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In today’s calorie-rich, ultra-processed, movement-sparing, chronic stress-inducing, so-called “toxic” environment, losing weight is hard work. But implementing a healthy and sustainable approach that keeps the weight off is even harder.

Short-term weight loss can be easier than long-term weight maintenance

Most of us can successfully achieve weight loss in the short term. But those who hop from one fad diet to the next often experience the metabolic roller coaster known as yo-yo dieting that jacks up our hunger hormones, plummets our metabolic rates, and causes a vicious spiral of weight loss followed by regain. Even most medical interventions to help treat obesity produce the typical trajectory of rapid weight loss followed by weight plateau and then progressive weight regain. In a meta-analysis of 29 long-term weight loss studies, more than half of the lost weight was regained within two years, and by five years more than 80% of lost weight was regained. This means that based on our best estimates, only one in five individuals who is overweight is successful in long-term weight loss.

What is so special about weight loss maintainers?

Based on studies from the National Weight Control Registry, a database of more than 4,000 individuals who have maintained at least 10% body weight loss for at least one year, we have insight into some tried and true tactics. These include various energy intake-reducing behaviors — limiting calorie-dense foods and sugar-sweetened beverages, portion control and a consistent eating pattern across days, increased fruit and vegetable consumption — as well as being physically active for at least an hour per day.

This makes sense and is consistent across the scientific literature. Any successful weight loss necessitates tipping and keeping the scale toward greater energy expenditure and less energy intake (a net negative energy balance). But how do these people actually sustain those weight loss-promoting behaviors over time, in order to build a lifestyle that does not leave them feeling persistently deprived, lethargic, and hangry (hungry + angry)?

The most important determinants of weight loss maintenance are those that cement changes in behavior. As more recent evidence confirms, the proper psychology for weight loss is critical for regulating the physiology that supports weight loss.

Self-regulation and self-efficacy are key to long-term success

Only recently have we started to evaluate the psychological and cognitive determinants of weight loss maintenance. We all have anecdotal evidence from family, friends, and colleagues. But systematically collecting, processing, and analyzing the qualitative experiences, strategies, and challenges from successful weight loss maintainers is difficult.

The data to date confirm the importance of self-regulation, and in particular self-monitoring of the day-to-day behaviors that drive energy intake and energy expenditure, especially eating behaviors. Those who have high self-efficacy (belief in your capacity to execute certain behaviors) for exercise in particular are more successful at sustaining weight loss. And more recently, researchers have been decoding elements of the proper mindset that instills high self-efficacy for the larger constellation of important weight management behaviors.

One recent study used machine learning and natural language processing to identify the major behavioral themes — motivations, strategies, struggles, and successes — that were consistent across a group of over 6,000 people who had successfully lost and maintained over 9 kilograms (about 20 pounds) of weight for at least a year. Among this large group, they consistently advised perseverance in the face of setbacks, and consistency in food tracking and monitoring eating behaviors, as key behavior strategies. And most of them stayed motivated by reflecting on their improved health and appearance at their lower weight.

Studies about successful weight loss miss many people

The evidence suggests that age, gender, and socioeconomic status are not significant factors in predicting weight loss maintenance. But most weight loss studies oversubscribe white, educated, and midlevel income-earning females. Given that the prevalence of obesity and its related comorbidities is disproportionately higher in more socially disadvantaged and historically marginalized populations, we need richer, more representative data to paint a full and inclusive picture of a successful weight loss psychology. We need to better understand the lived experience of all people so that we can determine the most powerful and unique motivations, effective behavioral strategies, and likely challenges and setbacks, particularly the environmental determinants that dictate the opportunities and barriers for engaging in and maintaining a healthier lifestyle.

Maintaining weight requires multiple tools, training, and support

What we can say for certain is that for any and all of us, maintaining weight loss necessitates getting comfortable with discomfort — the discomfort of occasionally feeling hungry, of exercising instead of stress eating, of honestly deciphering reward-seeking versus real hunger, and resisting the ubiquitous lure of ultrapalatable foods. This is no easy task, as it often goes against environmental cues, cultural customs, family upbringing, social influences, and our genetic wiring. In order to help each other achieve health and weight loss in our modern environment, we need to learn and practice the psychological tools that help us not only accept, but eventually embrace, this inevitable discomfort.

For my birthday last year, I received paddleboard lessons. I was always curious about the popular water sport and watched in fascination as people stood on almost-invisible boards, paddling along as if walking on water.

Paddleboarding was everything I expected and then some. Still, I quickly realized that it is a serious workout, like all paddle sports, such as kayaking and canoeing. It may look effortless, floating along and casually dipping a paddle in water. But much goes on beneath the surface, so to speak. As warmer weather beckons and paddle season arrives, it pays to get key muscles in shape before heading out on the water.

Tuning up muscles: Focus on core, back, arms, and shoulders

“Paddling a kayak, canoe, or paddleboard relies on muscles that we likely haven’t used much during winter,” says Kathleen Salas, a physical therapist with Spaulding Adaptive Sports Centers at Harvard-affiliated Spaulding Rehabilitation Network. “Even if you regularly weight train, the continuous and repetitive motions involved in paddling require endurance and control of specific muscles that need to be properly stretched and strengthened.”

