Before I go, I want to highlight the breathtaking evolution in health advice that has occurred since I joined The Times in 1965.The very first Personal Health column, published in The New York Times on Nov. 10, 1976, appeared under a headline that I, its author, took seriously and hoped readers would too: “Jogging Is Like a Drug: Watch Dosage, Beware the Problems.”In the decades that followed, Personal Health by Jane E. Brody has had a very rewarding run. Countless readers have told me how one or more of my columns had improved — or even saved — their lives or that of their loved ones. Doctors often wrote to say they used my columns to help inform their patients.When The Times asked me to take on this weekly assignment, I was assured I could discuss any topic relevant to people’s health and well-being. Rarely was there any debate over the topics I wanted to take on — though there was the column on masturbation in 1982, which was ultimately published four years later when the paper overcame its squeamishness about sexuality.However, the times, and The Times, have changed and, dear readers, I’ve decided the time has come for me to say farewell to writing this column. Others may well take up the cudgel. But before I go, I want to highlight the breathtaking evolution in information and advice about several major health topics that has occurred since I joined The Times as a health and science writer in 1965.I based the advice in these columns on the best available evidence at the time I wrote them. But the very nature of the scientific process dictates that medicine evolves, and will continue to do so. As occurred with the coronavirus, this evolution will necessarily spawn new health recommendations. Only one thing remains static and continues to jeopardize the health of all who fall for it: quackery.The developments I’ve highlighted below are ones that touched many of your lives, but they merely scratch the surface of health and lifesaving improvements I’ve witnessed during my 58 years in health journalism.Diet. One of the most significant shifts has concerned dietary fats. Having been schooled in research-based nutrition and health during my first job writing science in Minneapolis from 1963 to 1965, I cheered the 1977 Dietary Goals issued by the Senate Select Committee on Nutrition that urged Americans to eat less high-fat meat, butter, eggs and refined sugar and eat more fruits, vegetables and complex carbohydrates. The report fostered a dietary change that was already underway to replace heart-damaging saturated fats from animals, like butter and lard, with less saturated vegetable-based margarines and other solid vegetable fats.Then studies found the trans fats in these hydrogenated vegetable products were even more damaging to arteries than animal fats. Dietary recommendations evolved to feature olive oil, a mainstay of a Mediterranean style of eating, and other unsaturated fats like canola, grapeseed and nut oils. More recently, dietary advice has shifted away from labeling foods as “good” or “bad” and focusing instead on overall patterns of eating that promote good health. But time will tell whether specific dietary fats, or the much vaunted Mediterranean diet currently embraced by many doctors, will fall prey to future findings.Smoking. I’m very proud of the fact-based campaign I waged in The Times to curb Americans’ most dangerous yet readily avoidable habit. I reported on every new finding of smoking’s health-damaging effects and suggested paths to quitting. I hope I played a role in the albeit painfully slow decline in smoking by adults, from its peak of 42 percent in 1964 to 14 percent in 2019, the latest statistics from the Centers for Disease Control and Prevention. Alas, the recent resurgence of smoking by young adults after a 30-year decline is truly alarming. It remains to be seen where vaping and marijuana smoking will take us.Surgery. Early in my career, radical mastectomy was the gold standard for treating breast cancer, and I recall saying that would be my choice if I got this disease. Little by little, through large, costly clinical trials, this body-deforming operation has been almost entirely replaced by early detection and minimal surgery, often followed by radiation and chemotherapy, while survival rates have soared.Likewise, I’ve witnessed major improvements in surgery to remove cataracts (now an outpatient procedure); replace hips, knees, shoulders, elbows and even finger joints crippled by arthritis; and prevent heart attacks and strokes by bypassing obstructed arteries. Not to mention the ability to transplant organs between genetically different people, or even from animals to humans. Today, most recipients of heart and lung transplants achieve long-term benefits.Pediatric surgeons now operate to correct or minimize major potentially fatal defects, including spina bifida and obstructed airways, while babies are still in the womb. Intrauterine gene therapy, now being tested in fetal animals, is likely next. And bariatric surgeons can now safely facilitate substantial weight loss in teenagers and adults with health-threatening obesity when dietary changes don’t suffice.Sexuality and gender. Our understanding of human sexuality has also undergone a cataclysmic shift toward medical and cultural acceptance of lesbian, gay, transgender and queer people. It may shock you to learn that a Page 1 article I wrote in 1971 suggested that psychotherapy could help homosexuals become heterosexual, an idea that I, along with health professionals, now scorn as abusive.Medicine now recognizes and accepts a wide range of gender and sexual identities. Increasingly, people who identify as transgender, for example, are able to adopt a gender identity or gender expression that differs from what is typically associated with the “male” or “female” sex they were assigned at birth.Mental health. The closing of most psychiatric hospitals and deinstitutionalization of people with serious emotional disorders during the 1950s and ’60s lit a fire under long-needed efforts to develop better therapies for mental illness. There are now many effective medications and other treatments for common conditions including bipolar disorder, depression, anxiety, attention deficit hyperactivity disorder, post-traumatic stress disorder and psychosis.The recognition of autism as a spectrum disorder is fostering greater understanding of children and adults with this condition. Leaders in their field, like the animal scientist Temple Grandin and the actor Sir Anthony Hopkins, who have talked openly about being on the spectrum, are helping others find acceptance in society.More than anything else, what’s kept me writing beyond age 80 is the feedback I’ve received from readers with heartwarming personal accounts of lives transformed through the information and advice my column provided. May my successors glean as much satisfaction as I have from researching and writing about whatever the future holds.

