Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Be Cautious About Medications Offered for Bone Thinning

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Millions of American women are being diagnosed with osteopenia, which is not truly a disease, and many are told to take medication they may not need to prevent broken bones they might never get.

At the same time, millions of others are never properly diagnosed – or treated – for osteoporosis, a serious condition that can lead to potentially devastating fractures.

The widespread confusion about what degree of bone loss really is a red flag for future broken bones and what is simply a sign of normal aging has been rampant since, in 1994, the World Health Organization defined “osteopenia” and “osteoporosis” as certain ranges of scores on a bone density test.

Some doctors consider this range skewed, labeling too many — 34 million — Americans as having osteopenia, and too few — 10 million — at risk for the broken bones of osteoporosis. (Osteoporosis is generally considered a disease of women, but men can get it, too.)

Things have become even more muddled since 2002, when many older women stopped taking hormone therapy — which can help prevent bone loss – after a major study showed that it also raised the risk of breast cancer, heart disease and stroke. Between 2002 and 2003, sales of Fosamax, a drug used to prevent bone loss soared 19 percent, to $2.7 billion.

In essence, nobody quite knows what, if anything, an older women whose only sign of potential problems is mild bone loss should do. Should a woman at 50 start taking drugs like Fosamax, Actonel or Evista to guard against possible fractures in her 80s, when most fractures occur? Or should she wait until her bone tests get worse or there is a very real red flag, like having a fracture triggered by a minor fall?

The problem comes from “calling osteopenia a disease when it is not,” said Dr. Robert Neer , director of the osteoporosis center at Massachusetts General Hospital. The WHO defined osteoporosis too narrowly, leading many people to think they are not at high risk, and osteopenia too broadly, encouraging too many women to take medication, he said.

“We are overtreating a large number of healthy women who have a relatively minor risk of fracture and we are ignoring a sizable number of individuals at high risk of fracture,” Neer said.

The term “osteopenia” has “nomedical meaning,” added Dr. Steven Cummings, an epidemiologist at the University of California, San Francisco, who has led a number of large studies on osteoporosis and osteopenia. “I’ve seen patients who come in scared that they will become disabled soon because they have this ‘disease’ called osteopenia, when in fact they are normal for their age.”

Other critics, like Gillian Sanson , a women’s health educator in New Zealand and author of “The Myth of Osteoporosis,” go further. The medical establishment, she said, is “manufacturing patients” by over-medicalizing the normal bone loss that occurs with aging.

For the record, osteopenia is defined by the WHO as a score of minus 1 to minus 2.4 on the so-called DEXA test, which stands for dual energy X-ray absorptiomety. Osteoporosis is defined as a DEXA score of minus 2.5 or worse. Osteopenia can, but does not necessarily, progress to osteoporosis.

Indeed, while osteoporosis clearly raises the risk of fractures, many fractures also occur in people without it. A 2003 study showed that the proportion of fractures attributable to fragile bones was “modest” — somewhere between 10 and 44 percent.

“Low bone mineral density does raise the risk of hip fracture, but it’s only one of several factors like bad eyesight, bad coordination, use of Valium or similar drugs, overactive bladder and other conditions that contribute to the falls that can lead to broken bones,” said Dr. Nananda Col , an internist and women’s health expert at Rhode Island Hospital in Providence, RI.

In other words, a finding of mild osteopenia on a bone density test is not, by itself, enough reason to take medications. If there are no other risk factors, even a bone density test score as low as minus 2 “in an otherwise healthy young person may be normal,” said Dr. Eric Orwoll , an osteoporosis specialist at Oregon Health Sciences University in Portland, OR.

On the other hand, because osteopenia can, though does not always, lead to osteoporosis, many doctors believe it’s important to start treatment early to avoid broken bones later in life.

Dr. Joel Finkelstein , an osteoporosis specialist at Massachusetts General Hospital, said he sometimes prescribes medication to postmenopausal women with bone density scores of minus 1.5 to minus 2, even if they are still in their 50s.

“I do believe in treating a lot of these people to prevent the development of osteoporosis….I may be more aggressive than some other physicians.” Dr. Suzanne Jan de Beur , director of endocrinology at the Johns Hopkins Bayview Medical Center, said she prescribes medication to women with scores of minus 1.5 to minus 2 if there’s a family history of osteoporosis or other risk factors.

Dr. Joseph L. Melton, III, an epidemiologist at the Mayo Clinic in Rochester, MN, put it this way: Doctors who advise women to ignore osteopenia “are wrong, and people who advise everybody to treat it are wrong. It’s a personal decision based on family history and personal values.”

So, when should a woman be screened for potential bone loss? And how safe are the drugs for long term use?

In 2002, the US Preventive Services Task Force, a panel of independent experts convened by the government’s Agency for Healthcare Research and Quality, concluded that women aged 65 and older should be screened routinely for osteoporosis. It said screening should begin at 60 for women at increased risk, which includes a family history of hip fractures, current smoking, thinness and use of steroids such as Prednisone.

As for drug safety, a study published in March, 2004 in the New England Journal of Medicine showed that Fosamax (alendronate) appears to be safe for as long as 10 years. But a 1998 study showed that while Fosamax helps prevent fractures in women with osteoporosis, it does not do so in women with osteopenia and no previous fractures.

Fosamax and Actonel can cause small ulcers in the esophagus, or food tube; Evista can cause hot flashes, and rarely, blood clots.

There is no evidence yet that the widespread use of Fosamax and Actonel is causing any problems, said Col of Rhode Island Hospital. But the drugs do get incorporated into bone. “If 10 years down the line, it turns out that something is dangerous, it will be sitting in a lot of people’s bones. The benefits of treatment need to outweigh the risks.”

