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On average, how many hours do you sleep each night? For most healthy adults, guidelines suggest at least seven hours of slumber.

But these are general recommendations and not strict rules. “Some people need less than seven hours, while others might need more,” says Eric Zhou with the Division of Sleep Medicine at Harvard Medical School.

Do you need more or less sleep time?

We get it: you know people who swear they only need five hours of sleep per night, yet you feel foggy unless you log in eight to nine hours. The major reason for individual differences is that we often look at sleep the wrong way.

“Instead of focusing exclusively on the number of hours we sleep per night, we should also consider our sleep quality,” says Zhou.

Sleep quality means how well you sleep during the night. Did you sleep straight through? Or did you have periods where you woke up? If so, did it take you a long time to fall asleep? How did you feel when you woke up?

“If you awaken refreshed and feel like you have the energy to get through your day, then I would worry less about the exact number of hours you’re sleeping,” says Zhou.

How does sleep quality affect your health?

Sleep quality is vital for our overall health. Research has shown that people with poor sleep quality are at a higher risk for diabetes, heart disease, stroke, and mental health issues like anxiety and depression.

And that’s not all. “Poor sleep also can increase daytime fatigue and make it more difficult to enjoy life,” says Zhou.

Yet it’s normal for people’s sleep patterns to change over time. “Many people are not going to sleep in their 50s and 60s exactly like they did in their 20s,” says Zhou.

Many of these changes are age-related. For instance, your circadian rhythm — which regulates many bodily functions, including our sleep-wake cycle — can naturally get disrupted over time. This means people spend less time each night in restorative slow-wave sleep.

Production of melatonin, the sleep hormone, also gradually declines with age. “As a result of these changes, when we get older we may start to wake up earlier than we did when we were younger, or wake up more frequently during the night,” says Zhou.

How can you track sleep quality?

How can you better understand the factors likely contributing to your sleep quality? One way is to keep a sleep diary where you track and record your sleep.

Every day, record the time you went to bed, how long it took you to fall asleep, whether you had any nighttime awakenings (and if so, how long you were awake), and at what time you woke up. Also, keep track of how you feel upon awakening and at the end of the day.

“After a week or two, review the information to see if you can identify certain patterns that may be affecting your sleep quality, then make adjustments,” says Zhou.

For example, if you have trouble falling asleep, go to bed half an hour later than usual but maintain the same wake-up time. “It is common for people struggling with their sleep to try to get more sleep by staying in bed longer, but this disrupts their sleep patterns and diminishes their sleep quality,” says Zhou.

Three key strategies to support the quality of your sleep

Other strategies that can help support good sleep quality include:

• maintaining a consistent wake time, especially on weekends
• limiting daytime naps to 20 to 30 minutes, and at least six hours before the desired bedtime
• being physically active.

When it comes to sleep quality, consistency is vital. “People with good sleep quality often have a predictable sleep window where their sleep occurs,” says Zhou. “Good sleepers are likely to sleep around the same number of hours and stay asleep through the night.”

The bottom line on getting restful sleep

It’s unrealistic to expect perfect sleep every night. “If you have trouble sleeping one or two nights during the week, that can be related to the natural ebbs and flows of life,” says Zhou. “You may have eaten a big meal that day, drank too much alcohol while watching football, or had a stressful argument with someone. When tracking sleep quality, look at your overall sleep health week-to-week, not how you slept this Tuesday compared to last Tuesday.”

If you are doing all the right things for your sleep but still do not feel rested upon waking, talk to your doctor. This can help you rule out a sleep disorder like sleep apnea, or another health issue that can interfere with sleep such as acid reflux or high blood pressure. Other factors that can affect the quality of your sleep include taking multiple medicines, depression, anxiety, loneliness, and environmental changes like temperature, noise, and light exposure.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

About the Reviewer

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

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

Quelling the discomfort of atopic dermatitis, the most common form of eczema, can be a daily quest. This inflamed, itchy skin condition can interfere with sleeping, socializing, and many other activities.

If home remedies such as gentle cleansing and regular moisturizing don’t provide relief, your doctor might recommend a prescription treatment to apply to your skin. Which prescription cream is most effective? A new study boils it down to a few overall winners.

What is atopic dermatitis and the itch-scratch cycle?

Atopic dermatitis is a chronic inflammatory skin disease. The areas commonly affected include the face, hands, feet, or the skin folds of the elbows or behind the knees.

We don’t know exactly what causes atopic dermatitis. Genes, the environment, and an overactive immune system all seem to play a role in creating inflammation, which feels itchy. Scratching the itch creates more irritation and inflammation, which causes more itching.

As the itch-scratch cycle continues, the rash gets worse. The skin might tear, ooze, and crust over, which can be painful.

Which skin treatments were more effective in the study?

Some prescription topical skin treatments for atopic dermatitis are more effective than others, according to a 2023 study published online by The Journal of Allergy and Clinical Immunology.

