Why do women live longer than men?

As of 2024, while the average life expectancy in the U.S. climbed to 79, there was a striking and persistent gap between men and women. Women lived an average of 81.4 years, men 76.5. This five-year difference has been consistent over recent decades.

Why do women live so much longer than men?

Some of the difference is biologic and not anything men can change. Women have two X chromosomes, men one. This means that women have “backup” for loss of X chromosome gene deletions or losses. There is some animal data suggesting that the male Y chromosome has deleterious effects.

Women have stronger immune responses, letting them better fight off infections (but also making them more prone to auto-immune diseases like lupus).

Women have much more circulating estrogen than men, which seems to delay the onset of coronary disease, though women “catch up” after menopause when their estrogen levels drop.

There are many factors over which men do have control. Men are more likely than women to smoke and drink heavily, both negative factors for longevity.

Men are more likely to work in hazardous occupations (construction, fishing , forestry, police and fire, etc.) than women. Men also engage in more risky behaviors such as speeding in cars, fighting and extreme sports.

Women are much better than men at looking after their health – getting regular checkups, seeing a doctor if something seems wrong. Men tend to avoid doctors until forced to.

Women generally have much better social networks, a consistent factor promoting longevity. Men’s friendships tend to be less intense and less personal.

So, while we cannot (yet) engraft a second X chromosome into men, there are a lot of things men can do to emulate women and hopefully add a few years to their lives.


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TrumpRx - what is it good for?

In February, with much fanfare, TrumpRx was launched, claiming the ability to save US residents money on prescription drugs. Does it do so? Are there better ways to save money?

If you go to trumprx.gov, you are greeted by a glossy picture and a claim that “TrumpRx is rewriting the script, bringing major savings on essential medications to all Americans.”

Reality is less impressive than the rhetoric.

The site does not sell medications. Rather it directs you to manufacturers’ websites where you can (with a prescription) buy the medications directly from the companies, for cash – no insurance accepted. The list price is contrasted with the lower “TrumpRX” price.

43 medications are listed. All are brand name drugs. At least 18 are old-timers with much cheaper generic versions available at your local drug store, not only far cheaper than the list price but even cheaper than the discounted price offered.

An example: Protonix, an acid-suppressing medication, is shown with “an original price” of $497.28 for 30 tablets and a TrumpRx price of $200. Sounds good, no? Almost 60% off. It sounds good until you go to Amazon and see you can get the generic version, 30 tablets for $11.60.

Even for drugs where there is no generic yet available, you may well pay less at your pharmacy than the supposed savings offered via TrumpRx. Moreover, at the pharmacy you can use your health insurance, while using TrumpRx does not allow any insurance.

So, can you really save money on prescriptions? Yes, by following some commonsense rules.

First, always ask your prescriber if a generic is available for your condition. There are a few illnesses for which only one or a limited number of branded products will work, but such conditions are rare. For common conditions there are usually generic versions that are similarly effective.

Beware of manufacturer coupons that claim to let you pay little or nothing for a new branded drug – these have a limited lifetime, and when the promotion runs out you will be on an expensive medication for a long time.

Check the Mark Cuban Cost-plus Pharmacy (costplusdrugs.com). This has a large and growing number of medications at very reasonable prices.

Look for savings coupons on GoodRx.com.

If you have a condition for which only a very expensive drug will work, and your share will be financially stressful even using your insurance, call the manufacturer directly. Many have patient assistance programs that will lower your cost.

For a few items, including fertility drugs and weight loss drugs, TrumpRx may save you money – it does not take much time to look.


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Of Mice and Men - reading about medical "breakthroughs"

Researchers want people to appreciate their work and to get funding for more research, so they and the institutions for which they work want favorable publicity.

Reporters want to get bylines and publishers want readers, because more readers mean more advertising dollars. Thus, news outlets have every incentive to trumpet research results as big news, breakthroughs that will attract “eyeballs.”

Combine these aligned incentives with the fact that very few reporters have much background in science and you have a recipe for over-hyping minor advances or preliminary results as big news.

How can you critically read a story about a supposed major medical advance and know if it is truly important?

First, accept that mice are not humans. What works in mice may or may not work in people. Some 5% of initial promising results in lab rodents end up being similarly effective in humans. Even those that do cross over take a very long time before being useful – an average of 17 years between the first trial in mice and an approved human product.

What about human studies?

Be VERY skeptical of association as proving causation: the observational trial Researchers live in a “publish or perish” world and look for associations between habits or exposures and diseases or longevity that can form the basis of a published paper.

Good medical science depends on a controlled clinical trial, in which people are randomly assigned to the treatment being studied and are generally otherwise very similar. Observational trials may suggest linkages but almost never prove them.

The fact is that people who do one thing, like drink coffee, may do many other things differently. Coffee drinkers may be more likely to smoke, or eat donuts or work in offices than those who do not drink coffee. Unless the researchers have been able to match the people who do the thing studied with those who don’t, and can be sure that is the ONLY difference between them, the outcome may be due to something completely different.

Good trials, in addition to randomly assigning people to the treatment(s) being studied are double blinded. This means that neither the people being studied nor the researchers know which treatment or placebo they are getting. Other than death, few outcomes of a trial are absolutes. There is a strong placebo effect for most conditions, and if people know they are getting the active drug, many will feel better for that reason.