That applies to another drug, too: Forteo, the only medication that actually increases bone growth. The catch with Forteo is that it carries a special warning because, in rodents, it can trigger bone cancer.

Bottom line? Try to prevent thinning bones in the first place. Do weight-bearing exercise several times a week and walk briskly for 30 minutes a day or more. Get enough calcium — 1,200 to 1,500 milligrams (but not more) a day, plus 800 International Units of vitamin D, from food and, if necessary, supplements. Minimize use of Valium-type drugs. If problems like overactive bladder or poor eyesight are raising your risk of falls, get those treated, too.

And if one doctor recommends drugs to protect your bones on the basis of mild bone loss, consider getting a second opinion. Obviously, no one wants a broken hip. But no one should take any drug for decades without careful thought, either.

Water and Safety

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In the sparkling sunshine yesterday, runners at the finish line of the Boston Marathon said they had taken very much to heart the new warnings about drinking too much water during a race. ”I was conscious of not taking huge amounts of water,” said Ian Bloomfield, 52, of England, who pronounced himself ”quite pleased” with his time of 2 hours 45 minutes. ”I was very aware of hyponatremia,” the potentially fatal result of overhydration.  Brian Paff, 24, of Chicago said he had had hyponatremia in a college race. ”I passed out from it,” he said. Yesterday, he was careful not to drink too much.

In a dramatic turnabout, sports doctors now say that drinking too much water can be as bad or worse than not drinking enough. This holds for both endurance athletes and weekend warriors, though most people who exercise for just an hour or so don’t really need to worry about either dehydration or overhydration.

In a study published last week in the New England Journal of Medicine, Boston doctors, who have long made Marathon runners their living laboratory, found that hyponatremia (a low concentration of sodium in the blood because of too much water) occurred in 13 percent of participants. Of the 488 marathoners in the 2002 study, three had such low blood sodium that they were at risk of severe brain swelling, which can lead to brain damage, coma and death.It was during the 2002 Boston Marathon that 28-year-old Cynthia Lucerodied of hyponatremia. Worldwide, some researchers believe there may be as many as one death per marathon, though not all are due to hyponatremia. Sports drinks, once thought to be an athlete’s protection against hyponatremia, turn out not to be. Even though they contain some sodium, it’s not enough to make a difference, the study showed.Many endurance athletes, especially smaller, slower runners who take longer to finish and therefore have more time to drink, actually gain weight during marathons, sometimes as much as 8 to 10 pounds, said Dr. Christopher S.D. Almond, lead author of the study and a cardiology fellow at Children’s Hospital. Women are at greater risk because they tend to be smaller and slower and also, perhaps, because they may more diligently adhere to the old belief that it’s wise to drink lots of water.Excessive water drinking among athletes has become such a concern among sports doctors that guidelines are rapidly changing. At major endurance races around the country, including yesterday’s marathon, doctors now do an on-the-spot test for blood sodium levels on collapsed runners to differentiate between hyponatremia and dehydration. Giving fluids to someone with hyponatremia could be fatal.           

The Boston Marathon has had these tests at the finish line for several years and this year, for the first time, had them along the course as well. In addition, Marathon officials provided scales along the route and at the finish line, and encouraged runners to write their pre-race weight on their bibs to check for weight gain.”This has been a major paradigm shift in the last few years,” said Dr. Benjamin Levine, coauthor of an editorial in last week’s medical journal and a cardiologist at the Presbyterian Hospital of Dallas. ”It used to be thought that thirst was a poor measure” of impending dehydration and, therefore, that athletes should drink as much as they could before thirst set in. ”That is clearly not correct,” he said.In 2003, USA Track and Field, which governs track-and-field events, began saying that athletes should use thirst as a guide for fluid replacement. The International Olympic Committee Medical Association began recommending caution in fluid consumption last year, just prior to the Athens Games. The International Marathon Medical Directors Association now advises drinking no more than about 12 to 25 ounces of fluid an hour, especially for slower, back-of-the-pack runners.Other guidelines now in the works are likely to follow suit, including some from the American College of Sports Medicine and a consensus statement from experts who met recently in South Africa and will publish their recommendations this summer. This shift in thinking reflects the growing awareness the dangers of excess fluidconsumption.

”Hyponatremia is less common, but more dangerous” than dehydration, said Dr. Peter Moyer, medical director of Boston Fire, Police and Emergency Medical Services.  

Dehydration does have clear, adverse effects on performance, which is a major issue for elite athletes, said Michael Sawka, chief of the thermal and mountain medicine division at the US Army Research Institute of Environmental Medicine in Natick. 

”But if you’re not doing high-level performance and you’re not losing a lot of water, it’s not important to drink,” he said. ”There are no real adverse health consequences” to dehydration, except low blood pressure, ”susceptibility to heat exhaustion and, if you’re out there long enough, heat stroke.”    Like hyponatremia, heat exhaustion does make people feel ill, get nauseous, have muscle cramps and feel dizzy upon standing up quickly; heat stroke includes all that plus mental-status changes, such as confusion about one’s identity and location.  But dehydration ”would have to be extreme and prolonged, like being lost in the Sahara for days, to become fatal,” said Dr. William G. Goodman, a kidney specialist at the David Geffen School of Medicineat UCLA.  So how can you tell how much fluid you need during exercise? The best approach is to weigh yourself before and after exercise, said Dr. Arthur Siegel, chief of internal medicine at McLean Hospital in Belmont. If you lose, say, 3 percent of your body weight after a workout, ”that represents mild dehydration,” he said. It is enough, though, to be a ”green light” to rehydrate slowly, over eight to 12 hours. If you gain 3 percent of body weight, that’s serious — a red flag or hyponatremia.So, whether you’re a marathoner or a casual athlete, make it a point to weigh yourself before and after workouts. If you do gain weight, don’t drink fluids (salty broth is OK if you have a headache or salt craving) until after you have urinated spontaneously. The point is to let your body get rid of excess water.

