Good chocolate, I’ve come to learn, should taste richly of cocoa—a balanced blend of bitter and sweet, with notes of fruit, nuts, and spice. My favorite chocolate treat is nothing like that. It’s the Cadbury Creme Egg, an ovoid milk-chocolate shell enveloping a syrupy fondant center. To this day, I look forward to its yearly return in the weeks leading up to Easter. Most popular chocolate is like this: milky, sugary, and light on actual cocoa. Lots of sugary sweets contain so little of the stuff that they are minimally chocolate. M&M’s, Snickers bars, and Hershey’s Kisses aren’t staples of American diets because they are the best—rather, they satisfy our desire for chocolate while costing a fraction of a jet-black bar made from single-origin cocoa. But chocolate isn’t as economical as it once was. By one estimate, retail prices for chocolate rose by 10 percent just last year. And now this is the third year in a row of poor cocoa harvests in West Africa, where most of the world’s cocoa is grown. Late last month, amid fears of a worsening shortage, cocoa prices soared past $10,000 per metric ton, up from about $4,000 in January. To shoulder the costs, chocolate companies are gearing up to further hike the price of their treats in the coming months. Prices might not fall back down from there. Chocolate as we know it may never be the same. Chocolate has had “mounting problems for years,” Sophia Carodenuto, an environmental scientist at the University of Victoria, in Canada, told me. The farmers who grow them are chronically underpaid. And cocoa trees—the fruits of which contain beans that are fermented and roasted to create chocolate—are tough to grow, and thrive only in certain conditions. A decade ago, chocolate giants warned that the cocoa supply, already facing environmental challenges, would soon be unable to keep up with rising demand. “But what we’re seeing now is a little bit of an explosion” in the crop’s struggles, Carodenuto said. The simplest explanation for the ongoing cocoa shortage is extreme weather, heightened by climate change. Exceptionally hot and dry conditions in West Africa, partly driven by the current El Niño event, have led to reduced yields. Heavier-than-usual rains have created ideal conditions for black pod disease, which causes cocoa pods to rot on the branch. All of this has taken place while swollen shoot, a virus fatal to cocoa plants, is spreading more rapidly in cocoa-growing regions. Global cocoa production is expected to fall by nearly 11 percent this season, Reutersreported. In the past, when supply fell and prices rose, farmers were motivated to plant more cocoa, which led to a boost in supply five years later, when the new trees began to bear fruit, says Nicko Debenham, the former head of sustainability at the chocolate giant Barry Callebaut. Already, some West African farmers are racing to plant new trees. But they may not be able to plant their way out of future cocoa shortages. “Climate change is definitely a challenge” because it will make rainfall less predictable, which is a problem for moisture-sensitive cocoa trees, Debenham told me. Furthermore, rising temperatures and more frequent droughts will render some cocoa-growing regions unusable. Climate change isn’t the only problem. Cocoa crops in Côte d’Ivoire and Ghana, where 60 percent of the world’s cocoa come from, may already be in “structural decline,” Debenham said, citing disease, aging cocoa trees, and illegal gold mining on farmland. More important, the farmers who tend to the crops can’t afford to invest in their farms to increase their yields and bolster resilience against climate change. The bleak outlook for cocoa farmers threatens to doom cocoa-growing in the region altogether. In Ghana, the average cocoa farmer is close to 50 years old. A new generation of farmers is needed to maintain the cocoa supply, but young people may just walk away from the industry. No matter how you look at it, the future of cocoa doesn’t look good. With less cocoa available all around, chocolate may become more expensive. For high-end chocolate brands, whose products use lots of cocoa, the recent price hikes are reportedly an existential threat. Barry Callebaut has predicted that the companies it supplies with cocoa will raise chocolate prices by up to 8 percent in the next few months. Because companies buy beans in advance, it will take some time before retail prices reflect the current shortage, so further increases are likely. When cocoa prices go up, companies start reducing bar sizes and adding in substitutes such as fruit and nuts to reduce the amount of cocoa content. “They’ll try and use every trick in the book to keep the consumption levels up,” Debenham said. My beloved Cadbury Creme Egg, for example, is markedly smaller than it used to be. Now, as Bloomberg has noted, companies are promoting candies that contain less chocolate, such as the new Reese’s caramel Big Cup from Hershey’s, or treats that have no chocolate at all, such as gummies. Cocoa shortages will affect all kinds of chocolate, but mass-produced sweets may change beyond just the prices. The erratic temperatures brought about by climate change could change the flavor of beans, depending on where they are grown. Variability is a concern for commercial chocolate makers, who need to maintain consistent flavors across their products. They may counteract discrepancies among different batches of beans by combining them, then roasting them at a higher temperature, Johnny Drain, a food-science expert and co-founder of the cocoa-free chocolate brand Win-Win, told me. Doing so can eliminate unwanted qualities, but it may also remove desirable ones, resulting in a less interesting flavor overall. Even if an M&M contains a minimal amount of actual chocolate, a longtime consumer could notice a change in flavor. Commercial chocolate makers may also tweak their recipes to amp up or mimic chocolate flavors without using more cocoa. These candies contain relatively little cacao to begin with; only 10 percent of a product’s weight must be cocoa in order to qualify as chocolate in the eyes of the FDA. Some already use chocolatelike ingredients such as cocoa-butter equivalents, cocoa extenders, and artificial cocoa flavors. In some cases, the swaps are noticeable: Cadbury’s use of an emulsifying filler to reduce the amount of cocoa butter in its Caramello bars diminished “the rich creaminess of the original,” Bon Appétit noted in 2016. Newer chocolate alternatives may provide more satisfying counterfeits. Win-Win isn’t the only start-up producing cocoa-free chocolate, which is similar in concept to animal-free meat. The company uses plant ingredients to emulate the flavor and texture of chocolate—as do its competitors Foreverland and Voyage Foods. Another firm, California Cultured, grows actual cacao cells in giant steel tanks. [Read: Silicon Valley is coming for your chocolate] Cocoa-free chocolate is currently far more expensive than chocolate, but Drain hopes it will eventually become “cheaper than the cheapest chocolate.” At that point, he said, it’ll likely find its niche at the lowest end of the market, where chocolate plays a supporting role rather than a starring one—think chocolate-coated ice creams and granola bars with chocolate chips. Already, some of these products are labeled as having “chocolate flavor” or being “chocolatey” instead of “chocolate,” which has a strict FDA definition. Yet change is always tough to swallow. So much of the appeal of cheap chocolate is that it’s always been there—whether in the form of a Hershey’s Kiss, Oreo cookies, a bowl of Cocoa Puffs, or the shell of a fondant-filled egg. “You grow up with those tastes. It’s hard to fathom how pervasive it has been,” Carodenuto said. Chocolate lovers have weathered minor tweaks to these candies over the years, but the shifts happening today may be less tolerable—or at the very least more noticeable. The change that has been hardest to ignore is that cheap chocolate is no longer that cheap. from https://ift.tt/QspIez3 Check out http://natthash.tumblr.com
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At Hopscotch, Daryl Collins’s bottle shop in Baltimore, he happily sells wine to 18-year-olds. If a customer isn’t sure what variety they like (and who is, at that age?), Collins might even pull a few bottles off the shelves and pop the corks for an impromptu tasting. No Maryland law keeps these teens away from the Tempranillo, because at this shop, none of the drinks contain alcohol. The number and variety of zero- and low-alcohol beverages, a once-lagging category that academics and the World Health Organization refer to as “NoLos,” has exploded in the past five-plus years. The already growing “sober curious” movement—made up of adults who want to practice more thoughtful or limited alcohol consumption while still socializing over a drink at home or at a bar—snowballed during pandemic shutdowns. Today, about 70 NoLo bottle shops like Hopscotch dot the U.S., along with several dozen nonalcoholic, or NA, bars, most less than four years old. Nearly all of the products they’re stocked with were designed with adults in mind. But broken down to their most basic ingredients, many are hardly different from juice, soda, or kombucha. In theory, these are teen-friendly drinks. But not every bar or shop owner will sell to under-21s; state laws, too, when they exist, differ on what kind of alcohol-like beverages are appropriate for people too young to drink actual alcohol. As nonalcoholic adult beverages become more mainstream, they’re forcing a reckoning over what makes a drink “adult” if not the alcohol, and testing whether drinking culture can truly be separated from booze. Picture, for instance, a Shirley Temple, the consummate children’s drink. Add a shot of vodka, and it becomes a Dirty Shirley. Now replace the vodka with about an ounce of cinnamon-infused “Zero-Proof Vodka Alternative” from a sexy glass bottle. Can a 10-year-old have that Shirley Temple? What if the add-in is instead an ounce of tap water with an identical-tasting cinnamon extract? [Read: Millennials are sick of drinking] This puzzle is a diagnostic for how zero-proof entrepreneurs approach the allures and dangers of drinking culture, along with the role they’d like alternatives to play in changing it. Some think brand or bottle design makes a beverage “adult,” and worry that packaging elements more frequently associated with alcohol could open the door to consuming it. Others make decisions based on a drink’s name, how it was created, or what it’s an homage to—a mocktail with a distinct identity is preferable to one that impersonates a well-established recipe. The atmosphere matters too: Is the bar modeled more closely after a family-friendly taproom or an upscale cocktail joint? The decision to sell booze-like substances to under-21s is constrained by law. The federal government defines an alcoholic beverage as a drink with 0.5 percent or more alcohol by volume, in line with your average kombucha and lower than some apple, orange, and grape juices. (Beer