Well: Healing Teenage Cancer’s Scars

Personal Health

Jane Brody on health and aging.

Photo Credit Sarah Williamson

The teenage years can be tough enough under the best of circumstances. But when cancer invades an adolescent's life, the challenges grow exponentially.

When the prospects for treatment are uncertain, there's the fear of dying at so young an age. Even with an excellent chance of being cured, teenagers with cancer face myriad emotional, educational and social concerns, especially missing out on activities and losing friends who can't cope with cancer in a contemporary.

Added to that are the challenges of trying to keep up with schoolwork even as cancer treatment steals time and energy, and may cause long-lasting physical, cognitive or psychological side effects.

Sophie, who asked that her last name be withheld, was told at 15 that she had osteosarcoma, bone cancer. After a bout of how-can-this-be-happening-to-me, she forged ahead, determined to stay at her prestigious New York high school and graduate with her class.

Although most of her sophomore year was spent in the hospital having surgery and exhausting chemotherapy, she went to school on crutches whenever possible. She managed to stay on track, get good grades — and SAT scores high enough to get into Cornell University.

Now 20, Sophie is about to start her junior year and is majoring in biology and genetics with a minor in computer science. She plans to go to medical school, so this summer she has been studying for the MCATs and volunteering at a hospital.

Her main concern now is that people meet and get to know her as a whole, normal person, not someone who has had cancer, which is why she asked that I not identify her further.

"I'm pretty healthy, and I don't want people to think I'm weak and need special care," she said in an interview.

"Having cancer puts other issues into perspective," she added. "I feel like I have to do as much as I can. I've gotten involved in so much. I try to enjoy myself more. And I don't regret for a minute how I've been spending my time."

Sophie's determination to do the most she can and her desire for normalcy are hardly unusual, said Aura Kuperberg, who directs an extraordinary program for teenagers with cancer and their families at Children's Hospital Los Angeles. Dr. Kuperberg, who has a doctorate in social work, started the program, called Teen Impact, in 1988. It operates with the support of donations and grants and deserves to be replicated at hospitals elsewhere.

"The greatest challenge teens with cancer face is social isolation," she said in an interview. "Many of their peers are uncomfortable with illness, and many teens with cancer may withdraw from their friends because they feel they are so different and don't fit in."

In the popular young adult novel "The Fault in Our Stars," a teenager with advanced cancer says, "That was the worst part of having cancer, sometimes: The physical evidence of disease separates you from other people."

Within the family, too, teenagers can feel isolated, Dr. Kuperberg said. "Patients and parents want to protect one another. They keep up a facade that everything will be O.K., and feelings of depression and anxiety go unexpressed."

Teen Impact holds group therapy sessions for young patients, parents and siblings so they "don't feel alone and realize that their feelings are normal," Dr. Kuperberg said. The goal of the program, which also sponsors social activities, is to help young cancer patients — some still in treatment, others finished — live as normally as possible.

"For many, cancer is a chronic illness, with echoes that last long after treatment ends," Dr. Kuperberg said. "There are emotional side effects — a sense of vulnerability, a fear of relapse and death, and an uncertainty about the future that can get in the way of pursuing their hopes and dreams. And there can be physical and cognitive side effects when treatment leaves behind physical limitations and learning difficulties."

But, she added, there is often "post-traumatic growth that motivates teens in a very positive way."

"There's a lot of altruism," she said, "a desire to give back, and empathy, a sensitivity to what others are going through and a desire to help them."

Sophie, for example, took notes for a classmate with hearing loss caused by chemotherapy. She recalled her gratitude for the friend "who was there for me the whole time I was in treatment, who would come over after school and sit on the couch and do puzzles while I slept."

One frequent side effect of cancer treatment now receiving more attention is the threat to a young patient's future reproductive potential.

In an opinion issued this month, The American College of Obstetricians and Gynecologists urged doctors to address the effects of cancer treatment on puberty, ovarian function, menstrual bleeding, sexuality, contraceptive choice, breast and cervical cancer screening, and fertility.

"With survival rates pretty high now for childhood cancers, we should do what we can to preserve future fertility," said Dr. Julie Strickland, the chairwoman of the college's committee on adolescent health care. "We're seeing more and more cooperation between oncologists and gynecologists to preplan for fertility preservation before starting cancer treatment."

