The drug, Paxlovid, is lauded by experts as a powerful tool that can prevent hospitalization and death from COVID-19. But the high price and doctors’ hesitation to prescribe the pills mean the five-day treatment isn’t getting to everyone who would benefit from it.

“When you read in your local newspaper that in this hospital, they’ve got this many COVID patients, most of those are preventable hospitalizations,” said Dr. Amesh Adalja, a senior scholar at Johns Hopkins University who sees Paxlovid as a useful tool to treat COVID-19.

One Centers for Disease Control and Prevention study found that Paxlovid can decrease hospitalization risks among adults by 51%. The drug is recommended for older people and other adults with certain underlying conditions and can be prescribed for kids as young as 12.

When Paxlovid was first authorized for emergency use in the U.S. in December 2021, it was free for anyone who needed it. Once the government stopped funding the treatment, Pfizer set a list price of $1,390.

The drug remains free for people on federal insurance programs like Medicaid and Medicare through the end of this year, and uninsured people also can get it for free. But many of those people must go through a patient assistance program run by Pfizer to get the discounts. People on commercial insurance with high out-of-pocket costs can also get financial help through a separate co-pay assistance program.

Independent pharmacy owners find Paxlovid is expensive to carry because of reimbursement rates from commercial insurers, said Kurt Proctor, a senior vice president at the National Community Pharmacists Association.

“If you’re losing 5% on a $10 prescription, it’s very different than losing 5% on a $1,400 prescription product,” he said.

The high list price also is turning off some patients.

When Celise Ballow, of Junction, Utah, got COVID-19 recently, she never got the medication.

Ballow said her doctor declined to write her a prescription after telling her it wouldn’t be covered by her insurance. Now she wonders if she could have avoided some of the infection’s worst effects if she had been able to get the medication.

“I’m going on a month and a half and I’m still having nebulizer treatments. … I’m still exhausted,” Ballow said.

Another factor hurting uptake appears to be the long list of medications that shouldn’t be taken with Paxlovid. Many doctors may simply decide the risk of drug interactions isn’t worth it.

“If people are on four or five different medications, it does tend to be a pain to double check ‘is there an interaction here?’” said Dr. Sarah George, an infectious diseases professor at St. Louis University. Seeing a possible significant drug interaction “tends to put a physician off from prescribing a drug, even if there is a workaround,” she said.

Paxlovid isn’t the only antiviral medication for COVID-19. Merck’s Lagevrio is another available pill, though it’s proven to be less popular in the U.S. than Paxlovid. A third drug, Gilead’s Veklury, is given via infusion.

The people most likely to benefit from Paxlovid were the least likely to get it in 2022, according to a recent study.

The study by Harvard researchers found that Paxlovid was disproportionately given to Medicare patients with lower risk of severe infection. If it had been properly utilized, the authors concluded, more than 16,000 COVID-19 deaths could have been prevented.

Dr. Michael Barnett, a Harvard health policy researcher who co-wrote the study, said it shouldn’t be that way.

“There are very few medications and very few patients whose potential medication interaction with Paxlovid is so severe that they’re better off not taking Paxlovid,” he said. “Very few of them are important enough that it’s a big risk to stop for a week.”

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But the data also found that roughly one in six teens describe their use of two platforms — YouTube and TikTok — as “almost constant.”

Seventy-one percent of teens said they visit YouTube at least daily; 16% described their usage as “almost constant” according to the survey. A slightly larger group — 17% — said they used TikTok almost constantly. Those figures for Snapchat and Instagram came in at 14% and 8% respectively.

YouTube remains by far the most popular social platform among teens, with 93% responding that they use the service. That number was down two percentage points from 2022. Runners-up included TikTok, Snapchat and Instagram, although all three trailed YouTube in this measure by 30 percentage points or more. Three of those four platforms showed slight drops in usage over the past year, according to the survey. The exception, Snapchat, rose a single percentage point.

Facebook, whose overall usage by teens has dropped to 33% in 2023 from 71% in 2014-15, gets about the respect from teens you’d expect. Only 19% of teens reported checking Facebook daily or more frequently. Just 3% describe their usage as almost constant.

Social media is increasingly taking fire over the algorithmic techniques that platforms use to drawn in and retain younger users. In October, a coalition of 33 states, including New York and California, sued Meta Platforms for contributing to the youth mental health crisis, alleging that the company knowingly and deliberately designed features on Instagram and Facebook that addict children to its platforms. Meta has denied the charges.

The Pew survey, which was published Monday, was conducted from Sept. 26 to Oct. 23 with 1,453 teens aged 13 to 17.

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After a repeat blood test, a PET scan and a needle biopsy, she was diagnosed with Hodgkin lymphoma.

“I cried,” the retired real estate broker said. “Just a couple of tears and thought, ‘OK, now what do we do?’”

The Canby, Oregon, resident had volunteered to take a blood test that is being billed as a new frontier in cancer screening for healthy people. It looks for cancer by checking for DNA fragments shed by tumor cells.

Such blood tests, called liquid biopsies, are already used in patients with cancer to tailor their treatment and check to see if tumors come back.

