Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

How to cope with shock of cancer diagnosis

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Late last fall, Dartmouth Medical School researchers reported in the journal Cancer that all newly diagnosed breast cancer patients in their study experienced at least some level of distress, and nearly half met the criteria for a significant psychiatric disorder such as major depression or post-traumatic stress disorder.

Well, duh!

Is it really news that a serious medical diagnosis can shake a person to the core? The only surprise to me is that a study like this is necessary. While some medical schools are adding classes in things like “how to deliver bad news,” the medical establishment as a whole still isn’t as good as it could be at helping people who go in a heartbeat from merely having a medical appointment to wondering how long they have to live.

Sure, cancer specialists are busy, as Mark T. Hegel , the clinical psychologist who headed the Dartmouth study, put it. ” They have short visits. They are very focused on treating the cancer. They are not well trained to look at the psychological issues.”

But we’re talking major life-altering event here. And while there are books, groups, and therapists galore to help with the long haul — clarifying the diagnosis, bearing up under treatment, then living the rest of your life as best you can — there’s much less to help with the first days and weeks after your life has been turned upside down.

Unfortunately, I’m speaking from personal experience. My husband’s two cancer diagnoses over the past 11 years were devastating to both of us. Dealing with everything that came later, including his death last summer, has also been difficult, to put it mildly. But for sheer, soul-shattering shock, the first hearing of the bad news was in a class by itself.

I learned — the only way, the hard way — how to muddle through the early days of a terrible diagnosis. Eat. Sleep, with sleeping pills if necessary. Breathe. Talk to a few close people. Don’t, as I did, tell everybody every single medical bulletin — you’ll spend all day and evening on the phone. Triage your life: Cancel what you can, but not the fun things — in my case, exercise and singing.

Do cruise the Internet for information about the disease if that helps control your anxiety, but log off immediately if it upsets you too much. You have doctors. You don’t have to become the molecular biologist or brain surgeon who will fix everything. Despite my decades as a medical journalist, I found that truly understanding a complex diagnosis is a daunting intellectual and emotional task.

A life-altering diagnosis, in other words, moves you abruptly from a normal existence into a parallel universe of fear and disease, though illness, of course, is part of life, too.

Social psychologist Jessie Gruman puts it this way in her wonderful, forthcoming book, “AfterShock : What to do When the Doctor Gives You — or Someone You Love — a Devastating Diagnosis,” for which she interviewed more than 250 people.

“Every time I have received bad health news,” she writes, “I have felt like a healthy person who has been accidentally drop-kicked into a foreign country: I don’t know the language, the culture is unfamiliar, I have no idea what is expected of me, I have no map, and I desperately want to find my way home.”

Gruman, 53, who is president of the Center for the Advancement of Health, a nonprofit patient education group based in Washington, D.C., has been drop-kicked into this foreign world four times, each unexpectedly.

The first was Hodgkins’ disease, a type of cancer, at age 20. “I was a total wreck,” she recalled recently. Then cervical cancer, picked up by routine screening when she was 30. “I had a successive series of operations that ultimately left me without a uterus.” Then, at 47, a terrifying case of viral pericarditis — an infection in the sac around the heart that landed her in the intensive care unit for eight days. Then, at 50, colon cancer, another surprise picked up by a routine colonoscopy.

She’s fine now, and armed with hard-won wisdom. A bad diagnosis “is a crisis. Treat it like one. Don’t try to go on as though nothing is happening to you. Don’t go to work for at least 48 hours, and cancel your social engagements until you get your feet back under you.”

You have to put yourself first. “You owe no explanations to anyone right now,” she writes. “Talk if you want to talk, cry if you feel like it. There is no particular benefit or harm in either. You are not responsible for taking care of others who are distraught at your news.” What you do have to do is make sure to set up your next doctor’s appointment and remember that “you will not always feel like this.”

Hester Hill Schnipper , chief of oncology social work at Beth Israel Deaconess Medical Center, has gotten bad medical news twice in the last 12 years, both times a diagnosis of breast cancer. “The very beginning, psychologically, is the worst time,” said Hill, author of “After Breast Cancer: A Common-sense Guide to Life After Treatment.” Things “always get better than the first couple of days,” she said. “Everybody copes, because what is your choice?”

If you have an inkling that your doctor visit may yield bad news, take someone with you, said Nicholas Covino , a clinical psychologist who heads the Massachusetts School of Professional Psychology. People often hear bad news alone, he said, “then have to find their way home by themselves.”

Lastly, don’t be surprised if, on top of your other troubles, your self-esteem takes a nose dive, said Dr. John Wynn , medical director of PsychoOncology at the Swedish Medical Center in Seattle. “The feeling is often one of shame, of punishment,” said Wynn. It’s irrational, but people often feel, “I am bad because I am sick.”

In truth, you are not bad because you are sick, or vice versa. You are in crisis.

So if you have just gotten bad medical news, take Jessie Gruman’s words to heart: “You will not always feel like this.”

Benefits from aromatherapy tough to prove

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Aromatherapy — the use of plant oils to improve well-being — sounds lovely, doesn’t it? How wonderful if a whiff of lavender could make you feel drowsy, or a little dab of rosemary oil could relieve muscle pain.

There’s certainly a plausible biological basis for the idea that smells can have direct effects on the body. On the yucky side, for instance, nothing makes me nauseated more quickly than the odor of those pine tree-shaped “air fresheners” that taxi drivers hang in their cabs. On the positive side, for me, the scent of a fresh Christmas tree always evokes warm memories of childhood; or the smell of cookies baking in the oven can help sell a house.

But there’s little solid science behind many of the claims of medical benefit from aromatherapy, which usually means soothing the body through smells, but can also mean rubbing plant oils on the skin.

“There have been some pretty wild claims” about the effects of aromatherapy, said Dr. Charles J. Wysocki , a behavioral neuroscientist at the Monell Chemical Senses Center, a corporate-sponsored research institute in Philadelphia, who has spent more than 30 years studying smell.