If researchers are heavily invested (emotionally or financially) in drug A being better than drug B, they will be tempted to ignore side effects or encourage feeling better in the group given A.

Finally – be careful not to assume that “statistically significant” is always the last word. Statisticians devise ways to tell if trial results are purely due to chance. This is given as a “P value.” A P of 0.05 means there is only a 5% chance that the results were just luck; the lower the P value, the more likely there really was a difference between groups.

Small differences in outcome may be called statistically significant when their clinical significance is minor. When a study result says that people given A lived significantly longer than those given B, look carefully to see how much longer.

This is particularly common with trials of new cancer drugs. You may read a headline saying that cancer patients given X lived significantly longer than those given Y. Buried deep in the story may be the facts that those given X lived 6.5 months and those given Y lived 5.3 months – and that those given X had many more side effects and had to pay $50,000 more out of pocket. It is not so clear that you would always want to choose X.


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The last diet advice you need to read

Paleo, Keto, Carnivore, Intermittent Fasting , Whole30 – each diet purporting to solve all your health problems. None are terribly healthy and none solve all your health problems.

What do we know, based on lots of observation and backed by science, about what constitutes healthy eating?

First, make plants the foundation of your diet. Whole grains, fresh fruits and fresh (or frozen) vegetables should make up much of your food intake. Use legumes as a healthy source of protein. Use nuts or minimally-processed nut butter as a snack food. A plant-heavy diet reduces inflammation, reduces coronary disease and cuts your cancer risk.

Eat fatty fish, preferably wild-caught, 2-3 times a week to get more protein and omega-3.

Use red meat sparingly and do not eat processed meats such as bacon, hot dogs or salami. Despite the new USDA guidelines, heavy consumption of red meat adds to coronary risk and may be carcinogenic.

Avoid highly-processed foods. If you look at the label and see items you cannot pronounce and that are not found in normal kitchens, don’t buy it or eat it.

Get adequate dairy for calcium. Best are fermented dairy products such as yogurt, kefir and cheese.

Limit your alcohol intake. Modest (1-2 drinks/day for men, 1/day for women) alcohol intake probably reduces heart disease a bit and increases cancer a bit – sort of a wash. If you enjoy an occasional glass of wine, you do not have to stop, but you certainly do not have to drink for health reasons.

For coffee-drinkers, the news is good – 2-3 cups/day may lower dementia risk, reduces the risk of atrial fibrillation and seems to have no harmful effects. Do not drink it at night if it causes insomnia. Regular or green tea (but not herbal) probably has similar benefits.

Finally, loosen up occasionally. Very few foods are dangerous in small quantities; it is the day-to-day that matters. If you are taking your grandchildren to an amusement park, have an ice cream cone. If your boss has you over for a cook-out and serves hot dogs, eat one. You can get back on your normal healthy diet tomorrow.


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Supplements - What are they good for?

Supplements are a multi-billion-dollar business. Pushed by TikTok influencers and TV personalities, they cover everything from vitamins and minerals to a variety of gummies, powders and pills.

Supplements are not regulated the way pharmaceutical drugs are, meaning the FDA does not assess them for efficacy or safety before they are marketed. Only if serious side effects show up does the FDA get involved.

An important consequence of this lack of regulation is that many of these products do not contain what they claim to contain, and there have been many reports of seriously tainted products. A popular protein powder was found to contain lead.

While touted to solve all human ills, no supplement has been found in a scientific trial to prolong life. Resveratrol was all the rage until trials showed no benefit.

Many of the products pushed on-line or on-TV are expensive. I know of people spending hundreds of dollars monthly on supplements, most of which were useless.

Are there any that you should consider taking?

A standard multi-vitamin is safe and inexpensive. There is evidence that it has a modest effect on reducing dementia. The B12 and D included in multivitamins can make up for the reduced B12 absorption that is common is older adults and the lack of sunshine-produced Vitamin D that is common in winter.

Omega-3 is healthy for the circulatory system. The best way to get this is by eating fatty fish 2-3 times a week. If you don’t eat fish, an omega-3 capsule may be useful.

Even safe and useful products can be harmful in large doses. Vitamin D in excess causes elevated serum calcium, which in turn can cause nausea, constipation, kidney stones and bone pain. While 1 multivitamin daily may be good, 5 or 10 are likely to be bad.

When you see a product pushed by a celebrity or “influencer,” remember that they are usually either selling the product or being paid to tout its benefits. Keep your money in your pocket.


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Can we make healthcare affordable?

On January 15, President Trump announced a “great healthcare plan” that seemed to have three components. It would formalize his push for pharmaceutical companies to lower their prices, send funds to individuals to help pay their insurance premiums and mandate price transparency for any hospital or other provider who participates in Medicare.

Will this do any good? Given the sparsity of details, analyzing this “plan” is analyzing air, but probably not much.

Going back to President Nixon, U.S. presidents have decried the high cost of medical care. In 1971 Nixon pronounced health costs as a crisis when healthcare consumed 7% of the Gross Domestic Product (GDP). In 1992 President Clinton said that “healthcare costs are increasing at unsustainable rates.”

Well, here we are in 2026, and healthcare now consumes 18% of the U.S. GDP, roughly double the cost in peer-countries.

