Well: Bothered by a ‘Gummy Smile’

Photo Images of study subjects before, at left, and after receiving Botox treatments to correct their "gummy smile," which was defined by the study as two or more millimeters of "gingival exposure upon smiling."Credit Aesthetic Surgery Journal

Susanna Miller-Pence's teeth weren't the problem; her gums were. When she smiled, her upper lip stretched up so high that a ribbon of pinkish gum was exposed, giving her a so-called "gummy smile." She hated it.

"The doctor explained that my gums were longer than my teeth, so the dimensions weren't right," said Ms. Miller-Pence, 52, a psychoanalyst living in San Luis Obispo, Calif.

Fifteen years ago, she had a gingivectomy, an operation to remove some of the extra gum tissue. A month later, she was grinning broadly. "Now everyone comments on my smile," she said.

Gummy smiles occur for a variety of reasons, most commonly a short upper lip, excessive gum tissue or small teeth, all of which are genetic. According to Dr. Stan Heifetz, a cosmetic dentist in New York and White Plains whose office treated Ms. Miller-Pence, ideal smiles show up only to about two millimeters of gum. "Anything over three to four millimeters of gum showing starts to look 'gummy,' " he said.

Studies have been done with dentists, plastic surgeons, dermatologists and regular folk to assess smiles. Most everyone agreed that two millimeters or less of gum tissue showing was the level where most participants thought the smile looked normal. Participants started noticing the gum tissue at three to four millimeters, and thinking that too much gum tissue was showing at more than four millimeters, Dr. Heifetz said.

Doctors who specialize in cosmetic procedures estimate that about 14 percent of women and 7 percent of men have excessive gingival exposure when smiling.

"I believe the incidence is probably higher than we think, but we specialists just see and count the ones we treat, which are on the low side since not many people come to the doctor and ask about treatments for this," said Dr. Jessica Suber, an attending physician in plastic and reconstructive surgery at Southern Ohio Medical Center in Portsmouth. "It's something a lot of patients aren't aware of."

It's hard to know how many operations are done annually to correct a gummy smile; many patients combine it with other medical and aesthetic treatments. According to data from the American Dental Association Health Policy Institute, 569,160 gingivectomies were performed in 2005-6, the most recent years available.

In the past, surgery was the main treatment option, but that is often costly and painful. Doctors sever the muscles that elevate the upper lip so it can no longer rise as high, or they do a crown lengthening procedure that cuts away gum tissue so the crown appears longer.

In extreme cases, they might perform orthognathic surgery, which repositions the upper jaw if it sticks out too much. But this can be complicated and can take up to two years to complete, Dr. Heifetz said. Laser therapy is also sometimes used.

Now people are going another route: onabotulinumtoxinA, otherwise known as Botox.

For the last few years, dentists have been injecting Botox into the upper lip "elevator" muscles. It paralyzes the muscles, inhibiting contraction of the upper lip when smiling to prevent the gummy smile.

In contrast to surgery, Botox is quick and easy, doctors who do the procedure say.

A March 2014 study in Aesthetic Surgery Journal found that off-label use of Botox was a safe and effective procedure for gummy smile, albeit one that lasts only three to four months for the average patient, confirming the findings of an earlier report in the American Journal of Orthodontics and Dentofacial Orthopedics. The price is also more appealing than surgery: Botox costs around $350 (depending on the part of the country you are in and the doctor you see). Ms. Miller-Pence said she paid about $15,000 for surgery and crowns, which was not covered by insurance.

Botox goes directly into the lip tissue, so there's almost no risk of digesting it, said Dr. Peter Taub, a plastic and reconstructive surgeon at Mount Sinai Hospital in New York.

Stephanie McCarrell, a nurse anesthetist in Tampa, Fla.,says she has received Botox three times for her gummy smile, which has always bothered her.

"When I was a girl, the other kids made fun of me," said Ms. McCarrell, 36. "It really bothered me. I would smile without my teeth, just a closemouthed smile."

A few days after her injection, her upper lip had dropped and her gums were less visible, she said.

But Botox works only if the problem is in the lips, not the bone. And doctors have to be careful not to overinject the muscles, or they could create an unnatural look.

As Dr. Ariel Ostad, a cosmetic dermatologist in New York, said, "A little bit too much, and you really inactivate those muscles and when you smile, you smile crooked."

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Well: Statins May Speed Wound Healing

Statins, the widely used cholesterol-lowering drugs, may have a role in surgical wound healing, a new analysis suggests.

The review, published in The Annals of Thoracic Surgery, covered 20 studies of statins and surgical wound healing. They demonstrated various mechanisms by which statins can lower inflammation, improve the mechanical strength of a healing wound, promote the growth of blood vessels and reduce healing time.

Most were animal or laboratory tissue studies, but two were studies in humans. In one, a retrospective study of 10,782 patients having hernia surgery, statins showed no beneficial effect, but the study failed to account for the use of blood-thinning drugs, which may have affected the results. The other, in six human volunteers, showed that statins can reduce the activity of one of the mediators of inflammation — white blood cell production — without affecting its beneficial function in healing.

The lead author of the review, Dr. Gerard J. Fitzmaurice, a cardiac surgeon at Our Lady's Children's Hospital in Dublin, said that most cardiac patients were already on statins before surgery, and that the drugs were extremely safe.

"The caveat here is that the majority of this is animal research," he said. "But a human randomized trial is now merited to properly answer the question. If statins are beneficial, it could be a big progression in wound management."

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Well: Running 5 Minutes a Day Has Long-Lasting Benefits

Phys Ed

Gretchen Reynolds on the science of fitness.

Running for as little as five minutes a day could significantly lower a person's risk of dying prematurely, according to a large-scale new study of exercise and mortality. The findings suggest that the benefits of even small amounts of vigorous exercise may be much greater than experts had assumed.

In recent years, moderate exercise, such as brisk walking, has been the focus of a great deal of exercise science and most exercise recommendations. The government's formal 2008 exercise guidelines, for instance, suggest that people should engage in about 30 minutes of moderate exercise on most days of the week. Almost as an afterthought, the recommendations point out that half as much, or about 15 minutes a day of vigorous exercise, should be equally beneficial.

But the science to support that number had been relatively paltry, with few substantial studies having carefully tracked how much vigorous exercise is needed to reduce disease risk and increase lifespan. Even fewer studies had looked at how small an amount of vigorous exercise might achieve that same result.

So for the new study, published Monday in The Journal of the American College of Cardiology, researchers from Iowa State University, the University of South Carolina, the Pennington Biomedical Research Center in Baton Rouge, La., and other institutions turned to a huge database maintained at the Cooper Clinic and Cooper Institute in Dallas.

For decades, researchers there have been collecting information about the health of tens of thousands of men and women visiting the clinic for a check-up. These adults, after completing extensive medical and fitness examinations, have filled out questionnaires about their exercise habits, including whether, how often and how speedily they ran.

From this database, the researchers chose the records of 55,137 healthy men and women ages 18 to 100 who had visited the clinic at least 15 years before the start of the study. Of this group, 24 percent identified themselves as runners, although their typical mileage and pace varied widely.

The researchers then checked death records for these adults. In the intervening 15 or so years, almost 3,500 had died, many from heart disease.

But the runners were much less susceptible than the nonrunners. The runners' risk of dying from any cause was 30 percent lower than that for the nonrunners, and their risk of dying from heart disease was 45 percent lower than for nonrunners, even when the researchers adjusted for being overweight or for smoking (although not many of the runners smoked). And even overweight smokers who ran were less likely to die prematurely than people who did not run, whatever their weight or smoking habits.

As a group, runners gained about three extra years of life compared with those adults who never ran.

Remarkably, these benefits were about the same no matter how much or little people ran. Those who hit the paths for 150 minutes or more a week, or who were particularly speedy, clipping off six-minute miles or better, lived longer than those who didn't run. But they didn't live significantly longer those who ran the least, including people running as little as five or 10 minutes a day at a leisurely pace of 10 minutes a mile or slower.

"We think this is really encouraging news," said Timothy Church, a professor at the Pennington Institute who holds the John S. McIlHenny Endowed Chair in Health Wisdom and co-authored the study. "We're not talking about training for a marathon," he said, or even for a 5-kilometer (3.1-mile) race. "Most people can fit in five minutes a day of running," he said, "no matter how busy they are, and the benefits in terms of mortality are remarkable."

The study did not directly examine how and why running affected the risk of premature death, he said, or whether running was the only exercise that provided such benefits. The researchers did find that in general, runners had less risk of dying than people who engaged in more moderate activities such as walking.

But "there's not necessarily something magical about running, per se," Dr. Church said. Instead, it's likely that exercise intensity is the key to improving longevity, he said, adding, "Running just happens to be the most convenient way for most people to exercise intensely."

Anyone who has never run in the past or has health issues should, of course, consult a doctor before starting a running program, Dr. Church said. And if, after trying for a solid five minutes, you're just not enjoying running, switch activities, he added. Jump rope. Vigorously pedal a stationary bike. Or choose any other strenuous activity. Five minutes of taxing effort might add years to your life.

