Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Should you have that Mammogram?

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Let those biostatisticians slug it out down at the National Cancer Institute – I’m getting my yearly mammograms anyway.  Then again, the way things are going, should I?

Last week, the latest panel of experts took a crack at sorting out the decades-old mess about mammograms: Do these X-rays really save lives? Or do they just make us feel like we’re doing something, no matter how mystical,  to reduce the risk of dying from breast cancer?

The panel, called the P.D.Q. screening and prevention editorial board, is an independent group of specialists convened by the cancer institute. Its job is to sort out complicated data – the mammogram debate surely fits the bill – and put it up on NCI’s web site (www.cancer.gov).

Its specific mission was to review controversial assertions published last fall as a letter in the British journal Lancet by Danish researchers, Ole Olson and Peter C. Goetzsche, who looked at data from the seven key mammography studies.

The Danes concluded, and last week the P.D.Q. panel concurred, that there is insufficient evidence to prove that mammograms prevent deaths from breast cancer, according to Donald A. Berry, a panel member and chair of the biostatistics department at M.D. Anderson Cancer Center in Houston.

Among the flaws? Assessment of cause of death may not have been done in a “blinded” way in some research, that is, without knowing whether a woman was in the screening group or not. Some researchers did not exclude women with pre-existing cancer at equal rates in mammogram and control groups and other “egregious “mistakes, says Berry.

According to the Danish researchers, two of the seven studies were so flawed as to be completely useless  – the New York and Edinburgh studies, both of which found a benefit to mammography. Three other studies  – the  Two-County Study in Sweden, the Stockholm study and the Goteborg study,  all of which found a benefit to mammography – were deemed  of poor quality.

So far, that’s five studies, all showing a benefit, all deemed unreliable.

The two studies that the Danes thought were done properly were the Malmo study and the Canadian study. The Malmo study found a slight benefit to mammography. One part of the Canadian study found no benefit at all, and the part that focused on younger women found more deaths in the screening group, though this could have been due to chance.

Needless to say, the P.D.Q. panel’s interpretation of the Danes’ interpretation of the seven key studies is not universally accepted.

Dr. Daniel B. Kopans, director of the breast imaging division at Massachusetts General Hospital and a staunch advocate of mammography calls the Danish analysis and P.D.Q.’s acceptance of it ” a travesty…It’s a mistake to use the nonscience from the Danish study to dissuade women from potentially life-saving screening.”

The five studies the Danes rejected were actually “among the best done,” says Kopans, and the Canadian study, which the Danes applauded, was poorly done. “These guys don’t know what they’re talking about.”

This morass is both big news and same old, same old.

It’s big news because invasive breast cancer is estimated to have hit 192,000 women last year to have killed 40,200. It’s also important because women have fought hard to get mammograms covered by insurance and because many women believe (or have been led to believe) that if they just get mammograms, they’ll either be magically protected against breast cancer, or at least will have a better shot at surviving it if we do. (The first is obviously untrue, the second is what’s up for grabs.)

Among the continuing believers in mammography are the American Cancer Society and, with more ambivalence, the National Cancer Institute.

Dr. Robert C. Young, president of the American Cancer Society, stresses that the death rate from breast cancer has been declining in recent years. (It’s not clear, however, whether this is due to wider use of mammography or more aggressive treatments.) 

“With widespread use of mammography,” he argues, the presence of cancer in lymph nodes at the time of initial surgery “has gone from 60 percent in the 1980s to less than 30 percent in the 1990s. And the size of breast cancer lesions on average has gone from 3 centimeters in the 1980s to 2 centimeters now.” Furthermore,  he says, the real benefit of mammography may not be seen for another 15 to 20 years.

Dr. Peter Greenwald, director of cancer prevention at the National Cancer Institute, acknowledges that the institute’s recommendations “have not been totally consistent.” But he is sticking by current NCI recommendations: a mammogram every one to two years for women, starting in their 40s,  and starting earlier, for women at high risk whose doctors recommend it.

But this whole mess smacks of same old, same old, too. The seven studies now at issue are the same seven studies that researchers have been fighting about for years, particularly with regard to younger women.

At a consensus conference called by NCI in January, 1997, that panel of experts concluded that women in their 40s should make up their own minds about mammography because the survival benefit to younger women is so small.

That turned out to be a politically incorrect decision. The American Cancer Society disagreed vehemently. In February, the National Cancer Advisory Board, which oversees the NCI, got into the act. Then Congress, which oversees the NCI’s budget, weighed in, making it clear that if the NCI  did not recommend mammograms for younger women, its budget could be cut, recalls Berry.

Surprise, surprise, the NCI then reversed itself, recommending mammograms for younger women.

All of this might be considered academic squabbling were it not for one thing.  Many women dutifully have mammograms in part because they take  a “Why not? It can’t hurt” attitude.

But mammography can hurt (and not just the compression during the X-ray). One outcome of mammography can be more testing, some of it painful, most of it, anxiety provoking. The good news is that most suspicious mammograms turn out to be false alarms, but to be sure of this, women put themselves through biopsies and other tests.

Mammograms aren’t exactly foolproof in the other direction, either. In younger women, mammograms miss 25 percent of cancers; in women 50 and over, mammograms miss 15 percent of cancers.  That’s bad, too, obviously, because women may delay treatment.  

Women’s health advocates have long held a more nuanced view of mammography than lay women, arguing that while mammograms may detect breast cancer earlier than clinical (manual) exams, this is not really early detection, merely earlier.

The latest mess “confirms what many of us have suspected,” says Fran Visco, president of the Washington,D.C.-based National Breast Cancer Coalition. “The evidence behind screening mammography is poor, certainly for women under 50. For too long, we feel, mammography has taken up too much space in the world of breast cancer…we need to look more at how to prevent the disease, how to detect it early, at access to quality care for all women….those are the big issues.”

 “Mammography is not the answer to the breast cancer epidemic,” the coalition added in a prepared statement last week. ” In any age group, mortality reduction associated with mammography is less than 50 percent….Although it may be difficult to accept, it is vital that women know the truth about breast cancer screening and the false sense of security it provides.”

Cindy Pearson, executive director of the Washington, D.C.-based National Women’s Health Network, agrees. “It’s better that we know this and are confused than we are kept in the dark like in the old days.

 So, ladies, where does this leave us? Among other things, in the same boat as men, who are often urged to have PSA testing for prostate cancer without understanding that this test may lead to more and more invasive interventions, some of which may be damaging or of little survival value.

As for mammograms, the P.D.Q. panel is writing up its conclusions now and expects to finalize them in March. At that point, the NCI may or may not decide to alter its current recommendations.

None of this uncertainty is going to go away. It would probably help if everybody (the media included), obsessed a bit less about breast cancer, terrifying though it can be, and a bit more about statistically greater threats, like heart disease, for which there is ample evidence that improvements in exercise and diet can reduce risk.

Ultimately, the answer is not an endless series of expert panels endlessly re-hashing old data on an obviously imperfect test. The real answer is genuine prevention and cures that work.

Meanwhile, I’m keeping that mammogram appointment. 

A New Understanding of Depression

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At McLean Hospital in Belmont, brain researchers have hit upon what could become a totally new way to treat depression – blocking a brain chemical called dynorphin, the “evil cousin” of  endorphin, which triggers the “runner’s high.”

At the University of California, Los Angeles, psychiatrists have modified the standard EEG (or electroencephalogram) to predict which depressed patients will get better with drugs and which won’t – weeks before the patients can detect any changes in mood.

At the University of Toronto, scientists are tracing the specific components of depression – sadness, distorted thinking, disturbed sleep – to separate, but linked, regions of the brain. In the process, they’ve found one key region in the ” emotional brain,”  area 24a. If that’s overactive, depressed people improve with drug therapy; if it’s not, they won’t.

At Beth Israel Deaconess Medical Center in Boston, researchers are trying yet another approach – transcranial magnetic stimulation, which uses magnets placed on the scalp to stimulate the pre-frontal lobes of the brain, which are often sluggish in depression.

Depression, in other words, is no longer believed to be a mere deficiency of key brain chemicals – norepinephrine, dopamine and, perhaps most important, serotonin.

Today, brain researchers view this common illness, which strikes about 19 million Americans, as a malfunction of particular circuits that connect the limbic system, or “emotional brain,” with the pre-frontal cortex, or “thinking brain,” and the brain stem and hypothalamus, which control basic functions such as sleep, appetite and libido.

In truth, there never was much proof that depression was merely a serotonin deficiency. That was an inference from data showing that people who are aggressive or suicidal often have low serotonin, notes Dr. Peter Whybrow, director of the neuropsychiatric institute at UCLA. And from data showing that if researchers deprived people of tryptophan, a substance from which the body makes serotonin, they quickly got very depressed.

But now, despite the obvious efficacy of serotonin-boosting drugs such as Prozac, Zoloft and Paxil, it’s clear that when a person is depressed, there’s a lot more going wrong in specific areas of the brain than just low levels of serotonin.

The brain works by chemical and electrical signals. When an electric current passes through one cell, the cell releases a neurotransmitter, which floats to the next cell, causing it to “fire up electrically,” a process that, repeated cell after cell, activates whole circuits in the brain, notes Dr. Alvaro Pascual-Leone, director of the transcranial magnetic stimulation lab at Beth Israel. 

While most drug developers have focused on the chemical side of the equation, he notes, depression can also be treated by getting the electrical circuits back to normal. One way to do this is ECT, or electroconvulsive (“shock”) therapy, which causes a brain-wide seizure. ECT is effective, but it can also cause confusion and memory loss.