Scientists evaluated more than 200 randomized trials involving more than 43,000 people with atopic dermatitis (average age 18). The researchers compared almost 70 different prescription creams or ointments, which are broadly called topical treatments and are designed to be applied to affected areas of skin.

These treatments fall into five categories. If you have eczema, their generic names may or may not be familiar to you, but your medical team is likely to know them well:

• topical corticosteroids, divided into seven classes ranging from the most to the least potent, decrease the release of an inflammatory chemical called phospholipase A2
• topical Janus kinase (JAK) inhibitors interrupt inflammatory signals as they enter cells
• topical PDE4 inhibitors raise the production of a chemical called phosphodiesterase-4, or PDE4, and lower the body’s inflammatory response
• topical calcineurin inhibitors help suppress the production of chemical messengers that tell the body to ramp up its defenses
• other topical treatments, including antibiotics and prescription moisturizers.

Researchers looked at which medications had outcomes important to patients, including which

• were best at improving quality of life
• were best at reducing eczema-related severity, itch, sleep disturbances, or flare-ups
• caused the fewest serious side effects
• were discontinued least often due to serious side effects.

Which atopic dermatitis medications proved to be most effective?

The study yielded some predictable results and a surprise. The overall winners were

• two calcineurin inhibitors: pimecrolimus (Elidel) and tacrolimus (Protopic)
• moderate-potency topical corticosteroids, a large group that includes fluocinolone acetonide (Synalar cream 0.025%) and triamcinolone acetonide (Kenalog cream/ointment 0.1%).

What did these medications improve?

• Pimecrolimus improved six of seven outcomes, and was among the best at reducing sleep disturbances and eczema flares.
• High-dose tacrolimus (0.1%) improved five outcomes, and was among the best at reducing itch and eczema flares.
• Moderate-potency steroids improved four to six of the seven outcomes, and were best at reducing eczema itch, flares, and serious side effects.

“That’s in line with what we often prescribe,” says Dr. Connie Shi, a dermatologist who often treats people with eczema at Harvard-affiliated Brigham and Women’s Hospital. “The strongest topical steroids appeared to be the most effective at reducing eczema severity in the study. However, for longer-term maintenance we may consider switching to a moderate-potency steroid, or one of the nonsteroid options, to minimize the risk of thinning the skin, which can occur with long-term use of topical steroids.”

The surprise finding: the study found little to no effectiveness from using a topical cream twice daily versus just once daily. “The traditional advice is twice daily,” Dr. Shi says. “Once a day would make it more convenient to use, and it may help people stay on their medication regimen without decreasing effectiveness.”

Which treatments were less effective in this study? The researchers found that topical antibiotics were among the least effective treatments for eczema.

Should you change your treatment?

“While the study included more than 40,000 people, what worked for participants may not always work for you, as different people may respond differently to the same treatment,” Dr. Shi explains. “There are many factors to consider when prescribing a treatment, including your age, the areas on your skin that are affected, the severity of the eczema, and potential side effects.”

The bottom line? “If a treatment regimen is working for you, then continue it, as long as you don’t have any serious side effects,” she says. “If your current regimen isn’t working well, talk with your doctor or a dermatologist to see if there’s another prescription cream or ointment that you may want to try.”

About the Author

Heidi Godman, Executive Editor, Harvard Health Letter

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

About the Reviewer

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

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

Here’s a question you may not have been asked lately: what do you know about lymph nodes?

If your answer is “not much,” you’re not alone. But even as our lymph nodes maintain a low profile, they’re working around the clock to deal with potential health problems ranging from common viruses to deadly bacteria and even cancer.

Read on to learn more about these workhorses of the immune system as they stand guard against outside invaders and rogue elements within our bodies.

What are lymph nodes?

Your lymph nodes are one part of the immune system that helps defend the body against health threats. These bean-shaped, pea-sized mounds of tissue form a network of clusters throughout the body. They filter lymphatic fluid (lymph), a white-yellow fluid that originates in the bloodstream.

The human body has hundreds of lymph nodes. They’re most plentiful — and most noticeable — in the neck, armpits, and groin. They’re also abundant in the chest and abdomen, where they’re observable by imaging tests such as CT or MRI scans.

Sometimes, lymph nodes are called glands (as in: “when I had mono, I had swollen glands in my neck”), but that’s not really accurate. Glands such as the thyroid gland produce hormones or other chemicals that have effects elsewhere in the body. That’s not what lymph nodes do.

How does lymph reach our lymph nodes?

Lymph is created when plasma, the liquid part of blood, seeps out of tiny blood vessels and flows into connecting channels that link lymph nodes throughout the body. These connecting channels are known as the lymphatic drainage system.

After lymph passes through lymph nodes, it eventually returns to the bloodstream through lymphatic channels.

What do lymph nodes do?