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Well: Rustle, Tingle, Relax: The Compelling World of A.S.M.R.

A few months ago, I was on a Manhattan-bound D train heading to work when a man with a chunky, noisy newspaper got on and sat next to me. As I watched him softly turn the pages of his paper, a chill spread like carbonated bubbles through the back of my head, instantly relaxing me and bringing me to the verge of sweet slumber.

It wasn't the first time I'd felt this sensation at the sound of rustling paper — I've experienced it as far back as I can remember. But it suddenly occurred to me that, as a lifelong insomniac, I might be able to put it to use by reproducing the experience digitally whenever sleep refused to come.

Under the sheets of my bed that night, I plugged in some earphones, opened the YouTube app on my phone and searched for "Sound of pages." What I discovered stunned me.

There were nearly 2.6 million videos depicting a phenomenon called autonomous sensory meridian response, or A.S.M.R., designed to evoke a tingling sensation that travels over the scalp or other parts of the body in response to auditory, olfactory or visual forms of stimulation.

The sound of rustling pages, it turns out, is just one of many A.S.M.R. triggers. The most popular stimuli include whispering; tapping or scratching; performing repetitive, mundane tasks like folding towels or sorting baseball cards; and role-playing, where the videographer, usually a breathy woman, softly talks into the camera and pretends to give a haircut, for example, or an eye examination. The videos span 30 minutes on average, but some last more than an hour.

For those not wired for A.S.M.R. — and even for those who, like me, apparently are — the videos and the cast of characters who produce them — sometimes called "ASMRtists" or "tingle-smiths" — can seem weird, creepy or just plain boring. (Try pitching the pleasures of watching a nerdy German guy slowly and silently assemble a computer for 30 minutes.)

Two of the most well-known ASMRtists, Maria of GentleWhispering (more than 250,700 subscribers) and Heather Feather (more than 146,500 subscribers), said that although they sometimes received lewd emails and requests, many of their followers reached out to them with notes of gratitude for the relief from anxiety, insomnia and melancholy that their videos provided.

Some say the mundane or monotonous quality of the videos lulls us into a much-needed state of serenity. Others find comfort in being the sole focus of the A.S.M.R. actor's tender affection and care. Or perhaps the assortment of sounds and scenarios taps into pleasing childhood memories. I grew up falling asleep hearing the sounds from my father's home office: A computer engineer, he was continually sorting through papers, tapping keys  and assembling and disassembling PCs and MACs.

Dr. Carl W. Bazil, a sleep disorders specialist at Columbia University, says A.S.M.R. videos may provide novel ways to switch off our brains.

"People who have insomnia are in a hyper state of arousal," he said. "Behavioral treatments — guided imagery, progressive relaxation, hypnosis and meditation — are meant to try to trick your unconscious into doing what you want it to do. A.S.M.R. videos seem to be a variation on finding ways to shut your brain down."

So far, it seems to work for me. Like many insomniacs, I have over the years tried natural remedies like valerian root or melatonin, vigorous exercise regimens and strong sleeping pills like Ambien and Lunesta. But sleep rarely came. Nothing has worked as well and consistently as watching a man in an A.S.M.R. video sort through papers and his collection of Titanic paraphernalia.

But locating the neurological underpinnings of this trippy sensation won't be easy. Many of the scientists I reached out to shied away from the subject, saying the area is pseudoscience with a lack of published studies.

Bryson Lochte, a post-baccalaureate fellow at the National Institute on Drug Abuse who looked into A.S.M.R. for his senior thesis as a neuroscience major at Dartmouth College last year, has submitted his paper for publication in a scientific journal. Mr. Lochte said, "We focused on those areas in the brain associated with motivation, emotion and arousal to probe the effect A.S.M.R. has on the 'reward system' — the neural structures that trigger a dopamine surge amid pleasing reinforcements, like food or sex.

He compared A.S.M.R. to another idiosyncratic but well-studied sensation called musical frisson, which provokes a thrilling ripple of chills or goose bumps (technically termed piloerection) over one's body in emotional response to music. Mathias Benedek, a research assistant at the University of Graz in Austria who co-authored two studies on emotion-provoked piloerection, says A.S.M.R. may be a softer, quieter version of the same phenomenon. "Frisson may simply be a stronger, full-blown response," he said. And like A.S.M.R., the melodies that ignite frisson in one person may not in another.

Robert J. Zatorre, a professor of neuroscience at the Montreal Neurological Institute and Hospital at McGill University who has also studied musical frisson, said that "the upshot of my paper is that pleasurable music elicits dopamine activity in the striatum, which is a key component of the reward system" in the brain. Writing in The New York Times last year, in an article titled "Why Music Makes Our Brain Sing," he notes, "What may be most interesting here is when this neurotransmitter is released: not only when the music rises to a peak emotional moment, but also several seconds before, during what we might call the anticipation phase."

Perhaps the everyday experiences that A.S.M.R. videos capture — whispering, crinkling, opening and closing of boxes — evoke similar anticipatory mechanisms, sparking memories of past pleasures that we anticipate and relive each time we watch and listen.

"The whole topic is still very much unknown," Mr. Lochte said. "I would be very interested to see what other traits correlate with A.S.M.R sensitivity, whether it is an inherited attribute and what sort of physiological effects the sensation has on the body. All of these questions will be easy to answer with quick follow-up studies. Our study, we hope, will help lay the groundwork."

A version of this article appears in print on 07/29/2014, on page D6 of the NewYork edition with the headline: A Tingly Feeling, Then Zzzzzz.

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DealBook: Equinox Fitness Is Buying Rest of Millennium’s Gyms

Photo The Reebok Sports Club/NY gym is one of several properties Equinox Fitness has acquired in a $110 million deal.Credit Richard Perry/The New York Times

The high-end fitness industry may be awash in trendy concepts — CrossFit, boot camps and the like — but one of the biggest players in the luxury gym market is continuing to expand all the same. Equinox Fitness, the purveyor of expensive workout centers and risqué advertising, said it planned to announce as soon as Monday that it had acquired Sports Club/LA gyms in New York and four other cities, as well as the Reebok Sports Club/NY gym on the Upper West Side of Manhattan. All will soon bear the Equinox brand and feature the company's classes and products.

The $110 million deal, Equinox's second-biggest acquisition, is for the remaining gyms owned by Millennium Partners, the real estate company that sold half of its clubs to Equinox three years ago. That transaction was Equinox's biggest deal. More important, the new deal expands Equinox's empire to 73 locations worldwide, primarily in major cities like New York, San Francisco, Los Angeles and London.

Much has changed for Equinox since 2011, when it bought the first of the Sports Club/LA and Reebok Sports Club locations for $130 million. The company also bought SoulCycle, the popular spinning chain, and started the low-cost Blink Fitness brand, in an effort to grow in an economy recovering from recession.

Both are performing well, according to Harvey Spevak, the company's chief executive, with SoulCycle now operating 29 locations and Blink having opened more than two dozen gyms in New York and New Jersey. He declined to elaborate on the privately held company's performance, except to say that its growth remains strong.

Still, the most popular fitness trends today tend to be less luxurious than what Equinox has traditionally offered: CrossFit practitioners call their gyms "boxes" and eschew fancy machines for cold, hard iron. But Mr. Spevak argued that Equinox would continue to focus on its core offerings, while still covering seemingly durable fitness movements like yoga and spinning.

"A lot of the noise that's out there will dissipate over time," he said. "We're not feeling pressure from those."

Instead, Equinox is focused on introducing more advanced technology to help customers track their workouts and diets, including through an app for iPhones. And it still will position itself as a luxury experience for members; after all, it still sells Kiehl's cosmetics in its gyms, and will soon do so in its newest acquisitions.

"We will be much more sophisticated than anyone else in our industry," Mr. Spevak said.

A version of this article appears in print on 07/28/2014, on page B2 of the NewYork edition with the headline: Equinox Fitness Is Buying Rest of Millennium's Gyms.

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Well: Nursing Home Unthinkable? Be Prepared in Case It’s Inevitable

Photo Credit Ellen Weinstein

Personal Health

Jane Brody on health and aging.

Nobody looks forward to spending their final years in a nursing home, yet 1.4 million Americans are living in this often-feared institutional setting.

You may not want to place a loved one in a nursing home for more than a short-term recovery — but never promise an aging relative that it won't happen.

"When faced with the responsibilities of providing 24-hour care for an aging person with ever-increasing physical needs beyond what one person can physically handle, a nursing home frequently becomes the best alternative," Joanna R. Leefer writes in "Almost Like Home," a user-friendly guide to choosing a nursing home.

Nursing homes generally have had a bad reputation as smelly, indifferent places where people go to die. But "there are some homes that are better than being at home," Ms. Leefer said in an interview. "And there are many more good facilities than bad ones."

Ms. Leefer developed her expertise through personal and professional experience, and her book is replete with checklists and scores of relevant websites. She learned a lot firsthand as primary caregiver for her aging parents, one of whom lived three years with nursing-home-type care. She worked five years for an advocacy organization for older adults, and she founded a consulting firm, ElderCareGiving, to help families make difficult care decisions.

