TIME health

This Map Shows the Deadliest Counties in the U.S.

New rankings show the places in the U.S. that have largest percentage of people who die before the age of 75

Oglala Lakota County, South Dakota, is the deadliest county in America, at least by one measure: it is the place where residents are most likely to die before the age of 75, which health experts consider premature death.

The new edition of County Health Rankings from the University of Wisconsin Population Health Institute, places the county — which until very recently was called Shannon County — at the bottom of the class in the number of people who died before age 75, a common measure of public health.

Oglala Lakota County sits inside the Pine Ridge Indian Reservation, whose residents suffer from a number of well-documented health problems. While South Dakota has a number of counties with high rates of premature deaths, the unhealthiest region in the U.S. is arguably the heart of Appalachia, from eastern Kentucky into southwest Virginia and southern West Virginia. Many of the counties have rates of smoking and obesity north of 30% of the population.

The annual health rankings use a measure called “premature age-adjusted mortality” from the Centers for Disease Control and Prevention as one of their main indicators of overall health. This factor uses statistical methods to adjust for the overall distribution of ages in a county, so that one can compare mortality in any two counties independent of whether one has an overall younger population than the other.

Across the country, the median value for this figure is 376 people per 100,000, meaning 0.38% of population will die before age 75 in a given year. (That’s all people, not just those who pass away.) The value for Oglala Lakota County is 983.4, while the lowest in the nation, in Pitkin, Colo., is 118.5.

A sufficient sample size was not available for 69 counties, colored white in this map. The 25 counties with the lowest mortality rates and the 25 counties with the highest rates are listed below.

25 Counties With Lowest Mortality Rates

County Mortality Rate
1 Pitkin, Colo. 118.5
2 Summit, Colo. 121
3 Presidio, Texas 126.3
4 Mono, Calif. 148.5
5 Eagle, Colo. 148.7
6 San Miguel, Colo. 153.2
7 Custer, Colo. 163.9
8 Teton, Wyo. 164.1
9 Hartley, Texas 167
10 Douglas, Colo. 169.3
11 Fairfax, Va. 172.5
12 Ouray, Colo. 173.6
13 Aleutians West, Alaska 173.7
14 Loudoun, Va. 176.8
15 Morgan, Utah 177.8
16 Montgomery, Md. 178.9
17 Lincoln, S.D. 179.2
18 Summit, Utah 181.7
19 Sublette, Wyo. 183
20 Leelanau, Mich. 183.2
21 Marin, Calif. 185.3
22 Howard, Md. 190.1
23 Blaine, Idaho 191
24 Carver, Minn. 191.5
25 Los Alamos, N.M. 194

25 Counties With Highest Mortality Rates

County Mortality Rate
1 Shannon, S.D. 983.4
2 Todd, S.D. 878.2
3 McDowell, W.Va. 861.2
4 Sioux, N.D. 834.5
5 Dewey, S.D. 811.4
6 Corson, S.D. 792.6
7 Union, Fla. 780.6
8 Owsley, Ky. 777.6
9 Robertson, Ky. 745.4
10 Perry, Ky. 742.7
11 Leslie, Ky. 737.5
12 Powell, Ky. 736.8
13 Wyoming, W.Va. 731.4
14 Wolfe, Ky. 724.2
15 Roosevelt, Mont. 716.9
16 Tunica, Miss. 713.8
17 Breathitt, Ky. 712.3
18 Buffalo, S.D. 711.2
19 Clay, Ky. 705.3
20 Bolivar, Miss. 702.6
21 Benson, N.D. 700
22 Knott, Ky. 696.2
23 Mingo, W. Va. 695.5
24 Harlan, Ky. 686.5
25 Floyd, Ky. 685.5

Read next: These Are the American Cities With the Highest (and Lowest) Unemployment

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TIME neuroscience

How Air Pollution Affects Babies in the Womb

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A new study finds evidence that prenatal exposure to common pollutants can contribute to hyperactivity, aggression and more in kids

It makes sense that an expectant mom’s exposure to pollutants in the air can affect her still-growing baby’s lungs and respiratory system. But there’s increasing evidence that such compounds can also harm brain development and contribute to behavioral and cognitive problems later in childhood.

