Driving under the influence of marijuana: An explainer and research roundup
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Update 1: On May 16, 2024, the U.S. Department of Justice sent a proposed rule to the Federal Register to downgrade marijuana from a Schedule I to a Schedule III drug. This is the first step in a lengthy approval process that starts with a 60-day comment period.
Update 2: Two recent research studies were added to the “Studies on marijuana and driving” section of this piece on July 18, 2024.
As marijuana use continues to rise and state-level marijuana legalization sweeps the U.S., researchers and policymakers are grappling with a growing public safety concern: marijuana-impaired driving.
As of April 2023, 38 U.S. states had legalized medical marijuana and 23 had legalized its recreational use, according to the National Conference of State Legislatures. Recreational or medical marijuana measures are on the ballot in seven states this year.
The issue of marijuana-impaired driving has not been an easy one to tackle because, unlike alcohol, which has well-established thresholds of impairment, the metrics for marijuana’s effects on driving remain rather elusive.
“We don’t have that kind of deep knowledge right now and it’s not because of lack of trying,” says Dr. Guohua Li, professor of epidemiology and the founding director of the Center for Injury Science and Prevention at Columbia University.
“Marijuana is very different from alcohol in important ways,” says Li, who has published several studies on marijuana and driving. “And one of them is that the effect of marijuana on cognitive functions and behaviors is much more unpredictable than alcohol. In general, alcohol is a depressant drug. But marijuana could act on the central nervous system as a depressant, a stimulant, and a hallucinogenic substance.”
Efforts to create a breathalyzer to measure the level of THC, the main psychoactive compound found in the marijuana plant, have largely failed, because “the THC molecule is much bigger than ethanol and its behavior after ingestion is very different from alcohol,” Li says.
Currently, the two most common methods used to measure THC concentration to identify impaired drivers are blood and saliva tests, although there’s ongoing debate about their reliability.
Marijuana, a term interchangeably used with cannabis, is the most commonly used federally illegal drug in the U.S.: 48.2 million people, or about 18% of Americans reported using it at least once in 2019, according to the latest available data from the Centers for Disease Control and Prevention. Worldwide, 2.5% of the population consumes marijuana, according to the World Health Organization.
Marijuana is legal in several countries, including Canada, where it was legalized in 2018. Despite state laws legalizing cannabis, it remains illegal at the federal level in the U.S.
As states grapple with the contentious issue of marijuana legalization, the debate is not just about public health, potential tax revenues and economic interests. At the heart of the discussion is also the U.S. criminal justice system.
Marijuana is shown to have medicinal qualities and, compared with substances like alcohol, tobacco, and opioids, it has relatively milder health risks. However, it’s not risk-free, a large body of research has shown.
Marijuana consumption can lead to immediate effects such as impaired muscle coordination and paranoia, as well as longer-term effects on mental health and cognitive functions — and addiction. As its use becomes more widespread, researchers are trying to better understand the potential hazards of marijuana, particularly for younger users whose brains are in critical stages of development.
Marijuana and driving
The use of marijuana among drivers, passengers and pedestrians has increased steadily over the past two decades, Li says.
Compared with the year 2000, the proportion of U.S. drivers on the road who are under the influence of marijuana has increased by several folds, between five to 10 times, based on toxicology testing of people who died in car crashes, Li says.
A 2022 report from the National Transportation Safety Board finds alcohol and cannabis are the two most commonly detected drugs among drivers arrested for impaired driving and fatally injured drivers. Most drivers who tested positive for cannabis also tested positive for another potentially impairing drug.
“Although cannabis and many other drugs have been shown to impair driving performance and are associated with increased crash risk, there is evidence that, relative to alcohol, awareness about the potential dangers of driving after using other drugs is lower,” according to the report.
Indeed, many U.S. adults perceive daily marijuana use or exposure to its smoke safer than tobacco, even though research finds otherwise.
Several studies have demonstrated marijuana’s impact on driving.
Marijuana use can reduce the drivers’ ability to pay attention, particularly when they are performing multiple tasks, research finds. It also slows reaction time and can impair coordination.
“The combination is that you potentially have people who are noticing hazards later, braking slower and potentially not even noticing hazards because of their inability to focus on competing things on the road,” says Dr. Daniel Myran, an assistant professor at the Department of Family Medicine and health services researcher at the University of Ottawa.
In a study published in September in JAMA Network Open, Myran and colleagues find that from 2010 to 2021 the rate of cannabis-involved traffic injuries that led to emergency department visits in Ontario, Canada, increased by 475%, from 0.18 per 1,000 traffic injury emergency department visits in 2010 to 1.01 visits in 2021.
To be sure, cannabis-involved traffic injuries made up a small fraction of all traffic injury-related visits to hospital emergency departments. Out of 947,604 traffic injury emergency department visits, 426 had documented cannabis involvement.
Myran cautions the increase shouldn’t be solely attributed to marijuana legalization. It captures changing societal attitudes toward marijuana and acceptance of cannabis use over time in the lead-up to legalization. In addition, it may reflect an increasing awareness among health care providers about cannabis-impaired driving, and they may be more likely to ask about cannabis use and document it in medical charts, he says.
“When you look at the 475% increase in cannabis involvement in traffic injuries, rather than saying legalizing cannabis has caused the roads to be unsafe and is a public health disaster, it’s that cannabis use appears to be growing as a risk for road traffic injuries and that there seem to be more cannabis impaired drivers on the road,” Myran says. “Legalization may have accelerated this trend. Faced with this increase, we need to think about what are public health measures and different policy interventions to reduce harms from cannabis-impaired driving.”
Setting a legal limit for marijuana-impaired driving
Setting a legal limit for marijuana-impaired driving has not been easy. Countries like Canada and some U.S. states have agreed upon a certain level of THC in blood, usually between 1 to 5 nanograms per milliliter. Still, some studies have found those limits to be weak indicators of cannabis-impaired driving.
When Canada legalized recreational marijuana in 2018, it also passed a law that made it illegal to drive with blood THC levels of more than 2 nanograms. The penalties are more severe for blood THC levels above 5 nanograms. The blood test is done at the police station for people who are pulled over and are deemed to be drug impaired.
