Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Aging is one of the deepest mysteries of the universe

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After all, what’s the point? Once you’ve passed your genes on to the next generation, why stick around? Why take up space and use food and other scarce resources? It’s the young who need those things to live to reproductive age. So why do old animals even exist? Or old people?

Evolution has no reason to favor long life, Steven Austad, a former lion tamer and now a bio-gerontologist at the University of Alabama at Birmingham, points out. Quite the contrary, he says: “Evolution favors early, copious reproduction at the expense of later life survival.”[i]

S. Jay Olshansky, a biodemographer at the University of Illinois, Chicago, puts it this way: “We age because Mother Nature turns her back on us once we’re in the post-reproductive region of the lifespan. Natural selection didn’t build in a program to make us fall apart later in life.”[ii]

And yet here we are, a world with growing numbers of old people, even very, very old people. Was it “supposed” to be this way? Come to think of it, why is there even such a thing as menopause? Why do women live 30, 40, 50 years past reproduction? (There’s less of a question about old men – some can produce viable sperm until the day they die, though getting it to its proper destination can get iffy).

Perhaps, as one school of thought suggests, aging exists because old animals – especially females – provide evolutionary advantages, not to the old animal herself, but to her offspring and genetic relatives. It’s the so-called “grandmother effect.”[iii]

“If you are a human female and you are taking care of your grandchild… your act of taking care of your grandchild is a reproductive act,” at least in the eyes of evolutionary biologists, says Michael Rose, a professor of ecology and evolutionary biology at the University of California, Irvine.[iv]

Actually, grandfathers are sometimes just as important as grandmothers because they, too, share food, and sharing is evolutionarily crucial, says Harvard University evolutionary biologist Daniel Lieberman.[v]

A hunter-gatherer mother requires enough calories to sustain not just her own body but the bodies of her children as well, Lieberman notes, which means that hunter-gatherer females who are lactating and caring for young children struggle to get enough energy.

“But grandmothers and grandfathers are unencumbered – they can produce a surplus,” he says. “And that energy goes toward the family. As soon as humans started sharing, there was a strong selective pressure for longevity.” (Longevity, as we’ll soon see, is also fostered by “nice” environments, with lots of food around.[vi])

Among other things, older animals are handy because they know where to find long-forgotten watering holes or food supplies. Female post-menopausal killer whales (orcas) are terrific resources for their tribe – they know where scarce salmon are and are often the ones who lead others to food when supplies are low.[vii]

Old female elephants are great resources, too.[viii] In fact, elephant societies are famously matriarchal, with older females helping their herds survive droughts, food scarcity, poachers and, of course, lions.[ix] [x]

Some traditional human societies with long-lived men and women show a similar pattern, says Jared Diamond, a professor of geography at the University of California, Los Angeles who for more than 50 years has studied New Guinea farming societies.

To be sure, he says, nomadic, hunter-gatherer societies aren’t always kind to old people, who may be cast out to die or simply left behind if they can’t keep up with the group’s wandering.

But in sedentary traditional societies, old folks are valuable. “In traditional societies without writing, older people are the repositories of information,” Diamond says. “It’s their knowledge that spells the difference between survival and death for their whole society in a time of crisis caused by rare events for which only the oldest people alive have had experience.”[xi]

That’s exactly what happened in 1993, when an outbreak of the hanta virus triggered a spate of deaths on the Navajo reservation in the Four Corners area of the American Southwest. The virus, originally, and unfairly, dubbed the “Navajo flu” and since renamed the Sin Nombre (No Name) virus, is carried by deer mice. When the feces of deer mice dry up and become aerosolized, humans can unknowingly breathe the contaminated dust and come down with often-fatal pulmonary infections.

When the outbreak hit, scientists from New Mexico’s health department and the federal Centers for Disease Control and Prevention flocked to the Navajo reservation to study the virus.  But it was their wise decision to talk with Navajo elders that cracked the case.[xii] [xiii] [xiv]

The Navaho elders remembered that twice before in the 20th century, they had observed a connection between increases in rainfall, a booster crop of pinyon nuts, and a surge in the deer mouse population. In 1993, those exact conditions pertained – unusually heavy rains, lots of snowmelt, huge quantities of pinon nuts, a surge in deer mice, and a not-new-after-all epidemic deciphered by the oldest folks around.

Clearly, then, there are some benefits for the group as a whole to have to older animals or people around.

But this can’t be the whole story. After all, evolution didn’t “plan” for older people to hang around because evolution doesn’t “plan” anything. There must be some other reasons, including genetics, why some creatures live long past reproductive age.

Indeed there are. I explore many of these in my new book, Exercise is Medicine. I hope you’ll be as fascinated as I was.

[i] Austad, S. (personal communication, Feb. 23, 2016).

[ii] Olshansky, S.J. (personal communication, Aug. 15, 2016).

[iii] Abrams, L. (2012, Oct. 24). The Evolutionary Importance of Grandmothers. The Atlantic. Retrieved from https://www.theatlantic.com/health/archive/2012/10/the-evolutionary-importance-of-grandmothers/264039/

[iv] Rose, M. (personal communication, Aug. 15, 2016).

[v] Lieberman, D. (personal communication, Aug. 12, 2016).

[vi] Kaeberlein, M. (personal communication, Oct. 8, 2016).

[vii] Yong, E. (2015, Mar. 5). Why Killer Whales Go Through Menopause But Elephants Don’t. Phenomena, National Geographic. Retrieved from http://phenomena.nationalgeographic.com/2015/03/05/why-killer-whales-go-through-menopause-but-elephants-dont/

[viii] Yong, E. (2015, Mar. 5). Why Killer Whales Go Through Menopause But Elephants Don’t. Phenomena, National Geographic. Retrieved from http://phenomena.nationalgeographic.com/2015/03/05/why-killer-whales-go-through-menopause-but-elephants-dont/

[ix] Fishlock, V. (2011, Jun. 9). Why Matriarchs Matter in Elephant Society. International Fund for Animal Welfare. Retrieved from http://www.ifaw.org/united-states/node/2842

[x] Ogden, L.E. (2015, Jan. 26). The Power of Elephant Matriarchs. National Wildlife Federation. Retrieved from https://www.nwf.org/News-and-Magazines/National-Wildlife/Animals/Archives/2015/Elephant-Family-Behavior.aspx

[xi] Diamond, J. (2013, Nov.). How Societies Can Grow Old Better [Lecture transcript]. TED. Retrieved from https://www.ted.com/talks/jared_diamond_how_societies_can_grow_old_better/transcript?language=en

[xii] Wrobel, S. (1995). Serendipity, science, and a new hantavirus. FASEB Journal: Official Publication of the Federation of American Societies for Experimental Biology, 9(13). 1247–1254.

