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Animals renowned for their outstanding night vision include owls, cats, tarsiers (a tiny primate in Southeast Asia) — and even the dung beetle.

But humans? Not so much.

Over time, many people suffer from night blindness, also known as nyctalopia. This condition makes seeing in dim or dark settings difficult because your eyes cannot adjust to changes in brightness or detect light.

What are the dangers for those experiencing night blindness?

Night blindness is especially problematic and dangerous when driving. Your eyes cannot adjust between darkness and the headlights of oncoming vehicles, other cars may appear out of focus, and your depth perception becomes impaired, which makes it difficult to judge distances.

Night blindness also may affect your sight at home by making it hard for your vision to quickly adjust to a dark room after turning off the lights. “This can cause people to bump into furniture or trip and suffer an injury,” says Dr. Isabel Deakins, an optometrist with Harvard-affiliated Massachusetts Eye and Ear.

What happens in the eye to create night blindness?

The ability to see in low-light conditions involves two structures in the eye: the retina and the iris.

The retina, located in the back of the eye, contains two types of light-detecting cells called cones and rods. The cones handle color vision and fine details while the rods manage vision in dim light.

The iris is the colored part of your eye. It contains muscles that widen or narrow the opening of your pupil to adjust how much light can enter your eyes.

If your irises don’t properly react, the pupils can dilate and let in too much light, which causes light sensitivity and makes it hard to see in bright light. Or your pupils may remain too small and not allow in enough light, making it tough to see in low light.

What causes night blindness?

Night blindness is not a disease but a symptom of other conditions. “It’s like having a bruise on your body. Something else causes it,” says Dr. Deakins.

Several conditions can cause night blindness. For instance, medications, such as antidepressants, antihistamines, and antipsychotics, can affect pupil size and how much light enters the eye.

Eye conditions that can cause night blindness include:

• glaucoma, a disease that damages the eye’s optic nerves and blood vessels
• cataracts, cloudy areas in the lens that distort or block the passage of light through the lens
• dry eye syndrome.

However, one issue that raises the risk of night blindness that you can’t control is age. “Our eyes react more slowly to light changes as we age, and vision naturally declines over time,” says Dr. Deakins.  “The number of rods in our eyes diminish, pupils get smaller, and the muscles of the irises weaken.”

What helps if you have night blindness?

If you notice any signs of night blindness, avoid driving and get checked by an eye care specialist like an optometrist or ophthalmologist. An eye exam can determine if your eyeglass prescription needs to be updated.

“Often, a prescription change is enough to reduce glare when driving at night," says Dr. Deakins. “You may even need separate glasses with a stronger eye prescription that you wear only when driving at night.”

Adding an anti-reflective coating to your lens may help to cut down on the glare of the headlights of an oncoming car. However, skip the over-the-counter polarized driving glasses sold at many drug stores. "These may help cut down on glare, but they don't address the causes of night blindness," says Dr. Deakins.

An eye exam also will identify glaucoma or cataracts, which can be treated. Glaucoma treatments include eyedrops, laser treatment, or surgery. Cataracts are corrected with surgery to replace the clouded lens with an artificial one. Your eye care specialist can also help identify dry eye and recommend treatment.

Ask your primary care clinician or a pharmacist if any medications that you take may cause night blindness. If so, it may be possible to adjust the dose or switch to another drug.

Three more ways to make night driving safer

You also can take steps to make night driving safer. For example:

• Wash the lenses of your glasses regularly. And take them to an optician to buff out minor scratches.
• Keep both sides of your front and rear car windshields clean so that you can see as clearly as possible.
• Dim your dashboard lights, which cause glare, and use the night setting on your rearview mirror.

About the Author

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

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

Do you ever read the notes written by your doctor or health practitioner during a medical visit? If not, you might want to check them out. Usually, these medical notes are full of helpful insights about your health and reminders of recommendations discussed. And there’s medicalese, of course: hard-to-pronounce illnesses, medications, and technical terms.

But you may be surprised to see incorrect information or unexpected language, tone, or even innuendo. Was your past medical history really that “unremarkable”? Did you actually “deny” drinking alcohol? Did the note describe you as “unreliable”?

Here’s how to decipher unfamiliar lingo, understand some surprising descriptions, and flag any errors you find.

What’s in a medical note?

A standard medical note has several sections. These include

• a description of current symptoms
• past medical problems
• a list of medications taken
• family medical history
• social habits such as smoking, drinking alcohol, or drug use
• details of the physical examination
• test results
• a discussion of the big picture, along with recommendations for further evaluation or treatment.

Notes tend to be more complete for a new patient or annual exam. Follow-up notes may not cover all of these points.

What’s potentially confusing about medical notes?