The committee suggested that, when appropriate, young cancer patients be referred to a reproductive endocrinologist, who can explore the "full range of reproductive options," including the freezing of eggs and embryos.

For boys who have been through puberty, it has long been possible to freeze sperm before cancer treatment.

Although some female patients may be unwilling to delay treatment, even for a month, to facilitate fertility preservation, at the very least they should be offered the option, Dr. Strickland said in an interview.

She described experimental but promising possibilities, like freezing part or all of an ovary and then implanting it after cancer treatment ends. It is already possible to move ovaries out of harm's way for girls who need pelvic radiation.

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Well: Ask Well: Are Spray-On Sunscreens Safe?

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The short answer is that for now, not even the Food and Drug Administration knows.

In 2011, with the number of sunscreen sprays "greatly increasing," the agency asked their makers to demonstrate their safety and efficacy. Little was known about sprays compared to rub-on sunscreen products like lotions. It was unclear, for instance, how much sunscreen spray consumers typically use, or what amounts effectively get on the skin.

The F.D.A. also proposed adding a warning to package labels to address the possibility that inhaling aerosolized particles could be unhealthy: "When using this product, keep away from face to avoid breathing it."

Manufacturers of sunscreen sprays provided the data, and the F.D.A. is still reviewing that information. So we still don't know how effective sprays are at filtering ultraviolet radiation, let alone if inhalation results in health problems.

The Environmental Working Group, an advocacy organization, recommends consumers avoid all spray-on sunscreens of any particle size, especially ones that use mineral ingredients like zinc oxide and titanium dioxide, which they say may pose problems if inhaled. Paul Pestano, a research analyst at the group, cited a 2006 report from the International Agency for Research on Cancer, part of the World Health Organization, that concluded that titanium dioxide is "possibly carcinogenic to humans." That conclusion was based on research involving rats inhaling high doses, but it's still worrisome, he said.

There's another reason to choose sunscreen wisely. In 2013, the F.D.A. warned about the risk of burns in those applying sunscreen sprays near open flames, such as outdoor barbecue grills or citronella candles. Many sunscreen sprays contain ingredients, like alcohol, that can catch fire.

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Well: Food and the Dying Patient

Photo Credit Getty Images

The patient had dementia and could no longer swallow. The intricate workings of the muscles of her throat were failing, and she was no longer able to move food or liquids reliably into her stomach. Instead, they too frequently ended up in her lungs, and she drowned a little more with every swallow. She was admitted to my intensive care service with pneumonia from aspirated food that had turned the bottom part of her left lung into a wet sponge. Her blood oxygen levels had dropped so low that we had to support her breathing by inserting a tube.

Now, after she was on powerful antibiotics and life support for three days, her oxygen level had improved and her fevers had abated. She was getting better, in a manner of speaking.

This pneumonia was her third, and easily her worst, in four months. This pattern is typical of end-stage dementia, when patients lose control of their swallowing mechanism and often die from the pneumonias that result from food lodging in the lung. Usually, these patients have gone in and out of the hospital through a sort of revolving door; as soon as one pneumonia is chased away by antibiotics, another emerges.

Our medical system deals well with organ dysfunction. When a kidney isn't working, we can clean blood with a dialysis machine. When a person can't breathe, we can push air into the lungs. And if there is trouble swallowing, we can bypass the throat with a feeding tube that goes through the abdominal wall directly into the stomach.

That last option had been offered to this patient's family when she was admitted to the emergency room. "If she makes it through this, she could get a feeding tube so that this doesn't happen again," they were told. And so now that she was improving, her family was asking for the tube.

But contrary to popular belief, a feeding tube does not prolong life in a patient with dementia. It actually increases suffering. A stomach full of mechanically pumped artificial calories puts pressure on an already fragile digestive system, increasing the chance of pushing stomach contents up into the lungs. And surgically implanted tubes are a setup for complications: dislodgments, bleeding and infections that can result in pain, hospital admissions and the use of arm restraints in already confused patients. But maybe most important, the medicalization of food deprives the dying of some of the last remnants of the human experience: taste, smell, touch and connection to loved ones.

So why do so many demented patients die with feeding tubes?

Food is how we know best to care for one another, from breast to deathbed. And thus it runs contrary to every impulse we have as humans to stop feedings. As a dying person becomes unable to process food on her own, our tendency is to plug life into her with a tube pumping artificial nutrition.

