime is a meal-planning app with simple, healthy plant-based recipes that automatically create grocery lists for the ingredients.
  • List Ease creates lists for grocery runs. You can search for items to add or scan barcodes to add to lists.

“And if you prefer not to use apps, just jot down notes after a quick pantry or fridge inventory, or text yourself every time you remember something you need,” Oliveira advises. “With a little practice, you’ll quickly work out the best system for you.”

About the Author

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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

photo of Howard E. LeWine, MD

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