Now, one company is promoting its blood test to people with no signs of cancer as a way to detect tumors in the pancreas, ovaries and other sites that have no recommended screening method.

It’s an open question whether such cancer blood tests — if added to routine care — could improve Americans’ health or help meet the White House’s goal of cutting the cancer death rate in half over the next 25 years.

With advances in DNA sequencing and data science making the blood tests possible, California-based Grail and other companies are racing to commercialize them.

And U.S. government researchers are planning a large experiment — possibly lasting seven years and with 200,000 participants — to see if the blood tests can live up to the promise of catching more cancers earlier and saving lives.

“They sound wonderful, but we don’t have enough information,” said Dr. Lori Minasian of the National Cancer Institute, who is involved in planning the research. “We don’t have definitive data that shows that they will reduce the risk of dying from cancer.”

Grail is far ahead of other companies with 2,000 doctors willing to prescribe the $949 test. Most insurance plans don’t cover the cost. The tests are being marketed without endorsements from medical groups or a recommendation from U.S. health authorities. Review by the Food and Drug Administration isn’t required for this type of test.

“For a drug, the FDA demands that there is a substantial-high likelihood that the benefits not only are proven, but they outweigh the harms. That’s not the case for devices like blood tests,” said Dr. Barry Kramer of the Lisa Schwartz Foundation for Truth in Medicine.

Grail plans to seek approval from the FDA, but is marketing its test as it submits data to the agency.

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Can cancer blood tests live up to promise of saving lives?

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Researchers at the University of Notre Dame tested more than 230 commonly used cosmetics and found that 56% of foundations and eye products, 48% of lip products, and 47% of mascaras contained fluorine — an indicator of PFAS, so-called “forever chemicals” that are used in nonstick frying pans, rugs and countless other consumer products.

Some of the highest PFAS levels were found in waterproof mascara (82%) and long-lasting lipstick (62%), according to the study published Tuesday in the journal Environmental Science & Technology Letters. Twenty-nine products with higher fluorine concentrations were tested further and found to contain between four and 13 specific PFAS chemicals, the study found. Only one item listed PFAS, or perfluoroalkyl and polyfluoroalkyl substances, as an ingredient on the label.

A spokeswoman for the U.S. Food and Drug Administration, which regulates cosmetics, said the agency does not comment on specific studies. The FDA said on its website that there have been few studies of the presence of the chemicals in cosmetics, and the ones published generally found the concentration is at very low levels not likely to harm people, in the parts per billion level to the 100s of parts per million.

A fact sheet posted on the agency’s website says that “As the science on PFAS in cosmetics continues to advance, the FDA will continue to monitor″ voluntary data submitted by the industry as well as published research.

But PFAS chemicals are an issue of increasing concern for lawmakers who are working to regulate their use in consumer products. The study results were announced as a bipartisan group of senators introduced a bill to ban the use of PFAS in cosmetics and other beauty products.

The move to ban PFAS comes as Congress considers wide-ranging legislation to set a national drinking water standard for certain PFAS chemicals and clean up contaminated sites across the country, including military bases where high rates of PFAS have been discovered.

“There is nothing safe and nothing good about PFAS,″ said Sen. Richard Blumenthal, D-Conn., who introduced the cosmetics bill with Sen. Susan Collins, R-Maine. “These chemicals are a menace hidden in plain sight that people literally display on their faces every day.″

Rep. Debbie Dingell, D-Mich., who has sponsored several PFAS-related bills in the House, said she has looked for PFAS in her own makeup and lipstick, but could not see if they were present because the products were not properly labeled.

“How do I know it doesn’t have PFAS?” she asked at a news conference Tuesday, referring to the eye makeup, foundation, and lipstick she was wearing.

The Environmental Protection Agency also is moving to collect industry data on PFAS chemical uses and health risks as it considers regulations to reduce potential risks caused by the chemicals.

The Personal Care Products Council, a trade association representing the cosmetics industry, said in a statement that a small number of PFAS chemicals may be found as ingredients or at trace levels in products such as lotion, nail polish, eye makeup, and foundation. The chemicals are used for product consistency and texture and are subject to safety requirements by the FDA, said Alexandra Kowcz, the council’s chief scientist.

“Our member companies take their responsibility for product safety and the trust families put in those products very seriously,″ she said, adding that the group supports the prohibition of certain PFAS from use in cosmetics. “Science and safety are the foundation for everything we do.”

But Graham Peaslee, a physics professor at Notre Dame and the principal investigator of the study, said the cosmetics pose an immediate and long-term risk. “PFAS is a persistent chemical. When it gets into the bloodstream, it stays there and accumulates,″ Peaslee said.

No specific companies were named in the study, although supporting material indicates that researchers tested dozens of brands, including many household names.

The study did not seek to link any health effects to cosmetics use, but Peaslee said researchers found PFAS levels that ranged from a few parts to billion to thousands of parts per billion. He called the latter totals “worrisome.″

The chemicals also pose the risk of environmental contamination associated with manufacturing and disposal, he said.

The man-made compounds are used in countless products, including nonstick cookware, water-repellent sports gear, cosmetics, and grease-resistant food packaging, along with firefighting foams.