While paddling can be a whole-body effort (even your legs contribute), three areas do the most work and thus need the most conditioning: the core, back, and arms and shoulders.

• Core. Your core comprises several muscles, but the main ones for paddling include the rectus abdominis (that famed “six-pack”) and the obliques, located on the side and front of your abdomen. The core acts as the epicenter around which every movement revolves — from twisting to bending to stabilizing your trunk to generate power.
• Back: Paddling engages most of the back muscles, but the ones that carry the most load are the latissimus dorsi muscles, also known as the lats, and the erector spinae. The lats are the large V-shaped muscles that connect your arms to your vertebral column. They help protect and stabilize your spine while providing shoulder and back strength. The erector spinae, a group of muscles that runs the length of the spine on the left and right, helps with rotation.
• Arms and shoulders: Every paddle stroke engages the muscles in your arms (biceps) and the top of your shoulder (deltoids).

Many exercises specifically target these muscles, but here are three that can work multiple paddling muscles in one move. Add them to your workouts to help you get ready for paddling season. If you haven’t done these exercises before, try the first two without weights until you can do the movement smoothly and with good form.

Three great exercises to prep for paddling

Wood chop

Muscles worked: Deltoids, obliques, rectus abdominis, erector spinae
Reps: 8–12 on each side
Sets: 1–3
Rest: 30–90 seconds between sets

Starting position: Stand with your feet about shoulder-width apart and hold a dumbbell with both hands. Hinge forward at your hips and bend your knees to sit back into a slight squat. Rotate your torso to the right and extend your arms to hold the dumbbell on the outside of your right knee.

Movement: Straighten your legs to stand up as you rotate your torso to the left and raise the weight diagonally across your body and up to the left, above your shoulder, while keeping your arms extended. In a chopping motion, slowly bring the dumbbell down and across your body toward the outside of your right knee. This is one rep. Finish all reps, then repeat on the other side. This completes one set.

Tips and techniques:

• Keep your spine neutral and your shoulders down and back
• Reach only as far as is comfortable.
• Keep your knees no farther forward than your toes when you squat.

Make it easier: Do the exercise without a dumbbell.

Make it harder: Use a heavier dumbbell.

Bent-over row

Muscles worked: Latissimus dorsi, deltoids, biceps
Reps: 8–12
Sets: 1–3
Rest: 30–90 seconds between sets

Starting position: Stand with a weight in your left hand and a bench or sturdy chair on your right side. Place your right hand and knee on the bench or chair seat. Let your left arm hang directly under your left shoulder, fully extended toward the floor. Your spine should be neutral, and your shoulders and hips squared.

Movement: Squeeze your shoulder blades together, then bend your elbow to slowly lift the weight toward your ribs. Return to the starting position. Finish all reps, then repeat with the opposite arm. This completes one set.

Tips and techniques:

• Keep your shoulders squared throughout.
• Keep your elbow close to your side as you lift the weight.
• Keep your head in line with your spine.

Make it easier: Use a lighter weight.

Make it harder: Use a heavier weight.

Superman

Muscles worked: Deltoids, latissimus dorsi, erector spinae
Reps: 8–12
Sets: 1–3
Rest: 30–90 seconds between sets

Starting position: Lie face down on the floor with your arms extended, palms down, and legs extended.

Movement: Simultaneously lift your arms, head, chest, and legs off the floor as high as is comfortable. Hold. Return to the starting position.

Tips and techniques:

• Tighten your buttocks before lifting.
• Don’t look up.
• Keep your shoulders down, away from your ears.

Make it easier: Lift your right arm and left leg while keeping the opposite arm and leg on the floor. Switch sides with each rep.

Make it harder: Hold in the “up” position for three to five seconds before lowering.

It’s time to make summer plans, and for many families those plans include summer camp. After the past couple of years, the idea of getting out of the house, being active, and seeing other children sounds very appealing.

While COVID-19 is still with us, vaccines and the fact that so many people have gotten sick and developed some natural immunity has made activities like summer camp less treacherous. Unfortunately, this doesn’t mean that families don’t need to think about COVID-19 as they make their plans, because they still do.

What to do before signing up for summer camp this year

Before even thinking about camp, take into account your family’s particular risk factors. If children are 5 or older and haven’t been vaccinated, now is the time to get the vaccine. If you have any questions or concerns about the vaccine, please talk to your doctor. While you are at it, make sure that children are up to date on routine childhood vaccinations. Many children have gotten behind because of the pandemic.

Talk to your doctor about the pros and cons of camp if your child

• isn’t or can’t be vaccinated, since it’s important to think about factors that might make getting COVID riskier.
• has health problems like asthma or congenital heart disease that put them at higher risk of complications of COVID-19.
• has a weakened immune system for any reason. Whether or not your child is vaccinated, it’s always important to check in with their doctor before sending them to camp, or any group activity.

Questions to ask any camp you’re considering

These days, most communities have dropped mask mandates. While it’s certainly nice to not have to wear one — and to see people’s faces — masks do make a difference when it comes to preventing the spread of infection. COVID-19 is still causing illness and is likely to be with us beyond this summer. Before signing up for camp there are things parents should think about — and questions they should ask.