Scientists are exploring whether the onset of diabetes may in some cases herald the existence of one of the most deadly of all cancers.Pancreatic cancer is a nasty, stubborn killer that has thus far defied medicine’s best efforts at early diagnosis and curative treatment. In November, it claimed the life of my friend Peter L. Zimroth, a 78-year-old New York City attorney who was devoted to public service and who most recently oversaw the decline in the police department’s stop-and-frisk strategy.Mr. Zimroth had been on my “most admired” list even before he married the esteemed actress Estelle Parsons, who was 16 years his senior. Even during his yearlong, albeit losing, fight against cancer during the pandemic, Mr. Zimroth remained devoted to the public good, designing a brightly colored T-shirt and cap bearing an urgent plea, “Smash the Virus! Get the Shot,” and raising more than $73,000 to support research at Memorial Sloan Kettering Cancer Center, where doctors tried valiantly to buy him more time.Mr. Zimroth was fit and active and in otherwise good health before symptoms developed — in his case, stomach pains and constipation. By that time, the cancer had spread and it was too late to operate. His death follows that of several other well-known people who have succumbed to the same disease: Supreme Court Justice Ruth Bader Ginsburg, Representative John Lewis, the “Jeopardy!” host Alex Trebek and the Apple co-founder Steve Jobs.Although pancreatic cancer is a relatively rare cancer, it is so deadly it is now on track to become the country’s second leading cause of cancer-related deaths by 2040. Currently it accounts for about 3 percent of all cancers and 7 percent of cancer deaths. Overall, only one person in 10 diagnosed with pancreatic cancer survives five years. A cure is almost always a lucky accident, when the cancer is detected at an early, symptom-free stage during an unrelated abdominal scan or surgery and the tumor can be surgically removed.Dr. Brian M. Wolpin, director of the gastrointestinal cancer center at the Dana-Farber Cancer Institute in Boston, told me that this is such a hard cancer to find early because “it’s relatively uncommon in the population and the symptoms it causes, like weight loss, fatigue and abdominal discomfort, are nonspecific and more likely due to other conditions.” As a result, he said, “when 80 percent of patients walk through my door for the first time, I know that we are highly unlikely to cure their cancer.”Risk factors for pancreatic cancerStill, there are several major risk factors for developing pancreatic cancer. Smoking doubles the risk and accounts for about a quarter of all cases. Being obese, gaining excess weight as an adult and carrying extra weight around the waist, even if not otherwise very overweight, also increase one’s risk.That may be why Type 2 diabetes, which is most often related to being overweight, is an important risk factor as well. Other risks include chronic pancreatitis, a persistent inflammation of the pancreas often linked to heavy alcohol consumption and smoking, and workplace exposure to certain chemicals, like those used in dry cleaning and metal work industries.Older age is also a risk factor — some two-thirds of cases occur in those 65 and older. And family history may also play a role, including inherited genetic conditions like mutations in the BRCA1 or BRCA2 genes that are most often associated with breast and ovarian cancers.Diabetes as an early warning signIt’s long been known that the best chance of surviving most cancers results from early detection, when the malignancy is totally confined to the organ or tissue in which it originates. (Blood cancers present different issues.) The pancreas is a rather small, carrot-shaped organ, about six inches long and less than two inches wide, that lies well hidden between the ribs and the stomach.An early cancer in the pancreas doesn’t produce a lesion that can be felt, and it rarely causes symptoms that might prompt a definitive medical work-up until it has escaped the confines of the pancreas and spread elsewhere.But scientists are studying one possible early warning sign: a link between pancreatic cancer and newly developed Type 2 diabetes. Diabetes, too, arises in the pancreas, which contains specialized cells that produce the hormone insulin that regulates blood sugar levels. And while it’s not yet known which comes first, diabetes or cancer, some research suggests that the recent development of Type 2 diabetes may herald the existence of cancer hidden in this organ.New Developments in Cancer ResearchCard 1 of 5Progress in the field.

In “The Myth of Closure,” Pauline Boss offers guidance for moving forward amid the painful losses of the moment.Many people I know are waiting, patiently or otherwise, for life to return to normal. We are eager for the day when we can again live without fear of a deadly virus that lurks like a stalker, disrupting social and cultural events, travel, education and life’s milestones that once missed, can never be retrieved.And many people remain crippled by despair over the death of loved ones, as well as lost jobs, businesses, housing, income and even sleep. How, so many of us wonder, are we supposed to cope with so many obstacles blocking our way forward?One way is to call upon an age-old characteristic that enables us to weather adversity: resilience. Resilience is the ability to roll with the punches, “because if you’re brittle, you’ll break,” said Pauline Boss, professor emeritus at the University of Minnesota and author of the recently published book, “The Myth of Closure.” Dr. Boss, a family therapist, educator and researcher, is best known for her pioneering work on “ambiguous loss,” which is also the title of her 1999 book depicting unresolved, and often unresolvable, physical or emotional losses.“When the pandemic subsides, things will not go back to ‘normal’,” said Dr. Boss, who at 87 has lived through multiple upheavals, starting with World War II. With all that has happened during the pandemic, she wrote, “we can’t expect to go back to the normal we had.”In an interview, she told me, “Normal implies status quo, but things are always changing, and if you don’t change, you don’t grow. We will never be the same again. The pandemic is epic, a power greater than us, and we have to be flexible, resilient enough to bend in order to survive. And we will survive, but our lives will be forever changed.”Resilience allows us to adapt to stress and maintain one’s equilibrium when faced with adversity. “When resilient people are confronted with a crisis that takes away their ability to control their lives, they find something they can control,” Dr. Boss said. “At the start of the pandemic, many people turned to baking bread, home cooking and cleaning out drawers as something they could control. These were functional coping mechanisms.”However, she added, if people are unable to adapt when faced with a problem they can’t solve, “they often turn to absolute solutions that are dysfunctional, and make statements like ‘The pandemic is a hoax’ and ‘There’s no such thing as this virus.’”Although resilience is often viewed as an inherent personality trait that people either have or lack, studies have shown it is a characteristic that can be acquired. People can adopt behaviors, thoughts and actions that help to build resilience, at any age.Dr. Boss reassured parents that their children will be all right, despite pandemic-related academic and social disruptions. “Children are naturally resilient, and they will be stronger for having survived this bad thing that happened to them. They’ll bounce back and grow from it.”More than children, “we need to focus on adults,” she said. “This generation of parents has faced no world war, no global threat” of this scale. Many parents are struggling, though she worries that some may be over-shielding their children, which can erode their natural ability to solve problems and cope with adversity.Dr. Boss’s sentiments brought to mind the concerns my husband and I had in 1980, when our 10-year-old twin sons were facing enrollment in a public middle school where rampant misbehavior and physical threats were common. The boys declined our offer to send them to private school for those tumultuous three years, saying, “What would we learn about life in private school?”Moving forwardIn her new book, Dr. Boss offers guidelines for increasing one’s resilience to overcome adversity and live well despite painful losses. She quotes Dr. Viktor E. Frankl, an Austrian neurologist, psychiatrist, author and Holocaust survivor, who wrote, “When we are no longer able to change a situation, we are challenged to change ourselves.” She recommends that people use each guideline as needed, in no particular order, depending on the circumstances.Find meaning. The most challenging guideline for many people is to find meaning, to make sense of a loss, and when this is not possible to take some kind of action. Perhaps seek justice, work for a cause or demonstrate to try to right a wrong. When Dr. Boss’s little brother died from polio, her heartbroken family went door to door for the March of Dimes, raising money to fund research for a vaccine.Adjust your sense of mastery. Instead of trying to control the pain of loss, let the sorrow flow, carry on as best as you can and eventually the ups and downs will come less and less often. “We do not have power to destroy the virus, but we do have the power to lessen its impact on us,” she wrote.Rebuild identity. Also helpful is to adopt a new identity in sync with your current circumstances. When Dr. Boss’s husband became terminally ill, for example, her identity shifted over time from being a wife to being a caregiver, and after his death in 2020, gradually trying to think of herself as a widow.Normalize ambivalence. When you lack clarity about a loss, it’s normal to feel ambivalent about how to act. But Dr. Boss says it’s best not to wait for clarity; hesitation can lead to inaction and puts life on hold. Better to make less-than-perfect decisions than to do nothing.Revise attachment. Dr. Boss emphasizes that rather than trying to sever your attachment to a lost loved one, the goal should be to keep them present in your heart and mind and gradually rebuild your life in a new way, with a new sense of purpose, new friends or a new project. Accept the reality of the loss and slowly revise your attachment to the person who died. But, she says, “there is no need to seek closure, even if other relationships develop.”Discover new hope. Begin to hope for something new that enables you to move ahead with your life in a new way. Stop waiting, take action and seek new connections that can minimize isolation and foster support that in turn nurtures your resilience.Perhaps Dr. Boss’s most valuable advice when faced with pandemic losses: “What we need to hope for is not to go back to what we had, but to see what we can create now and in the future.” She suggests brainstorming with others and being willing to try new things. “Hope for something new and purposeful that will sustain you and give you joy for the rest of your life.”