alternatives are subject to additional regulation by the U.S. Alcohol and Tobacco Tax and Trade Bureau—which, among other requirements, bans the word beer from the packaging unless it’s part of the phrase near beer.) But state definitions of specific alcoholic beverages can zero in on processes and ingredients (such as malt) in a way that fails to distinguish between the real deal and NA alternatives. NoLo manufacturers keep their products below the 0.5 percent federal cutoff, but the drinks can still end up with murky legal status once they arrive on local shelves. Pennsylvania, for example, has a law that makes it illegal to supply under-21-year-olds with a NoLo analogue of any real adult beverage—something no other state prohibits. In Lafayette, Indiana, Rob Theodorow splits the policy at his combination bar and bottle shop, Generation NA, down the middle. Any NA beers, wines, and spirits (say, a six-pack from Athletic Brewing Co., Noughty’s Sparkling Rosé, or Seedlip’s ginlike Spice 94) are off-limits to under-21s. Customers over 18 are welcome to purchase drinks that are less reminiscent of those in a real liquor store—like wellness sodas made by brands such as Recess and Kin Euphorics—or to sample the beers at free tastings. [Read: The meaning of dry January] Selling NA drinks to younger people isn’t explicitly illegal under Indiana law, but even if he had a clear green light, Theodorow would draw the line at selling any product that ever contained alcohol—even fully dealcoholized drinks such as Heineken 0.0—to under-21s. “I am a big believer in trying to steer people away from alcohol,” he told me. To him, that means treating products that taste and look just like alcohol with the same discretion as those that actually contain alcohol. Some proprietors worry that developing a taste for NoLos will make young people more likely to desire the real thing. “When it comes to children, permitting them to consume any versions of beer or wine or spirits can normalize or desensitize them to the concept of alcoholic beverages,” says Cate Faulkner, a co-founder and the director of Zero Proof Collective, an industry group in Minnesota. Others are mostly concerned that selling younger people NoLo beverages could still feed the toxic side of drinking culture: Imagine 15-year-olds shotgunning NA beers in the backyard. “It’s not about the liquid so much as it is about the ritual,” Laura Silverman, the founder of the NA information hub Zero Proof Nation, told me. [From the July/August 2021 issue: America has a drinking problem] Still other advocates and entrepreneurs see NoLos as a way for young adults to form healthier habits. One of them is Laura Willoughby. She’s the director of partnerships at Club Soda, a shop and bar she co-founded that hosts many 16th-, 17th-, and 18th-birthday parties in London, where the legal drinking age is 18. “Once you take alcohol out of beer,” Willoughby told me, “it’s got four ingredients, no sugar, it’s hydrating, and it’s full of vitamin B-12. Aside from water, it’s the healthiest thing you can drink in the pub.” But she, like Theodorow, won’t offer anyone under the legal drinking age a nonalcoholic beverage made by a brand that also sells alcohol. Both abroad and in the U.S., these conversations are rooted in old questions about the “right age” and way to introduce young people to alcohol: Should it be done gradually throughout childhood, or all at once at 21? Research has yet to provide a clear answer, let alone one that applies to NoLos too. A few international studies have shown that, for young people, consuming NoLos is associated with drinking real alcohol, but the cultural role of alcohol varies greatly around the world. Some early evidence from Europe suggests that NoLos can worsen existing substance cravings in adults with alcohol-use disorder, but the zero-proof community is also full of people—including Silverman—who credit the drinks with helping them maintain sobriety. The answer will probably never be clear-cut. Molly Bowdrig, a clinical psychologist and postdoctoral scholar at the Stanford Prevention Research Center, just wrapped up one of the first-ever studies of U.S. consumers of nonalcoholic beverages; her strongest finding was that the way NA beverages change people’s relationships with alcohol is nuanced and varied. (Her research has yet to be peer-reviewed and published.) Without a firm consensus, Willoughby and other shop and bar owners told me that they often err on the side of caution and let parents make decisions about what their underage kids can drink. But even for parents deeply enmeshed in the NA industry, the decision isn’t straightforward. Collins’s own daughter is 9, and even after months of running Hopscotch, he struggled to describe what he would or wouldn’t let her drink. When I asked him, he paused, then collected four cans from the fridges along a shop wall. In his house, a nonalcoholic Bee’s Knees would be for adults only, because it shares a name with a real cocktail and has just 15 percent juice. But a Fauxmosa, with 65 percent juice and a distinct mocktail name, is kid-friendly in his book. White Claw’s new nonalcoholic seltzers, though functionally the same product as LaCroix or Spindrift, would only get the okay from Collins if served to his daughter in a glass. (“Imagine my daughter going to school and telling her teacher, ‘Hey, I had a White Claw on Saturday,” he says.) And he classified the last can, a seltzer flavored with hops, as an adult-only beverage “because of American culture,” in which the flavor of hops is closely associated with beer. [Read: Canned cocktails give Millennials what they’ve always desired] It was enough to make my head spin, even though the cocktails Collins mixed me when I arrived didn’t contain a drop of alcohol. His answers made sense, but others would have too. As long as these drinks exist in a liminal space in our culture, norms will grow and change in real time along with the kids subject to them. Maybe one day, we’ll look back to find that they’ve changed for alcohol too. from https://ift.tt/NdeqSFc Check out http://natthash.tumblr.com The legalization of cannabis in the United States—the biggest change in policy for an illegal substance since Prohibition ended—has been an unqualified success for approximately no one. True, the drug is widely available for commercial purchase, many marijuana-related charges have been dropped, and stoner culture has become more aligned with designer smoking paraphernalia featured on Goop than the bumbling spaciness of Cheech and Chong. But a significant part of the market is still underground, medical research is scant, and the aboveground market is not exactly thriving. Longtime marijuana activists are unhappy. Entrepreneurs are unhappy. So are people who buy weed, as well as those who think weed should never have been legal in the first place. The country is now poised to change the legal status of a new class of psychoactive drugs: psychedelics. They have shown early promise in treating mental-health issues, even though some enthusiasts are concerned that easing regulations without a better understanding of these drugs could put patients in a degree of danger. Oregon is now licensing centers that can administer psilocybin, and MDMA is moving toward FDA approval. In some ways, the fate of legalized pot could be read as a cautionary tale for how these drugs, too, could be left in a limbo that hardly anyone really likes. But as psychedelics enter the mainstream—becoming decriminalized, state-legal, or even FDA-approved—they will be dispensed and sold differently from marijuana. The process is unlikely to please everyone, but if advocates, manufacturers, and lawmakers can keep psychedelics from falling into the same traps that marijuana did, they have a chance of creating an industry that serves at least some Americans well. Despite its wide availability, cannabis is still illegal under federal law. Since 1970, it’s been listed as a Schedule I drug, meaning the government believes it carries a high likelihood of abuse and no medical value. Starting in the 1970s, states began passing laws lowering penalties for cannabis possession and allowing it for medical purposes and, eventually, recreational use. In 2013, U.S. Deputy Attorney General James M. Cole issued a memo declaring that the Justice Department would not strictly enforce federal marijuana laws in states that legalized it. Americans were eager to buy marijuana as states launched legalization programs, but in most states, cannabis hasn’t proved to be a great legal business. Because cannabis is still illegal at the federal level, many entrepreneurs don’t benefit from many of the tax breaks that other businesses do, meaning the industry essentially pays billions in extra taxes, according to an analysis by a cannabis-research firm. In most states, big corporations dominate the industry while small-business owners struggle to afford high licensing fees. One promise of legalization was its potential benefit to Black and Latino communities, who were disproportionately affected by the War on Drugs, but as of 2017, members of these communities accounted for single-digit percentages of state-sanctioned cannabis entrepreneurs. Because legal weed is sometimes more expensive than old-school dealer prices, plenty of people simply stick with the unregulated underground. In states like New York, the gap between what’s legal and what’s enforced has allowed illicit stores to pop up among the legitimate ones. [Read: America loves its unregulated wellness chemicals] That’s all in places where recreational use is legal. In the 14 states where only medical use is allowed, dispensaries must make a different calculus: They serve patients in need, but others treat them only as a loophole to access the drug—and are likely to go elsewhere if recreational access becomes available. In the 12 states where even medical marijuana is illegal, the only cannabis products legally available are a handful of medications that have been approved by the FDA, all for a narrow set of indications, such as vomiting among chemotherapy patients, AIDS-related anorexia, and certain kinds of seizures. Active clinical trials to study cannabis are few and far between, which means that the drug currently has no clear pathways to be federally approved for other indications. Psychedelics are much further behind in their journey to wider availability, but on the surface, they appear poised to mimic marijuana. The drugs are undergoing a sea change in public sentiment; Aaron Rodgers has a trip story, and so does Michael Bublé. Half of state governments have introduced psychedelics-related bills, some of them to form working groups that will dig into the science of psychedelics, and some to launch full-blown psilocybin industries. Assuming that reform moves at a comparable speed to cannabis, researchers have estimated that 25 states could legalize psychedelics in the next decade or so. Voters in Oregon and Colorado have already passed ballot initiatives that opened the way for psilocybin industries in their