TIME psychology

Living With Dying

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Marty Nemko holds a Ph.D. in educational psychology from UC Berkeley and is a career and personal coach.

An internal dialogue on how one might deal with a terminal diagnosis

Many people’s greatest fear is of getting a terminal disease with a likely long, painful ending. The following explores how one might successfully deal with it.

Imagine that you’ve just had a second opinion confirm that you have terminal cancer. Both doctors believe you have a few months to live, that surgery to remove the main tumor followed by aggressive chemotherapy and radiation would give you a 25% chance of living another year or two. Alternatively, you could opt to have just palliative care, which wouldn’t extend your life but would address pain issues and otherwise improve your quality of life.

Here is a fictional internal dialogue that such a person might have:

Person: I’m not going to have any treatment now. If I get bad pain, I’ll take the morphine, whatever.

Alter ego: Are you sure? You would have a 25% chance of another year or two.

Person: Surgery and then aggressive chemo and radiation means months of alternating among pain, puking, and exhaustion, all for just a 25% chance of a year or two, which would probably be a bad-quality year or two.

Alter ego: Don’t you want to increase your chances of seeing your child get married? They say they’re thinking about getting married next year.

Person: Who knows whether they actually will? And honestly, while seeing that would be great, I don’t think that’s worth the misery of surgery and aggressive radiation and chemo.

Alter ego: You’re not worried about the cost of treatment are you? It wouldn’t cost you a penny.

Person: It wouldn’t cost me a penny but when people opt for expensive, cost-ineffective treatment, it raises the cost of health care for everyone. If I’m dying, at least I want to die ethically. That will help give meaning to whatever time I have left.

Alter ego: You’ve tried to live ethically and so you want to die ethically.

Person: Yes.

Alter ego: What else are you going to do to die ethically?

Person: Mainly, I’m just going to try to be a nicer person. That’s what matters. When I’m gone, my legacy is in how I’ve benefited the living.

Alter ego: Are you going to keep working?

Person: Absolutely. Every customer I serve well contributes to my legacy. If I retire and just travel and watch movies, I’m squandering the precious time I have left.

Alter ego: What about the family?

Person: I’ll try to be kind to them. For example, I’ll try hard not to complain. I didn’t tell them when I was diagnosed with Stage 2 nor when I had the chemo. And I’m glad I didn’t—it spared them a lot, and having told them would have done me no good.

Alter ego: Isn’t it selfish not to tell them now? At least some of them would want to know, maybe to resolve old disputes.

Person: I really think, deep down, most or even all of them would rather I didn’t tell them until the very end.

Alter ego: But will you at least spend more time with the family now?

Person: Somehow, knowing I’ll die soon, the old saw about “blood is thicker than water” doesn’t feel compelling. I was thrust into my family at random and I don’t like some of them. If I want to be with people, it’s mainly my close friends, and yes, my sister. But most of the family? I don’t think so.

Alter ego: What about your will? You’ve been procrastinating doing it forever.

Person: Yes, now is the time.

Alter ego: Are you going to leave your money to family?

Person: I’ll ask family to take whatever personal possessions mean something to them—like my sister has always loved my dining room table. But I’m going to give my money to charity.

Alter ego: Are you going to tell them you’re doing that?

Person: That serves no purpose. They’ll just pressure me not to, and I want to decide without pressure. I worked hard for my money. Shouldn’t I have the right to decide what the right thing to do with it is?

Alter ego: But what charity?

Person: I want to donate to something that otherwise would go unfunded. I’m very pro-choice but giving my money to NARAL would be just a drop in the ocean. These days, resources for school programs for gifted kids have almost completely been reallocated to the lowest achievers: “No Child Left Behind.” I believe that all kids are entitled to an appropriate-level education, especially gifted kids, who have so much potential to be wise leaders, bridge builders….

Alter ego: And find a cure for cancer.

Person: Yes, find a cure for cancer. So I’m going to leave the money to some organization that works on behalf of gifted kids–maybe a nearby school’s foundation, earmarking it specifically for gifted kids and their teachers.

