Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Weight-loss surgery increasingly seen as treatment for diabetes

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Elizabeth Soto used to say no when her husband suggested they go dancing. “I didn’t want to go,” she said. “I felt tired and ugly.” She also was carrying 314 pounds on her 5-foot-7-inch frame and had diabetes.

She had gastric bypass surgery last June and now, at 235 pounds, the 38-year-old Chelsea resident said she feels “energetic and beautiful. I want to go out every weekend.” Even more astonishing, her blood sugar, which goes awry in diabetes, normalized within days of her surgery. A delighted Soto now proclaims: “My diabetes is gone.”

Doctors aren’t quite ready to call weight loss surgery a “cure” for Type 2 diabetes, the most common form. “I would use the term ‘remission,’ because if people regain the weight, the diabetes will come back,” said Dr. Martin Abrahamson, medical director of the Joslin Diabetes Center.

But doctors sure have begun encouraging their patients to get the surgery – for diabetes and a host of other problems. More and more doctors are recommending weight loss surgery to their obese and diabetic patients, and they are beginning to recommend it for less obese people, said Dr. George Blackburn, director of the Center for the Study of Nutrition Medicine at Beth Israel Deaconess Medical Center.

“We’ve all been blown away by the effectiveness of weight loss surgery,” he said. “The most severe type of obesity, leading to all these horrible diseases – diabetes, heart attack, back pain, cancer – can be treated by this surgery.”

Nationally, the number of weight loss operations soared 800 percent between 1998 and 2004, and another 11 percent between 2005 and 2006. Americans get more than 205,000 weight loss surgeries a year, according to the American Society for Metabolic and Bariatric Surgery – a number which is almost certain to keep climbing.

Research has shown that the surgery is getting far safer as it is performed more often. And more than 30 studies have found it effective for treating diabetes.

In the most recent example, a January study by Australian researchers, 60 obese, diabetic patients were randomly chosen to have laparoscopic adjustable gastric band surgery, a less drastic procedure than what Soto had, or regular treatment, which consisted of counseling on diet and exercise, plus medications, if necessary.

The results were stunning. Seventy-three percent of the surgical group were no longer diabetic at the end of the two-year study period, compared with 13 percent in the regular care group. The banding surgery, in which doctors place a balloon-like band around the stomach to make it smaller, had been assumed to be “the least effective operation for Type 2 diabetes, compared to the ‘gold standard,’ gastric bypass,” said Dr. Erik Dutson, an assistant clinical professor of surgery at the UCLA School of Medicine. But it turned that banding, though it acts more slowly, also reverses diabetes.

Last summer, a Swedish study showed that obese patients who had any of several types of surgery were 29 percent less likely to be dead a decade later than patients who had tried to control their weight through diet, exercise, and other methods.

And Utah researchers found a 40 percent reduction in deaths from all causes for obese patients who had weight-loss surgery compared with those who didn’t, as well as a 92 percent reduction in diabetes, 60 percent decline in cancer deaths and 56 percent drop in heart disease deaths for those who had had surgery.

To be sure, the surgery does not cure all problems. Many people still experience nausea, particularly if they eat sweets or greasy foods after the bypass surgery called Roux-en-Y.

Risk for suicide also appears to increase after weight-loss surgery, said Dr. Harvey Sugerman, editor in chief of the journal Surgery for Obesity and Related Diseases, perhaps because some patients “attributed all their depression to obesity. Then they have the operation, which takes care of the obesity, but they are still depressed.

“They thought the surgery would solve all their problems, but it didn’t,” he said.

Another factor in the rise of stomach surgery is doctors’ growing skill. The national in-hospital death rate from weight loss surgery declined from nine deaths for every 1,000 surgeries to two between 1998 and 2004, and has declined even further since then, said Blackburn, who also chairs a panel of 100 experts studying weight loss surgery.

In Massachusetts, the death rate dropped from an already-low average of 3 per 1,000 surgeries between 1998 and 2003 to a three-year average (2004, 2005, 2006) of less than 1 death per 1,000 surgeries, Blackburn said.

And the biggest payoff of weight loss surgery may be yet to come – avoiding surgery altogether if scientists can understand a key question: Why does diabetes get better literally within hours after gastric bypass, even before patients lose weight?

“That’s a very good question – every research center on the planet is working on it,” said Dutson of UCLA.

“There’s a Nobel Prize for anyone who can explain this,” added Dr. Daniel Jones, director of the bariatric surgery program at Beth Israel Deaconess Medical Center.

Researchers already have some clues. In Roux-en-Y surgery, part of the stomach is tied off and the small pouch that is left is connected directly to the small intestine, a procedure that allows food to bypass the upper part of the small intestine. The big plus is that when you “change the plumbing,” the production of insulin is increased, thereby reversing diabetes, Blackburn said.

Doctors suspect that bypass surgery somehow increases levels of a protein called GLP-1, which travels to the pancreas and tells beta-cells there to make insulin. (A new diabetes drug called Byetta seems to work in part through this mechanism.)

As the success of weight loss surgery grows, the number of patients clamoring for surgery is expected to soar further. Since 1991, federal guidelines have said that patients are eligible for weight loss surgery if their body mass index was 40 or more – someone who is 5-foot-6 and weighs 250 pounds, for example – or if it was 35 coupled with another serious condition such as diabetes, sleep apnea or heart disease.

But the recent Australian study pushed the envelope, offering surgery to less heavy patients. The US National Institutes of Health is already forming a committee to revisit its guidelines, Blackburn said.

For Linda Trainor, a nurse who works with weight loss surgery patients at Beth Israel Deaconess, watching obese and diabetic people get better is immensely gratifying. What she enjoys most, she said in an e-mail, “is their final freedom from self degradation.”

