We are in a winning position now, but have to be careful: Dr Rakesh Mishra - The Daily Guardian
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We are in a winning position now, but have to be careful: Dr Rakesh Mishra

Mutation of the virus is natural, but we need to restrict transmission by maintaining safety protocols, vaccinations and extensive genome surveillance, says the CSIR-CCMB director.

Shalini Bhardwaj

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Despite Covid-19 cases declining in India, the virus continues to be a cause for much worry, especially with states like Kerala and Maharashtra still reporting new cases because of mutated forms of the virus. However, if we keep up our guard through usual safety practices like wearing masks and social distancing and keep an eye on mutations using extensive genome surveillance, we can defeat coronavirus in India, said Dr Rakesh Mishra, Director of CSIR-CCMB, in an exclusive interview with The Daily Guardian. 

Q: Do you think the mutation of the coronavirus is a cause of concern?

A: The mutation is a natural process which will take place. But if we follow certain disciplines, we can limit the transmission of the virus. During this process, when the virus is multiplying, it will naturally create mutations. Some of them can be troublesome, so we shouldn’t give much chance for the virus to mutate and spread and create more problems for us.

Q: Some scientists are saying that the new strain in South Africa is more dangerous. Is that so?

A: At the moment it’s not confirmed that this virus is leading to more mortality. Some viruses are suspected to be more infectious, which might be true, but may not necessarily be a bigger problem, except when some of them are resistant to the vaccines, because that means they need more antibodies in the inactivation experimental condition. At this moment, none of them have been confirmed to not respond to the vaccines. But it can happen in the future. That’s the biggest problem with these viruses—they spread faster and create new versions of them and come up with new problems. In some mutations, some tests, particularly the RT-PCR may not work, because the binding to detect the virus mutant might be missed out. Therefore, mutations are something to be watchful for, so it is important to prepare extensive sequence genome surveys and have an idea of what is happening in the population.

Q: Are we doing enough sequencing in India to know about new mutant variants?

A: India has a policy to sequence 5 percent of all new cases that have a travel history or have come from abroad. The sequence is neutral to any variant and will detect any variant, old or new. 5 percent is a decent number to get an idea about new things that are coming up. 

Q: Do we have the technology to do the sequencing of mutant viruses?

A: Our sequencing technologies and expertise to analyse the sequences is far beyond the challenge that the virus genome poses. It is a very small genome and we sequence hundreds and thousands at a go and analyse them in a very short time, in less than a day. The key thing of genome sequencing of viruses is to collect the sample from a very well distributed place, so that we cover the whole country. If you sequence thousands of genomes from one mohalla or gali, it doesn’t mean much as they are likely to be the same. But you should be able to sequence samples from all parts of the country, all districts, all blocks, all cities and towns, and so on. If a certain percentage of positivity is seen, we will know if a new variant is emerging and spreading somewhere. We should be sequencing at least once in a week with a certain staggered plan. We can put more restrictions and block a particular region. So, the sequencing capacity isn’t an issue, rather the strategy and getting samples from the field. It is quite a challenge and we should have plans for that.

Q: Do you think new variants are becoming dominant? Where do we stand right now?

A: We are actually now in a winning position. Hospitals are not crowded and the recovery rate is very high. Vaccines have come and are being implemented and we understand this disease more, in terms of how it spreads, how much it can spread through the air, etc. So, this is the time when we should go for the kill and attack the disease from all aspects. So, mask-wearing, social distancing, practising a certain discipline, using as many vaccines as we can, convincing people that the vaccine is good and safe for them, and close surveillance by genome sequencing and watching out for the new emergence of new variants—through all these things together, in a few months, we can certainly control the disease. But if we don’t do these and depend only on the vaccine, it won’t be enough. The vaccine may be 70%-80% effective, which means that 20-30% percent will not respond to the vaccine, and may be less or not effective for the new variant. So, these are the tools but the important thing is that we shouldn’t drop our guard. We need to work in a collective manner and use all our ammunition against the virus.

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Medically Speaking

Diet and Mental Health

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Lifestyle components like eating habits, exercise, sleep and work patterns etc affect our well-being on a regular basis and many health problems both physical and mental, are associated with dis balance in our routine life.