Most medical notes aren’t written using plain language because they aren’t intended primarily for a nonmedical audience. So it’s common to run across:

• Medical jargon: You had an upset stomach and a fever. Doctors may say “dyspepsia” (upset stomach) and “febrile” (fever).
• Complicated disease names: Ever heard of “multicentric reticulohistiocytosis” or “progressive multifocal leukoencephalopathy?” These are just two of thousands of examples.
• Use of common language in uncommon ways: For example, your medical history might be called “unremarkable” and test results called "within normal limits” rather than “normal.”
• Abbreviations: You might see “VSS” and “RRR,” meaning “vital signs stable” with a pulse that has a “regular rate and rhythm.”

If you’re having trouble deciphering a note or understanding your health issues, tests, and recommendations, check in with your doctor’s office for clarifications. The more you understand about your health and your options for care, the better.

What if a medical note is incorrect?

Minor errors in medical notes are not rare: maybe you had your tonsils removed 30 years ago, not 10 years ago. But there can be more important errors: stating that arthritis in your left knee is severe when it’s actually the right knee that’s severe could lead to having x-rays (or even surgery!) on the wrong side. And not properly recording a family history of cancer or heart disease could mean missing out on timely screening tests or preventive treatments.

In an era of ever-increasing time pressure, use of voice recognition software, electronic record templates, drop-down menus, and ability to copy and paste text, it’s easier than ever for health care providers to make (and perpetuate) errors in the medical record.

If you do see an important error that could affect your health, ask your provider to amend it.

What if the language in a medical note seems offensive?

Numerous studies have highlighted the problem of stigmatizing language in medical notes that can leave people feeling judged or offended. Negative attitudes can affect the quality of our health care and willingness to seek care, and can also widen health disparities. One study linked stigmatizing language to higher rates of medical errors. Of note, this study found higher rates of stigmatizing language and medical error among black patients.

Examples include:

• Depersonalization: A note might describe a patient as “a drug abusing addict” rather than a person struggling with drug addiction.
• Insulting or inappropriate descriptors: Notes might contain subjective descriptions that paint the patient in an unflattering light without providing context. For example, the note might say “the patient is unkempt and is drug-seeking” rather than “the patient is experiencing homelessness and has severe, chronic pain.” If a person’s recall of medical events from the past is hazy, they may be called “unreliable.”
• Dismissiveness: A medical note may suggest a symptom is not real or is exaggerated, rather than taking the complaint seriously.
• An untrusting tone: Language such as “she claims she never drinks” or “he denies alcohol use” may suggest mistrust by the physician.

Why might this happen, anyway?

How does such language make its way into medical notes? (To be clear, these possible explanations are not justifications.)

• Tradition and training: Medical trainees, like other learners, tend to follow the lead of their mentors. So if stigmatizing language is used by an instructor, trainees may do the same.
• Time pressure: With medical documentation (as in most everything else), mistakes are more common if you’re rushing.
• Bias: Like everyone else, doctors have biases, including ones they aren’t aware of. How we are taught to think about people — by family, by society — can spill over into every area of life, including work.
• Frustration: Doctors may feel frustrated by patients who don’t follow their recommendations. That frustration can be reflected in their medical notes. For example, a note may say, “As expected, the patient’s blood sugar is high; he is still not checking his blood sugar or following the diet recommended by his nutritionist.”

If the language in a note is confusing or bothersome, ask about it. The Open Notes movement and federal legislation have given most of us much better access to our medical records. This has worthy goals — greater transparency and better communication with people about their medical care — and unintended consequences.

Is changing language in notes that health practitioners once shared mainly with each other a positive consequence? Mostly. Yet some doctors worry that notes will become less specific, accurate, or useful since they may leave out information that might upset a patient.

The bottom line

I encourage you to read your health providers’ notes about your care. If there is a substantial error or something you find confusing or objectionable, ask about it. By the way, a signed medical note cannot usually be revised. However, your doctor can make clarifications or correct mistakes in an addendum at the end of the note.

As more and more patients read their medical notes, it’s likely that health providers will be more conscientious about the language they use. So, wide access to medical notes may improve not only people’s understanding of their health, but also the quality of notes over time.

It's worth remembering that the medical note is not the most important thing that happens during a visit to your doctor. A great note isn’t the same as great care, and vice versa. Still, your medical notes can be a valuable source of health information that differs from all others, including trusted health sites and social media: they’re written by your doctor and they’re all about you.

About the Author

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

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

Americans love their ultra-processed foods, whether they come as cereal (like Cap’n Crunch, a favorite of mine as a kid), snack foods (like Cheetos), entr’es (like hot dogs), or desserts (like Twinkies). Sure, loading your plate with vegetables, fruits, fish, healthful oils, and grains in a Mediterranean-style diet boosts heart and brain health. But if you also eat some ultra-processed foods, is that bad for your brain health?