Finding a place that suits the needs of an aging relative or friend, and those who plan to visit, requires considerable preparation.

"The biggest mistake people make is waiting until the last minute, when faced with a crisis, to find a suitable facility," Ms. Leefer said. "You're forced into an impulsive decision that you're not likely to be happy with unless you're really very lucky."

She likened it to shopping for a new car: "Do the research, start looking around, find out what's available, what each facility offers, what's best for your loved one. Become an educated consumer."

Crass as it may seem, you might start with the cost. When paid for privately, the average ranges from $10,000 to $15,000 a month. Medicare does not pay for long-term nursing home care, only temporary skilled care, usually in the rehabilitation section of the home.

If the patient qualifies for Medicaid, and the nursing home accepts it, most of the cost is generally covered. The beneficiary must be age 65 or older, disabled and a United States citizen. He or she can have no more than a certain amount of assets, as determined by the state. Some patients become eligible by transferring savings and assets to a third party at least five years ahead of time.

Next, choose a reasonably convenient location for likely frequent visitors. You can search for possibilities online by township or ZIP code. Ask neighbors and friends in the area for any recommendations or information they might have about homes in the area.

Make a list of homes in the chosen area and check out the government's report card at NursingHomeCare.com. Every home that receives federal funding must be evaluated and rated on a scale of 1 to 5 (5 being best). The assessments are far from perfect; a recent study, for instance, found that star ratings often don't correspond to how patients feel about their nursing homes.

Still, Ms. Leefer suggests considering only homes with a rating of 3 or higher. Then start examining their characteristics.

What specialized services might the patient need — a dementia program, mobility practice, hospice care? Are there medical specialists on call? Is the home affiliated with a good nearby hospital? If the patient has a personal physician, you might prefer a home where that doctor has privileges.

If the patient is not fluent in English, are there staff members (and other residents) who speak the person's language? Are there activities that would interest the patient, including opportunities to go outdoors?

Don't rely on brochures. Take a tour, preferably more than once at different times, including mealtimes. Visit more than one floor. Does the place look and smell clean? An odor of urine is a clue to neglect. Are the rooms light and airy? Are residents permitted to have a few personal decorative items or furnishings?

Observe how patients are treated by staff members. Are they courteous, patient, friendly and respectful of patients' privacy? Are patients greeted by the staff and addressed by name? Are those that need it helped with eating and drinking?

Are there rigid wake-up, bed and meal times, or do patients have some choice? Do the menus offer selections? If possible, talk with a few of the residents and their family members.

Ms. Leefer suggests preparing a checklist for the nursing homes you are considering, listing issues relevant to quality of life, quality of care, safety, nutrition and hydration.

Admission to a nursing home is not automatic but based on such factors as bed availability, care requirements and the patient's condition. It is best to submit applications to chosen homes well in advance of a needed admission. Waiting lists can be longer than a year.

Your job does not end once a family member is admitted; monitoring the care provided is critical. At first, expect resistance from the patient, often accompanied by a loud desire to "get me out of here now." Visit often and stay as long as possible to ease the transition, Ms. Leefer says.

Be sure you or someone trustworthy is authorized to serve as the patient's health care proxy, so critical medical decisions can be made when he cannot speak for himself. Make sure you have access to medical records and be present when the patient is examined and dressed. Check for any hints of physical abuse and signs of incipient or existing bed sores, which can become infected and hasten death.

Find out the names of staff in charge of various services and speak to them about the patient's special needs or problems. Keep notes, dated, with any issues of concern.

Try to solve any problems with the nursing home staff. Be polite, soft-spoken and avoid confrontation. A hostile approach puts people on the defensive and is unlikely to get the patient's needs addressed.

If necessary, speak to the heads of departments; filing a formal complaint with the health department should be a last resort.

This is the first of two columns on choosing a nursing home.

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Well: Acetaminophen No Better Than Placebo for Back Pain

About two-thirds of adults have lower back pain at some point in their lives, and most are told to take acetaminophen, sold under brand names like Tylenol and Panadol. Medical guidelines around the world recommend acetaminophen as a first-line treatment.

But there has never been much research to support the recommendation, and now a large, rigorous trial has found that acetaminophen works no better than a placebo.

"Our result illustrates the problems in relying on that indirect evidence when setting guidelines," said Christopher M. Williams, a researcher at the George Institute for Global Health in Sydney and lead author of the new study, published Wednesday in The Lancet.

Dr. Williams and his colleagues randomly assigned 1,643 people with acute low back pain to one of three groups. The first was given two boxes: one "regular" box containing 500-milligram acetaminophen tablets, and a second "as-needed" box also containing acetaminophen.

The second group received a regular box of acetaminophen and an as-needed box containing a placebo. The third group received two boxes of placebos.

All participants were told to take six tablets every day from the regular box, and up to two tablets a day from the as-needed box for pain relief.

The three-month study found no differences among the groups in recovery time, pain, disability, function, symptom changes, sleep or quality of life. About three-quarters of the patients were satisfied with their treatment whether they received medicine, placebos or both.

Dr. Bart W. Koes, who wrote an editorial accompanying the paper, said that even though the study was large and methodologically sound, it was not necessarily the last word on the subject.

"The fact that it's no more effective than placebo does not mean that it doesn't work for a given patient," said Dr. Koes, a professor of general practice at Erasmus University Medical Center in Rotterdam, Netherlands.

Dr. Williams said that acetaminophen had been shown to be effective for headache, toothache and pain after surgery, but the mechanism of back pain is different and poorly understood. Doctors should not initially recommend acetaminophen to patients with acute low back pain, he said.

But, he added, "If patients already taking it feel they are getting a benefit, then it wouldn't be wise to tell them to stop."

Correction: July 24, 2014
Because of an editing error, an earlier version of this article misstated the source of a quotation by Dr. Bart W. Koes. He commented on the effectiveness of acetaminophen in an interview, not in an editorial in The Lancet.

A version of this article appears in print on 07/24/2014, on page A14 of the NewYork edition with the headline: Acetaminophen Isn't Much Help for Back Pain, a Study Finds.

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Well: The Workout: Practicing His Own Medicine

Credit Colin Archdeacon for The New York Times

Many doctors encourage their patients to exercise. But one who follows his own advice – and then some – is Dr. Jordan Metzl, a sports medicine physician at the Hospital for Special Surgery in New York.

Dr. Metzl's specialty is treating injuries without surgery. His favorite medicine, he says, is exercise: It is one he takes often and prescribes to all of his patients. He's completed over 40 marathons and Ironman competitions, and his goal is to do at least one Ironman every year.

To his patients, Dr. Metzl is not only the healer of their achy knees and sore shoulders, but a fitness instructor. He designed and teaches an exercise class he calls "Ironstrength," which combines high intensity cardio with strength training. The class is free, open to the public, and held at parks and other locations around New York City.

Recently, I showed up at Central Park on a weekday morning to give the class a try. After a fun but grueling hour of doing sprints, jump squats and push ups, I sat down with Dr. Metzl to talk about why exercise is the best medicine, how a strong kinetic chain makes you a better athlete, and why science shows that working out in a group is better than working out alone. Here are edited excerpts from our conversation.

Can you tell us about your role as a sports medicine doctor?

Well, I have three roles, I think. As a sports medicine doctor, I have a lot of people that come in to see me, and I try to fix their injuries and keep them from getting hurt again. I really believe that exercise is the best medicine, and I want everybody to be able to take that medicine all the time.

I also have a role as an athlete. This year I'll be doing my 32nd marathon and my 12th Ironman competition. And the reason I do that is I think everybody needs a goal, myself included.

And finally I think I have a role as a fitness instructor. It didn't start out that way, but what I've realized is that if I'm going to talk about exercise, I want to help people learn how to do it as well.

What are some of the more common injuries you see in your practice?

I see all kinds of sports injuries – everything from achy knees to achy backs, shins and shoulders. I see athletes of all ages. In my waiting room it could be everything from an elite level 10-year-old gymnast to a 75-year-old person who wants to run a marathon.

Tell us about your most recent book, "The Exercise Cure."

It takes what I believe in personally and puts it in a scientific approach, namely that exercise is medicine. I want people to learn how they can take exercise for their problems, whether its memory issues, depression, anxiety, heart disease or high cholesterol. How do you use exercise as a first line drug, and how do you talk to your physician about that? Those are things I want people to learn.

How long have you been teaching the Ironstrength class?

I started it a few years ago. The first time I did it I wondered if anyone was going to come. I just e-mailed some of my patients. We had about 25 people. But I've now built a listserv for this class of about 6,000 people. It's always free. Every fourth class we raise money for a different nonprofit. We do it in different places around the city, and people of all ages come and work together.

What is a typical class like?

When we do it in the summer outside, it's a combination of hill running and then plyometrics. When it's indoors – and I usually teach indoors at Equinox gym in the winter – we have just basically strength workouts twice a month. People come and they learn how to strengthen their bodies and prevent injuries.

Today's class was pretty challenging. Can you talk about about the exercises we did?

