Well: Want to Be More Creative? Take a Walk

Phys Ed

Gretchen Reynolds on the science of fitness.

If you are unable to think of a catchy, creative way to present sales data or begin a newspaper column, take a walk. A brief stroll, even around your office, can significantly increase creativity, according to a handy new study.

Most of us have heard by now that exercise, including walking, generally improves thinking skills, both immediately and in the longer term. Multiple studies have shown that animals and people usually perform better after exercise on tests of memory and executive function, which is essentially the ability to make decisions and organize thoughts (although prolonged, intense exercise can cause brief mental fatigue — so don't take a math test after a marathon).

Similarly, exercise has long been linked anecdotally to creativity. For millenniums, writers and artists have said that they develop their best ideas during a walk, although some of us also do our best procrastinating then.

But little science has supported the idea that exercise aids creativity.

So researchers at Stanford University recently decided to test that possibility, inspired, in part, by their own strolls. "My adviser and I would go for walks" to discuss thesis topics, said Marily Oppezzo, at the time a graduate student at Stanford. "And one day I thought: 'Well, what about this? What about walking and whether it really has an effect on creativity?'"

With the enthusiastic support of her adviser, Daniel Schwartz, a professor in the Stanford Graduate School of Education, Dr. Oppezzo recruited a group of undergraduate students and set out to see if she could goose their creativity. Gathering her volunteers in a deliberately dull, unadorned room equipped with only a desk and (somewhat unusually) a treadmill, Dr. Oppezzo asked the students to sit and complete tests of creativity, which in psychological circles might involve tasks like rapidly coming up with alternative uses for common objects, such as a button. Then the participants walked on the treadmill, at an easy, self-selected pace that felt comfortable. The treadmill faced a blank wall. While walking, each student repeated the creativity tests, which required about eight minutes.

For almost every student, creativity increased substantially when they walked. Most were able to generate about 60 percent more uses for an object, and the ideas were both "novel and appropriate," Dr. Oppezzo writes in her study, which was published this month in The Journal of Experimental Psychology: Learning, Memory, and Cognition.

But the practical import of that finding would seem to be negligible, if creativity were to increase only while someone was walking. Most of us cannot conduct brainstorming sessions on treadmills. So Dr. Oppezzo next tested whether the effects lingered after a walk had ended. She had another group of students sit for two consecutive sessions of test-taking and subsequently walk for about eight minutes while tossing out ideas for object re-use, then sit and repeat the test.

Again, walking markedly improved people's ability to generate creative ideas, even when they sat down after the walk. In that case, the volunteers who had walked produced significantly more and subjectively better ideas than in their pre-exercise testing period.

Finally, to examine another real-world implication of walking and creativity, Dr. Oppezzo moved portions of the experiment outdoors. "Most people would probably guess that walking outside should be much better for creativity" than pacing inside a drab office. But surprisingly, her study undermined that assumption. When volunteers strolled Stanford's pleasant, leafy campus for about eight minutes, they generated more creative ideas than when they sat either inside or outside for the same length of time. But they were not noticeably more creative as a result of their plein-air walk than when they subsequently walked on an indoor treadmill, facing a blank wall.

"It really seems that it's the walking that matters," in terms of spurring creativity, Dr. Oppezzo said, and not the setting.

Just how a brief, casual stroll alters the various mental processes related to creativity remains unclear, Dr. Oppezzo added. "This is an acute effect," she said, making it distinct from any long-term physiological changes that exercise might produce inside the human brain. "It may be that walking improves mood" as its primary effect, she said, and creativity blooms more easily within a buoyed-up mind.

Or walking may divert energy that otherwise would be devoted, intentionally or not, to damping down wild, creative thought, she said. "I think it's possible that walking may allow the brain to break through" some of its own, hyper-rational filters, she said.

But those are only a few of many likely explanations, she said, adding that she would probably go for a walk later to help her come up with other plausible theories and inventive experiments through which to test them.

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Well: Data Murky on Fertility Rates

Here's the question on the minds of people who spend tens of thousands of dollars on fertility treatments: What are my chances of having a healthy baby?

As it turns out, it's not always easy to tell.

Since 1992, clinics have been required to report their success rates, defined as the number of live births per in vitro fertilization cycle, to the Centers for Disease Control and Prevention. They are also supposed to report how many cycles they perform and whether the cycles involve the woman's own eggs or donor eggs, among other factors.

But there is little regulatory enforcement of these requirements by either the C.D.C. or the Society for Assisted Reproductive Technologies, the association that forwards this data to the agency. Roughly 10 percent of clinics do not report at all.

This is a multibillion-dollar industry, and there is financial pressure for clinics to claim frequent success. "Clinics are competing with each other based on pregnancy and live birthrates," said Dr. Vitaly Kushnir, a reproductive endocrinologist in New York who researches success rates. The clinics do not want give out negative data that might drive away patients.

Nationally, the data suggest that a 38- to 40-year-old woman using her own unfrozen eggs has on average a 21.6 percent chance per cycle of having a baby by means of assisted reproductive technology. The average treatment cost per cycle rings in at $12,400, according to the American Society for Reproductive Medicine.

A cycle, which can take on average from 60 to 90 days from the time of the initial consultation, typically starts with hormone injections, followed by egg retrieval, fertilization and then embryo transfer. But the national success rate does not distinguish between pregnancies occurring in the first cycle or a second, fifth or later cycle. The number of cycles needed to achieve a successful pregnancy makes a big difference to would-be parents in terms of money, time and emotional strain.

The clinics also are not required to report babies born full-term or not, or those born with birth defects. "The outcome data should be included to reflect the most important goals and measures of success in I.V.F. — a healthy baby and healthy mother," said Dr. Kushnir. Moreover, success rates at individual clinics may vary widely, depending in part on the populations they serve. Some clinics have been known to turn away women who may be difficult cases — older women or those with existing medical conditions, for example — to avoid depressing their success rates.

To potential patients browsing online, it may not be clear how these clinics define success. "Someone might think the success rate is the number of live births, when really the clinic is reporting the number of clinical pregnancies," said Jim Hawkins, a law professor at the University of Houston who has studied the claims made on the websites of fertility clinics.

Dr. Kushnir and other researchers have pushed for more public information on the health of babies and mother after I.V.F. At the moment, potential patients can check reported success rates online, with the Society for Assisted Reproductive Technologies and the C.D.C., which separates the data by pregnancy and live births.

Yet data on preterm birth, birth weight and birth defects are not made available to the public, although they are collected both by the society and the C.D.C. Reporting on birth defects may be inaccurate, because patient confidentiality laws make it difficult to obtain medical records after a baby is born, said Dr. Kevin Doody, a member of the executive council for the society.

The society's guidelines prohibit clinics from comparing themselves with other clinics, Dr. Doody said. He advised patients to avoid clinics that do so.

A cottage industry has arisen to interpret clinics' success rates in a personalized way relevant to fertility service patients. A company based in Los Altos, Calif., Univfy, sells the online tools PreIVF, for $49.50 (for those doing a first cycle) and PredictIVF for $100 (for those doing later cycles).

The products factor in age, height, weight, smoking history, previous pregnancy, clinical diagnosis, semen analysis and other lab results. (PreIVF is only for women using their own eggs.) The patient's data is then compared to a database of more than 10,000 previous I.V.F. patients, enabling a more apples-to-apples comparisons, said Dr. Mylene Yao, a founder of the company.

According to research presented last year at the Society of Gynecologic Investigators, to which Dr. Yao contributed, both tests predicted success far more accurately than traditional age-based algorithms used by the C.D.C. and the assisted reproductive society, which is also working on a similar predictor. That online tool would allow patients to obtain more personalized success rates based on national data, Dr. Doody said.

Dr. Yao advises patients to find out if they are likely to need one or more treatments, and how much each would cost. "Then ask how certain factors in your health history could impact your success rates, and how you compare to most others patients in your situation," she said.

And those clinic websites promising a quick trip to parenthood? Buyer beware.

"There is no need to trust a clinic's own assessment of whether it has a high success rate," said Mr. Hawkins, who encourages potential patients to check data posted online by the assisted reproductive society and the C.D.C.

"It is also important to try not to be swayed by appeals to emotions, like pictures of happy babies," he said.

A version of this article appears in print on 04/29/2014, on page D6 of the NewYork edition with the headline: Data Murky on Fertility Rates.

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Well: Reading Pain in a Human Face

How well can computers interact with humans? Certainly computers play a mean game of chess, which requires strategy and logic, and "Jeopardy!," in which they must process language to understand the clues read by Alex Trebek (and buzz in with the correct question).

But in recent years, scientists have striven for an even more complex goal: programming computers to read human facial expressions.

The practical applications could be profound. Computers could supplement or even replace lie detectors. They could be installed at border crossings and airport security checks. They could serve as diagnostic aids for doctors.

Researchers at the University of California, San Diego, have written software that not only detected whether a person's face revealed genuine or faked pain, but did so far more accurately than human observers.

While other scientists have already refined a computer's ability to identify nuances of smiles and grimaces, this may be the first time a computer has triumphed over humans at reading their own species.

"A particular success like this has been elusive," said Matthew A. Turk, a professor of computer science at the University of California, Santa Barbara. "It's one of several recent examples of how the field is now producing useful technologies rather than research that only stays in the lab. We're affecting the real world."

People generally excel at using nonverbal cues, including facial expressions, to deceive others (hence the poker face). They are good at mimicking pain, instinctively knowing how to contort their features to convey physical discomfort.

And other people, studies show, typically do poorly at detecting those deceptions.

In a new study, in Current Biology, by researchers at San Diego, the University of Toronto and the State University of New York at Buffalo, humans and a computer were shown videos of people in real pain or pretending. The computer differentiated suffering from faking with greater accuracy by tracking subtle muscle movement patterns in the subjects' faces.