It is precisely this lack of data that makes aromatherapy so important to study, said Ohio State University health psychologist Janice Kiecolt-Glaser. She is currently analyzing her results from a government-funded study in which she exposed one group to lavender, “which is supposed to be a relaxant,” she said, another to lemon, “which is supposed to be stimulating or uplifting,” and the third group to distilled water, which has no smell.

There is so little data supporting aromatherapy that the National Center for Complementary and Alternative Medicine, a branch of the government, does not even discuss aromatherapy on its website, though the agency is now funding one study: Kiecolt-Glaser’s.

Proponents of aromatherapy point to several studies that they claim show it works. Some data do suggest that pleasant odors such as rose, jasmine, and lavender might lower blood pressure, and a small study suggests that lemon oil might reduce the doses needed of antidepressants. But these studies were not rigorous.

Some better-designed studies, using placebo smells for comparison, showed no medical benefit from aromatherapy.

A 2001 study of 33 patients with postsurgical nausea found that oil of peppermint was no better than rubbing alcohol or saltwater in providing relief. A 2002 study of 17 hospice patients found that using a humidifier with plain old water was just as effective (and not very effective at that) as water with lavender oil in relieving anxiety and pain. A randomized, double-blind study in 2000 of 66 women awaiting abortions found that aromatherapy with essential oils (vetivert, bergamot, and geranium) was no more effective than a placebo smell (hair conditioner) at relieving anxiety. A 2003 randomized study of 313 cancer patients undergoing radiation similarly concluded that aromatherapy was psychologically “not beneficial.”

Worse yet, a study of 60 healthy men and women, published this year in Psychosomatic Medicine, showed that those exposed to either a pleasant odor (lemon) or an unpleasant odor (machine oil) actually had a greater response to experimentally induced pain than those exposed to no odor.

“It’s very difficult to demonstrate positive effects” from odors, said Wysocki. By contrast, “it’s very easy to demonstrate mood swings in the negative direction. If you expose people to nasty-smelling odors, they will get upset. If you expose them to vomit, some people will actually get sick and vomit.”

Perhaps that’s because the brain is hard-wired to detect “bad” smells — those like the smell of rotting food — that could signal danger.

Reactions to smells are also highly conditioned. “A child who experiences the smell of roses for the first time on a summer walk in the garden with his mother will have different memories of the smell of roses than a child who first experiences the smell of roses at his mother’s funeral,” said Wysocki.

Expectations also play a huge role in reaction to smells. In one of his own studies, Wysocki divided subjects into groups of 30 each and exposed them to the same, unknown smell. People in one group were told they were getting aromatherapy and they quickly got used to the smell and soon stopped smelling it at all, while a group that was told the smell could be dangerous in high concentrations was increasingly bothered by the odor as time went on, he said.

Because people expect a benefit from aromatherapy, it may help them feel better, said Cherie Perez , a research nurse supervisor at the University of Texas M.D. Anderson Cancer Center in Houston.

But it’s tough to pin down what’s going on when someone feels better after a massage with lavender oil, she said. Is it the massage? The oil being absorbed into the skin? The smell of the oil? The attention of the masseuse? All of the above?

My take on this? Enjoy a nice, warm bath if you want to relax. But don’t count on the expensive bath oil to help anyone but the company that sold it to you.

Physical therapy arrives, popularity surges for varied reasons

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So there I was, the quintessential battered athlete, standing in a silly, little “johnnie” so physical therapist Susan Lattanzi could put me through my paces.

I had arrived on her doorstep at Mount Auburn Physical Therapy Associates in Watertown because my right shoulder was killing me. I had just joined a swim team and suddenly increased my weekly yardage substantially. By the time I saw Lattanzi, I couldn’t swim 15 minutes without my shoulder screeching in protest.

She had me put my arm by my side, thumb facing forward, then lift it overhead alongside my ear. No problem. Then, another arm lift with my palm up and the arm raised to the side to shoulder level. Ouch!

My rotator cuff was damaged, but it felt better within weeks, after physical therapy with ultrasound to improve blood flow, deep friction massage to break up microscopic scarring, and home strengthening exercises.

No surgery! Back to swimming!

No one keeps good track of visits to physical therapists, but there is so much demand that there are now more than 200 training programs in the United States, up from 140 just 10 years ago. Physical therapists are also better trained than ever before, with the number getting doctorates soaring.

Despite the growing demand, in some ways, it’s easier than ever to see a physical therapist. Most states allows patients “direct access,”

without a referral from a doctor, though in some cases, insurance companies will not pay for physical therapy without a referral.

“Physical therapy is booming. We can’t get them out of school fast enough. Hospitals are crying out for physical therapists all over the country,” said Dr. Jeffrey B. Palmer, director of physical medicine and rehabilitation at Johns Hopkins Medical Institutions.

Part of the growing demand is because the population is getting older and creakier. But much of it, particularly for problems like back pain, he said, “is the desire for conservative management.”

Dr. Lyle Micheli, an orthopedic surgeon and director of sports medicine at Children’s Hospital Boston, said he now sends 90 percent of patients “to physical therapy instead of surgery.”

At the Spine Center at New England Baptist Hospital, Dr. Geno Martinez, who specializes in rehabilitation medicine, tells many patients that their back pain will improve if they get moving with the help of a physical therapist. Though some physicians still don’t believe it, he said, “in reality, back pain, in general, is not a surgical condition.”

Further driving the popularity of physical therapy is the fact that therapists can offer one-stop shopping, not just spinal manipulation or massaging muscles to get rid of tension. Physical therapists offer highly-individualized programs of specific exercises and therapy to heal injuries, said Diane Maeda, a physical therapist supervisor at the UCLA Medical Center. By contrast,  other physical therapists said, personal trainers in health clubs know how to build muscle, but often do not have the lengthy medical training that physical therapists do.

There is also growing evidence of the efficacy of physical therapy for specific problems.

In the old days, physical therapists often stuck to a one-size-fits-all approach, using the same techniques — massage, heat, stretching — for everybody. Now, they have a much better idea of which techniques work for which symptoms, especially with back pain.

Anthony Delitto, chairman of the department of physical therapy at the University of Pittsburgh, is one of the leaders in the emerging field of “evidence-based” physical therapy. Physical therapists, like others in medicine, are increasingly trying to base their treatments on research showing what works and what doesn’t.

