Category: 8. Health

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Early-life access to social and financial resources may influence how the brain approaches risk in adulthood, according to new research from the College of Human Ecology at Cornell University. The findings, published in Cerebral Cortex, suggest that while people from different backgrounds might take similar risks, the neural mechanisms behind those decisions vary.

The study examined how individuals who were raised in socially rich but financially limited environments compared with those raised in financially rich but socially limited environments approached risky decision-making tasks. The authors describe these differing upbringings as forms of “developmental resource asymmetry”.

Shared behaviours, distinct brain responses

The research team, led by postdoctoral researcher Minwoo Lee and supported by Marlen Z Gonzalez, assistant professor of psychology, recruited 43 undergraduate students at Cornell University. Participants were asked to play a computerized game that involved inflating virtual balloons for financial gain. Each additional pump increased both the reward and the chance the balloon would pop, resulting in the loss of earnings.

Participants were scanned using functional magnetic resonance imaging (fMRI) while playing. They also completed surveys assessing their current and past access to financial and social resources, including their parents’ income, neighbourhood quality during childhood and present levels of support from friends and family.

While the socially rich and economically rich groups did not differ in how often they took risks, their brain activity did. A region called the supramarginal gyrus showed higher activation in participants who were more cautious, pointing to a possible neural mechanism that helps to regulate impulsive actions.

“Distinct early-life environments may offer you different types of resources, and different strategies, to solve common problems in life. This, over time, may shape the specific cognitive mechanisms or contextual factors people rely on to solve similar problems as adults.”

Dr. Minwoo Lee.

Socially rich individuals rely on different networks

Within the socially rich group, risk-taking was linked to greater activation in brain areas responsible for visual and attentional processing. Interestingly, the extent of this brain activity was influenced by the level of social support available to participants at the time of the study. Those with higher current social support exhibited less additional neural activity and earned more money in the task, suggesting they needed to engage fewer cognitive resources to perform well.

These results imply that even when behavioural outcomes are the same, the cognitive strategies and neural pathways used to achieve them can differ depending on early-life resource environments. The researchers propose that people may develop unique ways of managing uncertainty based on the specific resources they grew up with.

Implications for educational and policy support

Understanding how early-life environments shape adult decision-making could help tailor interventions for students and others facing socioeconomic challenges. For example, students who grew up with strong social networks but limited finances may benefit from policies that enhance social integration in academic settings.

The authors note that using a student-only sample, while limited in demographic diversity, offered the advantage of studying individuals with varied backgrounds within a shared environment.

Reference: Lee M, Gonzalez MZ. Asymmetric access to social vs. economic resources during development calibrates socio-cognitive pathways to risk-taking in emerging adults. Cerebral Cortex. 2025;35(7):bhaf169. doi: 10.1093/cercor/bhaf169

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Fast food like cheeseburgers, fried chicken, and pizza shouldn’t be sold in hospitals, say most Americans in a new Physicians Committee for Responsible Medicine/Morning Consult poll. The poll comes as a new report from the Physicians Committee-a health advocacy nonprofit with 17,000 doctor members-finds that Chick-fil-A is located in at least 20 U.S. hospitals or medical centers.

When asked, “Do you believe fast food-such as fried chicken, cheeseburgers, or pizza-should be sold in hospitals to patients, visitors, and staff?” 52% of respondents said “no,” and 57% said that hospitals should not profit from fast food sold on their premises. Most respondents, 85%, agreed that these foods do not promote good health. The poll was conducted July 1 to 3, 2025, among 2,202 U.S. adults.

A new report from the Physicians Committee finds that Chick-fil-A is located in at least 20 U.S. hospitals or medical centers, according to the fast-food restaurant’s website.

“While many people consider chicken to be a healthier option than red meat, consuming chicken can increase cholesterol just as much as eating red meat,” says Anna Herby, DHSc, RD, CDCES, who is the nutrition education specialist for the Physicians Committee for Responsible Medicine and oversees the organization’s Healthy Hospital Program. “Hospital staff, visitors, and patients would benefit by choosing more chickpeas and other plant-based foods instead of chicken.”

Consuming chicken has been linked to higher cancer risk, and consuming fried chicken is linked to higher risk of heart disease. Earlier this year, a study found that eating 300 grams of poultry-about the size of a large chicken breast-per week was linked to an increased risk of gastrointestinal cancer and death from all causes. A study published in BMJ found that women who ate fried chicken once or more per day had a 13% higher risk of death from any cause compared with women who did not eat any fried food and a 12% increased risk of death from heart disease.

