The women walk into the surgeons’ offices with photos cued up on their phones. Miley Cyrus. Keira Knightley. Bella Hadid. I want my breasts to look like this, they say. They’ve already spent hours on YouTube watching plastic surgeons’ infomercials, on Instagram poring over before-and-afters, and on TikTok, where an army of ordinary women post about their breast reductions. “Ask me,” they say. Whether their nipple sensation has changed. What their boyfriends said. Whether they cared.
Sometimes a woman walks into her initial consultation with the bralette she hopes to wear. Or she’ll say, “I can’t wait for my braless summer.” Or that she looks forward to shopping for a $15 bikini top at Target, something cute and bright or floral, signaling a life so carefree its wearer might never need fat straps or eye hooks again. Breast reduction patients use words like “fit” and “strong.” They talk about “yoga boobs.”
Friends tell friends about their breast reductions. A surgeon named Donald Mowlds, in Newport Beach, Calif., sees a photo on his feed of a group of women at lunch and realizes he’s operated on all of them. Kelly Killeen, a surgeon in Beverly Hills, says one of her patients flashed her breasts to a friend at the makeup counter at Neiman Marcus and the friend walked across the street to make an appointment. Jamie Hanzo, who is 26 and lives in New Orleans, uses the same plastic surgeon as her mother.
Tiffany Dena Loftin, who is 35 and a labor organizer in Atlanta, was emboldened to undergo breast reduction after scrutinizing the naked breasts of her friend Jamira Burley, 36, over FaceTime: her bandages, her incisions, her bruised nipples. Loftin doesn’t like hospitals. Needles terrify her. But, Burley said, “Tiffany, the relief and the joy that I’m feeling is also available to you on the other side of your fear.”
After liposuction, breast augmentation is the most popular cosmetic surgery procedure in the country, with about 300,000 women choosing implants each year. But the growth area in cosmetic breast surgery is in making them smaller. In 2023, more than 76,000 American women had elective breast-reduction surgery, a 64 percent increase since 2019, according to the American Society of Plastic Surgeons. (That number doesn’t include gender-affirming top surgeries or breast reconstructions after illness.) The increase is reflected across all age groups, but especially among women under 30, who are enthusiastic consumers of plastic surgery in general, including face- and forehead lifts, procedures favored mostly by women their mothers’ age. Girls younger than 19 represent a small but fast-growing part of the market.
“I had big breasts my whole life,” a teenager’s mother will tell Dr. Mowlds in his office. “Here’s my daughter. She has questions.”
Reduction surgeries deemed “medically necessary” and covered by insurance represent a far smaller group than cosmetic operations, but the broad trend lines — a recent, sudden increase, especially among younger women — are the same, according to an analysis by the Health Care Cost Institute.
Not only do more women want to be small; they want to be smaller. Jerry Chidester, a plastic surgeon in Salt Lake City, said his patients used to ask for C cups. Now, they want Bs. He often does five breast reductions a week, mostly on young, postpartum mothers.
Hummingbirds are birds native to the Americas and comprise the biological family Trochilidae. With approximately 366 species and 113 genera, they occur from Alaska to Tierra del Fuego, but most species are found in Central and South America. As of 2024, 21 hummingbird species are listed as endangered or critically endangered, with numerous species declining in population.
Hummingbirds have varied specialized characteristics to enable rapid, maneuverable flight: exceptional metabolic capcity, adaptations to high altitude, sensitive visual and communication abilities, and long-distance migration in some species. Among all birds, male hummingbirds have the widest diversity of plumage color, particularly in blues, greens, and purples. Hummingbirds are the smallest mature birds, measuring 7.5–13 cm (3–5 in) in length. The smallest is the 5 cm (2.0 in) bee hummingbird, which weighs less than 2.0 g (0.07 oz), and the largest is the 23 cm (9 in) giant hummingbird, weighing 18–24 grams (0.63–0.85 oz). Noted for long beaks, hummingbirds are specialized for feeding on flower nectar, but all species also consume small insects.
They are known as hummingbirds because of the humming sound created by their beating wings, which flap at high frequencies audible to other birds and humans. They hover at rapid wing-flapping rates, which vary from around 12 beats per second in the largest species to 80 per second in small hummingbirds.