Delitto, for instance, has developed “prediction rules” for which patients with back pain will respond to which exercises.

But it’s not just back pain that sends people to physical therapists. In addition to shoulder problems like mine, people go for help with neurological diseases such as multiple sclerosis, stroke, and even dizziness, among other things.

For those with multiple sclerosis, said Palmer of Hopkins, physical therapy doesn’t change the course of the disease, but it can help them move better within their limits.

For stroke patients, there is “very good evidence that movement therapy can produce changes in the brain, or reprogramming,” Palmer said. Brain scans show physical therapy can alter the brain so that a function, like moving an arm, that would normally be controlled by the damaged area of the brain can eventually be controlled by another area.

Anne Hartnett, 61, a Watertown health educator and artist, said physical therapy was tremendously helpful for her headaches and balance problems. Almost two years ago, Hartnett had a virus that attacked her inner ear — which sends signals that help the brain perceive motion and the body’s position in space.

She went to see Janet Callahan, a physical therapist at Massachusetts General Hospital, who taught her a series of exercises in which she keeps her eyes steady on a fixed target while moving her head. Over time, Callahan said, this teaches the brain to respond better to motion and orientation signals from what is remaining of Hartnett’s inner ear function.

In the early months of therapy, Hartnett still could not stand and carry on a conversation without getting dizzy. She “lurched” around, she said, and felt that she had to explain to strangers that “I am not a drunk.”

The physical therapy, Hartnett said, is slowing giving her back her life: “It is a godsend.”

Endometriosis Can Afflict Young Women, Too

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Christina Shimek, a senior at St. Bernard’s High School in Fitchburg, is only 17, but she has already had more pain than many adults have in a lifetime.

A year ago, Shimek, who lives with her parents in Leominster, said she woke up one morning “in excruciating pain in my lower back and pelvic area. I was in tears.” Frantic, her parents took her to the hospital, where doctors assumed the trouble was her appendix and took it out. But it turned out to be normal.

The pain persisted. She missed school for four months, had to repeat chemistry and missed an important rite of passage, her “junior ring ceremony” in which students get their class rings. She went to two doctors, who “were both baffled,” she said. Finally, a nurse suggested endometriosis, a diagnosis confirmed by surgery.

Historically, endometriosis — in which tissue from the lining of the uterus, called the endometrium, escapes and lodges in other areas – has been thought of as a problem of adult women.

According to the National Institutes of Health, 5.5 million women in North America have endometriosis; there is no cure, but pregnancy can sometimes trigger a lasting remission and the disease often gets better at menopause. The disease causes infertility in 30 percent to 40 percent of women who have it.

Two-thirds of adults with endometriosis began getting symptoms before age 20, and endometriosis is increasingly being found in young women as well.

It’s hard enough for any woman, adult or teenager, to get a correct diagnosis of endometriosis because there are so many other causes of abdominal pain, including appendicitis, bowel disease and pelvic inflammatory disease. In fact, it takes an average of 9 years for most adult women to get a correct diagnosis, according to a review paper published last year by the American College of Obstetricians and Gynecologists.

But while adult women typically have two to three doctor visits before they get diagnosed, it takes more than four visits on average for teens whose symptoms began before age 15, partly because endometriosis in young women is still not on the radar screen for many doctors.

And teenagers themselves often put off seeing a doctor for fear they will get a pelvic exam, in which the doctor inserts a finger or metal instrument into the vagina to feel the cervix and ovaries.

“Some kids are so afraid of a pelvic exam they won’t even get out of the car,” said Dr. Marc Laufer, chief of gynecology at Children’s Hospital Boston and lead author of the review paper. Doctors sometimes use ultrasounds on girls uncomfortable with pelvic exams.

Nobody knows why endometriosis occurs in the first place — it may be from menstrual blood flowing backwards and into the abdomen, from endometrial cells migrating to the wrong place during fetal development, from normal cells in the pelvis turning into endometrial cells, or for some other genetic, immunologic or environmental reason. This aberrant tissue then causes painful scarring and bleeding, because it responds to the same monthly hormones as the uterine lining itself. (In rare cases, endometrial tissue even winds up in the nose, triggering monthly nosebleeds.)

Slowly, doctors are getting a better handle on how to treat endometriosis in young women, though the treatments don’t always work. The first line of attack is continuous use of birth control pills containing the hormones estrogen and progestin to shut down ovulation and stop periods, said Dr. Meredith Loveless, who runs the pediatric and adolescent gynecology service at Johns Hopkins University. Non-steroidal anti-inflammatory medications like Motrin or Advil can help control the pain.

If this approach doesn’t help, laparoscopic surgery — in which doctors insert instruments through tiny incisions — is the next step. The endometriosis lesions, or areas, are then cut out or destroyed.

To make sure they don’t grow back, doctors prescribe more hormones, either birth control pills or a drug called Lupron, which shuts down ovulation. Because Lupron triggers hot flashes, mood swings and interferes with the formation of bones at the time of peak bone growth, doctors don’t use it for girls under 16. For older teens, they give Lupron with “add-back” hormones — small doses of estrogen and progestin to prevent these side effects.

“The hope is that by treating young women with endometriosis earlier, we can get better outcomes in terms of both pain and fertility,” said Dr. Claire Templeman, an assistant professor of obstetrics, gynecology and surgery at the University of Southern California. “But so far, there’s no data on long-term outcomes.”

And even with aggressive treatment, the pain doesn’t always go away. Anna George, 20, a junior at Hamilton College who comes from West Roxbury, said surgery and Lupron did get her endometriosis under control, enabling her to return to her volleyball team, which she had to quit last year.

But things have not worked out so well for Shimek: “Now I know what I have, but the pain is still there,” she said. Despite surgery and Lupron, there are still “days I just can’t go to school because it hurts too much.” And she’s still haunted by the threat of infertility. “I want children. That’s the most important thing. I would be devastated if I couldn’t.”