states. But instead of following marijuana’s trajectory for reform—first decriminalization, then medical legitimacy, followed by recreational use—psychedelics are barreling down all those avenues at once. State-regulated psilocybin centers are shaping up to be less like cannabis dispensaries and more like a hybrid of a psychotherapy office, a medical clinic, and a spa. Rules in the psilocybin industry are much more restrictive than those for cannabis ever were, because many people believe unlocking the possible benefits of these drugs requires more careful support and perceive the risks of a bad trip as higher. Whereas Oregonians over 21 can pop into a dispensary, flash an ID, and take their bud (or gummies, or soda, or cookies) home, adults seeking psilocybin must undergo a comprehensive mental- and physical-health screening, then ingest their dose under the supervision of a trained and licensed facilitator. Meanwhile, researchers and start-ups are pushing psychedelics forward on the medical front. We might see the first MDMA approval to treat PTSD as soon as August. [Read: What if psychedelics’ hallucinations are just a side effect?] This air of legitimacy—the idea that psychedelics could be more serious drugs than cannabis—gives drugs like MDMA and psilocybin certain advantages. Psychedelics research is booming in a way that marijuana research never really has. Few scientists have overcome the hurdles of studying cannabis; for instance, by most accounts, the government-grown weed that researchers have to use is less potent than what’s sold at dispensaries, and has been known to arrive in labs already moldy. And with the thriving black market, pharmaceutical companies have seemed uninterested in sponsoring cannabis clinical trials. But for psychedelics, which support much less illegal trade, start-ups and nonprofits are leaning hard into the clinical-trial route. Sue Sisley, a physician and marijuana researcher who previously developed clinical trials for marijuana, says psychedelics have moved toward legalization so quickly in large part because they’re following Big Pharma’s traditional drug-development playbook. In some ways, the FDA-forward approach is a gamble for people hoping to create a psychedelics industry. For one thing, Ariel Clark, an Anishinaabe cannabis and psychedelics attorney, worries that this pathway could put the drugs firmly out of (legal) reach for the people who could most benefit from the protections that come with legalization, including the Indigenous communities that already use some psychedelics in traditional ceremonies. Currently, a single psilocybin session at an Oregon service center costs thousands; companies that receive FDA approval could possibly further inflate the prices of approved psychedelics and treatment. (That has already happened with ketamine.) Additionally, FDA approval of proprietary psychedelics might still leave growers paying the same high taxes that have caused small-cannabis-business owners to fold. “Farmers already have really low margins,” and taxes don’t help, says Hadas Alterman, a partner at Plant Medicine Law Group and a member of Oregon’s Psilocybin Advisory Board’s equity subcommittee. But even in a scenario that leaves small-time entrepreneurs in the dust, some advocates argue that medicalization would be a net good. Medicalization might not lead the United States to a hallucinogenic utopia, but compared with underground use, it very well could increase access to psychedelics, improve patient safety, and build a functional (if inequitable) industry. Psychedelics manufacturers and people with the means to afford their pricey treatments might be perfectly happy with that outcome. [Read: Psychedelics open your brain. You might not like what falls in.] Psychedelics are still in uncharted territory in the U.S. Even though start-ups are investing millions on the assumption that they’ll be approved as medicines, and state-run programs are charging ahead with developing their own psychedelic industries, research on the drugs is still in early days, and their exact path to legalization remains murky. But at the very least, lawmakers have a great model of what not to do. “Folks sitting in government saw what happened with cannabis,” Clark told me. One can only assume that they don’t want to repeat the experience. from https://ift.tt/8K5RvFb Check out http://natthash.tumblr.com Within the next couple of decades, a new generation of contraceptives could hit the American market. One, a pill that blocks certain cells from accessing vitamin A, might be able to limit fertility without flooding the body with hormones; another is an injection that temporarily blocks up the reproductive plumbing. The method that’s furthest along in trials is a topical gel that promises to induce temporary infertility when smeared daily on the shoulders and upper arms—without affecting mood or libido. “Overall, we don’t have any serious adverse events at all,” Christina Wang, a contraceptive researcher at the Lundquist Institute in California, and one of the developers of the gel, told me. This coming slew of treatments will be notable not only for their imaginative delivery methods, but for their target audience: men. For decades, men hoping to manage their fertility have been limited to just two imperfect options—condoms or vasectomies. But in recent years, researchers have taken massive steps toward developing simple, convenient, and effective contraceptive options for men with virtually zero side effects. Soon, women may not be forced to bear nearly the entire burden of preventing pregnancy. But the coming innovations won’t just be about expanding the menu of options for men. Better male contraception wouldn’t be on the way if not for the many scientific paths that female contraception has paved. Now women’s birth control—much of which still comes with plenty of irksome, sometimes risky, side effects—seems due for some kickbacks. True, the logistics of keeping an egg from exiting an ovary don’t completely overlap with the mechanics of keeping sperm out of the female reproductive tract. But in principle, “there are a lot of similarities,” Diana Blithe, the chief of the NIH’s Contraceptive Development Program, told me, which means one can easily inform the other. With an eye on what’s now being accomplished for male contraception, researchers may soon be able to deliver to women new forms of birth control that aren’t just more tolerable, but also more on-demand, less invasive, or even usable on male and female reproductive systems alike. In the six-plus decades since the debut of the birth-control pill, the list of contraceptive choices for women has lengthened impressively. People can opt for barrier methods, or choose among pills, patches, and implants; they can receive injections a few times a year, or select an intrauterine device that can last up to 10 years. “We have so many options, it’s almost like you’re in a cereal aisle,” Amy Alspaugh, a nurse and reproductive-health researcher at the University of Tennessee at Knoxville, told me. Read: The calendar of human fertility is changing Many methods are also ever-improving: IUDs, implants, and injections now have longer lifespans and are easier to insert and remove; doses of hormonal contraception have dramatically decreased. “We used to give basically like a horse dose of estrogen and progestin,” Alspaugh told me. “Now we give the lowest dose that we know we can give and still have it be effective,” in order to minimize side effects. Some researchers have been exploring new ways to deliver contraception--microneedles, for instance, or even microchip technology that might allow women to remotely tune their birth control. (The latter idea has raised privacy concerns galore.) The Population Council, an NGO based in New York, has been working on a multipurpose vaginal ring that will, in addition to preventing pregnancy, release an antiviral to protect women against HIV, Régine Sitruk-Ware, a reproductive endocrinologist and contraception researcher at the nonprofit, told me. By and large, though, the changes to female contraception have been incremental—more ingredient swaps than whole new recipes. Categorically, “we’ve had the same offerings for pretty much 30 years now,” Heather Vahdat, the executive director of the Male Contraceptive Initiative, told me. And plenty of women remain dissatisfied with the inconveniences and risks that come with the choices at hand. Some experience weight gain, acne, or nasty mood swings, or worry about the risk of stroke that can come with hormone-based pills. Others balk at the often-painful placement process for IUDs. Manually inserting a device into the lower abdomen probably wouldn’t be acceptable in other contexts without anesthesia, and yet, for women’s contraception, “we’ve socialized that into something acceptable,” Brian Nguyen, an ob-gyn and contraception researcher at the University of Southern California, told me. Nonhormonal methods such as condoms, diaphragms, and spermicide are easy to come by, but generally less effective than hormonal ones. They can also come with their own side effects. And women could certainly benefit from a greater variety of on-demand methods, Vahdat told me—contraception for when you have sex, “not just in case you have sex”—that would save them the trouble of weathering side effects all month, year, or decade long. Over the years, some researchers have argued that significant inconveniences and side effects are acceptable for female contraception. Women, after all, are weighing those costs against pregnancy, itself a risky condition that can come with life-threatening complications; men, meanwhile, take contraception to prevent pregnancy in someone else. I asked Vahdat whether the typical side-effect profile of currently available female contraceptives would pass muster in any of the male methods in trials. “Based on history,” she told me, “I think that it would not.” Several other experts agreed. In 2011, a worldwide trial for an injectable hormonal contraceptive for men was halted when an independent safety-review committee determined that the drug’s side effects “outweighed the potential benefits.” The side effects in question included mood swings and depression, both of which are frequently experienced by women on birth control. And yet, most of the participants who stuck with the study said that they wanted to keep using the injection. In recent years, Nguyen has heard more and more of the men in contraceptive trials cite their female partners’ negative experiences with birth control as reason for their participation. “Many think of risk to their partner as a risk themselves,” he said. [Read: The different stakes of male and female birth control] Still, the strict standards for the tolerability of male birth control could raise the floor for female methods too. Such crossover advances are already in the works. Researchers took care to formulate the topical contraceptive for men with a dose of natural testosterone, alongside progestin, the active ingredient that halts sperm production; the