What to know about this new study

A new study appears to deliver resounding yes: eating ultra-processed foods is linked to a greater risk of cognitive impairment and strokes.

This well-designed observational study examined data from the REGARDS (REasons for Geographic And Racial Differences in Stroke) project, a longitudinal study of non-Hispanic Black and white Americans ages 45 years and older. Study participants were initially enrolled between 2003 and 2007 and were given a number of questionnaires evaluating health, diet, exercise, body mass index, education, income, alcohol use, mood, and other factors. In addition, tests of memory and language were administered at regular intervals.

To examine the risk of stroke and cognitive impairment, data from 20,243 and 14,175 participants, respectively, were found usable based on the quality of the information from the questionnaires and tests. Approximately one-third of the sample identified as Black and the majority of the remaining two-thirds identified as white.

The results of the study

• According to the authors’ analysis, increasing the intake of ultra-processed foods by just 10% was associated with a significantly greater risk of cognitive impairment and stroke.
• Intake of unprocessed or minimally processed foods was associated with a lower risk of cognitive impairment.
• The effect of ultra-processed foods on stroke risk was greater for individuals who identified as Black compared to individuals who identified as white.

Study participants who reported following a healthy diet (like a Mediterranean, DASH, or MIND diet) and consumed minimal ultra-processed foods appeared to maintain better brain health compared to those who followed similar healthy diets but had more ultra-processed foods.

Why might ultra-processed foods be bad for your brain?

Here are some biologically plausible reasons:

• UPFs are generally composed of processed carbohydrates that are very quickly broken down into simple sugars, equivalent to eating lots of candy. These sugar loads cause spikes of insulin, which can alter normal brain cell function.
• Eating ultra-processed foods is associated with a higher risk of metabolic syndrome and obesity, well-established conditions linked to high blood pressure, abnormal blood lipid levels, and type 2 diabetes.
• There are unhealthy additives in ultra-processed foods to change the texture, color, sweetness, or flavor. These additives disrupt the microbiome in the gut and can lead to gut inflammation that can cause
  • the production of microbiome-produced metabolites that can affect brain function (such as short-chain fatty acids and lipopolysaccharides)
  • leaky gut, allowing toxins and inflammatory molecules to enter the bloodstream and go to the brain
  • altered neurotransmitter function (such as serotonin) that can impact mood and cognition directly
  • increased cortisol levels that mimic being under chronic stress, which can directly impact hippocampal and frontal lobe function, affecting memory and executive function performance, respectively
  • an increased risk for Alzheimer’s, Parkinson’s, and other neurodegenerative diseases due to inflammatory molecules traveling from the gut to the brain.
• Because ultra-processed foods have poor nutritional value, people will often be hungry shortly after eating them, leading to overeating and its consequences.

The take-home message

Avoid processed foods, which can include chips and other snack foods, industrial breads and pastries, packaged sweets and candy, sugar-sweetened and diet sodas, instant noodles and soups, ready-to-eat meals and frozen dinners, and processed meats such as hot dogs and bologna. Eat unprocessed or minimally processed foods, which — when combined with a healthy Mediterranean menu of foods — include fish, olive oil, avocados, whole fruits and vegetables, nuts and beans, and whole grains.

About the Author

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

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

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

Every year, over 4,500 people die from drowning in the United States — and, in fact, drowning is the leading cause of death for children ages 1 to 4. 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 life jackets for boating and other water sports.

The Centers for Disease Control and Prevention website has helpful information on preventing drowning. The American Red Cross offers an online water safety course for caregivers and parents and water safety videos for children. Many public pools and organizations like Boys & Girls Clubs and the YMCA offer swimming classes for all ages.

About the Author

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

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

About the Reviewer

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

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

Nantucket, a beautiful, 14-mile-long island off the coast of Massachusetts, has a 40-point resiliency plan to help withstand the buffeting seas surrounding it as climate change takes a toll. Perhaps we can all benefit from creating individual resilience plans to help handle the big and small issues that erode our sense of well-being. But what is resilience and how do you cultivate it?

What is resilience?

Resilience is a psychological response that helps you adapt to life’s difficulties and seek a path forward through challenges.

“It’s a flexible mindset that helps you adapt, think critically, and stay focused on your values and what matters most,” says Luana Marques, an associate professor of psychiatry at Harvard Medical School.

While everyone has the ability to be resilient, your capacity for resilience can take a beating over time from chronic stress, perhaps from financial instability or staying in a job you dislike. The longer you’re in that situation, the harder it becomes to cope with it.

Fortunately, it’s possible to cultivate resilience. To do so, it helps to exercise resiliency skills as often as possible, even for minor stressors. Marques recommends the following strategies.