Eat Fish, Be Happy

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Feeling depressed? Ask not what your parents did or didn’t do when you were a child. Ask yourself what you had for dinner last night, and the night before, and the night before that.

For half a dozen years now, the evidence has been growing that omega-3 fatty acids, the kind found in fatty fish like salmon, sardines and tuna, can help prevent and treat depression.

Rich in EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), these are among the “good” oils that have long been known to reduce the risk of heart attacks and strokes. They are also the oils that, in recent decades, in tandem with rising depression rates, Americans have not been getting enough of.

The case for linking low omega-3 levels to depression is strong, though not yet a slam-dunk. But there is little risk -and significant benefit – to following the American Heart Association recommendation to eat fish at least twice a week and, if you already have heart disease, taking at least 1 gram a day of supplements containing EPA and DHA. Unlike omega-6 fatty acids (from corn and safflower oils), which most of us overindulge in, omega-3s combat auto-immune diseases like rheumatoid arthritis , reduce cardiac arrhythmias and are crucial to the development of the spinal cord, brain and retina in infants and to healthy brain functioning in adults as well.

The latest evidence for the role of omega-3 fatty acids and depression came several weeks ago last month, when researchers from McLean Hospital in Belmont, reported that omega-3 fatty acids, plus uridine, another substance found commonly in food, prevented depression in rats just as well as antidepressant drugs. The effect of uridine was immediate, said Bill [cq] Carlezon [cq], director of the behavioral genetics lab at McLean. It took 30 days for omega-3 to kick in. But combining the two made omega-3 effective three times faster.

“There is something to this story,” said Dr. Andrew Leuchter [cq], vice chair of psychiatry at the Neuropsychiatric Institute at UCLA. “I have seen enough patients who treat themselves with omega-3 fatty acids to think these substances may have, at least in some individuals, potent effects on mood.”

No one knows exactly why omega-3s might protect against depression, but theories abound. One is that depression may, in part, be an inflammatory problem, which omega-3s can damp down, said Dr. Andrew Stoll, [cq], director of psychopharmacology at McLean. Another is that the oils keep cell membranes more fluid, making it easier for receptors to respond to neurotransmitters like serotonin, which is often deficient in depression. Another is that omega-3s may boost levels of serotonin.

Whatever the underlying mechanism, “the epidemiological evidence is huge,” Stoll said, that omega-3s can protect against depression.

Overall, major depression is 60 times more prevalent in countries where little fish is eaten, said Dr. Joseph R. Hibbeln [cq], senior clinical investigator at the National Institute on Alcohol Abuse and Alcoholism.

 In 1998, Hibbeln and others showed that high fish-eating countries like Japan and Taiwan have very low rates of depression, while low fish-eating countries like Germany and the United States have high rates. “When you compare rates of depression across populations, there is a consistent finding of strikingly lower rates of major depression, bipolar depression, seasonal affective disorder and postpartum depression in countries where people eat more seafood.”

A 2002 double-blind, placebo-controlled study of 20 people in Israel, for instance, showed that adding EPA to standard antidepressants significantly decreased depression after three weeks. A 2002 Scottish study of 60 people came to similar conclusions when patients added a 1-gram daily supplement of EPA to their standard treatment. (Interestingly, higher doses did not work as well.) A 2002 Taiwanese study of 28 people using both EPA and DHA also found significant improvement in depression scores, compared to placebo.

But not all studies support this. A New Zealand team studied 77 mildly depressed people and randomly assigned them to add 8 grams a day of fish oil or a placebo (olive oil) to standard antidepressant therapy. Mood improved in both groups.

A Finnish study that asked nearly 30,000 men to recall their fish oil consumption over the years also found no link between omega-3 fatty acids and depression or suicide, although studies based on recall are notoriously inaccurate. And a double-blind, placebo-controlled study of 35 people at Baylor College of Medicine in Houston found no improvement in depression when they gave patients only DHA, not EPA.

In the plus column, bi-polar depression, too, also known as manic-depression, also seems to be helped by omega-3 fatty acids. A study comparing 10 countries showed that higher fish consumption correlated with lower rates of bi-polar disorder. A 1999 study by Stoll of McLean showed that giving fish oil supplements to people with bi-polar disorder reduced episodes of depression and mania.

Omega-3 fatty acids also appear to reduce hostility and homicide. Several studies have found that low intake of fish and omega-3s correlates with higher rates of hostility, which is often associated with depression in males. A 36-country study showed lower rates of homicide in countries where people ate more fish.

And postpartum depression also appears linked to omega-3 levels. A study of women in 23 countries showed that women who ate less seafood and had lower rates of DHA in their breast milk were more likely to suffer postpartum depression. Pilot studies by Dr. Marlene Freeman [cq], director of the Women’s Mental Health Program at the University of Arizona, suggest taking DHA and EPA can reduce post-partum depression by 50 percent.

(Many pregnant women and nursing mothers, added Freeman, have been frightened about eating any kind of fish because of government warnings of particularly high mercury levels in a few species, king mackerel, shark, swordfish and tilefish. The Center for Science in the Public Interest, a nutrition advocacy group, says that sardines and salmon contain little mercury; women of reproductive age should probably limit their consumption of canned tuna to one can of white or two cans of light per week.)

Even borderline personality disorder, characterized by volatile interpersonal relationships and impulsivity, seems to respond to omega-3 treatment. Yet another McLean study of 30 patients found that EPA, without any other medication, improved symptoms of borderline personality.