"We have a fair amount of evidence to show that humans are paying attention to the wrong cues," said Marian S. Bartlett, a research professor at the Institute for Neural Computation at San Diego and the lead author of the study.

For the study, researchers used a standard protocol to produce pain, with individuals plunging an arm in ice water for a minute (the pain is immediate and genuine but neither harmful nor protracted). Researchers also asked the subjects to dip an arm in warm water for a moment and to fake an expression of pain.

Observers watched one-minute silent videos of those faces, trying to identify who was in pain and who was pretending. Only about half the answers were correct, a rate comparable to guessing.

Then researchers provided an hour of training to a new group of observers. They were shown videos, asked to guess who was really in pain, and told immediately whom they had identified correctly. Then the observers were shown more videos and again asked to judge. But the training made little difference: The rate of accuracy scarcely improved, to 55 percent.

Then a computer took on the challenge. Using a program that the San Diego researchers have named CERT, for computer expression recognition toolbox, it measured the presence, absence and frequency of 20 facial muscle movements in each of the 1,800 frames of one-minute videos. The computer assessed the same 50 videos that had been shown to the original, untrained human observers.

The computer learned to identify cues that were so small and swift that they eluded the human eye. Although the same muscles were often engaged by fakers and those in real pain, the computer could detect speed, smoothness and duration of the muscle contractions that pointed toward or away from deception. When the person was experiencing real pain, for instance, the length of time the mouth was open varied; when the person faked pain, the time the mouth opened was regular and consistent. Other combinations of muscle movements were the furrowing between eyebrows, the tightening of the orbital muscles around the eyes, and the deepening of the furrows on either side of the nose.

The computer's accuracy: about 85 percent.

Jeffrey Cohn, a University of Pittsburgh professor of psychology who also conducts research on computers and facial expressions, said the CERT study addressed "an important problem, medically and socially," referring to the difficulty of assessing patients who claim to be in pain. But he noted that the study's observers were university students, not pain specialists.

Dr. Bartlett said she didn't mean to imply that doctors or nurses do not perceive pain accurately. But "we shouldn't assume human perception is better than it is," she said. "There are signals in nonverbal behavior that our perceptual system may not detect or we don't attend to them."

Dr. Turk said that among the study's limitations were that all the faces had the same frontal view and lighting. "No one is wearing sunglasses or hasn't shaved for five days," he said.

Dr. Bartlett and Dr. Cohn are working on applying facial expression technology to health care. Dr. Bartlett is working with a San Diego hospital to refine a program that will detect pain intensity in children.

"Kids don't realize they can ask for pain medication, and the younger ones can't communicate," she said. A child could sit in front of a computer camera, she said, referring to a current project, and "the computer could sample the child's facial expression and get estimates of pain. The prognosis is better for the patient if the pain is managed well and early."

Dr. Cohn noted that his colleagues have been working with the University of Pittsburgh Medical Center's psychiatry department, focusing on severe depression. One project is for a computer to identify changing patterns in vocal sounds and facial expressions throughout a patient's therapy as an objective aid to the therapist.

"We have found that depression in the facial muscles serves the function of keeping others away, of signaling, 'Leave me alone,' " Dr. Cohn said. The tight-lipped smiles of the severely depressed, he said, were tinged with contempt or disgust, keeping others at bay.

"As they become less depressed, their faces show more sadness," he said. Those expressions reveal that the patient is implicitly asking for solace and help, he added. That is one way the computer can signal to the therapist that the patient is getting better.

A version of this article appears in print on 04/29/2014, on page D6 of the NewYork edition with the headline: A Truth-Teller for Fake Pain .

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Well: A Stroke You Must Have

Personal Health

Jane Brody on health and aging.

My father-in-law had been fishing from rowboats without incident since early childhood. But in August 1970, at age 66, alone on a Minnesota lake, he apparently fell out of the boat and drowned. He couldn't swim a stroke, yet never wore a life jacket.

I checked the statistics at the time: In a state with more than 11,000 lakes of 10 acres or more, plus 8,100 fishable rivers, half the adult population did not know how to swim.

Things are somewhat better today, but not enough. The Centers for Disease Control and Prevention reports that 37 percent of adults cannot swim the length of a 25-yard pool, meaning they probably could not make it to shore if they got into trouble in a natural body of water.

You might think children are the most vulnerable to drowning. Not so. While drowning has declined over all from 1999 to 2010, according to new data from the C.D.C., children and young adults account for the drop. Among adults ages 45 to 84, drownings increased nearly 10 percent. More than 70 percent of those who drown each year in the United States are adults, and the percentage of drownings in lakes, rivers and oceans rises with age. Nearly 80 percent of drowning victims are boys or men.

Fear of the water keeps many adults from learning to swim. And they may pass this reluctance on to their children, perpetuating a vicious cycle.

But it doesn't have to be this way, says Christopher Pompi, a civil engineer in Adams, Mass. As a young adult, Mr. Pompi spent time on the Jersey Shore, but he could not join his friends in the water because he didn't know how to swim.

With the help of the Swimming Saves Lives Foundation, the charitable arm of U.S. Masters Swimming, Mr. Pompi finally overcame his fear at age 38 and learned to swim. He had realized that if anything happened to his son in the water, he would have been unable to help.

He took the plunge under the remarkable tutelage of Bill Meier, the aquatics director at Bard College at Simon's Rock and a swim coach who teaches volunteer instructors how to turn land-huggers into competent swimmers seemingly in no time.

"In eight to 10 lessons I was swimming in the deep end," Mr. Pompi told me. "In six months, I went from not being able to do 10 bobs in the water to swimming like I was a young kid. Bill brought me to the point where I felt safe in the water and competent to help if anything happened."

Now 50, Mr. Pompi said he feels secure enough to have installed a pool at home where he and his three children can enjoy the water together.

"If you're not a capable swimmer, you need to become one," he said. "You never know when you'll need it."

Of course, swimming is also a great fitness activity that one can pursue into the ninth decade or beyond. It is gentle on the joints and can also be therapeutic.

For the last eight months, I've been doing the backstroke for half of my daily 40-minute swim to stabilize what had been progressive scoliosis. But an elderly friend with sciatica who was told by her doctor that swimming was the best thing for her back had to admit that she didn't know how.

Swimming can also help people maintain fitness when injuries prevent them from pursuing their usual physical activities. I first started swimming regularly year-round in my 30s when I injured my back and was unable to run, cycle or play tennis.

The Swimming Saves Lives Foundation awards grants, financed by membership fees and donations, to more than 2,000 local programs across the country to provide free or low-cost swimming lessons for adults.

"The goal is to enable adults to swim at least two lengths of a pool with confidence and, hopefully, instill a desire to continue swimming," said Rob Butcher, executive director of U.S. Masters Swimming.

Adults who can't swim are often embarrassed to say so and thus may be reluctant to sign up for a course. But think of how good it would feel to master a skill that has long eluded you.

Mr. Meier recalls a 75-year-old woman who thought she'd never be able to swim. "In just half an hour, the instructor had her doing laps and she was ecstatic," he said. "It's almost a miracle to see how fast people can go from being afraid of the water to be able to swim laps."

Mr. Meier travels widely to teach volunteers among the organization's 60,000 members how to instruct adults, regardless of their level of competence and confidence in the water. He has prepared an 11-page manual to help instructors teach all levels of students, from those too afraid to get out of the car in the pool parking lot to those who can swim but need to improve their strokes.

Most challenging, of course, are the very fearful, who may require 48 hours of instruction to become confident in deep water. One of the foundation's beneficiaries, Miracle Swimming, has licensed instructors in more than a dozen cities with the training, patience and commitment to teach extremely fearful adults.

While understandably these intensive longer courses are not cheap, Miracle Swimming says its students have fun while learning to swim, snorkel, even scuba dive. Lessons start with a very gradual introduction to the water, allowing each student to progress at his own pace.

Lessons for adults are widely available. Simply search online for "adult swimming lessons" to find the options in your area.

 

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Well: Ask Well: Do Foam Rollers Aid Workouts?

Q

At the gym, instead of traditional "stretching" I see tons of people rolling around on foam rollers. The foam rollers are in high demand and constantly in use. I now have one at home that I roll around on too. What does the research say about the benefits of foam rolling?

A

"Foam rolling is great, although it can hurt like heck," said Duane C. Button, an assistant professor of exercise science at Memorial University of Newfoundland in Canada.

A dense cylinder of foam usually about two feet long, this low-tech tool is very effective at improving range of motion during an exercise warm-up, Dr. Button said. In experiments that he oversaw with his colleague David Behm, volunteers who rolled back and forth with one of the devices under their leg muscles from five seconds to one minute showed a significant increase in those muscles' range of motion immediately afterward. More surprising, unlike stretching, which blunts muscles' ability to generate force, foam rolling did not affect volunteers' subsequent ability to jump or exert themselves otherwise.

Undulating over foam can be beneficial after exercise also, Dr. Button said. Additional experiments at his lab found that even after a "devastating workout" consisting of multiple sets of squats, volunteers who used a foam roller on their leg muscles were far less sore and better able to leap and perform other physical tasks 72 hours later than volunteers who didn't use the device.

But foam rollers are not for weenies. "You're pressing as much as half of your body weight" onto muscles while rolling, Dr. Button said, which can be excruciating.

If the discomfort is too much, he said, consider a roller massager, a smaller, hand-held foam device that you use like a rolling pin to knead tight or sore muscles. "They're more tolerable for many people, because you supply only as much pressure as you want," he said. The benefits for joint range of motion and muscle recovery are not quite as pronounced as from the larger rollers, he said, but remain measurable, while the pleasures are not inconsiderable. At the lab, he said, you can hear happy "ahhh's" as people roll.

Do you have a health question? Submit your question to Ask Well.

