Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Testicular cancer: scary but almost curable

by

David Cohan, a 34-year-old senior analyst at a Boston real estate investment trust company, says he “never wanted to be the poster child for testicular cancer.”

“But if it will help to save some lives and turn my experience into something much more positive, I’d like to do this,” says Cohan.”This” is going public with his battle – so far, highly successful – with a cancer most men barely whisper about.

Compared to breast or prostate cancer, which together will strike more than half a million Americans this year, testicular cancer is uncommon. This year, 7,200 men will get it – the numbers have climbed slowly in recent years for unclear reasons – and 350 will die.

Yet cancer of the testes remains shrouded in fear, in part because it affects the sexual organs – though not sexual function – and in part because it strikes men in their prime. It is the most common cancer in men between 15 and 35.

Much of this fear could be dissipated, cancer specialists say, if men understood two things: How important – and easy – it is to perform monthly self-exams. And how curable testicular cancer usually is.

Overall, 90 percent of men with testicular cancer can be cured. If the cancer is caught early, the cure rate is 98 percent; if it is caught later, it’s about 85 percent.

As the National Cancer Institute puts it, “there are treatments for all patients with cancer of the testicle, and most patients can be cured with available treatments.”

Testicular cancer begins when something goes wrong in the DNA in one of the primordial germ cells – cells that every male is born with and which later develop into sperm.

Though scientists don’t fully understand what triggers the cancer, they know that while it can run in families, it usually doesn’t, says Dr. Philip Kantoff, director of genitourinary oncology at the Dana-Farber Cancer Institute.

Some suspect that it follows trauma to the testes, pesticide exposure, viral infections or use of the hormone DES (diethylstilbesterol) by the patient’s mother during pregnancy.

But the only clear, well-established risk is being born with an undescended testicle, a condition called cryptorchidism that raises the risk of cancer about fivefold – for unknown reasons.

Tumors can grow fast, sometimes doubling in two weeks. But usually, they arise in only one testicle. And typically they are one of two types: a seminoma, the most common kind, or a nonseminoma, a cancer with a mix of cell types.

For both types, the first step is surgical removal of the testicle. Although it might seem easiest to do this through the scrotum, surgeons fear that as they cut through several layers of tissue, cancer cells might spill into the scrotum.

So they make an incision in the groin, just below the pubic hair line, and squeeze the testicle up through a natural passageway, the inguinal canal, says Dr. Michael O’Donnell, director of urological laparoscopic surgery at Beth Israel Deaconess Medical Center.

If the cancer is a seminoma and there are no signs that it has spread (Stage I), the next step is radiation of lymph nodes in the abdomen to reduce the risk of recurrence if the cancer has spread undetected.

Most men need only 17 treatments over three weeks, says Dr. Carolyn Lamb, a radiation oncologist at Boston’s Joint Center for Radiation Therapy. Typically, she adds, there are few side effects such as nausea.

To preserve fertility, the healthy testicle is protected with a device patients jokingly call “the clamshell.”

“I lost all sense of modesty, every morning having people put my testicle in clamshells,” recalls David Cohan, who lives in Boston. “I had to laugh,” as the technician helped him the first morning. “I said, ‘Aren’t you going to buy me dinner first?’ “

With Stage I nonseminomas, tumors are less responsive to radiation, so the options are different.

One is surgery to remove 20 to 40 lymph nodes in the abdomen. This is a big procedure involving an incision that runs along the bottom of the ribs on one side and down to the lower abdomen.

Chemotherapy, usually three cycles, is another effective option for early nonseminoma, as is “watchful waiting” – frequent monitoring with chest X-rays, CT scans and blood tests. This process is rigorous, but finite – if the cancer is going to spread, it usually does so within two years of diagnosis.

For Stage II cancers – those that have spread to the lymph nodes – chemotherapy is the usual option, though radiation is used if the cancer is a seminoma and only a few nodes are affected.

For Stage III cancers – those that have spread to organs like the lungs or liver – chemotherapy, often in high doses, is used. Some men with advanced cancer also have bone marrow transplants.

While chemotherapy can damage a man’s fertility, this is usually temporary. Radiation does not usually affect fertilitiy. And surgery can cause retrograde ejaculation, which means that sperm is formed but does not exit the penis normally; this is a permanent problem but one that can sometimes be treated with drugs.

All of which is more than David Cohan ever wanted to know.

Like many men with testicular cancer, Cohan found his own lump, “a tiny bump that was probably smaller than a pea.” He went to his doctor, who sent him that day for an ultrasound.

“Within an hour and a half,” he says, “I went from just looking into it to finding out I had cancer.”

Then, as he talked with the surgeon about removing his testicle, he got another rude surprise. Like many men who have a testicle removed, he had decided he wanted it replaced by a silicone implant.

But the controversy over silicone breast implants for women has made manufacturers so gun shy there is now a shortage of testicular implants, forcing many men to go without.

In the end, Cohan’s doctor found one but until the last minute, Cohan says, “I thought I’d have to go to Switzerland to buy a testicle on the black market.” He had asked his brother to go with him and could already “see us in trench coats in a bar handing over cash.”

Six months after treatment, Cohan threw himself into a new challenge – training for the Boston-New York AIDS bike ride.

Proud and healthy, he rejoices in that second victory: “I did the ride and I raised $ 8,800.”

  • How to do a self-exam

    • The American Cancer Society recommends that all men perform a testicular self-exam at least once a month, preferably after a warm bath or shower, when scrotal skin is most relaxed.

    Use both hands and gently roll each testicle between the thumbs and fingers. If you feel pain, this means you are pressing too hard.

    A normal testicle is oval, somewhat firm, free of lumps and should feel smooth to the touch. Try not to confuse the epididymis (the soft tube-like structure at the back of the testis) with a tumor. But if you find an area of firmness or a small lump or nodule on the front or side of the testicle, have it checked promptly by a doctor.

    For more information, call:

    1-800-ACS-2345, American Cancer Society.

    1-800-4-CANCER (1-800-422-6237), National Cancer Institute. (Or TTY, 1-800-332-8615)

  • Don’t delay acting, says one survivor

    • Peter Twombly, now 40 and the owner of a fish market in East Dennis on Cape Cod, was only 20 when he got testicular cancer.

    He had just survived “the turbulent teenage years of rebellion and invulnerability,” he recalls, and had started to “calm down and join the human race. So I got kind of mad about this, mad at myself, even though I didn’t have anything to do with it.”

    He had surgery, and then, because his cancer had metastasized to a spot near his aorta, he joined an aggressive chemotherapy protocol at the National Institutes of Health.

    This meant getting up at 5 a.m. to fly to Bethesda, Md., for treatment every three weeks for a year and a half, a grueling regimen he would have quit, except for his mother’s urging.

    Today, he says, he feels “fit as a fiddle.” He urges other men not to delay treatment for 10 months, as he did. “Don’t wait,” he says. “Have it treated right away. It’s not a death sentence to have treatment, but it is to ignore it.”

    Ginseng $350 million for not much

    by

    Ginseng has become the tonic of choice for tired Americans.

    Thinking it will make us better athletes or reduce our stress or just get us through the night shift, we now spend $ 350-to-$ 400 million a year on the stuff, making ginseng second only to garlic as the nation’s most sought-after herbal remedy.

    In fact, ginseng is a major reason why the herbal industry is doing so well – $ 1.5 billion a year in sales – just as herbals are a big reason for the blooming health of the $ 6 billion a year dietary supplement industry.

    But what’s truly astounding about all this is how little we know about ginseng.

    Did you know, for instance, that there are at least three different products that Americans call ginseng?

    There’s Panax ginseng, which is grown in Asia and gobbled up by Americans because it’s relatively cheap (about $ 15 for a two-month supply) and because Americans are relatively clueless about ginseng, compared to the Chinese with thousands of years of hands-on experience.

    There’s American ginseng or Panax quinquefolius, which grows wild in Appalachia (free-lance pickers get $ 500 a pound for it) and in Canada. It is sold mostly in China, where it is touted inaccurately as an aphrodisiac and for its supposed cooling effect in tropical weather.

    “Americans send their ginseng to China, they send theirs to us,” laughs herbal industry analyst Matthew Patsky of Adams, Harkness & Hill in Boston. “It doesn’t make any sense.” In Chinatown, he adds, there’s even “American ginseng that will have been shipped to China. . .and back to us!”

    And then there’s so-called Siberian ginseng, which is so different, chemically and botanically, from the first two that it should be called by its real name, Eleutherococcus senticosus, or eleuthero.

    Most of the studies, such as they are – and they range from passable to not-worth-looking-at – have been done on Panax ginseng, the Asian stuff, though a big problem in ginseng research generally is that researchers often don’t know which type they are studying.

    “There is no good clinical data for American ginseng,” says Gail Mahady co-author of a forthcoming review for the World Health Organization and a PhD pharmacognocist, or scholar of medicinal herbs, at the University of Illinois in Chicago. There was one good study, she says, but it showed no effect.

    In the test tube, though, there have been some encouraging results with American ginseng. Dr. Rosemary Duda, for instance, a surgical oncologist at Beth Israel Deaconess Medical Center, has found it inhibits growth of breast and prostate cancer cells.