In 2025, the average premium for a family plan was $26,993 - roughly 40% of the average worker’s salary. Even though much of this cost is borne by the employer (for those lucky enough to work for a company that offers health insurance), workers contributed an average of $6850 towards the cost.

Moreover, as insurance costs have skyrocketed, employers have tried to slow this by offering plans with high co-pays and deductibles, meaning that out-of-pocket costs have risen dramatically.

Keeping drug costs down is a start, but drug costs make up only 9-10% of healthcare spending.

When it costs $27,000, sending people $2000 to buy health insurance would not allow most lower income people to come anywhere near being able to afford it.

We have had mandated price transparency in law since 2021, and hospitals have proven very adept at making prices visible only to those with a PhD in computer science.

Yes, we MUST make healthcare affordable to all Americans, but this will require bold steps, with some pain for those currently getting rich off our dysfunctional, adminstration-burdened system, not “a concept of a plan.”


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The liver disease no one talks about

If you have diabetes, are overweight or have bad lipids, you may have MASLD: metabolic-associated steatotic liver disease – or fatty liver to be brief.

Most of us know that heavy alcohol use is bad for your liver, and years ago, most patients with cirrhosis (advanced liver damage with scarring and loss of function) were alcoholics.

In 2026, with the world-wide epidemic of overweight and obesity. MASLD has become the commonest cause of liver disease that can progress to cirrhosis. Up to 38% of adults have this! If you have Type 2 diabetes, that rises to 65%!

The first stage is fatty infiltration of the liver. If nothing is done, scarring and replacement of functioning liver tissue with fibrous (scar) tissue can follow. Eventually the liver loses much of its function, and the complications of a scarred non-functional liver ensue. These include jaundice, swelling of the legs and abdomen and bleeding.

Untreated MASLD is also the number one cause of liver cancer.

How can you prevent this cascade of catastrophes?

First, if you fit the risk profile (diabetic, overweight and/or high triglycerides), ask your doctor to check your liver. While most doctors know they should check your eyes if you have diabetes, many do not think about the liver.

Standard “liver function tests” are not routinely done and are not always abnormal in early stages of MASLD. While elevated liver enzymes may offer the first clue to the problem, 20-25% of people with biopsy-proven fatty livers have normal liver blood tests.

A better test is the “FIB-4” value, which is calculated from your age, two simple liver enzyme tests and the count of your blood platelets. If this is abnormal, an ultrasound test should be done to look for any scarring.

The good news is that getting your lipids and blood sugar under control and losing weight will reliably reduce fat in the liver and prevent you from going on to worse liver disease.

The GLP-1 drug semaglutide (Wegovy) has been proven to improve MASLD and is FDA-approved for this use. Though not studied for this use, the other GLP-1 agents would probably be equally effective.

You cannot live without your liver, so look after it!


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Who will care for me at home?

As birthrates fall and we live longer, western societies are aging. In the U.S., Canada and Britain, almost 20% of the population is over 65, while in Western Europe it ranges from 20 to 25%. Indeed, as baby boomers age, the fastest growing demographic is projected to be those 85+.

While today’s seniors are healthier than the elderly were a generation ago, aging eventually leads to the loss of some ability to live independently.

If an elder can no longer safely take a shower or grocery shop by themselves, what are their options?

As the last resort, moving to a nursing home is an option but, when asked, most seniors strongly prefer to age in their own home.

Besides being unappealing, nursing home care is expensive! In Massachusetts, a high cost of living state, the median cost of a semi-private room in a nursing home is $12,600 per month. Nationally, the median cost is $9555, which translates to $114,660 per year.

Staying at home instead of a nursing home means that help in the home will be needed. This can be provided by some combination of friends, family and paid caregivers.

Long-term, the U.S. must make policy decisions about how to cope with its aging population. In the immediate future, we need to provide more, and more affordable, help at home.

In 2024, some 3.2 million people worked as home health aides and personal care aides. To meet the demand, experts say that another 750,000 will be needed over the next decade.

Who are these people caring for our frail elders? Not surprisingly, almost 90% are women. About 30% are foreign-born, many from low-income countries such as the Dominican Republic, Jamaica, Haiti and the Philippines.

Home health workers are poorly paid, averaging $17/hour, and there is very high turnover. At the same time, the cost to care-recipients is high, averaging $34/hour. The difference is the money made by the agencies that employ the workers.

The agencies play a key role in vetting the home care workers. Given the possibility of physical abuse or theft by unknown individuals in the home of a dependent elder, hiring someone “off the street” is risky, yet keeping half of the cost seems excessive. If you or a loved one needs help at home, what are your options other than going through an agency?

The ideal option would be word of mouth. If a friend or neighbor has had a home aide that has been reliable, hiring them directly is an option. You can pay them more than they would get from an agency and still save money.

A better option would be for your state to set up a registry of vetted home health and personal care aides that individuals could access. The state could assume the responsibility for doing background checks and listing any complaints.

Massachusetts has such a registry, but it is only accessible to employers, not the public. Ask your state legislators to open the registry for public access.

The best fallback would be to call your local Visiting Nurse agency. They will either provide vetted home health aides or be able to direct you to a trusted local agency


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Are you taking too many pills?