Public health studies on exposed populations have associated the chemicals with an array of health problems, including some cancers, weakened immunity, and low birth weight. Widespread testing in recent years has found high levels of PFAS in many public water systems and military bases.

Blumenthal, a former state attorney general and self-described “crusader” on behalf of consumers said he does not use cosmetics. But speaking on behalf of millions of cosmetics users, he said they have a message for the industry: “We’ve trusted you and you betrayed us.″

Brands that want to avoid likely government regulation should voluntarily go PFAS-free, Blumenthal said. “Aware and angry consumers are the most effective advocate” for change, he said.

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Study: Half of US cosmetics contain toxic chemicals

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Since July, the small staff at Epicurious, a resource site for home cooks, has been scouring 55 years’ worth of recipes from a variety of Conde Nast magazines in search of objectionable titles, ingredient lists and stories told through a white American lens.

“It came after Black Lives Matter, after a lot of consciousness-raising among the editors and staff,” said David Tamarkin, the white digital director for Epicurious. “It came out of conversations that we had about how we can do better, where are we failing and where have our predecessors failed?”

Called the Archive Repair Project, the work is also an outgrowth of complaints and controversies at Conde Nast. But it’s just one effort on a full plate of initiatives, said Sonia Chopra, who’s been executive editor of Bon Appetit and Epicurious for about four months, working under the new editor in chief, Dawn Davis.

In all, the 25-year-old site (with a staff of 10) is a repository of a massive 35,000 recipes from Bon Appetit, Gourmet, Self, House & Garden, and Epicurious itself. They stretch back to 1965.

“The language that we use to talk about food has evolved so much from, sure, the 1960s but also the 1990s, and I think it is our duty as journalists, as people who work in food media, to make sure that we are reflecting that appropriately,” Chopra said.

Epicurious and Bon Appetit have been at the center of accusations that also plague others in the food world: undervaluing staffers of color, perpetuating structural racism, racial and gender discrimination, and more. Some of those issues led several Bon Appetit employees to leave earlier this year after Editor-in-Chief Adam Rapoport resigned over a 2004 Halloween “brownface” photo and amid allegations of racial discrimination.

While Conde Nast studies pay equity and have issued apologies and pledges to do such things as expand unconscious-bias education and create inclusion and diversity plans, the Archive Repair Project rolls on.

The bulk of Epicurious site traffic goes to the archive, mostly recipes but also articles and other editorial work, Tamarkin and Chopra said.

“Being such an old site, we’re full of a lot of ideas about American cooking that really go through a white lens,” Tamarkin said. “We know that American cooking is Mexican American cooking and Indian American cooking and Nigerian American cooking, that that’s the kind of cooking that’s really happening in this country every day.”

One of the first issues “repaired,” he said, was the use of the word “exotic.”

“I can’t think of any situation where that word would be appropriate, and yet it’s all over the site,” Tamarkin said. “That’s painful for me and I’m sure others.”

Another word requiring removal was a lime reference that included a racial slur directed at Black Africans, particularly in South Africa.

Other terms, such as “authentic” and “ethnic,” are also among repairs.

The work, Chopra said, is “certainly something that I think not just Conde Nast brands but all over food media and media, in general, are really thinking about.”

Since July, when Tamarkin outlined the project on Epicurious, he and his staff have fixed about 200 recipes and other work. Some repairs are more complicated than removing a single word, such as an entire story about the “ethnic” aisle at the grocery store.

“We have published recipes with headnotes that fail to properly credit the inspirations for the dish, or degrade the cuisine the dish belongs to. We have purported to make a recipe `better’ by making it faster, or swapping in ingredients that were assumed to be more familiar to American palates, or easier to find. We have inferred (and in some cases outright labeled) ingredients and techniques to be ‘surprising’ or `weird.’ And we have published terminology that was widely accepted in food writing at the time, and that we now recognize has always been racist,” Tamarkin wrote.

He noted: “Certainly there will be times when our edits do not go far enough; some of our repairs will need repairs.”

For Bon Appetit, that’s exactly what happened when an outcry among readers led it to make multiple changes including the headnote and references to Haiti on a pumpkin soup recipe put forth by Chef Marcus Samuelsson, a guest editor. The magazine referred to it as soup joumou, a beloved Haitian staple that symbolizes the country’s bloody liberation from its French colonizers.

It was not soup joumou, but was intended by Samuelsson as an homage. The magazine adapted an entry from one of his cookbooks, “The Rise: Black Cooks and the Soul of American Food.” Both Bon Appetit and Samuelsson, who is Black, apologized after calls of erasure and cultural appropriation.

Much of food media is facing race and ethnicity fallout that can be traced to white dominance in the highest echelons of the field. On the Epicurious repair project, for instance, just 31% of the people identifying and fixing the archive are staff of color.

Chopra said broader plans are in motion.

“We’re committed to building teams that are inclusive and thoughtful, and that means always assessing and reassessing our policies and processes. As we transition into 2021 with new leadership, we are examining these across the board, from hiring best practices to making sure we are communicating and working collaboratively and holistically across teams and platforms,” Chopra added.

