NYT > Health

Patient Money: For Most, Implants Beat Dentures, but at a Price

Fri, 30 Jul 2010 15:42:52 GMT

Dr. Robert M. Pick, a periodontist in Aurora, Ill., with a dental implant, which is fixed into the jaw.

Mark Panko still gets riled when he recalls the two years he suffered with traditional dentures.

Implants can be used to replace a single tooth or a mouthful.

“They fell out when I talked,” Mr. Panko, 56, a small-business owner in Woodridge, Ill., recalled. “I couldn’t taste my food — in fact, I could hardly chew. It was the most miserable time of my entire life.”

Mr. Panko, who lost his teeth in his early 50s because of a hereditary form of periodontal disease, eventually replaced his dentures with something better: dental implants. While many people wear dentures without discomfort, implants are now considered the preferred treatment for replacing lost teeth, said Dr. Robert Pick, an associate professor of surgery at the Feinberg School of Medicine at Northwestern University.

The procedure is straightforward. A surgeon places a titanium screw in the jaw bone, and prosthetic teeth are secured to the implant. They don’t wiggle or slip, as dentures can, and are healthier for the gums and bone. Most patients find implants easier to maintain than dentures.

“Best decision I ever made,” Mr. Panko said of his implants. “I could chew beer cans now.”

If only paying for them were so easy. For all their advantages, implants are expensive. Insurance coverage is usually minimal, and patients often are surprised by high out-of-pocket costs.

An implant to replace a single tooth can cost $3,000 to $4,500, depending on where you live. Implants to replace a full or partial set of teeth can run from $20,000 to as much as $45,000.

Why so much? Implants typically involve the work of both a surgeon and a dentist. Several office visits may be needed to put in the screws and to add the prosthetic teeth.

More dental insurance plans are covering the costs, but the annual reimbursement limit is typically $1,500, an amount that hasn’t changed in four decades. That may be enough to cover half the cost of a single implant; you will end up paying the rest.

Still, many patients may find it a worthwhile investment. Implants typically last a lifetime, with a failure rate of less than 5 percent.

Let’s say you lose one tooth. If you opt for a bridge, which costs almost as much as an implant but is more often covered by insurance, the dentist will grind down the two adjacent teeth to create a structure that secures the replacement tooth.

The ground teeth become more vulnerable to decay and nerve damage, and there’s a good chance you will require a root canal in the future, said Dr. Karl Gruendl, a dentist in Fenton, Mo., who advises insurance plans.

A study done for Washington Dental Service, the largest insurance carrier in Washington State, found that over a five-year period the maintenance costs for people with bridges were higher than for those who had implants.

“For a single tooth replacement, over the long run we think it’s more beneficial to get the implant,” said Dr. Ron Inge, dental director for Washington Dental Service. And that’s an insurance executive talking.

If you need to replace most or all of your teeth, dentures are clearly the cheaper alternative, costing around $2,500 for a set (upper and lower jaws). But the implants won’t move around, nor interfere with your sense of taste, as a denture might.

Implants also will help protect your bones over time. “The screw in your jawbone will trick the body into thinking you still have teeth,” said Dr. Ira Cheifetz, president of the American Association of Oral and Maxillofacial Surgeons. “The bone continues to grow and thrive.”

Implants aren’t appropriate for every patient, particularly those who smoke or already have substantial bone loss. If you are a candidate for the procedure, consider these cost-saving strategies.

YOUR PLAN BENEFITS If your dental insurance covers implants, bravo. If it does not, ask the carrier to give you an allowance toward what a bridge or conventional denture would have cost, Dr. Gruendl suggested.

See a dentist who belongs to your insurance network. Dental plans negotiate discounted rates with their network providers, which means the overall cost of the implant will be substantially less than the “retail” charge, said Evelyn Ireland, executive director of the National Association of Dental Plans.

How much less? Depending on the carrier, it might be as little as 5 percent of the standard price, or as high as 40 percent.

FINANCING OPTIONS Most dentists are willing to offer some kind of discount to patients who expect to have large bills. If you don’t have insurance or your plan doesn’t cover implants, ask your dentist for the rate provided to in-network insured patients.

Some dentists may let you pay them directly in installments. Mr. Panko, for example, is still paying off the $45,000 bill for the implants he got four years ago from Dr. Pick. Mr. Panko is pleased it worked out that way: “I have a longstanding relationship with my periodontist, and we worked out a payment plan.”

Many dentists also participate in financing programs, such as CareCredit and Wells Fargo Health Advantage, that let patients pay bills over time with no, or minimal, interest. With CareCredit, for instance, you pay no interest if you pay off your balance in full within two years. Ask your dentist about financing plans if you’re worried about paying your bills all at once.

AN ALTERNATIVE PROVIDER Dental schools sometimes have clinics where advanced students do implant procedures at reduced rates. Call Oral Health America (312-836-9900) to find a clinic near you.

START AN F.S.A. If you know you need one or more implants, but it’s not an emergency, fully fund your flexible spending account for next year. F.S.A.’s, which are offered by many employers, allow you to use pretax dollars to pay health care expenses. Depending on your tax bracket, pretax dollars can amount to an extra 20 percent to spend on the dental bill, compared to using taxed income.

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Getting Into Med School Without Hard Sciences

Fri, 30 Jul 2010 12:18:03 GMT

For generations of pre-med students, three things have been as certain as death and taxes: organic chemistry, physics and the Medical College Admission Test, known by its dread-inducing acronym, the MCAT.

Students in Mount Sinai’s Humanities and Medicine Program at the Metropolitan Museum of Art.

So it came as a total shock to Elizabeth Adler when she discovered, through a singer in her favorite a cappella group at Brown University, that one of the nation’s top medical schools admits a small number of students every year who have skipped all three requirements.

Until then, despite being the daughter of a physician, she said, “I was kind of thinking medical school was not the right track for me.”

Ms. Adler became one of the lucky few in one of the best kept secrets in the cutthroat world of medical school admissions, the Humanities and Medicine Program at the Mount Sinai medical school on the Upper East Side of Manhattan.

The program promises slots to about 35 undergraduates a year if they study humanities or social sciences instead of the traditional pre-medical school curriculum and maintain a 3.5 grade-point average.

For decades, the medical profession has debated whether pre-med courses and admission tests produce doctors who know their alkyl halides but lack the sense of mission and interpersonal skills to become well-rounded, caring, inquisitive healers.

That debate is being rekindled by a study published on Thursday in Academic Medicine, the journal of the Association of American Medical Colleges. Conducted by the Mount Sinai program’s founder, Dr. Nathan Kase, and the medical school’s dean for medical education, Dr. Robert Muller, the peer-reviewed study compared outcomes for 85 students in the Humanities and Medicine Program with those of 606 traditionally prepared classmates from the graduating classes of 2004 through 2009, and found that their academic performance in medical school was equivalent.

“There’s no question,” Dr. Kase said. “The default pathway is: Well, how did they do on the MCAT? How did they do on organic chemistry? What was their grade-point average?”

“That excludes a lot of kids,” said Dr. Kase, who founded the Mount Sinai program in 1987 when he was dean of the medical school, and who is now dean emeritus and a professor of obstetrics and gynecology. “But it also diminishes; it makes science into an obstacle rather than something that is an insight into the biology of human disease.”

Whether the study’s findings will inspire other medical schools to change admissions requirements remains to be seen.

Because MCAT scores are used by U.S. News and World Report and others to rank schools, the most competitive ones fear dropping the test, admissions officials said. And at least two recent studies found that MCAT scores were better than grade-point averages at predicting performance in medical school and on the series of licensing exams that medical students and doctors must take.

“You have to have the proper amount of moral courage to say ‘O.K., we’re going to skip over a lot of the huge barriers to a lot of our students,’ ” said Dr. David Battinelli, senior associate dean for education at Hofstra University School of Medicine.

But, Dr. Battinelli added, “Now let’s see how they’re doing 5 and 10 years down the road.” The Mount Sinai study did not answer the question.

There are a few other schools in the United States and Canada that admit students without MCAT scores, but Mount Sinai appears to have gone furthest in eschewing traditional science preparation, said Dr. Dan Hunt, co-secretary of the Liaison Committee on Medical Education, the medical school accrediting agency.

The students apply in their sophomore or junior years in college and agree to major in humanities or social science, rather than the hard sciences. If they are admitted, they are required to take only basic biology and chemistry, at a level many students accomplish through Advanced Placement courses in high school.

They forgo organic chemistry, physics and calculus — though they get abbreviated organic chemistry and physics courses during a summer boot camp run by Mount Sinai. They are exempt from the MCAT. Instead, they are admitted into the program based on their high school SAT scores, two personal essays, their high school and early college grades and interviews.

The study found that, by some measures, the humanities students made more sensitive doctors: they were more than twice as likely to train as psychiatrists (14 percent compared with 5.6 percent of their classmates) and somewhat more likely — though less so than Dr. Kase had expected — to go into primary care fields, like pediatrics and obstetrics and gynecology (49 percent compared with 39 percent). Conversely, they avoid some fields, like surgical subspecialties and anesthesiology.

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Added to the Recall List: Millions of Frozen Mice

Fri, 30 Jul 2010 13:13:08 GMT

Frozen mice sold as reptile food have been linked to hundreds of cases of salmonella in the United States and Britain.

Take mice from freezer. Thaw (but not in the microwave, please). Feed to pet snakes.

“Snakes got to eat,” said Steve Gilfillan of Council Bluffs, Iowa, who buys frozen mice by the thousands for his pet reptiles.

And do not forget to wash your hands.

That is the message from public health officials in the wake of salmonella outbreaks that have sickened more than 400 people, many of them snake owners or their children, in the United States and Britain.

The illnesses have been traced to frozen mice sold over the Internet as food for exotic pets by a small Georgia company called MiceDirect.

The company announced this week a recall involving millions of frozen mice and said that it would begin irradiating future shipments to kill infectious bacteria. MiceDirect also recalled frozen rats and baby chickens used as pet food by reptile fanciers, although those products had not been linked to the salmonella outbreaks.

The recall drew back the curtain on a world of exotic pet enthusiasts for whom there is nothing unusual about keeping a dozen snakes in the living room and a few zippered bags of mice in the freezer.

“It’s so much more convenient for the reptile keeper to have a bag of rodents in their freezer,” said Justin Kobylka, who raises and sells pythons in Toccoa, Ga., not far from the breeding operation of MiceDirect in Cleveland, Ga.

Buying frozen rodents saves repeated trips to the local pet shop to buy live mice, he said, and it spares squeamish owners from having to watch pets kill their prey. “Some people aren’t ready to make that leap,” Mr. Kobylka said.

Health officials said that owners of reptiles should be mindful that such pets, including snakes and turtles, often carry salmonella and have been the cause of outbreaks in the past. Rodents carry similar risks, whether kept as pets or used as food for other animals. In humans, salmonella typically can cause diarrhea, vomiting and stomach cramps.

Snakes can become infected after eating tainted mice, although the snakes may show no signs of illness, said Dr. Casey Barton Behravesh, a veterinarian and epidemiologist with the Centers for Disease Control and Prevention. Snake owners can become sick from handling the frozen or thawed mice, handling infected snakes or cleaning feces from an enclosure.

Steve Gilfillan, a deputy sheriff in Council Bluffs, Iowa, keeps “a couple hundred” garter snakes in several neat rows of roomy enclosures in his basement. The snakes, he said, are like part of the family, which leads to a certain familiarity.

“As far as precautions, I don’t know,” said Mr. Gilfillan, 51, who said his three children helped feed and care for his pets. “Snakes got to eat and snakes got to poop and you got to clean it up. It’s just the nature of keeping them.”

Mr. Gilfillan said he bought 10,500 mice from MiceDirect early this year, delivered to his door. He keeps them in the freezer compartment of a basement refrigerator. He said he had not heard about the recall until a reporter called him on Wednesday.

“I never thought that a mouse could have salmonella,” he said. “It just never entered my mind.”

Mr. Gilfillan and many other snake owners thaw mice to serving temperature in warm water. Dr. Barton Behravesh said people should not use a microwave oven, because the bacteria could spread to other food.

She also said that mice and reptiles should be kept out of the kitchen and away from areas where food is served. Reptile cages should not be cleaned in the kitchen sink, she said, and mice should not be kept in a freezer with food for humans.

And she said that reptile owners should wash their hands thoroughly after handling their pets or the rodents the pets eat.

The first salmonella outbreak linked to MiceDirect began in Great Britain in August 2008. Since then, more than 400 people have fallen ill there, about two-thirds of them have been children under 10, according to Chris Lane, a senior epidemiologist of the Health Protection Agency’s Center for Infections in London. Although the shipments of tainted mice were halted last year, people continue to get sick there, Mr. Lane said.