So today we did a combination of some skipping up a hill followed by some sprinting up a hill, and I alternated skipping and running. Skipping is a great example of what's called plyometrics. The muscles are rapidly elongating and contracting, much like when you're running. So it's a great way to strengthen your running muscles.
When you start sprinting up the hill, you're pushing not only your muscles but also your heart. Intensity matters in your workout. So what I've done in the sprinting part of this is to really push your lactate threshold and your VO2 max. It gets you breathing really hard, which teaches your heart to squeeze harder, to squeeze more blood, and that makes you more efficient at extracting oxygen from your blood. This intense training over time pushes your lactate threshold, meaning that your fatigue level gets further and further out the more you do it.

In the second part of the workout, you had us switch gears a bit.

Right. The second part of the workout was all strength based. We did plyometric jump squats to strengthen the butt muscles and the quads and the hamstrings. And we did a combination of push-ups and sit-ups and all kinds of exercises that strengthen the kinetic chain, which is all the muscles of the body connected tip to toe. This workout strengthens the whole body. If you have a hurt knee, for example, I want you to learn how to make all the muscles stronger so you take pressure off the knee. As an athlete, you do much better with a strong kinetic chain. It doesn't matter the sport: You can run faster, jump higher and hit a golf ball further if those muscles are stronger.

How often do you do this workout?

This kind of workout is great about twice a week. You can do it anywhere. You don't need a gym. You don't need any equipment. I believe body weight strengthening is the way to go. I have kids who are 9 and 10 years old doing this kind of stuff. I have grandmothers in their 80s doing it and everyone in between. Strength training is wonderful medicine for anybody. If you have arthritis, if you have osteoporosis, it really helps.

Is there research that shows any benefits to working out in a group?

There was actually a study done in England where they took rowers and they put them individually in a room and had them do "maximum erg" – essentially the maximum effort that they could do. And then they put all those people together and had them do it again. And the study found that there was a 15 to 20 percent increase as a group versus as an individual, meaning that you could work so much more effectively in a group than you can by yourself. Even if you think you're pushing yourself as hard as you can, you can always go a little bit harder if someone's encouraging you.

What's your personal workout like?

I do a combination of this kind of stuff once or twice a week. And then I do a lot of biking, a lot of running, a lot of swimming, just to try to keep myself as fit as I can be in the confines of my schedule and work, which is sometimes tough. But my overall hope is that I can keep myself going. I want to do this stuff until I'm 90 if I can. That's the plan.

Do you follow a special diet?

I'm not an absolutist. I eat a little bit of everything. I love pizza. I love hamburgers. But I try and lay off that kind of stuff before a race. But other than that I pretty much eat everything in moderation. I'm not a no-carb guy. I'm not a high protein guy. My general feeling is if you can stay away from stuff that doesn't expire until 2035, then you're in good shape.

How can people join one of your classes?

They can go to my Web site (drjordanmetzl.com), and click on the "subscribe" tab. You'll get my e-mails that tell you when the classes are. If you'd like to join me, we'd love to have you.

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Well: Acetaminophen No Better Than Placebo for Back Pain

About two-thirds of adults have lower back pain at some point in their lives, and most are told to take acetaminophen, sold under brand names like Tylenol and Panadol. Medical guidelines around the world recommend acetaminophen as a first-line treatment.

But there has never been much research to support the recommendation, and now a large, rigorous trial has found that acetaminophen works no better than a placebo.

"Our result illustrates the problems in relying on that indirect evidence when setting guidelines," said Christopher M. Williams, a researcher at the George Institute for Global Health in Sydney and lead author of the new study, published Wednesday in The Lancet.

Dr. Williams and his colleagues randomly assigned 1,643 people with acute low back pain to one of three groups. The first was given two boxes: one "regular" box containing 500-milligram acetaminophen tablets, and a second "as-needed" box also containing acetaminophen.

The second group received a regular box of acetaminophen and an as-needed box containing a placebo. The third group received two boxes of placebos.

All participants were told to take six tablets every day from the regular box, and up to two tablets a day from the as-needed box for pain relief.

The three-month study found no differences among the groups in recovery time, pain, disability, function, symptom changes, sleep or quality of life. About three-quarters of the patients were satisfied with their treatment whether they received medicine, placebos or both.

Dr. Bart W. Koes, who wrote an editorial accompanying the paper, said that even though the study was large and methodologically sound, it was not necessarily the last word on the subject.

"The fact that it's no more effective than placebo does not mean that it doesn't work for a given patient," said Dr. Koes, a professor of general practice at Erasmus University Medical Center in Rotterdam, Netherlands.

Dr. Williams said that acetaminophen had been shown to be effective for headache, toothache and pain after surgery, but the mechanism of back pain is different and poorly understood. Doctors should not initially recommend acetaminophen to patients with acute low back pain, he said.

But, he added, "If patients already taking it feel they are getting a benefit, then it wouldn't be wise to tell them to stop."

Correction: July 24, 2014
Because of an editing error, a quotation in an earlier version of this article was incorrectly attributed. Dr. Bart W. Koes spoke in an interview; the quotation did not come from his editorial in The Lancet.

A version of this article appears in print on 07/24/2014, on page A14 of the NewYork edition with the headline: Acetaminophen Isn't Much Help for Back Pain, a Study Finds.

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The New Old Age Blog: Stealing a Page From the Boomers’ Playbook

When we last checked in with Alice Fisher, Hurricane Sandy had forced her ailing 90-year-old parents out of their ruined co-op apartment in Long Beach, N.Y., where they had expected — with the enthusiastic approval of their two daughters — to live out their days.

Her parents' story had its harrowing moments: The slow realization that the home would not be habitable anytime soon. Finding a series of temporary living solutions. Finally making the dreaded, but necessary, move to a nursing home, where both the needs of her father, affected by dementia and requiring a wheelchair, and his still sprightly, although deaf, wife could be met in different wings of the same facility.

It was a story with one kind of happy ending that now has another.

Ms. Fisher's mother died last January, quickly and peacefully of congestive heart failure after an active and happy year in the home. She made new friends (one of them was teaching her sign language), went to synagogue regularly, attended a steady stream of 100th birthday parties, celebrated her own 70th wedding anniversary before a large crowd — and fussed over her clothes and makeup for the first time in years.

"She fully embraced her new home,'' Ms. Fisher said.

When Ms. Fisher and her sister went to tell their father about his wife's death, their visit was cut short: The health care aides urged them to leave so his grief could be soothed by his floor mates. Most were also cognitively impaired, yet they knew better than anyone — patting his arm, hugging him — how to communicate that they shared his sorrow.

While Ms. Fisher, 68, was already a geriatric professional — the director of senior constituent services for State Senator Liz Krueger of New York — the experience with her parents has left her with a skeptical perspective on aging in place.

It is "not the panacea that our government, our media, and the many senior service providers around the country are promoting,'' she wrote on a Facebook page called Confronting Ageism.

The page is Step 1 of her new mission: to be a community organizer for folks of a certain age and to help move the imperatives of an aging society to the front burner with the strategies of the civil, feminist and gay rights movements.

The page began in February with an eclectic collection of original essays, as well as aggregated articles on subjects like mandatory retirement, age-discrimination lawsuits, ageism in medicine and living options for the elderly. The site also includes reading lists, inspirational sayings and photos of celebrated older people, like Gloria Steinem, Bruce Dern and Jane Goodall, and others who have left us, like Maya Angelou.

Old is good, Ms. Fisher said, and comes in as many flavors as Baskin-Robbins ice cream. And ageism is still rampant — isn't it time to tackle that, as other groups, like The Conversation Project, have tried to break the silence about medical overtreatment of the elderly?

Confronting ageism, Ms. Fisher said, might begin with consciousness-raising groups so familiar to women in her generation. But these would include men as well: Ms. Fisher's presumption is that their issues overlap those of aging women, but manifest differently — involving care giving, their own physical changes with age, what body image and virility mean, how it feels to retire and enter a new stage in life.

But what to call this awkward, transitional stage of life? "Nobody has even put a name on it yet,'' Ms. Fisher said. That once was true of adolescence, too.

With a core group of about a dozen men and women interested in these issues — but not members of the "aging industrial complex," as Ms. Fisher refers to her professional colleagues — she is leading monthly meetings that have evolved from brainstorming sessions to a prototype of what consciousness-raising groups for the about-to-be-elderly might look like. A beta test, if you will.

Should they be coeducational? Yes, the group has decided. Should they consist of friends, as was usually the case with the women's groups of the 1960s and '70s? No, because strangers will bring new views to the table and will be more inclined to stay on topic than friends.

From these meeting will come a manual that will help others replicate groups of their own. From a hurricane to a movement — why not?

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Well: Acetaminophen No Better Than Placebo for Back Pain

About two-thirds of adults have lower back pain at some point in their lives, and most are told to take acetaminophen, sold under brand names like Tylenol, Anacin and Panadol. Medical guidelines around the world recommend acetaminophen as a first-line treatment.

But there has never been much research to support the recommendation, and now a large, rigorous trial has found that acetaminophen works no better than a placebo.

"Our result illustrates the problems in relying on that indirect evidence when setting guidelines," said Christopher M. Williams, a researcher at the George Institute for Global Health in Sydney and lead author of the new study, published Wednesday in The Lancet.

