Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

The agony of the feet

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Catherine Wright, 61, a retired telephone operator from Quincy who cheerfully admits she wore “fancy high heels” for years, sat propped up, admiring her podiatrist’s handiwork.

On her right foot, where a mish-mash of hammertoes and a nasty bunion had been, Wright had a long incision and a string of neat, black stitches from her big toe halfway along the top of her foot. Her other newly-straightened toes sported smaller incisions — and steel pins to keep them aligned as they healed.

“I don’t think it’ll ever be beautiful,” she said, as her husband Scotty looked the other way, “but I’ll paint up the toenails and be able to walk without pain.”

In the examining room next door, Irene Pozzi, 72, a retired clerical workerfrom Dorchester, gazed at her right foot, a monument to her ongoing battle with rheumatoid arthritis.

Her index toe lay at a right angle to her leg, crunched under her other toes. “I ignore it,” she said matter-of-factly, more interested in her glowing pink, freshly-scraped calluses.

In the waiting room, every seat was taken. A 62-year-old Roslindale man wondered why his foot swelled when he walked. A 57-year-old Dorchester woman wanted her excessively thick toenails cut. A 69-year-old Hingham woman had corns that needed some TLC.

But the crowd this recent January morning was actually nothing special. Business is always booming in the homey South Boston offices of podiatrist Edward Hurwitz, as it is for foot specialists nationwide, because most of us, as we age, either can’t or won’t take good care of our feet ourselves.

Every year, 5.4 million people with sore feet hobble to medical doctors, according to the National Center for Health Statistics.

And that doesn’t include the 68 million of us who take our aching bunions, heels spurs and ingrown toenails to podiatrists, who are not M.D.’s but have four years of post-college training in one of the nation’s seven schools of podiatric medicine.

Indeed, as we walk, run or stumble through life, 75 to 80 percent of us get foot problems of some sort, and the risk goes up sharply with age, says Glenn Gastwirth, deputy executive director of the American Podiatric Medical Association.

Usually, the problems are pedestrian — like hammertoes, a claw-like condition that is triggered by muscle problems and exacerbated by shoes that crunch up the toes; or bunions, which are caused by an inherited tendency toward misaligned big toes and are made worse by bad shoes.

But sometimes, foot problems can be deadly serious, especially for America’s 16 million diagnosed diabetics and another 8 million who have diabetes but don’t know it.

One in four people with diabetes develops foot problems, says podiatrist Pamela Colman of the 10,000-member podiatric association, and for many those problems are tragic.

Every year, government figures show, people with diabetes have more than 50,000 leg amputations above or below the knee, and 34,000 have foot or toe amputations. About half of these surgeries could be avoided with proper foot care.

The problem in diabetes, specialists say, is that excess sugar in the blood triggers a process called glycosylation, in which glucose molecules and their breakdown products infiltrate and stiffen bodily tissues. When this happens in peripheral nerves — like those in the arms, legs and feet — the ability of the nerves to function properly declines markedly.

And without good nerve function, people with diabetes simply don’t feel the pain that tells other people when blisters, calluses or ingrown toenails are becoming infected.

Because diabetes also causes circulatory problems, many people with diabetes also have decreased blood flow to the feet, which means immune cells can’t keep up with otherwise routine infections in the feet, says Geoffrey Habershaw, chief of podiatry at Deaconess Hospital and the Joslin Diabetes Center.

In that joint program and at one other center — the University of Texas Health Science Center in San Antonio — doctors are finding that good foot care reduces amputations.

At the Boston center, many people’s feet are saved by antibiotics — often a combination of several kinds to combat the mixed bag of germs in most foot infections — plus reconstructive surgery and bypass surgery to restore circulation.

The payoff has been dramatic. Fifteen years ago, nearly a third of diabetics with foot infections wound up with an amputation. Today, though the amputation rate is not falling nationwide, it is just 4 percent in the Deaconess-Joslin program.

Specialists are hoping that a two-year-old program called LEAP — Lower Extremity Amputation Prevention program — may bring similar benefits to more people.

Through the government’s LEAP program, health care providers learn to assess nerve function with a simple instrument called the Semmes-Weinstein monofilament, essentially a piece of fishing line that pops out of a plastic handle with 10 grams of force. If the individual cannot feel the tiny pricking sensation, it is a sign of faulty nerve function in the feet.

For most people, though, it’s not the dramatic complications of diabetes but the humdrum effects of aging that cause the most foot problems.

“As people age, ligaments lose elasticity,” especially in those who gain weight,” says Hurwitz of South Boston. “You don’t get bunions because you wore Mary Janes when you were 12, but from bad genes, bad shoes and wear and tear, as ligaments and tendons get loose.”

In fact, years of wearing attractive but orthopedically-disastrous footwear — including shoes that are too narrow and shoes with more than a one-inch heel — are the main reason women have four times the foot problems of men.

So if you’re among the millions who think it’s normal to kick off your shoes at night and moan, “My feet are killing me!” there’s a simple message: Think again.

Feet are not supposed to hurt. If yours do, it’s time to get help, from a podiatrist or an M.D. trained in orthopedics, like the 14,000 members of the American Orthopedic Foot and Ankle Society, who have four years of medical school plus four to six years of residency training.

