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Hydroxychloroquine and Chloroquine Prescribing Patterns by Provider Specialty Following Initial Reports of Potential Benefit for COVID-19 Treatment — United States, January–June 2020

Weekly / September 4, 2020 / 69(35);1210–1215

 

Lara Bull-Otterson, PhD1,2; Elizabeth B. Gray, MPH2; Daniel S. Budnitz, MD3,4; Heather M. Strosnider, PhD1,5; Lyna Z. Schieber, MD, DPhil1,6; Joseph Courtney, PhD1,5; Macarena C. García, DrPH1,7; John T. Brooks, MD8; William R. Mac Kenzie, MD1,7; Adi V. Gundlapalli, MD, PhD1,9 (View author affiliations)

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Summary

What is already known about this topic?

Hydroxychloroquine and chloroquine are approved to treat autoimmune diseases and to prevent and treat malaria. Earlier this year, they were widely reported to be of potential benefit in the prevention and treatment of COVID-19; however, current data indicate that the potential benefits of these drugs do not outweigh their risks.

What is added by the report?

New prescriptions by specialists who did not typically prescribe these medications (defined as specialties accounting for ≤2% of new prescriptions before 2020) increased from 1,143 prescriptions in February 2020 to 75,569 in March 2020, an 80-fold increase from March 2019.

What are the implications for public health practice?

Attention to updated clinical guidance, especially by nonroutine prescribers, will help safeguard supplies and ensure safe use of hydroxychloroquine and chloroquine for patients with approved indications.Views: 8,237

Related Materials

Hydroxychloroquine and chloroquine, primarily used to treat autoimmune diseases and to prevent and treat malaria, received national attention in early March 2020, as potential treatment and prophylaxis for coronavirus disease 2019 (COVID-19) (1). On March 20, the Food and Drug Administration (FDA) issued an emergency use authorization (EUA) for chloroquine phosphate and hydroxychloroquine sulfate in the Strategic National Stockpile to be used by licensed health care providers to treat patients hospitalized with COVID-19 when the providers determine the potential benefit outweighs the potential risk to the patient.* Following reports of cardiac and other adverse events in patients receiving hydroxychloroquine for COVID-19 (2), on April 24, 2020, FDA issued a caution against its use† and on June 15, rescinded its EUA for hydroxychloroquine from the Strategic National Stockpile.§ Following the FDA’s issuance of caution and EUA rescindment, on May 12 and June 16, the federal COVID-19 Treatment Guidelines Panel issued recommendations against the use of hydroxychloroquine or chloroquine to treat COVID-19; the panel also noted that at that time no medication could be recommended for COVID-19 pre- or postexposure prophylaxis outside the setting of a clinical trial (3). However, public discussion concerning the effectiveness of these drugs on outcomes of COVID-19 (4,5), and clinical trials of hydroxychloroquine for prophylaxis of COVID-19 continue.¶ In response to recent reports of notable increases in prescriptions for hydroxychloroquine or chloroquine (6), CDC analyzed outpatient retail pharmacy transaction data to identify potential differences in prescriptions dispensed by provider type during January–June 2020 compared with the same period in 2019. Before 2020, primary care providers and specialists who routinely prescribed hydroxychloroquine, such as rheumatologists and dermatologists, accounted for approximately 97% of new prescriptions. New prescriptions by specialists who did not typically prescribe these medications (defined as specialties accounting for ≤2% of new prescriptions before 2020) increased from 1,143 prescriptions in February 2020 to 75,569 in March 2020, an 80-fold increase from March 2019. Although dispensing trends are returning to prepandemic levels, continued adherence to current clinical guidelines for the indicated use of these medications will ensure their availability and benefit to patients for whom their use is indicated (3,4), because current data on treatment and pre- or postexposure prophylaxis for COVID-19 indicate that the potential benefits of these drugs do not appear to outweigh their risks.

Hydroxychloroquine and chloroquine prescriptions dispensed through outpatient retail pharmacies in the United States during January–June 2019 and January–June 2020 were examined using deidentified pharmacy transactions from the IQVIA National Prescription Audit database.** This database includes 92% of all outpatient retail prescriptions dispensed in the United States; prescription estimates were projected by IQVIA to represent all retail outpatient medication dispensing at the state and national levels.

New prescriptions for hydroxychloroquine and chloroquine were defined as those dispensed to a patient without a history of prescription for these medications in the preceding 12 months. Hydroxychloroquine accounted for approximately 99% of prescriptions dispensed during the study period. Refill/switch prescriptions were defined as those dispensed either as a refill of a previous prescription or as a new prescription with a change in medication strength or brand or switches between medications within the same therapeutic category (i.e., bidirectional switches of hydroxychloroquine and chloroquine). New and refill/switch prescriptions dispensed before reports of potential benefit on medication use for COVID-19 (during January–June 2019) were compared with new and refill/switch prescriptions during January–June 2020. Fold changes in the numbers of new prescriptions were calculated and defined as the ratio between the estimated number of prescriptions in March, April, May, and June 2020, with respect to the same months in 2019. The percentage of total dispensed prescriptions by specialty group was calculated using the total number of dispensed prescriptions by specialty group, divided by the overall total number of dispensed prescriptions for the month; the percentage of new prescriptions by a specialty group was calculated by dividing the new prescriptions dispensed for the specialty group by the total prescriptions for the specialty group. The percentage of new prescriptions dispensed to males was calculated as the number of new prescriptions for males divided by the total number of new prescriptions.

Prescriptions were not included if they were dispensed by mail order; mail-dispensed prescriptions accounted for <7.5% of dispensed hydroxychloroquine and chloroquine. Prescriptions by veterinarians were also excluded.

Prescriptions included information on the prescriber’s medical specialty, as defined by the American Medical Association (AMA) self-designated practice specialties.†† For this study, clinicians prescribing hydroxychloroquine or chloroquine were categorized based on the frequency of prescribing of hydroxychloroquine or chloroquine before the COVID-19 pandemic. Specialists from rheumatology, dermatology, allergy, and nephrology, who might have had experience using these drugs for indicated medical conditions within their specialty before the pandemic (collectively termed routine prescribers) were responsible for 62% of new hydroxychloroquine or chloroquine prescriptions in 2019. Allopathic and osteopathic physicians, who included internal medicine, family practice, general practice, and pediatrics, and nurse practitioners, physician assistants, and prescribers with unspecified specialty (per AMA classification) were grouped for this study into primary care prescribers; this group provided 35% of the new prescriptions in 2019. Other specialists were considered nonroutine prescribers§§ if, in 2019, their specialty prescribed ≤2% of hydroxychloroquine or chloroquine prescriptions. Nonroutine prescribing specialties are less likely under normal circumstances to directly manage patients with autoimmune disorders or provide prescriptions for malaria prophylaxis.

The overall estimated number of hydroxychloroquine or chloroquine prescriptions dispensed in March and April 2020 increased from 819,906 in 2019 to 1,312,859 in 2020 (Table). In 2019, 92% of prescriptions were refill/switch prescriptions. Refill/switch prescriptions increased 1.4-fold, from 377,222 in March 2019 to 536,804 in March 2020, and remained elevated in April (456,489; 1.2-fold higher than in April 2019) (Figure 1). New prescriptions for hydroxychloroquine or chloroquine in March 2020 (222,382) were 7.2-fold higher than the 30,737 prescriptions in March 2019; in April, the number of new prescriptions (106,184) was 3.3-fold higher than the 31,748 in April 2019 (Table).

Overall, 54% of new prescriptions in March and April 2020 were written by primary care prescribers. In March 2020, primary care prescribers wrote more new prescriptions than did routine prescribers, writing 10,350 dispensed prescriptions in 2019 compared with 108,705 in 2020, a 10.5-fold increase (Figure 2). Primary care prescribers continued to be the largest source of new prescriptions in April 2020, writing 67,055 prescriptions (63% of total new prescriptions).

During March and April 2020, nonroutine prescribers accounted for the largest percentage increase in new prescriptions compared with the same period in 2019 (81.3-fold and 18.1-fold increases in March and April, respectively). The nonroutine prescribing specialties with the highest prescribing volume and growth in March 2020 were ophthalmology, anesthesiology, and cardiology.