That’s more than enough evidence for me. Given the longstanding overall health benefits of omega-3 fatty acids and the newly-emerging psychiatric benefits, the conclusion is a no-brainer. Eat fish three times a week. And if you hate fish (as I do), take at least one gram a day of a supplement with EPA and DHA.     

A Commitment to Exercise

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This column is for everyone who hates to exercise, or would like to exercise, sort of, but really, truly, deeply believes they don’t have enough time or just can’t do it.

First, if you’re in this category, take heart: You’re not alone. Two-thirds of Americans are now overweight or obese, according to government figures, and more than half do not get enough physical activity – and that’s according to the old, wimpier guidelines.

Two weeks ago, federal health officials upped the ante, issuing tougher, new exercise standards as part of the Dietary Guidelines for Americans 2005. Like the old guidelines, the new ones recommend at least 30 minutes of moderate activity on most days of the week.  This figure is based on solid science and translates to walking two miles in 30 minutes, or the equivalent.

This will not make you buff and beautiful. But it will reduce your risk of high blood pressure, stroke, coronary artery disease, type 2 diabetes, colon cancer and osteoporosis.

Now – and here’s the tough part  – the new guidelines also say it may take an additional 30 minutes a day, for a total of 60, to prevent weight gain. And another 30  – 90 minutes in all – to sustain weight loss in previously overweight or obese people.

Granted, that does sound daunting. But here’s how to make it less so.

For openers, the 60 minute recommendation is not absolute and is not based on as much data as the 30 minute recommendation for general health or the 90 minute advice to prevent weight regain, said Steve Blair, president and CEO of the Cooper Institute in Dallas, a non-profit exercise research organization.

While some people may need 60 minutes a day to prevent weight gain, he said, others may hold the line with 40 and others may need more than 60.

“It’s not a flat 60 minutes for everybody,” explained Russell Pate, an exercise physiologist at the University of South Carolina and a member of the committee that advised the government on the new recommendations. “There is a wide range of activity levels that different people need to prevent weight gain.”

Okay, the time issue. You probably have more than you think: 24 hours a day, like everybody else.

The problem is that while “people’s leisure time has increased, most of that goes into watching television,” said Susan Hanson, a geographer at Clark University in Worcester, MA who chaired a committee convened by the National Research Council, part of the National Academy of Sciences, to study how the “built” environment affects physical activity. Studies reviewed by her committee show that the average American watches TV for three hours a day.

So, one obvious step is to skip 30 to 60 minutes of TV and walk instead – around the house, in the mall, outside, wherever.  Get a pedometer (they’re cheap – $15 and up) and see how many steps you take on an average day. If it’s 3,000, try to make it 4,000. If it’s 4,000, try to make it 5,000. At 10,000 a day, you’ll be close to the basic guideline.

If you absolutely can’t give up TV time, turn it to your advantage. Get up and walk during the commercials. Get a treadmill or exercise bike (used ones can be fine) and work out while you watch.

Buy light weights to lift as you watch your favorite shows. (They’re roughly $3.50 for a 5-pound dumbbell and $24 for a 10-pound ankle weight.) The best use of a weight “is to throw it through the front of the TV,” joked Dr. Christopher B. Cooper, an exercise physiologist and professor of medicine at the David Geffen School of Medicine at UCLA.

Used as intended, weights can build muscle mass. This doesn’t directly boost cardiovascular health, but every pound of muscle burns roughly 280 calories a week because muscle is metabolically active 24/7, not just while you’re pumping iron. A pound of fat, Cooper noted, burns less than 20.

There are other easy steps, too. If your goal is 60 minutes of exercise a day, break it into six 10-minute bouts. Take a walking break from the computer every hour.  Get off the bus a few stops earlier and walk the rest of the way. Go for a walking meeting with your boss.

If child care is your excuse, exercise with the kids, said Johanna Hoffman, an exercise physiologist at Johns Hopkins Weight Management Center.  Kids love those elastic resistance bands for building strength, she said. Or create a “walking schoolbus” whereby you walk your kids (and your neighbors’) to and from school when the weather’s decent.

If you’ve failed at exercising on your own, get a buddy and commit to walking or working out together. If lack of energy is your problem, don’t despair.  You may feel tired at first and only be able to walk a few blocks. But if you stick with it, you’ll find that exercise actually gives you energy.

Too much housework? Give yourself some credits for vacuuming, raking leaves, cutting grass, even ironing. These activities probably won’t equal walking briskly, but they’re better than sitting on the couch.

Finally, recognize that you will have setbacks. Don’t let these depress you into giving up. It’s a sad fact of life that if you weigh, say 150 pounds, walking a mile in 20 minutes will only burn about 100 calories (probably less than a cookie), said William J. Evans,  chief of the nutrition, metabolism and exercise lab at the University of Arkansas for Medical Sciences. If you’re out of shape and overweight, “the actual amount of calories you burn won’t be huge until you get better trained,” he said.

But, except for “the sickest of the sick,” it pays to start, even for people with severe heart failure, said Dr. Robert Sallis, a sports medicine expert fellowship at the Kaiser Permanente Medical Center in Fontana, CA. Sallis “prescribes” exercise for all his patients “except for those I’m admitting to the ICU,” or intensive care unit in a hospital.

Start off by just doing as much as you can, he said, and by following the “FITT” mnemonic, which stands for “frequency” (preferably, most days a week); “intensity” (hard enough so that you can’t sing but you can talk);  type (exercise that works major muscles groups like the arms and legs); and time (at least 30 minutes a day).

As with much else in life, the key is to just start. Then keep going.

Biology May be to Blame for Panic Attacks

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Carol Brown  is 54 now, healthy and happy. But until her early 40s, her life was one panic attack after another.

