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When is the pandemic “over”? In the early days of 2020, we envisioned it ending with the novel coronavirus going away entirely. When this became impossible, we hoped instead for elimination: If enough people got vaccinated, herd immunity might largely stop the virus from spreading. When this too became impossible, we accepted that the virus would still circulate but imagined that it could become, optimistically, like one of the four coronaviruses that cause common colds or, pessimistically, like something more severe, akin to the flu.

Instead, COVID has settled into something far worse than the flu. When President Joe Biden declared this week, “The pandemic is over. If you notice, no one’s wearing masks,” the country was still recording more than 400 COVID deaths a day—more than triple the average number from flu.

This shifting of goal posts is, in part, a reckoning with the biological reality of COVID. The virus that came out of Wuhan, China, in 2019 was already so good at spreading—including from people without symptoms—that eradication probably never stood a chance once COVID took off internationally. “I don’t think that was ever really practically possible,” says Stephen Morse, an epidemiologist at Columbia. In time, it also became clear that immunity to COVID is simply not durable enough for elimination through herd immunity. The virus evolves too rapidly, and our own immunity to COVID infection fades too quickly—as it does with other respiratory viruses—even as immunity against severe disease tends to persist. (The elderly who mount weaker immune responses remain the most vulnerable: 88 percent of COVID deaths so far in September have been in people over 65.) With a public weary of pandemic measures and a government reluctant to push them, the situation seems unlikely to improve anytime soon. Trevor Bedford, a virologist at the Fred Hutchinson Cancer Center, estimates that COVID will continue to exact a death toll of 100,000 Americans a year in the near future. This too is approximately three times that of a typical flu year.

I keep returning to the flu because, back in early 2021, with vaccine excitement still fresh in the air, several experts told my colleague Alexis Madrigal that a reasonable threshold for lifting COVID restrictions was 100 deaths a day, roughly on par with flu. We largely tolerate, the thinking went, the risk of flu without major disruptions to our lives. Since then, widespread immunity, better treatments, and the less virulent Omicron variant have together pushed the risk of COVID to individuals down to a flu-like level. But across the whole population, COVID is still killing many times more people than influenza is, because it is still sickening so many more people.

Bedford told me he estimates that Omicron has infected 80 percent of Americans. Going forward, COVID might continue to infect 50 percent of the population every year, even without another Omicron-like leap in evolution. In contrast, flu sickens an estimated 10 to 20 percent of Americans a year. These are estimates, because lack of testing hampers accurate case counts for both diseases, but COVID’s higher death toll is a function of higher transmission. The tens of thousands of recorded cases—likely hundreds of thousands of actual cases every day—also add to the burden of long COVID.

The challenge of driving down COVID transmission has also become clearer with time. In early 2021, the initially spectacular vaccine-efficacy data bolstered optimism that vaccination could significantly dampen transmission. Breakthrough cases were downplayed as very rare. And they were—at first. But immunity to infection is not durable against common respiratory viruses. Flu, the four common-cold coronaviruses, respiratory syncytial virus (RSV), and others all reinfect us over and over again. The same proved true with COVID. “Right at the beginning, we should have made that very clear. When you saw 95 percent against mild disease, with the trials done in December 2020, we should have said right then this is not going to last,” says Paul Offit, the director of the Vaccine Education Center at Children’s Hospital of Philadelphia. Even vaccinating the whole world would not eliminate COVID transmission.

This coronavirus has also proved a wilier opponent than expected. Despite a relatively slow rate of mutation at the beginning of the pandemic, it soon evolved into variants that are more inherently contagious and better at evading immunity. With each major wave, “the virus has only gotten more transmissible,” says Ruth Karron, a vaccine researcher at Johns Hopkins. The coronavirus cannot keep becoming more transmissible forever, but it can keep changing to evade our immunity essentially forever. Its rate of evolution is much higher than that of other common-cold coronaviruses. It’s higher than that of even H3N2 flu—the most troublesome and fastest-evolving of the influenza viruses. Omicron, according to Bedford, is the equivalent of five years of H3N2 evolution, and its subvariants are still outpacing H3N2’s usual rate. We don’t know how often Omicron-like events will happen. COVID’s rate of change may eventually slow down when the virus is no longer novel in humans, or it may surprise us again.

In the past, flu pandemics “ended” after the virus swept through so much of the population that it could no longer cause huge waves. But the pandemic virus did not disappear; it became the new seasonal-flu virus. The 1968 H3N2 pandemic, for example, seeded the H3N2 flu that still sickens people today. “I suspect it’s probably caused even more morbidity and mortality in all those years since 1968,” Morse says. The pandemic ended, but the virus continued killing people.

Ironically, H3N2 did go away during the coronavirus pandemic. Measures such as social distancing and masking managed to almost entirely eliminate the flu. (It has not disappeared entirely, though, and may be back in full force this winter.) Cases of other respiratory viruses, such as RSV, also plummeted. Experts hoped that this would show Americans a new normal, where we don’t simply tolerate the flu and other respiratory illnesses every winter. Instead, the country is moving toward a new normal where COVID is also something we tolerate every year.