During March and April 2019, most new prescriptions were dispensed to females (81%). In 2020, the estimated number of total new prescriptions for males was 93,776 in March (16.1-fold higher than March 2019), and 40,055 in April (6.8-fold higher than April 2019), accounting for 42% and 38% of all new prescriptions in March and April, respectively.

In May and June 2020, refill/switch prescriptions declined but remained elevated: 436,823 in May (1.1-fold higher than May 2019) and 461,670 in June (1.3-fold higher than June 2019). New prescriptions in May 2020 declined to 37,537 (7.9%) of all dispensed hydroxychloroquine or chloroquine prescriptions, with a similar number of dispensed prescriptions (38,803; 7.8%) in June 2020. In May 2020, the percentage of new prescriptions by those in nonroutine prescribing specialties declined to 18.5% from 82.5% in March and 54.2% in April.

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Discussion

In the United States, during March and April 2020, monthly hydroxychloroquine and chloroquine outpatient prescribing was higher than it was during the previous year. These medications are routinely prescribed for lupus and rheumatoid arthritis (hydroxychloroquine) and for antimalarial prophylaxis malaria treatment (chloroquine), and the annual rate of prescribing has not varied substantially from year to year (6). In contrast, new prescriptions written by primary care prescribers and nonroutine prescribing specialists increased significantly in 2020. Primary care prescribers provided 54% of new prescriptions dispensed at outpatient retail pharmacies during March–April 2020; the largest percentage increase in new prescriptions compared with the same period in 2019 was among nonroutine prescribers.

A large increase in new prescriptions occurred for adult males (16.1-fold increase in March 2020 compared with March 2019). This increase in hydroxychloroquine prescribing for males is notable given that females are historically more likely to receive a new hydroxychloroquine prescription for autoimmune disease, consistent with described prevalence of autoimmune disorders among females (78%) (7). By May and June 2020, the numbers of new prescriptions and the number of new prescriptions from nonroutine prescribing specialties had declined and were approaching those of 2019. These declines might have been influenced by publication of additional studies indicating that the medications were not found to be effective for treatment of COVID-19 and by FDA safety warning (8).

The findings in this report are subject to at least four limitations. First, mail-order prescriptions were not included in the study, nor were prescriptions given in inpatient settings, so data do not indicate total medication use nationwide. However, the data are weighted to be nationally representative, although they are based on a sample of 92% of outpatient prescriptions. Second, because specialty information was lacking for nurse practitioners, physician assistants, and unspecified specialties, these prescribers were categorized as primary care; however, it is possible that these providers were working in routine or nonroutine prescriber practices. In addition, allopathic and osteopathic physicians with internal medicine and subspecialty training potentially were not classified by subspecialty. Third, among patients receiving prescriptions, clinical indications, patients’ underlying medical conditions, and concurrent medications were unknown. Finally, no information was available to confirm whether the medication was taken or stored for future use or if any adverse events occurred.

If prescribing or prescribed these drugs, providers and patients should be familiar with the potential for drug interactions and adverse events associated with hydroxychloroquine or chloroquine use (8,9). The importance of obtaining a patient’s complete medical and medication history to evaluate risks should be emphasized to nonroutine prescribers of hydroxychloroquine or chloroquine. In the setting of polypharmacy and comorbid conditions, such as preexisting heart conditions, performing an electrocardiogram to evaluate the QT interval before starting these medications is advisable, because hydroxychloroquine or chloroquine can prolong the QT interval, leading to malignant arrhythmias such as torsade de pointes or ventricular fibrillation (9). Because of the long-terminal half-life of hydroxychloroquine (>40 days) (10), patients could continue to be at risk for drug interactions and adverse cardiac events after the course of therapy is completed.

Although federal guidelines now recommend against using hydroxychloroquine or chloroquine for the treatment or prevention of COVID-19, dispensing policies and restrictions vary significantly by state (8). Policies by boards of pharmacy in some states, such as New Jersey, require hydroxychloroquine prescriptions to include a diagnosis, documentation of a positive diagnostic test, and be limited to a 14-day supply.¶¶ In Texas, similar restrictions instituted in May expired in July.*** Several other states advise caution in prescribing hydroxychloroquine or chloroquine for COVID-19, while allowing for clinical judgement without policy limitations. Although dispensing of hydroxychloroquine or chloroquine prescriptions has been declining since March 2020, continued attention to updated clinical guidance (3,4), especially by nonroutine prescribers, will help safeguard supplies and ensure safe use of these medications for patients with approved indications.†††

 

 

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Icosapent Ethyl Reduces Plaque Volume in Patients With Elevated Triglycerides on Statin Therapy  

 

TAKE-HOME MESSAGE

  • This double-blind trial compared outcomes in 80 statin-treated patients with coronary atherosclerosis and with persistently elevated triglyceride (TG) levels who were randomized to receive icosapent ethyl (IPE) or placebo. Low-attenuation plaque (LAP) volume was assessed at baseline, 9 months, and 18 months. The prespecified primary endpoint, change in LAP at 18 months, differed significantly between the IPE and placebo groups. In the IPE group, there was a 17% reduction in LAP volume at 18 months. In contrast, the placebo group experienced a 109% increase in LAP volume over the same period. A similar pattern was detected for fibrous and fibrofatty plaque volumes, which also regressed with IPE treatment but progressed with placebo treatment. These differences in plaque volume persisted in adjusted analyses.
  • Based on these findings, IPE significantly improves LAP volume over 18 months compared with placebo. The results build on previous evidence to support the beneficial effects of IPE.   
 

Icosapent ethyl—does it affect plaque?

For many years, statin therapy has been the cornerstone in the reduction of cardiovascular (CV) events. However, even patients on maximal statin therapy were still having events. This led to the concept of residual risk. There are many other factors that continue to drive the CV events. To try to reduce this remaining risk, researchers have evaluated other lipid parameters. Triglyceride was an obvious target, but fenofibrates have not shown any benefit and most of the omega-3 interventions have not really worked.

Then in 2019, the REDUCE-IT study using icosapent ethyl showed a 25% reduction in the primary endpoint (HR, 0.75; 95% CI, 0.68–0.83; P < .001) in 4.9 years.1 Benefit was gained in patients with established ASCVD and also in primary prevention patients with diabetes and one risk factor. Many commentaries followed. Some experts explained that the purified and highly concentrated formulation was the key to the success. Others said that the mineral oil in the placebo was actually increasing events, while still others said it’s only one study, so it might just be by chance.

This study, EVAPORATE, was meant to shed some light on this compound. It is designed to see if 2 g twice daily of icosapent ethyl has any anti-atherosclerotic effects. In other words, this study was looking for a mechanism behind the findings of the REDUCE-IT trial. As a mechanistic trial, the number of participants can be much smaller; so, instead of the 8179 patients in the REDUCE-IT trial, this study had just 68 patients.

To assess the plaque, the researchers used multidetector computed tomography (MDCT) angiography, which can see plaque size in a noninvasive way. It can also give an estimate of the morphology of the plaques: calcified, fibrotic, fibrofatty, or LAP (low-attenuation plaque). The authors pointed out that LAP is the one most likely to rupture as it is thought to have a primarily necrotic core and hence is associated with CV events. In other words, LAPs are one of those “vulnerable” plaques that we often refer to.

After 18 months, the scans showed that the patients on icosapent ethyl had significant reductions in all the parameters except for the calcified one, which was reduced but not significantly. This makes sense because it is hard to change something that is calcified.

The biggest surprise was in the LAP data. In patients on icosapent ethyl, LAP was reduced by 17%, which is not earth-shattering; but, in the placebo group, LAP went up 109%. Thus, the natural disease process drives these vulnerable plaques, and icosapent ethyl seems to be able to stop that increase and even help some reduction in LAP. That may be the driving force behind the clinical results in IMPROVE-IT.2 By the way, they did not use mineral oil in the placebo arm; so, it is not mineral oil that is causing harm as was suggested by some experts.

This study, even though small in numbers, has provided useful insight into what might be driving residual risk in our patients, and perhaps making vulnerable plaques less vulnerable might be the ultimate goal.

References

  1. Bhatt DL, Steg PG, Miller M, et al. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med. 2019; 380(1):11-22. https://www.nejm.org/doi/10.1056/NEJMoa1812792
  2. Cannon CP, Blazing MA, Giugliano RP, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372(25):2387-2397. https://www.nejm.org/doi/full/10.1056/nejmoa1410489
 

 
 
 

Abstract

This abstract is available on the publisher's site.