In the U.S., five states — Ohio, Illinois, Montana, Washington and Nevada — have “per se laws,” which set a specific amount of THC in the driver’s blood as evidence of impaired driving, according to the National Conference of State Legislatures. That limit ranges between 2 and 5 nanograms of THC per milliliter of blood.
Colorado, meanwhile, has a “permissible inference law,” which states that it’s permissible to assume the driver was under the influence if their blood THC level is 5 nanograms per milliliter or higher, according to NCSL.
Twelve states, most which have legalized some form of marijuana of use, have zero tolerance laws for any amount of certain drugs, including THC, in the body.
The remaining states have “driving under the influence of drugs” laws. Among those states, Alabama and Michigan, have oral fluid roadside testing program to screen drivers for marijuana and other drugs, according to NCSL.
In May this year, the U.S. Department of Transportation published a final rule that allows employers to use saliva testing for commercially licensed drivers, including truck drivers. The rule, which went into effect in June, sets the THC limit in saliva at 4 nanograms.
Saliva tests can detect THC for 8 to 24 hours after use, but the tests are not perfect and can results in false positives, leading some scientists to argue against using them in randomly-selected drivers.
In a 2021 report, the U.S. National Institute of Justice, the research and development arm of the Department of Justice, concluded that THC levels in bodily fluids, including blood and saliva “were not reliable indicators of marijuana intoxication.”
Studies on marijuana and driving
Over the past two decades, many studies have shown marijuana use can impair driving. However, discussions about what’s the best way to measure the level of THC in blood or saliva are ongoing. Below, we highlight and summarize several recent studies that address the issue. The studies are listed in order of publication date. We also include a list of related studies and resources to inform your audiences.
State Driving Under the Influence of Drugs Laws
Alexandra N. Origenes, Sarah A. White, Emma E. McGinty and Jon S. Vernick. Journal of Law, Medicine & Ethics, July 2024.
Summary: As of January 2023, 33 states and D.C. had a driving under the influence of drugs law for at least one drug other than cannabis. Of those, 29 states and D.C. had a law specifically for driving under the influence of cannabis, in addition to a law for driving under the influence of other drugs. Four states had a driving under the influence of drug laws, excluding cannabis. Meanwhile, 17 states had no law for driving under the influence of drugs, including cannabis. “The 17 states lacking a DUID law that names specific drugs should consider enacting such a law. These states already have expressed their concern — through legislation — with drug-impaired driving. However, failure to name specific drugs is likely to make the laws more difficult to enforce. These laws may force courts and/or law enforcement to rely on potentially subjective indicators of impairment,” the authors write.
Associations between Adolescent Marijuana Use, Driving After Marijuana Use and Recreational Retail Sale in Colorado, USA
Lucas M. Neuroth, et al. Substance Use & Misuse, October 2023.
Summary: Researchers use data from four waves (2013, 2015, 2017 and 2019) of the Healthy Kids Colorado Survey, including 47,518 students 15 and older who indicated that they drove. They find 20.3% of students said that they had used marijuana in the past month and 10.5% said they had driven under the influence of marijuana. They find that the availability of recreational marijuana in stores was associated with an increased prevalence of using marijuana one to two times in the past month and driving under the influence of marijuana at least once. “Over the study period, one in ten high school age drivers engaged in [driving after marijuana use], which is concerning given the high risk of motor vehicle-related injury and death arising from impaired driving among adolescents,” the authors write.
Are Blood and Oral Fluid Δ9-tetrahydrocannabinol (THC) and Metabolite Concentrations Related to Impairment? A Meta-Regression Analysis
Danielle McCartney, et al. Neuroscience & Biobehavioral Reviews, March 2022.
Summary: Commonly used THC measurements may not be strong indicators of driving impairment. While there is a relationship between certain biomarkers like blood THC concentrations and impaired driving, this correlation is often weak. The study underscores the need for more nuanced and comprehensive research on this topic, especially as cannabis usage becomes more widespread and legally accepted.
The Effects of Cannabis and Alcohol on Driving Performance and Driver Behaviour: A Systematic Review and Meta-Analysis
Sarah M. Simmons, Jeff K. Caird, Frances Sterzer and Mark Asbridge. Addiction, January 2022.
Summary: This meta-analysis of experimental driving studies, including driving simulations, confirms that cannabis impairs driving performance, contrary to some beliefs that it might enhance driving abilities. Cannabis affects lateral control and speed — typically increasing lane excursions while reducing speed. The combination of alcohol and marijuana appears worse than either alone, challenging the idea that they cancel each other out.
Cannabis Legalization and Detection of Tetrahydrocannabinol in Injured Drivers
Jeffrey R. Brubacher, et al. The New England Journal of Medicine, January 2022.
Summary: Following the legalization of recreational marijuana in Canada, there was a notable increase in injured drivers testing positive for THC, especially among those 50 years of age or older. This rise in cannabis-related driving incidents occurred even with new traffic laws aiming to deter cannabis-impaired driving. This uptick began before legalization became official, possibly due to perceptions that cannabis use was soon-to-be legal or illegal but not enforced. The data suggests that while legalization has broad societal impacts, more comprehensive strategies are needed to deter driving under the influence of cannabis and raise public awareness about its risks.
Cannabis and Driving
Godfrey D. Pearlson, Michael C. Stevens and Deepak Cyril D’Souza. Frontiers in Psychiatry, September 2021.
Summary: Cannabis-impaired driving is a growing public health concern, and studies show that such drivers are more likely to be involved in car crashes, according to this review paper. Drivers are less affected by cannabis than they are by alcohol or cocaine, but the problem is expected to escalate with increasing cannabis legalization and use. Unlike alcohol, THC’s properties make it challenging to determine direct impairment levels from testing results. Current roadside tests lack precision in detecting genuine cannabis-impaired drivers, leading to potential wrongful convictions. Moreover, there is a pressing need for research on the combined effects of alcohol and cannabis on driving, as well as the impact of emerging popular forms of cannabis, like concentrates and edibles. The authors recommend public awareness campaigns about the dangers of driving under the influence of cannabis, similar to those against drunk driving, to address misconceptions. Policymakers should prioritize science-based decisions and encourage further research in this domain.
