A desire to turn over a new, more healthful leaf typically accompanies the start of a new year. My mail, for example, has been inundated with diet books, most of which offer yet another gimmick aimed ultimately at getting the gullible reader to eat less and exercise more.
Publishers assume, correctly, that the shock of the scale after nearly six weeks of overindulging on food and drink will prompt the purchase of one or more books on dieting by people who are desperate to return to their pre-Thanksgiving shape.
And really, it doesn’t matter whether you choose a diet based on your genotype or the phases of the moon, or whether you cut down on sugars and starches or fats. If you consume fewer calories than you need to maintain your current weight, you will lose.
My advice here is to save your money, toss out (or donate to a soup kitchen) the leftover high-calorie holiday fare, gradually reduce your portion sizes and return to your exercise routine (or adopt one if you spent too much of ’07 on your sofa).
Slowly but surely the pounds will come off. And as Aesop said, slow and steady does indeed win the race. Gradual weight loss, achieved on an eating-and-exercise regimen that you can sustain indefinitely, is most likely to be permanent weight loss.
If you’ve been reading this column for years, no doubt you already know that. But I believe it bears repeating at least once a year, not because I want to further depress the booksellers’ market, but because I’d rather you spend your hard-earned money on foods that can really help you achieve and maintain a healthy weight and good health.
The basics of good nutrition have not changed.
Meals replete with vegetables, fruits and whole grains and a small serving of a protein-rich food remain the gold standard of a wholesome diet. Still, at both ends of the age spectrum as well as in between, recent months have held some new findings — and some surprises — that are worth noting.
Perhaps most distressing to a chocoholic like me was a report in the Nov. 20 issue of the journal Circulation that while dark chocolate can indeed improve coronary circulation and decrease the risk of heart-damaging clots, most dark chocolate on the market is all but stripped of the bitter-tasting flavanols that convey this health benefit.
The color, in other words, tells you nothing. Now it’s up to manufacturers to label the flavanol content — not just the percentage of cocoa, which may have no flavanol at all.
Focus on Brain Food
As the population ages and the prevalence of dementia rises, increased attention has focused on how diet may help keep cognitive decline at bay. A heart-healthy diet that keeps clogged arteries from limiting the brain’s supply of oxygen and nutrients has been linked to a lower risk of dementia.
Likewise, omega-3 fatty acids in fish and fish oil, which counter inflammation, appear to protect the brain as well as the heart and joints. A recent analysis of 17 studies in the journal Pain found that daily supplements of these fatty acids significantly reduced inflammatory joint pain.
But now there may be a new kid on the block: vitamin B12. A 10-year study with 1,648 participants in Oxford, England, found an increased risk of cognitive decline in older adults who had low blood levels of vitamin B12. This vitamin is found only in foods from animals, yet it is common for older people, especially those on limited budgets, to cut back on foods like meats and fish.
Strict vegetarians, who have long been cautioned to take B12 as a supplement to prevent a deficiency, can add brain protection to the list of potential benefits. The rest of us should feel comfortable about eating red meat and poultry as long as it is lean and consumed in reasonable amounts. A serving of cooked meat, fish or poultry is only three to four ounces.
The British researchers noted that high blood levels of homocysteine had previously been linked to an increased risk of Alzheimer’s disease, and that B12 is one of the vitamins, along with folate and B6, that lower homocysteine levels. However, the researchers found no benefit to cognitive function from folate.
Foods to Fight Cancer
Here we come full circle. A decade after the American Institute for Cancer Research issued its first major report on diet and cancer, a new magnum opus in concert with the World Cancer Research Fund was published late last year. Based on 7,000 studies of 17 kinds of cancer, it concluded that being overweight now ranks second only to smoking as a preventable cause of cancer. “Convincing evidence” of an increased risk resulting from body fatness was found for cancers of the kidney, endometrium, breast, colon and rectum, pancreas and esophagus.
Other major findings of increased risk included red and processed meats for colon and rectal cancer, and alcoholic drinks for cancers of the mouth, throat, larynx, esophagus, breast, and colon and rectum.
“Convincing evidence” for cancer protection was found for physical activity against colon and rectal cancers, and for breastfeeding against breast cancer. “Probable” protection against various cancers was also found for dietary fiber; nonstarchy vegetables; fruits; foods rich in folates, beta-carotene, vitamin C and selenium; milk, and calcium supplements.
By JANE E. BRODY
Minggu, 23 Maret 2008
Study Ties Too Little Sleep With Too Much Weight
A study of 7-year-olds has found that sleeping less than nine hours a night was associated with being overweight or obese, even after accounting for amounts of television watching and physical exercise.
The study, being published Tuesday in the journal Sleep, also found that short sleep duration was associated with mood swings. The researchers had followed the subjects — 519 children in New Zealand — since birth, making periodic health and developmental assessments and interviewing their parents.
Sleep time did not affect I.Q. scores or measures of attention-deficit/hyperactivity disorder, but children who averaged less than nine hours’ sleep were significantly more likely than the others to be overweight.
Using sleep monitors, the scientists discovered some other patterns in the 7-year-olds. On average, the children stayed awake for 48 minutes after they went to bed, and slept about a half-hour longer on weekdays than weekends. They slept the least in the summer: 40 minutes longer on winter nights, 31 minutes longer in the fall and 15 minutes longer in the spring. Having a younger sibling cost a 7-year-old an average of 12 minutes of sleep per night.
“The study is important from the perspective of providing another means of preventing the development of obesity,” said Ed Mitchell, the senior author and a professor of child health research at the University of Auckland. “At least in New Zealand — and it needs to be confirmed in other age groups — this seems to be an important factor.”
By NICHOLAS BAKALAR
Conflict on the Menu
New York City’s new rules for menu labels at chain restaurants have set off a food fight among the nation’s obesity experts.
Most support the theory of the city’s health commissioner that forcing chain restaurants to list the calories alongside menu items — flagging that a Double Whopper With Cheese has 990 calories, for example — will make patrons think twice about ordering one. The rules are set to take effect at the end of March.
There is a countertheory, however, set forth by Dr. David B. Allison, the incoming president of the Obesity Society, a leading organization of obesity doctors and scientists. An affidavit he recently submitted to the United States District Court for the Southern District of New York has ignited a controversy within his organization.
In the filing, Dr. Allison argues that the new rules could backfire — whether by adding to the forbidden-fruit allure of high-calorie foods or by sending patrons away hungry enough that they will later gorge themselves even more.
“What harms (if any) might result” from the new rules? Dr. Allison wrote in the court filing. “That is difficult to predict.”
It might be only a scientific debate among nutrition experts, except for the fact that Dr. Allison was paid to write the document on behalf of the New York State Restaurant Association, which is suing to block the new rules.
Dr. Allison’s role in the debate has angered some members of the Obesity Society, setting off an e-mail fury since word of his court filing began to circulate. Some have pointed to Dr. Allison’s other industry ties, which have included advisory roles for Coca-Cola, Kraft Foods and Frito-Lay.
Many of the group’s 1,800 members are “completely mad that a president-elect of the Obesity Society, an organization that cares about obesity and cares about healthy eating, wants to hold back information from people that helps them make healthy choices,” said Dr. Barry M. Popkin, a member of the organization, who is director of the Interdisciplinary Obesity Center at the University of North Carolina, Chapel Hill.
Dr. Popkin has filed his own affidavit in the lawsuit, defending the city’s menu labeling plan.
The controversy highlights unresolved issues in the obesity field about industry ties and conflicts of interest, said Dr. Kelly D. Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University. “The field is incapable of policing itself,” Dr. Brownell said.
Spurred by Dr. Allison’s affidavit, the obesity group released a statement on Tuesday supporting calorie labeling on menus. “The Obesity Society believes that more information on the caloric content of restaurant servings, not less, is in the interests of consumers,” said the statement by the society, which is based in Silver Spring, Md.
Dr. Allison, a professor of biostatistics and nutrition at the University of Alabama, Birmingham, is scheduled to start a one-year term as president of the Obesity Society in October. He has defended his affidavit. In a telephone interview, he said he did not take a position for or against menu labeling in the document but merely presented the scientific evidence that the labeling might deter over-eating but might not and, in fact, might be harmful.
He also defended his work for the restaurant industry, but would not disclose how much he was paid for his efforts.
“I’m happy to be involved in the pursuit for truth,” Dr. Allison said. “Sometimes, when I’m involved in the pursuit for truth, I’m hired by the Federal Trade Commission. Sometimes I help them. Sometimes I help a group like the restaurant industry. I’m honored that people think my opinion is sufficiently valued and expert.”
The executive vice president for the restaurant association’s metropolitan New York chapters, E. Charles Hunt, said that Dr. Allison was retained by the association’s lawyers. “Obviously, a lot of it was in favor of our position,” Mr. Hunt said, “although he didn’t come right out and say that.”
Dr. Allison’s 33-page affidavit cites a study that found that dieters who were distracted while eating and presented with information that food was high in calories were more likely to overeat.
“To the extent that many NY diners consume food from restaurants while in a state of distraction or performing distracting tasks,” he writes, “we might hypothesize that the belief that the food is especially high in calories would trigger disinhibited increased consumption.”
He also says that for some people, the deterrent of a high-calorie label might be short-lived and end up making them even hungrier and likely to eat even more later — “inadvertently encouraging patrons to consume lower-calorie foods that subsequently lead to greater total caloric intake because of poor satiating efficiency of the smaller calorie loads.”
Dr. Allison was quoted advancing similar arguments in 2006 during a breakfast meeting sponsored by Coca-Cola at an international conference of obesity experts in Sydney.
Dr. Allison, who disclosed at the meeting that he was a consultant to Coca-Cola on obesity issues, warned that policies to restrict certain foods might backfire, citing research showing that birds put on weight when food is scarce, according to a newsletter article about the conference.
The new labeling rules by New York City’s Board of Health have support from a cross section of organizations, including consumer groups like Public Citizen and the Center for Science in the Public Interest, as well as doctor groups like the American Medical Association, the American Academy of Pediatrics, the American Diabetes Association and the American Heart Association.
While some chains already post calorie information on posters, fliers or on the Internet, public health officials argue that people may change their ordering habits or restaurants might change their menus if calorie labeling is more conspicuous.
The New York rule would require that chains with 15 or more restaurants nationally, including fast-food restaurants, put the information on their menus or menu boards.
This is the city’s second attempt to adopt such regulations. A judge struck down a menu-labeling plan last year, saying the law needed to be reworded. It has since been revised to comply with the judge’s order.
Similar requirements have been adopted in King County, Wash., which includes Seattle, and are under consideration by 21 other state and local governments.
New York’s health commissioner, Dr. Thomas R. Frieden, likened Dr. Allison’s claims to an argument that the world is flat.
“We don’t have 100 percent proof that it’s going to work, but we have a reasonable expectation it will be successful,” Dr. Frieden said.
“When places have to put ‘2,700 calories’ next to an appetizer,” Dr. Frieden said, “they might not have a 2,700-calorie appetizer anymore.”
By STEPHANIE SAUL
Body Mass Index
B.M.I. is a reliable indicator of total body fat, which is related to the risk of life-threatening diseases. The score is valid for both men and women, but it may overestimate body fat in athletes and others who have a muscular build. It may also underestimate body fat in older people and others who have lost muscle mass.
To determine your B.M.I.:
just click
To determine your B.M.I.:
just click
http://www.nytimes.com/ref/health/bmi.html
Jumat, 21 Maret 2008
Calorie Intake May Affect Bone Health of Young Women
When a young woman stops menstruating, doctors often take it as a red flag that she may not be eating enough, which, among other problems, can inhibit bone formation.
But a new study has found that some young women who have regular periods may still be eating so little that they endanger the health of their bones.
There are a number of reasons a teenager may not be consuming enough nutrients. Anorexia is a common one, but young women who work out intensively for a sport like gymnastics without increasing their energy intake are also at risk.
The study, by Anne Loucks and Aiden Shearer of Ohio University, looked at the role of nutrient intake and bone formation in women ages 18 to 32. It was presented last week at a meeting of the Endocrine Society.
For five days, the researchers restricted the women’s caloric intake and had them exercise for more than an hour and a half each day. The women were separated into two groups, one younger and one older.
When the researchers drew volunteers’ blood at the end of the five days, they found decreased levels of two markers for bone formation.
While earlier research found that calorie restriction did not disrupt the reproductive system in the older group of young women, the new study suggests that taking in too few calories still impairs their bone formation.
The implications may be greatest for women who exercise a lot and do not consume enough food.
“Regular menstrual cycles do not reliably indicate that they are eating enough for what they’re expending,” Dr. Loucks said.
But a new study has found that some young women who have regular periods may still be eating so little that they endanger the health of their bones.
There are a number of reasons a teenager may not be consuming enough nutrients. Anorexia is a common one, but young women who work out intensively for a sport like gymnastics without increasing their energy intake are also at risk.
The study, by Anne Loucks and Aiden Shearer of Ohio University, looked at the role of nutrient intake and bone formation in women ages 18 to 32. It was presented last week at a meeting of the Endocrine Society.