idea, experts told me, is to better recapitulate what’s naturally seen in men’s bodies, to minimize unnecessary side effects. Many female hormonal contraceptives, meanwhile, rely on a synthetic compound called ethinylestradiol that incompletely mimics the estrogen women’s bodies make—and appears to raise the risk of blood clots. The Population Council is now working on another vaginal ring that replaces ethinylestradiol with hormones better matched to female biology. Other conveniences may be trickier to translate. For example, researchers hope to someday offer men a more easily reversible vasectomy, in which a dissolvable or removable hydrogel is inserted into the vas deferens. But experts told me that temporarily stopping up the fallopian tubes is simply harder. Plus, whereas sperm are churned out constantly, eggs are released for fertilization on a cycle that can be tricky to measure and predict—which can make side effects frustratingly tough to control too, Nguyen told me. Targeted interventions are also more easily delivered to the testes than the ovaries. And their success is easier to verify: Men have long been able to check their own sperm count with a device that’s similar to an at-home COVID test, but no parallel exists for women, Wang told me. And because sperm take months to produce, male hormonal contraceptives might be more forgiving to users who miss a day of treatment—unlike many pills designed for women, which tend to be less flexible, Mitchell Creinin, a contraceptive researcher at UC Davis Health, told me. [Read: A vaccine for birth control?] The difficulty of wrangling eggs, though, doesn’t have to mean limiting options for women. Conception can’t happen unless egg and sperm actually meet—which means that just about any drug designed to waylay the functionality or motility of sperm could play a role in the female reproductive tract. The options go way beyond spermicide: The Population Council is working on a product that will modify the vagina’s acidity to stop sperm from swimming properly, Sitruk-Ware told me. And Deborah Anderson, an immunologist and reproductive-health researcher at Boston University, has been working on a dissolvable film imbued with sperm-blocking antibodies that can be placed into the vagina before sex, and seem to persist at high enough levels to provide contraception for 24 to 48 hours, she told me. A couple of drugs being trialed for men could even someday be marketed to women in some form—among them, a sperm-motility-blocking drug that, experts told me, might be deployable in the female reproductive tract too. With all the attention now being paid to men’s contraceptive preferences, some researchers worry that women’s needs will fall even further to the wayside. Jeffrey Jensen, a contraception researcher at Oregon Health & Science University, told me that even as grants for male methods continue to be green-lighted, his team has had to pause work on some female-contraceptive projects because of lack of funding in recent years. “Policy makers think that we’ve checked the box and that we can move on,” he said. And Sitruk-Ware said that, although researchers had at one point started developing a topical contraceptive gel for women, “donors were more interested in the gel for men.” Still, the arrival of male contraception is unlikely to dampen women’s enthusiasm for using their own methods, Allison Merz, an ob-gyn at UC San Francisco, told me. If anything, when those ultrasafe, ultra-effective products for men come to market, they’ll ignite more discussions over female contraception—and inspire more questions about why convenience and tolerability weren’t prioritized for women from the start. from https://ift.tt/cTpdsFX Check out http://natthash.tumblr.com A man comes to Northwell Health’s hospital on Staten Island with a sprained ankle. Any allergies? the doctor asks. How many alcoholic drinks do you have each week? Do you have access to firearms inside or outside the home? When the patient answers yes to that last question, someone from his care team explains that locking up the firearm can make his home safer. She offers him a gun lock and a pamphlet with information on secure storage and firearm-safety classes. And all of this happens during the visit about his ankle. Northwell Health is part of a growing movement of health-care providers that want to talk with patients about guns like they would diet, exercise, or sex—treating firearm injury as a public-health issue. In the past few years, the White House has declared firearm injury an epidemic, and the CDC and National Institutes of Health have begun offering grants for prevention research. Meanwhile, dozens of medical societies agree that gun injury is a public-health crisis and that health-care providers have to help stop it. Asking patients about access to firearms and counseling them toward responsible storage could be one part of that. “It’s the same way that we encourage people to wear seat belts and not drive while intoxicated, to exercise,” Emmy Betz, an emergency-medicine physician and the director of the University of Colorado’s Firearm Injury Prevention Initiative, told me. An unsecured gun could be accessible to a child, someone with dementia, or a person with violent intent—and may increase the chance of suicide or accidental injury in the home. Securely storing a gun is fundamental to the National Rifle Association’s safety rules, but as of 2016, only about half of firearm owners reported doing so for all of their guns. Some evidence shows that when health-care workers counsel patients and give them a locking device, it leads to safer storage habits. Doctors are now trying to figure out the best way to broach the conversation. Physicians talk about sex, drugs, and even (if your earbuds are too loud) rock and roll. But to many firearm owners, guns are different. Not so long ago, powerful physicians argued that if guns were causing so much harm, people should just quit them. In the 1990s, the director of the CDC’s injury center said that a public-health approach to firearm injury would mean rebranding guns as a dangerous vice, like cigarettes. “It used to be that smoking was a glamor symbol—cool, sexy, macho,” he told The New York Times in 1994. “Now it is dirty, deadly—and banned.” In the 2010s, the American Academy of Pediatrics’ advice was to “NEVER” have a gun in the home, because the presence of one increased a child’s risk of suicide or injury so greatly. (“Do not purchase a gun,” the group warned bluntly.) And when asked in 2016 whom they would go to for safe-storage advice, firearm owners ranked physicians second to last, above only celebrities. In the past couple of decades, some states have toyed with laws that curtail doctors’ ability to talk with patients about firearms and the information they can collect, to assuage gun owners’ privacy concerns. Only in Florida did the most restrictive version—what physicians call a “gag law”—pass, in 2011; six years later, a federal court struck it down. But “I think the gag orders, even though they’re not in effect now, really scared people,” Amy Barnhorst, an emergency psychiatrist and firearm-injury-prevention researcher at UC Davis, told me. A smattering of studies have found that doctors—particularly pediatricians—generally think talking with their patients about firearm safety is important, but most of the time, they’re not doing it. As of 2019, only 8 percent of firearm owners said their doctor had ever brought it up. That year, in California, Barnhorst launched the state-funded BulletPoints Project, a free curriculum that teaches health-care workers how and when to talk about firearms with their patients. The program instructs them to keep politics and personal opinions out of the conversation, and to ask only those patients who have particular reasons for extra caution—including people with children, those experiencing domestic violence, or those living with someone with a cognitive impairment. It also suggests more realistic advice than “Do not purchase a gun.” Maybe a patient has a firearm for self-defense (the most common reason to have one), so they’d balk at the idea of storing a gun unloaded and locked, with the ammunition separate. A health-care worker might recommend a quick-access lockbox instead. Researchers are now testing whether these firearm conversations have the best outcome if doctors broach them only when there’s a clear reason or if they do it with every patient. Johns Hopkins is trialing a targeted approach, talking about firearms and offering gun locks in cases where pediatric patients have traumatic injuries. Meanwhile, Northwell Health, which is New York State’s largest health system, asks everyone who comes into select ERs about gun access and offers locks to those who might need them. Both of these efforts are federally funded studies testing whether doctors feel confident enough to actually talk with patients about this, and whether those conversations lead people to store their firearms more securely. For doctors, universal screening means “there’s no decision point of who you’re going to ask or when you’re going to ask,” Sandeep Kapoor, an assistant professor of emergency medicine who is helping implement the program at Northwell Health, told me. So far, Northwell’s trial has screened about 45,000 patients, which signals that the approach can be scaled up. Kapoor told me that with this strategy, gun-safety conversations could eventually become as routine for patients as having their blood pressure taken. When she was in primary pediatrics, Katherine Hoops, a core faculty member at Johns Hopkins’s Center for Gun Violence Solutions, worked firearm safety into every checkup, as she would bike helmets and seat belts. (The American Academy of Pediatrics still maintains that the safest home for a child is one without a gun, but the organization now recommends that pediatricians talk about secure storage with every family, and offers a curriculum on how to have this conversation.) Universal screening can also find people whom a targeted approach might miss: The team at Northwell recently learned through screening questions that a 13-year-old who came in with appendicitis had been threatened with guns by bullies, and brought in his parents, a team of social workers, and the school to help. But a patient in the ER for a sprained ankle may understandably wonder why a doctor is asking about firearms. “There’s no context,” Chris Barsotti, an emergency-medicine physician and a co-founder of the American Foundation for Firearm Injury Reduction in Medicine, told me. The firearm community, he said, remembers when “the CDC wanted to stigmatize gun ownership,” so any movement for health care workers to raise these questions needs nuance. To his mind, these should be tailored conversations. Betz, of the University of Colorado, raises the question only when a patient is at risk, and believes that firearm safety can otherwise be in the background of a practice—for example, in a waiting room where secure-storage brochures are displayed alongside pamphlets on safe