In 2017, the American Medical Association adopted a resolution calling on hospitals to provide plant-based meals and remove processed meats, such as chicken nuggets, from menus.

Hospitals should set an example by ensuring that their restaurants serve more menu items that are cholesterol-free, low in saturated fat, and high in fiber-rich vegetables, grains, beans, and fruit. Meals like these have been shown to help prevent or improve the chronic diseases that bring people to the hospital.”

Dr. Anna Herby, DHSc, RD, CDCES, nutrition education specialist, Physicians Committee for Responsible Medicine

The Physicians Committee’s Healthy Hospital Program offers free resources to support institutions that want to make more plant-based options available to patients. With plant-based menu items, inpatient education tools, and printable recipes, patients will be empowered to take control of their health during their hospital stay and beyond.

Health coaching could be an effective patient education method for the management of chronic diseases such as multiple sclerosis (MS). According to a recently published study, findings revealed that health coaching was particularly effective in changing the lifestyle behavior of patients with chronic diseases and in improving their self-efficacy, physical as well as mental health status. These results suggested that health coaching may help clinicians engage patients in behavior change and enhance adherence to self-care routines outside the clinical setting.¹

In another study, findings showed that health and wellness coaching was effective on short-term outcomes of self-efficacy, depression, and quality of life among patients living with chronic illness.² Notably, the prior study reported that health and wellness coaching did not have an impact on patient anxiety at any time point and did not find evidence of long-term benefit. The previous study suggested that it may be useful to investigate the long-term impact of health and wellness coaching on patients with chronic diseases, observing whether the effects persist over a longer period of time or if booster interventions may be required.

Leading expert Cassandra Moore, MPH, CPH, presented on the integration of health and wellness coaching into MS care at the 2025 Consortium of Multiple Sclerosis Centers (CMSC) Annual Meeting, held May 28-31, 2025, in Phoenix, Arizona.³ Following the presentation, Moore, associate vice president of strategy and innovation at the National MS Society, spoke with NeurologyLive^® to further discuss how coaching can improve self-efficacy, physical and mental health, and quality of life in patients with MS. In the conversation, she emphasized that mindset may one of the key determinants for coaching success and explained how coaches can complement multidisciplinary teams in patients’ aspects of their care plans.

NeurologyLive: How have you seen health coaching influence clinical outcomes on patient adherence in MS care?

Cassandra Moore, MPH, CPH: There is a growing body of published research that provides evidence for the positive clinical benefits of health and wellness coaching. I referenced an article during my presentation titled The Impact of Health and Wellness Coaching on Patient-Important Outcomes and Chronic Illness Care: A Systematic Review and Meta-Analysis. This was published in 2023 and analyzed 30 studies published in the last 18 years that compared health and wellness coaching to standard clinical care or another intervention without coaching. They found that health and wellness coaching improved short-term self-efficacy, quality of life, and depression for patients with chronic conditions.

Another study titled The Effects of Health Coaching on Adult Patients With Chronic Diseases: A Systematic Review analyzed 13 studies published from 2009 to 2013, focusing on health coaching for adults with chronic diseases by health care professionals. They found statistically significant results for better weight management, increased physical activity, and improved physical and mental health status.

We implemented 2 cohorts of health and wellness coaching, and in our coaching program, we saw improved physical health for both cohorts and an improvement in mental health for the second cohort. We also saw an increase in self-efficacy for both cohorts. In addition to these more tangible outcomes, feedback that we have received suggests that coaching has had a profound result. One of our coaching participants said that she was on the verge of getting on medication for depression when she started coaching, and then after going through it, she had a completely different mindset. She’s no longer experiencing depression, and she’s feeling happy about the outlook of her life and health.

In what ways can health coaching be integrated into the multidisciplinary MS care teams and what role does it play initially in the treatment plan?

I think a lot of the coaches that we’ve worked with would love to be a part of the treatment team, and many of them consider themselves a part of the team as well. Coaching and the coach-coachee relationship is different from other relationships. For our program in particular, you spend on average 45 minutes talking with someone each week—you’re going to build a relationship with them. There might be a different layer of depth that comes from time spent together and sharing so many different aspects of your life that you may not get from, say, your neurologist.