The first case in the United States appeared in January 2010, according Dr. Barton Behravesh. The C.D.C. has identified more than 30 cases in 17 states with the same strain as the British outbreak. She said the cases were not concentrated in one region but spread across the country. Half the victims were under 12.

Accounts from both sides of the Atlantic suggest that American authorities were slow to react to indications of a problem.

British investigators looking into the outbreak found that many of the victims came from families where snakes were kept as pets. They eventually began looking at the frozen mice fed to the snakes and found shipments from MiceDirect that contained the same strain of salmonella as that isolated from the victims.

British officials contacted MiceDirect, Mr. Lane said, and the company promised to act to prevent further contamination.

Kristen Nordlund, a C.D.C. spokeswoman, said the British officials told the agency in May 2009 of the outbreak there and the connection to MiceDirect.

She said that the C.D.C. found no cases of infection in the United States at that time. But it did tell the Food and Drug Administration, which regulates pet food companies like MiceDirect, about the British investigation.

This spring the C.D.C. became aware of reports of salmonella and began an inquiry.

Siobhan DeLancey, an F.D.A. spokeswoman, said the agency was checking to see if it had a record of the 2009 contact from the C.D.C.. She said the F.D.A. was not told of the American outbreak until May and that investigators did not establish a likely connection with MiceDirect until the beginning of July.

It was not until July 6, however, that officials of the two agencies went to MiceDirect to conduct an inspection, according to a timeline provided by the F.D.A.

On July 21, the F.D.A. told the company that tests of its products and plant had found salmonella. Two days later, the agency said, MiceDirect agreed to a recall.

But the recall effort has been haphazard. The company’s recall notice was not prominently posted on its Web site until Thursday. And neither the company’s site nor the F.D.A.’s site gave clear instructions on what to do with mice that customers still had.

The owners of MiceDirect, John Callaham and Heath Biggers, did not return repeated phone calls from a reporter. In response to e-mails, they would not discuss details of the business but said affected customers should ship back unused products or destroy them.

Mr. Kobylka, the python breeder, is a friend of the company’s owners, and he posted a video of the operation on YouTube in February, showing a vast warehouse with row upon row of trays containing breeding mice and their babies. In the video, Mr. Biggers says the warehouse produces 80,000 mice a week. The recall covers more than a year’s production but the company did not say how many mice it had sold in that time.

Mr. Lane said the outbreak has persisted in Britain, perhaps because snake owners, unaware of the dangers, continue to use mice kept in their freezers.

“Bacterial infections don’t have borders,” Mr. Lane said. “Things can become contaminated and be exported very easily.”

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Are Migraines Linked to a Heart Defect?

Thu, 29 Jul 2010 17:37:37 GMT

Monitoring Elderly Parents

Thu, 29 Jul 2010 18:39:08 GMT

Elizabeth Roach’s health is remotely monitored by her son. A screen on her end in Virginia displays e-mail, photos, games and her blood pressure.

IN the wee hours of July 14, Elizabeth Roach, a 70-year-old widow, got out of bed and went to the living room of her Virginia ranch home. She sat in her favorite chair for 15 minutes, then returned to bed.

Michael Murdoch remotely tracks the well-being of his mother, Elizabeth Roach, from his home in Aurora, Colo.

She rose again shortly after 6, went to the kitchen, plugged in the coffee pot, showered and took her weight and blood pressure. Throughout the morning, she moved back and forth between the kitchen and the living room. She opened her medicine cabinet at 12:21 and closed it at 12:22. Immediately afterward, she opened the refrigerator door for almost three minutes. At 1:36, she opened the kitchen door and went outside.

All this information — including her exact weight (126 pounds) and blood pressure reading (139/98) — was transmitted via the Internet to her 44-year-old son, Michael Murdock, who reviewed it from his home office in suburban Denver.

All was normal — meaning all was well.

“Right now she’s not home,” Mr. Murdock said. That he deduced because the sensors he had installed throughout his mother’s home told him that the kitchen door — which leads outside — had not been reopened since 1:36, more than an hour earlier. The opening of the medicine cabinet midday confirmed to him that his mother had taken her medicine. And he was satisfied that she had eaten lunch because the refrigerator door was open more than just a few seconds.

In the general scheme of life, parents are the ones who keep tabs on the children. But now, a raft of new technology is making it possible for adult children to monitor to a stunningly precise degree the daily movements and habits of their aging parents.

The purpose is to provide enough supervision to make it possible for elderly people to stay in their homes rather than move to an assisted-living facility or nursing home — a goal almost universally embraced as both emotionally and financially desirable. With that in mind, a vast spectrum of companies, from giants like General Electric to start-ups like iReminder of Westfield, N.J., which has developed a system to notify families if loved ones haven’t taken their medicine, are looking for a piece of the market of families with an aging relative.

Many of the systems are godsends for families. But, as with any parent-child relationship, all loving intentions can be tempered by issues of control, role-reversal, guilt and a little deception — enough loaded stuff to fill a psychology syllabus. For just as the current population of adults in their 30s and 40s have built a reputation for being a generation of hyper-involved, hovering parents to their own children, they now have the tools to micro-manage their aging mothers and fathers as well.

Wendy A. Rogers, a psychology professor at Georgia Tech, who has studied such systems and seniors’ reactions to them, recalled a man who went into high alert when a sensor system showed a high level of activity in a room of his mother’s home. He called her to find out what was wrong — and it turned out that she had decided to paint the sunroom.

“I think the critical question is: Is this something the parent wants?” said Nancy K. Schlossberg, a counseling psychologist and professor emerita at the University of Maryland. She compared monitoring technology for elderly people to the infamous “nanny cams” — hidden cameras some parents use to spy on their children’s baby sitters. “Big Brother is watching you — there’s something about it that’s very offensive,” she said.

The decision, she said, must ultimately be made by the aging parent. “It has to be negotiated with the parents,” Dr. Schlossberg said. “You want to keep the relationship co-equal. If it’s not an agreement with the parent, it can be a very destructive thing.”

The system Mr. Murdock persuaded his mother to install is called GrandCare, produced by a company of the same name based in West Bend, Wis. It allows families to place movement sensors throughout a house. Information — about when doors were opened, what time a person got into and out of bed, whether there’s been any movement in a room for a certain time period — is sent out via e-mail, text message or voice mail. He said his GrandCare system cost $8,000 to install — about as much as two months at the local assisted-living facility, Mr. Murdock said — plus monthly fees of about $75. The company says that costs vary depending on what features a client chooses.

In addition to giving him peace of mind that his mother is fine, the system helps assuage that midlife sense of guilt. “I have a large amount of guilt,” Mr. Murdock admitted. “I’m really far away. I’m not helping to take care of her, to mow her lawn, to be a good son.”

His mother, Mrs. Roach, was nervous at first when her son brought up the idea of using the system. “I didn’t want to be invaded,” she said. “I didn’t understand the system and was concerned about privacy.” Now that it’s in place, she said, she’s changed her mind: “I was all wrong. I’m not feeling like I’m being watched all day.” And she really enjoys the system’s feature that lets her play games and receive photos and messages from her children and grandchildren. (She never learned to use e-mail.)

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Recipes for Health: Baked Large Limas With Spinach and Feta

Fri, 30 Jul 2010 02:20:37 GMT

This Greek-inspired dish makes a hearty one-dish meal, and it’s a great way to include nutrient-dense spinach in your diet. If you use baby spinach, the preparation will go quickly as the beans simmer.

Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat.

1/2 pound large limas, cooked

2 tablespoons extra virgin olive oil

2 garlic cloves, minced

2 pounds spinach, stemmed and cleaned thoroughly; or 1 pound baby spinach, rinsed

1/4 cup chopped fresh dill

1 tablespoon snipped chives

2 ounces feta cheese, crumbled (1/2 cup)

1. Cook the beans according to the directions. Remove from the heat, and drain through a colander set over a bowl. Transfer to a lightly oiled baking dish (1 1/2 to 2-quart), and add 1 scant cup of the broth.

2. Preheat the oven to 350 degrees. Heat a large skillet over high heat, and wilt the spinach, in batches, in the water left on the leaves after washing. Remove to a colander, rinse briefly with cold water, then squeeze out excess water and chop coarsely.

3. Heat 1 tablespoon of the olive oil over medium heat in the skillet, and add the garlic. Cook, stirring, until fragrant, 30 seconds to a minute. Add the spinach, dill and chives, and stir together just until the ingredients are combined, less than a minute. Remove from the heat. Season to taste with salt and pepper.

4. Spread the spinach in an even layer over the beans. Sprinkle the feta over the spinach, and drizzle on the remaining tablespoon of olive oil. Bake 30 minutes until sizzling. Serve hot or warm.

Yield: Serves four.

Advance preparation: The cooked beans will keep for four to five days in the refrigerator. You can prepare the spinach two to three days ahead and refrigerate. You can assemble the gratin several hours before you bake it.

Nutritional information per serving: 302 calories; 11 grams fat; 3 grams saturated fat; 13 milligrams cholesterol; 37 grams carbohydrates; 14 grams dietary fiber; 296 milligrams sodium (does not include salt added during preparation); 18 grams protein

Martha Rose Shulman can be reached at martha-rose-shulman.com.

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The Bay Citizen: In Mission, Aging Hospital Is Seen as a Bargaining Chip

Fri, 30 Jul 2010 04:50:02 GMT

Rujey Rubacalva, a nurse, working in the emergency room at St. Luke’s Hospital on July 20.

St. Luke’s hospital, in San Francisco’s Mission district, has been clinging to life for years.

A nonprofit, nonpartisan news organization providing local coverage of the San Francisco Bay Area for The New York Times. To join the conversation about this article, go to baycitizen.org.

David Soria Jr. and his wife, Norma, were among those waiting for care.

The hospital is run down and lacks air conditioning. It is licensed to support 229 beds, but on an average day just 130 are filled. In-patient psychiatric care, occupational health services and care for the sickest newborns are no longer offered.

“We’re left with patients who are chronically ill or who don’t really have the resources or stamina for any aggressive treatment,” said Mary Michelucci, who has been a nurse at St. Luke’s for 35 years.

California Pacific Medical Center, which operates St. Luke’s, once planned to shutter the 139-year-old hospital and turn it into an outpatient facility. But California Pacific — a not-for-profit affiliate of Sutter Health, a Northern California hospital network — is keeping St. Luke’s open, using it as a bargaining chip in an ambitious strategy to overhaul how it offers medical care in San Francisco.

California Pacific has proposed a $2.5 billion development plan that includes a new 555-bed, one-million-square-foot hospital at Van Ness Avenue and Geary Boulevard on Cathedral Hill, while scaling back or renovating other facilities. California Pacific operates four of the oldest hospitals in San Francisco, including St. Luke’s, which now caters mostly to immigrants, the poor and the elderly. One-third of all emergency room visits in the city — and half of all births — take place at California Pacific facilities.

The center’s plan has led to a fierce debate about where hospitals should be located in San Francisco, and about whether California Pacific’s strategy to consolidate many services at one primary location would ultimately limit services for patients now served by hospitals like St. Luke’s, where almost 90 percent of all patients are on Medi-Cal or Medicare.

St. Luke’s “has to be a world-class hospital, not just an afterthought,” said Supervisor David Campos, who represents District 9, where the hospital is located. “We want to make sure that quality health care is accessible in an equitable way for all San Franciscans.”

Tom Ammiano, a Democratic member of the State Assembly, said he was watching closely to see what type of patients the new hospital would cater to.

“Cathedral Hill is looming,” Mr. Ammiano said. “Is that going to be a showplace or a place that treats every San Franciscan equally?”

California Pacific officials said the new hospital would draw patients from around the city and the country with state-of-the-art specialized services, including organ transplants. They say consolidating such services would enable the hospital to provide quality care for city residents.

“We don’t have the luxury of just looking neighborhood by neighborhood,” said Judy Li, a vice president of health system innovation and community benefit with California Pacific. “We are looking to build a system that is viable for all of San Francisco.”

Last week, the San Francisco Planning Department published a draft of the environmental impact report on California Pacific’s development plans. To meet state seismic requirements, California Pacific is pushing to win approval before the end of the year and break ground in January 2011 with hopes of opening by 2015.

Citing obsolescence and lack of demand, California Pacific had hoped in 2007 to turn St. Luke’s into an outpatient facility in 2007. A public outcry ensued. Some feared that nearby San Francisco General Hospital would be overwhelmed with patients. Others lamented that southeast San Francisco would lose important medical services.

A panel was convened to study the future of St. Luke’s, with participants ranging from the city’s public health director to community leaders. Following the panel’s recommendations, California Pacific agreed to keep St. Luke’s open as a community hospital. Yet, it hopes to do so on a smaller scale, proposing a new $250 million, six-story building with 80 beds to replace the main 12-story tower, which would be razed.