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Well: Why Chocolate Is Good for Us

This column appeared in the April 27, 2014 issue of The New York Times Magazine.

In recent years, large-scale epidemiological studies have found that people whose diets include dark chocolate have a lower risk of heart disease than those whose diets do not. Other research has shown that chocolate includes flavonols, natural substances that can reduce the risk of disease. But it hasn't been clear how these flavonols could be affecting the human body, especially the heart. New findings from Virginia Tech and Louisiana State University, however, suggest an odd explanation for chocolate's goodness: It improves health largely by being indigestible.

Researchers at Louisiana State reached this conclusion after simulating the human digestive system in glass vessels. One represented the stomach and the small intestine, with their digestive enzymes, and a second reproduced a large-intestine-like environment, with gut microbes from human volunteers. The scientists then added cocoa powder to the stomach vessel.

The "stomach" and "small intestine" broke down and absorbed some of the cocoa. But while many of the flavonols previously identified in chocolate were digested in this way, there was still plenty of undigested cocoa matter. Gut bacteria in the simulated colon then broke that down further into metabolites, small enough to be absorbed into the bloodstream and known to reduce cardiac inflammation. Finally, the last undigested cocoa matter, now mostly fiber, began to ferment, releasing substances that improve cholesterol levels. And there was another health-giving twist to this entire process: The gut microbes that digested the cocoa were desirable probiotics like lactobacillus. Their numbers appeared to increase after the introduction of the cocoa, while less-salutary microbes like staphylococcus declined in number.

These findings are broadly consistent with those from Virginia Tech, published in March in The Journal of Agricultural and Food Chemistry. Researchers there began by feeding healthy lab mice a high-fat diet. Some of the mice were also given unsweetened cocoa extract; others were fed various types of flavonols extracted from the cocoa. After 12 weeks, most of the mice had grown fat and unwell, characterized by insulin resistance, high blood sugar and incipient diabetes. A few, however, had not gained weight. These animals had ingested one of the flavonol groups whose chemical structure seems to be too large to be absorbed by the small intestine.

What the results suggest, says Andrew Neilson, an assistant professor at Virginia Tech and the senior author of the mouse study, is that "there is something going on with cocoa in the colon," but what that means for chocolate lovers is not clear. Future experiments, he hopes, will tease out why one flavonol group impeded weight gain and the others did not. Do not hold your breath for a cocoa-based diet pill anytime soon, though. Cocoa's biochemical impacts are "extremely complex," he says.

Sadly, Dr. Neilson also points out that cocoa is not a chocolate bar, something whose added ingredients and processing reduce the number and type of flavonols, increase calories (cocoa itself has very few) and possibly change the response of gut bacteria to the cocoa. "The evidence does not show that you can eat a chocolate bar every day and expect to improve your health," he says. A few tablespoons of unsweetened cocoa powder sprinkled onto oatmeal or a handful of cocoa nibs — bits of the cacao bean, available at natural-food stores — would be better, he says less than sweetly.

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DealBook: Seeking the Right Chemistry, Drug Makers Hunt for Mergers

Updated, 9:12 p.m. | The pharmaceutical industry is regaining its swagger, as companies turn to big and sometimes daring deals to expand and reshape their operations.

On Tuesday alone, pharmaceutical companies announced $74 billion worth of potential deals, including an unorthodox $45.6 billion bid for Allergan, the maker of Botox, and a flurry of swaps and sales between Novartis of Switzerland and GlaxoSmithKline of Britain.

More deals in the cash-rich industry are expected. In recent months, Pfizer made a number of informal takeover approaches for AstraZeneca, including one that would have been worth over $100 billion, only to be rebuffed.

The moves by drug makers have helped fuel an overall surge in recent mergers volume, which this year has more than doubled from the same period last year, to nearly $1.1 trillion — the best start in deal-making since 2007, according to data from Thomson Reuters. Pharmaceutical deals made up about 9 percent of that activity, or $93.2 billion, its highest level since 2009.

The flurry of deals highlights the most extensive efforts yet by drug makers to bolster their businesses, in many cases pursuing growth as onetime blockbuster products lose patent protection. Instead of spending money researching new products that may yield little success, several companies are instead looking to buy likely winners.

"A couple of the biggest issues are whether or not these firms can continue to be innovative and bring out products that have strong pricing power," said Damien Conover, an analyst with Morningstar. "Innovation is improving from where it was five years ago, but it isn't to the point where these firms can generate strong growth."

After Pfizer lost its patent for Lipitor in 2011, it reported an 11 percent drop in overall sales the next year.

While so-called patent cliffs are not quite the issue they once were — Mr. Conover said the largest drops took place in 2012 — companies are still scrambling to find new profitable products. While many continue to spend money on in-house research and development, those efforts are yielding less fruit than hoped.

"The productivity, while improving, is not improving fast enough," he said.

Some drug makers regard deal-making as a normal course of business. Allergan's pursuer is Valeant, a Canadian pharmaceutical company whose growth strategy revolves around acquisitions. On Tuesday, it unveiled its unsolicited takeover bid for Allergan, hoping to create a powerhouse maker of eye-care and cosmetic treatments like Botox.

Based outside Montreal, Valeant has sought to become a major specialty drug maker over the last six years by buying up businesses that are hard to replicate. Its biggest deal to date was last year's takeover of Bausch & Lomb, the eye-care specialist, for $8.7 billion. Still, it has had its eye on bigger game, first broaching the idea of a merger with Allergan a year and a half ago.

But Valeant's current approach has raised eyebrows, since it has teamed up with William A. Ackman, an outspoken hedge fund mogul known to fight loudly for change at corporations. The two formed one of the most unusual corporate pairings in recent memory: After reaching a handshake agreement in February to back a takeover bid by Valeant, Mr. Ackman began quietly accumulating shares in Allergan, carefully avoiding tripping rules that would require him to disclose his holdings. On Monday evening, he acquired enough shares to give him control of 9.7 percent of Allergan, giving him a powerful perch from which to demand a merger with his partner.

On Tuesday, Valeant took the cover off its bid, offering cash and stock that was worth about $152.89 a share.

During a nearly four-hour presentation for investors, Mr. Ackman and Valeant executives talked up the benefits of the deal. Combined, Allergan and Valeant would have annual sales of more than $15 billion, while enjoying $2.7 billion in cost savings. And the merged drug maker would benefit greatly from Valeant's low tax rate.

Both Mr. Ackman and J. Michael Pearson, Valeant's chief executive, estimated that a combined company would be valued at more than $200 a share.

During the presentation, Mr. Ackman excitedly pointed to what the combined company could do: more mergers.

"We're looking beyond this transaction," the hedge fund manager said.

For its part, Allergan responded in a statement that it was evaluating the offer with its financial and legal advisers. The drug maker is likely to consider its options, including questioning the bidding team's unusually stealthy approach.

Late on Tuesday, Allergan said that it had adopted a shareholder rights plan, a defensive move meant to keep shareholders to stakes of less than 10 percent.

Shares of Allergan surged 15 percent on Tuesday, closing at $163.65. Valeant enjoyed a smaller jump in its stock, which rose 7.5 percent to $135.41, suggesting that its investors approved of its approach. One shareholder that publicly applauded the move was ValueAct Capital, an activist hedge fund that owns a nearly 5.7 percent stake and has a seat on Valeant's board.

Several corporate advisers said that the partnership could provide a new template for cooperative deal-making between activists and companies. By teaming up with skilled veterans of boardroom fights, corporate acquirers would gain invaluable allies. And hedge funds could eliminate time looking for potential buyers of companies in which they have investments, making their bets more certain.

"This structure and this partnership has not been seen before and is raising a lot of eyebrows" among both investors and companies, said David Hunker, a banker at JPMorgan Chase who helps clients defend against activist investors.

But some advisers cautioned that several circumstances made the Valeant-Ackman team unique. The two were introduced by a mutual friend who now works for Mr. Ackman, lending a personal touch to the partnership. The two displayed a warm relationship on stage during the presentation, with Mr. Pearson repeatedly stressing that the expensive setup was being paid for by his hedge-fund friend.

"I want to reassure our investors that we are still trying to save every penny," the Valeant executive joked.

And because the deal is potentially hostile, Mr. Ackman's involvement made sense, given his experience as a Wall Street brawler. As he explained during the presentation: "We buy stakes in companies and help them do the right thing for shareholders. We have ways of doing that."

A number of Wall Street counselors also saw big risks in Valeant's decision to work with Mr. Ackman. The agreement stipulates that should the deal succeed, Mr. Ackman must hold Valeant stock for at least a year. That means Valeant will have an outspoken activist as one of its largest shareholders. And if the deal fails to deliver on its promised cost savings, Mr. Ackman could turn on his partner.

"I don't think you're going to see a rush of these kinds of partnerships," said one corporate adviser not authorized to speak on the record about the matter. "But boardrooms are scared."

A version of this article appears in print on 04/23/2014, on page B1 of the NewYork edition with the headline: Seeking the Right Chemistry .

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Well: The Limits of ‘No Pain, No Gain’

Phys Ed

Gretchen Reynolds on the science of fitness.

Exercise makes us tired. A new study helps to elucidate why and also suggests that while it is possible to push through fatigue to reach new levels of physical performance, it is not necessarily wise.

On the surface, exercise-related fatigue seems simple and easy to understand. We exert ourselves and, eventually, grow weary, with leaden, sore muscles, at which point most of us slow or stop exercising. Rarely, if ever, do we push on to the point of total physical collapse.

But scientists have long been puzzled about just how muscles know that they're about to run out of steam and need to convey that message to the brain, which has the job of actually telling the body that now would be a good time to drop off the pace and seek out a bench.