In the same breath that President Biden said, “The pandemic is over,” he went on to say, “We still have a problem with COVID. We’re still doing a lot of work on it.” You might see this as a contradiction, or you might see it as how we deal with every other disease—an attempt at normalizing COVID, if you will. The government doesn’t treat flu, cancer, heart disease, tuberculosis, hepatitis C, etc., as national emergencies that disrupt everyday life, even as the work continues on preventing and treating them. The U.S.’s COVID strategy certainly seems to be going in that direction. Broad restrictions such as mask mandates are out of the question. Interventions targeted at those most vulnerable to severe disease exist, but they aren’t getting much fanfare. This fall’s COVID-booster campaign has been muted. Treatments such as bebtelovimab and Evusheld remain on shelves, underpublicized and underused.

At the same time, hundreds of Americans are still dying of COVID every day and will likely continue to die of COVID every day. A cumulative annual toll of 100,000 deaths a year would still make COVID a top-10 cause of death, ahead of any other infectious disease. When the first 100,000 Americans died of COVID, in spring 2020, newspapers memorialized the grim milestone. The New York Times devoted its entire front page to chronicling the lives lost to COVID. It might have been hard to imagine, back in 2020, that the U.S. would come to accept 100,000 people dying of COVID every year. Whether or not that means the pandemic is over, the second part of the president’s statement is harder to argue with: COVID is and will remain a problem.

A few months ago, I got food poisoning. The sequence of events that led to my downfall began with a carton of discounted grocery-store sushi purchased and consumed on a Thursday, which led to me waking up a little queasy on a Friday, which devolved into a 12-hour stretch of me vomiting and holding myself in a fetal position, until my legs ached from dehydration. On Saturday the smell of my partner cooking breakfast still made me gag; I sipped water, napped fitfully, and nibbled little golf balls of white rice.

But Sunday, glorious Sunday, I awoke to a marvelous lack of pain and fatigue. The brain fog was gone. My skin felt plump with fluids. Enthralled by recovery, I found myself behaving with uncharacteristic serenity. When I dropped and broke a ceramic bowl while unloading the dishwasher, I didn’t curse and freak out. Instead, I swept up the shards with cheer. I wouldn’t sweat the small stuff. I was my normal self again, and it felt sublime.

Yet as I relished in my newfound bliss, a foreboding thought gnawed at me: I knew that as the hours passed and the specter of illness retreated, my fresh perspective, too, would fade. So much of my exuberance was defined by absence, the lifting of the burden of aches and puking. It would only be a matter of time until normal felt normal again, and I’d be back to worrying about all the petty minutiae I always worry about.

People have different baselines of health, and some might be more or less appreciative of whatever condition they’re in. Even so, humans have long lamented the ephemeral joy of relief. The feeling manifests in all kinds of circumstances: meeting a deadline, passing a test, finishing a marathon. And it can be especially acute in matters of wellness. “Health is not valued, till sickness comes,” wrote the 17th-century British scholar Thomas Fuller. Or as the 19th-century German philosopher Arthur Schopenhauer bemoaned: “Just as we do not feel the health of our entire body but only the small place where the shoe pinches, so too we do not think of the totality of our well-functioning affairs, but of some insignificant trifle that annoys us.”

So many of us, in other words, are very bad at appreciating good health when we’re fortunate enough to have it. And anyone experiencing this transcendent gratitude is unlikely to hold on to it for long. Indeed, by Monday morning, the afterglow of recovery had worn off; I was engrossed in emails and work again, unaware that just 60 hours prior I could barely sit upright in bed, let alone at my desk. This troubled me. Am I cursed to be like this forever? Or is there anything I can do to change?

To some extent, I’m sad to report, the answer might well be no. While certainly some people can have experiences of major illness or injury that change their entire outlook on life, the tendency to revert to forgetfulness seems to run pretty deep in the human psyche. We have limited attentional resources, the UC Davis psychology professor Robert Emmons told me, so in the interest of survival, our brain tends not to waste them focusing on systems that are working well. Instead, our mind evolved to identify threats and problems. Psychologists call this negativity bias: We direct our attention more to what’s wrong than what’s right. If your body’s in check, your brain seems to reason, better to stress about the project that’s overdue or the conflict with your friend than sit around feeling like everything’s fine.

Read: Does ‘counting your blessings’ work?

A second psychological phenomenon that might work against any enduring joy in recovery from illness is hedonic adaptation, the notion that after positive or negative life events we, basically, get used to our new circumstances and return to a baseline level of subjective well-being. Hedonic adaptation has been used to explain why, in the long term, people who won the lottery were no happier than those who didn’t; and why romantic partners lose passion, excitement, and appreciation for each other over time.

Arguably, adaptation need not be seen as any great tragedy. For health, in particular, there’s an element of practicality in the human capacity to exist without fussy attentiveness. This is how we’re supposed to operate. “If our body isn’t causing us problems, it doesn’t actually pay to walk around being grateful all the time. You should be using your mental energy on other things,” Amie Gordon, an associate professor of psychology at the University of Michigan, told me. If we had to sense our clothes on our bodies all day, for example, we’d constantly be distracted, she said. (This is actually a symptom of certain chronic disorders, like fibromyalgia—Lauren Zalewski, a writer who was diagnosed with both fibromyalgia and lupus 22 years ago, told me that it makes her skin sensitive to the touch, as if she constantly has the flu.)