Access this abstract now 

AIMS

Despite the effects of statins in reducing cardiovascular events and slowing progression of coronary atherosclerosis, significant cardiovascular (CV) risk remains. Icosapent ethyl (IPE), a highly purified eicosapentaenoic acid ethyl ester, added to a statin was shown to reduce initial CV events by 25% and total CV events by 32% in the REDUCE-IT trial, with the mechanisms of benefit not yet fully explained. The EVAPORATE trial sought to determine whether IPE 4 g/day, as an adjunct to diet and statin therapy, would result in a greater change from baseline in plaque volume, measured by serial multidetector computed tomography (MDCT), than placebo in statin-treated patients.

METHODS AND RESULTS

A total of 80 patients were enrolled in this randomized, double-blind, placebo-controlled trial. Patients had to have coronary atherosclerosis as documented by MDCT (one or more angiographic stenoses with ≥20% narrowing), be on statin therapy, and have persistently elevated triglyceride (TG) levels. Patients underwent an interim scan at 9 months and a final scan at 18 months with coronary computed tomographic angiography. The pre-specified primary endpoint was changed in low-attenuation plaque (LAP) volume at 18 months between IPE and placebo groups. Baseline demographics, vitals, and laboratory results were not significantly different between the IPE and placebo groups; the median TG level was 259.1 ± 78.1 mg/dL. There was a significant reduction in the primary endpoint as IPE reduced LAP plaque volume by 17%, while in the placebo group LAP plaque volume more than doubled (+109%) (P = 0.0061). There were significant differences in rates of progression between IPE and placebo at study end involving other plaque volumes including fibrous, and fibrofatty (FF) plaque volumes which regressed in the IPE group and progressed in the placebo group (P < 0.01 for all). When further adjusted for age, sex, diabetes status, hypertension, and baseline TG, plaque volume changes between groups remained significantly different, P < 0.01. Only dense calcium did not show a significant difference between groups in multivariable modelling (P = 0.053).

CONCLUSIONS

Icosapent ethyl demonstrated significant regression of LAP volume on MDCT compared with placebo over 18 months. EVAPORATE provides important mechanistic data on plaque characteristics that may have relevance to the REDUCE-IT results and clinical use of IPE.

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Overwhelmingly strong results could end COVID-19 vaccine trials early, Fauci says

Liz Szabo
 
 
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said a COVID-19 vaccine could be available earlier than expected if clinical trials produce overwhelmingly positive results. <span class="copyright">(Alex Wong / Getty Images)</span>
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said a COVID-19 vaccine could be available earlier than expected if clinical trials produce overwhelmingly positive results. (Alex Wong / Getty Images)

COVID-19 vaccine could be available earlier than expected if ongoing clinical trials produce overwhelmingly positive results, Dr. Anthony Fauci, the nation’s top infectious disease official, said this week.

Although two ongoing clinical trials of 30,000 volunteers are expected to conclude by the end of the year, Fauci said an independent board has the authority to end the trials weeks early if interim results are overwhelmingly positive or negative.

The Data and Safety Monitoring Board could say, "The data is so good right now that you can say it’s safe and effective,” Fauci said Tuesday. In that case, researchers would have “a moral obligation” to end the trial early and make the active vaccine available to everyone in the study, he said, including those who had been given placebos — and accelerate the process to give the vaccine to millions.

Fauci’s comments come at a time of growing concern about whether political pressure from the Trump administration could influence federal regulators and scientists overseeing the nation’s response to the COVID-19 pandemic, and erode shaky public confidence in vaccines. Prominent vaccine experts have said they fear that President Trump is pushing for an early vaccine approval to help win reelection.

 

Fauci, the director of the National Institute of Allergy and Infectious Diseases, said he trusts the independent members of the Data and Safety Monitoring Board — who are not government employees — to hold vaccines to high standards without being influenced by politics. Members of the board are typically experts in vaccine science and biostatistics who teach at major medical schools.

“If you are making a decision about the vaccine, you’d better be sure you have very good evidence that it is both safe and effective,” Fauci said. “I’m not concerned about political pressure.”

The safety board periodically looks at data from a clinical trial to determine if it’s ethical to continue enrolling volunteers, who are randomly assigned to receive either an experimental vaccine or a placebo shot. Neither the volunteers nor the health workers who vaccinate them know which shot they’re receiving.

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What You See First Will Reveal Your Deep Psychological Secrets

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What You See First Will Reveal Your Deep Psychological Secrets

If you saw the Empty Boat first… 

You can hardly face your uncontrollable fear of the unknown. Sometimes, you wish you could predict everything in advance so you’ll be prepared for whatever comes your way, while other times, you jump right into the unknown because everything that follows is extremely exciting to you. You don’t always think about this, however, it’s there.
You can boldly fall in love and the scary part of it is what makes the whole thing very appealing to you. Although it may make you feel alive, you should be more careful because people can be more dangerous than you imagine.
Next time, try to take control of what’s happening and see how it’ll make you feel.

If you saw the Masked Woman first…

You are all about strong feelings and intense experiences. You like trying new things and find unimaginable joy in the first days of meeting someone attractive, the first heartbeats when you fall in love, and the first nights you stay awake texting or just replaying the beautiful moments in your head, especially if you’re not an official couple yet. You just can’t help but feel amused by all of it.

But someday, you’ll have to face the real world. Of course, the first days of any relationship are wonderfully romantic and full of sparks, but you should try to experience the deeper levels of a relationship to get an idea of having something much more meaningful. Only then, you can get a better taste of love.

So, what did you see first?  

If you saw the Boatman first… 

One of your hidden weaknesses is that you find it attractive when a person can successfully find a secret way into your mind and make you wonder.
At the moment, you are probably trying to handle some self-esteem problems. That’s why finding someone who can help you escape your own tormenting thoughts can feel like a fairytale or drug that makes want to come back for more.
Although all of these things can feel magical and love can even make your life brighter, you need to believe that you are your own hero. Enjoy the company of a supportive lover but never become dependent of their love for you.

If you saw the Couple first…

The lack of a deep sense of safety and security frightens the heck out of you. Of course, you are wild and free! You want to stay cool and ditch all sorts of commitments just like many of your friends. But even though you love living life wildly, it’s very important to you to have something real and meaningful. Deep down yourself, you enjoy the idea of building a life with someone you really appreciate. Just admit it, that’s what motivates you to go on dates!
You might want to take it easy for once! Don’t rush or force anything. Focus on becoming a better person and let all other things flow at their own rate. The best is yet to come.  

If you saw the Empty Boat first…  You can hardly face your uncontrollable fear of the unknown. Sometimes, you wish you could predict everything in advance so you’ll be prepared for whatever comes your way, while other times, you jump right into the unknown because everything that follows is extremely exciting to you. You don’t always think about this, however, it’s there.
You can boldly fall in love and the scary part of it is what makes the whole thing very appealing to you. Although it may make you feel alive, you should be more careful because people can be more dangerous than you imagine.
Next time, try to take control of what’s happening and see how it’ll make you feel.

If you saw the Masked Woman first…

You are all about strong feelings and intense experiences. You like trying new things and find unimaginable joy in the first days of meeting someone attractive, the first heartbeats when you fall in love, and the first nights you stay awake texting or just replaying the beautiful moments in your head, especially if you’re not an official couple yet. You just can’t help but feel amused by all of it.

But someday, you’ll have to face the real world. Of course, the first days of any relationship are wonderfully romantic and full of sparks, but you should try to experience the deeper levels of a relationship to get an idea of having something much more meaningful. Only then, you can get a better taste of love.

So, what did you see first?

 

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The Truth about Watermelons…and Benefits

y: Catherine Ebeling 
Co-author of the best-sellers:  The Fat Burning KitchenThe Top 101 Foods that Fight Aging & The Diabetes Fix

Nothing says “Summer” better than a cool, refreshing, sweet, juicy, delicious slice of ripe watermelon—no matter what time of year it is. But I often hear cautions on eating watermelon—that it is high glycemic, full of sugar, mostly water, not very nutritious, etc.

Right? Or wrong?

While watermelons are mostly water—90% or so, they are also full of vitamins A, B6, C, lycopene, antioxidants and minerals. Remember hearing about the lycopene in tomatoes? Watermelon, another red-colored fruit, is FULL of this powerful phytonutrient! In fact, watermelon has some of the highest levels of lycopene of all fruits and veggies. Just one cup of watermelon has 1 and a half times the lycopene of a large fresh tomato. And who eats just one cup of watermelon? I know I don’t!