[xiii] Foreman, J. (1993, Jun. 14), Stalking a Mystery Illness. The Boston Globe. Retrieved from https://www.highbeam.com/doc/1P2-8232177.html

[xiv] Foreman, J. (1993, Jun. 7). CDC Seeks Further Tests at Reservation for clues to disease. The Boston Globe. Retrieved from https://www.highbeam.com/doc/1P2-8231069.html

The Gender Gap

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Learning why men and women experience pain differently

It’s one of the more puzzling observations in medicine: The vast majority of chronic pain patients are women. Women suffer disproportionately from irritable bowel syndrome, fibromyalgia, headaches (especially migraines), pain caused by damage to the nervous system, osteoarthritis, jaw problems like TMJ, and much more. Women also report more acute pain than men after the same common surgeries.

In the lab, when researchers ask male and female volunteers to subject themselves to experimental pain — increasingly hot stimulation on the inner arm, immersion of the hand in very cold water, electrical jolts to the skin — women show lower pain thresholds (that is, they report pain at lower levels of stimulus intensity) and lower tolerance (they can’t bear intense pain as long).

Women are also better able to detect small gradations in pain stimuli. And they respond differently to certain opioid — painkilling — drugs. (It’s not clear whether men and women differ in sensitivity to cancer pain.)

But it’s only recently that researchers have begun to study the exact genetic, physiological, hormonal, and psycho-social factors that may underlie these sex differences. In part, that’s because pain researchers have been hampered by one — rather shocking — fact: Most basic pain research is still done in male mice and rats.

This has been “a catastrophe,” says McGill University pain geneticist Jeffrey Mogil, adding that the old rationale that menstrual cycles make females too difficult to study is bogus. Men and women, in fact, can be so different in the way their nervous systems process pain that someday there may be “pink pills for women, and blue pills for men,” he says. The lopsided research exists solely because of “inertia,” he adds.

Others agree, among them Dr. Roger B. Fillingim, lead author of an exhaustive 2009 review of sex and pain research published by the American Pain Society. In that paper, Fillingim, a pain researcher at the University of Florida, notes that while the National Institutes of Health now require routine inclusion of both sexes in human studies, much animal research “continues to eschew females.” Given that pain is mainly a female problem, he adds, this means research “that excludes females is incomplete at best and invalid at worst.”

Luckily, this shutout is not total, and of course, some human research does specifically address sex differences — with complex, and fascinating results.

Take hormones. Growing up, boys and girls show comparable patterns of pain until puberty, notes Dr. Navil Sethna, a pediatric anesthesiologist at Children’s Hospital Boston. “After puberty, certain types of pain are more common in girls, and even if the incidence is the same, reported pain severity is more intense in girls than boys, especially for headaches and abdominal pain,” says Sethna. This pattern persists through adulthood; the lifetime prevalence for migraines is 18 percent for women and 6 percent for men.

The same pattern holds for TMJ, temporomandibular joint disease — now called TMD — with no sex differences before puberty and significant differences afterward.

Not all studies agree, but many do show that after puberty, women experience striking fluctuations in their response to pain at different points in the menstrual cycle. This has been noted in irritable bowel syndrome, TMD, headache, and fibromyalgia. One explanation, some researchers say, is that estrogen protects against pain at high levels, and enhances it at low levels. (The male hormone testosterone seems to protect against pain.)

This theory fits with the observation that during pregnancy, when estrogen levels are high, women often get fewer migraines and TMD pain. And it fits with the observation that, after childbirth, when estrogen falls abruptly, the number of migraine attacks increases.

It may not be the absolute level of estrogen that is key, says Dr. Fernando Cervero, a pain researcher at McGill, but the fluctuations in hormonal levels during the menstrual cycle. (Estrogen levels climb in the first half of the cycle, then decline in the second half.) “It’s the change that produces the change” in perceptions of pain, he says.

What about that big hormonal change, menopause? That’s when estrogen falls abruptly. If the low estrogen-more pain theory is true, women should experience pain after menopause, but research results are all over the place.

Several studies have shown that women who combat low levels of estrogen by taking hormone replacement therapy actually have more back pain and more pain from TMD as well. Other studies detect no link between hormone replacement therapy and pain in older women. And still others show that when women taking hormone replacement therapy, their pain appears to go up and they may get more migraines.

Females “may have evolved sensory mechanisms that allow for greater acuity across sense organs” over the eons, says Dr. William Maixner, director of the Center for Neurosensory Disorders at the University of North Carolina, Chapel Hill. Females are more sensitive in general to changes in smell, temperature, visual cues, and other stimuli that may signal danger — traits that could have helped them in earlier times to protect the children they watched while the men were away. Experiencing pain in a more heightened way may be one more example of that sensitivity.

“The conditions that cause pain affect men and women differently in terms of prevalence and severity,” notes Dr. Daniel Carr, a professor of pain research at Tufts Medical Center. Some drugs also affect men and women differently. And then there’s “the whole social dimension and cultural dimension of being a woman versus being a man, which modifies” treatment choices. In other words, he says, “Whatever pain therapy one selects should have some flexibility to it.”

One thing is clear: In this culture, women are often encouraged to express pain, and men to hide it. But this doesn’t mean that friends, relatives — and doctors — react sympathetically to women’s expression of pain. In the clinic, this often translates to gender bias and under-treatment of pain, notes Fillingim.

Women, he says, should not put up with any doctor who says or implies that “you are just another whining woman.” But neither, he adds, should men stick with doctors who don’t respect them or believe their pain.

“There are doctors with a greater understanding of pain in general and a greater willingness to deal with it, and others who, if they can’t see it on an X-ray, don’t believe it’s real,” Fillingim adds. Bottom line? “Avoid that latter category.”