All that said, there are real costs to taking health for granted. For one, it can make you less healthy, if as a result you don’t take care of yourself. For another, maintaining some level of appreciation is a good way to avoid becoming an entitled jerk. Throughout the pandemic, for instance, there has been “this language around how the ‘only’ people dying are ‘old people’ or people with pre-existing conditions,” as if these deaths were more acceptable, Emily Taylor, a vice president for the Long-COVID Alliance, a group that advocates for research into post-viral illnesses, told me. Acknowledging that our own health is tenuous—and that certainly, many of us are going to get old—could counter this kind of callousness and encourage people to treat the elderly and those with chronic conditions or disabilities with more respect and kindness, Taylor argued.

In my view, there’s something to be gained on an individual level, too. In recent years I’ve seen friends and loved ones deal with life-altering injuries and diagnoses. I know that one’s circumstances can turn on a phone call or a moment of inattention. To be healthy, to have basic needs met—to have life be so “normal” that it’s even a little boring—is a luxury. While I am living in those blessedly unremarkable times, I don’t want my fortune to escape my notice. When things are good, I want to know how good I’ve got it.

Read: How to be thankful when you don’t feel thankful

What I want, really, is to hold on to a sense of gratitude. In the field of psychology, gratitude can be something of a loaded term. Over the past decade or so, articles, podcast episodes, self-help books, research papers, celebrities, and wellness influencers alike have all extolled the benefits of being thankful. (Oprah famously kept a gratitude journal for more than a decade.) At times, gratitude’s popularity has been to its own detriment: The modern-day gratitude movement has been criticized for overstating its potential benefits and pushing a Western, wealthy, and privileged perspective that can seem to ignore the realities of extreme suffering or systemic injustices. It’s also annoying to constantly be told that you should really be more thankful for stuff.

But part of the reason gratitude has become such a popular concept is due to bountiful research that does point to genuine emotional upsides. Feeling grateful has been associated with better life satisfaction, an increased sense of well-being, and a greater ability to form and maintain relationships, among other benefits. (The research on gratitude’s effects on physical health is inconclusive.) For me, though, the pull is less scientific and more commonsense anyway: Learning to genuinely appreciate day-to-day boons like having good health, or food in the fridge, seems like being able to tap into a renewable source of contentment. It’s always so easy to find stress in life. Let me remember the things to smile about, too.

One way to make the most of gratitude may be to reframe how people tend to think of it. A popular misconception, Emmons told me over email, is that gratitude is a positive emotion that results from something good happening to us. (This might also be part of the reason it can be hard to appreciate conditions like health that for many people remain stable day after day.) Gratitude is an emotion, but it can also be a disposition, something researchers call “trait gratitude.” Some people are more predisposed to feeling thankful than others, by virtue of factors like genetics and personality. But Emmons says this kind of “undentable thankfulness” can also be learned, by developing habits that contribute to more of a persistent, ambient awareness, rather than a conditional reaction to ever-changing circumstances.

What does this look like, practically speaking? “I don’t know that we can, with every breath we have every moment, feel grateful that we’re breathing. That’s a pretty tall order,” says Gordon. “But that’s not to say that you don’t build in a moment for it at some point in your day.” If you’re recovering from a cold, for example, you can practice pausing whenever you’re walking out the door to appreciate that your nose isn’t stuffy before just barreling on with life. Another tactic, from Emmons, is to reflect upon your worst moments, such as times you’ve been ill. “Our minds think in terms of counterfactuals,” he said, which are comparisons between the way things are and how they might have been. “When we remember how difficult life used to be and how far we have come, we set up an explicit contrast in our mind, and this contrast is fertile ground for gratefulness.”

Read: Don’t teach your kids to fear the world

You can also think of gratitude as an action, Emmons has written. This hews closer to the historical notion of gratitude, which as far back as the Roman days was associated with ideas like duty and reciprocity—when someone does something kind for us, we’re expected to return the favor, whether that’s thanking them, paying them back, or paying it forward. In that sense, being grateful for your body probably means doing your best to care for it (and, probably, refraining from risky behaviors like rolling the dice on discounted grocery-store sushi).

In 2015, Lauren Zalewski, the writer with fibromyalgia, founded an online community that supports people living with chronic pain by helping them to cultivate a grateful mindset. She tells me that before her diagnosis, she took her health for granted and “beat her body up.” Now, she eats vegan, takes supplements, does yoga, stretches, sleeps more, and gets sun regularly—these are the small things she has personally found helpful for managing her constant pain. “So while I am a chronically ill person,” she muses, “I consider myself pretty healthy.”

