DEAR MAYO CLINIC: I've had a sensitive stomach since I can remember. My life has been constantly inconvenienced by too many trips to the bathroom. My family thinks I have undiagnosed irritable bowel syndrome. I should have sought care sooner, but what can I do now to treat it? What causes IBS? What are its symptoms?

ANSWER: First off, you are not alone. Irritable bowel syndrome (IBS) is common and affects approximately 1 in 10 adults in the U.S. IBS is characterized by abdominal pain with disordered defecation (constipation, diarrhea or both). IBS can generally be easily treated with a combination of education, reassurance, diet and medications.

IBS is categorized as a disorder of gut-brain interaction. This means that the bidirectional pathway between the brain and the gut is overactive. Patients with IBS are more sensitive in their gut than other patients. IBS may develop due to genetic reasons or insults to the gastrointestinal (GI) tract including food poisoning, prior infections, surgeries, trauma and stressful life events. Stress can greatly affect the GI tract via the brain-gut axis. This can include physical, emotional or financial stress and other types.

The key symptom of IBS is abdominal pain, which would be present at least one day per week on average. In addition, patients have symptoms of disordered defecation, meaning constipation (going days without a bowel movement or straining during a bowel movement) or diarrhea (watery, loose and urgent bowel movements). Some patients have alternating constipation and diarrhea. Overriding symptoms for many patients include gas, bloating and distension, which means a visible or measurable increase in belly size. 

Patients often wonder when to see a healthcare professional. A diagnosis of IBS is based on:

• Unintentional weight loss
• New anemia
• Family history of IBS or colorectal cancer

It is important to note that for most patients, extensive testing is not required to make a diagnosis of IBS, but rather taking a careful history and performing a thoughtful physical exam while using the criteria above. Since IBS is a disorder of gut hypersensitivity and of the gut-brain axis, blood tests, X-rays, colonoscopies, CT scans and other tests generally do not reveal an underlying problem such as an ulcer or a blockage.

It is also important to note that the "best" therapy for IBS is very patient-independent. Every patient is a unique individual with different types and levels of symptoms: 

• Mild symptoms: Symptoms are somewhat bothersome but not intrusive.
• Moderate symptoms: Symptoms are affecting daily quality of life.
• Severe symptoms: You may have been to the emergency department because of your symptoms.

One of the exciting things in the field of gastroenterology is the recognition in the last 10 years that we have this very dynamic gut-brain connection, this bidirectional pathway. What that really means to a patient is that it's not just the standard prescription of over-the-counter medications for IBS with diarrhea or adding more fiber to help improve symptoms of constipation — it's using different therapies such as FDA-approved medications, behavioral therapy and diet to quiet down this hyperactive, extra-sensitive GI tract in either the brain or gut. This improves overall symptoms, especially that of abdominal pain, which is the cornerstone of the diagnosis of IBS. The future is exciting, and there is hope for you and many others. —Brian Lacy, M.D., Ph.D., Gastroenterology, Mayo Clinic, Jacksonville, Florida

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DEAR MAYO CLINIC: A friend from my book club recently had a stroke. I learned that women have a higher risk of strokes. What are the risk factors, and are there signs to watch for that indicate someone is having a stroke? 

ANSWER: A stroke can happen at any time and to anyone. You might be talking to your loved one and notice they're suddenly slurring their words. Or, while grocery shopping, you realize you can't move your hand to pick up a jar from the shelf. You can go from feeling as usual to feeling sick within a matter of seconds to minutes. Here are five key things to know about stroke.

1. Strokes affect the oxygen and nutrients supplied to your brain.

Strokes occur when nutrients and oxygen are not delivered to the brain through blood vessels, leading to the death of brain cells. This lack of delivery can be caused by a clot in a blood vessel obstructing the blood flow to the brain, known as an ischemic stroke, or when a blood vessel ruptures and prevents blood flow to the brain, known as a hemorrhagic stroke.

Sometimes, the obstruction to the blood flow and the resulting symptoms are caused by a temporary clot and are transient, resulting in a transient ischemic attack, or TIA, often called a ministroke.

2. Strokes can happen to anyone.

Strokes can happen to anyone regardless of age, gender or race. Certain risk factors can put you at a higher risk of stroke.