sex and posters on diabetes prevention. About half of firearm-owning patients agree that it’s sometimes appropriate for a doctor to talk with them about firearms, according to a 2016 study by Betz and her colleagues. They’re even more okay with it if they have a child at home. The physicians I asked said that the majority of the time, these conversations go smoothly. But Betz’s study also found that 45 percent of firearm-owning patients thought doctors should never bring up guns. Paul Hsieh, a radiologist and a co-founder of the group Freedom and Individual Rights in Medicine, wrote in an email that gun owners he’s spoken with “find the question about firearms ownership intrusive in a different way than questions about substance use or sexual partners.” Chethan Sathya, a pediatric trauma surgeon and the director of Northwell Health’s Center for Gun Violence Prevention, pointed out that those topics used to be contentious for physicians to talk about. To treat guns as a public-health issue, “we can’t be uncomfortable having conversations,” he told me. But doctors have more power in this situation than they do in others. They might tell someone with diabetes to stop having soda three times a day, but they can’t literally take soda away from a patient. With guns, they might be able to. In states with extreme-risk laws, if a health-care provider believes that their patient poses an immediate threat to themselves or others, they can work with law enforcement to petition the court to temporarily remove someone’s firearms; a handful of states allow medical professionals to file these petitions directly. There are many people “across America right now who own guns and won’t come to counseling, because they don’t want their rights taken away for real or imagined reasons,” Jake Wiskerchen, a mental-health counselor in Nevada who advocates for such patients, told me. They worry that if their doctor includes gun-ownership status in their medical record, they could be added to a hypothetical national registry of firearm owners. And if questions about guns were to become truly routine in a doctor’s office—such as on an intake form—he said owners might just lie or decide they “don’t want to go to the doctor anymore.” Physicians accordingly choose their words carefully. They talk about preventing firearm injury instead of gun violence—both because the majority of gun deaths are suicides, not homicides, and because it’s a less loaded term. Telling a diabetic patient to cut back on soda might work, but people “are not just going to throw their guns in the trash,” Barnhorst, of UC Davis, told me. “There’s a lot more psychological meaning behind firearms for people than there is for sodas.” Barsotti says a public-health approach to firearm safety requires more engagement with the upwards of 30 percent of American adults who own a firearm. Owners of shooting ranges and gun shops are already “practicing public health without the benefit of medical or public-health expertise,” he told me. They’re running their own storage programs for community members who don’t want their guns around for whatever reason; they’re bringing their friends for mental-health treatment when they might be at risk. Betz’s team collaborated with gun shops, shooting ranges, and law-enforcement agencies in Colorado to create a firearms-storage map of sites willing to hold firearms temporarily, and she counsels gun clubs on suicide prevention, as a co-founder of the Colorado Firearm Safety Coalition. Exam-room conversations can be lifesaving, but in curbing gun injury, Betz told me, health-care workers “have one role to play. We’re not the solution.” from https://ift.tt/3kmNL9l Check out http://natthash.tumblr.com For something that isn’t candy, Zyn nicotine pouches sure look a lot like it. The packaging, a small metal can, looks more than a little like a tin of mints. The pouches come in a wide variety of flavors: citrus, cinnamon, “chill,” “smooth.” And they’re consumed orally, more like jawbreakers or Warheads than cigarettes. America has found itself in the beginnings of a Zyn panic. As cigarette and vape use have trailed off in recent years, Zyn and other nicotine pouches are gaining traction. The absolute pouch-usage numbers are still not that high, but sales have more than quadrupled from late 2019 to early 2022. Although only adults 21 and older can legally purchase them—a fact that the product’s website directly points out—they are reportedly catching on with teens. “I’m delivering a warning to parents,” Senate Majority Leader Chuck Schumer said in January, calling for a crackdown, “because these nicotine pouches seem to lock their sights on young kids.” Earlier this month, a group of plaintiffs filed a class-action lawsuit accusing the tobacco giant Philip Morris International (PMI), which also makes Zyn, of purposefully targeting kids. (“We believe the complaints are without merit and will be vigorously defended,” a PMI spokesperson told me over email, adding that Zyn offers “adult-orientated flavors.”) On their surface, nicotine pouches seem to be a fad like any other, but they are the end result of a century of nicotine marketing and development that began with cigarettes and has now moved beyond. “It’s basically part of the long history of the candification of nicotine,” Robert Proctor, a Stanford historian who has written multiple books on tobacco, told me. Over the years, the tobacco industry has gradually introduced more and more products flavored and packaged like sweet treats. Now, with Zyn, the industry has finally devised a near-perfect one. [Read: The easy way for Joe Biden to save lives] Once, nicotine wanted to be the opposite of candy. In the 1920s, weight loss—or “reducing,” as it was then known—became a major craze, and the tobacco industry moved to market its products as a healthier alternative to candy. “Reach for a Lucky instead of a sweet!” read one ad. Candymakers were understandably aggrieved about this slight, but the industries made nice in 1930, when Lucky’s maker dropped “instead of a sweet!” from its slogan. Candy and cigarettes had commonalities. Both relied on sugar—candy because, well, obviously, and cigarettes to cut the bitter taste of tobacco. Both were placed near the checkout register, to encourage impulse purchases. Soon, the makers of both products established joint trade journals and labor unions, at least one of which exists to this day. (Yes, some of the workers who make Ghirardelli chocolate and Marlboro cigarettes are represented by the same union.) Around this time, tobacco companies warmed up to the potential of cigarettes made out of chocolate, bubblegum, or pure sugar. Candy cigarettes, they seem to have realized, were free advertising, a gateway for kids into the world of smoking. (“Just Like Daddy!” read the slogan on one brand’s boxes.) The more similar the candy replicas looked to the real deal, the better. By the 1950s, most of the top cigarette brands—Lucky Strike, Chesterfield, Philip Morris—had their candy equivalent made by other companies, with packaging that very closely matched the real thing. This was roughly the equivalent of a modern apple-juice maker packaging its product in a Jack Daniel’s bottle. These tobacco companies claim never to have encouraged this, but as Proctor details in his 2011 book, Golden Holocaust, they did nothing to discourage it either. The goal, he writes, was to “create Philip Morris in the minds of our future smokers.” (That Philip Morris and the current Philip Morris International are not technically the same company, having since rebranded and then split apart.) Over time, cigarettes themselves became more and more candylike—and the government has responded by cracking down. Menthol cigarettes went big in the 1950s and ’60s, and starting in the ’70s, companies introduced a wider range of even more candylike flavors: chocolate,strawberry, Twista Lime, Warm Winter Toffee. Flavored cigarettes were eventually banned in 2009—with the exception of menthol—because of their disproportionate popularity among kids. But flavored e-cigarettes such as Juul took their place just a few years later and quickly became the most popular tobacco product among American youth—until they, too, were mostly banned in 2020. Now, with products such as Zyn, the candification of nicotine is pretty much complete. Pouches don’t just taste like candy; they’re also packaged like candy and consumed like candy (don’t swallow them, though). Proctor told me he’s talked with people for hours before realizing they had a nicotine pouch in their mouth. “It’s the ultimate merger of two of the leading hazards of modernity,” he said. Other companies such as Velo and Lucy are selling nicotine pouches too. Lucy even calls one of its special pouch lines “Breakers” (which sounds suspiciously close to Icebreakers, though a spokesperson for the company told me in an email, “They are in no way intended to resemble ice breakers the mints or any other type of candy.”). And it’s not just pouches: Nicotine chewing gum and lozenges have become available in wide varieties of flavors and are packaged in candy-colored pastels. Nicotine gummies have been on the rise as well. [Read: Gummy vitamins are just candy] Unlike with cigarette-shaped candies or candy-flavored cigarettes, both of which were uncomplicatedly bad, there actually is a legitimate, good-faith argument to be had about the merits of Zyn and similar flavored products. On the one hand, they do not contain tobacco and are not smoked, which is largely what makes cigarettes so deadly. The tobacco industry has positioned these products as a way for adults to wean themselves off of cigarettes, and they sure seem to be much safer than cigarettes, which kill more than 480,000 Americans each year—more than the combined deaths from COVID and car-crash fatalities in 2021. So the more people popping flavored pouches or gummies rather than smoking cigarettes, the better. On the other hand, they are addictive, and flavored products have been shown to play a major role in hooking kids. The PMI spokesperson told me, “If you’re worried about your health, the best thing is to never start using nicotine or”—if you already do—“stop using it.” Whether the increase in the number of kids using nicotine is worth the decrease in the number of adults using cigarettes is hotly debated. There’s a dark irony to the fact we’re having this debate at all. A hundred years ago, tobacco companies invoked the idea, if not the specific language, of harm reduction when they marketed their cigarettes as a healthy alternative to candy. Now they’re making their own nicotine products more candylike and marketing them as a healthy alternative to cigarettes. The harm reducer has become the harm to be reduced. After all this, flavored nicotine pouches might end up banned, just like flavored cigarettes and vapes before them. But in the cat-and-mouse game that the tobacco industry has been playing with regulators, Zyn may have a better chance of persisting than anything before it. from https://ift.tt/MIW3yGT Check out http://natthash.tumblr.com