A potentially better though still experimental approach, Pascual-Leone thinks, is transcranial magnetic stimulation or TMS, which uses a magnetic field to kick-start just the pre-frontal lobes. That in turn may affect the limbic system, potentially easing depression without brain-wide seizures and memory loss.

The hallmark of depression, brain mapping shows, is too little activity in the right and left pre-frontal lobes (behind the eyes) and the right and left parietal lobes (on the side of the brain, toward the top), and too much activity in the limbic system, or emotional brain.

But the limbic system and pre-frontal lobes, which govern thinking, are actually wired together though specific neural circuits, notes Dr. Helen Mayberg, a professor of neurology and psychiatry at the University of Toronto who uses PET scans to measure blood flow and map “depression circuits” in the brain.

Indeed, the close links between the limbic system and pre-frontal lobes probably explain why depressed people not only feel bad emotionally but have trouble thinking. “For many people, yes, they are sad,” she says. “But what brings a lot of people to the doctor is the fact that they can’t think straight.”

In addition to the abnormal activity in the entire limbic system and pre-frontal lobes, scientists are finding changes in specific sub-regions when people are depressed.  The  hippocampus, for instance, a center for learning and memory, is often shrunk in depression, perhaps because it is damaged by the stress hormone, cortisol. Some scientists also think the amygdala, a fear processing center, may be involved.

And other sub-regions seem to play a role, too.  Mayberg, for instance, asks volunteers to recall a sad memory. When they start crying, she uses a PET scan to measure blood flow in the brain. The “hottest” area (the one with the biggest increase in blood flow) turns out to be a small part of the anterior cingulate called area 25, part of the limbic system. While this area gets more active,  the pre-frontal cortex, or thinking area, turns off.

In healthy people immersed in sad feelings, the brain can quickly shift back toward equilibrium. “The phone rings, the baby cries, the boss calls and you immediately disengage from the sadness and the thinking part of the brain turns back on,” she says. With depressed people, this ability to shift back to equilibrium is altered.

That may be because area 25 has direct links to area 24a, a monitoring center for emotions. In some depressed people, area 24a is virtually stuck in the “on” position, which may reflect the brain’s frantic attempt to handle upsetting feelings, Mayberg says. But that may be a good sign: Depressed people with high activity in area 24a typically get better with drug treatment, while those with low activity in 24a  don’t.

While PET scans like the ones Mayberg uses can detect changes deep in the brain, Dr. Andrew Leuchter at UCLA has found that he can predict which patients will respond to drugs with a simpler tool. Using a system called QEEG (for quantitative EEG), Leuchter studies depressed people with low activity in the pre-frontal lobes. Then he looks at what happens when they start taking Prozac, which typically takes six weeks to improve mood.

In the first few days, some people show a further decrease in pre-frontal lobe activity, particularly in the area closest to the eyes, followed about a week later, by an increase. But some people don’t show this initial decline. When Leuchter follows the patients over time, the ones who respond best to drugs are those who show the initial decline.

 “Once somebody has started on medication, we can see whether they will respond in under a week,” he says. Eventually, this should enable doctors to tell people who are likely to improve on a drug to be patient because their “brain changes are on the right track.” Those deemed unlikely to respond to a given drug can be given others drugs.

And then there are the lessons to be learned from depressed rats. Researchers who study depression in lab animals use a behavioral test called the “forced swim test.”

It works like this: Normal rats are put in a tub of water. Typically, they swim hard for 10 minutes, then give up and float until researchers take them out. The next day, they are put back in the water, whereupon they give up much faster, usually after 2 minutes. This, researchers say, illustrates the “learned helplessness” model of depression. If they are given Prozac, rats (unlike people) seem to experience an immediate benefit – they don’t stop swimming nearly as fast on the second day.

 “Every depression treatment  known to man – all drugs, electroshock therapy, TMS –  all affect the forced swim test,” says McLean neurobiologist William Carlezon.

In a recent paper in Journal of Neuroscience, Carlezon showed that there are other ways to keep rats swimming longer and, presumably, feeling good. The team focused on a protein called CREB, which activates a gene that makes dynorphin. A close cousin of endorphins and enkephalins, dynorphin is a natural painkiller. But unlike its cousins, it makes people feel “lousy, not euphoric,” says Carlezon.

Carlezon used injections into an area of the brain called the nucleus accumbens to increase or decrease  levels of CREB, and therefore dynorphin. When the rats had too much CREB, they gave up on the swim test after only one minute, suggesting that they were indeed depressed. When the researchers blocked CREB, the rats swam like champs, or more precisely, like rats on Prozac. The rats also swam a long time when given drugs that directly block dynorphin.

CREB, in other words, “is a molecular trigger for depression that acts by increasing dynorphin,” says Carlezon.  That suggests that drugs that fight depression faster than Prozac might be developed for humans, though so far no known dynorphin-blockers can enter the human brain.

Precisely how all these new pieces of the depression puzzle fit together remains a mystery. But it’s clear that not only is depression not a character flaw, it’s not even biochemically as simple as once thought. “As we  understand better the fundamental causes of depression,” says Dr. Scott Ewing, director of the depression and anxiety clinic at McLean, ” we can expect to see over the next decade antidepressants developed that will be more effective and more rapidly acting.”

Unnecessary Dentistry?

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He’s 81 now, this former Boston businessman, and when he retired to a southern state some years back, one of the most treasured things he left behind was his friend and dentist of 50 years, Dr. Wallace J. Gardner of  Cambridge.

In the south, the executive found a new dentist, who proposed a $5000 treatment plan involving multiple visits (including one 3-hour session) to replace some of his gold crowns and change his bite. The executive, who asked that his name not be used, was outraged. ” I had never had any trouble. I still had all my teeth.” “This really upset me very much,” says Gardner, waving the letter from his friend as he stood amid dozens of plaster casts of teeth in his workroom not long ago. Not only would the treatment the new dentist proposed be expensive, he says, “you should never put a dental patient in the chair and work on them for three hours at that age…. it’s too dangerous because of blood clots.”

Most dentists are honest, Gardner and many other dentists insist. But there are also cases like this one, Gardner says, in which proposed treatments are unnecessary – and possibly dangerous to boot.

Unnecessary dentistry is a touchy subject among the nation’s 155,000 dentists, who’ve already had more than enough bad press lately.

In August, Medicaid fraud investigators in Florida charged that criminals were snatching poor kids off street corners and delivering them to dentists for unneeded cleanings, X-rays and even extractions. The same week, the American Dental Association, huffy that the nation’s third largest dental insurer, Aetna, Inc. had claimed that certain dentists were overcharging patients, retaliated with a class action suit against the insurer.

In terms of outright fraud, the frequency is probably low. But more subtle things, like crowns that a person doesn’t really need? Routine removal of wisdom teeth in teenagers? Very frequent cleanings? In truth, there’s little hard data on these softer sins.

But the temptation for dentists to blur the lines between necessary procedures and those that are optional or cosmetic clearly exists.

A century ago, most Americans lost their teeth by middle age, according to last year’s Surgeon General’s report on oral health. Now, thanks to widespread fluoridation of the nation’s water supplies, most middle-aged Americans can expect to keep their teeth throughout their lives, and many kids have few or no cavities.

Indeed, this dramatic improvement in oral health is one of the 10 greatest public health advances of the last century, notes Dr. Raul Garcia, chairman of health policy and health services research at the Boston University School of Dental Medicine.

But with fewer cavities to fill,  dentists have had turn to other procedures to boost their incomes, says Dr. Marv Zatz, a New Jersey dentist who now works as a dental insurance consultant for Towers Perrin, a health, welfare and retirement consulting firm.

“Dentists have changed their whole paradigm,” he says. Today, “much of what they do is elective,” including tooth whitening, braces for adults and replacing dark fillings with white ones. 

Some dentists go so far as to urge patients to have their old, amalgam fillings (which contain tiny amounts of potentially toxic mercury) replaced, a practice that the National Institute of Dental and Craniofacial Research does not recommend.

One of the toughest critics of post-fluoride dentistry is Dr. Gordon Christensen, a Provo, Utah dentist who is on the editorial board of the Journal of the American Dental Association. In a recent issue of that journal, he blasted fellow dentists for “having a commercial, self-promotional orientation” and “planning and carrying out excessive treatment.”

Many dentists and plastic surgeons “may make something sound as though it’s absolutely necessary when in fact it’s elective,”  he added in a telephone interview. Since 50 percent of the average dentist’s income is now from cosmetic work,  he stressed, “people should be told what’s necessary…and what’s not.”

Making matters worse, other critics say, is that, compared to doctors, dentists have fewer national guidelines on specific practices and are more likely to work alone – with less professional scrutiny.

Take wisdom teeth, for example.

Many dentists believe that wisdom tooth extraction, for which Americans spend $2 billion a year, should be done in teenagers to avoid cysts or infections that might develop around the teeth in the future. Moreover, they say, young people heal so much more quickly than older ones that it makes sense to extract the teeth in late adolescence.

But no one really knows how much long term benefit, if any, there is to routine extraction of wisdom teeth that have not yet caused problems. The most recent government recommendations on the subject are 22 years old, which means they don’t include more recent data from studies that question routine extraction.

One relatively recent study, for instance, published in 1990 in the International Journal of Technology Assessment in Health Care suggested that instead of routinely pulling healthy wisdom teeth, it might make more sense, in terms of both economic costs and disability, to extract only those teeth that are impacted (emerging crookedly or stuck partway out of the gums) and clearly causing problems.