Risk factors are divided into two categories:

• Controllable — the ones you can control or improve
• Uncontrollable — those that are not within your control

Common controllable risk factors include:

• Atrial fibrillation, which increases stroke risk by five times
• Diabetes
• Excessive alcohol intake — an average of more than one drink per day for women or more than two drinks a day for men
• High blood pressure
• High cholesterol
• Obesity
• Obstructive sleep apnea
• Physical inactivity
• Smoking or vaping

Uncontrollable risk factors include:

• Gender
• Heredity
• Increasing age
• Race

3. Be prepared to spot the signs of a stroke.

Learn to recognize the signs of stroke quickly.

The American Stroke Association lists these symptoms to help you know when to seek medical care:

F = Face drooping: Ask the person to smile and see if the smile is uneven.

A = Arm weakness: Ask the person to raise both arms and see if one arm drifts down.

S = Speech difficulty: Ask the person to speak and see if the speech is slurred.

T = Time to call 911: Stroke is an emergency. Call 911 at once. Note the time when any of the symptoms first appear.

Other stroke symptoms to watch for include:

• Numbness of the face, arm or leg, especially on one side of the bod.
• Sudden confusion, trouble speaking or difficulty understanding speech.
• Sudden-onset, severe headache with no known cause.
• Sudden vision issues, such as trouble seeing in one or both eyes.
• Trouble walking, loss of balance, dizziness or coordination.

If you or someone you are with have any strokelike symptoms, seek immediate medical care.

4. A stroke is a medical emergency.

Every second counts when someone is experiencing a stroke. Once a stroke starts, the brain loses around 1.9 million neurons each minute. For every hour without treatment, the brain loses as many neurons as it typically does in nearly 3.6 years of regular aging.

While waiting for paramedics, do these things if possible:

• If the person is conscious, lay them down on their side with their head slightly raised and supported to prevent falls.
• Loosen any restrictive clothing that could cause breathing difficulties.
• If weakness is obvious in any limb, support it and avoid pulling on it when moving the person.
• If the person is unconscious, check their breathing and pulse, and put them on their side.
• If they do not have a pulse or are not breathing, start CPR straight away.

5. Women have an increased risk of stroke.

According to the American Stroke Association, stroke is the third most common cause of death in women. Over 90,000 women die from a stroke in the U.S. each year. Every 1 in 5 women will have a stroke, and about 55,000 more women than men have a stroke each year, with Black women having the highest prevalence of stroke.

The risk of stroke increases in women who smoke, have atrial fibrillation or migraines with aura, take birth control pills, use hormonal replacement therapy, are pregnant, or have preeclampsia.

Talk to your healthcare team about your stroke risk and ways to lower your risk by addressing controllable factors. — Prashant Natteru, M.B.B.S., M.D., Neurology, Mayo Clinic Health System, La Crosse, Wisconsin

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DEAR MAYO CLINIC: My 36-year-old sister recently noticed an unusual mole on her shoulder. She is scheduled for some tests. Her primary care physician believes it might be melanoma. What is melanoma? What treatment options are available, and is surgery necessary? Have there been recent advancements in treatments?  

ANSWER: While melanoma is much less common than other types of skin cancer, it is the most serious because it is more likely to metastasize, or spread, to other parts of the body. 

Melanoma starts in the melanocytes, which are cells that make the pigment that gives skin its color. The first signs of melanoma often are either a change in an existing mole or the development of a new pigmented or unusual-looking growth on the skin. 

The ABCDE guide helps you determine if a mole or a spot may indicate melanoma or another type of skin cancer:

• A is for asymmetrical shape. One half is unlike the other half.
• B is for border. Look for moles with irregular, notched or scalloped borders.
• C is for color. Look for growths that have changed color, have many colors or have uneven color.
• D is for diameter. Look for new growth in a mole larger than 1/4 inch (about 6 millimeters, or the diameter of a pencil eraser).
• E is for evolving. Watch for moles that change in size, shape, color or height, especially if part or all of the mole turns black. Moles may also evolve to develop new signs and symptoms, such as itchiness or bleeding.

If you notice any of these signs, make an appointment with your primary care clinician or a healthcare professional.