For most things, like bunions, corns, heel pain and the like, it probably doesn’t matter which type of specialist you see, as long as he or she is licensed. But podiatrists vary widely in surgical training and experience, so be sure to ask.

For problems above the foot — notably the ankle — it may best to see an orthopedic surgeon.

“If I were a patient with an ankle problem,” says Dr. Mark Myerson, director of foot and ankle services at Union Memorial Hospital in Baltimore, ”I would not go to a podiatrist because podiatrists, across the board, are not generally trained in ankle problems but in problems of the feet.”

The same goes, in his view, for bone fractures and deformities of the feet, including arthritis.

But many podiatrists, among them Habershaw of the Deaconess, disagree, noting that many podiatrists take advanced residency training after podiatry school.

Whomever you consult, what counts is getting help before minor problems become major.

Take it from Catherine Wright, who should know: “I just kept putting things off.”

SIDEBAR 1THE MOST COMMON FOOT PROBLEMS

 

– Blisters, caused by skin friction. Don’t pop them. Apply moleskin or a Band-Aid and leave in place until it falls off naturally in bath or shower. Keep feet dry and wear socks to cushion feet. Seek help if blisters become inflamed or painful.

– Bunions, misaligned big toe joints that can become swollen and tender. Bunions tend to run in families, but the tendency is aggravated by shoes that are too narrow in the toe. Surgery is recommended if the bunion affects your lifestyle.

– Corns and calluses, protective layers of dead skin caused by friction of bones against skin. Corns may be caused by too-tight shoes and crooked toes. Calluses are caused by friction from faulty foot mechanics, often from arches that are too high or too low. You should file calluses and corns with a pumice stone, but never cut them with sharp instruments. And don’t try to burn them off with acids.

– Hammertoes, a condition in which the toes are bent in a claw-like position. Usually caused by muscle imbalance, but can be aggravated by bad shoes. Buy shoes with ample toe room and soft uppers, the part of the shoe above the sole. If hammertoes affect lifestyle, surgery may be needed.

– Heel pain or heel spurs, caused by plantar fasciitis, an inflammation of the connective tissue on the bottom of feet. They’re caused by faulty foot structure that puts stress on the heel bones. Try over-the-counter anti- inflammatory drugs and ice. Orthotic devices may help redistribute weight.

– Ingrown nails, which dig into the skin because of improper trimming, shoepressure, injury, fungal infection, heredity or poor foot structure. Nails should be clipped straight across, slightly longer than the end of the toe.

– Neuromas, enlarged, benign growths of nerves, usually between the third and fourth toes, caused by bones rubbing against nerves. Orthotic devices and/ or cortisone injections may help, but surgery may be needed if neuromas affect lifestyle.

– Warts, caused by a virus that enters the skin through small cuts. Warts usually go away without treatment. Over-the-counter medication may help, but don’t use these acids on calluses. Warts can also be treated with minor surgery.

SIDEBAR 2A CHECKLIST FOR FOOT CARE

 

– Check your feet daily for cuts, sores, bumps and red spots, especially if you have diabetes. If you think an infection is brewing, see a foot specialist immediately.

– Have your doctor check your feet at every visit.

– Wash your feet in warm, not hot, water, every day. Do not soak feetbecause this can dry your skin. Dry well between the toes, then put on moisturizing cream to reduce skin cracks.

– Cut toenails straight across. Use an emery board to smooth sharp edges that could cut an adjacent toe.

And when you’re buying shoes:

– Have feet measured while you are standing.

– Try on both shoes and walk around.

– Don’t buy shoes that need “breaking in.” Shoes should feel reasonably comfortable as soon as you buy them.

– Don’t rely on remembering what your size is. Feet get bigger and brands vary.

– Shop for shoes late in the day, because feet swell.

– Get shoes that fit in front, back and sides and distribute your weight well.

– Select shoes with leather uppers, a stiff cup around the heel, appropriate cushioning and flexibility at the ball of the foot.

– If you’re going to wear socks, have them on when you try on shoes.

Specialists offer these tips on foot care:

– Athlete’s foot, a fungal skin disease that starts between the toes or on the bottom of the feet. Symptoms are scaly skin, itching, inflammation and blisters. You can help prevent infection by washing feet daily with soap and warm water, drying thoroughly, and changing shoes and hose often.

Fine-tuning the Pap Smear with Technology

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The humble Pap test, a screening test so good that American women now die of cervical cancer at only one-fifth the rate of 50 years ago, is one of the best tools in modern medicine.

Unlike mammograms, which detect breast cancers at an early stage, Pap tests spot abnormalities in cervical cells even before they become cancer.

In fact, if all women got Pap tests regularly, the incidence of cervical cancer — still the chief cause of cancer death in developing countries — could approach zero, specialists say.

Ironically, though, just as improvements are becoming available to make the Pap smear even better — by reducing the rate of both missed cancers and false alarms — cost-conscious health planners are wondering whether we can afford the new tests and even how often women should get Pap smears.

Cervical cancer is a sexually transmitted disease caused in virtually all cases by any one of four common papilloma viruses, which are spread primarily by genital skin contact. The major risks are having sex before age 20, having three or more sexual partners or having a history of abnormal Pap smears or genital warts. Smoking adds significantly to the risk because tobacco smoke bathes delicate cervical tissues in tar and nicotine.

Since the 1940s, when Dr. Georges Papanicolaou developed his now-famous method of scraping cells from the cervix, spreading them on a glass slide and examining them under a microsocope, the death rate from cervical cancer has plummeted, though it now seems to be rising again slightly in younger women. This year, it is expected to hit nearly 16,000 American women and kill nearly 5,000.

But those figures only begin to tell the story of what has become a $6 billion-a-year industry. Every year, American women have 55 million Pap smears — at $7 to $15 each — and four to five million of these are abnormal.

In most cases, the abnormal tests turn out to be nothing serious, says Dr. Ellen Sheets, director of the Pap smear evaluation center at Brigham and Women’s Hospital.

But in order to be sure, many women are sent into what doctors call secondary triage — more testing, usually with a $150 exam called colposcopy in which doctors use a high-powered microscope to look at the cervix. This is often followed by freezing, burning or using electrical wires to removesuspect tissue, at another $500 or more per patient.

All this is worth it, of course, if a woman leaves the doctor’s office 100 percent cured, as is usually the case when cervical abnormalities consist of mere dysplasia, the presence of abnormal cells, or carcinoma in situ, a noninvasive cancer.

But it can also be too much of a good thing.

Often, women whose Pap tests are only mildly abnormal “end up with a $500 procedure for a lesion that didn’t need to be treated in the first place,” says Dr. Michael Policar, former vice president of the PlannedParenthood Federation of America and now medical director of the Solano Partnership Health Plan, an HMO in Fairfield, Calif.

The problem, gynecologists say, is that Pap tests are nowhere near as accurate as women assume — or doctors would like.

Granted, things have improved since 1988, when Congress passed a law tightening lab practices following scandals over inaccurate tests read by overworked, underpaid technicians.

But even in good labs, human eyes still miss 20 percent or more of abnormal smears and, somewhat less frequently, tend to see abnormalities where none exist.

Because of this, researchers have been scrambling to fine-tune Pap testing with add-on technology, and a number of devices are now working their way through the US Food and Drug Administration approval process.

Several months ago, the FDA approved a system called PAPNET, which uses computers to re-read normal Pap smears already examined by human technicians. It’s not clear yet whether re-reading by computer “will be more helpful than human re-reading,” says Sheets of the Brigham.

Earlier this month, the FDA also approved for cervical screening a device developed by the Trylon Corp. in California, to be marketed soon by Pharmacia & Upjohn, Inc. in Michigan.

Called Pap Plus Speculosocopy, the device is a tiny light that is taped to a speculum, the standard device used to examine the cervix. After a Pap smear is done, the doctor simply swabs vinegar on the cervix and shines the blue- white light on it. Abnormal cells appear white, normal cells, dark.

The extra test adds $25 and five minutes to a Pap exam, but it can cut the rate of missed abnormalities to about 5 percent, says Dr. Steven Vasilev, director of gynecologic oncology at the City of Hope Medical Center in Duarte, Calif.

Vasilev, who has tested the device in hundreds of women, says “the returns are great, because you are decreasing the chance a patient will come back in two or three years” with cancer.

But many specialists are unconvinced the device will save enough lives to justify the cost. Dr. Diane Solomon, chief of the cytopathology section at the National Cancer Institute says, “I’m not convinced by the data I’ve seen so far.”

Neither is HMO medical director Policar, who says speculoscopy could be “a big deal” as a way to tell which women with abnormal Pap tests need expensive colposcopy. But as “the person who decides which tests to pay for and which not” in an HMO of 45,000 patients, he says he is not sure the test will prevent enough cases of cervical cancer to justify the extra cost.

Dr. Michele Follen Mitchell, director of colposcopy at M.D. Anderson Cancer Center in Houston, is also wary, though she has hopes for her own test, called fluorescence spectroscopy.

Down the line, other refinements may also help make Pap smears more accurate, including a machine to spread cells more uniformly on microscope slides and using infrared light and antibodies to spot abnormalities.

Even before such improvements become available, though, women should not hesitate to get Pap tests. Among all cancer detection tests, the standard Pap test is “probably the only true screening tool that has impacted the death rate,” says Sheets.

Even if doctors don’t know how often women should have it.

For years, the rule of thumb was a Pap test every year, and the AmericanCollege of Obstetricians and Gynecologists still recommends that for sexually active women.

If a woman doesn’t have a yearly Pap test, says Dr. Henry Klapholz, vice chairman of the obstetrics and gynecology department at Beth Israel Hospital, she may skip her annual pelvic exam, the main way of detecting ovarian cancer, as well.

But in 1988, a coalition of medical organizations changed Pap test guidelines. The guidelines say that “all women who are or have been sexually active, or who have reached age 18, should have an annual Pap smear and pelvic exam. After a woman has had three or more consecutive, satisfactory normal annual examinations, the procedure may be performed less frequently at the discretion of the woman and her doctor.”

Concerned about rising costs, “many insurers are pushing” for a three- year interval, says Sheets. In Europe, she adds, women get Pap smears every two or three years, yet have cervical cancer rates similar to those of American women, probably because they are less likely than Americans to skip scheduled exams.

“The real key,” says Cindy Pearson, program director for the National Women’s Health Network, is “to get tested regularly, at the very least every three years. This is the most preventable cancer we’ve got going

High-fat diet helping many with Epilepsy

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Jason Simon, now 15 and an 8th grader in Sandwich, was only 9 on the day when, as he recalls, he “woke up one morning with a bunch of men standing around to take me to the hospital.”

He had no idea what was going on, but his family was terrified. During the night, his sister had heard him making “gurgling noises,” the first sign Jason was having seizures.

At first, like many of the other 400,000 children with epilepsy — a condition in which people have recurrent seizures — Jason was treated with drugs. They worked, for a while.

But soon, like 30 percent of children on medications, Jason found that no matter which drugs he tried, he still had seizures — and the brain-numbing side effects of the drugs as well.

In 6th grade, he had so many dizzy spells and seizures that he missed 77 days of school. In 7th grade, he was taking 16 pills a day — but still missed 108 days of school.

Reluctantly, his parents agreed to surgery to remove the right temporal lobe of his brain, where his seizures — caused by abnormal discharges of electrical energy from brain cells — began.

Surgery did have one benefit. The courage it took to get through it left Jason “not scared of much anymore,” he says.

But though surgery helps some kids, it did nothing for his seizures. They soon came back, two or three times a day, each one causing him to stare and be unresponsive for a few seconds to several minutes.

Today, however, Jason is nearly seizure-free, thanks to a special diet that is 80 percent fat and has been sweeping the often-desperate world of epilepsy like a January blizzard.

No one is sure why it works, but the high fat/low protein/low carbohydrate diet seems to push the body into a starvation-like state called ketosis, says Dr. Gregory Holmes, director of the epilepsy program at Children’s Hospital in Boston.

Patients are first starved for several days to deplete the body’s stored sugar, then put on the diet, which contains almost no carbohydrates. Soon,
because the body has no glucose for fuel, cells begin burning fat from the diet instead, which slows the frantic firing of brain cells.

Burning fats in the absence of glucose leads to the production of fatty molecules called ketone bodies. Some scientists think ketone bodies may change the lipid membrane of brain cells to produce a lower firing rate. Others think the diet changes the rate at which charged particles called ions cross the lipid membranes of nerve cells. But the truth is, nobody knows.

So far, the diet is being studied only in kids, but there is “no theoretical reason” why it couldn’t help some of the 2 million adults with epilepsy as well, says Dr. Patricia Crumrine, director of the pediatric epilepsy program at Children’s Hospital in Pittsburgh.

In the approximately 200 children studied to date in a handful of medical centers, initial results suggest that 20-30 percent become “seizure-free, usually in a month to six weeks,” and about half have a 50-percent reduction in seizures, says Dr. John Freeman, director of pediatric neurology at Johns Hopkins Medical Institutions and the leading proponent of the ketogenic diet.

Most children stay on the diet for two years, he says. When it works right, seizures rarely return, even after normal diet is resumed. So far, there is no evidence that the high fat diet raises the risk of atherosclerosis, heart disease or stroke.

“Even if there were a slight increase,” says Freeman, “after two years, the children come off the diet” and any buildup of fatty plaques in arteries should disappear. “And even if you shortened the lives of these children by a year or two or five, you would have dramatically improved their quality of life.”

But there are caveats.

The diet is very stringent, even more so than diets for diabetes, and is appropriate only for children whose seizures are difficult to control by drugs. The slightest error — too much liquid, eating seven nuts instead of three or changing brands of sausage — can bring back the seizures.

Also, the diet “should only be done under medical supervision,” adds Freeman, noting that unconfirmed reports suggest at least three children have died after parents tried it on their own.

And while the diet may sound like a picnic, it isn’t.

Jason has lived on sausages and eggs, choked down heavy cream at every meal and, despite teenage temptation, has had little non-fatty food other than bouillon and lettuce since he started five months ago.

His parents are “always in the kitchen,” says his father, Steve, 42, a certified public accountant. “One of us is always cutting, cleaning, weighing” everything that goes into Jason’s mouth.

“You have to be totally committed — it’s an entire family commitment,” adds Jason’s mother, Lori, 39. “We never go out to eat anymore or have pizza at home. It’s absolutely amazing that Jason has the willpower to do this. I know I never could.”

Jason’s sister Julie, 12, says she has to eat any tempting foods she has out of his sight, be a good sport at holidays like Thanksgiving — when the whole family ate eggs — and put up with the fact that her parents “spend so much time on his meals.”

But the diet is toughest on Jason. Though he consumes 2,000 calories a day, he says, “It’s not enough. I’m always hungry.”

Which is precisely the point.

Ever since 400 B.C., people have observed that under conditions of starvation, seizures decline, says Dr. Ed Dodson, president of the Epilepsy Foundation of American.

Earlier this century, in fact, that knowledge led a few American doctors to deliberately starve their epilepsy patients. It often worked to reduce seizures, but the achievement — and interest in the diet — dropped from sight in the late 1930s when Dilantin, the first anti-epileptic drug, was developed.

But even as new drugs trickled onto the market, interest in the ketogenic diet never completely waned at Johns Hopkins, says researcher Freeman. Until recently, though, he used the diet with only eight to 12 children a year.

All that changed in October 1994, when Dateline NBC aired a program on the ketogenic diet, spurred by California movie-maker Jim (“Airplane” and ”Naked Gun”) Abrahams, whose 18-month-old son Charlie had become seizure- free on the diet.

Like Jason, Charlie had been given numerous drugs and had had brain surgery, his father says, yet still had dozens of seizures a day. Eventually, Abrahams quit work to pore over the medical literature, including Freeman’s book on the diet.

Abrahams, who founded the Charlie Foundation to publicize the diet, is thrilled that his son, now 3 1/2, is well, if a bit skinny. But he’s angry that all the doctors he had consulted for years knew nothing, or told him nothing, about it.

“We would not have drugged Charlie into oblivion if we had known about the diet,” Abrahams says. “And we certainly would never have let them carve into his brain.”

To some, the failure to take the ketogenic diet seriously smacks of the old days, when epilepsy carried so much stigma that patients were housed in ”colonies” for treatment so that other people would not have to see their jerking, twitching and other uncontrollable behaviors.

Some states laws forbade people with epilepsy to marry or have children, and some permitted involuntary sterilization of epileptics, says Dr. Orrin
Devinsky, director of the epilepsy program at New York University Medical Center.

But for kids like Jason Simon, the focus is not on past mistakes, but on the future. Thanks to the diet, he’s down to two seizures a month and four pills a day.

He hates the hunger, but he rarely complains, he says, “because complaining is not going to do anything. I figure why waste my breath. I’m just going to annoy myself and everybody else.”

Besides, he’s got his eye on more important things.

“I really want to drive when I’m older,” he says, “and I won’t be able to drive if I’m having seizures.”

SIDEBAR:

MEDICATIONS WORK FOR MOST

 

While the ketogenic diet can be useful for children whose epilepsy does not respond to medication, most people with epilepsy — adults and children alike — are helped by the growing array of available drugs, including newer ones like Lamictal and Neurontin.

If you are not sure whether you or your child is having seizures, ask your doctor — some seizures can be subtle and difficult to detect.

Often, doctors cannot tell what triggers seizures, though common causes are head trauma, infections, genetic defects and problems that occur as a child’s brain develops.

In general, seizures fall into two classes: partial seizures, in which the abnormal firing of nerve cells begins in just one part of the brain and then may spread; and generalized seizures, which begin in both sides of the brain at once.

Some partial seizures are so mild the patient merely twitches or feels odd but does not lose consciousness, though patients with complex partial seizures may lose consciousness.

Even in generalized seizures, some patients merely stare into space for 10 to 15 seconds, particularly with a type once called “petit mal” but now called “absence” (prounounced the French way). A child with an “absence” seizure may simply stop talking and stare, blink his eyes, then return to normal.

Other generalized seizures, particularly the tonic-clonic type once called ”grand mal,” are more severe. During these attacks, the body stiffens and jerks rhythmically, sometimes for up to three to five minutes.

Lay people often worry that a person having a seizure may swallow his tongue. This does not literally happen, though the base of the tongue may slip toward the back of the throat.

Contrary to a popular misconception, you should never put anything in the mouth of a person during a seizure. Instead, roll the patient onto his side and make sure the head is turned toward the ground to help clear the airway.

For more information, call:

The Epilepsy Foundation of America, 1-800-EFA-1000 (or 1-800-332-1000)

The Charlie Foundation to Help Cure Pediatric Epilepsy, 1-800-FOR-KETO (or 1-800-367-5386).

Drink up – or not? Studies in women are at odds on alcohol’s risks and benefits

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Last May, a huge Harvard study of more than 85,000 women showed that moderate drinking — about one drink a day — lowers the overall risk of death, without apparently raising the odds of dying from breast cancer.

Six weeks later, another big study — of more than 16,000 women — came to a more sobering conclusion: Over a lifetime, even one drink a day may slightly raise breast cancer risk.

Given that women are roughly six times more likely to die of heart disease than breast cancer, and that alcohol protects against heart disease in both men and women, perhaps women shouldn’t worry about a small increase in breast cancer risk from drinking.

But many do.

Which is precisely why the new data on women and drinking is so frustrating. Taken together, the data suggest that drinking decisions for women may be even more complex than for men because risks and benefits are more closely balanced.On top of that, evidence is piling up that women’s bodies are far more vulnerable than men’s to the toxic effects of booze.

All of which suggests that before you pour the next drink, ladies, you might want to ponder the research — on both sides.

Medically, the main argument for drinking is that it protects against heart disease, the leading killer of both men and women.

Alcohol can change the balance of lipoproteins in the blood, boosting ”good” cholesterol (HDL) and lowering “bad” (LDL), notes Dr. Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism.

It can also reduce, at least temporarily, the ability of platelets in the blood to form clots that can block coronary arteries.

And at least some types of alcohol, notably red wine, contain anti-oxidants that may keep LDL from oxidizing. In oxidized form, LDL leads to fatty plaques that clog vessels.

Primarily because of the cardiovascular effects, the Nurses’ Health Study of 85,709 women showed that moderate drinkers (women who had between one-half and one drink a day) had a 12 percent lower risk of death from all causes than women who drank nothing and a 26 percent lower risk those who drank heavily.

A drink was defined as a 4-ounce glass of wine, a 12-ounce can or bottle of beer and a half-ounce of spirits.

But not all women benefit from moderate drinking. In fact, the Nurses’ study showed that if a woman is at low risk of heart disease to begin with, either because she is under 50 or has no coronary risk factors, moderate drinking doesn’t carry any health benefit, though it won’t hurt either.

The women who do benefit are those at higher-than-normal risk of heart disease, notes Dr. Walter Willett , one of the authors and a professor of epidemiology and nutrition at the Harvard School of Public Heath.

Factors that raise heart disease risk include high blood pressure, high cholesterol, diabetes, obesity, a sedentary lifestyle and having a parent who had a heart attack before age 60.

And there’s other evidence that a drink or two may do more than just keep the heart doctor away.

One study of nearly 10,000 women over 65, published last year in the Journal of the American Medical Association, showed that women who drank moderately did better than nondrinkers on physical function tests, perhapsbecause alcohol was a sign that the drinkers had a more active lifestyle.

Another study, published in 1994 in the American Journal of Public Health, showed that women — and men — who drank moderately got less depressed under stress than teetotallers or heavy drinkers, again perhaps because moderate drinking was a marker for other healthful habits that offset stress.

But drinking clearly has a dark side for women, too, quite apart from the obvious — alcoholism and fetal alcohol syndrome.

At one and a half to two drinks a day, the Nurses’ study showed, the risk of dying from breast cancer — a risk that was invisible at lower levels — increases, perhaps because alcohol raises levels of the hormone estrogen, which promotes some breast cancers. At more than two and a half drinks a day, overall mortality begins to rise, too.

And the risk of breast cancer may increase with as little as one drink a day, says Matthew Longnecker, an epidemiologist at the National Institute of Environmental Health Sciences whose report on more than 16,000 women was published in June.

In contrast to the Nurses’ study, which focused on death rates, Longnecker studied the risk of getting breast cancer and found a daily drink was linked to a 40 percent increase in risk, suggesting that 5 to 10 of the 184,300 cases of breast cancer expected this year might be attributed to alcohol consumption.

“That is a stronger association than what had been found in previous studies,” he says, perhaps because he studied lifetime consumption, not recent drinking.

On the other hand, Dimitrios Trichopoulos, an epidemiologist at the Harvard School of Public Health, found in a smaller study of 2,400 women last year that it takes three drinks a day to increase breast cancer risk at all.

To some, like epidemiologist Lynn Rosenberg of Boston University, all this simply means that any causal link between alcohol and breast cancer is farfrom established. But she adds that since “we don’t know how to reduce the risk of breast cancer, even the hint of an increased risk may be enough to persuade some women, particularly younger women at low risk of heart disease, not to drink.”

Others, notably the Wine Institute, a California-based industry association, put a cheerier spin on ambiguous findings, especially the hint — from Longnecker’s study — that the kind of alcohol a woman drinks may affect breast cancer risk.

Longnecker acknowledges that he found wine “was not related to risk of breast cancer,” while beer and liquor were. Beer drinkers had a 25 percent increase in breast cancer risk and liquor drinkers, an 18 percent increase. If wine has an advantage, it might be because it contains so-called “phenolic compounds” that may be protective, he and his team wrote, while beer and liquor “may contain substances that have estrogenic activity.”

But he and other epidemiologists stress that other studies, including somefrom Italy and France, found an increased breast cancer risk even among wine drinkers, which means the issue is far from settled.

And there is growing evidence that women’s bodies are more vulnerable than men’s to alcohol, says Dr. Charles S. Lieber , director of the alcoholism research and treatment center at the Bronx Veterans Affairs Medical Center and professor of medicine at the Mt. Sinai School of Medicine in New York.

In men and women of equal size who consume equal amounts of alcohol, he says, blood levels of alcohol are higher in women, partly because women’s bodies contain less water and more fat, which means alcohol is less diluted in their blood. But women also make less of a stomach enzyme called alcohol dehydrogenase, which helps digest alcohol.

Lieber, whose team recently cloned the gene for this enzyme, says that unlike male alcoholics, who still make some alcohol dehydrogense, female alcoholics make virtually none. And for some women, the ulcer drug Tagamet also exacerbates the problem, making alcohol dehydrogenase even less active.

Women’s livers are particularly vulnerable to alcohol, too, he adds. French studies show men must have about five drinks a day to cause cirrhosis, or heavy scarring, of the liver, while women can get cirrhosis drinking only a glass and a half to two and a half glasses of wine a day.

The bottom line, he says, is that “one drink in a woman of average size is equivalent to two drinks for a man.”

And that is precisely what the revised US government dietary guidelines, issued last week, recommend for those trying to get the health benefits but not the risks of alcohol:

No more than one drink a day for women, two for men.

At this level of consumption, says Willett, alcohol “won’t have overall harmful effects and might even help some women.”

SIDEBAR

EARLY ABUSE IS OFTEN A FACTOR IN ALCOHOLISM

Though male alcoholics outnumber female alcoholics 3 to 1, women seem to suffer medical complications from drinking at far lower levels of alcohol consumption than men. And different factors seem to predispose women to problems with alcohol.

As with men, a family history of alcoholism raises women’s risk of alcoholism, perhaps even more so than for men.

But women, to a greater degree than men, tend to start abusing alcohol during periods of transition like divorce, or when they are in relationships with heavy drinkers, says Norma Finkelstein, director of the Coalition on Addiction, Pregnancy and Parenting in Cambridge.