A British analysis published last year in Health Technology Assessment reviewed 40 other studies and came to a similar conclusion – that routine removal of wisdom teeth to prevent future problems is often not justifiable.

In the US, oral surgeons, whose income depends heavily on wisdom tooth extraction, are currently conducting their own, multi-center study on the issue, says Dr. Louis Rafetto, a Wilmington, Delaware oral surgeon and spokesman for the American Association of Oral and Maxillofacial Surgeons.

But those results are several years away, which means patients are on their own trying to assess a dentist’s advice.

One Framingham woman, who asked that her name not be printed, feels that both her daughters, now in their 20’s, were “railroaded” into wisdom tooth extractions. “Nobody was willing to even consider whether it was necessary to take them all out,” she says.

And then there’s the issue of how often people need to have their teeth professionally cleaned. The dental association says that’s a judgment call best done case by case, says Dr. Matthew Messina, a Cleveland dentist and ADA spokesman.

But the recommended interval between seems to keep getting shorter. Traditionally, dentists said professional cleanings were needed every six months to prevent periodontal disease, an inflammatory response to bacterial infection that destroys the gums and bones around teeth. Seeing a dentist that often is a also good way to detect cavities or other problems, they argue.

But that 6-month interval has “transmigrated” into cleanings every three or four months for many people, says Dr. Richard Beyers, a dentist in Kitchener, Ontario and author of a recent paper in the Journal of the Canadian Dental Association.

That may make sense for people who are too physically or mentally impaired to brush and floss regularly.  Short intervals may also be essential for people who naturally  “form calculus very fast,” says Dr. Glenn Clark, a specialist in hard-to-diagnose oral medicine at the UCLA School of Dentistry. (Calculus is the mineral gunk on teeth that bacteria feed on, triggering periodontal disease.)

But in actuality, there’s so little evidence on the right interval for cleaning that the authors of a 1994 study in the Journal of Dental Education concluded  “it may be time to call all clinical dogma regarding treatment of adult periodontitis into question.”

So, what’s the answer? As the bumper stick says, “question authority.” If your dentist recommends a procedure that strikes you as overly expensive or invasive, ask whether you really need it. If you’re not convinced, get a second opinion.

And if you do go for a second opinion, take your X-rays with you. There’s no point in subjecting yourself to the extra (albeit low dose) radiation that X-rays entail, or to the expense.

SIDEBAR

If you want a second opinion on a dental procedure and don’t know where to turn, try calling a local dental school. Most states have at least one. In Boston, Harvard, Tufts and Boston University all run dental schools.

Procedures that you may want a second opinion on include the following:

  • Crowns: These can run $600 or more. Crowns are made of porcelain or plastic and are usually put on a tooth that has broken or in which a cavity is too large for a simple filling. Sometimes, they are used to provide a better contour for the tooth. If a crown is purely to change the appearance of a tooth, that’s an elective procedure. If it’s to enable you to chew better, it’s probably not elective.
  • Bonding:  This is a procedure in which the dentist etches the surface of the tooth and then covers it with a tooth-colored plastic material to provide a better appearance. It is often an elective procedure.
  • Deep scaling: This probing around the gums to remove debris is necessary – and therefore not elective – if you have periodontal disease, but is usually not necessary if you don’t. Whether or not you really need it is a judgment call by the hygienist and dentist.
  • Implants: These are permanent replacements for lost teeth. They consist of anchors that are surgically placed deep in the jawbone, to which posts, and then crowns, are attached. They are not usually considered elective.
  • Replacement of black fillings with white ones. If the old fillings are still functional, this is primarily a cosmetic procedure, therefore elective. Filling very tiny cavities – as opposed to watching and waiting to see if they get worse – is also often elective.

Polycystic Ovary Syndrome – Common but Underdiagnosed

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Okay, it’s Pop Quiz time: What syndrome affects at least 5 million American women, yet is believed to be vastly under-diagnosed, despite its rather startling symptoms: excessive facial hair, acne, high male hormone levels, irregular periods, infertility, significant weight gain and a strong tendency to become diabetic?

If you answered “polycystic ovarian syndrome” (or PCOS), you’re among the cognoscenti – and possibly well ahead of your doctors, who often spot pieces of the syndrome but fail to put it all together, much less treat it the new way – with drugs, including some usually used for diabetes, that can often reverse or at least control some of the most disturbing symptoms 

For years, many gynecologists told young women with irregular periods not to worry, or to simply take birth control pills. And that was partly right – the pills do help regularize cycles.

But acne, beards and abdominal hair?  Could doctors really have dismissed that as just a cosmetic thing? (Ah, yup.)  Dramatic weight gain? Could they have tossed that off as just another female character flaw? (You got it.) Out-of-whack insulin levels? Well, that may be a little more understandable – after all,  who would think to refer a woman with missed periods to a diabetes specialist?

In truth, PCOS has been recognized, by some doctors, for decades; in fact, it used to be called “diabetes of the bearded woman.” But it’s only recently that endocrinologists have really pieced together the links between the seemingly-obvious gynecological symptoms such as infertility and ovaries full of tiny cysts (un-released egg follicles), and the more complex and widespread hormonal disruption.

Today, PCOS is viewed as a serious hormonal imbalance triggered in part by faulty genes for sex hormones and other genes involved in a serious condition called insulin resistance, which often leads to diabetes.

Indeed, women with PCOS have seven times the normal risk of diabetes, as well as a higher risk of gestational diabetes (which starts while a woman is pregnant and can later become standard adult onset diabetes). Preliminary research also suggests that women with PCOS have a 50 percent increased risk of heart disease and stroke as well.

Essentially, PCOS is a “vicious cycle,” though it’s unclear which biochemical glitches come first, says Dr. Stanley Korenmann, an endocrinologist at the UCLA School of Medicine. Once the PCOS cycle gets started, the hallmark is insulin resistance, which can also be triggered or exacerbated by obesity and inactivity.

In insulin resistance, the pancreas goes into overdrive to make more and more insulin – a frantic attempt to get enough sugar into cells, notes Dr. Edward Horton, director of clinical research at the Joslin Diabetes Center in Boston. 

Even if a person is just insulin resistant and never develops outright diabetes,  the insulin resistance itself is linked to “a whole metabolic cluster” of problems, notes Horton. This cluster, dubbed Syndrome, is characterized by some of the well-known risk factors for heart disease: elevated triglycerides (fatty acids), low HDL (“good” cholesterol), high blood pressure, changes in blood clotting patterns and a build-up of fatty plaques in arteries.

And that’s just the beginning. In the ovary, excess insulin messes up the normal process by which an aromatase enzyme converts male hormones such as testosterone into estrogen. The result for many women with PCOS is unusually high levels of testosterone in the blood. The excess testosterone, in turn. causes women to sprout hair in a male pattern (on the face, chest and abdomen), and to get severe acne (which is driven by breakdown products of testosterone.)

And it gets worse. In this high-insulin, testosterone-excess state, the chemical signaling system between the hypothalamus in the brain and the pituitary gland, which lies just below the brain, goes awry, with the result that the pituitary never signals the ovary to release an egg. This means that ovulation fails, and when that happens, a woman becomes infertile.

In fact, PCOS is a leading cause of infertility.  But there’s another problem, too. Without ovulation, the uterine lining does not shed every month, which raises the risk of endometrial hyperplasia, a precursor of uterine cancer.

Excess testosterone can also lead to insulin resistance, which leads to even greater excess testosterone production by the ovaries and the cycle continues on its miserable way.

Given such complexity, perhaps it’s not surprising that many women, among them Kristin Rencher, a 37-year former investment banker from Portland, Ore., go from doctor to doctor and suffer through agonizing teenaged years (dating is tricky enough even if you’re not fat, bearded and pockmarked!), until they eventually, try and fail to get pregnant and wind up seeing a reproductive endocrinologist who finally diagnoses PCOS.

“Looking back, someone should have known something was wrong when I was 14,” says Rencher, who now heads the Portland-based Polycystic Ovarian Syndrome Association.

Rencher got her first period at 13, then had none for years. At 14, she developed severe acne. By 19, she began to get excessive hair on her face and abdomen, even between her breasts. She exercised and dieted, but still gained 25 pounds. She did get pregnant, with the help of a fertility drug, but it was only when she began trying to have a second child that she combed the web, diagnosed herself with PCOS and went to a reproductive endocrinologist, who confirmed her diagnosis.

Kim Maynard, 41, a Cohasset woman who works as an operations coordinator for a tour company, has an equally horrifying story: Irregular periods, 100 pounds of excess weight, multiple miscarriages (though she has had three children), excessive hair (even on her feet), and now, worst of all, a strong suspicion that her 16-year old  daughter, Amanda, is also developing PCOS.

The good news is that, thanks to the emerging view that insulin resistance is a core part of the PCOS problem, better treatments are becoming available, though so far, the drugs must be used “off label” because, although legally on the market, none have been approved specifically for PCOS by the US Food and Drug Administration.

The most important is the class of drugs called insulin sensitizers, says Dr. Andrea Dunaif, a leading PCOS researcher and chief of endocrinology at Northwestern University Medical School in Chicago. This class includes Glucophage (metformin), Avandia (rosiglitazone) and Actos (pioglitazone).

Several studies, including a pivotal one published several years ago in the New England Journal of Medicine, show that Glucophage can help correct the insulin resistance problem, “lower male hormone levels and, in a substantial percent of women, restore ovulation,” says Dunaif.  Glucophage may also boost the effectiveness of ovulation-stimulating drugs such as Clomid. (And a new, extended release version of Glucophage may have fewer side effects than the traditional one.)