I think an ultimate goal is holistic care, and sometimes there is a gap or hole in care teams. Whereas providers usually have one area of focus, coaches can really help patients incorporate and coordinate all aspects of their treatment plan. A patient might discuss their disease-modifying treatment with their neurologist, their mobility with their physical therapist, and their mental state with their psychotherapist. Then a coach can partner with patients and guide them in figuring out how to pull it all together, making goals informed by their treatment plan and discussing progress and setbacks thoughtfully. Health and wellness coaches really support people to achieve their self-directed goals and behavioral changes that are informed by any treatment plans prescribed by the rest of the professional health care team.

What patient characteristics or clinical scenarios could make someone a strong candidate for health coaching in their MS journey?

I don’t really think that there is a specific clinical scenario that would make someone a strong candidate for health coaching. A lot of it is readiness and mindset. In our coaching program, we worked with people who were newly diagnosed—defined as being diagnosed in the past 3 years—and most of those people agreed that it was a really good time for them to engage in coaching. For a lot of them, their lives had recently changed. They had a lot of questions, maybe were feeling uncertainty, so it was nice they had a coach to navigate their new normal.

Alternatively, one of our participants, who was very newly diagnosed, said that although she really enjoyed the program, her diagnosis was still so fresh, and she was still grieving, really—and she probably would have benefited more if she had gone through coaching a year later or so. I also spoke with a participant who shared that he thought coaching was the right time for him, but he was also chatting with his mentor about coaching. She was diagnosed over 20 years ago, and she said that she had been living in a stagnant state, and maybe coaching could be beneficial for her as well to get her moving and setting goals.

We had a pretty diverse demographic pool. We had people who weren’t experiencing disability at all and people who had experienced disability in life-changing ways, some people with progressive MS and some who had been diagnosed with relapsing-remitting. We had a range of races and ethnicities, people from all over the country, and even someone living outside of the country in one of our cohorts. We worked with both men and women, ages ranging from their 20s to late 60s.

We did have to do some general education at the start of the program around what exactly coaching is and what some of the benefits are. But primarily, I just think that people have to be in the place where they’re ready to maybe talk, or ready to make some changes, or ready to embrace health and wellness coaching. I think the mindset is the most important piece.

There are some profound barriers to health and wellness coaching, but I do think it is very beneficial, as we’ve seen in both of our cohorts. Encouraging everyone—if you are in a state of readiness—to maybe seek a health coach, maybe talk to one of your other providers about it, and really explore it more.

Transcript edited for clarity. Click here for more coverage of CMSC 2025.

REFERENCES
1. Boehmer KR, Álvarez-Villalobos NA, Barakat S, et al. The impact of health and wellness coaching on patient-important outcomes in chronic illness care: A systematic review and meta-analysis. Patient Educ Couns. 2023;117:107975. doi:10.1016/j.pec.2023.107975
2. Kivelä K, Elo S, Kyngäs H, Kääriäinen M. The effects of health coaching on adult patients with chronic diseases: a systematic review. Patient Educ Couns. 2014;97(2):147-157. doi:10.1016/j.pec.2014.07.026
3. Moore C. The Power of Health Coaching. Presented at: 2025 CMSC Annual Meeting; May 28-31; Phoenix, AZ. Thriving with MS: Harnessing Wellness Research & the Power of Health Coaching.

[KIGALI, SciDev.Net] After years of progress in reducing malaria cases, Rwanda is confronting a surprising resurgence and signs of treatment resistance that have forced officials to revisit vaccine intervention the country once declined.

Rwanda had recorded steady declines in malaria infections for nearly a decade, with cases falling from nearly five million in 2016, to just 430,000 in 2023 — about a 90 per cent reduction — according to figures from the Rwanda Biomedical Centre (RBC).

But these gains are now under threat, says Aimable Mbituyumuremyi, division manager for malaria and other parasitic diseases at the RBC, Rwanda’s health implementation agency.

In 2024, malaria cases rose by more than 45 per cent in one year, reaching 620,000.

Rwanda had previously opted out of receiving malaria vaccines during the first phase of distribution by the World Health Organization (WHO) and GAVI in 2023, confident in its consistent progress in reducing malaria over the last decade.

“But now, we’re experiencing a surge in the disease,” Mbituyumuremyi said in an interview with SciDev.Net.

“We’re considering using vaccines since all other measures have yet to work and malaria cases are increasing.”

The rise in cases began unexpectedly in January 2024, a time when malaria incidence usually declines, according to Mbituyumuremyi.

“It’s the first time we have experienced an increase in malaria cases in Rwanda since 2016,” he said.