There is no specific diet which treats psychiatric disorders but certain dietary choices and patterns are helpful in improving overall health as well as promote physical and mental stress tolerance which leads to better psychological health.

Foods to eat-

Among common diet plans, the Mediterranean diet has the strongest evidence supporting its ability to reduce the symptoms of depression.

Compounds in the Mediterranean diet that have links to lower depression rates include:

                  •                omega-3 fatty acids

                  •                vitamin D

                  •                methylfolate

                  •                s-adenosylmethionine

The Mediterranean diet consists of:

                  •                plenty of fruits and vegetables

                  •                whole grains

                  •                potatoes

                  •                cereals

                  •                beans and pulses

                  •                nuts and seeds

                  •                olive oil

                  •                low-to-moderate amounts of dairy products, fish, and poultry

                  •                very little red meat

                  •                eggs up to four times a week

                  •                low-to-moderate amounts of wine

Foods to avoid-

A 2010 study showed that women who ate unhealthful Western-style diets had more psychological symptoms. The foods that these participants were eating included:

                  •                processed foods

                  •                fried foods

                  •                refined grains, such as white bread

                  •                sugary products

                  •                beer

Similar unhealthful dietary patterns that typically lead to obesity, diabetes, and other physical health problems can also contribute to poor mental health.

The balanced Indian meal plans have necessary components for health and well being.

Summary-

                  •                Eat a combination of locally grown products like whole grains, fruits and vegetables and limited amounts of un refined fat like cold pressed mustard oil and desi ghee ( clarified butter).

                  •                Fish, nuts and seeds like walnuts, pistachios, almonds, flaxseeds and chia seeds have high amounts of omega3 fatty acids which are good for nerve health.

                  •                Poultry, eggs and dairy products are rich in Vitamin B12 which is associated with nerve health and better stress tolerance.

                  •                Balanced calorie intake with good nutritional components (complex carbohydrates, proteins, vitamins, minerals and healthy fatty acids) is the key to good health and weight management. Over eating and under eating both have negative effect on physical and mental well being.

                  •                Regular eating patterns are helpful in maintaining stable sugar levels and boost energy.

                  •                Water makes 60% of body. Drink plenty of plain water for good health.

                  •                Good gut health is linked to balance of good bacteria in our intestines which are plenty in probiotic foods like curd, chaach and fermented eatables like idli, dosa and kimchi.

                  •                Sodium is an essential nutrient that controls blood pressure. It is also needed to make nerves and muscles work properly. For this reason, patients need to consume the right amount. Many medicines reduce sodium levels which can lead to hyponatremia with significant nervous system problems. The AHA recommends no more than 2,300 milligrams a day, but patients should move toward an ideal limit of no more than 1,500 mg per day for most adults. Excessive salt comes from packaged and preserved food which in any case need to be avoided.

                  •                Avoid alcohol and nicotine, they may appear to reduce stress but eventually lead to low stress tolerance and mood instability.

                  •                Drugs like pot/weed/grass/opioids and other designer drugs increase vulnerability to major psychiatric disorders.

For specific metabolic disorders like Diabetes, Obesity, PCOD or inflammatory condition, please consult a dietitian.

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COVID 19 exacerbates burnout rate in doctors: How to address this crisis

Dr Shuchin Bajaj

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Long working hours, emergency calls, a never ending stream of patients and prolonged stress are factors that are common in the lives of doctors. In countries with a low doctor-patient ratio like India, doctors often experience overwhelming workload and excessive pressure. Factors such as lack of safety and vulnerability to violence further adds to this stress. Even before the coronavirus outbreak challenges healthcare providers like never before, physicians were experiencing a high rate of burnout. Several studies have pointed this out in recent years. A small but powerful indicative study published in the Indian Journal of Psychiatry in 2018 suggested that a significantly higher proportion of doctors in Indian setting experience stress, depression, and burnout. Out of the 445 responders in the study, 30.1% were found to have depression and 16.7% reported having suicidal thoughts. More than 90% of the participants reported some level of burnout.