Dr. Sandra Carson, a reproductive endocrinologist at the Baylor College of Medicine in Houston, agrees. “If you break the cycle by breaking insulin resistance, patients may ovulate. It’s been quite successful.”

That raises the question, though, of whether newly-pregnant women with PCOS should stay on Glucophage during pregnancy, says Dr. Veronica Ravnikar, director of reproductive endocrinology at the University of Massachusetts Medical Center in Worcester. There’s some evidence that doing so may decrease the risk of miscarriage, but many reproductive endocrinologists, including Ravnikar,  think it’s safer to stop the drug during pregnancy.

And while many women, including Kristin Rencher of Oregon, get dramatic weight loss on Glucophage, many others don’t, so insulin sensitizing drugs should not be considered miracle cures for obesity.

Soon, a new drug, not yet on the market, may be marketed specifically for PCOS. Made by INSMED, INS-1 is still in clinical trials and but is believed to be a promising insulin sensitizer. Other insulin sensitizing drugs are also in the works.

To cope with the hirsutism – excess hair growth – of PCOS, many women take Vaniqa, a topical cream that speeds up cell turnover and slows down growth of hair. Alternatively, drugs such as Aldactone (spironolactone), which block the action of male hormones, may also help, though such drugs can be toxic to a fetus.

A new birth control pill called Yasmin also has spironolactone-like effects, which means in theory it could help with excessive hair growth. Other birth control pills can also help control both excessive hair growth and acne, though many women with PCOS simply use bleaching, waxing, electrolysis or laser treatments to control excess body hair.

For those who don’t want to take birth control pills but are concerned about the risk of uterine cancer because of the lack of menstrual periods, one solution is to take a progesterone drug such as Prometrium every few months to induce a period.

The bottom line for any woman who thinks she, or her daughter, may have PCOS is to “keep searching for a doctor who will listen,” says Kim Maynard of Cohasset. “Look on the Internet. Get the support you need. There are a lot of books out there now – buy them and read them.”

Judy Foreman’s column appears every other week in Health & Science. Her past columns are available on Boston.com and www.myhealthsense.com. Her email address is foreman@globe.com.

Sidebar:

For more information, call the Polycystic Ovarian Syndrome Association (877-775-PCOS, or 7267) or visit the group’s website,www.pcosupport.org

You might also want to read books on PCOS, including “Living with P.C.O.S.,” by Angela Boss and Evelina Weidman Sterling.

Inducing Labor For Convenience

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You’re 39 weeks pregnant, not quite full-term. You’re still working, of course – after all, you’re a modern mom – and you’ve got everything under control. Except the obvious.

If you knew exactly when the baby was coming, you could tell your boss when to start the maternity leave clock ticking. You could tell your mother when to take time off from her job to come take care of your older child. You could tell your husband to go on that business trip. Your obstetrician wouldn’t exactly mind knowing the precise ETA of your new baby, either – after all, she’s got kids of her own and would much rather deliver babies between 9 and 5 on weekdays than pull all-nighters on weekends.

Besides, you’ve gained 35 pounds. It’s been a long, uncomfortable summer.  And you are definitely TOP, or “tired of pregnancy.”

So, why not do the modern, high tech thing and get your doctor to induce labor so that you, not Mother Nature, can decide when the baby will come?

Actually, there are lots of compelling reasons why not, and we’ll get to them in a minute. But more and more busy mothers-to-be, used to being in control of most things in their lives, are flat-out demanding that childbirth be as easy to schedule into their Palm Pilots as a corporate meeting. And many obstetricians are only too happy to oblige.

Between 1989 and 1999, the number of labor inductions – in which doctors hurry childbirth along with drugs to dilate the cervix and stimulate uterine contractions –  has soared to 775,245, according  to the National Center for Health Statistics. That’s a whopping 19.6 percent of live births, up from 8.2 percent in 1989.

In many cases, the induction of labor is done for legitimate medical reasons such as toxemia (high blood pressure and other symptoms), gestational diabetes or a birth that’s a week or two overdue (which means the placenta, the organ that supplies the fetus with oxygen and nutrients, may start to break down).

But increasingly, induction of labor is done for “elective”  reasons, that is, pure convenience. And while some obstetricians hail this move -as elective inductions rise, weekend deliveries decrease – many obstetricians and nurse-midwives worry that the trend may lead to more Caesarean sections if induction fails, more respiratory problems in babies born with not-quite-mature lungs, and more chance of uterine ruptures triggered by drugs such as prostaglandins and Pitocin.

The national health statistics center does not keep track of how many labor inductions are done for medical reasons, how many for convenience and how many for a combination of the two, such as a woman with a track record of short labors who lives far from the hospital.

But Dr. Lewis Rosenberg, an obstetrician-gynecologist at New Island Hospital in Bethpage, N.Y., believes elective inductions now constitute 40 percent of all inductions. 

The trend toward scheduling childbirth, he adds, is also propelled by managed care and the need for doctors who work as solo practitioners or in small groups to maximize their own efficiency. “If you’re going to be seeing a large number of patients in one day, the worst thing is to have a patient in labor – you have to reschedule a lot of people.”

Indeed, a recent online survey by Americanbaby.com, a parenting website, found that 36 percent of 827 respondents said they would  “consider” scheduling induced labor and another third said that while they wouldn’t do it themselves, they didn’t object to other women doing so.

And that probably underestimates the actual number of requests for elective inductions.

“Almost everyone who walks through the door to my office wants a scheduled childbirth,” says Dr. Laura E. Riley, 41, a maternal-fetal medicine specialist at Massachusetts General Hospital who counsels against it, from both professional and personal experience.

Five years ago, shortly before Christmas, Riley begged her obstetrician to induce labor. She was 39 weeks pregnant. “I didn’t want to deliver at Christmas,” she says. “I wanted the baby beforehand so I could be home with my two-year old.”

So the week before Christmas, Riley’s doctor admitted her to the hospital,  “started the Pitocin and cranked it up to the highest number,” recalls Riley. “I went from having cramps to the most unbelievable labor out of nowhere because there was no ramp-up time. It was awful.”

On top of that, the painkilling drugs – given by injection epidurally (into the space around the spinal cord) didn’t work.  “It was a fast labor, only two hours,” says Riley. “But it was so intense I thought I would go out of my mind. Fortunately, I was fine and the baby was fine. But in retrospect it was silly.”

Just how silly, however, is a matter of contentious debate.

The American College of Nurse-Midwives takes a dim view of elective inductions. The American College of Obstetricians and Gynecologists does, too, although that group says labor may be induced for “psychosocial” reasons. But the group  warns that obstetricians should be very sure if they induce labor in a woman who is not quite full-term that the fetal lungs are mature or that other tests show the fetus is developed enough to be born. Generally, this means the woman should be at least 39 weeks pregnant and that her cervix be “ripened,” that is, already be soft, flat and at least partially open.

The chief argument against elective induction of labor is that nature does such a brilliant job of orchestrating the delicate dance of chemical signals that cause the cervix to ripen and the uterus to begin contractions that it’s tough for mere mortals to do nearly as well.

One theory is that when the fetal brain is mature, notes Joyce Roberts, a nurse-midwife at Ohio State University, it sends signals to the fetal adrenal glands to secrete cortisol, a stress hormone. That in turn may trigger a shift in the placental metabolism of  the two key hormones of pregnancy, estrogen and progesterone, so that estrogen begins to dominate. That, in turn, may make the uterus more capable of contracting.

Meanwhile, scientists believe, the fetal lungs secrete signals signaling that they are mature, along with enzymes that trigger the release of prostaglandins, which in turn tell the cervix to ripen and the uterus to contract. Oxytocin, made in the mother’s body, triggers further uterine contracts. (It is the natural hormone of labor on which Pitocin is modeled.)

“To push those mechanisms is foolish,” she says. “There’s an optimal timing” in nature’s method  “and most of the time, it works out amazingly well.” When labor is induced “for no good reason, the fetus may not be optimally mature and the mother’s uterus may not be capable of good labor contractions.”

But some obstetricians argue that, when done carefully in the right patients, elective induction of labor can be safe.

“Personally, I think if the patient is well worked up in terms of the baby’s maturity” and if  the cervix is ripe, ” I don’t think there’s anything wrong with it,” says Dr. Alan De Cherney, chairman of obstetrics and gynecology at the UCLA School of Medicine. “But you have to do it in the right people.”

A good candidate, he adds, is a woman who has had one previous vaginal delivery, whose cervix is ripe and who is likely to go into labor spontaneously in a few days anyway.

Dr. Lewis Rosenberg, of New Island Hospital, agrees. “You have to make sure there is adequate dating” of the pregnancy to be sure the woman is at least 39 weeks pregnant. By 39 weeks, the fetal lungs contain enough of a crucial substance called surfactant that they are reasonably mature, which means there’s less than 1 percent chance of respiratory problems. (For babies born at 36 weeks, the risk of respiratory distress syndrome is 5 percent, and it goes up steeply with shorter and shorter pregnancies.)

Some obstetricians start an elective induction by rupturing the membranes of the amniotic sac (what lay people call “breaking the waters”) with a small, blunt  “amniotic hook.” Often, this starts spontaneous contractions. If it doesn’t, then Pitocin can be given, but once the waters are broken, the delivery should happen (by C-section, if necessary) within 24 hours because the risk of both maternal and fetal infection rises.