Robert Sisson, a 49-year-old manufacturing engineer for Raytheon who lives in South Boston, can vouch for that. Until November, Sisson tipped the scales at 376. Then he had the banding procedure. Now, he weighs 306, and his blood sugar levels are much better.

Hopping off his exercise bike recently to talk, he said, “I should have had it done years ago. My wife is going to get it done this year.” 

The unsung benefits of lifting weights

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I’m an exercise junkie — and proud of it. I swim, I run, I bike.

But, like many other people, I’m a disaster when it comes to lifting weights, also called strength, or resistance, training. The closest I come is lifting a few tiny dumbbells at home in front of the TV. And that’s only when the Red Sox are on.

This is about to change, and not just because of lingering New Year’s resolutions.

A growing body of evidence shows that strength training not only provides many benefits that aerobic workouts alone cannot, but also offers some of the same health benefits as aerobic conditioning.

It’s long been known that weight lifting becomes more important as you get older to prevent injury and preserve the strength to do normal things like climbing stairs, hauling groceries, and chasing grandchildren.

What’s comparatively new is that it does much more than that, potentially reducing the risk of developing heart disease, relieving neck pain, improving balance, and making it easier to battle the bulge — though it needs to be done properly to avoid injury.

The evidence for the value of strength training has grown so much that last year, the American College of Sports Medicine and the American Heart Association issued new recommendations for healthy adults 65 and older that stressed emphasized the importance of weight lifting.

The groups now recommend that all older Americans do eight 8 to 10 repetitions for each of the major muscle groups (biceps, quadriceps, hamstrings, etc.). Resistance exercises should be done on two or more non-consecutive days of the week.

The idea is to lift a weight that’s heavy enough to work each muscle group until it is fatigued, so the amount you lift will increase as your strength grows. Weight-bearing exercise, like walking or running, does not count as weight lifting — that means you really have to lift weights or work out on a resistance machine.

One of the biggest benefits of strength training is that it dramatically increases muscle mass, which aerobic exercise does not, noted William J. Evans, director of the Nutrition, Metabolism, and Exercise Laboratory at the University of Arkansas for Medical Sciences. More muscle mass is good not just because it makes you stronger but because it increases basal metabolic rate — muscle cells even at rest burn more calories than fat cells.

Moreover, while aerobic exercise can significantly, although temporarily, increase blood pressure, a potential concern for some heart patients, resistance training does so only minimally, Evans said. Weight training also gets results fast — it only takes resistance training twice a week for a few weeks to begin to see a significant effect, compared with three days a week with aerobics.

Indeed, the more researchers probe the benefits of weight training for specific conditions, the stronger the case they can make, said Miriam Nelson, director of the John Hancock Center for Physical Activity and Nutrition at Tufts University.

Although studies have not yet proven that strength training lowers the risk of osteoporosis, Nelson said, they do show it lowers the risk of fractures by improving balance, bone density, and muscle mass. Weight training is also good for people with arthritis, she said, because stronger muscles can take the pressure off inflamed joints.

Weight training has been shown to have other benefits, too.

Research by Steven N. Blair, an exercise scientist at the University of South Carolina, suggests that people with greater muscle strength may be somewhat less likely to develop metabolic syndrome, a cluster of factors that raise the risk of heart disease and diabetes, such as increased waist size, high fasting blood sugar, high triglycerides, low HDL or ”good” cholesterol, and high blood pressure. More studies are needed to confirm this association.

For older people with physical disabilities, 66 trials reviewed by Cochrane Collaboration, an international nonprofit group that evaluates health treatments, increasing strength and, to a lesser extent, function. A different 2007 Cochrane review of 34 studies showed that exercises, including strength training, can improve balance in women age 75 and older. Yet another 2007 Cochrane review of 34 studies on fibromyalgia (musculoskeletal pain) showed strength training may improve physical capacity.

And a Danish study just published last week showed that strength training aimed at shoulder and neck muscles can diminish the chronic neck pain that many people get from working of at computers.

I could go on. But I’m convinced. Weight training may not be as much fun as a run in the park. But I need it. I’m guessing you do, too.

Book on fertility and diet stirs buzz, skepticism

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Researchers at the Harvard School of Public Health have created a buzz with their new – and controversial – book, “The Fertility Diet.”

The book doesn’t actually come right out and claim that the new Harvard diet is a cure for infertility. But that’s the message desperate couples could be forgiven for getting, given its title, some of the authors’ public statements, the intense media hype, and, of course, the clout of almost anything with the Harvard imprimatur. That’s why some critics are upset.

The book, by epidemiologists Drs. Walter Willett and Jorge Chavarro and writer Patrick J. Skerrett, is based on the authors’ research, published in the November issue of “Obstetrics and Gynecology.”

In that paper, the authors reported on 17,544 women participating in the Nurses’ Health Study who recorded their diets and their quests to get pregnant in biennial questionnaires.

The study found that women had a lower risk of infertility due to anovulation – the failure to produce a viable egg every month – if they ate a diet that emphasized monounsaturated fats like olive oil over trans fats often found in baked goods; vegetable proteins such as in beans and nuts rather than animal sources such as red meat; whole grains instead of refined carbohydrates that cause too rapid a rise of blood sugar and insulin; some whole milk, a little ice cream or other high-fat dairy products daily; multivitamins containing folic acid; and iron from plants and supplements.

The study is groundbreaking because it “is one of the first times that anyone has shown that what you eat and drink can impact the reproductive system,” said Alice Domar, a psychologist who heads the Domar Center for Mind/Body Health at Boston IVF, one of the country’s largest infertility centers.

But it’s a huge leap to go from a statistical correlation to actually giving advice. The authors veer toward prescription when they say in their book, “We have discovered 10 simple changes that offer a powerful boost in fertility for women with ovulation-related infertility.” Ditto, in a cover story they wrote for the Dec. 10 issue of Newsweek, when they said their recommendations are aimed at preventing and “reversing” infertility – a conclusion Willett defended in an interview.