Our lymph nodes scour lymphatic fluid for infection or other potential triggers of illness. If threats are found, white cells called lymphocytes, and other immune cells within the lymph nodes, identify and try to eliminate them.

The main functions of your lymph nodes are:

• detecting and eliminating infectious organisms
• removing abnormal cells, including cancer cells and precancerous cells
• eliminating damaged cells or cell products that might cause illness.

Is it normal for lymph nodes to swell and become painful?

It’s normal for lymph nodes to enlarge and become tender when they’re doing their job, especially when reacting to an infection. These reactive lymph nodes can become as large as grapes and painful to touch. But that’s only temporary: they should return to normal promptly when the infection resolves.

For local infections such as a skin infection or sore throat, the lymph node enlargement is limited to the part of the body near the infection. However, for bodywide infections such as HIV or mononucleosis, lymph node enlargement may be more widespread.

Can disease begin in lymph nodes?

Though they usually function as a helpful part of the immune system, diseases sometimes start in lymph nodes.

Lymphoma is a type of cancer that begins in the lymph nodes or in lymphatic tissue elsewhere in the body (including bone marrow, the spleen, or the intestinal tract). Rare inflammatory conditions can also involve lymph nodes; two examples are Castleman disease and Kikuchi disease.

Infections can affect the lymphatic system. Lymphatic filariasis, a parasitic disease spread by mosquitoes, is a good example.

Imagining a world without lymph nodes

Because they play an important role in the body’s immune defense, having no lymph nodes would likely mean having more and longer-lasting infections. In addition, an infection that might ordinarily be confined to one part of the body might spread more easily.

Considering all the ways in which lymph nodes help us stay healthy, it may seem surprising how commonly they’re removed. One or more lymph nodes may be removed to determine if they are cancerous, or if a newly diagnosed cancer (such as breast cancer) has spread to the lymph nodes. But since we have hundreds of lymph nodes, this sort of lymph node removal is unlikely to cause problems with immune function.

Sometimes lymph node surgery impairs lymphatic drainage. When this occurs, fluid can accumulate in nearby tissues. Chronic swelling called lymphedema can be a complication.

The bottom line

While there are many steps you can take to maintain a healthy immune system and good health — choosing a healthy diet, exercising regularly, not smoking, and more — you can’t do for yourself what your lymph nodes do for you.

So, even though the humble lymph node is easy to overlook, we should all be glad we have them.

About the Author

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

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

Everyone has moments when their brain suddenly goes haywire. They repeatedly fixate on the same thought, like being stuck on a hamster wheel. Or their thoughts aimlessly bounce from one random topic to the next like a pinball.

People often refer to these thought patterns as racing thoughts, and the most common cause is anxiety, says Fairlee Fabrett, PhD, a psychologist at Harvard-affiliated McLean Hospital.

“People who struggle with racing thoughts are constantly worried about what needs to be done, what hasn’t been done, and what is next,” says Fabrett. “Or they obsess about past, present, or future situations.” For example, you replay a conversation with different versions of dialogue, ruminate about an upcoming meeting with your boss or medical appointment, or worry about an unlikely doomsday scenario.

“When racing thoughts take over your mind you can’t stay focused, and you feel trapped, which makes you even more anxious and stressed, and the cycle continues,” says Fabrett.

Breaking the cycle of anxiety and racing thoughts

How can you break this cycle and keep racing thoughts from controlling you? Here are five strategies to try.

Give yourself permission. Racing thoughts are often made worse by the anxiety over having racing thoughts. To escape this, give yourself permission to experience them. “Acknowledge that racing thoughts are just noise, it is what our minds sometimes do, and that’s okay,” says Fabrett. “This gives you a sense of control so you don’t feel helpless. When you put racing thoughts in their proper context, they feel less threatening and easier to manage.”

Get mindful. Practicing mindfulness can help change your thought patterns. For instance, try counting your breaths. Close your eyes and count to yourself as you take slow, steady breaths: count one on the inhale, two on the exhale, etc. When you reach 10, start over and repeat the process until you calm down. “This is also a great remedy before sleep when most people’s minds begin to ruminate,” says Fabrett. Also, practice this breath work at times when your thoughts are not racing, so you will have the skill when you need it.

Distract yourself. You can sometimes break the cycle by distracting your mind. “As soon as you notice yourself worrying again or thinking about things over and over, make an internal comment to yourself, like ‘here I go again, with my list of thoughts that never ends,” says Fabrett. Then make a conscious decision to do something else, like reading, listening to music, or calling a friend.

Get moving. It sounds like token health advice — exercise more — but movement is helpful for defusing anxiety. For instance, when an episode of racing thoughts strikes, do a set of push-ups, 10 jumping jacks, take a five-minute walk, or do household chores. “These not only help break the cycle of racing thoughts but give your mind something else to focus on,” says Fabrett. Also, try to build regular exercise into your life as well as these short bursts of activity. That can help relieve anxiety and stress.