Demographic And Policy-Based Differences in Behaviors And Attitudes Towards Driving After Marijuana Use: An Analysis of the 2013–2017 Traffic Safety Culture Index
Marco H. Benedetti, et al. BMC Research Notes, June 2021.
Summary: The study, based on a U.S. survey, finds younger, low-income, low-education and male participants were more tolerant of driving after marijuana consumption. Notably, those in states that legalized medical marijuana reported driving after use more frequently, aligning with studies indicating a higher prevalence of THC detection in drivers from these states. Overall, while the majority perceive driving after marijuana use as dangerous, not all research agrees on its impairment effects. Existing studies highlight that marijuana impacts motor skills and executive functions, yet its direct correlation with crash risk remains debated, given the variations in individual tolerance and how long THC remains in the system.
Driving Under the Influence of Cannabis: A Framework for Future Policy
Robert M. Chow, et al.Anesthesia & Analgesia, June 2019.
Summary: The study presents a conceptual framework focusing on four main domains: legalization, driving under the influence of cannabis, driver impairment, and motor vehicle accidents. With the growing legalization of cannabis, there’s an anticipated rise in cannabis-impaired driving cases. The authors group marijuana users into infrequent users who show significant impairment with increased THC blood levels, chronic users with minimal impairment despite high THC levels, and those with consistent psychomotor deficits. Current challenges lie in the lack of standardized regulation for drivers influenced by cannabis, primarily because of state-to-state variability and the absence of a federal statutory limit for blood THC levels. European nations, however, have established thresholds for blood THC levels, ranging from 0.5 to 50.0 micrograms per liter depending on whether blood or blood serum are tested. The authors suggest the combined use of alcohol and THC blood tests with a psychomotor evaluation by a trained professional to determine impairment levels. The paper stresses the importance of creating a structured policy framework, given the rising acceptance and use of marijuana in society.
Additional research
Cannabis-Involved Traffic Injury Emergency Department Visits After Cannabis Legalization and Commercialization
Daniel T. Myran, et al. JAMA Network Open, September 2023.
Driving Performance and Cannabis Users’ Perception of Safety: A Randomized Clinical Trial
Thomas D. Marcotte, et al. JAMA Psychiatry, January 2022.
Medicinal Cannabis and Driving: The Intersection of Health and Road Safety Policy
Daniel Perkins, et al. International Journal of Drug Policy, November 2021.
Prevalence of Marijuana Use Among Trauma Patients Before and After Legalization of Medical Marijuana: The Arizona Experience
Michael Levine, et al. Substance Abuse, July 2021.
Self-Reported Driving After Marijuana Use in Association With Medical And Recreational Marijuana Policies
Marco H. Benedetti, et al. International Journal of Drug Policy, June 2021.
Cannabis and Driving Ability
Eric L. Sevigny. Current Opinion in Psychology, April 2021.
The Failings of per se Limits to Detect Cannabis-Induced Driving Impairment: Results from a Simulated Driving Study
Thomas R. Arkell, et al. Traffic Injury Prevention, February 2021.
Risky Driving Behaviors of Drivers Who Use Alcohol and Cannabis
Tara Kelley-Baker, et al. Transportation Research Record, January 2021.
Direct and Indirect Effects of Marijuana Use on the Risk of Fatal 2-Vehicle Crash Initiation
Stanford Chihuri and Guohua Li. Injury Epidemiology, September 2020
Cannabis-Impaired Driving: Evidence and the Role of Toxicology Testing
Edward C. Wood and Robert L. Dupont. Cannabis in Medicine, July 2020.
Association of Recreational Cannabis Laws in Colorado and Washington State With Changes in Traffic Fatalities, 2005-2017
Julian Santaella-Tenorio, et al. JAMA Internal Medicine, June 2020.
Marijuana Decriminalization, Medical Marijuana Laws, and Fatal Traffic Crashes in US Cities, 2010–2017
Amanda Cook, Gregory Leung and Rhet A. Smith. American Journal of Public Health, February 2020.
Cannabis Use in Older Drivers in Colorado: The LongROAD Study
Carolyn G. DiGuiseppi, et al. Accident Analysis & Prevention, November 2019.
Crash Fatality Rates After Recreational Marijuana Legalization in Washington and Colorado
Jayson D. Aydelotte, et al. American Journal of Public Health, August 2017.
Marijuana-Impaired Driving: A Report to Congress
National Highway Traffic Safety Administration, July 2017
Interaction of Marijuana And Alcohol on Fatal Motor Vehicle Crash Risk: A Case–Control Study
Stanford Chihuri, Guohua Li and Qixuan Chen. Injury Epidemiology, March 2017.
US Traffic Fatalities, 1985–2014, and Their Relationship to Medical Marijuana Laws
Julian Santaella-Tenorio, et al. American Journal of Public Health, February 2017.
Delays in DUI Blood Testing: Impact on Cannabis DUI Assessments
Ed Wood, Ashley Brooks-Russell and Phillip Drum. Traffic Injury Prevention, June 2015.
Establishing Legal Limits for Driving Under the Influence of Marijuana
Kristin Wong, Joanne E. Brady and Guohua Li. Injury Epidemiology, October 2014.
Cannabis Effects on Driving Skills
Rebecca L. Hartman and Marilyn A. Huestis. Clinical Chemistry, March 2014.
Acute Cannabis Consumption And Motor Vehicle Collision Risk: Systematic Review of Observational Studies and Meta-Analysis
Mark Asbridge, Jill A. Hayden and Jennifer L. Cartwright. The BMJ, February 2012.
Resources for your audiences
The following resources include explainers from federal agencies and national organizations. You’re free to use images and graphics from federal agencies.
- CDC’s main marijuana page.
- CDC’s marijuana data and statistics.
- Marijuana Drug Facts from the National Institute on Drug Abuse.
- Health Effects of Marijuana from the CDC.
- Learn About Marijuana Risks from the Substance Abuse and Mental Health Services Administration.
- Marijuana and Lung Health from the American Lung Association.
- Substance Use Disorder 101 from the U.S. Department of Health & Human Services.
- What You Need To Know About Marijuana Use and Driving from the CDC.
- Does marijuana use affect driving? from the National Institute on Drug Abuse.
