TIME Exercise/Fitness

This Study Busts Your Work Out Excuse

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Brent Winebrenner—Getty Images/Lonely Planet Images

Air quality may not be the best in cities, but the benefits of physical activity can outweigh the harms of breathing in pollutants

Exercising outdoors is certainly preferable to being cooped up in a stuffy gym, but if you live in an urban area, the pollution from cars and buses may give you pause. It shouldn’t. Zorana Andersen from the center for epidemiology and screening at the University of Copenhagen and her colleagues report in the journal Environmental Health Perspectives that being active trumps some of the negative health effects that breathing in polluted air might have.

MORE: Pollution: Dangerous to Joggers

In a study involving 52,061 people who were followed for around 13 years, Andersen found that those who were more active were less likely to die during the study than those who were more sedentary, regardless of the pollutant levels where they lived. The researchers asked the participants to detail their physical activities, including their leisure sports, how much they walked, whether they biked or walked to work, and whether they spent time gardening. They compared these responses to the levels of nitrogen dioxide near their homes; NO2 is a gas produced from the burning of fossil fuels in cars, and is an ingredient for other harmful pollutants such as ozone and particulate matter, which can cause respiratory illnesses. Previous studies found that walking along a busy London street, for example, caused a drop in lung function and that cycling or running near high traffic roadways also compromised people’s respiratory functions slightly.

In Andersen’s study, however, people who participated in sports showed a 22% lower risk of dying from any cause during the 13-year followup, while those who cycled regularly showed a 17% lower risk and people who spent time gardening showed a 16% lower risk compared to those who didn’t do either of those activities — and regardless of the pollution levels where they lived.

MORE: Ozone Can Harm the Heart in as Little as Two Hours

“We found an even more positive message around physical activity than we even hoped for,” says Andersen. “Physiologically it’s plausible that you inhale more particles [of pollution] when you exercise in polluted areas, and we thought maybe the accumulated lifetime effect of this would reduce the benefit of exercise. But we don’t see that.”

Essentially, the benefits of being active were strong enough to overcome some of the negative effects of breathing in pollutants. That makes sense, she says, because even if people aren’t exercising to avoid inhaling pollutants, they are still exposed to them, and Andersen’s study shows that even if exercises might be exposed to slightly higher levels of compounds like NO2, that still doesn’t negate the positive effects of physical activity on their heart, blood sugar levels and more. In fact, for specific conditions, the benefits of exercising remained quite high; active people even in highly polluted areas had a 66% lower chance of dying early from diabetes compared to those who didn’t exercise.

She notes, however, that some cities may have significantly higher pollution levels than Copenhagen, where the participants lived, and it’s not clear yet how greater concentrations can affect the exercise-pollution-mortality balance. So if you have a choice for working out, biking or walking in a less polluted area, however, such as a park or a quieter side street, that might be a good idea. But don’t worry too much if you don’t. “Being active prolongs life more than staying away from air pollution,” says Andersen. “So pollution shouldn’t be a barrier to exercise.”

TIME Innovation

Five Best Ideas of the Day: March 30

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

1. Blue-collar jobs are coming back, and pay well. But women are missing out.

By Mitchell Hartman in Marketplace

2. Ikea is known for affordable, flat-pack furniture. Now they’re selling the U.N. flat-pack refugee housing.

By Amar Toor in the Verge

3. With an eye on the White House, politicians won’t admit it, but the ethanol mandate is terrible policy.

By Josiah Neeley in the American Conservative

4. With billions in profits, tech giants must lead the charge against inequality in Silicon Valley.

By John D. Sutter in CNN

5. Can better customer service make primary medical care affordable and sustainable?

By Margot Sanger-Katz in the Upshot

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

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 medicine

Who Should—And Who Shouldn’t—Take Vitamin D

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Here's what experts say, based on the latest evidence

Does your diet need a little extra D? For researchers, it’s one of nutrition’s most vexing questions. “It’s the wild, wild west,” says Dr. JoAnn Manson, chief of preventive medicine at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School. “The issue has become murkier over time rather than clearer.” Research is mixed about whether doctors should routinely test for vitamin D levels, like they do for cholesterol, and whether people should be supplementing their diets with vitamin D pills.

Case in point: a study just released in JAMA Internal Medicine showed that vitamin D did not lower the risk of falls among an elderly population in Finland. The study, which compared the effects of exercise against vitamin D supplements on falls and resulting injuries, did find, however, that exercise cut the chances of more severe injury from falls in half compared to those who didn’t exercise.