Dementia in a person in their 30s, 40s or 50s poses special challenges, starting with getting a diagnosis.Many people aren’t overly concerned when an octogenarian occasionally forgets the best route to a favorite store, can’t remember a friend’s name or dents the car while trying to parallel park on a crowded city street. Even healthy brains work less efficiently with age, and memory, sensory perceptions and physical abilities become less reliable.But what if the person is not in their 80s but in their 30s, 40s or 50s and forgets the way home from their own street corner? That’s far more concerning. While most of the 5.3 million Americans who are living with Alzheimer’s disease or other forms of dementia are over 65, some 200,000 are younger than 65 and develop serious memory and thinking problems far earlier in life than expected.“Young-onset dementia is a particularly disheartening diagnosis because it affects individuals in the prime years,” Dr. David S. Knopman, a neurologist at the Mayo Clinic in Rochester, Minn., wrote in a July 2021 editorial in JAMA Neurology. Many of the afflicted are in their 40s and 50s, midcareer, hardly ready to retire and perhaps still raising a family.Dementia in a younger adult is especially traumatic and challenging for families to acknowledge, and many practicing physicians fail to recognize it or even suspect it may be an underlying cause of symptoms.“Complaints about brain fog in young patients are very common and are mostly benign,” Dr. Knopman told me. “It’s hard to know when they’re not attributable to stress, depression or anxiety or the result of normal aging. Even neurologists infrequently see patients with young-onset dementia.”Yet recent studies indicate that the problem is far more common than most doctors realize. Worldwide, as many as 3.9 million people younger than 65 may be affected, a Dutch analysis of 74 studies indicated. The study, published in JAMA Neurology in September, found that for every 100,000 people aged 30 to 64, 119 had early dementia. The accompanying editorial by Dr. Knopman called young-onset dementia “an underappreciated problem.” Its diagnosis, Dr. Knopman wrote, is often delayed, and knowledge about its management is “in short supply as well.”The various causes of early-onset dementiaThe Dutch study found that overall, Alzheimer’s disease was the most common cause of young-onset dementia. But when symptoms developed before age 50, early-onset Alzheimer’s was a less likely explanation than two other causes: vascular dementia and frontotemporal dementia.Vascular dementia results from a blockage or injury to blood vessels in the brain that interfere with circulation and deprive the brain of oxygen and nutrients. Its most common symptoms, in addition to memory problems, are confusion, difficulty concentrating, trouble organizing thoughts or tasks, and slowed thinking.In frontotemporal dementia, portions of the brain that lie behind the forehead and ears shrink, resulting in dramatic personality changes, socially inappropriate or impulsive behavior and emotional indifference. Movement and memory problems typically develop later in the course of the disease. According to the Mayo Clinic, frontotemporal dementia often begins between the ages of 40 and 65 and may be misdiagnosed as a psychiatric problem.Lewy body disease is another cause of dementia in younger adults. It is associated with abnormal deposits of a protein called alpha-synuclein in the brain that affects brain chemistry and leads to behavioral, thought and movement problems. Most of the symptoms are similar to those seen in other dementias, and additional symptoms like hallucinations may resemble schizophrenia, but the decline in brain function occurs significantly faster. A distinguishing symptom of Lewy body dementia is having violent dreams and attempting to act them out, Dr. Knopman said.Alzheimer’s disease remains the most common cause of dementia in younger as well as older adults. There is an inherited form of Alzheimer’s that typically arises at younger ages, but those cases account for fewer than 10 percent of young-onset disease. Most cases of Alzheimer’s occur sporadically, for unknown reasons, though genetic factors may increase risk.People with Alzheimer’s typically have a buildup of abnormal substances — tau and beta-amyloid proteins — in the brain. Early symptoms include impaired memory, language problems, difficulty concentrating and finishing tasks, poor judgment and visual or spatial deficits that result in problems like driving errors and getting lost. Brain scans may show a loss of brain cells and an impaired ability to metabolize glucose that is indicative of degenerative brain disease.Probably the most publicized factor known to increase the risk of early dementia is repeated head injuries like those experienced by professional boxers, football and soccer players, and sometimes by military veterans.Once brain cells are injured or lost, there’s no going back. So preventing head injuries is the best possible protection at the moment. Many parents these days try to discourage youngsters from playing sports like football, in which repeated head injuries are common. However, proper and consistent use of helmets and not heading the ball in soccer can limit their risk of head injuries. Dr. Knopman said he’s less concerned with elementary school children playing such sports; the risk of developing dementia at a young age from repeated head trauma is much greater among those who played Division 1 football or became professional boxers.Among older adults in general, the same inflammatory factors associated with atherosclerosis, the clogging and hardening of the arteries that nourish the heart, can also afflict blood vessels that feed the brain. Body-wide inflammation linked to diabetes and heart disease can cause brain changes that promote dementia.Diagnosis of early-onset dementiaAccurately diagnosing young-onset dementia can be difficult and time-consuming and should start with a detailed medical history, Dr. Knopman said. “If doctors don’t ask the right questions, families may fail to mention a telltale symptom like violent dreams.”A thorough cognitive assessment of the person’s memory and language difficulties is critical, he said. Does the person stumble over words or say “white” when he means “black”? Neuropsychological tests can detect subtle difficulties with memory, visual, cognitive and executive functions.A brain scan is needed to rule out the possibility that a tumor is causing the person’s cognitive symptoms. A spinal tap and analysis of the spinal fluid can reveal elevated levels of tau and beta-amyloid proteins in the brain. An M.R.I. can depict shrinkage in specific parts of the brain. And a glucose PET scan can uncover abnormal patterns of sugar uptake in various parts of the brain that can help distinguish between Alzheimer’s disease, Lewy body dementia and frontotemporal dementia. “Different degenerative brain diseases have specific patterns of glucose uptake,” Dr. Knopman said.As with older dementia patients, it’s essential to keep young people with dementia safe. They should no longer drive, operate dangerous equipment, including the stove, or be left alone. All should wear an identifying tag day and night that alerts others to their condition.