“We’re alarmed that it’s not just a slight increment, but a significant one.”

According to Mbituyumuremyi, the number of annual deaths fell from 650 in 2016 to 67 in 2023, and more than two dozen districts entered the malaria pre-elimination phase.

He said between January and October 2024, the country recorded 620,000 malaria cases, an increase of nearly 200,000 compared to the same period in 2023.

October alone accounted for 112,000 of those cases, with almost 90 per cent of them (about 100,000) concentrated in just 15 of Rwanda’s 30 districts.

“At this time, we never expected such a burden because we were in the pre-elimination phase,” Mbituyumuremyi explained.

“We anticipated a progressive decrease, not even a slight increase.”

So far 17 African countries have rolled out the malaria vaccine with support from the World Health Organization and Gavi, the Vaccine Alliance.

“Now, we would like that consideration to be extended to us as well,” Mbituyumuremyi  added, referring to the distribution of vaccines.

Rwanda’s malaria resurgence comes despite investments in most malaria-prone districts.

Mbituyumuremyi tells SciDev.Net that Rwanda has invested heavily in existing control strategies, such as indoor residual spraying and mosquito net distribution.

He says the country has spent more than US$1.5 million per district on indoor spraying in a dozen districts.

Drug resistance

The RBC says several factors have contributed to the new surge in cases. These include growing mosquito resistance to drugs, shifting mosquito behaviour, and environmental changes that increase breeding sites.

Preliminary data shown to SciDev.Net by the RBC indicates that the effectiveness of the artemisinin drug is diminishing due to resistance.

Additionally, Mbituyumuremyi says mosquitoes are increasingly biting outdoors rather than indoors, raising the risk for people spending time outside at night.

Mbituyumuremyi also expressed concerns over the possible spread of the disease between countries.

“Preliminary investigations indicate that nearly all the most affected sectors are in the cross-border communities of Nyagatare, Gisagara, and Bugesera,” he said.

To combat drug resistance, Rwanda has started using alternative treatments.

“Since the end of last year, we have been receiving new anti-malaria drugs. While Coartem is being used less frequently, it has not been completely phased out. We are implementing a multiple first-line treatment strategy,” he explained.

Despite the setback, Rwanda still aims to be malaria-free by 2030.

Health officials are re-evaluating the country’s strategy, including the possible adoption of vaccines as part of a broader response.

This piece was produced by SciDev.Net’s Sub-Saharan Africa English desk.

Here’s some shocking truth: The science showing how poisonous the chemicals in our consumer products are is as strong as the science that led the government to ban lead from gasoline and place warnings about cancer on cigarette packs. Study after study from top-tier journals showcases how phthalates and BPA (both of which are found in cosmetics and personal care products, plus toys and food packaging) disrupt the normal functioning of hormone systems and are linked to cancer, asthma, birth defects, immune system damage, and infertility.

It’s overwhelming to think about how these toxic chemicals plague our lives. But that doesn’t mean we can’t do something about it. Wherever you are in your clean living journey is the perfect starting point. Even I started as a skeptic, so you don’t have to get into full-on activist mode (though I would love that).

None of these suggestions provide a full solution, but I encourage you to pick something to commit to doing regularly. Let’s aim for progress, not perfection. We are all worth the effort. Here are manageable ways to safely shop the market and suss out the greenwashers.

Buy half of what you typically consume.

This is the best and highest-impact way you can help reduce the demand for and use of toxic chemicals. It’s also the simplest. We (including myself) buy too much shit, and every product has impacts on human and planetary health. With the commodification of wellness and health, even of sustainability, we all need to reassess our consumption instead of buying into (literally) the idea that we need every product the market introduces to us.

Buy secondhand.

Repair products (like we used to). Maybe skip an iPhone model or two or three before you purchase your next one. And before you pop that next item into your cart, ask yourself: Do I really need this? If not, what’s the environmental impact if I click “purchase”?

Shop brands and retailers leading the way.

The Mind the Store campaign, created by the grassroots advocacy organization Toxic Free Future, ranks retailers annually based on the strength of their policies to remove toxic chemicals from their shelves. Although a top ranking doesn’t ensure that all of a retailer’s products are toxin-free, you’re voting with your dollar to support those retailers who are stepping up and taking this issue seriously. (Some of the top retailers from 2024 are Apple, Walmart, and Sephora.) Visit retailerreportcard.org for the full list. You can also shop some of my brand and product recommendations by following the frequently updated list at heyhilde.com.

Look for specific certifications.