MORE Want to Stay Healthy? Don’t Rely on Vitamins

But that doesn’t mean that vitamin D isn’t worth taking at all. The Institute of Medicine (IOM), and the U.S. Preventive Services Task Force (USPSTF) both recently reviewed all of the evidence on vitamin D and its health effects and concluded that in many cases, D supplementation is beneficial—with some important caveats. The two groups say that 600 international units (IU) are generally enough for most healthy adults and that higher doses of vitamin D don’t necessarily produce more health benefits. They also stress that those benefits are limited to bone health; there isn’t enough evidence to support the idea that taking the vitamin can protect against heart disease, cancer, diabetes or cognitive decline, all benefits suggested by some smaller studies.

“More isn’t necessarily better,” says Manson, who served on the IOM committee. “In some cases, it can be worse.”

Overdoing vitamin D can lead to calcium in the urine, which can cause kidney stones. Extremely high doses—around 10,000 IU a day—can trigger calcium deposits in the blood vessels, which can lead to clots that cause heart attacks. The IOM panel recommended no more than 4,000 IU of vitamin D daily to avoid these potential problems.

MORE Want to Build Endurance? Cut Back on Vitamin C and E Supplements

When people are tested for vitamin D deficiency and come up short, some researchers caution against treatment. In addition to the dosage risks, there’s also evidence that the lab tests for the type of vitamin D circulating in the blood, 25-hydroxyvitamin D, may not be the most reliable measure of a person’s D levels. Plus, not all labs use the same standard test for picking up 25 hydroxy D, and they set different standards for what are considered normal levels. “Clinicians are often left chasing a number, and trying to get patients’ blood levels up to a certain point,” says Manson. “But when you think about how many people are screened for vitamin D, and the concerns about the reliability in how it’s measured, and the differences in what is considered normal ranges across laboratories, it’s really concerning.”

Better data may be coming soon, however. Several large trials are underway in which people are randomly assigned to take different levels of vitamin D supplements so researchers can study their health outcomes, from bone problems to heart disease, cancer, diabetes and more. Manson is overseeing the largest of these, called VITAL, which has 26,000 participants. The results from these studies, which are being conducted in the U.S., Europe, Australia and New Zealand, should be available in 2017. “We should have conclusive answers in about three years,” Manson says.

The studies will also look specifically at whether vitamin D levels and metabolism differ across racial and ethnic groups. Some studies have hinted that disparities by race in heart disease and certain cancer risks may be due to vitamin D, and the randomized trials will hopefully provide more information on whether that’s true.

In the meantime, Manson says doctors and patients should follow the IOM and USPSTF guidelines: doctors should not order vitamin D blood tests for all of their patients, and people shouldn’t take more than 600 IU of the vitamin if they are otherwise healthy. The only people who may need regular testing for vitamin D deficiency, and possible supplementation, are those with malabsorption problems like Celiac disease, those who have had bypass surgery, or people who have already had fractures and have been diagnosed with osteoporosis. People taking certain medications, including treatment for tuberculosis, may also need to consider vitamin D pills.

For everyone else, however, universal screening isn’t necessary—and there isn’t any reason to take more than the recommended daily allowance of vitamin D.

Read next: The 4 Most Confusing Things About Sugar

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TIME health

What Experts Got Wrong About Viagra

Small blue Viagra pills, Pfizer's pharma
Suzanne Opton—The LIFE Images Collection/Getty Small blue Viagra pills, separated by machine, in 1998

March 27, 1998: Viagra is approved by the FDA

It was the miracle drug to beat all miracle drugs; an instant bestseller that topped the sales figures of Big Pharma’s other greatest hits: Prozac and Rogaine. After the FDA approved Viagra on this day, March 27, in 1998, sales of the drug rose quickly — pumped by an early rush that yielded at least 10,000 scripts a day, per a TIME cover story about the drug — and had staying power, as evidenced by Pfizer’s annual profit of about $1.8 billion as of 2013 and the fact that our email inboxes are still routinely barraged with spam offers for the drug.

It was a magic bullet for many men, but one that TIME initially feared would herald “the end of sex as we know it.”

“Could there be a product more tailored to the easy-solution-loving, sexually insecure American psyche than this one?” Bruce Handy wondered in the 1998 piece.

There were many who saw chemically-induced erection as a slippery slope to a Sleeper-style orgasmatron.