    There is somewhat more data on eleuthero in humans, Mahady says, but that research, too, “is not very good. Most studies were done in Russia in the Sixties.”

    Those studies often involved pilots, says Walter Lewis, a professor of biology at Washington University and senior botanist at the Missouri Botanical Garden. They took the stuff, they went up, they flew, they “got down and said they had a great flight. It was not a controlled situation.”

    “But they felt strongly about this and they may be right – it’s just that we haven’t got the experiments that test this,” says Lewis, who believes that ginseng “remains a medical mystery with no proven efficacy for humans.”

    Varro Tyler, professor of pharmacognosy emeritus at Purdue University, says “although some data suggest eleuthero may enhance performance, on the basis of existing evidence, its consumption as a tonic/adaptogen cannot now be recommended.”

    In the parlance of alternative medicine, an “adaptogen” is a substance believed to help people cope with stress.

    But what of Panax ginseng, the herb that the Chinese have gulped happily for millennia and Americans now consume in teas, capsules, extracts and, sometimes, as dried root – which, for the really exotic stuff, can cost thousands of dollars.

    “It’s selling very well, and I think the reason is people are looking for more energy,” says Marilyn Dale, nutrition team leader at the Bread & Circus supermarket chain. “It’s amazing to me that so many people know about it.”

    The Asian herb is chemically complicated, says Tyler, and some of its constituents have biological effects that are directly opposite to others. One component acts as a central nervous system sedative, another as a stimulant, notes the American Botanical Council, a nonprofit herbal research and educational organization in Texas.

    In hundreds of animal studies, Asian ginseng has been shown to act as a kind of general tonic – prolonging the time animals can swim, preventing stress-induced ulcers and boosting immune system activity.

    Data presented last week at a conference in Washington, D.C., by the manufacturer of Ginsana, the best-selling ginseng in the United States, suggest it also improves oxygen utilization, decreases buildup of lactic acid in athletes and may boost immunity.

    Still, cautions Tyler, “we are still almost totally ignorant of Panax ginseng’s effects on human beings, insofar as results obtained from appropriate clinical studies are concerned.”

    Mahady of Chicago agrees that “most of the clinical studies have poor methodology, no proper controls and usually no standardization of what ginseng products are used.” Still, she says, if those weak studies are lumped with test tube and animal experiments, “you can easily say ginseng can be used as a restorative agent to enhance mental and physical state.”

    Ara DerMarderosian, a pharmacognocist at the Philadelphia College of Pharmacy and Science, agrees ginseng may help with adaptation to stress and with endurance, but he, too, warns about the poor quality of studies from other countries.

    But if it’s not clear yet whether or how much ginseng will help you, it is clear that it probably won’t hurt you, as long as you don’t have diabetes or high blood pressure or consume too much caffeine while you’re taking it, Mahady says.

    Asian ginseng can raise blood pressure and stimulate release of insulin from the pancreas, which could lower blood sugar too rapidly in some diabetics.

    Ginseng can also cause adverse side effects in people taking antidepressants called monoamine oxidase inhibitors, and may cause insomnia, diarrhea and skin eruptions.

    For all that, though, the German “Commission E” monographs, regarded as the world’s best compilation of data on herbal remedies, conclude there are no known side effects of ginseng, and the WHO analysis concurs.

    Still, because there is little government regulation of herbs – the Food and Drug Administration does not conduct pre-market reviews, as it does for drugs – the role of herb cop has fallen to the industry itself.

    Perhaps the most extensive effort is a detailed analysis of roughly 400 ginseng products on the US market by the American Botanical Council, due out this summer.

    Council chief Mark Blumenthal says previous studies have shown that some ginseng products did not contain the kind or amount of ginseng stated on the label. The council study, so far, shows that more than 50 percent of the products are accurately labelled. When the research, which is funded by the herb industry, is published, the ABC will name brands that flunk the tests.

    So should you spend your money on ginseng?

    Tyler puts it this way: “If it really worked as an enhancer of athletic performance and endurance, the Olympic committee would ban it.” So far, he notes, the committee has not.

    But unless you have high blood pressure, diabetes or some other reason to steer clear of it, the usual dose – 1 to 2 grams as dried root or capsules, or 100 to 200 milligrams of extract a day – probably won’t hurt you.

    At the very least, says biologist Lewis, you can probably count on the good old placebo effect: “If you go out and spend $ 10 and if you take it religiously, it has to have an effect on your mid and body as a whole.”

    To learn more

    To read more about herbs, including ginseng, you might try:

    • “The Honest Herbal,” by Varro Tyler. Pharmaceutical Products Press (Haworth Press), Binghamton, N.Y.

    • “Herbs of Choice,” by Varro Tyler. Pharmaceutical Products Press (Haworth Press), Binghamton, N.Y.

    • “Herbal Prescriptions for Better Health,” by Donald J. Brown. Prima Publishing, Rocklin, Calif.

    • “HerbalGram,” a quarterly publication of the American Botanical Council in Austin, Texas, available at 1-800-373-7105 or on the Web at www.herbalgram.org

    • “The Random House Book of Herbs,” by Roger Phillips and Nicky Foy. Random House, N.Y.

    • “HerbalGram,” a quarterly publication of the American Botanical Council in Austin, Texas.

    Gingseng $350 million for not much

    by

    Ginseng has become the tonic of choice for tired Americans.

    Thinking it will make us better athletes or reduce our stress or just get us through the night shift, we now spend $350-to-$400 million a year on the stuff, making ginseng second only to garlic as the nation’s most sought-after herbal remedy.

    In fact, ginseng is a major reason why the herbal industry is doing so well – $1.5 billion a year in sales – just as herbals are a big reason for the blooming health of the $6 billion a year dietary supplement industry.

    But what’s truly astounding about all this is how little we know about ginseng.

    Did you know, for instance, that there are at least three different products that Americans call ginseng?

    There’s Panax ginseng, which is grown in Asia and gobbled up by Americans because it’s relatively cheap (about $ 15 for a two-month supply) and because Americans are relatively clueless about ginseng, compared to the Chinese with thousands of years of hands-on experience.

    There’s American ginseng or Panax quinquefolius, which grows wild in Appalachia (free-lance pickers get $500 a pound for it) and in Canada. It is sold mostly in China, where it is touted inaccurately as an aphrodisiac and for its supposed cooling effect in tropical weather.

    “Americans send their ginseng to China, they send theirs to us,” laughs herbal industry analyst Matthew Patsky of Adams, Harkness & Hill in Boston. “It doesn’t make any sense.” In Chinatown, he adds, there’s even “American ginseng that will have been shipped to China. . .and back to us!”

    And then there’s so-called Siberian ginseng, which is so different, chemically and botanically, from the first two that it should be called by its real name, Eleutherococcus senticosus, or eleuthero.

    Most of the studies, such as they are – and they range from passable to not-worth-looking-at – have been done on Panax ginseng, the Asian stuff, though a big problem in ginseng research generally is that researchers often don’t know which type they are studying.

    “There is no good clinical data for American ginseng,” says Gail Mahady co-author of a forthcoming review for the World Health Organization and a PhD pharmacognocist, or scholar of medicinal herbs, at the University of Illinois in Chicago. There was one good study, she says, but it showed no effect.

    In the test tube, though, there have been some encouraging results with American ginseng. Dr. Rosemary Duda, for instance, a surgical oncologist at Beth Israel Deaconess Medical Center, has found it inhibits growth of breast and prostate cancer cells.

    There is somewhat more data on eleuthero in humans, Mahady says, but that research, too, “is not very good. Most studies were done in Russia in the Sixties.”

    Those studies often involved pilots, says Walter Lewis, a professor of biology at Washington University and senior botanist at the Missouri Botanical Garden. They took the stuff, they went up, they flew, they “got down and said they had a great flight. It was not a controlled situation.”

    “But they felt strongly about this and they may be right – it’s just that we haven’t got the experiments that test this,” says Lewis, who believes that ginseng “remains a medical mystery with no proven efficacy for humans.”

    Varro Tyler, professor of pharmacognosy emeritus at Purdue University, says “although some data suggest eleuthero may enhance performance, on the basis of existing evidence, its consumption as a tonic/adaptogen cannot now be recommended.”

    In the parlance of alternative medicine, an “adaptogen” is a substance believed to help people cope with stress.

    But what of Panax ginseng, the herb that the Chinese have gulped happily for millennia and Americans now consume in teas, capsules, extracts and, sometimes, as dried root – which, for the really exotic stuff, can cost thousands of dollars.

    “It’s selling very well, and I think the reason is people are looking for more energy,” says Marilyn Dale, nutrition team leader at the Bread & Circus supermarket chain. “It’s amazing to me that so many people know about it.”

    The Asian herb is chemically complicated, says Tyler, and some of its constituents have biological effects that are directly opposite to others. One component acts as a central nervous system sedative, another as a stimulant, notes the American Botanical Council, a nonprofit herbal research and educational organization in Texas.

    In hundreds of animal studies, Asian ginseng has been shown to act as a kind of general tonic – prolonging the time animals can swim, preventing stress-induced ulcers and boosting immune system activity.

    Data presented last week at a conference in Washington, D.C., by the manufacturer of Ginsana, the best-selling ginseng in the United States, suggest it also improves oxygen utilization, decreases buildup of lactic acid in athletes and may boost immunity.