The first occurred when she was 16, in an elevator. Out of the blue, said Brown, who lives in Belmont, “my heart started racing, my hands were sweating, my breathing was shallow. I thought I was going to die. I didn’t tell anybody. I thought I was losing my mind. It lasted maybe a minute, maybe a minute and a half, but it was enough to begin the pattern of events.”

That pattern is horribly familiar to the 2.4 million Americans who get panic attacks.

In a panic attack, a person feels a rush of fear or distress with no sense of its cause. This is often accompanied by heart palpitations, shortness of breath or “air hunger,” numbness or tingling, lightheadedness, fear of going crazy, depersonalization (feeling like you are not really there), flushes ,chills, nausea, sweating, trembling or shaking. Many people rush to the hospital emergency room, fearful they are having a heart attack.

The first attack often makes a person so afraid of another that she – and women do get panic attacks more than men – soon avoids anything associated with it.

For Brown, who now works as director of program and resource development at the Jonathan O. Cole Mental Health Consumer Resource Center at McLean Hospital, that meant elevators. Then, after an attack on the highway, driving. Then the supermarket. Then agoraphobia, the fear of being trapped in any situation or place where a panic attack might happen, even situations where no attack has occurred before.

Years ago, doctors might have attributed panic attacks like Brown’s to some deep psychological problem. Now, they suspect biology.

“The biological hypotheses for panic disorders are based on several observations,” said

Dr. Srini  Pillay , director of the panic disorders research program at McLean.

“Pharmacologic medications can stop panic attacks and panic attacks can be induced by various compounds,” he said. Panic attacks also occur “out of the blue, suggesting some sudden alteration in chemistry.” They can also occur when a person is not anxious, and even occur during sleep, “suggesting panic attacks may be tied to biological rhythms.”

Family history plays a role, too, he noted. If you have a parent or sibling with panic attacks, you have four to eight times the normal risk of getting them, too.

In laboratory experiments, for instance, researchers have shown that panic attacks can be induced by sodium lactate or carbon dioxide, which change the acid-base balance in the brain, triggering shortness of breath, one of the hallmarks of panic attacks.

And panic attacks respond extremely well to medications likes Paxil, an SSRI, or selective serotonin reuptake inhibitor, which boosts the efficacy of serotonin. Indeed, while SSRIs are  about 60 percent effective against depression, they are effective 80 to 90 percent of the time in panic disorder, noted Dr. Alexander Neumeister, an associate professor at the Yale University School of Medicine. Carol Brown can vouch for that:  When she began taking Paxil 12 years ago, her panic attacks vanished.

Panic attacks also seem to occur in people who have overly sensitive “suffocation alarm” systems that cause the brain to perceive a shortage of oxygen when there is none.

These alarm signals, generated in the brain and in special receptors called carotid bodies in the large arteries in the neck, have a “periodic tendency to get fired off too easily and to misinterpret ordinary fluctuations as signals of suffocation,” said Dr. Donald Klein , a professor of psychiatry at Columbia University Medical Center who coined the term “panic attack” more than 40 years ago.

“In panic attacks,” he said, “there is this acute sense of ‘air hunger,’ of struggling to breathe, which is not part of normal fear.”

Moreover, scientists are closing in on the brain regions that may be involved in panic attacks. In a study published earlier this year, researchers showed for the first time, using PET scanning technology, that people who get panic attacks have one third fewer of a certain kind of serotonin receptor in their brains. Serotonin is a key regulator of mood.

In people with panic attacks, but not in normal controls, five areas of the brain showed up as deficient in serotonin receptors, said the leader of that study, Neumeister of Yale. “I think that people are born with this reduction” in receptors, he said, and that other factors subsequently “contribute to the fact that they develop symptoms.”

The good news is that, terrifying as they are, panic attacks are not in themselves harmful and rarely last more than a few minutes, although they can lead to dysfunctional behavior such as drinking, avoiding normal life activities and unnecessary visits to the ER.

 “Anywhere from 60 to 80 percent of people with panic attacks are vastly improved by cognitive behavioral therapy or medications or both,” said Dr.Chris  Hayward , an associate professor of behavioral sciences and psychiatry at Stanford University School of Medicine.

And some therapists, like Kamila  White , director of the behavioral medicine program at  Boston University’s Center for Anxiety and Related Disorders, argue that as many as 80 percent of people who have panic attacks, with or without agoraphobia, can be helped with behavioral treatment alone.

At BU’s center, people with panic attacks are taught to deliberately induce feelings of panic and distress – making themselves dizzy by spinning in a chair or breathless by breathing for several minutes through a straw. The goal, said White, is to learn that feelings of panic can be lived through, and that “even when you have extreme symptoms at the highest levels, you don’t lose control.”

But perhaps the best strategy is to combine medication and behavioral therapy, said Dr. Joe  Bienvenu , a psychiatrist at Johns Hopkins University School of Medicine. Even after panic attacks are controlled by drugs, people often “have not learned that they will not have more,” he said. “This really requires going there and dealing with this anticipatory fear.”

Alcoholism a Disease or a Moral Failing

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In the old days, people used to debate whether alcoholism was a disease or a moral failing. Now it is abundantly clear that not only is it a disease, but one with a strong genetic component.

At least 50 percent of the vulnerability to alcoholism is now believed to be triggered by genetics, and the other 50 percent by environment, such as living in a culture where heavy drinking is endemic.

What’s also increasingly clear is that many genes play a role and that genes work both ways — with some protecting people against alcoholism and others greatly raising the risk, said Dr. Mary-Anne Enoch, a research physician at the National Institute of Alcohol Abuse and Alcoholism.