These certifications—while imperfect—are the strongest for assessing ingredient safety and contaminants: EWG VERIFIED for beauty and personal care products (there is also an app version); MADE SAFE for other product categories like children’s toys and cleaners; EPA Safer Choice for cleaners and other household products; Clean Label Project, which tests supplements and protein powder for over two hundred common contaminants; Cradle to Cradle Certified Gold Material Health (for furniture and building materials); and GreenScreen Certified (for various product categories)

If a brand says its products are “clean” or “sustainable” or uses related marketing language, see if it defines these terms.

One of the best confirmations that a brand is legit is the presence of a dedicated page on its site that defines terms like “clean,” “sustainable,” etc., in detail. Any clean standard should go beyond retailer certifications and include explicit language about how they screen ingredients for safety, as well as details about testing programs (many “clean” brands are not actively screening their own ingredients or testing for things like heavy metals). If the brand sets public goals (such as reducing plastic or working toward climate goals around carbon reduction), it should also have details on how it’s going to hit those goals and transparently track progress. Anything short of sharing these important details is greenwashing.

Be wary of apps that claim to screen products.

Clearya and EWG Skin Deep are the two strongest, science-based apps that assess product and chemical safety. Some others, like Yuka and Think Dirty, are well-intentioned but fail to give you complete and accurate safety ratings. Although most of the consumer apps that cover a variety of product categories (with a heavy emphasis on beauty) were developed by individuals aiming to offer real guidance, their developers have limited, if any, experience in the science of environmental health, product formulation, or accurate assessment of risk.

I’ll give you an example: Yuka and Think Dirty give a “poor” ranking to any product that includes the preservative phenoxyethanol (a compound that EU regulations show can be safely used at concentrations under 1 percent, which is how most brands use it). Most personal care products need a preservative to prevent the growth of mold, yeast, and bacteria to protect the integrity of the formula while also protecting your health. But a few misguided studies about phenoxyethanol that were neither conducted scientifically nor applicable to its use in beauty products have stirred up the internet and led Yuka and Think Dirty to inappropriately ding products that contain the chemical.

Know what to prioritize.

Focus on products that are larger sources of exposure to the most toxic chemicals, items such as couches, mattresses, and cookware. If your budget can cover only some clean beauty products, prioritize the ones that stay on your skin all day (lotion, makeup) and worry less about those that rinse off, such as shampoo and conditioner. And know that safer does not always mean expensive; good old-fashioned white distilled vinegar (acidic, antimicrobial) is an effective way to clean your countertops, floors, and toilets. Perfection and total control are illusions—and it’s better to do something than nothing at all.

Cleaning House: The Fight to Rid Our Homes of Toxic Chemicals by Lindsay Dahl

Adapted from the book Cleaning House: The Fight to Rid Our Homes of Toxic Chemicals by Lindsay Dahl. Copyright © 2025 by Lindsay Dahl. Reprinted by permission of Dey Street Books, an imprint of HarperCollins Publishers.

Scientists have implemented a novel gene-editing approach that may be an effective treatment for alternating hemiplegia of childhood (AHC), a rare neurodevelopmental disorder in children, according to a recent study published in Cell.  

The approach, which uses gene-editing technology based on CRISPR, could serve as a one-time treatment option to target the underlying genetic mechanisms of the disease, said Alfred L. George, Jr., MD, the chair and Alfred Newton Richards Professor of Pharmacology and a co-author of the study. 

“Current treatments for AHC just manage the symptoms of the disease and do not modify the underlying cause. Gene editing corrects the root cause, so there’s a higher likelihood that these therapies will be disease-modifying,” said George, who is also director of the Center for Pharmacogenomics.  

AHC typically presents within the first 18 months of life and can cause recurrent bouts of temporary paralysis on one (hemiplegia) or both (quadriplegia) sides of the body, painful and involuntary muscle contractions (dystonia), muscle weakness and seizures. The disease affects one in one million individuals, according to estimates from the AHC Foundation, and children who have the disease require lifelong care.  

Most AHC cases are associated with genetic mutations in the ATP1A3 gene, which encodes a sodium-potassium pump that helps maintain the electrical charge of neurons so they can properly fire and function.   

In the study, the investigators used two novel gene-editing approaches — base editing and prime editing — to correct ATP1A3 mutations in human induced pluripotent stem cells (iPSC) from AHC patients in the George laboratory and two AHC mouse models at the Jackson Laboratory.  