So, a few years ago, scientists at the University of Utah in Salt Lake City began studying nerve cells isolated from mouse muscle tissue. Other research had established that contracting muscles release a number of substances, including lactate, certain acids and adenosine triphosphate, or ATP, a chemical involved in the creation of energy. The levels of each of those substances were shown to rise substantially when muscles were working hard.

To determine whether and how these substances contributed to muscular fatigue, the Utah scientists began adding the substances one at a time to the isolated mouse nerve cells. Deflatingly, nothing happened when the scientists added the substances individually.

But when they exposed the cells to a combination of all three substances, many of the nerve cells responded. In living muscle tissue, these neurons presumably would send messages to the brain alerting it to growing muscular distress. Interestingly, the scientists found that different neurons responded differently, depending on how much of the combined substances the scientists added to the lab plates containing the mouse nerve cells.

Since rodent nerve cells are not people, however, the scientists next decided to repeat and expand the experiment in humans. For a study published in February in Experimental Physiology, they recruited the thumbs of 10 adult men and women. The entire volunteers showed up at the lab, but only their thumbs were needed, since the researchers wanted to study muscles that were accessible and easily held still. Those in the thumb served nicely.

So, asking each volunteer not to move his or her hand, the researchers injected lactate, ATP or the various acids just beneath the tissue covering one of the muscles in the thumb. After the discomfort from the injection had faded, they asked the volunteers if they felt anything. None did.

They then injected volunteers' thumbs with the three substances combined and at a level comparable to the amounts produced naturally during moderate exercise. After a few minutes, the volunteers began to report sensations similar to fatigue, describing their thumbs as feeling heavy, tired, puffy, swollen and, in one case, "effervescent," although the thumbs had not been exercised at all.

In a subsequent injection, the researchers increased the amount of the combined substances until they approximated those produced during strenuous exercise. The volunteers reported intensified sensations of muscular fatigue and also some glimmerings of aching and pain.

Finally, the researchers upped the levels of the substances until they were similar to what is seen during all-out, exhausting muscular contractions. After this injection, the volunteers reported considerable soreness in their thumbs, as if the muscles had been completing a grueling workout.

What the study's findings indicate, said Alan R. Light, a professor at the University of Utah and senior author of the study, is that the feeling of fatigue in our muscles during exercise "probably begins" when these substances start to build up. Small amounts of the combined substances stimulate specific nerve cells in the muscles that, through complicated interactions with the brain, cause the first feelings of tiredness and heaviness in our working muscles.

These feelings bear only a slight relationship to the remaining fuel and energy in our muscles. They don't indicate that the muscle is about to be forced to stop working. But they are an early physiological warning system, a way for the body to recognize that somewhere up ahead lies a limit.

Each subsequent increase in the levels of lactate and other substances amplifies the sense of fatigue, Dr. Light said, until the substances become so concentrated that they apparently activate a different set of neurons, related to feelings of pain. At that point, the exercise starts to hurt and most of us sensibly will quit, staving off muscle damage should we continue.

Of course, improvements in physical performance sometimes demand that we continue through fatigue and on to achiness. "There is some truth" to the adage about "no pain, no gain," Dr. Light said. But disregarding all the signals from your muscles can be misguided, he said.

In recent experiments at his lab, cyclists who were given mild opiates that block the flow of nerve messages from the muscles to the brain and vice versa could ride faster than they ever had before, with a sense of unfettered physical ease — until, without warning, their leg muscles buckled and, limp and nearly paralyzed, they had to be helped from their bikes. "Ignoring fatigue and pain is not a good, long-term competitive strategy," Dr. Light said.

Better, he said, to attend to the messages from your muscles and calibrate training accordingly. Should your exercise goal be to become faster or stronger, find a pace or intensity that allows you to work out near and occasionally just beyond the boundary between fatigue and pain, a line that will differ for each of us and vary day to day. If on the other hand, your goal, like mine, is easier, pleasurable and sustainable exercise, consider an intensity at which your muscles grow only slightly heavy and tired and, if we are fortunate, effervescent.

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The Well Column: The Lure of Forbidden Food

The Well Column

Tara Parker-Pope on living well.

How hard will your child work for food?

In an experiment, researchers at Pennsylvania State University gave preschool children the opportunity to "work" for a food reward. All the child had to do was click a computer mouse four times to earn a cinnamon-flavored graham cracker.

But earning additional treats required progressively more effort. A second treat required eight clicks. Then 16. Then 32.

Some children were satisfied after one cracker, while others kept clicking for a few additional crackers. Most of the preschoolers were done after about 15 minutes, but some children stayed with it, accumulating as many as 2,000 clicks before the researchers ended the task after 30 minutes.

Children who are highly motivated by food — researchers have called them "reactive eaters" — are of particular interest to childhood health experts. Were they born this way? Or do parents create reactive eaters by imposing too many food rules and imposing restrictive eating practices at home?

The answer is probably a little bit of both. Genetics and biology play a role in the foods we like and the amounts we tend to eat. At the same time, studies show that children who grow up in homes with restrictive food rules, where a parent is constantly dieting or desirable foods are forbidden or placed out of reach, often develop stronger reactions to food and want more of it when the opportunity presents itself.

In the Penn State experiments, the same preschoolers who worked for food were later offered two types of graham crackers (Scooby-Doo or SpongeBob SquarePants) during their snack time. On five occasions, one type of graham cracker treat was freely available, while the other was placed in a glass bowl with a lid and put off limits. The restricted snacks were available for only five minutes of snack time.

Not surprisingly, the graham crackers that were off limits were enticing to all the preschoolers. But the children who had worked hardest in the clicking task — the "reactive" ones — also had the strongest response to the forbidden food.

They showed more interest in the off-limit snacks, and once they were available, took more and ate more than the children who had been less interested in clicking for food during the first experiment.

"The message is that restriction is counterproductive — it just doesn't work very well," said Brandi Rollins, a Penn State postdoctoral researcher and lead author of the study, which was published in February in the journal Appetite. "Restriction just increases a child's focus and intake of the food that the parent is trying to restrict."

Leann Birch, senior author of the Penn State studies and now food and nutrition professor at the University of Georgia, said additional research has shown that parents who impose highly restrictive food rules, such as putting desirable foods out of reach, tend to have children who are the most reactive to food in the laboratory.

"It's hard to talk cause-and-effect," said Dr. Birch. "The parents are responding to kids' reactivity, and the child is reacting to the parenting and to a general genetic predisposition. The only way to break the cycle is to try to get the parents to respond differently."

While restrictive feeding practices can backfire, that doesn't mean children should have unfettered access to all foods. Instead, parents should be aware that tight control over food can set off overeating in some children. The solution is to control the quality of the food in the home.

Don't buy soda, candy and chips and place them off limits on the top shelf of the pantry. Stock the house with healthful foods, and then allow children access and a reasonable amount of control over what they eat. At snack time, for instance, give them a choice between an apple or orange or vegetables with different dips.

The primary food rule should be "a high quality diet for all," said Dr. David Ludwig, director of the New Balance Foundation Obesity Prevention Center at Boston Children's Hospital.

Parents should not have different rules for themselves, or allow a thin child to eat junk food freely and restrict a sibling with a weight issue. Parents typically don't have to worry about an overweight child overeating when they are serving high-quality unprocessed foods. For instance, it's almost impossible to binge on apples. But process the apple into applesauce or juice, and it becomes a junk food that is easy to overeat.

Occasional treats outside the home are fine. "Take the kid out for ice cream once or twice a week, but don't keep it in the house," Dr. Birch said. Dr. Ludwig noted that with young children, parents needed to set more limits. But adolescents should be given more freedom to eat.

"I don't like the concept of telling a hungry child you can't eat," said Dr. Ludwig. "Ultimately, we want children to gain better connection to their inner satiety cues. So if their body is telling them they are hungry, don't ignore that — just pay close attention to the quality of the foods that are offered."

A version of this article appears in print on 04/22/2014, on page D6 of the NewYork edition with the headline: The Lure of Forbidden Food .

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The New Old Age Blog: For Stone Phillips, a Focus on the Home Front

Originally, Stone Phillips told me, he intended to shoot a kind of home movie.

His parents, after deliberating with their three children for a year, were about to leave their independent living apartment in St. Louis for a similar one in North Carolina, near their daughter's home. She would supervise their care as their mother's dementia progressed.

"I wanted to chronicle the move," Mr. Phillips, 59, the former network news correspondent and anchor, told me. "And I wanted to capture her before the dementia became too advanced."

So as Grace and Vic Phillips, then 88 and 92, began saying their goodbyes to their many local friends and neighbors, fellow church members, even that nice lady at the bank, their youngest child kept his camcorder rolling and asked lots of questions.

The elder Phillipses had lived in St. Louis for decades. She'd taught school; he'd been a chemical engineer at Monsanto. Leaving would be wrenching. "If that's what you think is best, I'll go with the program," Grace Phillips says onscreen, bravely trying to conceal confusion and anxiety beneath relentless sunniness. "It's going to be a whole new chapter."

At this point, the handwriting had been on the wall for many months. She was already experiencing memory loss. Her husband, who no longer drove, would have had trouble taking care of her on his own. She'd recently taken one of his blood pressure medications by mistake, passed out and wound up at the hospital. Their children lived in North Carolina, Wisconsin and New York. It was time.

"Even as she reluctantly consented, it was kind of heartbreaking," Mr. Phillips said. "It was difficult for them and for us; an unsettling process" — but one, he knew, that many families were experiencing. "The more the story unfolded, it occurred to me it could be shared." His family consented.

The resulting documentary, "Moving With Grace," has been shown by 20 public television stations around the country since its debut on the St. Louis affiliate almost a year ago. WNET in New York will air it on Sunday, April 20, at 7 p.m. KCTS in Seattle and KYVE in Yakima, Wash., will show it on May 11 — Mother's Day — at 2 p.m. Distributed by American Public Television, it's likely to pop up on other stations in coming months.