Hummingbirds have the highest mass-specific metabolic rate of any homeothermic animal. To conserve energy when food is scarce and at night when not foraging, they can enter torpor, a state similar to hibernation, and slow their metabolic rate to 1⁄15 of its normal rate. While most hummingbirds do not migrate, the rufous hummingbird has one of the longest migrations among birds, traveling twice per year between Alaska and Mexico, a distance of about 3,900 miles (6,300 km).
Hummingbirds split from their sister group, the swifts and treeswifts, around 42 million years ago. The oldest known fossil hummingbird is Eurotrochilus, from the Rupelian Stage of Early Oligocene Europe.
Imagine cruising down the highway when you notice your fuel tank running low. Your GPS indicates 10 gas stations lie ahead on your route. Naturally, you want the cheapest option. You pass the first handful and observe their prices before approaching one with a seemingly good deal. Do you stop, not knowing how sweet the bargains could get up the road? Or do you continue exploring and risk regret for rejecting the bird in hand? You won’t double back, so you face a now-or-never choice. What strategy maximizes your chances of picking the cheapest station?
Researchers have studied this so-called best-choice problem and its many variants extensively, attracted by its real-world appeal and surprisingly elegant solution. Empirical studies suggest that humans tend to fall short of the optimal strategy, so learning the secret might just make you a better decision-maker—everywhere from the gas pump to your dating profile.
The scenario goes by several names: “the secretary problem,” where instead of ranking gas stations or the like by prices, you rank job applicants by their qualifications; and “the marriage problem,” where you rank suitors by eligibility, for two. All incarnations share the same underlying mathematical structure, in which a known number of rankable opportunities present themselves one at a time. You must commit yourself to accept or reject each of them on the spot with no take-backs (if you decline all of them, you’ll be stuck with the last choice). The opportunities can arrive in any order, so you have no reason to suspect that better candidates are more likely to reside at the front or back of the line.
Let’s test your intuition. If the highway were lined with 1,000 gas stations (or your office with 1,000 applicants, or dating profile with 1,000 matches), and you had to evaluate each sequentially and choose when to stop, what are the chances that you would pick the absolute best option? If you chose at random, you would only find the best 0.1 percent of the time. Even if you tried a strategy cleverer than random guessing, you could get unlucky if the best option happened to show up quite early when you lacked the comparative information to detect it, or quite late at which point you might have already settled for fear of dwindling opportunities.
Amazingly, the optimal strategy results in you selecting your number one pick almost 37 percent of the time. Its success rate also doesn’t depend on the number of candidates. Even with a billion options and a refusal to settle for second best, you could find your needle-in-a-haystack over a third of the time. The winning strategy is simple: Reject the first approximately 37 percent no matter what. Then choose the first option that is better than all the others you’ve encountered so far (if you never find such an option, then you’ll take the final one).
Adding to the fun, mathematicians’ favorite little constant, e = 2.7183… rears its head in the solution. Also known as Euler’s number, e holds fame for cropping up all across the mathematical landscape in seemingly unrelated settings. Including, it seems, the best-choice problem. Under the hood, those references to 37 percent in the optimal strategy and corresponding probability of success are actually 1/e or about 0.368. The magic number comes from the tension between wanting to see enough samples to inform you about the distribution of options, but not wanting to wait too long lest the best pass you by. The proof argues that 1/e balances these forces.
The first known reference to the best-choice problem in writing actually appeared in Martin Gardner’s beloved “Mathematical Games” column here at Scientific American. The problem spread by word of mouth in the mathematical community in the 1950s, and Gardner posed it as a little puzzle in the February 1960 issue under the name “Googol,” following up with a solution the next month. Today the problem generates thousands of hits on Google Scholar as mathematicians continue to study its many variants: What if you’re allowed to pick more than one option, and you win if any of your choices are the best? What if an adversary chose the ordering of the options to trick you? What if you don’t require the absolute best choice and would feel satisfied with second or third? Researchers study these and countless other when-to-stop scenarios in a branch of math called “optimal stopping theory.”
I am a physician and a scientist. Over 12 years, I had the privilege of serving Presidents Barack Obama, Donald Trump and Joe Biden as the director of the National Institutes of Health. Before that, I led the U.S. component of the Human Genome Project.