90% of Americans 65 and older take at least one prescription medication. Half take 4 or more and 15% take 8 or more. The number of medications taken rises with age.

Add to that the many over-the-counter (OTC) pills such as pain relievers, acid suppressors and supplements that people take, and we are talking about a lot of medications.

While most of these are probably needed, some are not and some are harmful to your health.

There are many reasons people take medication they should not be using. A common reason is that we see many doctors, and each may be unaware of what the others are prescribing. This can lead to duplication – two pills with very similar actions – or to harmful interactions between medications.

Many medications are particularly dangerous to older people. These include muscle relaxants, sedatives and antihistamines, which can lead to dizziness and falls and/or confusion. A very valuable resource in this area is the Beers list of medications that may be harmful to older individuals, maintained by the American Geriatrics Society. It is easily available on-line – just Google “Beers list.”

While medicine has very few “always” or “never” rules, if you find that you are taking medication(s) on the Beers list, ask your doctor about this. You may be healthier stopping them.

I often saw patients taking two different strengths of the same medication. Clearly the dose was changed but the person did not know they were to stop the original pill, and the pharmacy kept refilling both.

There are numerous drug-drug interactions, many dangerous. One pill may affect the way the body handles another, leading to higher than safe levels of one or both. When they are prescribed by the same practitioner, a good electronic record will pick this up, but this will not happen if the prescribers do not share a common record.

If you have a primary care doctor, a valuable visit is the “brown bag visit.” Put ALL your medications, including OTC pills, in a bag and let your doctor review what you are taking. You may be surprised to find how many should be stopped.


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Oh, my aching knees

About 20% of Americans 45 and older have osteoarthritis of the knees, a condition which does not kill you, but which decreases your quality of life.

Osteoarthritis, by far the most common form of arthritis, is more than simple “wear and tear.” It does involve wearing away of the cartilage, the smooth “cushions” that cover the ends of the bones. It also involves the bone itself and the synovium, the lining of the joint.

Obesity is a risk factor for osteoarthritis of the knees and hips, but recreational running is not – it may even be protective. Both sedentary lifestyle and very high volume competitive running do increase the risk.

If you have it, what can you do to decrease your pain and be more active?

Rule number 1 is to stay active. Exercise such as walking lubricates the knees and lessens stiffness. If you enjoy running, keep at it. You may find that running on grass is easier than pavement, and be sure to experiment with different shoes.

In addition to aerobic exercise, strengthen your quads. Exercises such as straight leg raises with ankle weights and squats will build up the muscles that support the knee.

Tai chi has also been found to decrease pain and increase quality of life.

Weight loss, however you achieve it, helps.

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can be very helpful, but have side effects on the stomach, kidneys and heart. If you use them, use the lowest dose that works for as short a time as possible.

If you find yourself needing NSAIDs daily, ask your doctor for a prescription for a topical (gel or cream) NSAID, which is much safer. The only one available in the U.S. is diclofenac.

If these measures are not adequate, injection of cortisone-type drugs into the knee will usually give quite a bit of relief. The problem with “cortisone shots” is that the relief is temporary, rarely lasting more than 2-3 months, and repeated injections contribute to worsening of the underlying arthritis.

Hyaluronic acid injections are controversial. There are many trials comparing it to placebo injections and while the majority show benefit, many show no advantage of hyaluronic acid. Insurance companies may cite lack of proven benefit and refuse to pay for these injections. It does appear to be safe should you opt to try this.

If nothing works and you are willing to have surgery, knee replacement is the ultimate choice. This has good results for most people, but not all. Before opting for surgery, it is critical that you are willing to commit to a vigorous physical therapy program. The surgery is the start, but not the end.

To get the optimal benefit from a “total knee” (or a partial one), expect to spend 4 to 6 months of demanding PT; if you are half-hearted with your exercise program, you will be left with a so-so result. You will still probably have less pain than pre-surgery, but you will not have full knee motion.


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Cannabis - what is it good for?

While cannabis (marijuana) is still classified as a Schedule I drug at the federal level, meaning it has no legitimate medical use and a high potential for abuse, the same is not true at the state level. Forty states plus the District of Columbia allow licensed health professionals to prescribe cannabis products for medical use.

(24 states allow recreational use of cannabis – no prescription required.)

One consequence of the federal classification is that the NIH is not allowed to fund studies of medical marijuana use, and this has greatly limited good research on such use. Despite this, 27% of U.S. adults have tried marijuana at least once for medical purposes.

There are FDA-approved cannabis-like products (dronabinol, nabilone) which are approved for nausea and vomiting due to chemotherapy and for severe anorexia due to HIV/AIDS. Another, cannabidiol, is approved for rare pediatric seizure disorders. That, according to the FDA, is that.

Advocates, however, claim that cannabis can do wonders for just about every ailment. Are any of these claims valid?

Chronic pain is a common reason for cannabis use, and a recent study found that chronic pain patients using narcotics were able to reduce their narcotic use after using cannabis. Certainly marijuana is less dangerous than narcotics.

Most of the other reasons cannabis is used have limited or no good data supporting this use. Anxiety may improve but may get worse. Cannabis is used for insomnia, but the sleep it induces is often poor quality. Some PTSD sufferers report help.