Where is the camp, and where are the campers and staff from? A local day camp with children and staff mostly from a town with low numbers of COVID cases is going to be lower-risk than one in a community with higher numbers, or one that draws from many different communities, including some with higher numbers. The Centers for Disease Control and Prevention has a database of case numbers by county.

What is the vaccination status of the staff and campers? Ideally, all eligible staff and campers should be vaccinated — with not just their primary series, but any booster doses they are eligible to receive.

How is the camp screening for symptoms or exposures, and what guidelines do they have in place? This is most important when there are unvaccinated staff or campers, or in areas of higher case counts. The camp should have a plan for screening campers and staff for symptoms, with appropriate plans for staying home, testing, and quarantine based on the results of those screenings. Find out how exposures outside of camp will be handled for campers and staff. Sleepaway camps should have designated quarantine space, and access to testing. Ask about their testing requirements, as well.

Are activities mostly indoors or mostly outdoors? The more outdoor activities, the better. Indoor activities are safest in well-ventilated spaces.

What is the policy on wearing masks? Wearing a mask for 10 days after testing positive for COVID or being in close contact with someone who has it is essential to help others stay healthy. (Also follow recommendations for quarantine or isolation described in this tool from the CDC.) Masks may also be a good idea for indoor situations where people are close together — and some staff and campers might simply feel more comfortable wearing a mask. The camp should have a culture that allows those who choose to wear masks to feel comfortable doing so.

What is the plan for shared equipment and surfaces? One is far more likely to catch an infection from a person than a surface, but it’s important that anything that multiple people touch be wiped down regularly.

What is the plan for hand washing? Regular hand washing with soap and water or hand sanitizer is important to limit the spread of germs, including the virus that causes COVID-19. Parents should ask how often campers will be washing their hands, and about the availability of hand sanitizer.

What is the plan for meals? Eating together increases the risk of transmission of COVID-19. The risk is lower if people eat outdoors or have some space to spread out — and if they bring their own food rather than sharing.

As much as we may all feel done with COVID-19, the reality is that COVID-19 isn’t done with us. Children need the experiences camp can bring, especially after their lives have been so disrupted — and with just a few precautions, they can have fun and be safe too.

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Some people may be cautious when it comes to using oils in cooking or with their food. Eating fat with meals conjures thoughts of high cholesterol and, well, getting fat. The fact that some fats are labeled as “bad” adds to the confusion and misconception that all fats are unhealthy.

But that isn’t the case.

“It’s important to consume oils,” says Shilpa Bhupathiraju, assistant professor of medicine at Harvard Medical School and assistant professor of nutrition at Harvard’s T.H. Chan School of Public Health.

Oils and fats contain essential fatty acids — omega 3s and 6s, in particular — that are part of the structure of every single cell in the body, says Walter Willett, professor or epidemiology and nutrition at the Harvard T.H. Chan School of Public Health. They’re the building blocks of hormones, help decrease inflammation, and lower bad cholesterol and blood pressure. Oil also provides taste and satiety.

The key is knowing the right kind to use. It’s easier when you’re cooking at home, a little trickier when you’re eating out and you can’t control every step in the process. But it’s not just about picking the healthiest oils. They play a part in a healthy diet when they’re part of an eating plan that minimizes processed foods, simple carbohydrates, and sugar.

Healthy and not-so-healthy oils

In general, Willett says that the healthiest oils are liquid and plant-based. The one that comes to mind first is olive oil, and for good reason. “It’s stood the test of time,” he says. It helps lower blood cholesterol and provides antioxidants, and extra virgin is the ideal version, as it’s the first pressing and least refined.

After that, corn, canola, sunflower, safflower, and soybean all fall into the healthy column. The last one wasn’t always considered a healthy choice because it used to be hydrogenated, but now it’s in a natural state and a good source, says Willett.

On the unhealthy side, there’s lard, butter, palm oil, and coconut oil. The commonality is that they come in a semi-solid state and have a high level of saturated fat. The consumption of that fat increases LDL cholesterol (the bad kind), and has been associated with increased risk for cardiovascular disease and diabetes.

Willett says part of the challenge is cultural. Northern European tradition is based on eating animals and animal fats, and those fats, like butter and lard, come in solid form. The Southern European approach, like the Mediterranean diet, is based on plant-based oils, particularly olive.

While saturated fats provide none of the above-mentioned health benefits, they don’t have to be avoided entirely, just minimized to 5% of your diet, says Willett. For example, if you typically consume 2,000 calories a day, only 100 should come from saturated fats.

Eating out versus at home

If you’re eating at home and you’re using healthy oils, there is less concern about consuming the wrong fats or too much. Whether you’re frying, sautéing, or dressing a salad, you’re in control of all the factors. Using too much oil isn’t such a concern, Bhupathiraju says, since people usually regulate their intake through knowing when something will taste too oily.

Frying, in general, is often a worry, but it’s not necessarily unhealthy. It’s more about what’s being fried. Cheese, a saturated fat, wouldn’t be a great choice, but zucchini wouldn’t be bad, as Bhupathiraju says.