Dr. Williams and his colleagues randomly assigned 1,643 people with acute low back pain to one of three groups. The first was given two boxes: one "regular" box containing 500-milligram acetaminophen tablets, and a second "as-needed" box also containing acetaminophen.

The second group received a regular box of acetaminophen and an as-needed box containing a placebo. The third group received two boxes of placebos.

All participants were told to take six tablets every day from the regular box, and up to two tablets a day from the as-needed box for pain relief.

The three-month study found no differences among the groups in recovery time, pain, disability, function, symptom changes, sleep or quality of life. About three-quarters of the patients were satisfied with their treatment whether they received medicine, placebos or both.

Dr. Bart W. Koes, who wrote an editorial accompanying the paper, said that even though the study was large and methodologically sound, it was not necessarily the last word on the subject.

"The fact that it's no more effective than placebo does not mean that it doesn't work for a given patient," wrote Dr. Koes, a professor of general practice at Erasmus University Medical Center in Rotterdam, Netherlands.

Dr. Williams said that acetaminophen had been shown to be effective for headache, toothache and pain after surgery, but the mechanism of back pain is different and poorly understood. Doctors should not initially recommend acetaminophen to patients with acute low back pain, he said.

But, he added, "If patients already taking it feel they are getting a benefit, then it wouldn't be wise to tell them to stop."

A version of this article appears in print on 07/24/2014, on page A14 of the NewYork edition with the headline: Acetaminophen Isn't Much Help For Back Pain, A Study Finds .

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Well: How Our Arms Help Us Run

Phys Ed

Gretchen Reynolds on the science of fitness.

How we hold our arms affects how we run, but probably not in ways that most of us would expect, according to a new study of upper body biomechanics. The ideal arm swing may be the one that you're already using, the study concludes.

Distance running is, of course, physiologically costly, meaning that it requires large outlays of energy. Almost every aspect of the activity adds to that energy expenditure, like holding your body upright and metronomically swinging first one leg and then the other forward and toward the ground.

But scientists and some running-form coaches have speculated that pumping your arms, although requiring energy, reduces the overall metabolic cost of running by helping to balance the moving body, increase forward propulsion or, perhaps, provide a bit of bounce, helping to lift us off the ground with each stride. In this theory, swinging the arms makes it easier to run.

That idea, however logical it might sound, had not been proved. So for the new study, published last week in The Journal of Experimental Biology, researchers at the University of Colorado at Boulder invited 13 experienced adult runners to pull on their favorite running shoes and visit the university's locomotion lab.

During their first session, the runners were fitted with masks to track how much oxygen they took in and carbon dioxide they puffed out. Those measures establish energy usage. The runners stood quietly for seven minutes as the scientists determined their baseline numbers.

Then they ran on treadmills at a comfortable pace while holding their arms normally or in one of three increasingly unorthodox positions. In one instance, they held their arms loosely behind their back; in another, their arms were crossed at the chest, like a mummy's; and in the last, they held their hands, fingers entwined, at the back of their skulls. In each case, the volunteers ran for seven minutes, with a rest period between each run. Their respiration was monitored throughout.

On a separate lab visit, the runners wore reflective markers on their shoulders, trunk and legs and repeated the four variations on arm positioning, as the researchers filmed them with three-dimensional motion-capture cameras.

The results showed, as the scientists had expected, that the volunteers used the least energy and were most efficient when they ran normally, their arms swinging at their sides. With each change in arm position, their efficiency dropped. Holding their arms behind their backs required 3 percent more energy than running normally; draping them across their chests used 9 percent more; and parking them on their heads demanded 13 percent more energy.

The motion-capture recordings established why the oddball arm positions were so inefficient. When the runners did not swing their arms, the biomechanical measurements showed, they could not readily counterbalance the pendulum action of their legs. Their upper bodies began to oscillate. Like Weebles, they wobbled, increasing their bodily movements and energy expenditure. The runners' upward momentum did not change when they did not use their arms, undercutting the idea that arm swing provides bounce.

Essentially, the scientists found that arms were a nice accessory for runners to have.

"Normal arm swing is energetically a much cheaper way to counteract the motion of the legs than using the muscles in the torso," said Christopher Arellano, an National Institutes of Health postdoctoral fellow at Brown University and lead author of the study.

That conclusion, although foreseeable, had needed to be tested, said Rodger Kram, a professor of integrative physiology at the University of Colorado and the study's senior author. "Obviously, it's not likely that anyone would run with their hands on their head," he said, "but we wanted to see what would happen if they did." The answer is that every stride became a bit more grueling.

At the same time, the study's results offer surprising encouragement to those whose arm swing might be idiosyncratic.

"There was tremendous variation in the normal arm swings" of the volunteers, Dr. Arellano said. All bent their elbows, but apart from that, some were stiff and robotic, others noodly. Most but not all crossed their arms slightly in front of their chest with each swing. Efficiency was largely unaffected by these differences, the researchers concluded.

"This is good news," Dr. Kram said. "There's been a vogue for telling runners that they have to hold their arms this way or that way and not cross them in front of the chest."

But the study's findings emphasize that there is no single, ideal way to swing the arms, he said, as long as you swing them at all. "Most people," he said, "will settle into the arm swing that is the most efficient for them."

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Well: A Sleep Apnea Test Without a Night in the Hospital

Photo Donald G. McNeil Jr., given a diagnosis of mild apnea 10 years ago, found a home test less cumbersome than in a lab.Credit Michael Nagle for The New York Times

Where was I?

Sorry — must have nodded off for a decade.

Ten years ago, I spent two nights in a sleep lab at SUNY Downstate Medical Center, taking the test for sleep apnea, and wrote about it for Science Times.

Back then, "sleep technicians" wired me up like the Bride of Frankenstein: 15 sensors glued or clamped to my scalp, lip, eye sockets, jaw, index finger, chest and legs, two belts around my torso, and a "snore mike" on my neck.

As I slept, an infrared camera watched over me. And I ended up spending 23 hours in that hospital bed because the test wasn't over until you could lie in a dark room for 20 minutes without dozing off. I had such a sleep deficit that I kept conking out, not just all night, but all the next day.

So this year, when a company called NovaSom offered to let me try out a new home sleep-test kit that promises to streamline the process, I said yes.

In the decade since my ordeal, the pendulum has swung sharply in the direction of the home test, said Dr. M. Safwan Badr, past president of the American Academy of Sleep Medicine, which first recognized home testing for apnea in 2007. Insurers prefer it because it costs only about $300, about one-tenth that of a hospital test, and many patients like it, too.

Photo Donald G. McNeil Jr. preparing to take a sleep test ten years ago.Credit Downstate Medical Center

"Lots of people are reluctant to let a stranger watch them sleep," said Dr. Michael Coppola, a former president of the American Sleep Apnea Association who is now the chief medical officer at NovaSom.

Doctors estimate that 18 million Americans have moderate to severe apnea and 75 percent of them do not know it.

Home testing is not recommended for those with heart failure, emphysema, seizures and a few other conditions. And because it does not record brain waves as a hospital lab does, a home test can be fooled by someone who just lies awake all night staring at the ceiling. But it's useful for many people who exhibit the warning signs of apnea, such as waking up exhausted after a full night's sleep or dozing off at the wheel in bright daylight. And severe apnea can be lethal: starving the brain of oxygen all night quadruples the risk of stroke.

Ten years ago, after my long lab night, I was given a diagnosis of mild apnea.

The likely culprits were that I was overweight, had some bad habits — coffee-fueled evenings at work followed by late wine-fueled dinners at home — and that I had a "crowded airway." (The doctor looking down my throat said "Wow!" My uvula apparently resembles not a punching bag but a stalactite.)

The Downstate doctors made me abstain from coffee and alcohol for 24 hours and be tucked in just after 9 p.m. I protested that my life was not like that. But it had been years since I had negotiated bedtime with an authority figure. I lost.

After my diagnosis, they offered three options: I could lose weight, drink less and go to bed earlier. I could have airway surgery. Or I could sleep with a CPAP (continuous positive airway pressure) machine blowing air into my lungs.

For me, surgery was out. A cousin said it was the most painful thing he had ever endured, changed the way he spoke and didn't cure his apnea. I tried the CPAP and hated it: Although for many people it is a lifesaver, I felt as if I were sleeping inside Darth Vader's helmet. So I joined Weight Watchers and lost 35 pounds.

Ten years later, my habits are still imperfect — I still drink a bit more than I should, and I've gained back 15 pounds. In bad weeks, my BMI is 25, right on the border of normal and overweight. As for my snoring, depending on the audience, it has been described as "pretty awful" and "some of the least offensive I've heard."

The home test is done over three nights, and I made them as true-to-life as possible: I did the first with no alcohol or caffeine, then one with my typical amount, then one with too much. On Night 2, to add to the challenge, I invited over a friend and her dog.

The device arrived by mail (and is mailed back later). I was able to wire myself up without help in 15 minutes: a belt clipped around my chest, a finger poked into a blood-oxygen sensor and a breath sensor hooked over my ears and taped beneath my nose. All three plugged into a box the size of a computer modem strapped on my arm.