The coronavirus outbreak has hugely magnified this problem, exacerbating the burnout rate in doctors and other healthcare staff particularly those involved in treating COVID 19 patients. Burnout is a condition where an individual experiences overwhelming mental and physical exhaustion owing to excessive stress. It not just affects the mental and physical health of the individual but also impacts his/her job related outcomes.

The COVID 19 burnout in doctors

In China, a cross-sectional study published in JAMA Network Open Journal in March 2020 found that the coronavirus outbreak had a devastating impact on the mental health of healthcare workers. Out of the 1257 respondents, 50.4% were found to have symptoms of depression, 34.0% reported insomnia, 44.6% reported symptoms of anxiety and 71.5% reported distress. The researchers concluded that working in the frontline was an independent risk factor for worse mental health outcomes.

Doctors at the frontlines of the pandemic are facing extremely challenging working conditions. Long grueling working hours, constant emergencies, witnessing a high death rate and a persistent struggle to save lives not just cause physical exhaustion but also result in an emotional and mental turmoil. In countries where severely ill patients exceeded the healthcare capacity to treat, doctors had to actually choose whom to treat and whom to let die. Absence of a clear treatment route is another major work challenge.

Wearing PPEs for long hours is itself a major challenge. Once your PPE is on your ability to eat, drink water or even go to the washroom is restricted. The grueling heat makes long hours of wearing PPEs worse. However, the most significant challenge is the threat from the disease itself. Being in the midst of patients every day puts doctors at a high risk of caching the infection themselves. By first week of May, over 500 doctors, nurses and paramedics had already been infected by Coronavirus in the country. An AIIMS doctors was applauded for putting himself at significant risk when he removed his goggled and face shield to be able to clearly see and re-intubate a seriously ill patient. This tells us how doctors are putting themselves at risk during this global pandemic. As doctors get infected and result in a further depletion of workforce, the remaining physicians face an even greater workload.

Apart from all the above concerns, one major concern for doctors and healthcare staff is the threat of carrying the infection to their home and families.

How to address the burnout crisis

As much as it is important to ensure the safety of doctors, it is equally important to help them address the mental and physical outcomes of burnout. Governments, healthcare providers and hospitals must initiate a series of measures to help address this burnout crisis.

Adequate availability of protective equipment

Strict adherence to properly wearing PPEs has been found to be effective in minimizing infection rate among doctor and healthcare workers. It is extremely important therefore that governments and hospitals ensure adequate supply and sufficient availability of PPEs for doctors. Adequate supply of PPEs and addressing the shortage concerns also allays the mental stress and fear among doctors. It is also important to ensure that doctors do not have to wear the same protective equipment for more than 8-10 hours.

Access to counseling and mental health experts

The World Health Organization has advised doctors to take extra care of their health by consuming healthy food, taking adequate rest and staying active. The body has also recommended de-stressing and avoiding smoking or drugs. Hospitals must ensure that doctors have regular access to counseling support to advocate healthy living. They must also have access to mental health experts to give them a proper outlet for their mental and emotional turmoil.

Offering alternative stay arrangements

Governments and private healthcare providers must also arrange for alternative accommodation for doctors and other healthcare staff members to allow them stay away from their families during the time they are treating COVID 19 patients. This takes off the extra pressure and concern about carrying the virus home.

Reduce burden by adding to the manpower

With the number of patients rising steeply every day, we need to find innovative ways to have sufficient backup resource of doctors. In this situation, it makes sense to train final year MBBS and PG medical students in critical care and keep them ready to be deployed in case the need arises.  

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RISING DELTA CASES AND EXPECTED HERD IMMUNITY: WHERE DO WE STAND?

Dr Rahul Pandit

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Even as India continues to fight against the deadly Covid-19 virus, SARS-CoV-2 variants are emerging, spreading and causing governments & public health experts to develop the best strategies to contain their spread constantly. There are currently 11 variants of the SARS-CoV-2 virus that the World Health Organization Trusted Source is monitoring. One of these variants, the Delta Plus variant — also known as B.1.617.2.1 or AY.1 —first detected in India, February 2021, has spread to many parts of the world. Towards the end of August, Maharashtra recorded 103 Delta Plus cases. Approximately 65% of the reported cases were amongst the unvaccinated population.  

So, how is this variant different, and can it escape vaccine protection? 