Reading the Signs:

Endometriosis, in which tissue from the lining of the uterus escapes to the rest of the body, can be hard to diagnose. But, according to the National Institutes of Health, there are often telltale signs, among them:

Extremely painful menstrual cramps that may get worse over time

Chronic pelvic pain (including in the lower back)

Pain during or after sex

Intestinal pain

Painful bowel movements or painful urination during menstrual periods

Heavy menstrual periods

Premenstrual spotting or bleeding between periods

Infertility

Complicating matters is the fact that symptoms of endometriosis can mimic those of some bowel diseases.

Sunscreen Isn’t Perfect, But Still Worth Using

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“Any bad, blistering burn in your lifetime increases your risk for skin cancer,”      — Dr. John Williams, Brigham and Women’s Hospital

For years now, I have been, shall we say, a rather haphazard sunscreen user. And I’m not alone —  a fact that makes dermatologists apoplectic.

The American Academy of Dermatology, on its website, recently re-affirmed its message, saying that “scientific evidence supports the beneficial effects of proper sunscreen  usage.”The American Cancer Society recommends using “a sunscreen with a sun protection factor (SPF) of 15 or higher.” The federal Centers for Disease Control and Prevention does, too.

But, in this era of evidence-based medicine, I have three nagging questions:  How much need I really worry about skin cancer? How tightly linked are sun exposure and skin cancer? And how good is the evidence for the cancer-protective effect of sunscreens?

The answers, I have discovered, are complex, but are tipping me toward more diligent sunscreen use.

To be sure, skin cancer is not among the 10 leading causes of cancer deaths, according to 2006 projections by the American Cancer Society. But melanoma will strike 62,190 people this year and kill 7,910. It would kill many more if it weren’t caught and treated early. It’s also still rising, though more slowly than in the past.

Moreover, this year, there will be more than 1 million cases of basal and squamous cell cancers, which often occur in sun-exposed areas of skin, like the face, neck and hands. Most of these are curable because they, too, are usually caught early. But removing cancers, especially from the face, can be disfiguring.

Question number two: the sun exposure link.

For squamous cell cancer, that’s a no-brainer. “There is a very direct relationship between the amount of sun exposure over a lifetime and the development of squamous cell cancer,” said Marianne Berwick, chief of the division of epidemiology and  biostatistics at the University of New Mexico.

Dr. Martin A. Weinstock,  a Brown University dermatologist and chairman of the Skin Cancer Advisory Group for the American Cancer Society, said squamous cell cancer can be triggered by two kinds of ultraviolet light, UVB and, to a lesser extent, UVA. Moreover, actinic keratoses — reddish patches on the skin linked to sun exposure — are now seen as precursors to squamous cell cancer.

The links between sun exposure and the other two skin cancers are trickier to sort out.

“Nobody knows much about basal cell cancer,” said Berwick. But the “real mystery” is melanoma.

“There is definitely a debate about how much melanoma is linked to the sun. The majority of dermatologists feel it is partially linked to the sun,” said Dr. Rebecca Kazin, an associate professor of dermatology at Johns Hopkins University. “It has a large genetic component as well,” with melanoma often running in families.

In a combined analysis of three large studies published in the Journal of Clinical Oncology last year, Harvard researchers listed the risks for melanoma in the following order: Older age, male sex, family history of melanoma, high number of moles, history of severe sunburn, and light color hair. In other words, sun is one factor among many.

In addition to debating how big a role sun exposure plays in melanoma, researchers are also not sure what pattern of exposure confers the most risk. Some say it’s intermittent exposure – like when pale workaholics spend a week in the Caribbean scorching their skin. But age of exposure to the sun is important, too. When people migrate before age 15 from the rainy United Kingdom to sunnier Australia, they end up with a higher risk of melanoma, like native Australians, noted Weinstock. If they migrate later, their risk is low, like the British, suggesting that childhood exposure is a major factor.

And now, sunscreens. The evidence for sunscreen’s protective benefits varies depending on the type of skin cancer involved.

For squamous cell cancer, the evidence that sunscreen protects “is so strong that there is essentially no room for reasonable doubt,” said Weinstock of Brown. One persuasive study was a 1999 randomized controlled trial of nearly 1,400 people in Australia, which found that sunscreens were protective against squamous cell cancers.

For basal cell protection, Weinstock characterized the evidence for sunscreens as “substantial but indirect, and not sufficient to provide proof.” For melanoma, he said, the case for sunscreen efficacy “is strong, but not definitive proof.”

Over the years, European research has suggested that sunscreen use could actually increase the risk of developing skin cancer, perhaps because, by delaying sunburns, sunscreen use encouraged people to spend more time in the sun.

But at least for melanoma, a meta-analysis published in 2002 in the American Journal of Public Health looked at data on 9,000 people and concluded that there was no increased risk linked to sunscreen use. A separate review of 18 studies in 2003 went further, finding no relationship, good or bad, between sunscreen use and melanoma.

Further muddying the waters on sunscreens is a class action lawsuit now in Los Angeles Superior Court.  The suit alleges that some sunscreen makers are misleading consumers with labels that promise protection against UVB and UVA light when their products only protect against part of the UVA spectrum. The suit also alleges that some products wear off faster in water than advertised.

But if you’re worried, all you have to do is make sure the sunscreen you buy contains titanium dioxide, zinc oxide or avobenzone, which protect against the whole UVA spectrum. Most brands do now.

Sunscreens clearly help prevent sunburns, and “any bad, blistering burn in your lifetime increases your risk for skin cancer, including melanoma,” said Dr. John Williams, a dermatologist at Brigham and Women’s Hospital.

So, here’s my new vow. It’s time to mend my ways. Skin cancer isn’t the biggest health hazard out there, but it’s one I can do something about with very little effort. Even if the evidence for sunscreen is imperfect, using it takes so little effort and money, that I’ll be slathering the stuff on. At the very least, it smells good and is a nice moisturizer.

For The Facts on ‘Natural’ Remedies, Go Online

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We Americans now spend an estimated $20 billion a year on dietary supplements and so-called “natural” remedies, many of us blissfully — even willfully — ignorant of the actual medicinal value, or utter lack thereof, in of these products.