I am amazed by the medical progress that has been possible in the past few decades, both in alleviating suffering and saving lives. But I am also deeply troubled by the growing distrust of science in our society, just at the time when its insights are most needed. No recent experience highlights that disconnect more starkly than the last five years of the Covid pandemic. From my vantage point on the front lines of that battle against a dangerous virus, let me highlight both the triumphs and tragedies, and propose some actions that we can all take to re-anchor our troubled society to truth, science, faith, and trust — and put us back on an individual and collective journey that might be called the road to wisdom.
Go with me back to early 2020, as the worst pandemic in more than a century was spreading across the globe, and deaths in the United States were in the thousands every day. For me and hundreds of scientists who joined together during Operation Warp Speed, the most hopeful strategy was to develop a vaccine. We all worked to be sure the large-scale trials were scrupulously conducted, and that they involved a wide range of men and women of different racial and ethnic backgrounds.
What would success look like? The Food and Drug Administration had set the threshold for approval of this effort at 50 percent efficacy, about what the flu vaccine achieves most years. My colleague Tony Fauci and I frequently discussed our hopes for the outcome. Maybe it could be possible to reach 70 percent? I confess that I was fearful of failure. I also prayed a lot.
The results were revealed in late November 2020. For both the Pfizer-BioNTech and Moderna mRNA vaccines, there was 90 to 95 percent efficacy in preventing illness that caused respiratory symptoms and close to 100 percent efficacy in preventing severe disease and death. Side effects were minimal in the tens of thousands of volunteers who had taken part in each trial. It was a moment of profound relief, of gratitude toward all who had made this possible, of answered prayer. As I tried to speak to the dedicated team about the significance of what had just happened, I could not find words that could fully express the emotions of the moment. I was unable to hold back the tears.
Future historians will judge the development of safe and effective mRNA vaccines for Covid in 11 months as one of the greatest medical achievements in human history. We felt that at last we were on a path to conquering this disease and stopping the terrible death toll. And to a major extent, that came true: Current estimates by the Commonwealth Fund, a nonprofit foundation supporting research on health care, are that more than three million lives were saved in the United States between December 2020 and November 2022 by Covid vaccines. If you were vaccinated, you might be one of them. I might be also.
Yet ultimately more than 50 million adult Americans declined vaccination — even after the shots were made widely available at no cost. Though medicine and public health make poor bedfellows with politics, one’s political party was a strong predictor of resistance. So was religion, with white evangelical Christians (my own group) the most resistant of all. Public distrust, driven by social media, cable news and even some politicians, reflected a host of concerns: whether Covid-19 was real, whether it was really all that serious, whether the vaccines were rushed, whether there were common and serious side effects that had been hidden, whether the mRNA would alter the recipient’s DNA, and whether companies had skirted the rules about safety. More outlandish conspiracies also circulated on social media: that the vaccines contained microchips or cells from recently aborted fetuses, for example. People of faith were particularly hard hit by misinformation.
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An artwork from the series “Let no one say we were not here,” 2020-23. Credit…Lydia See
At a latitude of 78 degrees north lies the northernmost city in the world. It is an odd place. Way above the Arctic Circle—a mere 814 miles from the North Pole—Longyearbyen, in Norway’s Svalbard archipelago, is home to only 2,400 people but more than 1.3 million seeds.
The Svalbard Global Seed Vault is an underground storage facility designed to secure seeds to “ensure that food crop varieties are not lost” in the event of a global crisis such as war, terrorism, or climate change. Touted as “our insurance policy that we’re going to be able to feed the world in 50 years,” the vault has been situated at a location and depth in the Arctic intended to ensure that the seeds will not rot or sprout and will be available for use when needed. For further safety, the vault is refrigerated to zero degrees Fahrenheit and designed to withstand a magnitude 10 earthquake. (For comparison, the quake that produced the tsunami that devastated Fukushima, Japan, was magnitude 9.) On the surface, the seed repository sounds like a very solid idea. But it rests on shaky foundations.
The vault opened in 2008, following on an earlier iteration in which seeds were stored in a nearby coal mine. It is not specifically a response to the threat of climate change, but it is an epitome of climate-adaptation thinking. The logic behind it goes like this: Climate change is underway, and our political systems seem to be incapable of meaningful action to stop it, so we have little choice but to plan for a future when we will face serious climate disruption.
Chief among the disturbances will be disruptions to the food supply as punishing droughts and heat waves lead to widespread seasonal crop failures and important individual food species become impossible to grow in the places where people are used to growing them. When that happens, a supply of diverse seeds—including some adapted to hotter, harsher climates—may be just the thing we need to protect our food systems and stave off disaster.
