Showing posts with label Health. Show all posts
Showing posts with label Health. Show all posts

England Develops a Voracious Appetite for a New Diet





LONDON — Visitors to England right now, be warned. The big topic on people’s minds — from cabdrivers to corporate executives — is not Kate Middleton’s increasingly visible baby bump (though the craze does involve the size of one’s waistline), but rather a best-selling diet book that has sent the British into a fasting frenzy.




“The Fast Diet,” published in mid-January in Britain, could do the same in the United States if Americans eat it up. The United States edition arrived last week.


The book has held the No. 1 slot on Amazon’s British site nearly every day since its publication in January, according to Rebecca Nicolson, a founder of Short Books, the independent publishing company behind the sensation. “It is selling,” she said, “like hot cakes,” which coincidentally are something one can actually eat on this revolutionary diet.


With an alluring cover line that reads, “Lose Weight, Stay Healthy, Live Longer,” the premise of this latest weight-loss regimen — or “slimming” as the British call “dieting” — is intermittent fasting, or what has become known here as the 5:2 diet: five days of eating and drinking whatever you want, dispersed with two days of fasting.


A typical fasting day consists of two meals of roughly 250 to 300 calories each, depending on the person’s sex (500 calories for women, 600 for men). Think two eggs and a slice of ham for breakfast, and a plate of steamed fish and vegetables for dinner.


It is not much sustenance, but the secret to weight loss, according to the book, is that even after just a few hours of fasting, the body begins to turn off the fat-storing mechanisms and turn on the fat-burning systems.


“I’ve always been into self-experimentation,” said Dr. Michael Mosley, one of the book’s two authors and a well-known medical journalist on the BBC who is often called the Sanjay Gupta of Britain.


He researched the science of the diet and its health benefits by putting himself through intermittent fasting and filming it for a BBC documentary last August called “Eat, Fast and Live Longer.” (The broadcast gained high ratings, three million viewers, despite running during the London Olympics. PBS plans to air it in April.)


“This started because I was not feeling well last year,” Dr. Mosley said recently over a cup of tea and half a cookie (it was not one of his fasting days). “It turns out I was suffering from high blood sugar, high cholesterol and had a kind of visceral fat inside my gut.”


Though hardly obese at the time, at 5 feet 11 inches and 187 pounds, Dr. Mosley, 55, had a body mass index and body fat percentage that were a few points higher than the recommended amount for men. “Given that my father had died at age 73 of complications from diabetes, and I was now looking prediabetic, I knew something had to change,” he added.


The result was a documentary, almost the opposite of “Super Size Me,” in which Dr. Mosley not only fasted, but also interviewed scientific researchers, mostly in the United States, about the positive results of various forms of intermittent fasting, tested primarily on rats but in some cases human volunteers. The prominent benefits, he discovered, were weight loss, a lower risk of cancer and heart disease, and increased energy.


“The body goes into a repair-and-recover mode when it no longer has the work of storing the food being consumed,” he said.


Though Dr. Mosley quickly gave up on the most extreme forms of fasting (he ate little more than one cup of low-calorie soup every 24 hours for four consecutive days in his first trial), he finally settled on the 5:2 ratio as a more sustainable, less painful option that could realistically be followed without annihilating his social life or work.


“Our earliest antecedents,” Dr. Mosley argued, “lived a feast-or-famine existence, gorging themselves after a big hunt and then not eating until they scored the next one.” Similarly, he explained, temporary fasting is a ritual of religions like Islam and Judaism — as demonstrated by Ramadan and Yom Kippur. “We shouldn’t have a fear of hunger if it is just temporary,” he said.


What Dr. Mosley found most astounding, however, were his personal results. Not only did he lose 20 pounds (he currently weighs 168 pounds) in nine weeks, but his glucose and cholesterol levels went down, as did his body fat. “What’s more, I have a whole new level of energy,” he said.


The documentary became an instant hit, which in turn led Mimi Spencer, a food and fashion writer, to propose that they collaborate on a book. “I could see this was not a faddish diet but one that was sustainable with long-term health results, beyond the obvious weight-loss benefit,” said Ms. Spencer, 45, who has lost 20 pounds on the diet within four months and lowered her B.M.I. by 2 points.


The result is a 200-page paperback: the first half written by Dr. Mosley outlining the scientific findings of intermittent fasting; the second by Ms. Spencer, with encouraging text on how to get through the first days of fasting, from keeping busy so you don’t hear your rumbling belly, to waiting 15 minutes for your meal or snack.


She also provides fasting recipes with tantalizing photos like feta niçoise salad and Mexican pizza, and a calorie counter at the back. (Who knew a quarter of a cup of balsamic vinegar dressing added up to a whopping 209 calories?)


In London, the diet has taken off with the help of well-known British celebrity chefs and food writers like Hugh Fearnley-Whittingstall, who raved about it in The Guardian after his sixth day of fasting, having already lost eight pounds. (“I feel lean and sharper,” he wrote, “and find the whole thing rather exhilarating.”)


The diet is also particularly popular among men, according to Dr. Mosley, who has heard from many of his converts via e-mail and Twitter, where he has around 24,000 followers. “They find it easy to work into their schedules because dieting for a day here and there doesn’t feel torturous,” he said, adding that couples also particularly like doing it together.


But not everyone is singing the diet’s praises. The National Health System, Britain’s publicly funded medical establishment, put out a statement on its Web site shortly after the book came out: “Despite its increasing popularity, there is a great deal of uncertainty about I.F. (intermittent fasting) with significant gaps in the evidence.”


The health agency also listed some side effects, including bad breath, anxiety, dehydration and irritability. Yet people in London do not seem too concerned. A slew of fasting diet books have come out in recent weeks, notably the “The 5:2 Diet Book” and “The Feast and Fast Diet.”


There is also a crop of new cookbooks featuring fasting-friendly recipes. Let’s just say, the British are hungry for them.


This article has been revised to reflect the following correction:

Correction: March 2, 2013

An earlier version of this article misstated part of the name of the national healthcare organization in Britain. It is the National Health Service, not the National Health System. The article also misidentified the Balsamic product that has 209 calories per cup. It is Balsamic vinegar dressing, not Balsamic vinegar.



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Well: A Rainbow of Root Vegetables

This week’s Recipes for Health is as much a treat for the eyes as the palate. Colorful root vegetables from bright orange carrots and red scallions to purple and yellow potatoes and pale green leeks will add color and flavor to your table.

Since root vegetables and tubers keep well and can be cooked up into something delicious even after they have begun to go limp in the refrigerator, this week’s Recipes for Health should be useful. Root vegetables, tubers (potatoes and sweet potatoes, which are called yams by most vendors – I mean the ones with dark orange flesh), winter squash and cabbages are the only local vegetables available during the winter months in colder regions, so these recipes will be timely for many readers.

Roasting is a good place to begin with most root vegetables. They sweeten as they caramelize in a hot oven. I roasted baby carrots and thick red scallions (they may have been baby onions; I didn’t get the information from the farmer, I just bought them because they were lush and pretty) together and seasoned them with fresh thyme leaves, then sprinkled them with chopped toasted hazelnuts. I also roasted a medley of potatoes, including sweet potatoes, after tossing them with olive oil and sage, and got a wonderful range of colors, textures and tastes ranging from sweet to savory.

Sweet winter vegetables also pair well with spicy seasonings. I like to combine sweet potatoes and chipotle peppers, and this time in a hearty lentil stew that we enjoyed all week.

Here are five colorful and delicious dishes made with root vegetables.

Spicy Lentil and Sweet Potato Stew With Chipotles: The combination of sweet potatoes and spicy chipotles with savory lentils is a winner.


Roasted Carrots and Scallions With Thyme and Hazelnuts: Toasted hazelnuts add a crunchy texture and nutty finish to this dish.


Carrot Wraps: A vegetarian sandwich that satisfies like a full meal.


Rainbow Potato Roast: A multicolored mix that can be vegan, or not.


Leek Quiche: A lighter version of a Flemish classic.


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Doctor and Patient: Why Failing Med Students Don’t Get Failing Grades

Tall and dark-haired, the third-year medical student always seemed to be the first to arrive at the hospital and the last to leave, her white coat perpetually weighed down by the books and notes she jammed into the pockets. She appeared totally absorbed by her work, even exhausted at times, and said little to anyone around her.

Except when she got frustrated.

I first noticed her when I overheard her quarreling with a nurse. A few months later I heard her accuse another student of sabotaging her work. And then one morning, I saw her storm off the wards after a senior doctor corrected a presentation she had just given. “The patient never told me that!” she cried. The nurses and I stood agape as we watched her stamp her foot and walk away.

“Why don’t you just fail her?” one of the nurses asked the doctor.

“I can’t,” she sighed, explaining that the student did extremely well on all her tests and worked harder than almost anyone in her class. “The problem,” she said, “is that we have no multiple choice exams when it comes to things like clinical intuition, communication skills and bedside manner.”

Medical educators have long understood that good doctoring, like ducks, elephants and obscenity, is easy to recognize but difficult to quantify. And nowhere is the need to catalog those qualities more explicit, and charged, than in the third year of medical school, when students leave the lecture halls and begin to work with patients and other clinicians in specialty-based courses referred to as “clerkships.” In these clerkships, students are evaluated by senior doctors and ranked on their nascent doctoring skills, with the highest-ranking students going on to the most competitive training programs and jobs.

A student’s performance at this early stage, the traditional thinking went, would be predictive of how good a doctor she or he would eventually become.