In the latest study on the subject, published in JAMA Psychiatry, researchers for the first time pinpointed exactly which areas of the brain are affected if a baby is exposed to car exhaust and the byproducts of burning home heating oil. These polycyclic aromatic hydrocarbons (PAHs) have previously been linked to developmental delays, lower verbal IQ. signs of anxiety depression and problems with attention. But researchers haven’t been able to identify which areas of the brain are most vulnerable.

MORE: Children Exposed to More Brain-Harming Chemicals Than Ever Before

In this study, they recruited 40 mothers and their children living in the inner city who were participating in an ongoing study of pollution’s effect on development. They were selected because they had low exposure to environmental factors other than PAHs that could affect development, such as tobacco smoke, lead, insecticides and other chemicals. Based on measurements of PAH in their surroundings, about half of the mothers had PAH exposures below the median of those in the larger group, and half had PAH exposures higher than the median.

“The effects were extraordinarily powerful,” says Dr. Bradley Peterson, director of the Institute for the Developing Mind at Children’s Hospital Los Angeles and lead author of the study. “The more prenatal exposure to PAH, the bigger the white matter problems the kids had. And the bigger the white matter problems, the more severe symptoms of ADHD, aggression and slow processing they had on cognitive tasks.”

MORE: Mom’s Exposure to Air Pollution Can Increase Kids’ Behavior Problems

White matter is made up of the fibrous connections between nerve cells and is critical to helping neurons from one part of the brain communicate with their counterparts in other regions, and the babies with the highest exposure to PAH in the womb showed a dramatically lower volume of white matter in the left side of their brains. The entire left hemisphere, from the front to the back, was affected. “You would assume that an environmental exposure brought in by the blood and circulating to the brain would affect both sides of the brain,” says Peterson. “But the adverse effects of PAHs is located on one side; that’s surprising.”

The asymmetrical effect speaks volumes about how PAHs target brain tissue. Like other neurotoxins, they may preferentially seek out actively developing tissue. During gestation, the left side of the brain, which houses language capabilities, may be undergoing more intense structural changes in preparation for birth. This was supported by the fact that in the larger group of children in the study, those who were exposed to PAHs around age five didn’t show the same left-sided bias; in the older children, the pollutants affected both sides equally because the right hemisphere of the brain is undergoing active development at that time as well.

MORE: ADHD Linked to the Air Pregnant Women Breathe

Peterson suspects that the connection between PAHs and later behavioral and cognitive symptoms such as inattention, hyperactivity and slow processing speed may be due to how PAHs disrupt the normal communication between nerves in the left side of the brain and elsewhere.

The problem, he admits, is that moms-to-be can’t easily change where they live or work. And most people aren’t aware of how many PAHs they absorb on a daily basis. There are ways to minimize the risk of exposure, however. Expectant mothers can avoid secondhand smoke, a major source of the compounds. Not directly inhaling exhaust from cars on busy streets or smoke from fireplaces can also help, as can spending as much time as possible in parks or other areas free of burning fuels. It won’t eliminate the risk from living in an inner city and being surrounded by car emissions, but it can help, Peterson says. “Even if you can reduce your exposure from moderately high to moderate levels, it’s going to have a beneficial effect on the developing fetus,” he says.

TIME toxins

You Asked: Should I Dry Brush My Skin?

Illustration by Peter Oumanski for TIME

There may be benefits, but reducing cellulite isn’t one of them.

If you’re wondering what dry brushing is, the practice is exactly what it sounds like: Running a dry, soft-bristle brush over your bare skin. Methodologies vary, but most practitioners and beauty blogs recommend brushing your limbs and torso, always motioning toward your heart. Do this for a few minutes every day, they say, and you’ll increase blood flow and circulation, which will help your body and lymphatic system clear away toxins. Dry brushing is also thought to reduce cellulite and exfoliate, leaving your skin softer, more toned and better hydrated.