Shift your thoughts

In stressful situations, try to balance out your thoughts by adopting a broader perspective. “This will help you stop using the emotional part of your brain and start using the thinking part of your brain. For example, if you’re asking for a raise and your brain says you won’t get it, think about the things you’ve done in your job that are worthy of a raise. You’ll slow down the emotional response and shift your mindset from anxious to action,” Marques says.

Approach what you want

“When you’re anxious, stressed, or burned out, you tend to avoid things that make you uncomfortable. That can make you feel stuck,” Marques says. “What you need to do is get out of your comfort zone and take a step toward the thing you want, in spite of fear.”

For example: If you’re afraid of giving a presentation, create a PowerPoint and practice it with colleagues. If you’re having conflict at home, don’t walk away from your partner — schedule time to talk about what’s making you upset.

Align actions with your values

“Stress happens when your actions are not aligned with your values — the things that matter most to you or bring you joy. For example, you might feel stressed if you care most about your family but can’t be there for dinner, or care most about your health but drink a lot,” Marques says.

She suggests that you identify your top three values and make sure your daily actions align with them. If being with family is one of the three, make your time with them a priority — perhaps find a way to join them for a daily meal. If you get joy from a clean house, make daily tidying a priority.

Tips for success

Practice the shift, approach, and align strategies throughout the week. “One trick I use is looking at my calendar on Sunday and checking if my actions for the week are aligned with my values. If they aren’t, I try to change things around,” Marques says.

It’s also important to live as healthy a lifestyle as possible, which will help keep your brain functioning at its best.

Healthy lifestyle habits include:

• getting seven to nine hours of sleep per night
• following a healthy diet, such as a Mediterranean-style diet
• aiming for at least 150 minutes of moderate-intensity activities (such as brisk walking) each week — and adding on strength training at least twice a week
• if you drink alcohol, limiting yourself to no more than one drink per day for women and two drinks per day for men
• not smoking
• staying socially connected, whether in person, by phone or video calls, social media, or even text messages.

Need resilience training?

Even the best athletes have coaches, and you might benefit from resilience training.

Consider taking an online course, such as this one developed by Luana Marques. Or maybe turn to a therapist online or in person for help. Look for someone who specializes in cognitive behavioral therapy, which guides you to redirect negative thoughts to positive or productive ones.

Just don’t put off building resilience. Practicing as you face day-to-day stresses will help you learn skills to help navigate when dark clouds roll in and seas get rough.

About the Author

Heidi Godman, Executive Editor, Harvard Health Letter

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

About the Reviewer

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

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

Cognitive behavioral therapy (CBT) teaches people to challenge negative thought patterns and turn less often to unhelpful behaviors. These strategies can improve your mood and the way you respond to challenging situations: a flat tire, looming deadlines, family life ups and downs.

Yet there’s much more depth and nuance to this well-researched form of psychotherapy. It has proven effective for treating anxiety, depression, and other mental health conditions. Tailored versions of CBT can also help people cope with insomnia, chronic pain, and other nonpsychiatric conditions. And it can help in managing difficult life experiences, such as divorce or relationship problems.

What are the key components of CBT?

One important aspect of CBT relates to perspective, says psychologist Jennifer Burbridge, assistant director of the Cognitive Behavioral Therapy Program at Harvard-affiliated Massachusetts General Hospital.

“Therapists who practice CBT don’t see the problems or symptoms people describe as having one single cause, but rather as a combination of underlying causes,” she says. These include

• biological or genetic factors
• psychological issues (your thoughts, physical sensations, and behaviors)
• social factors (your environment and relationships).

Each of these factors contributes to — and helps maintain — the troublesome issues that might prompt you to seek therapy, she explains.

How does CBT describe our emotions?

Our emotions have three components: thoughts, physical sensations, and behaviors.

“Thoughts are what we say to ourselves, or 'self-talk,'” says Burbridge. Physical sensations are what we observe in our bodies when we experience an emotional situation: for example, when your heart rate rises in stressful circumstances. Behaviors are simply the things you do — or do not do. For instance, anxiety might prevent you from attending a social event.

All three components are interrelated and influence one another. That’s why CBT helps people to develop skills in each of them. “Think of it as a wellness class for your emotional health,” says Burbridge.

How long does CBT last?

CBT is a goal-oriented, short-term therapy. Typically it involves weekly, 50-minute sessions over 12 to 16 weeks. Intensive CBT may condense this schedule into sessions every weekday over one to three weeks.

Is CBT collaborative?

“When I first meet with someone, I’ll listen to what’s going on with them and start thinking about different strategies they might try,” Burbridge says. But CBT is a collaborative process that involves homework on the patient’s part.

What might that mean for you? Often, a first assignment involves self-monitoring, noting whether there are certain things, events, or times of day that trigger your symptoms. Future sessions focus on fine-tuning approaches to elicit helpful, adaptive self-talk, and problem-solving any obstacles that might prevent progress.