It’s good to be realistic about the climate future we are facing, but the seed vault embeds a conceit common to many adaptation plans: we know what we are facing, so if we plan well, things will go well. But already chinks in the vault’s armor have appeared. In 2017 the vault suffered a flood caused, ironically, by climate change. A very warm (but increasingly not exceptional) winter combined with heavy spring rain to thaw part of the surrounding permafrost, flooding the entrance and threatening the safety of the seeds. Changes have been made to the vault’s entrance to lessen this particular risk, but the breach—less than a decade after the vault opened—shows that we humans are not very good at anticipating change, even in the short run.
Boosters of the seed vault sustain the logic of their effort in part by effacing the embarrassment of the flood. The timeline of the vault on the website of the vault’s partner, CropTrust, does not mention it. When asked about the flood by a reporter for the Guardian, a representative of the Norwegian government, which owns and operates the vault, said: “It was not in our plans to think that the permafrost would not be there and that it would experience extreme weather like that … The question is whether this is just happening now, or will it escalate?”
You don’t have to be a climate scientist to know the Arctic is losing permafrost; in Svalbard, the dislocation is obvious even to an untrained eye. And it’s long been known that the Arctic would warm more rapidly than the rest of the globe: Princeton University geophysicist Syukuro Manabe predicted this effect—known as polar amplification—in the 1970s (he belatedly won a Nobel Prize in 2021 for this work). Today the Arctic is warming four times faster than the rest of the planet. Even if the entire world were to stop burning fossil fuels now, global temperatures would not return to normal for decades or centuries to come. Given the state of action (or inaction) on climate, we don’t have to ask whether Arctic warming and permafrost loss will escalate. It is a near certainty.
The conversation in which your parents tell you to keep an eye out for rusty nails is basically a rite of passage. They tell you about the dangers of rust; explain the see something, say something protocol for things that look like they could puncture you; and foreshadow the harsh punishment for disobeying—lockjaw.
This advice certainly comes from a good place. But it’s also fundamentally wrong.
This is not to say that tetanus isn’t as bad as parents promise. In North America, the Cleveland Clinic estimates, 10 percent of cases are fatal. In countries with inadequate or inaccessible medical care, the number is believed to be much higher.
Even survival takes its toll. On Friday, the U.S. Centers for Disease Control and Prevention released a new installment in its “Notes from the Field” series about an unvaccinated 6-year-old boy in Oregon who contracted tetanus after he got a cut in his forehead. The bacteria incubated inside his little body for a few days, then suddenly manifested in horrible jaw clenching and muscle spasms, heart rate, blood pressure, and body temperature irregularities. He lived, but only after 57 days in the hospital and more than $800,000 in medical bills.
But counter to what rusty nail warnings might have you believe, the disease has nothing to do with iron oxide, the chemical compound more commonly known as rust. Rather, tetanus is a product of the bacteria Clostridium tetani, which is in dirt, dust, and feces—in other words, everywhere. It can enter your body through puncture wounds, yes, but also through superficial cuts, bug bites, surgical procedures, and any other rupture to your skin. It can come from stepping on a rusty nail, or tending the soil in your garden. That’s why it’s so essential to track your booster shots: You need one every decade, not just when you rip your palm open on a rusty chain link fence. Waiting for a classic tetanus injury won’t work when anything could, in theory, be a tetanus injury.
If the bacteria enter your body and you aren’t up-to-date on your vaccinations, the tiny invaders begin to multiply rapidly. This incubation period, which lasts between three and 21 days, according to the CDC, is symptom free. But as the bacteria begin to die inside you, they form a neurotoxin that attacks the nervous system. Specifically, it inhibits the chemical GABA, which regulates muscle contractions. The result is a body-wide state of tension, from lockjaw in your face to uncontrollable arching spasms in your back to permanently-curled toes.
How rusty nails came to be so closely associated with tetanus isn’t clear. Iron oxide is basically harmless to the human body; millions of people drink water transported by rusty iron pipes with no health effects. (Bridges aren’t so lucky—rusting has buckled many an iron span.) Perhaps it’s some classic American folklore. Or, as Esther Inglis-Arkell argued on the site i09, it has something to do with the anaerobic environment in which the tetanus-causing Clostridium tetani bacteria thrives. As iron oxidizes, it eats up atmospheric oxygen, creating a low-oxygen environment for the bacteria to grow. While rust doesn’t cause tetanus, the two may have a symbiotic (and symbolic) relationship.
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Rusty nails aren’t the only threat. Photo from Deposit Photos.
The best areas to see vivid fall foliage this year will be outside of the traditionally popular tourist destinations due to the weather across the United States leading up to peak leaf-peeping season.
Meteorological fall is underway, pumpkin spice flavors are being infused into food and drinks, and college football season has kicked off. However, there’s no better sign that autumn has arrived than a hillside of trees transformed into an ocean of yellow, orange, and red
Due to recent and upcoming weather patterns across the United States, the most breathtaking displays of fall foliage may emerge in regions beyond the usual hotspots that have captivated leaf-peepers in recent years.
Ingredients for brilliant fall foliage
The vibrancy of fall foliage is significantly influenced by the weather during the summer and early fall.
One of the key factors is consistent rainfall throughout the summer. Drought can stress the trees, causing them to shed their leaves early, as well as resulting in duller colors. Too much rain can also be detrimental. “If there’s a lot of rain from late summer into the early fall, you can get mold to develop on some of the trees and also invite lots of insects,” AccuWeather Lead Long-Range Meteorologist Paul Paselok said.
Additionally, sunny days paired with cool nights in early autumn can enhance the colors. This weather pattern accelerates the breakdown of green chlorophyll in leaves, revealing brilliant shades of orange, red, and yellow. However, while cool weather is beneficial, frost can be harmful since it halts the production of colorful pigments in the leaves, abruptly ending the leaf-peeping season.
Where will the best fall foliage be this year?
All of the ingredients are coming together to make 2024 a great year for fall foliage from the Great Lakes through the Mississippi River Valley, including areas in more than a dozen states.
“I think the best places to go are parts of the Midwest,” Pastelok said, adding, “The trees should have nice reds and oranges, and that could extend all the way down to parts of the Ozarks and parts of southern Missouri.”
In the Northeast, the best displays are expected across upstate New York and northern Pennsylvania, including popular destinations such as the Adirondacks, the Finger Lakes, and the Pennsylvania Grand Canyon.
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Colorful trees lining a lake in White Mountains National Forest, New Hampshire. (Getty Images/Cappi Thompson)
Dementia robs us of everything that matters. Our memories. Our connections. Our story. Every three seconds, another person in the world hears the devastating news that they have dementia. No wonder, then, that it is the most feared condition among people aged over 55.
But, after decades of relentless research across the globe, that is all set to change.
Investments in dementia research are finally leading to breakthroughs, as life-changing treatments that may slow the progression of Alzheimer’s come within close reach. And we’re understanding more and more about how we can reduce our risk of developing dementia. This progress is mirrored by active and growing investment in drug development in the field of neurology around the world, which is fueling further innovation and drug discovery.
For a field that has seen no progress since the 1990s, when symptomatic drugs in the form of cholinesterase inhibitors were introduced, it certainly does feel that the time to turn the tide on this devastating condition has finally arrived.
The power of recent scientific discoveries, coupled with lessons from a litany of past research failures, means there is now a new sense of urgency on both sides of the Atlantic. We now need to see action on two fronts: to reduce the number of people affected by dementia in the future, and to minimize its impact on those who do develop the condition.
But this action demands a seismic shift in the way our health systems approach dementia care. This will take time and resources, so health systems and physicians need to be supported to manage this change.
The current state of play
In the past year, we’ve seen the arrival of the Alzheimer’s drug lecanemab (Leqembi) into U.S. healthcare and more recently, in Japan and China. A second Alzheimer’s drug, donanemab, is rapidly following suit, and, regulatory decisions from several countries are expected over the coming months.
Although the benefits of these drugs are modest, and with significant side effects for some, it nonetheless marks the arrival of a new wave of treatments that can slow the course of Alzheimer’s disease rather than just treating its symptoms. It’s a new dawn for dementia, signaling a step-change in the way it will be perceived and diagnosed.
Despite this success, we don’t have a straightforward path ahead to rapid, equitable access to these drugs once they are licensed. Work supported by the Davos Alzheimer’s Collaborative is highlighting shared challenges while acknowledging country-specific obstacles linked to healthcare infrastructure, demographics, and clinical practices. For many countries, the current state of play is going to make accessing these treatments practically impossible in the short term.
When your kids get down and dirty in the kitchen, not only do they learn about food but they also have fun! It’s even more fun when they get to eat what they have prepared with their own two hands. Parents and caregivers can use this moment to show kids how to increase the nutritional value of their lunches. Here are several best practices when showing kids how to create well-rounded meals.
Add calcium. Pediatric nutrition expert Malina Malkani, MS, RDN, CDN and author of Safe and Simple Food Allergy Prevention reminds parents to include a good source of calcium at lunch. “As kids exit the toddler years, calcium intake tends to decrease. According to data from NHANES, 49% of children between ages 4-18 are not meeting their daily needs for this essential, bone-building nutrient.”1 Yogurt, cheese, kefir, cottage cheese, edamame, fortified soy milk, and chia seeds all offer a good amount of calcium in lunch foods that are easy to pack.
Include a combination of protein, fiber, and fat. These three nutrients—whether including all or some of them at a meal—”can help slow the rate of digestion and prevent the dips and spikes in blood sugar that lead to low energy, irritability, and lack of focus,” explains Malkani.
Let the child choose between two options. Jill Castle, MS, RDN is the founder of The Nourished Child and author of Kids Thrive at Every Size: How to Nourish Your Big, Small, or In-Between Child for a Lifetime of Health and Happiness. Castle recommends providing your child with two options when negotiating foods to pack for lunch. For example, you can include both strawberries and a clementine that way they can select which one they prefer during their lunch.
Choose at least four food groups to pack for lunch. Castle provides the example of turkey and cheese on whole grain bread paired with grapes and pretzels. There are endless possibilities, but teach your child to count the foods that come from each food group.
Let your child do the work: Castle says letting your child do most of the work “will encourage their independence, [teach them to] engage with hands-on tasks, and [help them] learn while doing.”
Use a school lunch planner: Another smart tip from Castle is to create a school lunch planner. “A planner can help you map out a week of lunch meals with input from your child, and make the process of lunch packing easier.”
Use after-school snack time wisely: Castle says to take advantage of this time for discussing, planning, and preparing for the next day’s lunch ideas.
Nutritious Ingredients to Stock Up On
Start with simple recipes that focus on nutritious ingredients when your kids are younger and build on their skills as they evolve in the kitchen. Consider stocking up on these ten nutritious ingredients that are simple for young kids to meal prep for lunch.
Frozen, shelled edamame: Thaw and have your kids pack it as a side or snack, they can also use it as a base for “hummus” when they’re ready to use the blender.
Chia seeds: Your child can mix chia seeds into yogurt parfaits, use it as a base for a nutrient-rich pudding, toss it into salads, or sprinkle it into nut butter sandwiches.
Yogurt tubes or pouches: Include this grab-and-go food as a calcium-rich side or base for yogurt parfaits that kids can assemble during lunchtime if they prefer not to assemble in advance. You can also try freezing a yogurt pouch in advance as it helps to keep the rest of the packed foods cold and it will still be chilled by the time kids are ready to eat them.
Peanut butter or nut-free butter (like sunflower, yellow split pea, soy): Use nut butter for sandwiches or as a topping for toast or bagel. You can also have your child melt nut butter in the microwave and drizzle it on plain yogurt, or they can mix it with soy sauce and toss with warm noodles.
Eggs: Either purchase hard-cooked eggs for younger kids or older kids can learn to boil them stovetop. Use for an egg sandwich with cheese and ham.
Pasta or noodles: Pasta is simple to make for older kids who know how to use the stove (or you can pre-cook them for younger kids). Kids can toss the pasta with chopped veggies to create a cold salad, or they can toss with a tomato, Alfredo, or vodka sauce for a hot lunch (and bring it to school in a thermos). You can also show them how to serve it plain or with butter for picky eaters.
Cheese: Have your child add slices to sandwiches or pack some cheese as a side in their lunchbox. Shredded cheese can be sprinkled over veggies and cubes can be skewered with fruit.
Carrots: Kids can choose from sliced canned carrots, baby carrots, or peeled and sliced carrots. It’s a simple side to add to lunches, and a veggie that kids love to dip.
Mandarins or clementines: These easy-to-peel fruit are a simple snack even for the littlest hands and can help add fiber and vitamin C to their diet.
Raisins: Dried fruit has a long shelf-life and is easy to grab and pack in any lunch box. It can be topped over yogurt or eaten right out of the mini box.
Henry, a carpenter in his late 50s who worked for a small business, had been making and refinishing furniture for years. Then he started having difficulty using tools. The quality of his work rapidly declined, and eventually, he was fired. At home, his wife grew frustrated with him for forgetting their conversations. He was not doing a good job with chores such as loading and unloading the dishwasher.
Henry went to see a doctor, who referred him for cognitive testing. The results came back “invalid.” Among the potential diagnoses the neuropsychologist came up with was “malingering”—basically faking his cognitive impairment. The specialist apparently did not anticipate that someone so young might have dementia. As a result, Henry’s application for disability benefits was denied.
By the time Henry walked into my clinic at Washington University in St. Louis, he and his family were confused and desperate. His wife thought perhaps Henry was being lazy and didn’t want to work or help around the house. But he seemed to struggle with simple tasks, such as dressing himself, and his problems were getting worse. She was worried.
As a cognitive neurologist, many patients come to see me because they’ve noticed subtle changes in their memory and thinking. Their major question is, “Do my symptoms represent the beginning of a progressive neurological illness like Alzheimer’s disease?” The answer is often not clear at their first visit, even after I take a detailed history, do brain imaging, and check routine blood work. Mild problems with memory and thinking are relatively common and can have many causes, such as poor sleep, stress, sleep apnea, various medical conditions, and certain medications.
When patients with subtle changes in memory and thinking come to our clinic and the cause is unclear, a common strategy has been “cognitive monitoring”—watching patients over time to see if their problems get better, stay the same, or get worse. Some patients improve after interventions such as stopping a medication or starting treatment for sleep apnea. Some patients continue to experience cognitive difficulties but never really worsen. And some patients progressively decline until it becomes clear that they have a neurological disorder. Which leads to another difficult question: Are their symptoms caused by Alzheimer’s disease?
Clinicians define dementia as a decline in memory and thinking that affects a patient’s function in everyday activities. There is a continuum of dementia, from being unnoticeable by people who do not know the patient well to causing complete dependence on others for dressing, bathing, eating, toileting and other simple tasks. Dementia, particularly when very mild, can have many causes, some of which are treatable. Alzheimer’s is the most common cause of dementia in patients older than 65 years. It is characterized by specific brain changes, including the deposition of amyloid plaques. These brain changes slowly worsen over time and can be detected 10 to 20 years before the onset of symptoms.
Not long ago, it was impossible to know for sure whether a patient with cognitive impairment had Alzheimer’s disease or some other cause of dementia without an autopsy. In recent years, we have vastly improved our diagnostic capabilities. We can now offer blood tests that can enable earlier and more accurate diagnoses of large numbers of people.
Spinal taps and amyloid PET scans
In 2012, the U.S. Food and Drug Administration approved amyloid PET scans, which can reveal the presence of the amyloid plaques characteristic of Alzheimer’s disease and which are thought to initiate a cascade of brain changes that culminate in dementia. In 2022, the FDA approved the first test for Alzheimer’s disease that measured amyloid proteins in the cerebrospinal fluid or CSF.
For more than a decade, neurologists like me had been using CSF tests to determine whether patients with cognitive impairment were likely to have Alzheimer’s brain changes. While neurologists perform spinal taps to collect CSF to test for a variety of conditions, and it is safe and well-tolerated, most people have never had a spinal tap and it may seem scary. Even if the CSF testing provides a more certain diagnosis, patients often aren’t interested in having a spinal tap unless it has a major impact on their care. Patients will ask, “If I test positive, is there anything you would do differently?” For years, in most cases, I have said, “Probably not,” and that I would still treat them with the same medications and follow them in the same way. For this reason, we didn’t do many tests for Alzheimer’s—as my patients put it, “There’s nothing we can do about it anyway.”
Film and Writing Festival for Comedy. Showcasing best of comedy short films at the FEEDBACK Film Festival. Plus, showcasing best of comedy novels, short stories, poems, screenplays (TV, short, feature) at the festival performed by professional actors.
Credit…Maggie Shannon for The New York Times
Beautiful Hummingbird
Jonathan Kitchen/Getty Images
Scott Brundage
Colorful trees lining a lake in White Mountains National Forest, New Hampshire. (Getty Images/Cappi Thompson)
Joey Guidone/Theispot
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James' World 2 