It is possible to artificially trigger an unripe cervix to ripen with drugs, chiefly, prostglandin gels. But a woman whose cervix was unripe to begin with has a higher risk of C-section than one who is induced with an already ripe cervix.

“If the cervix is ripe, the risk for C-section is probably low,” concedes Riley of MGH. “However, many people want elective induction with an unripe cervix or want drugs to ripen it. My personal opinion is that any form of intervention that is unnecessary is probably not in anybody’s best interest.”

But that doesn’t stop Riley’s patients from begging for induced labor anyway, even trying to bribe her with chocolates. “A tremendous number of people want an induction because they want to control everything. Most are control freaks…..I can completely relate because I am one of them. But I  don’t do very many elective inductions. I refuse because of the risks.”

SIDEBAR

The American College of Obstetricians and Gynecologists recommends that labor be induced only if the doctor is sure that the fetal lungs are mature or that at least one of the following criteria of fetal maturity have been met:

  • The fetal heartbeat has been documented for 20 weeks by a stethoscope or 30 weeks by a more sophisticated “Doppler” test of gestational age.

  • It has been 36 weeks (or more) since reliable lab tests showed the presence on a blood or urine test to detect a hormone called HCG, or human chorionic gonadotropin, a sign of pregnancy.

  • The fetus can be assumed to be at least 39 weeks old as judged by an ultrasound measurement of the length of the fetus from crown to rump, obtained at 6 to 12 weeks of pregnancy.

  • An ultrasound taken at 13 to 20 weeks confirms a gestational age of 39 weeks determined by the doctor’s clinical impression and a physical exam.

It is also important, the doctors’ group says, that medical personnel carefully monitor uterine contractions stimulated by Pitocin because they can cause fetal distress and uterine rupture. And a recent paper in the New England Journal of Medicine suggests that inducing labor after a woman has had a previous C-section may lead to a higher incidence of uterine rupture.

The Lesson Of Old Geniuses

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Grandma Moses first picked up a paintbrush at 78, reportedly after arthritis forced her to give up the embroidery for which she was already well-known. She went on to paint for more than 20 years, finishing her last big canvas at 101.

Giuseppe Verdi, the Italian composer, was also no slouch in old age. He produced his greatest masterpiece, “Otello,” at age 74, and his final opera, “Falstaff,” at 80.

Albert Einstein didn’t rest on his youthful laurels, either. After winning the Nobel Prize in physics at age 42, he became a political activist, crusading against atomic weapons until his death at 76.

And Nelson Mandela? The anti-apartheid leader didn’t even become president of South Africa until he was 76.

Despite such dazzling late-in-life success stories, neuroscientists for decades were pessimistic about the aging brain. Sure, a few standout individuals blossomed in their 70s and beyond, but they could point out that for every Einstein, there was an Isaac Newton, an equally great scientist who spent his later years preoccupied with alchemy and other pseudoscience.

The neuroscientists’ gloom was based on their belief that aging causes a steady loss of neurons (brain cells) all over the brain. They “knew” the adult brain could not generate new neurons. Worst of all, scientists assumed that nothing could be done to boost the odds of having a healthy, aging brain.

“It was thought that these changes began among individuals in young adulthood and progressed inexorably across the adult lifespan,” said Marilyn Albert, director of the Gerontology Research Unit at Massachusetts General Hospital.

Much of that, scientists have learned over the past decade, was too pessimistic. The aging brain, it turns out, is surprisingly “plastic” – capable of remodeling itself, growing new cells, and compensating in remarkable ways for the very real losses in processing speed that come with aging. And the brain is quite good at using the knowledge accumulated over decades to function well in everyday life.

Today, thanks to better techniques for studying post-mortem brain tissue, more sophisticated brain scans of living people and perhaps most important, a shift in emphasis from studying sick older people to studying healthy ones, neuroscientists have a much rosier view.

“The changes that occur with aging are much less widespread in the brain than we used to think,” Albert said. “And we now know there is a lot that people can do to maximize brain function in later life.” Many studies have contributed to this increasingly optimistic view of brain aging, but a few have proved pivotal.

In 1998, a team led by Fred H. Gage, a neuroscientist at the Salk Institute in La Jolla, Calif., showed that, contrary to popular belief, the adult human brain contains cells that can divide and become healthy, new neurons.

Though this had been previously shown in rats, cats and some monkeys, the Gage study electrified researchers in part because dividing brain cells were found even in the hippocampus, a region crucial for learning and memory. Equally impressive, dividing cells were found in people as old as72.

“The good news is that the adult brain retains the capacity for cell genesis and neurogenesis,” Gage said. “And this capacity persists throughout life. It is amazing.”

Just as important, Gage noted, researchers are discovering that physical exercise and intellectual enrichment can help stimulate this capacity.

Marian Diamond, a neuroanatomist at the University of California at Berkeley, has pioneered the study of brain improvement with more than 30 years of testing the mental capacities of rats in different types of cages normal cages with little inside and enriched cages containing lots of toys.

After leaving the animals in the cages for specified periods of time, Diamond sacrifices them and examines their brains to count the number of dendrites – filaments that extend outward from brain cells to pick up information. Whether the rats were young or old (the equivalent of 90 in human years), an enriched  environment seems to stimulate proliferation of dendrites, she found.

“This is why we’ve gone to the optimistic view of aging,” Diamond said.

Gage’s team, too, has shown the power of an enriched environment to keep aging brains healthy. In fact, his team has shown that an enriched environment leads not just to new dendrites but to a 15 percent increase in new brain cells in the hippocampus of rats, even those that, until the experiment, had spent their whole lives in normal, that is, boring, cages.

Even more important, Gage said, what really matters in an enriched environment is exercise. Rats given the chance to run to their hearts’ content on running wheels doubled the rate at which new brain cells evolved into mature neurons, he said.

Other animal studies published in 1998 and 1999 suggest one reason for this. Exercise seems to trigger an increase in secretion of a natural chemical called brain-derived neurotrophic factor, or BDNF, which stimulates brain cell growth. But only vigorous, aerobic exercise – not stretching or toning – produces this effect.

In humans, physical exercise is also now known to be one of four key ways to protect cognitive function, according to a coalition of researchers sponsored by the MacArthur Foundation Research Network on Successful Aging. The other three protective factors are education (the more, the better), good lung function to maintain good oxygenation of the brain, and having a sense of control over one’s life.

Granted, it’s a bit of a leap from having a sense of control over one’s life to proving that stress is bad for aging brains, but psychologist Elizabeth Gould at Princeton University has shown that, at least in rats, this is true. Stress hormones block production of new brain cells in the hippocampus, she said, and other studies show that levels of stress hormones increase in aging humans. That suggests that stress may adversely affect the aging human brain and, possibly, that stress reduction techniques might offset it.

Amid the encouraging news, it is still true, as earlier studies suggested, that there is some shrinkage of brain tissue with aging, primarily in the frontal cortex, which is responsible for executive functions such as planning and organizing.

There is also some brain cell loss in clumps of nerve cells deep in the brain, such as the nucleus basalis and the substantia nigra. The loss of these cells is believed to decrease the brain’s ability to produce certain chemical messengers, such as acetylcholine, dopamine and serotonin.

And it’s well-documented that older people process information more slowly and have more trouble switching between tasks, said Jordan Grafman, chief of the neuroscience section of the National Institute of Neurological Disorders and Stroke. But it’s also well-documented that older people have bigger vocabularies and larger stores of acquired knowledge.

Moreover, even when older people do suffer losses in specific skills such as certain types of memory, their brains can compensate, said Denise C. Park, a psychologist at the University of Michigan. Brains scans such as PET and functional MRIs show that for intellectual tasks that a younger person would perform using only one hemisphere of the brain, an older person often recruits the other hemisphere or other areas in the same hemisphere to help out.

“You don’t need tremendous processing speed and working memory in everyday life, so long as you are in familiar surroundings,” Park said. “In real life, what counts is stored knowledge, wisdom and well-learned skills.”

So, Park suggested, the next time you wonder whether an older person is still competent, Park suggests, ponder this: A 1999 study that she did showed that it’s not older folks who forget to take their pills – it’s harried, middle-aged professionals.

SIDEBAR: Some Mental Skills Decline With Age… But Wisdom And Common Sense May Increase.

  KEEPING THE BRAIN IN MIND

A growing body of research suggests there are a number of things you can do to improve brain function in later life.

  • Physical exercise: It helps build new brain cells, as well as strong muscles.
  • Mental exercise: Duke University neurobiologist Larry Katz, author of”Keep Your Brain Alive,” suggests doing “neurobics” to keep your brain humming with novelty, including simple tricks like brushing your teeth with your non-dominant hand, taking a different route to work and finding your car keys by touch instead of sight
  • Stress reduction: Nobody has proved in humans that lower levels of stress hormones help maintain healthy brain function, but they have shown that stress harms the brains of rats.
  • Stay connected: Harvard psychiatrist George Vaillant, author of the forthcoming book called “Aging Well,” said that maintaining rich emotional ties is crucial to healthy aging of mind and body.
  • Be creative: Your older years may be your best ones, said Dr. Gene Cohen, author of “The Creative Age.” Many people, he said, enter a liberation phase in their 60s and 70s and use a newly found sense of inner freedom to paint, write or create new social programs.
  • Finally, ask your doctor if you should take ibuprofen or similar drugs. A growing body of evidence suggests these medications help prevent cognitive decline and Alzheimer’s disease, probably by blocking inflammation that can destroy brain cells.