Certain thinking patterns are often associated with anxiety or depression, says Burbridge. Therapists help people recognize these patterns and then work with patients to find broader, more flexible ways to cope with difficult situations.

“We’re cognitive creatures with big frontal lobes that help us analyze situations and solve problems. That’s useful in some situations. But at other times, when you’re trying to manage your emotions, it may be better to pause and acknowledge and accept your discomfort,” says Burbridge.

Which CBT tools and strategies can help?

That particular skill — paying attention in the present moment without judgement, or mindfulness — is a common CBT tool. Another strategy that’s helpful for anxiety, known as exposure or desensitization, involves facing your fears directly.

“People avoid things that make them nervous or scared, which reinforces the fear,” says Burbridge. With small steps, you gradually expose yourself to the scary situation. Each step provides learning opportunities — for example, maybe you realize that the situation wasn’t as scary as you though it would be.

By trying new things instead of avoiding them, you begin to change your thought patterns. These more adaptive thinking patterns then make it more likely you will try new or challenging experiences in the future, thereby increasing your self-confidence.

How does CBT work?

Brain imaging research suggests conditions like depression or anxiety change patterns of activity in certain parts of the brain. One way CBT may help address this is by modifying nerve pathways involved in fear responses, or by establishing new connections between key parts of the brain.

A 2022 review focused on 13 brain imaging studies of people treated with CBT. The analysis suggested CBT may alter activity in the prefrontal cortex (often called the “personality center”) and the precuneus (which is involved in memory, integrating perceptions of the environment, mental imagery, and pain response).

Who might benefit from CBT?

CBT is appropriate for people of all different ages. This can range from children as young as 3 years — in tandem with parents or caregivers — to octogenarians. In addition to treating anxiety and depression, CBT is also effective for

• eating disorders
• substance abuse
• personality disorders
• attention deficit hyperactivity disorder (ADHD)
• obsessive compulsive disorder (OCD).

Additional evidence shows CBT may help people with different health issues, including irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, insomnia, migraines, and other chronic pain conditions. The therapy may also benefit people with cancer, epilepsy, HIV, diabetes, and heart disease.

“Many medical conditions can limit your activities. CBT can help you adjust to your diagnosis, cope with the new challenges, and still live a meaningful life, despite the limitations,” says Burbridge.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

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

About the Reviewer

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

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

If you spend time outdoors — which we all should do, for all sorts of reasons — you are likely to encounter biting bugs. Most of the time the bites are just a nuisance. But besides the fact that sometimes they can be painful or itchy, bug bites can lead to illness — like Lyme disease from ticks, or Zika, malaria, or West Nile disease from mosquitoes. So preventing bites is a good idea for all of us, and certainly for children.

Simple precautions will help

Before talking about insect repellents, it’s important to remember that there are simple and effective precautions, nearly all of which don’t involve any chemicals. For example:

• Empty out any standing water outside your home. That’s where mosquitoes breed.
• Wear long-sleeved shirts and long pants if you are going to be in areas with lots of biting insects. If you treat clothes (and shoes and gear) with 0.5% permethrin, it can be helpful.
• Be aware that mosquitoes are most likely to be out at dusk and dawn, and plan activities accordingly.
• To avoid tick bites, avoid wooded and brushy areas and keep to the center of paths when you hike. Be sure to do a tick check when you come home — not just of all the people in your group, but also any pets or gear that came along. Taking a shower soon after arriving home can help with both tick checks and washing off any unattached ticks.

Make choices about insect repellent

Insect repellents can be very useful. Some are more effective than others, and some can have side effects, so it’s important to do your homework. The Environmental Protection Agency has a great interactive tool that can help you choose the best repellent for your particular situation.

The most effective repellent is DEET (N, N-diethyl-meta-toluamide). It works against both mosquitoes and ticks, and is definitely the go-to repellent if you really want or need to prevent bites. The higher the concentration, the longer it lasts: 10% will give you about two hours of coverage, while 30% can protect you for about five hours. The American Academy of Pediatrics (AAP) recommends not using more than 30% on kids, and not using any repellents on infants less than 2 months old.

The most common side effect is skin irritation, and if you ingest it (you never know with little kids) it can lead to nausea and vomiting. Eye irritation is possible, which is why you should never spray any repellent directly to the face, but rather put it on your hands and then carefully apply to the face. In very rare cases, like one in every 100 million users, DEET can lead to brain problems such as seizures if used in high doses. This is an incredibly rare side effect, and not something that should stop you from using it, especially if you are in an area with a lot of ticks, or an area with lots of disease-carrying mosquitoes.

Here are some alternatives with minimal to no side effects (eye irritation most common; avoid as noted above):

• oil of lemon eucalyptus, or PMD (the manmade alternative). This works nearly as well as DEET.
• picaridin, which works better against mosquitoes than ticks
• 2-undecanone
• IR-3535, the active ingredient in Avon products, although it is not very effective
• citronella, although it is even less effective.