California Pacific administrators said St. Luke’s was currently larger than what the Mission needed. “To put a 200- or 300-bed hospital here would be insane,” said Geoffrey Nelson, director of enterprise development for the medical center.

On a recent afternoon, almost half of the rooms in the St. Luke’s intensive-care unit were vacant. Three visiting children played at an abandoned nurses station, where they spun on the chairs. The I.C.U. was treating just eight patients, although there were rooms for as many as 15.

kmieszkowski@baycitizen.org

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French Mother Indicted in Smothering of Infants

Fri, 30 Jul 2010 07:01:08 GMT

PARIS — A nursing assistant in her mid-40s from a small village in northern France was charged with murder Thursday in the smothering of eight of her own infants, born in secret over nearly two decades. It appeared to be France’s worst case of infanticide.

Eric Vaillant, a French prosecutor, speaking to the news media on Thursday.

Dominique Cottrez

The defendant, Dominique Cottrez, who is a married mother of two grown daughters, confessed to killing the newborns and hiding their remains in a garden and in the garage of her home, according to Éric Vaillant, public prosecutor of Douai.

Her husband, Pierre-Marie Cottrez, a carpenter and municipal council member, said he did not know of the killings or his wife’s pregnancies. Initially detained by police, he was released from custody without charge.

The couple’s daughters — who are in their 20s and are mothers — also expressed shock.

Mrs. Cottrez was first questioned by the police Tuesday, after the owners of a home previously belonging to her parents discovered the remains of two infants in plastic bags buried in the house’s garden. Mrs. Cottrez, considered a witness at the time she was questioned, Agence France-Presse reported, confessed to being the mother of the children.

She soon admitted to killing other newborns, said Mr. Vaillant. On Tuesday afternoon, investigators searching Mrs. Cottrez’s home in Villers-au-Tertre found six cadavers in four sealed plastic bags hidden in the garage.

“She explained that she didn’t want any more children and that she did not want to see a doctor about using contraception,” Mr. Vaillant said. He said Mrs. Cottrez’s weight had made the birth of her first daughter, now 22, difficult, prompting apprehension about doctors. It also very likely helped to conceal her subsequent pregnancies, he added.

Mrs. Cottrez admitted to “voluntarily suffocating the newborns at birth,” he said. He said she had been “completely aware” of each of her pregnancies before the births, which occurred between 1989 and 2006 or 2007.

Mrs. Cottrez was being held Thursday in an undisclosed location and undergoing psychiatric testing.

Her daughters, each of whom has a young son, were present in court Thursday, having come to support their parents, they said.

“We never noticed anything,” the women, identified only as V. and E. Cottrez, told the regional newspaper La Voix du Nord, calling their mother a “courageous” woman who “did not complain.”

Mrs. Cottrez regularly watched her grandsons, they said.

“I’m raising my child alone; Mom was there in the maternity ward with me,” the daughter said. “We both had tears in our eyes.”

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Books of The Times: Stefanie Syman’s Yoga History, ‘The Subtle Body’

Fri, 30 Jul 2010 04:50:36 GMT

The story of yoga in America, as many journalists have pointed out, is the story of assimilation, diversification and, more recently, commodification. Although there are many devoted students of yoga, who regard it as an exacting physical and spiritual discipline, there are also many trendy yoga consumers today, who regard it simply as another form of exercise like spinning or Pilates, as a hip new way to stay fit and lower stress, or even as a celebrity-inspired fad. Arguing that the varieties of yogic experience in America can “leave you metaphorically standing on your head,” a recent article in The Hindustan Times noted there are now such things as circus yoga, nude yoga, pre- and postnatal yoga, acro yoga (acrobatics), Christian yoga, hip-hop yoga, even yoga for dogs (“doga”).

Stefanie Syman

THE SUBTLE BODY

The Story of Yoga in America

By Stefanie Syman

Illustrated. 390 pages. Farrar, Straus & Giroux. $28.

Excerpt: âThe Subtle Bodyâ (pdf)

According to Yoga Journal, nearly 16 million Americans were practicing yoga in 2008, and the yoga industry earns some $6 billion a year in the United States. The Canadian company Lululemon, which sells items like the $118 Lulu Zen Wrap and the wildly popular $98 groove pant, reportedly has a market cap of more than a billion dollars. Yoga for Foodies events, staged at spas and restaurants around the country, feature yoga sessions, followed by multicourse meals that include red wine and chocolate. And celebrity yogis, NPR reports, have become “brands unto themselves, complete with book deals, fashion lines, studio franchises and intellectual property lawsuits.”

So how did yoga arrive at this point? How did a centuries-old spiritual discipline, associated with meditative practices in Buddhism and Hinduism, become a fitness routine subscribed to by professional athletes, C.E.O.’s, Hollywood stars and suburban soccer moms? This is the story that the journalist Stefanie Syman — a founder of the Web magazine Feed — proposes to tell in her new book, “The Subtle Body: The Story of Yoga in America.”

Certainly the subject has the makings of a compelling cultural history — one that might explore the collision of East and West, American attitudes toward religion and the mind-body split, and the mainstreaming of countercultural attitudes and trends. But while Ms. Syman has amassed a lot of entertaining anecdotes about the history of yoga in this country, her overall narrative suffers from odd gaps and elisions. She fails to give the lay reader a real appreciation of yoga’s ancient history and the evolution of various practices and schools. And the final chapters feel truncated and rushed; they do not even seem to draw usefully on a plethora of recent newspaper, magazine and radio reports about the latest permutations of the yoga boom in America.

What Ms. Syman does do deftly is trace how the likes of Emerson (with his interest in Indian thought) and Thoreau (with his practice of meditation) helped create a context in which an American yoga could take root. And she provides a lively gallery of larger-than-life characters who would contribute to (or undermine, or co-opt) the progress of yoga in the United States — beginning with Swami Vivekananda, who came to America in 1893 to raise money for the poor in India, and who drew large audiences at the World Parliament of Religions, convened as part of the World’s Columbian Exposition in Chicago.

From Vivekananda, Ms. Syman moves on to Pierre Bernard (the subject of a recent biography, “The Great Oom” by Robert Love), a self-promoting entrepreneur who founded a secretive, cultlike society called the Tantrik Order and who was accused of being a white slave trafficker.

Bernard’s story “could have ended here,” Ms. Syman writes: “a two-bit occultist and lothario who, like many a charismatic leader, was felled by a combination of his own recklessness and bad timing,” but the guru managed to reinvent himself. In 1919 his disciple and wife, Blanche De Vries, opened the Yoga Gymnosophy on East 53rd Street in Manhattan — a luxurious series of studios where yoga poses and breathing exercises were taught. That same year she and Bernard created the Braeburn Country Club (later renamed the Clarkstown Country Club) in Nyack, N.Y., where well-to-do members could choose from a startling array of activities, from practicing yoga to joining a cross-dressed baseball team to watching circus trapeze acts.

Among the other yoga gurus and entrepreneurs profiled in these pages is Theos Bernard, Pierre Bernard’s half nephew, who gained fame as a “spiritual adventurer” after journeying to India and Tibet in search of teachers, and who opened the American Institute of Yoga and the Pierre Health Studios in Manhattan. There is also Indra Devi, a middle-aged, Russian-Swedish immigrant who arrived in Hollywood in 1947, opened a small yoga studio and quickly acquired celebrity students like Greta Garbo, Gloria Swanson, Jennifer Jones and Robert Ryan. The brand of Hatha yoga she taught was, in Ms. Syman’s words, “simple, practical, and adaptive” — accessible to Americans with its emphasis on health and well-being, not spiritual uplift.

Whereas Devi had broadened the appeal of yoga by reducing it, basically, to a set of “health exercises,” says Ms. Syman, the psychedelic cowboys Timothy Leary and Richard Alpert, armed with psilocybin, mescaline and LSD, would steal “yoga from the health seekers and weight-conscious” and “put it back in the temple, where they believed it belonged” or at least restore “some of its spiritual import.”

The “marriage of acid and yoga” at the Avalon Ballroom in San Francisco on Jan. 29, 1967; Allen Ginsberg sitting in the lotus position and chanting in Lincoln Park in Chicago as the police clubbed protesters during the Democratic National Convention of 1968; the swami Satchidananda delivering an invocation at Woodstock and exhorting the massive crowd to channel its energies — such scenes are all captured by Ms. Syman with plenty of energy and verve. She goes on to chronicle how the ’60s version of yoga — with “its promise of physical-psycho-spiritual transmutation” — gave way in successive decades to more narrowly defined versions, from what one instructor dismissively calls “the marshmallow school of yoga” (in which “you sort of lie on the floor and exhale a whole lot”) to more demanding forms that merged the athletic and the ascetic.

That children practiced yoga on the White House lawn during the 2009 Easter Egg Roll, Ms. Syman writes, is a measure of how thoroughly this ancient spiritual discipline — once regarded as exotic, bohemian, even threatening — has been assimilated by the American mainstream and transformed.

“We had turned a technique for God realization,” she writes, “that had, at various points in time, enjoined its adherents to reduce their diet to rice, milk, and a few vegetables, fix their minds on a set of, to us, incomprehensible syllables, and self-administer daily enemas (without the benefit of equipment), to name just a few of its prerequisites, into an activity suitable for children.”

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Sanofi Said to Plan a Bid of $70 for Genzyme

Thu, 29 Jul 2010 05:20:38 GMT

Sanofi-Aventis is likely to make an unsolicited offer of up to $70 a share for Genzyme, raising the stakes for what could become one of the year’s biggest deals, people briefed on the matter said Wednesday.

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Sanofi’s board met on Wednesday and agreed to let management make a formal proposal, one of these people said. At $70 a share, Sanofi’s bid would be worth about $18.6 billion.

Sanofi would most likely issue a bear hug letter that would outline its proposed bid, these people said. Such a letter is friendly on its surface, but signals a willingness to go hostile if necessary.

Such a move could put pressure on Genzyme’s directors, some of whom have been more receptive to Sanofi’s informal approach than others, these people said. A bear hug letter could also rally Genzyme shareholders.

Genzyme’s shares have climbed about 26 percent since reports surfaced last Friday of Sanofi’s approach.

Sanofi approached Genzyme earlier this year about a potential combination, one that would bolster Sanofi’s drug pipeline and significantly increase its presence in biopharmaceuticals.

Adding Genzyme, one of the four largest biotechnology companies and a maker of vaccines for genetic disorders, would be one of Sanofi’s largest deals to date. Genzyme’s market value last Thursday was about $14.5 billion, the day before reports of Sanofi’s approach.

If Sanofi continues to pursue Genzyme, it will need to deal with two formidable activist investors who have stakes in the biotech company: Carl C. Icahn and Ralph Whitworth, both of whom have representatives on the Genzyme board. Both have pushed Genzyme to take steps to increase its stock price.

Genzyme makes drugs like Cerezyme, a treatment for Gaucher’s disease, and Fabrazyme, for Fabry disease.

The company has struggled to improve its stock performance after it battled a viral contamination problem at its main production plant in Boston last year.

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The Cruelest Month: For Some Fitness Buffs, July Heat Is No Obstacle

Thu, 29 Jul 2010 07:00:20 GMT

Haleigh Perilla sweats through a Bikram Yoga class in Midtown Manhattan, where the room is heated. Studio attendance has hardly dropped during July.

To escape the relentless heat, some seek out shade, basements or air-conditioned cocoons. Others head for places even hotter than the awful outdoors.

A weeklong series as July heads to the record books as the hottest month in New York City.

Some runners relish exerting themselves in the heat. There were several doing a loop in Central Park on Wednesday.

On Wednesday, inside a small, mirrored yoga studio in Midtown that was as sticky as a jungle, 21 people twisted their otter-slick limbs into knots as sweat soaked through their towels and dripped to the floor.

Outside, it was 87 degrees. Inside, it was 106 — and as sour-smelling as a gym locker.

Five minutes in the room made one long for the 34th Street station’s subway platform. That was exactly the point.

“It’s not going to feel hot outside when I go out,” said Celester Rich, whose bald head was glistening after class. “I used to complain, ‘Oh, it’s so hot out.’ But now I don’t care anymore. It doesn’t even bother me.”

“If you can handle this,” he added, “you can handle everything.”

The city’s Bikram Yoga studios, where participants stretch and sweat prodigiously inside heated rooms, belong to the sparse ranks of New York places that are warmer than the sidewalk outside — pizza ovens, saunas, perhaps a stuck elevator.

Yet Jen Lobo, an owner of Bikram Yoga NYC, which has four studios across the city, says that the July heat, on pace to break the record for the hottest month in city history, has hardly affected attendance.

Indeed, the hot weather seems to draw out a certain type of person undaunted by the elements. While many people cower beneath fans until nightfall, some hearty souls head to hot yoga rooms, running tracks or bike paths to — gasp! — exercise, no matter the hour or the temperature.