Unfortunately, there’s not much research to back up these health claims. “I know dry brushing is popular, but the actual benefits are unclear,” says Dr. Tina Alster, director of the Washington Institute of Dermatologic Laser Surgery and a clinical professor at Georgetown University.

Alster says that rubbing the skin—with a brush, your hand or anything else—will increase blood flow and circulation, giving your skin a flushed, youthful and “slightly swollen” appearance. (The same thing happens if you pinch your cheeks.) But your skin will return to normal very quickly after you’ve stopped brushing it, Alster says. There’s no evidence this temporary surge in blood flow will help your body remove waste or toxins, she adds.

Dry brushing will clear away dead skin cells. But exfoliating isn’t necessary for those in their teens and twenties. “When you’re young, your skin’s outermost layer will automatically turn over without any mechanical help,” Alster explains. Beginning in your thirties and increasing as you age, Alster says your skin’s cells can grow “stickier,” which can lead to accumulation and a dull appearance. “Exfoliation can help remove those stuck-together cells,” she says. “But you want to do it very gently and infrequently, or you may do more harm than good.”

Brushing too frequently or vigorously—or using a brush with rough bristles—could cause “micro-cuts” in your skin that may lead to infection, Alster says. Exfoliating more than once a week could also break down your skin’s protective barriers, leaving your hide less hydrated and prone to irritation, says Dr. Marc Glashofer, a New York-based dermatologist and member of the American Academy of Dermatology. For that reason, Glashofer says people with eczema or dry skin should avoid dry brushing altogether.

Glashofer mentions a common skin condition called keratosis pilaris (KP), which consists of many small rough bumps that tend to show up on the backs of arms and thighs. Dry brushing these areas could theoretically be beneficial, he says, but there’s no evidence yet.

And when it comes to reducing cellulite, both Glashofer and Alster say there’s nothing to back up such claims. “If brushing the skin twice per day would eliminate cellulite, you would have heard a lot more about it and there’d be some scientific proof,” Glashofer says.

Of course, not everything that benefits your body is easily captured by medical research. From meditation to massage, many practices once dismissed by clinicians have recently been linked to meaningful psychological and physical benefits. It’s possible dry brushing may one day fall into this category, but that day hasn’t arrived yet.

“If you like dry brushing and your skin looks good, that’s fine,” Alster says. “But would I encourage it as a dermatologist? Definitely not.”

TIME Diet/Nutrition

The Dangers of Buying Breast Milk Online: Study

Baby bottles with days of the week on adhesive notes
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Experts are urging women to avoid this dangerous market

In the DIY corner of the internet, buying, selling and trading breast milk is a booming online business—and that’s a dangerous thing, according to a new editorial in The BMJ.

A multidisciplinary team of researchers decided to investigate the practice whereby new mothers buy breast milk from strangers online and feed it to their infants. It’s a practice the researchers conclude is growing—and fastest in the U.S. Some women unable to breastfeed see it as a healthier alternative to formula, and online breast milk is often cheaper than the kind you find at a regulated milk bank, where the milk is screened, collected, pasteurized and stored according to strict protocol, the authors say.

MORE: I Bullied Myself Into Breastfeeding

But the online market for breast milk is almost entirely unregulated and it can put young children at risk. There are no requirements to test sellers for diseases that may transmit by drinking breast milk, like HIV and hepatitis B and C, the piece says. In one 2013 study, a different group of researchers discovered that 21% of milk samples bought online tested positive for cytomegalovirus, a type of herpes virus that spreads through secretions and can have a long-term impact on the immune system.

The health concerns extend beyond hidden viruses, the researchers point out. Another study found that of 101 breast milk samples bought online, 92 of them had detectable bacterial growth—partly because they weren’t pasteurized, and partly because a quarter of them shipped so poorly that they arrived unfrozen or damaged. And breast milk, like most other liquids for which people pay a premium, seems to be a magnet for fraud. Cow’s milk, water and even soy milk are sometimes added as adulterants to dilute breast milk and increase its volume, says editorial co-author Sarah Steele, lecturer at the Global Health, Policy and Innovation Unit at Queen Mary University London.