Because watermelon is one of the best sources of lycopene with more than 6,500 micrograms in less than half a cup, you are getting an army’s worth of inflammation-fighting antioxidant activity! Lycopene from the red flesh of watermelon is very stable, even after the watermelon has been cut and stored in the refrigerator. Lycopene is thought to be even more powerful than its other orange/red colored ally, beta carotene—found in red and orange fruits and veggies.

Cardiovascular Benefits

Lycopene is a powerful natural anti-inflammatory and antioxidant, valued for its role in protecting the cardiovascular system, bone health, and preventing cancer. Along with lycopene, watermelons contain another powerful phytochemical, citrulline, an amino acid. Citrulline gets converted into another important chemical in the body, arginine, or L-arginine. Arginine is used to create nitric oxide, which has powerful benefits on the heart and blood vessels. NO can actually cause blood vessels to relax and open up, lowering blood pressure and helping the body carry more oxygen to parts of the body where it is needed–like muscles, your heart and your brain. A study from Florida State University found that watermelon could make a significant difference in lowering blood pressure–especially in overweight people, by relaxing the blood vessel walls.

Citrulline, when it converts into arginine, can also help prevent excess accumulation of fat in fat cells, because it blocks an enzyme that stores this fat. And because citrulline is a precursor to nitric oxide, it can also help improve erectile dysfunction in men, in a similar way that Viagra works—although you would have to quite a bit of watermelon to get the same effect as Viagra.

As you can see in this article, watermelons are on the list of foods that beat statins for heart health!

It’s All About the Lycopene

Carotenoids are powerful antioxidants, capable of destroying free radicals which attack our bodies and can contribute to chronic disease and aging. In one study of 13,000 adult Americans, low levels of carotenoids were a key predictor of early death. Especially low blood levels of lycopene! Lycopene protects our cardiovascular system, the male reproductive system, and in the skin, it protects and prevents UV damage from the sun.

Several studies have been conducted showing the strong link between levels of lycopene and heart disease. Analyses from the Physicians Health Study showed a 39% decrease in stroke risk in men with the highest blood levels of lycopene. Another study in Finland following 1,000 men for 12 years has had similar results as well.

Lycopene is also responsible for limiting the enzyme responsible for making cholesterol, so eating foods with more lycopene also helps to reduce cholesterol—specifically, LDL cholesterol.  (Side note:  speaking of heart health, did you know that grass fed dairy fat actually contains nutrients that help unclog your arteries)

Anti-Cancer Power

Lycopene is a life-saver in more ways than one! Besides its cardiovascular benefits, lycopene’s antioxidant power extends to anti-cancer effects as well. A 2014 meta-analysis of 10 studies shows dietary lycopene to be protective against ovarian cancers, as well as brain tumors and breast tumors.

And of course, we know about lycopene’s value in fighting prostate cancer. In several studies, higher intakes of foods containing lycopene and a higher serum or plasma concentration of lycopene was associated with a very significant decreased risk of prostate cancer—especially the more lethal kind of prostate cancer. When researchers studied only the men who had had at least one high risk PSA test, the subjects had a 50% decreased risk of lethal prostate cancer.

“Based on these results, we hypothesize that the consumption of a diet rich in lycopene-containing foods reduces the aggressive potential of prostate cancer by inhibiting the neoangiogenesis that occurs in tumor development,” Dr. Giovannucci’s team reported online ahead of print in the Journal of the National Cancer Institute.”

Other studies have shown lycopene’s powerful cancer fighting ability effective against lung cancer, esophageal, stomach, pancreatic, colorectal, and cervical cancers as well.

Extremely Good for Rehydration

Watermelons get their name because they are over 90% water, and that water is full of electrolytes and potassium which helps you stay hydrated or to rehydrate. The perfect fruit to eat on hot summer days, or after a hard, sweaty workout! And that delicious juice can also help prevent muscle soreness—especially if you have watermelon before your intense workout.

Its Not Just the Red Part

While most of us only eat the juicy red flesh of the watermelon, the whole thing is actually edible and chock full of nutrients! From the red center to the stem end, and also the blossom end–including the white part near the rind–are a plethora of impressive antioxidants, flavonoids, lycopene, and vitamin C. Even the green rind is full of nutrients. The rind is full of chlorophyll, and contains even more citrulline than the red flesh. Try throwing your watermelon rinds into the blender with fresh squeezed lime juice for a healthy slushy treat.

It is still best, however, to pick ripest, reddest watermelon you can find. Lycopene content continues to increase all the way up until the time the watermelon is at its reddest and ripest.

And don’t spit out those seeds, unless you are in a watermelon seed-spitting contest! The black watermelon seeds are not only edible, but actually extremely good for you. They are full of iron, zinc, fiber and protein. Seedless watermelons are ok to eat too—they are not genetically modified, only hybrid forms of watermelon bred especially for their no-seed content.

Watermelons also are rich in anti-inflammatory substances including cucurbitacin E, tripterpenoid which help to block the pain and inflammation of certain enzymes, in a similar fashion as NSAID’s like ibuprofen and aspirin.

While being very low in calories (only about 46 calories in a cup), watermelon also contains an impressive variety of other important essential nutrients including:

  • Vitamin A
  • Vitamin C
  • Vitamin B6
  • Potassium
  • Magnesium

The Age Old Question—How Do You Pick the Perfect Watermelon?

It can be a huge gamble finding the perfect, red, sweet watermelon. But—if you know what to look for, there is a real method to finding the best one. Look on the underside of the watermelon for a pale, butter-colored yellow spot—not white or green. This is one of the best indicators of the ripeness of the watermelon. Also pick up a few and choose the one that is heaviest for its size. Many people ‘thump’ the watermelon to check its ripeness too—listen for the best hollow bass sound.

Be aware that watermelons do contain a reasonable quantity of fructose, so be mindful of your sugar intake, and eat watermelon in moderation.  With that said, because watermelons are so filling, and have both high water content AND high fiber content, the old myth that watermelons are high glycemic is not entirely true… This is because the “glycemic load” of a watermelon is actually fairly low since it’s nearly impossible to overeat large quantities of a food that is as filling as watermelon.

So enjoy your watermelon, knowing you’re doing your body good!  Also try my friend Danette’s watermelon & lime juice drink here

References:
Charnow, (Feb 2014). Lycopene May Decrease Prostate Cancer Risk. Retrieved from http://www.renalandurologynews.com/prostate-cancer/lycopene-may-decrease-prostate-cancer-risk/article/335907/
Figueroa, Wong, Kalfon. (2014). Effects of Watermelon Supplementation on Aortic Hemodynamic Responses to the Cold Pressor Test in Obese Hypertensive Adults. American Journal of Hypertension, 2014; DOI: 10.1093/ajh/hpt295
Furhrman, J., MD. How Tomatoes Can Protect You Against Heart Attack and Stroke. Retrieved from http://www.timigustafson.com/2013/how-tomatoes-can-protect-you-against-heart-attack-and-stroke/
Hak AE, Ma J, Powell CB, et al. (2004). Prospective study of plasma carotenoids and tocopherols in relation to risk of ischemic stroke. Stroke 2004; 35:1584-1588.
Journal of the National Cancer Institute. (Feb 1999). Tomatoes, Tomato-Based Products, Lycopene, and Cancer: Review of the Epidemiologic Literature. Retrieved from http://jnci.oxfordjournals.org/content/91/4/317.full
Karppi J, Laukkanen JA, Sivenius J, et al. (2012). Serum lycopene decreases the risk of stroke in men: A population-based follow-up study. Neurology 2012; 79:1540-1547.
Karppi J, Laukkanen JA, Makikallio TH, et al. (2011). Low serum lycopene and beta-carotene increase risk of acute myocardial infarction in men. Eur J Public Health 2011.
Mateljan, G. World’s Healthiest Foods. Retrieved from http://www.whfoods.com/genpage.php?tname=foodspice&dbid=31
Mercola, J., DO. (2014). 6 things you didn’t know about watermelon. Retrieved from http://articles.mercola.com/sites/articles/archive/2014/07/21/watermelon-nutrition.aspx#_edn15
Szalay,J. (October, 2014). Watermelon: Health Benefits, Risks & Nutrition Facts. Retrieved from http://www.livescience.com/46019-watermelon-nutrition.html
Shardell MD, Alley DE, Hicks GE, et al. Low-serum carotenoid concentrations and carotenoid interactions predict mortality in US adults: the Third National Health and Nutrition Examination Survey. Nutr Res 2011; 31:178-189.