Alter ego: You also need to make a living will and give it to the doctors, and when it comes time, tape it over your bed. You know you don’t want to be kept alive by extraordinary means.

Person: Right—a tube shoved down my throat when I’m already in bad pain and going to die soon anyway? Nope.

Alter ego: Right.

Person: And then there’s hospice. Dad spent his last six months in in-home hospice and it was a blessing. He wanted to die in his home and he was able to, with the hospice nurses making sure he died as comfortably as possible. That’s how I want to go.

Alter ego: You’ve done enough thinking about this crap for now. Do something fun.

Person: Somehow, what I feel like doing now is helping another customer. When I’m done working for the day, I’ll do something for myself, like maybe start writing my memoir.

Alter ego: Maybe with a glass of wine?

Person: I think champagne.

Alter ego: Champagne? You’re nuts!

Person: And I plan to be a little more nutty.

Marty Nemko holds a Ph.D. specializing in education evaluation from U.C. Berkeley and subsequently taught there. He is the author of seven books and an award-winning career coach, writer, speaker and public radio host specializing in career/workplace issues and education reform. His writings and radio programs are archived on www.martynemko.com.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME health

Revlon Removes Some Dangerous Chemicals From Its Products

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A petition signed by over 100,000 consumers brings about the change

Cosmetics giant Revlon announced Thursday that two long-chain parabens and a formaldehyde-releasing chemical would no longer be used as ingredients in its products, in a move that was applauded by environmental and health advocates.

Long-chain parabens have been linked to endocrine disruption, while formaldehyde may cause cancer.

Revlon was responding to a petition demanding the change signed by more than 100,000 people. The petition was organized by the non-partisan nonprofit Environmental Working Group.

Two long-chain parabens (isobutylparaben and isopropylparaben) have now been removed from Revlon cosmetics, as has DMDM hydantoin, which releases formaldehyde. Revlon is also reformatting a product that contained butylparaben.

“We are pleased that Revlon has acted to remove these toxic ingredients,” Environmental Working Group Executive Director Heather White said in a statement. “We urge all companies to do the same.”

TIME health

Changing the Face of Medical Education in the U.S.

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Zocalo Public Square is a not-for-profit Ideas Exchange that blends live events and humanities journalism.

We have a focus on wellness, prevention, chronic disease management, and finding ways to deliver health care in the most cost-effective setting

The United States spends more money on health care than any other country in the world. So how does Costa Rica outperform the United States in every measure of health of its population?

Costa Rica is healthier because its government spends more money than ours does on prevention and wellness.

In our country, we have left vast segments of the population without affordable care and we do not focus on wellness or chronic disease management. We don’t consistently control the glucose levels in diabetics and, consequently, too many go blind or lose a limb. Too often, hypertension goes untreated until the patient has a stroke or kidney disease. Then, all too often, these individuals go on medical disability with far more societal expense than the cost of the original health management.

Sadly, it has become the American way to leave many chronic diseases untreated until they become emergency situations at exorbitant cost to the U.S. healthcare system. For many patients, this care is too late to prevent life-changing disabilities and an early death.

When people ask me why we started the UC Riverside School of Medicine last year – the first new public medical school on the West Coast in more than four decades – I talk about the need for well-trained doctors here in inland Southern California. But we also wanted to demonstrate that a health care system that rewards keeping people healthy is better than one which rewards not treating people until they become terribly ill.

As we build this school, we have a focus on wellness, prevention, chronic disease management, and finding ways to deliver health care in the most cost-effective setting, which is what American health care needs.

We also teach a team approach to medicine—another necessary direction for our health care system. If you have a relatively minor problem, your doctor might refer you to a nurse practitioner or physician assistant for follow-up. This kind of team care makes financial and clinical sense, particularly since we have such a national shortage of primary care doctors. The good news: Even among physicians, the team approach, or medical home model, is gaining ground, with the Affordable Care Act accelerating change.