Applying insect repellent — and sunscreen

Whatever you use, follow label directions and be sure that you are careful as you apply it to all exposed skin. It’s best to spray in an open area — and spray clothing too. Pump bottles and wipes with insect repellent may help you apply products carefully. Try to choose the best product for your situation so that you can apply it just once; the EPA tool is great for that. Don’t forget sunscreen; apply that first so your skin can absorb it.

The Centers for Disease Control and Prevention (CDC) has more information about applying insect repellent on children and preventing bites from mosquitoes and ticks.

Also visit the Harvard Health Publishing Lyme Wellness Initiative to learn about preventing –– or living with –– Lyme disease and other tick-borne illnesses.

About the Author

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

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

Each year, more than 4.5 million dog bites occur in the United States. Despite what you might assume, most of these incidents don’t happen when an unfamiliar dog attacks someone in a park or another outdoor location. Instead, most dog bites are inflicted by a pet dog in a home.

Here’s advice for avoiding these upsetting and potentially serious injuries — and the steps you should take if you sustain a dog bite.

Why do dog bites happen?

Some dog bites happen by accident when people wrestle or play tug-of-war with their dog. But most of the time, dogs bite people as a reaction to feeling stressed, threatened, scared, or startled, according to the American Veterinary Medical Association (AVMA). More than half of dog bites occur in children, and they’re far more likely to be seriously injured than adults.

“People don’t always heed the behavioral signals that a dog is uncomfortable,” says Dr. Christopher Baugh, associate professor of emergency medicine at Harvard Medical School. For example, some dogs are highly territorial and will bark, growl, snap, and lunge if outsiders enter their space — whether that’s an apartment, yard, or crate. Or dogs may exhibit resource guarding, which shows up as anxious, aggressive behavior around food, toys, or beds.

“These situations can be high-risk, and children in particular have less awareness of that risk,” says Dr. Baugh, who has children and two mixed-breed rescue dogs, Harley and Roxi.

What can you do to prevent dog bites?

Any dog — even a sweet, cuddly dog — can bite if provoked, according to the AVMA. Never leave young children alone with a dog without adult supervision. And teach children to never disturb a dog while it’s eating, sleeping, or caring for puppies.

In a study of 321 facial dog bites treated at Harvard-affiliated Massachusetts General Hospital over a 20-year period, 88% of the bites were from known dogs. Most were in adults and occurred after playing with the dog, feeding the dog, and placing their face close to the dog. However, the hand (usually a person’s dominant hand) is probably the most common location for a dog bite in an adult, says Dr. Baugh.

Other tips from the CDC to prevent dog bites include the following:

• Always ask a dog’s owner if it’s okay to pet their dog, even if the dog appears friendly.
• Make sure the dog sees and sniffs you before reaching out to pet it.
• Don’t pet a dog that seems to be hiding, scared, sick, or angry.

What if an unfamiliar dog approaches you? Remain calm and still, avoiding eye contact with the dog. Stand with the side of your body facing the dog and say “no” or “go home” in firm, deep voice. Wait for the dog to retreat or move yourself slowly away.

What should you do if you’re bitten by a dog?

Clean the wound with mild soap and running water, then cover it with a clean bandage or cloth. Some online resources recommend applying an antibiotic ointment or cream. But these products are recommended only for people with clear evidence of an infection, such as redness, pus, pain, swelling, or warmth, according to the American Academy of Dermatology.

If the injury is serious — with a bite on the face, heavy bleeding, or a possible broken bone — go to the emergency room. That’s also a good idea if you’re bitten by an unknown or stray dog, in the rare event that you might need medicines to prevent rabies (rabies post-exposure prophylaxis).

“Often, people are shocked after being bit and will understandably focus all their attention on their wound,” says Dr. Baugh. The dog’s owner may check in to see if you’re okay, but then walk away. But you should get the person’s contact information and make sure the dog is vaccinated against rabies, he says.

Keep in mind that:

• Emergency rooms are often crowded with long waits, so an urgent care clinic is a good option if the injury doesn’t require immediate attention.
• Some wounds require stitches, ideally within 12 to 24 hours.
• The doctor may prescribe antibiotics to prevent possible infections, especially if you have health problems such as a weakened immune system or diabetes.
• You may also need a tetanus booster if you haven’t had one in the past 10 years. If your vaccine history isn’t available or you can’t remember, you’ll get a tetanus booster just in case.

What if a dog bite is less serious?

Let’s say you have a less serious bite from a family dog known to have a current rabies vaccine. Bites that don’t require stitches can be cleaned with mild soap and running water, then evaluated by your regular health care provider. They may tell you to simply monitor the wound for signs of infection.