Food Fight – The Latest Skinny on Diets

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In the swampy world of nutrition books, clarity and credibility are as scarce as tofu and sprouts at Dunkin’ Donuts.But clarity and credibility are precisely the reasons you should toss out your old diet books, forget the government’s famous but flawed food pyramid, and get your hands on a new book, “Eat, Drink and Be Healthy,” by Walter Willett, a nutritionist based at Harvard University.

His book is powerful not only for its independence from both doctrinaire nutritionists and New Age nonsense, but for its no-holds-barred attack on the nutrition advice doled out by the US Department of Agriculture in posters and brochures that reach millions of schoolchildren each year.

Among other things, the USDA food pyramid utterly fails to make clear that there are both good (unsaturated) and bad (saturated and trans) fats, as well as good (whole grain) and bad (refined) carbohydrates.The Agriculture Department, citing longstanding policy, declined to comment on Willett’s criticisms.

Willett, whose lean figure is visible proof that he follows his own advice, is one of the nation’s leading nutrition researchers and chairman of the nutrition department at the Harvard School of Public Health.

Unlike most nutrition books out there, his is based on mountains of data from huge epidemiological studies. And his willingness to simply say that the federal pyramid is wrong is welcome news to nutrition researchers in a country where so much of the debate about diets is based on special-interest advertising (“Beef: It’s what’s for dinner”) or celebrity endorsements of fad weight-loss plans.

Perhaps this is the summer of science in the nutrition debate. Tufts University nutritionist Miriam Nelson, virtually a one-woman health advice industry, also has written a diet book, “Strong Women Eat Well,” that finds Americans get lousy nutrition advice from many quarters.

For instance, Americans who load up on refined carbohydrates, including supposedly healthful low-fat cookies, which are actually high in calories, have been getting steadily fatter, often without violating USDA guidelines, noted Nelson, an associate professor at the university’s School of Nutrition Science and Policy.

Half of all adults Americans are now overweight, studies show, and more than 20 percent are obese, twice as many as in 1960; diabetes also has risen nearly 40 percent in the last 20 years.

Yet, you could look at the USDA pyramid and conclude all sorts of bad nutritional habits are fine – for instance, that it’s OK to eat three servings a day of red meat. It’s not: Red meat is loaded with artery-clogging saturated fat.

You could also figure, looking at the food pyramid, that it’s OK to eat six to 11 helpings a day of Wonder Bread. Wrong again: White breads are made from refined carbohydrates, which lower good HDL cholesterol and can lead to weight gain.

The reason the pyramid gives such erroneous messages, Willett said, is that it was cooked up primarily by the Agriculture Department and was”yanked this way and that by competing powerful interests,” which include the formidable meat, dairy and sugar industries.

The pyramid, in Willett’s view, “was built on shaky scientific ground back in 1992” and has been steadily eroded by new data ever since.   

But, when one looks, as Willett does, not at industry’s claims but at data from big research projects, the picture becomes far more nuanced, and presumably, accurate. Willett uses large studies such as the Nurses’ Health Study of 122,000 women; the Physicians’ Health Study of 22,000 male doctors; the Health Professionals’ Follow-up Study of 52,000 male doctors, dentists and veterinarians; the Iowa Women’s Health Study of 42,000 women; and numerous others.

Among other things, the emerging data show it’s time to re-think how we classify carbohydrates. The old way was to label them “simple” or”complex,” depending on the number of sugar molecules linked together.   

A better distinction, Willett said, is between whole grains (good carbohydrates) and refined (bad). The good category includes brown rice, oats, whole-wheat pasta and beans, and you should base your diet on these. The bad ones are regular pasta, white bread, white rice, some cereals and commercially baked cookies and the like made with refined flour.

Why are pasta and the other refined carbohydrates such no-nos? Because they are essentially simple sugar. The minute you swallow these starches, your digestive system transforms them into glucose and pumps it into the bloodstream almost as fast as if you had eaten jelly beans. The result is a spike of insulin, the hormone that escorts sugar into cells. Once glucose enters cells, your blood-sugar levels plummet, your brain interprets that as a hunger signal and you want to eat again. Worse yet, this sugar-insulin roller coaster can lead to diabetes and heart disease.

In fact, Willett said, it is now clear that the bad carbohydrates – the refined ones that the body rapidly metabolizes – are more likely to cause heart disease, probably by lowering good cholesterol and raising triglycerides (three fatty acids linked together), than some good kinds of oil, like the unsaturated fats in walnuts.

Dr. Gerald Reaven, professor of medicine at Stanford University School of Medicine, agreed. People trying to reduce cholesterol “would do better by eating less carbohydrate and substituting good fats” such as those in nuts, he said.

Just as the USDA food pyramid lumps all carbohydrates together at the bottom of the pyramid, it lumps all fats and oils together at the top of the pyramid, with a “use sparingly” label. That’s partly right: Bad fats should be used sparingly. These are the saturated fats (from whole milk or red meat) and the trans fats (trans-fatty acids) found in vegetable shortenings and some margarines. Saturated fats contribute to clogged arteries, resulting in heart attacks and strokes, and trans-fats are even worse, Willett said.

In fact, trans-fats are so worrisome that Nelson recommends sometimes eating butter despite its high saturated fat content because many margarines contain trans-fats.

But just as important as avoiding the bad fats is increasing the good fats in your diet, Willett said. The good fats are the monounsaturated and polyunsaturated types found in olive, canola or peanut oil, nuts, other plant products and fish. These fats can lower the bad kind of cholesterol without lowering the good.

Willett also has weighed in in favor of moderate alcohol consumption. Although more than one drink of alcohol a day can raise the risk of breast cancer, for instance, he noted that this risk can be offset by the B vitamins, particularly folate, that are standard in most multivitamins.

And what about the current darling of health-food industry advertising, soy? It does help lower cholesterol, Willett noted, but it doesn’t reduce hot flashes in menopausal women much. And in high doses (three to four glasses of soy milk a day or supplements), it may actually drive proliferation of breast-cancer cells, not retard it.

Unlike many nutritionists who often stick to an”eat-your-vegetables-or-else” line, Willett also advocates a multivitamin a day, on top of loads of fruits and vegetables.

As for potatoes, both Willett and Nelson take a dim view. Nelson said it’s OK to eat a small one occasionally. Willett said that because the starch in a potato turns to sugar soon after digestion, it shouldn’t even be dignified by the term vegetable.

Willett also attacks those annoying milk mustache ads, noting that, despite what the USDA says, there are more reasons not to drink milk in large amounts than there are to drink it – among them the high calories and saturated fat in whole milk. Nelson takes a somewhat softer line, arguing the milk campaign is “not ridiculous” for children and young adults who may not get enough protein otherwise.

The bottom line? Eat more good fats and fewer bad ones. Eat more good carbohydrates and fewer bad. Substitute a small handful of walnuts for a midafternoon cookie. Get more of your protein from beans and nuts, fish, poultry and eggs, and less from red meat. Drink alcohol, but not to excess, and pop a multivitamin while you’re at it.

Most important, get or keep your weight low and stable. Health risks may begin to accrue at a shockingly low body mass index of 22, suggesting that a 6-foot man weighing 165 pounds could have a weight problem. (To calculate your body mass index, or BMI, divide your weight in pounds by your heightin inches; divide that number by your height in inches and multiply that number by 703.) 

The benefits to eating right are huge – a lower risk of heart attack, stroke, high blood pressure, high cholesterol, diabetes and certain cancers, including those of the uterus, colon and kidney and, for women past menopause, of the breast.

On balance, that seems well worth trading your morning bagel for a nice big bowl of kashi.

When Illness Tests Marriage Vows

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Several years ago, Dr. Michael J. Glantz, a brain cancer specialist, was struck by what appeared to be an extraordinary number of divorces and separations among his patients, many of whom had primary brain tumors that were expected to kill them in 15 months.Not only did there seem to be lots of breakups, but most of them seemed to occur when the women got sick. So, Glantz, who was then at Brown University and is moving this summer to the University of Arizona, began keeping track.

To the surprise of his male but not his female colleagues, Glantz found that 17 out of 183 married brain cancer patients had endured a divorce or separation within about a year of their diagnosis – an overall divorce rate of 9 percent. More importantly, he said, 14 of the 17 divorced or separated patients – 82 percent – were women.

To see whether this was tied to something particularly stressful about brain cancer, which can alter personality and cognitive function, Glantz also studied two other groups: 107 married patients with multiple sclerosis, a chronic disease that is not usually fatal, and 172 married patients with cancers that neither arose in nor had spread to the brain.

Divorces in those cases, too, he found, disproportionately occurred when it was the wife who was sick – 96 percent of the cases with MS, 78 percent of the cases of systemic cancer.

One rather unappealing interpretation is obvious: That women hang in there with sick husbands while men bail out on sick wives. But stay with this a bit longer, guys. And, ladies, don’t despair. This is not heading to the all-men-are-cads conclusion you may be expecting.

For years, when researchers probed the emotional impact of cancer and other serious illnesses, they usually focused on the patient. Today, there’s a growing realization that, at least in the emotional sense, it’s the couple or the whole family that “has” the disease.

In fact, the well spouse sometimes feels more distress than the sick one, who at least can throw his or her efforts into survival. And, while some men do have trouble taking on the nurturing role, researchers say, many do it quite well. In fact, many couples get closer when one member has cancer, especially if the marriage was strong to start with. Beth and David Savard of Methuen can vouch for that, though things got very shaky while she was in the midst of chemotherapy for breast cancer six years ago. Both 35 now, they were 29 and the parents of a 2-year-old when Beth was diagnosed. David could deal with the factual issues about cancer, she said, but he shut down emotionally.