MORE: 2,500 Tons of the Food We Eat Is Fake

“As our research has revealed, 75% of mothers go online when they have an issue with infant feeding,” Steele says. “They resort to the internet to find out the information, usually because they’re embarrassed, or because they feel like they’re failing their infant, or because they’re exhausted.” But even though mothers are readily discovering this alternative feeding source, doctors aren’t talking about it, Steele says.

Infants aren’t the only ones drinking breast milk. Some bodybuilding websites tout it as a “natural superfood” for adults or a drink for “post-workout recovery,” Steele says—but the same risks for virus transmission apply.

In the piece, Steele and her co-authors call for more regulation of the industry. “Even healthcare professionals aren’t entirely aware of just how dangerous it is and just how many samples are contaminated,” she says. Despite these risks, “It’s not a small industry,” Steele says. According to her data, one milk-selling website, OnlyTheBreast.com, had 27,000 members last year and gains 700-800 each month.

TIME neuroscience

Your Brain Learns New Words By Seeing Them Not Hearing Them

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Chris Ryan—Getty Images/Caiaimage

To be a really proficient reader, it’s not enough to “hear” words. You also have to see them

We start to talk before we can read, so hearing words, and getting familiar with their sounds, is obviously a critical part of learning a language. But in order to read, and especially in order to read quickly, our brains have to “see” words as well.

At least that’s what Maximilian Riesenhuber, a neuroscientist at Georgetown University Medical Center, and his colleagues found in an intriguing brain-mapping study published in the Journal of Neuroscience. The scientists recruited a small group of college students to learn a set of 150 nonsense words, and they imaged their brains before and after the training.

Before they learned the words, their brains registered them as a jumble of symbols. But after they were trained to give them a meaning, the words looked more like familiar words they used every day, like car, cat or apple.

MORE: Mistakes to Avoid When Learning a Foreign Language

The difference in way the brain treated the words involved “seeing” them rather than sounding them out. The closest analogy would be for adults learning a foreign language based on a completely different alphabet system. Students would have to first learn the new alphabet, assigning sounds to each symbol, and in order to read, they would have to sound out each letter to put words together.

In a person’s native language, such reading occurs in an entirely different way. Instead of taking time to sound out each letter, the brain trains itself to recognize groups of letters it frequently sees together — c-a-r for example — and dedicates a set of neurons in a portion of the brain that activates when these letters appear.

In the functional MRI images of the volunteers’ brains, that’s what Riesenhuber saw. The visual word form area, located in the left side of the visual cortex, is like a dictionary for words, and it stores the visual representation of the letters making up thousands of words. This visual dictionary makes it possible to read at a fast pace rather than laboriously sounding out each letter of each word every time we read. After the participants were trained to learn the meaningless words, this part of their brains was activated.

MORE: An Infant’s Brain Maps Language From Birth, Study Says

“Now we are seeing words as visual objects, and phonetics is not involved any more,” he says. “We recognize the word as a chunk so we go directly from a visual pattern to the word’s meaning, and we don’t detour to the auditory system.”

The idea of a visual dictionary could also help researchers to better understanding reading or learning disorders like dyslexia. More research could reveal whether the visual word form area in people with such disabilities is different in any way, or whether they tend to read via more auditory pathways. “I helps us understand in a general way how the brain learns, the fastest way of learning, and how to build on prior learning,” says Riesenhuber.

TIME Diet/Nutrition

There Might Be More Nutritious Chocolate On the Horizon

Chocolate Splash
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Researchers create a new process to make chocolate richer in antioxidants

Scientists are looking to make chocolate a not-so-guilty pleasure.

Emmanuel Ohene Afoakwa, a professor of food science and technology at the University of Ghana, and his team have figured out a new process for making chocolate that’s healthier and contains more antioxidants. Chocolate’s antioxidants are thought to be responsible for some of its health perks related to cardiovascular health and memory support. Capitalizing on those antioxidants could not only provide better nutrition, but could be of interest to the candy industry. The researchers presented their process at the American Chemical Society’s national meeting in Denver on Tuesday.