The best part: By shifting the box or laying it on the pillow, I could sleep almost normally. At the hospital, my 15 wires had felt like marionette strings keeping me on my back. At home, I could flip from side to side, as usual.

The first night was during a major snowstorm. I ate dinner early and drank only water, tired myself out by shoveling a foot of snow and was soon so bored that I went to bed at 8:30. I slept 10 hours and even had dreams. (The usual: Trapped in a giant men's room. Sounds kinky, but even Freud would agree that its deeper meaning is: "Hey, stupid! You need to go! Wake up!")

On the second night, my friend and I had dinner with wine and talked till midnight. She said the tape mustache holding the sensor under my nose was not as dashing as Errol Flynn's. That night was fitful — the house furnace ran too hot, the dog yipped unpredictably. I finally put in my radio earbuds to block the noise, so I didn't notice that a wire had come loose and the device was telling me off, intoning, "Check finger sensor!" over and over.

On the third night, I met another friend to hash out his marital woes over about five beers, walked home and went to bed woozy. I dropped off fast but woke up soaked in sweat at 3 a.m.

Each morning, as I plugged the device in to recharge, it beamed the night's data to NovaSom.

A few days later, I got my results in a phone call from Dr. Coppola.

They were better than I had expected.

"It's plenty of data," he said. "We got 21 hours of recording time. And you're all good."

Apnea is measured on the apnea/hypopnea index — how many times an hour a person stops or nearly stops breathing for at least 10 seconds. Below five times is minimal, five to 15 is mild, 15 to 30 is moderate, more than 30 is severe.

My three nights were 1.5, 0.7 and 2.4. So, even on the third, alcohol-heavy night, I was in the "minimal" range, though I'd had a 10-minute cluster of apneas at 2 a.m. that dropped my oxygen level to 78 percent — the normal is 90 percent or higher. "Probably you were sleeping on your back at that moment," Dr. Coppola said.

One thing did trouble me, I told him: "This says I snored 98 percent of the time? That's impossible. I have witnesses."

"That's not really snoring," he said. "It's any loud breathing. The mike is sensitive."

My previous apnea diagnosis, Dr. Coppola said, was probably a result of the big trail of brain-wave sensor wires forcing me to sleep on my back, which closed my already narrow airway. Lab monitoring, he said, "creates false sleep scenarios."

"The good news," he added, "is that your lifestyle changes made a big difference. So keep the weight off, don't drink more, and you should be O.K."

Maybe easier said than done. But we'll see.

A version of this article appears in print on 07/22/2014, on page D3 of the NewYork edition with the headline: A Test You Want to Sleep Through .

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Well: How Many Americans Are Lesbian, Gay or Bisexual?

As it has for decades, the Centers for Disease Control and Prevention last week released its annual National Health Interview Survey on the health of Americans. But this year, there was a difference: For the first time, the respondents were asked about their sexual orientation.

Of 34,557 adults ages 18 and older, the survey reported, 1.6 percent said they were gay or lesbian. Some critics say the numbers are low, but they fall in the range of other surveys. In the new survey, however, only 0.7 percent of respondents described themselves as bisexual; other studies have reported higher numbers.

Adults who identified themselves as gay, lesbian or bisexual reported some different behaviors and concerns — for example, more alcohol consumption and cigarette smoking — than those who said they were straight.

But it can be difficult to elicit information that many people consider private. The New York Times spoke about such challenges with Gary J. Gates, a demographer at the Williams Institute at the U.C.L.A. School of Law, which focuses on law and policy issues related to sexual orientation and gender identity. Some of Dr. Gates's findings were echoed in the new survey. This interview was edited and condensed.

How was this survey conducted?

Survey takers had a computer that guided them through questions which they asked the respondent in person, and they used flash cards to show them potential answers.

Why do you think the figure for bisexuality was lower than in other surveys?

There is evidence that bisexuals perceive more stigma and discrimination than gay and lesbian people. They are much less likely to tell important people around them that they are bisexual.

The way this survey was conducted, the stigma experienced by bisexuals may have mattered more in their reluctance to tell the survey takers than it did for gay and lesbian people. If it were an anonymous interaction by phone or Internet, the stigma might not be as important. And N.H.I.S. did report that bisexuals reported high levels of psychological distress.

Were there other weaknesses in the survey?

They measured sexual orientation: straight, gay, lesbian or bisexual. But they didn't measure gender identity. They didn't ask, "Are you transgender?" or "Do you present your gender differently than the sex that was recorded on your birth certificate?" That is a serious gap.

You have written about best practices for surveying L.G.B.T. People. What are some considerations?

It depends on what question you want answered. When we ask about sexual orientation, we say, "Do you think of yourself as gay, straight or bisexual?" But you might want to focus on sexual behavior and health risk. Then you get a very different group than when you measure people's sexual identity.

In some surveys, two-thirds of those who say that they have had some same-sex sexual encounters would identify as heterosexual. I don't take a stand on whether they are, just that they reported same-sex behavior.

So how people identify themselves to survey takers reflects just that?

Yes. In the N.H.I.S., a little over 2 percent identify as lesbian, gay or bisexual. That's different than saying a little over 2 percent of the population is lesbian, gay or bisexual.

Some critics say that such efforts do not capture minority communities, where there may be resistance to complying with government survey takers.

There isn't much difference in the racial and ethnic characteristics of the straight population and the L.G.B. population in the N.H.I.S. There is a popular conception that there is a lower willingness to report L.G.B. identities among minorities, but very few surveys find that to be the case.

I don't want my words to ever be construed that I don't believe there is some portion of the population who is unwilling to disclose their identities to survey takers. But that's a largely unknowable number, because you're asking how many didn't do something.

Conversely, are there some groups who will disclose more readily than others?

In the Gallup data I've worked with, if you're under 30, 6 percent identify as L.G.B.T. If you're older, it's closer to 3 percent. But it's not that proportionally there are more L.G.B.T. people among the young, but that young people are more likely to disclose.

What about the 1.1 percent that the N.H.I.S. Said responded, "I don't know the answer" or something else?

The N.H.I.S. followed up with them. Thirty percent said they hadn't figured out their sexual orientation. Another 30 percent said they didn't understand the words gay, straight or lesbian. And 30 percent just refused to answer the question or reiterated, "Don't know."

How can survey takers obtain more reliable numbers?

We get accurate responses from people who are willing to identify. Is that accurate in terms of this almost existential thing we call sexual orientation? No. There are people who internally think of themselves that way who are not willing to tell the survey taker.

But some surveys then ask, "Who have you told about your sexual orientation?" And a small number respond, "No one." So there are people who will just identify themselves to a survey taker but to no one else in their life.

My argument is that these surveys are accurate portraits of who is willing to disclose in that setting, but it's not an accurate assessment of, for lack of a better word, the closet.

A version of this article appears in print on 07/22/2014, on page D4 of the NewYork edition with the headline: Questions of Orientation.

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Well: 3 Things to Know About Niacin and Heart Health

Photo Credit Stuart Bradford

Recent studies published in The New England Journal of Medicine are adding to concerns about the safety and effectiveness of niacin, a popular drug for the prevention of cardiovascular disease. The studies reveal that although this B vitamin can reduce triglyceride levels, raise "good" cholesterol levels (HDL) and reduce "bad" cholesterol levels (LDL), it does not produce the benefits that patients and their doctors might expect. And the studies are revealing serious harms. Here are three things you need to know about niacin.

First, these new studies failed to show that niacin reduced the risk of heart disease and stroke.

The studies found that patients taking niacin had about the same rates of heart disease, stroke and death as those who took a placebo pill with no active ingredients.

Niacin has been known to affect lipid levels since the 1950s. Scientists have examined it in countless studies, almost all of which were not designed to determine if it led to fewer heart attacks, strokes and deaths. The largest previous study to assess whether niacin reduced the risk of heart disease compared with a placebo started in the 1960s, an era that is hardly relevant to medicine today, when so many patients are taking cholesterol-lowering statins.

Therefore, scientists designed these two new studies to determine whether niacin helped patients avoid heart disease and stroke in the statin era. The National Institutes of Health sponsored an American study, and the drug company Merck funded a large international study. One tested extended-release niacin, and the other evaluated a combination of extended-release niacin and laropiprant, an agent designed to make the niacin more tolerable.

Both studies failed to show that niacin reduced the risks of heart disease, stroke and death. Researchers even stopped the American study prematurely because the possibility of finding any benefit became so remote that its continuation seemed futile. Additional follow-up analyses conducted in both studies did not show that niacin provided a convincing benefit to any group of patients.

Second, niacin causes multiple side effects, many of which are serious.

Niacin can be hard to tolerate. It frequently causes uncomfortable flushing and itching, the reason the Merck trial tested niacin with another agent designed to block these nuisance effects.