Delta Plus is a sub-lineage of the Delta variant first detected in India, acquiring the spike protein mutation K417N. In June, this variant was designated as a Variant of Concern (VoC) by the Indian government, citing its perceived increased transmissibility, ability to bind more strongly to receptors on lung cells, and potential to evade an antibody response.

Is the Delta plus variant more threatening?

The Delta variant has been held responsible for the second wave in India. Several other countries consider Delta as the factor behind a sudden surge of cases. It can be a trigger to the third wave. 

While India is battling against the Delta plus variant, few other parts of the world are bearing the brunt of C.1.2, a new SARS-CoV-2 variant. It was first reported in South Africa during May and eventually spread to China, England, the Democratic Republic of Congo, Mauritius, Portugal, and Switzerland. India has no cases of the new strain so far, and globally Delta variant is the more dominant one. However, what is of concern here is that the C.1.2 variant has a mutation rate of 41.8 mutations per year, i.e. twice the current global mutation rate of other strains, and it can evade the antibodies developed to ward off the Alpha or Beta variants. 

What impact does virus mutation have on the human body? 

The standard process of mutations impacts us when it leads to changes in transmission levels or on treatment. Mutations can have positive, negative, or neutral effects on human health. For example, negative impacts may include clustering of infections, increased transmissibility, ability to escape immunity and infect others who have poor immunity, neutralization escape from monoclonal antibodies, improved binding to lung cells and increased severity of infection.But positive impacts can make the virus becomes non-viable.

At this rate, how and when will we achieve herd immunity? 

A population is said to achieve herd immunity when large percentages of individuals become immune to a disease. Based on mathematical calculations, if vaccines could provide a lifelong, fail-safe shield against infection with SARS-CoV-2, it would need to reach 60-72% of people to establish herd immunity. But if vaccines are only 80% effective at preventing infection, 75-90% of people would need to be immunized — a high bar. 

If a third wave is triggered, a rise in infection rates may pose the toughest challenge yet for the government, owing to the weaker health infrastructure and staff availability. Robust serological surveys can show where the community is in terms of seropositivity, and in a way, low case numbers are an outcome of the spread slowing. However, in the journey towards herd immunity, many other factors determine daily case numbers and daily deaths, including the age and morbidity profile of those affected. 

Moreover, experts opine that herd immunity doesn’t confer immunity to the virus itself but only reduces the risk that vulnerable people will encounter the pathogen. 

However, most herd-immunity calculations don’t consider behavior changes, interventions, and rules. For instance, if people follow good physical distancing, the R0 (R0, pronounced “R nought,” is a mathematical term that indicates how contagious an infectious disease is) will go down, if they stop following the same after a while, the R0 will go up again. This will change the herd immunity threshold accordingly. 

Until large-scale vaccinations are made available, current forms of social distancing and use of face masks, along with all-inclusive case finding, testing, contact tracing, and isolation, need to continue. History tells us that we have never achieved herd immunity via natural infection concerning a novel virus, and SARS-CoV-2 is no different. Vaccination is therefore paramount. 

The writer is the Director-Critical Care, Fortis Hospitals Mumbai & Member-Maharashtra Covid-19 Taskforce

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Study finds diet may contribute to cognitive resilience in elderly

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A new study has found that older adults may benefit from a specific diet called the MIND diet, even when they develop protein deposits known as amyloid plaques and tangles. The findings were published in the ‘Journal of Alzheimer’s Disease’. Ageing takes a toll on the body and on the mind. For example, the tissue of ageing human brains sometimes develops abnormal clumps of proteins that are the hallmark of Alzheimer’s disease. How can you protect your brain from these effects?

Researchers at Rush University Medical Center have found that older adults may benefit from a specific diet called the MIND diet even when they develop these protein deposits, known as amyloid plaques and tangles. Plaques and tangles are a pathology found in the brain that builds up in between nerve cells and typically interfere with thinking and problem-solving skills.

Developed by the late Martha Clare Morris, ScD, who was a Rush nutritional epidemiologist, and her colleagues, the MIND diet is a hybrid of the Mediterranean and DASH (Dietary Approaches to Stop Hypertension) diets.

Previous research studies have found that the MIND diet may reduce a person’s risk of developing Alzheimer’s disease dementia.