In the meantime, Tamarkin and his crew are slowly pressing on with their archive repairs at Epicurious, where “Asian” is no longer the name of a cold rice noodle salad, and a vadouvan spice blend has lost its mention as “exotic.”

“A lot of these problems happened because there was a lack of thoughtfulness,” Tamarkin said, “so the solutions require that we be thoughtful now.”

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Epicurious is righting cultural wrongs one recipe at a time

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In most recent news, the Centers for Disease Control and Prevention reports that 73% of nurses who have been hospitalized from COVID-19 had obesity. In addition, a recent study found that obesity could interfere with the effectiveness of a COVID-19 vaccine.

I am an obesity specialist and clinical physician working on the front lines of obesity in primary care at the University of Virginia Health System. In the past, I often found myself warning my patients that obesity could take years off their life. Now, more than ever, this warning has become verifiable.

More damage than believed

Initially, physicians believed that having obesity increased only your risk of getting sicker from COVID-19, not your chance of being infected in the first place. Now, newer analysis shows that not only does obesity increase your risk of being sicker and dying from COVID-19; obesity increases your risk of getting infected in the first place.

In March 2020, observational studies noted hypertension, diabetes, and coronary artery disease as the most common other conditions – or co-morbidities – in patients with more severe COVID-19 disease. But it was the editors of Obesity journal who first raised the alarm on April 1, 2020, that obesity would likely prove to be an independent risk factor for more severe effects of COVID-19 infection.

Additionally, two studies including nearly 10,000 patients have shown that patients who have both COVID-19 and obesity have a higher risk of death at days 21 and 45 compared to patients with a normal body mass index, or BMI.

And a study published in September 2020 reported higher rates of obesity in COVID-19 patients who are critically ill and require intubation.

It is becoming overwhelmingly evident from these studies and others that those with obesity are facing a clear and present danger.

Stigma and lack of understanding

Obesity is an interesting disease. It is one that many physicians talk about, often in frustration that their patients cannot prevent or reverse it with the oversimplified treatment plan that we have been taught in our initial training; “Eat less and exercise more.”

It is also a disease that causes problems physically, such as sleep apnea and joint pain. It also affects one’s mind and spirit due to societal and medical professionals’ bias against those with obesity. It can even adversely affect the size of your paycheck. Can you imagine the outcry if the headline read “Patients with high blood pressure earn less”?

We doctors and researchers have understood for quite some time the long-term consequences of excess weight and obesity. We currently recognize that obesity is associated with at least 236 medical diagnoses, including 13 types of cancer. Obesity can decrease one’s lifespan by up to eight years.

Despite knowing this, U.S. physicians are not prepared to prevent and reverse obesity. In a recently published survey, only 10% of medical school deans and curriculum experts feel that their students were “very prepared” in regards to obesity management. Half of the medical schools responded that expanding obesity education was a low priority or not a priority. An average of 10 hours total was reported as dedicated to obesity education during their entire training in medical school.

And doctors sometimes don’t know how or when to prescribe medications for patients with obesity. For example, eight FDA-approved weight loss medications are on the market, but only 2% of eligible patients receive prescriptions for them from their physicians.

What goes on in the body

So, here we are, with a collision of the obesity epidemic and the COVID-19 pandemic. And a question I find patients asking me more and more: How does obesity create more severe disease and complications from COVID-19 infection?

There are many answers; let’s start with structure.

Excess adipose tissue, which stores fat, creates a mechanical compression in patients with obesity. This limits their ability to take in and completely release a full breath of air.

Breathing takes more work in a patient with obesity. It creates restrictive lung disease, and in the more serious cases, lead to hypoventilation syndrome, which can cause a person to have too little oxygen in their blood.

And then there is function. Obesity results in an excess of adipose tissue, or what we colloquially call “fat.” Over the years, scientists have learned that adipose tissue is harmful in and of itself. One may say that adipose tissue acts as an endocrine organ all its own. It releases multiple hormones and molecules that lead to a chronic state of inflammation in patients with obesity.

When the body is in a constant state of low-grade inflammation, it releases cytokines, proteins that fight inflammation. They keep the body on guard, simmering, and ready to fight disease. That’s all well and good when they are kept in check by other systems and cells. When they are chronically released, however, an imbalance can occur that causes injury to the body. Think of it like a small but contained wildfire. It’s dangerous, but it’s not burning the entire forest.

COVID-19 causes the body to create another cytokine wildfire. When a person who is obese has COVID-19, two small cytokine wildfires come together, leading to the raging fire of inflammation that damages the lungs even more so than patients with normal BMI.

Additionally, this chronic state of inflammation can lead to something called endothelial dysfunction. In this condition, instead of opening up, blood vessels close down and constrict, further decreasing oxygen to the tissues.

In addition, increased adipose tissue may have more ACE-2, the enzyme that allows the coronavirus to invade cells and begin to damage them. A recent study has shown an association of increased ACE-2 in adipose tissue rather than lung tissue. This finding further strengthens the hypothesis that obesity plays a major role in more serious COVID-19 infections. So in theory, if you have more adipose tissue, the virus can bind to and invade more cells, causing higher viral loads that stay around longer, which can make the infection more severe and prolong recovery.