- Drug-Impaired Driving from the National Highway Traffic Safety Administration.
This article first appeared on The Journalist’s Resource and is republished here under a Creative Commons license.
Don’t Forget…
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Glycemic Index vs Glycemic Load vs Insulin Index
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How To Actually Use Those Indices
Carbohydrates are essential for our life, and/but often bring about our early demise. It would be a very conveniently simple world if it were simply a matter of “enjoy in moderation”, but the truth is, it’s not that simple.
To take an extreme example, for the sake of clearest illustration: The person who eats an 80% whole fruit diet (and makes up the necessary protein and fats etc in the other 20%) will probably be healthier than the person who eats a “standard American diet”, despite not practising moderation in their fruit-eating activities. The “standard American diet” has many faults, and one of those faults is how it promotes sporadic insulin spikes leading to metabolic disease.
If your breakfast is a glass of orange juice, this is a supremely “moderate” consumption, but an insulin spike is an insulin spike.
Quick sidenote: if you’re wondering why eating immoderate amounts of fruit is unlikely to cause such spikes, but a single glass of orange juice is, check out:
Which Sugars Are Healthier, And Which Are Just The Same?
Glycemic Index
The first tool in our toolbox here is glycemic index, or GI.
GI measures how much a carb-containing food raises blood glucose levels, also called blood sugar levels, but it’s just glucose that’s actually measured, bearing in mind that more complex carbs will generally get broken down to glucose.
Pure glucose has a GI of 100, and other foods are ranked from 0 to 100 based on how they compare.
Sometimes, what we do to foods changes its GI.
- Some is because it changed form, like the above example of whole fruit (low GI) vs fruit juice (high GI).
- Some is because of more “industrial” refinement processes, such as whole grain wheat (medium GI) vs white flour and white flour products (high GI)
- Some is because of other changes, like starches that were allowed to cool before being reheated (or eaten cold).
Broadly speaking, a daily average GI of 45 is considered great.
But that’s not the whole story…
Glycemic Load
Glycemic Load, or GL, takes the GI and says “ok, but how much of it was there?”, because this is often relevant information.
Refined sugar may have a high GI, but half a teaspoon of sugar in your coffee isn’t going to move your blood sugar levels as much as a glass of Coke, say—the latter simply has more sugar in, and just the same zero fiber.
GL is calculated by (grams of carbs / 100) x GI, by the way.
But it still misses some important things, so now let’s look at…
Insulin Index
Insulin Index, which does not get an abbreviation (probably because of the potentially confusing appearance of “II”), measures the rise in insulin levels, regardless of glucose levels.
This is important, because a lot of insulin response is independent of blood glucose:
- Some is because of other sugars, some some is in response to fats, and yes, even proteins.
- Some is a function of metabolic base rate.
- Some is a stress response.
- Some remains a mystery!
Another reason it’s important is that insulin drives weight gain and metabolic disorders far more than glucose.
Note: the indices of foods are calculated based on average non-diabetic response. If for example you have Type 1 Diabetes, then when you take a certain food, your rise in insulin is going to be whatever insulin you then take, because your body’s insulin response is disrupted by being too busy fighting a civil war in your pancreas.
If your diabetes is type 2, or you are prediabetic, then a lot of different things could happen depending on the stage and state of your diabetes, but the insulin index is still a very good thing to be aware of, because you want to resensitize your body to insulin, which means (barring any urgent actions for immediate management of hyper- or hypoglycemia, obviously) you want to eat foods with a low insulin index where possible.
Great! What foods have a low insulin index?
Many factors affect insulin index, but to speak in general terms:
- Whole plant foods are usually top-tier options
- Lean and/or white meats generally have lower insulin index than red and/or fatty ones
- Unprocessed is generally lower than processed
- The more solid a food is, generally the lower its insulin index compared to a less solid version of the same food (e.g. baked potatoes vs mashed potatoes; cheese vs milk, etc)
But do remember the non-food factors too! This means where possible:
- reducing/managing stress
- getting frequent exercise
- getting good sleep
- practising intermittent fasting
See for example (we promise you it’s relevant):
Fix Chronic Fatigue & Regain Your Energy, By Science
…as are (especially recommendable!) the two links we drop at the bottom of that page; do check them out if you can
Take care!
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In Praise Of Walking – by Dr. Shane O’Mara
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At 10almonds we talk often of the health benefits of walking, so what’s new here?
As the subtitle suggests: a new scientific exploration!
Dr. Shane O’Mara is a professor of experimental brain research—and a keen walker. Combining his profession and his passion, he offers us a uniquely well-grounded perspective.
While the writing style is very readable, there’s a lot of science referenced here, with many studies cited. We love that!
We begin our journey by learning what we have in common with sea squirts, and what we have different from all other apes. What we can learn from other humans, from toddlers to supercentenarians.
As one might expect from a professor of experimental brain research, we learn a lot more about what walking does for our brain, than for the rest of our body. We’ve previously talked about walking and cardiovascular health, and brown adipose tissue, and benefits to the immune system, but this book remains steadfastly focused on the brain.
Which just goes to show, what a lot there is to say for the science-based benefits to our brain health, both neurologically and psychologically!
One of the things at which Dr. O’Mara excels that this reviewer hasn’t seen someone do so well before, is neatly tie together the appropriate “why” and “how” to each “what” of the brain-benefits of walking. Not just that walking boosts mood or creativity or problem-solving, say, but why and how it does so.
Often, understanding that can be the difference between being motivated to actually do it or not!
Bottom line: if there’s a book that’ll get you lacing up your walking shoes, this’ll be the one.
Click here to check out “In Praise of Walking” on Amazon, and start reaping the benefits!
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Never Too Old?
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Age Limits On Exercise?