For all the talk about the lack of health insurance in this country, we don’t often discuss the other side of the problem – the fact that many Americans get more care than they need. You may have heard advertisements that you should have your wife or mother get a total body scan for Mother’s Day, because it will find cancer or heart disease. There is no evidence that this screening is a good idea. But in the U.S., we often encourage people to do things that have no proven benefit, and our churches or community centers sponsor these activities.

For all these reasons, we must shift the focus of health care to prevention. Two of the most profitable prescription drugs in the U.S., according to some sources, are those that reduce blood cholesterol and prevent blood clots—both symptoms of coronary heart disease, a largely preventable condition. Shouldn’t we be spending at least as much on prevention as we do on prescriptions? Closely connected to prevention is wellness. So many of our health problems in the United States are self-inflicted, because we smoke, eat too much, and don’t exercise. Doctors need to “prescribe” effective smoking cessation programs, proper diets and exercise as an integral part of care.

One way to accomplish this shift is to teach it to future doctors. At UC Riverside, we are supplementing the traditional medical school curriculum with training in the delivery of preventive care and in outpatient settings. Our approach is three-pronged..

First, we work with local schools and students to increase access to medical school through programs that stimulate an interest in medicine and help disadvantaged students become competitive applicants for admission to medical school or other professional health education programs. These activities start with students at even younger than middle school age, because that is when students begin to formulate ideas about what they want to be when they grow up. We focus on students from Inland Southern California because students who live here now will be among those best equipped to provide medical care to our increasingly diverse patient population. Doctors who share their patients’ cultural and economic backgrounds are better at influencing their health behaviors.

Second, we recruit our medical students specifically with a focus on increasing the number of physicians in Inland Southern California in primary care and short-supply specialties. Our region has just 40 primary care physicians per 100,000 people—far below the 60 to 80 recommended—and a shortage in nearly every kind of medical specialty. Students who have been heavily involved in service such as the Peace Corps, or who are engaged in community-based causes, are more likely to go into primary care specialties and practice in their hometowns.

Then, we teach our medical students an innovative curriculum. For instance, the Longitudinal Ambulatory Care Experience, called LACE for short, replaces the traditional “shadowing” preceptorship, where students follow around different physicians. Instead, our students participate in an a three-year continuity-of-care primary care experience that includes a sustained mentor-mentee relationship with a single community-based primary care physician. In this experience, they “follow” a panel of patients and gain an in-depth understanding of the importance of primary care, prevention and wellness. Our approach also includes community-based research that grounds medical students in public health issues such as the social determinants of health, smoking cessation, early identification of pre-diabetic patients, weight loss management and the use of mammograms to detect breast cancer.

We try to remove the powerful financial incentive for medical students to choose the highest paying specialties in order to pay off educational loans. We do this with “mission” scholarships that cover tuition in all four years of our medical school. This type of scholarship provides an incentive for students to go into primary care and the shortest-supply specialties and to remain in Inland Southern California for at least five years following medical school education and residency training. If the recipients practice outside of the region or go into another field of practice before the end of those five years, the scholarships become repayable loans.

Third, we are creating new residency training opportunities in our region to capitalize on the strong propensity for physicians to practice in the geographic location where they finish their post-M.D. training. Responding to our region’s most critical shortages, we are concentrating the programs on primary care specialties like family medicine, general internal medicine, and general pediatrics, as well as the short-supply specialties of general surgery, psychiatry, and OB/GYN. We are also developing a loan-repayment program for residents linked to practice in our region.

Ultimately, we hope our ideas for how to change health care will succeed and be adopted by others. It might take 30 years, but we believe what we are doing at the UC Riverside School of Medicine will change the face of medical education in the U.S.

G. Richard Olds is vice chancellor of health affairs and the founding dean of the UC Riverside School of Medicine. He wrote this for Zocalo Public Square. Zocalo Public Square is a not-for-profit Ideas Exchange that blends live events and humanities journalism.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME health

For Breast Cancer: It’s Not Nature vs. Nurture—It’s Both

Dean Ornish is Founder and President of the non-profit Preventive Medicine Research Institute and Clinical Professor of Medicine at UCSF.