    Still, cautions Tyler, “we are still almost totally ignorant of Panax ginseng’s effects on human beings, insofar as results obtained from appropriate clinical studies are concerned.”

    Mahady of Chicago agrees that “most of the clinical studies have poor methodology, no proper controls and usually no standardization of what ginseng products are used.” Still, she says, if those weak studies are lumped with test tube and animal experiments, “you can easily say ginseng can be used as a restorative agent to enhance mental and physical state.”

    Ara DerMarderosian, a pharmacognocist at the Philadelphia College of Pharmacy and Science, agrees ginseng may help with adaptation to stress and with endurance, but he, too, warns about the poor quality of studies from other countries.

    But if it’s not clear yet whether or how much ginseng will help you, it is clear that it probably won’t hurt you, as long as you don’t have diabetes or high blood pressure or consume too much caffeine while you’re taking it, Mahady says.

    Asian ginseng can raise blood pressure and stimulate release of insulin from the pancreas, which could lower blood sugar too rapidly in some diabetics.

    Ginseng can also cause adverse side effects in people taking antidepressants called monoamine oxidase inhibitors, and may cause insomnia, diarrhea and skin eruptions.

    For all that, though, the German “Commission E” monographs, regarded as the world’s best compilation of data on herbal remedies, conclude there are no known side effects of ginseng, and the WHO analysis concurs.

    Still, because there is little government regulation of herbs – the Food and Drug Administration does not conduct pre-market reviews, as it does for drugs – the role of herb cop has fallen to the industry itself.

    Perhaps the most extensive effort is a detailed analysis of roughly 400 ginseng products on the US market by the American Botanical Council, due out this summer.

    Council chief Mark Blumenthal says previous studies have shown that some ginseng products did not contain the kind or amount of ginseng stated on the label. The council study, so far, shows that more than 50 percent of the products are accurately labelled. When the research, which is funded by the herb industry, is published, the ABC will name brands that flunk the tests.

    So should you spend your money on ginseng?

    Tyler puts it this way: “If it really worked as an enhancer of athletic performance and endurance, the Olympic committee would ban it.” So far, he notes, the committee has not.

    But unless you have high blood pressure, diabetes or some other reason to steer clear of it, the usual dose – 1 to 2 grams as dried root or capsules, or 100 to 200 milligrams of extract a day – probably won’t hurt you.

    At the very least, says biologist Lewis, you can probably count on the good old placebo effect: “If you go out and spend $ 10 and if you take it religiously, it has to have an effect on your mid and body as a whole.”

    To learn more

    To read more about herbs, including ginseng, you might try:

    • “The Honest Herbal,” by Varro Tyler. Pharmaceutical Products Press (Haworth Press), Binghamton, N.Y.
    • “Herbs of Choice,” by Varro Tyler. Pharmaceutical Products Press (Haworth Press), Binghamton, N.Y.
    • “Herbal Prescriptions for Better Health,” by Donald J. Brown. Prima Publishing, Rocklin, Calif.
    • “HerbalGram,” a quarterly publication of the American Botanical Council in Austin, Texas, available at 1-800-373-7105 or on the Web at www.herbalgram.org
    • “The Random House Book of Herbs,” by Roger Phillips and Nicky Foy. Random House, N.Y.
    • “HerbalGram,” a quarterly publication of the American Botanical Council in Austin, Texas.

     

    Pill Mills

    by

    Weight loss center pinning hopes for fat profits on diet drugs – and doctors hired to prescribe them on demand.

    So. You’re determined to lose those 20 pounds this year. Okay, maybe a little more. Really. Once and for all.

    You go to your friendly family doctor, who’s been badgering you for years to gets those pounds off with diet and exercise.

    You explain that you’ve tried. And tried. And tried. You beg for some of those trendy prescription diet pills like the recently-approved Redux or the two-drug combo “fen/phen.”

    To your dismay, your doctor says no, you’re not that fat – you don’t have a body mass index, or BMI, of 30 or more.

    Not fat enough? With 300,000 Americans dying every year from obesity and you on your way to joining them? With everyone from your once-favorite doctor to your nearest and dearest begging you to slim down lest you face some medical disaster?

    Vowing to get your pills elsewhere, you march straight to the nearest Jenny Craig, Diet Workshop, or Nutri/System center.

    The question is, should you?

    Weeeellll, maybe. But there are a few things that you, or any other frustrated, well-padded American, should know about the commercial weight loss industry before you plunk down your hard-earned bucks – usually hundreds of them. Such as:

    The desperation factor – theirs, not yours. The commercial weight loss industry has been struggling for years because of public discouragement about dieting and consumer resistance to the high price of programs, says industry analyst John LaRosa, director of Marketdata Enterprises, Inc. in Tampa.

    And that means that the big chains are extremely eager – caveat emptor – to woo customers back. And, like you, they are pinning many of their hopes on diet pills.

    So far, Weight Watchers International, Inc., the industry leader, has resisted jumping on the pill mill bandwagon because, as spokeswoman Linda Carilli puts it, “We are not a medical organization. Our primary focus is on behavior modification and it will continue to be that.”

    But the other big chains have no such qualms. Jenny Craig, Nutri/System and Diet Workshop have recently added diet pills to their programs and hired doctors to dispense them. Locally, centers like Doctors Weightloss Program and Medical Weight Loss Center have also sprung up to meet the consumer demand for the newly respectable weight loss drugs.

    Misleading ads. The Federal Trade Commission doesn’t believe ads that say or imply you can lose lots of weight fast and keep it off – with or without pills – and neither should you. That goes double for ads that make you think that pills alone – without exercise and better eating habits – will work.

    A case in point: One ad for the Medical Weight Loss Center in Chestnut Hill, which runs regularly in the Globe, touts “Hot New Diet Pills! Fen/Phen & Redux. Lose 20 lbs in 4 weeks.”

    “There is absolutely no evidence in the medical literature that people can lose 20 pounds of body fat in four weeks safely on these drugs,” says Dr. George Blackburn, medical director of the center for the study of nutrition and medicine at Beth Israel Deaconess Medical Center. You might lose 20 pounds if you were severely obese, he says, but it would be water, not fat.

    In recent years, the FTC has cracked down on misleading advertising, forcing Diet Workshop, Nutri/System and Physicians Weight Loss Centers, among others, to change some ads. Complaints are still pending against Weight Watchers and Jenny Craig, says FTC spokeswoman Mary Haley.

    So if the ads tempt you, keep in mind this reasonable expectation: If you take the pills and stick to a behavior modification and exercise program, you’ll probably lose about 10 percent of your body weight, then level off.

    There certainly are medical benefits to be had from losing even just 5 percent of body weight, Blackburn notes, but it is “rare indeed” for people to lose more than 10 percent, and many regain weight when they stop the pills. Although Redux is approved for long-term use, there are no data on its safety for more than one year.

    Pre-signed prescriptions. You might think you could assure yourself decent medical care if you picked a weight loss center with a medical-sounding name, and there are plenty to choose from, including Medical Weight Loss Center, Doctors Weight Loss Program and Physicians Weight Care Associates.

    But that is not necessarily the case. In fact, a major problem occurred in just such a center, Medical Weight Loss Center in Chestnut Hill.

    Last fall, WBZ-TV 4’s Liz Walker caught Dr. Richard Cohen of that center using pre-signed prescriptions for diet pills, which nurse-practitioners then handed out to patients. The center also prescribed diet drugs for a WBZ producer who had been told by Blackburn that she did not need them.

    It is against federal Drug Enforcement Administration guidelines to pre-sign prescriptions. In a recent interview, Cohen said, “I did it because I didn’t know you weren’t supposed to.”

    He added that he was “just trying to do the best for people. What I did was technically not proper, but it had nothing to do with their care.” Cohen added that he no longer pre-signs prescriptions and tries to individualize care. But he remains under investigation by the Board of Registration in Medicine.

    Outside the commercial diet centers, many doctors acknowledge that patient demand for pills is growing – and hard to resist.

    Dr. William Dietz, director of clinical nutrition at Boston Floating Hospital at the New England Medical Center, worries about the ease with which patients get pills at some centers.

    “It certainly is a bad idea,” he says, for doctors to prescribe diet pills “without a review of whether a patient needs it or whether a patient needs to lose only five pounds.”

    Dr. Carl Aselton, a general practitioner in rural Maine, echoes that, but he acknowledges that some patients “get mad” when he refuses to write diet pill prescriptions. “My wife, my secretary and my nurse all bring up the question, too.”

    Some doctors in commercial weight loss centers insist they do screen patients and prescribe pills only when they are medically necessary, that is, when a person has a body mass index of 30 or more or has obesity-related medical problems and a BMI of 27.

    One of those is Dr. Robert Nierman, medical director of the Doctors Weightloss Program in Lexington. He insists that some centers are not truly “physician-based,” but his is.

    “Ninety-five of people on medications are seen by me each time,” he says. “This is a legitimate medical practice with a large volume. It’s not a business, it’s a practice.”

    Still, the mere idea of being hired by a commercial weight loss center to prescribe diet pills is anathema to many doctors.