But perhaps the most telling factor is that many of the 4 million American women who abuse alcohol or are alcoholics were physically or sexually abused as children, says the National Council on Alcoholism and Drug Depencence, Inc., in New York.

But socioeconomic factors also play a part. Alcohol use is most prevalent among white women, according to the Commonwealth Fund Commission on Women’s Health. Seventeen percent of white women report moderate to heavy drinking, compared with 11 percent of African American women, 9 percent of Latinas and 6 percent of Asian women.

Alcohol use also increases with income and education, the Commonwealth Fund found. Roughly 8 percent of women without a high school education are moderate to heavy drinkers, versus 20 percent of those with at least some college. Heavy drinking was defined in this study as having more than two drinks a day.

Some states, Massachusetts foremost among them, have made a special effort to create women-only alcohol treatment programs. Research suggests that when men and women are treated together, “the men do better and the women do worse” because women “pay attention to what men need, not what they need,” says Finkelstein.

Co-ed treatment groups can make it more difficult for women to talk about sex abuse, incest, violence and feelings of guilt and shame about raising children while drinking or having drunk alcohol during pregnancy, which can lead to fetal alcohol syndrome, adds Alan Milner, director of the Massachusetts Drug and Alcohol Hotline.

Women drinkers also face more scorn from society than men, adds Dr. Roger Weiss, clinical director of the alcohol and drug abuse program at McLean Hospital in Belmont.

Once in treatment, though, women who are both depressed and alcoholic do better than women who are not depressed, he says, though this is not true for men. Perhaps, he says, depression makes women “more ready for treatment.”

SIDEBAR:

If you need information or help with an alcohol problem, you may call:

The Coalition on Addiction, Pregnancy and Parenting, 617-661-3991.

The Alcohol and Drug Abuse Hotline, 617-445-1500 or 1-800-327-5050. For the deaf, the TTY number is 617-354-0997.

Alcoholics Anonymous, 617-426-9444.

Exercise Appears to Boost Immune System – to a point

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You head out the door, virtue personified, for the first run, or at least brisk walk, of the year.

You know — who doesn’t by now? — that regular exercise is great for your heart, your muscles, your mental health.

You may even think — as exercisers usually do — that working out is a tonic for your immune system. Indeed it may be, provided you don’t push yourself to the max too often.

But as the once-tiny field of research into exercise and immunity blossoms — the two-year old International Society of Exercise and Immunology wrapped up its second meeting in Europe recently — researchers are finding that the links between exercise and immunity are more slippery than once thought.

The emerging picture, they say, is that any connection between exercise and, say, the risk of getting a cold, probably follows a J-curve, with both too little and too much exercise being deleterious, and moderate exercise, potentially beneficial.

But caveats are in order.Compared to research on exercise and heart function, the study of exercise and immunity is in its infancy. Just figuring out what to measure is tricky

because exercise varies in type, intensity and duration, people vary in basic fitness and the immune system is one of nature’s most complex creations.

Links between exercise and immunity are “interesting, but speculative,” says Dr. Jerome Groopman, chief of hematology and oncology at Deaconess Hospital.

“What’s required is a very critical look at how immune function is measured in these studies,” he says.

Some studies do show that the activity of some immune cells “can be affected by exercise,” says Roger Fielding, an exercise physiologist atBoston University. The problem is how to interpret this.

Blood counts of immune cells called neutrophils, for instance, “go up if you do a bout of exercise,” Fielding says. But this may only be a sign that the inflammatory process by which the immune system repairs exercise-induced muscle tears is working, not a sign the body is better primed to fight infections or cancer.

With other measures, like observed increases in natural killer cells, it’s unclear whether changes are big enough or last long enough to impact immunity, he says, adding, “I’m very skeptical.”

Still, the consensus is that regular, moderate exercise “will boost some aspects of immune function,” says William Evans, director of the Noll Physiological Research Center at Pennsylvania State University in University Park. “And it’s likely that people who exercise regularly have lower rates of certain kinds of cancer and greater resistance to infection.”

Studies from Texas, for instance, show that deaths from all causes — including cancer — are lower in people who are regular, moderate exercisers than in sedentary people.

“There’s also evidence,” says Evans, “that people who exercise regularly have higher levels of IL-1, a natural substance that raises body temperature — producing fever — and helps kill invading organisms.

David Nieman, professor of health and exercise science at Appalachian State University in Boone, N.C., has been finding growing evidence of links between exercise and immunity.

In two randomized, controlled studies, Nieman, president-elect of the exercise and immunology society, compared overweight, sedentary women who began a program of brisk walking for 45 minutes, five days a week, with matched controls who remained sedentary. He found the walkers suffered only half as many sick days for colds as the others.

More intriguing, Nieman found that the number of immune cells — some of which normally live in the spleen and lymph nodes — increased temporarily in the walkers’ bloodstreams. There, at least in theory, they’d be more available to fight off germs.

Other researchers have shown that “graded exercise” may help people with HIV infection or chronic fatigue and immune dysfunction syndrome (CFIDS) — perhaps by improving mood, which in turn may influence immune function. But this remains unproven.

Dr. Leonard Calabrese, head of clinical immunology at Ohio’s Cleveland Clinic, has found that his chronic fatigue patients feel better if they walk a bit — three to four minutes a day — and increase this by one to two minutes every two weeks.