Certain groups of people, for instance, like many Japanese, Chinese and Jews, carry genes that protect against alcoholism by raising levels of particular liver enzymes so that it’s unpleasant to keep drinking because of nausea, flushing and rapid heart beat.

Others, including many Caucasians, carry genes that act in the brain rather than the liver and raise the risk of becoming an alcoholic, although if people with these genes never touch a drop, they will never become alcoholics. Overall, those with a parent or sibling who is alcoholic, are at three to four times the normal risk.

Even with no genetic predisposition, people can become alcoholic by constant exposure to alcohol, which turns on genes in brain cells “that set up a vicious cycle of wanting or needing more and more alcohol,” said Bill Carlezon Director of the Behavioral Genetics Laboratory at McLean Hospital in Belmont.

The goal of this genetics research is to better understand alcoholism in order to design better drugs to protect people from it.

The latest statistics, released in August by the government, show that alcohol problems are on the rise. An estimated 17.6 million American adults — 8.5 percent of the population — now fit the diagnostic criteria for having an alcohol use disorder. Definitions vary, but alcohol abuse is often defined as recurrent drinking that disrupts work, school or home life and/or occurs in hazardous situations; alcohol dependence, also known as alcoholism, is defined as impaired control over drinking, preoccupation with drinking, withdrawal symptoms and/or high tolerance to alcohol.

For several years now, researchers have suspected that heavy drinkers drink as a form of self-medication — to calm overactive circuits in the brain.

Several months ago, researchers at Indiana University School of  Medicine reported findings on a study of 1,547 families that support this theory.

The researchers, led by Howard J. Edenberg, a professor of biochemistry, molecular biology and molecular genetics, found that variations in one gene raise the risk of alcoholism. This gene acts on GABA, one of the brain’s chief inhibitory neurotransmitters whose job is to slow down — or calm — the firing of certain brain nerves. Tranquilizing drugs like Valium and alcohol increase the ability of GABA to calm neural circuits.

People with a “high risk” variant of the GABA gene are at 40 percent increased risk of becoming alcohol-dependent.

According to researchers at University of California, San Diego, another GABA gene also seems to raise the risk of alcoholism, in this case by programming people to have a weak response to alcohol.  These people need to drink large quantities of alcohol to get the same effect other people would get from less, said Dr. Marc Schuckit, a professor of psychiatry at the San Diego VA Hospital and UCSD medical school. This trait is common in some Native Americans and Koreans.         

On the flip side, the genetic protection against alcoholism only goes so far — it can be overridden if a person persistently drinks heavily, Dr. Deborah Hasin, a professor of clinical public health at Columbia University, has shown.

Hasin studied Jews with the protective gene who had grown up in Israel and those who had emigrated to Israel from Russia, where heavy drinking is common. The Russian Jews were more likely to be alcoholics, said Hasin, showing that both genetics and environment clearly play a role.

That finding was also supported by a study by Christina Barr, a research fellow at the National Institute on Alcohol Abuse. She found that female monkeys who were separated from their mothers in childhood AND had a high risk gene were more likely to become alcoholics than monkeys with just the gene or just the unpleasant history.

The bottom line? So far, there are no genetic tests to tell if you’re predisposed to alcohol problems. But if you’re worried, talk to your doctor or drop in on an Alcoholics Anonymous meeting.

Some drugs may also help if your drinking is serious. Naltrexone can help reduce the craving for alcohol. Ondansetron can help reduce relapse in some alcoholics. Antabuse (disulfiram) helps by making people feel sick if they drink. And acamprosate (Campral), widely used in Europe but not yet available here, helps reduce alcohol craving.

Diabetes and Heart Disease are Closely Linked

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More than 30 years ago, when Dr. David Heber was an intern at Beth Israel Deaconess Medical Center, he asked the senior doctors the same question over and over.

“How come all my patients have high blood pressure, high cholesterol and diabetes? Are these things linked?” His mentors would shrug and say, “Dave, common things occur commonly. Go back to work,” he said.

Today, doctors know Heber’s intuition was right. Type 2 diabetes and heart disease are physiologically linked. What’s more, according to new government figures, a whopping 64 million Americans now have what’s called Metabolic Syndrome [cq caps], also known as  insulin resistance, which doubles the risk of heart disease and raises diabetes risk by 30 percent.

“It’s a chain from obesity to diabetes to heart disease,” said Heber, now director of UCLA’s Center for Human Nutrition. “In the next 10 years, 80 percent of all heart disease will be due to Type 2 diabetes.”

Granted, you may never have heard of Metabolic Syndrome. But you probably have it if you have any three of the following five factors:

Pump Head – a Possible Outcome of Coronary Bypass Surgery

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When Bill Clinton, 58, underwent quadruple coronary bypass surgery on Labor Day, the former president, like most Americans who have similar operations, spent time – in his case, 73 minutes – hooked up to a heart-lung machine while surgeons re-routed blood vessels to his heart.

With luck and his relative youth and health going for him, Clinton will hopefully rebound fit in both heart and mind from the bypass surgery, in which doctors replace clogged arteries to the heart with veins and arteries taken from elsewhere in the body.

But many people who go through the procedure — as 305,000 Americans did in 2001, the latest year for which figures are available — find that at least for a few days, often for weeks and sometimes for years afterwards, their brains don’t work as well as they did before.

Doctors who acknowledge the problem -and some still pooh-pooh it – call it post-surgical “neurocognitive deficits.” Everybody else calls it “pump head,” reflecting  the widespread, though unproven, belief that it’s the process of blood being pumped through a heart-lung machine while the heart is stopped for surgery that causes small blood clots, air bubbles or other debris to travel to the brain, disrupting memory.