A disturbing aspect of these recent studies is that in addition to the discomfort that many patients have, they show that niacin can cause more serious side effects. In the international study, niacin increased the risk of gastrointestinal events such as diarrhea and ulcers by 28 percent; musculoskeletal problems such as muscle damage and gout by 26 percent; rashes, skin ulcerations and other serious skin-related problems by 67 percent; infections by 22 percent; and gastrointestinal bleeding or other bleeding by 38 percent. In addition, patients on niacin were 32 percent more likely to receive a diagnosis of diabetes than those not on the drug, and in those with diabetes, niacin increased the risk of serious problems with disease management by 55 percent. Safety problems were also apparent in the American study, in which those taking niacin had a higher risk of gastrointestinal problems and infections than those taking a placebo. It is the concordance of these studies in showing harms that is so convincing.

But perhaps the most striking finding of the international study occurred before the trial started. Like many large trials, the study was designed to determine if patients would tolerate the drug before they were randomly assigned to receive niacin with laropiprant or a placebo. In this so-called run-in phase of the study, a third of those who were deemed ideal candidates and received the niacin combination withdrew from the study, mainly because of skin, gastrointestinal, musculoskeletal and diabetes side effects. So, under careful study conditions, a third of the patients could not even tolerate the drug. The risks that were discovered seem all the more important, because they occurred among individuals who initially tolerated the medication.

Third, there are still experts who say that the recent studies do not provide adequate evidence to stop recommending niacin.

No study is perfect, and for niacin advocates, many of whom have spent their careers promoting and prescribing the drug, the results of the new trials evoked disbelief. I was on a panel with a prevention specialist who told an audience of doctors that it made no sense to believe the published trials when personal experience told them otherwise. He then launched into a defense of treatments like niacin.

More reasoned critiques have rightly indicated that the trials focused on high-risk patients, almost all of whom were taking statins and had low levels of LDL cholesterol, the bad stuff. They ask whether niacin might be useful in patients with different lipid profiles, or in those who cannot tolerate statins or who had not already had a diagnosis of heart disease, or in patients with an even higher risk of heart disease and stroke. They mostly question whether these trials studied populations that were already receiving intensive treatment and were unlikely to benefit from more drugs. Even the authors of the Merck-sponsored study acknowledge, in the last sentence of their article, that they cannot say whether niacin might be beneficial for patients at even higher risk of having a heart attack or stroke or those with higher LDL levels.

The predicament is that the pursuit of more trials of niacin, particularly given the harms that were recently shown, is unlikely. Uncertainty about niacin may linger, accompanied by uncertainty about which patients it may benefit. Harder to dispute will be the drug's serious side effects. Safety issues alone, even if niacin were beneficial, should give many people reason to avoid it.

Bottom line: If you are taking niacin, talk with your doctor about whether you should continue. Many patients will probably choose to bypass a medication without clear benefit and with documented harms. For those who decide to continue taking the medication, the hope would be for an experience different from those of the tens of thousands of participants in the recent trials. If you are not taking niacin, then realize that there is little reason to start.

Harlan Krumholz is a cardiologist and the Harold H. Hines, Jr. Professor of Medicine, director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation and a director of the Robert Wood Johnson Foundation Clinical Scholars Program at Yale University School of Medicine.

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Well: A Vasectomy May Increase Prostate Cancer Risk

Men with vasectomies may be at an increased risk for the most lethal form of prostate cancer, researchers have found. But aggressive cancer nonetheless remains rare in these patients.

Earlier studies had hinted at a connection between vasectomies and prostate cancer. Many experts have dismissed the idea of a link: Men who have vasectomies may receive more medical attention, they said, and therefore may be more likely to receive a diagnosis. The new study, published this month in The Journal of Clinical Oncology, sought to account for that possibility and for other variables.

Researchers at Harvard reviewed data on 49,405 men ages 40 to 75, of whom 12,321 had had vasectomies. They found 6,023 cases of prostate cancer among those men from 1986 to 2010.

The researchers found no association between a vasectomy and low-grade cancers. But men who had had a vasectomy were about 20 percent more likely to develop lethal prostate cancer, compared with those who had not. The incidence was 19 in 1,000 cases, compared with 16 in 1,000, over the 24-year period.

The reason for the increase is unclear, but some experts have speculated that immunological changes, abnormal cell growth or hormonal imbalances following a vasectomy may also affect prostate cancer risk.

Dr. James M. McKiernan, interim chairman of the department of urology at Columbia, said the lack of a clear causal mechanism was a drawback of the new research.

"If someone asked for a vasectomy, I would have to tell them that there is this new data in this regard, but it's not enough for me to change the standard of care," he said. "I would not say that you should avoid vasectomy."

The lead author, Lorelei A. Mucci, an associate professor of epidemiology at the Harvard School of Public Health, emphasized that a vasectomy does not increase the risk for prostate cancer over all. "We're really seeing the association only for advanced state and lethal cancers," she said.

She agreed with Dr. McKiernan that the new data are not a reason to avoid a vasectomy. "Having a vasectomy is a highly personal decision that men should make with their families and discuss with their physicians," she said. "This is one piece of evidence that should be considered."

A version of this article appears in print on 07/18/2014, on page A13 of the NewYork edition with the headline: Study Links Vasectomies to Lethal Cancer Risk.

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The New Old Age: Warming Times in a Cold Land

Photo A scene from the new film "Land Ho!"Credit Sony Pictures Classics

Attention, moviegoers interested in aging who thought "The Iron Lady" was too depressing, "Nebraska" was too depressing, and "Amour" was off-the-charts depressing. I've got a tip for you: "Land Ho!"

Part road movie, part character study, this quiet indie film follows two former brothers-in-law on an improvisatory vacation. Mitch, a bombastic divorced surgeon with a salty vocabulary, thinks the more reserved Colin needs to "reach down and grab a handful of guts" to recover from widowhood and then a divorce. So he books a flight to Iceland — why Iceland? why not? — and they're off on a series of low-intensity adventures.

As they motor around the spectacular countryside and have rambling conversations, what passes for a plot involves questions like whether their rented Hummer will make it through a pool of uncertain depth on a remote road, or whether they will find their way back to the hotel after a late-night hike. The story meanders, and the growing friendship has its ups and downs, but note this: Nobody gets dementia. Nobody dies.

In fact, the movie never actually reveals how old these guys are, though the actors playing them (Earl Lynn Nelson, actually an ocular plastic surgeon in Kentucky, and Paul Eenhoorn) are 72 and 65, respectively.

Age permeates their story — "We're the oldest people in here, by a lot," Colin observes at a dance club in Reykjavik — but it surfaces, wafts through their conversations (often improvised), then dissipates again. One man refers, glancingly, to loneliness; the other briefly wonders how to live after retirement. Then they're off to see the geysers or pick up women. (My one quibble: Hooray for late-life lust, but Mitch's relentless casual sexism is no more cute or endearing than in a younger man.)

"Land Ho!" opened last week in New York and Los Angeles, and will open in other California cities and in Arizona this weekend and next. It comes to Connecticut, Colorado, Washington and its suburbs, and the New York-New Jersey suburbs in August.

It requires tolerance for an ambling pace (you can read The Times's review here) and the grumbly reactions that long treks in close quarters can provoke, but it's a gem.

And I suspect a number of New Old Age readers will want to cheer this exchange toward the end: Colin muses that he'll miss Iceland. "Don't get that Sunday afternoon attitude," Mitch says. "Good times are still a-comin'."

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

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Well: A Vasectomy May Increase Prostate Cancer Risk

Men with vasectomies may be at an increased risk for the most lethal form of prostate cancer, researchers have found. But aggressive cancer nonetheless remains rare in these patients.

Earlier studies had hinted at a connection between vasectomies and prostate cancer. Many experts have dismissed the idea of a link: Men who have vasectomies may receive more medical attention, they said, and therefore may be more likely to receive a diagnosis. The new study, published this month in The Journal of Clinical Oncology, sought to account for that possibility and for other variables.

Researchers at Harvard reviewed data on 49,405 men ages 40 to 75, of whom 12,321 had had vasectomies. They found 6,023 cases of prostate cancer among those men from 1986 to 2010.

The researchers found no association between a vasectomy and low-grade cancers. But men who had had a vasectomy were about 20 percent more likely to develop lethal prostate cancer, compared with those who had not. The incidence was 19 in 1,000 cases, compared with 16 in 1,000, over the 24-year period.

The reason for the increase is unclear, but some experts have speculated that immunological changes, abnormal cell growth or hormonal imbalances following a vasectomy may also affect prostate cancer risk.

Dr. James M. McKiernan, interim chairman of the department of urology at Columbia, said the lack of a clear causal mechanism was a drawback of the new research.

"If someone asked for a vasectomy, I would have to tell them that there is this new data in this regard, but it's not enough for me to change the standard of care," he said. "I would not say that you should avoid vasectomy."

The lead author, Lorelei A. Mucci, an associate professor of epidemiology at the Harvard School of Public Health, emphasized that a vasectomy does not increase the risk for prostate cancer over all. "We're really seeing the association only for advanced state and lethal cancers," she said.

She agreed with Dr. McKiernan that the new data are not a reason to avoid a vasectomy. "Having a vasectomy is a highly personal decision that men should make with their families and discuss with their physicians," she said. "This is one piece of evidence that should be considered."