Just before noon on Wednesday, with the mercury well on its way to the high of 89 degrees, a shirtless 68-year-old man named Nick Nave, his skin tanned to a coconut brown, ran a loop through Central Park, part of an eight-mile daily regimen. He shrugged off the sun, the meteorologists and the record books.

“I adore running in the heat,” he said, taking a brief pause from his jog. He wore eccentric blue sunglasses and carried a yellow T-shirt in one hand and a buzzing BlackBerry in the other. “I thrive on it.”

He said he ran much faster in the heat than in cool weather, and he credited his taste for the sun to his childhood in Israel.

He was far from the only runner on Wednesday to thumb his nose at the thermometer.

Tourists, mothers, marathoners and retirees circled Central Park, some with concessions made for the heat, others stubbornly without.

Diana Cano, 20, a student visiting from Mexico City, said she had discovered a little quirk about running in the sun. “You sweat more and you feel like you’re doing more even though you’re doing exactly the same,” she said. Take a jog for, say, 15 minutes, she said, and “it’s like an hour.”

But for others, that is exactly the problem. Many runners preparing for the New York marathon, to be held on Nov. 7, have had to carry on their training programs through the hottest days of July.

For them, this summer has been a game of balancing miles and degrees: on one scale there was 26.2, and on the other there were 103, 100 and a bushel of 90s. Usually, the 26.2 wins out.

“I’ve got an obsession with my training, so even on days when I probably shouldn’t have gone out, I’ve forced myself to,” said Aled Jones, an information technology specialist preparing for his first marathon.

He said he had run on the hottest days of the summer when “the air burns; you’ve got hot air burning the back of your throat.” His water bottles, ice when he sets out, melt within 20 minutes — along with the rest of him.

“Everything I’m wearing, from my socks to my underwear, is just soaked by the time I’m finished,” Mr. Jones said. “It’s not pleasant. Then you have to deal with the chafing, which can be kind of embarrassing.”

Perhaps he should head to Bikram Yoga NYC in Midtown, where no one seemed embarrassed about anything — not their shirts, which looked as if they had been doused by a fire hose; or their aromas, which could stop Army tanks cold.

Soon after the class on Wednesday finished at 1 p.m., Mr. Rich, his bald head now dry, stepped onto Eighth Avenue, where people shielded their eyes from the sun and bodega flowers wilted in plastic wrap.

He spread his arms wide and called out, “This is nothing, dude.”

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Washington State Moves to Tighten Controls on Pain Killers

Thu, 29 Jul 2010 15:55:55 GMT

In an unusual move, a state government is developing regulations meant to stop doctors from prescribing higher doses of powerful — and often dangerous — pain killers for patients who are not benefiting from them.

Dr. Alex Cahana, a pain specialist, is involved in devising regulations to stem the use of prescribed narcotics in Washington State.

The effort, in Washington State, represents the most sweeping attempt yet to stem what some experts see as the excessive use of prescribed narcotics, and it is being closely watched by medical professionals elsewhere. Among other things, Washington would apparently become the first state that would require a doctor to refer patients on escalating doses of pain killers for evaluation if they were not improving.

Experts in pain treatment and drug abuse prevention say the growing use of long-acting pain killers like OxyContin, fentanyl and methadone has been a crucial factor in a nationwide epidemic of overdose deaths, largely from the abuse of such drugs.

Nationwide, fatalities from prescription drug overdoses are the second-leading cause of accidental death behind car accidents and, in some states, are the leading cause, according to the Centers for Disease Control and Prevention.

Last year, narcotic pain killers accounted for 7 percent of all prescribed drugs, and the number of patients annually taking long-acting versions of these medications has increased about 30 percent over the last decade.

But a long-running debate has thwarted efforts to address the problem both at the federal and state level.

Drug makers and patient groups have complained that new restrictions would unfairly punish pain sufferers who rely on the drugs, while others, including some doctors and regulators, have argued that the drugs are potentially so dangerous that they need to be even more tightly controlled.

However, the Washington State initiative appears to reflect a growing view that the status-quo is no longer acceptable. Last Friday, an advisory panel to the Food and Drug Administration overwhelmingly rejected an agency proposal to better control drugs like OxyContin as too weak because it did not mandate special training for doctors who prescribe such medications.

The effort in Washington is also directed at controlling how doctors use narcotics to treat legitimate pain patients, not at people who illegally obtain the drugs for recreational use. While many patients benefit from pain killers, there is growing evidence from studies, including one in Washington State, that others suffer significant side effects, including lethargy, increased sensitivity to pain and, in the most severe instances, potentially fatal overdoses.

“This is not just about addicts but little old ladies with arthritis starting to die because of this kind of medical practice,” said Dr. Alex Cahana, a pain specialist involved in devising the regulations in Washington State.

Lawmakers in Washington State adopted voluntary narcotics use guidelines three years ago, but a statewide survey last year indicated that many doctors were not following them and about half were not even aware of them.

At the direction of the Washington State Legislature, a panel of doctors, nurses, regulators and others are compiling a set of medical practices that physicians and other prescribers would be legally expected to follow when treating patients with long-term pain from causes other than cancer.

The regulations would not affect how narcotics are used to treat patients with cancer or those at the end of life because experts agree that such patients should receive as much pain medication as necessary.

The panel is expected to require that, among other things, doctors refer patients to a pain specialist for review when their daily medication increases to a specified dosage level and they do not show improvement. The specialist can then determine whether to continue the drug, reduce it or use other treatments like physical therapy.

Recently, the Centers for Disease Control issued a similar recommendation to doctors.

Pain specialists and regulators in Washington State said they believed that the requirements were essential because doctors were giving high daily dosages of powerful drugs for ailments like back pain for far too long without evidence that the medications worked.

The law that created the new regulatory effort in Washington State did not propose specific sanctions or penalties. However, officials there said that a doctor who chose to ignore the new rules could face sanctions from state licensing boards, including potentially losing the right to practice. The company that makes OxyContin, Purdue Pharma, lobbied against the law, saying the new regulations could deprive patients of appropriate treatment.

The initiative sprang out of the efforts of Dr. Cahana and two other people, including a Washington State representative, James C. Moeller, who is also a substance abuse counselor.

Mr. Moeller, who works at a facility in Vancouver, Wash., run by Kaiser Permanente, said he had treated a steady procession of patients in recent years, nearly all of them young and physically dependent or psychologically addicted to high dosages of pain killers.

In the process, Mr. Moeller said, he realized that many doctors who prescribed such drugs had little training in either pain management or substance abuse. So, wearing his legislator’s hat, he drafted a bill to require doctors to take a training course to prescribe narcotics.

He said he quickly encountered opposition to the idea from a professional group that represented doctors. At that point, Dr. Cahana and the third man, Dr. Gary M. Franklin, the medical director of the state’s Department of Labor and Industries, stepped in.

The two doctors, through different routes, had arrived at the same conclusion — that too many pain patients were getting drugs at dosages that were too high for too long.

“There is a dissonance in not recognizing the nexus between poor pain management and the hyperconsumption of opioids,” said Dr. Cahana, who works at the University of Washington Medical Center in Seattle, using a medical term for narcotic pain killers like OxyContin.

For his part, Dr. Franklin, whose department oversees the state’s workers’ compensation program, said he had long seen the problem play out among claimants. “Injured workers were coming into the system with low back pain and dying two or three years later” from drug overdoses, he said.

This year, Dr. Cahana and Dr. Franklin testified during a legislative hearing on the proposed training requirement, suggesting that legislation should instead require a set of medical practices based on the best available evidence. Dr. Franklin said that a draft of rules would probably be finished by this fall and that the new regulations would be in place by next year.

A major hurdle to making the program work is the lack of pain management specialists, particularly in rural areas of the state, where patients on the narcotics could be referred for evaluation. Dr. Franklin said the state hoped to increase the use of telephone consultations as well as help to finance the training of doctors in pain treatment.

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Novartis Plans Giveaway of New Children’s Medicine

Thu, 29 Jul 2010 05:17:27 GMT

The Swiss drug giant Novartis plans to give away up to 250,000 bottles of its new liquid children’s medicine, Triaminic Fever Reducer Pain Reliever, in an effort to woo parents frustrated by a nationwide recall and shortage of a competing product — liquid children’s Tylenol.

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Both the Tylenol, made by a unit of Johnson & Johnson, and the new Triaminic product contain acetaminophen, a drug that mitigates pain and fever. Novartis valued its marketing program, which offers rebates to consumers who buy the Triaminic fever medication from Aug. 2 through Aug. 8, at $1.5 million . Triaminic, a 50-year-old brand, already makes children’s cough and cold medicines.

Industry analysts said Novartis had made a strategic move to gain market share at an opportune moment.

McNeil Consumer Healthcare, the Johnson & Johnson unit, recalled an estimated 136 million bottles of liquid children’s Tylenol and other pediatric medications in April because of manufacturing deficiencies. McNeil, to make an upgrade, has closed a plant in Pennsylvania that made the drugs involved in the recall, causing a shortage of children’s medications at many drugstores.

“If you are going to take on children’s Tylenol, now is the time to do it,” said Mick Kolassa, the chairman of Medical Marketing Economics, a firm that consults with drug makers about product marketing and pricing. “It’s a beautiful opportunity. There’s concern. There’s a shortage. There’s a wide opening in the marketplace.”

Sales at McNeil fell $200 million in the second quarter because of the recall and plant shutdown, Johnson & Johnson executives said last week during a conference call with investors. They estimated that the problems at McNeil would reduce annual sales by about $600 million.

McNeil brands like Tylenol, Motrin and Benadryl have long dominated the market for children’s medicines. But many parents were frustrated by the scope of the recall, said Dr. Jeannette Levenstein, a pediatrician in Encino, Calif., who has written about the issue on the parenting Web site strollertraffic.com And, she added, they have been frustrated by a dearth of generic alternatives.

“It certainly has put a dent in our parents’ capability to keep their kids’ cool and their own sensibilities in line when they are clamoring for generics and they are nowhere to be found,” Dr. Levenstein wrote in an e-mail on Wednesday.

Now Novartis is hoping to build brand loyalty with its new children’s fever and pain relief syrup.

The company was already developing a fever product before the Tylenol recall. But the company sped up the introduction of its product to fill a void in the marketplace, a company spokeswoman said.

“We accelerated the timing because, given the lack of availability of some over-the-counter children’s analgesic products, we felt it was an important time to offer parents a reliable fever reducer and pain reliever product for their children from a trusted brand,” Julie Masow, a spokeswoman for Novartis Consumer Health, wrote in an e-mail.

The Triaminic giveaway campaign uses the slogan “restock your medicine cabinet,” a phrase intended to remind people of the McNeil products they may have thrown out because of the recall, Mr. Kolassa, the industry consultant, said.

“It’s saying, O.K., you’ve gotten rid of the Tylenol because of the problems and now here’s a chance to replace it,” Mr. Kolassa said. “It’s a savvy move.”

Even so, some industry analysts said it was difficult to quantify the size of the market opportunity for products that compete with children’s Tylenol.

“Novartis is trying to take advantage of this opportunity to capture a portion of the market left vacant with a brand that will reassure parents,” two analysts at Raymond James wrote Wednesday in a note to investors. But consumers could turn to generic alternatives, the analysts wrote, so “the impact for Novartis is tough to evaluate at this stage.”

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Antismoking Efforts Lose Ground to Obesity Fight

Wed, 28 Jul 2010 06:18:26 GMT

When the Robert Wood Johnson Foundation decided in 1991 to take on Joe Camel, it became the nation’s largest private funding source for fighting smoking. The foundation spent $700 million to help knock the cartoon character out of advertisements, finance research and advocacy for higher cigarette taxes and smoke-free air laws and, ultimately, to aid in reducing the nation’s smoking rate almost by half.

Michelle Obama had a vegetable garden planted at the White House and is leading a new campaign against childhood obesity.

The Robert Wood Johnson Foundation took on Joe Camel in the 1990s. It is now spending $500 million to battle childhood obesity.

But a few years ago, the Johnson foundation, based in Princeton, N.J., added another target to its mission, pledging to spend $500 million in five years to battle childhood obesity. As the antiobesity financing rose to $58 million last year, a new compilation from the foundation shows, the organization’s antismoking grants fell to $4 million.

The steep drop-off in private funds illustrates the competition under way for money as public health priorities shift. In the race for preventive health care dollars, from charities and from federal and state government sources, the tobacco warriors have become a big loser. And the nation’s battle to shed pounds has in its corner the White House, with Michelle Obama leading a new campaign against childhood obesity. Shortly after the first lady kicked off the “Let’s Move” program, the administration awarded more funds to fight obesity than tobacco through two big new money sources for preventive health. The funds, totaling $1.15 billion, came from economic stimulus and health care reform legislation. They still provided more than $200 million for tobacco-use prevention, but much more to grapple with obesity.