But in the mid-1990s, a group of researchers decided to examine grading criteria and asked directors of internal medicine clerkship courses across the country how accurate and consistent they believed their grading to be. Nearly half of the course directors believed that some form of grade inflation existed, even within their own courses. Many said they had increasing difficulty distinguishing students who could not achieve a “minimum standard,” whatever that might be. And over 40 percent admitted they had passed students who should have failed their course.

The study inspired a series of reforms aimed at improving how medical educators evaluated students at this critical juncture in their education. Some schools began instituting nifty mnemonics like RIME, or Reporter-Interpreter-Manager-Educator, for assessing progressive levels of student performance; others began to call regular meetings to discuss grades; still others compiled detailed evaluation forms that left little to the subjective imagination.

Now a new study published last month in the journal Teaching and Learning in Medicine looks at the effects of these many efforts on the grading process. And while the good news is that the rate of grade inflation in medical schools is slower than in colleges and universities, the not-so-good news is that little has changed. A majority of clerkship directors still believe that grade inflation is an issue even within their own courses; and over a third believe that students have passed their course who probably should have failed.

“Grades don’t have a lot of meaning,” said Dr. Sara B. Fazio, lead author of the paper and an associate professor of medicine at Harvard Medical School who leads the internal medicine clerkship at the Beth Israel Deaconess Medical Center in Boston. “‘Satisfactory’ is like the kiss of death.”

About a quarter of the course directors surveyed believed that grade inflation occurred because senior doctors were loath to deal with students who could become angry, upset or even turn litigious over grades. Some confessed to feeling pressure to help students get into more selective internships and training programs.

But for many of these educators, the real issue was not flunking the flagrantly unprofessional student, but rather evaluating and helping the student who only needed a little extra help in transitioning from classroom problem sets to real world patients. Most faculty received little or no training or support in evaluating students, few came from institutions that had remediation programs to which they could direct students, and all worked under grading systems that were subjective and not standardized.

Despite the disheartening findings, Dr. Fazio and her co-investigators believe that several continuing initiatives may address the evaluation issues. For example, residency training programs across the country will soon be assessing all doctors-in-training with a national standards list, a series of defined skills, or “competencies,” in areas like interpersonal communication, professional behavior and specialty-specific procedures. Over the next few years, medical schools will likely be adopting a similar system for medical students, creating a national standard for all institutions.

“There have to be unified, transparent and objective criteria,” Dr. Fazio said. “Everyone should know what it means when we talk about educating and training ‘good doctors.’”

“We will all be patients one day,” she added. “We have to think about what kind of doctors we want to have now and in the future.”

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Global Health: After Measles Success, Rwanda to Get Rubella Vaccine


Rwanda has been so successful at fighting measles that next month it will be the first country to get donor support to move to the next stage — fighting rubella too.


On March 11, it will hold a nationwide three-day vaccination campaign with a combined measles-rubella vaccine, hoping to reach nearly five million children up to age 14. It will then integrate the dual vaccine into its national health service.


Rwanda can do so “because they’ve done such a good job on measles,” said Christine McNab, a spokeswoman for the Measles and Rubella Initiative. M.R.I. helped pay for previous vaccination campaigns in the country and the GAVI Alliance is helping to finance the upcoming one.


Rubella, also called German measles, causes a rash that is very similar to the measles rash, making it hard for health workers to tell the difference.


Rubella is generally mild, even in children, but in pregnant women, it can kill the fetus or cause serious birth defects, including blindness, deafness, mental retardation and chronic heart damage.


Ms. McNab said that Rwanda had proved that it can suppress measles and identify rubella, and it would benefit from the newer, more expensive vaccine.


The dual vaccine costs twice as much — 52 cents a dose at Unicef prices, compared with 24 cents for measles alone. (The MMR vaccine that American children get, which also contains a vaccine against mumps, costs Unicef $1.)


More than 90 percent of Rwandan children now are vaccinated twice against measles, and cases have been near zero since 2007.


The tiny country, which was convulsed by Hutu-Tutsi genocide in 1994, is now leading the way in Africa in delivering medical care to its citizens, Ms. McNab said. Three years ago, it was the first African country to introduce shots against human papilloma virus, or HPV, which causes cervical cancer.


In wealthy countries, measles kills a small number of children — usually those whose parents decline vaccination. But in poor countries, measles is a major killer of malnourished infants. Around the world, the initiative estimates, about 158,000 children die of it each year, or about 430 a day.


Every year, an estimated 112,000 children, mostly in Africa, South Asia and the Pacific islands, are born with handicaps caused by their mothers’ rubella infection.


Thanks in part to the initiative — which until last year was known just as the Measles Initiative — measles deaths among children have declined 71 percent since 2000. The initiative is a partnership of many health agencies, vaccine companies, donors and others, but is led by the American Red Cross, the United Nations Foundation, the Centers for Disease Control and Prevention, Unicef and the World Health Organization.


This article has been revised to reflect the following correction:

Correction: February 27, 2013

An earlier version of this article misstated the source of the vaccine and some financing for the campaign. The vaccine and financing is being provided by the GAVI Alliance, not the Measles and Rubella Initiative.




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Advanced Breast Cancer May Be Rising Among Young Women, Study Finds


The incidence of advanced breast cancer among younger women, ages 25 to 39, may have increased slightly over the last three decades, according to a study released Tuesday.


But more research is needed to verify the finding, which was based on an analysis of statistics, the study’s authors said. They do not know what may have caused the apparent increase.


Some outside experts questioned whether the increase was real, and expressed concerns that the report would frighten women needlessly.


The study, published in The Journal of the American Medical Association, found that advanced cases climbed to 2.9 per 100,000 younger women in 2009, from 1.53 per 100,000 women in 1976 — an increase of 1.37 cases per 100,000 women in 34 years. The totals were about 250 such cases per year in the mid-1970s, and more than 800 per year in 2009.


Though small, the increase was statistically significant, and the researchers said it was worrisome because it involved cancer that had already spread to organs like the liver or lungs by the time it was diagnosed, which greatly diminishes the odds of survival.


For now, the only advice the researchers can offer to young women is to see a doctor quickly if they notice lumps, pain or other changes in the breast, and not to assume that they cannot have breast cancer because they are young and healthy, or have no family history of the disease.


“Breast cancer can and does occur in younger women,” said Dr. Rebecca H. Johnson, the first author of the study and medical director of the adolescent and young adult oncology program at Seattle Children’s Hospital.


But Dr. Johnson noted that there is no evidence that screening helps younger women who have an average risk for the disease and no symptoms. We’re certainly not advocating that young women get mammography at an earlier age than is generally specified,” she said.


Expert groups differ about when screening should begin; some say at age 40, others 50.


Breast cancer is not common in younger women; only 1.8 percent of all cases are diagnosed in women from 20 to 34, and 10 percent in women from 35 to 44. However, when it does occur, the disease tends to be more deadly in younger women than in older ones. Researchers are not sure why.


The researchers analyzed data from SEER, a program run by the National Cancer Institute to collect cancer statistics on 28 percent of the population of the United States. The study also used data from the past when SEER was smaller.


The study is based on information from 936,497 women who had breast cancer from 1976 to 2009. Of those, 53,502 were 25 to 39 years old, including 3,438 who had advanced breast cancer, also called metastatic or distant disease.


Younger women were the only ones in whom metastatic disease seemed to have increased, the researchers found.


Dr. Archie Bleyer, a clinical research professor in radiation medicine at the Knight Cancer Institute at the Oregon Health and Science University in Portland who helped write the study, said scientists needed to verify the increase in advanced breast cancer in young women in the United States and find out whether it is occurring in other developed Western countries. “This is the first report of this kind,” he said, adding that researchers had already asked colleagues in Canada to analyze data there.


“We need this to be sure ourselves about this potentially concerning, almost alarming trend,” Dr. Bleyer said. “Then and only then are we really worried about what is the cause, because we’ve got to be sure it’s real.”


Dr. Johnson said her own experience led her to look into the statistics on the disease in young women. She had breast cancer when she was 27; she is now 44. Over the years, friends and colleagues often referred young women with the disease to her for advice.


“It just struck me how many of those people there were,” she said.


Dr. Donald A. Berry, an expert on breast cancer data and a professor of biostatistics at the University of Texas’ M. D. Anderson Cancer Center in Houston, said he was dubious about the finding, even though it was statistically significant, because the size of the apparent increase was so small — 1.37 cases per 100,000 women, over the course of 30 years.


More screening and more precise tests to identify the stage of cancer at the time of diagnosis might account for the increase, he said.


“Not many women aged 25 to 39 get screened, but some do, but it only takes a few to account for a notable increase from one in 100,000,” Dr. Berry said.


Dr. Silvia C. Formenti, a breast cancer expert and the chairwoman of radiation oncology at New York University Langone Medical Center, questioned the study in part because although it found an increased incidence of advanced disease, it did not find the accompanying increase in deaths that would be expected.


A spokeswoman for an advocacy group for young women with breast cancer, Young Survival Coalition, said the organization also wondered whether improved diagnostic and staging tests might explain all or part of the increase.


“We’re looking at this data with caution,” said the spokeswoman, Michelle Esser. “We don’t want to invite panic or alarm.”


She said it was important to note that the findings applied only to women who had metastatic disease at the time of diagnosis, and did not imply that women who already had early-stage cancer faced an increased risk of advanced disease.