Since the beginning of time, humans have fed their dying by hand.  Spooned slowly so as not to overwhelm, a trickle of broth or a favorite food ground up to taste may be the last small pleasures for a dying body.

But hand feeding has increasingly become a quaint piece of human history.  We fed until they would take no more, and knew that we had done everything we could. But with the feeding tube, we can, and feel we must, keep going.  Patients frequently die with plastic tubes weaving mysteriously under their gowns, entering bodies at unnatural angles, rendering them a little more alien to us.  Those who are most needed sit a little further away from the bed, afraid to dislodge tubes that are supposedly keeping their loved one alive.   And the patient's mouth will usually remain dry and empty until the end.

My last conversation about the patient's feeding took place on my way to my car Friday afternoon. The patient's sister was walking in as I was walking out. She thanked me for the care I'd provided and told me they had decided to go with the tube. "I couldn't not feed her," she said. "I can't leave her starving."

The next day, my patient was wheeled down to the operating room for her feeding tube, then a few hours later wheeled back to intensive care. Over the next couple of weeks, her sister sat on a chair beside her most days, wearing the requisite paper gown and gloves for guests of patients with resistant bacteria from prolonged hospital stays. She sat off to the side, separated from her sister by tubes, bedrails and the bustle of activity around them.

But the patient never went home to her sister and their beloved soap operas.  She died two weeks later in the intensive care unit, a different pneumonia in her lungs.

In the face of death, food and hope are highly seductive. But once again, I was left wondering: Does our need to feed our dying loved ones blind us to what's really best for them?

Jessica Nutik Zitter is an attending physician at Highland Hospital in Oakland, Calif. She is board certified in critical care and palliative care medicine.

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Well: What Is So Special About Iyengar Yoga?

Slide Show

This week, the international yoga community said goodbye to a beloved teacher, B.K.S. Iyengar, who died at the age of 95. He is credited with bringing yoga to the Western world and making it accessible to every age and walk of life. To learn more about what makes Iyengar yoga so special to those who practice it, I spoke with Carrie Owerko, a teacher at the Iyengar Yoga Institute of Greater New York. She was also a student of B.K.S. Iyengar, and studied with him in India in February. Here's an edited version of our conversation.

Q. Why was B.K.S. Iyengar such an important teacher?

B.K.S. Iyengar was really a pioneer. He was one of the people who brought yoga to the West and really made it popular because he made it approachable for anyone. He felt that yoga was for everybody. No matter what the challenges — physical challenges, mental challenges or age — he didn't see any limitation.

I think one of his main contributions was making yoga accessible, but also the degree of attention he gave to the practices of asana, or postural yoga, and to pranayama, the breathing exercises, was immense. He was also an amazing communicator. He was constantly finding new ways to help his students increase their capacity to be aware of what was going on in their bodies and minds.

Iyengar is a lot of the yoga people experience in the United States. The teacher may not be teaching Iyengar, but that teacher has been influenced by Iyengar yoga in some way.

What is unique about Iyengar yoga?

What distinguishes Iyengar yoga is the very high degree of attention paid to alignment. Props may be used to increase awareness and to make the poses accessible. Sometimes we hold the poses longer than students might be used to in a flow-style class. There is an emphasis on movement, but then learning how to calmly abide in the body.

The diversity of practice is another distinguishing element. We don't do one sequence every day. That is the case in other popular types of yoga where there might be a consistent sequence repeated day to day. Even though we do repeat some of the same poses, there is a lot of diversity in the sequencing. In my experience that helps prevent injury and overuse. His approach is therapeutic in nature. That is a huge aspect to the practice.

Why did B.K.S. Iyengar use props in his teaching?

Take the yoga block. Everybody knows a yoga block. It's something you can get at Bed Bath & Beyond. The prototype of the yoga block was actually a rock or cinder block from B.K.S. Iyengar's garden. When he was teaching students, he would sometimes place students over his knee for a supported back arch if they couldn't support themselves. The story goes that he asked his daughter to go in the yard and bring this cinder block to help. That was the beginning of the yoga block. He would use whatever was in the environment — tables, chairs, ropes. The more common props — belts, straps, blocks and chairs, this is the type of equipment that was not really used in the practice of yoga. Now everybody is using them. There are never enough props to go around.

Is there a distinguishing pose or style of pose that is unique to Iyengar?