A new book offers guidance on how family members can support a critically ill loved one who ends up in the hospital’s intensive care unit.In the last two years, the letters I.C.U. have become almost as familiar to the listening and reading public as PBS and NBC, as intensive care units across the country have been overwhelmed with people suffering from severe Covid-19. Meanwhile, medical personnel continue to struggle to care for patients with serious injuries, diseases or surgical complications who also require critical care.Intensive care can be a difficult and traumatizing experience for patients whose lives depend on it. And, according to the author of an extraordinarily thorough and helpful new book, the families and friends of patients who require prolonged stays in an I.C.U. often suffer along with them. Their fears skyrocket and unanswered questions abound. What is happening to my loved one? What are all these tubes, machines, flashing lights and warning bells? Who is in charge here? Whom can I talk to?In her new book, “The I.C.U. Guide for Families: Understanding Intensive Care and How You Can Support Your Loved One,” Dr. Lara Goitein, who spent 12 years as an intensive care physician, provides comprehensive yet easy-to-understand answers to myriad questions like these and many others you might not think to ask. Ideally, families would have this book at the ready when needed, like a first-aid manual, because the initial days in an I.C.U. are often the most stressful and disconcerting.“It helps to be educated and know how you can contribute,” said Dr. Goitein, a pulmonary and critical care physician in Santa Fe. The goal, she said, is to assure the best possible outcome for patients and their loved ones, all of whom can experience a version of post-traumatic stress disorder following a long stay in an I.C.U.Juli Barde of Portland, Ore., whose husband Rick, then 59, was in an I.C.U. for six weeks early in the pandemic with near-fatal Covid, said she stayed with him for four or five hours every day to provide comfort and be his advocate. “I watched carefully and learned a lot,” Ms. Barde told me. “With three tubes in his trachea, he couldn’t speak for himself, so I had to speak for him. I can read his facial expressions and knew what was going to bother him.” And when careless nursing care led to a serious complication, Ms. Barde was there to call for a replacement nurse and report the incident to a supervisor.Of course, few families can spend half their waking hours in an I.C.U. But by understanding what is happening, recognizing the signs of improvement and deterioration in a patient’s condition and knowing when it’s appropriate to intervene on the patient’s behalf can result in better care all around. That’s what makes Dr. Goitein’s book so valuable and destined to remain on my bookshelf until my dying day.The ability to hope for the best but prepare for the worst is likely the biggest challenge families face when a loved one is in an I.C.U. with a condition from which recovery is uncertain. Although 80 to 90 percent of I.C.U. patients — many of whom are very sick — are eventually able to transfer out of intensive care and leave the hospital, families need a realistic picture of what survival will be like.For patients who were treated in an I.C.U., Dr. Goitein said, “many improve over the first year, and some need help for symptoms that persist for a year or longer. But most of those who make it through that first year, by three years they are independent.”Patients’ future prospects depend greatly on the reason they required I.C.U. care in the first place, as well as their age, prior physical condition, emotional health and resilience and their ability to pursue needed rehabilitation. Among those who required prolonged life support, only a minority go directly home after being discharged from the hospital, Dr. Goitein reported. A fifth are transferred to an inpatient rehabilitation facility, another fifth go to a skilled nursing facility and more than a third require long-term acute care.“Most people focus on very small hopes, and they expect the patient to survive, go home and be the same person he was before,” Dr. Goitein said. “But a long, difficult battle with illness can result in psychiatric as well as physical disability. It’s more stressful than people estimate.”For patients who needed more than two days of mechanical ventilation in the I.C.U., family caregivers typically spend an average of more than five hours a day giving care during the first half-year after hospital discharge, she said. How well the family copes often depends on how carefully they plan and prepare before the patient comes home. Are there grab bars in the bathroom? Will a walker or wheelchair fit through doorways? Can the patient communicate readily with the caregiver?After a long stay in an I.C.U., it’s not uncommon for patients to experience what doctors call “post-intensive care syndrome,” or PICS. “Overall, about half of survivors will have at least one cognitive, psychiatric or physical problem that persists for weeks, months or even years after discharge,” Dr. Goitein wrote. These may include problems with memory, concentration and problem-solving. Emotional consequences like depression, anxiety, post-traumatic stress disorder and sleep disturbances sometimes persist for years. Overcoming I.C.U.-induced physical weakness can take several years, and regaining independence in activities of daily living, like getting dressed and preparing meals, can require fierce determination and infinite patience on the part of both patient and caregiver.An excellent resource for patients and their families following I.C.U. care is Thrive, an online initiative of the Society for Critical Care Medicine. The site maintains a partial list of clinics that provide specialized care for patients after an I.C.U. stay.It’s also important for families to know when “enough is enough,” Dr. Goitein said. For patients who’ve been on prolonged life support in the I.C.U., it can be very challenging for families to come to terms with their failure to improve and inability to wean them off the machines keeping them technically alive.Ideally, well before a life-threatening crisis, patients will have completed an advance directive and assigned a trusted health care proxy or agent, who has a clear understanding of their wishes and can speak for them when they cannot speak for themselves. What are the patients’ values? What makes their life meaningful? What level of disability would they consider intolerable?The proxy’s job, Dr. Goitein said, “is to put their own desires and beliefs aside and choose what the patient would have wanted for himself,” in effect respecting the autonomy of a terminally ill person who is no longer able to communicate their wishes. When family members disagree, she said, discussion with the doctor in charge may facilitate a decision.