For five days, the researchers restricted the women’s caloric intake and had them exercise for more than an hour and a half each day. The women were separated into two groups, one younger and one older.
When the researchers drew volunteers’ blood at the end of the five days, they found decreased levels of two markers for bone formation.
While earlier research found that calorie restriction did not disrupt the reproductive system in the older group of young women, the new study suggests that taking in too few calories still impairs their bone formation.
The implications may be greatest for women who exercise a lot and do not consume enough food.
“Regular menstrual cycles do not reliably indicate that they are eating enough for what they’re expending,” Dr. Loucks said.
By ERIC NAGOURNEY
Big Yawn, Cooler Brain?
Over the years, there have been many theories for why people yawn. It has been associated with sleepiness and boredom, and, incorrectly, with low oxygen levels in the blood.
“No one knows why we yawn,” says Andrew C. Gallup, a psychology professor at the State University of New York at Albany.
Now Dr. Gallup and fellow researchers have a new explanation: yawning, they said, is a way for the body to cool the brain.
Writing in the May issue of Evolutionary Psychology, they reported that volunteers yawned more often in situations in which their brains were likely to be warmer.
To prove their theory that yawning regulates brain temperature when other systems in the body are not doing enough, the researchers took advantage of the well-established tendency of people to yawn when those around them do — the so-called contagious yawn.
The volunteers were asked to step into a room by themselves and watch a video showing people behaving neutrally, laughing or yawning. Observers watching through a one-way mirror counted how many times the volunteers yawned.
Some volunteers were asked to breathe only through their noses as they watched. Later, volunteers were asked to press warm or cold packs on their foreheads.
“The two conditions thought to promote brain cooling (nasal breathing and forehead cooling) practically eliminated contagious yawning,” the researchers wrote.
The study may also help explain why yawning spreads from person to person.
A cooler brain, Dr. Gallup said, is a clearer brain.
So yawning actually appears to be a way to stay more alert. And contagious yawning, he said, may have evolved to help groups remain vigilant against danger.
By ERIC NAGOURNEY
“No one knows why we yawn,” says Andrew C. Gallup, a psychology professor at the State University of New York at Albany.
Now Dr. Gallup and fellow researchers have a new explanation: yawning, they said, is a way for the body to cool the brain.
Writing in the May issue of Evolutionary Psychology, they reported that volunteers yawned more often in situations in which their brains were likely to be warmer.
To prove their theory that yawning regulates brain temperature when other systems in the body are not doing enough, the researchers took advantage of the well-established tendency of people to yawn when those around them do — the so-called contagious yawn.
The volunteers were asked to step into a room by themselves and watch a video showing people behaving neutrally, laughing or yawning. Observers watching through a one-way mirror counted how many times the volunteers yawned.
Some volunteers were asked to breathe only through their noses as they watched. Later, volunteers were asked to press warm or cold packs on their foreheads.
“The two conditions thought to promote brain cooling (nasal breathing and forehead cooling) practically eliminated contagious yawning,” the researchers wrote.
The study may also help explain why yawning spreads from person to person.
A cooler brain, Dr. Gallup said, is a clearer brain.
So yawning actually appears to be a way to stay more alert. And contagious yawning, he said, may have evolved to help groups remain vigilant against danger.
By ERIC NAGOURNEY
Carbon Monoxide Detectors Not Standard in Hotel Rooms
Carbon monoxide detectors are not hard to find. They are available in many stores, and a growing number of people are using them in their homes.
But if you go looking for one in a hotel room, a new study says, chances are it will not be there.
Writing in The American Journal of Preventive Medicine, researchers said that from 1989 to 2004, they found 68 incidents that affected more than 700 guests, 41 employees and 20 rescue workers. Twenty-seven of the people died.
Even after these episodes, the researchers found, most of the hotels where they took place still did not install the detectors. Federal law requires that hotels install smoke detectors, but it does not require carbon monoxide detectors.
The lead author of the study, Dr. Lindell K. Weaver of the University of Utah School of Medicine, said that “although one’s individual risk is extremely low,” hotel guests should not have to put up with it.
A few states and municipalities have passed laws intended to protect guests from carbon monoxide, the study said. But until hotels begin using detectors consistently, the researchers advised, travelers should consider carrying portable ones.
By ERIC NAGOURNEY
But if you go looking for one in a hotel room, a new study says, chances are it will not be there.
Writing in The American Journal of Preventive Medicine, researchers said that from 1989 to 2004, they found 68 incidents that affected more than 700 guests, 41 employees and 20 rescue workers. Twenty-seven of the people died.
Even after these episodes, the researchers found, most of the hotels where they took place still did not install the detectors. Federal law requires that hotels install smoke detectors, but it does not require carbon monoxide detectors.
The lead author of the study, Dr. Lindell K. Weaver of the University of Utah School of Medicine, said that “although one’s individual risk is extremely low,” hotel guests should not have to put up with it.
A few states and municipalities have passed laws intended to protect guests from carbon monoxide, the study said. But until hotels begin using detectors consistently, the researchers advised, travelers should consider carrying portable ones.
By ERIC NAGOURNEY
Safety: A Health Benefit to Playing by the Rules
By ERIC NAGOURNEY
Published: March 11, 2008
When you put high school students in motion on a field or court with a ball, sooner or later someone is going to get hurt. But a new study suggests that many fewer injuries would occur if the rules of the games were better followed.
The researchers, writing in the February issue of Injury Prevention, reported that in many cases, injuries occurred when a player was making an illegal play. In all, they said, this was true for more than 6 percent of the injuries in football, soccer, basketball, wrestling and baseball.
The study’s lead author, Christy Collins of the Research Institute at Nationwide Children’s Hospital in Ohio, said any injury that occurred when a rule had been broken — say, illegal contact with another player — should be avoidable.
For the study, researchers looked at injuries at 100 high schools over two years. The schools made weekly reports about when players were hurt and what was happening at the time.
About a third of the injuries were to the head or face. More than 10 percent put the player out for the season. Even soccer scored high in the “injury during illegal play” category. Football players were the most likely to be injured — but not when the rules were being broken.
Girls were no more likely to play by the rules than boys. In fact, girls’ soccer had more injuries during illegal play than boys’ soccer. It is not clear if girls play rougher or if referees give them less slack, Ms. Collins said.
Published: March 11, 2008
When you put high school students in motion on a field or court with a ball, sooner or later someone is going to get hurt. But a new study suggests that many fewer injuries would occur if the rules of the games were better followed.
The researchers, writing in the February issue of Injury Prevention, reported that in many cases, injuries occurred when a player was making an illegal play. In all, they said, this was true for more than 6 percent of the injuries in football, soccer, basketball, wrestling and baseball.
The study’s lead author, Christy Collins of the Research Institute at Nationwide Children’s Hospital in Ohio, said any injury that occurred when a rule had been broken — say, illegal contact with another player — should be avoidable.
For the study, researchers looked at injuries at 100 high schools over two years. The schools made weekly reports about when players were hurt and what was happening at the time.
About a third of the injuries were to the head or face. More than 10 percent put the player out for the season. Even soccer scored high in the “injury during illegal play” category. Football players were the most likely to be injured — but not when the rules were being broken.
Girls were no more likely to play by the rules than boys. In fact, girls’ soccer had more injuries during illegal play than boys’ soccer. It is not clear if girls play rougher or if referees give them less slack, Ms. Collins said.
For the Overweight, Bad Advice by the Spoonful
Americans have been getting fatter for years, and with the increase in waistlines has come a surplus of conventional wisdom. If we could just return to traditional diets, if we just walk for 20 minutes a day, exercise gurus and government officials maintain, America’s excess pounds would slowly but surely melt away.
A month-long series of discussions with reporters and experts on weight loss, fitness, children's health, emotional well-being and nutrition.
Gina Kolata on Fitness
This week Times reporter Gina Kolata hosts a discussion on exercise and losing weight. Ask questions and share your thoughts with other readers.
Scientists are less sanguine. Many of the so-called facts about obesity, they say, amount to speculation or oversimplification of the medical evidence. Diet and exercise do matter, they now know, but these environmental influences alone do not determine an individual’s weight. Body composition also is dictated by DNA and monitored by the brain. Bypassing these physical systems is not just a matter of willpower.
More than 66 percent of Americans are overweight or obese, according to the federal Centers for Disease Control and Prevention, in Atlanta. Although the number of obese women in the United States appears to be holding steady at 33 percent, for most Americans the risk is growing. The nation’s poor diet has long been the scapegoat. There have been proposals to put warning labels on sodas like those on cigarettes. There are calls to ban junk foods from schools. New York and other cities now require restaurants to disclose calorie information on their menus.
But the notion that Americans ever ate well is suspect. In 1966, when Americans were still comparatively thin, more than two billion hamburgers already had been sold in McDonald’s restaurants, noted Dr. Barry Glassner, a sociology professor at the University of Southern California. The recent rise in obesity may have more to do with our increasingly sedentary lifestyles than with the quality of our diets.
“The meals we romanticize in the past somehow leave out the reality of what people were eating,” he said. “The average meal had whole milk and ended with pie.... The typical meal had plenty of fat and calories.”
“Nostalgia is going to get us nowhere,” he added.
Neither will wishful misconceptions about the efficacy of exercise. First, the federal government told Americans to exercise for half an hour a day. Then, dietary guidelines issued in 2005 changed the advice, recommending 60 to 90 minutes of moderate exercise a day. There was an uproar; many said the goal was unrealistic for Americans. But for many scientists, the more pertinent question was whether such an exercise program would really help people lose weight.
The leisurely after-dinner walk may be pleasant, and it may be better than another night parked in front of the television. But modest exercise of this sort may not do much to reduce weight, evidence suggests.
“People don’t know that a 20-minute walk burns about 100 calories,” said Dr. Madelyn Fernstrom, director of the weight-management center at the University of Pittsburgh Medical Center. “People always overestimate the calories consumed in exercise, and underestimate the calories in food they are eating.”
Tweaking the balance is far more difficult than most people imagine, said Dr. Jeffrey Friedman, an obesity researcher at Rockefeller University. The math ought to work this way: There are 3,500 calories in a pound. If you subtract 100 calories per day by walking for 20 minutes, you ought to lose a pound every 35 days. Right?
Wrong. First, it’s difficult for an individual to hold calorie intake to a precise amount from day to day. Meals at home and in restaurants vary in size and composition; the nutrition labels on purchased foods — the best guide to calorie content — are at best rough estimates. Calorie counting is therefore an imprecise art.
Second, scientists recently have come to understand that the brain exerts astonishing control over body composition and how much individuals eat. “There are physiological mechanisms that keep us from losing weight,” said Dr. Matthew W. Gilman, the director of the obesity prevention program at Harvard Medical School/Pilgrim Health Care.
Scientists now believe that each individual has a genetically determined weight range spanning perhaps 30 pounds. Those who force their weight below nature’s preassigned levels become hungrier and eat more; several studies also show that their metabolisms slow in a variety of ways as the body tries to conserve energy and regain weight. People trying to exceed their weight range face the opposite situation: eating becomes unappealing, and their metabolisms shift into high gear.
The body’s determination to maintain its composition is why a person can skip a meal, or even fast for short periods, without losing weight. It’s also why burning an extra 100 calories a day will not alter the verdict on the bathroom scales. Struggling against the brain’s innate calorie counters, even strong-willed dieters make up for calories lost on one day with a few extra bites on the next. And they never realize it. “The system operates with 99.6 percent precision,” Dr. Friedman said.
The temptations of our environment — the sedentary living, the ready supply of rich food — may not be entirely to blame for rising obesity rates. In fact, new research suggests that the environment that most strongly influences body composition may be the very first one anybody experiences: the womb.
According to several animal studies, conditions during pregnancy, including the mother’s diet, may determine how fat the offspring are as adults. Human studies have shown that women who eat little in pregnancy, surprisingly, more often have children who grow into fat adults. More than a dozen studies have found that children are more likely to be fat if their mothers smoke during pregnancy.
The research is just beginning, true, but already it has upended some hoary myths about dieting. The body establishes its optimal weight early on, perhaps even before birth, and defends it vigorously through adulthood. As a result, weight control is difficult for most of us. And obesity, the terrible new epidemic of the developed world, is almost impossible to cure.
Published on August 30, 2007.
A month-long series of discussions with reporters and experts on weight loss, fitness, children's health, emotional well-being and nutrition.
Gina Kolata on Fitness
This week Times reporter Gina Kolata hosts a discussion on exercise and losing weight. Ask questions and share your thoughts with other readers.
Scientists are less sanguine. Many of the so-called facts about obesity, they say, amount to speculation or oversimplification of the medical evidence. Diet and exercise do matter, they now know, but these environmental influences alone do not determine an individual’s weight. Body composition also is dictated by DNA and monitored by the brain. Bypassing these physical systems is not just a matter of willpower.
More than 66 percent of Americans are overweight or obese, according to the federal Centers for Disease Control and Prevention, in Atlanta. Although the number of obese women in the United States appears to be holding steady at 33 percent, for most Americans the risk is growing. The nation’s poor diet has long been the scapegoat. There have been proposals to put warning labels on sodas like those on cigarettes. There are calls to ban junk foods from schools. New York and other cities now require restaurants to disclose calorie information on their menus.