The concern with fried foods, and eating out in general, is what kind of oil is being used and how. With deep fryers, if the oil isn’t regularly changed, it repeatedly gets reheated and trans fats are created. These can produce inflammation in the body, which can lead to heart disease, type 2 diabetes, and contributes to the breakdown of cell membranes.

The easiest move is to avoid eating all fried foods. But Willett says that, again, that’s not always necessary. The use of trans fats was prohibited in 2018, so it’s likely a restaurant is using a healthier oil. Even so, eating fried foods occasionally isn’t too harmful.

Focus on maintaining a healthy diet, with good oils

Willett says that people get the majority of their calories from two sources — fats and carbohydrates — and “what’s important is both should be healthy,” he says.

When you eat healthy carbs and fats, you don’t have to worry about how much you’re eating of either. “The ratio doesn’t make much difference. They’re both healthy,” he says. The focus in on overall eating. A healthy diet can consist of mostly whole grains like brown rice, steel-cut oats, wheat berries, and quinoa. The less something is milled and made into a powder, the more slowly it will release into the body, preventing sudden spikes in blood sugar.

While low-fat diets had some popularity in the 1990s, low-fat products aren’t healthier. Willett says that research has shown that low-carb diets are more effective for weight loss than low-fat ones, and that low-fat diets are not more effective for weight loss than higher-fat ones.

The best approach to eating well is the science-backed recommendation of having lots of colors on your plate. Orange, yellow, green, and red foods supply various antioxidants and phytochemicals that may be protective to the body. When you compose your diet like this, chances are you’ll eat more slowly and consume fewer empty calories, Bhupathiraju says.

“Enjoy fats,” Willett says. “Good olive oil is good for you. It will help you enjoy the salad and make the eating experience and eating of vegetables more enjoyable.”

We all have habits we’d like to get rid of, and every night we give ourselves the same pep talk: I’ll go to bed earlier. I will resist that cookie. I will stop biting my nails. And then tomorrow comes, we cave, and feel worse than bad. We feel defeated and guilty because we know better and still can’t resist.

The cycle is understandable, because the brain doesn’t make changes easily. But breaking an unhealthy habit can be done. It takes intent, a little white-knuckling, and some effective behavior modification techniques. But even before that, it helps to understand what’s happening in our brains, with our motivations, and with our self-talk.

We feel rewarded for certain habits

Good or bad habits are routines, and routines, like showering or driving to work, are automatic and make our lives easier. “The brain doesn’t have to think too much,” say Dr. Stephanie Collier, director of education in the division of geriatric psychology at McLean Hospital, and instructor of psychiatry at Harvard Medical School.

Bad habits are slightly different, but when we try to break a bad one we create dissonance, and the brain doesn’t like that, says Dr. Luana Marques, associate professor of psychology at Harvard Medical School. The limbic system in the brain activates the fight-flight-or-freeze responses, and our reaction is to avoid this “threat” and go back to the old behavior, even though we know it’s not good for us.

Often, habits that don’t benefit us still feel good, since the brain releases dopamine. It does this with anything that helps us as a species to survive, like eating or sex. Avoiding change qualifies as survival, and we get rewarded (albeit temporarily), so we keep reverting every time. “That’s why it’s so hard,” Collier says.

Finding the reason why you want to change

But before you try to change a habit, it’s fundamental to identify why you want to change. When the reason is more personal — you want to be around for your kids; you want to travel more — you have a stronger motivation and a reminder to refer back to during struggles.

After that, you want to figure out your internal and external triggers, and that takes some detective work. When the bad-habit urge hits, ask when, where, and with whom it happens, and how you are feeling, be it sad, lonely, depressed, nervous. It’s a mixing and matching process and different for every person, but if you notice a clue beforehand, you might be able to catch yourself, Collier says.

The next part — and sometimes the harder part — is modifying your behavior. If your weakness is a morning muffin on the way to work, the solution might be to change your route. But environments can’t always be altered, so you want to find a replacement, such as having almonds instead of candy or frozen yogurt in lieu of ice cream. “You don’t have to aim for perfect, but just a little bit healthier,” Collier says.

You also want to avoid the all-or-nothing mindset, which leads to quick burnout, and instead take micro-steps toward your goal, Marques says. If you stay up until midnight but want to be in bed at 10, the reasonable progression is: start with 11:45; the next night 11:30; the next 11:15 … It builds success and minimizes avoiding the new habit.

It also helps to remember that urges follow a cycle. They’re initially intense, then wane, and usually go away in about 20 minutes. Collier suggests to set a timer and focus on “just getting through that.”

In that waiting period, seeking new sensations can provide useful distraction. You can go outside and feel the wind and smell the air. You can do something physical. Collier also likes using hot and cold. In the extreme, it’s submerging your face into a bowl of water, which can slow down your heart rate. But it could also be holding an ice cube or taking a hot shower. “You’re focused on the sensation and not the urge,” she says.

Accept that success isn’t a straight line

As you try to change, there will be bumps and setbacks, which are part of the process of lasting change. The problem is that we’re our own worst critics, and some people view anything except total success as complete failure.