The changes in financing are also evident across the country. State governments have used tobacco’s billions to balance their budgets while cutting $150 million from antitobacco programs over the last two years. On the airways, obesity public service announcements are lining up while a “Truth” campaign about tobacco languishes for lack of money.

“Don’t forget tobacco,” pleaded a commentary this month in The New England Journal of Medicine.

One in five Americans still smokes.

But one in three is obese.

And competition for attention is growing between the two biggest issues in public health.

“I don’t see anybody else rushing into the vacuum,” says Dr. Steven A. Schroeder, former president of the Johnson foundation. “The sad thing is, smoking, despite all the harm it does, is left pretty much an orphan.”

Dr. James S. Marks, senior vice president of the foundation, said it had to pick its targets. “When we made the commitment to spend $500 million in obesity, we made the commitment to see if we couldn’t do for childhood obesity what we did in tobacco,” he said.

The decline in state funding to prevent smoking has distressed advocates. The 1998 Tobacco Master Settlement Agreement between 46 states and cigarette companies provided more than $200 billion through 2025. For a while it financed preventive programs like the “Truth” media campaign from the antismoking group American Legacy Foundation. But as states used money elsewhere, “Truth” spending declined, to a low of $35 million last year from $104 million in 2000.

“The industry outspends us in a day what we spend in a year,” said David Dobbins, chief operating officer of Legacy.

And even as states were raising taxes on cigarettes to record levels — a proven way to deter smoking — they were shifting that revenue to general funds. Both tobacco industry analysts and antismoking groups say that states have become addicted to tobacco money but are using less of it for prevention efforts.

“Overall funding on tobacco control is down because of dramatic cuts in state spending in recent years,” Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, said in an interview. “In the last several years we’ve seen the rapid progress in both adult and youth smoking rates slow to a crawl largely because of a decline in overall spending at the state level on tobacco prevention and cessation.”

State funding for antitobacco programs dropped to $567 million last year, from $717 million two years earlier, a 21 percent cut, according to an advocacy groups’ report titled “A Broken Promise to Our Children.”

While the federal government has made up for some of the state decline in antitobacco funding, it is spending even more on antiobesity efforts. And despite politic statements, there is undeniable competition for public health money.

“In our reaction to the obesity epidemic, sometimes we have taken our eye off other issues,” Terry F. Pechacek, of the Centers for Disease Control and Prevention office on smoking and health, said in a recent interview.

But Dr. Howard K. Koh, assistant secretary for health, focused on what he said was unprecedented funding from the federal government for both issues.

“Rather than pitting one disease against another, we want to uphold comprehensive prevention policies,” he said in a phone interview. Dr. Koh said the administration was directing $722 million to tobacco control and research this year and $821 million to obesity control and research.

The tobacco funding includes industry fees to set up a new regulatory office in the Food and Drug Administration. About half of the tobacco funding and most of the obesity funding is in research financed by the National Institutes of Health, illustrating the relative newness of obesity research.

In addition, the 2009 economic stimulus package included $650 million for “prevention and wellness strategies.” In February, state smoking quit lines received more than $44 million. In March, obesity programs received 62 percent of a $372 million award while tobacco programs received 38 percent.

Kathleen Sebelius, secretary of health and human services, made the awards in March a month after joining with Mrs. Obama to help kick off the first lady’s campaign against childhood obesity.

Stanton A. Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco, asked, “Given that tobacco kills four times as many people as obesity does, why is the government putting more money into obesity?”

Kenneth E. Thorpe, a professor of health policy and obesity researcher at Emory University in Atlanta, defended the shifting resources, noting that obesity rates had doubled since 1985. And health problems related to being overweight now account for about 30 percent of the increase in health care spending, he said.

“The smoking rate, fortunately, has been coming down. Not far enough, but that’s moving in the right direction. Obesity is moving in the wrong direction,” he said.

Congress also created a $15 billion, 10-year Prevention and Public Health Investment Fund as a part of health care reform.

The first $250 million went in June to increase the number of primary care doctors, nurses and other health care workers — more to battle sickness than promote wellness, critics said. Jeff Levi, executive director of the Trust for America’s Health, a nonprofit advocacy group, said he was disappointed that the money was “diverted.”

Dr. Koh, the assistant secretary, who is an oncologist and formerly a Harvard professor and Massachusetts state health chief, said, “It was a one-time investment and we need those providers to deliver preventive services.”

Out of the second $250 million, $16 million went in June to obesity prevention and $16 million to tobacco cessation. Parts of other funds could be used for those purposes. But the nation’s leading antismoking groups had written Ms. Sebelius in April asking for about 30 percent of the total, which would have been $150 million.

Next year the prevention fund from health care reform rises to $750 million and to $1 billion after that, so the dueling organizations fighting smoking or obesity will be competing for a much larger pot of money.

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Texas Battles Health Law Even as It Follows It

Wed, 28 Jul 2010 10:40:18 GMT

AUSTIN, Tex. — There are more uninsured residents of Texas — 6.1 million and counting — than there are people in 33 states. The state’s elected officials might be expected, therefore, to cheer a federal health care law that is likely to deliver billions of dollars from Washington to Austin and cover millions of low-income Texans.

Gov. Rick Perry is working to turn back the health care law even as Texas policy makers work to put its provisions into effect.

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Instead, the Republican political leadership has greeted the law and its anticipated costs with open hostility, leaving policy makers to move forward with a complex set of changes even as the governor, attorney general and ranking legislators rage against it. The same awkward dichotomy exists in many of the 21 states that are challenging the health reform act’s constitutionality, but are nonetheless required to follow it while their lawsuits meander through the courts.

In Austin, legislative hearings and agency planning sessions proceed despite Gov. Rick Perry’s vow to fight “on every front available” against a law that he characterizes as “socialism on American soil.” Bureaucrats apply for federal grants and collaborate with the Obama administration at the same time that Attorney General Greg Abbott strategizes to eviscerate the law in court.

“Sometimes it seems a little schizophrenic,” acknowledged State Representative John M. Zerwas, a Republican who favors the law’s repeal but also leads a House committee that seeks to maximize its benefits to Texas. “There are plenty of laws out there that I might not agree with. But if the law of the land says we have to do it, the last thing I want is for Texas to not be prepared or not put things in place to comply.”

The antipathy toward the law in Texas is rooted in deeply conservative politics that have been further stirred up in a gubernatorial election year. Because one in four Texans is uninsured, the highest ratio in the country, the law’s advocates argue that Texas stands to gain as much as any state. But leaders in Austin are focused on the fiscal threat it poses, which they estimate could cost the state $27 billion in the 10 years beginning in 2014.

“You can say a chicken in every pot, a car in every garage and health care for all, if taken in isolation,” said Mr. Abbott, a leader among the Republican attorneys general who are suing the federal government in Florida. “But none of those are good things if it requires breaking the Constitution and breaking the bank to do it.”

States share in the cost of Medicaid, the government insurance program for the poor, and the new health law will vastly expand eligibility by offering coverage to childless adults

State agency leaders said politics had not interfered to date with that task, or with new requirements to create a health insurance exchange and oversee strict regulations on health insurers.

“I don’t have any sense that I’m being held back in any way,” said Billy Millwee, the state Medicaid director.

That view was echoed by Thomas M. Suehs, the commissioner of health and human services, who said the governor “expects me to implement the federal law in the most cost-effective, efficient manner.”

Mr. Perry, who is seeking re-election to a third full term after filling George W. Bush’s seat, declined to be interviewed.

Obama administration officials, while noting the incongruity, said they had been impressed that politically antagonistic states like Texas were complying with, and taking full advantage of, the new law. The Texas Department of Insurance, for instance, has applied for a planning grant to create a more muscular process for reviewing proposed premium increases, a White House priority.

“That’s sort of the operational norm in Texas,” said F. Scott McCown, executive director of the Center for Public Policy Priorities, which advocates for safety-net programs in the state. “Your leadership may be railing against Washington, but federal supremacy still requires that the people in the trenches get the work done.”

That dynamic may be tested down the road as states decide how aggressively to market the Medicaid expansion that begins in 2014, when most Americans will be required to obtain coverage.

Texas traditionally has set among the country’s most restrictive Medicaid eligibility thresholds. This has limited its Medicaid rolls, as have burdensome application requirements, outmoded computers, inadequate staffing and difficulties in signing up children born to illegal immigrants.

Mr. Perry, whose antagonism toward Washington is central to his political persona, would seem to be in tune with public opinion. Sixty percent of Texans questioned in May for a University of Texas/Texas Tribune poll said they opposed the health care law. Only 28 percent said they liked it.

The Democratic nominee for governor, Mayor Bill White of Houston, has not made an issue of Mr. Perry’s approach. He said in an interview that he also opposed the health care law because of its potential impact on the federal deficit.

In late April, Mr. Perry announced that Texas would not establish the temporary high-risk insurance pool required by the law, leaving that task to the federal government. Twenty other governors made the same choice, arguing that the new law did not provide enough money for the pools, and that states would be left holding the bag.

Some Democrats find the position inconsistent. “You can’t run around saying the federal government wants to take over Texas, but then when we have an opportunity to do it ourselves leave it to the federal government,” said State Representative Garnet F. Coleman, a Democrat.

Democrats also accuse the Perry administration of producing a sticker-shock cost estimate for the state’s share of Medicaid expansion. To come up with his 10-year projection, Mr. Suehs skipped the law’s first four years, when states bear little cost. He also assumed an increase in enrollment that some analysts say is inflated.

The commissioner projects that 2.3 million people will be added to the Medicaid rolls by 2023, nearly doubling the current enrollment of 3.1 million. Thanks largely to job losses during the economic downturn, enrollment has surged 12 percent in the past year.

Mr. Suehs and other state officials worry about a severe shortage of doctors who are willing to accept low Medicaid payments, which the state is about to cut by 1 percent. They also are concerned about the continuing strain on hospitals from treating an estimated 800,000 uninsured illegal immigrants, who will not be eligible for subsidized coverage under the new law.

But among the reasons the law could be expensive for Texas is the state’s past failure to enroll many of those already eligible for Medicaid. Going forward, Washington will pay a much smaller share of the cost for those recipients than for those who gain coverage because of expanded eligibility.

The federal government would still pay nearly 90 percent of the state’s total costs. But that is providing little comfort in a tax-averse Capitol that faces an $18 billion shortfall in its budget over the next two years.

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Essay: Lifesaving Medications, Through a Back Door

Tue, 27 Jul 2010 15:48:04 GMT

One of my big headaches at the moment is a patient — call him Ralph — who appears to be one of the most successful small-time alchemists in all of New York.

He creates gold from dross modern-style, filling his prescriptions every month like clockwork and then selling the unopened bottles for hundreds of dollars each on a street corner somewhere. A Medicaid card financed at great expense by his fellow citizens should really not be used as a cash card, and shortly I plan to help dismantle his enterprise.

But sitting in a darkened auditorium the size of a football field in Vienna last week, one of the 20,000 attendees at the big biennial international AIDS conference, I began to think about Ralph in a new light.

It’s all about global access to lifesaving drugs these days, and things are looking up in a ‘been down so long’ sort of way. Against all odds, more than 5 million H.I.V. infected people worldwide are on treatment, a minority of those who need it, but still a creditable start. Whether the international funds that created this momentum will sustain it is another story, already competing health agendas are draining some of it away.

Knowing Ralph as I do, I can easily predict his reaction to this and all similar statistics from the rest of the world: he shrugs, he smiles. “What’s that got to do with me?”

In the past, I might have agreed with him. It can be remarkably difficult to make any solid mental and emotional connection between AIDS in wealthy countries and the roiling new infections of the third world. Here, it is all about fine tuning regimens, learning to cope with the drug side effects long term. There, it is all blood and triage, high-energy battlefield medicine. There, it is all about saving lives, and here we have Ralph, selling his life away.

Ralph — middle-aged, with a bald spot and a paunch — was born in New York and has lived here all his life. He worked at a blue-collar job in Midtown Manhattan until technology made his job obsolete. He has been a recreational drug user for decades and developed AIDS at least 15 years ago. The fact that he is still alive today is testament to the fact that some of the truisms about his disease are actually not uniformly true: it doesn’t kill everyone, at least not right away, even if they habitually play fast and loose with their meds.

As far as I can figure out, Ralph takes his pills for a few months out of the year. I got records from the last clinic he was asked to leave when his entrepreneurial tendencies became clear, and his blood tests are fascinating. Some months they look pretty good, other months they are terrible, with sky-high levels of virus and almost no immune cells.

I assume those are the months when his bottles of a particularly valuable combination AIDS pill — one of my other patients tells me each bottle will fetch many hundreds of dollars on the black market — move from Ralph’s possession to someone else’s.