Nobody really knows how common “pump head” is because, outside of research studies, most cardiac patients aren’t tested on intellectual function before and after surgery. Detecting all but the most subtle cognitive changes “depends on how hard you look,” said Dr. William Cohn [cq], director of minimally invasive surgical technology at the Texas Heart Institute in Houston.

Nonetheless, it has now been “convincingly demonstrated that measurable cognitive dysfunction is actually a common complication of CABG (coronary artery bypass graft) surgery, with an incidence of 80 to 90 percent at hospital discharge,” as Duke University researchers Dr. Daniel B. Mark [cq] and Dr. Mark F. Newman [cq]put it in an editorial in the Journal of the American Medical Association in 2002.

Even five years after discharge, 42 percent still show measurable cognitive decline, Mark and Newman found in their own study, published in 2001 in the New England Journal of Medicine, though some of this might have been due to normal aging.

In most patients with  “pump head,” the deficits are real, but small. “It’s not that you can’t solve a problem,” said Mark, “but that you can’t solve it as quickly.”

Many cardiologists, among them Dr. Christopher Cannon [cq] of Brigham and Women’s Hospital in Boston, also believe that deficits are most likely to occur in older patients who, in addition to having clogged arteries to the heart, may have blockages in blood vessels in the brain as well. In other words, what some see as a consequence of heart surgery may be a consequence of generalized atherosclerosis.

At the moment, there is no cure for “pump head.” Nor do doctors understand why some patients who get it get better over time and others do not.

Though it’s not clear today that the heart-lung machine is the real culprit in “pump head,” many doctors for years assumed it was and focused their prevention efforts  on the machine itself.

Cinnamon Joins Cholesterol Battle

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A common spice already enjoyed by many Americans appears to lower blood sugar and cholesterol, a potential boon to millions of people with diabetes and millions of others with high cholesterol.

The spice is cinnamon. In a paper published in December in Diabetes Care, researchers from the Beltsville Human Nutrition Research Center in Maryland, part of the US Department of Agriculture, reported on a  small, but encouraging study of 60 people with Type 2 diabetes in Pakistan.

It showed that as little as one gram a day of cinnamon -one-fourth of a teaspoon twice a day – can lower blood sugar by an average of 18 to 29 percent, triglycerides (fatty acids in the blood) by 23 to 30 percent, LDL (or “bad”) cholesterol by 7 to 27 percent and total cholesterol by 12 to 26 percent.

Although some scientists suspect that cinnamon may be toxic at very high doses, at the small doses used in this study, the spice appears to be safe, said Richard Anderson, (CQ)  the lead scientist in the Beltsville lab and senior author of the paper.

To be sure, one small study on 60 people and a handful of other studies on the biochemistry of cinnamon in cells in lab dishes provide far too little data to recommend that Americans immediately start wolfing down large quantities of the spice. On the other hand, the USDA study was “impressive,” said Melinda Maryniuk (CQ) , a senior dietician at the Joslin Diabetes Center in Boston.  Cinnamon “can’t harm in small doses, it may help, and it’s not adding calories,”  she said.

She warned, however, that people with Type 2 (or adult-onset) diabetes should monitor their blood sugar more frequently if they take cinnamon because it could intensify the effects of diabetes medications, including insulin.

Alice Lichtenstein (CQ), a professor of the Friedman School of Nutrition Science and Policy at Tufts University, added another caveat:  Don’t use the news on cinnamon to indulge regularly in calorie-laden cinnamon buns or muffins.

Scientists already have a pretty good, albeit incomplete, idea of how cinnamon may work, at least in diabetes, said Don Graves (CQ) , an adjunct professor of biochemistry at the University of California in Santa Barbara and a guest investigator at the Sansum Diabetes Research Institute, also in Santa Barbara.

An active, water-soluble ingredient in cinnamon, proanthocyanidin (cq) , part of a family of chemicals called polyphenols that are often found in plants,  somehow worms its way inside cells.

Once inside, it helps to phosphorylate, or activate, the part of the insulin receptor that sticks into the cell. (The other end of the receptor sticks out through the cell membrane into the bloodstream to catch molecules of insulin, which escort sugar to cells.)

Then, once the receptor is activated, whether by insulin or proanthocyanidin, a cascade of chemical reactions occurs so that the cell can use energy from sugar. Cinnamon, in other words, does much “the same thing as insulin,” said Graves.

“Cinnamon makes insulin more efficient,” added Anderson of the USDA.  In  diabetes, the problem is that insulin no longer does a good job of  escorting sugar into cells. Cinnamon “makes cells more sensitive to the insulin that is available. And if you improve insulin sensitivity, you improve blood lipids. Insulin is the driver.”

Dr. Frank Sacks (CQ), a physician at Brigham and Women’s Hospital and professor of nutrition at the Harvard School of Public Health, is cautious.  “There are certainly substances in plants that have very strong biological effects, so the concept is fine,” he said. And plant derivatives “are being intensively researched at many places – that’s a hot topic.”

But people should not rely on cinnamon to replace statin drugs, used by 20 million Americans to lower cholesterol.  “Cinnamon is a lot less effective than statins,” he said. Statins were tested in rigorous studies on 70,000 people for five years or more.” Compared to that, the research on cinnamon is weak. It’s also curious, he said, that the USDA study found that the beneficial effects of cinnamon lasted for at least 20 days after people stopped taking it. “I don’t know of any drug or product whose effects persist for 20 days.”

On the other hand, Dr. Andrew Greenberg, director of the obesity metabolism laboratory at Tufts, has reviewed the existing literature on cinnamon and is impressed enough to be starting a collaboration with Anderson, whose preliminary findings he described as “very exciting and promising.”