Looking back on my food-poisoning incident, I think I was primed to ruminate more deeply than usual on the topics of sickness and health. In the past two and a half years, I’ve watched COVID-19 show that anyone can get ill, perhaps seriously so. Now, as the head of the World Health Organization tells us that “the end is in sight” for the pandemic  (and President Joe Biden controversially declares the pandemic over), it’s tempting to imagine that humanity is on the brink of waking up the morning after a hellish sickness.

It’s probably delusional to hope that even a global pandemic could prompt some kind of long-term collective mental shift about the impermanence of health, and of life. I didn’t become a radically different person after recovering from puking my guts out a few months ago either. But maybe the simple act of remembering the health we still have in the pandemic’s wake can make a small difference in how we go forward—if not as a society, then at least as individuals. I’m sure I’ll never fully override my tendency to take my body for granted until it’s too late. But for now, each day, I still get the golden opportunity to try. And I’d like to take it.

Until recently, running was a major part of Emma Zimmerman’s life. The 26-year-old freelance journalist and graduate student was a competitive distance runner in college and, even after she graduated, logged about 50 miles per week. So she tentatively tried to return to her running routine roughly a week after a probable case of COVID-19 in March, doing her best to overcome the malaise that followed her initial allergy-like symptoms. Each time, though, “I’d be stuck in bed for days with a severe level of crippling fatigue,” Zimmerman says.

Months later, Zimmerman still experiences health issues including exhaustion, migraines, brain fog, nausea, numbness, and sensitivity to screens—a constellation of symptoms that led doctors to diagnose her with Long COVID. Though she can’t know for sure, she fears those workouts early in her recovery process may have worsened her condition.

“I had no idea that I should try to rest as hard as I needed to rest,” she says.

Stories like Zimmernan’s—illness, improvement, exercise, crash—are common in the Long COVID world. And they highlight what many researchers, patients, and advocates say is one of the most powerful tools for managing, and potentially even preventing, Long COVID: rest.

The only guaranteed way to avoid Long COVID is not to get infected by SARS-CoV-2. But if someone does get sick, “Rest is incredibly important to give your body and your immune system a chance to fight off the acute infection,” says Dr. Janna Friedly, a post-COVID rehabilitation specialist at the University of Washington who recovered from Long COVID herself. “People are sort of fighting through it and thinking it’ll go away in a few days and they’ll get better, and that doesn’t really work with COVID.”

Researchers are still learning a lot about Long COVID, so it’s impossible to say for sure whether rest can truly prevent its development—or, conversely, whether premature activity causes complications. But anecdotally, Friedly says many of the Long COVID patients she sees are working women with families who rushed to get back to normal as soon as possible. It’s hard to give one-size-fits-all guidance about how much rest is enough, but Friedly recommends anyone recovering from COVID-19 stay away from high-intensity exercise for at least a couple weeks and avoid pushing through fatigue.

For people who have already developed Long COVID, rest can also be useful for managing symptoms including fatigue and post-exertional malaise (PEM), or crashes following physical, mental, or emotional exertion. The U.S. Centers for Disease Control and Prevention recommends “pacing,” an activity-management strategy that involves rationing out activity and interspersing it with rest to avoid overexertion and worsening symptoms.

In an international study published last year, researchers asked more than 3,700 long-haulers about their symptoms. Almost half said they found pacing at least somewhat helpful for symptom management. Meanwhile, when other researchers surveyed about 500 long-haulers for a study published in April, the overwhelming majority said physical activity worsened their symptoms, had no effect, or brought on mixed results. That may be because long-haulers have impairments in their mitochondria, which generate energy cells can use, recent research suggests.

Before Long COVID existed, researchers and patients encouraged rest and pacing for the management of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). The condition’s hallmark symptoms include PEM and serious, long-lasting fatigue—diagnostic criteria that many people with Long COVID now meet. A study of more than 200 people with Long COVID published in January found that 71% had chronic fatigue and almost 60% experienced PEM.

For years, clinicians tried to treat ME/CFS patients by gradually increasing their physical activity levels. But that practice has since been shown to be not only ineffective, but often harmful, because people with ME/CFS “have a unique and pathogenic response to overexertion” due to cellular dysfunction, explains Jaime Seltzer, director of scientific and medical outreach at the advocacy group MEAction. Most people with ME/CFS prefer pacing over exercise-based therapy, one 2019 study found.

To pace effectively, people must learn to pick up on cues that they’re overdoing it and unlearn ingrained ideas about productivity, Seltzer says. “If you’re doing laundry, for example, there’s nothing that says you have to fold every single item in one sitting,” she says. Breaking up tasks may feel odd, but it can be crucial for preserving energy.

People with new Long COVID symptoms should keep a log of their diet, activity, sleep, and symptoms for a couple weeks to learn their triggers, Friedly says. For those who can afford one, a fitness tracker or other wearable can also be helpful for assessing how much exertion is too much, Seltzer says. Once someone has an idea of behaviors that improve or worsen symptoms, they can use that information to plan their days and divide activities into manageable chunks.

For many people who test positive for COVID-19, however, even taking a few days off from work to isolate is a financial and logistical challenge. Many people have no choice but to return to physically taxing work or responsibilities like child care as soon as possible. “Rest is absolutely advice that’s weighted socioeconomically and politically,” Seltzer says.