“He was not talking about his feelings. I was trying to talk about mine, but I couldn’t talk to him because I was not getting a response.”

They were about to see a divorce lawyer when they went to a We Can Weekend, an annual family retreat sponsored by the American Cancer Society. During that weekend, David began to talk and cry with other men whose wives had cancer. He began to tell Beth how helpless he felt, she recalled. He even voiced the most frightening feeling of all – that she would die and he would have to raise their child alone.

Many couples say that “when cancer came in, communication went out,” Beth Savard said. But it needn’t be that way. Today, Beth said, she and David are “very, very talkative. We share a lot.”

Having cancer or a spouse with cancer, particularly brain cancer, has”got to be the most stressful thing in the world,” said Dr. John Henson, executive director of the brain tumor center at Massachusetts General Hospital. And generally, he has found, couples are extremely supportive of each other.

But often, he said, the spouse with cancer often has some level of denial, “which is probably a healthy coping mechanism.” The healthy spouse even may be more emotionally affected, something that Henson said has nothing to do with gender.

Frank McCaffrey, a clinical social worker who runs support groups at Beth Israel Deaconess Medical Center for men whose wives have advanced cancer, agreed. If the spouse who gets cancer has historically been the one who has provided most of the emotional caretaking, he said, the well spouse, regardless  of gender, “has to evolve and be able to understand that the patient, the ill spouse, can’t provide the same emotional caring and support that they have been.”

Not surprisingly, this is easier if the marriage is good to start with. “If the marriage was teetering before, it gets harder. They are the ones at most risk,” said Dr. Jimmie Holland, chief of psychiatry and behavioral science at Memorial  Sloan-Kettering Cancer Center in New York.

Even Glantz’s data, alarming as it seems at first blush, does not actually prove that the divorce rate is higher than normal among couples in which one spouse has cancer or MS.

If anything, the opposite may be true.

According to data released in May by the National Center for Health Statistics, 43 percent of first marriages end in separation or divorce within 15 years; 20 percent end within five years.

It’s statistically risky to compare national divorce rates, which include many young couples, with divorce rates in couples in which one spouse gets a serious disease, in part because the latter couples are often older, and possibly more mature. But Glantz’s study suggests that couples dealing with at least one serious illness, MS, have a lower than average divorce rate, just 24 percent after a median of 14 years of followup.

That doesn’t surprise Steven Marcus, 58, a free-lance editor in Brookline who has been married for 25 years to Kit Crowe, 51, a librarian who was diagnosed  with MS just after their marriage. In recent years, he said, Kit has not been able to work full time, and “it’s been scary for me to be the primary  wage-earner – that freaks me out sometimes.”

But splitting up has never crossed is mind.

“You do the best you can,” he said. “It’s a question of love. Even if you’re freaked out, that’s not enough to make you run.”

And even when a couple divorces soon after the woman gets cancer, that doesn’t prove that her husband abandoned her.

Laurel Northouse, a nurse with a doctorate in research who studies the impact of cancer on couples at the University of Michigan School of Nursing, has studied couples in which the wife has breast cancer. She has found not only that the  divorce rate within the first 12 months of diagnosis is a fairly low 3 to 4 percent, but that sometimes it’s the woman who decides not to spend whatever time she has left with a man she no longer loves.

A divorce soon after cancer may look “like the husband is leaving her, but she may be saying, `Enough already,’ ” Northouse said.

In a study of colon cancer published last year, she said, female care givers of men with cancer actually reported more distress than their husbands. One reason for that, Northouse said, is that when husbands become care givers, they are often seen as heroes doing more than society expects.

“Nobody brings casseroles to women when their husbands are sick because people assume a woman can do the caretaking, that she’s a natural care giver. But women need help, too.”

On the other hand, when men become care givers, they often don’t ask for the support they need because they may be too stoic, said Betty Ferrell, a nurse-researcher at City of Hope National Medical Center in Duarte, Calif. Men “really do feel the financial burden. They feel they must try to keep things normal, to keep going to work.”

The bottom line is that when life-threatening disease strikes, the marriage needs attention as well as the disease itself, said psychologist David Cella of Northwestern University Medical School. “It’s very easy for people to put all the attention on the treatment. But some attention should be spared to focus on the couple.”The American Cancer Society is enrolling volunteers in a new study of quality  of life among cancer survivors and their families. Call 1-800-ACS-2345 begin_of_the_skype_highlighting              1-800-ACS-2345      end_of_the_skype_highlighting.

Men Have A Biological Clock, Too

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For years, many prospective parents – and doctors as well – have blithely assumed that, if an older couple’s baby has birth defects, it’s most likely because of the woman’s advancing age.

And there’s some truth to this. The risk of mental retardation due to Down syndrome, for instance, clearly rises with advancing maternal age – from one in 1,000 at age 29 to one in 100 births at age 40. Other diseases in which a child inherits an extra copy of a particular chromosome are also linked to older mothers.

But, increasingly, scientists are discovering that, by focusing almost exclusively on mothers-to-be, they might have been barking up the wrong genome. A man, or more accurately his sperm, also has a biological clock. And it’s ticking can be just as spooky as a woman’s, perhaps even more so because its virtually impossible to do prenatal tests to pick up all the possible genetic mutations in sperm.

“There’s always been this myth that fathers can be fathers until they die, and that would be fine. It’s always the mother who had to be young,” said Dr. Eric Vilain, a geneticist and pediatrician at the University of California at Los Angeles.  But that’s because the risks associated with advancing paternal age have been routinely “underestimated.”

In fact, the risk of new mutations – those that haven’t shown up in a family before – is four to five times greater for fathers age 45 and older than for those ages 20 to 25, according to the American College of Medical Genetics. And the risk goes up linearly with time.

For the population as a whole, the average age of a father at the time of conception is still a relatively youthful 27. But it’s tough to know precisely how many men over 40 are fathering children because birth certificates often list only the age of the mother, noted T. J. Mathews, a demographer at the National Center for Health Statistics. You can’t infer the age of the father from that of the mother since many men marry younger women, either the first time around or when they start a new family after divorce.

The latest and most dramatic evidence of the risks of late fatherhood was revealed in April when Columbia University researchers published results from a large study in Israel.

Led by Dr. Dolores Malaspina, a Columbia psychiatrist, the team correlated the birth records of nearly 88,000 people born in Jerusalem between 1964 and 1976 with records from the Israel Psychiatric Registry. They found that men between the ages of 45 and 49 were twice as likely as those under 25 to have children with schizophrenia, and the children of men who were 50 or older had three times the risk. Overall, they found that advancing paternal age accounted for as many as one in every four cases of schizophrenia.

The huge sample allowed researchers to distinguish between the effects of maternal and paternal age, said Dr. Susan Harlap, a co-author and an obstetrician-gynecologist at New York University. In some other studies, she said, researchers couldn’t do that and, hence, gave too much weight to maternal age as a risk factor for particular problems.

Over the years, geneticists have linked a number of other diseases to advancing paternal age, including achondroplasia, or dwarfism; Marfan’s syndrome, which can lead to the fatal rupture of a major blood vessel; and Apert’s syndrome, or the malformation of the skull, hands and feet.

Retinoblastoma, an eye cancer; neurofibromatosis, or fleshy growths of abnormal nerve tissue; and some types of prostate cancer also have been linked with older fathers. And some diseases caused by genes on the X-chromosome, among them hemophilia, Duchenne muscular dystrophy and Hunter syndrome, have been linked to advanced age not of a child’s father but of his maternal grandfather. In these cases, an older man passes on a defective gene on the X chromosome to his daughter, who, like Queen Victoria, becomes an unaffected carrier who can pass the disease to her sons.

When certain diseases caused by genetic defects show up in a family for the first time, the odds are seven to 10 times greater that the mutation has occurred in the DNA of the father rather than that of the mother, said Dr. Victor McKusick, professor of medical genetics at Johns Hopkins University.

And there’s a good reason for this: Sperm cells are constantly dividing to create more sperm, which provides ample opportunity for tiny mistakes – mutations – to occur as the DNA is copied. By age 15, sperm cells have undergone roughly 35 cell divisions. By age 20, it’s 150; by 40, it’s 610; and by 50, 840 – hundreds of opportunities, in other words, for tiny glitches in DNA copying that result in point mutations, or defects in a single gene.

By contrast, when a baby girl is born, her tiny ovaries are full of eggs that are almost mature. The eggs just sit there  – not dividing – in a kind of suspended animation for decades. Once a woman hits puberty and starts ovulating, a single egg completes a cell division each month, the final stage of egg maturation. The egg is then released into the Fallopian tubes, where it may be fertilized by incoming sperm.

Because a woman’s eggs are so quiescent for so long, “there’s very little chance for things to get messed up,” said James Crow, emeritus professor of genetics at the University of Wisconsin.

When genetic accidents do occur in a woman, though, they are big ones – typically an extra copy of a whole chromosome. Researchers do not know why the odds of “trisomy,” or an extra chromosome,  increase as a woman ages. But when the fetus gets an extra copy of chromosome 21, the result is Down syndrome. With an extra copy of 13 or 18, the result is severe mental retardation and birth defects; with an extra copy of the  X chromosome, the result is Klinefelter’s syndrome, in which males are usually infertile.