Inhaled marijuana lowers eye pressure, but this effect wears off within a few hours, making it of minimal benefit for glaucoma.

Migraines, inflammatory bowel disease and fibromyalgia are often treated with cannabis, but again, there is little solid evidence of lasting benefit.

Why not “just give it a try”?

Cannabis is not harmless. Acute side effects include heart racing, drop in blood pressure, dizziness, impaired coordination and slowed reaction time. Driving after cannabis use is as bad as driving under the influence of alcohol.

With chronic use, particularly daily use, there is evidence that cannabis increases the risk of heart attacks and strokes. Use by adolescents and young adults is associated with cognitive defects and lower IQ scores in adulthood. Regular users can have a severe vomiting illness requiring emergency department visits. Susceptible individuals can develop psychosis and/or increased anxiety.

If you are considering using cannabis for a medical condition, discuss it with your doctor. If what you have been using is not working, there may be better options. Marijuana should be a last choice, not your first.


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Could I be having a heart attack?

Until the late 20th century, getting to the hospital quickly with a heart attack was not that critical. Very little was done for heart attack sufferers beyond letting them rest and treating some complications.

Around 1990, use of clot-dissolving drugs to dissolve the clot in the coronary artery that caused the heart attack became the standard of care. The earlier they were given, the better they worked, and the mantra became “time is muscle.” The drugs worked best when given within 6 hours of symptom onset.

In the early 2000’s, an even better treatment became standard: angioplasty - opening the blocked coronary artery by putting a catheter in the artery and opening the artery with a small inflatable balloon. Current best practice is to then put in a stent to keep the artery open.

What has happened in the past 35 years with these advances is that the early (30 day) death rate from an acute heart attack has fallen from over 20% to under 5%. To achieve these results, the earlier the better. Hospitals strive to get a patient from arrival at the emergency room to the cath lab in under 90 minutes. Most hospitals that provide emergency angioplasty have systems in place to achieve this goal.

The weakest link? The patient calling 911! To get the best contemporary care and to have the best odds of surviving a heart attack, it is key that someone experiencing a heart attack gets care ASAP.

How do you suspect you may be suffering a heart attack? The textbook description is crushing pain felt under the sternum (breastbone). The pain is often felt in the jaw and/or left arm as well. You may get sweaty, and you may feel nausea. The pain is not always excruciating – heart attacks are not as painful as childbirth or kidney stones – but there is something about it that tells you “this is serious.”

Unfortunately, your body has not always read the textbook.

Some people experience sudden shortness of breath rather than pain. Some become profoundly weak. Some feel abdominal rather than chest pain. In most situations, this is a new symptom, one you have not had before.

Women, particularly young women, much more than men, are likely to have non-textbook symptoms, and as such are more likely to delay seeking care and/or be treated less urgently than men who show up complaining of “something sitting on my chest.” Some 40% of younger (under 50) women with heart attacks do not complain of chest pain. (By the time women pass 65, they have similar symptoms as men.)

If you experience symptoms that may be a heart attack, call 911 and get an emergency ambulance. Do not drive yourself to the emergency room. In some communities, the advanced Emergency Medical Technicians who arrive may be able to initiate treatment even before you get to the hospital.

In virtually every situation, arriving by ambulance will get you seen and treated faster than presenting at the front desk.

If it is not a heart attack? Great – you will be allowed to go home and follow up with your doctor for any more testing needed. Never be “embarrassed” by a false alarm. Every emergency physician will tell you it is better to come in when you are not having a heart attack than to stay home and suffer the consequences when it is one.


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What you need to know about influenza

First, you should know that influenza is a serious illness, not a bad cold. If someone says they missed work yesterday because they had “a touch of flu,” it was not influenza. We get upper respiratory illnesses from a myriad of viruses, and most are annoying but not serious.

Influenza comes with a high fever, bad cough (including possible pneumonia), feeling too weak to do normal activities and the possibility of dying. In the U.S., depending on the influenza strain, between 20,000 and 60,000 adults die of influenza each year. Those at highest risk are the very old and the very young.

Experts are expecting this to be a bad season since it was bad in the southern hemisphere during their May to September flu season, and that usually predicts what we will experience in our November to March season.

Another troubling factor is that there is a new strain circulating, already causing the majority of influenza cases in Britain and Japan, which is not targeted in this year’s vaccines. The influenza virus constantly mutates, trying to evade our immune system.

Until we switch to the “just-in-time” production of flu vaccines using mRNA technology, we are going to be using educated guesswork to decide what to put in the vaccines. Some years the experts guess right and other years, like this one, the virus fools us.

So, what should you do?

Number 1: get vaccinated! Even if the vaccine is not perfect, it will reduce your chances of getting influenza and it will markedly reduce your likelihood of being sick enough to be hospitalized or die. If you are over 65, get the high-dose vaccine.

The national association of cardiologists recently emphasized that flu vaccines prevent hospitalizations and deaths in people with cardiovascular disease.

Number 2: wear a mask when you are indoors in crowded places like theatres or Black Friday stores. Masks are not a panacea but do reduce transmission of respiratory viruses by about 25%.

Number 3: if you are sick and coughing, stay home. Sharing your toys is good. Sharing your viruses is not.