People with Long COVID or ME/CFS may be able to secure workplace accommodations, such as working from home, taking on a role that can be done sitting instead of standing, or applying for disability if necessary. Seltzer also suggests leaning on friends, faith groups, or mutual aid networks for help with some tasks. Beyond that, Friedly recommends looking for creative ways to use less energy throughout the day. When she was living with Long COVID symptoms, she bought many pairs of identical socks so she’d never have to waste time and effort searching for a match.

Things like that “may seem small,” she says, “but if you add those up throughout the day, they make a big difference in terms of how much energy you’re expending.”

Write to Jamie Ducharme at [email protected].

If you spend a lot of time online, you may have noticed that parts of the internet have caught fasting fever. Online message boards are awash in posts touting the benefits of time-restricted eating and other intermittent-fasting approaches that involve going without caloric foods or drinks for an extended period of time—anywhere from 12 hours to several days. These online testimonials have helped popularize intermittent fasting, and they often feature two common-sense rationalizations: One, that human beings evolved in environments where food was scarce and meals occurred sporadically; and two, that the relatively recent shift to near round-the-clock eating has been disastrous for our intestinal and metabolic health.

Mining the internet for accurate information, especially when it comes to dieting, can feel like panning for gold. You’ve got to sift through a lot of junk to find anything valuable. But this is one case where nuggets may be easy to find. A lot of the published peer-reviewed research on intermittent fasting makes the same claims you’ll find on those Reddit message boards. “Until recently, food availability has been unpredictable for humans,” wrote the authors of a 2021 review paper in the American Journal of Physiology. “Knowledge of early human evolution and data from recent studies of hunter-gatherer societies suggest humans evolved in environments with intermittent periods of food scarcity.” They say that fasting regimens may provide a period of “gut rest” that could lead to several meaningful health benefits, including improved gut microbe diversity, gut barrier function, and immune function.

The past decade has witnessed an explosion in fasting-relatedid research. (According to Google Scholar, the last five years alone contain almost 150,000 articles that examine or mention fasting.) While that work has helped established links between intermittent fasting and weight loss, as well as other benefits, it’s not yet clear when (or if) fasting can help fix a sick gut. “I would still consider the evidence moderate,” says Dr. Emeran Mayer, a professor of medicine and founding director of the Goodman Luskin Microbiome Center at the University of California, Los Angeles. “[Fasting] looks like a prudent way to maintain metabolic health or reestablish metabolic health, but it’s not a miracle cure.”

When it comes to gut conditions such as inflammatory bowel disease (IBD), he says the research is either absent or inconclusive. To his point, researchers have found that Ramadan fasting—a month-long religious period when people don’t eat or drink between sunrise and sunset—can substantially “remodel” the gut’s bacteria communities in helpful and healthy ways. However, among people with IBD, studies on Ramadan fasting have also found that a person’s gut symptoms may grow worse.

While it’s too early to tout fasting plans as a panacea for gut-related disorders, experts say there’s still reason to hope these approaches may emerge as a form of treatment. It’s clear that some radical, and perhaps radically beneficial, things happen when you give your body breaks from food.

How fasting could repair the gut

For a series of recent studies, a team of researchers based in the Netherlands and China examined the effects of Ramadan-style intermittent fasting on the gut microbiome—the billions of bacteria that reside in the human gastrointestinal tract. (Ramadan comes up a lot in published research because it provides a real-world opportunity for experts to examine the effects of 12- or 16-hour fasts, which is what many popular intermittent fasting diets espouse.) “We really wanted to know what intermittent fasting does to the body,” says Dr. Maikel Peppelenbosch, a member of that research team and a professor of gastroenterology at Erasmus University Medical Center in the Netherlands. “Generally, we’ve seen that intermittent fasting changes the microbiome very clearly, and we view some of the changes as beneficial. If you look at fasting in general, not only Ramadan, you see certain types of bacteria increasing.”

For example, he says that intermittent fasting pumps up the gut’s population of a family of bacteria called Lachnospiraceae. “In the intestines, bacteria are constantly battling for ecological space,” he explains. Unlike some other gut microorganisms, Lachnospiraceae can survive happily in an empty GI tract. “They can live off the slime the gut makes itself, so they can outcompete other bacteria in a fasting state.” Lachnospiraceae produces a short-chain fatty acid called butyrate, which seems to be critically important for gut health. Butyrate sends anti-inflammatory signals to the immune system, which could help reduce pain and other symptoms of gut dysfunction. Butyrate also improves the barrier function of the intestines, Peppelenbosch says. This is, potentially, a very big deal. Poor barrier function (sometimes referred to as “leaky gut”) is a hallmark of common GI conditions, including inflammatory bowel disease. If intermittent fasting can turn down inflammation and also help normalize the walls of the GI tract, those changes may have major therapeutic implications.