Observational studies like the Nurses’ Health Study do not prove that a behavior causes or prevents a health problem, only that it might do so. To prove that diet affects fertility, researchers would have to take a group of women with diagnosed infertility and randomly put half on a special diet and half on a regular diet and compare conception rates.

This would be an interventional study, which would have come closer to the “gold standard” of medical research and would have provided the solid ground to offer advice. Such a study could also show how long a woman would need to eat this way to affect her fertility.

Dr. Guy Ringler, a fertility specialist at California Fertility Partners and a board member of the American Fertility Association, cautioned in an e-mail that the new findings are interesting but “not sufficient to conclude that a modified diet in an infertile population would improve fertility. There need to be randomized, prospective studies comparing the different diets before such claims could be made.”

So where’s the harm in a little hype? Since the diet is basically a healthy one, except for the controversial suggestion to eat more high fat dairy, including ice cream, it is unlikely to cause direct harm. But a woman who follows the diet and still doesn’t get pregnant may blame herself, even though the diet isn’t proven effective.

Worse yet, a woman may follow the diet and postpone seeing a doctor. “If you’re 22 and you follow this diet for six months, that’s no big deal. But if you’re 42, you can’t afford to postpone seeing a doctor and try this diet in the meantime,” said Domar.

Dr. Gil Wilshire, a reproductive endocrinologist at Boone Hospital Center in Columbia, Mo., put it even more strongly: “This book is blatantly irresponsible. I am going to be cleaning up the damage from this book for years to come. I will be having women who wasted one, two, three years of their lives with imprecise, ineffective treatment. Those are precious years you can’t get back.”

But the book has obvious market appeal. Infertility is a source of heartache for more than 6 million American couples, although infertility due to problems with ovulation only account for about one-quarter of these cases. The diet won’t help if male biology – such as inadequate production of viable sperm – is the problem, as the authors themselves note. Or if the woman has blocked fallopian tubes or fibroids that impair the lining of the uterus.

All this said, the observations make biological sense, particularly the idea that certain foods may influence levels of hormones involved in ovulation and conception.

For instance, a diet high in refined carbohydrates is detrimental to ovulation because it sends blood sugar and insulin, the hormone that escorts sugar into cells, skyrocketing, Willett said in a telephone interview. Too much insulin makes the ovaries overproduce testosterone, the male hormone. Meanwhile, insulin reduces production by the liver of a protein called SHBG (sex hormone binding globulin), which captures testosterone. The net result of these processes is too much testosterone in the bloodstream, which can impede ovulation.

The ice cream recommendation is surprising, Willett acknowledged, and a bit tricky to explain. But his research suggested that “higher fat dairy products were related to better fertility and lower fat dairy was related to lower fertility. The reason? We’re only speculating, but it may well be that the relatively modest amounts of estrogen and progesterone that are present in the fatty part of whole milk can have a positive effect on fertility,” he said.

The Harvard team is not recommending a switch to high-fat dairy for a whole lifetime – if consumed long-term, high fat dairy products can increase the build-up of fatty plaques in artery walls, contributing to heart attacks.

The take-home message? If you’re having trouble getting pregnant, see your doctor before you hit the bookstore.

Let the post-diet era begin

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Is permanent, significant weight loss really possible?

If you’re talking merely10 to 20 pounds — and nobody knows the actual figure — you probably can diet and exercise your way to a svelter self and stay there, provided you stick with your weight control program rigorously. Forever.

But if you’re among the two-thirds of Americans who are overweight or obese, permanent, substantial weight loss appears to be almost impossible by diet and exercise alone.

Only about 1 to 2 percent of obese people can permanently lose weight through diet and exercise alone, said Dr. Lee  Kaplan, director of the weight center at Massachusetts General Hospital.

“Dieting is like holding your breath,” he said. “You can do it, but not for long. Your body is stronger than your willpower.”

In other words, Americans have probably wasted way too much time, money and hope on diet programs that don’t help enough. It still makes sense, however, to eat as healthily as you can, and to do whatever you can to avoid gaining any more weight.

One famous study conducted at the University of Minnesota during World War II illustrates the ineffectiveness of severe dieting. The researchers put 36 physically and emotionally healthy young men of normal weight on a strict diet, allowing them only half the calories they were used to. The men lost weight, but became psychological wrecks, obsessing about food, bingeing, and, even after the diet was over, eating way too much, often 8,000 to10,000 calories a day, until they regained the weight they had lost, recounted New York Times science writer Gina Kolata in her recent book, “Re-thinking Thin.”

In another classic study in the 1950s, researchers at Rockefeller University in New York City recruited obese people who were so desperate to lose weight that they agreed to live in the hospital for eight months, including a four-month period in which they subsisted on only 600 calories a day of liquid formula. They lost weight, Kolata noted. But, to the dismay of subjects and researchers, they all quickly regained the weight they had lost.

That’s because the basic biochemistry of the body’s weight management system can work against even highly motivated dieters.

When a very fat person loses a lot of weight by diet and exercise, the brain goes into panic mode, reading a complex array of chemical signals as proof of impending starvation. Metabolism slows. The body hangs on to every calorie it can get. The chemical signals that trigger appetite soar, creating a drive to eat so powerful you can’t resist. From the standpoint of evolution, this makes sense: Our DNA was built when we were hunter-gatherers to protect us against starvation not obesity. Consider one of the best-studied weight control hormones, leptin, which is made in fat cells and is designed to tell the brain: “Stop Eating. I’m full.”