It’s not entirely our fault that we buy this stuff so blindly. In 1994, Congress limited the power of the US Food and Drug Administration to regulate supplements and herbal medicines, which now are allowed to get — and stay — on the market unless clear evidence of harm is found.

We’ve been left largely to our own devices to figure out which alternative remedies actually work, and are safe, and which are pure snake oil.

Happily, a few reasonably trustworthy websites have sprung up allowing consumers to evaluate how much credible research there is (or isn’t) for a particular supplement,  how the “natural” remedy in question interacts with other such products or with prescription drugs, and what the major side effects are.

(I put “natural” in quotes, by the way, because the term is meaningless for health products. Pills from health food stores are not intrinsically safe, gentle or non-toxic just because they are called “natural.”  And they’re much less likely than prescription drugs to even contain the ingredients listed on the labels.)

To facilitate comparisons among my favorite sites, I’ve tracked how they rate three of the top-selling products: black cohosh, often used to treat hot flashes; Echinacea, used to treat and prevent colds; and the combination of glucosamine-chondroitin, used to ease the pain of osteoarthritis. In truth, it’s hard to tell how solid the science is for these, and many other, alternative remedies, but some sites do a better job than others at pointing out the products’ shortcomings. Some information on these sites is free, but for details, you often have to pay (typically $15 to $50) per year.

For starters, I recommend the site run by the National Center for Complementary and Alternative Medicine (part of the National Institutes of Health). It is quite helpful and easy to use. To check on echinacea, for instance, go to http://nccam.nih.gov/health/echinacea. The information is succinct, noting that studies show echinacea does not appear to prevent colds or other infections, nor does it shorten the lengths of colds or flu.

For black cohosh, the site says studies are mixed for menopausal relief and notes that it has been linked with liver problems, though the site cautions that it’s not clear if black cohosh is truly to blame. As for glucosamine-chondroitin, the site includes the GAIT study results showing the remedy did not provide significant relief for osteoarthritis patients, except for a small subset of people.

Another of my favorite sites, because it is the most aggressively critical, is www.worstpills.org the creation of Public Citizen’s Health Research Group in Washington, D.C., which takes no money from government or industry and relies on membership fees and product sales. The site is very thorough and put all three of my test supplements in the “Do Not Use” category.

Worstpills.org concludes, for instance, that “there is no significant evidence that black cohosh alleviates menopausal symptoms.” Among adverse effects, it cites two cases in the medical literature of liver transplants possibly linked  to the supplement.

As for echinacea, the site concludes that there is “no convincing evidence” that it reduces the frequency or severity of the common cold.

On glucosamine-chondroitin, www.worstpills.org  includes information from the most recent and most credible study (the so-called GAIT trial, published in February, 2006 in the New England Journal of Medicine) which found a non-commercial form of the combination ineffective except for a subgroup of people with moderate-to-severe pain.

Another good site is www.herbalgram.org  (click on “herbal information”), run by the Texas-based American Botanical Council and its chief guru, Mark Blumenthal. The council gets half its funding from the supplement/herbal industry, and the other half from health professionals and researchers. Despite its industry backing, I find the site thorough, accurate and fairly independent.

On black cohosh, herbalgram.org  put out a special article in March after an Australian government agency warned the substance was linked to liver toxicity. The site goes deep on black cohosh and notes that a leading black cohosh product, Remifemin, now carries a warning label about potential liver toxicity.

On echinacea, herbalgram.org has so much material it’s tough to find a bottom line. It acknowledges the lack of efficacy for treating or preventing colds, but points out that the most recent clinical trial was done with doses that were too low to be effective, Blumenthal said. The group did not evaluate glucosamine-chondroitin because it is not an herbal product.

Consumer Reports is another good site. A few weeks ago, the group added a rating system for “natural” remedies to its website — www.consumerreports.org/mg/natural-medicine/ratings.htm. The massive amount of information in these ratings of 14,000 herbs, vitamins and nutritional supplements comes directly from a respected source used by pharmacists and physicians, the Natural Medicines Comprehensive database, which gets no industry funding and is supported only by subscriptions from physicians and pharmacists.

The Consumer Reports site provides a huge amount of detail about each product and possible interactions with other medications. Despite its vastness, it’s easy to use. It goes easy on black cohosh, calling it “possibly effective” for hot flashes, though it does note possible interactions with drugs like cisplatin, the cancer drug. A “possibly effective” rating means there is some evidence of efficacy and possibly some negative evidence.

The site is also kind to Echinacea and glucosamine-chondroitin, calling them both “possibly effective.” Echinacea, said the database editor, Dr. Phil Gregory in an e-mail, is not effective at all in preventing colds, and is only possibly effective in treating an existing cold. On glucosamine-chondroitin, he said that although the GAIT trial looked at the combination, most research uses glucosamine sulfate alone and that does appear to be effective.

One other government site rates a mention. It’s run by the FDA, and lists dietary supplements the agency has issued safety alerts for (

http://www.cfsan.fda.gov/~dms/ds-warn.html) It has issued no such alerts for black cohosh, echinacea or glucosamine-chondroitin.

 My take on all this is that there are probably some useful, safe supplements out there.

But the whole field of dietary and herbal supplements is basically faith-based medicine, so I’m glad there are some websites to check with to make sure while I think I’m doing myself some good, I’m not accidentallly doing harm.

Carotid Stents Get Better, But Proof They Work is Scant

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Stents, long famous for their success in propping open clogged arteries in the heart, are now being used in neck arteries in an effort to reduce strokes.

Technical advances have made the stents safer to insert in neck arteries, and some experts now fear that doctors may adopt the procedure — and patients may clamor for it — before there is sufficient research to support it.

With carotid stenting, doctors insert a mesh device into a clogged carotid artery in the neck to keep blood flowing to the brain. The stents can be placed in the carotid arteries without general anesthesia.

”The procedure is less invasive and recovery is faster than with endarterectomy,” the traditional surgical approach to fixing narrowed arteries, said Dr. Marc Mayberg, executive director of the Seattle Neuroscience Institute, a research center. But he said carotid stenting ”may be overapplied in patients who actually don’t need it, who don’t need any treatment at all, or who would do well on medications alone.”