Psychological stress activates the fear center in the brain, setting into motion a cascade of reactions that can lead to heart attacks and strokes.You’re probably familiar with these major risk factors for heart disease: high blood pressure, high cholesterol, smoking, diabetes, obesity and physical inactivity. And chances are your doctor has checked you more than once for these risks and, I would hope, offered advice or treatment to help ward off a heart attack or stroke.But has your doctor also asked about the level of stress in your life? Chronic psychological stress, recent studies indicate, may be as important — and possibly more important — to the health of your heart than the traditional cardiac risk factors. In fact, in people with less-than-healthy hearts, mental stress trumps physical stress as a potential precipitant of fatal and nonfatal heart attacks and other cardiovascular events, according to the latest report.The new study, published in November in JAMA, assessed the fates of 918 patients known to have underlying, but stable, heart disease to see how their bodies reacted to physical and mental stress. The participants underwent standardized physical and mental stress tests to see if their hearts developed myocardial ischemia — a significantly reduced blood flow to the muscles of the heart, which can be a trigger for cardiovascular events — during either or both forms of stress. Then the researchers followed them for four to nine years.Among the study participants who experienced ischemia during one or both tests, this adverse reaction to mental stress took a significantly greater toll on the hearts and lives of the patients than did physical stress. They were more likely to suffer a nonfatal heart attack or die of cardiovascular disease in the years that followed.I wish I had known that in 1982, when my father had a heart attack that nearly killed him. Upon leaving the hospital, he was warned about overdoing physical stresses, like not lifting anything heavier than 30 pounds. But he was never cautioned about undue emotional stress or the risks of overreacting to frustrating circumstances, like when the driver ahead of him drove too slowly in a no-passing zone.The new findings underscore the results of an earlier study that evaluated the relationship between risk factors and heart disease in 24,767 patients from 52 countries. It found that patients who experienced a high level of psychological stress during the year before they entered the study were more than twice as likely to suffer a heart attack during an average follow-up of five years, even when traditional risk factors were taken into account.The study, known as Interheart, showed that psychological stress is an independent risk factor for heart attacks, similar in heart-damaging effects to the more commonly measured cardiovascular risks, explained Dr. Michael T. Osborne, a cardiologist at Massachusetts General Hospital.But what about the effects of stress on people whose hearts are still healthy? Psychological stress comes in many forms. It can occur acutely, caused by incidents like the loss of a job, the death of a loved one, or the destruction of one’s home in a natural disaster. A recent study in Scandinavia found that in the week following a child’s death, the parents’ risk of a heart attack was more than three times the expected rate. Emotional stress can also be chronic, resulting, for example, from ongoing economic insecurity, living in a high-crime area or experiencing unrelenting depression or anxiety. Bereaved parents in the Scandinavian study continued to experience an elevated cardiac risk years later.How stress damages the heartDr. Osborne participated with a team of experts led by Dr. Ahmed Tawakol, also at Massachusetts General, in an analysis of how the body reacts to psychological stress. He said the accumulated evidence of how the brain and body respond to chronic psychological stress strongly suggested that modern medicine has been neglecting a critically important hazard to heart health.It all starts in the brain’s fear center, the amygdala, which reacts to stress by activating the so-called fight-or-flight response, triggering the release of hormones that over time can increase levels of body fat, blood pressure and insulin resistance. Furthermore, as the team explained, the cascade of reactions to stress causes inflammation in the arteries, fosters blood clotting and impairs the function of blood vessels, all of which promote atherosclerosis, the arterial disease that underlies most heart attacks and strokes.Dr. Tawakol’s team explained that advanced neuroimaging made it possible to directly measure the impact of stress on various body tissues, including the brain. A prior study of 293 people initially free of cardiovascular disease who underwent full-body scans that included brain activity had a telling result. Five years later, individuals found to have high activity in the amygdala were shown to have higher levels of inflammation and atherosclerosis.Translation: Those with an elevated level of emotional stress developed biological evidence of cardiovascular disease. In contrast, Dr. Osborne said, “people who are not tightly wired” are less likely to experience the ill heart effects of stress.The researchers are now investigating the impact of a stress-reducing program called SMART-3RP (it stands for Stress Management and Resiliency Training-Relaxation Response Resiliency Program) on the brain as well as biological factors that promote atherosclerosis. The program is designed to help people reduce stress and build resilience through mind-body techniques like mindfulness-based meditation, yoga and tai chi. Such measures activate the parasympathetic nervous system, which calms the brain and body.Defusing stress and its effectsEven without a formal program, Dr. Osborne said individuals could minimize their body’s heart-damaging reactions to stress. One of the best ways is through habitual physical exercise, which can help to tamp down stress and the body-wide inflammation it can cause.Given that poor sleep increases stress and promotes arterial inflammation, developing good sleep habits can also reduce the risk of cardiovascular damage. Adopt a consistent pattern of bedtime and awakening, and avoid exposure at bedtime to screens that emit blue light, like smartphones and computers, or use blue-light filters for such devices.Practice relaxing measures like mindfulness meditation, calming techniques that slow breathing, yoga and tai chi.Several common medications can also help, Dr. Osborne said. Statins not only reduce cholesterol, they also counter arterial inflammation, resulting in a greater cardiovascular benefit than from their cholesterol-lowering effects alone. Antidepressants, including the anesthetic ketamine, may also help to minimize excessive amygdalar activity and ease stress in people with depression.

Popular pain relievers and antidepressants, as well as alcohol and herbal supplements, are among the many substances that can contribute to hypertension.High blood pressure remains a leading cause of death and disability in America today. Nearly half of adults have high blood pressure, and only a quarter of them have their blood pressure under control, putting them at increased risk of heart attack, stroke, dementia, kidney disease and other ills.Before the coronavirus pandemic, high blood pressure caused or contributed to more than half a million deaths a year in the United States, according to the Centers for Disease Control and Prevention. Those numbers have most likely increased, as blood pressure readings have shot up during the pandemic.You may have long thought your blood pressure was within normal limits. But in 2017, based on better long-term data, experts lowered the numbers that constitute a healthy blood pressure, resulting in a greater proportion of the population with this risky condition. The former upper limit of “normal” blood pressure, once believed to be 140 over 90 millimeters of mercury, was recognized as too high to prevent serious health problems over time. The current upper limit of normal is 130 over 80, and a blood pressure consistently above 120 over 80 is now considered problematic.There are many reasons for the nation’s high rate of uncontrolled hypertension, the medical term for high blood pressure. Being overweight and, for many, excessive consumption of salt lead the list, followed by inconsistent use of medically prescribed remedies and a failure to adopt lifestyle measures that can reduce elevated blood pressure.Now, a new study has highlighted another problem often unknown to patients and overlooked by doctors that can complicate treatment of hypertension and swell the ranks of those with uncontrolled high blood pressure: the large number of medications and supplements people take, some of which can raise blood pressure and undermine the benefits of otherwise effective treatment.The study involved 27,599 adults, 35.4 percent of whom had uncontrolled hypertension, who were part of the National Health and Nutrition Examination Surveys. The periodic surveys, which are known as NHANES and track the health of a representative sample of Americans, found that many people took medications and other substances that could raise an otherwise normal blood pressure or limit the effectiveness of treatment prescribed to lower an elevated blood pressure.Among adults in the survey, 17.5 percent whose hypertension was not adequately controlled were taking prescription drugs that can raise blood pressure, the researchers reported. And 18.5 percent of survey participants with hypertension that was effectively treated were also taking such drugs, suggesting that some of these people might not otherwise need blood pressure treatment.The study was published online in November in JAMA Internal Medicine. Its senior author, Dr. Timothy S. Anderson, a primary care doctor at Beth Israel Deaconess Medical Center in Boston, said he and his colleagues hoped to alert more doctors and patients to