“Obese people usually have high levels of leptin because they have so many fat cells making it,” said Dr. Eleftheria Maratos-Flier, an obesity researcher and associate professor of medicine at Beth Israel Deaconess Medical Center. “The heavier you are, the higher the circulating leptin.” In theory, being fat should mean that the brain would be flooded with  “stop eating” signals.

But when people go on severe diets, “they lose more leptin than you would expect. So the brain thinks there is less fat than there ought to be,” which makes people eat more, she said.

And leptin is just one of many hormones involved in weight control. “In the stomach and intestines alone,” Kaplan said, “there are 36 hormones that regulate weight, and another 30 in the brain. The end result of all these chemicals is to keep our energy stores, that is, fat, in balance.”

Put differently, some researchers believe that one reason weight loss programs ultimately fail is that diet and exercise do not change the body’s “set point,” the thermostat-like mechanism in the hypothalamus and other parts of the brain that keep weight fairly constant.

Dr. David Heber, director of the UCLA Center for Human Nutrition, is more optimistic about the effectiveness of dieting. “The set point can be changed. Yes, there are signals to eat and to hoard fat, but having said that, humans do adapt to starvation and do change,” he said. While the hormones that control appetite and satiety do tilt the equation toward regaining lost weight, “psychology trumps physiology. I see people every day who have overcome their genes and kept their excess weight off for decades.”

Many researchers do agree that one weight loss strategy does seem to change the set point — bariatric surgery, the stomach-stapling procedure. Doctors used to think it worked by simply reducing the size of the stomach, preventing people from eating much. Now, they think it works because, with less stomach tissue pumping out hormones such as ghrelin, which stimulates appetite, a person’s appetite and satiety signals may be altered to help them eat less.

So if dieting sets up a battle between our free will and our hormones, are America’s fat masses wasting their time desperately trying to lose weight?

To some, including the National Association to Advance Fat Acceptance, a civil rights organization that is fighting discrimination against fat people, all this suggests not so much a hopeless message as a liberating one. “Most people do not choose to be fat,” said the group spokeswoman, Peggy Howell.  “But once people are fat, it is next to impossible to change that. It’s far healthier to accept who you are and get on with your life than to be obsessed with what goes into your mouth.”

That makes a lot of sense to me, though I resist the idea that our genes are the big culprits because we have basically the same genes today that our skinnier grandparents had.  What’s changed is our lifestyles – more sitting around eating Twinkies, less walking to and from daily activities.

So, here’s my take. Because of the body’s complex biochemistry, it’s very difficult to lose weight once you gain it. So, exercise as much as you can — for general health, in addition to weight control. Eat right — fewer refined carbs, more fruits and veggies — again, for general health. If you’re fat, don’t just blame your genes and let yourself get fatter and fatter.

At the same time, be gentle with yourself, and with fat people you see.

Fitness plays a key role in battling cancer

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So. You get the worst news of your life: Cancer.

You dutifully sign on for chemo, surgery, radiation. You also vow to eat better. More fruits and veggies, less saturated fat — all that good stuff should tip the odds in your favor, right?

There’s actually surprisingly little evidence that such dietary changes prolong survival — except perhaps for colon cancer.What is crystal clear, though, is the importance of exercise and weight control. Gone is the folk wisdom that people with cancer should avoid getting too thin. The real threat, say cancer nutritionists, is becoming or remaining overweight. At a basic metabolic level, excess weight and lack of exercise may not only add diabetes and heart disease to your cancer troubles, but can impair immune function and even boost levels of hormones, including insulin and estrogen, that may drive some tumors.

For cancer patients who had been hoping that a good diet might improve their survival odds, some seriously disappointing news came out earlier this summer when scientists from the University of California in San Diego reported long-awaited results from the Women’s Healthy Eating and Living study. This randomized, controlled trial followed more than 3,000 women who had been treated for early stage breast cancer. After an average of 7.3 years of follow-up, the researchers found that women randomly assigned to a diet very high in vegetables, fruit, and fiber and very low in fat (15 to 20 percent of calories) did no better in terms of recurrence or death than women who simply stuck to a “5-a-day” diet with five servings of fruits and veggies.

Somewhat better news came last December with publication of a different study, called the Women’s Intervention Nutrition Study, led by Dr. Rowan T. Chlebowski, a medical oncologist at the Los Angeles Biomedical Research Institute. This team studied 2,400 women who had been treated for early-stage breast cancer and randomly assigned them to a dietary fat reduction group or regular diet group. After five years of follow up, there were significantly fewer recurrences among members of the lower fat group, most of whom lost weight.

The trouble is, said Chlebowski, it’s not clear whether it was the low fat diet per se or losing weight that conferred the benefit. And cues from other research suggest that losing weight, in part because it brings insulin levels into better control, may be the real key.

“Obesity is linked to worse outcomes in a variety of cancers, especially cancers of the breast, colon and prostate,” said Dr. Matthew Smith, director of genito-urinary medical oncology at Massachusetts General Hospital. For instance, in men with prostate cancer, “obesity is associated with a greater risk of prostate cancer recurrence after surgery or radiation,” said Smith. And  nfortunately, the hormone treatment that is often used to fight prostate cancer can itself contribute to obesity.

“Many cancer survivors and their families worry about weight loss as a manifestation of advanced cancer, when in fact, weight loss — intentional weight loss — and maintenance of ideal body weight may be one of the most effective strategies to improve overall health and the reduce the risk of recurrence,” Smith said.

“Weight gain, especially fat gain, can also impair immune responsiveness and in women with breast cancer, weight  gain may stimulate production of estrogen, which drives some breast tumors,” said Dr. Richard Rivlin, a nutrition specialist at Weill Medical College of Cornell University.

Even more discouraging, some drugs, such as tamoxifen, that women take to reduce breast cancer recurrence, can actually cause weight gain, said Dr. Lee Kaplan, director of the weight center at Massachusetts General Hospital.