I don't know of a pose that we do exclusively in Iyengar that is not done in other styles. But the headstand and shoulder stand are really important poses in our practice. They are not always taught in other styles of yoga. We have alternatives for people who are not able to do them. If someone comes to an Iyengar class, they know there will be some inverted pose that is taught. We don't require people to do them but we try to make them accessible and safe. We insist on a yoga blanket to prevent overstretching of the neck area. Iyengar yoga is very cautious and mindful.

When did you last practice with B.K.S. Iyengar?

In February of this year I was in India and B.K.S. Iyengar was in the practice. Even though his daughter and son and now his granddaughter are teaching the majority of the classes now, he would be in the practice hall every single day correcting people and engaging people. Even at 95 years old, he couldn't help himself. He had to teach. It was his calling.

Do you have any special memories of him?

There were several different times where we had exchanges and encounters. He notices everything. One memory that stands out — I hadn't been to India for a few years. He saw me and said, "Oh, a little bit thin." I had only lost like three pounds and thought, "How could he possibly notice that?" We were laughing. My mother doesn't even do that.

Another time when he was in the United States for his book tour, we had done a demonstration of poses at the City Center in New York to celebrate his book tour. He loved the theatrical, and we did this demonstration and he was very enthusiastic.

I remember when we were at the institute he looked me in the eye and said, "You have to maintain.'' To someone who doesn't practice yoga, that might not mean anything, but we had worked so hard. It pushes you to break into new territory and challenge yourself, and after doing that you might back off. But that thing about maintaining the practice, that really stuck. Excellence is what he wanted of us. It's hard to put into words what you feel for someone who has changed your life.

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Well: Is Breakfast Overrated?

Photo Credit Illustration by Ben Wiseman

For years, we've heard that breakfast is the most important meal of the day. But scientific support for that idea has been surprisingly meager, and a spate of new research at several different universities — published in multiple articles in the August issue of The American Journal of Clinical Nutrition — could change the way we think about early-hours eating.

The largest and most provocative of the studies focused on whether breakfast plays a role in weight loss. Researchers at the University of Alabama at Birmingham and other institutions recruited nearly 300 volunteers who were trying to lose weight. They randomly assigned subjects to either skip breakfast, always eat the meal or continue with their current dietary habits. (Each group contained people who habitually ate or skipped breakfast at the start, so some changed habits, and others did not.)

Sixteen weeks later, the volunteers returned to the lab to be weighed. No one had lost much, only a pound or so per person, with weight in all groups unaffected by whether someone ate breakfast or skipped it.

In another new study — this one of lean volunteers — researchers at the University of Bath determined the resting metabolic rates, cholesterol levels and blood-sugar profiles of 33 participants and randomly assigned them to eat or skip breakfast. Volunteers were then provided with activity monitors.

After six weeks, their body weights, resting metabolic rates, cholesterol and most measures of blood sugar were about the same as they had been at the start, whether people ate breakfast or not. The one difference was that the breakfast eaters seemed to move around more during the morning; their activity monitors showed that volunteers in this group burned almost 500 calories more in light-intensity movement. But by eating breakfast, they also consumed an additional 500 calories each day. Contrary to popular belief, skipping breakfast had not driven volunteers to wolf down enormous lunches and dinners — but it had made them somewhat more sluggish first thing in the morning.

Together, the new research suggests that in terms of weight loss, "breakfast may be just another meal," said Emily Dhurandhar, the assistant professor at the University of Alabama who led the study there. Skipping breakfast in these studies, she said, did not fatten people.

Each study was fairly short-term, however, and involved a limited range of volunteers. More randomized experiments are needed before we can fully understand the impact of breakfast, said James Betts, the professor who led the study of lean people. It's not yet clear, for instance, whether heavy people's bodies respond differently to morning meals than lean people's, or if the timing and makeup of breakfast matters.

For now, the slightly unsatisfying takeaway from the new science would seem to be that if you like breakfast, fine; but if not, don't sweat it. "I almost never have breakfast," Dr. Betts said. "That was part of my motivation for conducting this research, as everybody was always telling me off and saying I should know better." Based on the results of these studies, he said his habits won't change.

Neither will those of Dr. Dhurandhar, who enjoys a morning meal. But, she said, "I guess I won't nag my husband to eat breakfast anymore."

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Well: Feeding Your Canine Athlete

Photo Dogs are endowed with more endurance-related muscle fibers than cats, making them better running companions.Credit IStock

Phys Ed

Gretchen Reynolds on the science of fitness.