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9 Easy Yoga Poses to Reverse Bad Posture

 

Roll out your yoga mat! These poses will help you strengthen the muscles that cause you to slouch, making good posture effortless.

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Roll out your yoga mat! These poses will help you strengthen the muscles that cause you to slouch, making good posture effortless. 

Think about it: From the time we are in kindergarten to the time we get desk jobs, many of us are sitting for most of the day.

When this happens, it’s almost impossible to keep proper posture and avoid slouching. Over time, poor posture causes some muscles to become overly tight while opposing muscles become weak.

Suffering from a sore neck, back and shoulders? Get our mobility guide to ease pain and soreness.
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Muscles that become tight:

  • Hamstrings
  • Quadriceps
  • Hip flexors
  • Lower back
  • Calves
  • Chest
  • Shoulders
  • Muscles of the front of the neck: sternocleidomastoid and scalene

Muscles that weaken:

  • Glutes
  • Abs
  • Latissimus dorsi
  • Rhomboids
  • Muscles in the back of the neck: trapezius

You can reverse the damaging effects of poor posture with these nine simple yoga poses. They work to release different muscle groups while simultaneously strengthening other muscles.

To do this stretching routine, you’ll need a yoga mat, a yoga strap (or towel), and two yoga blocks. You can do this sequence up to three times per week, allowing for at least one day of rest between each set.


Cobra | 5 breaths

9 Easy Yoga Poses to Reverse Bad Posture

One of the most common signs of poor posture is rounded shoulders, stemming from a tight and shortened chest and a forward head. This pose brings the shoulders and the neck back into alignment while also strengthening the entire back.

  1. Lie face down on your mat with your toes untucked. Place your forehead on the mat and keep your neck long.
  2. Bend your elbows and place your palms on the mat next to your ribs.
  3. Press the tops of your feet into your mat. Inhale to lift your forehead, chest, palms and kneecaps off the mat.
  4. Squeeze your shoulder blades together. Hold for 5 slow breaths, then release on an exhale.

Bound Locust Pose | 8 breaths

9 Easy Yoga Poses to Reverse Bad Posture

This pose draws the shoulders back into alignment and strengthens the entire back, the glutes, and the hamstrings.

  1. Start by lying on your belly with your forehead on your mat and your toes untucked.
  2. Interlace your fingers behind your lower back and pull your legs together.
  3. Keep your neck long as you inhale to lift your chest, feet, and legs off of the ground.
  4. If you can, lift your hands up off your lower back. Hold for 8 breaths, then exhale to release slowly.  

Shoulder Pigeon | 8 breaths per side

9 Easy Yoga Poses to Reverse Bad Posture

This pose relieves tightness in the chest, shoulders, and hips.

  1. Lie down on your belly with your legs straight back behind you.
  2. Bring both arms straight out to your side, palms down, so that your wrists are in line with your shoulders. Rest your right cheek on the mat.
  3. Press into your left palm and roll onto your right shoulder. Bend your left knee and set your left foot down on the floor behind your right leg. The knee should point up and you should feel the hip and chest opening.
  4. Hold for 8 breaths and then roll back to your belly.
  5. Repeat on the other side

Cow Face Arms | 8 breaths per side

9 Easy Yoga Poses to Reverse Bad Posture

This pose uses a yoga strap to help to open up tight shoulders, triceps, and lats.

  1. Begin in a comfortable seat on a chair or on a yoga block. Hold the end of a yoga strap or towel in your right hand.
  2. Reach your right arm straight up. Bend the elbow and reach your right hand down towards your upper back.
  3. Reach your left arm straight down. Then bend the elbow and reach your left hand up your lower back, grabbing the other end of the strap.
  4. Walk your hands towards one another and see if you can get your hands to touch. Hold for 8 breaths.
  5. Repeat on the other side.

Bridge Pose | 8 breaths

9 Easy Yoga Poses to Reverse Bad Posture

Sitting puts quadriceps and hip flexors into a shortened state, often leading to tight and weak hamstrings and lower back. This pose helps to lengthen tight hip flexors and quadriceps while also strengthening the lower back and hamstrings.

  1. Lie on your back with your knees bent and feet on the ground at hip-width distance. Walk your feet as close to your body as you can.
  2. Place your arms down alongside your body with your palms face down. They should be nearly touching your feet.
  3. Exhale as you press your palms into the ground to lift your hips up towards the ceiling.
  4. Hold for 8 slow breaths in and out of the nose, then slowly roll back down to your back one vertebra at a time.

Runner’s Lunge | 8 breaths per side

9 Easy Yoga Poses to Reverse Bad Posture

The pose relieves tight hip flexors and calves while strengthening the core.

  1. Start in a push-up position with your shoulders stacked over your wrists.
  2. Pick up your right foot and place it outside of your right hand. Heel-toe it forward and out slightly to bring your right ankle underneath your right knee. Point the toe outward at a 45-degree angle.
  3. Draw your navel up and in towards your spine and feel your hip flexors releasing. Hold for 8 breaths.
  4. Repeat on the other side.

Downward Facing Dog | 8 breaths

9 Easy Yoga Poses to Reverse Bad Posture

This pose relieves tight hamstrings, calves, lats, and shoulders while strengthening the arms, core, and upper back to help keep your posture erect.

  1. Start in a push-up position with your hands lined up underneath your shoulders. Spread your fingers wide and press firmly into the mat while engaging your abs and your quadriceps.
  2. On an exhale, lift your hips towards the ceiling to make an upside down V-shape with your body.
  3. Press your chest up and back towards your thighs to find length through your lats and shoulders. Make your back as straight as possible, bending into the knees as needed.
  4. Lower your heels towards the ground to feel a stretch through your calves and hamstrings. Keep your abs engaged the entire time and gaze towards your navel. Hold for 8 slow breaths.

Supine Twist | 8 breaths per side

9 Easy Yoga Poses to Reverse Bad Posture

This pose improves range of motion in the spine and relieves tension in the lower back, upper back, chest, and shoulders.

  1. Lie down on your back and hug your right knee into your chest.
  2. Reach your right arm out to the side and cactus it so that your elbow is bent and your palm faces up.
  3. Use your left hand to guide your right leg across your body to come into your supine twist. Make sure to keep your right shoulder on the ground.
  4. Close your eyes and hold for 8 breaths.
  5. Repeat on the other side.

Supported Fish Pose | Hold 2-5 minutes

9 Easy Yoga Poses to Reverse Bad Posture

This relaxing pose relieves tightness in the chest and shoulders, reversing poor posture caused by sitting.

  1. Begin by placing a yoga block at a low or medium height across the top of your mat. Then place another block underneath it at the same height so that it is going vertically down your mat, creating a T. The blocks should be a few inches apart.
  2. Use your hands to lower yourself down onto the blocks, with the top block supporting your head and the bottom block resting between your shoulder blades.
  3. Lay with your legs long and your arms resting alongside your body, palms face up.
  4. Close your eyes and relax for 2-5 minutes.

Your Next Workout: 7 Soothing Yoga Poses for Sciatica Pain

Roll out your yoga mat! These poses will help you strengthen the muscles that cause you to slouch, making good posture effortless.

 
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About Kelly Collins

Kelly is a certified Personal Trainer with NASM, a Yoga Alliance Registered Yoga Teacher, and has her B.S. in Kinesiology from San Diego State University. She is co-owner of Roaming Yogi Adventures, a yoga and adventure-based retreat. She believes that having fun and well-rounded exercise is the key to maximizing strength, flexibility, and mental health.

For more posts by Kelly, click here.

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7 Natural Skin Benefits of Coffee (Plus DIY Scrub + Face Masks)

 

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Sure, most of us have experienced coffee’s ability to make groggy mornings better, but your morning brew can give your skin a natural boost, too!  

Perhaps you’ve also come across the other remarkable benefits of a daily brew, such as reducing the risk of developing Alzheimer’s and Parkinson’s disease by up to 65 percent, reducing risk of heart disease, stroke, colorectal and liver cancer, and even our risk of developing type 2 diabetes (1234).