Marques says to try to take a third-person perspective and think about how you’d react to a friend who said that having one bag of chips had ruined their whole diet. You’d be kind and reassuring, not critical, so give yourself the same treatment. A lot of the struggle with self-criticism is not seeing thoughts as facts, but merely thoughts. It takes practice, but it’s the same idea as with meditation. You treat what comes into your head as clouds, acknowledging them and letting them roll on through. “Everyone has distorted thoughts all the time,” Marques says. “It’s what you do with them.”

It also helps to reduce stress and minimize that sense of failure to know that the goal isn’t to make the old habit disappear, because it won’t. You’re just trying to strengthen the new routine so eventually it takes over, and the old habit isn’t even a thought. But it’s a constant process, made easier with self-compassion, because there’s no way to prepare for every situation or be able to predict when and where a trigger might happen.

“You can’t prepare for life,” Collier says. “Life is going to throw things at you.”

Discovering the cause of a disease is not easy. One reason is that the vast majority of diseases do not have a single cause. Instead, most diseases occur because multiple factors combine to cause the disease.

One factor is genes. Some people are born with one or more genes that make them vulnerable to a disease. Other factors come from your environment and behavior: what you eat, the air you breathe, the amount of physical activity you engage in, and habits such as smoking. Recent research finds that certain viruses may also be important contributing factors in causing multiple sclerosis (MS).

Multiple sclerosis harms cells in the brain and spinal cord — but why?

Multiple sclerosis is a disease of the brain and spinal cord that can cause many neurological symptoms, including arm and leg weakness, loss of vision, and difficulty thinking, as well as severe fatigue. Over the past 50 years we’ve learned that MS is an autoimmune disease: in various ways, the immune system attacks the brain and/or the spinal cord, leading to the symptoms of the illness.

However, we haven’t figured out why: what causes the immune system to go on the attack? Over the years, several viruses have been proposed as causes of MS, only to have subsequent research show that they were not. That led some MS doctors and scientists to discount viruses as possible causes.

Yet growing evidence in recent years points to several viruses that may be triggers of MS. The strongest evidence is for Epstein-Barr virus (EBV). This virus infects most people in developed nations like the US in their teen or young adult years.

Once a person is infected, the virus quietly remains alive in the body for the rest of a person’s life. In most people, it causes no health problems. But, rarely, it can cause certain cancers. Now, it has been linked to multiple sclerosis.

Delving deeper into a link between Epstein-Barr virus and MS

A large, long-term study from Harvard, published in the prestigious journal Science, attracted a lot of attention. Blood samples were repeatedly collected from 10 million US military personnel over 20 years. The samples were tested for evidence of infection with EBV.

Over the 20 years, some people in the study developed MS. The researchers compared two groups: people who were not infected with EBV when they entered military service, but then became infected later on; and people who remained uninfected by the virus. Those in the first group were 32 times more likely to develop MS than those in the second group. On average, symptoms of MS began about five years after a person became infected with EBV.

What do these findings tell us? The study provides strong evidence that a new infection with EBV is one important factor — maybe even a necessary factor — in causing MS. But the story is more complicated than that. Think about this: About 95% of all humans become permanently infected with EBV by early adulthood, but fewer than 1% of people develop MS. So, just being infected with EBV doesn’t mean a person will get MS — far from it. Indeed, other factors besides EBV infection also must be involved in causing MS.

Those other factors almost certainly include being born with certain genes that make you vulnerable to getting MS. Being infected with other viruses, as well as EBV, also may be important factors.

But which viruses? In my opinion, growing evidence indicates that a “cousin” of EBV, called human herpesvirus-6A, also may be important in triggering MS. And the genes of endogenous retroviruses also may be factors.

What are endogenous retroviruses?

About 8% of the genes that we are born with come from ancient viruses called retroviruses. These viral organisms successfully inserted their genes into the genes of the animals that preceded, and led to, humans. Some of those genes can be turned on to make proteins that affect our immune systems. Finally, there is evidence that each of these viruses — EBV, human herpesvirus-6A, and endogenous retroviruses — can activate one another, and gang up to cause a disease.

Going forward: New research may offer new leads for prevention

If the Epstein-Barr virus is one important factor in causing multiple sclerosis, then it is possible that vaccines against EBV might lead to fewer cases of MS. Indeed, several scientific groups around the world are working on such vaccines.

One company that made the mRNA vaccine for COVID-19 is working on an mRNA EBV vaccine. The National Institutes of Health also is developing a vaccine. However, it is unlikely we will know if they are effective against EBV, or against the development of MS, for at least a decade. Still, the linkage with this virus may prove to be an important milestone in ultimately conquering multiple sclerosis.

When you think about progressive brain disorders that cause dementia, you usually think of memory problems. But sometimes language problems — also known as aphasia — are the first symptom.

What’s aphasia?

Aphasia is a disorder of language because of injury to the brain. Strokes (when a blood clot blocks off an artery and a part of the brain dies) are the most common cause, although aphasia may also be caused by traumatic brain injuries, brain tumors, encephalitis, and almost anything else that damages the brain, including neurodegenerative diseases.