Keep an eye out for it. "Moving With Grace" is a frank and moving story that Mr. Phillips hopes will stimulate discussions in other families. His was fortunate that his parents agreed to relocate and could afford a continuing care retirement community. But in many ways, theirs is becoming a universal saga.

Since moving into their new complex in June 2011, the couple has graduated from independent to assisted living. Vic Phillips, feeling isolated and depressed at first, found assisted living friendlier. Now 95, he works out daily in the gym and solves crossword puzzles online.

Grace Phillips, 91, remains "her cheery, rosy, amazing self," her son said. But she has declined since he shot the film. When her son flies in from New York, sometimes she recognizes him and "sometimes she thinks I'm a nice young man who's come to visit."

Soon, she will need to move into the memory care unit, and the couple will be separated for the first time since they married in 1945. At least, their children think, they will be only a few hallways apart.

Mr. Phillips is glad they moved when they did. And he's glad, for personal reasons, to have recorded his still-vibrant mother a couple of years ago. "It's a treasure for me, seeing her be herself," he said.

He's a professional, but you don't have to be to follow his lead. "I'd encourage people: Take out your phone, do some interviews, get some video," he said. "It's precious to have."

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Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."

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This post has been revised to reflect the following correction:

Correction: April 21, 2014

An earlier version of this post incorrectly described Vic Phillips's position at Monsanto. He was a chemical engineer, not an executive.

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Well: Lifesaving Procedure With an Image Problem

Personal Health

Jane Brody on health and aging.

Sandra Haber, a 65-year-old psychologist in Brooklyn, wants everyone to know how easy it is now to donate bone marrow. Hers was failing.

She was anemic, bled easily and had little resistance to infection. As her condition progressed toward leukemia, doctors at Memorial Sloan-Kettering Cancer Center urged her to get a bone-marrow transplant. Fortunately, there was a donor: Testing showed that a sister living in New Mexico was a perfect match.

But at first Ms. Haber's sister was hesitant about donating, fearful of the general anesthesia, painful withdrawal of marrow from a hip bone and difficult recovery she thought was involved. Nonetheless, she came to New York for further tests and learned that the process was simple and safe: basically a lengthy blood donation after a week of daily injections to spur her own bone marrow to produce an oversupply of stem cells.

About 90 percent of bone marrow "transplants" are now done this way, most often with stem cells from a matched donor's blood, sometimes from a baby's umbilical cord and placenta or the patient's own stem cells. After the recipient's own dysfunctional marrow is destroyed by intensive chemotherapy and sometimes total body radiation, the donated stem cells are infused into the recipient's blood through a special intravenous line, called a central line. The cells find their way to bone marrow, where they gradually restore the recipient's ability to produce red and white blood cells and platelets.

"A stem cell transplant is not a walk in the park," Ms. Haber said. "It's more like a marathon than a sprint, and the healing process is long and not linear."

It typically takes six months to a year to regain full blood cell production and immune function.

But it is far from the ordeal that traditional marrow transplantation can be. Even Ms. Haber's weeks in the hospital in relative isolation were not especially difficult. She described the fatigue afterward as more of a hardship, but that too abated as she has gradually regained her former energy. Last week she prepared a Seder for 27 relatives.

Now Ms. Haber wonders why a sign in her hospital still reads "Bone Marrow Transplant Unit," when in fact marrow donation is a rarity and the thought of it may scare off potential donors.

Many in need of healthy bone marrow die before a good match can be found. Ms. Haber thinks if the language changed, far more people from diverse ethnic and racial groups might be willing to join bone marrow donor registries — whose names perhaps should also be changed.

Donors must be healthy and age 18 to 60. All that registration involves is a cheek swab from which the donor's tissue type is analyzed and stored in a national database.

When someone who needs new bone marrow has no close match among eligible relatives, doctors check the registry for a matching volunteer elsewhere. The need is especially great for patients who are African-American, Asian or of mixed ethnic or racial backgrounds.

A match is determined by checking proteins called HLA antigens present on cells from the donor and recipient. As with other traits, people inherit the genes that determine these antigens from each parent; the more genetically distant the parents, the less common the mix of antigens is likely to be. Without a very close match, the donor's cells are likely to attack the recipient's tissues, a potentially fatal complication called graft-versus-host disease.

Stem cell transplants can help people whose bone marrow is diseased or dysfunctional and unable to produce the red blood cells that carry oxygen, white blood cells that fight infections, or platelets that enable the blood to clot. Such conditions include cancers like leukemia, certain lymphomas, multiple myeloma and aplastic anemia; inherited disorders like sickle cell anemia and thalassemia; and severe immune deficiency disorders in newborns.

For cancer patients, a stem cell transplant offers an additional benefit: The new blood cells can attack errant cancer cells that may have survived the original chemotherapy.

Two years ago Steven Satrom, 66, a retired engineer in Allentown, Pa., developed acute myeloid leukemia, a disease that responds fully to chemotherapy in fewer than half of cases. Mr. Satrom decided to try chemo first, but when his cancer recurred eight months later, a stem cell donation gave him a renewed lease on life.

Like Ms. Haber, he was lucky enough to have a well-matched sibling. Treatment began with chemotherapy to kill off the cancer cells. His brother flew in from Oklahoma, and after a thorough health checkup, was hooked up to two intravenous lines, one to remove blood and pass it through a machine that extracted stem cells, the other to return his blood.

Mr. Satrom was hospitalized in modified isolation for several weeks while the donated stem cells repopulated his bone marrow and reduced his susceptibility to infection. Like Ms. Haber, he was given drugs to fight bacterial, fungal and viral infections. Mr. Satrom also took anti-rejection drugs to quell a graft-versus-host reaction.

Upon returning home, both Mr. Satrom and Ms. Haber were told to avoid fresh, uncooked foods (unless they could be peeled at home), red meat, shellfish and raw fish, and not to eat restaurant or takeout food.

"I simply cooked everything myself and had small dinner parties for family and friends," Ms. Haber said. Both patients also had to avoid handling pets and their waste, and to reduce their exposure to people, especially young children, who might have an infectious disease.

Now, six to eight months after their transplants, the restrictions have been greatly reduced, though both recipients soon must be revaccinated against childhood diseases, because they lost that protection when their own bone marrow was destroyed.

Stem cell transplants are also expensive, averaging $100,000 to $200,000. Prospective patients are urged to check with their insurance carriers before embarking on the process. Both Ms. Haber and Mr. Satrom said they were fortunate to be covered for everything except deductibles and co-pays.

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The New Old Age: Are Blood Pressure Drugs Worth the Falls?

For older Americans, high blood pressure is a fact of life. By one common estimate, more than 70 percent of those over age 70 contend with it. That means medication to lower blood pressure has become a fact of life, too.

Diuretics, beta blockers, calcium channel blockers, the unpronounceable renin-angiotensin system blockers — in a study looking at a national sample of almost 5,000 Medicare beneficiaries with hypertension, more than 85 percent were taking at least one of these classes of blood pressure drugs. Most took two or three, or more.

They did so because randomized clinical trials, the supposed gold standard of medical research, have shown that these drugs reduce heart failure, heart attacks and stroke without scary side effects. "The prevailing notion is that these medications are safe, with very few adverse effects," said Dr. Mary Tinetti, chief of geriatrics at the Yale School of Medicine, and lead author of the study.

But the people enrolled in clinical trials, she pointed out, are typically healthier than older adults in general. Investigators often exclude people who have other medical problems — "co-morbidities," in doctor-speak — or who are taking several other medications. Yet the great majority of the older people who show up at doctors' offices do have multiple chronic conditions and are taking lots of prescription drugs.

So Dr. Tinetti and her team have been looking into whether anti-hypertensive drugs might be causing problems in the real world beyond clinical trials. They followed those 5,000 older people (average age: 80) with hypertension for up to three years, and the results of their study are disturbing: The risk of serious fall injuries — fractured bones, brain injuries or dislocated joints — was significantly higher among those who took anti-hypertensives than among those who didn't.

Over the three-year follow-up, 9 percent of the subjects were badly hurt by falls, which can have a devastating effect. "The outcomes are just as serious as the strokes and heart attacks for which we give these medications," Dr. Tinetti told me in an interview. "Serious fall injuries are as likely to lead to death or lasting functional disability."

More than half of the people in the study group were classified as moderate users of anti-hypertensives based on the number and doses of the drugs they took. In that category, serious fall injuries were 40 percent higher than among people who didn't take anti-hypertensives.

In the group considered high-intensity users, serious injuries from falls were 28 percent higher than among non-users. And the risk more than doubled among drug users who'd already had a serious fall injury in the previous year.

Although this study doesn't prove that taking the drugs led to the falls, anti-hypertensive medications are among the logical suspects. "They can drop people's blood pressure too much when they stand," Dr. Tinetti said. "They can make them fatigued, confused, dizzy. Those are all risk factors for falls."

(Medical authorities already advise relaxing the goals for lowered blood pressure among older patients. The most recent guidelines from an expert panel say that patients over age 60 with hypertension, but without diabetes or kidney disease, should aim for 150/90. The previous recommendation had been 140/90, but more recent research suggests that was unreasonably low — though patients who reached those numbers without problems need not change their regimens. The 140/90 target holds for those with diabetes or kidney disease.)

The Yale findings, which were published this month in JAMA Internal Medicine, mean that blood pressure management enters one of those increasingly common medical gray zones, in which individuals and caregivers have to ask a lot of questions and balance the trade-offs.

Do you avoid a heart attack by using drugs associated with an almost equal risk of breaking a hip or injuring your brain? Especially since another Yale study using the same sample found that use of anti-hypertensive drugs didn't reduce the rate of cardiovascular events, though it did reduce mortality among those who suffered them?