“Doctors are trying to be more thoughtful about prescribing antibiotics and limit their use in low-risk situations, because overuse contributes to antibiotic resistance and exposes people to potential side effects without any benefit,” says Dr. Baugh.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

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

About the Reviewer

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

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

Editor's note: Health inequities have long been an issue for people in the LGBTQ+ community. We're pleased to share a post from our colleagues in Corporate Learning at Harvard Medical School focusing on solutions that health care leaders can champion.

Health care business professionals can improve patient outcomes and reduce health inequities by championing the health care needs of the lesbian, gay, bisexual, transgender, queer and/or questioning, intersex, asexual, and two-spirit (LGBTQIA2+) community. These issues are an important priority for health care professionals year-round, not just during Pride Month.

Research shows that the LGBTQIA2+ community faces disproportionate adverse health conditions due to health inequities. It’s important for those working in the health care industry to be aware of the challenges the LGBTQIA2+ community faces to help make systemic changes and improve health outcomes.

The LGBTQIA2+ community — which is less likely to trust the health care system — is a rising part of the population. The 2022 national Gallup survey shows that at least 20% of Gen Z identifies as LGBTQIA2+. This includes our coworkers, customers, and clients, says Dr. Alex Keuroghlian, a psychiatrist at Massachusetts General Hospital and faculty advisor for LGBT and Allies at Harvard Medical School (LAHMS).

“LGBTQIA2+ people experience pervasive stigma and discrimination, as well as numerous adverse social determinants of health, all of which negatively impact health outcomes,” says Dr. Keuroghlian. “Health care professionals, organizations, and governmental agencies need to intentionally provide clinical care and design health systems and policies, in a manner that is culturally responsive and improves health outcomes for LGBTQIA2+ people.”

Due to the politicized nature of these issues, health care providers around the world, including in several U.S. states, face limitations and backlash when providing gender-affirming care. In some places, Dr. Keuroghlian says, “legal restrictions on access to gender-affirming care create challenges for clinicians to deliver this care and for transgender and gender diverse people to safely receive it.”

Everyone in health care — including health care business professionals — can work to improve health outcomes and decrease inequities. “It is critical for all businesses to offer welcoming, inclusive, and affirming work environments and service delivery for LGBTQIA2+ people,” Dr. Keuroghlian says.

Supporting LGBTQIA2+ health begins in the workplace

With thoughtful action, health care business professionals can contribute to greater health equity for these underserved individuals. Some ways to do so include:

1. Take an active interest in better understanding the needs and perspectives of the LGBTQIA2+ community.

Conducting research, including surveys and consumer focus groups, is a good way to help better understand specific health needs and priorities. “This community has historically been excluded from studies and research that would be very helpful in understanding their needs and their challenges,” says Dr. Enrique Caballero, an endocrinologist at Brigham and Women’s Hospital and the faculty director of International Innovation Programs in the HMS Office for External Education. “We need to get to know the population better.”

2. Prioritize inclusive language.

Whether you are involved directly in care delivery or other aspects of health care, pay attention to the words you use — for both customers and employees. Gendered language in job postings, informational or marketing materials, and even casual conversation can be off-putting. That means lost opportunities for organizations and LGBTQIA2+ individuals. Slight shifts in language and conscious efforts like adding pronouns to your email signature speak volumes.

3. Train staff to be community allies.

Gaining awareness of our unconscious biases and making shifts in our everyday language doesn’t happen overnight. Health care industry businesses can help their staff be better allies to the LGBTQIA2+ community by providing access to workshops delivered by community members.

“No one becomes fully competent after one conversation, lecture, or video,” Dr. Caballero says. “It’s a lifelong process in which we all learn how to be more respectful, inclusive, and to embrace diversity.”

4. Support companies and community organizations that focus on LGBTQIA2+ health.

Show, don’t tell. Making financial contributions to organizations already on the ground and working with this population demonstrates that you aren’t just concerned about the bottom line. You are truly dedicated to helping the LGBTQ+ population access good health care.

5. Hire LGBTQIA2+ staff.

The best way to ensure your company is prioritizing health equity is by having a diverse group at the decision-making table. It is crucial to have employees that represent the diversity of your customer base — not only diversity in gender expression and sexuality, but also diversity in race, ethnicity, age, ability, and beyond.

“Part of our obligation is to really open the doors for everybody,” Dr. Caballero says. “Talent is not exclusive to a particular group, and I think that is important to embrace as an organization.”

6. Include LGBTQIA2+ representation in all communications.

Diverse representation is key. Make a pointed effort to include same-sex couples, non-traditional family units, and transgender and non-binary individuals in all kinds of communications, participating in everyday activities.