“People always want a quick fix,” one psychiatrist complained to TIME. “They think Viagra is magic, just like they thought the G spot worked like a garage-door opener.”

Seventeen years later, sex as we know it hasn’t ended — it’s still happening in more or less the usual ways, whether or not Viagra is a part of it. But what was a godsend for men hasn’t opened any doors for women with sexual dysfunction. That’s not for lack of trying: A drug hailed as “the female Viagra” has undergone extensive clinical trials and been submitted to the FDA three times so far, most recently last month, but has never been approved, as Cosmopolitan reports.

The two drugs operate differently, as one might expect: while Viagra stimulates blood flow to the genitals, it doesn’t act on the brain. The proposed drug for women, flibanserin, instead works on neurotransmitters to increase sexual desire.

The fact that there are now several drugs on the market for men’s sexual troubles and none for women constitutes sexism, some have argued, especially since an estimated 16 million women over the age of 50 suffer from some form of sexual dysfunction. A new campaign called “Even the Score” focuses on just this disparity, calling on the FDA to make “safe & effective treatments for low [female] desire” a priority.

In the meantime, a North Carolina doctor has patented a spinal implant that can produce orgasms at the push of a button, although he’s had trouble securing the funding to perfect the device. He calls it the Orgasmatron.

Read the 1998 cover story, here in the TIME Vault: The Potency Pill

TIME Innovation

Five Best Ideas of the Day: March 26

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

1. Al Qaeda and ISIS are locked in an ideological war, and for once, it’s good to be their mutual enemy.

By Daniel Byman and Jennifer Williams in Lawfare

2. For the millions left behind by America’s new economy, disability claims — legitimate or otherwise — are skyrocketing.

By Chana Joffe-Walt in Planet Money by National Public Radio

3. Maybe universities shouldn’t measure prestige by the number of applicants they turn away.

By Jon Marcus in the Hechinger Report

4. When younger women have heart attacks, they’re twice as likely to die as their male counterparts. Is medicine’s gender bias to blame?

By Maya Dusenbery in Pacific Standard

5. Can the triumph and tragedy of soccer help Harvard students appreciate the humanities?

By Colleen Walsh in the Harvard Gazette

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

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 medicine

What We Learn When We Sequence the Genes of an Entire Nation

In a genetic milestone, researchers have amassed DNA data from an entire population of people. Here’s what we can learn from that information

Experts say that genetic sequencing may be the future of medicine, shaping how we understand and ultimately treat disease. If that’s the case, then the people of Iceland have a leg up on the rest of us.

In four groundbreaking papers published in Nature Genetics, scientists from Iceland describe the results of a massive gene-sequencing effort involving 2,636 people. Because the island country is relatively isolated, it’s a genetic goldmine. It enjoys a founder effect, which means that most residents can trace their lineage back to a few founding fathers, and that genetic variants have been passed down from generation to generation. That makes it possible to infer the distribution of the genetic variants found in the study’s 2,636 people to the remaining 325,000 Icelanders.

When they did that, the researchers, led by Kari Stefansson, CEO of deCODE Genetics/Amgen, were able find mutations linked to Alzheimer’s disease, liver disease, thyroid disorders and atrial fibrillation. They also identified almost 8% of the population who have lost function of at least one of their genes and calculated the rate of mutations in the Y-chromosome among men.

In recent years, the practice of mining large numbers of human genomes by comparing people with and without specific diseases has led to a growing list of genetic culprits behind conditions such as Alzheimer’s, cancer and more. But by studying such a genetically unique population, Stefansson says, he was able to pick up even rare genetic changes that have emerged more recently and occur less frequently but might still be important contributors to disease. Those, he says, will be important clues to better understanding the biological roots of health problems, as well as finding new drugs and treatments for them. “What we anticipate is that all human diversity is going to be explained by the diversity in the sequence of the genome, either solely by the diversity in the sequence or by the interface of that diversity and the environment,” he says. “That includes the diversity and risk of disease and the ability to resist them.”

MORE: The Iceland Experiment

The mutation associated with Alzheimer’s, for example, in the ABCA7 gene, hasn’t popped up in previous searches, but the gene is involved in transporting lipids across membranes, a process that may contribute to the build up of sticky protein plaques in the brains of Alzheimer’s patients.