A few types of tests are used to diagnose melanoma. The first is a punch biopsy performed with a circular blade pressed into the skin around the suspicious mole. Another technique is called an excisional biopsy, which uses a scalpel to remove the entire mole and a very tiny bit of normal skin around it. It’s also important to have a total skin exam at the initial diagnosis because some patients will have a second primary melanoma found at the same time.

Once melanoma is diagnosed, your care team will determine the extent of the cancer by measuring its thickness, identifying whether it has spread to the lymph nodes and looking for signs of cancer beyond the skin. If there's a chance the cancer could spread to nearby lymph nodes, you might need a sentinel node biopsy. During this procedure, dye is injected into the area where your melanoma was removed and flows to the closest lymph node or nodes. Those lymph nodes, called the sentinel lymph nodes, are removed and tested for cancer cells. 

Understanding the stage of melanoma will help your healthcare team create a treatment plan. Melanoma treatment often starts with surgery to remove the cancer. The treatment for thinner melanomas generally removes the melanoma with a margin of tissue, typically 1 to 2 centimeters of normal tissue. If the sentinel lymph node biopsy determines that the cancer has spread or your melanoma grows deeper into the skin, active surveillance with imaging, additional surgery and/or systemic treatment may be recommended.

Other treatments include radiation therapy and systemic therapy. Recent advancements have significantly improved the prognosis for patients diagnosed with melanoma. These include targeted therapies, an approach that uses medicine that attacks specific chemicals in cancer cells, and immunotherapies, which use medicines that help the body's immune system to kill cancer cells. Either option might be recommended for selected patients. Some patients also may benefit from systemic therapy before an operation.

Clinical trials have led to recent advancements in melanoma treatment because physician-scientists can test new and better approaches. Efforts are being made to enhance the accessibility and ease of patient participation in clinical trials. If you are interested in participating in a clinical trial, ask your care team about what options might be available.

While melanoma is a serious form of skin cancer, you can reduce your risk. Exposure to ultraviolet (UV) light is considered the leading cause of melanoma. UV light comes from the sun and tanning lamps and beds. You can reduce your risk by avoiding tanning beds, wearing broad-spectrum sunscreen with SPF 30 or higher, avoiding sun exposure during peak hours (10 a.m.–3 p.m.) and wearing sun protective gear outdoors. Use about 1 ounce of sunscreen and reapply every two hours, or more if you've been sweating or swimming. 

If you notice rapidly growing or changing skin lesions, it's important to notify your primary care physician or a care team member. The earlier melanoma is found, the better the chance of successful treatment. — Tina Hieken, M.D., Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, Minnesota

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DEAR MAYO CLINIC: I am in my 30s and overweight, but I thought I was too young to worry about cholesterol. I just learned my cholesterol is high. I know diet and exercise are important. Do I need medication? 

ANSWER: Cholesterol is a type of fat in our blood. Our bodies need a small amount of cholesterol to build the structure of cell membranes, make certain hormones and help with metabolism, such as producing vitamin D. The catch: We don't need too much cholesterol. 

Atherosclerosis, also known as narrowing of the arteries, happens when cholesterol builds up and blocks blood flow. This buildup is called plaque, which can clog arteries and can burst, leading to a blood clot. Atherosclerosis can cause heart problems such as chest pain (angina) or heart attack. It also can lead to problems in the brain, including transient ischemic attack, stroke, peripheral artery disease in the legs or arms, and even kidney failure.

Cholesterol and triglycerides are types of lipids. They travel in our blood by attaching to proteins. Adults 20 and older should ask their healthcare team about their lipid profile and how to interpret the numbers. 

• Low-density lipoprotein (LDL) cholesterol: We call LDL "bad" cholesterol. Below 100 milligrams per deciliter (mg/dl) is optimal for healthy people in the absence of coronary artery disease. If you have heart disease, your LDL should be below 70 mg/dl. Treatment decisions to reach appropriate levels need to be based on personal risk factors.

• High-density lipoprotein (HDL) cholesterol: We call HDL "good" cholesterol. It absorbs cholesterol in the blood and brings it to the liver, which flushes it from the body. For females, it should be above 50 mg/dl. For males, it should be above 40 mg/dl.

• Triglycerides: Triglycerides are a type of fat we use for energy. If you have too high of a triglycerides level, it can cause heart disease. Less than 150 mg/dl is optimal. 