    Dr. Richard Levy,, an internist and emergency medicine physician at the Boston Veterans Administration Medical Center in Jamaica Plain, was recruited recently by a representative for Jenny Craig. He declined.

    “I think in the hearts of most physicians, we don’t enter the profession to act as hired guns to write prescriptions for diet pills,” says Levy. “I think if somebody is hired specifically to promote prescriptions for a particular medication, they are already compromising themselves.”

    1. AS SALES SOAR, SO DO THE COMPLAINTS

    Keith Van Gasken, 45, a Lynn man who works in a health management company, swears by fen/phen. He says it has helped him trim down to 195 pounds, from 270 a year ago.

    The pills, which contain two drugs called fenfluramine and phentermine, are “an absolute godsend,” he says, because they curb his hunger so he can stick to his diet without much agony.

    A different drug, Redux, gets raves from a 35-year-old Medford woman who requested anonymity because she is “very, very overweight.” She has lost 20 pounds in three months and hopes “to finally get the weight off and keep it off.”

    Americans are in love, once again, with diet drugs – not the old addictive amphetamines that gave diet pills a bad name, but the current crop of non-addictive appetite suppressants.

    Compared to their precedessors, these drugs, which also act on the brain and are considered controlled substances, are relatively safe. But as the popularity of diet pills soars, so do reports of side effects, some minor, some not.

    Electronic chatters on American Online, for instance, trade worries about “phen brain,” or short-term memory loss.

    “My first experience with this side effect was horrible,” complained one dieter. “It happened at about the five-week period on meds. I couldn’t find my accordion file that held my checkbook and billing statements, which I am usually extremely organized with. By the time I located it, the bills were all past due.”

    Others complain of unusually vivid dreams, hair loss, heavy menstrual periods and mood changes, such as becoming, as one writer put it, “incredibly depressed and crabby.”

    Redux, too, gets its share of complaints, including dry mouth, mild drowsiness and diarrhea. Except for dry mouth, these usually subside in a few days.

    But both Redux and fen/phen also raise the risk of a more serious side effect, pulmonary hypertension, which can be fatal.

    In August, European researchers reported in the New England Journal of Medicine that dexfenfluramine (a molecule in both Redux and fen/phen) increases the risk of this condition, in which blood vessels to the lungs become thickened and scarred.

    The risk is 23 times higher in patients using diet drugs for three months or more. But because pulmonary hypertension is rare, even this means only 28 of every million people taking dexfenfluramine will get the lung problems every year.

    Even so, some people on diet drugs get so worried they rush to the emergency room when they needn’t, says Dr. George Blackburn, medical director of the center for the study of nutrition and medicine at Beth Israel Deaconess Medical Center.

    Their fears could hardly have been helped by the credibility problem that developed when it turned out that two authors of an editorial in the New England Journal of Medicine, which was favorable to diet drugs, had been paid consultants to companies that stood to gain from robust sales. The Journal apologized for the mess in October.

    Still, worries about side effects haven’t dampened sales. Just seven months after its approval by the Food and Drug Administration, Redux has captured 11 percent of the market with 2.4 million prescriptions to date, though sales have leveled off recently, says Bill Noonan, a spokesman for IMS America, a firm that tracks pharmaceutical sales.

    Fenfluramine and phentermine, which have been on the market separately for decades but are not FDA-approved for combination use, are doing well, too, boosted by a 1992 study showing the potency of the pairing. Two generic versions of phentermine alone accounted for 11 million prescriptions last year.

    That’s because the pills really work, at least for the first six months. After that, weight loss mysteriously tapers off.

    Both Redux and fen/phen work by acting in the brain to reduce carbohydrate craving, says Judith Wurtman,, a cognitive scientist at the Massachusetts Institute of Technology and co-inventor of Redux.

    Specifically, dexfenfluramine boosts the activity of a brain chemical called serotonin, she notes, adding that a serotonin deficiency underlies both carbohydrate craving and depression.

    In fact, researchers have wondered whether anti-depressant drugs like Prozac, called SSRIs or selective serotonin reuptake inhibitors, might also help people lose weight. But they don’t – and the FDA warns ary control with helping him lose 75 pounds, agrees.

    Diet pills “can be powerful tools but only if you do the behavioral stuff, too,” he says. “If you don’t, I’d recommend that you don’t even start.”

    People who need to lose 55 to 90 pounds who are interested in participating in a free, 12-month study on Redux at MIT may call 617-253-3437.

    1. Body mass index

    To learn your body mass index click HERE to visit the National Institute of Health web site. Just follow the directions and enter your height and weight, then click the Conpute BMI button.

    1. Are you overweight?

    There are various ways to gauge whether you are overweight, but one of the best is the body mass index, which uses a formula that takes into account both height and weight.

    In general, if you are 35 or older, you are considered obese if you have a BMI of 27 or more. If you are younger, a BMI of 25 or more indicates obesity. To qualify for Redux or fen/phen you should have a BMI of 30 or more, or a BMI of 27 along with health problems like diabetes or high blood pressure.

    These rules of thumb are not absolute. If you are a body builder with lots of muscle and no fat, you can have a high BMI and still be healthy. On the other hand, a BMI as low as 25 can elevate your risk of diabetes or heart disease, notes Dr. William Dietz, a nutritionist at New England Medical Center.

    If your BMI is high, do something about it, but take comfort in the fact that you are not alone. Based on a BMI of 25, half the country is overweight; based on a BMI of 27, one third is.

    Some doctors and commercial weight loss centers also use body fat analysis to gauge who should qualify for weight loss drugs. According to the National Institutes of Health, women are considered obese if they have more than 30 percent body fat, and men, more than 25 percent fat.

    But it can be difficult to measure body fat accurately, so beware of any center that tells you your BMI is okay but that you qualify for drugs only on the basis of body fat analysis.

     

     

    Tempest in a juice box

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    Is your toddler is getting pudgy? Is your preschooler shorter than the other kids? Are your kids’ teeth sprouting white spots or brown stains?

    If so, the culprit may be the juice craze that’s sweeping the nation, as well-meaning parents stuff lunchboxes and backpacks with juice boxes and kids guzzle the stuff all day.

    Last week, a study published in the journal Pediatrics found that kids who drank more than 12 ounces of fruit juice a day were more likely to be short or fat, though not both, than kids who drank less than 12 ounces.

    The American Academy of Pediatrics quickly chimed in with a different warning — that too much juice with a type of sugar called sorbitol, found in pear and apple juice, can cause diarrhea, abdominal pain or bloating.

    And last year, the American Dental Association published yet another study that showed that drinking too much fruit juice, which often contains fluoride, can trigger a process called fluorosis that leaves white or dark brown spots on kids’ teeth.

    Health researchers have long been appalled at America’s worsening dietary habits, in part because 22 percent of kids and teen-agers are now overweight, up 47 percent from 30 years ago.

    But while fast foods, take out meals and the usual no-nos like potato chips and cookies get most of the blame in the public mind, researchers are increasingly recognizing that what kids drink — from the obviously non-nutritious soda pop to the seemingly innocuous fruit juices — can contribute, too.

    Last fall, a study by researchers at New York Hospital-Cornell Medical Center’s Nutrition Information Center concluded that “liquid nutrition,” including high-calorie fruit juices and soft drinks consumed by kids and teen-agers, may play a key role in the growing problem of childhood obesity.

    It’s not just that juices have lots of calories — 155 of them in an 8-ounce box of grape juice, for instance — but that juices may be “replacing other more important nutrients,” says Dr. William Dietz, director of clinical nutrition at the Floating Hospital for Children at New England Medical Center.

    “Consumption of juice and soda has increased and milk has decreased,” says Dietz, who is a consultant to the Milk Processors Education Program and its “milk mustache” campaign. “I don’t think there is any reason why children should drink more than one glass of juice a day, about eight ounces.”

    In fact, the emerging consensus from those concerned about kids’ health is that many children would be better off drinking a little less juice and a little — or even a lot — more skim or lowfat milk and plain old water. Not to mention eating more real fruit, which has fiber and other goodies, too.

    But before you dump the fruit juice out with the bathwater, consider the finer points of all this.

    Last week’s study in Pediatrics, conducted by Dr. Barbara Dennison, a pediatrician at Bassett Hospital in Cooperstown, N.Y., is somewhat less scary than it sounds at first.

    Dennison’s team studied 168 healthy kids — 94 two-year olds and 74 five-year olds, recording weight, height and dietary habits, including how much juice they drank. The researchers counted only the real stuff — 100 percent fruit juice, including mixed juices like Juicy Juice — not juice-flavored drinks.

    Only 19 kids (11 percent of the study group) drank 12 ounces of juice a day or more, a tiny number on which to make weighty dietary recommendations. But of these 19, eight (or 42 percent) were short. Of those who drank less than 12 ounces a day — the rest of the kids in the study — only 14 percent were short.

    The team also found that those few kids who drank 12 ounces of juice a day or more were tubby. About half of them — that’s 10 kids — were in the 75th percentile for body mass index, a commonly used measure that includes both height and weight. By contrast, among those who drank less juice — all the other kids — 32 percent were overweight.

    Dennison has several hypotheses to explain her results. Perhaps, she says, kids who drink lots of juice don’t get other nutrients they need: “That would explain why they are short.”