The approaches, which were developed by David Liu, PhD, the Thomas Dudley Cabot Professor of the Natural Sciences at Harvard University and senior author of the study, are similar yet have differences in their versatility.  

Base editing uses the same gene targeting strategy employed by CRISPR, except the DNA cleaving function of the core enzyme (Cas9) is disabled while a second tethered enzyme converts one nucleotide base, or building block of a DNA strand (e.g., adenine) to another (e.g., guanine).  

“Adenine base editing specifically works by correcting mutations in which a guanine is mutated into adenine. It operates essentially by enzymatic conversion of adenine back to guanine. The CRISPR technology enables highly specific targeting using a short synthetic ‘guide’ RNA that directs the protein complex to a very specific site in the genomic DNA of a cell,” George said.  

Prime editing also uses CRISPR to target a specific genomic location, but instead of using an enzyme that chemically modifies one base into another, it brings along an enzyme that rewrites the genetic code of the DNA, according to George.  

Using these two approaches, the investigators were able to correct five different ATP1A3 mutations with 43- to 90-percent efficiency. Importantly, the study demonstrated that prime editing of mutant ATP1A3 in mice at birth prevented major manifestations of AHC from developing. 

Moving forward, the investigators aim to optimize the approach so that it can be safely and effectively used to treat patients.  

“There are many steps between now and when this may be used in persons affected with AHC, but this study was a major proof of concept that the molecular defect responsible for AHC could be corrected and make the disease less severe or eliminated,” George said.  

Using the new approach, the scientists are also interested in determining which symptoms of the disease are reversible and at what point in the patient’s life span they could be reversed, according to George.  

“Instinctively, most experts think earlier treatment is better, but we don’t really know. We need to investigate how effective these treatments are at reversing the manifestations of the disease when employed later in life,” George said.  

Christine Simmons, PhD, research assistant professor of Pharmacology, was a co-author of the study.  

The work in this study conducted at Northwestern was supported by the National Institutes of Health grant NS125785, the Alternating Hemiplegia of Childhood Foundation, the Cure AHC Foundation, RARE Hope (formerly Hope for Annabel), and the For Henry AHC Foundation.

A modified version of a diet known to lower blood pressure is also effective at lowering glucose in adults with type 2 diabetes, according to a clinical trial led by researchers at the Johns Hopkins Bloomberg School of Public Health.

The study builds on the DASH diet—Dietary Approaches to Stop Hypertension—developed in the mid-1990s by an interdisciplinary team of researchers supported by National Institutes of Health funding to address high blood pressure in the general population. The DASH diet emphasizes fruits, vegetables, and low-fat dairy products, and is low in saturated fat and cholesterol.

To understand the DASH diet’s impacts in patients with diabetes, a team led by Johns Hopkins researchers modified the diet for people with type 2 diabetes. The DASH for Diabetes—DASH4D—diet is similar to the DASH diet but lower in carbohydrates and higher in unsaturated fats. The research team also reduced potassium levels in the DASH4D diet to improve safety for individuals with chronic kidney disease.

A new study, published online August 5 in Nature Medicine, found that the DASH4D diet helped participants with type 2 diabetes control glucose levels.

For the study, 89 participants with type 2 diabetes ate prepared meals at a clinical research center for 20 weeks, half of the time on the DASH4D diet and half on a standard diet modeled after what U.S. adults typically eat. Participants’ blood glucose levels were measured using wearable continuous glucose monitoring (CGM) devices.

The new study, named DASH4D CGM, found that when participants consumed the DASH4D diet, they had a clinically meaningful reduction of average blood glucose level and an increase in average time spent with blood glucose in the recommended range compared to when they consumed a standard diet. Participants eating the DASH4D diet had blood sugar levels that were on average 11 mg/dL lower than when eating the standard diet and stayed in the optimal blood glucose range for an extra 75 minutes a day.  

Both effects are considered clinically meaningful for people with diabetes, as they may lower risks of heart disease, kidney disease, and other long-term adverse consequences of diabetes. The researchers hope that the results will lead to incorporating the DASH4D diet into clinical guidelines and improve type 2 diabetes management in the broader population.

“The original DASH diet has long been recommended for people with diabetes and other health conditions due to its effectiveness in lowering blood pressure, but this is the first time a controlled study has shown a significant improvement in glucose control as well,” says study senior author Elizabeth Selvin, PhD, MPH, Director of the Welch Center for Prevention, Epidemiology and Clinical Research and professor in the Bloomberg School’s Department of Epidemiology.