Don’t spoil the holiday season by catching or giving influenza


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Using AI for health information

Health information has always been one of the top reasons people turn to the Internet. “Dr. Google” has helped answer many questions, though the fact that savvy programmers could ensure high placement and that sponsored sites got preferred placement meant that the results were sometimes suspect.

Facebook has also become where too many people get health information, even though misinformation about many subjects exceeds valid information. Just because someone says something loudly does not make it true.

Another terrible place to get health information is from “influencers” on TikTok or Instagram, most of whom are paid to push a product or service.

I have long advocated that seekers after valid health information turn to trusted sites maintained by non-profits or major health systems.

For information about vaccines, Google “Vaccine Information Center,” a site maintained by The Children’s Hospital of Philadelphia. For female health issues, go to ACOG.org and click on For Patients (this is the American College of Obstetrics and Gynecology). For children’s health, go to Healthychildren.org, a site maintained by the American Academy of Pediatrics. For general health questions, there is a wealth of good material at clevelandclinic.org under the Health Library tab.

The newest way to get help with health-related questions is to use one of the Large Language Model (LLM) “chatbots,” such as Gemini, Claude or ChatGPT, and use of these programs has exploded. Health questions are among the top inquiries they handle.

Before getting into specific suggestions, it is crucial to remind you that these programs do not think – they apply statistical methods to generate relevant text in response to queries. You can think of them as “autocorrect on steroids.” Just as your phone or email program usually anticipates what you are going to say and advance types it, LLMs generally give helpful responses. They also can be wildly off-base, having no “common sense” to check their replies.

If you are asking a chatbot for advice, be as specific as possible. The more detail you give them, the better their response. Don’t say “I have a cough. What could it be?” Say: “I am a healthy 32-year-old with 3 days of a dry cough, a mild sore throat and a fever of 99 to 100.”

Ask the bot what more it wants to know. A follow-up to its initial response should be “what else do you want to ask me to help answer my question?”

Remember that chatbots want to please. They will always give you an answer, even if they must invent something. So-called “hallucinations” are a very real phenomenon.

They will also appear confident in their responses when they should not be – if something appears odd, ask them for the source of their information – and check that source.

Do not rely solely on an LLM. They are best used as the start of a health information search, not the end. They can prime you for what to ask your doctor and can give you alternatives to consider.

Chatbots are great at retrieving information, but they are not health professionals and they do not know anything about you beyond what you tell them.

Unless you want your personal information to be public, use the "incognito" mode that most LLMs allow.


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Should you drink raw milk?

RFK Jr and his choice for the next U.S. Surgeon General, Casey Mean, are fervent advocates of drinking raw (unpasteurized) milk. Should you listen to them?

In 1862, Louis Pasteur invented a method of killing bacteria in wine and beer without affecting the taste. Beginning in 1920, Americans began to pasteurize milk using his method.

The process is simple: milk is rapidly heated to at least 161 degrees F (71.7 C) for at least 15 seconds and then rapidly cooled. This extends the shelf-life of milk and kills the harmful bacteria that can be transmitted in milk.

Today, about 3% of Americans consume raw milk and the MAHA movement wants to increase that number. Much of the rationale is simply “freedom to choose,” while touted benefits include more nutritional content and better taste. There have also been some observational studies that claimed that children who drank raw milk had fewer allergies.

The taste issue is false – it is impossible for most people to taste any difference. Pasteurization has minimal effect on the nutritional value of milk. A few vitamins may be decreased by pasteurization, but these are not in high content in milk in any form.

Since most children who currently drink raw milk live on farms, it is hard to say whether it is the milk or the farm environment that leads to fewer allergies. (We know that children who are allowed to play in the dirt have fewer allergies than those who are kept in pristine environments.)

What is clearly true is that drinking unpasteurized milk can lead to serious infections. Each year there are milk-associated outbreaks of infections with listeria, campylobacter, salmonella and toxin-producing E Coli. These are not trivial illnesses, and can be particularly dangerous to small children or those with immune deficiencies. Virtually every outbreak has been associated with drinking raw milk.

Can you follow Dr. Mean’s advice to “look the farmer in the eye and pat the cow” before drinking milk from that farm? No. Up to a third of all raw milk sampled contains harmful bacteria, and a healthy-appearing animal can be the source.

Protect yourself and protect your children – only consume dairy products that are pasteurized!


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The Basics of Medicare

Since we are in the Medicare “open enrollment” period, Oct 15-Dec 7, now is a good time for a quick review.

Medicare was enacted in 1965. It established parts A and B. Part A is free to all Americans 65 and older and to younger people with chronic kidney disease or who are chronically disabled. It pays 80% of hospital bills after a deductible. Part B, for which you pay, covers doctor fees and most outpatient services. Part B also has a deductible and covers 80% of the charges.

While Medicare B is voluntary, it would be playing Russian roulette to not take it, as you would have no coverage for doctor bills. Most people pay $185/month for Medicare Part B, though this goes up for those with higher incomes. It also goes up if you delay enrolling.

Medicare Part D became available in 2006. It is optional and helps pay for prescriptions. You must sign up and choose a plan annually. Typical premiums run about $50/month.

Because A and B only cover 80% of your medical bills, and these bills can mount up dramatically if you have a serious illness, most people pay for a supplemental policy to cover the 20%. These so-called “medigap” plans are offered by private insurers, not the government.