    Other kids may gain weight because they drink juice on top of everything else they normally consume, she says, thus consuming more calories per kilogram of body weight than other kids. Although kids who dranks lots of juice and those who didn’t consumed roughly the same amount of calories, the high juice drinkers gained weight because they took in more calories than their metabolisms needed.

    Few of the kids in Dennison’s study drank soda pop, she adds, because they were so young and because “a lot of parents go out of their way to get 100 percent juice.” Because preschoolers need two servings of fruit a day, she says, it’s fine for one to be a glass of juice, but the other should be real fruit.

    Needless to say, the National Food Processors Association is less than thrilled by Dennison’s findings. Rhona Applebaum, the group’s executive vice president for scientific and regulatory affairs, notes that this was only an observational study and could not establish cause and effect. Applebaum also objects to calling “excessive” anything over 12 ounces of juice a day: “That is arbitrary.”

    If Dennison’s study were the only concern, this might be just a tempest in a juice box. But it’s not.

    It’s long been known, for instance, that if you put a baby to bed with a bottle of juice (or even milk), the result can be rampant tooth decay. Sugars in the drink cause bacteria in the mouth to release toxins that break down tooth enamel, a process that is accelerated because saliva that would normally wash away the sugars is decreased during sleep.

    And then there’s all that fluoride.

    A team of dentists, led by researchers at the University of Iowa, last year contacted manufacturers of 532 ready-to-drink juices, frozen-juice concentrates and juice-flavored drinks to see how much fluoride was in their products. More than half of products contained too much fluoride, they found, although parents would never know this because package labels say nothing about fluoride concentrations.

    In the right amounts — 0.3 to 0.6 parts per million — fluoride prevents tooth decay, according to the Academy of General Dentistry. That’s why many towns add fluoride to drinking water, why toothpaste makers put fluoride in their products and why dentists give kids fluoride treatments.

    But with fluoride, “sometimes you could have too much of a good thing,” says Dr. William Chase, a dentist in Adrian, Mich., and a spokesperson for the dental academy. If juice drinks are manufactured in communities where the water supply has high fluoride levels, the result can be an excess of fluoride — and white or brown spots on the teeth.

    The dental study found that 43 percent of juice products had fluoride concentrations above the recommended maximum (0.6 parts per million) and 19 percent were above 1.0 part per million.

    White grape juice, the researchers found, had the highest fluoride concentrations, probably because the skins from grapes contained fluoride from pesticides. Grape juices made after skins were removed had no detectable fluoride.

    Tea and prune, cranberry, pear, red grape, cherry and apple-grape juices all had mean fluoride concentrations greater than 0.6 parts per million, the researchers found. The mean fluoride level in straight apple juice was just under 0.6 parts per million. Orange juices, lemonades, fruit nectars and pineapple juices usually had less.

    Because excess fluoride can be harmful, especially for 6-to-9-year-old kids whose permanent teeth are still forming, parents should say no to fluoride treatments at the dentist’s office if their children drink a lot of juice, says Chase. Another thing you can do, he says, is join forces with dentists to get manufacturers to list fluoride content on juice labels.

    But this doesn’t mean kids should switch to soda. Even sugar-free soda can be harmful because the carbonation attacks tooth enamel.

    The bottom line, say the New York nutrition researchers, is to get kids and teen-agers to cut their overall consumption of high-calorie fruit juices and soft drinks.

    You can get there by diluting juices 3 to 1 with water, putting kids’ favorite cups near a water cooler and putting water bottles in kids lunch boxes at least several times a week.

    And when your child gets thirsty, offer water. “That’s what the body wants,” says Dietz. “There’s no need to accompany water with calories.”

     

    The downside for female athletes

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    It was a moment that 14-year-old Meaghan O’Connor of Dover, N.H., says may stay with her for the rest of her life.

    She was charging for the ball in the midst of a heated basketball game last summer. Suddenly, another girl’s knee smashed into hers.

    “I fell to the floor,” recalls O’Connor. Right away, “it got all swollen. I was crying.”

    Her parents took her home and put ice on her knee, and at first that seemed to do the trick. But a week later, she tried to play again. Her knee really hurt, she recalls. Perhaps even more ominous, it kept buckling as she played.

    Her parents took her to one doctor, then another. The diagnosis? A torn ACL, or anterior cruciate ligament, the most common severe joint injury in sports today, and a particular plague for vigorous young women like O’Connor.

    A generation ago, it was rare to see a healthy young woman limping in to see her doctor with a knee wrecked in friendly combat on high school or college playing fields.

    Today, a knee freshly bandaged from surgery or a high-tech knee brace has become a sign of the times for young female jocks, the kind of dubious honor that shows both how far women have come in crashing the barriers to full participation in sports — and the price some are paying for their shot at athletic glory.

    In 1982-83, for instance, there were 80,000 female athletes competing in college sports, according to the National Collegiate Athletic Association. By 1994-1995, the figure had swelled to 110,500, with a 9 percent increase in 1989 to 1992 alone, the NCAA says.

    In high school sports, the figures are even more dramatic. In 1971, before the federal law known as Title IX mandated that girls and boys get comparable athletic opportunities, fewer than 300,000 girls participated, according to the National Federation of State High School Associations.

    A year later, thanks to Title IX, the number had soard to more than 800,000. Today, there are 2.4 million.

    The downside of all this forward motion, sad to say, is that men and women now have a chance to injure themselves at roughly similar rates in many sports.

    But certain sports, especially those like soccer and basketball that demand a lot of pivoting and fast changes of speed and direction, seem to take a higher toll on women than on men.

    Especially on the anterior cruciate ligament in the knee.

    In one recent study, Dr. Elizabeth Arendt, medical director of men’s and women’s varsity athletics at the University of Minnesota, and Randall Dick, associate director of sports sciences at the NCAA, documented striking gender differences in ACL injuries in soccer and basketball, sports in which the rules are comparable for men and women.

    Overall, they found, the rate of the injury during the five-year study was three to four times higher among females than males. In basketball, women were three times more likely to rip their ACLs; in soccer, twice as likely. Most of the damage was from non-contact, twisting injuries.

    “It’s peculiar why this shows a gender or sex difference,” says Arendt. In fact, “It’s rather alarming that we don’t know the answer, but we don’t know it for men, either.”

    Part of the reason the anterior cruciate ligament takes such a beating is that evolution hasn’t yet come up with a better solution for a joint that must be both flexible and capable of carrying tremendous weight.

    This means that you may be asking for knee trouble if you play hard, both in contact sports like football and some non-contact sports like skiing. In skiing, modern technology — in the form of boots that lock the leg in a forward position — actually makes things worse by making the ligament vulnerable to rips if you fall over backwards.

    But for growing numbers of young female basketball and soccer players — and for many researchers — the most pressing question is why the risk of the ligament injury is especially acute for women.

    One theory is that women’s wider hips cause the femur, or thigh bone, to come into the knee at a broader angle. Men’s hips, knees and feet usually line up straight, says Nicholas Giurleo, director of physical therapy at Concord Avenue Physical Therapy Associates in Cambridge.

    But in women, he says, wider hips may make the knees slightly “knocked” or tilted inward, which can make the joints more vulnerable.

    Wider hips may also explain why women’s kneecaps slide around too much side to side, adds Lori Thein Brody, a physical therapist at the University of Wisconsin in Madison.

    Another theory is that women and men may have a different balance between the quadriceps muscle on the front of the thigh and the hamstrings at the back.

    In general, men have bulkier muscles because they have higher levels of male hormones, but even in women with impressive quads, the hamstrings may be relatively weak. Because the hamstrings work with the ligament to stabilize the knee, if they are weak or underused, the knee may be in jeopardy.

    Women are also more loose-jointed than men because female hormones make some ligaments stretch, a decided benefit during childbirth but a risk if knees are too loose.

    Regardless of why women’s knees are more vulnerable, once the ligament is damaged, the best treatment is to let the knee heal for four to six weeks so that the joint regains its range of motion, then to operate, says Dr. Bertram Zarins, chief of sports medicine at Massachusetts General Hospital.

    In surgery to reconstruct torn anterior cruciate ligaments, which is performed more than 10,000 times a year and is considered 90 to 95 percent successful — the repairs are usually made through small viewing tubes called arthroscopes inserted into the knee.

    In addition, doctors often make a two-to-three-inch incision to “harvest” a small piece of the kneecap tendon to replace the damaged ligament.

    In the procedure, doctors snip off the dangling ends of the damaged ligament, then take a third of the tendon that anchors the kneecap — with small pieces of bone still attached at either end — and screw it into tunnels made in the ends of the thigh bone and the tibia, where the ligament was anchored.

    The graft “is almost the same size as the ACL and is the same strength,” says Zarins, adding that the tendon from which it was taken regrows and regains its original strength. Though most reconstructive surgery uses this technique, some Boston surgeons use a piece of the hamstring instead of the patellar tendon.

    Like Meaghan O’Connor, some patients who have this surgery spend 23 hours a day for a week with the knee in a continuous passive motion machine to keep it from freezing up as it heals.

    The encouraging news, say orthopedic specialists, is that while recovery from ACL surgery used to take a year, accelerated rehabilitation programs now allow athletes to return to sports in about six months.