The Yale team actually asked that leading question of a small group of 123 people over age 70 who had high blood pressure and were at risk for falls. Given that doctors could not magically reduce their cardiovascular risk without increasing fall risk and medication side effects, what was most important to them?

About half the group said their priority was reducing cardiovascular risk over reducing serious fall injuries and medication symptoms. The other half placed greater importance on fewer falls and side effects.

It's a question millions of older people now have to ask themselves, and not only themselves. "It's time to ask your doctor, 'Knowing all my other conditions and my fall risks, do I need all these medications?'" Dr. Tinetti said. "'Are they doing me more harm than good?'"

I wondered aloud how many physicians were prepared to have this possibly lengthy discussion. Dr. Tinetti answered, "It's really up to patients and their caregivers to make it clear: 'This is something important to me.'"

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Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."

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Well: Ask Well: Are Exercise Cool Downs Necessary?

A

A lot of cardiovascular exercise routines call for a cool-down at the end. Is this necessary?

"For a long time, the theory was that cooling down by continuing to exercise at a lower intensity would help the legs flush out lactate" and avoid soreness the next day, said Ross Tucker, a South African physiologist and a founder of the website The Science of Sport. "That's still dogma among many coaches and athletes."

But it is a myth. "We now know that lactate isn't responsible for muscle damage or soreness," Dr. Tucker said, and cooling down does not rid muscles of it anyway.

The available scientific evidence shows, in fact, little benefit from cooling down as most of us do it, with a prolonged, slow easing of physical effort. In a representative 2007 study, healthy adults briskly walked for 30 minutes backward on a treadmill set at an incline to simulate going downhill, an activity known to induce sore muscles.

Some of the group warmed up first with a gentle, forward-facing 10-minute walk. Others did the same afterward, as a cool-down. A few did neither. Two days later, the walkers who had warmed up reported less muscle soreness than the others. But those who had cooled down were just as sore as those in the control group.

Which is not to say that you should abruptly end a workout. During lengthy, strenuous exercise, blood vessels in your legs expand, and blood can pool there if you shift suddenly from high to zero exertion, resulting in dizziness or fainting. A few minutes of jogging, walking or other light exertion will normalize blood flow, Dr. Tucker said.

Meanwhile, there is no evidence that longer cool-downs are harmful, Dr. Tucker pointed out, so if you enjoy cooling down, continue. You have little to lose, except time.

Do you have a health question? Submit your question to Ask Well.

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Well: The Antidepressant Generation

"I think our experiment failed," the young graduate student told me, referring to our attempt to take her off the antidepressant she'd been on for seven years. She was back in my campus office after a difficult summer break, and as she talked about feeling unsettled and upset, I wondered about the broader experiment playing out on college campuses across the country.

Antidepressants are an excellent treatment for depression and anxiety. I've seen them improve — and sometimes save — many young lives. But a growing number of young adults are taking psychiatric medicines for longer and longer periods, at the very age when they are also consolidating their identities, making plans for the future and navigating adult relationships.

Are we using good scientific evidence to make decisions about keeping these young people on antidepressants? Or are we inadvertently teaching future generations to view themselves as too fragile to cope with the adversity that life invariably brings?

My patient had started medication as a college freshman, after she'd become depressed and spent much of her time in bed. She was forced to take a medical leave but improved quickly, returned to school and graduated. She married soon after and worked for a few years, feeling well all the while.

Professional guidelines recommend six to nine months of medicine for first episodes of depression. But my patient had never been advised to stop taking it. She reluctantly agreed to my recommendation to taper off her antidepressant.

For a couple of months she didn't feel any different, except, she said, things "moved" her more than before. It wasn't that she was sad more frequently. Rather, she was having emotional reactions, including tearfulness, more readily. This didn't seem problematic to either of us.

When I recommend to my patients that they come off antidepressants, I encourage them to choose a relatively transition-free time in their lives, so that we don't mistake what might be a normal reaction to a stressful situation for symptoms of recurrent depression. But because I work with university students, it's close to impossible to find such a time.

Indeed, the psychologist Jeffrey Arnett calls the young adult years "the age of instability." Dr. Arnett coined the term "emerging adulthood" to define a new psychological developmental stage for 18- to 29-year-olds in industrialized countries. But now, growing numbers of young people experience rapidly changing living situations, classes, jobs and relationships only while taking an antidepressant.

My patient had moved away from her husband to start graduate school, since his job kept him in another state. She'd expected the temporary separation to be hard but navigated it smoothly, focusing on school, with occasional visits.

In the summer, she moved in with him and was surprised to feel emotionally "muted." It was nothing like her college depression, but she worried. She'd counted on the reunion being easy.

As she looked back, she acknowledged that moving again, leaving behind new school friends and routines, and not having the structure of school or work to fill her time might have challenged anyone. She noticed small ways in which she and her husband were growing in different directions, and this alarmed her. She wanted to resume medication, thinking that maybe the summer would have gone better with an antidepressant.

Major depression in adults is often recurrent: half of people with first episodes will have a second episode. The current standard of care is to recommend medicine indefinitely after three or more recurrences, or even after a second episode if certain other risk factors are present.

However, these recommendations are based on evidence gathered in clinical trials of moderate-to-severe depression in adults older than the students I treat. Many studies were short-term; few followed patients for longer than two years. Some were funded by the pharmaceutical industry, which has a financial stake in keeping people on medicine indefinitely.

Children and adolescents increasingly take antidepressants. In 2009, a large trial called the Treatment for Adolescents With Depression Study showed that those who took an antidepressant in conjunction with therapy for nine months were much less depressed, and less suicidal, in the year after stopping treatment than those without treatment — so clearly treatment is critical. But for how long? And is medicine on its own, without therapy, sufficient?

More students arrive on campus already on antidepressants. From 1994 to 2006, the percentage of students treated at college counseling centers who were using antidepressants nearly tripled, from 9 percent to over 23 percent. In part this reflects the introduction of S.S.R.I. antidepressants, a new class of drugs thought to be safer and have fewer side effects than their predecessors.

At the same time, direct-to-consumer advertising of prescription drugs also became commonplace. Some of this very helpfully reduces stigma, allowing people who are suffering from depression to get much-needed relief. But it also creates demand where genuine need may be less clear.

College deans have written about incoming freshman being "crispies" or "teacups": the crispies so burned out by the pressures of high school that they get to college unable to engage in the work, and the teacups so fragile or overprotected in their formative years that they fall apart at the first stress they encounter.

In my experience, the attempt to stop antidepressants in college students goes well less often than the prevalence of depression suggests it should. Some students probably do have chronic mental health issues that require long-term treatment. But others are also drinking alcohol heavily, or using drugs like marijuana or their roommate's Adderall, or suffering from other problems, such as eating disorders, that they'd rather not confront.

Others have just experienced loss, or rejection, and medicine may have become a panacea to which they turn at the first signs of unhappiness. Some resume antidepressant use on their own, and by the time they return to see me it's impossible to assess whether they in fact had a recurrence of their depression; we're often then committed to another course of treatment. We now know that the young adult brain is still changing and developing much more than previously assumed. But we still lack a clear understanding of how psychiatric medicines might affect this brain development.

My patient and I reviewed her symptoms, and I assessed her for serious risks, such as thoughts of suicide. This is a critical part of psychiatric care, and often where the psychiatric encounter ends — with a prescription. That may be completely appropriate when driven by clinical judgment. But sometimes it's a matter of expediency. The doctor doesn't have the time to go into all the other treatment options, or the student lacks the time or motivation to pursue therapy, or stop drinking, or work on self-care.

Insurance often doesn't cover much therapy; medicine is cheaper in the short-term. My patient was not in another major depressive episode, but she didn't want to wait "until it got to that point."

We discussed the milder and more chronic form of depression known as dysthymia. Though she hadn't had symptoms long enough to warrant that diagnosis, the most conservative approach was still to just resume the medicine.

But my patient's symptoms were only one part of a compelling life story: that of a young woman trying to balance personal aspirations with intimacy. She was discounting her emotional reactions to difficult life events. These struggles might be the very moments that precipitate personal growth.

Emerging adults are at such a critical juncture in their lives; it seemed important for my patient to have a chance to explore her relationship with her husband and her expectations about work and love and herself. She agreed, opting to try therapy first and defer medication.

We walk a thinning line between diagnosing illness and teaching our youth to view any emotional upset as pathological. We need a greater focus on building resilience in emerging adults. We need more scientific studies — spanning years, not months — on the risks and benefits of maintenance treatment in emerging adults. Maybe someday, treating people like this young graduate student, I won't have to feel like we're conducting an experiment of one.

Doris Iarovici, a psychiatrist at Duke University, is the author of "Mental Health Issues and the University Student."

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Well: Younger Skin Through Exercise

Phys Ed

Gretchen Reynolds on the science of fitness.

Exercise not only appears to keep skin younger, it may also even reverse skin aging in people who start exercising late in life, according to surprising new research.

As many of us know from woeful experience, our skin changes as the years advance, resulting in wrinkles, crow's feet and sagging skin. This occurs because of changes within our layers of skin. After about age 40, most of us begin to experience a thickening of our stratum corneum, the final, protective, outer layer of the epidermis, itself the top layer of your skin. The stratum corneum is the portion of the skin that you see and feel. Composed mostly of dead skin cells and some collagen, it gets drier, flakier and denser with age.

At the same time, the layer of skin beneath the epidermis, the dermis, begins to thin. It loses cells and elasticity, giving the skin a more translucent and often saggier appearance.

These changes are independent of any skin damage from the sun. They are solely the result of the passage of time.