Genetics and lifestyle are both in play

In 2003, a mountain climber (Aron Ralston) became trapped under an 800 pound boulder while canyoneering alone in Utah. After five days stuck beneath the massive boulder, Ralston amputated his own right hand, freeing himself and saving his life.

Last year, Angelina Jolie underwent a prophylactic bilateral mastectomy because she has a BRCA1 mutation that greatly increases her risk of breast cancer in hopes that it would save her life as well.

In both cases, after careful and thoughtful consideration, two individuals decided to sacrifice important parts of their bodies in order to survive.

And in both cases, there were critics.

Rex Tanner, a 10-year search-and-rescue veteran and commander of Grand County Search and Rescue, questioned if Ralston had other options.

Melissa Etheridge publicly criticized Angelina Jolie for undergoing a prophylactic double mastectomy. “I wouldn’t call it the brave choice. I actually think it’s the most fearful choice you can make when confronting anything with cancer.”

When Etheridge was diagnosed with breast cancer, she chose to make changes in diet and lifestyle as well as having a lumpectomy and undergo chemotherapy. (Etheridge is BRCA2 positive, which has a lower risk of developing breast cancer than the BRCA1 mutation carried by Jolie.)

BRCA1 and BRCA2 are genes that help prevent cancer by repairing DNA. Some people have mutations in these genes that impair their ability to serve that function, thus significantly increasing the risk of breast cancer and ovarian cancer. The estimated risks of developing breast cancer by age 70 are 55% to 65% for women who carry a deleterious mutation in the BRCA1 gene (and maybe as high as 85%) and 45% to 47% for women who carry a deleterious mutation in the BRCA2 gene.

Given these odds, it’s understandable why some women elect to have prophylactic bilateral mastectomies. It can be a rational choice, not a fearful one. These are intensely personal and private decisions that I deeply respect, made by people who I imagine have given great thought and consideration to various options. Only they know what they’re really feeling.

At the same time, I do not agree with a recent article that stated, “Shame on Melissa Etheridge for using her privilege and public platform to blame herself for her breast cancer.”

To say that diet and lifestyle may play a role in breast cancer does not mean that people who change their lifestyle are blaming themselves or that you can always prevent breast cancer by eating and living more healthfully. You do what you can even though there is not certainty.

Having the BRCA mutation significantly increases the risk of breast cancer, but it is not always the only factor. Lifestyle choices may increase or decrease the risk of breast cancer, but that knowledge is an opportunity to empower ourselves, not to blame.

According to the National Cancer Institute, “Even with total mastectomy, not all breast tissue that may be at risk of becoming cancerous in the future can be removed.” Because of this, a bilateral prophylactic mastectomy reduces the risk of breast cancer by 95% in women who have the BRCA mutation and by up to 90% in women who have a strong family history of breast cancer—but not by 100%. Thus, even if a woman decides to have a prophylactic mastectomy, she may also benefit from making lifestyle changes as well.

While studies may provide information on risks in populations, there is an element of mystery in applying these studies to an individual. At least 15% of women with the BRCA1 mutation and at least 50% of women with the BRCA2 mutation do not get breast cancer—lifestyle factors may play a role.

Not everyone who eats meat, smokes, and is overweight, stressed, and sedentary gets breast cancer—protective genes may play a role. And you may eat well, move more, love well, and stress less and still die of breast cancer. Genes may override the best lifestyle, but not always.

While there is no assurance that lifestyle changes may prevent breast cancer in those who have the BRCA mutation, there is evidence that lifestyle changes are worth making, whether or not a person decides to undergo prophylactic surgery.

For example, high serum levels of insulin-like growth factor I (IGF-I) are associated with an increased risk of breast cancer, especially in women with the BRCA mutation. IGF-I contributes to a chronic inflammatory state, which has been linked with an increased risk of many chronic diseases, including breast cancer.

Serum IGF-I levels were higher in those consuming animal protein (particularly dairy) and lower in those consuming vegetables.

In one study, women with the highest levels of IGF-I had a 3.5-fold increased breast cancer risk, compared to those with the lowest. However, women with the BRCA mutation who had the highest levels of IGF-I were seven times more likely to develop breast cancer than those with low IGF-I levels. In this context, lifestyle changes may be particularly important in those with the BRCA mutation.