But the notion that Americans ever ate well is suspect. In 1966, when Americans were still comparatively thin, more than two billion hamburgers already had been sold in McDonald’s restaurants, noted Dr. Barry Glassner, a sociology professor at the University of Southern California. The recent rise in obesity may have more to do with our increasingly sedentary lifestyles than with the quality of our diets.
“The meals we romanticize in the past somehow leave out the reality of what people were eating,” he said. “The average meal had whole milk and ended with pie.... The typical meal had plenty of fat and calories.”
“Nostalgia is going to get us nowhere,” he added.
Neither will wishful misconceptions about the efficacy of exercise. First, the federal government told Americans to exercise for half an hour a day. Then, dietary guidelines issued in 2005 changed the advice, recommending 60 to 90 minutes of moderate exercise a day. There was an uproar; many said the goal was unrealistic for Americans. But for many scientists, the more pertinent question was whether such an exercise program would really help people lose weight.
The leisurely after-dinner walk may be pleasant, and it may be better than another night parked in front of the television. But modest exercise of this sort may not do much to reduce weight, evidence suggests.
“People don’t know that a 20-minute walk burns about 100 calories,” said Dr. Madelyn Fernstrom, director of the weight-management center at the University of Pittsburgh Medical Center. “People always overestimate the calories consumed in exercise, and underestimate the calories in food they are eating.”
Tweaking the balance is far more difficult than most people imagine, said Dr. Jeffrey Friedman, an obesity researcher at Rockefeller University. The math ought to work this way: There are 3,500 calories in a pound. If you subtract 100 calories per day by walking for 20 minutes, you ought to lose a pound every 35 days. Right?
Wrong. First, it’s difficult for an individual to hold calorie intake to a precise amount from day to day. Meals at home and in restaurants vary in size and composition; the nutrition labels on purchased foods — the best guide to calorie content — are at best rough estimates. Calorie counting is therefore an imprecise art.
Second, scientists recently have come to understand that the brain exerts astonishing control over body composition and how much individuals eat. “There are physiological mechanisms that keep us from losing weight,” said Dr. Matthew W. Gilman, the director of the obesity prevention program at Harvard Medical School/Pilgrim Health Care.
Scientists now believe that each individual has a genetically determined weight range spanning perhaps 30 pounds. Those who force their weight below nature’s preassigned levels become hungrier and eat more; several studies also show that their metabolisms slow in a variety of ways as the body tries to conserve energy and regain weight. People trying to exceed their weight range face the opposite situation: eating becomes unappealing, and their metabolisms shift into high gear.
The body’s determination to maintain its composition is why a person can skip a meal, or even fast for short periods, without losing weight. It’s also why burning an extra 100 calories a day will not alter the verdict on the bathroom scales. Struggling against the brain’s innate calorie counters, even strong-willed dieters make up for calories lost on one day with a few extra bites on the next. And they never realize it. “The system operates with 99.6 percent precision,” Dr. Friedman said.
The temptations of our environment — the sedentary living, the ready supply of rich food — may not be entirely to blame for rising obesity rates. In fact, new research suggests that the environment that most strongly influences body composition may be the very first one anybody experiences: the womb.
According to several animal studies, conditions during pregnancy, including the mother’s diet, may determine how fat the offspring are as adults. Human studies have shown that women who eat little in pregnancy, surprisingly, more often have children who grow into fat adults. More than a dozen studies have found that children are more likely to be fat if their mothers smoke during pregnancy.
The research is just beginning, true, but already it has upended some hoary myths about dieting. The body establishes its optimal weight early on, perhaps even before birth, and defends it vigorously through adulthood. As a result, weight control is difficult for most of us. And obesity, the terrible new epidemic of the developed world, is almost impossible to cure.
Published on August 30, 2007.
Watch Your Weight? Sure.. But, Don’t Worry About It
Worrying about weighing too much may be bad for you, no matter how much you actually weigh.
Stuart Goldenberg
Using results from a telephone health survey run by the Centers for Disease Control and Prevention, researchers analyzed data on more than 170,000 men and women nationwide. Among other information about health and lifestyle, all reported height and weight, how much they would like to weigh and how many days in the past month they had felt physically or mentally unhealthy.
The study, to be published in the March issue of The American Journal of Public Health, found that men who wanted to lose 1 percent, 10 percent and 20 percent of their body weight reported 0.05, 0.9 and 2.7 unhealthy days a month, respectively. Women with the same weight-loss desires reported 0.1, 1.6 and 4.3 total unhealthy days a month. The results held even after controlling for age and body mass index.
The authors acknowledge that their findings depend on self-reports, and that women tend to say they weigh less than they do, while men claim to be taller than they are. But controlling for many variables — like diabetes, hypertension and smoking — did not significantly alter the conclusions.
“We need to re-engineer what public health agencies are telling people,” said Dr. Peter Muennig, the lead author and an assistant professor at the Mailman School of Public Health at Columbia. “The ‘diet and exercise’ part is good, but the ‘get thin’ part may be dangerous.”
Stuart Goldenberg
Using results from a telephone health survey run by the Centers for Disease Control and Prevention, researchers analyzed data on more than 170,000 men and women nationwide. Among other information about health and lifestyle, all reported height and weight, how much they would like to weigh and how many days in the past month they had felt physically or mentally unhealthy.
The study, to be published in the March issue of The American Journal of Public Health, found that men who wanted to lose 1 percent, 10 percent and 20 percent of their body weight reported 0.05, 0.9 and 2.7 unhealthy days a month, respectively. Women with the same weight-loss desires reported 0.1, 1.6 and 4.3 total unhealthy days a month. The results held even after controlling for age and body mass index.
The authors acknowledge that their findings depend on self-reports, and that women tend to say they weigh less than they do, while men claim to be taller than they are. But controlling for many variables — like diabetes, hypertension and smoking — did not significantly alter the conclusions.
“We need to re-engineer what public health agencies are telling people,” said Dr. Peter Muennig, the lead author and an assistant professor at the Mailman School of Public Health at Columbia. “The ‘diet and exercise’ part is good, but the ‘get thin’ part may be dangerous.”
By NICHOLAS BAKALAR
The Worst Foods in America
We’ve all seen examples of fat-laden, high-calorie foods. But now a popular new nutrition book has picked the worst of the bunch.
The book,
“Eat This, Not That!”by Men’s Health editor-in-chief David Zinczenko, has become one of the hottest selling nutrition guides in book stores. The diminutive volume is filled with pictures of what not to eat and photos of better substitutes. It compares food choices at favorite restaurants, supermarkets and holiday items. The comparisons are always interesting and often surprising. Who knew a Starbucks Black Forest Ham, Egg and Cheddar Breakfast Sandwich is a better choice than the chain’s Bran Muffin with Nuts?
Chances are you won’t agree with every item. For instance, in a comparison of choices for a child’s Easter basket, I can’t figure out why Jelly Belly Jelly Beans, with 150 calories, are an “eat this,'’ while Marshmallow Peeps, with 140 calories, are a “not that.'’
The book includes a clever ranking of the country’s 20 worst foods in various categories. Here are some of them:
- Worst Fast Food Meal: McDonald’s Chicken Selects Premium Breast Strips with creamy ranch sauce. Chicken sounds healthy, but not at 870 calories.
- Worst Drink: Jamba Juice Chocolate Moo’d Power Smoothie. With 166 grams of sugar, you could have had eight servings of Ben & Jerry’s.
- Worst Supermarket Meal: Pepperidge Farm Roasted Chicken Pot Pie. One pie packs 64 grams of fat.
- Worst “Healthy” Burger: Ruby Tuesday Bella Turkey Burger. With 1,145 calories, not a very healthy choice.
- Worst Airport Snack: Cinnabon Classic Cinnamon Roll. Packed with 813 hot gooey calories and 5 grams of trans fats.
- Worst Kids’ Meal: Macaroni Grill Double Macaroni ‘n Cheese. With 62 fat grams, it’s the equivalent of 1.5 full boxes of Kraft Mac ‘n Cheese.
- Worst Salad: On the Border Grande Taco Salad with Taco Beef. A salad with 102 grams of fat and 2,410 mg of sodium.
- Worst Dessert: Chili’s Chocolate Chip Paradise Pie with Vanilla Ice Cream. At 1,600 calories, it’s like eating the caloric equivalent of three Big Macs.
Senin, 17 Maret 2008
On the Other End of the Line, Discipline
By BRAD MELEKIAN
Published: March 6, 2008
“CLOSE your eyes, breathe deeply, and imagine yourself at your most well. What does it look like?”
The voice on the other end of the phone belonged to neither a guru nor my primary doctor, but to a wellness coach, and the question wasn’t rhetorical. The coach, Dr. Julie Desch of Palo Alto, Calif., wanted me to “paint a picture with words.”
Such is the initial session with a wellness coach — essentially a life coach for your body. You say what you want to do to be healthier, and you are told to do it, together you work on the how, and you pay $50 to $150 for the hour on the phone. Counseling is rarely done in person.
While executive coaches help the ambitious and life coaches offer direction to the aimless, wellness coaches are the fitness industry’s version of a paid motivator. Not so long ago, their clients were those with injuries, illness or pounds to shed, but more recently coaches have been making a play for the perfection-minded, and their motto seems to be “You can always be more fit!”
By helping clients identify goals, coaches say, they can assist people in making behavioral changes that lead to weight loss, more regular exercise or a victory on competition day.
After I completed an online “well-being assessment” that asked about my “energy drains and energy boosters,” medical history and nutrition and exercise habits, Dr. Desch told me that I was only 74 percent well. Apparently, sitting at a desk and eating a steady diet of burritos does not lead to optimal health.
Wellness coaches, often hired by corporations as preventive medicine, are now being sought out more often by individuals, coaches say. And the number of those coaches is growing. In 2000, Wellcoaches, an alliance whose training program is endorsed by the American College of Sports Medicine, trained 100 coaches. Last year, it trained 1,000.
“We’re seeing this as a continuing trend over the last two years,” said Walter Thompson, a professor of kinesiology at Georgia State University who surveyed fitness trends last year. “We think wellness coaching is today where personal training was 20 years ago.”
I found Dr. Desch, a Stanford-educated pathologist and certified athletic trainer, through Wellcoaches. After I told her what my barriers to wellness were — the words “work” and “life in general” escaped my lips — we established simple goals for the next three months. It would help, I said, if I ate home-cooked dinners with my wife instead of takeout at my desk, and I’d feel better if I re-established a lapsed exercise routine. Dr. Desch asked me to make dinner arrangements with my wife, to pick up a yoga-class schedule and to plan to reconvene in a week.
Because the industry is unregulated, there is no way to tell how many people call themselves wellness coaches. What qualifies a person to be a coach is also murky.
Type “wellness coach” into an online search engine and you’ll find an assortment of characters, many with little to no discernible background in either the medical or exercise fields. Some have self-published books with titles that vaguely reference “holistic” health. Frothy self-help jargon is common. (“It’s time to get un-stuck ... in concentrated you-time,” one site reads.)
But educated and well-trained coaches can make a difference, clients, coaches and fitness professionals said. “A coach is somebody who can use behavior-modification techniques effectively,” Dr. Thompson said. “Some personal trainers can do that, but most can’t.”
Rather than viewing wellness coaches as adversaries, trainers are succumbing to the coaching phenomenon. “We’re seeing some trainers looking to expand their reach by going into wellness coaching,” said Cedric Bryant, the chief science officer at the American Council on Exercise. “It could be a complementary matchup,” Dr. Bryant said.
While wellness coaches are expected to be knowledgeable about fitness, their main function is more psychological. But Charles A. Maher, a professor of psychology at Rutgers, worries that coaches may present themselves as having more expertise than they do. “If somebody wants to sit down with someone else and talk about their goals and life direction, that happens every day in any corporation,” Dr. Maher said. “Some people might just call that mentoring.”
Wellness coaches can earn $50,000 to $150,000 a year. To train with Wellcoaches, which offers a 13-week online program for $895, applicants need a health or fitness credential, like personal training certification. “We’re not selling snake oil here,” said Dino Costanzo, the chairman of the A.C.S.M.’s committee on certification. “But there are people out there who certainly are.”
Ms. Moore, the founder of Wellcoaches, is helping start a coaching psychology initiative in Massachusetts, a collaboration between McLean Hospital and Harvard Medical School, which would promote research into the fields of coaching and develop more effective training.
Mary Mahoney, 29, of San Jose, Calif., is a registered dietitian who, while healthy, felt “stuck at a plateau” in her exercise regimen. She sought out a coach and not a trainer, she said, because “I knew that I could figure out the technique, but I didn’t know how to incorporate it into my routine in such a way that it would stick.”
Working with a wellness coach for the past year (at an hourly rate of $75), she has taken up an all-body exercise program, lost 10 pounds and increased her lung function.
Not surprisingly, you can also hire a computer program as your wellness coach at Web sites like wellpeople.com ($39.95 a year). Dr. Desch said she tried it and was impressed.
The City of Las Vegas and organizations like Coca-Cola, Sherwin-Williams and Con-way Freight have hired wellness coaches in the last few years.