Now the study has shown that participants who followed the MIND diet moderately later in life did not have cognition problems. “Some people have enough plaques and tangles in their brains to have a postmortem diagnosis of Alzheimer’s disease, but they do not develop clinical dementia in their lifetime,” said Klodian Dhana, MD, PhD, lead author of the paper and an assistant professor in the Division of Geriatrics and Palliative Medicine in the Department of Internal Medicine at Rush Medical College.

“Some have the ability to maintain cognitive function despite the accumulation of these pathologies in the brain, and our study suggests that the MIND diet is associated with better cognitive functions independently of brain pathologies related to Alzheimer’s disease,” added Dhana.

In this study, the researchers examined the associations of diet — from the start of the study until death — brain pathologies and cognitive functioning in older adults who participated in the Rush Alzheimer’s Disease Center’s ongoing Memory and Ageing Project, which began in 1997 and includes people living in greater Chicago. The participants were mostly white without known dementia, and all of them agreed to undergo annual clinical evaluations while alive and brain autopsy after their death. The researchers followed 569 participants, who were asked to complete annual evaluations and cognitive tests to see if they had developed memory and thinking problems.

Beginning in 2004, participants were given an annual food frequency questionnaire about how often they ate 144 food items in the previous year. Using the questionnaire answers, the researchers gave each participant a MIND diet score based on how often the participants ate specific foods.

The MIND diet has 15 dietary components, including 10 “brain-healthy food groups” and five unhealthy groups — red meat, butter and stick margarine, cheese, pastries and sweets, and fried or fast food. To adhere to and benefit from the MIND diet, a person would need to eat at least three servings of whole grains, a green leafy vegetable and one other vegetable every day — along with a glass of wine — snack most days on nuts, have beans every other day or so, eat poultry and berries at least twice a week and fish at least once a week.

A person also must limit intake of the designated unhealthy foods, limiting butter to less than 1 1/2 teaspoons a day and eating less than a serving a week of sweets and pastries, whole fat cheese, and fried or fast food. Based on the frequency of intake reported for the healthy and unhealthy food groups, the researchers calculated the MIND diet score for each participant across the study period.

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‘Second-hand’ psychological stress can lead to depression

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Scientists have successfully endeavoured in connecting the dots between psychological stress and depression with the elucidation of a vicarious social defeat stress mouse model. The findings of the study were published in the journal ‘Behavioural Brain Research’. Depression is a serious medical condition that plagues modern society.

Several theories have been proposed to explain the physiological basis of depression, of which the “neurogenic hypothesis of depression” has garnered much attention.

The theory follows that deterioration in brain regions, like the hippocampus, can result in depression. This deterioration can be caused by physical and psychological stress. While the depressive effects of physical stress have been well studied, little is known about psychological stress in this regard.

Recent research has explained how vicarious social defeat can cause psychological stress in mice.

This involves the mouse being made to experience the defeat of another mouse in an experimental social setting. Using this model, a group of scientists from Japan attempted to establish a link between depressive symptoms and hippocampal neurogenesis.

Professor Akiyoshi Saitoh from Tokyo University of Science, one of the lead authors of the study, further explained the motivation behind this research, “The number of individuals suffering from depression has been on the rise the world over. However, the detailed pathophysiology of depression still remains to be elucidated. So, we decided to focus on the possible mechanism of psychological stress in adult hippocampal neurogenesis, to understand its role in depressive disorders.”

After exposing the mice to chronic vicarious social defeat stress, Professor Saitoh and the team, including Mr Toshinori Yoshioka and Dr Daisuke Yamada from Tokyo University of Science, analysed their behaviour and brains in close detail.

Aside from behavioural deficits like social withdrawal, the stressed mice also showed a significant decrease in the survival rate of newborn neurons in the dentate gyrus, a region in the hippocampus responsible for sensory perception and memory, compared to the non-stressed controls.

This condition persisted for up to four weeks, after “stressing” the mice. However, cell growth, differentiation, and maturation did not differ between the groups of mice during the period of observation.