This is Judy Foreman’s last Health Sense column for a while. She is writing a book on chronic pain, provisionally titled “A Nation in Pain: Treating Our Biggest Health Problem.” She invites readers to send their personal stories of pain to:judyforeman@myhealthsense.com

The Big Thaw

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Freezing human eggs is gaining in popularity, but declaring it a success would be premature

Doctors have been freezing sperm for 60 years and embryos (fertilized eggs) for 30. The first pregnancy from a frozen egg occurred in 1986.

But it’s been only in the past few years that fertility specialists have begun freezing eggs with any regularity — so short a time that two major professional groups, the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine, still consider egg freezing experimental. They caution that a request to freeze eggs should be considered by an institutional review board before being granted.

Freezing eggs for non-medical reasons — a healthy woman choosing to harvest and preserve her eggs for conceiving a baby sometime in the future — is new enough that there are few reliable statistics on how successful the procedure is. “Success” in such cases means a take-home baby, not just an egg that is frozen without damage, or thawed safely, or even fertilized to yield a genetically normal, healthy embryo.

“So few women who have frozen eggs have come back to use them [that it’s impossible] to quote a clear pregnancy rate on it,” says Dr. Elizabeth Ginsburg, medical director of assisted reproductive technologies at Brigham and Women’s Hospital. There hasn’t been time to collect enough data, since women usually plan to freeze eggs for many months or years before retrieving them for conception.

But the idea is clearly catching on. Nationwide, roughly half of 282 US fertility centers surveyed offer egg freezing, according to researchers at the University of Southern California, who conducted the study and published findings last month in Fertility and Sterility, a journal of the American Society for Reproductive Medicine. There are about 400 fertility centers in the United States.

Egg freezing, not usually covered by insurance, can cost $10,000 or more per procedure. Beyond the initial expense, there are annual fees, often hundreds of dollars, to maintain the eggs.

At Boston IVF, a leading fertility cen ter in the United States and one of the oldest as well, typical fees are $6,000 for the harvesting and freezing of eggs, which does not cover the cost of hormones and medications, egg thawing, subsequent fertilization, or transfer of eggs to the uterus. The center has begun offering seminars on the process to young women, many of whom are just out of college or grad school and heading into the workforce.

A woman who decides on egg freezing is given hormones to stimulate egg production. At Boston IVF, egg retrieval is performed under general anesthesia, though other centers may use IV sedation plus pain-killing drugs.

Two-thirds of the clinics in the USC survey reported that they made the service available to women for elective reasons. Traditionally, egg freezing “has been used in women with cancer who face imminent loss of ovarian function. But recently, the technology has advanced to the point where it is worth using for women who want to preserve their oocytes for social reasons,” says Dr. Briana Rudick, a reproductive endocrinologist at the University of Southern California and the lead author of the survey.

There are no reliable numbers for how many women have chosen to have their eggs frozen so far. About 60 women have done so at Boston IVF, most of them as a hedge against their advancing age, says Dr. Kim Thornton, clinical director of the center’s egg-freezing program. So far, none has returned for the next step, she said.

Worldwide, more than 900 babies have been born from frozen eggs, according to a 2009 study conducted by researchers at the New York University Fertility Center, and published last year in Reproductive BioMedicine Online.

Of course, there are no guarantees that freezing eggs will preserve fertility, just as there are no guarantees — at any age — that a woman can get pregnant naturally. In both cases, the odds get worse as egg quality declines with age.

“Humans are the poorest of all mammalian species in terms of chromosomal integrity,” says Dr. Geoffrey Sher, founder of the Sher Institutes for Reproductive Medicine in Las Vegas. “With humans, even when they’re young, there’s only a 2 in 5 chance that an egg is normal. By the time a woman is 45, approximately 1 in 15 is normal.”

“Pregnancy rates at age 40 are pretty low even with fresh eggs,” says Ginsburg, at Brigham and Women’s. “You can chop that by two-thirds if it’s frozen eggs.”

Still, several advances are nudging the use of egg-freezing forward. One is “vitrification,” in which eggs are frozen within 15 minutes. Typically, eggs have been frozen slowly, over several hours, using programmable freezers that drop temperatures step by step. While many fertility clinics still use this method, ice crystals can form, making egg survival only about 60 percent, says Michael Tucker, scientific director at Georgia Reproductive Specialists in Atlanta. The claim with vitrification is that the egg survival rate may rise to 80 percent or even higher.

Testing the genetic viability of both eggs and embryos has also boosted interest in freezing. Several methods are available, including CGH, or comparative genomic hybridization, which checks eggs or embryos to be sure they have the correct number of chromosomes. Some embryos appear normal under the microscope but have the wrong number of chromosomes, meaning they are not viable, says Sher of Las Vegas.

Bottom line, a woman who wants to conceive a child at some point in the future should carefully consider the options — the risks, costs, and unknowns.

Regarding the use of egg freezing, Ginsburg advises not waiting too long. “If you want to have a child and it’s feasible socially, do it. . . . I get infertile patients, married for five years, who couldn’t imagine having a baby in [their] small apartment. That’s a bad reason to wait until age 35. It’s really sad, and I see it a lot.”

Egg Freezing

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Doctors have been freezing sperm for 60 years and embryos (fertilized eggs) for 30. The first pregnancy that resulted from a frozen egg occurred in 1986.

But it’s been only in the past few years that fertility specialists have begun freezing eggs with any regularity – so short a time that two major professional groups, the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine still consider egg freezing experimental. They caution that a request to freeze eggs should be reviewed by an institutional review board before being granted.

Freezing eggs for non-medical reasons — a healthy woman choosing to harvest and preserve her eggs for conceiving a baby sometime in the future — is new enough that there are few reliable statistics on how successful the procedure is. “Success” in such cases means a take-home baby, not just an egg that is frozen without damage, or thawed safely, or even fertilized to yield a genetically normal, healthy embryo.

“So few women who have frozen eggs have come back to use them [that it’s impossible] to quote a clear pregnancy rate on it,” says Dr. Elizabeth Ginsburg, medical director of assisted reproductive technologies at Brigham and Women’s Hospital. There hasn’t been time to collect enough data, since women usually plan to freeze eggs for many months or years before retrieving them for conception.