Cincom, a software development company in Cincinnati, began offering coaching services to employees in January. One employee said it has already paid off for him. Dave Schwarber, a 55-year-old executive, said someone from Wellcoaches helped him effect simple lifestyle changes to lose 25 pounds.
With two knee replacements causing pain and work stress keeping him up at night, Mr. Schwarber, who had worked with a personal trainer after an injury, said he wanted to try a different approach. “If someone tells me what to do, I’m not going to do it. With the wellness coach, you set your own goals.”
Mr. Schwarber said his coach helped him put into practice “simple stuff” like portion control and exercise routines like riding a stationary bike and working with free weights.
As for me, I was surprised to report to Dr. Desch that the week since our session had gone well. My wife and I had actually cooked together each night, and I had not only picked up a yoga schedule, but made it to a few classes.
This, Dr. Desch said, is the effectiveness of wellness coaching — helping a client take goals from the abstract to small, achievable tasks. But considering the price, I wondered if I might have achieved the same changes with a list of goals on a notepad and stepped-up resolve. On the other hand, I hadn’t taken action on my goals until a coach made me accountable.
Mr. Schwarber said that it was exactly that — accountability — that helped him lose weight. He tells the story of relating his success to a colleague.
“What happens if you don’t follow through on the goals you set?” the colleague asked.
“Nothing,” Mr. Schwarber answered. “You just don’t do it.”
Published: March 6, 2008
“CLOSE your eyes, breathe deeply, and imagine yourself at your most well. What does it look like?”
The voice on the other end of the phone belonged to neither a guru nor my primary doctor, but to a wellness coach, and the question wasn’t rhetorical. The coach, Dr. Julie Desch of Palo Alto, Calif., wanted me to “paint a picture with words.”
Such is the initial session with a wellness coach — essentially a life coach for your body. You say what you want to do to be healthier, and you are told to do it, together you work on the how, and you pay $50 to $150 for the hour on the phone. Counseling is rarely done in person.
While executive coaches help the ambitious and life coaches offer direction to the aimless, wellness coaches are the fitness industry’s version of a paid motivator. Not so long ago, their clients were those with injuries, illness or pounds to shed, but more recently coaches have been making a play for the perfection-minded, and their motto seems to be “You can always be more fit!”
By helping clients identify goals, coaches say, they can assist people in making behavioral changes that lead to weight loss, more regular exercise or a victory on competition day.
After I completed an online “well-being assessment” that asked about my “energy drains and energy boosters,” medical history and nutrition and exercise habits, Dr. Desch told me that I was only 74 percent well. Apparently, sitting at a desk and eating a steady diet of burritos does not lead to optimal health.
Wellness coaches, often hired by corporations as preventive medicine, are now being sought out more often by individuals, coaches say. And the number of those coaches is growing. In 2000, Wellcoaches, an alliance whose training program is endorsed by the American College of Sports Medicine, trained 100 coaches. Last year, it trained 1,000.
“We’re seeing this as a continuing trend over the last two years,” said Walter Thompson, a professor of kinesiology at Georgia State University who surveyed fitness trends last year. “We think wellness coaching is today where personal training was 20 years ago.”
I found Dr. Desch, a Stanford-educated pathologist and certified athletic trainer, through Wellcoaches. After I told her what my barriers to wellness were — the words “work” and “life in general” escaped my lips — we established simple goals for the next three months. It would help, I said, if I ate home-cooked dinners with my wife instead of takeout at my desk, and I’d feel better if I re-established a lapsed exercise routine. Dr. Desch asked me to make dinner arrangements with my wife, to pick up a yoga-class schedule and to plan to reconvene in a week.
Because the industry is unregulated, there is no way to tell how many people call themselves wellness coaches. What qualifies a person to be a coach is also murky.
Type “wellness coach” into an online search engine and you’ll find an assortment of characters, many with little to no discernible background in either the medical or exercise fields. Some have self-published books with titles that vaguely reference “holistic” health. Frothy self-help jargon is common. (“It’s time to get un-stuck ... in concentrated you-time,” one site reads.)
But educated and well-trained coaches can make a difference, clients, coaches and fitness professionals said. “A coach is somebody who can use behavior-modification techniques effectively,” Dr. Thompson said. “Some personal trainers can do that, but most can’t.”
Rather than viewing wellness coaches as adversaries, trainers are succumbing to the coaching phenomenon. “We’re seeing some trainers looking to expand their reach by going into wellness coaching,” said Cedric Bryant, the chief science officer at the American Council on Exercise. “It could be a complementary matchup,” Dr. Bryant said.
While wellness coaches are expected to be knowledgeable about fitness, their main function is more psychological. But Charles A. Maher, a professor of psychology at Rutgers, worries that coaches may present themselves as having more expertise than they do. “If somebody wants to sit down with someone else and talk about their goals and life direction, that happens every day in any corporation,” Dr. Maher said. “Some people might just call that mentoring.”
Wellness coaches can earn $50,000 to $150,000 a year. To train with Wellcoaches, which offers a 13-week online program for $895, applicants need a health or fitness credential, like personal training certification. “We’re not selling snake oil here,” said Dino Costanzo, the chairman of the A.C.S.M.’s committee on certification. “But there are people out there who certainly are.”
Ms. Moore, the founder of Wellcoaches, is helping start a coaching psychology initiative in Massachusetts, a collaboration between McLean Hospital and Harvard Medical School, which would promote research into the fields of coaching and develop more effective training.
Mary Mahoney, 29, of San Jose, Calif., is a registered dietitian who, while healthy, felt “stuck at a plateau” in her exercise regimen. She sought out a coach and not a trainer, she said, because “I knew that I could figure out the technique, but I didn’t know how to incorporate it into my routine in such a way that it would stick.”
Working with a wellness coach for the past year (at an hourly rate of $75), she has taken up an all-body exercise program, lost 10 pounds and increased her lung function.
Not surprisingly, you can also hire a computer program as your wellness coach at Web sites like wellpeople.com ($39.95 a year). Dr. Desch said she tried it and was impressed.
The City of Las Vegas and organizations like Coca-Cola, Sherwin-Williams and Con-way Freight have hired wellness coaches in the last few years.
Cincom, a software development company in Cincinnati, began offering coaching services to employees in January. One employee said it has already paid off for him. Dave Schwarber, a 55-year-old executive, said someone from Wellcoaches helped him effect simple lifestyle changes to lose 25 pounds.
With two knee replacements causing pain and work stress keeping him up at night, Mr. Schwarber, who had worked with a personal trainer after an injury, said he wanted to try a different approach. “If someone tells me what to do, I’m not going to do it. With the wellness coach, you set your own goals.”
Mr. Schwarber said his coach helped him put into practice “simple stuff” like portion control and exercise routines like riding a stationary bike and working with free weights.
As for me, I was surprised to report to Dr. Desch that the week since our session had gone well. My wife and I had actually cooked together each night, and I had not only picked up a yoga schedule, but made it to a few classes.
This, Dr. Desch said, is the effectiveness of wellness coaching — helping a client take goals from the abstract to small, achievable tasks. But considering the price, I wondered if I might have achieved the same changes with a list of goals on a notepad and stepped-up resolve. On the other hand, I hadn’t taken action on my goals until a coach made me accountable.
Mr. Schwarber said that it was exactly that — accountability — that helped him lose weight. He tells the story of relating his success to a colleague.
“What happens if you don’t follow through on the goals you set?” the colleague asked.
“Nothing,” Mr. Schwarber answered. “You just don’t do it.”
I Love You, but You Love Meat
By KATE MURPHY
SOME relationships run aground on the perilous shoals of money, sex or religion. When Shauna James’s new romance hit the rocks, the culprit was wheat.
“I went out with one guy who said I seemed really great but he liked bread too much to date me,” said Ms. James, 41, a writer in Seattle who cannot eat gluten, a protein found in wheat, barley and rye.
Sharing meals has always been an important courtship ritual and a metaphor for love. But in an age when many people define themselves by what they will eat and what they won’t, dietary differences can put a strain on a romantic relationship. The culinary camps have become so balkanized that some factions consider interdietary dating taboo.
No-holds-barred carnivores, for example, may share the view of Anthony Bourdain, who wrote in his book “Kitchen Confidential” that “vegetarians, and their Hezbollah-like splinter faction, the vegans ... are the enemy of everything good and decent in the human spirit.”
Returning the compliment, many vegetarians say they cannot date anyone who eats meat. Vegans, who avoid eating not just animals but animal-derived products, take it further, shivering at the thought of kissing someone who has even sipped honey-sweetened tea.
Ben Abdalla, 42, a real estate agent in Boca Raton, Fla., said he preferred to date fellow vegetarians because meat eaters smell bad and have low energy.
Lisa Romano, 31, a vegan and school psychologist in Belleville, N.Y., said she recently ended a relationship with a man who enjoyed backyard grilling. He had no problem searing her vegan burgers alongside his beef patties, but she found the practice unenlightened and disturbing.
Her disapproval “would have become an issue later even if it wasn’t in the beginning,” Ms. Romano said. “I need someone who is ethically on the same page.”
While some eaters may elevate morality above hedonism, others are suspicious of anyone who does not give in to the pleasure principle.
June Deadrick, 40, a lobbyist in Houston, said she would have a hard time loving a man who did not share her fondness for multicourse meals including wild game and artisanal cheeses. “And I’m talking cheese from a cow, not that awful soy stuff,” she said.
Judging from postings at food Web sites like chowhound.com and slashfood.com, people seem more willing to date those who restrict their diet for health or religion rather than mere dislike.
Typical sentiments included: “Medical and religious issues I can work around as long as the person is sincere and consistent, but flaky, picky cheaters — no way” and “picky eaters are remarkably unsexy.”
Jennifer Esposito, 28, an image consultant who lives in Rye Brook, N.Y., lived for four years with a man who ate only pizza, noodles with butter and the occasional baked potato.
“It was really frustrating because he refused to try anything I made,” she said. They broke up. “Food is a huge part of life,” she said. “It’s something I want to be able to share.”
A year ago Ms. Esposito met and married Michael Esposito, 51, who, like her, is an adventurous and omnivorous eater. Now, she said, she could not be happier. “A relationship is about giving and receiving, and he loves what I cook, and I love to cook for him,” she said.
Food has a strong subconscious link to love, said Kathryn Zerbe, a psychiatrist who specializes in eating disorders at Oregon Health and Science University in Portland. That is why refusing a partner’s food “can feel like rejection,” she said.
As with other differences couples face, tolerance and compromise are essential at the dinner table, marital therapists said. “If you can’t allow your partner to have latitude in what he or she eats, then maybe your problem isn’t about food,” said Susan Jaffe, a psychiatrist in Manhattan.
Dynise Balcavage, 42, an associate creative director at an advertising agency and vegan who lives in Philadelphia, said she has been happily married to her omnivorous husband, John Gatti, 53, for seven years.
“We have this little dance we’ve choreographed in the kitchen,” she said. She prepares vegan meals and averts her eyes when he adds anchovies or cheese. And she does not show disapproval when he orders meat in a restaurant.
“I’m not a vegangelical,” she said. “He’s an adult and I respect his choices just as he respects mine.”
In deference to his wife, Mr. Gatti has cut back substantially on his meat consumption and no longer eats veal. For her part, Ms. Balcavage cooks more Italian dishes, her husband’s favorite.
In New York City, Yoshie Fruchter and his girlfriend, Leah Koenig, still wrestle with their dietary differences after almost two years together. He is kosher and she is vegetarian. They eat vegetarian meals at her apartment, where he keeps his own set of dishes and utensils. When eating out they mostly go to kosher restaurants, although they “aren’t known for inspired cuisine,” said Ms. Koenig, 25, who works for a nonprofit environmental group.
SOME relationships run aground on the perilous shoals of money, sex or religion. When Shauna James’s new romance hit the rocks, the culprit was wheat.
“I went out with one guy who said I seemed really great but he liked bread too much to date me,” said Ms. James, 41, a writer in Seattle who cannot eat gluten, a protein found in wheat, barley and rye.
Sharing meals has always been an important courtship ritual and a metaphor for love. But in an age when many people define themselves by what they will eat and what they won’t, dietary differences can put a strain on a romantic relationship. The culinary camps have become so balkanized that some factions consider interdietary dating taboo.
No-holds-barred carnivores, for example, may share the view of Anthony Bourdain, who wrote in his book “Kitchen Confidential” that “vegetarians, and their Hezbollah-like splinter faction, the vegans ... are the enemy of everything good and decent in the human spirit.”
Returning the compliment, many vegetarians say they cannot date anyone who eats meat. Vegans, who avoid eating not just animals but animal-derived products, take it further, shivering at the thought of kissing someone who has even sipped honey-sweetened tea.
Ben Abdalla, 42, a real estate agent in Boca Raton, Fla., said he preferred to date fellow vegetarians because meat eaters smell bad and have low energy.
Lisa Romano, 31, a vegan and school psychologist in Belleville, N.Y., said she recently ended a relationship with a man who enjoyed backyard grilling. He had no problem searing her vegan burgers alongside his beef patties, but she found the practice unenlightened and disturbing.
Her disapproval “would have become an issue later even if it wasn’t in the beginning,” Ms. Romano said. “I need someone who is ethically on the same page.”
While some eaters may elevate morality above hedonism, others are suspicious of anyone who does not give in to the pleasure principle.
June Deadrick, 40, a lobbyist in Houston, said she would have a hard time loving a man who did not share her fondness for multicourse meals including wild game and artisanal cheeses. “And I’m talking cheese from a cow, not that awful soy stuff,” she said.
Judging from postings at food Web sites like chowhound.com and slashfood.com, people seem more willing to date those who restrict their diet for health or religion rather than mere dislike.
Typical sentiments included: “Medical and religious issues I can work around as long as the person is sincere and consistent, but flaky, picky cheaters — no way” and “picky eaters are remarkably unsexy.”
Jennifer Esposito, 28, an image consultant who lives in Rye Brook, N.Y., lived for four years with a man who ate only pizza, noodles with butter and the occasional baked potato.
“It was really frustrating because he refused to try anything I made,” she said. They broke up. “Food is a huge part of life,” she said. “It’s something I want to be able to share.”
A year ago Ms. Esposito met and married Michael Esposito, 51, who, like her, is an adventurous and omnivorous eater. Now, she said, she could not be happier. “A relationship is about giving and receiving, and he loves what I cook, and I love to cook for him,” she said.
Food has a strong subconscious link to love, said Kathryn Zerbe, a psychiatrist who specializes in eating disorders at Oregon Health and Science University in Portland. That is why refusing a partner’s food “can feel like rejection,” she said.
As with other differences couples face, tolerance and compromise are essential at the dinner table, marital therapists said. “If you can’t allow your partner to have latitude in what he or she eats, then maybe your problem isn’t about food,” said Susan Jaffe, a psychiatrist in Manhattan.
Dynise Balcavage, 42, an associate creative director at an advertising agency and vegan who lives in Philadelphia, said she has been happily married to her omnivorous husband, John Gatti, 53, for seven years.
“We have this little dance we’ve choreographed in the kitchen,” she said. She prepares vegan meals and averts her eyes when he adds anchovies or cheese. And she does not show disapproval when he orders meat in a restaurant.
“I’m not a vegangelical,” she said. “He’s an adult and I respect his choices just as he respects mine.”
In deference to his wife, Mr. Gatti has cut back substantially on his meat consumption and no longer eats veal. For her part, Ms. Balcavage cooks more Italian dishes, her husband’s favorite.
In New York City, Yoshie Fruchter and his girlfriend, Leah Koenig, still wrestle with their dietary differences after almost two years together. He is kosher and she is vegetarian. They eat vegetarian meals at her apartment, where he keeps his own set of dishes and utensils. When eating out they mostly go to kosher restaurants, although they “aren’t known for inspired cuisine,” said Ms. Koenig, 25, who works for a nonprofit environmental group.
Regimens: Diet Supplement Seen as Risky for Some Users
By NICHOLAS BAKALAR
Probiotics, the potentially beneficial bacteria and yeasts available as diet supplements and in some foods, may not be as helpful as widely believed. A new study suggests that under certain circumstances, they can be deadly.
Researchers studied 296 patients at risk for severe pancreatitis, a potentially lethal inflammation of the pancreas. Each was randomly assigned to receive either a commercially available probiotic or an identical-looking placebo. All patients were otherwise given conventional treatment.
There was no significant difference between the two groups in severity of illness at the start of the trial. But while 31 percent of the probiotics group required intensive care, only 24 percent of the placebo group needed it. Eighteen percent of those who took probiotics, but only 10 percent of the others, required surgical intervention. In the probiotics group 24 people died, a death rate more than twice that of those given the placebo.
Several smaller studies have associated probiotics with a reduction of infections. But this study, published online Thursday in The Lancet, was the largest randomized, double-blinded trial of its kind, and the authors found no other reason for the harmful effects.
Probiotics, the potentially beneficial bacteria and yeasts available as diet supplements and in some foods, may not be as helpful as widely believed. A new study suggests that under certain circumstances, they can be deadly.
Researchers studied 296 patients at risk for severe pancreatitis, a potentially lethal inflammation of the pancreas. Each was randomly assigned to receive either a commercially available probiotic or an identical-looking placebo. All patients were otherwise given conventional treatment.
There was no significant difference between the two groups in severity of illness at the start of the trial. But while 31 percent of the probiotics group required intensive care, only 24 percent of the placebo group needed it. Eighteen percent of those who took probiotics, but only 10 percent of the others, required surgical intervention. In the probiotics group 24 people died, a death rate more than twice that of those given the placebo.
Several smaller studies have associated probiotics with a reduction of infections. But this study, published online Thursday in The Lancet, was the largest randomized, double-blinded trial of its kind, and the authors found no other reason for the harmful effects.
High Mercury Levels Are Found in Tuna Sushi
By MARIAN BURROS
Recent laboratory tests found so much mercury in tuna sushi from 20 Manhattan stores and restaurants that at most of them, a regular diet of six pieces a week would exceed the levels considered acceptable by the Environmental Protection Agency.
Sushi from 5 of the 20 places had mercury levels so high that the Food and Drug Administration could take legal action to remove the fish from the market. The sushi was bought by The New York Times in October.
“No one should eat a meal of tuna with mercury levels like those found in the restaurant samples more than about once every three weeks," said Dr. Michael Gochfeld, professor of environmental and occupational medicine at the Robert Wood Johnson Medical School in Piscataway, N.J.
Dr. Gochfeld analyzed the sushi for The Times with Dr. Joanna Burger, professor of life sciences at Rutgers University. He is a former chairman of the New Jersey Mercury Task Force and also treats patients with mercury poisoning.
The owner of a restaurant whose tuna sushi had particularly high mercury concentrations said he was shocked by the findings. “I’m startled by this,” said the owner, Drew Nieporent, a managing partner of Nobu Next Door. “Anything that might endanger any customer of ours, we’d be inclined to take off the menu immediately and get to the bottom of it.”
Although the samples were gathered in New York City, experts believe similar results would be observed elsewhere.
“Mercury levels in bluefin are likely to be very high regardless of location,” said Tim Fitzgerald, a marine scientist for Environmental Defense, an advocacy group that works to protect the environment and improve human health.
Most of the restaurants in the survey said the tuna The Times had sampled was bluefin.
In 2004 the Food and Drug Administration joined with the Environmental Protection Agency to warn women who might become pregnant and children to limit their consumption of certain varieties of canned tuna because the mercury it contained might damage the developing nervous system. Fresh tuna was not included in the advisory. Most of the tuna sushi in the Times samples contained far more mercury than is typically found in canned tuna.
Over the past several years, studies have suggested that mercury may also cause health problems for adults, including an increased risk of cardiovascular disease and neurological symptoms.
Dr. P. Michael Bolger, a toxicologist who is head of the chemical hazard assessment team at the Food and Drug Administration, did not comment on the findings in the Times sample but said the agency was reviewing its seafood mercury warnings. Because it has been four years since the advisory was issued, Dr. Bolger said, “we have had a study under way to take a fresh look at it.”
No government agency regularly tests seafood for mercury.
Tuna samples from the Manhattan restaurants Nobu Next Door, Sushi Seki, Sushi of Gari and Blue Ribbon Sushi and the food store Gourmet Garage all had mercury above one part per million, the “action level” at which the F.D.A. can take food off the market. (The F.D.A. has rarely, if ever, taken any tuna off the market.) The highest mercury concentration, 1.4 parts per million, was found in tuna from Blue Ribbon Sushi. The lowest, 0.10, was bought at Fairway.
When told of the newspaper’s findings, Andy Arons, an owner of Gourmet Garage, said: “We’ll look for lower-level-mercury fish. Maybe we won’t sell tuna sushi for a while, until we get to the bottom of this.” Mr. Arons said his stores stocked yellowfin, albacore and bluefin tuna, depending on the available quality and the price.
At Blue Ribbon Sushi, Eric Bromberg, an owner, said he was aware that bluefin tuna had higher mercury concentrations. For that reason, Mr. Bromberg said, the restaurant typically told parents with small children not to let them eat “more than one or two pieces.”
Koji Oneda, a spokesman for Sushi Seki, said the restaurant would talk to its fish supplier about the issue. A manager at Sushi of Gari, Tomi Tomono, said it warned pregnant women and regular customers who “love to eat tuna” about mercury levels. Mr. Tomono also said the restaurant would put warning labels on the menu “very soon.”
Scientists who performed the analysis for The Times ran the tests several times to be sure there was no mistake in the levels of methylmercury, the form of mercury found in fish tied to health problems.
The work was done at the Environmental and Occupational Health Sciences Institute, in Piscataway, a partnership between Rutgers and the Robert Wood Johnson Medical School.
Six pieces of sushi from most of the restaurants and stores would contain more than 49 micrograms of mercury. That is the amount the Environmental Protection Agency deems acceptable for weekly consumption over a period of several months by an adult of average weight, which the agency defines as 154 pounds. People weighing less are advised to consume even less mercury. The weight of the fish in the tuna pieces sampled by The Times were 0.18 ounces to 1.26 ounces.
In general, tuna sushi from food stores was much lower in mercury. These findings reinforce results in other studies showing that more expensive tuna usually contains more mercury because it is more likely to come from a larger species, which accumulates mercury from the fish it eats. Mercury enters the environment as an industrial pollutant.
In the Times survey, 10 of the 13 restaurants said at least one of the two tuna samples bought was bluefin. (It is hard for anyone but experts to tell whether a piece of tuna sushi is bluefin by looking at it.)
By contrast, other species, like yellowfin and albacore, generally have much less mercury. Several of the stores in the Times sample said the tuna in their sushi was yellowfin.
“It is very likely bluefin will be included in next year’s testing,” Dr. Bolger of the F.D.A. said. “A couple of months ago F.D.A. became aware of bluefin tuna as a species Americans are eating.”
A number of studies have found high blood mercury levels in people eating a diet rich in seafood. According to a 2007 survey by the New York City Department of Health and Mental Hygiene, the average level of mercury in New Yorkers’ blood is three times higher than the national average. The report found especially high levels among Asian New Yorkers, especially foreign-born Chinese, and people with high incomes. The report noted that Asians tend to eat more seafood, and it speculated that wealthier people favored fish, like swordfish and bluefin tuna, that happen to have higher mercury levels.
The city has warned women who are pregnant or breast-feeding and children not to eat fresh tuna, Chilean sea bass, swordfish, shark, grouper and other kinds of fish it describes as “too high in mercury.” (Cooking fish has no effect on the mercury level.)
Dr. Kate Mahaffey, a senior research scientist in the office of science coordination and policy at the E.P.A. who studies mercury in fish, said she was not surprised by reports of high concentrations.
“We have seen exposures occurring now in the United States that have produced blood mercury a lot higher than anything we would have expected to see,” Dr. Mahaffey said. “And this appears to be related to consumption of larger amounts of fish that are higher in mercury than we had anticipated.”
Many experts believe the government’s warnings on mercury in seafood do not go far enough.
“The current advice from the F.D.A. is insufficient,” said Dr. Philippe Grandjean, adjunct professor of environmental health at the Harvard School of Public Health and chairman of the department of environmental medicine at the University of Southern Denmark. “In order to maintain reasonably low mercury exposure, you have to eat fish low in the food chain, the smaller fish, and they are not saying that.”
Some environmental groups have sounded the alarm. Environmental Defense, the advocacy group, says no one, no matter his or her age, should eat bluefin tuna. Dr. Gochfeld said: “I like to think of tuna sushi as an occasional treat. A steady diet is certainly problematic. There are a lot of other sushi choices.”
Recent laboratory tests found so much mercury in tuna sushi from 20 Manhattan stores and restaurants that at most of them, a regular diet of six pieces a week would exceed the levels considered acceptable by the Environmental Protection Agency.
Sushi from 5 of the 20 places had mercury levels so high that the Food and Drug Administration could take legal action to remove the fish from the market. The sushi was bought by The New York Times in October.
“No one should eat a meal of tuna with mercury levels like those found in the restaurant samples more than about once every three weeks," said Dr. Michael Gochfeld, professor of environmental and occupational medicine at the Robert Wood Johnson Medical School in Piscataway, N.J.
Dr. Gochfeld analyzed the sushi for The Times with Dr. Joanna Burger, professor of life sciences at Rutgers University. He is a former chairman of the New Jersey Mercury Task Force and also treats patients with mercury poisoning.
The owner of a restaurant whose tuna sushi had particularly high mercury concentrations said he was shocked by the findings. “I’m startled by this,” said the owner, Drew Nieporent, a managing partner of Nobu Next Door. “Anything that might endanger any customer of ours, we’d be inclined to take off the menu immediately and get to the bottom of it.”
Although the samples were gathered in New York City, experts believe similar results would be observed elsewhere.
“Mercury levels in bluefin are likely to be very high regardless of location,” said Tim Fitzgerald, a marine scientist for Environmental Defense, an advocacy group that works to protect the environment and improve human health.
Most of the restaurants in the survey said the tuna The Times had sampled was bluefin.
In 2004 the Food and Drug Administration joined with the Environmental Protection Agency to warn women who might become pregnant and children to limit their consumption of certain varieties of canned tuna because the mercury it contained might damage the developing nervous system. Fresh tuna was not included in the advisory. Most of the tuna sushi in the Times samples contained far more mercury than is typically found in canned tuna.
Over the past several years, studies have suggested that mercury may also cause health problems for adults, including an increased risk of cardiovascular disease and neurological symptoms.
Dr. P. Michael Bolger, a toxicologist who is head of the chemical hazard assessment team at the Food and Drug Administration, did not comment on the findings in the Times sample but said the agency was reviewing its seafood mercury warnings. Because it has been four years since the advisory was issued, Dr. Bolger said, “we have had a study under way to take a fresh look at it.”
No government agency regularly tests seafood for mercury.
Tuna samples from the Manhattan restaurants Nobu Next Door, Sushi Seki, Sushi of Gari and Blue Ribbon Sushi and the food store Gourmet Garage all had mercury above one part per million, the “action level” at which the F.D.A. can take food off the market. (The F.D.A. has rarely, if ever, taken any tuna off the market.) The highest mercury concentration, 1.4 parts per million, was found in tuna from Blue Ribbon Sushi. The lowest, 0.10, was bought at Fairway.
When told of the newspaper’s findings, Andy Arons, an owner of Gourmet Garage, said: “We’ll look for lower-level-mercury fish. Maybe we won’t sell tuna sushi for a while, until we get to the bottom of this.” Mr. Arons said his stores stocked yellowfin, albacore and bluefin tuna, depending on the available quality and the price.
At Blue Ribbon Sushi, Eric Bromberg, an owner, said he was aware that bluefin tuna had higher mercury concentrations. For that reason, Mr. Bromberg said, the restaurant typically told parents with small children not to let them eat “more than one or two pieces.”
Koji Oneda, a spokesman for Sushi Seki, said the restaurant would talk to its fish supplier about the issue. A manager at Sushi of Gari, Tomi Tomono, said it warned pregnant women and regular customers who “love to eat tuna” about mercury levels. Mr. Tomono also said the restaurant would put warning labels on the menu “very soon.”
Scientists who performed the analysis for The Times ran the tests several times to be sure there was no mistake in the levels of methylmercury, the form of mercury found in fish tied to health problems.
The work was done at the Environmental and Occupational Health Sciences Institute, in Piscataway, a partnership between Rutgers and the Robert Wood Johnson Medical School.
Six pieces of sushi from most of the restaurants and stores would contain more than 49 micrograms of mercury. That is the amount the Environmental Protection Agency deems acceptable for weekly consumption over a period of several months by an adult of average weight, which the agency defines as 154 pounds. People weighing less are advised to consume even less mercury. The weight of the fish in the tuna pieces sampled by The Times were 0.18 ounces to 1.26 ounces.
In general, tuna sushi from food stores was much lower in mercury. These findings reinforce results in other studies showing that more expensive tuna usually contains more mercury because it is more likely to come from a larger species, which accumulates mercury from the fish it eats. Mercury enters the environment as an industrial pollutant.
In the Times survey, 10 of the 13 restaurants said at least one of the two tuna samples bought was bluefin. (It is hard for anyone but experts to tell whether a piece of tuna sushi is bluefin by looking at it.)
By contrast, other species, like yellowfin and albacore, generally have much less mercury. Several of the stores in the Times sample said the tuna in their sushi was yellowfin.
“It is very likely bluefin will be included in next year’s testing,” Dr. Bolger of the F.D.A. said. “A couple of months ago F.D.A. became aware of bluefin tuna as a species Americans are eating.”
A number of studies have found high blood mercury levels in people eating a diet rich in seafood. According to a 2007 survey by the New York City Department of Health and Mental Hygiene, the average level of mercury in New Yorkers’ blood is three times higher than the national average. The report found especially high levels among Asian New Yorkers, especially foreign-born Chinese, and people with high incomes. The report noted that Asians tend to eat more seafood, and it speculated that wealthier people favored fish, like swordfish and bluefin tuna, that happen to have higher mercury levels.
The city has warned women who are pregnant or breast-feeding and children not to eat fresh tuna, Chilean sea bass, swordfish, shark, grouper and other kinds of fish it describes as “too high in mercury.” (Cooking fish has no effect on the mercury level.)
Dr. Kate Mahaffey, a senior research scientist in the office of science coordination and policy at the E.P.A. who studies mercury in fish, said she was not surprised by reports of high concentrations.
“We have seen exposures occurring now in the United States that have produced blood mercury a lot higher than anything we would have expected to see,” Dr. Mahaffey said. “And this appears to be related to consumption of larger amounts of fish that are higher in mercury than we had anticipated.”
Many experts believe the government’s warnings on mercury in seafood do not go far enough.
“The current advice from the F.D.A. is insufficient,” said Dr. Philippe Grandjean, adjunct professor of environmental health at the Harvard School of Public Health and chairman of the department of environmental medicine at the University of Southern Denmark. “In order to maintain reasonably low mercury exposure, you have to eat fish low in the food chain, the smaller fish, and they are not saying that.”
Some environmental groups have sounded the alarm. Environmental Defense, the advocacy group, says no one, no matter his or her age, should eat bluefin tuna. Dr. Gochfeld said: “I like to think of tuna sushi as an occasional treat. A steady diet is certainly problematic. There are a lot of other sushi choices.”
Prevention: At Middle Age, Add Alcohol to the Diet?
By Nicholas Bakalar
Several recent studies have found that moderate drinking is associated with a lower risk for cardiovascular disease. Now a new study, published in the March issue of The American Journal of Medicine, suggests that teetotalers who begin having a drink or two a day in middle age may also get significant benefit.
The researchers followed 7,697 healthy men and women ages 45 to 64 enrolled in a large study of atherosclerotic illness, focusing on 442 who were nondrinkers at the start of the study but moderate drinkers at the six-year point. Then they tracked this group for cardiovascular disease over the next four years and compared them with people who continued to abstain.
After controlling for age, physical activity, smoking and other cardiovascular risks, they found that new moderate drinkers were 38 percent less likely than abstainers to suffer a cardiovascular event during the four-year period. On average, they also had lower cholesterol and lower blood pressure, and there was no increase in mortality.
So, should middle-aged nondrinkers start imbibing?
“If there’s a benefit to it, I’m not sure it should be restricted to people who just didn’t happen to start yet,” said the lead author, Dr. Dana E. King, professor of family medicine at the Medical University of South Carolina. “Exercise is good for you, but you have to be cautious if you start in middle age. In the same way, moderate alcohol consumption can be part of a healthy lifestyle if you don’t have contraindications to it.”
Several recent studies have found that moderate drinking is associated with a lower risk for cardiovascular disease. Now a new study, published in the March issue of The American Journal of Medicine, suggests that teetotalers who begin having a drink or two a day in middle age may also get significant benefit.
The researchers followed 7,697 healthy men and women ages 45 to 64 enrolled in a large study of atherosclerotic illness, focusing on 442 who were nondrinkers at the start of the study but moderate drinkers at the six-year point. Then they tracked this group for cardiovascular disease over the next four years and compared them with people who continued to abstain.
After controlling for age, physical activity, smoking and other cardiovascular risks, they found that new moderate drinkers were 38 percent less likely than abstainers to suffer a cardiovascular event during the four-year period. On average, they also had lower cholesterol and lower blood pressure, and there was no increase in mortality.
So, should middle-aged nondrinkers start imbibing?
“If there’s a benefit to it, I’m not sure it should be restricted to people who just didn’t happen to start yet,” said the lead author, Dr. Dana E. King, professor of family medicine at the Medical University of South Carolina. “Exercise is good for you, but you have to be cautious if you start in middle age. In the same way, moderate alcohol consumption can be part of a healthy lifestyle if you don’t have contraindications to it.”
Disparities: Men Likelier to Be Told to Replace a Knee
By NICHOLAS BAKALAR
Women are less likely than men to get a recommendation for knee replacement, a Canadian study reports, even when they have the same symptoms.
The researchers selected one man and one woman, both 67, who had identical levels of knee osteoarthritis, as confirmed by two physicians who examined the patients and their X-rays. Then the pair visited 29 orthopedic surgeons and 38 family physicians, with instructions to present their symptoms in exactly the same way: a standard opening sentence describing their problem and ending with the question, “Do you think I need a new knee?”
The researchers found that two-thirds of the doctors recommended knee replacement for the man, while only a third thought it appropriate for the woman. The study, led by Dr. James G. Wright, a professor of surgery at the University of Toronto, appears in the March 11 issue of The Canadian Medical Association Journal. (Knee replacements are covered under the Canadian national health plan.)
Only 12 of the doctors were women, not enough to determine whetehr male and female doctors would perform differently. Of the female physicians, five recommended surgery only to the man; two only to the woman; three to both; and two to neither.
“Women are less likely to get this very effective surgical procedure,” Dr. Wright said. “They should be more aggressive in challenging doctors, especially by getting second opinions.”
Women are less likely than men to get a recommendation for knee replacement, a Canadian study reports, even when they have the same symptoms.
The researchers selected one man and one woman, both 67, who had identical levels of knee osteoarthritis, as confirmed by two physicians who examined the patients and their X-rays. Then the pair visited 29 orthopedic surgeons and 38 family physicians, with instructions to present their symptoms in exactly the same way: a standard opening sentence describing their problem and ending with the question, “Do you think I need a new knee?”
The researchers found that two-thirds of the doctors recommended knee replacement for the man, while only a third thought it appropriate for the woman. The study, led by Dr. James G. Wright, a professor of surgery at the University of Toronto, appears in the March 11 issue of The Canadian Medical Association Journal. (Knee replacements are covered under the Canadian national health plan.)
Only 12 of the doctors were women, not enough to determine whetehr male and female doctors would perform differently. Of the female physicians, five recommended surgery only to the man; two only to the woman; three to both; and two to neither.
“Women are less likely to get this very effective surgical procedure,” Dr. Wright said. “They should be more aggressive in challenging doctors, especially by getting second opinions.”
For the Very Old, a Dose of ‘Slow Medicine’
By ABIGAIL ZUGER, M.D.
It was two decades ago that a group of culinary mavericks took a giant step backward down the evolutionary trail with the “slow food” movement. Instead of fast food produced by the assembly lines of giant consortiums, they championed products of small-scale agriculture — time-consuming to prepare, beautiful to behold, very good for you.
Now (and, some might add, at last) doctors are following suit, rejecting the assembly line of modern medical care for older, gentler options. The substituted menu is not for all patients — at least not yet. For the very elderly, however, most agree the usual tough love of modern medicine in all its hospital-based, medication-obsessed, high-tech impersonality may hurt more than it helps.
In its place, doctors like Dennis McCullough, a family physician and geriatrician at Dartmouth Medical School, suggest “slow medicine” — as he puts it, “a family-centered, less expensive way.”
This medicine is specifically not intended to save lives or to restore youthful vigor, but to ease the inevitable irreversible decline of the very old.
Dr. McCullough directs his book to the children of elderly parents, and he pegs it to the story of his mother. She evolved from a vital, healthy 85-year-old retiree to a feeble 92-year-old dying in hospice care, not from any particular disease so much as the aggressive frailty common among the oldest of old people.
His bottom line is this: It is up to friends and relatives to rescue the elderly from standard medical care. And slow medicine, like slow food, involves a lot of hard work. Readers who sign on will acquire a staggering list of tasks to perform, some of which may be just as tiring and tear-producing as chopping onions.
First, while the aging parent is still vital and lively, children must not fool themselves that this happy situation will last forever. This is the time, Dr. McCullough suggests, to reinsert themselves back into the parent’s life, to show up at doctor visits and to raise unpleasant topics like advance directives and health proxies.
After few more years, it is time to address the “Should you still drive?” and “Can you still manage at home?” issues, and to help create routines that compensate for a slipping memory and slightly wobbly balance.
Medical crises will inevitably arise; the child must be vigilant for a hospital’s bad habits when caring for elderly patients. An “advocacy team” of friends and relatives should be mustered to help protect the hospitalized parent; a wider “circle of concern” should be tapped for moral support.
Still down the road is the complex world of rehabilitation, either home-based or institutional, and the even more complex spectrum of available nursing options for the slightly impaired, the seriously impaired and those near death.
All the while, medical care for the parent should favor the tried and true over the high tech. For instance, Dr. McCullough points out that instead of a yearly mammogram, a manual breast exam may suffice for the very old, and home tests for blood in the stool may replace the draining routine of a colonoscopy.
The parent’s doctors should be nudged to justify flashy but exhausting diagnostic tests, and to constantly re-evaluate medication regimens. The high-blood-pressure pills that are life-saving at 75 may cause problems at 95, and paid companionship or a roster of visitors may prove to be antidepressants at least as effective as any drug.
The pace of care should be slowed to a crawl. For doctors, that means starting medications at low doses and increasing them gradually. For children, that means learning not to panic and yell for an ambulance on every bad day. And for a good overall picture of a parent’s condition, a child is well advised to ignore the usual medical and nursing jargon and to focus instead on the sound of the parent’s own voice. “No one,” Dr. McCullough says, “can be a bigger expert on a parent’s voice than a former teenager trained in the same household.”