Many people who run or walk with their dogs treat them like human running partners, offering them sips of Gatorade or half of a sports bar during a workout. But the latest science about performance nutrition for canines underscores that dogs are not people. They have more fur and cellular mitochondria, the small structures in cells that generate energy; lower body weights; and fewer fecal-related inhibitions than their human companions, each of which affects their nutritional needs.

To learn more about sports nutrition for dogs, I spoke recently with Dr. Joseph Wakshlag, a professor of clinical nutrition and sports medicine at Cornell University College of Veterinary Medicine in Ithaca, N.Y., and the author of a comprehensive new review about nutrition for active dogs, published this month in Veterinary Clinics of North America: Small Animal Practice. Among its many tidbits of knowledge, the article notes that dogs are endowed with more endurance-related muscle fibers than cats, making them better running companions; competing in a Frisbee or agility competition is, for a dog, glorious fun but relatively little exercise, requiring only about 25 percent more calories than lying on a rug; and consuming sports drinks tends to cause dogs to empty their intestines soon afterward, often with little warning.

This is all useful information, as were Dr. Wakshlag's replies to my questions. What follows are excerpts from our conversation.

How much exercise qualifies a dog as an athlete, and do canine athletes have special dietary needs?

It's similar to human athletes. There are sprinters, acrobats, marathon runners, all with different nutritional considerations. On the one hand, you have earthdogs — the dachshunds and such — designed for fast, short sprints, and then there are sled dogs that run 50 miles or more. Your typical running companion would be somewhere in between. In general, I'd say that if a dog is running continuously for more than 30 minutes, you should probably take a look at its diet, in terms of performance.

Does that mean feed it like a human runner?

No. Humans and dogs fuel exercise very differently. When we run, we start out burning mostly glycogen, which is stored carbohydrates. Dogs don't, partly because they have more mitochondria in their muscles than we do. Dogs burn fat as their primary endurance fuel, and carbohydrates are not very important for them.

So there's no reason to give a dog a sports bar, which is full of carbohydrates, during a run?

No. Same for those gel packets. I see people sharing them with their dogs. The dog may like it, but its not helping its running. Fat is the fuel for performance dogs.

So should an athletic dog's diet contain lots of fat?

That's a good question. For dogs jogging along with you for 20 minutes a few times a week, a normal commercial dog food containing about 15 or 16 percent fat should be fine. But if you and your dog run five or 10 miles a day, that dog likely needs a slightly higher-fat diet.

There are special high-performance dog foods now that contain as much as 20 percent fat. Or you can just add a teaspoon of olive oil to your dog's kibble. That increases fat intake by 1 or 2 percent, which can be plenty. On the other hand, fat is somewhat indigestible and can lead to greater fecal mass. So if you increase your dog's fat intake, be prepared to carry an extra plastic bag or two when you go running.

What about protein? How important is it?

Vital. Athletic dogs need protein to build and maintain muscle. In general, their diet should consist of at least 25 percent protein, preferably from meat. In one study, dogs fed plant-based soy protein experienced far more musculoskeletal injuries than dogs consuming meat protein.

And treats? Are they a good idea?

It depends on what else your dog is eating. The biggest health problem for most dogs is overweight. If you took your dog for a two-mile walk and reward him with a Milk-Bone, you've just given him more calories than he burned. A pat on the head would be healthier.

Do you recommend raw-food diets, which have become popular for dogs?

The raw-food diets available at pet stores are fine, if expensive. I do not recommend that people create their own raw-food diets at home. It's difficult to include all of the necessary nutrients, and there can be food-borne illnesses.

Any advice on hydration for exercising dogs?

Dogs don't sweat like we do. They pant to cool themselves. But they do lose fluids during activity. On the other hand, they are much better than most people at rehydrating. We did a study with search-and-rescue dogs working in 90-degree heat. They replaced their fluid losses almost drop for drop.

My advice would be to make sure that water is available if you'll be running with your dog for more than 30 minutes. But don't share your Gatorade. Dogs don't need carbohydrates or electrolytes, and the only study I know of that tested sports drinks in dogs found that the main outcome was gastrointestinal distress.

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Well: Legal Marijuana for Parents, but Not Their Kids

Photo Credit Stuart Bradford

The Well Column

Tara Parker-Pope on living well.