Part C, establishing what is now called Medicare Advantage, began in 1997. It gives private insurance companies a fixed amount per person per year to cover their medical expenses. The theory was that private health insurers would provide equal or better care and save the government money, a theory that has been proven wrong.

Medicare Advantage plans advertise heavily, and promise lower costs and extra benefits. At this time of year, you will be inundated with direct mail, phone calls and media blitzes trying to entice you to join an Advantage plan.

If you join such a plan, you must still pay your Part B premium, but typically will not have to pay for a medigap plan or Part D. Your monthly insurance premiums will usually thus be lower. There is, however, no free lunch. Under traditional Medicare A and B, you can be treated by almost every doctor and hospital in the country. This is not true for Advantage plans.

In return for the lower insurance cost, you will be restricted in the doctors and hospitals you can use and you will find that your doctors’ recommendations are subject to the whims of the insurance companies. Most hospital care and any expensive test or medication will only be covered if the insurance company approves it. I do not have space here to cover all the issues, and strongly recommend you Google “John Oliver Medicare Advantage” (the 31 minute one) for a biting and humorous look at the problem.

People who sign up for Medicare Advantage when they are healthy can be fine if they stay healthy. If they develop a serious illness they may regret their choice, as they find that the doctors and hospitals they would like to use for their care are not available.

Switching back to traditional Medicare would seem like an option, but there is a catch. When you first go on Medicare, you have free choice of medigap plans. They cannot refuse you because you are in poor health. If you try to sign up for one of these plans later, they can refuse to cover you at all or refuse to pay for pre-existing conditions. Just when you would need that 20% covered, it will not be, so you are locked into your Advantage plan.

My strong advice is that if you can afford the extra cost, start and stay with traditional Medicare and a good medigap plan. Otherwise, if you choose an Advantage plan, stay healthy!


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Time to say goodbye to Benadryl?

Diphenhydramine, commonly known by the brand name Benadryl, has been sold since 1946. It is an “antihistamine,” meaning it blocks the body’s receptors for the chemical histamine, which is released in response to allergens.

Diphenhydramine works very well to lessen allergy symptoms and is used not only as the sole ingredient in Benadryl but as all or part of the makeup of some 300 mostly over-the-counter medicines.

Diphenhydramine crosses into the brain and makes us drowsy. This “side effect” has caused it to become a widely used sleeping aid. Most OTC sleep aids have diphenhydramine (or doxylamine, a very similar product) as their active ingredient.

The problem with using these older antihistamines for allergy relief is that they are sedating and may make users too drowsy to safely drive or do other tasks requiring attention. They can be especially problematic for older adults and have been linked to falls and auto accidents. Regular use has also been linked to risk of dementia.

They can also be a problem with small children, causing extreme sedation and even coma. Also, oddly enough, in some children they have a paradoxical effect of causing agitation.

For allergy relief three newer antihistamines are available: loratadine (Claritin), cetirizine (Zyrtec) and fexofenadine (Allegra). These do not get into the brain and are much less likely to be sedating.

How about for sleep?

For very occasional use, diphenhydramine and other older antihistamines are probably OK. Like most sleeping pills, the sleep induced by antihistamines is not natural, with little REM sleep, and the sedation can linger well into the next day. It is not dissimilar to the sleep you get after drinking too much alcohol.

Better choices are melatonin or chamomile, which work immediately, or magnesium, which must be taken regularly and build up in your system. If you find yourself using an antihistamine to sleep more than 2-3 times a month, ask your doctor about alternatives.

So, yes, it is probably time to say adios to diphenhydramine, doxylamine and all the older antihistamines. Be sure to read the labels on OTC products before you buy them.


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Public Health is Not a Partisan Issue

This fall has seen a major outbreak of listeria, a bacterium that can spread via many foods, sickening people in 15 states, with at least 19 hospitalized and four deaths. The outbreak has been tied to packaged pasta meals made by Fresh Realm.

How did we know this and so were able to recall products sold by Fresh Realm? We knew it because of the Foodborne Diseases Active Surveillance Network, commonly called FoodNet. This highly successful program monitors labs in 10 states around the country and actively investigates possible food-borne illnesses.

Despite its critical role in protecting Americans from food-borne illness, the program was drastically curtailed recently. While not closed, staffing was cut and henceforth only two of the prior eight pathogens will be monitored – listeria one of the six cut, along with campylobacter, even though these two bacteria made thousands sick and killed 72 people in 2022.

More recently, draconian cuts were made to the staff of the Communicable Disease Center (CDC), supposedly due to the government shut-down and President Trump’s goal of destroying “Democrat programs.” [Note that about half the staff fired on Friday were reinstated over the weekend!]

When I need to know about the description of a tropical disease that may have been imported to the U.S. or want to follow disease outbreaks anywhere in the world, the first place I look is the CDC-published MMWR (Morbidity and Mortality Weekly Reports). This publication is usually the first to report on new and emerging infectious diseases.

No longer, I guess, as virtually the entire staff of MMWR were fired last Friday.

Despite RFK Jr’s insistence that his top priority was the burden of chronic disease in America, most of the staff guiding our response to chronic disease was also fired, along with those monitoring and responding to the opioid crisis.