7. Acknowledge any missteps.

On an institutional level, company acknowledgments can go a long way in rebuilding trust with the LGBTQIA2+ community. Within the organization, it’s valuable to encourage ongoing communication about company culture.

“All organizations should have a system in place for people to provide feedback on how things are going and to report anything that they want to call the leadership team's attention to,” Dr. Caballero says. “Having a system that truly listens to members of the organization — and being sure that follow-up action is taken — is very important.”

8. Make action consistent beyond Pride Month.

Embracing the LGBTQIA2+ community consistently and with commitment all year long “is truly an opportunity for everyone,” Dr. Caballero says. “This is not good just for the members of the community, but for everybody that works in a place that embraces diversity, equity, and inclusion.”

Industry professionals turn to HMS for custom corporate learning programs, including on topics like LGBTQIA2+ health, that leave a lasting impact on participants. To provide these programs, HMS leverages faculty expertise from throughout the School and the entire Harvard University community to share with health care teams. To learn about HMS Corporate Learning custom programs, read about the approach or hear from clients themselves.

About the Author

Corporate Learning Staff

Harvard Medical School’s Corporate Learning solutions provide emerging and established companies with the knowledge they need to address the industry's toughest business challenges. Their extensive portfolio of learning solutions helps teams achieve their potential by advancing … See Full Bio View all posts by Corporate Learning Staff

Drug side effects are common, and often quite troublesome.

Major side effects, such as severe or even life-threatening allergic reactions, require immediate treatment and discontinuation of the drug. More minor symptoms may be tolerable when weighed against drug benefits. And sometimes, these go away on their own as the body gets used to the drug.

But there’s another type of side effect you hear much less about: ones that are beneficial. Though uncommon, they’re worth keeping in mind when you’re starting a new medicine.

Aren’t all side effects bad?

The term side effect is usually assumed to be a bad thing. And that’s typically true. But that leaves out the “good” side effects. Relatively little is published on this, so it’s not clear how common they are. But four notable examples include:

• Minoxidil (Rogaine, Gainextra, other brands). Developed in the 1970s for high blood pressure, this drug also increased hair growth in study subjects. What was initially considered a bothersome side effect eventually became its primary use: topical forms of this drug are commonly used to treat hair loss.
• Diphenhydramine (Benadryl or generic versions). This common treatment for allergic conditions has the side effect of drowsiness. For adults with allergy issues and trouble sleeping, the sedative effect can be helpful. Regular, long-term use of diphenhydramine is not recommended, as it may increase the risk of dementia.
• Sildenafil (Viagra or generic versions). Originally developed as a treatment for high blood pressure and angina, it didn’t take long for male users to realize the drug could trigger erections within 30 to 60 minutes. The makers of sildenafil recognized that under the right circumstances, this could be a highly beneficial side effect. In 1998 it was approved as a treatment for erectile dysfunction.
• Semaglutide (Ozempic, Wegovy, Rybelsus). This drug was developed to treat diabetes, but early users noticed reduced appetite and significant weight loss. Now, several formulations of these related drugs are approved for diabetes and/or weight loss.

In the best study I’ve read on the topic, researchers found more than 450 reports of serendipitous beneficial effects of various drugs since 1991. And that may be an underestimation, since report forms did not specifically ask for or label this type of side effect, according to the study authors.

Silver linings: Repurposing and repackaging drugs

While the discovery of helpful drugs can arise unexpectedly, drug developers are increasingly using a more intentional approach: using side effect profiles to look for new uses.

For example:

• A drug reported to cause reduced sweating as a side effect may be effective for hyperhidrosis, a condition marked by excessive sweating.
• Drugs reported to cause low blood pressure as a side effect might be effective treatments for high blood pressure (hypertension).
• New treatments for breast cancer may include older medicines that have a similar side effect profile as known anti-cancer drugs.

The availability of large side effect registries has made this method of identifying drugs for repurposing a more realistic option. So, even negative side effects can have a silver lining.

Bad side effects and the nocebo effect

While side effects can be positive, most are not. Medication side effects are a common reason people give for not taking prescribed drugs regularly. And adverse reactions to medicines prompt up to 8% of hospital admissions, according to one analysis.

To make matters worse, in some cases the expectation of side effects seems to make them more likely to occur. Called the nocebo effect, it increases the chances of experiencing a negative side effect and seems due, at least in part, to expectations. Contrast this with the placebo effect, where a sugar pill or another inactive treatment can lead to benefit.

The bottom line

Many people avoid taking medications because they fear possible side effects. That’s understandable. But not taking a medication can mean missing out on its benefits. And anticipation or expectation of side effects can increase the chances you’ll have them.

So, while it’s important to be aware of the most common side effects caused by the medicines you take, it’s also important not to overestimate your chances of experiencing them. And remember: there’s always a chance you’ll have a side effect you actually welcome.

About the Author

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

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