But the idea is clearly catching on. Nationwide, roughly half of 282 US fertility centers surveyed offer egg freezing, according to researchers at the University of Southern California, who conducted the study and published findings last month(june) in Fertility and Sterility, a journal of the American Society for Reproductive Medicine. There’s a total of about 400 fertility centers in the US.

Egg freezing, not usually covered by insurance, can cost $10,000 or more per procedure. Beyond the initial expense, there are annual fees, often hundreds of dollars, to maintain the eggs. At Boston IVF, a leading fertility center in the US and one of the oldest as well, typical fees are $6000 for the harvesting and freezing of eggs, which does not cover the cost of hormones and medications, subsequent fertilization, or transfer of eggs to the uterus. The center has begun offering seminars on the process to young women, many of who are just outof college or grad school and heading into the work force.

At BostonIVF, egg retrieval is performed under general anesthesia, though other centers may use IV sedation plus pain-killing drugs.

Two-thirds of the clinics in the USC survey reported that they made the service available to women for elective reasons. Traditionally, egg freezing “has been used in women with cancer who face imminent loss of ovarian function. But recently, the technology has advanced to the point where it is worth using for women who want to preserve their oocytes for social reasons,” says Dr. Briana Rudick, a reproductive endocrinologist at the University of Southern California and the lead author of the survey.

There are no reliable numbers for how many women have chosen to have their eggs frozen so far. About 60 women have done so at BostonIVF, most of them as a hedge against their advancing age, says Dr. Kim Thornton (cq), clinical director of the center’s egg-freezing program. So far, none has returned for the next step, she said.

Worldwide, more than 900 babies have been born from frozen eggs, according to a 2009 study conducted by researchers at the New York University Fertility Center, and published last year in Reproductive BioMedicine Online.

Of course, there are no guarantees that freezing eggs will preserve fertility, just as there are no guarantees – at any age – that a woman can get pregnant naturally. In both cases, the odds get worse as egg quality declines with age.

“Humans are the poorest of all mammalian species in terms of chromosomal integrity,” says Dr. Geoffrey Sher, founder of the Sher Institutes for Reproductive Medicine in Las Vegas, N.M. “With humans, even when they’re young, there’s only a 2 in 5 chance that an egg is normal. By the time a woman is 45, approximately one in 15 is normal.”

“Pregnancy rates at age 40 are pretty low even with fresh eggs,” says Ginsburg , at Brigham and Women’s. “You can chop that by two-thirds if it’s frozen eggs.”

Still, several advances are nudging the use of egg-freezing forward. One is “vitrification,” in which eggs are frozen within 15 minutes. Typically, eggs have been frozen slowly, over several hours, using programmable freezers that drop temperatures step by step. While many fertility clinics still use this method, ice crystals can form, making egg survival only about 60 percent, says Michael Tucker, scientific director at Georgia Reproductive Specialists in Atlanta. The claim with vitrification is that the egg survival rate may rise to 80 percent or even higher.

Testing the genetic viability of both eggs and embryos has also boosted interest in freezing. Several methods are available, including CGH, or comparative genomic hybridization, which checks eggs or embryos to be sure they have the correct number of chromosomes. Some embryos appear look normal under the microscope but have the wrong number of chromosomes, meaning they are not viable, says Sher of Las Vegas. Bottom line, a woman who wants to conceive a child at some point in the future should carefully consider the options — the risks, costs, and unknowns.

Regarding the use of egg freezing, a more recently available choice, Ginsburg advises, “If you want to have a child and it’s feasible socially, do it. … I get infertile patients, married for five years, who couldn’t imagine having a baby in [their] small apartment. That’s a bad reason to wait until age 35. It’s really sad, and I see it a lot.” 

High Water Marks

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There’s no question swimming is good for you. Is it better than running or walking? Not so fast.

 Is swimming the best exercise for lifelong health?

After all, you can swim with just your arms if you have a bum knee, or with just your legs if you have sore arms. You can swim with arthritis. Or a recently replaced hip.

An article in the May-June 2010 issue of SWIMMER floats the notion that swimming just might be a life preserver. The report is based on the first major study comparing the long-term benefits of swimming with other activities, which concluded that “swimmers had lower mortality rates than those who were sedentary, walkers or runners.”

The research was conducted by Steven Blair, a leading exercise scientist from the University of South Carolina, and funded by the National Institutes of Health and the National Swimming Pool Foundation. It appeared in the International Journal of Aquatic Research and Education, a peer-reviewed journal published by Human Kinetics and the foundation. The 2008 study followed 40,547 men ages 20-90 who completed health exams between 1971 and 2003.

But is swimming really better for you? And if so, why?

Blair himself, in a telephone interview, is cautious. The 13-year study, he says, does “show that swimmers have lower death rates” than sedentary people, walkers, and runners. “That’s what the data show.” But are swimmers more fit than runners? “It doesn’t quite make sense to me,” he says and laughs.

Over the course of the research, 1,336 of the 20,356 runners (or 6.6 percent) had died, compared with only 11 of the 562 swimmers (1.9 percent). But the number of swimmers was so small that if a few more had died, it could have significantly changed the conclusions, he says.

In addition, the study was “observational,” that is, the researchers simply followed the different groups of people over time to see how they fared, as opposed to randomly assigning them to different types of exercise — a more rigorous way to conduct research.

“My guess is that there were a lot of differences between people who chose to be swimmers instead of runners or walkers. Swimmers may have been healthier to begin with so their lower death rate may have had nothing to do with swimming,” says Dr. Steven Woloshin, a professor of medicine at the Dartmouth Institute who analyzes the interpretation of scientific studies.

The study had other limitations: Only men were studied. It also didn’t track whether participants continued with the exercise they were doing at the start of the study period. And while the study did classify the runners and walkers by pace, it didn’t specify swim ming paces at all — no differentiation was made between the swimmers who dogpaddle a bit and never get their hair wet, and those who are dynamos in the water.

Still, after the authors adjusted their findings for differences in age, weight, smoking status, and other risk factors, the swimmers had lower all-cause mortality than the men who were sedentary, walkers, or runners.

In another 2008 study led by Blair, of men and women subjects using treadmill tests and other measures of cardiorespiratory fitness, runners scored the best, with swimmers a close second.

On the downside for swimming, one of its chief benefits — being weightless in the water, a boon for aching joints — can also be a disadvantage.