Regardless of what you weigh, exercising is key. A study published in 2005 by Harvard Medical School researchers on nearly 3,000 women with breast cancer showed that women who walked the equivalent of three to five hours a week at an average pace had a lower risk of dying from their cancer. Two studies on people with colon cancer showed that walking six hours a week significantly reduces the risk of recurrence.

So, what to do? Two-thirds of the food on your plate should come from fruits, vegetables, whole grains and beans and no more than one-third from meat, fish or chicken, Karen Collins, nutrition advisor to the American Institute for Cancer Research, as nonprofit research group based in Washington, D.C. It’s not that the evidence is there to prove all this will prolong your life if you’ve already got cancer, but this stuff is so good for you it just makes sense to eat this way 

Eating less meat and more fruits and veggies may make a difference if you’ve got colon cancer, said Dr. Jeffrey Meyerhardt, a gastrointestinal oncologist at the Dana-Farber Cancer Institute. In one of his studies, Meyerhardt showed that people with colon cancer who eat more meals of a typical Western diet — with lots of red meat, refined grains and sugary foods — have three times the risk of recurrence or death than those who eat less of these foods.

Dr. Lidia Schapira, a breast cancer specialist at Mass. General, put it this way: “Even though the data are imprecise and conflicting, we can’t wait to eat until better data are in.”

The fading allure of vitamins

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My love affair with vitamins and supplements is over: With a few exceptions — stay tuned — I’m tossing them out.

Things started going south for this romance 13 years ago when a Finnish study of 29,000 male smokers showed a higher rate of lung cancer in men who took beta-carotene and vitamin E and, more shockingly, found that those who took beta-carotene had an 8 percent higher risk of death from all causes. Two years later, an American study reported similar findings for beta-carotene.

My love affair with vitamins and supplements is over: With a few exceptions — stay tuned — I’m tossing them out.

Things started going south for this romance 13 years ago when a Finnish study of 29,000 male smokers showed a higher rate of lung cancer in men who took beta-carotene and vitamin E and, more shockingly, found that those who took beta-carotene had an 8 percent higher risk of death from all causes. Two years later, an American study reported similar findings for beta-carotene.

I’ve never been a smoker, but a red flag is a red flag. Out went the beta-carotene.

Then came the bad news on vitamin E, for which I had had high hopes as a general disease-preventer. A 2004 analysis by Dr. Edgar R. Miller, of Johns Hopkins University, found an increase in deaths from all causes in people taking more than 400 International Units a day of vitamin E. In 2005, the Women’s Health Study of nearly 40,000 healthy women showed 600 international units of vitamin E taken every other day provided no overall benefit for heart disease or cancer.

Out went the vitamin E.

Along the way, I tossed my echinacea, which I once swore by for preventing or shortening the duration of colds. (Never underestimate the placebo effect!) Though proponents still contend the studies are flawed, I now believe the debunkers — among them the researchers who published a major study in 2005 in the New England Journal of Medicine showing that echinacea has no effect on colds.

Did I mention vitamin C? Oh, how I wanted to believe this famous antioxidant would keep me from getting cancer and all those colds! But despite numerous studies, “we haven’t been able to show a benefit,” Miller said.

The latest disillusionment came in February with a Danish study published in the Journal of the American Medical Association. When the researchers pooled the data from 47 reasonably unbiased studies involving 180,938 people, they found a 7 percent increased risk of death from all causes in those taking beta-carotene, a 16 percent increased risk of death in those taking vitamin A, and a 4 percent increased risk of death in those taking vitamin E.

Jeffrey Blumberg , a nutritionist and director of the antioxidants laboratory at Tufts University, among others, said that this study was based on flawed methodology, including the fact that the researchers left out of their analysis a number of studies that might have tipped the results in a different direction. But, to me, that’s clearly not a strong endorsement of vitamins.

(An important caveat here: If I were at risk of developing advanced age-related macular degeneration, a leading cause of vision loss, I would talk with my doctor about taking vitamin C, E, beta-carotene, and zinc. A National Eye Institute study published in 2001 showed that this combination can slow progression of the disease. On the other hand, a study in March in the Archives of Ophthalmology showed no benefit to beta carotene pills alone.)

Multivitamins? Somehow, I can’t part with mine yet, mostly because, try as I might, I still don’t eat enough fruits and veggies. But my faith is slipping. A state-of-the-science conference sponsored by the National Institutes of Health synthesized data from a number of randomized, controlled trials, the gold standard of clinical research. In a paper published in 2006 in the Annals of Internal Medicine, the scientists concluded, disappointingly, that the “evidence is insufficient to prove the presence or absence of benefits from use of multivitamin or mineral supplements to prevent cancer and chronic disease.” (For more, go to consensus.nih.gov.)

Adding to the speed at which the scales have been falling from my eyes is the latest news from ConsumerLab.com, a private company that tests vitamins, both for manufacturers and consumers.

ConsumerLab reported in January that 52 percent of the multivitamins it examined were contaminated with lead, didn’t disintegrate properly, or had more or less of certain ingredients than indicated on the label. While Centrum Silver passed, a multivitamin called AARP Maturity flunked because it failed to disintegrate properly. (An AARP spokesperson said it believes “the validity of the ConsumerLab study is in serious question” and is therefore still “evaluating whether or not to continue to make the product available.”)

A children’s product called Yummi Bears Multivitamin and Mineral flunked, too, because it contained too much vitamin A, which can be toxic. (A spokeswoman for the company said other, independent tests show Yummi Bears products meet all label claims and that there is no basis for concern about vitamin A levels in the product.) Vitamin Shoppe Multivitamins for Women flunked because it had too much lead; a company spokesman said last week that the company has removed the product from stores.