ACE-2 can be helpful in counteracting inflammation, but if it otherwise bound to COVID-19, it cannot assist with this.

The novel SARS COVID-19 virus has forced the medical profession to face the reality that many U.S. physicians inherently know. When it comes to prevention of chronic diseases such as obesity, the U.S. health care system is not performing well. Many insurers reward physicians by meeting metrics of treating the effects of obesity rather than preventing it or treating the disease itself. Physicians are reimbursed, for example, for helping patients with Type 2 diabetes to attain a certain A1C level or a set blood pressure goal.

I believe is time to educate physicians and provide them with resources to combat obesity. Physicians can no longer deny that obesity, one of the strongest predictors for COVID-19 and at least 236 other medical conditions, must become public enemy number one.

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Obesity harms the body in real time, not just over a lifetime

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As health care specialists and researchers, we have long seen the potential of telehealth, providing health care remotely with technology, which has been around for several decades. Despite evidence it could safely treat and manage a range of health conditions in a cost-effective manner, widespread adoption of the practice had been limited by issues including insurance coverage, restrictions on prescribing, and technology access.

On March 27, 2020, The Coronavirus Aid, Relief and Economic Security Act, or CARES Act, removed many of the barriers to widespread telehealth use. Soon after, the Centers for Medicare & Medicaid released a toolkit encouraging state Medicaid agencies to adopt CARES policy changes to promote the expansion of telehealth. Many private insurers followed suit. Collectively, these policy changes facilitated the explosion of telehealth. Now, due to the financial strain on health care systems and insurers, the increase in telehealth use may be forced to shrink even though the public health crisis remains.

At the very beginning of the pandemic, the use of telehealth went from 13,000 to 1.7 million visits per week among Medicare recipients. Between mid-March and mid-June 2020, during the height of the national lockdown, over 9 million telehealth visits were conducted for Medicare recipients. Private insurers, who mimicked the CARES Act policy changes, also reported exponential increases – with telehealth claims increasing over 4,000% from the previous year.

Telehealth is typically used for new health concerns like a sore throat, psychotherapy, and in-home monitoring with mobile devices for chronic conditions like diabetes, high blood pressure, or heart failure. Telehealth is convenient because it can be done from anywhere and more frequently than in-person visits.

The changes triggered by the CARES Act were intended to last only until the public health emergency was considered over. Making telehealth coverage expansions permanent could lead people to use their insurance coverage more often by making care more convenient, thus costing private insurance companies more money.

Provider compensation is traditionally based on the amount of time spent with the patient and how complicated and risky the exam and procedures are to perform. Historically, telehealth was reimbursed at a lower rate than in-person care. The CARES Act had addressed this payment disparity by mandating the same rate for telehealth visits as in-person visits for those insured by Medicare, with more than 80 new telehealth services being reimbursed at the same rate as in-person services.

Many private insurers followed suit and paid providers who conducted telehealth visits at the same rate as office visits. Now, that’s all changing due to financial loss by insurance companies. As of Oct. 1, telehealth visits are not always paid at the same rate as in-person visits by these private insurers.

Several big private insurers are pulling back some of their coverage of telehealth for non-COVID issues. Companies including UnitedHealthcare have already rolled back policies that waived co-pays and other fees for non-COVID-related appointments. Other plans such as Anthem BlueCross BlueShield have extended their coverage through the end of the year, but only the first two sessions are free for the consumer.

Further complicating matters is that every private insurance plan and many state-funded Medicaid plans have different sets of rules and dates for what telehealth treatments they cover. This means some patients are paying more. Costs are getting confusing. Patients may end up with a surprise bill – or they may delay care due to cost.

A system under pressure

Health care providers and hospital systems are also in limbo. They don’t know whether they’ll lose telehealth payments when the federal public health emergency for the pandemic lapses or what to expect from private health insurance companies.

Hospitals and health systems have had to meet unprecedented challenges in 2020 – increasing testing, treating infected patients, expanding intensive care unit capacity, safeguarding staff and non-COVID-19 patients, procuring personal protective equipment and canceling nonemergency procedures. These challenges have created historic financial pressures for health care offices and hospitals. The American Hospital Association estimates that the country’s health care systems are losing an average of US$50.7 billion per month.

This financial crisis puts telehealth in jeopardy. Providers and health systems still have to pay salaries and purchase expensive technological equipment, making it difficult to accept a reduced rate for telehealth visits. Without payment parity, in the current financial crisis, health care systems will not be able to continue to offer telehealth services.

What’s next

A continued increase in COVID-19 cases is expected this fall, just as insurance providers are starting to diminish coverage for telehealth visits.

Our team – and teams across every state – will undertake a rigorous evaluation of each of the CARES Act policy changes (and similar Medicaid and private insurer changes) and their impact. These evaluations will provide information on how telehealth affects the cost and cost effectiveness in the future.