When the antidrug educator Tim Ryan talks to students, he often asks them what they know about marijuana. "It's a plant," is a common response.

But more recently, the answer has changed. Now they reply, "It's legal in Colorado."

These are confusing times for middle and high school students, who for most of their young lives have been lectured about the perils of substance abuse, particularly marijuana. Now it seems that the adults in their lives have done an about-face.

Recreational marijuana is legal in Colorado and in Washington, and many other states have approved it for medical use. Lawmakers, the news media and even parents are debating the merits of full-scale legalization.

"They are growing up in a generation where marijuana used to be bad, and maybe now it's not bad," said Mr. Ryan, a senior prevention specialist with FCD Educational Services, an antidrug group that works with students in the classroom.

"Their parents are telling them not to do it, but they may be supporting legalization of it at the same time."

Antidrug advocates say efforts to legalize marijuana have created new challenges as they work to educate teenagers and their parents about the unique risks that alcohol, marijuana and other drugs pose to the developing teenage brain.

These educators say their goal is not to vilify marijuana or take a stand on legalization; instead, they say their role is to convince young people and their parents that the use of drugs is not just a moral or legal issue, but a significant health issue.

"The health risks are real," said Steve Pasierb, the chief executive of the Partnership for Drug-Free Kids. "Every passing year, science unearths more health risks about why any form of substance use is unhealthy for young people."

Already nearly half of teenagers — 44 percent — have tried marijuana at least once, according to data from the partnership. Regular use is less common. One in four teenagers report using marijuana in the past month, and 7 percent report frequent use — at least 20 times in the past month.

Even in the states where marijuana is legal, it remains, like alcohol, off-limits to anyone younger than 21. But the reality is that once a product becomes legal, it becomes much easier for underage users to obtain it.

This summer, the Partnership for Drug-Free Kids released its annual tracking study, in which young people were asked what stopped them from trying drugs. Getting into trouble with the law and disappointing their parents were cited as the two most common reason young people did not use marijuana. The concern now is that legalization will remove an important mental barrier that keeps adolescents from trying marijuana at a young age.

"Making it legal makes it much more accessible, more available," said Dr. Nora Volkow, the director of the National Institute on Drug Abuse. "This is the reality, so what we need to do is to prevent the damage or at least minimize it as much as possible."

Drug prevention experts say the "Just Say No" approach of the 1980s does not work. The goal of parents should not be to prevent their kids from ever trying marijuana.

Instead, the focus should be on practical reasons to delay use of any mind-altering substance, including alcohol, until they are older.

The reason is that young brains continue to develop until the early 20s, and young people who start using alcohol or marijuana in their teens are far more vulnerable to long-term substance-abuse problems.

The brain is still wiring itself during adolescence, and marijuana — or any drug use — during this period essentially trains the reward system to embrace a mind-altering chemical.

"We know that 90 percent of adults who are addicted began use in teenage years," Mr. Pasierb said. "They programmed the reward and drive center of their teenage brain that this is one of those things that rewards and drives me like food does, like sex does."

Studies in New Zealand and Canada have found that marijuana use in the teenage years can result in lost I.Q. points. Mr. Pasierb says the current generation of young people are high achievers and are interested in the scientific evidence about how substance use can affect intelligence.

"You have to focus on brain maturation," he said. "This generation of kids wants good brains; they want to get into better schools. Talk to a junior or senior about whether marijuana use shaves a couple points off their SATs, and they will listen to you."

Because early exposure to marijuana can change the trajectory of brain development, even a few years of delaying use in the teen years is better. Research shows that young adults who smoked pot regularly before the age of 16 performed significantly worse on cognitive function tests than those who started smoking in their later teenage years.

Drug educators say that one benefit of the legalization talk is that it may lead to more research on the health effects of marijuana on young people and more funding for antidrug campaigns.

The Partnership for Drug-Free Kids plans to continue its "Above the Influence" marketing campaign, which studies show has been an effective way of reaching teenagers about the risks of drug use. The campaign does not target a specific drug, but it teaches parents and teens about the health effects of early drug use and tries to empower teens to make good choices.

"Legalization is going to make the work we do even more relevant," Mr. Pasierb said. "It's part of the changing drug landscape."

A version of this article appears in print on 08/19/2014, on page D1 of the NewYork edition with the headline: In Drug Fight, Erratic Cues For Teenagers .

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Well: Picking Apart Objections to Eating Fish

Photo Credit Brian Stauffer

Personal Health

Jane Brody on health and aging.