In Tuesday’s newsletter, we asked you your opinion on whether we should exercise less as we get older, and got the above-depicted, below-described, set of responses:
- About 42% said “No, we must keep pushing ourselves, to keep our youth“
- About 29% said “Only to the extent necessary due to chronic conditions etc”
- About 29% said “Yes, we should keep gently moving but otherwise take it easier”
One subscriber who voted for “No, we must keep pushing ourselves, to keep our youth“ wrote to add:
❝I’m 71 and I push myself. I’m not as fast or strong as I used to be but, I feel great when I push myself instead of going through the motions. I listen to my body!❞
~ 10almonds subscriber
One subscriber who voted for “Only to the extent necessary due to chronic conditions etc” wrote to add:
❝It’s never too late to get stronger. Important to keep your strength and balance. I am a Silver Sneakers instructor and I see first hand how helpful regular exercise is for seniors.❞
~ 10almonds subscriber
One subscriber who voted to say “Yes, we should keep gently moving but otherwise take it easier” wrote to add:
❝Keep moving but be considerate and respectful of your aging body. It’s a time to find balance in life and not put yourself into a positon to damage youself by competing with decades younger folks (unless you want to) – it will take much longer to bounce back.❞
~ 10almonds subscriber
These will be important, because we’ll come back to them at the end.
So what does the science say?
Endurance exercise is for young people only: True or False?
False! With proper training, age is no barrier to serious endurance exercise.
Here’s a study that looked at marathon-runners of various ages, and found that…
- the majority of middle-aged and elderly athletes have training histories of less than seven years of running
- there are virtually no relevant running time differences (p<0.01) per age in marathon finishers from 20 to 55 years
- after 55 years, running times did increase on average, but not consistently (i.e. there were still older runners with comparable times to the younger age bracket)
The researchers took this as evidence of aging being indeed a biological process that can be sped up or slowed down by various lifestyle factors.
See also:
Age & Aging: What Can (And Can’t) We Do About It?
this covers the many aspects of biological aging (it’s not one number, but many!) and how our various different biological ages are often not in sync with each other, and how we can optimize each of them that can be optimized
Resistance training is for young people only: True or False?
False! In fact, it’s not only possible for older people, but is also associated with a reduction in all-cause mortality.
Specifically, those who reported strength-training at least once per week enjoyed longer lives than those who did not.
You may be thinking “is this just the horse-riding thing again, where correlation is not causation and it’s just that healthier people (for other reasons) were able to do strength-training more, rather than the other way around?“
…which is a good think to think of, so well-spotted if you were thinking that!
But in this case no; the benefits remained when other things were controlled for:
❝Adjusted for demographic variables, health behaviors and health conditions, a statistically significant effect on mortality remained.
Although the effects on cardiac and cancer mortality were no longer statistically significant, the data still pointed to a benefit.
Importantly, after the physical activity level was controlled for, people who reported strength exercises appeared to see a greater mortality benefit than those who reported physical activity alone.❞
See the study: Is strength training associated with mortality benefits? A 15 year cohort study of US older adults
And a pop-sci article about it: Strength training helps older adults live longer
Closing thoughts
As it happens… All three of the subscribers we quoted all had excellent points!
Because in this case it’s less a matter of “should”, and more a selection of options:
- We (most of us, at least) can gain/regain/maintain the kind of strength and fitness associated with much younger people, and we need not be afraid of exercising accordingly (assuming having worked up to such, not just going straight from couch to marathon, say).
- We must nevertheless be mindful of chronic conditions or even passing illnesses/injuries, but that goes for people of any age
- We also can’t argue against a “safety first” cautious approach to exercise. After all, sure, maybe we can run marathons at any age, but that doesn’t mean we have to. And sure, maybe we can train to lift heavy weights, but if we’re content to be able to carry the groceries or perhaps take our partner’s weight in the salsa hall (or the bedroom!), then (if we’re also at least maintaining our bones and muscles at a healthy level) that’s good enough already.
Which prompts the question, what do you want to be able to do, now and years from now? What’s important to you?
For inspiration, check out: Train For The Event Of Your Life!
Take care!
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Related Posts
Never Too Old?
10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.
Age Limits On Exercise?
In Tuesday’s newsletter, we asked you your opinion on whether we should exercise less as we get older, and got the above-depicted, below-described, set of responses:
- About 42% said “No, we must keep pushing ourselves, to keep our youth“
- About 29% said “Only to the extent necessary due to chronic conditions etc”
- About 29% said “Yes, we should keep gently moving but otherwise take it easier”
One subscriber who voted for “No, we must keep pushing ourselves, to keep our youth“ wrote to add:
❝I’m 71 and I push myself. I’m not as fast or strong as I used to be but, I feel great when I push myself instead of going through the motions. I listen to my body!❞
~ 10almonds subscriber
One subscriber who voted for “Only to the extent necessary due to chronic conditions etc” wrote to add:
❝It’s never too late to get stronger. Important to keep your strength and balance. I am a Silver Sneakers instructor and I see first hand how helpful regular exercise is for seniors.❞
~ 10almonds subscriber
One subscriber who voted to say “Yes, we should keep gently moving but otherwise take it easier” wrote to add:
❝Keep moving but be considerate and respectful of your aging body. It’s a time to find balance in life and not put yourself into a positon to damage youself by competing with decades younger folks (unless you want to) – it will take much longer to bounce back.❞
~ 10almonds subscriber
These will be important, because we’ll come back to them at the end.
So what does the science say?
Endurance exercise is for young people only: True or False?
False! With proper training, age is no barrier to serious endurance exercise.
Here’s a study that looked at marathon-runners of various ages, and found that…
- the majority of middle-aged and elderly athletes have training histories of less than seven years of running
- there are virtually no relevant running time differences (p<0.01) per age in marathon finishers from 20 to 55 years
- after 55 years, running times did increase on average, but not consistently (i.e. there were still older runners with comparable times to the younger age bracket)
The researchers took this as evidence of aging being indeed a biological process that can be sped up or slowed down by various lifestyle factors.
See also:
Age & Aging: What Can (And Can’t) We Do About It?
this covers the many aspects of biological aging (it’s not one number, but many!) and how our various different biological ages are often not in sync with each other, and how we can optimize each of them that can be optimized
Resistance training is for young people only: True or False?
False! In fact, it’s not only possible for older people, but is also associated with a reduction in all-cause mortality.
Specifically, those who reported strength-training at least once per week enjoyed longer lives than those who did not.
You may be thinking “is this just the horse-riding thing again, where correlation is not causation and it’s just that healthier people (for other reasons) were able to do strength-training more, rather than the other way around?“
…which is a good think to think of, so well-spotted if you were thinking that!