Clearly, telehealth is in jeopardy now as patients are paying more, health care practices are receiving less, and the risk of infections increases. While the diminished risk of infection through the use of telehealth seems positive, it is clear to us that insurers are trying to drive patients back to the in-person care model. How will vulnerable populations and the fragile health care system respond? Will patients and providers still have a choice in how they receive and provide care, or will we lose the innovation gained during this period?

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About the authors: 
Jennifer A. Mallow is Associate Professor of Nursing, West Virginia University. Steve Davis is Associate Professor of Health Policy, Management, and Leadership, West Virginia University

Health insurers are starting to roll back coverage for telehealth

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Since 2010, depression, self-harm and suicide rates have increased among teen boys. But rates of major depression among teen girls in the U.S. increased even more – from 12% in 2011 to 20% in 2017. In 2015, three times as many 10- to 14-year-old girls were admitted to the emergency room after deliberately harming themselves than in 2010. Meanwhile, the suicide rate for adolescent girls has doubled since 2007.

Rates of depression started to tick up just as smartphones became popular, so digital media could be playing a role. The generation of teens born after 1995 – known as iGen or Gen Z – were the first to spend their entire adolescence in the age of the smartphone. They’re also the first group of teens to experience social media as an indispensable part of social life.

Of course, both boys and girls started using smartphones around the same time. So why are girls experiencing more mental health issues?

Mining three surveys of more than 200,000 teens in the U.S. and U.K., my colleagues and I were able to find some answers.

The screens we use

We found that teen boys and girls spend their digital media time in different ways: Boys spend more time gaming, while girls spend more time on their smartphones, texting and using social media.

Gaming involves different forms of communication. Gamers often interact with each other in real-time, talking to each other via their headsets.

In contrast, social media often involves messaging via images or text. Yet even something as simple as a brief pause before receiving a response can elicit anxiety.

Then, of course, there’s the way social media creates a hierarchy, with the number of likes and followers wielding social power. Images are curated, personas cultivated, texts crafted, deleted and rewritten. All of this can be stressful, and one study found that simply comparing yourself with others on social media made you more likely to be depressed.

And, unlike many gaming systems, smartphones are portable. They can interfere with face-to-face social interaction or be brought into bed, two actions that have been found to undermine mental health and sleep.

Are girls more susceptible than boys?

It’s not just that girls and boys spend their digital media time on different activities. It may also be that social media use has a stronger effect on girls than boys.

Previous research revealed that teens who spend more time on digital media are more likely to be depressed and unhappy. In our new paper, we found that this link was stronger for girls than for boys.

Both girls and boys experience an increase in unhappiness the more time they spend on their devices. But for girls, that increase is larger.

Only 15% of girls who spent about 30 minutes a day on social media were unhappy, but 26% of girls who spent six hours a day or more on social media reported being unhappy. For boys, the difference in unhappiness was less noticeable: 11% of those who spent 30 minutes a day on social media said they were unhappy, which ticked up to 18% for those who spent six-plus hours per day doing the same.

Why might girls be more prone to unhappiness when using social media?

Popularity and positive social interactions tend to have a more pronounced effect on teen girls’ happiness than boys’ happiness. Social media can be both a cold arbiter of popularity and a platform for bullying, shaming, and disputes.

In addition, girls continue to face more pressure about their appearance, which could be exacerbated by social media. For these reasons and more, social media is a more fraught experience for girls than for boys.

From this data on digital media use and unhappiness, we can’t tell which causes which, although several experiments suggest that digital media use does cause unhappiness.

If so, digital media use – especially social media – might have a more negative effect on girls’ mental health than on boys’.

Looking ahead
What can we do?

First, parents can help children and teens postpone their entry into social media.

It’s actually the law that children can’t have a social media account in their own name until they are 13. This law is rarely enforced, but parents can insist that their children stay off social media until they are 13.

Among older teens, the situation is more complex, because social media use is so pervasive.

Still, groups of friends can talk about these challenges. Many are probably aware, on some level, that social media can make them feel anxious or sad. They might agree to call each other more, take breaks or let others know that they’re not always going to respond instantly – and that this doesn’t mean they are angry or upset.

We’re learning more about the ways social media has been designed to be addictive, with companies making more money the more time users spend on their platforms.

That profit may be at the expense of teen mental health – especially that of girls.

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Jean Twenge is Professor of Psychology, San Diego State University. Jean Twenge has received speaking honoraria from for-profit and non-profit entities for presenting research.

Why Teen Depression Rates Are Rising Faster for Girls than Boys

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Though there are notable differences in health research findings on tobacco and marijuana, the juxtaposition strikes some as jarring after generations of Americans have gotten the message that smoking endangers their health.

“We’re trying to stop people from smoking all kinds of things. Why do you want to legalize marijuana?” a New York City councilman, Republican Peter Koo, asked at a recent city hearing about the state’s potential legalization of so-called recreational pot use.

Marijuana advocates say there’s no comparison between joints and tobacco cigarettes. A sweeping federal assessment of marijuana research found the lung-health risks of smoking weed appear “relatively small” and “far lower than those of smoking tobacco,” the top cause of preventable death in the U.S.