Another study showed that soy intake was associated with a lower risk of breast cancer but meat intake was associated with a higher risk of breast cancer. Both the protective effects of soy and the harmful effects of meat consumption were higher in those with BRCA mutations.

In the EPIC study of 366,521 women, an increased risk of breast cancer was associated with high saturated fat intake and alcohol intake. In postmenopausal women, BMI was positively and physical activity negatively associated with breast cancer risk.

Those aged 50 to 65 reporting a high intake of animal protein (but not plant protein) in their diet had a 400% higher risk of dying from cancer during the following 18 years, in part because diets high in animal protein increase IGF-I levels.

Those with BRCA mutations who had gained a significant amount of weight since age 18 were 4.6 times more likely to have developed breast cancer.

Another study found a strong and significant inverse relationship between the quality of diet and BRCA-associated risk of breast cancer. Those with BRCA mutations who had high intakes of diverse fruits and vegetables had a significantly lower risk of developing breast cancer.

Lifestyle changes may slow, stop, or even reverse the progression of early-stage prostate cancer. Many experts believe that what’s true of prostate cancer may also be true of at least some forms of breast cancer, although not necessarily those with the BRCA mutation.

These comprehensive lifestyle changes may beneficially change gene expression in over 500 genes in only three months—upregulating genes that are protective, downregulating genes that promote illness, particularly the RAS oncogenes that promote prostate cancer, breast cancer, and colon cancer. But there is no evidence proving that lifestyle changes directly affect the expression of BRCA genes.

These lifestyle changes may increase telomerase and lengthen telomeres, the ends of our chromosomes that control aging on a cellular level. Telomeres usually shorten as we get older, and as our telomeres get shorter, the risk of premature death from many forms of cancer (including some forms of breast cancer), heart disease, and dementia increase.

Whether or not someone chooses to have a prophylactic mastectomy, changing diet and lifestyle may reduce the risk of developing breast cancer. And in comparison to removing both breasts, it’s hard to view changing lifestyle as a radical intervention. Lifestyle changes may help reduce risk, but no study has shown that lifestyle changes alone can eliminate the risk of breast cancer, especially in those carrying the BRCA mutation.

According to Dr. Laura Esserman, Director of the UCSF Carol Franc Buck Breast Care Center, “If someone from a BRCA family wants to do everything they can do to avoid the fate many of their relatives may have faced, diet and lifestyle should be as much a part of their strategy as prophylactic surgery. Some women will want to do all they can, some will pick and choose among the risk-reducing options. But diet and lifestyle will improve their health in many other ways, not just reduce their risk of cancer, so it ought to be part of any choice going forward.”

No one has all the answers, so whatever a woman who has the BRCA mutation chooses to do requires courage and an element of faith. And a lot of love and support.

Dean Ornish is Founder and President of the non-profit Preventive Medicine Research Institute and Clinical Professor of Medicine at UCSF. He is the author ofThe Spectrum and five other bestsellers. He is a leading researcher in how comprehensive lifestyle changes may reverse heart disease and other chronic illnesses without drugs or surgery and may even begin to reverse aging at a cellular level.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME disability

Watch This Woman Take Her First Steps in Ten Years

With the help of a motorized exoskeleton, journalist Nikki Fox was able to stand and walk on her own

Journalist Nikki Fox, who serves as a disability correspondent for BBC News, was born with muscular dystrophy and hadn’t taken a step on her own in ten years. But in the video above, Fox was able to briefly walk again with the help of a device known as an exoskeleton, which was strapped to her body. The motorised robotic equipment, which she was able to control herself, allowed her to stand and take slow steps, without the aid of another person.

“My legs hadn’t been that straight since 1995,” Fox told the BBC. “What was quite unbelievable was how I felt afterwards. Standing for half an hour would usually be quite tough but it wasn’t.”

[BBC]

TIME global health

This Is Now the Average Life Expectancy Worldwide

Southern sub-Saharan Africa was the only region worldwide to have a decline in life expectancy

Life expectancy across the globe has increased by more than six years since 1990 to 71.5 years, according to a new study.