Not to mention the fact that daily coffee consumption is associated with an overall lowered risk of mortality, with a 20-30 percent lower risk of premature death (56).

This coffee cookbook is filled with healthy recipes and reveals the natural benefits of your morning brew.
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Even so, the amazing benefits of coffee don’t stop there.

It turns out that coffee is great for another part of the body: our skin. These claims stem from the fact that coffee has a high antioxidant capacity and that the caffeine content can help improve circulation. But how exactly does this translate into a glowing complexion?


Natural Skin Benefits of Coffee

Delve into the many skin benefits of coffee below (plus, age-defying and brightening recipes!)

1. Reduces Inflammation

coffee grounds hand scrub
Coffee has been widely studied for its anti-inflammatory properties. Its caffeine content, coupled with potent antioxidant substances like polyphenols and hydrocinnamic acids, may be responsible for this effect (7).

This is great news for those suffering from breakouts, as the antioxidants in coffee can help soothe red and inflamed breakouts.  

2. Packed with Antioxidants

Coffee is rich in polyphenols, a group of antioxidants also found in foods like berries, tea, chocolate, and wine. In addition to giving these foods their vibrant and deep colors, these substances work to fight free radicals and slow down the process of aging due to DNA damage. As a bonus, they have also been shown to help protect against ultraviolet radiation and slow down aging of the skin caused by heavy sun exposure (89). [tweet_quote] Coffee can help fight free radicals and slow the aging process due to DNA damage.[/tweet_quote]

Interestingly, studies ranging from America to Poland, Spain, France and Japan report that coffee is the single biggest source of dietary antioxidants in their diets (101112).

So enjoy that second cuppa without guilt (as long as it’s early in the day, so you’re not interfering with your sleep, of course), and don’t forget to slather on some of those antioxidant-packed granules as featured in our age-defying coffee mask below:

 

coconut-coffee-mask-ingredients.jpg

time
Total time:25 mins
Prep Time:5 mins
 

Age-Defying Coconut Coffee Mask

Recipe by:author 
These antioxidant-packed face mask will keep your skin looking young.

Ingredients

  •  1 T coffee grounds
  •  1 T raw cacao powder
  •  1 T coconut milk (from the can - preferably BPA-free)
  •  1 T raw honey

Instructions

  •  Combine all of the ingredients and apply to a clean face. Let sit for 15-20 minutes, then rinse with warm water.

3. Gently Exfoliates

coffee as a facial exfoliant
Due to its slightly coarse nature, coffee – especially finely-ground coffee – makes an excellent exfoliator. These granules help slough away dead skin cells and, although research is limited, has been said to help stimulate lymph drainage and increase blood flow (13). Both of these are beneficial when it comes to achieving glowing skin as well as for removing toxins.

Check out the coffee face scrub featured at the bottom of this post for a brightening and softening recipe.

4. Reduces Cellulite

coffee scrub to remove cellulite
It turns out that caffeine may be one of the best contenders in the topical fight against cellulite.

Aside from its ability to increase circulation – which can ultimately help smooth the appearance of cellulite – the caffeine in coffee has been tied to a lipolytic effect on fat cells (meaning it essentially breaks down fat). Studies have shown the effect to be quite substantial, detailing that:

“Emulsion with caffeine caused a reduction of 17% on the diameter of the fatty cells compared with the control … and emulsion … was considered to promote the lipolytic action on fatty tissue, acting as a complement to treat cellulite (14).” [tweet_quote] Coffee can increase circulation and help break down fat when used topically.[/tweet_quote]

In other words, applying a topical caffeine solution to skin caused a decrease in fatty cell size of 17 percent.

This is also an important factor when it comes to diminishing the appearance of cellulite, as excess fat beneath the skin layer tends to protrude in an uneven manner (which is what leads to cellulite’s rumpled appearance). The less protruding fat tissue you have, the less chance for cellulite appearance (15).

One thing to keep in mind here is that caffeine can actually enter your body through the skin, so if you have a sensitivity or high blood pressure, you might want to use a coffee scrub sparingly and check with your doctor (16).

5. Brightens Skin

women holding coffee cups on a wooden table
The antioxidants in coffee we mentioned earlier can also revive dull, tired skin by ushering needed nutrients into the pores. Alongside its ability to increase circulation (thanks to its caffeine content), topical java can quickly brighten your complexion when used in a mask or scrub (17).

6. Reduces Puffiness

Have you ever had a day where your face seemed a bit puffier than normal, or perhaps one where you’ve woken up with slightly swollen eyes? Luckily, not only will a cup of brewed java heighten your spirits, but it can also help reduce this puffiness when applied topically. [tweet_quote] Puffy face or swollen eyes? A topical coffee mask can fix that.[/tweet_quote]

This is because caffeine and various compounds like methylxanthine in coffee have a diuretic effect, which can aid in reducing edema, or swollen tissues due to excess fluid retention (18).

 

depuff-coffee-mask.jpg

time
Total time:20 mins
Prep Time:5 mins
 

De-Puff Coffee Mask

Recipe by:author 
These coffee mask is targeted towards reducing swelling.

Ingredients

  •  2 T espresso or finely ground coffee
  •  4 T coconut milk
  •  1 T honey

Instructions

  •  Combine ingredients and let mask sit on your face for roughly 15 minutes. Rinse and pat dry.

7. Minimizes Dark Circles

Caffeine steals the show once again when it comes to dark circles under the eyes. Studies have shown that topical applications of caffeine “increase the microcirculation of blood in the skin,” effectively pushing along stagnant blood from dark, tired eyes (19). However, if you’re going to apply coffee as an eye-opener, you may want to do it in the morning, as caffeine can be absorbed into circulation through the skin, possibly affecting sleep (20).

As you can see, the benefits of coffee for the skin are extensive, and are derived mainly from its natural antioxidant and caffeine content. To get you started on producing your own exfoliating scrubs using ingredients probably already in your kitchen, check out the brightening coffee facial scrub below:

 

brightening-face-scrub.jpg

time
Total time:7 mins
Prep Time:5 mins
 

Brightening and Softening Coffee Face Scrub

Recipe by:author 
The caffeine in this face scrub can help fix those dark under-eye circles.

Ingredients

  •  3 T ground coffee
  •  1 T coconut palm sugar
  •  1 T olive/jojoba oil
  •  1-2 drops fresh lemon juice

Instructions

  •  Mix all dry ingredients, then add in your choice of oil. Massage onto face using gentle circular motions. Rinse and pat dry.

skin benefits of coffee infographic
(Read This Next: 4 Easy, Natural Homemade Face Mask Recipes)

 
 
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Megan Patiry

About Megan Patiry

Megan is an inquisitive nutrition and wellness writer harboring an editorial love affair with the decadent and the nutritious. She is a dedicated researcher in all areas of ancestral health, a certified specialist in fitness nutrition, personal trainer, and professional almond milk latte addict.

For more posts by Megan, click here.

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THE NUANCE

Could the Flu Shot Offer Protection Against Covid-19?

Experts say it’s more important than ever that people get the flu vaccine

Markham Heid

Earlier this year, a team of researchers based primarily at Johns Hopkins University examined county-level health data collected from all 50 states and the District of Columbia. The team was looking for associations between last season’s flu vaccine and deaths attributed to Covid-19.

After adjusting for more than a dozen variables that could have confused their findings — such as race, income, education level, health status, and access to hospital care — the researchers concluded that among adults age 65 and older, a group that accounts for the vast majority of coronavirus-related deaths, high rates of vaccine coverage were associated with a significant drop in Covid-19 deaths. Each 10% increase in flu vaccine coverage within a community corresponded with a 28% reduction in coronavirus deaths, they found.

“Our findings suggest that influenza vaccination can possibly play a protective role in preventing the worst Covid-19 outcomes,” says Luigi Marchionni, co-author of the paper and an associate professor at Johns Hopkins Medicine.

In his team’s paper, which was posted online June 26 and has not yet undergone peer review or formal publication, Marchionni and his colleagues were quick to highlight their study’s limitations — which included a lack of Covid-19 reporting consistency among states and localities. But he says that he and his group have since performed additional analyses on the data, and their conclusions have held up. He also references a similar study from Brazil, which found evidence that people vaccinated against the flu were less likely than the unvaccinated to suffer from severe or deadly cases of Covid-19.