Lachnospiraceae is only one of several types of helpful bacteria that research has linked to fasting plans. But at this point, there are still a lot of gaps in the science. Peppelenbosch says the guts of people with bowel disorders don’t seem to respond to fasting in exactly the same way as the guts of people without these health issues. “In ill people, we see the same changes to the microbiome, but it’s not as clear cut as in healthy volunteers,” he says. “So we are now actually trying to figure out what’s going on there.”

Healthy microbiome shifts aren’t the only possible benefits that researchers have linked to intermittent fasting. UCLA’s Mayer mentions a phenomenon called the migrating motor complex. “This is rarely mentioned in fasting articles today, but when I was a junior faculty it was one of the hottest discoveries in gastroenterology research,” he says. The migrating motor complex refers to recurrent cycles of powerful contractions that sweep the contents of the gut, including its bacteria, down into the colon. “It’s this 90-minute recurring contractile wave that swoops down the intestine, and its strength is comparable to a nutcracker,” he says. Essentially, this motor complex behaves like a street-cleaning crew tidying up after a parade. It ensures the gut is cleared out and cleaned up in between meals, via 90-minute repeating cycles that fasting allows to be become more frequent. It also helps rebalance the gut’s microbial populations so that more of them are residing in the colon and lower regions of the GI tract. “But it’s stopped the minute you take a bite—it turns off immediately,” he says.

Mayer says that modern eating habits—so-called “grazing,” or eating steadily throughout the day—leave little time for the migrating motor complex to do its thing. “This function has been relegated to the time when we sleep, but even this has been disrupted because a lot of people wake up in the middle of the night and snack on something,” he says. “So those longer periods of time when we re-cleanse and rebalance our gut so that we have normal distributions of bacteria and normal population densities—that has been severely disturbed by these lifestyle changes.”

Ideally, Mayer says people could (for the most part) adhere to the kind of time-restricted eating program that allows a full 12-to-14 hours each day for the motor complex to work. “If you don’t snack, this motor complex would happen between meals, and you’d also get this 12- to 14-hour window at night where the digestive system was empty,” he explains. In other words, sticking to three meals a day and avoiding between-meal bites (or nighttime snacks) could be sufficient. But again, it’s not clear whether this sort of eating schedule can undo gut damage or treat existing dysfunction.

Read More: The Truth About Fasting and Type 2 Diabetes

More potential benefits

Another possible perk of fasting involves a biological process called “autophagy.” During autophagy, old or damaged cells die and are cleared away by the body. Some researchers have called it a helpful housekeeping mechanism, and it occurs naturally when the body goes without energy (calories) for an extended period of time. There’s been some expert speculation, based mostly on evidence in lab and animal studies, that autophagy could help strengthen the gut or counteract the types of barrier problems seen in people with IBD. But these improvements have not yet been demonstrated in real-world clinical trials involving people.

Meanwhile, some experts have found that fasting may help recalibrate the gut’s metabolic rhythms in helpful ways. “By changing the timing of the diet, this will indeed change activity of the
microbiome, and that may have downstream impacts on health,” says Dr. Eran Elinav, principal investigator of the Host-Microbiome Interaction Research Group at the Weizmann Institute of Science in Israel.

Some of Elinav’s work, including an influential 2016 paper in the journal Cell, has shown that the gut microbiome undergoes day-night shifts that are influenced by a person’s eating schedule, and that lead to changing patterns of metabolite production, gene expression, and other significant elements of gut health. “If you change the timing of diet, you can flip the circadian activity of the microbiome,” he says. This is likely to have health implications, though what those are, precisely, remains murky.

Read More: What We Know About Leaky Gut Syndrome

Fasting isn’t going anywhere

It’s clear that when you eat, including how often you eat, matters to the health of your gut. But the devil’s in the details. At this point, it’s not clear how intermittent fasting can be used to help people with gut-related disorders or metabolic diseases.

“For a condition like IBD, it’s important to differentiate between what you do during a flare and what you do to prevent the next flare,” Mayer points out. The research on people observing Ramadan suggests that, at least during a flare, fasting may make a person’s IBD symptoms worse. Figuring out whether fasting could also lead to longer-term improvements is just one of many questions that needs to be answered.

While plenty of unknowns remain, experts say that common approaches to fasting appear to be safe for most people. Time-restricted eating, for example, involves cramming all your day’s calories into a single six-to-eight-hour eating window. Even among people with metabolic diseases such as Type 2 diabetes, research suggests that this form of fasting is safe, provided a person is not taking blood-glucose medications.

That said, there simply isn’t much work on intermittent fasting as a treatment for gut problems. Also, there is very little research on more extreme forms of fasting, such as plans that involve going without calories for several days at a stretch. These diets may turn out to be therapeutic, but they could also turn out to be dangerous. If you’re considering any of these approaches, talk with your health care provider first.

“We really need much better studies to compare all the different fasting protocols,” says Peppelenbosch. “But generally speaking, increasing the space between calorie consumption is a good thing for you. The body is not made to be eating all day.”

Contact us at [email protected].

9/23/2022|9:04

Wastewater surveillance uses local sewer systems to measure the health of the population and can be especially useful to detect infectious diseases that can be asymptomatic. The practice is currently being used to combat COVID-19 and could be a useful tool to fight Monkeypox and the resurgence of polio.