“Larger improvements were seen in participants who had higher blood glucose levels at the start of the trial,” says Michael Fang, PhD, MHS, an assistant professor also in the Bloomberg School’s Department of Epidemiology. “For those with the highest glucose levels—HbA1c above 8%—the DASH4D diet increased their time in the optimal blood glucose range by about three hours per day—a very significant benefit.”

Diabetes and hypertension are widespread in the U.S. largely because of unhealthy diets high in animal fat, sugar, and salt. An estimated 35 million Americans have type 2 diabetes, according to the Centers for Disease Control and Prevention. Several large clinical trials have shown that the DASH diet—which limits meat, sugary and salty foods, and sugary drinks and is rich in fruits, vegetables, and whole grains—is effective in reducing high blood pressure.

The DASH4D CGM study led by Selvin was part of a larger Hopkins-led clinical trial, published this spring. The main trial found the DASH4D diet lowered blood pressure among individuals with type 2 diabetes.  

Of the 89 people who completed the DASH4D CGM study, 67% were female and 88% were African American. Trained staff prepared meals—eventually totaling more than 40,000—for participants at a central testing site during the 2021–2024 study period. Each participant spent, in a random order, five weeks on a low-sodium DASH4D diet, five weeks on a high-sodium DASH4D diet, and five weeks each on low-sodium and high-sodium standard diets. (Sodium levels differed in order to test the effects of sodium on hypertension.) Participants wore CGM devices during weeks three and four in every five-week diet period. All the diets had the same number of calories.

“This trial design is what we call a ‘crossover’ design—we compared participants with themselves under different diet conditions, which reduced inter-individual variability and enhanced statistical power, allowing us to detect meaningful treatment effects despite what might initially appear to be small sample size,” Selvin says.

For participants on the DASH4D diet, blood glucose levels also were less variable generally, and did not enter the hypoglycemic range any more often than for the standard diets.

“We’re encouraged by these results and believe this can make a major impact on population health,” says Fang. “The DASH4D diet was specifically designed to be sustainable and easy to follow.”

“DASH4D Diet for Glycemic Control and Glucose Variability in Type 2 Diabetes: A Randomized Crossover Trial” was co-authored by Michael Fang, Dan Wang, Casey Rebholz, Justin Echouffo-Tcheugui, Olive Tang, Nae-Yuh Wang, Christine Mitchell, Scott Pilla, Lawrence Appel, and Elizabeth Selvin.

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK128900, K23DK128572, and K01DK138273) and the National Heart, Lung, and Blood Institute (T32HL007024 and K23HL153774). Abbott Diabetes Care provided the CGM systems for the study.

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Media contacts: Jon Eichberger je@jhu.edu or Kris Henry khenry39@jhu.edu

 

Introduction

The vaginal pessary is a commonly used intervention for management of pelvic organ prolapse, ideal for its safety profile and efficacy in patients even with the most severe medical comorbidities or who are otherwise poor surgical candidates. Commonly encountered adverse events related to pessary use include vaginal discharge, bleeding, and superficial mucosal erosion. However, more severe complications such as full-thickness vaginal erosion, pessary migration into the bladder, and rectovaginal and vesicovaginal fistula not only present with significant comorbidity for patients but also pose significant challenges for surgeons when attempting to repair such defects. Cases of staged transvaginal or open fistula repair due to Gellhorn pessary erosion into the bladder have been reported.^3-5 We present a rare case of ring pessary erosion resulting in complete bladder rupture with eversion and grade 4 prolapse of bladder, ureters, cervix, and small bowel through the vaginal vault repaired in a single stage entirely via transvaginal approach.

Case Presentation

A 73-year-old woman with multiple medical comorbidities, including poorly controlled eczema, 50 pack-year smoking history, and grade 4 uterine prolapse, was managed with a ring pessary in 2020 during the COVID-19 pandemic. Over the next 4 years, she was unreliable with follow-up, reporting a total of 3 pessary changes. After she presented to an outside emergency department with a urinary tract infection, her pessary was removed, and subsequent cystoscopy and hysteroscopy revealed erosion into the bladder and uterus. Upon presentation to our clinic, examination demonstrated grade 4 uterine, bladder, and vaginal vault prolapse with nodular edema of the vaginal wall and cervix. The bladder was ruptured, bivalved at the midline, with complete eversion and exposure of the bladder lumen and excoriated intravesical mucosa, including ureteral orifices (UOs) (Figures 1A-C). CT scan revealed a large volume of pelvic fat prolapsing below the pubococcygeal line. Pelvic congestion with poorly visualized bladder presumed to represent complete bladder, uterine, and vaginal prolapse. Pelvic ureters were severely J-hooked bilaterally with moderate dilation down to the prolapsed bladder (Figures 2A-B).