Schedule worry time. Sometimes it’s best to let racing thoughts run their course; otherwise, they may linger indefinitely. To do this, schedule worry time. When anxious racing thoughts occur, recognize them, but tell yourself that now is not worry time and you will deal with them later. Then at a fixed time of your choosing, do nothing but explore those thoughts and work through them. For example, write down the thoughts that come to mind without editing, including all the worst-case scenarios you can think of.

“You can also talk about them aloud and ask what makes you nervous and why,” says Fabrett. “This allows you to confront your anxiety head-on, but on your schedule without taking away from other activities,” says Fabrett. Set a limit to worry time, like 10 to 20 minutes. When the time is up, you move on.

If racing thoughts regularly affect your life or interfere with sleep, talk to your doctor or a mental health professional. “Frequent racing thoughts may be related to anxiety disorders, attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), trauma, or other mental health issues that need exploring,” says Fabrett.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

About the Reviewer

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

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

Middle school can be challenging for many students. It’s tougher academically than elementary school, with more work and higher expectations. Even just changing classes — which for most students starts in middle school — can be stressful. It can be challenging socially, as students try to find friends and community amidst what can be very tough peer pressure. It’s also when some students start to experiment with sexuality and substance use, which can be overwhelming — even when glimpsed secondhand through the experiences of friends.

So what can parents do? Here are some suggestions for helping your middle schooler navigate these new waters.

Support schoolwork and socializing

Help them stay organized and on task. Keeping assignments and tests straight with multiple classes is an adjustment. Encourage your child to use a daily or weekly planner (paper or online). Help them work out a schedule that makes sure they get their homework done while also still having time for exercise and other activities. Fight the urge to micromanage; the idea is to help your child gain skills — and any true gaining of skills involves making some mistakes.

Be mindful of the effects of screen time — and social media. Screen time has a way of eating into things like homework, sleep, and other important uses of time. And social media can not only be distracting but a source of anxiety for middle schoolers. Everything and everyone looks perfect on social media, whether or not they are. It’s easy to feel less than or left out. Have ground rules about device use, such as no use during meals or homework, and charging the phone outside of the bedroom at night.

Get to know their teachers and school culture. Go to the fall open house. Sign up for any conferences or other resources offered to parents. Join the PTO or look for chances to volunteer, to the extent that you can around your own responsibilities. It can give you useful context and connect you with other parents.

Support healthy habits

Keep healthy habits in mind. A healthy diet, regular exercise, and getting a good night’s sleep are crucial. If life is particularly busy, think about making some healthy snacks, lunches, or dinners ahead of time on the weekend. Exercise can be as simple as a walk — maybe even to school or with the dog.

Encourage your child to get involved — but not overscheduled. Joining a club, sport, or other school-sponsored activity is a great way to make friends and grow as a person. At the same time, all of us need downtime. Make sure that downtime gets scheduled along with any extracurricular activities. Some of that downtime should be fun family time, like a game or movie night, or going out for ice cream, or whatever your child enjoys.

Strengthen bonds — yours and theirs

Keep the lines of communication open. Eat meals together, make sure to carve out time to be together and talk — or rather, listen. It’s always a good idea to listen more than one talks, and this is particularly true in middle school. Ask open-ended questions. Make it clear that you won’t judge. Be supportive and positive. Try to validate strong emotions, which can help defuse them.

Remember that the point isn’t to give advice but to help them feel comfortable talking to you, something that won’t be true for long if the conversation turns to your opinions. Sometimes it’s easier to talk when it’s less intense, like while watching a movie or sitting in the car — using media can also be a useful way to start conversations about tricky things like relationships.

Keep your expectations reasonable and fair. Your child does not need to get straight As in middle school to get into a good college. Nor do they need to be the lead in the school play or the best on their sports team. Have some ground rules about homework, healthy habits, and follow-through on commitments (and agreed-upon chores), but keep the emphasis on quality of life rather than achievement. This is a time of finding their way; let them do that.

Ask for help if you need it. If your child is struggling in some way, there is always someone who can help — such as a teacher, guidance counselor, a friend or family member, or your pediatrician. Adolescence is tough for both the child and the parent; we all do better when we do tough things together rather than alone.

About the Author

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

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

The news these days is overwhelming in its awfulness. Acts of terrorism, wars, and heated conflicts constantly erupt throughout the world. Climate change looms, contributing to wildfires and flooding. Incomprehensible shootings occur with numbing regularity. The pandemic seems to be shifting from an immediate threat to health to an endemic illness — yet it’s still affecting us. The news has been so horrible, and so unrelenting, that it is hard to even process it.

Imagine processing it as a child?

Our first instinct is usually to shelter our children from the news and not say anything about it to them at all. That’s completely understandable, and if your child is very young or you are certain for some other reason that they aren’t going to hear about it, then not saying anything is a viable option.