So, what’s left in my dietary supplement drawer?

Not much. Omega-3 fish oils, vitamin D, and calcium. Omega-3’s are still on my “good” list because considerable research suggests they lower the risk of cardiovascular disease and abnormal heart rhythms. In ConsumerLab testing, omega-3 fish oils, thankfully, were found to be free of mercury, PCBs, and other potential contaminants. Vitamin D is still on my list because it helps protect against certain cancers and with absorption of calcium. Calcium is still there because it seems to help protect against bone loss, although recent research has raised some questions, so this might be next to go.

For me, the most pressing question now is how to have the most fun with the handful of twenties I’m not spending on supplements! 

Heart attack at 43, Boston Marathon at 56

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Today, Larry Haydu will attempt something that most people would have assumed was impossible — and perhaps even unadvisable. Haydu, 56, who was almost completely sedentary until last summer, will run the Boston Marathon.

He and 11 teammates — all exempted from having to qualify for today’s race — are running as part of an experiment dreamed up by exercise physiologists and nutritionists at Tufts University and NOVA, which is making a documentary on the project that will air in the fall.

The idea, said Miriam Nelson, a Tufts nutritionist, three-time Boston Marathoner and the project’s chief scientific consultant, is to see whether totally out-of-shape people, some of whom also have chronic diseases and weight problems, can reverse the health effects decades of inactivity.

Haydu, a licensed clinical social worker, is determined to run the 26 miles, 285 yards in about five-and-a-half hours. Here’s betting he will do that, or even better, though no one, least of all Haydu himself, would have predicted that he would at all run, given his history.

Thirteen years ago, Haydu had a serious heart attack while shoveling snow. He had been a high school sprinter and soccer player and, despite a sedentary lifestyle as an adult, still clung “to the notion that I was in pretty good shape, but just didn’t happen to be exercising.”

The heart attack at age 43, he said, “jolted me out of this fantasy that I was still young and fit.” He remembers tucking his then 5-year old daughter into bed shortly after his attack and catching sight of his shadow on the wall. “I thought, I am not going to be just a shadow in her life…I was scared about dying, but I thought, ‘Goddamn it, I am not going to.’ “

He improved his diet, and religiously took his heart medications — statins, niacin, beta-blockers, a daily aspirin. He even fantasized about running a marathon “but bemoaned the fact that I never would because I had had this heart attack and was older and hadn’t exercised much.”

But last spring, his daughter Jessica, now a college student, learned about the Tufts/NOVA experiment and suggested he sign up. He went through a battery of tests with his own cardiologist to see whether it would be safe to begin rigorous training, and, like the other recruits, then began regular testing by the Tufts scientists.  The researchers checked cholesterol, C-reactive protein (a marker of inflammation), weight, body scans to assess the ratio of fat to muscle, and “VO2 max,” a test that measures how efficiently  the body can deliver oxygen to the muscles.

Until the NOVA show airs, the Tufts scientists won’t talk about the medical changes they’ve seen in their novice athletes. But Haydu provided the Globe with before-and-after test results from his private doctor. His total cholesterol levels, already within normal range, presumably because of his medications, haven’t changed much. But what delights him is that his HDL, or “good” cholesterol, has jumped from a respectable 64 to a dazzling 82 milligrams per deciliter. He’s lost five pounds off his already skinny frame, and is convinced he’s gained muscle.

Not that the training has been easy. At first, he recalled, “I went out to run and found I could manage 100 yards” — just the length of a football field. Gradually, he ran/walked his way up to two miles, then four, eventually running, alone or with the group, 5 to 7 hours a week.

Recently, he and the others ran  20 miles, along the actual marathon route.

The experience, he said, has been as “transformative” mentally as it has been physically, in large part because of the close bonds the 12 teammates formed.

The most valuable benefit has been “the whole trajectory around trusting my body. That took a hit when I had the heart attack,” he said, “and a mini hit” when he tore a muscle last winter training. Going out in the cold winter months also took a leap of faith  because doctors had told him that it was the cold air combined with the sudden exertion of shoveling and his unfitness that triggered his heart attack. Nervously at  first, then with more confidence, he ran through the winter, often an 8-mile loop through Sudbury.

Now, he’s ready, he said last week, sitting comfortably in his Sudbury living room with his Wheaten terrier, “Sophie,” snoring softly beside him. His lean face glows with confidence and health. He’s learned not just to run but to manage the “head games” and discouraged thinking that often plagues distance athletes. When he hits the hills today, or begins to sag, he will tell himself: “I’m strong. I can do this.”

He will have another secret weapon as well — his daughter, who plans to run the Newton Hills part of the race with him.

Running the marathon, he said, feels “like renewing the commitment I made to her when she was 5.”

The balance between life and disease

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Like many other Americans lately, I’ve found myself thinking hard about – and personally identifying with – the dilemma faced by Elizabeth Edwards and her husband, John, the former senator and would-be president.

His career, her health. Not an easy balancing act. Who should sacrifice for whom? How much? Nobody wants to be – or live with – a martyr. But nobody wants to deal with – or watch a loved one deal with – cancer unsupported, either. Ultimately, everybody’s mental health counts – the sick partner’s, the healthy one’s, and the kids’.

For 11 years, my husband, Tom, and I grappled with these dilemmas, first because of his lymphoma, and for the last five or six years, because of his prostate cancer as well. We knew, of course, that there were millions of other couples in similar situations, but that didn’t help much. We had to juggle each other’s needs – and each make sense of our own – with every up and down of the cancer roller coaster.

He had a need, which was sometimes tough for me, to minimize things, and to remain fiercely independent. I was more emotional.