• Total cholesterol: This is the sum of LDL and HDL cholesterol plus 20% of triglyceride levels. A total cholesterol level below 200 mg/dl is desirable.

Some people who are overweight may get heart disease not because their LDL is high but, rather, because their HDL is low and their triglycerides are high. That relationship can cause heart disease as much or even more than just high LDL cholesterol. These lipid abnormalities are significant for young people in their 30s or 40s who are overweight. Their triglyceride levels increase, and their HDL lowers. They're becoming prediabetic. Their LDL is staying the same, but they're still heading to heart disease. 

Treating high cholesterol depends on individual risk. The higher the risk — for example, with someone who already had a heart attack — a higher percent of reduction is needed. Medication to lower cholesterol can reduce LDL by about 60% to 65%. Lifestyle changes can reduce LDL by 10% to 15%. 

Several medications can help manage lipids. Discuss options with your healthcare team.

The body's ability to handle cholesterol is genetically determined. Genetic disorders that raise cholesterol levels are common. Familial hypercholesterolemia usually is caused by a genetic mutation preventing the body from clearing cholesterol. People with the condition are more likely to require medication to reduce their cholesterol levels. 

For people with genetic disorders that expose them to elevated cholesterol since birth, heart disease can happen at a younger age. So we start treating their high cholesterol with medication at a young age. 

Beyond medication, lifestyle modifications help manage lipids:

• Limit meat and dairy intake; they have saturated fat, which raises LDL cholesterol.
• Consume more fish, soluble fiber, fruit and vegetables. 
• Avoid diets high in carbohydrates, particularly refined carbs like sugar and white flour. They raise the blood sugar level quickly, raising triglycerides. Reducing simple refined carbohydrates helps lower triglycerides and weight because you store less fat. 
• Control your weight. It lowers your triglycerides and improves your HDL levels. 
• Exercise about 150 minutes of aerobic activity a week at a moderate intensity. Moderate intensity means you must breathe through your mouth. If you're breathing through your nose, that is low intensity. Exercise prevents cholesterol from building up, but it doesn't change LDL concentration levels. You must burn about 2,000 calories a week to lower LDL concentration. However, exercise helps lower triglyceride levels and maintain weight loss. 
• Do strength training at least twice a week. It helps your cardiovascular and muscular systems. Not everything we do to prevent heart disease is about cholesterol. 

The National Heart, Lung and Blood Institute recommends people get their first cholesterol screening between ages 9 and 11, and repeat it every five years. For men 45 to 65 and women 55 to 65, cholesterol screenings should occur every one to two years. Over 65? Test annually. More frequent testing may be needed for people who have or are at risk for coronary artery disease. — Regis Fernandes, M.D., Cardiovascular Medicine, Mayo Clinic, Phoenix

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DEAR MAYO CLINIC: We hear a lot about "heart-healthy" diets, but the guidance seems to always change. It's confusing to me. What foods are important, and what should we avoid? 

ANSWER: One of the most important factors for a healthy heart is to try to follow a healthy diet. We usually recommend a Mediterranean diet, which is mostly based on trying to eat more white meat, such as fish and chicken, instead of red meat, such as beef or pork. This type of diet also focuses on eating more vegetables, fruits, nuts, seeds, legumes, beans, whole grains and olive oil. 

Studies have shown that people living in Mediterranean countries, such as Italy and Greece, are less likely to die of heart disease. The World Health Organization recognizes the Mediterranean diet as a healthy eating pattern. Many nutrition experts in the U.S. recommend it and it is important to follow the diet long term in order to see heart benefits.

Cutting out trans fats in fried food, frozen pizza and microwave popcorn, and added sugar in soda, sweets and pastries is also important for your heart health. Switching your snacks, especially before or after exercising, from cookies or chocolates to carrots or broccoli, can help you continue to snack but with beneficial ingredients. Staying hydrated helps your heart pump blood more effectively and benefits your blood vessels and muscles. Drink at least 2 liters of water each day.

Avoiding tobacco and alcohol consumption are important factors to prevent future cardiovascular conditions. It has been shown that after just one year of quitting tobacco use, your risk of having a cardiovascular event drops in half in comparison with patients who smoke tobacco. That's how big the impact of quitting tobacco use is on your heart, and it's never too late to stop. Alcohol use can trigger difficulty for you to fall asleep, and sleep disorders have been linked to heart disease. Incorporating these healthy habits will make you more likely to have refreshed sleep.  