A version of this article appears in print on 07/18/2014, on page A13 of the NewYork edition with the headline: Study Links Vasectomies to Lethal Cancer Risk .

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Well: 3 Things to Know About Niacin and Heart Health

Photo Credit Stuart Bradford

Recent studies published in The New England Journal of Medicine are adding to concerns about the safety and effectiveness of niacin, a popular drug for the prevention of cardiovascular disease. The studies reveal that although this B vitamin can reduce triglyceride levels, raise "good" cholesterol levels (HDL) and reduce "bad" cholesterol levels (LDL), it does not produce the benefits that patients and their doctors might expect. And the studies are revealing serious harms. Here are three things you need to know about niacin.

First, these new studies failed to show that niacin reduced the risk of heart disease and stroke.

The studies found that patients taking niacin had about the same rates of heart disease, stroke and death as those who took a placebo pill with no active ingredients.

Niacin has been known to affect lipid levels since the 1950s. Scientists have examined it in countless studies, almost all of which were not designed to determine if it led to fewer heart attacks, strokes and deaths. The largest previous study to assess whether niacin reduced the risk of heart disease compared with a placebo started in the 1960s, an era that is hardly relevant to medicine today, when so many patients are taking cholesterol-lowering statins.

Therefore, scientists designed these two new studies to determine whether niacin helped patients avoid heart disease and stroke in the statin era. The National Institutes of Health sponsored an American study, and the drug company Merck funded a large international study. One tested extended-release niacin, and the other evaluated a combination of extended-release niacin and laropiprant, an agent designed to make the niacin more tolerable.

Both studies failed to show that niacin reduced the risks of heart disease, stroke and death. Researchers even stopped the American study prematurely because the possibility of finding any benefit became so remote that its continuation seemed futile. Additional follow-up analyses conducted in both studies did not show that niacin provided a convincing benefit to any group of patients.

Second, niacin causes multiple side effects, many of which are serious.

Niacin can be hard to tolerate. It frequently causes uncomfortable flushing and itching, the reason the Merck trial tested niacin with another agent designed to block these nuisance effects.

A disturbing aspect of these recent studies is that in addition to the discomfort that many patients have, they show that niacin can cause more serious side effects. In the international study, niacin increased the risk of gastrointestinal events such as diarrhea and ulcers by 28 percent; musculoskeletal problems such as muscle damage and gout by 26 percent; rashes, skin ulcerations and other serious skin-related problems by 67 percent; infections by 22 percent; and gastrointestinal bleeding or other bleeding by 38 percent. In addition, patients on niacin were 32 percent more likely to receive a diagnosis of diabetes than those not on the drug, and in those with diabetes, niacin increased the risk of serious problems with disease management by 55 percent. Safety problems were also apparent in the American study, in which those taking niacin had a higher risk of gastrointestinal problems and infections than those taking a placebo. It is the concordance of these studies in showing harms that is so convincing.

But perhaps the most striking finding of the international study occurred before the trial started. Like many large trials, the study was designed to determine if patients would tolerate the drug before they were randomly assigned to receive niacin with laropiprant or a placebo. In this so-called run-in phase of the study, a third of those who were deemed ideal candidates and received the niacin combination withdrew from the study, mainly because of skin, gastrointestinal, musculoskeletal and diabetes side effects. So, under careful study conditions, a third of the patients could not even tolerate the drug. The risks that were discovered seem all the more important, because they occurred among individuals who initially tolerated the medication.

Third, there are still experts who say that the recent studies do not provide adequate evidence to stop recommending niacin.

No study is perfect, and for niacin advocates, many of whom have spent their careers promoting and prescribing the drug, the results of the new trials evoked disbelief. I was on a panel with a prevention specialist who told an audience of doctors that it made no sense to believe the published trials when personal experience told them otherwise. He then launched into a defense of treatments like niacin.

More reasoned critiques have rightly indicated that the trials focused on high-risk patients, almost all of whom were taking statins and had low levels of LDL cholesterol, the bad stuff. They ask whether niacin might be useful in patients with different lipid profiles, or in those who cannot tolerate statins or who had not already had a diagnosis of heart disease, or in patients with an even higher risk of heart disease and stroke. They mostly question whether these trials studied populations that were already receiving intensive treatment and were unlikely to benefit from more drugs. Even the authors of the Merck-sponsored study acknowledge, in the last sentence of their article, that they cannot say whether niacin might be beneficial for patients at even higher risk of having a heart attack or stroke or those with higher LDL levels.

The predicament is that the pursuit of more trials of niacin, particularly given the harms that were recently shown, is unlikely. Uncertainty about niacin may linger, accompanied by uncertainty about which patients it may benefit. Harder to dispute will be the drug's serious side effects. Safety issues alone, even if niacin were beneficial, should give many people reason to avoid it.

Bottom line: If you are taking niacin, talk with your doctor about whether you should continue. Many patients will probably choose to bypass a medication without clear benefit and with documented harms. For those who decide to continue taking the medication, the hope would be for an experience different from those of the tens of thousands of participants in the recent trials. If you are not taking niacin, then realize that there is little reason to start.

Harlan Krumholz is a cardiologist and the Harold H. Hines, Jr. Professor of Medicine, director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation and a director of the Robert Wood Johnson Foundation Clinical Scholars Program at Yale University School of Medicine.

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Well: A Family Plot

Photo Credit Victor J. Blue for The New York Times

As a gift one year, an eminently practical cousin presented my family with five funeral plots in a Cape Cod cemetery — sufficient for Mom and Dad, my two siblings and me. As Cousin Nina told my father, "they were cheaper by the dozen," so she had purchased not five but 12, giving the rest to other cousins. I was 11 at the time.

Nina was a bit of an outlier in our family, which was never known for dwelling on final dispositions. In fact, my journalist father, who harangued me when growing up about the proper use of tenses and moods, would later in life preface any mention of his own passing with "If I die…" To which I had the satisfaction of responding that this was no time for the subjunctive, "Dad, it's when, not if."

But it wasn't just denial that stood in the way of us choosing a final resting place; my parents also had little tradition to go on. My maternal grandparents were buried deep in a Queens mausoleum that I've never visited; my father's father had his ashes buried under one of his prize rose bushes in the backyard of a house now owned by God knows who. My other grandmother? Soon after dying, she was dispatched to New York University's medical residents.

On this subject, I am a very different beast from my parents. Perhaps because I'd been given a cancer diagnosis early in life or because I'm a planner par excellence, I've long had a manila folder in my desk called "Notes for SP Funeral/Memorial."

Among the detritus is a program from a friend's gorgeous church wedding; it's there because I'd like to make sure my funeral is held there. Then there's a Post-it that says I want "The Mary Tyler Moore Show" theme song ("Who can take a nothing day….") played. Oh, and there's a photograph of the Arlington National Cemetery grave markers for President and Mrs. Kennedy, specifying that my stone be from the same Massachusetts foundry.

By 35, I had planned my last party. My after-party, however, remained as opaque as my parents'. None of us were planning to use Nina's gift, but I had nowhere else in mind as my final resting place.

Until one day in Sag Harbor, N.Y., an old whaling village where as a child I'd had happy memories of Fourth of July parades and strawberry shortcake. Drawn there again as an adult, I drove past a cemetery called Oakland. A local poet described it like this: "I have stood alone and quiet in the filtered sunlight beneath the old trees, listening to the sighing winds and the chattering of birds …" Eureka.

Walking the grounds, I discovered that many notables had been interred there: the choreographer George Balanchine; two Iranian princes; and a Revolutionary War hero, David Hand, who is buried with his five wives. I put in a call to ask about the availability of plots, and a Mr. Yardley said they still had some in the original burial ground – although like everything in the Hamptons nowadays, they were "adding on."

We scheduled a visit. My parents canceled. ("We need to take the dog to the vet.") We rescheduled; they canceled again. ("Oh no, we're double booked.") On the fourth try, we made it out there: Mom, Dad, my sister Julie (and her wife) and me. (My brother and his wife didn't want any part of this real estate "deal.")

In the dead of winter, Mr. Yardley walked us to a site where, lo and behold, we could have six plots for $600 apiece — cheaper by the half-dozen in this case, and surely the best real estate deal on the East End.

Photo Credit Steven Petrow

Mom, who was complaining that her feet were "frostbitten," was willing to say yes if it got us closer to lunch and a gimlet. I could see Dad was ambivalent, not as much about Oakland but about dying. As is customary for him, he took off to wander a bit, heading down toward the new "development." Ten minutes later, he returned and said: "O.K., we'll do it. I saw Clay Felker's grave marker over there. This is a good 'hood for me." Dad was satisfied to share his final quarters in the company of the founder and editor of New York magazine.

And so we agreed to buy all six plots. My mom especially liked the notion that – eventually – we'd all be together again. A decade later, we're all still here, not there, with the deed to my plot in my manila folder. Yes, we all now have a shady place to call home for eternity. Older and more like my dad these days, I've also caught myself misusing my tenses, "If I die…."

I guess old subjunctives die hard.

Steven Petrow is a writer who lives in Hillsborough, N.C.

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