the ways medications or other substances might be contributing to increased blood pressure. Increased awareness would be especially helpful before patients were prescribed drugs to lower blood pressure or given more potent drugs to enhance the effectiveness of current treatment.For some medical conditions unrelated to hypertension, switching to a different drug might bring a patient’s elevated blood pressure back down to normal. For example, the study authors suggested, women on an estrogen-containing oral contraceptive, which can raise blood pressure, might be switched to a progestin-only or nonhormonal contraceptive. Similarly, those taking a nonsteroidal anti-inflammatory drug, or NSAID, to control pain might use acetaminophen instead.There’s a long list of prescribed medications, as well as over-the-counter drugs and recreational substances and supplements, that can interfere with effective treatment for hypertension. In addition to estrogen-containing drugs and NSAIDS, the list includes widely used medicines like antidepressants and oral steroids such as cortisone; substances like nicotine, alcohol and cocaine; herbal supplements like licorice or ginseng; and, of course, salt. Caffeine, too, can raise blood pressure over the short-term in some people.When doctors fail to ask patients what else they may be taking, using or consuming that can affect blood pressure — or if patients neglect to mention all of the over-the-counter and herbal remedies and prescription drugs they take — patients may be prescribed an unnecessary or more potent blood pressure drug that may have bothersome side effects.Dr. Anderson said that doctors were “taught to screen patients initially for other drugs being taken that can raise blood pressure, but patients are not necessarily rechecked for such drug use over time.” He said that it was important for doctors to take good medical histories, including what might have changed in patients’ lives since their blood pressures were last under control.“Maybe there was a change in diet that caused a quick rise in blood pressure,” Dr. Anderson said. “For example, some patients are very salt-sensitive,” he said. “Along with age and weight, it’s the strongest predictor of high blood pressure over time.” Changing just one frequently consumed high-salt food, like pizza, cured meats or canned soup, may be enough to lower the risk of hypertension.Complicating matters is that people’s reactions to various substances, like the commonly prescribed S.S.R.I. antidepressants, are “very idiosyncratic,” he explained. “A particular S.S.R.I. may have a high impact on blood pressure in some patients but not others.”For patients with hypertension who need to take a drug that can raise blood pressure, Dr. Anderson advised using a home blood pressure monitor. A sudden rise in blood pressure after starting a new drug can help alert the prescribing doctor to the need to switch to an alternative remedy if one is available.Even if you’ve had normal blood pressure for five or more decades, there’s a 90 percent chance that you’ll develop hypertension as you get older, which makes it all the more important to modify risks like dietary salt and excess weight while you’re still healthy. Even a modest weight loss of 10 pounds can both reduce the risk of developing hypertension and lower blood pressure in overweight people who already have this condition.Another common predictor is a sedentary lifestyle. Adopting a habit of regular physical activity can help people maintain a normal blood pressure throughout life. Other effective measures to control hypertension include quitting smoking and limiting consumption of alcohol. “Even a modest reduction in smoking and drinking can have a positive impact on blood pressure,” Dr. Anderson said.Before you start medication for hypertension, show your doctor a list of all the drugs — prescribed and otherwise — you take, and disclose any problematic substances, especially high amounts of dietary salt, you regularly use or ingest.

All that “stuff” in our drawers, closets and corners is a hazard, but there are ways to keep it at bay.Many of us took advantage of the long, lonely hours of the 2020 Covid-19 lockdowns to cleanse our closets, drawers and cabinets of clothing from a bygone era, packaged foods long past their expiration dates and files no longer relevant. At first, I was among them and enthusiastically tackled the low-hanging fruit: ill-fitting dresses and suits, shoes I could no longer walk in, hundreds of empty plastic and glass containers.It felt good initially, but I soon lost interest in decluttering and lacked the mental and physical energy to tackle what remained.And, I assure you, after living in the same house for 55 years, there was a lot more to get rid of. Empty spaces have a way of filling up. I actually envy friends and neighbors who downsized and had to dispose of dumpsters full of items no longer used or useful.But when a leaking pipe recently saturated the carpet in my finished basement, where for decades I’ve stored everything I didn’t know what to do with but couldn’t bring myself to throw out, I was thrown back into action. There’s nothing like a crisis, minor or major, to force one to come to terms with an unmanageable accumulation of stuff.Clutter is a hazardPeople like me, who fill storage areas as long as the living spaces remain orderly, do not rise to the seriousness of being a hoarder, which is considered its own psychiatric diagnosis. But clutter has its own risks. Among them are the chronic and repeated stresses that can arise, for example while searching frantically through stacks of miscellany for an important paper or racing to clear piles of junk before visitors arrive.Not to mention risking a fall over objects left where they don’t belong. When my friend of 61 years, who can’t seem to dispose of anything, had complications from a head injury that kept him in the hospital for many weeks, his wife felt compelled to clear their apartment of untold objects lying about before his return home.In addition, clutter is distracting, stealing attention from worthy thoughts and tasks. It saps time and energy and diminishes productivity. And, a 2015 study at St. Lawrence University found that a cluttered bedroom goes hand in hand with a poor night’s sleep.The burden of clutter doesn’t even end when we die. When my friend Michael and his brothers cleaned out their 92-year-old mother’s house in Florida after she died, among the many multiples they found were eight identical jars of mustard, five dozen cans of pineapple chunks, 72 rolls of paper towels, 11 walkers and four wheelchairs. Costly truckloads of clutter had to be carted away. I’d like my family to have better things to fret or chuckle over when I die.Reasons we clutterYou may wonder why people like me and my friend’s mother collect so many things we likely will never need. Fear of running out is one reason I often buy in bulk, especially when desired products are on sale. A similar fear undoubtedly resulted in the frenetic run on toilet paper, pasta and canned beans at the onset of the pandemic. I never forgot what a neighbor said when, in the midst of a block party, she was asked where she kept her extra paper towels. “In the store,” she replied.When feeling low, I’m not above indulging in retail therapy, often buying yet another bathing suit or cozy fleece to add to my extensive collection. Scott Bea, a clinical psychologist at the Cleveland Clinic, has noted that our consumer society drives many people to collect stuff they don’t need.Some also feel compelled to hold on to the past, like a friend who keeps the programs of every event he’s attended over the last six decades. Out of guilt or sentiment, some find it hard to part with useless gifts from people they love or admire. “What if they come over one day and discover it’s gone?” is a common rationale.I have many reasons for not parting with a long-unused item. If it’s something I long treasured, like the silverware and china my husband and I bought with our wedding gifts 46 years ago, I want to give them to someone I know will appreciate and use them. And I have a quasi-irrational fear that as soon as I dispose of something, I will find I need it.Still, I routinely bite the bullet and donate to charities that collect clothing and household items in my neighborhood. I also live on a block with lots of pedestrian traffic and if I put giveaways — from shampoos and shoes to pots and picture frames — in front of the house, they tend to disappear within hours.When I realized it was time to part with decades-old professional files, I enlisted the aid of a helper, instructing them not let me see anything that was being discarded from my drawers. Now to do the same with the hundreds of work-related books I’ll never open again!Tips to tackle declutteringEstablish a plan. You may want to go room by room or focus on a category like coats or shoes, but avoid changing course midstream before you’ve finished the task you started.Set reasonable goals based on your available time and stamina. If a whole closet is too intimidating, even as small a task as clearing items from a single drawer or shelf can get you started in the right direction.If a more gradual approach is more manageable, consider my friend Gina’s suggestion: keeping a container in each room to house giveaways. When she tries something on that no longer fits or looks good, it goes directly into the donation bag, not back in the closet.If needed, get help from a friend, family member or paid consultant who won’t have the same attachment to your possessions.Create three piles — keep, donate and discard. Don’t second-guess your initial assessment; immediately trash the discard pile and schedule a pickup for the donations or take them to a worthy destination.If your clutter includes items you’re storing for other people, consider giving them a deadline to pick them up, or suggest they rent a storage locker.Finally, avoid backsliding. Resist refilling the spaces you clear with more stuff.