When a new RSV vaccine for pregnant people arrived last fall, Sarah Turner, a family-medicine physician at Lutheran Hospital, in Indiana, couldn’t help but expect some pushback. At most, about half of her eligible pregnant patients opt to get a flu vaccine, she told me, and “very few” agree to the COVID shot. But to Turner’s surprise, patients clamored for the RSV shot—some opting in even more eagerly than they did for Tdap, which protects newborns against pertussis and had previously been her easiest sell. For once, expectant parents were the ones starting conversations about immunizations. Each year in the U.S., respiratory syncytial virus hospitalizes an estimated 58,000 to 80,000 kids under the age of 5; the risks are highest for infants, for whom the virus is “enemy No. 1,” says Sallie Permar, an immunologist and pediatrician in chief at NewYork-Presbyterian/Weill Cornell Medical Center. But this past season marked the first time that the U.S. had two tools that could substantially shrink that toll: a vaccine for pregnant people, who can then pass antibodies to their child, and a monoclonal antibody, known as nirsevimab, that is given directly to infants. Their arrival feels akin “to the end of polio,” Anne-Marie Rick, a pediatrician and clinical researcher at Children’s Hospital of Pittsburgh, told me: With both shots in widespread use, the risks of winter illness could forever look different for the youngest Americans. But some experts worry that these powerful shots are being squandered. The CDC’s seasonal recommendations governing their use may simply be “too strict,” Permar told me. In keeping with those guidelines, many practices stopped giving the maternal vaccine at the end of January; the main window for administering the monoclonal antibody is expected to close at the end of this week. The next eligibility windows won’t open for months. The U.S has two brand-new shots that protect extraordinarily well against a deadly respiratory virus—and that people actually want to take—and it is holding them back. The guiding principle behind the CDC’s recommendations has logic to it. RSV is a seasonal virus, and both injections are thought to offer protection for about six months. For the maternal vaccine, which is administered between 32 and 36 weeks of pregnancy, the clock on the baby’s protection starts after birth. So if a pregnant person gets the vaccine in June—outside of the CDC’s recommended window—and has their baby in July, their child may be vulnerable again come February, before RSV season typically ends. In theory, spring and summer infants might be better protected by getting nirsevimab starting in October, when RSV usually arrives. Current guidelines also require a choice between the two options: Most infants that benefit from maternal vaccination are not eligible to also receive nirsevimab. [Read: The worst pediatric-care crisis in decades] This past season, though, nirsevimab was in severely short supply—in large part because drug companies seem to have underestimated demand, William J. Muller, a pediatric-infectious-disease expert at Northwestern who helped trial the monoclonal antibody, told me. Many hospital systems also balked at the cost of the new drug, which is pricier than the maternal vaccine, wasn’t yet bundled into the expense of delivering infants, and wasn’t consistently covered by insurance. The shortfalls became so dire that Sanofi, nirsevimab’s manufacturer, stopped taking new orders for certain doses of the monoclonal antibody as early as October. The CDC issued a health alert, calling on providers to restrict administration of those doses to only the highest-risk infants. “In our hospital system, we had some for the NICU babies, and that was literally it,” Turner, of Lutheran Hospital, told me. Nirsevimab should be more available this year: Spokespeople from AstraZeneca and Sanofi told me that the companies are “confident we will meet the global demand” for the antibody in 2024. But last year set quite a low bar. And when the window for administration opens in October—potentially already coinciding with RSV’s rise—supplies could go fast, as parents who haven’t been able to get shots for themselves or their babies rush to catch up, Grace Lee, a pediatrician at Stanford, who advised the CDC on its RSV guidance, told me. (The CDC did not respond to a request for comment.) Opening the administration window earlier for either the vaccine or the monoclonal antibody could ease that burden: The U.S. starts immunizing people against the flu well ahead of the season’s start, Lee said, because “it’s just not feasible to vaccinate the entire U.S. population in a week.” For several years, too, “RSV has been on the move,” Permar told me, thanks in large part to pandemic mitigations. The virus was virtually absent in 2020, only to come roaring back for a bizarrely early season that began during the summer of 2021 and had mostly concluded by the end of January 2022. In the past two seasons, the virus has also arrived somewhat early, starting with a September rise. If that pattern holds, waiting until September to vaccinate pregnant people or until October to immunize infants might leave many newborns more vulnerable than they need to be for weeks or months. Many experts do anticipate that RSV’s pattern will quickly settle back to its norm. Over the decades, its consistency “has been remarkable,” says Sarah Long, a pediatrician at Drexel University who advised the CDC on its guidelines for both new RSV interventions. But even in more predictable years, RSV transmission varies across regions—sometimes kick-starting during the summer in the South and lingering until spring further north. The recommendations “can’t be a one-size-fits-all” across the U.S., says Shabir Madhi, a vaccinologist at the University of the Witwatersrand, in South Africa, who helped lead clinical trials of the maternal vaccine. These are judgment calls: France opens its nirsevimab window earlier than the U.S.; Belgium will allow some pregnant people to receive a vaccine as early as the spring. The U.K. is weighing whether to offer both injections at any time of year. One argument for the current seasonal window is that giving a vaccine or a monoclonal antibody injection too early might mean recipients miss out on protection at the end of the season, Karen Acker, a pediatrician at Weill Cornell, told me. But Permar and others are hopeful that the effects of the new RSV interventions might last longer than five or six months, which is about when clinical trials stopped directly testing their effects. Early data for nirsevimab, for instance, suggests that a little bit of protection may even trickle into subsequent seasons, Muller told me. [Read: Fall’s vaccination routine didn’t have to be this hard] RSV is also of greatest threat to children within the first few months of life, when their respiratory tracts are still tiny and developing. Given the choice between offering the maternal vaccine a little early—which could leave an older infant a bit more vulnerable at the season’s end—and waiting to administer nirsevimab to a young infant after RSV season has started, the former might actually be the safer strategy. Plus, summer babies who don’t get nirsevimab at the hospital are less likely to get it later, especially if their parents aren’t regularly taking them to see a pediatrician. Giving a shot on the early side is better than never giving one all, Joshua Salomon, a health-policy researcher at Stanford, told me. In theory, the CDC’s guidelines do make room for adjustments in administration windows, in accordance with local RSV trends. But those decisions can be difficult to execute when providers have to place orders ahead of time and store vials in limited space. So far, many doctors’ offices and hospitals have stuck to the months outlined by the CDC guidance. “The cutoff dates have been taken very dogmatically,” Rick told me. At the start of the past season, infants just one day over the recommended dosing age of eight months or younger were denied nirsevimab, Turner told me. Then, a lot of providers simply stopped offering the maternal vaccine after January 31, or simply ran out. When both the need and the enthusiasm for a vaccine or drug is strong, taking every opportunity for protection makes sense. Several experts I talked with supported wider windows; Permar thinks the U.S. should even consider offering the maternal vaccine year-round. To her mind, restrictions regarding both seasonality and gestational age too strongly limit the chances that a baby will be protected. Some providers also noted that, given all the uncertainties, they would recommend the maternal vaccine as primary defense, leaving nirsevimab as the backup—simply because the vaccine can be delivered first. A maternal shot can set babies up with protection from the moment of birth, a sort of insurance policy that can guard against nirsevimab supply or delivery issues. A wider window of vaccine eligibility might not be a perfect solution. But it could get more infants protected when they most need it—putting to best use a shot that people are actually willing to get. from https://ift.tt/bwi2spJ Check out http://natthash.tumblr.com Recently, a balmy spring day left me feeling parched. I needed a beverage—stat!—and had forgotten my water bottle at home. I ducked into a nearby CVS to pick up a drink. The choices were so overwhelming, I nearly forgot my thirst. The drink aisle included a bevy of the usual thirst-quenching options—and some that looked like they belonged in an apothecary rather than next to the LaCroix. Row upon row of multicolored cans and bottles held drinks with purposes beyond mere hydration and flavor. Some promised to improve my energy, immunity, or gut health. Others claimed to stimulate mind states such as clarity, balance, or calm. Fizzy or flat, juice or tea, high in protein or in probiotics? Drinks with a purpose, known as “functional beverages,” have become unavoidable in many supermarkets, drugstores, and gas stations across the country. On top of Vitamin Water and traditional energy drinks like Red Bull and Monster, you can find options such as BRĒZ, a supposedly mood-shifting elixir infused with mushrooms and cannabis and SkinTē, a “collagen sparkling tea.” Kin Euphorics, a line of drinks launched by the supermodel Bella Hadid that’s available at Target, sells one meant to boost energy, level up immunity, and make your skin glow. Simply picking out a drink has never been harder. Drinks have always been about more than taste and hydration—think of coffee, alcohol, and soda. Energy drinks first appeared in stores inthe 1960s, before exploding in popularity in the 2000s. Yet the expansion of a drink’s promised effects beyond inebriation or energy is “a little bit newer,” Ernest Baskin, a food-marketing professor at Saint Joseph’s University, told me. Some of the products I spotted at the pharmacy included an caffeinated shot called Tru Energy and its extra-strength sibling, Tru Power; pastel-colored cans of Recess, a seltzer with magnesium and