Dr. J. Leonard Lichtenfeld
, deputy chief medical officer of the American Cancer Society, said he and an epidemiologist for the society thought the increase was real.


“We want to make sure this is not oversold or that people suddenly get very frightened that we have a huge problem,” Dr. Lichtenfeld said. “We don’t. But we are concerned that over time, we might have a more serious problem than we have today.”


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Global Health: After Measles Success, Rwanda to Get Rubella Vaccine


Rwanda has been so successful at fighting measles that next month it will be the first country to get donor support to move to the next stage — fighting rubella too.


On March 11, it will hold a nationwide three-day vaccination campaign with a combined measles-rubella vaccine, hoping to reach nearly five million children up to age 14. It will then integrate the dual vaccine into its national health service.


Rwanda can do so “because they’ve done such a good job on measles,” said Christine McNab, a spokeswoman for the Measles and Rubella Initiative, which will provide the vaccine and help pay for the campaign.


Rubella, also called German measles, causes a rash that is very similar to the measles rash, making it hard for health workers to tell the difference.


Rubella is generally mild, even in children, but in pregnant women, it can kill the fetus or cause serious birth defects, including blindness, deafness, mental retardation and chronic heart damage.


Ms. McNab said that Rwanda had proved that it can suppress measles and identify rubella, and it would benefit from the newer, more expensive vaccine.


The dual vaccine costs twice as much — 52 cents a dose at Unicef prices, compared with 24 cents for measles alone. (The MMR vaccine that American children get, which also contains a vaccine against mumps, costs Unicef $1.)


More than 90 percent of Rwandan children now are vaccinated twice against measles, and cases have been near zero since 2007.


The tiny country, which was convulsed by Hutu-Tutsi genocide in 1994, is now leading the way in Africa in delivering medical care to its citizens, Ms. McNab said. Three years ago, it was the first African country to introduce shots against human papilloma virus, or HPV, which causes cervical cancer.


In wealthy countries, measles kills a small number of children — usually those whose parents decline vaccination. But in poor countries, measles is a major killer of malnourished infants. Around the world, the initiative estimates, about 158,000 children die of it each year, or about 430 a day.


Every year, an estimated 112,000 children, mostly in Africa, South Asia and the Pacific islands, are born with handicaps caused by their mothers’ rubella infection.


Thanks in part to the initiative — which until last year was known just as the Measles Initiative — measles deaths among children have declined 71 percent since 2000. The initiative is a partnership of many health agencies, vaccine companies, donors and others, but is led by the American Red Cross, the United Nations Foundation, the Centers for Disease Control and Prevention, Unicef and the World Health Organization.


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Off the Dribble: Salley Offers a Healthy Assist

When Carmelo Anthony went on a vegetarian diet a few weeks ago and caused the biggest culinary conundrum in sports since fried chicken and beer had starring roles in the Red Sox clubhouse, John Salley could only shake his head.

Anthony’s diet was blamed for his sluggish play and the Knicks’ 3-4 record during the 15-day fast.

Anthony admitted that his body felt “depleted out there.”

But Salley, the former N.B.A. player, said that if Anthony had eaten a vegetarian diet correctly, he would have felt invigorated and anything but depleted.

And not just for two weeks but for the entire season.

For Salley, many of his salad days in the N.B.A. really were salad days. Particularly kale salad.

Salley, a 6-foot-11 power forward and center, became a vegetarian in January 1991 after he felt he had to make changes in his lifestyle, much like Anthony’s stated desire for “clarity in his life.”

Vegetarians do not eat meat, fish or poultry, but may eat dairy products like cheese, eggs, yogurt or milk.

Salley had read a story about the Celtics’ Robert Parish, whom he had always admired, and his interest in yoga and a red-meat-free diet.

While Parish’s regimen was not total vegetarian, he recently said that it made a difference in his career, helping him withstand the rigors of playing center against behemoths in the paint.

“My diet consisted of chicken, fish, seafood, salad, pasta and organic when possible,” he said. “I had very little sugar and drank a gallon of water every day. I also ate rice and beans, peas, cabbage, mustard, collards greens and assorted nuts. I would always focus on healthy eating. My success depended on my body and I tried to do right by it. ”

His body responded with 20 years of service in his Hall of Fame career. Parish retired at 43.

Salley was striving for similar health and success.

“I was 27, and I felt I had to change my life,” Salley said. “My knees were sore, my joints ached, I had back problems and my cholesterol was 275. ”

When he was with the Pistons, Salley visited a nutritionist in Detroit who advised him to eliminate fried foods and adopt a macrobiotic diet (grains and vegetables).

Salley, invigorated and healthy, had his best season in 1991. A defensive specialist, he had more energy and quickness and averaged a career best 9.5 points a game.

He kept his healthy diet a secret from his burly Bad Boy Piston steak-and-pork-chop teammates, who included Bill Laimbeer, Rick Mahorn and Dennis Rodman.

“I would tell them all the time,” Salley said, “if you go into a steak house it’s not that they have a certain thing inside the dead flesh or they cook it differently. They make it the same way everybody else does. All you’re doing is eating dead food.”

Salley would search out health food restaurants with a few tables or just counter service for his diet staples of quinoa, kale, spinach, stir fried vegetables, brown rice and wheatgrass on the menu.

“It was hard to find places in 1991,” he said. “So many times I would go into restaurants and ask the cook to steam my vegetables and make me the lightest fish.”

But it was worth it.

“I was playing so well it was crazy,” he said.

During his career, Salley, who retired in 2000, won four championships with the Detroit Pistons, the Chicago Bulls and the Los Angeles Lakers.

He now follows a vegan diet, which eliminates all dairy foods in addition to animal products.

“I’m eating raw,” said Salley, 48. “And I make all my food with no sugar, no salt and no oil.”

Salley is familiar with Anthony’s foray into vegetarian living. The Knicks star followed the Daniel Fast based on the book of Daniel in the Bible, which espouses a diet of mainly liquid and vegetables.

“He felt depleted because you need to find a natural source of vitamin B12,” Salley said.

B12 is not found in any significant amounts in plant food, and a deficiency can cause fatigue, weakness and tingling in the legs.

It can also cause irritability. Anthony said his diet might have caused him to lash out at Kevin Garnett in a game against the Boston Celtics.

“He didn’t take any supplements to help his body,” Salley said. “He did not get his body to heal. It’s like cutting yourself and not putting a Band-Aid on. He just got part of the plan right.”

Salley is working to make sure children get the plan right with food choices. He spreads the word about healthy eating in the community, having lobbied Congress for more vegetarian options in school lunches.

Although Anthony may have struggled to maintain his vegetarian diet, other N.B.A players and athletes have embraced it.

James Jones of the Miami Heat and Anthony’s teammate A’mare Stoudemire are vegetarians.

Baseball’s Prince Fielder, the triathlete Brendan Brazier, the mixed martial artist Mac Danzig, the bodybuilder Derek Tresize and the tennis player Serena Williams are among athletes who are vegans or vegetarians.

Dr. Joel Kahn, a clinical professor of medicine at Wayne State University School of Medicine and medical director of wellness programs, preventive cardiology, and cardiac rehabilitation at Detroit Medical Center, has counseled Salley and other athletes about the benefits of vegan and vegetarian diets.

“A plant-based, whole-food diet low on sugar and gluten is very anti-inflammatory and ideal for rapid recovery from workouts,” he said.

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Well: Savory Pie Recipes for Health

Pie is an indulgence often saved for holiday time. But this week Martha Rose Shulman shows us how to bake a pie and eat it too, without the guilt. She offers savory vegetable pies, showcased in whole grain crusts. She writes:

This week I slowed down and made pies: savory ones filled with vegetables … I used a number of different crusts for my winter pies. My favorite remains the whole wheat yeasted olive oil crust that I have used before in this column, but I also worked with a simple Mediterranean crust made with a mix of whole wheat flour, all-purpose flour and olive oil. And for those of you who are gluten-free, I made another foray into gluten-free pastry and produced one I liked a lot, which was a mix of buckwheat flour, millet flour and potato starch. It had a strong nutty flavor that worked well with a very savory, very vegan, tofu and mushroom “quiche.” They are all simple to mix together and easy to roll or press out. And if you don’t feel like dealing with a crust, just use Greek phyllo. The important things, after all, are the savory vegetables inside.

Here are recipes for a pie crust and four savory winter vegetable pies.

Whole Wheat Mediterranean Pie Crust: A simple Mediterranean crust made with a mix of whole wheat flour, all-purpose flour and olive oil.


Mixed Greens Galette With Onions and Chickpeas: A tasty way to use bagged greens in a dish with Middle Eastern overtones.


Goat Cheese, Chard and Herb Pie in a Phyllo Crust: A garlicky mix of greens and your choice of herbs inside a crispy phyllo crust.


Tofu Mushroom ‘Quiche’: A vegan dish with a deep, rich flavor.


Winter Tomato Quiche: Canned tomatoes can be used in the off season for a delicious dinner.


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Living With Cancer: Arrivals and Departures

After being nursed and handed over, the baby’s wails rise to a tremolo, but I am determined to give my exhausted daughter and son-in-law a respite on this wintry evening. Commiserating with the little guy’s discomfort — gas, indigestion, colic, ontological insecurity — I swaddle, burp, bink, then cradle him in my arms. I begin walking around the house, swinging and swaying while cooing in soothing cadences: “Yes, darling boy, another one bites the dust, another one bites the dust.”

I kid you not! How could such grim phrases spring from my lips into the newborn’s ears? Where did they come from?

I blame his mother and her best friend. They sang along as this song was played repeatedly at the skating rink to which I took them every other Saturday in their tweens. Why would an infatuated grandma croon a mordant lullaby, even if the adorable one happily can’t understand a single word? He’s still whimpering, twisting away from me, and understandably so.

Previously that day, I had called a woman in my cancer support group. I believe that she is dying. I do not know her very well. She has attended only two or three of our get-togethers where she described herself as a widow and a Christian.

On the phone, I did not want to violate the sanctity of her end time, but I did want her to know that she need not be alone, that I and other members of our group can “be there” for her. Her dying seems a rehearsal of my own. We have the same disease.

“How are you doing, Kim?” I asked.

“I’m tired. I sleep all the time,” she sighed, “and I can’t keep anything down.”

“Can you drink … water?” I asked.

“A little, but I tried a smoothie and it wouldn’t set right,” she said.

“I hope you are not in pain.”

“Oh no, but I’m sleeping all the time. And I can’t keep anything down.”

“Would you like a visit? Is there something I can do or bring?” I asked.

“Oh, I don’t think so, no thanks.”

“Well,” I paused before saying goodbye, “be well.”

Be well? I didn’t even add something like, “Be as well as you can be.” I was tongue-tied. This was the failure that troubles me tonight.

Why couldn’t I say that we will miss her, that I am sorry she is dying, that she has coped so well for so long, and that I hope she will now find peace? I could inform an infant in my arms of our inexorable mortality, but I could not speak or even intimate the “D” word to someone on her deathbed.

Although I have tried to communicate to my family how I feel about end-of-life care, can we always know what we will want? Perhaps at the end of my life I will not welcome visitors, either. For departing may require as much concentration as arriving. As I look down at the vulnerable bundle I am holding, I marvel that each and every one of us has managed to come in and will also have to manage to go out. The baby nestles, pursing his mouth around the pacifier. He gazes intently at my face with a sly gaze that drifts toward a lamp, turning speculative before lids lower in tremulous increments.

Slowing my jiggling to his faint sucking, I think that the philosopher Jacques Derrida’s meditation on death pertains to birth as well. Each of these events “names the very irreplaceability of absolute singularity.” Just as “no one can die in my place or in the place of the other,” no one can be born in this particular infant’s place. He embodies his irreplaceable and absolute singularity.

Perhaps we should gestate during endings, as we do during beginnings. Like hatchings, the dispatchings caused by cancer give people like Kim and me a final trimester, more or less, in which we can labor to forgive and be forgiven, to speak and hear vows of devotion from our intimates, to visit or not be visited by acquaintances.

Maybe we need a doula for dying, I reflect as melodious words surface, telling me what I have to do with the life left to be lived: “To love that well, which thou must leave ere long.”

“Oh little baby,” I then whisper: “Though I cannot tell who you will become and where I will be — you, dear heart, deliver me.”


Susan Gubar is a distinguished emerita professor of English at Indiana University and the author of “Memoir of a Debulked Woman,” which explores her experience with ovarian cancer.

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Well: Effects of Bullying Last Into Adulthood, Study Finds

Victims of bullying at school, and bullies themselves, are more likely to experience psychiatric problems in childhood, studies have shown. Now researchers have found that elevated risk of psychiatric trouble extends into adulthood, sometimes even a decade after the intimidation has ended.

The new study, published in the journal JAMA Psychiatry on Wednesday, is the most comprehensive effort to date to establish the long-term consequences of childhood bullying, experts said.

“It documents the elevated risk across a wide range of mental health outcomes and over a long period of time,” said Catherine Bradshaw, an expert on bullying and a deputy director of the Center for the Prevention of Youth Violence at Johns Hopkins University, which was not involved in the study.

“The experience of bullying in childhood can have profound effects on mental health in adulthood, particularly among youths involved in bullying as both a perpetuator and a victim,” she added.

The study followed 1,420 subjects from Western North Carolina who were assessed four to six times between the ages of 9 and 16. Researchers asked both the children and their primary caregivers if they had been bullied or had bullied others in the three months before each assessment. Participants were divided into four groups: bullies, victims, bullies who also were victims, and children who were not exposed to bullying at all.

Participants were assessed again in young adulthood — at 19, 21 and between 24 and 26 — using structured diagnostic interviews.

Researchers found that victims of bullying in childhood were 4.3 times more likely to have an anxiety disorder as adults, compared to those with no history of bullying or being bullied.

Bullies who were also victims were particularly troubled: they were 14.5 times more likely to develop panic disorder as adults, compared to those who did not experience bullying, and 4.8 times more likely to experience depression. Men who were both bullies and victims were 18.5 times more likely to have had suicidal thoughts in adulthood, compared to the participants who had not been bullied or perpetuators. Their female counterparts were 26.7 times more likely to have developed agoraphobia, compared to children not exposed to bullying.

Bullies who were not victims of bullying were 4.1 times more likely to have antisocial personality disorder as adults than those never exposed to bullying in their youth.

The effects persisted even after the researchers accounted for pre-existing psychiatric problems or other factors that might have contributed to psychiatric disorders, like physical or sexual abuse, poverty and family instability.

“We were actually able to say being a victim of bullying is having an effect a decade later, above and beyond other psychiatric problems in childhood and other adversities,” said William E. Copeland, lead author of the study and an associate professor of psychiatry and behavioral sciences at Duke University Medical Center.

Bullying is not a harmless rite of passage, but inflicts lasting psychiatric damage on a par with certain family dysfunctions, Dr. Copeland said. “The pattern we are seeing is similar to patterns we see when a child is abused or maltreated or treated very harshly within the family setting,” he said.

One limitation of the study is that bullying was not analyzed for frequency, and the researchers’ assessment did not distinguish between interpersonal and overt bullying. It only addressed bullying at school, not in other settings.

Most of what experts know about the effects of bullying comes from observational studies, not studies of children followed over time.

Previous research from Finland, based on questionnaires completed on a single occasion or on military registries, used a sample of 2,540 boys to see if being a bully or a victim at 8 predicted a psychiatric disorder 10 to 15 years later. The researchers found frequent bully-victims were at particular risk of adverse long-term outcomes, specifically anxiety and antisocial personality disorders. Victims were at greater risk for anxiety disorders, while bullies were at increased risk for antisocial personality disorder.

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DNA Analysis, More Accessible Than Ever, Opens New Doors


Matt Roth for The New York Times


Sam Bosley of Frederick, Md., going shopping with his daughter, Lillian, 13, who has a malformed brain and severe developmental delays, seizures and vision problems. More Photos »







Debra Sukin and her husband were determined to take no chances with her second pregnancy. Their first child, Jacob, who had a serious genetic disorder, did not babble when he was a year old and had severe developmental delays. So the second time around, Ms. Sukin had what was then the most advanced prenatal testing.




The test found no sign of Angelman syndrome, the rare genetic disorder that had struck Jacob. But as months passed, Eli was not crawling or walking or babbling at ages when other babies were.


“Whatever the milestones were, my son was not meeting them,” Ms. Sukin said.


Desperate to find out what is wrong with Eli, now 8, the Sukins, of The Woodlands, Tex., have become pioneers in a new kind of testing that is proving particularly helpful in diagnosing mysterious neurological illnesses in children. Scientists sequence all of a patient’s genes, systematically searching for disease-causing mutations.


A few years ago, this sort of test was so difficult and expensive that it was generally only available to participants in research projects like those sponsored by the National Institutes of Health. But the price has plunged in just a few years from tens of thousands of dollars to around $7,000 to $9,000 for a family. Baylor College of Medicine and a handful of companies are now offering it. Insurers usually pay.


Demand has soared — at Baylor, for example, scientists analyzed 5 to 10 DNA sequences a month when the program started in November 2011. Now they are doing more than 130 analyses a month. At the National Institutes of Health, which handles about 300 cases a year as part of its research program, demand is so great that the program is expected to ultimately take on 800 to 900 a year.


The test is beginning to transform life for patients and families who have often spent years searching for answers. They can now start the grueling process with DNA sequencing, says Dr. Wendy K. Chung, professor of pediatrics and medicine at Columbia University.


“Most people originally thought of using it as a court of last resort,” Dr. Chung said. “Now we can think of it as a first-line test.”


Even if there is no treatment, there is almost always some benefit to diagnosis, geneticists say. It can give patients and their families the certainty of knowing what is wrong and even a prognosis. It can also ease the processing of medical claims, qualifying for special education services, and learning whether subsequent children might be at risk.


“Imagine the people who drive across the whole country looking for that one neurologist who can help, or scrubbing the whole house with Lysol because they think it might be an allergy,” said Richard A. Gibbs, the director of Baylor College of Medicine’s gene sequencing program. “Those kinds of stories are the rule, not the exception.”


Experts caution that gene sequencing is no panacea. It finds a genetic aberration in only about 25 to 30 percent of cases. About 3 percent of patients end up with better management of their disorder. About 1 percent get a treatment and a major benefit.


“People come to us with huge expectations,” said Dr. William A. Gahl, who directs the N.I.H. program. “They think, ‘You will take my DNA and find the causes and give me a treatment.' ”


“We give the impression that we can do these things because we only publish our successes,” Dr. Gahl said, adding that when patients come to him, “we try to make expectations realistic.”


DNA sequencing was not available when Debra and Steven Sukin began trying to find out what was wrong with Eli. When he was 3, they tried microarray analysis, a genetic test that is nowhere near as sensitive as sequencing. It detected no problems.