I wish I knew more about the black market for prescription drugs in our country. It is one of the many germane items that have yet to make it into the continuing medical education curricula. Most of what I know comes from patients, with a few facts from the odd phone conversation with the Medicaid fraud unit. It seems that the exuberant market for narcotics and sedatives is mostly domestic — these pills have become the most abused drugs in the country, more than heroin, more than cocaine. Patients can sell them off a few at a time and make a few dollars.

But those sealed bottles of lifesaving AIDS medication that net thousands of dollars have another destination. They go out of the country, to eager markets in the Caribbean and elsewhere in the developing world. There the seals will be broken and the pills will be taken by desperate men and women who want to live. A reporter for Mother Jones painstakingly traced this modern trade route a few years ago, from the patients selling their pills along Ninth Avenue to a doctor in the Dominican Republic slipping patients a contact number to buy the drugs. “It is something I cannot fight,” the doctor said. “People want to live.”

At these international conferences many of the delegates are H.I.V. infected and, by definition, healthy, or at least well enough to travel. Periodically a presenter will show videos of the sick ones back at home: skeletal before the drugs arrive; weeping with joy and gratitude afterward.

And I think of Ralph: his luck, his profligacy, and the fact that in a way he is actually doing more for the international effort than I am. Or, in a strange way, helping me do my part.

Ralph is a tough nut to crack. He has been through many doctors — all ringing his death knell in ever more emphatic tones — and doesn’t pay much attention to the lectures any more. His health seems to be pretty good. He is a little overweight and his legs hurt, but he hasn’t been hospitalized in years. If my experience with patients like him over the years is any guide, he will change his modus operandi only when he does become as skeletal and desperately ill as the people in those videos.

Or, perhaps, his life will be saved in another way. When the world’s supply of lifesaving meds expands enough, the middleman on the corner will no longer interested be in Ralph’s small contribution. Then he will have to take those meds himself. Think of it, Mr. Gates and Mr. Clinton, all you folks at Pepfar and Unaids, all you big hearts and big pockets of the world: among the lives you save will be Ralph’s.

Dr. Abigail Zuger, who writes the monthly Books column, is an infectious-disease physician in Manhattan.

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Advance on AIDS Raises Questions as Well as Joy

Fri, 30 Jul 2010 00:02:04 GMT

HOPE AMID ANGUISH Francis Byarugaba, 32, was too weak to stand in line as he waited to be seen at a clinic in April in Kanyantorogo, Uganda.

VIENNA — The best AIDS-prevention news in years was released here last week at a world conference on the disease: a vaginal gel, called a microbicide, that can be used without a man knowing it, gave women a 39 percent chance of avoiding infection with the deadly virus.

The new H.I.V. protection gel for women.

VIENNA A wide-angle shot of activists demanding more funds for fighting AIDS during a global conference last week.

Thirty-nine percent is, obviously, not perfect, though the women in the South African trial who used the gel most faithfully did better, achieving 54 percent protection.

After more than a dozen microbicide failures, it was a huge relief, and led to cheering and standing ovations for the researchers here.

“This is a field that’s known a lot of pain,” said Catherine Hankins, chief scientific adviser for Unaids, the United Nations’ AIDS-fighting agency.

There was general relief that the data was not as shaky as that of an AIDS vaccine trial released in September.

“There’s a certain feeling of ease and pleasure for me as a scientist that any way you slice the data, it’s statistically significant,” said Dr. Anthony S. Fauci, a top AIDS expert in the United States government, which paid most of the trial’s costs.

There was an unexpected bonus: the gel protected women even better against genital herpes. (The investigators were not sure why, but it contained tenofovir, an antiviral drug, and AIDS and herpes are both viral.)

Now experts are pondering the many questions raised by the news.

How much more testing will it need to win approval from drug regulators?

Would more than 1 percent tenofovir in the gel, or a two-drug mix, work better?

Can it be made cheaply enough for poor countries? (The gel costs 2 cents a dose, but the applicators are 40 cents because they are patented and were frequently redesigned to be more comfortable.)

The women had sex an average of five times a month, and were instructed to insert gel before and afterward. Would one dose, which would be easier and cheaper, work just as well?

Will it protect prostitutes, who have sex with many men in succession? Is it safe enough to use daily?

Can pregnant women use it? (Some women got pregnant and gave birth, but were taken off the gel quickly to reduce any risk.)

Would women who use it but got infected anyway develop hard-to-cure drug-resistant infections?

And, although it was tested on poor African women, might it appeal to Western women, some of whom might worry more about herpes than AIDS?

Might it also work for anal sex, and protect gay men?

The investigators and other experts said they had only partial hints of answers, but most were encouraging.

And, given that this is AIDS research, which inevitably creates controversy, some hard questions were raised.

If it was known after the first year that the gel was working, why wasn’t the trial stopped?

And what will happen to the 889 African women who, in the words of Mark Harrington, an AIDS activist, “put their bodies on the line for this study”? Would they be able to keep getting the product that might have saved their lives?

Some questions were easy, said Dr. Salim Abdool Karim, a study leader and professor of epidemiology at both the University of KwaZulu-Natal in South Africa and Columbia University.

The price of a dose could fall below that of a condom because the applicators are just molded plastic and, without patents restrictions, “the Chinese could make them for half a penny,” he said.

Others, like what drug and dose combinations are best and safest, must be tackled in future trials. A complex multination trial of several methods, including microbicide, is due to end in 2013, but a rapid new one may be designed as quickly as possible.

Globally, more than a million women a year die of AIDS, so speed is important.

The gel has never been tested in men, but has protected monkeys given anal doses of the simian version of the virus. Dr. Karim said samples he took found that tenofovir in the women’s vaginal linings had migrated to their rectal linings too, meaning they might also have been protected against anal sex.

“The tissue between the two is very thin,” he said.

Using a gel rather than a pill meant the drug infused the genital tracts but hardly reached the blood. That lowered the chances that a woman who got infected anyway would develop tenofovir-resistant virus, experts said.

No woman developed it, but they were tested so often that the virus would have had little time to mutate.

Dr. Kevin A. Fenton, director of the AIDS division of the Centers for Disease Control and Prevention, said the one-two AIDS-and-herpes punch “could make it more attractive to American women.”

It’s not clear whether men would like gels, and tenofovir pills are being tested in uninfected gay men, but the results “are a real shot in the arm to the field,” he said.

The trial was not stopped early, Dr. Karim said, because the independent review board that could have done so wanted results so overwhelming that they would have equaled the results of two generally favorable trials, “and we didn’t achieve that level of efficacy.”

Dr. Sheena McCormack, a British microbicide researcher, recalled penicillin tests of 70 years ago. Those researchers gave it to their sickest patients, not a random sample, and it still worked astonishingly well. This, she said, more resembled trials of circumcision as an AIDS preventive, which took three to be convincing.

What happens to the 889 women is unclear. Dr. Quarraisha Abdool Karim, Dr. Karim’s wife and research partner, said more gel needed to be made and she hoped to enroll them quickly in a new trial so they could get it.

Mr. Harrington said he thought they ought to have a choice of being in another trial or just getting the gel indefinitely, even though it is not legally approved by any drug-regulatory agency yet.

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Following a Script to Escape a Nightmare

Tue, 27 Jul 2010 13:45:56 GMT

THERAPY Computers track data at the Maimonides clinic in Albuquerque.

ALBUQUERQUE — Her car is racing at a terrifying speed through the streets of a large city, and something gruesome, something with giant eyeballs, is chasing her, closing in fast.

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UNTANGLING Marcia Naughton, who has post-traumatic stress disorder, was wired with sensors before going to bed at the clinic.

It was a dream, of course, and after Emily Gurule, a 50-year-old high school teacher, related it to Dr. Barry Krakow, he did not ask her to unpack its symbolism. He simply told her to think of a new one.

“In your mind, with thinking and picturing, take a few minutes, close your eyes, and I want you to change the dream any way you wish,” said Dr. Krakow, founder of the P.T.S.D. Sleep Clinic at the Maimonides Sleep Arts and Sciences center here and a leading researcher of nightmares.

And so the black car became a white Cadillac, traveling at a gentle speed with nothing chasing it. The eyeballs became bubbles, floating serenely above the city.

“We call that a new dream,” Dr. Krakow told Ms. Gurule. “The bad dream is over there” — he pointed across the room — “and we’re not dealing with that. We’re dealing with the new dream.”

The technique, used while patients are awake, is called scripting or dream mastery and is part of imagery rehearsal therapy, which Dr. Krakow helped develop. The therapy is being used to treat a growing number of nightmare sufferers. In recent years, nightmares have increasingly been viewed as a distinct disorder, and researchers have produced a growing body of empirical evidence that this kind of cognitive therapy can help reduce their frequency and intensity, or even eliminate them.

The treatments are controversial. Some therapists, particularly Jungian analysts, take issue with changing nightmares’ content, arguing that dreams send crucial messages to the waking mind.

Nightmares are important because they “bring up issues in bold print,” said Jane White-Lewis, a psychologist in Guilford, Conn., who has taught about dreams at the Carl Jung Institute in New York.

While Dr. White-Lewis acknowledged that she does not treat patients suffering from severe trauma, she said that if a nightmare is eliminated, “you lose an opportunity to really get some meaning out of it.” Changing eyeballs into bubbles, she added, might have robbed Ms. Gurule of the chance to find out what the eyeballs were trying to tell her.

Nightmares have fascinated and perplexed people for centuries, their meaning debated by therapists and analysts of all schools of thought, their effects so powerful that one terrifying nightmare can affect a person for a lifetime.

A nightmare is “a disturbing dream experience which rubs, bites and sickens our soul, and has an undercurrent of horsepower, lewd demons, aggressive orality and death,” Dr. White-Lewis wrote in “In Defense of Nightmares,” her contribution to a 1993 book of essays about dreams.

From 4 to 8 percent of adults report experiencing nightmares, perhaps as often as once per week or more, according to sleep researchers. But the rate is as high as 90 percent among groups like combat veterans and rape victims, Dr. Krakow said. He said treatment for post-traumatic stress needed to deal much more actively with nightmares.

He and other clinicians are increasingly using imagery rehearsal therapy, or I.R.T., to treat veterans and active-duty troops in the Iraq and Afghanistan wars. Last month, Dr. Krakow conducted a workshop on imagery rehearsal and other sleep treatments for 65 therapists, sleep doctors and psychiatrists, including many working with the military. And the technique has drawn more attention from other researchers in the last several years. Anne Germain, an associate professor of psychiatry at the University of Pittsburgh School of Medicine, is comparing two treatments — behavioral therapy, including imagery rehearsal, and the blood-pressure drug prazosin, which has been found to reduce nightmares.

Preliminary results from a study of 50 veterans showed that both treatments were effective in reducing nightmares and symptoms of P.T.S.D., she said, though they differed from patient to patient. She is continuing to study what factors may lead to those differences.

Deirdre Barrett, a psychologist at Harvard Medical School who is an expert on dream incubation, inducing dreams to resolve conflicts , and on the connection between trauma and dreams — said she was struck by the growing interest in nightmares as a result of war trauma and torture.

“Within the community of psychologists who have put an emphasis on dreams it used to be about interpretation,” she said. “And now therapists are getting the message that you can influence dreams, ask dreams about particular issues and change nightmares.”

And Hollywood has just produced its own spin on the idea of controlling dreams, with the release earlier this month of "Inception" a thriller whose plot swirls through the darkest layers of the dream world. Underlying the story is the concept of lucid dreaming, another technique used by clinicians to help patients afraid of their dreams understand that they are dreaming while a dream is in progress. Dr. Barrett supports the use of Dr. Krakow’s technique, although she said that ideally the nightmare work should be integrated with psychiatry and behavioral therapies to treat the underlying condition.

Still, Dr. Barrett said, “Barry has made a huge contribution by getting the numbers, getting the statistics and getting the proof that it can work.”

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N.F.L. Toughens Warning On Risks of Head Injury

Tue, 27 Jul 2010 20:37:47 GMT

The National Football League is producing a poster that bluntly alerts its players to the long-term effects of concussions, using words like “depression” and “early onset of dementia” that those close to the issue described as both staggering and overdue.

A new poster, with tougher language about the effects of brain injuries, will be hung in all N.F.L. locker rooms.

The latest news, notes and analysis as N.F.L. teams explore off-season roster moves.

The poster, soon to be hung in locker rooms leaguewide, becomes by far the N.F.L.’s most definitive statement on the cognitive risks of football, which it had discredited for most of the past several years as academic studies and reports of deceased players’ brain damage mounted.

The new document also warns players that repeated concussions “can change your life and your family’s life forever,” a clear nod to retired players’ wives who have spoken out on the issue, occasionally before Congress. A draft of the poster also features photographs of unnamed youngsters in various sports with the reminder, “Other athletes are watching.”