But in this case no; the benefits remained when other things were controlled for:
❝Adjusted for demographic variables, health behaviors and health conditions, a statistically significant effect on mortality remained.
Although the effects on cardiac and cancer mortality were no longer statistically significant, the data still pointed to a benefit.
Importantly, after the physical activity level was controlled for, people who reported strength exercises appeared to see a greater mortality benefit than those who reported physical activity alone.❞
See the study: Is strength training associated with mortality benefits? A 15 year cohort study of US older adults
And a pop-sci article about it: Strength training helps older adults live longer
Closing thoughts
As it happens… All three of the subscribers we quoted all had excellent points!
Because in this case it’s less a matter of “should”, and more a selection of options:
- We (most of us, at least) can gain/regain/maintain the kind of strength and fitness associated with much younger people, and we need not be afraid of exercising accordingly (assuming having worked up to such, not just going straight from couch to marathon, say).
- We must nevertheless be mindful of chronic conditions or even passing illnesses/injuries, but that goes for people of any age
- We also can’t argue against a “safety first” cautious approach to exercise. After all, sure, maybe we can run marathons at any age, but that doesn’t mean we have to. And sure, maybe we can train to lift heavy weights, but if we’re content to be able to carry the groceries or perhaps take our partner’s weight in the salsa hall (or the bedroom!), then (if we’re also at least maintaining our bones and muscles at a healthy level) that’s good enough already.
Which prompts the question, what do you want to be able to do, now and years from now? What’s important to you?
For inspiration, check out: Train For The Event Of Your Life!
Take care!
Don’t Forget…
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Anti-Inflammatory Diet 101 (What to Eat to Fight Inflammation)
10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.
Chronic inflammation is a cause and/or exacerbating factor in very many diseases. Arthritis, diabetes, and heart disease are probably top of the list, but there are lots more where they came from. And, it’s good to avoid those things. So, how to eat to avoid inflammation?
Let food be thy medicine
The key things to keep in mind, the “guiding principles” are to prioritize whole, minimally-processed foods, and enjoy foods with plenty of antioxidants. Getting a healthy balance of omega fatty acids is also important, which for most people means getting more omega-3 and less omega-6.
Shopping list (foods to prioritize) includes:
- fruits and vegetables in a variety of colors (e.g. berries, leafy greens, beats)
- whole grains, going for the most fiber-rich options (e.g. quinoa, brown rice, oats)
- healthy fats (e.g. avocados, nuts, seeds)
- fatty fish (e.g. salmon, mackerel, sardines) ← don’t worry about this if you’re vegetarian/vegan though, as the previous category can already cover it
- herbs and spices (e.g. turmeric, garlic, ginger)
Noping list (foods to avoid) includes:
- refined carbohydrates
- highly processed and/or fried foods
- red meats and/or processed meats (yes, that does mean that organic grass-fed farmers’ pinky-promise-certified holistically-raised beef is also off the menu)
- dairy products, especially if unfermented
For more information on each of these, plus advice on transitioning away from an inflammatory diet, enjoy:
Click Here If The Embedded Video Doesn’t Load Automatically!
Want to learn more?
You might also like to read:
How to Prevent (or Reduce) Inflammation
Take care!
Don’t Forget…
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What to Know About Stillbirths
10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.
Series: Stillbirths:When Babies Die Before Taking Their First Breath
The U.S. has not prioritized stillbirth prevention, and American parents are losing babies even as other countries make larger strides to reduce deaths late in pregnancy.
Every year, more than 20,000 pregnancies in the U.S. end in a stillbirth, the death of an expected child at 20 weeks or more of pregnancy. Research shows as many as 1 in 4 stillbirths may be preventable. We interviewed dozens of parents of stillborn children who said their health care providers did not tell them about risk factors or explain what to watch for while pregnant. They said they felt blindsided by what followed. They did not have the information needed to make critical decisions about what happened with their baby’s body, about what additional testing could have been done to help determine what caused the stillbirth, or about how to navigate the process of requesting important stillbirth documents.
This guide is meant to help fill the void of information on stillbirths. It’s based on more than 150 conversations with parents, health care providers, researchers and other medical experts.
Whether you’re trying to better prepare for a pregnancy or grieving a loss, we hope this will help you and your family. This guide does not provide medical advice. We encourage you to seek out other reliable resources and consult with providers you trust.
We welcome your thoughts and questions at mailto:stillbirth@propublica.org. You can share your experience with stillbirth with us. If you are a health care provider interested in distributing this guide, let us know if we can help.
Table of contents:
- What Is Stillbirth?
- Are Stillbirths Preventable?
- What to Expect After a Stillbirth.
- Grieving After a Stillbirth.
- What You Might Say and Do After a Loved One Experiences a Stillbirth.
What Is Stillbirth?
Many people told us that the first time they heard the term stillbirth was after they delivered their stillborn baby. In many cases, the lack of information and awareness beforehand contributed to their heartache and guilt afterward.
Stillbirth is defined in the U.S. as the death of a baby in the womb at 20 weeks or more of pregnancy. Depending on when it happens, stillbirth is considered:
- Early: 20-27 weeks of pregnancy.
- Late: 28-36 weeks of pregnancy.
- Term: 37 or more weeks of pregnancy.
About half of all stillbirths in the U.S. occur at 28 weeks or later.
What is the difference between a stillbirth and a miscarriage?
Both terms describe pregnancy loss. The distinction is when the loss occurs. A miscarriage is typically defined as a loss before the 20th week of pregnancy, while stillbirth is after that point.
How common is stillbirth?
Each year, about 1 in 175 deliveries in the U.S. are stillbirths — that’s about 60 stillborn babies every day — making it one of the most common adverse pregnancy outcomes, but it is rarely discussed.
If you are surprised by that fact, you are not alone. Many people we spoke to did not know how common stillbirths are. Leandria Lee of Texas said she spent her 2021 pregnancy unaware that her daughter, Zuri Armoni, could die in the last phase of her pregnancy.
“If I was prepared to know that something could happen, I don’t think it would have been as bad. But to not know and then it happens, it affects you,” she said of her stillbirth at 35 weeks.