How neurodegenerative diseases cause aphasia

Neurodegenerative diseases are disorders that slowly and relentlessly damage the brain. After ruling out a brain tumor with an MRI scan, you can usually tell when aphasia is from a neurodegenerative disease, rather than a stroke or other cause, by its time course: Strokes happen within seconds to minutes. Encephalitis presents over hours to days. Neurodegenerative diseases cause symptoms over months to years.

Alzheimer’s disease is the most common neurodegenerative disease, but there are other types as well, such as frontotemporal lobar degeneration. Different neurodegenerative diseases damage different parts of the brain and cause different symptoms. When a neurodegenerative disease causes problems with language first and foremost, it is called primary progressive aphasia.

How is primary progressive aphasia diagnosed?

Primary progressive aphasia is generally diagnosed by a cognitive behavioral neurologist and/or a neuropsychologist who specializes in late-life disorders. The evaluation should include a careful history of any language and other problems that are present; a neurological examination; pencil-and-paper testing of thinking, memory, and language; blood tests to rule out vitamin deficiencies, thyroid disorders, infections, and other medical problems; and an MRI scan to look for strokes, tumors, and other abnormalities that can affect the brain’s structure.

The general criteria for primary progressive aphasia include:

• difficulty with language is the most prominent clinical feature at the onset and initial phases of the neurodegenerative disease
• these language problems are severe enough to cause impaired day-to-day functioning
• other disorders that could cause the language problems have been looked for and are not present.

There are three major variants of primary progressive aphasia

Primary progressive aphasia is divided into different variants based on which aspect of language is disrupted.

Logopenic variant primary progressive aphasia causes word-finding difficulties. Individuals with this variant have trouble finding common, everyday words such as table, chair, blue, knee, celery, and honesty. They know what these words mean, however.

Semantic variant primary progressive aphasia causes difficulty in understanding what words mean. When given the word, individuals with this variant may not understand what a table or chair is, which color is blue, where to find their knee, what celery is good for, and what honesty means.

Nonfluent/agrammatic variant primary progressive aphasia causes effortful, halting speech in which individuals know what they want to say but cannot get the words out. When they can get words out, their sentences often have incorrect grammar. Although they know what the individual words mean, they may have trouble understanding a sentence with complex grammar, such as, “The lion was eaten by the tiger.”

Different primary progressive aphasia variants are caused by different diseases

These primary progressive aphasia variants are not diseases themselves. They are symptoms of brain problems. Not sure what I mean? Consider three other symptoms: fever, headache, and chest pain. As you know, each of these symptoms may be caused by different underlying diseases.

The logopenic variant of primary progressive aphasia is usually caused by Alzheimer’s disease. Does that surprise you? What this means is that although Alzheimer’s disease typically begins with memory loss, in some individuals it can start with trouble finding words. Memory problems typically begin a few years later. (Why do we call it Alzheimer’s disease if it doesn’t start with memory problems? Because Alzheimer’s disease is defined by the pathology that we see under the microscope when we examine the brain tissue, not by its symptoms.)

The semantic variant of primary progressive aphasia is usually caused by frontotemporal lobar degeneration, and specifically by accumulation of TDP-43. TDP-43 is an abnormal protein that accumulates in — and ultimately kills — brain cells.

The nonfluent/agrammatic variant of primary progressive is also usually caused by frontotemporal lobar degeneration, but this time it is most often due to tau pathology. Tau accumulation leads to tangles inside cells that damage and then destroy them.

Can primary progressive aphasia be treated?

The treatments available for primary progressive aphasia are generally strategies and systems to help individuals with these disorders communicate better.

• Thinking of information related to the word they are looking for can sometimes help individuals with logopenic variant primary progressive aphasia. For example, if they are searching for the word lion, thinking of yellow, Africa, big cat, mane, and similar words may help.
• Using your tone of voice, facial expression, and body language can be helpful to communicate with individuals with semantic variant primary progressive aphasia, as can pantomiming the message you are trying to convey.
• Using pictures, either on paper or in a tablet-based application, can be helpful to individuals with all variants of primary progressive aphasia.

Unfortunately, there are no cures for primary progressive aphasia, and no medications that have been shown to be effective. Most patients with primary progressive aphasia develop other cognitive problems over time, leading to a more general dementia.

If you suspect that you (or your loved one) may have primary progressive aphasia, start by meeting with your doctor. If your doctor is concerned, they will send you (or your loved one) to the right specialist.

Before going any further, here’s the main thing parents should know about swimming lessons: all children should have them.

Every day, about 11 people die from drowning in the United States. Swimming lessons can’t prevent all of those deaths, but they can prevent a lot of them. A child doesn’t need to be able to swim butterfly or do flip turns, but the ability to get back to the surface, float, tread water, and swim to where they can stand or grab onto something can save a life.

10 things parents should know about swimming lessons

As you think about swimming lessons, it’s important to know:

1.  Children don’t really have the cognitive skills to learn to swim until they are around 4 years old. They need to be able to listen, follow directions, and retain what they’ve learned, and that’s usually around 4 years old, with some kids being ready a little earlier.