The new poster, which will also become a brochure given to all players, presents a stark change in league approach. It replaces a pamphlet given since 2007 that said, “Current research with professional athletes has not shown that having more than one or two concussions leads to permanent problems if each injury is treated properly,” and also left open the question of “if there are any long-term effects of concussion in N.F.L. athletes.”

The sobering new warning could affect not just the behavior of current N.F.L. players and youth athletes, but also how retired players’ claims of cognitive decline are handled under the disability plan operated jointly by the league and the players union.

“That poster is shocking,” said Domonique Foxworth, a cornerback for the Baltimore Ravens. “It gives people facts before they take risks. But it’s not exactly a new revelation.”

Matt Birk, the Ravens’ center, said: “To put it out there in writing in locker rooms, at least it’s publicly acknowledging that, ‘Hey, this is real.’ There’s risks in everything you do, and this one is real. You can’t sweep it under the rug anymore.”

Greg Aiello, a league spokesman, said in an e-mail message that the poster, spearheaded by the league’s new head, neck and spine medical committee and written in collaboration with the players union and the Centers for Disease Control and Prevention, “is intended to present the most current and objective medical information on concussions and will be distributed to the players and clubs in the near future.” He said Commissioner Roger Goodell provided his full support.

“We took a very firm stance,” said Dr. Thom Mayer, the union’s medical director and a member of the committee who worked on the text. “This is a clear step forward in educating players.”

The poster lists symptoms that players should look out for, including headaches, confusion, memory problems and feeling more emotional, and warns them not to ignore symptoms.

Beyond detailing the symptoms and severity of head injuries, the poster extends the league’s broad redirection in concussion policy since last fall. Then, the league adopted stricter rules regarding when players can return from head injuries, and then only with an independent neurologist’s permission.

Other changes to playing rules, practice procedures and equipment are being considered, with history suggesting that alterations could be adopted at the college and youth levels.

The new language is a glaring departure from words used by the league’s old concussion committee, whose comments and research that played down the evidence of concussion risks eventually led to its chairmen’s resignations. Their successors, who directed the poster project, Dr. H. Hunt Batjer and Dr. Richard Ellenbogen, did not return phone messages Monday.

The league’s reversal is not necessarily complete. On April 30, an outside lawyer for the league, Lawrence L. Lamade, wrote a memo to the lead lawyer for the league’s and union’s joint disability plan, Douglas Ell, discrediting connections between football head trauma and cognitive decline. The letter, obtained by The New York Times, explained, “We can point to the current state of uncertainty in scientific and medical understanding” on the subject to deny players’ claims that their neurological impairments are related to football.

Mr. Lamade did not return a message left Monday at his law firm, Akin Gump Strauss Hauer & Feld in Washington. Mr. Aeillo said the league would comment on the letter at a later time.

Brent Boyd, 53, a Minnesota Vikings lineman in the 1980s, is among scores of players whose symptoms of early-onset dementia have been ruled ineligible for the considerably higher disability payments given to players with on-field injuries. That denial took place soon after the last of three plan-chosen doctors ruled in 2001 that a particular concussion Boyd sustained “could not organically be responsible for all or even a major portion” of his condition.

Denied the higher benefits by the disability board, Mr. Boyd has been fighting to reverse the decision ever since. Two months ago, another of his appeals was denied because, the reply noted, “There are no changed circumstances,” and Mr. Boyd refused to see a fourth doctor.

Mr. Aiello and a union spokesman, George Atallah, declined to discuss any possible effect the new poster might have on disability claims. Most likely, the onus will remain on players to assert that their individual conditions did derive from professional football — similar to how players must handle worker’s compensation claims — although that assertion could gain credence with the league’s imprimatur.

Meanwhile, the most immediate effects of the new poster could be on the mind-set of current and future players. Mr. Birk said that some players would still try to play through head injuries “because the culture is so strong, but it’s a good start.”

Mr. Foxworth said: “Ninety-nine percent of the people who put helmets on don’t get the payback we do, but they’re taking the same risks. It’s probably more valuable to them than it is to a lot of us.”

Chris Nowinski, a co-director of the Sports Legacy Institute and an advocate for youth concussion awareness, said he was relieved to learn about the new language. “The old pamphlet that said ‘no evidence of any long-term effects,’ it slowed down progress — it helped create a latency environment when the evidence showed great urgency for change,” he said. “There’s a greater need for culture change on the lower levels. When coaches and people around the games don’t have all the information, simple documents and simple messages are the most important.”

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18 and Under: Q. Did You Ever Smoke Pot? A. It’s Complicated.

Mon, 12 Jul 2010 22:21:39 GMT

Many years ago, when I was a resident in pediatrics, an adolescent patient asked me if I had ever smoked pot. It wasn’t a friendly question, more an oh-yeah-says-you response to my own inquiries, warning me off.

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No patient has asked me that for decades. But recently, I have found myself in several all-pediatrician conversations about the topic.

Doctors, and the parents who look to them for advice, need a way to integrate their standards of honesty with what we know about preventing substance abuse — and with new research that makes it clear we know a lot more today than anyone did when we were young. (Which may help explain some of the dumb decisions made by so many of us, including me.)

In particular, scientists understand much more about the neurobiology of the teenage brain and the risks of experimenting with drugs and alcohol during adolescence. While we used to think the brain was relatively mature by 16 or 18, in fact it is still developing into the mid-20s.

What does develop early is the pleasure-seeking area, the nucleus accumbens. The regions that help with abstract thinking, decision-making and judgment are still maturing, and therefore less likely to inhibit the pleasure-seeking behavior. So drugs and alcohol can actually lead to permanent changes in the way the brain works — in particular, many experts think, a greater likelihood of addiction in adulthood.

But giving sage advice to the young has never been a simple task, and when a parent’s own history is brought up, it gets even more complicated.

There’s a moral question, for grown-ups who pride themselves on honesty and openness. There’s a fear that no matter how carefully you spell out the lesson of your own story, you may be offering your child an implicit lesson about the lack of consequences, a kind of I-did-it-and-I’m-fine parable.

And there’s a common parental anxiety about losing the moral high ground, a fear that someday this will be thrown back in your face. That can be especially troubling in more fraught situations, when children or parents (or both) are dealing with drug and alcohol problems.

“That comes up all the time when I’m counseling parents,” said Dr. Sharon Levy, director of the adolescent substance abuse program at Children’s Hospital Boston. “They say, ‘Well, what should I tell her — or not?’ ”The research on this point is limited. But there is evidence to suggest that when parents provide more information and better modeling early on, their children’s risk of substance abuse goes down. And a 2009 study by the Hazelden addiction treatment center in Minnesota found evidence that many teenagers believed that parental honesty about alcohol use was a positive influence.

Of course, every parent, every child and every situation is different, and there is no fixed rule that says parents and doctors need to offer any particular information about their drug or alcohol use, past or present.

Instead, it’s important to figure out “why are you asking, what’s going on around you?” said Dr. Janet F. Williams, professor of pediatrics at the University of Texas Health Science Center at San Antonio and head of the American Academy of Pediatrics’ committee on substance abuse.

“What you think they want to know may not be at all why they’re asking,” she said. And as with other important conversations, take account of the child’s developmental stage; you answer a question from a 12-year-old and a 22-year-old in different terms and in different detail.

You don’t need to tell everything. But if you decide to answer, don’t lie. “Tell them without glorifying it,” Dr. Levy said, “and if you think you made a mistake, tell them that too.”

In fact, a child who asks a parent this question may be worrying over how and when to bring it up. Don’t assume that the agonizing and the self-consciousness are all on your conflicted, guilty parental side.

Treat the question with respect, and use it, as the experts would say, to keep the conversation going. It may not be a question you particularly want to be asked, but it’s a larger conversation that as parents, we know we need to encourage. (Two useful Web sites are teens.drugabuse.gov, which has information geared to adolescents; and teen-safe.org, which offers advice on talking with teenagers.)

What about that familiar parental nightmare, the angry adolescent who reacts to discipline or reproof by turning it around on you with an accusation about your own transgressions? Deborah R. Simkin, a psychiatrist who is a liaison to Dr. Williams’s committee from the American Academy of Child and Adolescent Psychiatry, drew an analogy to an alcoholic who resists treatment by trying to bring up other people’s issues.

“The kid’s trying to divert the attention from an appropriate intervention by a parent,” she said. In such cases, the parent’s response should be clear: “We’re not going to discuss what I did, we’re going to discuss what you did.”

What we want to do as parents is transmit wisdom — even if we acquired it the hard way — without our children’s having to take risks. “So you drove without a seat belt and you didn’t die in a car accident, does that mean you want your kid driving without a seat belt?” Dr. Levy asked. Or as Dr. Williams put it:

“If the way it’s presented is, ‘This is risky, and I hope that you don’t have to touch the hot stove to find out you get burned,’ they don’t have to take the same chance.”

And finally, after all the cautions and the anxieties, it’s essential to come back to the positives — “always remembering to notice the good about your child,” Dr. Williams said.

After all, the most important message a parent can give is not about the mistakes that can derail a child, but about the joys of finding your way.

Tell your child, in Dr. Simkin’s words, that “I would prefer you to work on finding your passion, finding what in life you want to do” — and celebrate that potential.

And for that very reason, Dr. Williams said, “I would like them to have every brain cell they can have.”

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Mind: Accepting That Good Parents May Plant Bad Seeds

Wed, 14 Jul 2010 02:50:38 GMT

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“I don’t know what I’ve done wrong,” the patient told me.

She was an intelligent and articulate woman in her early 40s who came to see me for depression and anxiety. In discussing the stresses she faced, it was clear that her teenage son had been front and center for many years.

When he was growing up, she explained, he fought frequently with other children, had few close friends, and had a reputation for being mean. She always hoped he would change, but now that he was almost 17, she had a sinking feeling.

I asked her what she meant by mean. “I hate to admit it, but he is unkind and unsympathetic to people,” she said, as I recall. He was rude and defiant at home, and often verbally abusive to family members.

Along the way, she had him evaluated by many child psychiatrists, with several extensive neuropsychological tests. The results were always the same: he tested in the intellectually superior range, with no evidence of any learning disability or mental illness. Naturally, she wondered if she and her husband were somehow remiss as parents.

Here, it seems, they did not fare as well as their son under psychiatric scrutiny. One therapist noted that they were not entirely consistent around their son, especially when it came to discipline; she was generally more permissive than her husband. Another therapist suggested that the father was not around enough and hinted that he was not a strong role model for his son.

But there was one small problem with these explanations: this supposedly suboptimal couple had managed to raise two other well-adjusted and perfectly nice boys. How could they have pulled that off if they were such bad parents?

To be sure, they had a fundamentally different relationship with their difficult child. My patient would be the first to admit that she was often angry with him, something she rarely experienced with his brothers.

But that left open a fundamental question: If the young man did not suffer from any demonstrable psychiatric disorder, just what was his problem?

My answer may sound heretical, coming from a psychiatrist. After all, our bent is to see misbehavior as psychopathology that needs treatment; there is no such thing as a bad person, just a sick one.

But maybe this young man was just not a nice person.

For years, mental health professionals were trained to see children as mere products of their environment who were intrinsically good until influenced otherwise; where there is chronic bad behavior, there must be a bad parent behind it.

But while I do not mean to let bad parents off the hook — sadly, there are all too many of them, from malignant to merely apathetic — the fact remains that perfectly decent parents can produce toxic children.

When I say “toxic,” I don’t mean psychopathic — those children who blossom into petty criminals, killers and everything in between. Much has been written about psychopaths in the scientific literature, including their frequent histories of childhood abuse, their early penchant for violating rules and their cruelty toward peers and animals. There are even some interesting studies suggesting that such antisocial behavior can be modified with parental coaching.

But there is little, if anything, in peer-reviewed journals about the paradox of good parents with toxic children.

Another patient told me about his son, now 35, who despite his many advantages was short-tempered and rude to his parents — refusing to return their phone calls and e-mail, even when his mother was gravely ill.

“We have racked our brains trying to figure why our son treats us this way,” he told me. “We don’t know what we did to deserve this.”

Apparently very little, as far as I could tell.

We marvel at the resilient child who survives the most toxic parents and home environment and goes on to a life of success. Yet the converse — the notion that some children might be the bad seeds of more or less decent parents — is hard to take.

It goes against the grain not just because it seems like such a grim and pessimistic judgment, but because it violates a prevailing social belief that people have a nearly limitless potential for change and self-improvement. After all, we are the culture of Baby Einstein, the video product that promised — and spectacularly failed — to make geniuses of all our infants.

Not everyone is going to turn out to be brilliant — any more than everyone will turn out nice and loving. And that is not necessarily because of parental failure or an impoverished environment. It is because everyday character traits, like all human behavior, have hard-wired and genetic components that cannot be molded entirely by the best environment, let alone the best psychotherapists.