A recent study published in PLOS One and conducted by Beth Israel Deaconess Medical Center researchers in Boston reveals virtual reality use during hand surgery led to significant reductions in intraoperative anesthetic without negatively impacting patient-reported outcomes. 

In a small, eight-month randomized controlled trial, researchers evaluated 34 patients undergoing hand surgery and the amount of anesthesia administered intraoperatively in conjunction with or without VR use.

The VR group received significantly less propofol per hour than the control group. Notably, post-anesthesia care unit (PACU) length of stay was markedly decreased in the VR group, with patients discharged from the PACU 22 minutes earlier than control patients.

Patients were divided into a control group, provided anesthesia as recommended by an anesthesiologist during surgery, and a VR group, which viewed programming of their choice via a virtual reality headset and noise-canceling headphones.

The virtual programming, provided by telehealth VR clinic company XRHealth, was designed to promote relaxation and calmness, such as a peaceful meadow, forest or mountain top. Patients could also listen to a guided meditation in the immersive environments or select from a library of videos on a web-based user interface displayed as a theater screen surrounded by a “starry sky” background. 

WHY IT MATTERS

A common practice for anesthesia during hand surgery combines regional anesthesia administered before surgery and monitored anesthesia care during surgery. 

Although patients receive anesthesia preoperatively, they may need additional anesthesia intraoperatively, which can result in oversedation and potentially avoidable complications. 

Researchers in the above study noted, “VR could prove to be a valuable tool for patients and providers by distracting the mind from processing noxious stimuli resulting in minimized sedative use and reduced risk of oversedation without negatively impacting patient satisfaction.”

However, they did report limitations within the study, including participants being aware of the possibility of reduced sedative dosage. There could also be selection bias, as results from patients who agreed to minimal sedation may not be generalizable to the population as a whole.

Also, providers in the study were not blinded, which could have contributed to the dramatic differences in Propofol dosing between groups, researchers wrote. 

“Because of the potential for bias to influence both of these outcomes, our results should be interpreted as preliminary and needing validation in future trials. Further, given these major limitations, our results are therefore best suited to describe how the incorporation of VR immersion into current anesthesia practice for hand surgery can compare with the standard of care, not to serve as proof that VR is an effective pain control modality or is superior to other distraction techniques,” researchers noted. 

THE LARGER TREND

Extended reality (i.e., virtual, augmented and mixed reality) is currently used in various forms within the operating room and affects patients and surgeons.

Surgeons use augmented reality technology via Augmedics’ xvision system, for spine surgery. Augmedics’ technology allows a surgeon to see a 3D model of a patient’s spine during implant surgery and has demonstrated 99.1% percutaneous screw placement accuracy. 

Precision XR’s Surgical Theater enables surgeons to visualize a surgical experience by inputting 3D-imaging models into virtual reality. Providers perform a conventional scan of a patient’s body (MRI, CT scan, etc.). That scan is reconstructed into a 3D image in virtual reality for surgeons to analyze in-depth to prepare for an operation.  

Headspace Health has revealed two acquisitions this year, the latest coming earlier this month when the digital mental health company announced the purchase of mental wellness app Shine. 

In a crowded field of mental health startups, the company is using acquisitions to augment its product and add new capabilities. Leslie Witt, Headspace’s chief product and design officer, said the Shine deal is part of a larger effort to offer content that caters to the needs of more groups, including people of color, women and the LGBTQIA+ community. 

Headspace Health also scooped up Sayana, maker of AI-enabled mental health-tracking and sleep apps. And Headspace itself is the result of a merger between meditation app Headspace and virtual mental healthcare company Ginger, which closed nearly a year ago. 

Witt sat down with MobiHealthNews to discuss the company’s acquisition strategy, how its offering may change in the future and what’s next for the competitive digital mental health sector.

MobiHealthNews: So, this wasn’t Headspace’s first acquisition this year. How do you choose your acquisition targets? Do you think you’ll continue at a similar pace?

Leslie Witt: I think, as I’m sure you’re seeing, the long-rumored consolidation of mental health and behavioral health areas is starting to happen. In some ways, the biggest part of our story that merges with that is the merger of Ginger and Headspace proper. 

But we see a lot of opportunity across three lenses. Most of the acquisitions that we’ve made, both as a combined entity and some of the ones that we’ve made separately, fit the lens of either content that aligns with our core mission and helps to augment our reach from a self-serve mental health perspective, capabilities that bring new levels of tech — particularly around AI, conversation and community — and then talent.

All of these have been in the frame of small tuck-ins, where we’re not looking to sustain their offering as a stand-alone, but instead to incorporate the talent that they bring to the table into our core areas of prioritization, to accelerate our capability building and then to augment our content libraries.

MHN: You’ve been at Headspace for about two years, not too long before the merger with Ginger. How has the experience changed from the product point of view?

Witt: I’ll share with you a bit of why I joined Headspace, which was fundamentally to answer what we were hearing from our potential members — often members who came in and then didn’t find what they needed, which was higher-acuity mental health services and care. And from our enterprise buyers, they were seeing this well-loved brand, a well-known brand that was attracting 30%, 50% of their employee base to sign up and open a front door to care. 