A single-stage transvaginal approach was performed for complete repair of the above-mentioned findings. Bilateral ureteral stents were placed into the exposed and laterally displaced ureteral orifices prior to reduction of the bladder prolapse. An intact urethral meatus and bladder neck were identified, although distorted, within the edematous anterior vaginal wall above the cystotomy. The large bladder defect was mobilized, leaving a 5-mm perimeter of vaginal epithelium for closure, beginning anteriorly sparing the urethra and bladder neck, moving posteriorly around the defect until a large enterocele and bilateral stented ureters were encountered. A LigaSure was used to excise the nodular vaginal mucosa adherent to the bladder base and enterocele, at which point the uterine fundus became visible with notably elongated vascular pedicles and pelvic ligaments. At this point, the bladder was reduced, a transvaginal hysterectomy was performed, and the remaining large vaginal wall nodules were excised. All specimens were sent for pathology. The enterocele sac was dissected off to allow debridement of the remaining vaginal wall. The enterocele sac was closed with a 2-0 Monocryl purse string suture. The posterior vaginal wall was closed in 2 layers, first with a 0 polydioxanone (PDS) interrupted layer, followed by closure of the vaginal epithelium with a 2-0 polyglactin (Vicryl) running suture.

At this point, the bladder was addressed, now assuming a fairly normal shape, with UOs and stents visualized away from the large defect. The bladder was closed in a T shape for the least amount of tension. Full-thickness interrupted 2-0 Monocryl sutures were used to reapproximate the bladder edges, incorporating the 5-mm rim of vaginal epithelium for added strength. The bladder base was then reconstructed with a series of running and interrupted full-thickness 2-0 Monocryl sutures to ensure a watertight closure.A 22-French 2-way silicone Foley catheter was placed, and a leak test was performed, at which point 2 areas were oversewn using 3-0 Monocryl. Additional anterior vaginal wall was resected to facilitate final closure. Anteriorly, the vaginal epithelium was closed in similar layers of interrupted deep 0 PDS and superficial running 2-0 Vicryl (Figure 3A-B). A Kerlix gauze was used for a vaginal pack and secured in place by sewing the labia closed with a single 0 silk stitch.

The patient was admitted overnight for observation. The silk stitch and vaginal pack were removed, and she was discharged without complications on postoperative day 1. A cystogram was performed at 3 weeks postoperatively, which demonstrated normal bladder contour without extravasation of contrast (Figures 4A-B). A cystoscopy with bilateral ureteral stent removal was performed in clinic the same day.

Discussion

Pessaries are a safe and effective form of nonsurgical management for pelvic organ prolapse. However, neglected pessaries can result in severe complications.⁴Minor complications related to pessary use such as vaginal discharge, bleeding, and superficial mucosal erosion are reported at rates as high as 83% of women using a pessary for greater than 1 year.² There are, however, exceedingly rare reports of severe adverse complications.¹ Gellhorn and donut pessaries are known to be more commonly associated with worse complications, including full-thickness erosion and vesicovaginal or rectovaginal fistula, than ring-type pessaries.² Although the majority of pessary complications can be managed conservatively with removal of pessary, vaginal rest, and initiation of vaginal estrogen, more severe adverse events will require surgical intervention.

There is limited information in the literature to guide the management of fistulae and prolapse repair related to pessary erosion.⁴Staged repair, either open or transvaginal, is currently the mainstay of treatment. Single-stage transvaginal repair appears to be much less common, especially in the case of such severe presentation, as with our patient. To our knowledge, this is the first documented case of complete eversion and prolapse of ruptured bladder with associated grade 4 prolapse of uterus and cervix, ureters, and small bowel secondary to ring pessary erosion with successful single-stage repair entirely via transvaginal approach.

Conclusion

Major complications of ring pessaries are rare but present considerable challenges to surgeons and patients when they do occur. We present favorable outcomes associated with a severe ring pessary erosion and bladder rupture using a single-stage transvaginal approach.

ACKNOWLEDGEMENTS:

This research did not receive any specific grant or funding from funding agencies in the public, commercial, or not-for-profit sectors.

REFERENCES

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