But recently, researchers at McMaster University in Ontario began to wonder if such alterations were inevitable. Earlier studies at McMaster involving mice that were bred to age prematurely had shown that a steady regimen of exercise could stave off or even undo the signs of early aging in these animals. When members of this breed of mice remained sedentary, they rapidly grew wizened, frail, ill, demented, and graying or bald. But if they were given access to running wheels, they maintained healthy brains, hearts, muscles, reproductive organs, and fur far longer than their sedentary labmates. Their fur never even turned gray.

Of course, we humans long ago swapped our fur for naked skin. But if exercise could keep animals' outer layer from changing with age, it might, the researchers speculated, do the same for our skin.

To test that possibility, the scientists first gathered 29 local male and female volunteers ages 20 to 84. About half of the participants were active, performing at least three hours of moderate or vigorous physical activity every week, while the others were resolutely sedentary, exercising for less than an hour per week. Then the researchers asked each volunteer to uncover a buttock.

"We wanted to examine skin that had not been frequently exposed to the sun," said Dr. Mark Tarnopolsky, a professor of pediatrics and exercise science at McMaster who oversaw the study, which was presented this month at the American Medical Society for Sports Medicine annual meeting in New Orleans.

The scientists biopsied skin samples from each volunteer and examined them microscopically. When compared strictly by age, the skin samples overall aligned with what would be expected. Older volunteers generally had thicker outer layers of skin and significantly thinner inner layers.

But those results shifted noticeably when the researchers further subdivided their samples by exercise habits. They found that after age 40, the men and women who exercised frequently had markedly thinner, healthier stratum corneums and thicker dermis layers in their skin. Their skin was much closer in composition to that of the 20- and 30-year-olds than to that of others of their age, even if they were past age 65.

But as the researchers realized, other factors, including diet, genes and lifestyles, might have influenced the differences in skin condition between the exercising and sedentary groups. It was impossible to know whether exercise by itself had affected people's skin or been incidental to lucky genetics and healthy lives.

So the researchers next set a group of sedentary volunteers to exercising, after first obtaining skin samples from their buttocks. The volunteers were aged at 65 or older and, at the study's start, had normal skin for their age. They began a fairly straightforward endurance training program, working out twice a week by jogging or cycling at a moderately strenuous pace, equivalent to at least 65 percent of their maximum aerobic capacity for 30 minutes. This continued for three months. At the end of that time, the researchers again biopsied the volunteers' skin.

But now the samples looked quite different, with outer and inner layers that looked very similar to those of 20- to 40-year-olds. "I don't want to over-hype the results, but, really, it was pretty remarkable to see," said Dr. Tarnopolsky, himself a middle-aged exerciser. Under a microscope, the volunteers' skin "looked like that of a much younger person, and all that they had done differently was exercise."

How exercise changes skin composition is not completely clear, but in a separate portion of the study, the researchers checked for alterations in the levels of certain substances created by working muscles. Called myokines, these substances are known to enter the bloodstream and jump-start changes in cells far from the muscles themselves. In this case, the scientists found greatly augmented levels of a myokine called IL-15 in the skin samples of volunteers after exercise. Their skin samples contained almost 50 percent more IL-15 after they had been exercising than at the start of the study.

The researchers suspect that additional myokines and substances are also involved in the skin changes related to exercise, Dr. Tarnopolsky said, making it unlikely that any IL-15 pill, salve or injection will ever replicate the skin benefits of a workout.

Nor is there evidence that exercise reverses wrinkling and other damage from the sun, some of which many of us accumulate during outdoor exercise. Still, Dr. Tarnopolsky said, "it is astonishing to consider all of the intricate ways in which exercise changes our bodies" —including the skin beneath our shorts.

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Well: A Number That May Not Add Up

Personal Health

Jane Brody on health and aging.

In July 1998, the National Institutes of Health changed what it means to be overweight, defining it as a body mass index of 25 or greater for adults. The cutoff had been 28 for men and 27 for women, so suddenly about 29 million Americans who had been considered normal became overweight even though they hadn't gained an ounce.

The change, based on a review of hundreds of studies that matched B.M.I. levels with health risks in large groups of people, brought the country in line with definitions used by the World Health Organization and other health agencies. But it also prompted many to question the real meaning of B.M.I. and to note its potential drawbacks: labeling some healthy people as overweight or obese who are not overly fat, and failing to distinguish between dangerous and innocuous distributions of body fat.

More recent studies have indicated that many people with B.M.I. levels at the low end of normal are less healthy than those now considered overweight. And some people who are overly fat according to their B.M.I. are just as healthy as those considered to be of normal weight, as discussed in a new book, "The Obesity Paradox," by Dr. Carl J. Lavie, a cardiologist in New Orleans, and Kristin Loberg.

Unlike readings on a scale, B.M.I. is based on a person's weight in relation to his height. It is calculated by dividing weight in kilograms by height in meters squared (or, for those not metric-savvy, weight in pounds divided by height in inches squared and the result multiplied by 703).

According to current criteria, those with a B.M.I. below 18.5 are underweight; those between 18.5 and 24.9 are normal; those between 25 to 29.9 are overweight; and those 30 and higher are obese. The obese are further divided into three grades: Grade 1, in which B.M.I. is 30 to 34.9; Grade 2, 35 to 39.9; Grade 3, 40 and higher.

Before you contemplate a crash diet because your B.M.I. classifies you as overweight, consider what the index really represents and what is now known about its relationship to health and longevity.

The index was devised in the 1830s from measurements in men by a Belgian statistician interested in human growth. More than a century later, it was adopted by insurers and some researchers studying the distribution of obesity in the general population. Though never meant to be an individual assessment, only a way to talk about weight in large populations, B.M.I. gradually was adopted as an easy and inexpensive way for doctors to assess weight in their patients.

At best, though, B.M.I. is a crude measure that "actually misses more than half of people with excess body fat," Geoffrey Kabat, an epidemiologist at the Albert Einstein College of Medicine, has noted. Someone with a "normal" B.M.I. can still be overly fat internally and prone to obesity-related ills.

Calling B.M.I. an imperfect predictor of a person's health risks, the Centers for Disease Control and Prevention cautions doctors against using it as a diagnostic tool.

For one thing, body weight is made up of muscle, bone and water, as well as body fat. B.M.I. alone is at best an imprecise measure of how fat a person may be. When Arnold Schwarzenegger was Mr. Universe, his B.M.I. was well in the obese range, yet he was hardly fat.

Another problem: the distribution of excess body fat makes a big difference to health. Those with lots of abdominal fat, which is metabolically active, are prone to developing insulin resistance, elevated blood lipids, high blood pressure, diabetes, premature cardiovascular disease, and an increased risk of erectile dysfunction and Alzheimer's disease.

But fat carried in the hips, buttocks or thighs is relatively inert; while it may be cosmetically undesirable, it is not linked to chronic disease or early death.

Furthermore, a person's age, gender and ethnicity influence the relationship between B.M.I., body fat and health risk. Among children, a high B.M.I. is a good indicator of excess fat and a propensity to remain overly fat into adulthood. But for an elderly person or someone with a chronic disease, a B.M.I. in the range of overweight or obesity may even be protective. Sometimes — after a heart attack or major surgery, for example — extra body fat can provide energy that helps the patient to survive. An added layer of fat can also protect against traumatic injuries in an accident.

On average, women have a higher percentage of body fat in relation to total weight than do men, but this does not necessarily raise their health risks. And African-Americans, who tend have heavier bones and weigh more than Caucasians, face a lower risk to health even with a B.M.I. in the overweight range.

Physical fitness, too, influences the effects of B.M.I. In an editorial in JAMA last year, Dr. Steven B. Heymsfield and Dr. William T. Cefalu of the Pennington Biomedical Research Center in Baton Rouge, La., noted that "cardiorespiratory fitness" is an independent predictor of mortality at any level of fatness.

While experts continue to debate whether a person can be "fit and fat," Keri Gans, a dietitian in New York and former spokeswoman for the Academy of Nutrition and Dietetics, points out that physical activity and a healthy diet tend to offset the risks of being overweight.

"You don't need to be thin to be fit," she said. At any weight, fitness can reduce the risk of developing heart disease, lung disease, diabetes or high blood pressure.

At the other end of the weight spectrum, people with a low-normal or below-normal B.M.I. (less than 18.5) face a different set of health risks. They may lack sufficient reserves to survive a serious health problem, and they are prone to osteoporosis, infertility and serious infections resulting from a weakened immune system.

Last year a widely publicized meta-analysis covering more than 2.88 million people and 270,000 deaths found that those whose B.M.I. indicated they were overweight and those with Grade 1 obesity were not at a greater risk of death than those in the normal range. And a new analysis of 32 studies by researchers in Australia concluded that for older people, being overweight did not increase mortality, but the risk rose for those at the lower end of normal, with a B.M.I. of less than 23.

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The New Old Age: Wounded by the Language of War

When did the language we use to talk about death start to resemble a Pentagon briefing, full of military references and combat analogies?

Maybe it dates to 1971, when Richard Nixon declared a "war on cancer." Or much earlier, in the late 1800s, when doctors began using the word "armamentarium" to describe all the techniques, materials and equipment available to treat disease.

Certainly these metaphors have since become pervasive, among patients and physicians, the public and the news media. Family members seek aggressive treatment for an ailing relative, saying, "He's a fighter," or "She's a survivor." We talk about whether people with terminal diseases want "heroic measures" or not.

And when people die, we portray them not as having succumbed to disease, but as having struggled to the very end before being vanquished by a superior foe. Recent death notices in The New York Times (which are placed by families, as opposed to the obituaries written by reporters) memorialized a woman in her 90s who died "after a valiant battle against Alzheimer's and Parkinson's" and a 93-year-old man who died "after a long-fought battle with prostate cancer."

The bellicose wording "reflects some of the death-denying and death-defying feelings we find in our culture," said Dr. Daniel Johnson, a palliative-care physician in Denver who directs the Kaiser Permanente Care Management Institute. "Society sees death as the enemy, so it's not surprising we turn to language that references war."