But if they aren’t very young, or if you ever have the news on where they can see, or if they are ever in settings where people might have the news on or talk about it, it might not be so viable. If children are going to hear about something, they really should hear about it from you.

Also, as parents it’s important that we give our children the perspective and skills they need to navigate this scary world where, let’s be honest, bad things happen. The way you talk to children about tragedies in the news can help them cope not just now, but in the future.

The American Academy of Pediatrics has all sorts of resources to help parents talk with children about tragedies. Here are four simple things all parents can and should do:

1. Tell them what happened, in simple terms. Be honest, but skip the gory details. Answer their questions just as simply and honestly. If you think — or know — that your child has already heard something, ask them what they’ve heard. That way you can correct any misinformation, and know not only what you need to explain but also what you may need to reassure them about.

2. Be mindful of the media that your child sees. The news can be very graphic, and because the media are as much in the business of gaining viewers as of delivering news, they tend to make things as dramatic as possible and play footage over and over again. When the planes flew into the Twin Towers on 9/11, my husband and I were glued to the television, not realizing that one of our daughters, who was 3 years old at the time, thought that planes were literally flying into buildings again and again. It wasn’t until she said, “Are those planes going to come here too?” that we shut off the TV and didn’t turn it back on again until all the children were in bed.

3. Make sure your child knows that you and others are always doing everything you can to keep them safe. Talk about some of the ways you keep them safe, ways that are relevant to the tragedy you are talking about. Make a safety plan as a family for things like extreme weather or getting separated. Help them think about what they might do if they are ever in a scary situation, and who they could turn to for help. Which leads me to the most important thing to do…

4. Look for the helpers. The wonderful Fred Rogers often talked about how when he saw scary things on the news, his mother would tell him to look for the helpers, because there are always people who are helping. That may be the best thing we can do as parents: help our children look for the helpers. In all of the recent tragedies, as in all tragedies, there were so many helpers and heroes. When we concentrate on those people, not only do we give our children hope, but we may empower them to one day be helpers too.

The world can be a scary place, yet there is much we can do — from a very young age — to help children build strengths and nurture resilience, even in the face of tragedy.

About the Author

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

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

First, some good news: Merkel cell cancer is exceptionally uncommon. Roughly 1,600 cases occur in the US annually. But this rare skin cancer sometimes goes unnoticed initially. That's worrisome because it often metastasizes early — that is, spreads to other parts of the body such as the lungs and bones.

Here's what to know about Merkel cell skin cancer: where and how it starts, what it looks like, who is more likely to get it, how it's diagnosed and treated — and most importantly, steps you can take to help prevent it.

Where and how does Merkel cell cancer start?

Merkel cells are tiny oval-shaped cells found in the outermost layer of skin. Seen close to nerve endings, they help with the perception of touch.

Rarely, these cells begin to multiply uncontrollably, creating clusters of cancerous cells. Typically the tumors occur in regions that receive greater sun exposure, such as the face, neck, and back of the hand.

Sun exposure isn't the only factor, though. A virus called MCV, or Merkel cell polyomavirus, is thought to trigger development of this cancer in about 80% of all cases. Aging increases the risk of this cancer, and plays a role, too.

What does Merkel cell cancer look like?

It appears as a reddish or purplish bump on the skin and often grows rapidly. Most people don't experience any pain or itching.

Unfortunately, the tumor cells may spread to different parts of the body, including the brain, lungs, bones, and other areas of the skin. This may occur early: nearly half of people with Merkel cell cancer have metastases when first diagnosed.

Who is most likely to develop Merkel cell cancer?

Certain factors increase risk for developing Merkel cell cancer:

• age older than 65
• high exposure to ultraviolet light from sunlight or tanning beds
• fair skin
• family or personal history of skin cancers
• gender (men are more than twice as likely to be affected as women).

People are also more likely to get this cancer if their immune systems aren't strong because they

• take drugs that lower their immune response such as high doses of steroids
• have certain health problems such as blood disorders or HIV
• have had organ transplants and need to take immunosuppressive drugs.

What steps can you take to prevent Merkel cell cancer?

Protect your skin from the sun. Wear UV-protective clothing that covers your trunk, arms, and legs. Wide-brim hats can protect your scalp, face, and part of the neck. Regularly apply broad-spectrum sunscreen on all uncovered skin.

Do not use tanning beds. They increase your chance of developing skin cancers.

Visit your dermatologist regularly for a total skin check if you have had skin cancer, or if a family member (parent, sibling, or child) has had it.

Tell your dermatologist or medical team if you notice any skin changes. Any new mole, bump, or lump should be checked.

How do I find out if I have Merkel cell carcinoma?

If a dermatologist suspects you have Merkel cell cancer or another skin cancer, they will remove a small piece of the skin lesion to look at it under a microscope. This procedure will confirm if the lesion is skin cancer.

How is Merkel cell cancer treated?