“Swimming does not build bone” like running does, says Dr. Michael Holick, an osteoporosis expert at the Boston University School of Medicine. “It’s pounding the pavement that is translated to hip and spine bone strength. Even treadmills and elliptical machines are not the same.”

On the other hand, he says, “there’s no evidence that swimming makes [bone loss] worse.” And swimmers do develop good muscles, and muscle mass “usually equates with higher bone density.”

The most important message of all the research is that physical activity of any sort is crucial for good health and longer life.

“There are so many things people can do for physical activity,” says I-Min Lee, an epidemiologist at Harvard Medical School who studies physical activity and health. “You can pick what you like. We’re not forcing everybody to run or play tennis.”

Blair’s findings about the benefits of swimming are “encouraging, though by no means definite,” Lee says.

Peter Katzmarzyk, a professor of epidemiology at the Pennington Biomedical Research Center in Baton Rouge, La., who also studies exercise and health, agrees. “I can’t say everybody should be swimming as opposed to other things,” he says. But at the very least, the study shows that swimming “accrues the same benefits as other activities, and that was never shown before.”

A sedentary lifestyle is a major risk factor for premature mortality from all causes. It’s also a risk for many chronic diseases, including Type 2 diabetes, cardiovascular disease, and cancer.

Put the other way around, people who expend more than 1,000 calories a week in exercise cut their risk of dying — from all causes — by 20 to 30 percent, and those who do more cut their risk even more. Physically active people have lower (healthier) fasting blood glucose levels and insulin resistance, and are better able to control their weight. They also have lower blood pressure, total cholesterol, and “bad” low-density cholesterol.

As for swimming as an exercise choice, more research is needed. But the data so far suggest that it’s right up there with running as a great way to get and stay fit. And it’s certainly easier on the knees, a huge advantage for many people as they age.

Besides, there really is something about sliding into the water, outdoors or in a pool, and moving quietly along. After all, life evolved in the water. Why not head back in?

 

Those Restless Legs…

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Restless legs syndrome keeps you going (even if you want to
stop).

The symptoms of restless legs syndrome sound so bizarre —
creepy-crawly feelings and an uncontrollable urge to move the legs, especially
at bedtime — that until recently, many people who experienced it simply weren’t
believed when they described it to others.

Betsy Dunn, an 85-year-old Cambridge businesswoman who has had
restless legs for nearly 30 years, remembers a doctor saying she must be
depressed. “I walked out and never went back,” she says. “All I needed him to
say was, ‘I don’t know what this is, but together we will find out.’ ”

In severe cases, like that of Donald Loveland, 75, a retired Duke
University computer scientist now living in Dennis, the urge to move the legs
overwhelms everything else, including pain. Right after back surgery, he
recalls, “it was actually painful to be up but I had to get up anyway.”

Ron Blum, 38, a Jamaica Plain e-mail marketer who first noticed
his symptoms as a 7-year-old, recalls that the minute he lay down and tried to
sleep, “my left leg felt like it had to go for a walk.” Though he never told
his parents, he’d get up and walk for hours in circles. It wasn’t until years
later that a friend heard about RLS. “He called me up and said, ‘Ron, I know
what you have. It has a name.’ ”

It also has growing recognition. RLS may affect some 12 million Americans, according to the National Institute of Neurological Disorders and Stroke, as reported on the
National Institutes of Health website (www.ninds.nih.gov/disorders).
The NIH supports research into the condition at major medical institutions
across the country, as well as within its own labs.

The NIH report notes that the number of RLS sufferers may be even
higher than estimated. Some people with the condition don’t seek medical
attention, believing that they will not be taken seriously, that their symptoms
are too mild, or that their condition is not treatable. Some physicians wrongly
attribute the symptoms to nervousness, insomnia, stress, arthritis, muscle
cramps, or aging.

“You can think of RLS today as where sleep apnea was 10 to 15
years ago,” says Dr. John Winkelman, a psychiatrist, RLS expert, and medical
director of Sleep Health Centers, which is affiliated with Brigham and Women’s
Hospital.

“We used to think of sleep apnea as a bunch of fat guys snoring,”
says Winkelman, who consults for drug companies that make RLS medications. “We
are also just beginning to recognize the potential negative medical
consequences of RLS.” A number of studies have hinted that the syndrome might
be associated with more serious conditions.

Not to mention the toll RLS takes on the quality of life.

“There were many, many nights when I would sleep for only two and
a half or three hours,” recalls Roberta Kittredge, a 65-year old retired
teacher in Hampton, N.H., who first got RLS when she was pregnant. (Some
studies suggest a link between RLS and high estrogen levels.) “Every night I
went to bed positive I would sleep, and two or three minutes later, I was out
of bed and walking the floor for hours and hours.”

There is currently no single diagnostic test for RLS.

“We know what’s wrong,” says Richard Allen, an associate
professor of neurology at Johns Hopkins University. “The neurobiology of RLS is
definitely clear.”

Levels of iron fall too low in parts of the brain, resulting in
reduced availability of dopamine, a neurotransmitter that carries information
between the body’s cells involved with movement that is also deficient in such
disorders as Parkinson’s disease. In addition, four genes have been linked to
RLS, which often appears in families.

The dopamine connection helps explain why RLS has such a distinct
circadian rhythm, says Allen, who also consults for companies that make RLS
drugs. Dopamine levels follow a clear 24-hour pattern, with levels lowest in
the evening. Moreover, presumably because both RLS and Parkinson’s involve low
dopamine, some of the dopamine-enhancing drugs used to treat Parkinson’s — like
Mirapex and Requip — also can reduce or eliminate RLS symptoms in some
patients. Side effects may include nausea and headache. Taking iron supplements
has been helpful in decreasing or halting RLS symptoms for some patients.

“I would probably be dead by now because of exhaustion,” says
retired Newton architect Paul Dudek, 70, whose life improved dramatically when
he was finally diagnosed and treated with medication.

Dopamine also plays an important role in erectile function, and
epidemiologist Xiang Gao of the Harvard School of Public Health has shown that
men with relatively severe RLS have nearly double the normal risk of erectile
dysfunction. (Xiang Gao has no ties to RLS drug companies.)

But dopamine isn’t the only neurotransmitter that plays into the
RLS picture. Histamine, for one, is a powerful brain stimulant, so drugs that
block histamine — antihistamines such as Benadryl — can significantly
exacerbate RLS symptoms.