So far, he said, ”there is little scientific data yet to show that stents are an effective way to prevent strokes, while there is such data for endarterectomy,” which involves cutting open the arteries and scraping out fatty debris. Every year, roughly 150,000 Americans undergo this procedure.

The new procedure does have a growing number of fans.

Carotid stenting is clearly ”the coming thing,” said Dr. Barry T. Katzen, medical director of the Baptist Cardiac and Vascular Institute in Miami. ”We are very excited about this technology.”

Although carotid stenting has been around since the early 1990s, it is taking off now because engineers have devised a way to catch debris that can be knocked off artery walls during insertion of the stent — and could otherwise travel to the brain and cause strokes.

”We now have equipment that is much smaller, much more elegant,” making the procedure easier and safer, said Dr. Piotr Sobieszczyk, a cardiologist at Brigham and Women’s Hospital. ”In the future this may well be the preferred way of treating carotid artery blockages.”

The addition of the debris filter has been ”crucial to the rapid development of this procedure,” said Sobieszczyk.

Carotid stenting got another boost last year when Medicare agreed to pay for the procedure in certain patients.

Despite its promise, though, stenting will probably not be the first choice for many people at risk of stroke.

In 2003, the latest year for which statistics are available, more than 700,000 Americans had strokes and nearly 158,000 were killed by them, according to the American Heart Association. High blood pressure, smoking, and clogged carotid arteries are all risk factors for strokes. Carotid stents are designed to address the small percentage of strokes that are caused by a buildup of plaque in the carotid arteries.

While there are not as much data on stenting as on surgery to prevent strokes, a major study called SAPPHIRE, published in 2004, did show that carotid stents were just as effective at reducing strokes in high-risk patients as endarterectomy and were linked to fewer heart attacks during the procedure. After three years, stroke risk in both groups about 5 percent, said Katzen, one of the study’s authors.

There are risks to both procedures. The major risks of endarterectomy include infection and injury to nerves in the neck, plus bleeding and heart rhythm disturbances; the major risks of stenting include bleeding from the artery in the groin through which the stent is threaded, and heart rhythm disturbances.

On the plus side, there is preliminary evidence that carotid stenting may improve cognitive function, said Dr. Rod Raabe, an interventional radiologist at the Sacred Heart Medical Center in Spokane, Wash. A study Raabe presented in March at the annual meeting of the Society of Interventional Radiology showed a statistically significant improvement in memory and other cognitive skills after stenting, even in patients who had not had strokes.

But the big outstanding question is this: Should stenting be used for people at moderate risk of stroke who have no overt symptoms, like transient ischemic attacks, also known as mini-strokes. That issue is now being addressed in a study called CREST funded by the National Institutes of Health, which is still open to new patients.

Until that study is finished, the prudent course, if you’re are at risk for stroke — because of high blood pressure, being a smoker, having clogged carotid arteries, or other risk factors — is to talk with your doctor and try medications first to reduce your risk. If these don’t work and you need something more invasive to keep your carotid arteries open, ask your doctor about endarterectomy and stents and how much training your doctor has had in these procedures. And don’t be afraid to get a second opinion.

Runners Who Don’t Train Well Can Have Marathon of Miseries

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Today, as an estimated 20,000 runners begin their mad dash from Hopkinton to Boston, Dr.  Wood, a cardiologist, four-time marathoner and co-director of the Massachusetts General Hospital Women’s Cardiovascular Health Center, will be setting up shop in the corner of the medical tent at the finish line.

As soon as they’re finished, about 25 amateur runners will stroll or hobble over to Wood’s corner to let her take a sample of their blood. They will also get a non-invasive test to see how well their hearts are working after the stress of running for about 4 hours. As they have done every year since 2003, Wood and her MGH colleagues will then compare these post-race test results to the pre-race exams done two weeks earlier.

The MGH findings on Boston marathoners  – three published papers to date and two pending – are sobering and lend support to the idea that while moderate exercise is perhaps the most important thing a person can do for health, taking it to extremes, like a marathon, may not be.

Among marathon runners, the biggest cardiac risk seems to arise in people who train the least. People who worked up to a marathon by running at least 45 miles a week for at least three to four months “were golden,” said Wood. “They didn’t get into any trouble at all. If they trained less than 35 miles a week, they were in big trouble.”

Translated for the rest of us, this means that “sudden, strenuous activity can trigger a heart attack,” said Dr. Arthur Siegel , a 20-time marathoner and director of internal medicine at Harvard’s McLean Hospital.

Roughly 450,000 Americans now run in marathons every year. And 325,000 do triathlons, which involves swimming, biking and running, according to USA Triathlon, the sport’s organizing body. Many of these are not well-trained athletes but newcomers who race to raise money for charities. That means, said Siegel, that in many such events, participants “are getting older and slower. That’s where the cardiac risk comes in, especially for middle-aged men with previously silent heart disease.”

The key to healthy exercise, in other words, is moderation and consistency, especially if you are new to a sport.

Moderate exercise is unarguably good for you. “The greatest hazard of exercise is not doing it,” said Dr. Harvey Simon.   Simon is an avid runner, former marathoner, MGH internist and author of “The No Sweat Exercise Plan,” which advocates very moderate exercise – even as moderate as gardening and housework – instead of extreme exertion like marathoning.

Study after study has shown that moderate, regular exercise can indeed reduce the risk of heart disease, diabetes, stroke, hip fracture and some kinds of cancer.

But exercising moderately takes patience and persistence. If you have not been exercising regularly,  you should work up over several weeks to walking 45 minutes a day at least five days a week, said exercise physiologist Kerry Stewart  at Johns Hopkins School of Medicine.

At first, you may have to stop every few minutes and rest, he said. That’s fine, just start up again. If you get chest pains or severe shortness of breath, of course, stop and call your doctor. Obviously, if you have heart disease or have had a heart attack, check with your doctor before starting or substantially increasing your workouts. 

To gauge whether you’re working hard enough, you can take your pulse or use a strap-on heart monitor, available at many sports stores. If you’re healthy, the goal is to work out at about 70 percent of your maximum heart rate, which can be determined by a stress test in a doctor’s office.