I grew up eating fish. My family enjoyed a fish meal at least once a week, usually mackerel, salmon trout (now called steelhead) or flounder. Lox, pickled herring, smoked white fish and sable were occasional treats.

In summer, when I caught little sunfish and perch in a local lake, my mother dutifully cleaned and pan-fried them. Yum!

My sons like fish, and fishing, too. They often took sardine sandwiches for lunch at school; I knew they would not be traded for PB&J. When they pulled a five-pound carp from a Minnesota river, I stuffed and baked it, to the delight of dinner guests. I'm thrilled, too, that all four grandsons like fish.

So it baffles me that fish remains so unloved in comparison with the other sources of animal protein: red meat and poultry.

I know all the excuses: "I don't know what to buy." "I don't know how to prepare it." "It smells up the kitchen." "I once ate bad fish and never touched it again."

There are ways to overcome these objections. (A decade ago, I produced a seafood cookbook with Richard Flaste to facilitate this.) And it helps to know how and why to choose certain fish and shellfish over others.

Let's start with health. Fish is good for you, better than heart-damaging red meat and even better than lean poultry. Oily fish like salmon, mackerel, bluefish, herring and sardines are rich in omega-3 fatty acids. These are polyunsaturated fatty acids that may protect against heart attacks and stroke, help control blood clotting and build cell membranes in the brain. They are also important to an infant's visual and neurological development.

Omega-3s may also help ameliorate a variety of conditions, such as cancer, depression, inflammatory bowel disease, and autoimmune disorders like lupus and rheumatoid arthritis.

The best evidence for the benefits comes from studies of people who have long eaten fish, as opposed to taking supplements of omega-3s.

Nearly three decades ago, Dutch researchers published a groundbreaking study in The New England Journal of Medicine. Intrigued by the extremely low death rate from coronary heart disease among Greenland Eskimos, the Dutch team followed 872 men aged 40 to 59 for 20 years and found that those who ate as little as one or two fish meals a week had a 50 percent lower death rate from heart attacks than those who did not eat fish.

Other studies linked fish consumption to a reduced risk of strokes, although later research concluded that the lifesaving benefit was limited to people at high risk of cardiovascular disease.

Given that heart disease and stroke are the leading causes of death among Americans, you'd think this research might have drastically lifted our consumption of fish. Alas, relatively little change has occurred.

Fish consumption reached a high of 16.6 pounds per person a year in 2004, and has declined slightly since, according to the Department of Agriculture. "Asians eat about 35 pounds of fish a year, including bony fish," Paul Greenberg, the author of two popular books on seafood, told me.
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This may help to explain the longer life expectancy of the Japanese.

Although meat intake by Americans has nose-dived from a peak of nearly 150 pounds a person in 1971, it is still at 100 pounds per capita. Poultry intake has risen from 41 pounds in the 1960s to 99 pounds a person today.

If choosing which fish to buy is your issue, search out a specialty store or supermarket seafood counter that has a knowledgeable clerk. Ask for recommendations and preparation ideas. Plenty of stores will have recipes available. A useful guide to the most environmentally friendly choices can be found at www.seafoodwatch.org.

Make sure you're getting fresh fish, which should not smell "fishy." The freshest fish is sold frozen, unless it comes from local waters. I avoid buying fish on Mondays because most wholesale markets are closed on Sundays and Monday's fish is more likely to be old.

If the fish you buy is wrapped in plastic, it will become smelly unless it's frozen right after purchase. I always rinse and pat dry fish before cooking it.

If you live near a coast, check out farmer's markets or stores for locally caught fish and shellfish, which is likely to be freshest and more flavorful.

Farmed fish is not necessarily the ecological or health disaster some claim it to be. American catfish, for example, is "our most successfully farmed fish, and the process creates wetlands that birds use a lot," Mr. Greenberg said. Farmed salmon now comes mostly from Chile, where it cannot disrupt wild populations.

Most mussels come from farms and help to clean the water they live in. They are low in fat and calories, are good sources of omega-3s and are very low in cholesterol. On the other hand, shrimp (half of it farmed, often under questionable conditions), squid and lobster are high in cholesterol.

Those concerned about cooking fish and its odoriferous aftereffect have two options: Grill it outdoors, or choose fish when you dine out or take out.