One of the frustrations with RLS is that symptoms are usually
triggered just when a person needs to sit or lie still, such as on long plane
trips or when sitting in the audience at concerts and other presentations.
Symptoms tend to be most severe at night.

Once asleep, 80 percent of people with RLS also exhibit another
condition: periodic limb movement during sleep (PLMS), in which the legs jerk
as often as every 20 or 30 seconds. Researchers from the University of Montreal
and elsewhere have shown that each involuntary PLMS leg movement is associated
with a dramatic increase in blood pressure.

Studies suggest RLS might be associated with more serious medical
problems, such as increased risk of heart disease and stroke.

If a link between RLS and high blood pressure is confirmed, the impact
would be dramatic. “Hypertension is a powerful predictor of premature death,”
says Dr. David Rye, a neurologist at Emory University who studies the genetics
of RLS and PLMS and has the conditions himself. Rye also consults with
companies that make RLS drugs.

So far, though a number of researchers have noted associations
between RLS and other diseases, no one has established causality between RLS
and the other conditions. RLS is not an established risk factor for
cardiovascular disease in the way that cholesterol is, for example.

While understanding the condition is a complicated task, RLS
patient Kittredge can offer some hard-won advice to people who might be
suffering in silence and shame: “Find an educated doctor . . . who understands
RLS,” she says. “There is hope out there. I am living proof.”

 

Keep Pedaling!

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Whether you do it to lose weight, maintain weight loss, or just have fun, exercise is essential for good health.

As a nation, we are obviously getting fatter and fatter. Yet we seem ever more confused about how to lose weight. We’re particularly fuzzy on the question of how big a role exercise plays, or whether we just have to count calories.

So here’s the deal. Yes, you can count calories or weigh yourself every day. If your weight is up today compared with yesterday, you probably ate more calories than you burned. If it’s less, you burned more than you ate – provided you didn’t drink gallons of liquid the day before, throwing the scale off.

It comes down to simple arithmetic, and you’ve heard it before: Calories in, calories out. You will absolutely, inevitably gain weight if you eat more calories than you expend in basic metabolism – breathing, digesting, sleeping, etc. – plus whatever else you do, such as chasing the kids around, walking, vacuuming, or going to the gym.

Except that most of us can’t – or won’t – do the math, probably because it’s so depressing.

We routinely overestimate the number of calories we spend in physical activity, and underestimate the calories from food. For instance, when I swim hard for an hour, which I do regularly, I probably use up 400 to 600 calories. But when I eat a blueberry muffin, which I’m afraid I also do regularly, I take in nearly 400 calories. So, I have to swim pretty fast for 40 minutes just to offset one lousy muffin. It’s not fair! I swim for health (and fun). But if my only goal were weight loss, it would be easier to just not eat that muffin.

“The problem is people’s inability to know how many calories they burn and eat,” says Dr. George Blackburn, associate director of the Division of Nutrition at Harvard Medical School. “If you put a person in a metabolic chamber, where you know exactly what they eat and what they burn, the calories in, calories out idea is always reconfirmed.”

So, if it takes an awful lot of exercise to make a dent in the calories in-out equation, is exercise pointless? No way. It’s essential for good health. Regular physical exercise reduces the risk of early death, coronary heart disease, stroke, high blood pressure, type 2 diabetes, colon and breast cancer, and depression, according to the 2008 Physical Activity Guidelines for Americans (www.health.gov/paguidelines).

Moreover, even if exercise doesn’t help much in the battle to lose weight, it is essential to maintain weight loss, says Dr. Timothy Church, director of Preventive Medicine Research at the Pennington Biomedical Research Center in Baton Rouge, La.

“This whole thing is not rocket science,” he says. “You can take weight off through a whole variety of strategies. But people don’t lose weight and keep it off unless they are physically active. There are tons and tons of studies on this.”

Among them is a series of studies by researchers at the University of Pittsburgh who showed last year that it takes a considerable amount of exercise – expending 2,000 calories, which requires four or more hours of exercise – per week to maintain a 10 percent weight loss, even on a low-calorie diet.

If your goal is weight loss, as opposed to overall health, does it matter what you eat? No. And yes. And it goes without saying that any diet should involve lots of fruits and veggies, whole grains, and reasonable, not gigantic, portions.

But it still comes down to calories. In February, a two-year study of more than 800 overweight adults showed that people can lose weight if they reduce calories, regardless of the percentages of fat, protein, and carbohydrates in their diets. The study, by researchers from the Harvard School of Public Health, the Pennington Biomedical Research Center, and the National Institutes of Health, was published in the New England Journal of Medicine.

Some foods are more “addictive” than others because they have a bigger effect on the brain chemicals that control the “reward” circuits in our brains. From a neurobiological point of view, sweets, fats, and salty foods make us want to eat more of the same, as Dr. David S. Kessler, the former head of the US Food and Drug Administration, makes clear in his new book, “The End of Overeating.” Obviously, eating more leads to weight gain.

Overall, says Blackburn, the body can’t store calories from protein as amino acids, so it either makes protein from them or converts them to carbohydrates. Excess dietary carbohydrate is first stored as glycogen, but if the body already has enough of that, excess carbs are stored as body fat. Excess dietary fat also gets stored as body fat.

And what about the question of whether exercise increases or decreases appetite?

Exercise can suppress appetite, says Blackburn, because it triggers not only the chemical dopamine, which governs the brain’s reward system, but also endorphins, those feel-good brain chemicals. These substances act on the hunger and satiety areas of the brains for as long as four hours afterward. “You don’t need cigarettes, or drugs, or food, all those things in the pleasure areas of the brain, because exercise has already activated them,” says Blackburn.

A review article in 2007 from researchers at Tufts University also concluded that there is a “spontaneous reduction in hunger associated with participation in exercise.”

Psychologically, as opposed to biochemically, some experts theorize that exercise might lead people to believe they can reward themselves with treats afterward or that they may be tempted to be less active for the rest of the day. And some studies, says exercise physiologist William J. Evans of the University of Arkansas for Medical Sciences, suggest that if you exercise, say, for 40 minutes a day, you will “then compensate by decreasing how active you are at other times of the day, leaving total energy expenditure unchanged” or that you might reward yourself with extra food. Then again, other studies say both of those theories are wrong.