2.  That said, swim lessons between 1 and 4 years old can be useful. Not only are some kids simply ready earlier, younger children can learn some skills that can be useful if they fall into the water, like getting back to the side of a pool.

3.  The pool or beach where children learn must be safe. This sounds obvious, but safety isn’t something you can assume; you need to check it out for yourself. The area should be clean and well maintained. There should be lifeguards that aren’t involved in teaching (since teachers can’t be looking at everyone at all times). There should be something that marks off areas of deeper water, and something to prevent children from getting into those deeper areas. There should be lifesaving and first aid equipment handy, and posted safety rules.

4.  The teachers should be trained. Again, this sounds obvious — but it’s not always the case. Parents should ask about how teachers are trained and evaluated, and whether it’s under the guidelines of an agency such as the Red Cross or the YMCA.

5.  The ratio of kids to teachers should be appropriate. Preferably, it should be as low as possible, especially for young children and new swimmers. In those cases, the teacher should be able to have all children within arm’s reach and be able to watch the whole group. As children gain skills the group can get a bit bigger, but there should never be more than the teacher can safely supervise.

6.  There should be a curriculum and a progression — and children should be placed based on their ability. In general, swim lessons progress from getting used to the water all the way to becoming proficient at different strokes. There should be a clear way that children are assessed, and a clear plan for moving them ahead in their skills.

7.  Parents should be able to watch for at least some portion. You should be able to see for yourself what is going on in the class. It’s not always useful or helpful for parents to be right there the whole time, as it can be distracting for children, but you should be able to watch at least the beginning and end of a lesson. Many pools have an observation window or deck.

8.  Flotation devices should be used thoughtfully. There is a lot of debate about the use of “bubbles” or other flotation devices to help children learn to swim. They can be very helpful with keeping children safe at the beginning, and helping them learn proper positioning and stroke mechanics instead of swimming frantically to stay afloat, but if they are used, the lessons should be designed to gradually decrease any reliance on them.

9.  Being scared of the water isn’t a reason not to take, or to quit, swimming lessons. It’s common and normal to be afraid of the water, and some children are more afraid than others. While you don’t want to force a child to do something they are terrified of doing, giving up isn’t a good idea either. Start more gradually, with lots of positive reinforcement. The swim teacher should be willing to help.

10.  Just because a child can swim doesn’t mean he can’t drown. Children can get tired, hurt, trapped, snagged, or disoriented. Even strong swimmers can get into trouble. While swimming lessons help save lives, children should always, always be supervised around water, and should wear lifejackets for boating and other water sports.

The Centers for Disease Control and Prevention website has helpful information on preventing drowning.

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If dementia is a general term that means thinking and memory has deteriorated to the point that it interferes with day-to-day function, what are the top three disorders that cause dementia in older individuals?

Did you think of Alzheimer’s disease? Good! Alzheimer’s is the most common cause of dementia. Did you also think of vascular dementia or strokes? Excellent! Vascular dementia is the second most common cause. What about the third?

It’s not Lewy body dementia, although Lewy body dementia (encompassing both dementia with Lewy bodies and Parkinson’s disease dementia) is the fourth most common cause. Individuals with this disorder often have features of Parkinson’s disease, visual hallucinations of people and animals, fluctuations in attention and alertness, and they may act out their dreams in bed.

It’s not frontotemporal dementia. Individuals with this disorder are often in their 60s or younger. They generally have problems with behavior or language.

So what’s the answer? It’s LATE, which stands for limbic-predominant age-related TDP-43 encephalopathy.

What’s LATE?

In LATE, a protein called TDP-43 (which stands for transactive response DNA binding protein of 43 kDa) accumulates in brain cells. Once it accumulates, it injures and ultimately destroys the cells.

LATE generally damages many of the same areas affected by Alzheimer’s disease. These regions include

• the amygdala, involved in emotional regulation
• the hippocampus, involved in learning and memory
• the temporal lobe, involved in words and their meanings
• portions of the frontal lobes, involved with keeping information in mind and manipulating it.

What are the symptoms of LATE?

Because LATE affects many of the same brain regions as Alzheimer’s disease, it often presents with similar symptoms, including

• memory loss (impairment in episodic memory)
• trouble finding and understanding words (impairment in semantic memory)
• trouble keeping information in mind (impairment in working memory)

How common is LATE?

By itself, LATE is estimated to cause about 15% to 20% of all dementias. Many people with dementia also have LATE pathology in addition to one or more other pathologies in their brain. For example, an individual may have the plaques and tangles of Alzheimer’s pathology, plus LATE pathology, plus ministrokes (vascular pathology). It turns out that about 40% of people with dementia have at least some LATE pathology in their brain. All of this means that LATE is, indeed, very common.

How is LATE diagnosed and why haven’t you heard of it before?

LATE can only be diagnosed with certainty at autopsy. However, we can get a hint that LATE might be present when an older individual shows the memory loss and word-finding problems common in Alzheimer’s disease, but special tests used to confirm the diagnosis of Alzheimer’s come up negative.

The reason that you — and most clinicians — haven’t heard about LATE before is that we didn’t realize just how common it is. It was only when we began obtaining results of special tests to diagnose Alzheimer’s disease in living individuals (such as with a lumbar puncture or amyloid PET scan) that we began seeing the prevalence of LATE.