    Even that, of course, is a long time in the life of a healthy young athlete like O’Connor, who has been chafing at the bit since her surgery in August.

    She plans to run track this spring to get in shape for basketball next summer. For her, as for many young female athletes, the joy of sports is well worth the risk.

    In fact, when her doctor told her that the only way to make sure she didn’t re-injure her knee was to quit basketball, she had her answer all ready: “I didn’t want to do that.”

    SIDEBAR 1:

    REPAIRING A TORN ANTERIOR CRUCIATE LIGAMENT

    PLEASE SEE MICROFILM FOR CHART DATA

    GLOBE STAFF GRAPHIC/DAVID BUTLER

    SIDEBAR 2:

    Some tips to avoid injury

    If you’re serious about a sport — and equally serious about not wrecking your knees — there are several things you can do, say physical therapists and doctors who specialize in sports medicine.

    While many of these tips can help athletes avoid knee injuries in general, they are designed for female athletes who want to avoid injury to the ACL, or anterior cruciate ligament.

  • Coaching. Get a good coach as soon as you start doing any sport seriously. Parents don’t count, unless they’re trained as coaches. Ask your coach, nicely, what credentials and training she or he has had.
  • Skill level. Play with people at your level. In basketball, if you play with klutzes below your level, they may make up for their lack of skills with brute force. And if they can’t move as fast as you, you may end up tripping over them. On the other hand, if you’re the klutz, you may twist yourself into knee-wrecking contortions to keep up.
  • Fatigue and pain. Don’t play when you’re exhausted and don’t play through real pain. Among other things, this means distinguishing between “I’m sick of this and I want to go home” feelings and the sharp, stabbing pain of genuine injury, a pain that comes back as soon as you start playing again.
  • Shoes. It’s common sense to wear shoes with good arch support and shock-absorbing capacity — in sports as well as the rest of your life. But studies are mixed on whether shoes can be blamed for women’s ACL injuries. If your shoes are too “good,” that is, give you too much traction, your foot won’t give way on fast stops, and the resulting torque on your knee can rip the ligament.
  • Posture. For many women, the “default posture” — how you stand when you’re not thinking about it — is with the knees hyperextended or arched slightly backward. Some researchers think that if you habitually stand this way, you may land wrong on jumps, too.
  • Landings. Many ACL injuries could be prevented if athletes were taught to land correctly from jumps — with knees bent, not hyperextended, and with feet under the hips. Landing on bent knees gives the hamstrings a chance to stabilize the knee.
  • Fast stops, cuts and turns. When you have to decelerate and change direction fast, take three small “stutter steps” instead of one big one. When this three-step stop was taught to two major women’s basketball teams, the incidence of ACL injuries dropped 89 percent over several years.
  • Weights. Get to the weight room. Take the time — three sessions a week — to build up your leg muscles, especially your hamstrings. Try to work with a trainer certified by a recognized organization such as the National Strength and Conditioning Association. If you think you’re headed for trouble, get a physical therapist to check you for any abnormalities in your gait and imbalances between muscle groups.
  • Warm-ups. Never start jumping and pivoting hard unless you’re thoroughly warmed up, i.e., actually sweating.
  • Stick with the sport you love — sensibly. It may make sense to switch sports if you think the one you’ve chosen is too risky. But don’t let the naysayers get you down too easily.

    • Decades ago, when women first started competing in long distance running events, half fainted at the finish, prompting the International Olympic Committee to conclude that women were too delicate for the tough stuff, says Dr. Elizabeth Arendt, medical director of men’s and women’s varsity athletics at the University of Minnesota.

    That’s a “Neanderthal” attitude, she says. Life is inherently risky, and “people play a sport because they love it.”

    Eat, drunk and be miserable

    by

    First you have the eggnog. Then the turkey and stuffing and the puddles of gravy, or maybe a huge slab of roast beef surrounded by a sea of mashed potatoes.

    Then the rolls, with butter, of course. Maybe a veggie or two for color. And wine, naturally, the more the merrier.

    Then the pecan might-as-well-make-it-a-la-mode pie. Then the mints and the coffee, lightened, because it’s Christmas, with real cream — make that whipped.

    Then — surprise, surprise — the heartburn, that burning and churning in the chest that is the hallmark of GERD, a not-so-charming acronymn for an even less charming affliction: gastroesophageal reflux disease.

    More than 60 million Americans experience GERD and heartburn at least once a month, government figures show, and 25 million belch their way through this post-prandial misery every day.

    But the holiday season is when the gastronomic gods can really take their revenge on a nation of hearty eaters who can’t “just say no.”

    And so, we suffer — most of us mildly, some seriously. In fact, heartburn can be intensely frightening because its symptoms are easily confused with those of a heart attack.

    Fortunately, even severe forms of heartburn and reflux can be treated with a growing array of drugs and, if necessary, surgery.

    If you’re young, you may never have heard of GERD because your lower esophageal sphincter, a circular muscle that opens to let food pass into the stomach then closes again, is doing a fine job of keeping food where it belongs, in your stomach.

    Ideally, this sphincter “should be as tight as your pursed lips when you’re whistling Dixie,” says Dr. Andrew Plaut, chief of the Digestive Diseases Research Center at the New England Medical Center.

    But in many older people, as well as those who are overweight and possibly some with anatomical problems such as hiatal hernia (which causes part of the stomach to stick up into the chest through the diaphragm), the sphincter may work poorly.

    An “incompetent” sphincter relaxes too much, allowing partially digested food and stomach acids to “slosh north,” Plaut says.

    Sometimes, the backflow reaches as far as the mouth, where it can cause sore throats and tooth decay. Sometimes it washes into the windpipe and the lungs, where it can irritate delicate tissues and cause aspiration pneumonia.

    More often, the acids simply flow partway up the esophagus — especially if you lie down too soon after eating — and cause a burning pain that moves up the chest, says Dr. Walter Hogan, a gastroenterologist at the Medical College of Wisconsin.

    In fact, this burning, upwardly mobile pain is one of the key ways to differentiate heartburn — which actually has nothing to do with the heart — from a heart attack, he adds. In general, it’s probably heartburn if your chest pain comes on repeatedly after eating, is accompanied by difficulty swallowing or regurgitation and gets better with antacids.

    On the other hand, it may be a heart attack if your chest pain gets worse with exercise and better with rest. If you’re in doubt, of course, see a doctor fast, though even doctors may have a tough time telling heartburn from heart attack. Sometimes, it may take several tests — including an electrocardiogram or EKG — to see if it is heartburn.

    In some cases, the case for reflux can be clinched if doctors can see, by looking through a tube called an endoscope put down your throat, that the lining of your esophagus is inflamed. A chronically inflamed esophagus can lead to strictures — scar tissue that can narrow the esophagus — and Barrett’s esophagus, a pre-cancerous change in the cells that line the esophagus.

    In other cases, doctors may ask you to swallow a drink containing a chemical called barium, then watch on X-rays to see if acids flow up from your stomach to the esophagus.

    If they still can’t decide whether you have reflux or heart problems, they may place a thin tube in your esophagus — a minor, non-surgical procedure — to monitor the pH, or acidity. If the acid level is consistently high, you probably have GERD.

    They can also check the strength of your sphincter with so-called manometric tests, in which pressure sensors in a tube placed in your esophagus detect how well your esophageal muscles are contracting, says Dr. Mark Callery, a gastrointestinal surgeon at the University of Massachusetts Medical Center in Worcester. If your muscles are weak, you probably have GERD. If so, there are lots of treatments.

    “The most important thing you can do,” says Plaut, “is elevate the head of your bed” with bricks, books, wood or the Yellow Pages under the bed or a triangular foam wedge placed on your mattress.

    Adding a few pillows won’t suffice, he says, because the whole bed must be on a slant to keep your stomach lower than your esophagus. This technique really helps, he says, and “unless you have satin sheets, everybody stays in bed.”

    The other utterly basic remedy, says Callery, is to go easy on foods that contribute to reflux because they decrease the muscle tone in the esophageal sphincter. Nobody really knows why some foods affect sphincter tone more than others, but if certain foods make your reflux worse, it pays to avoid them.

    Unfortunately, the list of foods to avoid probably includes many of the goodies likely to be on your holiday table, like all the fried and fatty stuff (which can also make reflux worse by making your stomach empty more slowly), chocolate, mints, including the peppermint in candy canes, and alcohol.

    Other culprits include coffee, tea, cola, beer and even whole milk dairy products, because these can increase acidity. If your esophagus is damaged, citrus fruits, pepper, tomatoes and raw onions can worsen things.

    Of course, if you take away all the foods you love, “you may get so unhappy that you’d prefer to have a little heartburn,” notes Plaut, adding that pleasure counts, too.

    You may also be able to help by quitting smoking and losing weight, yet another reason to stick to those perennial New Year’s resolutions.

    You can buy your way to gastric comfort and joy, too. If your reflux is mild or occasional, you can probably control it with over-the-counter acid neutralizers like Tums, Rolaids, Mylanta, Maalox, Pepto-Bismol and the like. Some people also use foaming antacids such as Gaviscon.