Some standard self-help muzziness creeps around the edges of this book, with reflections on the value of scrapbooks to preserve family memories and admonitions that “it is always the right time to say ‘thank you’ and ‘I love you.’ ” Dr. McCullough’s decision to call each stage of old age a “station” (as in “The Station of Crisis,” “The Station of Decline” and “The Station of Prelude to Dying”) may be a little too religious for some and far too reminiscent for others of the food stations at large catered events.
Instead, he might have steeled the book’s spine with a few hard-headed tips for those who would valiantly try to slow the twin Mack trucks of the modern doctor and the modern hospital. How should relatives go about applying the brakes to their fast doctors without alienating them or earning for themselves the label of troublemaker? Dr. McCullough, by his own report, works in something of a paradise when it comes to geriatric care, but in many medical venues the phrase “slow down” is an obscenity.
Still, he has written a valuable book, chilling and comforting in equal measure. A similar book directed at fast doctors, fast hospital administrators and fast insurers might be the next welcome stride backward down the path.
It was two decades ago that a group of culinary mavericks took a giant step backward down the evolutionary trail with the “slow food” movement. Instead of fast food produced by the assembly lines of giant consortiums, they championed products of small-scale agriculture — time-consuming to prepare, beautiful to behold, very good for you.
Now (and, some might add, at last) doctors are following suit, rejecting the assembly line of modern medical care for older, gentler options. The substituted menu is not for all patients — at least not yet. For the very elderly, however, most agree the usual tough love of modern medicine in all its hospital-based, medication-obsessed, high-tech impersonality may hurt more than it helps.
In its place, doctors like Dennis McCullough, a family physician and geriatrician at Dartmouth Medical School, suggest “slow medicine” — as he puts it, “a family-centered, less expensive way.”
This medicine is specifically not intended to save lives or to restore youthful vigor, but to ease the inevitable irreversible decline of the very old.
Dr. McCullough directs his book to the children of elderly parents, and he pegs it to the story of his mother. She evolved from a vital, healthy 85-year-old retiree to a feeble 92-year-old dying in hospice care, not from any particular disease so much as the aggressive frailty common among the oldest of old people.
His bottom line is this: It is up to friends and relatives to rescue the elderly from standard medical care. And slow medicine, like slow food, involves a lot of hard work. Readers who sign on will acquire a staggering list of tasks to perform, some of which may be just as tiring and tear-producing as chopping onions.
First, while the aging parent is still vital and lively, children must not fool themselves that this happy situation will last forever. This is the time, Dr. McCullough suggests, to reinsert themselves back into the parent’s life, to show up at doctor visits and to raise unpleasant topics like advance directives and health proxies.
After few more years, it is time to address the “Should you still drive?” and “Can you still manage at home?” issues, and to help create routines that compensate for a slipping memory and slightly wobbly balance.
Medical crises will inevitably arise; the child must be vigilant for a hospital’s bad habits when caring for elderly patients. An “advocacy team” of friends and relatives should be mustered to help protect the hospitalized parent; a wider “circle of concern” should be tapped for moral support.
Still down the road is the complex world of rehabilitation, either home-based or institutional, and the even more complex spectrum of available nursing options for the slightly impaired, the seriously impaired and those near death.
All the while, medical care for the parent should favor the tried and true over the high tech. For instance, Dr. McCullough points out that instead of a yearly mammogram, a manual breast exam may suffice for the very old, and home tests for blood in the stool may replace the draining routine of a colonoscopy.
The parent’s doctors should be nudged to justify flashy but exhausting diagnostic tests, and to constantly re-evaluate medication regimens. The high-blood-pressure pills that are life-saving at 75 may cause problems at 95, and paid companionship or a roster of visitors may prove to be antidepressants at least as effective as any drug.
The pace of care should be slowed to a crawl. For doctors, that means starting medications at low doses and increasing them gradually. For children, that means learning not to panic and yell for an ambulance on every bad day. And for a good overall picture of a parent’s condition, a child is well advised to ignore the usual medical and nursing jargon and to focus instead on the sound of the parent’s own voice. “No one,” Dr. McCullough says, “can be a bigger expert on a parent’s voice than a former teenager trained in the same household.”
Some standard self-help muzziness creeps around the edges of this book, with reflections on the value of scrapbooks to preserve family memories and admonitions that “it is always the right time to say ‘thank you’ and ‘I love you.’ ” Dr. McCullough’s decision to call each stage of old age a “station” (as in “The Station of Crisis,” “The Station of Decline” and “The Station of Prelude to Dying”) may be a little too religious for some and far too reminiscent for others of the food stations at large catered events.
Instead, he might have steeled the book’s spine with a few hard-headed tips for those who would valiantly try to slow the twin Mack trucks of the modern doctor and the modern hospital. How should relatives go about applying the brakes to their fast doctors without alienating them or earning for themselves the label of troublemaker? Dr. McCullough, by his own report, works in something of a paradise when it comes to geriatric care, but in many medical venues the phrase “slow down” is an obscenity.
Still, he has written a valuable book, chilling and comforting in equal measure. A similar book directed at fast doctors, fast hospital administrators and fast insurers might be the next welcome stride backward down the path.
Many Doctors, Many Tests, No Rhyme or Reason
By SANDEEP JAUHAR, M.D.
I recently took care of a 50-year-old man who had been admitted to the hospital short of breath. During his monthlong stay he was seen by a hematologist, an endocrinologist, a kidney specialist, a podiatrist, two cardiologists, a cardiac electrophysiologist, an infectious-diseases specialist, a pulmonologist, an ear-nose-throat specialist, a urologist, a gastroenterologist, a neurologist, a nutritionist, a general surgeon, a thoracic surgeon and a pain specialist.
He underwent 12 procedures, including cardiac catheterization, a pacemaker implant and a bone-marrow biopsy (to work-up chronic anemia).
Despite this wearying schedule, he maintained an upbeat manner, walking the corridors daily with assistance to chat with nurses and physician assistants. When he was discharged, follow-up visits were scheduled for him with seven specialists.
This man’s case, in which expert consultations sprouted with little rhyme, reason or coordination, reinforced a lesson I have learned many times since entering practice: In our health care system, where doctors are paid piecework for their services, if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur.
Though accurate data is lacking, the overuse of services in health care probably cost hundreds of billions of dollars last year, out of the more than $2 trillion that Americans spent on health.
Are we getting our money’s worth? Not according to the usual measures of public health. The United States ranks 45th in life expectancy, behind Bosnia and Jordan; near last, compared with other developed countries, in infant mortality; and in last place, according to the Commonwealth Fund, a health-care research group, among major industrialized countries in health-care quality, access and efficiency.
And in the United States, regions that spend the most on health care appear to have higher mortality rates than regions that spend the least, perhaps because of increased hospitalization rates that result in more life-threatening errors and infections. It has been estimated that if the entire country spent the same as the lowest spending regions, the Medicare program alone could save about $40 billion a year.
Overutilization is driven by many factors — “defensive” medicine by doctors trying to avoid lawsuits; patients’ demands; a pervading belief among doctors and patients that newer, more expensive technology is better.
The most important factor, however, may be the perverse financial incentives of our current system.
Doctors are usually reimbursed for whatever they bill. As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. If you cut the amount of air you take in per breath, the only way to maintain ventilation is to breathe faster.
Overconsultation and overtesting have now become facts of the medical profession. The culture in practice is to grab patients and generate volume. “Medicine has become like everything else,” a doctor told me recently. “Everything moves because of money.”
Consider medical imaging. According to a federal commission, from 1999 to 2004 the growth in the volume of imaging services per Medicare patient far outstripped the growth of all other physician services. In 2004, the cost of imaging services was close to $100 billion, or an average of roughly $350 per person in the United States.
Not long ago, I visited a friend — a cardiologist in his late 30s — at his office on Long Island to ask him about imaging in private practices.
“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was.
“I tried to practice ethical medicine, but it didn’t help. It didn’t pay, both from a financial and a reputation standpoint.”
His nuclear imaging camera was in an adjoining “procedure” room. He broke down the monthly costs for me: camera lease, $4,500; treadmill lease, $400; office space, $1,000; technician fee, $1,800; nurse fee, $1,000; and miscellaneous expenses of $200.
“Now say I get on average $850 per nuclear stress test,” he said. “Then I have to do at least 10 stress tests a month just to cover the costs, no profit going into my pocket.”
“So,” I said, “there’s pressure on you to do more than 10 stress tests a month, whether your patients need it or not.”
He shrugged and said, “That is what I have to do to break even.”
Last year, Congress approved steep reductions in Medicare payments for certain imaging services. Deeper cuts will almost certainly be forthcoming. This is good; unnecessary imaging is almost certainly taking place, leading to false-positive results, unnecessary invasive procedures, more complications and so on.
But the problem in medicine today is much larger than imaging. Doctors are doing too much testing and too many procedures, often for the sake of business. And patients, unfortunately, are paying the price.
“The hospital is a great place to be when you are sick,” a hospital executive told me recently. “But I don’t want my mother in here five minutes longer than she needs to be.”
Dr. Sandeep Jauhar is a cardiologist on Long Island and the author of the new memoir “Intern: A Doctor’s Initiation.”
I recently took care of a 50-year-old man who had been admitted to the hospital short of breath. During his monthlong stay he was seen by a hematologist, an endocrinologist, a kidney specialist, a podiatrist, two cardiologists, a cardiac electrophysiologist, an infectious-diseases specialist, a pulmonologist, an ear-nose-throat specialist, a urologist, a gastroenterologist, a neurologist, a nutritionist, a general surgeon, a thoracic surgeon and a pain specialist.
He underwent 12 procedures, including cardiac catheterization, a pacemaker implant and a bone-marrow biopsy (to work-up chronic anemia).
Despite this wearying schedule, he maintained an upbeat manner, walking the corridors daily with assistance to chat with nurses and physician assistants. When he was discharged, follow-up visits were scheduled for him with seven specialists.
This man’s case, in which expert consultations sprouted with little rhyme, reason or coordination, reinforced a lesson I have learned many times since entering practice: In our health care system, where doctors are paid piecework for their services, if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur.
Though accurate data is lacking, the overuse of services in health care probably cost hundreds of billions of dollars last year, out of the more than $2 trillion that Americans spent on health.
Are we getting our money’s worth? Not according to the usual measures of public health. The United States ranks 45th in life expectancy, behind Bosnia and Jordan; near last, compared with other developed countries, in infant mortality; and in last place, according to the Commonwealth Fund, a health-care research group, among major industrialized countries in health-care quality, access and efficiency.
And in the United States, regions that spend the most on health care appear to have higher mortality rates than regions that spend the least, perhaps because of increased hospitalization rates that result in more life-threatening errors and infections. It has been estimated that if the entire country spent the same as the lowest spending regions, the Medicare program alone could save about $40 billion a year.
Overutilization is driven by many factors — “defensive” medicine by doctors trying to avoid lawsuits; patients’ demands; a pervading belief among doctors and patients that newer, more expensive technology is better.
The most important factor, however, may be the perverse financial incentives of our current system.
Doctors are usually reimbursed for whatever they bill. As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. If you cut the amount of air you take in per breath, the only way to maintain ventilation is to breathe faster.
Overconsultation and overtesting have now become facts of the medical profession. The culture in practice is to grab patients and generate volume. “Medicine has become like everything else,” a doctor told me recently. “Everything moves because of money.”
Consider medical imaging. According to a federal commission, from 1999 to 2004 the growth in the volume of imaging services per Medicare patient far outstripped the growth of all other physician services. In 2004, the cost of imaging services was close to $100 billion, or an average of roughly $350 per person in the United States.
Not long ago, I visited a friend — a cardiologist in his late 30s — at his office on Long Island to ask him about imaging in private practices.
“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was.
“I tried to practice ethical medicine, but it didn’t help. It didn’t pay, both from a financial and a reputation standpoint.”
His nuclear imaging camera was in an adjoining “procedure” room. He broke down the monthly costs for me: camera lease, $4,500; treadmill lease, $400; office space, $1,000; technician fee, $1,800; nurse fee, $1,000; and miscellaneous expenses of $200.
“Now say I get on average $850 per nuclear stress test,” he said. “Then I have to do at least 10 stress tests a month just to cover the costs, no profit going into my pocket.”
“So,” I said, “there’s pressure on you to do more than 10 stress tests a month, whether your patients need it or not.”
He shrugged and said, “That is what I have to do to break even.”
Last year, Congress approved steep reductions in Medicare payments for certain imaging services. Deeper cuts will almost certainly be forthcoming. This is good; unnecessary imaging is almost certainly taking place, leading to false-positive results, unnecessary invasive procedures, more complications and so on.
But the problem in medicine today is much larger than imaging. Doctors are doing too much testing and too many procedures, often for the sake of business. And patients, unfortunately, are paying the price.
“The hospital is a great place to be when you are sick,” a hospital executive told me recently. “But I don’t want my mother in here five minutes longer than she needs to be.”