Can LATE be treated?

Because LATE was (and still is) often confused with Alzheimer’s disease, it is almost certain that when the main drugs that are FDA-approved to treat Alzheimer’s disease were evaluated, individuals with LATE were included in those studies. This means that there is every reason to believe that drugs like donepezil (brand name Aricept), rivastigmine (Exelon), memantine (Namenda), and galantamine will all be effective for individuals with dementia due to LATE.

How can you find out more about LATE?

There has been an explosion of scientific papers about LATE in just the last few years. If you have a science background, you might want to peruse them or watch the wonderful scientific symposium on this disorder held by the National Institute on Aging (NIA). If you don’t have a science background, take a look at the NIA or Wikipedia pages on LATE.

My favorite summer activities officially kick in when the calendar flips to May. It’s prime time for open water swimming, running, cycling, hiking, and anything else that gets me outside and moving. Yet, my first step is to get my legs in shape.

“Legs are the foundation for most activities,” says Vijay Daryanani, a physical therapist at Harvard-affiliated Spaulding Rehabilitation Hospital. “They’re home to some of the body’s largest muscles, and building healthy legs can improve one’s performance, reduce injury, and increase endurance.”

Four leg muscle groups to build for summer activities

Four muscles do the most leg work: quadriceps, gluteus maximus (glutes), hamstrings, and calves. Here is a look at each.

Quadriceps (quads). Also known as the thigh muscles, the quads are a group of four muscles (hence the prefix “quad’). They extend your leg at the knee and power every leg action: stand, walk, run, kick, and climb.

Glutes. The body’s largest muscles, the glutes (your buttock muscles) keep you upright and help the hips and thighs propel your body forward.

Hamstrings. The hamstrings are a group of three muscles that run along the back of your thighs from the hip to just below the knee. They allow you to extend your leg straight behind your body and support hip and knee movements.

Calves. Three muscles make up the calf, which sits in the back of the lower leg, beginning below the knee and extending to the ankle. They work together to move your foot and lower leg and push you forward when you walk or run.

Spotlight muscle strength and length

Strength and length are the most important focus for building summer-ready legs, says Daryanani. “Strengthening leg muscles increases power and endurance, and lengthening them improves flexibility to protect against injury.”

If you are new to exercise or returning to it after time off, first get your legs accustomed to daily movement. “Start simply by walking around your home nonstop for several minutes each day, or climbing up and down stairs,” says Daryanani.

After that, adopt a walking routine. Every day, walk at a moderate pace for 20 to 30 minutes. You can focus on covering a specific distance (like one or two miles) or taking a certain number of steps by tracking them on your smartphone or fitness tracker. You won’t just build leg strength — you’ll reap a wide range of health benefits.

There are many different leg muscle-building exercises, some focused on specific activities or sports. Below is a three-move routine that targets the four key leg muscles. Add them to your regular workout or do them as a leg-only routine several times a week. (If you have any mobility issues, especially knee or ankle problems, check with your doctor before starting.)

To help lengthen your leg muscles and increase flexibility, try this daily stretching routine that includes several lower-body stretches.

Dumbbell squats

Muscles worked: glutes and quads

Reps: 8-12

Sets: 1-2

Rest: 30-90 seconds between sets

Starting position: Stand with your feet apart. Hold a weight in each hand with your arms at your sides and palms facing inward.

Movement: Slowly bend your hips and knees, leaning forward no more than 45 degrees and lowering your buttocks down and back about eight inches. Pause. Slowly rise to an upright position.

Tips and techniques:

• Don’t round or excessively arch your back

Make it easier: Do the move without holding weights.

Make it harder: Lower yourself at a normal pace. Hold briefly. Stand up quickly.

Reverse lunge

Muscles worked: quads, glutes, hamstrings

Reps: 8-12

Sets: 1-3

Rest: 30-90 seconds between sets

Starting position: Stand straight with your feet together and your arms at your sides, holding dumbbells.

Movement: Step back onto the ball of your left foot, bend your knees, and lower into a lunge. Your right knee should align over your right ankle, and your left knee should point toward (but not touch) the floor. Push off your left foot to stand and return to the starting position. Repeat, stepping back with your right foot to do the lunge on the opposite side. This is one rep.

Tips and techniques:

• Keep your spine neutral when lowering into the lunge.
• Don’t lean forward or back.
• As you bend your knees, lower the back knee directly down toward the floor with the thigh perpendicular to the floor.

Make it easier: Do lunges without weights.

Make it harder: Step forward into the lunges, or use heavier weights.

Calf raises

Muscles worked: calves

Reps: 8-12

Sets: 1-2

Rest: 30 seconds between sets

Starting position: Stand with your feet flat on the floor. Hold on to the back of a chair for balance.

Movement: Raise yourself up on the balls of your feet as high as possible. Hold briefly, then lower yourself.

Make it easier: Lift your heels less high off the floor.

Make it harder: Do one-leg calf raises. Tuck one foot behind the other calf before rising on the ball of your foot; do sets for each leg. Or try doing calf raises without holding on to a chair.