Notably, the cell survival rate was restored in the stressed mice after treatment with a chronic antidepressant called fluoxetine. Regarding the results, Mr Toshinori Yoshioka added, “We have found out that chronic mental stress affects the neurogenesis of the hippocampal dentate gyrus. Also, we believe that this animal model will play an important role in elucidating the pathophysiology of depression, and in the development of the corresponding novel drug.”

Overall, this study has provided important insights into the pathophysiology of depression. Also, it goes without saying how this study paves the way for future research into the role of psychological stress in depression.

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STUDY SUGGESTS COVID-19 PANDEMIC TRIGGERED A CYCLE OF MENTAL HEALTH STRUGGLES, PHYSICAL INACTIVITY

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NORTH CAROLINA: The Covid-19 pandemic has created a cyclical public health problem by both exacerbating mental health challenges and making it more difficult for people to maintain physical activity, suggests a recent multi-state study. The study also revealed that lower-income households struggled more with both mental health challenges and maintaining physical activity levels. These findings were written in the paper ‘Examining the relationship between physical activity and mental health during the Covid-19 pandemic across five U.S. States’, and have been published in the journal Preventive Medicine Reports.

“We know that physical activity is important for helping people maintain their mental health, but this study reveals the unforgiving cycle that the pandemic has imposed on many people,” said Lindsey Haynes-Maslow, co-author of the study and an associate professor of agricultural and human sciences at North Carolina State University.

“The pandemic has increased psychological distress, which makes it more difficult for people to maintain their physical activity levels. This, in turn, further hurts their mental health, which makes them less likely to be active, and so on. Once you get on this roller coaster ride, it’s hard to get off. And all of this is exacerbated by the pandemic making it harder for people to find safe spaces in which to exercise,” added Haynes-Maslow.

For this study researchers were focused on two questions: How is the pandemic influencing physical activity and mental health status? And how, if at all, do physical activity and mental health status relate to each other?

To address those questions, the researchers conducted an in-depth, online survey of 4,026 adults in Louisiana, Montana, North Carolina, Oregon and West Virginia. The survey was conducted between April and September of 2020.

The researchers found that the more physically active people were, the better their mental health status.

That held true even when accounting for an individual’s race/ethnicity, household income and other socioeconomic demographic variables.

The researchers also found that the higher an individual’s household income, the more likely they were to be able to maintain pre-pandemic physical activity levels. Specifically, people in households that earned less than USD 50,000 per year were 1.46 times less likely to maintain their pre-pandemic levels of physical activity as compared to people in households that earned more than USD 50,000 per year.

In addition, the survey found that participants in urban areas were more likely to report difficulty maintaining their pre-pandemic physical activity levels, as compared to study participants in rural areas.

“This rural/urban finding was somewhat surprising, because normally – when we’re not in a pandemic – people in rural areas tend to report more mental health challenges than their urban counterparts,” Haynes-Maslow said.

“Fortunately, the survey was designed to help understand each study participant’s mental health and physical activity levels before and during the pandemic,” said Shelly Maras, co-author of the paper and a PhD candidate at NC State. “The survey also included open-ended questions that allowed us to analyze rich, qualitative data related to respondents’ mental health and physical activity.”

The open-ended survey results revealed that many participants struggled with staying active during stay-at-home orders, but rural participants talked about how their open spaces and places provided more opportunities to get outside and get moving. Participants also talked about how caregiving, exhaustion and mental health stressors kept them from being active, perpetuating the cycle.

“Our findings drive home that mental health is a persistent challenge during this pandemic,” said Annie Hardison-Moody, co-author of the study and an associate professor of agricultural and human sciences at NC State. “This survey data helps us understand what people were going through during those early months of the pandemic. It also helps us understand the importance of having access to open spaces and the barriers that are in place preventing people from accessing those spaces.”

“We’re still in a pandemic,” Haynes-Maslow said. “But it’s clear that we need a playbook in place for what we do in future crises to help people be active and protect their mental health.”

“We need structural changes in communities to ensure people have equitable access to safe spaces where they can be active. That will require policy changes and funding to create the necessary infrastructure: sidewalks, streetlights, green spaces. This will require significant investment, and it will take time, so we need to begin acting on this now. It is much less expensive to invest now than it is to pay for the long-term consequences of poor physical and mental health,” Haynes-Maslow concluded.

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