“The progress we are seeing against a variety of illnesses and injuries is good, even remarkable, but we can and must do even better,” said lead study author Christopher Murray, a University of Washington professor, in a press release.

The study, published Wednesday in the Lancet journal, showed declines in the number of deaths from cancer and cardiovascular disease in high-income countries as well as in deaths from diarrhea and neonatal complications elsewhere. Both of these trends contributed to the overall decline. Importantly, medical funding for fighting infectious diseases has grown since 1990 and helped drive the improvement, according to Murray.

Still, despite the improvement, the number of deaths from a number of ailments increased. Perhaps most dramatically, deaths from HIV/AIDS joined the list of the top 10 causes of premature death. The number of annual deaths from the ailment rose from 2.07 million in 1990 to 2.63 million in 2013, the equivalent of a 344% increase in years of lost life. The increase in deaths from HIV/AIDS made southern sub-Saharan Africa the only region worldwide to experience a decline in life expectancy.

Other ailments that caused an increased loss of life include liver cancer caused by hepatitis C, which soared 125% since 1990, and deaths from disorders related to drug use, which increased by 63%.

TIME Obesity

Law Enforcement Is the Fattest Profession, Study Finds

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Along with firefighters and security guards

Police officers, firefighters and security guards have the highest rates of obesity of all professions, according to a Wall Street Journal analysis of data from the American Journal of Preventive Medicine.

According to the Journal, 40.7% of police, firefighters and security guards are obese. Other jobs with high obesity rates include clergy, engineers and truckers.

On the other side of the obesity scale is a grouping of economists, scientists and psychologists, with an obesity rate of 14.2%. Other professions with low obesity rates are athletes, actors and reporters.

Read more at The Wall Street Journal

MONEY Health Care

4 Smart Year-End Strategies for Maximizing Your Health Benefits  

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Dental plans often have annual coverage caps. Have you used up yours yet? Peter Dazeley—Getty Images

In these winter months, don't overlook these valuable health perks—and the crucial deadlines for getting your money's worth.

The first and last months of the year can be the best time to use your health insurance benefits. Here’s how to make the most of four common scenarios:

You’ve Met Your Deductible

This is the amount you must pay for your own health care before your insurance starts covering a larger portion of the costs. If you’re close to that cut-off, consider a last-minute appointment, says Carrie McLean, director of customer care at online insurance exchange eHealth.com.

“If you’ve already met your deductible for 2014, or are close to it, medical care rendered before the end of the year may be covered at a lower out-of-pocket cost,” McLean says. “Conversely, if you expect to have a lot of health care expenses in 2015, you may want to schedule non-emergency medical care for early next year so you can fulfill your deductible as soon as possible.”

You Have Unused Dental Benefits

In most cases, dental coverage works differently from regular health insurance. This benefit is often capped at $1,000 to $3,000 annually, according to the American Dental Association. If you have unused benefits remaining, now may be the time to schedule a last-minute appointment, especially if you might need serious dental work soon. That way, you can spread the cost over both years and pay less out of pocket for dental care.

You Have an Leftover FSA Money

If you set up a flexible spending account, or FSA, through your employer as a supplemental benefit to your health insurance, you were able to contribute pre-tax money to it each year and use that money for qualifying health expenses. Now’s the time to check your balance.

Some FSAs allow you to roll over up to $500 of unused funds into the following year, or give you a 2 1/2-month grace period to spend the money, but many don’t. In that case, you’ll forfeit your remaining balance.

If you have funds left in your FSA, or you are over your rollover limit, it’s time to spend the money. The good news is that a lot of expenses qualify, starting with purchases you’ve already made. If you can prove it, you can reimburse yourself for health costs you paid earlier in the year, says Craig Rosenberg, benefits specialist at human resource firm Aon Hewitt.

“Check to see if there are any out-of-pocket health care expenses you haven’t submitted for reimbursement. It’s easy to forget co-pays, prescription drug expenses, or certain medical supplies,” says Rosenberg.