He wanted to go through his first chemotherapy infusions alone, reading his physics journals and his newspapers. I wanted to be there. That’s what “good” wives did. But this particular man felt my particular presence would overly-dramatize things. He could do better, he felt, pretending that he was just sitting there reading, as usual, even while powerful drugs dripped into his arm.

So I let him — I developed a kind of rule; we worked as a team, but he was the patient, so on big decisions, he got two votes and I got one. Once, though, because he had seemed more anxious than usual before an infusion, I showed up at the hospital uninvited. That time, we were both glad I did.

Like Elizabeth Edwards, Tom, who died last year, was amazingly generous in encouraging me to keep up my own life, almost to the very end, when I did drop everything. So, for year after uncertain year, he would tell me to keep working, keep swimming, keep singing with my singing group, keep going to my book group, keep going to see my grandkids. All of which I did, with some guilt, but also, to be honest, with considerable relief. Unlike Tom, I had the luxury of getting away from cancer once in a while, and I like to think it helped us both that I did.

Still, I asked him over and over how, given his situation, he could be so generous. I didn’t think I would be. But Tom didn’t seem to see it as generosity. He saw it as protecting his best asset – me – from despair and burnout.

I never did burn out, but I did despair. We spent hours and hours over the years talking, and crying, about Tom’s fears and sadness and my dread of losing him. I always felt selfish and weak when he sympathized with my fear of life without him. But he kept telling me that, precisely because of that, I had the tougher job. I’m not sure if that’s correct, but his acknowledgement of how tough it was for me helped.

When I first read of the Edwards’ decision to stay in the presidential race, I was horrified. I thought he was being utterly selfish, that they were painting an overly optimistic view of her prognosis and that he should drop out now and focus on being her husband.

But then I thought about her, and Tom. From Tom’s example, I could believe that, from the bottom of her soul, she would not want him to give up his (and their) dream, would not want to take on the “sick role” any sooner than necessary, would not want to be a burden. I think she is absolutely right to urge him to keep running. I’m less sure whether he’s right to agree.

Unlike Tom and me, the Edwards’ case involves the rest of the country, or could. If he wins and she’s dying, how could he possibly balance her needs against the world’s ? But they’re not there yet. Cancer is a chronic disease until it becomes a fatal one, and, as we discovered, it’s quite possible to have many good, relatively disease-free times for many years.

On the other hand, cancer is a crapshoot. You never quite know how pessimistic or optimistic to be. You never quite know which doctors are giving it to you straight, or who’s right about the statistics and the studies and the chances.

So, you do your best, individually and together. And you never really know if you did it “right.”

Advice for all ages: Don’t skip the dentist

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Earlier this month, a team of researchers from the University of Connecticut and London announced that aggressive treatment of gum disease can improve the function of blood vessel walls in the body, potentially reducing the risk of heart attacks.

A few weeks before that, researchers from the Harvard School of Public Health reported a study of more than 51,000 male health professionals, which showed that men who had gum disease, or periodontitis, were far more likely than those without it to get pancreatic cancer.

Other studies have shown links between gum disease and diabetes, heart disease, stroke and even — though this is more controversial — pregnancy problems such as low-birth-weight infants. The evidence is accumulating faster than you can say “don’t forget to floss” that taking good care of your teeth — and treating gum disease aggressively — may be one of the best things you can do not just for your mouth, but for your overall health. With pancreatic cancer, for instance, previous studies had suggested such a link, but those studies were muddied because many participants smoked, and smoking is a risk factor for both diseases. This time, even among never-smokers, gum disease was linked to a doubling of the cancer risk, said epidemiologist Dominique Michaud, the first author, of the Harvard School of Public Health. It’s still not clear, cautioned Michaud, whether that means the gum disease led to the cancer.

Chronic inflammation anywhere, including swollen gums, makes the body release nasty chemicals called cytokines that have been linked to many problems, including diabetes and heart disease. The crucial point, in other words, is that “oral infections have systemic effects,” said Dr. Thomas Van Dyke , a professor of periodontology and oral biology at the Boston University School of Dental Medicine.

In some cases, these systemic effects are probably linked to the direct spread of oral bacteria through the bloodstream to other parts of the body, but most

In other cases, oral bacteria have been found in plaques in artery walls, though it is not clear whether these bacteria are a cause of heart disease or merely incidental, said Dr. Bruce Pihlstrom , acting director of the center for clinical research at the National Institute of Dental and Craniofacial Research, part of the National Institutes of Health.

But most of the systemic problems linked to periodontitis, which affects millions Americans to varying degrees, are believed to be problems of chronic inflammation.

The clearest example of that is the association between periodontitis and diabetes, said Dr. Robert J. Genco , a periodontologist at the University of Buffalo. He and others have shown that people with diabetes have more severe periodontal disease and have it at an earlier age than non-diabetics. And it’s a two-way street: People with diabetes who also have periodontitis have more trouble controlling blood sugar than diabetics without periodontitis.

It makes sense. Cytokines, such as those generated in chronic gum inflammation, can disrupt the system by which insulin, the hormone that escorts sugar into cells, sends chemical signals inside cells. This can trigger insulin resistance, which often leads to diabetes.

And obesity — long known as a major cause of diabetes, in part because fat cells in the abdomen pump out so many cytokines — is also now seen as a direct risk factor for periodontitis, said Genco. (Like Van Dyke, Genco is a co-author of a special Scientific American publication on oral health paid for by Proctor & Gamble, makers of Crest toothpaste and Oral-B electric toothbrushes. It is available online at www.dentalcare.com/soap/products/index_promotion_sa.htm.)

Cytokines can also trigger inflammation in artery walls, raise blood pressure, worsen cholesterol profiles and increase the tendency for blood to clot, which can lead to potentially fatal heart attacks.

Animal studies have also shown that deliberately inducing periodontitis triggers plaque buildup in the coronary arteries, said epidemiologist Kaumudi J. Joshipura , director of the division of dental public health at the University of Puerto Rico in San Juan.