Dr. Sandeep Jauhar is a cardiologist on Long Island and the author of the new memoir “Intern: A Doctor’s Initiation.”
When Is a Heart Attack Not a Heart Attack?
By LISA SANDERS, M.D.
1. Symptoms
The patient’s symptoms and blood tests indicated heart attack (left) but could also have pointed to damaged skeletal muscle tissue (right).
Multimedia
Graphic
“I don’t think he had a heart attack,” the patient’s wife declared emphatically. “I don’t care what the doctor in the hospital said.” The patient nodded his agreement. “But we need to be sure,” she added in a distinctive Long Island accent. That’s why they had gone to see Dr. Bruce Decter in New Hyde Park, N.Y., a cardiologist just out of training — to get a second opinion from someone a little closer to the books. The patient, a lanky 42-year-old man with a chiseled jaw, retreating hairline and skinny ponytail, seemed tired and anxious and grateful to have his childhood sweetheart do all the talking.
He had chest pain off and on for most of his adult life. His internist didn’t think it was his heart, and a normal stress test done the previous year seemed to confirm that. Then the week before his visit to Decter, his chest began to hurt while making love. It spread to his left shoulder and arm. And it didn’t go away. He hardly slept at all that night because of the pain and a gnawing anxiety that this time it really was a heart attack.
First thing the next morning he went to his internist. An EKG was normal, but the patient was so worried that his doctor arranged for him to see a cardiologist that afternoon. By then the patient was pale, sweaty and shaking. “I think you’re having a heart attack,” the cardiologist told the patient and then sent him straight to the E.R. The EKG done in the hospital was normal, but a series of blood tests indicated that he was having a heart attack, and a big one. He was rushed to the cardiac catheterization lab to see if the clogged vessel could be reopened. To the doctors’ utter amazement, there was no blockage; his heart looked fine.
Still, the cardiologist was certain that the patient had some kind of heart problem. As he explained it, there was either a blockage that reopened on its own, or he had a spasm in one of the coronary arteries. In either case, the patient was lucky that his heart hadn’t been permanently damaged. The cardiologist started the patient on a beta blocker — a medication that has been shown to protect the heart. But the chest pain kept coming.
2. Investigation
At his office, a week after the trip to the E.R., Decter examined the patient, a fit middle-aged man. His blood pressure was perfect. His heart rate was regular and slow. In fact, his entire exam was completely normal. He got another EKG. Also normal. The patient’s blood tests from the E.R. seemed to indicate that he had had a heart attack, but none of the EKGs or the angiogram revealed any abnormality.
The problem for Decter was one that doctors face regularly: how to reconcile tests that contradict one another. Often patients, and even doctors, think that test results provide a definitive answer — like the solution in today’s paper to yesterday’s crossword. But every test carries a risk of being wrong, and all tests need to be interpreted. This is never clearer than when different tests seem to tell different stories. Could these apparently contradictory results be shaped into a single narrative that made sense?
The blood test in question measures an enzyme that is released when a muscle like the heart is injured. That enzyme, creatine phosphokinase, abbreviated as CPK, was normal when the patient first presented to the emergency room but rose to a level 20 times higher than normal over the next several hours. In a patient who has chest pain that comes on with exertion, an elevated CPK usually means that the patient is having a heart attack.
But damage to any muscle will cause CPK to increase, so there is an additional test that can determine whether the enzymes are leaked from a damaged heart or from damaged skeletal muscle. When Decter called the lab for results of this test, he found that the CPK hadn’t come from the heart; it had come from the muscles of the arms and legs. “You’re right,” Decter told the anxious patient. “You didn’t have a heart attack.” But at this point, the young cardiologist acknowledged, he wasn’t at all sure what the patient did have.
The patient considered himself pretty healthy, he told the doctor. He took no medicine, had never smoked and exercised daily. In fact, the only other time he’d ever been in the hospital was when he was 21 and had mononucleosis. His urine then was really dark — “the color of Coca-Cola” — and the doctors were worried.
When Decter heard that, something stirred in his memory. Cola-colored urine. Perhaps this was the key. Had he had this kind of dark urine since then? he asked. The patient told him that a couple of times a month his urine would turn brown and he’d feel achy all over. It happened whenever he was sick or tired or when he exercised too hard. He’d told lots of doctors about it, but none of them could figure out what was going on.
Decter knew he was on to something. Urine that dark is usually caused by muscle breakdown. When muscle cells are damaged, they leak CPK, but they also spill several other chemicals. One of them, the compound that gives skeletal muscle its distinctive deep red hue, can turn urine a dark brown. Were the brown urine and the elevated CPK caused by the same problem? Were they both signs of some longstanding disease process that was destroying this patient’s muscle?
Decter sent his patient to Dr. Alfred E. Slonim, a pediatric endocrinologist by training who spent his career investigating diseases of the muscle. The patient called Decter after seeing the specialist, almost speechless with excitement. Slonim spent more than an hour with him and his wife, getting the history of his strange illness. “Tell him about what happens on Yom Kippur,” his wife prompted near the end of the interview. Every year on the Jewish day of atonement, the patient would fast for a day, from sunset to sunset. And every year, he would spend the day after Yom Kippur in bed, crippled by an aching in his muscles and passing dark brown urine. Once he said that, Slonim had the diagnosis: the patient had a form of the genetic disease known as carnitine palmitoyltransferase deficiency or CPT.
3. Resolution
In this rare genetic disease, patients are missing the necessary biological equipment to burn fat for energy. Normally the body uses a type of sugar provided by the diet or stored in the liver to keep the body running. When that sugar is used up, the body switches to fat for fuel. Patients with CPT can’t do that. Instead, when they run out of sugar, their bodies are forced to turn to the second backup form of energy: muscle. When this patient’s body depleted the normal fuel — because of decreased intake (fasting or illness) or increased metabolic activity (exercise or fever) — it had to turn to the energy stored in muscle just to keep the biological motor running.
This diagnosis finally allowed the patient and Decter to make sense of the original story. The CPT gave the patient terrible, chronic heartburn; the delicate tissue of the esophagus, when injured, can cause a pain that feels to many patients very much like the classic presentation of a heart attack. Certainly this patient thought he was having one the night he had sex. He didn’t sleep and didn’t eat all the next day when he was in the E.R., and that is what triggered the attack on his muscles and elevated his CPK numbers. “It’s incredible that it took a wrong diagnosis to get to the right one,” the patient told me. There’s no cure for this disease, but frequent meals can help ward off many attacks.
As for Decter, he says he doesn’t believe that this disease is quite as rare as he was told in medical school. Over the past decade, he has seen four patients with unexplained elevations in their CPKs and no evidence of heart disease. Two have tested positive for CPT-like genetic disorders. He’s still trying to figure out the other two.
1. Symptoms
The patient’s symptoms and blood tests indicated heart attack (left) but could also have pointed to damaged skeletal muscle tissue (right).
Multimedia
Graphic
“I don’t think he had a heart attack,” the patient’s wife declared emphatically. “I don’t care what the doctor in the hospital said.” The patient nodded his agreement. “But we need to be sure,” she added in a distinctive Long Island accent. That’s why they had gone to see Dr. Bruce Decter in New Hyde Park, N.Y., a cardiologist just out of training — to get a second opinion from someone a little closer to the books. The patient, a lanky 42-year-old man with a chiseled jaw, retreating hairline and skinny ponytail, seemed tired and anxious and grateful to have his childhood sweetheart do all the talking.
He had chest pain off and on for most of his adult life. His internist didn’t think it was his heart, and a normal stress test done the previous year seemed to confirm that. Then the week before his visit to Decter, his chest began to hurt while making love. It spread to his left shoulder and arm. And it didn’t go away. He hardly slept at all that night because of the pain and a gnawing anxiety that this time it really was a heart attack.
First thing the next morning he went to his internist. An EKG was normal, but the patient was so worried that his doctor arranged for him to see a cardiologist that afternoon. By then the patient was pale, sweaty and shaking. “I think you’re having a heart attack,” the cardiologist told the patient and then sent him straight to the E.R. The EKG done in the hospital was normal, but a series of blood tests indicated that he was having a heart attack, and a big one. He was rushed to the cardiac catheterization lab to see if the clogged vessel could be reopened. To the doctors’ utter amazement, there was no blockage; his heart looked fine.
Still, the cardiologist was certain that the patient had some kind of heart problem. As he explained it, there was either a blockage that reopened on its own, or he had a spasm in one of the coronary arteries. In either case, the patient was lucky that his heart hadn’t been permanently damaged. The cardiologist started the patient on a beta blocker — a medication that has been shown to protect the heart. But the chest pain kept coming.
2. Investigation
At his office, a week after the trip to the E.R., Decter examined the patient, a fit middle-aged man. His blood pressure was perfect. His heart rate was regular and slow. In fact, his entire exam was completely normal. He got another EKG. Also normal. The patient’s blood tests from the E.R. seemed to indicate that he had had a heart attack, but none of the EKGs or the angiogram revealed any abnormality.
The problem for Decter was one that doctors face regularly: how to reconcile tests that contradict one another. Often patients, and even doctors, think that test results provide a definitive answer — like the solution in today’s paper to yesterday’s crossword. But every test carries a risk of being wrong, and all tests need to be interpreted. This is never clearer than when different tests seem to tell different stories. Could these apparently contradictory results be shaped into a single narrative that made sense?
The blood test in question measures an enzyme that is released when a muscle like the heart is injured. That enzyme, creatine phosphokinase, abbreviated as CPK, was normal when the patient first presented to the emergency room but rose to a level 20 times higher than normal over the next several hours. In a patient who has chest pain that comes on with exertion, an elevated CPK usually means that the patient is having a heart attack.
But damage to any muscle will cause CPK to increase, so there is an additional test that can determine whether the enzymes are leaked from a damaged heart or from damaged skeletal muscle. When Decter called the lab for results of this test, he found that the CPK hadn’t come from the heart; it had come from the muscles of the arms and legs. “You’re right,” Decter told the anxious patient. “You didn’t have a heart attack.” But at this point, the young cardiologist acknowledged, he wasn’t at all sure what the patient did have.
The patient considered himself pretty healthy, he told the doctor. He took no medicine, had never smoked and exercised daily. In fact, the only other time he’d ever been in the hospital was when he was 21 and had mononucleosis. His urine then was really dark — “the color of Coca-Cola” — and the doctors were worried.
When Decter heard that, something stirred in his memory. Cola-colored urine. Perhaps this was the key. Had he had this kind of dark urine since then? he asked. The patient told him that a couple of times a month his urine would turn brown and he’d feel achy all over. It happened whenever he was sick or tired or when he exercised too hard. He’d told lots of doctors about it, but none of them could figure out what was going on.
Decter knew he was on to something. Urine that dark is usually caused by muscle breakdown. When muscle cells are damaged, they leak CPK, but they also spill several other chemicals. One of them, the compound that gives skeletal muscle its distinctive deep red hue, can turn urine a dark brown. Were the brown urine and the elevated CPK caused by the same problem? Were they both signs of some longstanding disease process that was destroying this patient’s muscle?
Decter sent his patient to Dr. Alfred E. Slonim, a pediatric endocrinologist by training who spent his career investigating diseases of the muscle. The patient called Decter after seeing the specialist, almost speechless with excitement. Slonim spent more than an hour with him and his wife, getting the history of his strange illness. “Tell him about what happens on Yom Kippur,” his wife prompted near the end of the interview. Every year on the Jewish day of atonement, the patient would fast for a day, from sunset to sunset. And every year, he would spend the day after Yom Kippur in bed, crippled by an aching in his muscles and passing dark brown urine. Once he said that, Slonim had the diagnosis: the patient had a form of the genetic disease known as carnitine palmitoyltransferase deficiency or CPT.
3. Resolution
In this rare genetic disease, patients are missing the necessary biological equipment to burn fat for energy. Normally the body uses a type of sugar provided by the diet or stored in the liver to keep the body running. When that sugar is used up, the body switches to fat for fuel. Patients with CPT can’t do that. Instead, when they run out of sugar, their bodies are forced to turn to the second backup form of energy: muscle. When this patient’s body depleted the normal fuel — because of decreased intake (fasting or illness) or increased metabolic activity (exercise or fever) — it had to turn to the energy stored in muscle just to keep the biological motor running.
This diagnosis finally allowed the patient and Decter to make sense of the original story. The CPT gave the patient terrible, chronic heartburn; the delicate tissue of the esophagus, when injured, can cause a pain that feels to many patients very much like the classic presentation of a heart attack. Certainly this patient thought he was having one the night he had sex. He didn’t sleep and didn’t eat all the next day when he was in the E.R., and that is what triggered the attack on his muscles and elevated his CPK numbers. “It’s incredible that it took a wrong diagnosis to get to the right one,” the patient told me. There’s no cure for this disease, but frequent meals can help ward off many attacks.
As for Decter, he says he doesn’t believe that this disease is quite as rare as he was told in medical school. Over the past decade, he has seen four patients with unexplained elevations in their CPKs and no evidence of heart disease. Two have tested positive for CPT-like genetic disorders. He’s still trying to figure out the other two.
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