The human papillomavirus vaccine can prevent six potentially lethal malignancies, but inoculation is meeting with rising resistance from parents.Vaccine hesitancy is hardly limited to shots against Covid-19. Even the HPV vaccine, which can prevent as many as 90 percent of six potentially lethal cancers, is meeting with rising resistance from parents who must give their approval before their adolescent children can receive it.The Food and Drug Administration licensed this lifesaving vaccine in 2006 to protect against sexually transmitted infection by HPV, the human papillomavirus. Most of us will get infected with HPV during our lifetimes, certain strains of which can lead to cancers of the cervix, vagina and vulva in women; cancers of the anus and back-of-the-throat in both women and men; and penile cancer in men. HPV can also cause genital warts.But the vaccine only works if it’s administered before people become infected by the virus. And that often means getting vaccinated before teens and young adults have any form of sexual activity, including oral sex and skin-to-skin contact without penetration.More than half of adolescents ages 15 to 19 report having had oral sex, and one in 10 say they have had anal sex. Unless they are vaccinated, more than 80 percent of women become infected with HPV by age 50. And while most infections clear on their own, enough persist to cause many thousands of cancers years later. There is no treatment for an HPV infection.Yet Kalyani Sonawane, a researcher at the University of Texas Health Science Center, and her colleagues reported in March that parental intent not to vaccinate their adolescents against HPV rose from 50.4 percent in 2012 to 64 percent in 2018. Many parents resisted the vaccine despite their doctors’ recommendations, Dr. Sonawane said. Ironically, parents were most resistant — at 68.1 percent — to vaccinating girls, the very group for whom this vaccine was initially developed to prevent cervical cancer.Fifty years in the makingResearchers had long known that cervical cancer behaves like a venereal disease, transmitted through sexual contact. It is rare in virgins and most common among women with early sexual experience and multiple partners.An infectious cause was suspected but difficult to prove. In 1968 on Page 1 of The Times, I reported a link between cervical cancer and a sexually transmitted virus called Type 2 herpes. It turned out to be a red herring. Finally, in the 1980s, the human papillomavirus was correctly identified as the cause of cervical cancer, which led to the development and marketing of a highly effective vaccine in 2006.Now, if not for the slow adoption of the HPV vaccine by the parents of adolescents, we would likely be well on our way to eliminating nearly all cases of cervical cancer and the five other HPV-caused cancers, 45,000 cases of which are diagnosed annually in the United States, Dr. Abraham Aragones, a public health researcher at Memorial-Sloan Kettering Cancer Center told me.A highly effective vaccineUntil recently, the vaccine’s ability to prevent cancer was presumed but not proved. Cervical cancer risk rises with age, most often occurring in midlife or later, so it can take many years to confirm the vaccine’s ability to protect against cancer.Now a new study in Britain of an early version of the vaccine found that within 13 years of vaccine administration, there were 87 percent fewer cases of cervical cancer among young women immunized between ages 12 and 13, compared to unvaccinated women. Significantly lower cancer rates were also found among women immunized between ages 14 and 16 and between 16 and 18, although the greatest benefit occurred among those vaccinated at the youngest ages, before most girls were likely exposed to the virus through sexual contact.The British study involved a vaccine called Cervarix, that protects against two variants of the virus. The current American version of the HPV vaccine, called Gardasil-9, is even more effective: It protects against nine variants of the virus and is expected to prevent more than 90 percent of HPV-related cancers, Dr. Aragones said. A recent analysis in JAMA Pediatrics found a similar decrease in cervical cancer incidence and mortality in young women since the vaccine was introduced.Based on a steadily declining incidence of cervical cancer and a high rate of vaccine coverage in Australia, researchers there predicted that the country would have fewer than four new cases of cervical cancer per 100,000 women by 2028 and virtually none by 2066.To be sure, regular Pap smears that detect precancerous cervical lesions have helped greatly to prevent the development of invasive cancer, but early detection efforts do not fully eliminate the risk of cervical cancer. This year, the American Cancer Society estimates that 14,480 new cases of invasive cervical cancer will be diagnosed in the United States and about 4,290 women will die from it. And there is no screening test like the Pap smear for the other five HPV-caused cancers.Parents’ buy-in remains the biggest obstacleOnce the real cancer culprit was identified as the human papillomavirus and a vaccine to prevent it finally developed, convincing parents to have their young daughters immunized has been an uphill battle for practitioners. Few have the time and factual ammunition to counter parental fears and misinformation about this vaccine.Getting parents to agree to immunizing boys has faced an additional obstacle. The original approval of the vaccine to prevent cervical cancer prompted many parents to question its value for boys, for whom the vaccine was approved three years later. Parental resistance to immunizing their sons rose to 59.2 percent in 2018, up from 44.4 percent just six years earlier“Parents and providers don’t necessarily appreciate the burden of HPV-caused cancers among men,” said Dr. Dean A. Blumberg, chief of pediatrics at UC Davis Children’s Hospital. “Oral-pharyngeal cancer rates are almost five times higher in men than in women, and they’ve increased in recent years with the rise in oral sex. The vaccine is important for the boys to protect their own health and the health of their future partners.”How the vaccine is administeredBetween ages 9 and 15, two shots of HPV vaccine are required, administered six months apart; from age 15 on, three shots are needed. Side effects are usually mild, like pain or swelling at the injection site and perhaps brief fever, fatigue, nausea or muscle pain. The vaccine’s cost is nearly always covered by insurance.Dr. Sonawane said parental misconceptions about the vaccine’s safety are commonplace, and doctors rarely have the time to debunk vaccine misinformation parents find online. “Positive information about vaccines doesn’t get posted on social media,” she observed.Some parents fear that immunizing their children against HPV will encourage them to engage in sexual activity, although there is no evidence this happens. Dr. Aragones, among others, suggested that the best way for doctors to minimize parental opposition is to describe the vaccine’s anticancer role, limit discussing the link to sexual activity and include the immunization with the other vaccines that are routinely given to adolescents.