Following diet trends such as making the switch to strictly plant-based or vegan or going gluten- or lactose-free is individual to each person because patients may have an intolerance to this type of food or its components. In general, low-sugar, low-salt and low-carb diets are usually helpful for all our patients to stay out of cardiovascular risk. 

By maintaining a healthy lifestyle, you can avoid some medical conditions in the future such as hypertension, diabetes and high cholesterol. These conditions increase your risk of having a cardiovascular event such as a heart attack or a stroke. One of my best tips is to start adjusting your lifestyle little by little but consistently, taking baby steps — even if you adjust just one factor per day or per week, whether that's trying to cut down on the amount of high sugar, high fat or high salt in your diet. Little by little and with time, those changes will remain and will help you prevent any type of long-term medical condition in the future. — Juan Cardenas Rosales, M.D., Internal Medicine, Mayo Clinic, Jacksonville, Florida

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DEAR MAYO CLINIC: My neighbor had a stroke and received a "clot buster" medication. Then, I found out my uncle had a surgery after a stroke. Can you help me understand different kinds of stroke treatments? My neighbor seems almost back to normal, but my uncle is still in rehabilitation because of some paralysis on his left side.

ANSWER: We have excellent treatments to reverse stroke symptoms, but these treatments are incredibly time dependent. This is a good opportunity to remind people to seek emergency medical care — call 911 — as soon as possible at the first sign of a stroke.

Treatments also depend on the type of stroke. During an ischemic stroke, blood vessels in the brain are blocked or narrowed. During a hemorrhagic stroke, there's bleeding into the brain.

The first treatment for stroke is to potentially offer a medication called tissue plasminogen activator (TPA) that helps dissolve blood clots. This often is called a clot buster. It has to be given within 4.5 hours from when symptoms began.

These drugs are administered by IV, and they can help dissolve blood clots in the brain and restore blood flow. The faster you're able to restore blood flow, the less likely that the stroke symptoms are permanent. 

Another treatment for stroke is a flexible tube called a catheter that is placed in the blood vessels at the groin. The catheter is navigated up to that clot in the brain using X-ray. A device can be administered to help remove that blood clot. This procedure can help with large clots that can't be dissolved with TPA. This procedure often is performed in combination with TPA that's injected into the bloodstream.

Hemorrhagic stroke is treated by lowering blood pressure to help prevent continued bleeding. So if people are on blood thinners, we use other medications to try to reverse the blood thinner medications. If patients have a coagulopathy, or a tendency to bleed, medication is used to try to reverse that. 

Then there are surgical interventions that potentially help remove that blood in the brain to prevent the downstream swelling that can occur after a brain bleed.

Unfortunately, stroke outcomes are incredibly variable. We'd love to have excellent outcomes for every patient who experiences an acute stroke. But with timeliness of treatment, we are much more likely to have a favorable outcome. 

The goal is to keep people independent after their stroke. So the faster someone arrives to the hospital, the more likely to achieve that outcome. 

Stroke symptoms include trouble speaking and understanding others; numbness or weakness, often on one side of the face, arms or legs; vision problems; a severe headache; and trouble walking. 

We use an acronym you may have heard previously to help people recognize warning signs of a stroke:

FAST

• F = Face drooping: Ask the person to smile. Does one side of the face droop?
• A = Arm weakness: Ask the person to raise both arms and see if one arm drifts down or if one arm is unable to be lifted.
• S = Speech difficulty: Ask the person to speak and see if the speech is slurred.
• T = Time to call 911: Stroke is an emergency.

With any of these signs, call 911 or emergency medical care at once to allow for the treatment of stroke. Note the time when any of the symptoms first appear. — Stephen English Jr., M.D., Neurology, Mayo Clinic, Jacksonville, Florida

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DEAR MAYO CLINIC: I've signed up on my driver's license to be an organ donor if I die. It's important to me. I've also considered being a living kidney donor. I don't personally know someone who needs a kidney, but I've seen billboards and other advertisements from people seeking a kidney donor. Does that have something to do with a donor chain? I am not sure how it works. I'm a little scared and not quite ready to commit. 