The people who have lost function of at least one gene—called knockout genes in the genetic world—could also provide valuable hints about the pathways to disease. Even with a gene knocked out, most of these people are functioning, and Stefansson says researchers still study them in more detail to figure out how they are affected by their non-functioning genes. In animal research, knockouts are useful to see how prominent and important a gene is for health functioning. Stefansson anticipates that there may be redundancies built into the human genome to compensate for some knockouts, so finding these backup systems might be key to understanding why certain people get sicker with a disease while others remain relatively unaffected.

MORE: Scientists Identify Rare Gene Mutation that Protects Against Alzheimer’s

The sequences are also giving scientists a sharper picture of our past. The Y chromosome analysis shows that the last common ancestor sharing the Y chromosome among homo sapien men dates back 239,000 years, putting it closer to the common ancestor for the mitochondrial DNA passed down by women via their eggs. It also revealed how quickly mutations on the Y chromosome are occurring, which “gives us information about the age of our species, which is related to how diverse we are,” says co-author Agnar Helgason of deCODE and University of Iceland. “It tells us how quickly we are evolving.”

deCODE, which was acquired by the biotechnology company Amgen in 2012, is also investigating the new trove of genetic information for possible drug targets. “What this kind of work and insight into the human genome does is make approaches to influence the genome [and find treatments for disease] more rational,” says Stefansson.

How quickly that will happen isn’t clear yet, but having more information could make the process more efficient. “I’m willing to go so far as to say that there is nothing in human nature that may not have a reflection in the genome, or have something in the genome that associates with it,” he says. “We are made from the basis of the information coded in the genome.”

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 Research

Study Links Widely Used Pesticides to Antibiotic Resistance

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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 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.

MORE New Test May Predict Alzheimer’s 10 Years Before Diagnosis

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.”

MORE Breakthrough Discoveries of Alzheimer’s Genes

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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TIME medicine

Your Doctor Likely Orders More Tests Than You Actually Need

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Javier Larrea—Getty Images/age fotostock RM

The surprising non-medical reasons why emergency room doctors order too many tests

When you’re rushed to an emergency room, the doctors immediately order a battery of tests to figure out what’s wrong. But while scans and blood draws can tell them an incredible amount about what’s ailing you and the best treatment you should get, study after study shows that all of this testing isn’t actually leading to better care. Now, a new survey of emergency room doctors suggests why.

Of the 435 ER physicians asked about the tests they order for their patients, more than 85% admitted that in general, they call for too many tests, even if they know the results won’t really help them decide how to treat their patients. Reporting in the journal Academic Emergency Medicine, the authors also say that nearly all of the doctors—97%—admitted to personally ordering unnecessary imaging tests.

“So many physicians acknowledged that they ordered tests for no medical reason, which makes it clear that physicians feel enormous pressure to behave in a way they may not want to,” says Dr. Hemal Kanzaria, an emergency room physician at University of California Los Angeles and lead author of the study.

Such unnecessary testing is contributing to an estimated $210 billion in additional health care costs; ideally, appropriately used testing should reduce costs by detecting and diagnosing problems early, so patients can get the right treatments and avoid more expensive care.

The top two reasons the doctors ordered these tests were fear of missing something that would help them diagnose their patients, and protection against malpractice. “The over-testing is not due to lack of knowledge on the physicians’ part or poor medical judgment. It more likely reflects the fact that as a society, we don’t like uncertainty, and that has led to an oversimplification of medical care,” says Kanzaria. “There is the thought that if there is any possibility of disease, then we should do something about it, and if there is any doubt, we should test. If the test helps one patient, then everyone should get the test.” So even when doctors know that a test won’t add much information to their treatment decision, they’re more concerned that the patient will want to know why the test wasn’t performed.

Such decision-making behavior won’t change until more systemic problems in the way health care is delivered and paid for are addressed, the study authors say. They note that the way physicians are held accountable for medical decisions also needs to change, and patients need to become more involved in treatment decisions. That way, they say, the cultural expectation that doctors can never get a diagnosis wrong may start to fade. Doctors also need to be better trained and educated about the latest technologies and which patients will benefit most from them, they add.

The doctors also said that they’d welcome patients becoming more involved in the decision-making process. There isn’t data suggesting that such shared decision-making would reduce unnecessary testing, but if doctor and patient are more open about the reasons for testing or not testing, then perhaps fewer tests might be done for non-medical reasons.

“We need to be more cognizant of the culture within and outside of medicine that contributes to over-testing, and we need to address these systems and drivers,” says Kanzaria. “That’s what I hope will result from this work.”

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