Unlike for cigarettes, there’s evidence of certain health benefits from marijuana, such as easing chronic pain. And marijuana can be used without smoking it. Most states now have legal medical pot programs; 10 states and the District of Columbia have approved recreational use.

“They’re different products, and they need to be treated differently,” says Mason Tvert, a spokesman for the pro-legalization Marijuana Policy Project.

At the same time, studies have shown crossover between marijuana and tobacco use. And while smoking cannabis may be less dangerous than tobacco to lung health, pot doesn’t get an entirely clean slate.

Some health officials and anti-smoking activists also worry about inserting legal marijuana into the growing world of vaping, given uncertainties about the smoking alternative’s long-term effects.

Here’s a look at the issues, science and perspectives:

Smoking pot vs. tobacco

While cigarette smoking is the top risk factor for lung cancer, some of scientific evidence suggests there’s no link between marijuana smoking and lung cancer. That’s according to a 2017 federal report that rounded up nearly two decades of studies on marijuana, research that’s been limited by the federal government’s classification of marijuana as a controlled substance like heroin.

While cigarette smoking is a major cause of heart disease, the report concluded it’s unclear whether marijuana use is associated with heart attacks or strokes.

But there’s strong evidence linking long-term cannabis smoking to worse coughs and more frequent bouts of chronic bronchitis, according to the report from the National Academies of Sciences, Engineering and Medicine.

The report also looked at other effects, finding a mix of possible risks, upsides and unknowns. For example, the report said marijuana can ease chemotherapy-related nausea and adults’ chronic pain but also found evidence the drug is linked to developing schizophrenia and getting in traffic crashes.

In recent weeks, studies have echoed concerns about high-potency pot and psychosis and documented a rise in marijuana-related emergency room visits after legalization in Colorado.

Tobacco and marijuana use can also go together. Blunts — marijuana in a cigar wrapper that includes tobacco leaves — have gained popularity. And studies have found more cigarette smokers have used pot, and the other way around, compared to nonsmokers.

“One substance reinforces the use of the other, and vice versa, which can escalate a path to addiction,” says Dr. Sterling McPherson, a Washington State University medical professor studying marijuana and tobacco use among teens.

The National Academies report found pot use likely increases the risk of dependence on other substances, including tobacco.

To some public health officials, it makes sense to legalize marijuana and put some guardrails around it.

“For tobacco, we know that it’s inherently dangerous and that there is no safe amount of tobacco to use,” says the New York City Health Department’s acting director of tobacco policy, Dr. Achala Talati. Whereas with marijuana, her colleague Rebecca Giglio added, “we see this as an opportunity to address the harms of criminalization while also regulating cannabis.”

But health department opinions vary, even within the same state: New York’s Association of County Health Officials opposes legalizing recreational weed.

So, what about vaping?

Vaping — heating a solution into a vapor and inhaling it — has been pitched as a safer alternative to smoking.

Experts have said vaping pot is probably less harmful to the lungs than smoking it, though there’s little research on the health effects over time, and they worry about its potency when vaped.

The American Lung Association is concerned that vaping will ultimately prove damaging to lung health and is alarmed about a surge in underage e-cigarette use. And adding legal marijuana to the picture “only makes it a more complicated issue,” says Erika Sward, an assistant vice president.

Others, though, think policymakers should view vaping as a relatively safe way to use pot.

“I would say the risks are going to be less with that form of consumption,” says Rebecca Haffajee, a University of Michigan health policy professor who co-wrote a 2017 piece calling for recreational marijuana programs to allow only nonsmokable forms of the drug.

Meanwhile, some local governments have adjusted public smoking bans to cover both vaping and pot. The Los Angeles County Board of Supervisors tweaked its prohibition just last month.

Two views

As a former cigarette smoker, New Yorker Gary Smith is dismayed that his home state might OK smoking pot.

He knows research hasn’t tied smoking marijuana to lung cancer, which killed three cigarette smokers in his family and struck him 20 years after he quit; he’s been treated. But he fears the respiratory risks of marijuana smoking aren’t fully known.

“It’s crazy that the government, in order to raise (revenue from) taxes, they’re permitting people to suck this stuff into your lungs,” says Smith, 78, an accountant from Island Park.

Hawaii physician and state Rep. Richard Creagan feels no less strongly about cigarettes. The ex-smoker and Democrat from Naalehu this year unsuccessfully proposed all but banning them by raising the legal age to 100.

Meanwhile, he’d like Hawaii to legalize recreational marijuana, an idea that fizzled in the state Legislature this year.

Creagan, 73, thinks pot benefits people’s well-being more than it risks their health, and he expects non-smoking alternatives will reduce the risks. Plus, he figures legal marijuana could replace cigarette tax revenue someday.

“That coupling,” he says, “was sort of in my head.”

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Smoking Pot vs. Tobacco: What Science Says

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The U.S. Food and Drug Administration held a public hearing May 31 to gather more information on the science, manufacturing and sale of cannabis compounds like CBD. But in the meantime, it has issued more warning letters to companies for making unapproved health claims about CBD products.