ANSWER: First, thank you for considering making a difference in the lives of others with the gift of life through transplant. Participating in your state donor registry or the National Donate Life Registry helps people make their wishes about organ donation known in case of their death.

Living-donor transplantation is an option for some organs. For people over 18 born with two functioning kidneys, they can donate one and continue to live a healthy life. An altruistic living-donor kidney transplant chain begins when someone donates a kidney without a specific individual in mind. That can start a chain effect of donors. 

Another way to begin a chain is if a person intends to donate to a family member or friend, but they aren't a direct match. Instead, the person donates to someone else who is a match, and that individual's donor then donates either to the original intended recipient or starts a chain effect of individuals whose donors aren't necessarily a direct match to them, allowing many people to get transplanted.

There's no limit on the chain. It can occur within one transplant program or at multiple transplant programs. In fact, we've had chains that have involved the Mayo Clinic Transplant Center at our three campuses in Rochester, Minnesota; Jacksonville, Florida; and Phoenix; as well as at several institutions around the country.

Kidney function is necessary to live. These two bean-shaped organs remove waste from the blood by producing urine. They play a role in controlling blood pressure, fluid balance, red blood cell counts and more. Living with one healthy kidney is possible, making living kidney donation an option.

What I always tell potential donors is that coming forward as a potential donor is a commitment to find out information; it's not a commitment to donate. You can come forward, learn a little bit and decide it may not be for you.

Learning more about the living organ donor process often helps calm people's concerns. While any medical procedure has risks, you should know we expect living donors to live a completely normal life after donation with no restrictions in terms of activities or diet. Typically, donors have a short stay in the hospital, about a day or two. The recovery period is six to eight weeks, but donors often feel back to normal within one to two weeks after donation. 

Potential donors go through an evaluation online with a basic screening and health questionnaire. Then a donor coordinator contacts you to discuss. If you decide to pursue donation and are a potential candidate, further medical evaluation is done. 

The more people we bring into the donor candidate pool, the more benefit to everyone who is waiting for a kidney transplant. We encourage people to reach out among their community members to ensure we have equal opportunity and equal access of living donation to everyone who might need a donor.

The biggest thing I would say is thank you to all of our donor heroes — the deceased donors and their family members and our living-donor heroes who inspire us to do what we do every day. — Shennen Mao, M.D., Transplant Surgery, Mayo Clinic, Jacksonville, Florida

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DEAR MAYO CLINIC: I'm hearing more about the exposome and the role of the environment on our health. Can you tell me more about how it is being studied? I'm worried about the future when I read about studies that show microplastics and chemicals accumulating in our environment. 

ANSWER: The Centers for Disease Control and Prevention defines the exposome as the measure of all environmental exposures, from prenatal stages through a person's lifetime, and how those exposures interact with genetic factors to affect health. The term is very inclusive. It includes, for example, diet; pollution; and natural substances, such as radiation. Everyone's exposome is unique.

I appreciate your concern about environmental exposures. The point I like to make is that not all exposures are harmful. Some exposures may protect us from disease. When we're talking about the exposome, it includes elements that are a risk for health, such as tobacco use, and elements protecting us from illness, such as access to green space.

Historically, researchers have studied some environmental exposures. Epidemiological studies in the past have told us that excessive alcohol use, for example, has an effect on the human body, and this relates to disease. We have also known that exposures to some bacteria cause disease, such as salmonella or tuberculosis.

But given that there are millions of different types of environmental exposures, better and more systematic studies are needed to understand what this means to our health. 

As a scientific field, the exposome explores exposures that have an effect on humans biology. For me, as a physician and researcher, I would like to know more about exposures that affect our genes, cells and organs, or, in other words, how exposures affect human biology. Your exposome is the environmental complement to your complete set of DNA, called your genome. 

Scientists have more recently realized that only about 15% of most disease risk can be attributed to genetic elements. So we are left with the question: What else contributes to disease? Families, of course, share not only genes but their environment. They live in the same household. And this is how exposome science started, to try to be able to assess environmental exposures. 

Over the last roughly 50 years, chemicals have been mass produced by humans. Decades ago, we couldn't measure chemicals in our bloodstream in a scalable and affordable way. So we used questionnaires to ask, "Do you smoke?" "Do you drink?" "Have you been exposed to pesticides?" We were looking for the outcomes of those exposures to human health. 