A large study published in 2003 in the on-line journal Stroke showed that people who had lost a lot of teeth were more likely to have both severe periodontal disease and clogged coronary arteries. Another study that year showed a direct link between periodontal disease and stroke in people who had never smoked. And a study published in 2005 in the journal Circulation showed that older adults with higher levels of periodontitis-causing bacteria in their mouths also had thicker arteries in the neck that supply the brain, a predictor of heart attack and stroke.

Pregnancy complications, too, have been linked to gum disease, perhaps because chronic inflammation leads to high levels of a hormone-like substance, called prostaglandin E-2, which can induce labor. But last year, a study in the New England Journal of Medicine of 823 women with periodontal disease showed that treatment did not lower the risk of premature or low birth-weight babies. A second government study of 1,800 more women is now underway.

Bottom line? “The associations between periodontitis and systemic disease are provocative and important,” said Pihlstrom of the national dental institute.

But even if there were no links to systemic health, “taking care of your mouth is important for its own sake,” Pihlstrom said. Regular brushing, flossing and visits to a dentist can help reduce the risk of periodontitis — and can help you keep your teeth as you get older.

Favorite books on alternative medicine

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One of the many perks of writing about health is that you end up with a terrific collection of books. A decade ago, most of the tomes on my groaning shelves were the traditional sort  –  biology textbooks, medical dictionaries, pharmaceutical references and the like.

Lately, thanks to a deluge of new titles,  I’ve got an impressive library of books on alternative and complementary medicine as well. Some are so dense and soporific that I wouldn’t recommend them to any but the most determined reader.  Some are so light and fluffy as to be useless.

But many are quite good. So, without further ado, herewith my favorites.

The prettiest, and at $16.47, the least expensive, book in my collection is the “Mayo Clinic Book of Alternative Medicine” (2007), which is chock full of colorful images  –  thin women doing yoga, peaceful women smelling blossoms, huge garlic heads floating in space.

By contrast, the text explaining things like acupuncture or hypnosis seems a bit bland. But there is lots of good information in the  “sidebars” and I really like the book’s system of  green, yellow or red  traffic lights to signal approval, caution, or disapproval for various treatments. This is especially useful for herbs. Valerian, for instance, the herbal sleeping pill, gets a green light, while kava, the anti-anxiety herb that once appeared so promising, gets a red light because of potential liver toxicity.

Another graphically-pleasing, very solid reference is  ” The Duke Encyclopedia of New Medicine ” (more thin women doing yoga, more women running through meadows and getting massaged, more gigantic garlic heads). I like this 2006 book because it costs only $26.37 and has easy-to-use information about how the body works and about specific diseases, as well as a whole separate section on alternative and complementary therapies.

The latter section is excellent, though it includes some crazy stuff I would have left out. Like sophrology, supposedly the study of “harmonious consciousness”  (with a picture of a bare-chested guy rock climbing), and “neuocranial restructuring,”  manipulating the skull bones to treat medical problems. Like the Mayo book, Duke uses red and green color strips with check marks to indicate benefits and risks. To its credit, Duke rates sophrology as having minimal benefit (and minimal risk), and warns people in no uncertain terms to stay away from neurocranial restructuring.

Another general guide to the field is the “Fundamentals of Complementary and Integrative Medicine,” by  Dr. Marc Mizzoni [cq], who is also an anthropologist. At $56.03, this 2006 book is not cheap and, though it’s good for gaining general knowledge in the field, it doesn’t provide the nitty-gritty assessment of various techniques and individual herbs that many consumers may be looking for.

The American Botanical Council’s 2003 book, “The ABC Clinical Guide to Herbs,” has no color pictures, but, even at $69.56, is a must-have resource if you’re seriously into herbs. It has lots of footnotes on the 29 most commonly-used herbs and easy-to-read tables showing what different studies on the major herbs have shown. With chamomile, for example, used worldwide in teas, the ABC guide gives precise descriptions of chemical composition, details its uses for stomach upsets (and for some skin problems), lists dosages, contraindications,  regulatory status in 12 countries and common brand names.  

Another excellent source on herbs, for $59.95, is the third edition (2004) of the PDR for Herbal Medicines, put out by Thomson Healthcare. With write-ups on roughly 600 herbs, it’s more encyclopedic than the ABC guide, although the ABC guide is easier to use because it summarizes research studies in a more accessible way. Both books are helpful for serious herbalists, herbalist wannabes and physicians trying to figure out what’s in the stuff their patients are taking.

For those seeking a detailed understanding of the scientific basis of   “natural medicine,” there’s a very thorough 2,000-page, 2-volume set called the “Textbook of Natural Medicine” by Joseph E. Pizzorno, Jr. and  Michael T. Murray. But at $229, this 2006 reference is probably best perused in a library. Far more useful, in my view, and distinctly cheaper at $43.96, is The Clinician’s Handbook of Natural Medicine (2002), by the same authors, plus Herb Joiner-Bey. It’s especially useful for figuring out what dietary supplements may help for various illnesses.

For me, thumbing through the pages of these books is the quickest way to zero in on information I need. Granted, books are more expensive than the free information on the web, but I’m old fashioned enough to prefer turning pages. And if you don’t want to pay, you can always go to the library. In fairness, though, there are some great resources on the Internet as well, the first place many people turn to for medical information.

There are some great sources on alternative medicine there, too, among them www.nccam.nih.gov, the site of the National Center for Complementary and Alternative Medicine. I also like www.worstpills.org, run by Public Citizen’s Health Research Group; www.herbalgram.org, run by the previously-mentioned American Botanical Council; and a Consumer Reports site, www.consumerreports.org/mg/natural-medicine.

Happy reading and good health!