Afoakwa and his team showed that tweaks to the storage and roasting processes can result in chocolate with more healthy compounds, but still the same sweet flavor.

The trick is to intervene in one of the many steps before cocoa turns into the chocolate. In typical chocolate-making, pods are first taken from cocoa trees and the cocoa beans are extracted, fermented and roasted. But during the roasting process many of the polyphenols, or antioxidants, in cocoa beans are lost. To protect them, the researchers decided to add a storage step to the process. They split 3oo pods into four different storage groups: no storage, three-day storage, seven-day storage and 10-day storage. The researchers found that seven days of storage resulted in the highest antioxidant levels after roasting.

Next, the researchers experimented with the roasting process, since that’s when most antioxidant content is lost. Normally beans are roasted for 10 to 20 minutes at 248-266 degrees Fahrenheit, the researchers say, but they decided to slow the process down and instead roast the beans at 242 degrees for 45 minutes. The lower temperature and longer roasting process also resulted in higher antioxidant activity compared to the beans that went through the usual roasting.

“I have been working on cocoa for some time, and my interest is on creating techniques that can enhance the flavor and the quality of the beans,” says Afoakwa. “We’re trying to find out how some of these practices can be enhanced to help farmers produce beans of higher quality.”

Afoakwa says his team recommends consumers choose dark chocolate over milk or white chocolate since dark chocolate typically has more antioxidants and less sugar. The researchers are continuing to identify changes to the chocolate-making process that could increase the candy’s nutritional content. The researchers are currently receiving funding from the Belgium government.

“We believe there will be a high benefit for confectionary industry,” Afoakwa says.

TIME Research

Study Links Widely Used Pesticides to Antibiotic Resistance

Tractor and crop sprayer spraying in field
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Glyphosate, 2,4-D, and dicamba found to affect bacteria in ways that could promote resistance to common antibiotics

This has not been a good week for glyphosate, the active ingredient in Roundup and other herbicides. On Friday, the World Health Organization (WHO) announced that it had classified glyphosate, the United States’ most widely used pesticide, as “probably carcinogenic to humans.”

Now, the chemical has another strike against it. A new study published by the American Society of Microbiology’s journal mBio has linked glyphosate and two other widely-used herbicides–2,4-D and dicamba–to one of the most pressing public health crises of our time: antibiotic resistance.

This study found that exposure to these herbicides in their commercial forms changed the way bacteria responded to a number of antibiotics, including ampicillin, ciprofloxacin, and tetracycline–drugs widely used to treat a range of deadly diseases.

Dicamba, 2,4-D, and glyphosate have been in use for decades, so why have their antibacterial-resistance effects not been documented before? As the study’s lead author, Jack Heinemann, professor of genetics at the University of Canterbury in New Zealand, explains, when pesticides are tested for adverse effects, “it’s the lethal toxicity that people focus on.” In other words, how much of the chemical will kill an organism.

“What makes our study different, is that it is looking at a sub-lethal effect,” says Heinemann. “The effect we see requires that the bacteria stay alive.”

Previous studies done by other researchers have found that substances chemically similar to dicamba and 2,4-D can cause antibiotic resistance, Heinemann explains. So he and his colleagues decided to investigate whether these herbicides would produce similar effects. They added glyphosate to the study because it is chemically unlike the other two. But, to their surprise, it also produced some antibiotic resistance.

Heinemann explains that because these herbicides are not “supertoxic” to the bacteria the study tested—E. coli and Salmonellathey are not killed outright at levels typically used to kill weeds. Instead, the bacteria stay alive while activating proteins known as efflux pumps in order to rid themselves of toxins. And this defense mechanism can make the bacteria develop resistance to the threat from which it is defending itself.

Scientists know that overuse of antibiotics in humans can decrease their effectiveness. In the same way, says Heinemann, “exposure to these pesticides make the pathogens stronger.”

Although this study only looked at two laboratory strains of human pathogens, the antibiotics examined represent what he calls “broad classes” of drugs we’ve come to depend on to fight infections and the herbicides are three of the most-used worldwide.

Heinemann also notes that the different pesticides produced a variety of responses. While all three produced an antibacterial-resistant response to some of the antibiotics, some of the combinations his team tested produced no response and some increasedthe antibiotic’s effect.

Although the study is likely to be seen as controversial by some, University of Massachusetts Dartmouth assistant professor of biology, Dr. Mark Silby says it “followed established protocols” and the existing scientific literature supports its findings.

“This is a very carefully designed study,” says Dr. Michael Hansen, a senior staff scientist at Consumers Union. “It’s incredibly important work showing the complexity of an effect that hadn’t been thought about before.” The mechanisms by which the bacteria respond to toxics–in this case herbicides–are already well-known, Hansen explains. What’s new and important is looking at non-lethal levels of exposure in combination with the antibiotics.

The weed-killers used in the study were purchased at a local store and were used at levels specified in use directions, which means the scientists were testing chemicals actually in use worldwide rather than a special laboratory sample of the active compound.

How could any of this affect people?

“These herbicides are now used at such a scale that we can almost use the term ubiquitous,” says Heinemann. For one, glyphosate is used on about 94 percent of the soybeans and 89 percent of the corn grown in the U.S, while 2,4-D is the third-most widely used herbicide in the U.S., while dicamba ranks fifth in use worldwide.

The levels at which the researchers saw effects were higher than the residues allowed on food, but below what is often used in rural settings, says Heinemann.

The results of Heinemann’s study suggest there is probably a small chance that exposure through food would produce these effects, but they could be a concern in areas where the pesticides are being applied, says Hansen. Thus, the people most likely to be affected are farmers, farmworkers, and other people who live in agricultural communities.

Also to consider is the approval earlier this year of a new pesticide that combines glyphosate and 2,4-D and soybean and cotton seeds genetically engineered to resist dicamba, all of which are expected to increase use of these pesticides.

Pesticide-induced antibiotic resistance could also affect honeybees since many commercial hives are now being treated with antibiotics. It’s possible, Heinemann says, that “comingling of antibiotics and herbicides could be compromising the effectiveness of those antibiotics,” and thus honeybee health.

Meanwhile, Monsanto says it disagrees with WHO’s announcement on glyphosate. “All labeled uses of glyphosate are safe for human health and supported by one of the most extensive worldwide human health databases ever compiled on an agricultural product,” the company says in a statement on its website.

Neither Monsanto nor other pesticide manufacturers have had the opportunity to respond to the new mBio study. But the Council for Biotechnology Information said on its website “GMO Answers” last month, that glyphosate had once been considered for use as an antibiotic but that “levels needed to kill microbes are relatively high, and resistance can develop readily.” In other words, the phenomenon Heinemann and colleagues observed is not entirely unexpected.

“A jigsaw puzzle is a good metaphor,” for how these effects fit together, says the scientist.

The next steps in this research will be to test additional bacteria and pure samples of the pesticides. But for now, it’s clear that “further work is needed,” says Hansen. “This is something we need to look at as we expand the use of these herbicides.”

This article originally appeared on Civil Eats.

TIME Smoking

These 4D Ultrasound Photos Show How Fetuses Respond to Their Mothers’ Smoking

See the difference between smokers and non-smokers

A group of researchers have released 4D ultrasound photographs that show the impact smoking during pregnancy has on fetus movement in the womb.

Dr Nadja Reissland, Durham University

The top row shows fetuses of smoking mothers and the bottom row represents those of non-smokers.

The study, out of Durham University in the UK, found that the fetuses of women who smoke have higher rates of facial touching and mouth movement — normally there would be a declining rate. This suggests that fetuses who are exposed to cigarettes have a delayed development in the central nervous system.

“These results point to the fact that nicotine exposure per se has an effect on fetal development over and above the effects of stress and depression,” lead researcher Dr. Nadja Reissland said in a release.

The study looked at 20 fetuses, four of which had mothers smoking an average of 14 cigarettes per day. Although researchers say that a larger study is needed to confirm the results.

Conclusion: Maybe don’t take your pregnancy health advice from Mad Men.

TIME Cancer

Why Angelina Jolie Chose to Have Her Ovaries Removed

"This surgery decision is more straightforward than the decision to have the breasts removed.”

In an op-ed in the New York Times, Angelina Jolie Pitt announced that she recently had surgery to remove her ovaries and fallopian tubes. The procedure put her into menopause at age 39, and she will take replacement hormones for another decade or so.

“It is not easy to make these decisions,” she writes. She describes how she felt she “still [had] months to make the date” for her operation as she prepared herself both physically and emotionally to end her reproductive years.

MORE: The Angelina Effect

But cancer experts say that Jolie did the right thing. While her decision to remove both her breasts before she developed breast tumors was controversial, her latest choice to have her ovaries removed is less so, although equally difficult from both an emotional and physical point of view. “This surgery decision is more straightforward than the decision to have the breasts removed,” says Dr. Karen Lu, chair of gynecologic oncology at MD Anderson Cancer Center. “And it’s definitely a stronger recommendation than for the bilateral prophylactic mastectomy.”

For women like Jolie, who harbor either of the BRCA1 or BRCA2 mutations (Jolie is positive for BRCA1), their risk of breast cancer is anywhere from 80% to 90% higher than that of women without the genetic aberrations. But there are ways that doctors can screen for even the smallest tumors in the breast and therefore get a heads up when the cancer is growing. That allows many women to choose to keep their breasts and have a lumpectomy followed by radiation, with more frequent and vigilant screening for any additional or recurrent growths.

There isn’t that luxury with ovarian cancer, which is often caught once the cancer has progressed and is harder to treat. Women with the BRCA mutations have an up to 50% greater chance of developing this type of cancer, and there are no good ways of screening for it; a blood test that picks up a protein common to ovarian tumors isn’t specific to the cancer, so it could provide false positive or false negative results. In most cases, the cancer is well advanced before doctors, or patients, even know it’s there. “It is incurable in most cases for the vast majority of women,” says Lu.

That’s why the National Comprehensive Cancer Network, and the American Congress of Obstetricians and Gynecologists strongly recommend that women with BRCA1 mutations have their ovaries and fallopian tubes removed by age 40, and those with BRCA2 mutations by age 45.

MORE: Angelina Jolie’s Double Mastectomy: What We Know About BRCA Mutations and Breast Cancer

That doesn’t mean it isn’t still a difficult one to make. For women who learn they have a BRCA mutation in their 20s or 30s, for example, and have no history of cancer — yet —they have to decide whether they want to have children at all, or whether they want to continue adding to their family if they already have, or whether they are ready to enter menopause. For such pre-vivors of cancer, who are at higher risk of the disease but haven’t yet developed tumors, the choice between invasive surgery, and a theoretical risk of something occurring in the future, is agonizing.

For them, there may be other options soon. Researchers at MD Anderson, for example, are testing whether women and keep their ovaries for a little longer if they have their fallopian tubes removed first, since there are signs that ovarian cancer may start in the tubes. Jolie writes about promising studies that suggest birth control pills can lower the risk of ovarian cancer in women with BRCA mutations, but the data is still conflicting.

For now, the option that gives women with BRCA their best chance of avoiding ovarian cancer is surgery.”We are absolutely trying to develop medicinal approaches to reducing risk, and understand the disease better,” says Dr. Larry Norton, medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan Kettering Cancer Center. “But right now, as of this minute, there is no medicinal or herbal approach to reduce risk anywhere close to what we can do with surgery.”

“I feel deeply for women for whom this moment comes very early in life, before they have had their children,” Jolie writes. “But it is possible to take control and tackle head-on any health issue. I feel at ease with whatever will come, not because I am strong but because this is a part of life. It is nothing to be feared.”

MORE: Angelina Jolie’s Double Mastectomy: It’s Not the Only Option

TIME medicine

Many Doctors Don’t Tell Patients They Have Alzheimer’s

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PASIEKA—Getty Images/Science Photo Library RM

It’s hard to believe in today’s era of transparency in modern medicine, but there’s a diagnosis that doctors still try to keep from their patients

In a surprising new survey of patients who were asked about their interactions with their doctors, 45% of people whose doctors treated them for Alzheimer’s never told these patients that they had the degenerative brain disorder.