A frequent kitchen mistake is overcooking fish. It should appear a little raw when taken from the oven or stovetop, Mr. Greenberg suggested. "By the time it gets to the table, it will be properly done," he said. I agree.

Some people have to be cautious about seafood. Anyone with a clear-cut allergy to any fish or shellfish, which can be life-threatening, should avoid it and learn what other varieties may cross-react.

Pregnant women are advised to limit their consumption of fish like tuna and swordfish with high levels of mercury, which can injure the developing fetal brain. But prior pregnancy restrictions on raw fish (sushi and sashimi) have been lifted, so long as the fish has been frozen at 0 to minus 4 degrees for at least three days to kill any possible parasites.

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Well: Vitamin D Tied to Alzheimer’s Risk

Low vitamin D is associated with an increased risk for Alzheimer's disease and other forms of dementia, according to a new report, though whether low vitamin D is a cause of the disorders remains unknown.

The scientists measured blood levels of vitamin D in 1,658 men and women, average age of 73, without dementia at the start of the study. Over an average follow-up of more than five years, 171 developed dementia.

The study, published online in the journal Neurology, controlled for many dementia risk factors — including age, education, sex, body mass index, smoking, alcohol use, diabetes and hypertension. It found that compared with those who had vitamin D levels of 50 or more nanomoles per liter, those with levels of 25 to 50 had a 53 percent increased risk for all-cause dementia and a 69 percent increased risk for Alzheimer's disease. People with readings of 25 or less were more than twice as likely to have Alzheimer's or another form of dementia.

There is little agreement on the ideal vitamin D level, but according to the National Institutes of Health, levels below 50 are inadequate.

"These are exciting and suggestive results, but they're only observational," said a co-author, Iain A. Lang, a senior lecturer at the University of Exeter. "We can't say anything about whether people should be supplementing, because that's beyond the scope of what we looked at."

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Well: The Downside of Running With Others

Photo Credit Jordan Siemens/Getty Images

My husband won't talk to me when we run. Me, I need to carry on a conversation from the minute I start running to the minute I stop. The chitchat helps me forget the misery of the task at hand. But more than that, when I run alone, my mind will bully me into slowing down or stopping. When I run with other people, my mind won't dare speak up – and I wind up running longer and faster than when I run alone.

With that in mind, I joined a local running club and posted a message on Facebook saying I was looking for running mates. "I ain't fast, but I ain't that slow, either," I wrote. Within hours, two women responded.

For weeks now, I've been running with Susanne and Tina, though Tina knows so many runners, we'll often have a third or fourth woman tag along. I live by the ocean so we run along the boardwalk, talking all the while, about our kids' accomplishments, our fights with spouses, or about relationships that fell apart before they'd even begun. I feel like I have a gang, a team, mates.

They've also helped my speed and endurance. For years, my usual run has been just over three miles, at a rate of about 11:30 a mile. On my first outing with my new running mates, I ran four miles at an 11-minute-mile pace. On our second, I ran nearly 4.5 miles, at a pace of about 10:30 a mile. I was delighted. My inner voice could no longer hold me back, mostly because I was no longer listening.

But running with others, I soon learned, can have its downsides too. One rainy morning recently, I thought about skipping my run. But I'd skipped one the week before, also because of rain. Tina had wound up going that day and said the rain held off and that it was a beautiful run.

So I put on a waterproof running jacket, which made a swishing noise as the sleeves brushed against my torso. I liked the sound. I felt like a real runner. I was going out in the rain, something I would never have done alone.

I called out to my husband: "See you later. I'm running with the big dogs. I've got a gang now, you know." I could hear the song from the recent Lego movie in my head: "Everything is awesome. Everything is cool when we're part of a team."

When I arrived at the coffee shop where we usually meet, Tina was already there with another runner. I'd messaged her the night before, asking whether the new runner was a Speedy Gonzales.

"I don't understand," she'd texted back.

I initially thought she didn't understand my reference. I'm more than a decade older than she is, and when I saw her at the coffee shop tried to explain who Speedy Gonzales was.

"I know who he is," she said. "I'm just tired of people complaining about how slow they are."

The other woman chimed in that she was slow, though I wasn't sure I believed her. She'd just come from swimming laps at the local pool. I'd just come from my bed.

As we started to run, Tina asked her how her Triple-T training was going.

"What's a Triple-C?" I asked.

"Triple-T — it's four races in one weekend," the woman replied. