Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Thyroid ills catch many by surprise

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To listen to Lisette Mancini, a 40-year old Walpole audiologist and mother of three, you might be tempted to conclude that thyroid troubles are a blessing.

Years ago, as a student at Boston College, her metabolism was cranked so high she “flew through school because I had so much time to study. I never slept. I was never tired,” she recalls. She got all A’s, carried a double major, and did an honors thesis.

Sure, she was always hungry. But that meant she could eat three dinners a night and not get fat. She was always hot, but she’d just open the window and wear T-shirts while her roommate bundled up.

But this was no blessing. Mancini’s heart raced even when she lay down. Her periods were erratic. She was elated one minute, catatonic the next. Her skin was so greasy she needed two showers a day — but she never worried about any of it, like millions of others whose thyroid problems creep up on them.

Finally diagnosed with hyperthyroidism, she had surgery to remove most of the butterfly-shaped gland in her neck that was producing too much thyroid hormone, which is crucial for basic metabolism. The tiny bits left supplied normal levels — and she was fine for years.

But then, like many women, she developed problems from too little thyroid after her first pregnancy. Now she had hypothyroidism and felt like “a total zombie.”

Mancini’s problems may seem extreme, but the trouble she — and some of her doctors — had in spotting the warning signs is so common that the American College of Physicians and the American Society of Internal Medicine recently issued new guidelines calling for thyroid screening for all women over 50.

The American Association of Clinical Endocrinologists, who specialize in hormone problems, goes even further. Since 1995, that group has urged not just screening but treatment for patients whose thyroid tests are abnormal, even if they have no symptoms, says Dr. Stanley Feld of Dallas, a past president.

An estimated 11 million Americans, many of them women over 50, have hypothyroidism, or an underactive thyroid, which results in fatigue, forgetfulness, depression, chilliness, weight gain, elevated cholesterol and goiter, an enlarged thyroid gland. Many more people are never diagnosed because the symptoms are chalked up to aging or “the blues.”

Another 2 million Americans, many of them women aged 20 to 40, have hyperthyroidism, or an overactive thyroid, which causes nervousness, weight loss, intolerance to heat and goiter.

Hyperthyroidism is also often underdiagnosed, especially in older people with subtle symptoms, says Dr. Mark Helfand, an internist at Oregon Health Sciences University in Portland.

Both hypothyroidism and hyperthyroidism can result from a misguided attack by the body’s immune cells and antibodies on the thyroid gland — in the first case, inhibiting or destroying the gland, in the second, kicking it into high gear.

With hypothyroidism, the most common cause is an auto-immune syndrome called Hashimoto’s thyroiditis, which often runs in families; with hyperthyroidism, the most common cause is an auto-immune condition called Graves’ disease, which also tends to run in families, though here, too, not everyone with a family history of thyroid troubles is at risk.

The screening now widely recommended is a blood test for TSH, or thyroid stimulating hormone, which is made by the pituitary gland. When the pituitary senses the body is not making enough thyroid hormone, TSH levels rise, signalling the thyroid gland to make more. The test picks up minute fluctuations in TSH.

If your TSH is abnormal, doctors add another test to detect blood levels of thyroid hormone itself. It’s a clear sign you need treatment for hypothyroidism if your TSH is elevated and your thyroid hormone levels are low. You need treatment for hyperthyroidism if the reverse is true — low TSH and high thyroid hormone levels.

Where things get tricky is with “subclinical” disease, particularly hypothyroidism — when TSH is elevated but thyroid hormone is normal, says Dr. Robert D. Utiger, an endocrinologist and deputy editor of the New England Journal of Medicine.

Many specialists, Feld among them, recommend treatment even for subclinical disease because patients with subtle symptoms often feel better.

But the data are “unimpressive,” says Utiger. According to the American College of Physicians, studies of people who have subclinical disease and symptoms are inconclusive, and people with no symptoms have not been shown to benefit from treatment.

Complicating things is the fact that patients who deny symptoms may have them nevertheless, says Dr. John C. Morris, a Mayo Clinic endocrinologist, though this may only become clear when the doctor asks more questions.

“It’s a subtle thing,” adds Feld. “You don’t wake up one day” with hypothyroidism. “You get a little bit that way, then a little more.”

The treatment for hypothyroidism is straightforward, and “great, provided you need it,” says Helfand. Thyroid supplements — chiefly, levothyroxine (which comes in generic form and in brands such as Synthroid or Levoxyl,) are safe, effective and cheap — about $20 for a three-month supply.

The catch is that doses have to be monitored lest you go from having too little thyroid hormone to too much, which can lead to osteoporosis and increased risk of a heart rhythm abnormality called atrial fibrillation.

Like hypothyroidism, hyperthyroidism can also appear in subclinical form. But it, too, is readily treatable.

One treatment is radioactive iodine (a one-time capsule) to shrink the thyroid gland. This does not seem to cause cancer, thyroid specialists say, though many patients are leery.

An alternative is the drugs Tapazole or PTU (propylthiouracil) that block production of thyroid hormone.

Yet another is surgery to remove the thyroid gland, or most of it, though this can be difficult to do without disrupting the adjacent glands that control calcium metabolism.

In many cases, once an overactive thyroid problem is treated, you will end up with hypothyroidism, which means you’ll need to take a thyroid hormone replacement drug.

Recently, there’s been growing concern that iodine deficiency in the American diet may increase the risk of thyroid problems, especially during pregnancy, says Dr. Reed Larsen, chief of the thyroid division at Brigham and Women’s Hospital in Boston.

The thyroid gland makes hormone from iodine, which is present in many foods, including salt and fish. But a recent government study of urine samples showed that between 1974 and 1994, the proportion of Americans deficient in iodine has grown from 2.4 percent to 11.7 percent. Iodine deficiency in pregnant women has also grown — from 1 percent to 7 percent.

“We thought we had cured this by putting iodine in salt,” Larsen says. It’s unclear why this deficiency is growing, but some suspect that people are using less salt and that iodine is used less often as a preservative in bread.

Pregnant women, especially if they have an auto-immune disease, should be especially alert to thyroid problems. In many women, stored thyroid hormone spills into the blood as soon as pregnancy is over, causing hyperthyroidism. After several weeks, the pituitary gland signals the thyroid gland to cut production of the hormone, which then can trigger hypothyroidism.

“You go from palpitations and fretfulness, which you think is because you’ve just had a baby. . .to feeling dragged out and tired, which you say is because you just had a baby,” says Feld, adding that doctors overlook the possibility of thyroid problems for the same reasons.

The bottom line, whether you’re young or old, female or male, recently pregnant or not, is that if you feel inexplicably tired — or wired — talk to your doctor. And ask about a TSH test.

Talk about what really ails you

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You sit there in that silly little gown, trying to act normal. The doctor comes in. You exchange hellos, then launch into why you’re there.

Within 18 seconds, according to a study of more than 1,000 doctor-patient encounters, the doctor interrupts. Suddenly, you blank out on that chest pain two weeks ago and start babbling about your toenail fungus and how many colds you get. You anxiously scan the doctor’s face as he probes your belly.

At the end, clothed and courageous again, you pause, hand on doorknob, and blurt out why you came: You’re too depressed to sleep. You’re drinking too much. And you get these chest pains.

The doctor sighs. Another tortured medical visit.

Even with a doctor who’s a sweetheart at home and a patient who’s a dynamo at work, communication tends to fall apart in the doctor’s office. The power balance is weird. Patients are scared and tongue-tied, not to mention half-naked. Doctors are busy.

The result, all too often, is frustration on both sides, as well as missed diagnoses and malpractice suits, say those who study patient-physician interactions and ways to improve them.

A big part of the problem, of course, is time. The widespread perception, among patients and doctors alike, is that the length of visits is shrinking, particularly with managed care.

“I don’t know of any good, current information about whether they’re shrinking, but patients and doctors seem to think so,” says Dr. Harold Sox, president of the American College of Physicians and chairman of the department of medicine at Dartmouth Medical School. Asked how long a family doctor’s visit lasts these days, he guesses, “Oh, golly. . .around 8 minutes.”

Maybe even seven, if you believe the January-February issue of “Gratefully Yours,” a newsletter from the National Library of Medicine, though this figure is based purely on anecdotes.

What data there are, in fact, seem to point the other way, says Donald B. White, spokesman for the American Association of Health Plans. According to “Socioeconomic Characteristics of Medical Practice, 1997,” a book put out by the American Medical Association, doctors say the average length of their visits has actually increased from 24.3 minutes in 1985 to 26.9 minutes in 1996.

A more precise study – an analysis of national ambulatory care surveys published in March, 1998 – shows that between 1979 and 1994, average doctor visits, at least for kids and teenagers, grew from 11.8 minutes to 14.2 minutes.

Other studies suggest the average visit for a checkup today is 15 minutes, “about half as long as doctors say they need,” says Dr. Christopher Forrest, an assistant professor at the Johns Hopkins School of Public Health.

So the real issue, whether you get 24 minutes for a checkup or four for a raging sore throat, is how to make the most of the time you get. And that means telling the doctor up front – not when you’re leaving – what’s on your mind, preferably your two or three main concerns, not a litany of 20 vague complaints.

It means remembering to mention other professionals (medical specialists as well as alternative types like chiropractors) you see and all medications (including herbs) that you take. It means asking questions when you don’t understand. And perhaps most difficult, it means having the courage to mention things you’re shy about, like troubling bowel habits, sexually transmitted diseases and anxiety or depression.

“Most people are very impressed with technology like cardiograms and blood tests,” says Dr. Marc D. Silverstein, director of the Center for Health Care Research at the Medical University of South Carolina.

But talking is far more important than tests. In studies at the Mayo Clinic, Silverstein found that history-taking – when you tell the doctor what’s been bothering you – identifies 10 times as many problems as urinalysis, and five times as many as a complete blood count.

That fits with what the American Society of Internal Medicine has been saying for years – that 70 percent of all correct diagnoses are made just by talking with patients.

So how can you communicate most effectively?

“Prepare, prepare, prepare,” says Dr. Barbara Korsch, a pediatrician at Children’s Hospital of Los Angeles and member of the National Academy of Sciences who pioneered the study of doctor-patient relationships. Patients often complain that they never get to ask the most important question, she says.

You can make sure you do, but you have to set priorities.  “That doesn’t mean you have to burst in and have an emotional explosion, but you can come in with an agenda in mind, or written down,” she says.

Be specific, adds Molly Mettler, senior vice president at Healthwise, Inc., a health information organization in Idaho. If you think you’ll forget, bring notes on when symptoms begin, what time of day they occur, what type of pain you feel.

And ask about alternatives for treatments or tests your doctor suggests, says Maysel Kemp White, associate director at the Bayer Institute for Health Care Communication in West Haven, Conn.

It may also help to “rehearse out loud” what you want to say, says Dr. Sheldon Greenfield, director of the Primary Care Outcomes Research Institute at New England Medical Center in Boston.

With his wife, psychologist Sherrie Kaplan, Greenfield has conducted studies showing that when patients are coached on how to present problems in an assertive but not adversarial way, they get more answers from doctors – and fare better, with improvements in blood sugar, blood pressure and other measures.

And if your doctor cuts you off, either ask to finish your thought or ask if you can come to back to it in a minute.

The bottom line is that most doctors want to listen. In fact, they’re taught an oft-cited dictum: Listen to your patients – they’re giving you the diagnosis.

It’s the doctor’s job to ask for details. But he can’t listen to what you don’t tell him. Previous “Health Sense” columns are available through the Globe Online searchable archives at http://www.boston.com. Use the keyword columnists and then click on Judy Foreman’s name.

Being prepared helps

Here’s how to talk to your doctor effectively:

  • Be prepared, with written notes and questions if necessary.
  • Prioritize – talk about your 2-3 most important concerns.
  • Write down the doctor’s answers to your questions.
  • If you need more time, schedule another visit.
  • Bring a relative or friend if you need help communicating, or remembering what the doctor says.
  • But if you’re concerned about domestic abuse and the abuser wants to accompany you, ask the doctor to see you alone.
  • For general checkups – whose usefulness is a matter of debate, at least for younger people – it may be best to see a primary care physician. If you want to see a specialist such as a gynecologist, ask if that doctor is comfortable doing a checkup.
  • Tell the doctor about other health professionals you see and any treatments and drugs, including herbs, you use.
  • Don’t assume your doctor is negligent if he says you don’t need some standard tests. Many of them are unnecessary, says the US Preventive Services Task Force, a government panel. The important ones are a cholesterol test, a blood pressure check, a colorectal cancer screening test, and, for women, a Pap smear and mammogram. The value of the PSA test for prostate cancer is still a matter of hot debate.

For more information, you might read:

  • “Healthwise Handbook, a Self-Care Manual for You,” by Healthwise, Inc., Boise, Idaho. (On the net, www.betterhealth.com)
  • “The Intelligent Patient’s Guide to the Doctor-Patient Relationship,” by Dr. Barbara M. Korsch and Caroline Harding, Oxford University Press, New York and Oxford.
  • “Talking with Your Doctor, A Guide for Older People,” a booklet by the National Institute on Aging. (1-800-222-2225 or on the net, www.nih.gov/nia.) Supplies are limited.

 

When a staple of diet can be lethal

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Max Collins, now 8 and a second grader in Burlington, was a baby when a tiny taste of peanut butter nearly killed him.

No sooner had his mom, Lisa, now 32, spread a smidgeon on Max’s lips than he began vomiting and screaming. Huge hives sprouted on his skin. “It was almost simultaneous,” Lisa says. “I never knew foods could cause something life-threatening.”She rushed him to the nearest emergency room, where health workers, suspecting a potentially fatal allergy attack, pumped him full of epinephrine and Benadryl. Max survived, and hasn’t been near a peanut since – no small feat given that peanuts can lurk in any number of unsuspected places, from bakery-bought cakes to a restaurant meal cooked in a pan that has traces of peanut from a previous recipe.

Food allergies, once dismissed as rare or insignificant, are getting new respect. In response to requests from people with peanut allergies, the federal Department of Transportation told 10 major airlines in August that they must provide peanut-free “buffer zones” if a passenger with an allergy requests it. (Under pressure from peanut producers, however, the agency has been re-examining that policy.)

School systems, too, are grappling with ways to balance the needs of allergic kids with the rights of others to their p-b-and-j’s. Instead of bans – which can arouse antagonism without guaranteeing safety – many schools now offer peanut-free cafeteria tables, no-sharing policies for lunches or candy bars that may contain traces of peanuts, and instructions for teachers on handling allergy emergencies.

Still, food allergies – the big ones are to peanuts, tree nuts like walnuts and pecans, shellfish, fish, eggs, milk, wheat, and soy – pose a delicate problem.

On the one hand, the mere notion of killer food strikes some as ludicrous, though 100 to 125 people die every year from allergies to food – mainly peanuts – estimates Dr. Hugh Sampson, director of the Jaffe Food Allergy Institute at New York’s Mt. Sinai School of Medicine. He is also medical director for the Food Allergy Network in Fairfax, Va., a nonprofit education group.

Government statistics count only 88 deaths from food allergies between 1979 and 1995, but both sets of numbers are considered soft.

On the other hand, many people who think they have a food allergy – 25 percent of adults, according to one survey – do not, says Anne Munoz-Furlong, founder of the Food Allergy Network.

In reality, only 1 to 2 percent of people truly have a food allergy, she says. But that’s more than 5 million Americans and the number – hard data are scarce – appears to be growing, especially for allergies to peanuts, which are actually in the legume, not the nut family.

Despite the lack of solid data, many pediatricians and allergists believe peanut allergies are on the rise.

“The problem has doubled or tripled since I have been in practice for the last 15 years,” says Dr. John Saryan, an allergist at the Lahey Clinic in Burlington who thinks peanut consumption by nursing mothers may be partly to blame.

There’s no proof that the three proteins in peanuts that trigger allergies cross the placenta to the fetus during pregnancy. But there is evidence that peanut allergens are present in breast milk.

When a baby nurses, his immune system begins making a type of antibody called IgE to peanut allergens in breast milk. When an allergy-prone child is then exposed later in life to a larger dose of allergens – in a peanut butter sandwich, for instance – the allergens combine with his antibodies, triggering release of histamine and other chemicals from mast cells that line the respiratory and digestive tracts and the skin.

This leads to hives, vomiting, and swelling of the bronchial tubes as fluids seep out of blood vessels. The end result can be life-threatening anaphylactic shock – characterized by severe breathing problems and a drop in blood pressure.

Allergic reactions are especially dangerous in children who have asthma, says Dr. Dean Metcalfe, chief of the laboratory of allergic diseases at the National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health.

In most cases, it takes ingestion of a peanut product to produce a reaction, not merely touching it or inhaling peanut dust. (Peanut oils are considered safe, by the way, as long as they are made by acid extraction and heat distillation, as most commercial products are.)

But for some, even airborne exposure can be a problem, says Mike Hanson, a 43-year-old lawyer from Hingham whose son Dan, now 7, once reacted to the “airborne smell” of peanuts at a hotel. And that, he says, makes plane trips terrifying. “When 300 people open bags of peanuts at the same time, you can smell it. You are trapped. There’s no fresh air, no way out.”

Allergist Sampson agrees, saying some people have had such severe reactions after other passengers opened bags of peanuts that planes had to make emergency landings.

The allergens clearly linger in airplane ventilation systems, says Dr. John Yunginger, an allergist and pediatrician at the Mayo Clinic, whose data were used by the federal government. What’s not clear from his data, though, is whether enough peanut particles linger in the air to make people sick.

For some people, living with a food allergy is simply a nuisance. “Oh, I almost died several times,” says Paul Kelley, 63, a physicist and director of the electro-optics technology center at Tufts University who is severely allergic to peanuts.

When he visited China, where peanuts are used extensively in cooking, Kelley had a friend write him a sign to flash in restaurants saying, “Do not feed this white monkey peanuts.” But basically, he says, “I guess I’m oblivious.”

Not Lisa Collins. To protect her son, Max, she reads every label on every food product. She takes him only to restaurants with standardized menus, like McDonald’s. She talks to school staff to make sure other kids don’t give him peanut butter sandwiches or candy bars.

And when Max goes to birthday parties, he takes along something to eat rather than birthday cakes from a bakery, which could contain peanut allergens if mixing bowls and other utensils were previously used for foods containing peanuts.

Lisa also makes sure that wherever Max goes, there’s an adult with an EpiPen nearby, to give him an injection of epinephrine if he develops a reaction to unwittingly ingested peanuts.

“The threat is always with us,” she says, “but the more aware people are, the safer Max is.”

Some tips for averting perils in food allergies

Any food can potentially cause anaphylactic shock, a potentially life-threatening reaction. The most common culprits are peanuts, tree nuts, shellfish, fish, eggs, and milk.

  • Milk and eggs cause the most common food allergies in children, but unlike with many other allergies, people often outgrow them as they get older. Not so with peanut allergies.

  • Labels on food products are supposed to say whether the product contains allergy-triggering substances, but the labeling process is not foolproof. Labels do not have to say whether the food was processed in a vat also used for peanut products, which means cross-contamination is a slight possibility. In September, the Pillsbury Co. recalled some cookie dough products because the packages may have contained walnuts not listed on the label. Other companies have recalled products because labels failed to list peanuts, eggs, milk, pecans, hazelnuts or almonds.

  • If your school-age child has a food allergy, request a meeting with the principal, school nurse, cafeteria personnel, and teacher to make sure they know how to handle an emergency.

  • Use role-playing to teach your child ways to avoid contact with food allergens in the cafeteria or to resist peer pressure to try a new food.

  • Send a spoil-proof lunch to be kept at school in case your child loses or forgets his allergy-safe lunch one day. This can include a can of tuna, crackers, canned fruit, and fruit juice.

  • If you or your child has a severe food allergy, carry an EpiPen (pre-measured epinephrine) and a written emergency plan. School-age children and adults may also want to wear a bracelet describing the allergy.

  • If you have a family history of asthma, hay fever or eczema, avoid peanuts if you are pregnant or nursing, and don’t let your child eat peanut products before age 3. (After that, a child’s maturing immune system may be less sensitive to peanut allergens.)

  • Remember: As little as 1/20 of a peanut can cause a fatal reaction in someone who is highly allergic.

For more information on food allergies, call the Food Allergy Network, 1-800-929-4040 begin_of_the_skype_highlighting              1-800-929-4040      end_of_the_skype_highlighting or try the Net, at www.foodallergy.org.

Four new drugs promise major relief for arthritis

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For years, millions of Americans with arthritis have been caught in a troublesome trap.

If they don’t take medication, they often suffer severe pain and life-wrecking disability. Yet if they do, they risk worrisome side effects. Some drugs, like methotrexate and high dose prednisone, can suppress the immune system. Others — notably painkillers like aspirin, Anacin, Advil, Motrin IB and others — can cause stomach ulcers and bleeding.

Every year, in fact, more than 60,000 Americans are hospitalized with complications from prescription and over-the-counter painkillers known as NSAIDS (pronounced EN-SAIDS), or non-steroidal anti-inflammatory drugs; thousands die.

But this grim picture could soon change dramatically, thanks to four drugs that are expected to be in drugstores soon: Arava, Enbrel, Celebra and Vioxx.

“In the last two decades, there hasn’t been any time like this, with four new drugs that appear to be very effective and very safe,” says Dr. Arthur Weaver, director of clinical research at the Arthritis Center of Nebraska and past president of the American College of Rheumatology.

These are “very exciting times,” adds Dr. Michael Schiff, medical director of clinical research at the Denver Arthritis Clinic, who calls two of the drugs “breakthrough medications.”

“Breakthrough” is a word researchers don’t use lightly, but it may be justified — though longterm side effects are still unknown.

Take Enbrel, the first arthritis drug in a relatively new class of compounds called biological response modifiers, which rev up or damp down specific components of the immune system.

Less than two weeks ago, an FDA advisory panel unanimously recommended approval of Enbrel for people with rheumatoid arthritis who have not improved on other treatments. The Food and Drug Administration usually follows the recommendations of its panels, and a decision is expected soon.

In rheumatoid arthritis, which affects 2 million Americans, an unknown factor — perhaps a virus — causes the immune system in genetically susceptible people to attack the synovium, a layer of cells that lines the joints. The result is chronic inflammation, pain, stiffness and joint destruction.

An additional 20 million Americans suffer from osteoarthritis, caused by wear and tear on joints.

A major culprit in many cases of arthritis is a natural substance called TNF-alpha, or tumor necrosis factor, that enters cells through a special receptor and helps promote inflammation. Enbrel, an injectable drug made by Immunex Corp. that has been studied in more than 1,000 patients, acts as a decoy receptor, mopping up TNF before it can enter cells, says Dr. Lee S. Simon, a rheumatologist at Beth Israel Deaconess Medical Center in Boston.

(Another drug that blocks TNF, Remicade, has already been approved by the FDA — for Crohn’s disease. But that means doctors can prescribe it for other problems, and evidence suggests it can help people with rheumatoid arthritis.)

Even more exciting, says Dr. Michael Weinblatt, director of clinical rheumatology at Brigham and Women’s Hospital, is Arava, made by Hoechst Marion Roussel. Following studies in 2,200 patients, it was approved by the FDA on Sept. 11.

Like the drug methotrexate, Arava actually modifies disease progression in rheumatoid arthritis. Taken orally, it inhibits pyrimidine, a building block of DNA. This affects immune cells called T cells, reducing inflammation in the synovium.

Promising though they are, nobody knows yet what the longterm side effects of Enbrel and Arava might be, warns Dr. Doyt Conn, medical director of the Atlanta-based Arthritis Foundation.

And then there are the new “super aspirin” drugs called Cox-2 inhibitors: Celebra, by Searle, and Vioxx, by Merck, as well as others in the pipeline. In late August, the FDA agreed to a fast-track review of Celebra, which means it could be approved in early 1999; Merck plans to file for approval late this year.

Unlike Enbrel and Arava, the Cox-2 inhibitors are aimed primarily at people with osteoarthritis, though they may be used, with other drugs, for rheumatoid arthritis, too.

In arthritis, it’s not just TNF that drives inflammation, but often other natural chemicals as well, notably the prostaglandins, which trigger those all-too-familiar symptoms: pain, swelling, redness and heat.

Prostaglandins are made in cells under the direction of an enzyme called Cox, or cyclooxygenase, and many painkillers work by blocking this enzyme. But it turns out that there is not just one Cox enzyme, as scientists used to think, but at least two. Cox-1 releases “good” prostaglandins that protect the stomach and kidneys. Cox-2, made primarily by cells at the site of an inflammation, releases “bad” prostaglandins that further drive inflammation.

The reason NSAIDs are a mixed blessing is that they work against both Cox enzymes, blocking both the bad and the good prostaglandins.

The new Cox-2 drugs block only the bad prostaglandins, which means they “hold the promise of being as effective as the old NSAIDs in managing pain and inflammation without the same side effects,” says Conn of the Arthritis Foundation.

So far, Celebra has been studied in trials of nearly 13,000 people. One of them was Rich Dillon, a 53-year old firefighter from Lincoln, Neb. who gave up long games of raquetball because of osteoarthritis in his knees. Celebra, he says, “makes a great difference,” and he can play short games again.

It appears to be living up to its billing as a stomach-friendly painkiller. In one study, notes Simon of Beth Israel, no one taking Celebra (a twice-a-day pill) developed an ulcer, but 19 percent of those taking a prescription form of naproxen, an NSAID, did.

Vioxx, a once-a-day pill tested so far in studies involving 9,000 people worldwide, appears to be even more potent than Celebra at blocking Cox-2, though it may also increase edema, or swelling.

In addition to these drugs, the FDA next month is expected to consider expanded use of a blood-filtering device called Prosorba that removes antibodies that contribute to inflammation.

Financially, the combined impact of the new arthritis drugs is expected to be “huge,” says Maryann Quinn, an industry analyst at BT Alex. Brown, Inc. in New York. Celebra alone could do $500 million in sales in 1999, she says.

The drugs will be expensive — an estimated $3,000 to $4,000 a year for Arava, $6,000 to $8,000 a year for Enbrel, for instance.

And the Cox-2 drugs in particular will help treat symptoms, but probably won’t alter the underlying course of disease.

Still, this slew of new drugs could finally bring safe relief to millions. It’s been years, says Weinblatt of the Brigham, “since we’ve had such promising therapies.”

SIDEBAR:

Help for Alzheimer’s?

It’s not just arthritis sufferers who may benefit from the new Cox-2 inhibitor drugs, but people with cancer and Alzheimer’s disease as well.

In recent years, 14 studies have shown that NSAIDs — drugs like Anacin, Advil, Nuprin, and others — can slow progression of Alzheimer’s disease by 30 to 50 percent, says Dr. Clifford Saper, chief of neurology at Beth Israel Deaconess Medical Center in Boston.

That’s probably because inflammation, well-known as a culprit in arthritis, plays a role in Alzheimer’s, too. As parts of the brain become clogged with deposits of a protein called beta-amyloid, inflammation often develops around these sites.

The NSAIDs probably slow progression of Alzheimer’s by blocking so-called Cox enzymes, which promote inflammation. But the NSAIDs have a major drawback: They often cause ulcers by causing changes in the stomach lining. By contrast, the new Cox-2 drugs block inflammation just as well as the old NSAIDs, but are far gentler on the stomach.

With colleagues at other centers, Saper is testing several hundred people with mild Alzheimer’s, giving some Celebra, a new Cox-2 inhibitor, and others a dummy pill. After six months, researchers will re-test all participants to see whether Celebra slows progression of the dementia.

The Cox-2 inhibitors may also lower the incidence of colon cancer, says Dr. Jerome Groopman, chief of experimental medicine at Beth Israel. Several studies in the last decade have shown that NSAIDs can reduce the risk of colon cancer by 50 percent.

Colon cancer often arises after a two-step process. In the first step, a gene mutation leads to high levels of the Cox-2 enxyme, which results in growths called polyps. Another mutation then causes the polyps to become cancerous.

In mice, Celebra seems to block formation of polyps, thus stopping cancer before it starts. Studies are underway to see if the drug can prevent colon cancer in people at high risk. Someday, “we may be able to exploit this for people with already-established tumors,” Groopman says.

For more information, you may call the Arthritis Foundation at 1-800-283-7800, or contact them on the Net at www.arthritis.org.

The other ways the sexes differ

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Women, at least in America, outlive men by six years.

So how, then, do you account for this:

Women are five times as likely as men to get migraines and osteoporosis, two to three times as likely to get seriously depressed, and much more likely to get diseases like lupus, rheumatoid arthritis and scleroderma, in which the immune system attacks the body’s own organs.

Women are also more susceptible to damage from tobacco and alcohol. In men and women of equal size who consume equal amounts of alcohol, blood levels are higher in women because they metabolize alcohol differently.

Certain biological basics differ, too. Women’s hearts beat faster. And food travels more slowly through women’s intestines, which may explain why they have more constipation and slightly more colon cancer. Women also respond differently to pain and to some anesthetics.

Granted, men fall prey to heart disease earlier in life than women, and they suffer more than their share of cluster headaches and violent deaths, especially when they’re young. But the enigma remains.

How can females — and for that matter, female mammals in general — outlive males, yet have such a disproportionate share of some diseases? Beyond the obvious Adam and Eve stuff, in other words, how do women’s and men’s bodies differ, and how important are these differences to health and medicine?

That’s exactly what researchers in a new field, gender-specific medicine, are trying to find out — a quest with potentially life-saving consequences, because women and men not only get certain diseases at different rates but often have different symptoms for the same disease.

Heart disease, for instance, is the number one killer of both men and women, though women on average get it 10 years later in life because they are protected until menopause, in part by the hormone estrogen.

But unlike men, women often don’t experience the “classic” heart attack symptoms: feeling as if there’s “an elephant on their chest,” or pain radiating down their arms, says Dr. Marianne J. Legato, director of the Partnership for Women’s Health at Columbia University College of Physicians and Surgeons.

Instead, many women, perhaps 15 to 20 percent, feel pain in the upper abdomen and have nausea, sweating and shortness of breath, says Legato, a pioneer in gender-specific medicine. Unless doctors are alert, women’s heart attacks may be dismissed as stomach aches and their breathlessness, as anxiety.

Sex hormones, and the ways they influence immune reactions, metabolism, and other functions, are one major factor in gender differences.

Osteoporosis, for instance, is clearly tied to low levels of estrogen, which is produced by the ovaries and keeps bones strong. The risk of osteoporosis rises steeply at menopause as estrogen levels decline.

Men have less osteoporosis largely because they continue to produce testosterone (which the body converts to estrogen) at a comparatively steady rate throughout life, notes Dr. Andrea Dunaif, chief of the Division of Women’s Health at Brigham and Women’s Hospital.

And it’s not just bones that respond. Receptors for estrogen, androgens and other hormones are scattered throughout the body, and researchers are just beginning to understand why, says Dr. JoAnn Manson, an endocrinologist at Brigham and Women’s and a principal investigator of the Women’s Health Initiative, an ongoing nationwide study of older women.

Perhaps the most puzzling gender differences are those in the immune system, most notably in auto-immune diseases that occur when immune cells and antibodies attack the body’s own tissues. Here, too, some researchers suspect a hormone connection.

“About 90 percent of auto-immune diseases occur more often in women than men,” says Dr. Robert Lahita, chief of rheumatology at St. Luke’s-Roosevelt Hospital in New York.

Women are nine times more likely to get systemic lupus erythematosus, three to four times more likely to get rheumatoid arthritis, four times more likely to get scleroderma, and two to three times more likely to get multiple sclerosis.

Both men and women make so-called TH1 cytokines, which promote inflammation and production of immune cells, as well TH2 cytokines, which stimulate antibodies. Estrogen may trigger extra production of some TH2 cytokines and may also inhibit cells that suppress inflammation, which would contribute to auto-immune disease, Lahita says.

But precisely how hormones influence cytokine production is a matter of debate — and intense research, much of it focused on pregnancy, a time when both hormones and the immune system play out a fascinating and perplexing script.

During pregnancy, levels of estrogen and another hormone, progesterone, are high. But if high estrogen were the sole reason women get more auto-immune diseases than men, you’d think that all that pregnancy would make auto-immune diseases worse. And that isn’t so.

In fact, some auto-immune diseases, like rheumatoid arthritis, actually go into remission, while others, like lupus, do not, notes Dr. J. Lee Nelson, a rheumatologist at Fred Hutchinson Cancer Center in Seattle.

Multiple sclerosis also gets better in some women during pregnancy, but often gets worse again after delivery.

What is clear is that evolution has deemed it important to make these immune shifts in pregnancy — probably for the survival of both mother and fetus.

That’s because some cells from the fetus inevitably cross the placenta and wind up in the mother’s bloodstream. If the mother’s immune system reacted too strongly to these fetal cells, which are half “foreign” because of the father’s DNA, she would reject the fetus, Nelson notes. This means her immune system must become “tolerant” of this foreign tissue. Yet the mother’s immune system can’t become too quiescent or she would come down with endless infections.

Teasing apart the intricate hormonal and immunological shifts during pregnancy has implications not just for women with auto-immune diseases, but for a basic understanding of how gender influences biology.

“Research on women, and the changes in sex hormones at menopause and during pregnancy, has already resulted in a whole new understanding of the importance of these hormones to the functioning of all systems in the body, from brain to skin,” says Legato.

But many questions remain. The big one is why, given the burden of so many gender-specific diseases, do women still live longer than men?

That’s “the great puzzle,” says Wanda Jones, deputy assistant secretary for women’s health at the Department of Health and Human Services.

“And if we understood that better, maybe we could help men live longer.'”

SIDEBAR:

Reconciling differences

Confronting gender-specific medicine:

  • If you’re a woman, ask your doctor if that means you should take a different dose of drugs than the package label says and whether you should expect different side effects.
  • Remember that alcohol has a more potent effect on women than on men and, cigarette for cigarette, tobacco is more deadly for women, too, not to mention more addictive.
  • When you read results from a study done on men, ask your doctor if the results apply to women as well. And vice versa.
  • If you’re a woman at risk for heart attack, remember that your symptoms may not be exactly like men’s chest pain, but may be pain in the upper abdomen, nausea, and shortness of breath.
  • The need for vitamins and minerals — including supplements — varies by gender, too. In general, adults need 1,000 milligrams a day of calcium, but postmenopausal women need 1,500 a day unless they’re taking estrogen. Men rarely need iron supplements, but menstruating women may. Women of childbearing age may also need 400 micrograms a day of folic acid.
  • Migraine headaches, acne, panic attacks, and seizures often get worse just before menstruation. A diabetic woman’s need for insulin may increase at this time, too.
  • If you’re a man with heart disease, make sure you’re not being given overly aggressive treatment. Women sometimes get treatment that’s not aggressive enough, but men are sometimes treated too aggressively — with clot-busting drugs, bypass surgery, and other interventions. So ask your doctor.

For more information on the subject, you might want to read “Gender-Specific Aspects of Human Biology for the Practising Physician,” by Dr. Marianne J. Legato, Futura Publishing Co., Armonk, N.Y.

The debt we owe the guinea pigs

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Fifty years ago this month, a band of researchers fanned out through the neighborhoods of Framingham, urging residents to sign up for a study designed to track ordinary people to try to detect early signs of heart disease – then, as now, the No. 1 killer of Americans.

One of the 5,209 who agreed was Ida Leach, now 83.

With her late husband, Henry, Ida Leach worked at the Dennison Manufacturing Co., making labels and crepe paper. The young couple eagerly agreed to undergo two hours of free medical testing every couple of years, and years later enrolled their kids and their spouses, too – an act that would prove life-saving.

Today, thanks to the Leaches and about 10,500 other volunteers, the Framingham researchers have published more than 1,000 scientific papers on heart disease, and spent $ 43 million.

Along the way, they’ve discovered most of what we now take for granted about heart disease – that cigarettes increase the risk (1960), that high cholesterol and blood pressure do, too (1961), that exercise lowers risk while obesity raises it (1967), that homocysteine (an amino acid) in the blood raises it (1990).

Those findings, like those from major studies of cancer and other diseases, are of inestimable benefit to society. But as the Leaches discovered, the personal benefits of becoming a human guinea pig can be enormous, too.

Twelve years ago, their son-in-law, Kenneth Kaczmarowski, of South Milwaukee, was in town for a regular family visit-cum-checkup, more than 15 years after he first accepted the Leaches’ suggestion that he, too, enter the study.

“I was a thick-headed Pollack,” says Kaczmarowski, now 57. “I kept saying nothing was really wrong.”

But the vigilant Framingham team, alarmed by his test results, thought otherwise and urged him to get help, fast. He did: a septuple coronary bypass that saved his life.

Over the last half-century, hundreds of thousands of people – some healthy, some deathly ill – have volunteered for studies that have changed medical treatment.

Over the last 40 years, for instance, 50,000 women with breast cancer have participated in groundbreaking trials run by Dr. Bernard Fisher of Pittsburgh, scientific director of a study of how various treatment combinations affect survival.

Among other things, Fisher’s studies showed that for most women with breast cancer, survival was the same whether a woman had a mastectomy, a lumpectomy (removal of just the cancerous lump) or a lumpectomy plus radiation, a finding that has spared countless from losing a breast. Nowadays, however, women usually have radiation plus lumpectomy because that reduces the chance for a local recurrence.

Fisher’s studies have revolutionized treatment in other ways, too. They’ve shown the efficacy of chemotherapy and the hormone tamoxifen, and demonstrated that many women with early cancer benefit from systemic (whole body) treatment with chemotherapy, tamoxifen or both, in addition to surgery and radiation.

Volunteers with heart disease have also helped change medical history, says Dr. Patrice Desvigne-Nickens, director of the heart research program at the National Heart, Lung and Blood Institute, sponsor of the Framingham study.

Over the years, she says, key studies have shown that for many people with severe heart disease, bypass surgery is more effective than drug treatment; that clot-busting drugs (TPA and streptokinase) can open arteries and save the lives of people who have just had heart attacks; that lowering cholesterol, too, can be life-saving.

In many such research projects, people volunteer out of altruism, hoping the knowledge gained from testing a new cancer drug for cancer or tracking symptoms of a disease will help other people.

But many say they reap personal benefits as well, a fact researchers hope will lure more people into trials.

Sometimes, as in the Framingham study, all you have to do is agree to undergo free, thorough checkups every few years. The risks in this kind of “observational” trial are few, chiefly a little time lost from work and perhaps babysitting costs.

There is, of course, a potential risk to confidentiality because so many researchers pore over each blood test or chest X-ray. But researchers take pains to guard the privacy of medical records.

“We do not release them to anyone for any reason under any circumstances without a signed release each time,” says Dr. Daniel Levy, director of the Framingham study.

“Usually, there isn’t a name linked to the data. There may be a number, but that’s not given to insurance companies,” adds Dr. JoAnn Manson, an endocrinologist at Brigham and Women’s Hospital. She is a principal investigator in the Women’s Health Initiative, an ongoing, nationwide study to determine the health consequences of hormone replacement therapy, low fat diet, and vitamin D and calcium supplements in older women.

Perhaps the greatest risk in joining an observational trial is actually a benefit: You may get bad news sooner than you otherwise would, because you’re watched so closely. Levy, for instance, recently discovered breast cancer in a woman who was there for a routine visit for the heart study.

With interventional, as opposed to observational, studies, the risks and benefits of volunteering are slightly different. These studies involve patients who already have a disease or are at high risk for it. Often, they’re divided into two or more groups randomly, then given different drugs or other treatments. Typically, neither the patients nor their doctors are told who is in which group.

Many people hesitate to join such a trial, fearing that they’ll be among the group that gets a placebo, or dummy drug, in place of a real treatment.

In many cancer studies, however, “this isn’t much of an issue,” says Mary McCabe, head of the office of clinical research promotion at the National Cancer Institute. That’s because patients usually get either the new treatment or the best available standard care.

And while people often assume a new treatment is better, nobody really knows, which is precisely why the study is needed.

As a volunteer, you have the right be fully informed about the study and to drop out at any time, notes McCabe of NCI, though you should discuss this with your doctor.

If you’re pregnant, of course, the pros and cons of joining an interventional study get trickier, but if your doctor suggests it, it’s worth considering.

The bottom line is that you should never feel coerced into joining a study, says Manson of the Brigham. But if you’re comfortable with it, the benefits – to you, as well as society at large – often outweigh the risks.

After 50 years in the Framingham study, Ida Leach needs no convincing: “There are no disadvantages, as far as I can see.”

Information on studies

Although some studies are not recruiting new volunteers, many others are.

The Framingham Heart Study, for instance, is still seeking minority volunteers for a waiting list. (Telephone 508-935-3438)

The National Cancer Institute has numerous ongoing studies. For more information call 1-800-4-CANCER or search the web at http://cancertrials.nci.nih.gov.

You can also check the bulletin board sections of newspapers and listen for ads recruiting volunteers on radio and TV, or call major teaching hospitals for information about participating in research studies in your area.

 

Fish oil seen cutting risk of Mental Illness

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Fish oils that are already believed to reduce the risk of heart disease may help combat a number of serious psychiatric illnesses as well, researchers said yesterday.

At an international conference sponsored by the National Institutes of Health, scientists said that though the data are preliminary, a growing body of evidence suggests that higher consumption of essential fatty acids in the oils, notably one called omega-3, appears linked to a lower risk of depression and better treatment of manic-depression and schizophrenia.

Essential fatty acids must be consumed in the diet or as supplements because the body cannot make them. A major dietary source of omega-3 is fatty fish such as mackerel, Atlantic salmon, bluefish, halibut, herring, and sockeye salmon.

The researchers did not make specific recommendations for consuming fish or omega-3 supplements. But previous research suggested that eating fish two to three times a week is healthful, says Larry Lindner, executive editor of the Tufts University Health & Nutrition Letter.

People seeking to increase their consumption of omega-3 fatty acids also can eat green leafy vegetables, nuts, flaxseed, and canola oils, which contain fatty acids that the body can make into two chemicals, called EPA and DHA, that are thought to produce the health benefits. The researchers said they had no definitive answers on whether DHA, which is found in breast milk, should be added to infant formula in America, as it is in Europe and Asia.

Consuming high quantities of omega-3 supplements, however, can suppress immune function, conceivably leaving people more vulnerable to infection. On the other hand, Lindner said, omega-3 supplements seem to help people with arthritis, an auto-immune disorder. A 3,000-milligram daily dose has been shown to reduce arthritis symptoms caused by immune system damage to joint tissue. Omega-3 also can reduce the ability of the blood to clot, which means it could be hazardous in a person with a bleeding disorder.

The research includes data suggesting that countries where large quantities of fish are eaten have lower rates of depression than countries where fish is not a major part of the diet, said Dr. Joseph R. Hibbeln, chief of the outpatient clinic at the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health.

Major depression is 60 times more prevalent in some countries than others, Hibbeln said. Fish consumption appears to be an “important protective factor.”

Lindner called the link between fish oils and reduced incidence of depression “provocative,” but said it was “too early to make a recommendation that people suffering from a mood disorder should eat more fish or start taking omega-3 supplements.”

Hibbeln’s team found that higher blood levels of two omega-3 fatty acids (EPA and DHA) in both normal people and alcoholics correlated with higher levels of an important brain chemical, serotonin. This suggests, he said, that consuming omega-3 fatty acids may influence production of serotonin. Many scientists believe that low levels of serotonin are linked to depressive, suicidal, or violent behavior.

In one study of 18 suicidal patients, higher blood levels of EPA were linked to lower scores on tests that predict suicide, Hibbeln noted. The emerging data, taken as a whole, suggest that EPA and DHA may reduce depressive and suicidal behavior.

Dr. Andrew L. Stoll, director of psychopharmacology at Brigham and Women’s Hospital in Boston, reported what he called “very exciting” results from a study of about 50 patients with manic-depression, or bipolar disorder, which affects an estimated 2 million Americans.

About half the patients were given 10 grams a day of omega-3 (equal to several servings of fish) in a special formulation and the other half received a placebo made of olive oil. All patients continued to receive their usual medications as well.

The study was planned to last nine months, said Stoll, but after four months the rate of relapse in the omega-3 group was dramatically lower, prompting researchers to stop the study early. Although it is not totally clear how omega-3 works, Stoll said, it appears to act like lithium and valproate, two manic-depression medications that block transmission of neurochemical signals inside brain cells.

Omega-3 fatty acids also appear to help reduce symptoms of schizophrenia in people taking standard medications, said Dr. Malcolm Peet, head of psychiatry at the University of Sheffield in the United Kingdom. Schizophrenia, which affects 1 percent of the population, produces delusions, hallucinations, apathy, and withdrawal.

Peet has found that levels of fatty acids are lower in people with schizophrenia. In three small studies, he said, giving omega-3 supplements to schizophrenic patients appears to lessen the severity of symptoms.

Good for you, no matter how you slice them

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Ripening in the late-summer sun, filling garden baskets and salad bowls, reddening gazpacho in kitchen blenders, simmering in saucepans for spaghetti sauce, tomatoes might just be the best, maybe the only, reason for welcoming the end of summer.

And beyond the tempting taste – a blessed relief from the cardboard baseballs we get the rest of the year – tomatoes are actually good for you.

Very good, in fact, according to growing body of evidence.

Three years ago, Harvard epidemiologists and nutritionists led by Dr. Edward Giovannucci studied nearly 48,000 male health professionals and found that those who ate the most tomatoes, tomato sauce, tomato juice, and pizza (!) were 21 percent less likely to get prostate cancer than those who ate the least. In fact, the biggest tomato-eaters were 34 percent less likely to get the most virulent form of prostate cancer.

The magic ingredient is probably lycopene, a powerful antioxidant. Scientists think that antioxidants retard cancer, heart disease, and aging by combatting free radical damage to DNA and other cellular structures caused oxygen metabolism.

The Harvard team decided to study tomatoes because they knew that lycopene, a pigment known as a carotenoid that gives tomatoes their red color, winds up in high concentrations in the prostate, says Dr. Meir Stampfer, one of the authors. “Plus we knew about this intriguing Italian north-south gradient.”

That was a study showing that men in southern Italy, who eat lots of tomatoes, get less prostate cancer than men in the north, who eat fewer. Despite its size, the Harvard study doesn’t prove cause-and-effect, warns Stampfer: “People who eat tomatoes probably eat other good things.”

But other studies add to the growing view that tomatoes carry considerable health benefits.

Nearly a decade ago, a study by the Johns Hopkins School of Hygiene and Public Health found that high blood levels of lycopene were linked to lower risk of pancreatic and bladder cancer, notes Inke Paetau Robinson, a research nutritionist at the Agriculture Research Service, part of the US Department of Agriculture.

In 1991, another study found that consuming a lot of lycopene and having high blood levels of the stuff appeared to reduce the risk of precancerous lesions in the uterine cervix. Two Israeli test tube studies have also shown that lycopene slows the growth of breast and uterine cancer cells and may also help prevent tumors.

And in 1994, a large Italian study found that the risk of digestive tract cancers was reduced among men and women who ate seven servings or more of tomatoes and tomato products a week.

And it’s not just cancer risk that seems to fall with high consumption of the juicy red fruit. (Technically, tomatoes are fruits, not veggies, because they develop from flowers and have one or more seeds.)

Last year, a European study of about 1,300 men called EURAMIC, published in the American Journal of Epidemiology, studied fat samples from men who had had heart attacks and compared them with fat from men who had not. (Lycopene is stored in fat.)

The study found that men whose fat had high concentrations of lycopene had about half the risk of heart attack as those with lower levels.

Again, Stampfer, the Harvard epidemiologist and nutritionist, warns that this association doesn’t prove cause-and-effect. But it does make theoretical sense: Antioxidants in general are known to keep “bad” cholesterol (LDL) from being oxidized and thus building up as dangerous plaques on artery walls.

Although nutritionists often recommend eating fruits and vegetables raw to get the maximum health benefits, that doesn’t hold for tomatoes, notes Jennifer Nelson, director of clinical dietetics at the Mayo Clinic.

Tomato products – like pasta and barbeque sauces – that are made from cooked tomatoes actually provide more lycopene than raw tomatoes, because cooking helps free lycopene from its tight packaging with fiber, she says.

But tomato juice doesn’t raise lycopene levels much, unless it’s made from cooked tomatoes or is consumed with fat, which helps lycopene absorption.

Since the body can’t make lycopene, you have to eat it – not such tough duty since it also comes in watermelon, strawberries, and red grapefruit, though tomatoes are far and away the most abundant source.

The question is, how much lycopene do you need? Unfortunately, nobody knows, though the Harvard study found a beneficial effect with a few servings a week – and pizza counts. So does ketchup!

From a weight control point of view, tomatoes are a nearly-perfect food. A raw tomato weighing 4 1/3 ounces has only 26 calories, says Larry Lindner, executive editor of the Tufts University Health & Nutrition Letter. It also has less than half a gram of fat, one gram of protein, and six grams of carbohydrates, plus fiber and vitamins A and C.

So if your garden is churning out more tomatoes than you can handle, don’t panic. Make salads. Make gazpacho. Make pasta sauce. Give tomatoes to the less fortunate.

And if nature isn’t ripening tomatoes fast enough for your need, simply pick some and put them in brown paper bags. This traps ethylene, a natural gas that tomatoes emit as they ripen, and speeds things up.

But most important, enjoy the bounty. It’ll be gone long before you can say “Halloween.”

Sun-dried tomatoes

Just as raisins are made by drying grapes, sun-dried tomatoes are make by taking the water out of tomatoes, which concentrates the nutrients, including the calories. In fact, it takes 17 pounds of fresh tomatoes to make one pound of sun-drieds. For sun-dried tomatoes NOT packed in oil, here’s how it stacks up.

Tomatoes
Sun-dried
Fresh
Calories
258
 21
Fat
3 grams
0.33 grams
Calcium
110 milligrams
5 milligrams
Folate
68 micrograms
15 micrograms
 Vitamin C
39 milligrams
19 milligrams
Vitamin A
874 International Units
623 International Units
 

SOURCE: US Department of Agriculture and Tufts University Health & Nutrition Letter. Globe staff chart

Ginkgo stock is continues to rise

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Like many others at midlife or beyond, Wendy Fink, a health educator in her 50s, was appalled at the way her memory kept conking out.

“I was having trouble getting words,” says Fink, who lives in Royalston. “I was feeling very stressed about this.” So she tried ginkgo, an herbal memory-booster that’s getting new respect in mainstream medicine, albeit for genuine dementia, not run-of-the-mill “senior moments.”

“It seems simplistic,” Fink says of her four-month trial of ginkgo last winter, “but my problem went away. I feel much clearer, brighter, more myself.” She has “no idea,” she adds, why the improvement has persisted although she no longer takes the ginkgo.

The fact that she can’t explain it is hardly surprising, given that there’s little evidence that ginkgo helps healthy people like Fink with age-related memory decline.

But the lack of evidence doesn’t seem to be deterring the hopeful, who last year spent $ 270 million on ginkgo, making it the third best-selling herbal remedy, after echinecea, the cold-fighter, and ginseng, the energy-booster.

Sales “took off” last fall, among both healthy folks and those with dementia, after the Journal of the American Medical Association published a study showing it improves mental functioning in people with dementia, says Thomas Aarts, executive editor of the Nutrition Business Journal in San Diego.

Even the government is intrigued. The National Institute on Aging and the Office of Alternative Medicine are jointly sponsoring a two-year study in 42 patients with Alzheimer’s disease at Oregon Health Sciences University.

The ginkgo tree responsible for all this is a natural wonder. It’s so ancient – its ancesters appeared 300 million years ago – it’s known as a “living fossil. And it’s so resistant to environmental toxins that it thrives in smoggy cities worldwide. And therein may lie its secrets.

The tree’s resistance to insects and toxins may stem from its chemical makeup, says Varro Tyler, a plant medicine specialist emeritus at Purdue University and co-author of “Rational Phytotherapy, a Physicians’ Guide to Herbal Medicine.”

Its two main constituents are the flavonoids, which gobble up free radicals (harmful byproducts of oxygen metabolism), and the ginkgolides, which inhibit a natural platelet activating factor and therefore make the blood less likely to form clots that can clog arteries.

Ginkgolides are devilishly complicated molecules. In fact, Harvard chemist Elias J. Corey, who won the 1990 Nobel Prize for developing a method to synthesize complex organic molecules, including ginkgolide B, recalls that he became interested in the ginkgo molecule precisely “because it was such a challenge.”

Because ginkgo seems to boost blood flow and combat free radicals, the German Commission E, a government-appointed panel that reviews herbal therapies, recommended it in 1994 for dementia-related memory deficits, dizziness, ringing in the ears.

Ginkgo may also help alleviate impotence caused by anti-depressant drugs, according to Tyler.

So far, there have been more than 100 studies on ginkgo by plant medicine scholars, including 36 German studies in the 1980s in which patients with declining intellectual function appeared to benefit from 120 to 160 milligrams a day of ginkgo extracts. German authorities later criticized these studies for not including measurements of daily functioning as well as symptoms of disease progression.

But two recent studies did include those measures. In 1996, a Berlin study of 156 patients with Alzheimer’s disease or stroke-related dementia showed that a particular ginkgo biloba extract called EGb761 was a modestly effective and safe treatment, at a relatively high dose of 240 mg a day.

Last year, in the JAMA study of 202 dementia patients that sent American sales soaring, Dr. Pierre L. Le Bars, executive research director at the New York Institute of Medical Research in Tarrytown, also found that extract modestly effective.

About 27 percent of patients responded to ginkgo, Le Bar says, about the same response rate that occurs with a prescription drug called Cognex and less than the 40 to 50 percent response rate to another prescription drug, Aricept.