You can also estimate your maximum heart rate by taking the number 220 and subtracting your age; if you’re 60, your maximum heart rate is 160, so your “target” heart rate during exercise should be about 112 beats per minute. You can also use the subjective “perceived exertion” scale, which runs from 6 (no effort) to 20 (your absolute max). The goal is to have your perceived exertion be about 12 to 14. An even simpler way is to use the “sing/talk test:” Work hard enough that you can’t sing but can talk.

Moderation is the key, said Simon of MGH. “I used to preach ‘No pain, no gain,’ but now I say, “No pain, big gain,’ ” he said. The whole “aerobics doctrine” that a person needs a lot of strenuous exercise “inspired the few, but discouraged the many,” he said. Even just walking at the extremely leisurely pace of half an hour per mile has benefits.

In other words, you shouldn’t under-do exercise, but you shouldn’t overdo it, either. Chronic fatigue, trouble sleeping, muscle tiredness, nagging congestion or sore throat, persistent aches and pains and depression are common signs that you may be working out too hard, said Siegel. To avoid this, try not to increase your exercise duration or intensity by more than 10 percent over any two-week period.

Experienced athletes “know how delicate the balance is between training to obtain optimal performance and overtraining to the point where muscle function begins to deteriorate,” said Dr. Christopher Cooper , an exercise physiologist at UCLA. But for amateurs, finding that balance point can be hard.

As for marathoners, Wood and her MGH colleagues have found that running 26.2 miles can lead to clear signs of cardiac stress. They have found that cardiac troponin, a chemical that only shows up in blood tests when heart muscle is damaged, rises in 60 percent of runners, and in some, it rises so high that “if you had just looked at these scores, these people would have been admitted to the hospital for heart attacks,” Wood said.

They’ve found that another chemical, BNP (for brain natriuretic peptide), another red  flag for cardiac dysfunction, also goes up after a marathon in 60 percent of runners. Platelets also become activated and more likely to form the clots that can trigger heart attacks, according to a just-published paper by Siegel and Alexander Kratz, director of the hematology lab at MGH.  And, as shown on echocardiograms, the heart’s ability to relax after each beat remains impaired for at least several weeks in most marathoners.

Bottom line? You don’t have to run a marathon to get into good shape. Just put on comfortable shoes, get out and walk. Moderately. And consistently.

Inflammation is Culprit in Many Ailments

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The idea is as simple as it is radical: Chronic inflammation, spurred by an immune system run amok, appears to play a role in medical evils from arthritis to Alzheimer’s, diabetes to heart disease.

There’s no grand proof of this “theory of everything.” But doctors say it’s compelling enough that we should act as if it were true — which means eating an “anti-inflammatory diet,” getting lots of physical activity, and losing the dangerous, internal belly fat that pumps out the chemicals that drive inflammation (More on this nasty chemistry later).

Inflammation, of course, is not all bad. In fact, because it’s part of the typical immune response, it’s essential for battling germs and healing wounds. The familiar redness, heat, swelling and pain that come from, say, a hangnail or a splinter are signs of inflammation at work.

It’s when the inflammation process fails to shut off after an infection or injury is over that trouble sets in. Persistent, low-level inflammation may set the stage for the chronic diseases of later life, many doctors now believe.

Over the evolutionary eons, “we developed these important host defenses to let us get to reproductive age,” said Dr. Peter Libby, chief of cardiovascular medicine at Brigham and Women’s Hospital. “Now, the lifespan has almost doubled, and these same [immune responses] contribute to diseases in the end.”

Chronic inflammation is so similar in different diseases, Libby said, that when he lectures, he uses many of the same slides, whether he’s talking about diseases of the heart, kidneys, joints, lung or other tissues.

Only a few years ago, heart attacks were explained as a plumbing problem — blood vessels that became clogged with atherosclerotic plaque as “bad” (LDL) cholesterol was deposited on vessel walls.  Now, doctors know that this bad cholesterol gets embedded inside artery walls as well, where the immune system “sees” it as an invader to be attacked. The on-going inflammation in arteries, essentially a revved up immune response, can eventually damage arteries and cause “vulnerable” plaque to burst. It is because inflammation is now seen as such a hallmark of heart disease that many doctors use a test for inflammation called CRP to help assess a person’s cardiac risk.

It’s long been known that type 1 diabetes is linked to inflammation the body’s immune system attacks the cells that make insulin. Now, new research is suggesting that type 2 diabetes, the kind that generally sets in in adulthood, often begins with insulin resistance, in which cells stop responding properly to insulin. Doctors now know that during chronic inflammation, one of the chemicals released is TNF, or tumor necrosis factor, which makes cells more resistant to insulin.

“No one would have thought these things were related,” but they are, said Dr. Walter Willett, chairman of the department of nutrition at the Harvard School of Public Health. The TNF connection also helps explain why obesity, particularly abdominal obesity, leads to diabetes. “Fat cells used to be thought of as storage depots for energy, as metabolically inactive,” said Libby. “Now we know that fat cells are little hotbeds of inflammation — excess fat in the belly is a great source of inflammation.”

Auto-immune diseases like rheumatoid arthritis are also believed to be linked to inflammation. In arthritis, for instance, inflammatory cells called cytokines lead to the production of enzymes that break down cartilage in joints.

Inflammation also plays some role in Alzheimer’s disease, said Linda Van Eldik, a neurobiologist at the Northwestern University Feinberg School of Medicine.

Whenever the brain is injured or infected, cells in the brain called glia pump out cytokines. Normally, this response shuts down when the injury or infection is over.

“But in chronic neurodegenerative diseases like Alzheimer’s, these glial cells are activated too high or too long or both,” Van Eldik said. The plaques and tangles in patients’ brains attract the attention of glial cells, making them pump out even more cytokines to try to repair this damage and creating chronic inflammation.

Even cancer may have some inflammatory triggers, though the links are less well worked out, said Dr. David Heber, director of the UCLA Center for Human Nutrition. Among its other tricks, inflammation promotes the release of free radicals, dangerous forms of oxygen that can damage DNA. At chronic, low doses, Heber said, “free radicals can stimulate tumors to grow.”