The Director of the CDC was fired last month because she refused to be a rubber stamp for ideologues and said she would rely on science rather than politics in her decision-making.

I have met many CDC employees over the years. They are dedicated professionals who could generally be earning more in the private sector but believe in the life-saving mission of the CDC.

We cannot sit idly by while the agencies that keep us healthy are gutted. Write to the White House. Write to your senators and representative. Public health protects Republicans, Democrats and independents. It must not be allowed to fall victim to partisan politics.


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Is acetaminophen harmful in pregnancy?

The short answer to that question is: probably not but we cannot be absolutely certain.

Let me beg your indulgence in an explanation about why that is the only honest answer I can give you.

The “gold standard” in assessing the risks and benefits of any medication is the “controlled trial”. In such a trial, a large group of people are randomly assigned to drug A or drug B or to Drug A or placebo. This tends to ensure that differences in outcomes between the people taking one treatment or the other are due to the treatment and not to the characteristics of the people taking them. With a large enough group and truly random assignment, differences among the subjects are assumed to be evenly spread.

Historically, drug trials have excluded pregnant women because the trial sponsors worried that they would be sued for any bad birth outcomes. While this did protect the trial sponsors, it meant that most of the time, we were totally in the dark about the safety and efficacy of drugs when prescribed to pregnant women.

The fallback has been the “observational trial.” You look at a group who took a given drug and compared their outcomes to a group who did not.

The enormous problem with observational trials is that they are often comparing apples to oranges. People who take a medicine on their own are not the same as those who do not.

Let us take acetaminophen as an example. We know that about 60% of women take it during pregnancy. Most of the trials that report more neurodevelopmental disorders (autism, ADHD) in acetaminophen users compare women who used it with those who did not.

What is the commonest reason for acetaminophen use? It is fever. Thus, acetaminophen users are much more likely to have had febrile illnesses than those who did not use it. If there is an increased incidence of autism among users, the culprit might just as easily be the febrile illness, not the drug.

Until someone – and realistically it will have to be the NIH, as no commercial firm will pay for it – does a controlled trial comparing pregnancy outcomes among women who take acetaminophen with those who take a placebo, we will be offering advice either way with imperfect data.

The closest I can find to a good study is one out of Sweden that used successive pregnancies of women who had more than one child, comparing the siblings and looking at acetaminophen use. This study found no increase in autism, ADHD or learning problems caused by acetaminophen use. Again, though, this was an observational study.

Strengthening this conclusion is a similar study reported this year from Japan that also concluded there was no association of acetaminophen use and autism or ADHD.

Given this, what is the best advice you can take?

First, as is true for all medications, take medication only when you need it. A temperature of 99.6 does not need treatment. A temperature of 102 is harmful to the fetus and should be treated. If you have a backache that can be relieved with heat or a backrub, skip the pills. If you are very uncomfortable, acetaminophen is clearly safer than anti-inflammatories such as ibuprofen or naproxen, that are known to cause fetal malformation, or narcotics.

Second, try to take it for as short a time as possible. The limited data we have suggests that chronic use is worse than occasional use, and that makes physiological sense.


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Does the MAHA movement truly care about America's children?

The Trump administration recently released a long-promised report decrying the sorry state of the health of American children and saying how it planned to change this.

They correctly begin by noting that “Despite outspending peer nations by more than double per capita on healthcare, the United States ranks last in life expectancy among high-income countries – and suffers higher rates of obesity, heart disease, and diabetes.” Unfortunately, they then largely focus their prescriptions on the wrong solutions.

The four areas on which they propose to work to improve our children’s health are ultra-processed food; chemicals in our environment; the lack of exercise due to the digital age; and over-medication and excessive vaccination.

I support (and have written about) reducing the over-abundance of ultra-processed food, particularly the use of high fructose corn syrup in our diet, but to date the RFK Jr-run FDA has spent its energy on trivia such as red food coloring rather than going after big agriculture and big food.

Our food supply does contain too many pesticides, but hunger and malnutrition threaten more American children than do pesticides, and the gutting of the social safety net by the Trump administration will make this problem worse.

More exercise is good for us all, children and adults, so we should be expanding access to outdoor spaces, including national parks, not limiting them as has been done with cutbacks to the National park service.

What is most telling about this report is what it does NOT cover. The chemical that is the biggest threat to health is nicotine and the carcinogens in cigarettes, but there is not a word in this report about tackling the problem of youth vaping, which has been shown to lead to nicotine addiction and life-long smoking.

The insistence on reducing childhood vaccination, a cause that has made millions for Kennedy through his referrals of plaintiffs to class-action suits, is an enormous threat to children’s health. The disinformation spread by Kennedy and his allies has led to reduced rates of vaccination. Fewer children are being vaccinated, which means that diseases once thought eliminated, such as measles and whooping cough, are already making a resurgence. Thousands of American children, and millions world-wide, will die if the anti-vax movement holds sway.

Finally, no mention in the report is made of the leading cause of death in U.S. children and adolescents: death from motor vehicle accidents and firearms. Unlike every other western country, an American teenager is much likely to die by suicide or homicide with a gun than from illness. If RFK Jr and his followers truly cared about America’s children, gun control would be top of their priority list. Its absence says it all.


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