Graded exercise seems to benefit people with HIV infection, too, provided they are in decent shape to start with.

Among Calabrese’s HIV patients, exercise seems to boost natural killer cells and at least does not decrease the number of CD4 cells, the main type of immune cell attacked by the AIDS virus.

Weight lifting, he finds, doesn’t seem to affect the immune system, though it helps retain lean body mass.

And as with so much else in life, however, if you overdo it, exercise can become too much of a good thing. In fact, though many peopleexercise too little, some do far too much, especially world class athletes who, says Evans of Pennsylvania, “are always on the edge of overtraining.”

“Excessive exercise can backfire,” agrees Dr. Kenneth Cooper, founder of the Cooper Aerobics Center in Dallas. He believes too muchexercise stimulates an outpouring of free radicals, chemicals formed in the body when oxygen is burned.

Whether free radicals — which the body fights by increasing production of anti-oxidant enzymes — impair immune function is not clear, but Cooper
recommends taking anti-oxidant supplements anyway, though others say the data to justify this is incomplete.

At the very least, there’s growing evidence that athletes who push too hard for too long seem to be more susceptible to colds.

In 1987, Nieman surveyed 2,311 runners training for the Los Angeles marathon, including in his study both those who raced and those who dropped out for nonmedical reasons. He found that those who raced were six times more likely to get colds afterwards, a sign of how stressful the long race can be.

To see which immune components might be involved, he then coaxed 50 marathoners into his lab — by offering $100 a head — and asked them to run for 90 minutes to three hours on a treadmill at 80 percent of maximum aerobic capacity.

By measuring blood levels of immune cells — neutrophils, monocytes, natural killer cells, T cells and B cells — before and after the run, he found immune cells “leave the blood and go to muscles,” presumably to repair damaged muscle fibers.

This suggests, he says, that the risk of infection may increase temporarily after a long, hard workout because “the front lines don’t have as many soldiers,” though immune function does bounce back to normal nine to 24 hours later.

Nieman also measured runners’ levels of cortisol, a hormone and powerful immunosuppressant that soars in response to both mental and physical stress. He found that after a 3-hour morning run, cortisol soars and stays high all day.

For that reason, Nieman recommends that exercisers stay out of “cortisol country.” The way to do that, his studies show, is to work out at 70 percent of your maximum heart rate for no more than 90 minutes per session.

The bottom line, says exercise physiologist Edmund Burke at the University of Colorado, is that while exercise is necessary, if done to excess “it’s a double-edged sword.”

And while most of us need to hear primarily the first half of that message, some need to hear the last.

Indeed, Bicycling magazine, citing two small but alarming studies in Poland and Australia, recently warned that while riding hundreds of miles a week leads to fitness, it may also lead to impaired immunity.

Nieman came to that same conclusion two years ago. After running 58 marathons, he quit. “My own research was convincing me it was not a healthy thing to do,” he said.

To increase fitness without damaging muscles or the immune system, exercise physiologists suggest several DOs and DON’Ts:

SIDEBAR:
EXERCISE: THE RIGHT WAY AND WRONG WAY TO DO IT

DOs

  • Spend at least 30 minutes on moderate physical activity on most, preferably all, days — brisk walking, cycling, swimming, yard work, etc. — either continuously or in 10-minute bouts.
  • If you run, a good goal is 10 to 15 miles a week. More than that won’t boost longevity or health, and running more than 30 miles a week may be detrimental.
  • To maintain muscle mass and bone density, lift weights two to three times a week. Weights should be heavy enough that you can only lift them 8 to 10 times before needing a rest.
  • For cardiovascular conditioning, keep your heart rate at 65 to 90 percent of maximum for 30 minutes, three to five times a week. To find the right range for your heart rate, subtract your age from the number 220, then multiply the result by 0.65 to get the minimum, by 0.9 for the maximum.
  • If you have a serious disease such as HIV infection, chronic fatigue syndrome or cancer, ask your doctor about exercising. Moderateexercise, under supervision, may be beneficial.
  • Eat a balanced diet, with lots of fruits and vegetables, and allow time for sleep and rest.
  • The data is incomplete, but some specialists recommend anti-oxidant supplements if you exercise heavily: 1,000 milligrams a day of vitamin C, 400 International Units of vitamin E and 25,000 International Units of beta- carotene.
  • Follow the NECK UP rule for exercising with a cold — if symptoms are primarily nasal, exercise as usual.

DON’Ts

  • Don’t exercise if you have symptoms below the neck such as a bad cough or a fever or muscle aches. Muscle aches may be a sign of infection with the coxsackie virus; exercise can cause this virus to migrate to the heart, with potentially fatal consequences. If you’re coughing from bronchitis, exercise may trigger asthma.
  • Don’t exercise hard for any more than 90 minutes at a time to avoid release of cortisol, a stress hormone and immune suppressant.
  • Don’t over train lest you compromise immunity, especially if you have other stresses like major job problems or divorce.
  • Don’t expose yourself to unnecessary germs if you’re training hard. Avoid crowds when you can, wash hands and disinfect things other people touch, like telephones, door knobs or keyboards.
  • Don’t lose weight too fast. Losing more than two pounds a week may compromise T cells. If you exercise and starve yourself, your body may interpret this as stress and pump out cortisol.