“My husband and I looked at each other and said, ‘The good news is that everything is fine; the bad news is that everything is not fine,' ” Ms. Sukin said.


In November 2011, when Eli was 6, Ms. Sukin consulted Dr. Arthur L. Beaudet, a medical geneticist at Baylor.


“Is there a protein missing?” she recalled asking him. “Is there something biochemical we could be missing?”


By now, DNA sequencing had come of age. Dr. Beaudet said that Eli was a great candidate, and it turned out that the new procedure held an answer.


A single DNA base was altered in a gene called CASK, resulting in a disorder so rare that there are fewer than 10 cases in all the world’s medical literature.


“It really became definitive for my husband and me,” Ms. Sukin said. “We would need to do lifelong planning for dependent care for the rest of his life.”


This article has been revised to reflect the following correction:

Correction: February 19, 2013

An earlier version of this article misstated the name of a medicine taken by two teenagers who have a rare gene mutation. The drug is 5-hydroxytryptophan, not 5-hydroxytryptamine.



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Personal Health: Health Effects of Smoking for Women

The title of a recent report on smoking and health might well have paraphrased the popular ad campaign for Virginia Slims, introduced in 1968 by Philip Morris and aimed at young professional women: “You’ve come a long way, baby.”

Today that slogan should include: “. . . toward a shorter life.” Ten years shorter, in fact.

The new report is one of two rather shocking analyses of the hazards of smoking and the benefits of quitting published last month in The New England Journal of Medicine. The data show that “women who smoke like men die like men who smoke,” Dr. Steven A. Schroeder, a professor of health and health care at the University of California, San Francisco, wrote in an accompanying editorial.

That was not always the case. Half a century ago, the risk of death from lung cancer among men who smoked was five times higher than that among women smokers. But by the first decade of this century, that risk had equalized: for both men and women who smoked, the risk of death from lung cancer was 25 times greater than for nonsmokers, Dr. Michael J. Thun of the American Cancer Society and his colleagues reported.

Today, women who smoke are even more likely than men who smoke to die of lung cancer. According to a second study in the same journal, women smokers face a 17.8 times greater risk of dying of lung cancer, than women who do not smoke; men who smoke are at 14.6 times greater risk to die of lung cancer than men who don’t. Women who smoke now face a risk of death from lung cancer that is 50 percent higher than the estimates reported in the 1980s, according to Dr. Prabhat Jha of the Center for Global Health Research in Toronto and his colleagues.

After controlling for age, body weight, education level and alcohol use, the new analysis found something else: men and women who continue to smoke die on average more than 10 years sooner than those who never smoked.

Dramatic progress has been made in reducing the prevalence of smoking, which has fallen in the United States from 42 percent of adults in 1965 (the year after the first surgeon general’s report on smoking and health) to 19 percent in 2010. Yet smoking still results in nearly 200,000 deaths a year among people 35 to 69 years old in this country. A quarter of all deaths in this age group would not occur if smokers had the same risk of death as nonsmokers.

The risks are even greater among men 55 to 74 and women 60 to 74. More than two-thirds of all deaths among current smokers in these age groups are related to smoking. Over all, the death rate from all causes combined in these age groups “is now at least three times as high among current smokers as among those who have never smoked,” Dr. Thun’s team found.

While lung cancer is the most infamous hazard linked to smoking, the habit also raises the risk of death from heart disease, stroke, pulmonary disease and other cancers, including breast cancer.

Furthermore, changes in how cigarettes are manufactured may have increased the dangers of smoking. The use of perforated filters, tobacco blends that are less irritating, and paper that is more porous made it easier to inhale smoke and encouraged deeper inhalation to achieve satisfying blood levels of nicotine.

The result of deeper inhalation, Dr. Thun’s report suggests, has been an increased risk of chronic obstructive pulmonary disease, or C.O.P.D., and a shift in the kind of lung cancer linked to smoking. Among nonsmokers, the risk of death from C.O.P.D. has declined by 45 percent in men and has remained stable in women, but the death rate has more than doubled among smokers.

But there is good news, too: it’s never too late to reap the benefits of quitting. The younger you are when you stop smoking, the greater your chances of living a long and healthy life, according to the findings of Dr. Jha’s international team.

The team analyzed smoking and smoking-cessation histories of 113,752 women and 88,496 men 25 and older and linked them to causes of deaths in these groups through 2006.

Those who quit smoking by age 34 lived 10 years longer on average than those who continued to smoke, giving them a life expectancy comparable to people who never smoked. Smokers who quit between ages 35 and 44 lived nine years longer, and those who quit between 45 and 54 lived six years longer. Even quitting smoking between ages 55 and 64 resulted in a four-year gain in life expectancy.

The researchers emphasized, however, that the numbers do not mean it is safe to smoke until age 40 and then stop. Former smokers who quit by 40 still experienced a 20 percent greater risk of death than nonsmokers. About one in six former smokers who died before the age of 80 would not have died so young if he or she had never smoked, they reported.

Dr. Schroeder believes we can do a lot better to reduce the prevalence of smoking with the tools currently in hand if government agencies, medical insurers and the public cooperate.

Unlike the races, ribbons and fund-raisers for breast cancer, “there’s no public face for lung cancer, even though it kills more women than breast cancer does,” Dr. Schroeder said in an interview. Lung cancer is stigmatized as a disease people bring on themselves, even though many older victims were hooked on nicotine in the 1940s and 1950s, when little was known about the hazards of smoking and doctors appeared in ads assuring the public it was safe to smoke.

Raising taxes on cigarettes can help. The states with the highest prevalence of smoking have the lowest tax rates on cigarettes, Dr. Schroeder said. Also helpful would be prohibiting smoking in more public places like parks and beaches. Some states have criminalized smoking in cars when children are present.

More “countermarketing” of cigarettes is needed, he said, including antismoking public service ads on television and dramatic health warnings on cigarette packs, as is now done in Australia. But two American courts have ruled that the proposed label warnings infringed on the tobacco industry’s right to free speech.

Health insurers, both private and government, could broaden their coverage of stop-smoking aids and better publicize telephone quit lines, and doctors “should do more to stimulate quit attempts,” Dr. Schroeder said.

As Nicola Roxon, a former Australian health minister, put it, “We are killing people by not acting.”

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Cuomo Bucks Tide With Bill to Lift Abortion Limits





ALBANY — Bucking a trend in which states have been seeking to restrict abortion, Gov. Andrew M. Cuomo is putting the finishing touches on legislation that would guarantee women in New York the right to late-term abortions when their health is in danger or the fetus is not viable.




Mr. Cuomo, seeking to deliver on a promise he made in his recent State of the State address, would rewrite a law that currently allows abortions after 24 weeks of pregnancy only if the pregnant woman’s life is at risk. The law is not enforced, because it is superseded by federal court rulings that allow late-term abortions to protect a woman’s health, even if her life is not in jeopardy. But abortion rights advocates say the existence of the more restrictive state law has a chilling effect on some doctors and prompts some women to leave the state for late-term abortions.


Mr. Cuomo’s proposal, which has not yet been made public, would also clarify that licensed health care practitioners, and not only physicians, can perform abortions. It would remove abortion from the state’s penal law and regulate it through the state’s public health law.


Abortion rights advocates have welcomed Mr. Cuomo’s plan, which he outlined in general terms as part of a broader package of women’s rights initiatives in his State of the State address in January. But the Roman Catholic Church and anti-abortion groups are dismayed; opponents have labeled the legislation the Abortion Expansion Act.


The prospects for Mr. Cuomo’s effort are uncertain. The State Assembly is controlled by Democrats who support abortion rights; the Senate is more difficult to predict because this year it is controlled by a coalition of Republicans who have tended to oppose new abortion rights laws and breakaway Democrats who support abortion rights.


New York legalized abortion in 1970, three years before it was legalized nationally by the Supreme Court in Roe v. Wade. Mr. Cuomo’s proposal would update the state law so that it could stand alone if the broader federal standard set by Roe were to be undone.


“Why are we doing this? The Supreme Court could change,” said a senior Cuomo administration official, who spoke on the condition of anonymity because the governor had not formally introduced his proposal.


But opponents of abortion rights, already upset at the high rate of abortions in New York State, worry that rewriting the abortion law would encourage an even greater number of abortions. For example, they suggest that the provision to allow abortions late in a woman’s pregnancy for health reasons could be used as a loophole to allow unchecked late-term abortions.


“I am hard pressed to think of a piece of legislation that is less needed or more harmful than this one,” the archbishop of New York, Cardinal Timothy M. Dolan, wrote in a letter to Mr. Cuomo last month. Referring to Albany lawmakers in a subsequent column, he added, “It’s as though, in their minds, our state motto, ‘Excelsior’ (‘Ever Upward’), applies to the abortion rate.”


National abortion rights groups have sought for years to persuade state legislatures to adopt laws guaranteeing abortion rights as a backup to Roe. But they have had limited success: Only seven states have such measures in place, including California, Connecticut and Maryland; the most recent state to adopt such a law is Hawaii, which did so in 2006.


“Pretty much all of the energy, all of the momentum, has been to restrict abortion, which makes what could potentially happen in New York so interesting,” said Elizabeth Nash, state issues manager at the Guttmacher Institute, a research group that supports abortion rights. “There’s no other state that’s even contemplating this right now.”