Treatment depends on where the tumor is, its size, and whether it has spread. That can be determined by removing lymph nodes near the tumor and through scans.

• If the tumor has not spread: Surgical removal can be done to remove the tumor and a margin of normal skin around it.
• If cancer cells have spread to other parts of the body: Radiation treatment is an option. Chemotherapy, a treatment with medications, may be recommended, though it is not as effective as radiation. Immunotherapy, which can help the immune system recognize and kill cancer cells, is also an option in some cases.

There is a high risk that this cancer will come back after treatment. So people who have had it should regularly see a dermatologist or their cancer team for surveillance.

About the Authors

Lais Lopes Almeida Gomes, Contributor

Dr. Lais Lopes Almeida Gomes is a dermatology research fellow at Massachusetts General Hospital, and a pediatric dermatologist in Brazil. Her clinical and research interests include atopic dermatitis and global health. She is part of the … See Full Bio View all posts by Lais Lopes Almeida Gomes

Neera Nathan, MD, MSHS, Contributor

Dr. Neera Nathan is a dermatologist and researcher at Massachusetts General Hospital and Lahey Hospital and Medical Center. Her clinical and research interests include dermatologic surgery, cosmetic dermatology, and laser medicine. She is part of the … See Full Bio View all posts by Neera Nathan, MD, MSHS

The fall calendar doesn’t just warn us of impending cold temperatures: It also points toward seasonal upticks in cases of RSV (respiratory syncytial virus), COVID, and influenza. These respiratory viruses were dubbed a “tripledemic” last year. After they collided to overload health care systems across the country, hospitalizations rose in tandem for all three illnesses over the fall and winter months.

Warding off severe cases — which may lead to hospitalization or death — should be top of mind, especially for those who are most vulnerable, a Harvard expert says. And updated versions of all three vaccines are now available to help protect us.

Why do cases of flu, RSV, and COVID typically rise in fall?

“This is typically the time of year we start to see viral infections increase, which has a lot to do with kids going back to school,” says Dr. John Ross, an assistant professor of medicine at Harvard Medical School who is board-certified in infectious diseases.

“Also, we’re starting now to have weather that’s more favorable for viral transmission, particularly lower humidity. Viruses survive better in dry air. And drier air also affects our airways and makes them more vulnerable to being infected.”

Who is eligible for each shot?

Eligibility recommendations vary by age and vulnerability to serious illnesses. Additionally, some shots are designed to help protect specific groups against serious illness.

The CDC recommends these shots for the following groups.

RSV

• Babies under 8 months and older infants at risk of severe RSV: A new shot, nirsevimab (Beyfortus), provides antibodies that protect against RSV for about five months.
• If you’re pregnant: One vaccine (Abrysvo) is approved at 32 weeks to 36 weeks of pregnancy. Having this shot during pregnancy protects infants during the first six months of life.
• If you’re over 60: Two vaccines (Arexvy and Abrysvo) are approved. Ask your health provider if you should consider getting one.

COVID

• Everyone 6 months and older should consider getting one of the updated COVID boosters, which were approved and authorized for emergency use by the FDA in early September. 
• Age 5 and older: Regardless of prior vaccination, children and adults are eligible for one dose of an updated mRNA vaccine if it’s been at least two months since their last COVID vaccine, the FDA says.

Flu

• Everyone 6 months and older should receive a flu vaccine.
• Different vaccines are approved for different age groups and for people with certain health issues or allergies. Most protect against four strains of flu virus (quadrivalent vaccines) expected to circulate this season.
• Three vaccines could potentially be more effective for people over 65: Fluzone High-Dose Quadrivalent vaccine; Flublok Quadrivalent Recombinant vaccine; and Fluad Quadrivalent adjuvanted flu vaccine. If these are not available, it’s fine to get any other flu shot approved for your age and health issues or allergies.

Who is likely to benefit most?

Getting the right vaccines can help people avoid missed work or school days and running the risk of making others sick. And the protection offered by these shots is especially important for certain groups.

For all three viruses, the people most vulnerable to severe illness are similar, Dr. Ross says, including

• adults 65 and older
• those with compromised immune systems or underlying lung conditions such as COPD and asthma
• those who are pregnant.

“Certainly with COVID and flu, pregnancy outcomes are worse with those infections,” Dr. Ross says. “I’m not saying that RSV isn’t a risk for pregnant mothers, but there’s not much data. The reason pregnant women are offered RSV vaccination is so the maternal antibodies they produce protect the newborns, because they’re at very high risk for RSV with very bad outcomes.”

Additionally, an even wider range of people are more prone to complications from the flu, according to the CDC. This includes

• infants under 2
• people with heart disease, neurologic conditions, blood disorders, endocrine disorders such as diabetes, obesity, kidney disease, liver or metabolic disorders
• people who have had a stroke.

What else should you know about flu, COVID, and RSV shots?