Led by researchers at the Alzheimer’s Association, the scientists looked at Medicare claim data from 2008 to 2010 for 16,000 people. They were asked, among other things, whether their doctors had ever told them they had Alzheimer’s disease. When the researchers then matched the respondents’ answers to their medical records, and the diagnostic codes that their doctors used to describe their care, only 45% of those who were billed for Alzheimer’s-related care were told by their doctors of their disease.

MORE New Research on Understanding Alzheimer’s

“What struck us was that physicians generally understand the positive benefits of disclosing the diagnosis, and agree with those benefits,” says Keith Fargo, director of scientific programs and outreach at the Association, who oversaw the analysis of the survey data. “But many still don’t do disclosure in their own practice.”

One of the few papers investigating the phenomenon of Alzheimer’s diagnoses found that as few as 36% of doctors said they usually told their patients if they had Alzheimer’s. The main reasons for the intentional omission? Fear of causing emotional distress in their patients and the lack of time and resources to fully explain what the diagnosis means. This was true of both primary care doctors as well as neurology specialists who have more expertise in brain-related disorders.

Dr. Robert Wergin, president of the American Academy of Family Physicians, advocates for transparency and honesty in disclosing diagnoses to his patients in his practice in Milford, Nebraska. But he understands why many physicians might be reluctant to use the word “Alzheimer’s” with their patients. “Labels are important,” he says. “When I label you and say you’ve got Alzheimer’s disease, then you’re likely to say, ‘Well that’s it for me, I better start looking for nursing homes.’”

MORE This Alzheimer’s Breakthrough Could Be a Game Changer

Alzheimer’s is a challenging diagnosis to make on several levels. First, it can only be definitively diagnosed at autopsy, when doctors can see the hallmark amyloid plaques and tangles that cause the gradual loss of memory and cognitive function. There is no blood test or brain scan that can conclusively tell doctors that a patient does or does not have the condition; while promising versions are being developed, it’s still a diagnosis that doctors make based on reports of the patients’ changing intellectual abilities and on psychiatric tests that aren’t specific for Alzheimer’s.

It’s also difficult to tell patients they likely have Alzheimer’s because there are currently no effective drugs for the disease. Medications can slow the effects of the cognitive decline, but nothing can stop or reverse the march of worsening symptoms. Wergin notes that once a patient is labeled with Alzheimer’s it could, at least before the Affordable Care Act, affect that patient’s ability to get insurance for nursing home care. “Once I label you, it’s in your chart. If an insurance company extracts your data, I’m not going to insure you because you are at higher risk of drawing on your coverage,” he says.

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Wergin says that doctors may be over-anticipating the emotional distress that an Alzheimer’s diagnosis can bring. While the news is certainly difficult, most patients and their caregivers may already be aware that a neurodegenerative disease like Alzheimer’s may be present. And while there are no treatments that physicians can prescribe for their patients — at least not yet — Fargo and Beth Kallmyer, vice president of constituent services at the Association, note that it’s particularly important for Alzheimer’s patients and their families to know what to expect so they can begin planning. “There might not be a pill that slows the disease down or there might not be cures, but there are things people can do to impact their everyday quality of life,” says Kallmyer. “They can build a care team, and prepare advanced directives. And if a caregiver has knowledge of the disease, they can make things better in the day to day world of the person with the disease. If they don’t know about the diagnosis, they may not get that support.”

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But making doctors more comfortable with the diagnosis will take more structural changes in the way we deliver health care. The Alzheimer’s Association is supporting legislation that would reimburse doctors and their staff for a longer discussion about Alzheimer’s and how to plan for the disease. More medical schools are also including discussion about such planning in their curricula, as doctors in coming decades will be increasingly called upon to make this difficult disclosure.

Read next: A Simple 3-Part Test May Predict Alzheimer’s

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