And there are undoubtedly more instances of trisomy than most people realize because lethal abnormalities often trigger spontaneous miscarriages. “If you do chromosome studies of the products of miscarriage, a high percentage have chromosome damage,” said Dr. Wayne Grody, director of the DNA diagnostics laboratory at UCLA.

But even the single gene defects more common in sperm can have large consequences. In Marfan’s syndrome, for instance, connective tissues in the eyes, bones and blood vessels may be affected. Some people with Marfan’s go undiagnosed until, like Olympic volleyball star Flo Hyman, they die suddenly when a major blood vessel called the aorta ruptures.

And knowing which gene is at fault can be a mixed blessing. In 1994, for instance, when the gene for achondroplasia, a type of dwarfism, was discovered, some hailed it a breakthrough because it meant genetic testing was now possible. But others feared it could lead to further stigmatizing of dwarfism as a defect rather than a variation from the average.

Still, many couples would like to be able to test a fetus to see if it carried any of the potential genetic defects associated with rising paternal age, “but there’s no good way to test,” said Michelle Fox, a genetic counselor at UCLA.

In women, amniocentesis and chorionic villus sampling – both of which are somewhat invasive – can detect whole-chromosome abnormalities, such as Down syndrome. And many women who get pregnant in their late 30s or later do have their fetuses tested.

But it’s much more difficult to test for genetic problems linked to aging sperm because there aren’t enough probes to test all the possible single-gene defects. If an older man has already had one child with a syndrome linked to advanced paternal age, however, doctors can sometimes test a subsequent fetus for that same defect if the gene is known.

With so much uncertainty, the best advice for couples in which an older man wants to be a father is to ask a genetics counselor about a series of ultrasounds of the fetus. This approach is controversial because not all defects show up on ultrasound, and some that do may become visible only late in pregnancy.

And for women seeking to get pregnant through sperm donation? The best advice is to ask for a donor age 40 or under. For a more complete list of diseases linked to advancing paternal age, visit the web: www.ncbi.nlm.nih.gov/omim.

Some Advice: Make Sure That Personal Trainer Is Fully Trained

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Marybeth Turner, a 35-year-old Lexington mother of two young children, has great legs. And arms. And abs. And strength. And balance. And endurance.

Perhaps not surprisingly, given all that, she also has a personal trainer, in her case a huge, gentle guy named John Damon, co-head trainer at the Mt. Auburn Club in Watertown.

“Squeeze. Don’t move your neck,” he coaches as Turner does abdominal crunches while balancing on her back on a big fitness ball. Moments later, he urges, “Keep going; you’re looking good!” as she steps up repeatedly onto a 20-inch-high platform.

“I thought I was in shape until I started working out with John. . . . I was a runner. I was very active,” says a smiling Turner, who looks dazzlingly fit. But she’s become even fitter since she started personal training eight months ago. “I’ve become physically stronger and I have more energy.”

Personal trainers are to fitness what San Pellegrino water is to dining out – a bit expensive, perhaps, but definitely capable of adding a certain fizz to things.

The question is, do personal trainers really know what they’re doing? The short answer is, some do, but it’s hard to tell which ones because personal training is a totally unregulated industry. Unlike physical therapists or dieticians – or even hairdressers and manicurists – personal trainers are not licensed by states. That means anyone with visible biceps, a business card and a clipboard can call himself a personal trainer, and charge anywhere from $35 to $125 an hour or more to watch you work out.

To be sure, some trainers are, or claim to be, certified, but the certification process ranges from rigorous to bogus. Some trainers have not only been to college but have doctorates in exercise physiology. Others have barely made it out of high school, have trained at a weeklong workshop and would be hard pressed to tell a fast-twitch muscle from a slow one, much less advise a heart attack survivor about how to walk her way back to health.

What’s more, the risk of getting a know-nothing trainer may increase as the health club industry booms, outstripping the supply of qualified trainers. The number of Americans who belong to clubs grew from 24 million in 1995 to 31 million in 1999, according to the International Health, Racquet and Sportsclub Association, a Boston-based trade group for the country’s 17,000 health clubs.

To keep up with the demand, more than 300 organizations are churning out personal trainers and there are 65,000 of them in the country, according to IDEA, a San Diego-based organization for fitness professionals. The Aerobics and Fitness Association of America alone certifies about 8,000 new trainers a year.

So, with all those folks out there just waiting to buff you up, what should you ask for? For starters, all this:

Certification. Obviously, it’s no guarantee, but if the trainer is not certified at all, keep looking. If he says he is, ask by whom. The consensus among trainers is that the toughest standards are those of the American College of Sports Medicine, followed, in roughly this order, by the National Strength and Conditioning Association, the American Council on Exercise, the Aerobic and Fitness Association of America and the Cooper Institute.

Education. Ask what academic degrees and courses your trainer has taken. An advanced degree may not be essential, but some study of health or physiology is important.

A trainer should ask you for a detailed medical history. If he doesn’t, “that’s a red flag,” said Walt Thompson, professor of kinesiology and health at Georgia State University and chairman of the certification and education committee for the American College of Sports Medicine. If you have or have had serious health problems, you should also get clearance from your doctor for the type of exercise you’re planning to do. Ask if the trainer is certified in cardiopulmonary resuscitation and first aid. If he or she is not, go elsewhere, said Damon of the Mt. Auburn Club.

A good trainer shouldn’t let you work out on the first visit. Instead, he should ask about your goals (and make sure they’re realistic) and assess your condition – testing your strength, taking your blood pressure, measuring body composition (fat versus lean tissue), joint flexibility, and perhaps putting you on a treadmill, stationary bike or rowing machine to gauge cardiovascular fitness.

If a trainer tries to make you progress too fast, be wary. A general rule of thumb is never to increase workouts by more than 10 percent from one week to the next. For instance, if you did 20 minutes on the exercise bike each session last week, do two minutes more each time this week. The same goes for increasing weights in strength training. A good trainer should change your routine (so you continue to progress) every eight weeks.

If you’re very sore after the training sessions, or if you get injured, that’s another red flag. Mild soreness after strength training (weight lifting) is good: It means the muscle is rebuilding itself. But extreme soreness – if you can’t comb your hair after upper body workouts or walk upstairs after leg lifts – it means your muscles are seriously inflamed.

If your trainer leaves you alone on any of the equipment, either during an assessment or a real workout, fire him. A personal trainer should be just that – not dividing his attention between you and other clients or wandering away to chat with his chums. He should also offer a truly personalized program, not a canned list of exercises you could get from a book.

If your trainer offers nutritional advice, guarantees you’ll lose weight, or worse, tries to sell you supplements, dump him.

“The biggest problem is personal trainers giving advice about dietary things,” said Bill Evans, director of the nutrition, metabolism and exercise lab at the University of Arkansas for Medical Sciences. “They have no training in that. Their information can be just wrong and sometimes dangerous,” including telling older people who may be undernourished to cut food intake.

The same goes for medical advice. Though some trainers do have some health training, many don’t, which means they’d better not give medical advice, said Wayne Wescott, fitness research director at the South Shore YMCA in Quincy. “If someone comes in and says, `I’m taking these medications. What does that mean for exercise?’ I say, `Let’s talk to your physician together.’ “

Before you sign up, ask your trainer for names of other people he or she worked with, and call them, said Roger Fielding, associate professor of health sciences and exercise physiology at Sargent College at Boston University. Be specific: If you’re an older person, ask for names of other older people he’s worked with; the same goes if you’re recovering from a heart attack or have an underlying illness such as diabetes.

Ask if the trainer carries liability insurance. He or she should for your protection and that of the trainer.

When a trainer writes up your exercise program, he or she should make clear what the fee is, along with hours and rules about whether you have to pay if you miss a session. Many offer one session free. It’s a warning sign if a trainer tries to sign you up for a very long-term commitment or asks you to pay cash under the table.

Finally, pay attention to the social and emotional signals the trainer is sending. A big part of the trainer’s job is to encourage and motivate you. If the trainer does all the talking, doesn’t listen to your concerns, or seems mostly interested in wearing revealing clothes and strutting his or her stuff, find someone less narcissistic.

 

Judy Foreman is a Lecturer on Medicine at Harvard Medical School. Her column appears every other week. Past columns are available on www.myhealthsense.com.

SIDEBAR 1: Walking Toward Fitness

A personal trainer may be just what you need, but you can get many of the health benefits of exercise by plain old walking.

In March, for instance, Harvard researchers published results in the Journal of the American Medical Association of a study of nearly 40,000 women showing that even light-to-moderate exercise lowers the risk of heart disease.

“The evidence continues to mount that even moderate intensity exercise like brisk walking for 30 minutes a day – can lower the risk of heart disease, Type II diabetes, stroke, osteoporosis, colon cancer, breast cancer and premature death,” said Dr. JoAnn E. Manson, chief of preventive medicine at Brigham and Women’s Hospital.

In her new book, “The 30-Minute Fitness Solution,” Manson and her co-author, Patricia Amend, take the guesswork out of figuring out a moderate exercise program. They also highlight nutritional tips, strength-training exercises and specific fitness goals you should set for working out on exercise equipment.

SIDEBAR 2: Information Available On The Internet

There’s no shortage of information on personal trainers available from health clubs and on the Internet. Here’s a sampling:

  •   Aerobics and Fitness Association of America: www.afaa.com

  • American College of Sports Medicine: www.acsm.org

  • American Council on Exercise: www.acefitness.org

  • Cooper Institute: www.cooperinst.org

  • IDEA, a membership organization for fitness professionals: www.IDEAfit.com

  • National Strength and Conditioning Association: www.nsca-lift.org