Products containing CBD are already in stores and sold online, so it’s easy to believe there must be something special about the ingredient. But the claims are largely unproven and quality control standards don’t exist.

A look at what we know as U.S. regulators work out what will and won’t be allowed:

What is CBD?

CBD is one of more than 100 compounds found in marijuana. It’s extracted using alcohol or carbon dioxide in factories. It’s added to oils, mixed into creams and lotions and sold in candies and liquid drops.

Widely sold online, CBD now is going mainstream with major retailers offering salves and balms for the skin. Prices range from $12 to $150 an ounce at high-end shops.

CBD often comes from a cannabis plant known as hemp, which is defined by the U.S. government as having less than 0.3% THC. That’s important because THC is what causes marijuana’s mind-altering effect.

CBD doesn’t get people high, although it may be calming. Keep in mind some CBD products may contain THC, whether or not the label says so.

People drug tested for work, addiction programs or because they take prescription opioids should take note: CBD products have caused people to fail urine drug screens.

Is it a miracle cure?

If you believe the hype, CBD treats pain, relieves anxiety and both helps you sleep and keeps you focused.

Most claims are based on studies in rats, mice or in test tubes. Some human research has been done, but in small numbers of people.

One exception: For two rare seizure disorders, the evidence for CBD was strong enough to convince the FDA to approve GW Pharmaceutical’s drug Epidiolex, which contains a purified form.

The FDA announced Tuesday it has sent warning letters to three companies marketing products with what outgoing Commissioner Scott Gottlieb called “egregious, over-the-line claims” for CBD’s effects on cancer, Alzheimer’s disease, fibromyalgia and drug addiction. Among the cited examples: “CBD successfully stopped cancer cells” in cervical cancer.

Gottlieb said the agency “won’t tolerate this kind of deceptive marketing to vulnerable patients.”

Advanced Spine and Pain LLC of Mount Laurel, New Jersey (doing business as Relievus); Nutra Pure LLC of Vancouver, Washington; and PotNetwork Holdings Inc. of Fort Lauderdale, Florida, did not immediately return calls and emails seeking comment on the warning letters.

Only drugs that have been reviewed by the FDA as safe and effective can make claims that they treat or prevent diseases or medical conditions. Many CBD producers attempt to sidestep the issue by using only vague language about general health and well-being.

Any side effects?

Scant research means not much is known about side effects either. In epilepsy research, CBD changed the way the body processed other drugs. That suggests CBD could interact with medications in ways we still don’t know about.

The most common side effects of the CBD drug Epidiolex include sleepiness, decreased appetite, diarrhea, increases in liver enzymes, exhaustion, rash and infections. FDA’s Gottlieb noted Tuesday the potential for liver injury and other risks can be handled with medical supervision but less is known about how that would be managed without oversight. And there are questions about overlap if multiple CBD products are used.

Is it legal?

For now, the agency has said CBD is not allowed as an ingredient in food, drinks or dietary supplements.

In stating its position, the FDA cited a provision of the law prohibiting food makers from using active drug ingredients or those that are the subject of substantial research. But the agency doesn’t have the resources to police all the CBD products that are already available, said Marc Scheineson, a former FDA official.

“They’re not going to pull a thousand products from the market,” he said.

The FDA’s authority is over interstate commerce, and local officials have taken differing approaches. In New York, Los Angeles and elsewhere, officials are warning eateries to stop selling it in food and drinks. Maine passed a law allowing it in foods and other products in the state.

Skin creams and cosmetics may be on safer footing with the FDA, but that too remains uncertain, said Camille Gourdet of RTI International, a nonprofit research institute in Durham, North Carolina. Though cosmetics aren’t subject to premarket approval by the FDA, they could run afoul of regulations if they make specific health claims.

Marijuana itself is illegal under federal law; most states that have legalized it allow marijuana-infused foods and candies, called edibles.

Are CBD labels accurate?

What you buy may contain much less CBD than the label states — or much more. It may include more THC than you want and it may be contaminated with mold or pesticides. Ask to see testing reports.

A 2017 study in the Journal of the American Medical Association found 70% of CBD products were mislabeled. Researchers used an independent lab to test 84 products from 31 companies.

“You’re really flying by the seat of your pants when you buy this stuff,” said author Marcel Bonn-Miller of University of Pennsylvania.

A product labeled as containing 100 milligrams of CBD may only have 5 milligrams or it may have 200, said Bonn-Miller, now an adviser for a company that sells CBD and other cannabis products. He did not work in the industry when he did the research.

“I wouldn’t trust any of it until I knew independently it was safe,” Bonn-Miller said.

What is ahead?

CBD research is planned or underway for cancer, autism, diabetic neuropathy, fibromyalgia, chronic pain, alcoholism with PTSD and psychiatric conditions. Results will take years, but some people aren’t waiting.

“They are vulnerable and really hoping to feel better,” said Karen Hande, a nurse practitioner at Vanderbilt-Ingram Cancer Center in Nashville.

She became an expert in CBD because so many of her cancer patients were trying it. She tells them the evidence isn’t enough to back the claims, but “they want to believe something is going to work.”

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CBD Showing up Everywhere, but Does it Work?

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