Beyond broad guidance determining who’s eligible for each type of vaccine, Dr. Ross offers other useful insight that may guide your choices.

When is the best time to get a flu shot?

The CDC recommends getting a flu shot in September or October, and Dr. Ross agrees. “These are usually the months the flu vaccine becomes available and vaccine clinics are easiest to find,” he says. “My personal approach is just to get the vaccine when it’s available, so you don’t forget.”

Will the updated COVID vaccines protect against newer strains of the virus?

The latest mRNA shots by drugmakers Pfizer and Moderna are monovalent, meaning they protect against one variant — XBB.1.5, the most recent to descend from Omicron earlier in 2023. Though that strain is no longer dominant, the boosters should still guard against closely related subvariants that are now circulating, Dr. Ross says. “People can feel comfortable about their protection regardless,” he says.

What else should I know about RSV shots?

The version meant for infants, Beyfortus, isn’t a vaccine at all. It’s a monoclonal antibody product that directly delivers antibodies that protect babies for the duration of a single fall-winter RSV season. These antibodies can prevent RSV or lessen its severity.

Dr. Ross says adults over 60 considering RSV vaccination should be aware of the potential for two rare but potentially serious side effects of the nervous system: the autoimmune conditions Guillain-Barre syndrome and acute disseminated encephalomyelitis, or ADEM. Guillain-Barre can lead to bodywide paralysis, while ADEM can cause weakness and seizures. The risk of these side effects after RSV vaccination in adults is about one in 7,000 — far higher than occurs after flu vaccination, Dr. Ross notes.

“If you’re a totally healthy 60-year-old, I’m not sure it makes sense to get the RSV vaccine,” he says. “It’s a conversation you should have with your doctor.”

How should I schedule shots if I’m getting several vaccines?

Research suggests that it’s safe to get both flu and COVID vaccines at the same time. Reactions (such as muscle aches, fatigue, and headache) are slightly higher when flu vaccine and an mRNA COVID vaccine are combined, according to one study, though these reactions usually are mild and disappear quickly.

“Because RSV vaccines are newer, I don’t think we know much about combining these shots with other vaccines,” says Dr. Ross. Scheduling this vaccine separately is a good idea, although you should talk to your doctor about potential risks and benefits for your situation.

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

About the Reviewer

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

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

It’s no secret that the typical American diet isn’t very healthy. Only about one in 10 American adults eats the recommended daily amount of fruit (1-1/2 to 2 cups) or vegetables (2 to 3 cups). These dietary shortfalls are even more pronounced among people in lower income groups. And the health impacts are substantial: In the United States, poor diets have been linked with more than 300,000 annual deaths from heart disease and diabetes.

Produce prescriptions enable health care workers to give vouchers for free or discounted produce at grocery stores or farmers’ markets to people living in low-income neighborhoods. A recent study asks whether these programs might help people at risk for heart disease eat more fruits and vegetables, and possibly improve health issues like high blood pressure. While Dr. Anne Thorndike, an associate professor of medicine at Harvard Medical School who studies cardiometabolic disease prevention and nutrition security, questions some findings in the study, she notes that there are lessons to be learned here.

How was the study done?

The study pooled data on nine different produce prescription programs given out in 22 locations spread over a dozen states across the country. A total of about 2,000 adults and 1,800 children from low-income neighborhoods were enrolled. Participants received vouchers or cards to buy produce worth $15 to $300 per month (depending on family size). They also attended nutrition classes.

The programs lasted between four and 10 months. At the start and end of each program, participants filled out questionnaires about their fruit and vegetable consumption and health status. The questionnaires also asked about food insecurity, which is not having access to adequate food to meet one’s basic needs. Blood pressure, blood sugar, height, and weight were recorded for some program participants.

What were the findings?

During the produce prescription program, adults ate nearly one additional cup of fruits and vegetables per day; children ate an extra quarter-cup daily. In adults, these changes were associated with lower blood pressure in people who had high blood pressure and lower blood sugar in people who had diabetes. The researchers also documented drops in body mass index (BMI) among adults with obesity.

All glowing results, right? Well, maybe not.

“Because of the study’s limitations, including a lack of a comparison group — which is standard practice in diet studies — those potential health benefits are hard to prove,” says Dr. Thorndike. In addition, the investigators relied on statistical techniques to account for high rates of missing data from some programs, which could also skew results.

It’s hard to imagine how eating an extra serving of produce daily could lower BMI values within six months, says Dr. Thorndike. “However, there’s so much strong data that associates eating a healthy diet, particularly one that includes plenty of fruits and vegetables, with a lower rate of almost every chronic disease, including heart disease, cancer, and dementia,” she adds.

The bottom line

While flawed, this research is interesting, and highlights the need to improve diet quality for all Americans, especially those who face added barriers due to their financial circumstances.

“I’m a huge believer in produce prescriptions,” says Dr. Thorndike, “and part of my research mission is to determine the best way to design and deliver them so people get the greatest possible health benefit.”