But that can have unhappy real world consequences, Dr. Johnson recently cautioned in a talk at the Association of Health Care Journalists' national conference. Patients have taken him aside to confess that they dread another round of chemotherapy but fear disappointing those who expect them to "fight."

"They're nervous about what their doctors and their families might think," he told me in an interview. What they may actually want to say is that "I've lived a really good life, and now I want to spend time with my family" instead of at a dialysis center or in intensive care.

To spend one's final weeks or months free of that pressure can be "potentially transformative and beautiful," Dr. Johnson said. Often, though, to "give up" has become shameful.

Consider the couple whom Patrice Villars, a gerontological and palliative-care nurse-practitioner, is working with at the VA Medical Center in San Francisco. He's nearly 90, has metastatic lung cancer, can no longer leave his hospital bed, and has lost his appetite — a normal, expected development at the end of life.

But his wife urges him to eat and to "just try harder." His life expectancy is measurable in days or weeks, Ms. Villars said, regardless of what he eats.

Ms. Villars, who complained about the "losing the battle" meme on the GeriPal blog a few years ago, has come to see this language as stemming from the grief of those about to be left behind.

"It's intolerable to think of losing someone they care so deeply about," she told me. "I think it's true for health care providers, too. We feel helpless and sad, and we don't know where to put that."

But, she added, war words make us judgmental. "I worry about the implication that somehow, someone was deficient or a loser or didn't do something right if they died," she told me. "People die."

The idea that sick and old people must wage war is on my mind lately, as well. For some people in some situations, all-out combat against a reversible condition makes sense. In late January, when a beloved cousin of mine, Rae LeRoy, had trouble breathing and went to the hospital, it seemed logical to treat what initially looked like pneumonia. She was a vibrant 93-year-old still living in her house, driving to club meetings, doing water aerobics; perhaps she could regain her strength and continue her active life a while longer.

But one hospitalization followed another, a too-familiar cycle of 911 calls, release to a rehabilitation center and re-admission. She had developed heart failure, not a curable condition. Each hospital stay left her further weakened.

Was it time to shift to comfort care, to call a hospice? Her longtime doctor not only discouraged the idea when Rae's daughter asked that entirely reasonable question, but scoffed at it: "We're not anywhere near that." She wanted Rae to continue The Fight.

But why? Rae had fulfilled every obligation, lived life fully, and now she was weeping with fatigue, saying, "I can't do it anymore, I'm so tired." Is "fighting," which presumably means using everything in the armamentarium, the only way to show courage at the end of life?

A palliative-care physician finally sat down with Rae and her children in late March, explained her options and told her, "You decided how you wanted to live, and now you get to decide how you want to die." Rae chose to stop going to the hospital, enter hospice care, say goodbye to friends and family — a valiant decision in my book, and her children's — and let death come as it would. It came in days.

She didn't want to die, bloodied and exhausted, on a battlefield. She wanted peace.

Others will make different decisions (and I'd like to hear about your families' experiences), but they might feel freer to make them if they were released from the language of war and the expectations that accompany it. If immortality has become the only victory, we're all failures.

---

Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."

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Well: Great Grain Salads

For the next few weeks you'll be hearing a lot from me about a conference I attended in March at the Culinary Institute of America in Napa Valley. Called "Healthy Kitchens, Healthy Lives," this conference, presented by the Culinary Institute of America, the Harvard School of Public Health and the Samueli Institute, brings together medical professionals with chefs and nutrition researchers to explore food and its relationship to health. Now in its 10th year, the conference has inspired hospitals to install teaching kitchens. Surgeons whose knowledge of knives had been limited to the scalpel have learned to wield a chef's knife as they participate in kitchen workshops run by chefs from the Culinary Institute and chefs presenting at the conference.

Whole grains, legumes, nuts and vegetables were the focus of most of the cooking demonstrations by the likes of Joyce Goldstein, Suvir Saran, John Ash, Iliana de la Vega, Mollie Katzen, Barton Seaver, Patrick Clark, Aaron Brown and the conference co-director, Dr. David Eisenberg of Harvard (along with his very charming 17-year-old daughter, Naomi). This, of course, was right up my alley, and as always I came home with many new ideas.

One frequent message in the cooking demonstrations was that fresh herbs, if you use them in quantity, are as much a green vegetable as, say, broccoli. This can be especially reassuring during the seasons when fresh green vegetables are in short supply. I took this to heart with the salads I'm presenting this week; they're packed with herbs. At this time of year I can also include the enticing spring vegetables that are hitting the farmers' markets, so I roasted asparagus and artichokes and served them alongside the grains in two of this week's salads, and served another one on a bed of spinach. All of the salads can be served as main dishes; they are great keepers, so make some over the weekend and use them for lunch throughout the week.

Rainbow Quinoa Salad With Mixed Nuts, Herbs and Dried Fruit: This salad is inspired by one demonstrated at the "Healthy Kitchen, Healthy Lives" conference in Napa Valley.

Barley and Herb Salad With Roasted Asparagus: This can be a main-dish salad or a side, enlivened with intensely delicious roasted asparagus.

Bulgur and Chickpea Salad With Roasted Artichokes: Quartering and roasting the artichokes instead of steaming them whole intensifies flavor and cuts down on preparation time for this salad.

Red and Basmati or Jasmine Rice With Peanuts, Asian Dressing and Baked Tofu: With a little advance preparation, this spicy salad can be made in 30 minutes.

Middle Eastern Black Rice and Lentil Salad on a Bed of Spinach: The hues of this crunchy salad indicate that it's an antioxidant-rich dish.

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The New Old Age: Wounded by the Language of War

When did the language we use to talk about death start to resemble a Pentagon briefing, full of military references and combat analogies?

Maybe it dates to 1971, when Richard Nixon declared a "war on cancer." Or much earlier, in the late 1800s, when doctors began using the word "armamentarium" to describe all the techniques, materials and equipment available to treat disease.

Certainly these metaphors have since become pervasive, among patients and physicians, the public and the news media. Family members seek aggressive treatment for an ailing relative, saying, "He's a fighter," or "She's a survivor." We talk about whether people with terminal diseases want "heroic measures" or not.

And when people die, we portray them not as having succumbed to disease, but as having struggled to the very end before being vanquished by a superior foe. Recent death notices in The New York Times (which are placed by families, as opposed to the obituaries written by reporters) memorialized a woman in her 90s who died "after a valiant battle against Alzheimer's and Parkinson's" and a 93-year-old man who died "after a long-fought battle with prostate cancer."

The bellicose wording "reflects some of the death-denying and death-defying feelings we find in our culture," said Dr. Daniel Johnson, a palliative-care physician in Denver who directs the Kaiser Permanente Care Management Institute. "Society sees death as the enemy, so it's not surprising we turn to language that references war."

But that can have unhappy real world consequences, Dr. Johnson recently cautioned in a talk at the Association of Health Care Journalists' national conference. Patients have taken him aside to confess that they dread another round of chemotherapy but fear disappointing those who expect them to "fight."

"They're nervous about what their doctors and their families might think," he told me in an interview. What they may actually want to say is that "I've lived a really good life, and now I want to spend time with my family" instead of at a dialysis center or in intensive care.

To spend one's final weeks or months free of that pressure can be "potentially transformative and beautiful," Dr. Johnson said. Often, though, to "give up" has become shameful.

Consider the couple whom Patrice Villars, a gerontological and palliative-care nurse-practitioner, is working with at the VA Medical Center in San Francisco. He's nearly 90, has metastatic lung cancer, can no longer leave his hospital bed, and has lost his appetite — a normal, expected development at the end of life.

But his wife urges him to eat and to "just try harder." His life expectancy is measurable in days or weeks, Ms. Villars said, regardless of what he eats.

Ms. Villars, who complained about the "losing the battle" meme on the GeriPal blog a few years ago, has come to see this language as stemming from the grief of those about to be left behind.

"It's intolerable to think of losing someone they care so deeply about," she told me. "I think it's true for health care providers, too. We feel helpless and sad, and we don't know where to put that."

But, she added, war words make us judgmental. "I worry about the implication that somehow, someone was deficient or a loser or didn't do something right if they died," she told me. "People die."

The idea that sick and old people must wage war is on my mind lately, as well. For some people in some situations, all-out combat against a reversible condition makes sense. In late January, when a beloved cousin of mine, Rae LeRoy, had trouble breathing and went to the hospital, it seemed logical to treat what initially looked like pneumonia. She was a vibrant 93-year-old still living in her house, driving to club meetings, doing water aerobics; perhaps she could regain her strength and continue her active life a while longer.

But one hospitalization followed another, a too-familiar cycle of 911 calls, release to a rehabilitation center and re-admission. She had developed heart failure, not a curable condition. Each hospital stay left her further weakened.

Was it time to shift to comfort care, to call a hospice? Her longtime doctor not only discouraged the idea when Rae's daughter asked that entirely reasonable question, but scoffed at it: "We're not anywhere near that." She wanted Rae to continue The Fight.

But why? Rae had fulfilled every obligation, lived life fully, and now she was weeping with fatigue, saying, "I can't do it anymore, I'm so tired." Is "fighting," which presumably means using everything in the armamentarium, the only way to show courage at the end of life?

A palliative-care physician finally sat down with Rae and her children in late March, explained her options and told her, "You decided how you wanted to live, and now you get to decide how you want to die." Rae chose to stop going to the hospital, enter hospice care, say goodbye to friends and family — a valiant decision in my book, and her children's — and let death come as it would. It came in days.

She didn't want to die, bloodied and exhausted, on a battlefield. She wanted peace.

Others will make different decisions (and I'd like to hear about your families' experiences), but they might feel freer to make them if they were released from the language of war and the expectations that accompany it. If immortality has become the only victory, we're all failures.

---

Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."

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