There are other chemical overlaps between inflammation and cancer, too, said Dr. Robert Tepper , president of research and development for Millennium Pharmaceuticals in Cambridge. The same protein signaling molecules called chemokines that tell white blood cells when to flock to an injury or infection, also tell cancer cells when and where to spread, suggesting a link between cancer spread and the inflammatory response.

That’s the bad news. Now, the good: There’s a lot you can do to reduce the risks of chronic inflammation. First and foremost is to lose weight if you’re chubby, especially around the middle. It’s visceral fat that pumps out the lion’s share of pro-inflammatory cytokines. Exercise, of course, is the way to do it — anything that gets you moving and burns calories will help.

And diet is crucial. “Some types of food we eat can cause inflammation and others can decrease it,” said Lisa Davis, a nutritionist at the Center for Human Nutrition at the Johns Hopkins School of Public Health. On the good side, the Mediterranean diet, which is rich in fruits, vegetables, fish and olive oil, was shown in a randomized study in 2004 to be linked to reductions in weight, C-reactive protein and insulin resistance.

You can eat fats, but eat the right kind, like olive oil, and include those rich in omega-3 fatty acids, like that found in salmon, tuna, walnuts, soy and flax seed oil.

Finally, you can also consider statin drugs, which lowers cholesterol and may reduce the inflammation associated with heart disease. Also consider taking a baby aspirin a day, though you should check with your doctor first. Ditto for NSAIDS — over-the-counter non-steroidal anti-inflammatory drugs – which reduce inflammation but cause bleeding and other side effects.

Reducing the inflammation in your life won’t guarantee you’ll live forever, but it’s a step in the right direction.

Social Support Shields Spouse from Damage of Caregiving

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Yolanda Spencer is eternally grateful for the weekly visits from fellow members of the Bethel AME Church in Jamaica Plain. Without them, she’s not sure how she would have survived the last eight years, since her husband Vincent, now 62, fell off a ladder and became a quadriplegic.

An accident like Vincent’s “is such a devastating thing to happen to a family,” said Yolanda, adding that both of their relatives live far away. Having church members nearby “has been really really supportive.”

A pair of recent studies show just how detrimental such caregiving can be for the health of a spouse. And also, how close social connections like the ones the Spencers, who are black, have with friends from church can offset some of this risk.

Although marriage is generally good for health, the stress of caring for a spouse with a disabling illness can shorten the life of a caregiving spouse, a Harvard Medical School physician and sociologist Dr. Nicholas Christakis showed in a major study published late last month. How well one spouse fares after the death of the other hinges in large part on race, Christakis found in a separate, large study also published a few weeks ago.

While whites married to whites suffer a “large and enduring widowhood effect” when one spouse dies, blacks married to blacks don’t, probably because they have stronger social ties — to church and to extended family — that offset the trauma of losing a spouse, Christakis said.

Actually, it’s the wife’s race that really counts, according to the study, of 410,272 older couples, published in the American Sociological Review. A black man married to a white woman suffers from being widowed just as much as if he were white because her kin might reject him after her death, Christakis suggested. But if a man, black or white, is married to a black woman, he is buffered from the widowhood effect because her black kin accept him as part of the family and continue to provide social and emotional support.

In other words, Christakis said, one of the many things a black wife does is connect her husband with her kin, putting him in a “supportive context” that continues even after her death.

“When you marry someone, you really do marry their family,” said Gail Wyatt, a professor in the department of psychiatry at the David Geffen School of Medicine at UCLA who was not part of the study. “It’s marriage in the context of other people that is the protective thing.”

Many blacks and immigrant families are used to communal caregiving of the very old and the very young, Wyatt said. As immigrants adapt to American ways, however, they tend to “shift toward the white model.”

In general, research shows that marriage benefits a person’s health, especially if that person happens to be male. Married men, on average, live seven years longer than single guys, and married women, two years longer than their single sisters. Married people have better mental health than never-marrieds, too, though, again, it’s men who benefit more from marriage.

But the emerging view of the link between marriage and health is more subtle than that — that “marriage is good for you, except when it isn’t,” as Janice Kiecolt-Glaser, a professor of psychiatry at Ohio State University, put it, only half in jest. In her own work, Kiecolt-Glaser has shown that wounds heal more slowly than normal in caregivers of spouses with dementia, a sign that the stress of caregiving impacts the immune system.

Researchers have long known that the death of one spouse raises, at least temporarily, the risk of death for the surviving spouse. What Christakis’ team showed in the other new study was that it’s not just being widowed that can ruin the health of the healthier spouse, but the stress of caregiving as well. The causes of excess death in the caretaking spouse include accidents, suicides, heart attacks, infections, lung disease and diabetes, according to the study of 518,240 couples aged 65 and older.

In the first 30 days after a spouse’s hospitalization — a marker for the time of diagnosis — the risk of death for the partner was almost as great as it would be if the spouse had died. After a husband’s hospitalization, a wife faces a 44 percent higher risk of death than if her husband were well, the study found. A husband faces a 35 percent increased risk.

Perhaps even more startling, a woman taking care of a husband with dementia or psychiatric illness was at greater risk of dying than if she were actually widowed. Taking care of a spouse with cancer, on the other hand, was much less deleterious to the healthier spouse, probably Christakis said, because cancer, while potentially lethal, is often not as disabling day-to-day.

Suzanne Mintz has been taking care of her husband for 30-plus years, since he was diagnosed with multiple sclerosis. Over the years, she has suffered four bouts of serious depression, in part because of her husband’s illness, and the couple separated twice. They are now back together — with more support, including home health aides. She said she co-founded the National Family Caregivers Association (nfcacares.org), a non-profit advocacy organization in Kensington, MD., in part to help caregivers get the kind of support she needed.

The moral of the story is clear. Get — and stay — married if you can find someone to love.

Take good care of each other. If one of you gets sick or disabled, don’t try to manage alone.

Get help — and social contact — from as many sources as you can, including churches, community groups and social service agencies.

And if you do become widowed, try to maintain the family and community ties you had when you were married. It could be a matter of life or death.