But that front door only led so far. I fundamentally believe in the power of mindfulness and meditation tools, but they can’t serve all mental health needs. And particularly when someone’s in a state of acute anxiety, acute depression, they need access to professional, human services. 

For Headspace, it led to a direct realization that we had no viable and fast paths forward without merging, and Ginger was the perfect partner to pair with. We’ve been working across that landscape of services for the last year to ensure that we truly can open the front door to care for all. That we can learn who you are, what you need, assess your goals, triage you in a personalized capacity to the right kind of handoff of care, to the right beginning. And get you on a path where we’re really establishing the dimensions of a lifelong mental health journey, helping you build habits of practice that give you deeper self-care capability that then can scale up when the need occurs. 

MHN: What are some of your goals to change your offering in the future?

Witt: One is personalization – not just of services, but of measurement and outcome – so that we can continuously be in a learning and improvement loop where we understand what you need from the onset, serve up the right thing, evaluate whether or not that actually had efficacy for you, and do that both at the level of the individual and in aggregate.

We are building out what I often call the middle piece, the bridge that exists between the self-serve content in the Headspace app and the text-based coaching, teletherapy and telepsychiatry of the Ginger service. 

To really focus on more clinical content and programmatic content, we have launched a stress program. That’s a 30-day program that really takes you in a clinical and behavioral science-backed way from an introduction to stress reduction into a habit and practice of stress reduction. We’re doing the same across anxiety and sleep, and see a lot of potential to begin to hybridize the interplay between coaching and that human level of support into the core product itself. 

And then, last but not least, I think we have a lot of opportunity around community. We see folks almost engaging in kind of cohort-based ways around certain areas of content. [For example,] we see people coming to Headspace in moments of grappling with infertility and see a lot of potential and desire to begin to link community and peer-based support.

MHN: There are a lot of digital mental health companies right now, and you mentioned earlier we may be at the beginning of a combination wave. How do you think the space overall will change this year?

Witt: Some of the ways that I see the game changing is that we are going back to, in very good ways, some of our pre-COVID norms. And with that, I think there’s a lot of pressure on [figuring out] what is the persistence, the relevance of telehealth.

What we are generally finding is that, of all of the telehealth services, the ones that are the most sticky in a digitally delivered format are actually behavioral health.

We are beginning to lean into addressing some of that adolescent mental health crisis. I think that is under-tackled right now. And as a mom of 11-year-old twins who sees what is happening within that landscape, there needs to be more entrants in this space. And we need to celebrate those who’ve already been there and make sure that their ability and access is continued to be expanded for all. 

We also are seeing where enterprises played an outsized role in leaning into employee access to mental health services. More and more need and buy-in is coming through from the public sector. We have a relationship with L.A. County, and we see a lot of potential to partner with governments, with educational institutions, and more broadly with health systems in order to ensure that the goals of health parity and health equity are met.

JAMA Health Forum published a cross-sectional study suggesting reimplementing that licensure restrictions on out-of-state telemedicine, which were lifted due to the COVID-19 pandemic, would have the most significant effect on patients living near a state border, those in rural locations, and those receiving primary care or mental health treatment. 

“Relaxation of state restrictions would likely offer immediate convenience to patients who live near a state border and those receiving primary care and mental health treatment,” the study’s authors wrote. “These patients are subject to an accident of geography; two patients receiving the same care may have very different experiences. A patient with a primary care physician who lives in the middle of a state can access care via telemedicine. However, a similar patient living near a state border with a primary care physician in the neighboring state now will have to physically travel to that appointment.”

WHY IT MATTERS

When COVID-19 emerged, many states temporarily allowed physicians to provide care in states in which they did not hold a license, thus allowing for the increased availability of providers to those in areas with fewer medical facilities and resources. 

Researchers aimed to determine which patients and specialties were using out-of-state telemedicine visits among Medicare beneficiaries during COVID-19. They analyzed 100% Medicare fee-for-service (FFS) claims from January through June 2021.  

This period was chosen because it was after the impact of the early pandemic, when vaccines were available and the healthcare system stabilized but before temporary licensing regulations began to lapse. 

Researchers noted that in the first half of 2021, 8,392,092 patients had been seen by a provider via telemedicine, 5% of which had one or more telemedicine visits with an out-of-state provider.

Patients living in a county close to a state border accounted for 57.2% of all out-of-state telemedicine visits, and 64.3% of those out-of-state visits were with a primary care or mental health clinician. In 62.6% of all out-of-state visits, prior in-person visits occurred between the same patient and healthcare provider.

Compared with patients who only had in-state telehealth appointments, those accessing out-of-state care were more likely to be dual-eligible for Medicaid and live in rural areas. 

Researchers note there are limitations to their analysis, including its concentrated focus on the Medicare population, and its evaluation based on the patient’s home address and the clinician’s practice address, which could be inaccurate. They also focused on patients who had in-state and out-of-state telemedicine visits, not ones who had telemedicine visits in general.