“December can be a good time to stock up on health supplies,” he adds, and that goes for a lot of expenses, from bandages to braces and more.

If your FSA has a grace period, you have until March 15, 2015 to use your 2014 funds. In that case, it might be a good idea to schedule checkups for January so the costs count toward next year’s deductible. Check your FSA summary of benefits first, because in some cases that grace period is only for vision and dental expenses.

You Have an HSA

Whatever you do, don’t confuse your health savings account, or HSA, with an FSA and hurry to spend it, Rosenberg says. “FSAs have ‘use-it-or-lose-it’ rules that apply each year, but HSAs do not,” he says. “Any funds in your HSA are yours to keep indefinitely, even if you change jobs.”

Some even look at HSAs as a retirement savings vehicle since the funds can be used to pay for Medicare premiums and medical costs in retirement. That’s a big deal: Fidelity Investments estimates that the average couple retiring this year will face $220,000 in medical costs in retirement.

You may even want to add funds to your HSA now, McLean says. “Maximize on your tax saving by funding [the HSA] fully before year’s end,” she says, but know the limit. The contribution cap for HSAs in 2014 is $3,300 for individuals, or $6,550 for families.

Lacie Glover writes for NerdWallet Health, a website that helps consumers lower their medical bills.

TIME Food & Drink

This is What Alcohol Does to Your Sleep

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Sorry to burst your champagne bubble, but drinking more alcohol often adds up to less sleep

You may want to think twice before pouring that nightcap—it turns out alcohol could be wreaking major havoc on your sleep. Even though it’s the season for spiked hot cocoa, extra glasses of wine, and alcohol-fueled holiday parties, climbing into bed after downing all those drinks can leave you feeling less than jolly the next morning.

Alcohol wakes you up at night.

While knocking back a glass or two might help you fall asleep faster, going to bed with a buzz may also lead to a worse night’s sleep. Scientists reviewed 20 different studies and concluded that the tradeoff to dozing off after consuming alcohol is waking up more easily later on in the night.

It cuts into your REM sleep.

REM sleep is essential to a good night’s rest. It has a long list of benefits, including daytime alertness, improved learning, and better long-term memory, as well as allowing us to process our emotions, saysDr. Philip Gehrman, an assistant professor in the Department of Psychiatry at the University of Pennsylvania. The problem with alcohol is that it has a significant impact on REM sleep, which can hurt long-term memory and make us more irritable. “Basically, alcohol is a REM suppressant,” saysGehrman. “The more we drink, the less REM we get.”

Too many drinks can trigger heartburn.

And that uncomfortable burning sensation wake us up or keep us awake in the first place. Alcohol has been known to relax the lower esophageal sphincter, the muscle between your stomach and esophagus that’s supposed to be closed except for when you’re swallowing food. However, when you throw too many drinks into the mix, the muscle can relax and stay open for too long, causing stomach acid to come back up, which results in a burning feeling. Unfortunately, caffeine can have a similar effect, so if eliminating alcohol doesn’t decrease your heartburn, you may want to cut back on that too.

It sends you to the bathroom.

While “breaking the seal” may be a total myth, alcohol’s effect on the bladder is a real one. The fact is that consuming alcohol, a diuretic, can make you go more. Our bodies generally produce less urine at night than throughout the day, allowing us to sleep about six to eight hours without needing to visit the bathroom. However, drinking alcohol before bed can cause us to wake up in the middle of the night with the urge to go, disrupting our sleep cycle.

Alcohol and sleeping aids absolutely do not mix.

Whether you’re taking a prescription or leaning on other sleep aids, mixing them with alcohol can be harmful and sometimes downright dangerous. Both alcohol and most sleep medications target the neurotransmitter GABA, which calms our nervous activity. Because many sleep aids and alcohol target the same neural system, drinking too much can turn into a deadly combination, inhibiting parts of the brain that are necessary for survival like breathing and heart beating, Gehrman says. While many new sleep medications may not have as large of a risk, the safest bet is to never mix any kind of sleep aid with alcohol.

This article originally appeared on RealSimple.com.

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