Aim for an overall healthful dietary pattern, the American Heart Association advises, rather than focusing on “good” or “bad” foods.There are no “good” foods and “bad” foods. Rather, it’s your overall dietary pattern that matters most when it comes to healthful eating.That’s the main message from the American Heart Association in its latest nutrition guidelines to improve the hearts and health of Americans of all ages and life circumstances.The experts who wrote the guidelines recognize that people don’t eat nutrients or individual ingredients. They eat foods, and most people want to enjoy the foods they eat while staying within their budgets and, the association hopes, without injuring their bodies.This doesn’t mean you need to totally avoid Big Macs, Cokes and French fries, but it does mean you should not regularly indulge in such fare if you want to stay healthy.Dr. Robert H. Eckel, a former president of the American Heart Association, and an endocrinologist and lipid specialist at the University of Colorado Denver, told me he “occasionally” indulges in foods outside a wholesome dietary pattern. The operative word here, though, is “occasionally.”Dr. Neil J. Stone, a preventive cardiologist at the Feinberg School of Medicine at Northwestern University, who praised the thoughtfulness and expertise of the guidelines committee, said in an interview, “There’s no such thing as one diet that fits all, but there are principles to form the basis of diets that fit everyone.”He added: “The goal is to make good nutrition possible for all. The healthier we can keep everybody in this country, the lower our health costs will be.”In the 15 years since the heart association last issued dietary guidelines to reduce the risk of cardiovascular disease, almost nothing has changed for the better. The typical American diet has remained highly processed. Americans consume too much added sugars, artery-clogging fats, refined starches, red meat and salt and don’t eat enough nutrient-rich vegetables, fruits, nuts, beans and whole grains that can help prevent heart disease, diabetes and cancer.But rather than become discouraged, the association decided to try a different approach. For too long, nutrition advice has been overly focused on individual nutrients and ingredients, Alice H. Lichtenstein, the guidelines’ chief author, told me, and it hasn’t been focused enough on overall dietary patterns that can best fit people’s lives and budgets.So instead of a laundry list of “thou shalt not eats,” Dr. Lichtenstein said, the association’s committee on nutrition and cardiovascular disease chose to promote heart-healthy dietary patterns that could suit a wide range of tastes and eating habits. In avoiding “no noes” and dietary revolutions, the new guidelines can foster gradual evolutionary changes meant to last a lifetime.The committee recognized that for people to adopt and stick to a wholesome dietary pattern, it should accommodate personal likes and dislikes, ethnic and cultural practices and life circumstances, and it should consider whether most meals are consumed at home or on the go.For example, rather than urging people to skip pasta because it’s a refined carbohydrate, a more effective message might be to tell people to eat it the traditional Italian way, as a small first-course portion. Or, if pasta is your main course, choose a product made from an unrefined carbohydrate like whole wheat, brown rice or lentils.“We’re talking about lifelong changes that incorporate personal preferences, culinary traditions and what’s available where people shop and eat,” said Dr. Lichtenstein, a professor of nutrition science and policy at the Friedman School at Tufts University. “The advice is evidence-based and applies to everything people eat regardless of where the food is procured, prepared and consumed.”The guidelines’ first principle is to adjust one’s “energy intake and expenditure” to “achieve and maintain a healthy body weight,” a recommendation that may be easier to follow with the next two principles: Eat plenty of fruits and vegetables, and choose foods made mostly with whole grains rather than refined grains. If cost or availability is an issue, as is the case in many of the country’s food deserts where fresh produce is scarce, Dr. Lichtenstein suggested keeping bags of frozen fruits and vegetables on hand to reduce waste, add convenience and save money.Some wholesome protein choices that the committee recommended included fish and seafood (although not breaded and fried), legumes and nuts, and low-fat or fat-free dairy products. If meat is desired, choose lean cuts and refrain from processed meats like sausages, hot dogs and deli meats that are high in salt and saturated fat.The committee’s advice on protein foods, published during the climate talks in Glasgow, was well-timed. Choosing plant-based proteins over animal sources of protein not only has health value for consumers but can help to foster a healthier planet.Experts have long known that animal products like beef, lamb, pork and veal have a disproportionately negative impact on the environment. Raising animals requires more water and land and generates more greenhouse gases than growing protein-rich plants does.“This is a win-win for individuals and our environment,” Dr. Lichtenstein said. However, she cautioned, if a plant-based diet is overloaded with refined carbohydrates and sugars, it will raise the risk of Type 2 diabetes and heart disease. And she discouraged relying on popular plant-based meat alternatives that are ultra-processed and often high in sodium, unhealthy fats and calories, and that “may not be ecologically sound to produce.”To protect both the environment and human health, the committee advised shifting one’s diet away from tropical oils — coconut, palm and palm kernel — as well as animal fats (butter and lard) and partially hydrogenated fats (read the nutrition label). Instead, use liquid plant oils like corn, soybean, safflower, sunflower, canola, nut and olive. They have been shown to lower the risk of cardiovascular disease by about 30 percent, an effect comparable to taking a statin drug.As for beverages, the committee endorsed the current national dietary guideline to avoid drinks with added sugars (including honey and concentrated fruit juice). If you don’t currently drink alcohol, the committee advised against starting; for those who do drink, limit consumption to one to two drinks a day.All told, the dietary patterns that the committee outlined can go far beyond reducing the risk of cardiovascular diseases like heart attacks and strokes. They can also protect against Type 2 diabetes and a decline of kidney function, and perhaps even help foster better cognitive abilities and a slower rate of age-related cognitive decline.The earlier in life a wholesome dietary pattern begins, the better, Dr. Lichtenstein said. “It should start preconception, not after someone has a heart attack, and reinforced through nutrition education in school, K through 12.”And during annual checkups, Dr. Eckel said, primary care doctors should devote three to five minutes of the visit to a lifestyle interview, asking patients how many servings of fruits, vegetables and whole grains they consume and whether they read nutrition labels.