adaptogens to promote calmness; and Poppi, a soda for gut health. Even the energy drinks are no longer just a few hyper-sweet, hyper-caffeinated options: Newer brands tout health benefits, such as added vitamins, and come in a wider variety of formulations, including seltzers, coffees, and teas. These functional beverages are booming. By one estimate, the industry is expected to be worth $54 billion in North America alone this year. Grocers report that functional beverages are vying for prime shelf space traditionally occupied by sodas, bottled water, and even alcohol. Encountering the staggering range of supplements, nutrients, and other additives now present in the drink aisle can make choosing a drink feel deeply stressful, more like picking up medication than grabbing a bottle on the go. Part of the reason functional drinks have exploded is the same reason that there are lots of protein bars and low-sugar snacks: If it sounds healthy, more people will buy it. Americans are “increasingly interested in health,” Baskin said. That’s how you end up with something like Bai—a line of “water beverages” infused with antioxidants and electrolytes—and prebiotic sodas that contain ingredients including live bacteria and fiber. Even Nestlé’s Nesquik, a chocolate drink I enjoyed as a child, comes in a “protein power” version. The fact that these drinks can be sold at a premium has endeared them to stores, Baskin said. A single can of Celsius energy drink or Olipop prebiotic soda costs $3 at Target. Of course, as in all things wellness, whether any of these products actually does what it says to do is far from guaranteed. Certainly, a drink stuffed with huge amounts of caffeine will be energizing. Others are more suspect. A sparkling water brand called Good Idea goes so far as to claim to balance blood sugar. Safety Shot, packaged in cans labeled with a blue medical cross, is sold as a hangover cure, promising to rapidly lower blood-alcohol levels. (Products marketed as supplements, as opposed to beverages, are less rigorously regulated by the FDA.) Drink makers have swooped in to capitalize on the ongoing cultural obsession with hydration—one in which Stanley Cups are a must-have item and influencers suggest that clear skin is just a bottle of water away. That has created an opening for more fantastical functional beverages that promise to be a quick fix for all kinds of health concerns—stress, anxiety, insomnia, and unhappiness. Read: It’s just a water bottle Recess, one of the drinks I saw at CVS, is positioned as an antidote to a hectic world, helping sippers feel “calm cool collected.” Among the ingredients it highlights are hemp and adaptogens, a category loosely defined as substances that help the body deal with stress. Some drinks claim to promote a shift in mood, equating health with happiness; others, to induce sleep. An energy shot called Magic Mind, touting buzzy ingredients such as nootropics, lion’s-mane mushrooms, and the calming plant ashwagandha, is marketed as a path to a clear mind. Maybe it’s not surprising that people crave products claiming to bottle some form of respite. Younger adults, to whom most of these drinks are targeted, are drinking less booze but also using more marijuana: They want altered states, if just not in alcohol form. In lieu of happy-hour drinks at a bar, some functional beverages are positioned as something to gather around. One called hiyo describes itself as a “mindful social tonic”; another, called Three Spirit, is meant to “make moods and enhance connections.” Yet as I stood in the drink aisle, with its shelves of mood elixirs and wellness tonics, these products strangely made me feel worse. Passing on these drinks can seem like a missed opportunity; after all, who doesn’t need some kind of boost these days? Perhaps the appeal of these beverages is less about their actual effect and more about the feeling they sell—that you can take a step toward self-optimization one sip at a time. I had walked into the grocery store just wanting a drink, but being confronted with all those options made me anxious that I didn’t want enough—as if my current state was unacceptable. After spotting a bottle of Kin Euphorics, I pulled up its website and filled out an online quiz: “How do you want to feel?” it asked. Energized, rejuvenated, balanced, or calm? All I wanted to feel was hydrated. from https://ift.tt/AZg7TGt Check out http://natthash.tumblr.com I first met Daniel Kahneman about 25 years ago. I’d applied to graduate school in neuroscience at Princeton University, where he was on the faculty, and I was sitting in his office for an interview. Kahneman, who died today at the age of 90, must not have thought too highly of the occasion. “Conducting an interview is likely to diminish the accuracy of a selection procedure,” he’d later note in his best-selling book, Thinking, Fast and Slow. That had been the first finding in his long career as a psychologist: As a young recruit in the Israel Defense Forces, he’d assessed and overhauled the pointless 15-to-20-minute chats that were being used for sorting soldiers into different units. And yet there he and I were, sitting down for a 15-to-20-minute chat of our own. I remember he was sweet, smart, and very strange. I knew him as a founder of behavioral economics, and I had a bare familiarity with the work on cognitive biases and judgment heuristics for which he was soon to win a Nobel Prize. I did not know that he’d lately switched the focus of his research to the science of well-being and how to measure it objectively. When I said during the interview that I’d been working in a brain-imaging lab, he began to talk about a plan he had to measure people’s level of delight directly from their brain. If neural happiness could be assessed, he said, then it could be maximized. I had little expertise—I’d only been a lab assistant—but the notion seemed far-fetched: You can’t just sum up a person’s happiness by counting voxels on a brain scan. I was chatting with a genius, yet somehow on this point he seemed … misguided? I still believe that he was wrong, on this and many other things. He believed so, too. Daniel Kahneman was the world’s greatest scholar of how people get things wrong. And he was a great observer of his own mistakes. He declared his wrongness many times, on matters large and small, in public and in private. He was wrong, he said, about the work that had won the Nobel Prize. He wallowed in the state of having been mistaken; it became a topic for his lectures, a pedagogical ideal. Science has its vaunted self-corrective impulse, but even so, few working scientists—and fewer still of those who gain significant renown—will ever really cop to their mistakes. Kahneman never stopped admitting fault. He did it almost to a fault. Whether this instinct to self-debunk was a product of his intellectual humility, the politesse one learns from growing up in Paris, or some compulsion born of melancholia, I’m not qualified to say. What, exactly, was going on inside his brilliant mind is a matter for his friends, family, and biographers. Seen from the outside, though, his habit of reversal was an extraordinary gift. Kahneman’s careful, doubting mode of doing science was heroic. He got everything wrong, and yet somehow he was always right. In 2011, he compiled his life’s work to that point into Thinking, Fast and Slow. Truly, the book is as strange as he was. While it might be found in airport bookstores next to business how-to and science-based self-help guides, its genre is unique. Across its 400-plus pages Kahleman lays out an extravagant taxonomy of human biases, fallacies, heuristics, and neglects, in the hope of making us aware of our mistakes, so that we might call out the mistakes that other people make. That’s all we can aspire to, he repeatedly reminds us, because mere recognition of an error doesn’t typically make it go away. “We would all like to have a warning bell that rings loudly whenever we are about to make a serious error, but no such bell is available, and cognitive illusions are generally more difficult to recognize than perceptual illusions,” he writes in the book’s conclusion. “The voice of reason may be much fainter than the loud and clear voice of an erroneous intuition.” That’s the struggle: We may not hear that voice, but we must attempt to listen. Kahneman lived with one ear cocked; he made errors just the same. The book itself was a terrific struggle, as he said in interviews. He was miserable while writing it, and so plagued by doubts that he paid some colleagues to review the manuscript and then tell him, anonymously, whether he should throw it in the garbage to preserve his reputation. They said otherwise, and others deemed the finished book a masterpiece. Yet the timing of its publication turned out to be unfortunate. In its pages, Kahneman marveled at great length over the findings of a subfield of psychology known as social priming. But that work—not his own—quickly fell into disrepute, and a larger crisis over irreproducible results began to spread. Many of the studies that Kahneman had touted in his book—he called one an “instant classic” and said of others, “Disbelief is not an option”—turned out to be unsound. Their sample sizes were far too small, and their statistics could not be trusted. To say the book was riddled with scientific errors would not be entirely unfair. If anyone should have caught those errors, it was Kahneman. Forty years earlier, in the very first paper that he wrote with his close friend and colleague Amos Tversky, he had shown that even trained psychologists—even people like himself—are subject to a “consistent misperception of the world” that leads them to make poor judgments about sample sizes, and to draw the wrong conclusions from their data. In that sense, Kahneman had personally discovered and named the very cognitive bias that would eventually corrupt the academic literature that he cited in his book. In 2012, as the extent of that corruption became apparent, Kahneman intervened. While some of those whose work was now in question grew defensive, he put out an open letter calling for more scrutiny. In private email chains, he reportedly goaded colleagues to engage with critics and to participate in rigorous efforts to replicate their work. In the end, Kahneman admitted in a public forum that he’d been far too trusting of some suspect data. “I knew all I needed to know to moderate my enthusiasm for the surprising and elegant findings that I cited, but I did not think it through,” he wrote. He acknowledged the “special irony” of his mistake. Kahneman once said that being wrong feels good, that it gives the pleasure of a sense of motion: “I used to think something and now I think something else.” He was always wrong, always learning, always going somewhere new. In the 2010s, he abandoned the work on happiness that we’d discussed during my grad-school interview, because he realized--to his surprise—that no one really wanted to be happy in the first place. People are more interested in being satisfied, which is something