One factor that matters without question, in terms of controlling food intake, is how fast you eat. “It takes about 20 minutes for food to get digested and formulated into hormones for your brain to know what you did, to get that signal to the brain,” says Blackburn. If you wolf down your food, you’ll finish your second helping before your brain has registered your first.

As for the perennial question of how much exercise you need, the new federal guidelines, released last year, say adults “gain substantial health benefits” from getting 2 1/2 hours a week of moderate intensity aerobic activity, or 1 hour and 15 minutes of vigorous physical activity.

Moderate activity means walking briskly, water aerobics, ballroom dancing, and even gardening. Vigorous activity means racewalking, jogging or running, swimming laps, jumping rope or hiking uphill. The guidelines also recommend weight training at least two days a week.

Boiled down, my personal mantra is this: You have to do both – diet to keep caloric intake under control, and exercise for fitness and fun. 

Essay: Time to give up the ‘fighting’ metaphor

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A little over a year ago, just after Ted Kennedy was diagnosed with brain cancer, I wrote a column suggesting that we stop urging him to “Fight, Ted, fight!” and instead grant him the freedom to live as fully as possible with his cancer until the end, which, sadly, came earlier this week.The fighting metaphor, especially when applied to cancer, drives me nuts. Cancer is not a war or a football game. It’s an involuntary dance with a partner you didn’t choose. The fighting metaphor is insidious because it not so subtly implies that if you fight, you can “win.” And that if the cancer takes your life, if you “lose,” it is to some extent your fault. It’s not only patients and their loved ones who fall into this battlefield thinking, but doctors, too, who often see death as a failure. Their failure.

In truth, cancer doesn’t care whether you fight or not, whether you win or not. It’s simply there, just like all the other horrible, debilitating, scary, painful, life-wrecking chronic diseases that millions of Americans deal with every day.

It’s time to grow up about this whole fighting thing. Time to give up our so American, so na

Evil weed or useful drug?

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The pros and cons of medical marijuana

Marcy Duda, a former home health aide with four children and two granddaughters, never dreamed she’d be publicly touting the medical benefits of “pot.”

But marijuana, says the 48-year-old Ware resident, is the only thing that even begins to control the migraine headaches that plague her nine days a month, which she describes as feeling like “hot, hot ice picks in the left side of my head.”Duda has always had migraines. But they got much worse 10 years ago after two operations to remove life-threatening aneurysms, weak areas in the blood vessels in her brain. None of the standard drugs her doctors prescribe help much with her post-surgical symptoms, which include nausea, vomiting, loss of appetite, and pain on her left side “as if my body were cut in half.”

With marijuana, however, “I can at least leave the dark room,” she says, “and it makes me eat a lot of food.”

The culture wars over marijuana, for recreational and medical use, have been simmering for decades, with marijuana (cannabis) still classified (like heroin) as a Schedule I controlled substance by the US government, meaning it has no approved medical use. (There is a government-approved synthetic form of marijuana called Marinol available as a prescription pill for treating nausea, vomiting, and loss of appetite, though advocates of the natural stuff say it is not as effective as smoked pot.)

Some, like David Evans, special adviser to the nonprofit Drug Free America Foundation of St. Petersburg, Fla., applaud the government’s view, saying marijuana has not gone through a rigorous US Food and Drug Administration approval process.

But that skepticism frustrates leading marijuana researchers like Dr. Donald Abrams, a cancer specialist at San Francisco General Hospital.

“Every day I see people with nausea secondary to chemotherapy, depression, trouble sleeping, pain,” he says. “I can recommend one drug [marijuana] for all those things, as opposed to writing five different prescriptions.”

The tide seems to be turning in favor of wider medical use of marijuana. The Obama administration announced in March that it will end the Bush administration’s practice of frequently raiding distributors of medical marijuana. Thirteen states, including Vermont, Rhode Island, and Maine, now allow medical use of marijuana, according to Bruce Mirken, spokesman for the Marijuana Policy Project, which advocates legalization of pot. Last week, however, New Hampshire Governor John Lynch vetoed legislation that would have legalized medical marijuana in that state.

Research on medical marijuana is hampered by federal regulations that tightly restrict supplies for studies. But there is a growing body of studies, much of it supportive of the drug’s medical usage, though some of it cautionary. Given the intense politics involved, it’s true, as Abrams puts it, that “you can find anything you want in the medical literature about what marijuana does and doesn’t do.”

With that in mind, here’s an overview of what the research says about the safety and effectiveness of using marijuana to treat various ailments.

Pain: Marijuana has been shown effective against various forms of severe, chronic pain. Some research suggests it helps with migraines, cluster headaches, and the pain from fibromyalgia and irritable bowel syndrome because these problems can be triggered by an underlying deficiency in the brain of naturally-occurring cannabinoids, ingredients in marijuana. Smoked pot also proved better than placebo cigarettes at relieving nerve pain in HIV patients, according to two recent studies by California researchers. Marijuana also seems to be effective against nerve pain that is resistant to opiates.

Cancer: The active ingredients in cannabis have been shown to combat pain, nausea, and loss of appetite in cancer patients, as well as block tumor growth in lab animals, according to a review article in the journal Nature in October 2003. But there’s vigorous debate about whether smoking marijuana increases cancer risk.

Some studies that have looked for a link between cancer risk and marijuana have failed to find one, including a key paper from the University of California-Los Angeles and the University of Southern California published in 2006. “We had hypothesized, based on prior laboratory evidence, including animal studies, that long-term heavy use of marijuana would increase the risk of lung and head and neck cancers,” said Hal Morgenstern, a coauthor and an epidemiologist at the University of Michigan School of Public Health. “But we didn’t get any evidence of that, once we controlled for confounding factors, especially cigarette smoking.”

Research published by a French group this year and by Kaiser Permanente, a California-based HMO, in 1997 came to a similar conclusion.

But a state health agency in California, the first state to legalize marijuana for medical use in 1996, recently declared pot smoke (though not the plant itself) a carcinogen because it has some of the same harmful substances as tobacco smoke. The active ingredient in marijuana can increase the risk for Kaposi’s sarcoma, a common cancer in HIV/AIDS patients, Harvard researchers reported in the journal Cancer Research in August 2007. And British researchers reported in May 2009 in Chemical Research in Toxicology that laboratory experiments showed that pot smoke can damage DNA, suggesting it might cause cancer.