Compared to a placebo or dummy drug, a relatively low dose of ginkgo (120 mg a day) is linked to slight improvements in intellectual function, social behavior, and mood, Le Bars found.

In other words, ginkgo is promising, but not dazzling.

In fact, the effects of ginkgo are “so minuscule that. . .they may mean little from a functional point of view,” adds Dr. Thomas Perls, a geriatrician at Beth Israel Deaconess Medical Center. “Ginkgo is barking up the right tree. I just don’t know if it’s the right dog.”

Still, it’s being taken ever more seriously by researchers.

Jerry Cott, head of adult psychopharmacology research at the National Institute of Mental Health, says ginkgo has been shown in test tubes to protect neurons. And data suggest, he says, that ginkgo “is potentially more effective than vitamin E,” which in high doses can slow progression of dementia symptoms.

But there’s no evidence yet that ginkgo can actually prevent Alzheimer’s, “and that’s where we really need the answer,” adds Cott, who is helping the World Health Organization design a study to find out.

Marilyn Albert, director of gerontology research at Massachusetts General Hospital, agrees: “I’d be cautious, because the government does not oversee manufacturing of ginkgo and other products sold as dietary supplements. And this drug, like any other, might potentially interact with other medications.”

Still, barring reports of horrible side effects, the appeal of ginkgo is likely to continue to grow. So if you want to try it, start with 60 to 180 mg a day in divided doses, suggests Barry Taylor, a naturopathic doctor at the New England Family Health Center in Weston who says he’s recommended ginkgo to “hundreds” of patients.

But make sure the label says the capsules contain roughly 24 percent ginkgo flavonoids (also called flavonone glycosides) and 6 percent terpene lactones (also called ginkgolides A, B and C and bilobalide, a related compound.)

Discontinue ginkgo if you get a rash or other allergy. And because ginkgo can make blood less likely to clot, don’t take it without consulting your doctor if you have a bleeding disorder or take blood-thinning drugs, including aspirin.

A childhood with no cones or hotdogs?

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When the seventh and posthumous – edition of Dr. Benjamin Spock’s “Baby and Child Care” was published recently, the guru’s endorsement of a vegetarian diet for kids over 2 caused many nutritionists and doctors to choke on their leafy greens.

Dr. T. Berry Brazelton, professor emeritus of pediatrics at Harvard Medical School, thinks it’s “absolutely hopeless” to try to get kids to eat enough vegetables to offset the loss of nutrients they would suffer from giving up meat and milk.

Dr. Ronald Kleinman, author of the kids’ nutrition guide, “Let Them Eat Cake!” and chief of pediatric gastroenterology and nutrition at Massachusetts General Hospital, calls it a “terrible recommendation for the population as a whole.”

Even Dr. Steven Parker, the Boston Medical Center pediatrician who co-authored Spock’s last edition, can’t stomach the elderly pediatrician’s “advocacy of what amounts to a vegan diet for kids – no meat, fish, dairy or eggs.”

“This was an area upon which we didn’t agree,” says Parker, noting there’s little data – for or against – a vegan diet for kids. So how did they resolve it? “Spock trumped Parker.”

But not everybody thinks it’s nuts to feed kids a diet limited to grains, legumes, seeds, veggies, and fruits. After all, that does leave peanut butter, pasta, bagels, and cereal.

And not everyone thinks it’s impossible to do in a culture where kids are bombarded by images of burgers and ice cream.

Dr. Neal Barnard, president of the Washington-based Physicians’ Committee for Responsible Medicine, an animal rights group, contends that a vegetarian diet for kids is a valuable way to reduce diet-associated diseases in later life because “childhood is a time when adult dietary patterns are set.”

The American Dietetic Association says “appropriately planned vegan” and vegetarian diets that include dairy products and eggs “satisfy nutrient needs of infants, children, and adolescents and promote normal growth.” The American Academy of Pediatrics adds that if meal planning is adequate, vegan children grow normally.

Reed Mangels, 41, a nutritionist and registered dietician in Amherst who has been feeding her kids a vegan diet for years, says it’s “quite doable.” They’re happy with bean burritos, soy milk on cereal, lots of p-b-and-j’s, veggie burgers, and veggie hot dogs. “We’re talking quick and easy,” she says.

But are we talking enough protein, minerals, and calories?

That depends.

A good vegan diet is “perfectly compatible with good health and is probably preferable to a diet of Coca-Cola, pizza, and MacDonald’s,” says Dr. Walter Willett, professor of nutrition and epidemiology at the Harvard School of Public Health.

If parents consult a registered dietician and use fortified cereals and plan meals well, a vegetarian diet that includes milk and eggs can be “a fine option” for kids,” says Johanna Dwyer, director of the Frances Stern Nutrition Center at Tufts and one of the few nutritionists who has studied the issue. “But I take a dim view of a strict vegan diet for kids” – one that excludes eggs and dairy products.

If, however, parents are haphazard about nutrition and ignore other health measures – such as routine immunizations – a vegetarian diet can contribute to poor growth and anemia.

Without any animal products, for instance, kids may become deficient in iron, calcium, some B vitamins, vitamin D, and zinc. In Northern climates like Boston’s, vitamin D deficiency can be a particular problem because the body makes the vitamin from precursors that are activated by sunshine.

And some kids who avoid animal products may become so deficient in vitamin B-12 they are at increased risk of seizures, adds Willett, who suggests that vegan kids take a multi-vitamin supplement daily.

Milk is a particular bone of contention.

Six years ago, Spock (who went on a nondairy, low fat, meatless diet in 1991, at age 88) triggered controversy when, with Barnard of the animal rights group, he proclaimed that neither adults nor kids should drink cow’s milk, contending that it “causes intestinal blood loss, allergies, indigestion and contributes to some cases of childhood diabetes.”

Milk may be “culturally normal” to Americans, though it’s not for much of the rest of the world, but it interferes with absorption of iron, Barnard contends.

Willett disagrees: Milk doesn’t interfere with iron absorption “in any major way” and is such a rich source of calcium that if a child is on a dairy-free diet, he should take a calcium supplement – 800 to 1,000 milligrams a day.

You can get enough calcium from vegetables, adds Kleinman of MGH, but it takes four cups of broccoli to equal a cup of milk.

And while a report in 1992 in the New England Journal of Medicine did suggest that cow’s milk may increase the risk of diabetes in genetically-susceptible children – perhaps by triggering production of antibodies that attack the pancreas – research since then has debunked that notion, Kleinman adds.

And what of the anti-milk argument that the fatty liquid leads to clogged arteries, even in kids?

Both the National Cholesterol Education Program, a government-sponsored committee of nutrition specialists, and the American Academy of Pediatrics say that fats should not be restricted in kids under two, but after that they should follow the same guidelines as adults – a diet of not more than 30 percent fat. In other words, kids should eat dairy products, but the low-fat kinds.

Getting enough protein is not a serious problem for children on vegan diets, provided the sources of plant protein are varied – not just carrots, celery, and lettuce, but beans and other legumes. While nutritionists once thought it was necessary to eat “complementary” proteins such as beans and grains at the same meal to get the full range of amino acids, many now think it’s fine just to balance proteins over 24 hours.

But getting enough calories on a veggie diet can be a problem. Granted, 30 percent of American kids are obese – they eat too many calories and expend too few in exercise. But kids on veggie diets, which are low in fat and high in fiber, may not provide enough energy for a growing child.

Very high fiber diets, says Dwyer of Tufts, means some kids “just can’t eat enough, especially when they are small and are being weaned from breast milk. They eat all the time.”

For Reed Mangels, the vegan mom, the bottom line is that even if parents don’t follow all of Spock’s recommendations, at least he’s made “people think a little bit about what kids eat.”

But Parker, Spock’s co-author, thinks a diet of all veggies is silly, especially since there’s little evidence that the eating habits you form in childhood stick with you for life.

“Personally,” he says, “I think a childhood without ice cream just isn’t worth it.”