In most statehouses, the push by lawmakers has been in the opposite direction. The past two years has seen more provisions adopted at the state level to restrict abortion rights than in any two-year period in decades, according to the Guttmacher Institute; last year, 19 states adopted 43 new provisions restricting abortion access, while not a single significant measure was adopted to expand access to abortion or to comprehensive sex education.


“It’s an extraordinary moment in terms of the degree to which there is government interference in a woman’s ability to make these basic health care decisions,” said Andrea Miller, the president of NARAL Pro-Choice New York. “For New York to be able to send a signal, a hopeful sign, a sense of the turning of the tide, we think is really important.”


Abortion rights advocates say that even though the Roe decision supersedes state law, some doctors are hesitant to perform late-term abortions when a woman’s health is at risk because the criminal statutes remain on the books.


“Doctors and hospitals shouldn’t be reading criminal laws to determine what types of health services they can offer and provide to their patients,” said M. Tracey Brooks, the president of Family Planning Advocates of New York State.


For Mr. Cuomo, the debate over passing a new abortion law presents an opportunity to appeal to women as well as to liberals, who have sought action in Albany without success since Eliot Spitzer made a similar proposal when he was governor. But it also poses a challenge to the coalition of Republicans and a few Democrats that controls the State Senate, the chamber that has in the past stood as the primary obstacle to passing abortion legislation in the capital.


The governor has said that his Reproductive Health Act would be one plank of a 10-part Women’s Equality Act that also would include equal pay and anti-discrimination provisions. Conservative groups, still stinging from the willingness of Republican lawmakers to go along with Mr. Cuomo’s push to legalize same-sex marriage in 2011, are mobilizing against the proposal. Seven thousand New Yorkers who oppose the measure have sent messages to Mr. Cuomo and legislators via the Web site of the New York State Catholic Conference.


A number of anti-abortion groups have also formed a coalition called New Yorkers for Life, which is seeking to rally opposition to the governor’s proposal using social media.


“If you ask anyone on the street, ‘Is there enough abortion in New York?’ no one in their right mind would say we need more abortion,” said the Rev. Jason J. McGuire, the executive director of New Yorkers for Constitutional Freedoms, which is part of the coalition.


Members of both parties say that the issue of reproductive rights was a significant one in November’s legislative elections. Democrats, who were bolstered by an independent expenditure campaign by NARAL, credit their victories in several key Senate races in part to their pledge to fight for legislation similar to what Mr. Cuomo is planning to propose.


Republicans, who make up most of the coalition that controls the Senate, have generally opposed new abortion rights measures. Speaking with reporters recently, the leader of the Republicans, Dean G. Skelos of Long Island, strenuously objected to rewriting the state’s abortion laws, especially in a manner similar to what the governor is seeking.


“You could have an abortion up until the day the child would be born, and I think that’s just wrong,” Mr. Skelos said. He suggested that the entire debate was unnecessary, noting that abortion is legal in New York State and saying that is “not going to be changed.”


The Senate Democratic leader, Andrea Stewart-Cousins of Yonkers, who is the sponsor of a bill that is similar to the legislation the governor is drafting, said she was optimistic that an abortion measure would reach the Senate floor this year.


“New York State’s abortion laws were passed in 1970 in a bipartisan fashion,” she said. “It would be a sad commentary that over 40 years later we could not manage to do the same thing.”


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Doctor and Patient: Afraid to Speak Up to Medical Power

The slender, weather-beaten, elderly Polish immigrant had been diagnosed with lung cancer nearly a year earlier and was receiving chemotherapy as part of a clinical trial. I was a surgical consultant, called in to help control the fluid that kept accumulating in his lungs.

During one visit, he motioned for me to come closer. His voice was hoarse from a tumor that spread, and the constant hissing from his humidified oxygen mask meant I had to press my face nearly against his to understand his words.

“This is getting harder, doctor,” he rasped. “I’m not sure I’m up to anymore chemo.”

I was not the only doctor that he confided to. But what I quickly learned was that none of us was eager to broach the topic of stopping treatment with his primary cancer doctor.

That doctor was a rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital’s then lackluster cancer center. Within a few months of the doctor’s arrival, the once sleepy department began offering a dazzling array of experimental drugs. Calls came in from outside doctors eager to send their patients in for treatment, and every patient who was seen was promptly enrolled in one of more than a dozen well-documented treatment protocols.

But now, no doctors felt comfortable suggesting anything but the most cutting-edge, aggressive treatments.

Even the No. 2 doctor in the cancer center, Robin to the chief’s cancer-battling Batman, was momentarily taken aback when I suggested we reconsider the patient’s chemotherapy plan. “I don’t want to tell him,” he said, eyes widening. He reeled off his chief’s vast accomplishments. “I mean, who am I to tell him what to do?”

We stood for a moment in silence before he pointed his index finger at me. “You tell him,” he said with a smile. “You tell him to consider stopping treatment.”

Memories of this conversation came flooding back last week when I read an essay on the problems posed by hierarchies within the medical profession.

For several decades, medical educators and sociologists have documented the existence of hierarchies and an intense awareness of rank among doctors. The bulk of studies have focused on medical education, a process often likened to military and religious training, with elder patriarchs imposing the hair shirt of shame on acolytes unable to incorporate a profession’s accepted values and behaviors. Aspiring doctors quickly learn whose opinions, experiences and voices count, and it is rarely their own. Ask a group of interns who’ve been on the wards for but a week, and they will quickly raise their hands up to the level of their heads to indicate their teachers’ status and importance, then lower them toward their feet to demonstrate their own.

It turns out that this keen awareness of ranking is not limited to students and interns. Other research has shown that fully trained physicians are acutely aware of a tacit professional hierarchy based on specialties, like primary care versus neurosurgery, or even on diseases different specialists might treat, like hemorrhoids and constipation versus heart attacks and certain cancers.

But while such professional preoccupation with privilege can make for interesting sociological fodder, the real issue, warns the author of a courageous essay published recently in The New England Journal of Medicine, is that such an overly developed sense of hierarchy comes at an unacceptable price: good patient care.

Dr. Ranjana Srivastava, a medical oncologist at the Monash Medical Centre in Melbourne, Australia, recalls a patient she helped to care for who died after an operation. Before the surgery, Dr. Srivastava had been hesitant to voice her concerns, assuming that the patient’s surgeon must be “unequivocally right, unassailable, or simply not worth antagonizing.” When she confesses her earlier uncertainty to the surgeon after the patient’s death, Dr. Srivastava learns that the surgeon had been just as loath to question her expertise and had assumed that her silence before the surgery meant she agreed with his plan to operate.

“Each of us was trying our best to help a patient, but we were also respecting the boundaries and hierarchy imposed by our professional culture,” Dr. Srivastava said. “The tragedy was that the patient died, when speaking up would have made all the difference.”

Compounding the problem is an increasing sense of self-doubt among many doctors. With rapid advances in treatment, there is often no single correct “answer” for a patient’s problem, and doctors, struggling to stay up-to-date in their own particular specialty niches, are more tentative about making suggestions that cross over to other doctors’ “turf.” Even as some clinicians attempt to compensate by organizing multidisciplinary meetings, inviting doctors from all specialties to discuss a patient’s therapeutic options, “there will inevitably be a hierarchy at those meetings of who is speaking,” Dr. Srivastava noted. “And it won’t always be the ones who know the most about the patient who will be taking the lead.”

It is the potentially disastrous repercussions for patients that make this overly developed awareness of rank and boundaries a critical issue in medicine. Recent efforts to raise safety standards and improve patient care have shown that teams are a critical ingredient for success. But simply organizing multidisciplinary lineups of clinicians isn’t enough. What is required are teams that recognize the importance of all voices and encourage active and open debate.

Since their patient’s death, Dr. Srivastava and the surgeon have worked together to discuss patient cases, articulate questions and describe their own uncertainties to each other and in patients’ notes. “We have tried to remain cognizant of the fact that we are susceptible to thinking about hierarchy,” Dr. Srivastava said. “We have tried to remember that sometimes, despite our best intentions, we do not speak up for our patients because we are fearful of the consequences.”

That was certainly true for my lung cancer patient. Like all the other doctors involved in his care, I hesitated to talk to the chief medical oncologist. I questioned my own credentials, my lack of expertise in this particular area of oncology and even my own clinical judgment. When the patient appeared to fare better, requiring less oxygen and joking and laughing more than I had ever seen in the past, I took his improvement to be yet another sign that my attempt to talk about holding back chemotherapy was surely some surgical folly.

But a couple of days later, the humidified oxygen mask came back on. And not long after that, the patient again asked for me to come close.

This time he said: “I’m tired. I want to stop the chemo.”

Just before he died, a little over a week later, he was off all treatment except for what might make him comfortable. He thanked me and the other doctors for our care, but really, we should have thanked him and apologized. Because he had pushed us out of our comfortable, well-delineated professional zones. He had prodded us to talk to one another. And he showed us how to work as a team in order to do, at last, what we should have done weeks earlier.

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Phys Ed: Getting the Right Dose of Exercise

Phys Ed

Gretchen Reynolds on the science of fitness.

Fitness Tracker

Marathon, half-marathon, 10k and 5K training plans to get you race ready.

A common concern about exercise is that if you don’t do it almost every day, you won’t achieve much health benefit. But a commendable new study suggests otherwise, showing that a fairly leisurely approach to scheduling workouts may actually be more beneficial than working out almost daily.

For the new study, published this month in Exercise & Science in Sports & Medicine, researchers at the University of Alabama at Birmingham gathered 72 older, sedentary women and randomly assigned them to one of three exercise groups.