    A more sophisticated — and often more effective — solution is to take so-called H-2, or histamine-blocking, drugs like Zantac, Tagamet, Pepcid and Axid, which are available over the counter in low doses and by prescription in higher doses. H-2 drugs block the histamine receptors on stomach cells, stopping the signal that tells these cells to make acid.

    If H-2 blockers don’t work, you can try a class of drugs called proton pump inhibitors, which are available only by prescription. Two such drugs, called Prilosec and Prevacid, were approved for GERD this year by the Food and Drug Administration, although they were already on the market for peptic ulcers.

    You may also get relief from prescription drugs such as Propulsid or Reglan, which help empty the stomach by increasing the movement of stomach contents to the intestines.

    As a last resort, there’s surgery, specifically a procedure called fundoplication. Operating through small tubes surgically inserted into the abdomen, doctors wrap part of the stomach tissue around the bottom of the esophagus to form a kind of collar that can prop up an ineffective esophageal sphincter.

    While surgery should be used only if all else fails, says Callery of UMass, it works very well and usually means that patients no longer need to take any reflux medicines.

    But the best way to deal with heartburn is to not get it.

    So as you face the groaning board this year, think not only of the tempting tastes and tender feelings of your host or hostess, but of your humble esophagus, which seeks nothing more in life than to be a one-way street for your indulgences.

    Don’t eat everything in sight, and if you do, don’t lie down.

    Remember: The gastronomic gods don’t want you to get heartburn. That’s why they left you a sinkful of dirty dishes that can be dealt with only one way: standing up.

    In estrogen replacement therapy, less may be better

    by

    Call it coffee klatch research. Or book group medicine. Or just plain winging it.

    By whatever name, women of a certain age are trying to figure out for themselves — and with each other — the answers to a midlife question doctors won’t have good answers to for years:

    If you’re taking postmenopausal estrogen and cut your dose, say, in half, can you lower the risk of breast cancer that goes with the normal dose — many women’s biggest fear — yet still get the benefits to your heart and bones and ward off hot flashes?

    Two new studies — still unpublished, but presented at recent scientific meetings — suggest that women who lower their estrogen are on the right track, though it goes without saying that you shouldn’t do this without checking with your doctor first.

    The studies suggest — and that’s really suggest, not prove — that low-dose estrogen may indeed provide at least some of the well-established benefits of the stan-

    Don’t change dosage without checking with a doctor

    dard dose estrogen regimen, most notably protection against osteoporosis.

    Nobody has a clue yet whether lowering estrogen will also reduce the increased risk of breast cancer associated with hormone use, though that hypothesis is both logical and appealing to millions of women who have been scared silly since last year, when a big Harvard research project, the Nurses’ Health Study, documented the increased risk.

    The Harvard study found that menopausal women who took estrogen alone raised their risk of breast cancer by about 30 percent, and that those who also took another hormone called progestin raised their risk about 40 percent.

    Women who have not had hysterectomies often take progestin with estrogen to avoid the increased risk of uterine cancer that taking estrogen alone poses. In the Harvard study, the risk of breast cancer was increased only among women who had been taking hormones for five years or more.

    The troubling Harvard study is a prominent peak in a mountain range of conflicting data on estrogen therapy. There are many good reasons to take estrogen — it reduces the risk of heart disease (which kills six times more women than breast cancer), raises “good” cholesterol and lowers “bad” and clearly wards off osteoporosis.

    Estrogen may also protect against Alzheimer’s disease, and it reduces symptoms like hot flashes and vaginal dryness.

    Yet many women shy away from hormone therapy because of the added, albeit modest, increased risk of breast cancer.

    In the larger of the new studies, Dr. Morris Notelovitz, director of the Women’s Medical and Diagnostic Center in Gainsville, Fla., tested 406 post-menopausal women on various doses of an estrogen pill called Estratab for two years.

    All of the women, including those receiving a placebo (a lookalike drug with no estrogen), took 1,000 milligrams a day of calcium, and none took progestin. During the study, neither the women nor the doctors knew who was getting which dose.

    The results, presented in September at the North American Menopause Society meeting in Chicago, were very encouraging.

    The low dose of 0.3 milligrams a day — half the usual dose of 0.625 mg — increased bone mineral density in the spine and hip without increasing the risk of endometrial hyperplasia, or pre-cancerous cells in the uterus.

    The Florida study, if confirmed by other research, means not only that Estratab, which is derived from plant estrogens, can protect bones, but that it can do so without apparently raising the risk of uterine cancer, says Dr. Joseph Mortola, director of reproductive endocrinology at Cook County Hospital in Chicago and a participant in the study.

    More work needs to be done, he cautions, but the Florida study, which was funded by Solvay Pharmaceuticals, the maker of Estratab, means some women may be able to avoid taking progestins like Provera to protect the uterus. Progestins can cause bloating, depression and other side effects.

    Still, because the data are preliminary, he says, any woman with a uterus who takes only estrogen, even at low doses, and does not take progestin should have an annual endometrial biopsy to make sure she has not developed uterine cancer.

    And while it is not yet clear whether low-dose estrogen carries a lower risk for breast cancer, Mortola says the Florida study did find that low-dose estrogen may help protect the heart as well as the bones.

    Low-dose estrogen, he says, seemed to have a positive effect on blood lipids — raising good cholesterol and lowering bad, although this finding was not statistically significant.

    The low-dose estrogen also reduced hot flashes and vaginal dryness, Mortola noted.

    A drawback of the Florida study is that it did not look at Premarin, the estrogen supplement that is derived from horse urine and used most often by American women.

    But a small study of about two dozen women by Dr. Karen Prestwood, a specialist in osteoporosis and an assistant professor at the University of Connecticut Health Center, did.

    In data presented this fall to the American Society for Bone and Mineral Research, Prestwood found that women taking only 0.3 milligrams a day of Premarin got roughly the same protection against bone loss as those taking 0.625 milligrams.

    In related research, Prestwood studied another estrogen formulation called Estrace, a synthetic form of estradiol, the main type of estrogen found in the body.

    As long as women also took 1,500 milligrams a day of calcium, low doses (0.5 mg) Estrace — the equivalent of 0.3 mg of Premarin — protect against osteoporosis, she found.

    Dr. Isaac Schiff, chief of obstetrics and gynecology at Massachusetts General Hospital, says the new studies follow the logic used for years with birth control pills — reducing the dose to decrease side effects yet still achieve contraception.

    “The same thinking is carrying over to estrogen replacement therapy,” he says, adding that the findings are “taking us to a new plateau.” Still, he does not recommend low dose estrogen for everyone, though he does prescribe it for some patients.

    There may one more benefit to low dose estrogen, though it has yet to be proved, says Dr. Joann Manson, co-director of women’s health at Brigham and Women’s Hospital in Boston.

    A small study by Boston researchers showed recently that women who take estrogen and drink alcohol may raise blood levels of estrogen to more than three times the intended dose.

    This study focused on Estrace, not Premarin, and the hormone users drank quite a bit — the equivalent of three glasses of wine.

    Yet the emerging data suggest that women who drink may want to ask their doctors if they should switch to low dose estrogen.

    No matter what the doctor says, it’ll make for an interesting discussion at your next coffee klatch.

    SIDEBAR:

    Variations on a theme

    Estrogen pills and patches — and their dosages — as approved by the US Food and Drug Administration:

    • Estrogen-only pills
    • Premarin: 2.5 milligrams, 1.25 mg, 0.9 mg, 0.625 mg or 0.3 mg.
    • Estratab: 2.5 mg, 1.25 mg, 0.625 mg, or 0.3 mg.
    • Estrace: 2 mg, 1 mg or 0.5 mg. (The latter is roughly equivalent to 0.625 mg of Premarin.)
    • Ogen: 1.5 mg.
    • OrthoEst: 1.25 mg, 0.625 mg or 0.615 mg.
    • Menest: 2.5 mg, 1.25 mg, 0.625 mg, 0.3 mg.
    • Estrogen-progestin combination pills
    • PremPro: one tablet contains 0.625 mg of estrogen and 0.5 mg of medroxyprogesterone (Provera)
    • PremPhase: a two-tablet combination regimen containing 0.625 mg of estrogen and 0.25 mg of medroxyprogesterone. [CORRECTION – DATE: Monday, December 23, 1996: CORRECTION: Because of inaccurate information supplied by the FDA, dosages for two estrogen-progestin pills described by Health Sense columnist Judy Foreman last Monday were incorrect. The amount of medroxyprogesterone in is 5 mg; in PremPhase it is 2.5 mg.]
    • Estrogen patches (which last from 3 to 7 days)
    • Vivelle, which provides daily doses of 0.1mg; 0.075 mg; 0.05 mg; or 0.0375 mg.
    • Estraderm, which provides daily doses of 0.1 mg or 0.05 mg.
    • FemPatch, which provides a daily dose of 0.025 mg.
    • Climara, which provides daily doses of 0.1 mg or 0.05 mg.

    The hottest thing in the cold war is zinc

    by

    It remains to be seen whether the latest remedy for the common cold is really any better than chicken soup, a hot toddy by the fire and a few days off, but enthusiasts are seizing on the latest evidence that zinc lozenges may reduce cold misery this sneezing season.

    There have been eight studies so far on whether zinc can shorten the duration of colds, and the score stands at 4-4.