The federal government’s National Institute on Drug Abuse says that it is “not yet determined” whether marijuana increases the risk for lung and other cancers.

Respiratory problems: Smoking one marijuana joint has similar adverse effects on lung function as 2.5 to 5 cigarettes, according to a New Zealand study published in Thorax in July 2007. A small Australian study published in Respirology in January 2008 showed that pot smoking can lead to one type of lung disease 20 years earlier than tobacco smoking.

Addictive potential: The National Institute on Drug Abuse says “repeated use could lead to addiction,” adding that some heavy users experience withdrawal symptoms such as irritability and sleep loss if they stop suddenly.

Mental effects: Cannabis may increase the risk of psychotic disorders, according to a 2002 study in the American Journal of Epidemiology. And the national drug abuse agency warns that “heavy or daily use of marijuana affects the parts of the brain that control memory, attention, and learning.” A study of 15 heavy pot smokers published in June 2008 in the Archives of General Psychiatry showed loss of tissue in two areas of the brain, the hippocampus and amygdala, regions that are rich in receptors for marijuana and that are important for memory and emotion, respectively.

Vaporizing vs. smoking: The push now among proponents of medical marijuana is toward inhaling the vapor, not smoking. Vaporizing is a safe and effective way of getting THC, the active ingredient, into the bloodstream and does not result in inhalation of toxic carbon monoxide, as smoking does, according to a study by Abrams published in 2007 in Clinical Pharmacology and Therapeutics.

Bottom line: From a purely medical, not political, point of view, my take is that if I had medical problems that other medications did not help and that marijuana might, I’d try it – in vaporized form.

Just as Marcy Duda does. “You use it as you need it. You can be normal. You can function,” she says. “I don’t get high. I get by.”

Finally, a study older folks can be happy about

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Good news, folks! Some things actually get better with age, and I’m happy to say that emotional stability is one of them. It says so right in the authoritative Journal of Neuroscience.

Ever since Freud, psychologists have focused almost exclusively on misery — our fears, our depressions, sadness, anger, hostility, aggression, you name it. Now, thank goodness, the young discipline of “positive psychology” is gaining ground as psychologists and neuroscientists try to figure out what makes people happy.

One of the most provocative studies in this new field was published last summer in the neuroscience journal. Australian researchers studied 242 healthy people aged 12 to 79. The subjects were shown pictures of fearful faces and happy faces, while their brain responses were tracked with functional MRI scans and EEG, or electroencephalograms, which show the regions of the brain active at any given moment. The findings suggest that people get less neurotic, more able to control fear, and more emotionally stable as they age, an observation that fits with other data.

Specifically, the Australian team found that the amygdala — a deep brain center for processing raw feelings, especially fear — becomes less reactive to fearful stimuli between older and middle years, while a higher brain center, the medial prefrontal cortex, which governs planning and judgement, gets more active between the middle and later years.

This suggests that healthy, older people “are less bothered by things. They are more in control of their reactions to fear,” said Dr. Andrew Leuchter, director of the Laboratory of Brain, Behavior and Pharmacology at the David Geffen School of Medicine at UCLA.

The findings also suggest that aging is not only linked to “putting the brakes on” negative emotions, but to “releasing the brakes” on positive emotions, said Lea Williams [cq], a neuroscientist at the University of Sydney in Australia and lead author of the study. These findings, she said in an e-mail, “are consistent with people reporting that they focus more on quality of life as they get older. Our many experiences do impact our emotional brain systems in a way that helps attain a better sense of comfort with oneself and the world.”

The neuroscience data fits with some epidemiological data. A 2004 study from the US Centers for Disease Control and Prevention showed that young people report more sad, blue or depressed days per month than older people – 3.4 per month for 20 to 24 year olds, versus just over 2 days for people 65 to 74.

Another government study, the 2003 National Health Interview Survey, asked people how often they felt sad, hopeless, worthless or that everything was an effort. The least sad were people aged 65 to 74. Only 2.6 percent of this group said they felt sad all or most of the time, in contrast to 3 percent of the 18 to 44 year olds. After age 75, however, it’s not clear whether the happy trend continues — and a lot more research is needed.

The idea that many people do indeed mellow with age makes sense to Dr. George Vaillant, a senior psychiatrist at Brigham and Women’s Hospital and director of the Harvard Study of Adult Development who for decades has studied the way people change over the years.

Older people “modulate emotion better than the young, which lets them be more ‘Buddhist’ and thus happier because their frontal lobes are better connected to their limbic system,” the deeper region of the brain where emotions are processed, wrote Vaillant, the author of “Aging Well,” in an e-mail.

The general trend toward greater happiness with age makes sense to Harvard’s chief happiness guru Tal Ben-Shahar, too. Ben-Shahar, who taught one of Harvard College’s most popular courses, “Positive Psychology, said in an e-mail interview that “one of the reasons why we are happier with age is that we simplify our lives. We focus on what’s really important to us, while discarding things that are less personally meaningful.”

“When we experience negative emotions, we are more accepting and also are secure in the knowledge that ‘this, too, shall pass,'” he said.

Evolution may also play a role in helping people get less fearful and more sanguine with age, said biological anthropologist Helen Fisher of Rutgers University.

“A young person has everything to look forward to and everything to gain or lose,” she said.  It make sense for younger people to watch out for negative things that might kill them, while older people who have already succeeded in passing on their genes have less to fear, she said. “It’s now adaptive for them to be less vigilant about all the exigencies of life, to stay calm and keep others calm.”

Even though the odds are good that you will get happier as you age, there’s no need to wait. Younger people, like those in Ben-Sharar’s Harvard classes, can learn the basic skills. The first, he said, is to give yourself permission to feel negative emotions like sadness, fear or anxiety. The sooner you do, the faster these feelings will pass.

It’s also key, he said, to engage regularly in activities that you find pleasurable and meaningful. Remember, too, that happiness is mostly “dependent on our state of mind, not on our status or the status of our bank account. Barring extreme circumstances, our level of well-being is determined by what we choose to focus on and by our interpretation of external events.”

To which I say: Amen!