One group began lifting weights once a week and performing an endurance-style workout, like jogging or bike riding, on another day.

Another group lifted weights twice a week and jogged or rode an exercise bike twice a week.

The final group, as you may have guessed, completed three weight-lifting and three endurance sessions, or six weekly workouts.

The exercise, which was supervised by researchers, was easy at first and meant to elicit changes in both muscles and endurance. Over the course of four months, the intensity and duration gradually increased, until the women were jogging moderately for 40 minutes and lifting weights for about the same amount of time.

The researchers were hoping to find out which number of weekly workouts would be, Goldilocks-like, just right for increasing the women’s fitness and overall weekly energy expenditure.

Some previous studies had suggested that working out only once or twice a week produced few gains in fitness, while exercising vigorously almost every day sometimes led people to become less physically active, over all, than those formally exercising less. Researchers theorized that the more grueling workout schedule caused the central nervous system to respond as if people were overdoing things, sending out physiological signals that, in an unconscious internal reaction, prompted them to feel tired or lethargic and stop moving so much.

To determine if either of these possibilities held true among their volunteers, the researchers in the current study tracked the women’s blood levels of cytokines, a substance related to stress that is thought to be one of the signals the nervous system uses to determine if someone is overdoing things physically. They also measured the women’s changing aerobic capacities, muscle strength, body fat, moods and, using sophisticated calorimetry techniques, energy expenditure over the course of each week.

By the end of the four-month experiment, all of the women had gained endurance and strength and shed body fat, although weight loss was not the point of the study. The scientists had not asked the women to change their eating habits.

There were, remarkably, almost no differences in fitness gains among the groups. The women working out twice a week had become as powerful and aerobically fit as those who had worked out six times a week. There were no discernible differences in cytokine levels among the groups, either.

However, the women exercising four times per week were now expending far more energy, over all, than the women in either of the other two groups. They were burning about 225 additional calories each day, beyond what they expended while exercising, compared to their calorie burning at the start of the experiment.

The twice-a-week exercisers also were using more energy each day than they had been at first, burning almost 100 calories more daily, in addition to the calories used during workouts.

But the women who had been assigned to exercise six times per week were now expending considerably less daily energy than they had been at the experiment’s start, the equivalent of almost 200 fewer calories each day, even though they were exercising so assiduously.

“We think that the women in the twice-a-week and four-times-a-week groups felt more energized and physically capable” after several months of training than they had at the start of the study, says Gary Hunter, a U.A.B. professor who led the experiment. Based on conversations with the women, he says he thinks they began opting for stairs over escalators and walking for pleasure.

The women working out six times a week, though, reacted very differently. “They complained to us that working out six times a week took too much time,” Dr. Hunter says. They did not report feeling fatigued or physically droopy. Their bodies were not producing excessive levels of cytokines, sending invisible messages to the body to slow down.

Rather, they felt pressed for time and reacted, it seems, by making choices like driving instead of walking and impatiently avoiding the stairs.

Despite the cautionary note, those who insist on working out six times per week need not feel discouraged. As long as you consciously monitor your activity level, the findings suggest, you won’t necessarily and unconsciously wind up moving less over all.

But the more fundamental finding of this study, Dr. Hunter says, is that “less may be more,” a message that most likely resonates with far more of us. The women exercising four times a week “had the greatest overall increase in energy expenditure,” he says. But those working out only twice a week “weren’t far behind.”

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Well: Straining to Hear and Fend Off Dementia

At a party the other night, a fund-raiser for a literary magazine, I found myself in conversation with a well-known author whose work I greatly admire. I use the term “conversation” loosely. I couldn’t hear a word he said. But worse, the effort I was making to hear was using up so much brain power that I completely forgot the titles of his books.

A senior moment? Maybe. (I’m 65.) But for me, it’s complicated by the fact that I have severe hearing loss, only somewhat eased by a hearing aid and cochlear implant.

Dr. Frank Lin, an otolaryngologist and epidemiologist at Johns Hopkins School of Medicine, describes this phenomenon as “cognitive load.” Cognitive overload is the way it feels. Essentially, the brain is so preoccupied with translating the sounds into words that it seems to have no processing power left to search through the storerooms of memory for a response.


Katherine Bouton speaks about her own experience with hearing loss.


A transcript of this interview can be found here.


Over the past few years, Dr. Lin has delivered unwelcome news to those of us with hearing loss. His work looks “at the interface of hearing loss, gerontology and public health,” as he writes on his Web site. The most significant issue is the relation between hearing loss and dementia.

In a 2011 paper in The Archives of Neurology, Dr. Lin and colleagues found a strong association between the two. The researchers looked at 639 subjects, ranging in age at the beginning of the study from 36 to 90 (with the majority between 60 and 80). The subjects were part of the Baltimore Longitudinal Study of Aging. None had cognitive impairment at the beginning of the study, which followed subjects for 18 years; some had hearing loss.

“Compared to individuals with normal hearing, those individuals with a mild, moderate, and severe hearing loss, respectively, had a 2-, 3- and 5-fold increased risk of developing dementia over the course of the study,” Dr. Lin wrote in an e-mail summarizing the results. The worse the hearing loss, the greater the risk of developing dementia. The correlation remained true even when age, diabetes and hypertension — other conditions associated with dementia — were ruled out.

In an interview, Dr. Lin discussed some possible explanations for the association. The first is social isolation, which may come with hearing loss, a known risk factor for dementia. Another possibility is cognitive load, and a third is some pathological process that causes both hearing loss and dementia.

In a study last month, Dr. Lin and colleagues looked at 1,984 older adults beginning in 1997-8, again using a well-established database. Their findings reinforced those of the 2011 study, but also found that those with hearing loss had a “30 to 40 percent faster rate of loss of thinking and memory abilities” over a six-year period compared with people with normal hearing. Again, the worse the hearing loss, the worse the rate of cognitive decline.

Both studies also found, somewhat surprisingly, that hearing aids were “not significantly associated with lower risk” for cognitive impairment. But self-reporting of hearing-aid use is unreliable, and Dr. Lin’s next study will focus specifically on the way hearing aids are used: for how long, how frequently, how well they have been fitted, what kind of counseling the user received, what other technologies they used to supplement hearing-aid use.

What about the notion of a common pathological process? In a recent paper in the journal Neurology, John Gallacher and colleagues at Cardiff University suggested the possibility of a genetic or environmental factor that could be causing both hearing loss and dementia — and perhaps not in that order. In a phenomenon called reverse causation, a degenerative pathology that leads to early dementia might prove to be a cause of hearing loss.

The work of John T. Cacioppo, director of the Social Neuroscience Laboratory at the University of Chicago, also offers a clue to a pathological link. His multidisciplinary studies on isolation have shown that perceived isolation, or loneliness, is “a more important predictor of a variety of adverse health outcomes than is objective social isolation.” Those with hearing loss, who may sit through a dinner party and not hear a word, frequently experience perceived isolation.

Other research, including the Framingham Heart Study, has found an association between hearing loss and another unexpected condition: cardiovascular disease. Again, the evidence suggests a common pathological cause. Dr. David R. Friedland, a professor of otolaryngology at the Medical College of Wisconsin in Milwaukee, hypothesized in a 2009 paper delivered at a conference that low-frequency loss could be an early indication that a patient has vascular problems: the inner ear is “so sensitive to blood flow” that any vascular abnormalities “could be noted earlier here than in other parts of the body.”

A common pathological cause might help explain why hearing aids do not seem to reduce the risk of dementia. But those of us with hearing loss hope that is not the case; common sense suggests that if you don’t have to work so hard to hear, you have greater cognitive power to listen and understand — and remember. And the sense of perceived isolation, another risk for dementia, is reduced.

A critical factor may be the way hearing aids are used. A user must practice to maximize their effectiveness and they may need reprogramming by an audiologist. Additional assistive technologies like looping and FM systems may also be required. And people with progressive hearing loss may need new aids every few years.

Increasingly, people buy hearing aids online or from big-box stores like Costco, making it hard for the user to follow up. In the first year I had hearing aids, I saw my audiologist initially every two weeks for reprocessing and then every three months.

In one study, Dr. Lin and his colleague Wade Chien found that only one in seven adults who could benefit from hearing aids used them. One deterrent is cost ($2,000 to $6,000 per ear), seldom covered by insurance. Another is the stigma of old age.

Hearing loss is a natural part of aging. But for most people with hearing loss, according to the National Institute on Deafness and Other Communication Disorders, the condition begins long before they get old. Almost two-thirds of men with hearing loss began to lose their hearing before age 44. My hearing loss began when I was 30.

Forty-eight million Americans suffer from some degree of hearing loss. If it can be proved in a clinical trial that hearing aids help delay or offset dementia, the benefits would be immeasurable.

“Could we do something to reduce cognitive decline and delay the onset of dementia?” he asked. “It’s hugely important, because by 2050, 1 in 30 Americans will have dementia.

“If we could delay the onset by even one year, the prevalence of dementia drops by 15 percent down the road. You’re talking about billions of dollars in health care savings.”

Should studies establish definitively that correcting hearing loss decreases the potential for early-onset dementia, we might finally overcome the stigma of hearing loss. Get your hearing tested, get it corrected, and enjoy a longer cognitively active life. Establishing the dangers of uncorrected hearing might even convince private insurers and Medicare that covering the cost of hearing aids is a small price to pay to offset the cost of dementia.