For example, in my laboratory, we were studying a rare liver disease called primary sclerosing cholangitis, and we asked a decade ago whether patients were exposed to pesticides, as well as other environmental elements. But the questionnaires didn't show a difference between healthy people and those with primary sclerosing cholangitis. 

Years later, when we could use blood tests to measure chemicals in the bloodstream, we found a significant difference in a specific pesticide present among primary sclerosing cholangitis patients compared with healthy people.

So, based on several studies, we now know that pesticides are in our food chain and in our bloodstream in small amounts, and we need to know how they affect human biology and disease.

Also, massive plastic production within the last 70 years also has created microparticles that can be found inside people's tissues. We need to study these exposures both in health and in diseases such as cancer, heart disease, stroke, respiratory illness and autoimmune disease.

Nevertheless, when we do studies, often we find chemicals that are more prevalent in healthy people compared to patients with diseases. Scientists are working to identify those elements associated with wellness or with a lack of disease because these substances may protect us from illness. For example, some studies have shown that drinking coffee may reduce risk of neurological disease or liver disease. We need to understand this in more depth for therapeutic opportunities.

Current methodologies enable us to measure the exposome better than before through blood, urine, saliva and hair. I envision that 10 years from now, if not earlier, we will have screens of exposures that we will measure in our bloodstream. That will become part of a person's care at some point in the future and help us guide lifestyle changes, prevention strategies and make diagnosis as well as treatment decisions for patients. — Konstantinos Lazaridis, M.D., Gastroenterology/Hepatology and Center for Individualized Medicine

Learn more about the exposome:

• Tomorrow’s Cure: How a lifetime of exposures impact health – exposome explained
• Researchers link environmental exposures to liver disease

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DEAR MAYO CLINIC: When the holidays end, it's hard to have things to look forward to and find motivation to exercise. How can I stay ahead of the slump and help my family stay active?

ANSWER: As winter settles in, shorter days and colder nights can feel dull. But the mystery of winter nights also offers opportunities for fun, joy, connection and adventure through outdoor activities. Winter nights can be turned into an enchanting experience.

Dressing appropriately is the key to embracing nighttime winter fun in colder climates based on the activity and weather. This may include layers, a hat and mittens or gloves. Don't forget to check the weather forecast.

Give these cold-weather activities a try:

• Hiking. Many parks maintain trails for winter hiking and offer guided nighttime nature events. Wear appropriate footwear or strap-on snowshoes. Stick to well-marked trails and take along water and a flashlight.
• Ice skating or sledding. Many cities offer outdoor rinks and designated sledding spots. Neighborhood hills or a DIY backyard rink can provide nearby fun. Check that rinks are well-maintained and choose sledding hills free of obstacles. Inspect your skates and sleds before using them and don't forget to wear helmets.
• Play tag or build snow creations. Playing in the snow brings laughter and exercise. Dress in layers to keep warm and dry, and take breaks indoors to warm up and avoid frostbite.
• Playground discovery. Playgrounds are fun year-round, even in winter. Try swinging or rolling snowballs down the slides for a new twist on winter playground fun. Watch for icy patches on equipment, and ensure the area is well-lit to avoid slips or falls in the dark.
• Stargazing. Winter nights often offer clearer skies, making it ideal for stargazing. Bring a blanket, download a star map app on your phone to enhance your viewing knowledge and pack warm beverages. Dress warmly, bring a flashlight, and let someone know your location if you're venturing to a remote spot.

For those in warmer climates, winter nights offer unique opportunities to celebrate without the snow. Here are a few ideas:

• Beach bonfire or sunset picnic. Grab some blankets, pack snacks or an easy meal, and bring hot drinks to enjoy the evening. If you're setting up a bonfire, use designated fire pits and follow any local guidelines. Remember to bring flashlights or lanterns, and always pack out what you bring in to leave the area clean.
• Evening hike. Winter months offer cooler evenings that are perfect for exploring local trails. Many parks organize guided night hikes or special stargazing events. Stick to familiar trails and bring plenty of water, as nights in the desert or arid areas can be drier than expected. Always carry a flashlight or headlamp and let someone know your hiking route.
• Holiday light boat parade. Many coastal or lakeside communities organize holiday-light boat parades with boats decorated in festive lights. Bundle up and be sure to bring a flashlight to navigate docks and dark areas safely.
• Nighttime zoo or garden lights tour. Many zoos and botanical gardens offer night tours during the holiday season with sparkling lights and seasonal decorations throughout. Wear comfortable shoes and keep kids close by. Use designated paths and trails.
• Outdoor movie night. Set up a projector and screen in your backyard or a park. Relax with blankets, popcorn and hot chocolate or cider. Check the weather forecast for rain or wind and ensure everyone wears warm layers of clothing. Safely set up any heaters or lanterns.