“We’re most likely going to face a dual pandemic this fall,” he says, referring to the ongoing SARS-CoV-2 crises and the predictable resurgence of seasonal influenza. “Our findings point to some obvious reasons for getting the influenza vaccination.”

How the flu vaccine could provide an immune boost

Marchionni takes pains to explain that his team’s work was observational, meaning they were examining population-level data in an effort to find patterns and associations. They were not assessing individual Covid-19 patients in order to identify underlying explanations for their findings.

But after delivering that caveat, he says that there’s some evidence that the flu vaccine may trigger one or more immune system changes that may repel the novel coronavirus.

“There is an epitope, meaning a piece of antigen that the immune system can recognize, that is similar between influenza and SARS-CoV-2,” he says. It’s possible that the flu vaccine could teach the immune system to be on guard for this antigen, which could provide a coronavirus-blocking benefit.

He also says that the flu vaccine could induce a general “boost” to the immune system’s innate defenses, which could help it repel SARS-CoV-2.

If vaccinated people are generally healthier, then that alone could explain the association between the flu shot and lower rates of Covid-19 deaths.

There are other possible explanations for the observed association between flu vaccine coverage and reduced Covid-19 risk. During the spring, a number of reports documented cases in which people were infected with both the flu and SARS-CoV-2 at the same time. It’s not yet certain that coinfection with both viruses results in more extreme illness, but experts say that this is possible — and probably likely.

“Coinfection could absolutely make things worse,” says Steven Pergam, MD, an infectious disease specialist and associate professor at the Fred Hutchinson Cancer Research Center in Seattle. “If someone gets sick from the flu and their immune system is already on high alert and then they get Covid-19 on top of that, I worry that could shift them into a really severe Covid situation.”

The flu vaccine can prevent influenza infections, Pergam explains, and it can also reduce the severity of illness among those who become infected with flu. Both of these benefits could theoretically reduce the risk of life-threatening illness among those also infected with SARS-CoV-2, he says.

It’s also possible that someone who contracts the flu and then recovers from it is at greater risk for a bad case of Covid-19 due to lingering immune system changes or deficiencies. T-cells are a category of specialized white blood cells that help regulate the immune system. Research has shown that, following a case of the flu, people have reduced T-cell diversity and also a greater proportion of influenza-specific T-cells in the lungs. If a person is infected with the novel coronavirus, these T-cell imbalances may lead to the “exaggerated inflammatory response” that is associated with severe Covid-19 disease, Marchionni says.

But others say there could be a simpler explanation for the observed associations between the flu shot and reduced Covid-19 risks.

“Patients who get the [flu] vaccine are also likely to be more health-conscious [than those who don’t],” points out Michael Ison, MD, a professor in the Division of Infectious Diseases at Northwestern University’s Feinberg School of Medicine. If vaccinated people are generally healthier, then that alone could explain the association between the flu shot and lower rates of Covid-19 deaths, he says.

Ison says that, for other reasons, it’s important for everyone to get the flu shot this year. But he’s not convinced that the influenza vaccine provides any special Covid-19-weakening immune benefits.

Other vaccines could offer an immune-system boost

The influenza vaccine isn’t the only one that researchers believe may offer some coronavirus-related benefits. Some are exploring the possibility that active but weakened polio or tuberculosis vaccines could stimulate the immune system in ways that protect people from SARS-CoV-2.

“When you vaccinate people with some of these live attenuated viral vaccines, the immune system produces a number of factors, such as interferons, which have a general antiviral effect,” says Paul Offit, MD, director of the Vaccine Education Center at Children’s Hospital of Philadelphia.

Offit says that the National Institutes of Health is exploring the potential benefits of these vaccines, which could theoretically be deployed cheaply and widely among at-risk groups in an effort to block the spread of SARS-CoV-2. “Some people are pushing for this, but it’s not clear yet whether that will move forward,” he adds.

“When you vaccinate people with some of these live attenuated viral vaccines, the immune system produces a number of factors, such as interferons, which have a general anti-viral effect.”

The importance of getting the flu vaccine

While experts say that the coronavirus-weakening power of the flu vaccine is far from proven, they unanimously agree that everyone should get a flu shot this fall.

“Every year, the recommendation for the influenza vaccine is for everyone over six months of age to get it, and it’s more important to get it this year than normal,” says Offit.

Why? During the 2018–19 flu season, the Centers for Disease Control and Prevention estimates that roughly 36 million Americans came down with the flu, which led to more than 16 million health care visits or consultations and 500,000 hospitalizations. “If all this happens concurrently with Covid-19, you can see how that would quickly overwhelm the health care system,” Offit says.

Northwestern’s Ison reiterates these concerns and says that they underscore the need for people to get the flu shot, which is already available at many nationwide pharmacies. “I think that most individuals should go ahead and get the vaccine as early as possible,” he says. Those who are immunocompromised may want to wait until October, he adds, because their body’s protective immune response to the vaccine may not last until the end of the flu season.

Apart from the flu shot, he says that Covid-19-related safety measures like social distancing and masks can also protect people from seasonal respiratory infections like influenza. Good compliance with these protocols has led to an unusually mild flu season in countries like Australia, where the flu tends to circulate earlier in the year than it does in the U.S. But, due in part to poor adherence to these safety measures, Ison says that the U.S. “hasn’t done a good job of controlling Covid-19,” and so may be in for a rough flu season.

“Flu vaccination this year is going to be very important,” he adds.

WRITTEN BY

Health and science writer. Father of two. Technoskeptic, though not a technocynic. TABLE OF CONTENTS

WRITTEN BY

Markham Heid

Health and science writer. Father of two. Technoskeptic, though not a technocynic.

Your life, sourced by science. A Medium publication about health and wellness.

 
 
 
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Xinmei Liu

THE COVID AUDIT

In our new series, real life meets public health advice

Wouldn’t it be nice, as you go about your confusing, nerve-wracking, coronavirus-avoiding days, to have an epidemiologist on call to answer your many questions? …

 

Yes, we need to wash our hands. We also need to love out loud.

 
 
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Photo: EyeEm/Getty Images

Before the Covid-19 pandemic, it was easy to feel disconnected from the experience of serious illness, especially as a young or otherwise well person.

As a palliative care physician, my experience is quite the opposite. Every day I care for patients whose reality is life-limiting illness, and this spring I found myself at the bedside of patients dying of coronavirus. With Covid-19 cases in the U.S. surpassing the five million mark, this pandemic has upended our once protective narrative of separation. It has brought death into our homes and forced us all to acknowledge it directly.

Though my work as a physician prepares me more than most, it was not until my own sister’s life lay in transient shadows that I realized how impossible it is to be prepared for the unexpected loss of someone we love. Looking back, it was then that I started to learn that living with emotional intentionality may just be our only way to try. …

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Common systemic conditions associated with dry eye disease

January 15, 2020
Jade Coats, OD  More than 30 million people suffer from
 
Jade Coats, OD headshot
Jade Coats, OD. In practice at McDonald Eye Associates in North West Arkansas. 

More than 30 million people suffer from dry eye syndrome (DES), but less than 1 million are actually receiving treatment.1

Pinpointing the exact cause of dry eyes can sometimes be difficult because the condition is often multifactorial with several contributing factors leading to intermittent blur, fluctuations in vision, and stinging or watery eyes.

Related: Dry eye signs may signal risk for diabetic foot ulcers

Common systemic and autoimmune diseases have been found to be associated with an increased risk of dry eye disease; therefore, it is especially important to be familiar with these systemic conditions that contribute to aqueous deficiency and/or evaporative dry eye disease.

Dry eye disease is known to be multifactorial, with inflammation being a key contributing factor to the vicious dry eye cycle.1 Most commonly, evaporative dry eye causes tear hyperosmolarity which destroys the ocular surface cells. This damage causes an inflammatory response, leading to chronic dysfunction of the tear secretion, further increasing the tear osmolarity. In contrast, aqueous deficient dry eye involves inflammation attacking and damaging the lacrimal glands causing a decrease in tear production. 