Katherine Bouton is the author of the new book, “Shouting Won’t Help: Why I — and 50 Million Other Americans — Can’t Hear You,” from which this essay is adapted.


This post has been revised to reflect the following correction:

Correction: February 12, 2013

An earlier version of this article misstated the location of the Medical College of Wisconsin. It is in Milwaukee, not Madison.

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Personal Health: Getting the Right Addiction Treatment

“Treatment is not a prerequisite to surviving addiction.” This bold statement opens the treatment chapter in a helpful new book, “Now What? An Insider’s Guide to Addiction and Recovery,” by William Cope Moyers, a man who nonetheless needed “four intense treatment experiences over five years” before he broke free of alcohol and drugs.

As the son of Judith and Bill Moyers, successful parents who watched helplessly during a 15-year pursuit of oblivion through alcohol and drugs, William Moyers said his near-fatal battle with addiction demonstrates that this “illness of the mind, body and spirit” has no respect for status or opportunity.

“My parents raised me to become anything I wanted, but when it came to this chronic incurable illness, I couldn’t get on top of it by myself,” he said in an interview.

He finally emerged from his drug-induced nadir when he gave up “trying to do it my way” and instead listened to professional therapists and assumed responsibility for his behavior. For the last “18 years and four months, one day at a time,” he said, he has lived drug-free.

“Treatment is not the end, it’s the beginning,” he said. “My problem was not drinking or drugs. My problem was learning how to live life without drinking or drugs.”

Mr. Moyers acknowledges that treatment is not a magic bullet. Even after a monthlong stay at a highly reputable treatment center like Hazelden in Center City, Minn., where Mr. Moyers is a vice president of public affairs and community relations, the probability of remaining sober and clean a year later is only about 55 percent. (Hazelden also published his book.)

“Be wary of any program that claims a 100 percent success rate,” Mr. Moyers warned. “There is no such thing.”

“Treatment works to make recovery possible. But recovery is also possible without treatment,” Mr. Moyers said. “There’s no one-size-fits-all approach. What I needed and what worked for me isn’t necessarily what you or your loved one require.”

As with many smokers who must make multiple attempts to quit before finally overcoming an addiction to nicotine, people hooked on alcohol or drugs often must try and try again.

Nor does treatment have as good a chance at succeeding if it is forced upon a person who is not ready to recover. “Treatment does work, but only if the person wants it to,” Mr. Moyers said.

Routes to Success

For those who need a structured program, Mr. Moyers described what to consider to maximize the chances of overcoming addiction to alcohol or drugs.

Most important is to get a thorough assessment before deciding where to go for help. Do you or your loved one meet the criteria for substance dependence? Are there “co-occurring mental illnesses, traumatic or physical disabilities, socioeconomic influences, cultural issues, or family dynamics” that may be complicating the addiction and that can sabotage treatment success?

While most reputable treatment centers do a full assessment before admitting someone, it is important to know if the center or clinic provides the services of professionals who can address any underlying issues revealed by the assessment. For example, if needed, is a psychiatrist or other medical doctor available who could provide therapy and prescribe medication?

Is there a social worker on staff to address challenging family, occupational or other living problems? If a recovering addict goes home to the same problems that precipitated the dependence on alcohol or drugs, the chances of remaining sober or drug-free are greatly reduced.

Is there a program for family members who can participate with the addict in learning the essentials of recovery and how to prepare for the return home once treatment ends?

Finally, does the program offer aftercare and follow-up services? Addiction is now recognized to be a chronic illness that lurks indefinitely within an addict in recovery. As with other chronic ailments, like diabetes or hypertension, lasting control requires hard work and diligence. One slip need not result in a return to abuse, and a good program will help addicts who have completed treatment cope effectively with future challenges to their recovery.

How Families Can Help

“Addiction is a family illness,” Mr. Moyers wrote. Families suffer when someone they love descends into the purgatory of addiction. But contrary to the belief that families should cut off contact with addicts and allow them to reach “rock-bottom” before they can begin recovery, Mr. Moyers said that the bottom is sometimes death.

“It is a dangerous, though popular, misconception that a sick addict can only quit using and start to get well when he ‘hits bottom,’ that is, reaches a point at which he is desperate enough to willingly accept help,” Mr. Moyers wrote.

Rather, he urged families to remain engaged, to keep open the lines of communication and regularly remind the addict of their love and willingness to help if and when help is wanted. But, he added, families must also set firm boundaries — no money, no car, nothing that can be quickly converted into the substance of abuse.

Whether or not the addict ever gets well, Mr. Moyers said, “families have to take care of themselves. They can’t let the addict walk over their lives.”

Sometimes families or friends of an addict decide to do an intervention, confronting the addict with what they see happening and urging the person to seek help, often providing possible therapeutic contacts.

“An intervention can be the key that interrupts the process and enables the addict to recognize the extent of their illness and the need to take responsibility for their behavior,”Mr. Moyers said.

But for an intervention to work, Mr. Moyers said, “the sick person should not be belittled or demeaned.” He also cautioned families to “avoid threats.” He noted that the mind of “the desperate, fearful addict” is subsumed by drugs and alcohol that strip it of logic, empathy and understanding. It “can’t process your threat any better than it can a tearful, emotional plea.”

Resource Network

Mr. Moyer’s book lists nearly two dozen sources of help for addicts and their families. Among them:

Alcoholics Anonymous World Services www.aa.org;

Narcotics Anonymous World Services www.na.org;

Substance Abuse and Mental Health Services Administration treatment finder www.samhsa.gov/treatment/;

Al-Anon Family Groups www.Al-anon.alateen.org;

Nar-Anon Family Groups www.nar-anon.org;

Co-Dependents Anonymous World Fellowship www.coda.org.


This is the second of two articles on addiction treatment. The first can be found at “Effective Addiction Treatment.”

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For Families Struggling with Mental Illness, Carolyn Wolf Is a Guide in the Darkness





When a life starts to unravel, where do you turn for help?




Melissa Klump began to slip in the eighth grade. She couldn’t focus in class, and in a moment of despair she swallowed 60 ibuprofen tablets. She was smart, pretty and ill: depression, attention deficit disorder, obsessive-compulsive disorder, either bipolar disorder or borderline personality disorder.


In her 20s, after a more serious suicide attempt, her parents sent her to a residential psychiatric treatment center, and from there to another. It was the treatment of last resort. When she was discharged from the second center last August after slapping another resident, her mother, Elisa Klump, was beside herself.


“I was banging my head against the wall,” the mother said. “What do I do next?” She frantically called support groups, therapy programs, suicide prevention lines, anybody, running down a list of names in a directory of mental health resources. “Finally,” she said, “somebody told me, ‘The person you need to talk to is Carolyn Wolf.’ ”


That call, she said, changed her life and her daughter’s. “Carolyn has given me hope,” she said. “I didn’t know there were people like her out there.”


Carolyn Reinach Wolf is not a psychiatrist or a mental health professional, but a lawyer who has carved out what she says is a unique niche, working with families like the Klumps.


One in 17 American adults suffers from a severe mental illness, and the systems into which they are plunged — hospitals, insurance companies, courts, social services — can be fragmented and overwhelming for families to manage. The recent shootings in Newtown, Conn., and Aurora, Colo., have brought attention to the need for intervention to prevent such extreme acts of violence, which are rare. But for the great majority of families watching their loved ones suffer, and often suffering themselves, the struggle can be boundless, with little guidance along the way.


“If you Google ‘mental health lawyer,’ ” said Ms. Wolf, a partner with Abrams & Fensterman, “I’m kinda the only game in town.”


On a recent afternoon, she described in her Midtown office the range of her practice.


“We have been known to pull people out of crack dens,” she said. “I have chased people around hotels all over the city with the N.Y.P.D. and my team to get them to a hospital. I had a case years ago where the person was on his way back from Europe, and the family was very concerned that he was symptomatic. I had security people meet him at J.F.K.”


Many lawyers work with mentally ill people or their families, but Ron Honberg, the national director of policy and legal affairs for the National Alliance on Mental Illness, said he did not know of another lawyer who did what Ms. Wolf does: providing families with a team of psychiatrists, social workers, case managers, life coaches, security guards and others, and then coordinating their services. It can be a lifeline — for people who can afford it, Mr. Honberg said. “Otherwise, families have to do this on their own,” he said. “It’s a 24-hour, 7-day-a-week job, and for some families it never ends.”


Many of Ms. Wolf’s clients declined to be interviewed for this article, but the few who spoke offered an unusual window on the arcane twists and turns of the mental health care system, even for families with money. Their stories illustrate how fraught and sometimes blind such a journey can be.


One rainy morning last month, Lance Sheena, 29, sat with his mother in the spacious family room of her Long Island home. Mr. Sheena was puffy-eyed and sporadically inattentive; the previous night, at the group home where he has been living since late last summer, another resident had been screaming incoherently and was taken away by the police. His mother, Susan Sheena, eased delicately into the family story.


“I don’t talk to a lot of people because they don’t get it,” Ms. Sheena said. “They mean well, but they don’t get it unless they’ve been through a similar experience. And anytime something comes up, like the shooting in Newtown, right away it goes to the mentally ill. And you think, maybe we shouldn’t be so public about this, because people are going to be afraid of us and Lance. It’s a big concern.”


Her son cut her off. “Are you comparing me to the guy that shot those people?”


“No, I’m saying that anytime there’s a shooting, like in Aurora, that’s when these things come out in the news.”


“Did you really just compare me to that guy?”


“No, I didn’t compare you.”


“Then what did you say?”


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