Some doctors have told us they don’t introduce the possibility of a stillbirth because they don’t want to create additional anxiety for patients.
Other doctors say withholding information leaves patients unprepared.
“We have this idea that we can’t scare the patient, which to me is very paternalistic,” said Dr. Heather Florescue, an OB-GYN near Rochester, New York, who works to inform doctors and patients about stillbirth prevention.
What causes stillbirths?
There is a lot we don’t know about stillbirths because there hasn’t been enough research. The cause of the stillbirth is unknown in about 1 in 3 cases.
What we do know is that a number of factors may cause or increase the risk of a stillbirth, including:
- The baby not growing as expected.
- Placental abnormalities or problems with the umbilical cord.
- Genetic or structural disorders that cause developmental issues.
- High blood pressure before pregnancy or preeclampsia, a potentially fatal complication that usually appears late in pregnancy and causes high blood pressure.
- Diabetes before or during pregnancy.
- An infection in the fetus, the placenta or the pregnant person.
- Smoking.
- Being 35 or older.
- Obesity.
- Being pregnant with more than one baby.
But not all doctors, hospitals or health departments perform tests to identify the potential cause of a stillbirth or determine if it could have been prevented. Even when a cause is identified, fetal death records are rarely updated. This means data is sometimes inaccurate. Researchers strongly encourage doctors to perform a stillbirth evaluation, which includes an examination of the placenta and umbilical cord, a fetal autopsy and genetic testing.
If your hospital or doctor does not proactively offer one or more of these exams, you can ask them to conduct the tests. Research shows that placental exams may help establish a cause of death or exclude a suspected one in about 65% of stillbirths, while autopsies were similarly useful in more than 40% of cases.
Are Stillbirths Preventable?
Not all stillbirths are preventable, but some are. For pregnancies that last 37 weeks or more, one study found that nearly half of stillbirths are potentially preventable.
Dr. Joanne Stone, who last year was president of the Society of Maternal-Fetal Medicine, leads the country’s first Rainbow Clinic at Mount Sinai Hospital in New York. The clinic is modeled on similar facilities in the United Kingdom that care for people who want to conceive again after a stillbirth. She said many doctors used to think there was nothing they could do to prevent stillbirth.
“People just looked at it like, ‘Oh, it was an accident, couldn’t have been prevented,’” said Stone, who also is the system chair of the obstetrics, gynecology and reproductive science department at the Icahn School of Medicine. “But we know now there are things that we can do to try to prevent that from happening.”
She said doctors can:
- More closely monitor patients with certain risk factors, like high blood pressure, diabetes or obesity.
- Ask about prior infant loss or other obstetrical trauma.
- Carefully assess whether a baby’s growth is normal.
- Work to diagnose genetic anomalies.
- Teach patients how to track their baby’s movements and encourage them to speak up if they notice activity has slowed or stopped.
- Deliver at or before 39 weeks if there are concerns.
What are the risks of stillbirth over the course of a pregnancy?
The risk of a stillbirth increases significantly toward the end of pregnancy, especially after 39 weeks. The risk is higher for people who get pregnant at 35 or older. The risk begins to climb even earlier, around 36 weeks, for people pregnant with twins.
What you and your doctor can do to reduce the risk of stillbirth.
While federal agencies in the U.S. have yet to come up with a checklist that may help reduce the risk of stillbirth, the Stillbirth Centre of Research Excellence in Australia has adopted a Safer Baby Bundle that lists five recommendations:
- Stop smoking.
- Regularly monitor growth to reduce the risk of fetal growth restriction, when the fetus is not growing as expected.
- Understand the importance of acting quickly if fetal movement decreases.
- Sleep on your side after 28 weeks.
- Talk to your doctor about when to deliver. Depending on your situation, it may be before your due date.
The American College of Obstetricians and Gynecologists has compiled a list of tests and techniques doctors can use to try to reduce the risk of a stillbirth. They include:
- A risk assessment to identify prenatal needs.
- A nonstresstest, which checks the fetus’s heart rate and how it changes as the fetus moves.
- A biophysical profile, which is done with an ultrasound to measure body movement, muscle tone and breathing, along with amniotic fluid volume.
The group stressed that there is no test that can guarantee a stillbirth won’t happen and that individual circumstances should determine what tests are run.
Are some people at higher risk for stillbirth?
Black women are more than twice as likely to have a stillbirth as white women. There are a number of possible explanations for that disparity, including institutional bias and structural racism, and a patient’s pre-pregnancy health, socioeconomic status and access to health care. In addition, research shows that Black women are more likely than white women to experience multiple stressful life events while pregnant and have their concerns ignored by their health care provider. Similar racial disparities drive the country’s high rate of maternal mortality.
How to find a provider you trust.
Finding a doctor to care for you during your pregnancy can be a daunting process. Medical experts and parents suggest interviewing prospective providers before you decide on the right one.
Here is a short list of questions you might want to ask a potential OB-GYN:
- What is the best way to contact you if I have questions or concerns?
- How do you manage inquiries after hours and on weekends? Do you see walk-ins?
- How do you manage prenatal risk assessments?
- What should I know about the risks of a miscarriage or stillbirth?
- How do you decide when a patient should be induced?
If a provider doesn’t answer your questions to your satisfaction, don’t be reluctant to move on. Dr. Ashanda Saint Jean, chair of the obstetrics and gynecology department at HealthAlliance Hospitals of the Hudson Valley in New York, said she encourages her patients to find the provider that meets their needs.
“Seek out someone that is like-minded,” said Saint Jean “It doesn’t have to be that they’re the same ethnicity or the same race, but like-minded in terms of the goals of what that patient desires for their own health and prosperity.”
What to know in the last trimester.
The last trimester can be an uncomfortable and challenging time as the fetus grows and you get increasingly tired. During this critical time, your provider should talk to you about the following topics:
- Whether you need a nonstress test to determine if the fetus is getting enough oxygen.
- The best way to track fetal movements.
- What to do if your baby stops moving.
- Whether you are at risk for preeclampsia or gestational diabetes.
Rachel Foran’s child, Eoin Francis, was stillborn at 41 weeks and two days. Foran, who lives in New York, said she believes that if her doctor had tracked her placenta, and if she had understood the importance of fetal movement, she and her husband might have decided to deliver sooner.