— Aicha Katty, DNP, Family Medicine, Mayo Clinic Health System, Owatonna, Minnesota

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DEAR MAYO CLINIC: I'm 52 years old and enjoy long walks with my husband and our dog. I recently started to experience pain in my left calf during our walks. The leg pain goes away when I rest. Because I have a history of high blood pressure, I went to see my primary care physician and was diagnosed with peripheral artery disease. What is this condition, and what treatments are available? Will I need surgery?

ANSWER: Peripheral artery disease is a common, chronic medical condition that affects circulation in the body due to narrowed arteries. The narrowing of arteries is caused by a buildup of fatty deposits, called plaque, which reduces blood flow from the heart to different regions of the body. This can affect the arms, but most commonly, it is an issue found in the legs. 

The risk of developing peripheral artery disease increases with age, particularly for those over 65 or after 50 if you have certain risk factors. Factors that can contribute to your risk include:

• A family history of peripheral artery disease, heart disease or stroke
• High blood pressure
• High cholesterol
• Diabetes
• Chronic kidney disease
• Obesity (a body mass index over 30)
• Smoking tobacco/using tobacco products

Many people with peripheral artery disease have mild or no symptoms, while others experience leg pain when walking or even at rest. The severity of your symptoms and the extent of the blockage are used to categorize the stage of your peripheral artery disease and inform specific treatment options.

There are two stages of peripheral artery disease. The early stage is called claudication, when people experience pain when walking or engaging in activity. In this stage, the pain begins during exercise and ends with rest. It is usually felt in the calves, thighs and buttocks. 

The advanced, severe stage of peripheral artery disease is called critical limb threatening ischemia. During this stage, pain is often felt in the feet, even without walking, and is worse during rest or when lying down. You also may experience open sores or wounds on your limbs or feet that won't heal. Critical limb threatening ischemia may cause tissue death or gangrene on your feet. If this goes untreated, it can lead to leg amputation.

Treatment for peripheral artery disease varies depending on its severity. When it's diagnosed early, lifestyle changes and treatment of underlying medical conditions are often enough to manage symptoms. This may mean taking appropriate medications to control high blood pressure and high cholesterol, controlling blood sugar levels if you have diabetes, quitting smoking, eating a healthier diet with fewer fatty and highly processed foods, and regular exercise or engaging in a walking program. 

For more advanced disease, restoration of blood flow is necessary in addition to lifestyle changes. Therefore, the goal of surgery is to restore blood flow and prevent leg amputation. 

One treatment option is percutaneous endovascular surgery, a minimally invasive approach. In this operation, the surgeon guides a thin, flexible tube called a catheter through the groin, foot or wrist to the narrowed part of the artery. A tiny balloon is inflated to widen the blocked artery and improve blood flow. A stent, a small wire mesh tube, may also be placed in the artery to keep it open.

The more invasive surgical option is bypass surgery. The surgeon creates a path around the blocked artery using either a healthy blood vessel from another part of the body or a synthetic one. One end of the healthy vein is connected to the artery above the blockage, and the other is attached below the blockage so that the blood will detour into the bypass. 

When diagnosed with peripheral artery disease, it’s important to consult a vascular surgeon to determine the best treatment for you. Vascular surgeons can perform both minimally invasive procedures and complex bypass surgery. 

By incorporating lifestyle changes and treating any underlying medical conditions early, you can significantly improve your quality of life and prevent progression to more severe stages of disease. Peripheral artery disease is a marker for your overall cardiovascular health, and managing it correctly can lead to a longer, healthier life. — Fahad Shuja, M.B.B.S., Vascular Surgery, Mayo Clinic, Rochester, Minnesota

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