“The central pitch of any child psychiatrist now is that the illness is often in the child and that the family responses may aggravate the scene but not wholly create it,” said my colleague Dr. Theodore Shapiro, a child psychiatrist at Weill Cornell Medical College. “The era of ‘there are no bad children, only bad parents’ is gone.”

I recall one patient who told me that she had given up trying to have a relationship with her 24-year-old daughter, whose relentless criticism she could no longer bear. “I still love and miss her,” she said sadly. “But I really don’t like her.”

For better or worse, parents have limited power to influence their children. That is why they should not be so fast to take all the blame — or credit — for everything that their children become.

Dr. Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College in Manhattan.

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Recalibrated Formula Eases Women's Workouts

Mon, 05 Jul 2010 21:12:47 GMT

Mind: Polishing Tools for Your Fuse Box of Emotions

Tue, 06 Jul 2010 19:58:05 GMT

The longing for President Obama to vent some fury at oil executives or bankers may run far deeper than politics. Millions of people live or work with exasperatingly cool customers, who seem to be missing an emotional battery, or perhaps saving their feelings for a special occasion. People who — unlike the mining operators in the gulf — have a blowout preventer that works all too well.

Sang-froid has its place, especially during a crisis; but so does Sigmund Freud, who described the downside of suppressed passions. Those exhortations being directed at the president could be just as easily be turned on countless co-workers, spouses, friends (or oneself):

Lose it. Just once. See what happens.

“One reason we’re so attuned to others’ emotions is that, when it’s a real emotion, it tells us something important about what matters to that person,” said James J. Gross, a psychologist at Stanford University. When it’s suppressed or toned down, he added, “people think, damn it, you’re not like us, you don’t care about the same things we do.”

The study of what psychologists call emotion regulation is fairly new, and for obvious reasons has focused far more on untamed passions than on the domesticated variety. Runaway emotion defines many mental disorders, after all; restraint is typically associated with good mental health, from childhood through later life.

Yet social functioning is a different matter. Research in just the past few years has found that people develop a variety of psychological tools to manage what they express, and those techniques often become subconscious, affecting social interactions in unintended ways. The better that people understand their own patterns, the more likely they are to see why some emotionally charged interactions go awry — whether from too little control or, in the president’s case, perhaps too much.

Most scientists agree that a person’s range of possible emotional expression is a matter of inborn temperament. Growing up is, in one sense, a living education in how to manage that temperament so it elicits help from others and does not torment oneself.

“As we grow, the prefrontal areas of the brain develop, and we become more biologically able to control our impulses as well,” said Stefan G. Hofmann, a professor of psychology at Boston University.

Psychologists divide regulation strategies into two broad categories: pre-emptive, occurring before an emotion is fully felt; and responsive, coming afterward. The best known of the latter category, and one of the first learned, is simple suppression. First-graders will cover a smile with their hand when a classmate does something embarrassing; in time, many become far more adept, reflexively masking surprise, alarm, even rage with a poker face.

Suppression, while clearly valuable in some situations (no laughing at funerals, please), has social costs that are all too familiar to those who know its cold touch. In one 2003 Stanford study, researchers found that people instructed to wear a poker face while discussing a documentary about the atomic bombings of Hiroshima and Nagasaki made especially stressful conversation partners.

In another, published last year, psychologists followed 278 men and women as they entered college, giving questionnaires and conducting interviews. Those who scored highest on measures of emotion suppression had the hardest time making friends.

“An individual who responds to the college transition by becoming emotionally guarded in the first few days,” the authors wrote, will most likely miss opportunities for friendships.

Pre-emptive techniques can work in more subtle ways. One of these is simple diversion, reflexively focusing on the good and ignoring the bad — rereading the praise in an evaluation and ignoring or dismissing any criticism. A 2009 study led by Derek Isaacowitz of Brandeis University found that people over 55 were much more likely than those aged 25 and under to focus on positive images when in a bad mood — thereby buoying their spirits. The younger group was more likely to focus on negative images when feeling angry or down.

More striking, Dr. Isaacowitz found in another study that older people were twice as likely as younger ones to be what he called “rapid regulators” — people whose mood bounced back quickly, sometimes within minutes, after ruminating on depressing memories.

“We have found in general that older people tend to regulate their emotions faster, and are not as motivated to explore negative information, to engage negative images, as younger people are,” said Dr. Isaacowitz, who led the study. “And it makes some sense, that younger adults would explore the negative side of things, that they need to and maybe want to experience them — to experience life — as they develop their own strategies to regulate.”

Socially speaking, in short, the ability to shrug off feelings of disgust or outrage may suit an older group but strike younger people as inauthentic, even callous.

Finally, people may choose the emotions they feel far more often than they are aware — and those choices, too, can trip up social interactions. A series of recent experiments led by Maya Tamir, a psychologist at Hebrew University in Jerusalem and at Boston College, has found that people subconsciously prime themselves to feel emotions they believe will be most useful to them in an anticipated situation. The researchers call these instrumental emotions.

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Paying for Dental Implants

Fri, 30 Jul 2010 15:39:22 GMT

When Unemployed Means Unhealthy Too

Thu, 29 Jul 2010 20:02:12 GMT

The Roving Runner Rides a Bike

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Personal Health: What Do You Lack? Probably Vitamin D

Thu, 29 Jul 2010 03:04:38 GMT

Vitamin D promises to be the most talked-about and written-about supplement of the decade. While studies continue to refine optimal blood levels and recommended dietary amounts, the fact remains that a huge part of the population — from robust newborns to the frail elderly, and many others in between — are deficient in this essential nutrient.

If the findings of existing clinical trials hold up in future research, the potential consequences of this deficiency are likely to go far beyond inadequate bone development and excessive bone loss that can result in falls and fractures. Every tissue in the body, including the brain, heart, muscles and immune system, has receptors for vitamin D, meaning that this nutrient is needed at proper levels for these tissues to function well.

Studies indicate that the effects of a vitamin D deficiency include an elevated risk of developing (and dying from) cancers of the colon, breast and prostate; high blood pressure and cardiovascular disease; osteoarthritis; and immune-system abnormalities that can result in infections and autoimmune disorders like multiple sclerosis, Type 1 diabetes and rheumatoid arthritis.

Most people in the modern world have lifestyles that prevent them from acquiring the levels of vitamin D that evolution intended us to have. The sun’s ultraviolet-B rays absorbed through the skin are the body’s main source of this nutrient. Early humans evolved near the equator, where sun exposure is intense year round, and minimally clothed people spent most of the day outdoors.

“As a species, we do not get as much sun exposure as we used to, and dietary sources of vitamin D are minimal,” Dr. Edward Giovannucci, nutrition researcher at the Harvard School of Public Health, wrote in The Archives of Internal Medicine. Previtamin D forms in sun-exposed skin, and 10 to 15 percent of the previtamin is immediately converted to vitamin D, the form found in supplements. Vitamin D, in turn, is changed in the liver to 25-hydroxyvitamin D, the main circulating form. Finally, the kidneys convert 25-hydroxyvitamin D into the nutrient’s biologically active form, 1,25-dihydroxyvitamin D, also known as vitamin D hormone.

A person’s vitamin D level is measured in the blood as 25-hydroxyvitamin D, considered the best indicator of sufficiency. A recent study showed that maximum bone density is achieved when the blood serum level of 25-hydroxyvitamin D reaches 40 nanograms per milliliter or more.

“Throughout most of human evolution,” Dr. Giovannucci wrote, “when the vitamin D system was developing, the ‘natural’ level of 25-hydroxyvitamin D was probably around 50 nanograms per milliliter or higher. In modern societies, few people attain such high levels.”

A Common Deficiency

Although more foods today are supplemented with vitamin D, experts say it is rarely possible to consume adequate amounts through foods. The main dietary sources are wild-caught oily fish (salmon, mackerel, bluefish, and canned tuna) and fortified milk and baby formula, cereal and orange juice.

People in colder regions form their year’s supply of natural vitamin D in summer, when ultraviolet-B rays are most direct. But the less sun exposure, the darker a person’s skin and the more sunscreen used, the less previtamin D is formed and the lower the serum levels of the vitamin. People who are sun-phobic, babies who are exclusively breast-fed, the elderly and those living in nursing homes are particularly at risk of a serious vitamin D deficiency.

Dr. Michael Holick of Boston University, a leading expert on vitamin D and author of “The Vitamin D Solution” (Penguin Press, 2010), said in an interview, “We want everyone to be above 30 nanograms per milliliter, but currently in the United States, Caucasians average 18 to 22 nanograms and African-Americans average 13 to 15 nanograms.” African-American women are 10 times as likely to have levels at or below 15 nanograms as white women, the third National Health and Nutrition Examination Survey found.

Such low levels could account for the high incidence of several chronic diseases in this country, Dr. Holick maintains. For example, he said, in the Northeast, where sun exposure is reduced and vitamin D levels consequently are lower, cancer rates are higher than in the South. Likewise, rates of high blood pressure, heart disease, and prostate cancer are higher among dark-skinned Americans than among whites.

The rising incidence of Type 1 diabetes may be due, in part, to the current practice of protecting the young from sun exposure. When newborn infants in Finland were given 2,000 international units a day, Type 1 diabetes fell by 88 percent, Dr. Holick said.

The current recommended intake of vitamin D, established by the Institute of Medicine, is 200 I.U. a day from birth to age 50 (including pregnant women); 400 for adults aged 50 to 70; and 600 for those older than 70. While a revision upward of these amounts is in the works, most experts expect it will err on the low side. Dr. Holick, among others, recommends a daily supplement of 1,000 to 2,000 units for all sun-deprived individuals, pregnant and lactating women, and adults older than 50. The American Academy of Pediatrics recommends that breast-fed infants receive a daily supplement of 400 units until they are weaned and consuming a quart or more each day of fortified milk or formula.

Given appropriate sun exposure in summer, it is possible to meet the body’s yearlong need for vitamin D. But so many factors influence the rate of vitamin D formation in skin that it is difficult to establish a universal public health recommendation. Asked for a general recommendation, Dr. Holick suggests going outside in summer unprotected by sunscreen (except for the face, which should always be protected) wearing minimal clothing from 10 a.m. to 3 p.m. two or three times a week for 5 to 10 minutes.

Slathering skin with sunscreen with an SPF of 30 will reduce exposure to ultraviolet-B rays by 95 to 98 percent. But if you make enough vitamin D in your skin in summer, it can meet the body’s needs for the rest of the year, Dr. Holick said.

Can You Get Too Much?

If acquired naturally through skin, the body’s supply of vitamin D has a built-in cutoff. When enough is made, further exposure to sunlight will destroy any excess. Not so when the source is an ingested supplement, which goes directly to the liver.

Symptoms of vitamin D toxicity include nausea, vomiting, poor appetite, constipation, weakness and weight loss, as well as dangerous amounts of calcium that can result in kidney stones, confusion and abnormal heart rhythms.

But both Dr. Giovannucci and Dr. Holick say it is very hard to reach such toxic levels. Healthy adults have taken 10,000 I.U. a day for six months or longer with no adverse effects. People with a serious vitamin D deficiency are often prescribed weekly doses of 50,000 units until the problem is corrected. To minimize the risk of any long-term toxicity, these experts recommend that adults take a daily supplement of 1,000 to 2,000 units.

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Really?: The Claim: Exercise Can Worsen Chronic Heartburn

Tue, 27 Jul 2010 17:54:00 GMT

THE FACTS

For people with chronic heartburn, minimizing exercise might seem like a no-brainer: too much running and jumping can induce acid reflux.

But the right type of exercise, with a few precautions, may actually improve the condition. Studies have found that short bouts of fairly moderate exercise at least a couple of times a week can cut the risk of gastroesophageal reflux disease, or GERD, in part because it reduces body mass index, a primary risk factor.

One study published in 2004, which included more than 3,000 people who reported reflux, found that a half-hour session of exercise once a week or more (along with regular consumption of high-fiber foods) helped cut the risk of the condition in half.

Two steps can help: avoiding food for two hours beforehand, and steering clear of high-carbohydrate sports drinks.

But the specific exercise is crucial. Scientists found that aerobic exercises with the highest “agitation of the body,” like vigorous running, consistently induced acid reflux, even in people who did not have chronic heartburn. Less agitating exercise — pedaling on a stationary bike, for example — caused fewer problems.

Another factor is body position. Bench presses, leg curls or any other exercise that involves lying flat sharply raise the risk of acid reflux. One study in 2009 showed that surfers have several times the risk of GERD as other athletes. “Paddling in the prone position on hard surfboard surfaces leads to increased intra-abdominal pressure,” the authors wrote.

THE BOTTOM LINE

Moderate exercise, with the right precautions, can reduce reflux.

ANAHAD O’CONNOR scitimes@nytimes.com

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Eldercare Questions

Thu, 29 Jul 2010 21:01:06 GMT