different. “I was very interested in maximizing experience, but this doesn’t seem to be what people want to do,” he told Tyler Cowen in an interview in 2018. “Happiness feels good in the moment. But it’s in the moment. What you’re left with are your memories. And that’s a very striking thing—that memories stay with you, and the reality of life is gone in an instant.” The memories remain. from https://ift.tt/0fcrXBY Check out http://natthash.tumblr.com “In my lifetime, I never dreamed that we would be talking about medicines that are providing hope for people like me,” Oprah Winfrey says at the top of her recent prime-time special on obesity. The program, called Shame, Blame and the Weight Loss Revolution, is very clear on which medicines she means. At one point, Oprah stares into the camera and carefully pronounces their brand names for the audience: “Ozempic and Wegovy,” she says. “Mounjaro and Zepbound.” The class of drugs to which these four belong, called GLP-1 receptor agonists, is the reason for the special. For a brief and telling moment, though, Oprah’s story of the revolution falters. It happens midway through the program, when she’s just brought on two obesity doctors, W. Scott Butsch and Amanda Velazquez, to talk about the GLP-1 wonder drugs. “Were you all surprised in your practices when people started losing weight?” she asks. Butsch gets a little tongue-tied: “Yeah, I mean, I think we have—we’ve already been using other medications for the last 10, 20 years,” he says. “But these were just a little bit more effective.” Oprah is nonplussed. She didn’t know about these other drugs, before Ozempic, that were already helping people with obesity. “Where was I?” she cries. “Where was the announcement?” Velazquez milks the moment for a laugh—“We didn’t have TikTok; that was our problem,” she says—and the show moves on. Whatever the identity of these medicines that came before, these almost-as-effective ones, they will not receive another mention. The show proceeds as if they don’t exist. And yet: They do. Amid the hype around the GLP-1s, with their multibillion-dollar sales and corresponding reputation as a modern miracle of medicine, a sort of pharmaco-amnesia has taken hold across America. Patients and physicians alike have forgotten, if indeed they ever knew, that the agents of the “weight-loss revolution”—Ozempic and Wegovy, Mounjaro and Zepbound—are just the latest medications for obesity. And that older drugs—among them Qsymia, Orlistat, and Contrave—are still available. Indeed, the best of these latter treatments might produce, on average, one-half the benefit you’d get from using GLP-1s in terms of weight loss, at less than one-30th the price. That result should not be ignored. Given the lack of widespread insurance coverage for the newer drugs, as well as marked lapses in supplies, many people have been left out of Oprah’s revolution. For last week’s special, she interviewed a mother and her daughter who say, to pursed-lipped expressions of concern, that they’d love to be on a drug like Wegovy or Zepbound, but “cannot access it financially.” Although the Centers for Medicare and Medicaid Services has just announced that GLP-1 drugs for obesity may now be covered for seniors who also have cardiovascular disease, insurers have been pulling back. Next week, the North Carolina state workers’ health plan will cut off GLP-1 coverage for close to 25,000 people. Other, older drugs could help curb this crisis. [Read: Older Americans are about to lose a lot of weight] The newer drugs are much more potent. Semaglutide, the active ingredient in Ozempic and Wegovy, produced an additional 12 percent loss of body weight, on average, compared with placebos in clinical trials; the equivalent result for the highest dose of tirzepatide, which is in Mounjaro and Zepbound, was 18 percent. Meanwhile, the most popular of the older drugs for treating obesity, an amphetamine derivative called phentermine, has been shown to produce, on average, a 3 or 4 percent loss of total body weight. When phentermine is prescribed along with another older drug called topiramate—they’re sold in combination as Qsymia—the effect is stronger: more than 9 percent additional weight loss as compared with placebo, according to one trial. The newer drugs have also been investigated in very large numbers of patients and been shown to measurably reduce obesity-related complications such as strokes, heart attacks, and death. “We have all this data showing that GLP-1 drugs are reducing cardiovascular events and having other benefits,” Eduardo Grunvald, the medical director of the weight-management program at UC San Diego Health, told me, “and we have no data on the other drugs on those issues.” (Like many prominent obesity doctors, including Butsch and Velazquez, Grunvald has received thousands of dollars in consulting fees and honoraria from the maker of Wegovy. He has also received payments from the company behind Contrave.) All else being equal, the GLP-1s are the better option. But all else is rarely equal. For one thing, the average weight-loss effects reported in the literature can’t tell you how each specific patient will respond to treatment. When people take Wegovy or Zepbound, more than half of them are strong responders, according to the published research, with weight loss that amounts to more than 15 percent. At the same time, roughly one in seven people gets no clear benefit at all. The older drugs also have a diversity of outcomes. Qsymia doesn’t seem to work for about one-third of those who take it, but another third finds Ozempesque success, losing at least 15 percent of body weight. “I’ve had patients who have lost as much or more weight with Qsymia as they do with GLP-1s,” Grunvald said. “It’s about finding that lock and key for a particular individual.” [Read: Ozempic can turn into No-zempic] Depending on that fit, a patient may end up saving quite a bit of money. Since 2016, Sarah Ro, a primary-care physician based in Hillsborough, North Carolina, has run a weight-management program that serves rural communities. She’s been treating patients with the older drugs, she told me, and getting good results: “I regularly have people losing 50 pounds on phentermine alone, or phentermine-topiramate.” These drugs are generally covered by insurance, but Ro prescribes them as generics that are cheap enough to pay for out of pocket either way. “It’s like 10 to 11 bucks for phentermine, and 12 bucks for topiramate,” she said. A similar month’s supply of Wegovy or Zepbound injections is listed at more than $1,000. “I have to be honest with you, the whole craze and wave of uptake of the GLP-1 medications was a little bit of a surprise to me,” Grunvald said. “We had this decade of drugs that were actually effective, but people really didn’t latch onto them.” Again, he emphasized the obvious fact that the GLP-1 medications work much better, overall, than the old ones. But he and other experts with whom I spoke suggested that the higher potency alone cannot explain an utter turnabout in patient demand, from nearly zero to almost unmanageable. Several noted that the older drugs are “stigmatized,” as Grunvald put it. In particular, a lot of people are wary of phentermine, on account of its status as an amphetamine derivative, and also its connection to the “fen-phen” scandal of the 1990s, when it was sold as part of an enormously popular (and effective) drug combination that turned out to have dangerous effects on people’s hearts. But as David Saxon of the University of Colorado’s Anschutz Medical Campus explained to me, the problems with fen-phen derived from the “fen” and not the “phen”—which is to say, a different drug called fenfluramine. “Phen,” for its part, has been prescribed as a weight-loss drug for more than half a century—far longer than any GLP-1 agonist has been on the market—and has shown no clear signs of causing serious problems. Its known side effects are similar to those of Adderall, a drug that is now used by more than 40 million Americans. Topiramate brings other risks, including birth defects, tingling sensations, and changes in mood. Especially at higher doses, it can lead to brain fog. But again, the specifics here will vary from one patient to the next. And GLP-1s have their own side effects, most notably gastrointestinal distress that can be quite unpleasant. About one-sixth of people taking semaglutide are forced to stop; a guest on Oprah’s special said she had to quit after ending up in the emergency room, vomiting blood. Some of these patients may do just fine on phentermine or topiramate. “Honestly, I see more side effects with the GLP-1 drugs than with the other drugs,” Grunvald told me. “I get more messages and phone calls about side effects than I used to.” Some of the older drugs’ peculiar side effects can even wind up being useful, Ro suggested. Many of her patients with obesity are fond of Mountain Dew, she told me; some are drinking two liters every day. She counsels cutting back on sugary beverages, but topiramate can really help, because it can distort the taste of carbonation. In the clinical literature, this dysgeusia is deemed unwanted—it’s called a “taste perversion.” For Ro, it can be a tool for weaning off unhealthy habits. “We have such a wonderful response to using topiramate,” she said. Now she’s girding for the change in North Carolina’s health-insurance coverage for state workers. She tells her patients not to panic; if they can’t afford to pay for Wegovy or Zepbound out of pocket, she can switch them to different agents. “Everybody’s talking about GLP-1s, and it’s like, ‘GLP-1s or bust,’” she said. “And I’m going, ‘Hello! You know, my patients never had that much access to GLP-1s anyway.’” Those patients may not end up getting the best possible treatments for obesity—add this to the running list of health disparities—but they can have a drug that works. For anyone who is living with meaningful complications of obesity, having some weight loss will likely be better than having none at all. If Oprah never got the memo, the problem may have less to do with medicine than with expectation. The older drugs can work, but their average effects on body weight are in the range of 5 to 10 percent, which is about what some people can expect to achieve through major changes to their lifestyle. “Remember, you’re fighting against the cultural current that says, ‘What, you’re taking one of those medicines? That’s awful! You ought to be able to do that yourself,’” Ted Kyle, a pharmacist and an obesity-policy consultant, told me. “The efficacy is not enough to get you over that hump of cultural resistance, and of the stigma attached to taking medicines for obesity.” And then, when a patient on an older drug has reached their new plateau for body weight, which could be just 10 pounds less than where they were before, they may not be so inclined to keep up with their prescription. Are they really going to stay on a medication for the rest of their life, if its effects are not utterly transformative?
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