One note of caution is that coumarin, a substance found in cinnamon, may trigger cancer in animals. Cinnamon also contains cinnamaldehyde, which is toxic. But these toxic components are fat-soluble, while the beneficial ingredient, proanthocyanidin, is water-soluble. Water-soluble extracts of cinnamon are available in which “all the bad components are left behind,” said Anderson. (Ground cinnamon does allow both water- and fat-soluble components to be absorbed, but at the doses recommended, it does far more good than harm, he said; cinnamon sticks placed in hot water release only water-soluble components.)

It’s easy to add cinnamon to the diet, by sprinkling at bit of powder on cereal or coffee or soaking a cinnamon stick in a cup of tea. In fact, noted Anderson, one of his colleagues who did not have diabetes was able to lower his blood sugar just by using a cinnamon stick regularly in tea.

There may be an indirect health benefit to be had from cinnamon, too, according to Taiwanese scientists writing in the July 14 issue of Agriculture and Food Chemistry. Cinnamon oil, they found, kills mosquito larvae more effectively than DEET, a common pesticide and mosquito repellent. The next step is to test it against adult mosquitoes.

Optimism isn’t the cure

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Nancy Achin Audesse, 45, knows a thing or two about serious illness and optimism.  

Audesse, executive director of the Massachusetts Board of Registration of Medicine, has had cancer four times: Hodgkin’s disease when she was 14, the first round of breast cancer at 33, the second bout (which included a relapse of the first, plus a whole new tumor) at 34 and melanoma at 37.”For someone who should have kicked off years ago, I’m fabulous,” she said recently. “I’m here, doing good deeds, trying to make health care better.” All along, she said, she has been “blessed by having a wacky sense of humor.”

But despite her seemingly relentless optimism, Audesse, who lives in Wenham, is quick to voice outrage at a belief that still runs rampant in our New Age-besotted culture: The idea that a positive attitude can mean the difference between life and death: “It’s not fair to put that guilt and emotional burden on a person.”

Indeed, there’s little scientific evidence for the idea that attitude influences survival. A new, albeit flawed, study published in March in the journal Cancer showed that optimistic people with lung cancer fared no better than those with bleaker expectations.

Overall, for every study that suggests a survival advantage to having a positive attitude, there are at least three that find no such effect, said Dr. Pamela Goodwin, a medical oncologist who directs the Marvelle Koffler Breast Center at Mount Sinai Hospital at the University of Toronto.

What is a useful attitude, psychiatrists and cancer specialists say, is to adopt whatever philosophy helps you stick with your treatment plan and to be “authentic,” that is, to acknowledge and express your honest feelings, positive or negative. And if, at some point, it is no longer realistic to hope for a cure, to re-focus your hope toward a more realistic goal: maximizing day-to-day quality of life.

 Dr. Jerome Groopman, chief of experimental medicine at Beth Israel Deaconess Medical Center and author, most recently, of “The Anatomy of Hope,” said he welcomed the Australian study, despite its flaws, because “there is this burden that patients carry, this mantra in the popular mind that is derived from some of the New Age books of the 1970s – that depression, anger and unprocessed emotions are what cause cancer. This is completely unsubstantiated.”

The insidious, flip side of this belief is “that, as the disease progresses, your character flaws will lead to your own demise. This is extremely cruel, scientifically incorrect – yet a very widely-held notion,” he said.

Dr. Jimmie Holland, an attending psychiatrist at Memorial Sloan-Kettering Cancer Center in New York and author of “The Human Side of Cancer,” agreed. “People can be pessimistic and do well,” she said, adding that optimism and pessimism are character traits “that have nothing to do with coping with your illness.” She laments what she calls “the tyranny of positive thinking.”

In many ways, life-threatening illness is like rape. Many people find it easier to believe that ill fortune hits people who have somehow asked for it – as in rapes blamed on women for wearing provocative clothing or being in the wrong part of town – than to accept that life can be a crapshoot in which very bad things happen to very good people, for no fair reason.

“People would rather feel guilty than helpless, that’s why people go for this stuff,” said Dr. David Spiegel, associate chair of psychiatry and behavioral science at Stanford University and author of “Living Beyond Limits.” People “want to have the fantasy of control, even if it makes them feel guilty.” Years ago, Spiegel ran a study suggesting that women with advanced breast cancer who participated in group therapy that encouraged them to express their feelings lived 18 months longer than those who had no such therapy. But other researchers have been unable to replicate these findings.

The real message from this work, he said, is to not get caught in “the prison of positive thinking,” but to “face what you have to face. If it makes you sad, cry. If it makes you angry, deal with that. If it makes you value the things you value, do that.” A hidden bonus is that some people with serious illness discover is that “cancer cures neurosis,” he added, meaning that some people learn to shed the fruitless worries of ordinary life by facing mortality and learning to “really appreciate the things that matter.”

Dr. Donna Greenberg, a psychiatrist at Massachusetts General Hospital who consults at the hospital’s cancer center, put it bluntly. “Patients shouldn’t be afraid that having a bad thought is going to make their tumor grow.” The idea “that if we will it, it will work out” is a “very American concept,” she said. “But life is more complicated than that.”

Feeling that you have to fake it – to help yourself or spare others your distress – may even make things worse, at least psychologically, because feelings of “inauthenticity” can be distressing in and of themselves, said Ellen Langer, a professor of psychology at Harvard University and author of “The Power of Mindful Learning.”

The bottom line? If you have cancer or any other serious disease and a positive attitude, that’s great. At the very least – and this is no small benefit – that may improve your day-to-day quality of life. But if you feel down, don’t feel you have to keep “soldiering on as if nothing happened,” Audesse advised. “Sometimes, you don’t want to be courageous. You want to curl up in a corner and suck your thumb.”