She remembers that her son was “very active” until the day before he was stillborn.
“I would have gone in earlier if someone had told me, ‘You’re doing this because the baby could die,’” she said of tracking fetal movement. “That would have been really helpful to know.”
Researchers are looking at the best way to measure the health, blood flow and size of the placenta, but studies are still in their early stages.
“If someone had been doing that with my son’s,” Foran said, “my son would be alive.”
A placental exam and an autopsy showed that a small placenta contributed to Foran’s stillbirth.
How often should you feel movement?
Every baby and each pregnancy are different, so it is important to get to know what levels of activity are normal for you. You might feel movement around 20 weeks. You’re more likely to feel movement when you’re sitting or lying down. Paying attention to movement during the third trimester is particularly important because research shows that changes, including decreased movement or bursts of excessive activity, are associated with an increased risk of stillbirth. Most of the time, it’s nothing. But sometimes it can be a sign that your baby is in distress. If you’re worried, don’t rely on a home fetal doppler to reassure you. Reach out to your doctor.
Saint Jean offers a tip to track movement: “I still tell patients each day to lay on their left side after dinner and record how many times their baby moves, because then that will give you an idea of what’s normal for your baby,” she said.
Other groups recommend using the Count the Kicks app as a way of tracking fetal movements and establishing what is normal for that pregnancy. Although there is no scientific consensus that counting kicks can prevent stillbirths, the American College of Obstetricians and Gynecologists and other groups recommend that patients be aware of fetal movement patterns.
Dr. Karen Gibbins is a maternal-fetal medicine specialist at Oregon Health & Science University who in 2018 had stillborn son named Sebastian. She said the idea that babies don’t move as much at the end of pregnancy is a dangerous myth.
“You might hear that babies slow down at the end,” she said. “They don’t slow down. They just have a little less space. So their movements are a little different, but they should be as strong and as frequent.”
What to Expect After a Stillbirth
What might happen at the hospital?
Parents are often asked to make several important decisions while they are still reeling from the shock and devastation of their loss. It’s completely understandable if you need to take some time to consider them.
Some other things you can ask for (if medical personnel don’t offer them) are:
- Blood work, a placental exam, an autopsy and genetic testing.
- A social worker or counselor, bereavement resources and religious or chaplain support.
- The option to be isolated from the labor rooms.
- Someone to take photos of you and your baby, typically either a nurse or an outside group.
- A small cooling cot that allows parents to spend more time with their babies after a stillbirth. If one is not available, you can ask for ice packs to put in the swaddle or the bassinet.
- A mold of your baby’s hands and feet.
- Information about burial or cremation services.
- Guidance on what to do if your milk comes in.
Getting an autopsy after a stillbirth.
Whether to have an autopsy is a personal decision. It may not reveal a cause of death, but it might provide important information about your stillbirth and contribute to broader stillbirth research. Autopsies can be useful if you are considering another pregnancy in the future. Families also told us that an autopsy can help parents feel they did everything they could to try to understand why their baby died.
But several families told us their health care providers didn’t provide them with the right information to help with that decision. Some aren’t trained in the advantages of conducting an autopsy after a stillbirth, or in when and how to sensitively communicate with parents about it. Some, for example, don’t explain that patients can still have an open-casket funeral or other service after an autopsy because the incisions can easily be covered by clothing. Others may not encourage an autopsy because they think they already know what caused the stillbirth or don’t believe anything could have been done to prevent it. In addition, not all hospitals have the capacity to do an autopsy, but there may be private autopsy providers that can perform one at an additional cost.
You can read more about autopsies in our reporting.
Paying for an autopsy after a stillbirth.
If you decide you want an autopsy, you may wonder whether you need to pay out-of-pocket for it. Several families told us their providers gave them incomplete or incorrect information. Many larger or academic hospitals offer autopsies at no cost to patients. Some insurance companies also cover the cost of an autopsy after a stillbirth.
When hospitals don’t provide an autopsy, they may give you names of private providers. That was the case for Rachel Foran. The hospital gave her and her husband a list of numbers to call if they wanted to pay for an autopsy themselves. The process, she said, shocked her.
“I had just delivered and we had to figure out what to do with his body,” Foran said. “It felt totally insane that that was what we had to do and that we had to figure it out on our own.”
An independent autopsy, records show, cost them $5,000.
What is a certificate of stillbirth and how do I get one?
A fetal death certificate is the official legal document that records the death. This is the document used to gather data on and track the number of stillbirths in the country. Many states also issue a certificate of stillbirth or a certificate of birth resulting in stillbirth, which acknowledge the baby’s birth. Families told us they appreciated having that document, since typical birth certificates are not issued for stillbirths. You can usually request a certificate from the vital records office.
Grieving After a Stillbirth
What are the effects of stillbirths on parents and families?
Over and over, families told us the effects of losing a baby can reverberate for a lifetime.
Bereavement support groups may help provide a space to share experiences and resources. Hospitals and birth centers may suggest a local grief group.
We talked with Anna Calix, a maternal health expert who became active in perinatal loss prevention after her son Liam was stillborn on his due date in 2016. Calix leads grief support groups for people of color in English and Spanish.
She suggested rededicating the time you would have spent taking care of a new baby to the grief process.
“You can do that by addressing your own thoughts and feelings and really experiencing those feelings,” Calix said. “We like to push those feelings away or try to do something to distract and avoid, but no matter what we do, the feelings are there.”
It’s important, she said, to give yourself permission to grow your connection with your child and work through thoughts of guilt or blame.
What You Might Say and Do After a Loved One Experiences a Stillbirth
Finding the right words can be difficult. The following are a few suggestions from parents who went through a stillbirth.
Helpful:
- Acknowledge the loss and offer condolences.
- Ask if the baby was named and use the name.
- Allow space for the family to talk about their baby.
Unhelpful:
- Avoid talking about the baby.
- Minimize the loss or compare experiences.
- Start statements with “at least.”
Suggested phrases to avoid:
- “You’re young. You can have more kids.”
- “At least you have other children.”
- “These things just happen.”
- “Your baby is in a better place now.”
Don’t Forget…
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