*Important to note: Although the prevalence of DES is more common in women and may increase with age, dry eye symptoms affects people of all ages.1

Click here to see a dry eye video related to this article (video A)

Click here to see a dry eye video related to this article (video B)

Related: Blood-derived serum tears go beyond conventional therapy

 

Diabetes

The Centers for Disease Control (CDC) reports more than 30 million Americans, or approximately 10 percent of the United States’ (U.S.) population, has diabetes mellitus (DM), with another 7.2 million likely undiagnosed.2 Both type 1 and type 2 diabetes affect the way the body regulates glucose, and it has been documented that the incidence of dry eye is correlated with increased levels of glycated hemoglobin (HbA1c).3

Related: How IPL can help dry eye

The Beaver Dam Eye Study identifies diabetes as one of the leading systemic risk factors for dry eye with nearly 20 percent of participants between ages 43 and 86 exhibiting dry eye symptoms.1 In another study, insulin dependent diabetics demonstrated significantly decreased reflex tearing and increased conjunctival surface disease.4

For patients with DM, it is important to remember that the decline in tear film function has been shown to be more severe in patients with advanced diabetic retinopathy3. Knowing this, it is important to recognize dry eye disease and its role in overall visual function for patients with diabetes mellitus.

Click here to see a dry eye video related to this article (video A)

Click here to see a dry eye video related to this article (video B)

Related: How to incorporate nutrition into dry eye practice

Autoimmune disease: Rheumatoid arthritis (RA), Lupus, and Sjögren’s syndrome (SS).

Rheumatoid arthritis is characterized as a chronic autoimmune disease that primarily targets the synovial tissues, damaging the joints of the body. Research has shown that chronic systemic inflammation has been identified as causing eye complications such keratoconjunctivitis sicca in up to 70 percent of RA patients.5 Interestingly, in that same study, only 12 percent of patients were currently being treated for ocular surface disease.5

Related: Surgical update 2019: What every OD needs to know

Systemic lupus erythematous (SLE) is another chronic autoimmune disease that causes inflammation of various organs including skin, heart, joints, blood vessels, liver, kidney, and the eyes. It is thought that a higher concentration of cytokines and inflammatory markers in the tears of SLE patients may cause aqueous deficient dry eye disease. The prevalence of keratoconjunctivitis sicca symptoms in SLE has also been reported between 28 and 36 percent.6

Sjögren’s syndrome (SS) is a chronic autoimmune disease that attacks exocrine glands such as the salivary and lacrimal glands.7 With likely many people undiagnosed, SS affects nearly 4 million Americans with 10 percent of SS patients suffering from significant aqueous deficient dry eye disease.7

With pharmaceutical options including Restasis (0.05% cyclosporine, Allergan), Cequa (0.09% cyclosporin, Sun Pharmaceutical), and Xiidra (5% lifitegrast, Novartis), optometrists now have multiple options to treat the signs and symptoms of dry eye disease by decreasing the inflammatory response and breaking down the dry eye cycle.

Click here to see a dry eye video related to this article (video A)

Click here to see a dry eye video related to this article (video B)

Related: Offer IPL as a treatment for MGD and dry eye disease  

Thyroid-related disorders: Grave’s disease, Hashimoto’s thyroiditis

Thyroid disease has been shown to be associated with increased risk of dry eye, suggesting that hormone dysfunction may play a role in early onset of symptoms.1 Both Grave’s disease (hyperthyroidism) and Hashimoto’s disease (hypothyroidism) are associated with an abnormal production of thyroid hormone and can cause a combination of both aqueous deficient and evaporative dry eye disease.

Related: Recognize signs and treatment for patients with persistent PSP

Nearly 50 percent of patients affected by Graves’ disease suffer from thyroid-associated ophthalmopathy (TAO), a progressive eye disorder that is linked to an inflammatory response of the orbital tissues. TAO ranges from no signs or symptoms to severe vision loss, and may also be characterized by lagophthalmos, exophthalmos, restrictive myopathy, proptosis, and diplopia. Most commonly, a classic presentation of eyelid retraction and proptosis occurs in in 80 to 90 percent of patients with Graves’ disease.8

Similarly with Hashimoto’s thyroiditis, proptosis is found to be a risk factor supporting previous research that found an increased palpebral fissure width might lead to ocular surface drying and tear film hyperosmolarity.8 Due to the increased ocular surface exposure caused by proptosis and eyelid retraction, a lubricating ointment at night can be recommended for overnight use to ensure proper eyelid seal.

Click here to see a dry eye video related to this article (video A)

Click here to see a dry eye video related to this article (video B)

Related: Dry eye signs may signal risk for diabetic foot ulcers

Sleep disorder: Obstructive sleep apnea (OSA)

Obstructive sleep apnea affects more than 18 million Americans and is a life-threatening sleep disorder causing decreased blood oxygen levels. With nearly one in four men and one in 10 women affected by interrupted breathing during sleep, it is important to identify undiagnosed patients who may exhibit other ocular manifestations of sleep apnea.9

Related: New guidelines in OSD evaluation before surgery

In addition to evaporative dry eye symptoms, one prospective study of sleep apnea patients referred for a sleep study found that over 25 percent increasing to 40 percent among those with severe sleep apnea, also suffered from floppy eyelid syndrome.9

The common treatment option for sleep apnea includes the use of a continuous positional airway pressure (CPAP). Nighttime ointment can be helpful for OSA patients to ensure that the eyes are protected and lubricated, even if a mask leak exposes the cornea to constant air.

Click here to see a dry eye video related to this article (video A)

Click here to see a dry eye video related to this article (video B)

Related: Overlooked causes of dry eye

Allergies and asthma

Patients with allergies and asthma have been reported to have a higher incidence of dry eye disease. It is important to note that many patients suffering from allergic co-morbidities may be treating their symptoms with an over-the-counter oral or topical antihistamine, unaware that it could be contributing to their DED. Medications such as antihistamines, leukotriene receptor antagonists, and inhaled corticosteroids used in the treatment of asthma and allergies have been shown to exhibit adverse effects such as tear film dysfunction.10

Related: Why OAB should be considered before cataract removal

Research has also indicated an association of risk factors for dry eye disease in patients with other systemic disease such as osteoporosis, migraine headaches, and anxiety/depression.1

In conclusion, systemic disease and autoimmune conditions are frequently associated with an increased risk of dry eye syndrome. These patients are often affected by a combination of both evaporative and aqueous deficient dry eye; therefore, cognizance of a patient’s entire health history can help lead ODs to the root cause of chronic DES.

Asking a few extra questions during an eye exam regarding the status of a patient’s systemic conditions, and educating about their risk for dry eye, has been helpful in combating this disease by setting up realistic expectations of a treatment plan to control and maintain comfort.

Click here to see a dry eye video related to this article (video A)

Click here to see a dry eye video related to this article (video B)

More by Dr. Coats: Minimize symptoms of dry eye disease in refractive surgery patients

References:

1. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam offspring study: prevalence, risk factors, and health-related quality of life. Am J Ophthalmol. 2014;157(4): 799–806.

2. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2017.

3. Yu L, Chen X, Qin G, Xie H, Lv P. Tear Film function in type 2 diabetic patients with retinopathy. Ophthalmologica. 2008;222(4):284-91.

4. Goebbels M. Tear secretion and tear film function in insulin dependent diabetics. Br J Ophthalmol. 2000;84(1):19–21.

5. Piper H, Douglas KM, Treharne GJ, Mitton DL, Haider S, Kitas GD. Prevalence and predictors of ocular manifestations of RA: is there a need for routine screening? Musculoskeletal Care. 2007 Jun;5(2):102-17.

6. Resch MD, Marsovszky L, Németh J, Bocskai M, Kovács L, Balog A. Dry eye and corneal langerhans cells in systemic lupus erythematosus. J Ophthalmol. 2015;2015:543835.

7. Coursey TG, de Paiva CS. Managing Sjögren's Syndrome and non-Sjögren Syndrome dry eye with anti-inflammatory therapy. Clin Ophthalmol. 2014 Aug 4;8:1447–58.

8. Selter JH, Gire AI, Sikder S. The relationship between Graves' ophthalmopathy and dry eye syndrome. Clin Ophthalmol. 2014 Dec 31;9:57–62.

9. Santos M, Hofmann RJ. Ocular Manifestations of Obstructive Sleep Apnea. J Clin Sleep Med. 2017;13(11):1345–1348.

10. Bielory L. Ocular toxicity of systemic asthma and allergy treatments. Curr Allergy Asthma Rep. 2006 Jul;6(4):299-305.
 

 

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