The study also helps raise awareness about food insecurity, which affects about one in 10 American households. At the start of the study, more than half of the households participating reported food insecurity. Among all the participants, reported rates of food insecurity dropped by one-third by the end of the program compared to the start.

“We all need to acknowledge that many people are less healthy because they can’t get access to or afford the foods they need to prevent or treat disease,” Dr. Thorndike says. Broadening the focus beyond produce to “prescribe” other types of healthy foods, such as whole grains and lean proteins, may be another helpful solution, she adds.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

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

About the Reviewer

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

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

Three months into the year is a good time to recalculate if you’ve been slacking on your resolution to eat healthy. And if you’ll be leaving home base or school soon and foraging for yourself (plus or minus roommates), it’s a great time to learn about healthy, low-cost choices for your grocery list.

The basics: A weekly shop

A healthy diet is rich in vegetables, fruits, legumes (beans or lentils), whole grains, nuts, seeds, lean proteins, and low-fat dairy products. Trying to fill your cart with all of those goodies can feel overwhelming. But just think in terms of twos.

“Get two fruits and two vegetables of different colors, and two types of lean protein — such as fresh, frozen, or canned fish, chicken or lean ground turkey, or plant-based options,” suggests Nancy Oliveira, a registered dietitian and manager of the Nutrition and Wellness Service at Harvard-affiliated Brigham and Women’s Hospital.

Oliveira also recommends getting two foods in each of these categories on your weekly shopping trip:

• plant proteins, such as canned or dried beans, tofu, tempeh, veggie burgers, or unsalted nuts or seeds
• whole grains, such as whole-grain bread, whole-grain pasta, brown or black rice, quinoa, or farro
• dairy or nondairy milk items, such as nonfat Greek yogurt or cheese.

Go ahead and add one or two healthy treats or snacks, such hummus or dried apricots.

Do you need to choose organic foods?

Organic produce is grown without synthetic fertilizers and pesticides, which are linked to many health problems. While US scientists debate whether foods grown with organic fertilizers (such as animal waste) are safer for your health, other countries, including European Union nations, have banned or phased out synthetic pesticides still used in the United States.

That doesn’t mean that everything you buy must be organic. But try to stay away from conventionally grown produce with thin skins, such as strawberries, spinach, kale, peaches, and grapes. They tend to absorb more chemicals compared to produce with thick skins, such as avocados or pineapples.

The Environmental Working Group creates an annual list to help shoppers avoid high-pesticide produce, and another one that highlights the least contaminated produce.

Buying cost-conscious fresh food and staples

Healthy food, especially organic produce, has a reputation for being expensive. But it doesn’t have to be. Just do a little comparison shopping, and follow Oliveira’s tips to save money on a grocery run:

• Shop in a smaller store with fewer choices.
• Never enter a store hungry, since you might buy more than you normally would.
• Carry a shopping list and stick to it.
• Go directly to the aisles you need. Avoid browsing elsewhere, which may lead to extra purchases.
• Be flexible, have several options within your food categories, and go with sale items.
• Always check the day-old produce cart that offers perfectly edible fresh produce at 50% to 75% off regular prices.
• Buy unseasoned canned or frozen whole foods such as vegetables, chicken, or fish (salmon, sardines, tuna), which are often cheaper than fresh versions.
• Wait for sales of healthy nonperishable staples like quinoa, brown rice, whole-grain pasta, and high-fiber cereals.
• Use coupons and coupon apps.

Easy healthy snacks to reach for

Move on from easy grab-n-go snacks, which are typically processed foods. They often contain unhealthy ingredients and promote overeating. Instead, Oliveira suggests keeping healthy snacks on hand, such as:

• unsalted mixed nuts
• string cheese
• grapes and berries (rinse before eating)
• clementines, bananas, or other fruits that don’t need washing
• a rice cake with nut butter or hummus
• fat-free Greek yogurt
• a peeled hard-boiled egg.

“To save money, buy certain foods in larger amounts when possible, such as an 8-ounce bar of cheese that you slice into small cubes and store in a sealed container in the fridge,” Oliveira says.

Crowdsource shopping tips and savings

Don’t be shy about asking for shopping tips from friends and family members who’ve already developed shortcuts, and grocery store staffers who can offer insider advice.

You can also turn to apps for help. Oliveira recommends two faves:

• Mealime is a meal-planning app with simple, healthy plant-based recipes that automatically create grocery lists for the ingredients.
• List Ease creates lists for grocery runs. You can search for items to add or scan barcodes to add to lists.

“And if you prefer not to use apps, just jot down notes after a quick pantry or fridge inventory, or text yourself every time you remember something you need,” Oliveira advises. “With a little practice, you’ll quickly work out the best system for you.”

About the Author

Heidi Godman, Executive Editor, Harvard Health Letter

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

About the Reviewer

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

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