    But the latest study, done by Dr. Michael L. Macknin and colleagues at the Cleveland Clinic and published in the Annals of Internal Medicine, is stirring high hopes, not to mention brisk sales of the little zinc candies.

    In fact, the manufacturer of COLD-EEZE, the lozenges studied in Cleveland, can’t keep its zinc gluconate product – roughly $ 5 for a few days’ supply – on the shelves of drug and health food stores.

    By Christmas, two more formulations, Fast Dry and ColdFree, based on a slightly different chemical formulation called zinc acetate, are expected to hit the stores.

    For all the buzz, nobody knows quite why zinc might help. In the test tube, zinc does seem to stop some viruses from growing. And if you are deficient in zinc, taking some may boost your immune system. (But watch out: too much can do the opposite.)

    In the Cleveland study, 100 volunteers, who all had colds and worked at the clinic, were divided into two groups. Half took a fairly high dose (four to eight 13.3 milligram zinc gluconate lozenges a day). The others took a placebo, which was supposed to taste like the real COLD-EEZE.

    Neither patients nor doctors knew who got what.

    The zinc lozenges “worked remarkably well,” says Macknin, shortening the duration of cold symptoms nearly by half. The folks who sucked on the zinc gluconate candies suffered only 4.4 days of cold symptoms, while the others hung on to their misery for the usual 7.6 days.

    And the cold symptoms many people hate most – coughing, headache, hoarseness, nasal congestion, nasal drainage and sore throat – went away the quickest.

    The only bothersome side effects, says Macknin, were nausea and the bad taste of the candies. The flavor has since been improved – you still wouldn’t confuse it with Godiva chocolate, but it’s not too bad. Still, some people dropped out of the study because of the taste, and others said it ruined their ability to enjoy food.

    Still, Macknin says he and his wife and son now swear by the stuff.  His his 11-year-old daughter, though, says she’d “rather be sick.”

    Overall, the Cleveland study was “very well done,” says Dr. Ananda Prasad, a professor at Wayne State School of Medicine who studied zinc for years.

    “Do I recommend that people take it? Yes, based on that study, it’s worth trying,” he says. And a competing formulation based on zinc acetate “will be better.”

    So far, zinc acetate has not been studied in clinical trials, but the inventor of both formulations, George Eby, an entrepreneur in Austin, Texas, is convinced that acetate will prevail because it tastes better.

    Eby discovered zinc’s apparent benefits accidentally when his daughter, who had leukemia, started taking zinc and bounced back unusually quickly from a cold. He believes that zinc acetate may actually cure colds, not just reduce their duration.

    Not everyone shares his zeal.

    Dominick Iacuzio, who heads the influenza and related diseases program at the National Institute of Allergy and Infectious Diseases, cautions that zinc “is controversial,” in part because the data is inconsistent.

    And Dr. Jack Gwaltney, a virologist and epidemiologist at the University of Virginia Health Sciences Center, is even more critical.

    In studies he did of zinc and cold germs half a dozen years ago, Gwaltney measured both virus and zinc levels in volunteers’ blood – something the Cleveland team did not do – and found that high zinc levels did not make colds go away faster.

    This suggests that the zinc in multi-vitamins, helpful as it may be in offsetting zinc deficiency, probably won’t do much for colds.

    Furthermore, Gwaltney says, cold viruses grow mostly in the nose, not the throat, and it’s not clear that zinc from lozenges can get to where it might do any good.

    In addition, he believes the Cleveland study was flawed because the placebo may not taste enough like the real thing. Macknin counters that only about half of his subjects guessed right about which substance they were taking, so the taste difference could not have been huge.

    Jeff Blumberg, associate director of the Tufts University nutrition research center, warns against excessive enthusiasm for zinc, because more is distinctly not better.

    The 15 milligrams of zinc found in multi-vitamins is fine, he says. But older people who take zinc as pills start to have immunosuppression at 50 milligrams a day; it probably takes higher doses of zinc from lozenges to induce immunosuppression.

    Some research also suggests that large doses of zinc can lower levels of “good” cholesterol, or HDL.

    Given all that, perhaps it’s not surprising that two prestigious health newsletters – the University of California at Berkeley’s Wellness Letter and Health News, put out by the Massachusetts Medical Society – view zinc lozenges differently.

    The Massachusetts group cautiously endorses the lozenges. But the Berkeley folks say that while COLD-EEZE’s ads tell consumers to “break it to Grandma gently” that they’re going off chicken soup, “We say let Grandma and Grandpa stay at the stove a while longer.”

    Lozenges hard to find

    Although available as dietary supplements in some health food stores and other retail outlets, zinc remedies for colds can be tough to find because consumer demand is outstripping supply in many areas of the country. In fact, there’s a sign-up list for the lozenges in stores in Chicago, and elsewhere shelves become bare as soon as they are stocked.

    So if you’re determined to find the stuff – and remember, these putative cold remedies and the specific claims for their effectiveness have not been reviewed or approved by the FDA – here are some hints.

    Drugs seem to help hair loss and a “baldness cure”

    by

    Beth Stein, a 39-year-old New Jersey advertising copywriter, began losing her hair at 19 – presumably because of the same bad genes that affect everyone in her family, male and female.

    At first, her part just seemed to be getting wider. Soon, whenever she shampooed her hair, she’d wind up with 15 or 20 strands in her hands. Eventually, her hair became so thin it was hard to style it in a way that covered her head.

    “When this happens to people, especially to a woman, it’s extremely emotionally distressing and socially crippling,” she says. “I went to doctors. I tried a lot of phony treatments. I cried a lot. It was pretty devastating.”

    Then, several months ago, she spotted an ad in the Yellow Pages for a New York doctor touting a new way to make hair grow.

    It turned out to be a hair spray made from two drugs already approved by the Food and Drug Administration: minoxidil, the active ingredient in Rogaine, an over-the-counter potion that boosts hair growth in some people, and tretinoin, the chief constituent of Renova and Retin A, prescription-only drugs that combat wrinkles and acne.

    Never mind that the doctor’s homemade concoction, though not illegal, had never been tested in controlled clinical trials, so there is no solid proof that it’s safe, and that it works.

    Never mind that the doctor isn’t a dermatologist, the type of medical specialist who usually treats hair growth problems.

    Never mind even that the physician, Dr. Adam LewenbergCQ, was using an idea originally developed by someone else, Louisiana biochemist and use patent holder Gail S. BazzanoCQ, who has a tale to tell of running afoul of a giant cosmetics company in her quest to get her hair growth product on the market.

    Like many of America’s 20 million balding women and 40 million balding men, all that Beth Stein wanted was more hair.

    Until recently, at least, that has been a quixotic quest.

    Though most of us couldn’t care less until something surprising happens – like waking up one day and realizing a once-robust hairline is drifting out of sight – our hair grows, falls out and grows again in a steady cycle throughout life.

    In the growth or “anagen” phase, scalp hair grows for about two years, says Dr. Barbara Gilchrest, chairman of the dermatology department at Boston University School of Medicine.

    If you can grow hair down to your knees, it means you have an unusually long anagen phase; if you can’t grow it past your collar, you’ve got a short one. (The reason eyebrows never get very long – in case you were pulling your hair out over that one – is that eyebrow hairs have a very short, 2-month cycle.)

    At the end of the anagen phase, the hair follicle, from which the hair shaft grows, enters a short “catagen” phase in which it shrinks back to a smaller size. In the third or “telogen” phase, the follicle just sits dormant for several months.

    Eventually, the hair gets loose, falls out, and the cycle begins again. At any given moment, about 90 percent of hairs on the scalp are in the growing phase and 10 percent are resting – and in some lucky souls, this process continues throughout life.

    But in many men and women, hair follicles eventually wimp out, probably because of the effect of male hormones called androgens. New evidence suggests a female hormone, estrogen, may be involved, too.

    In men, who often have what’s called “male pattern baldness,” thinning starts at the forehead and works its way back, sometimes merging with another bald spot that begins at the crown of the head. Women don’t usually have creeping hairlines, but wind up with thin spots or very sparse hair all over.

    With each hair cycle, male hormones activate receptors in the follicle, slowly turning large follicles into small ones that produce only wispy hairs. This process is especially pronounced in people who are genetically predisposed to balding.

    “It’s as if the factory wears out,” says Dr. Robert Stern, a dermatologist at the Beth Israel Deaconess Medical Center. “The factory starts to turn out an inferior product, then it just goes out of business.”

    Still, there is enormous variation in the degree of hair loss in both men and women. At the same hormone levels, for instance, some men are as bald as the proverbial billiard ball, and some as hairy as the Biblical Samson on a good day.

    Eunuchs, by the way, always have lots of hair because they have been castrated and have very low levels of male hormone, a link that was discovered almost 50 years ago in a chance comparison of two twins.

    One brother was mentally ill and confined to an institution, where he was castrated. Years later, the other brother went to visit and doctors were shocked – the institutionalized man had a full head of hair while his brother was bald, says Dr. Michael Holick, chief of the BU endocrinology, nutrition and diabetes department.

    When the first brother was given hormones, he went bald, too.

    Because most guys consider castration a high price to pay for a manly mane, researchers have been hustling to find other options for both men and women with hair loss. Here’s what they’re coming up with: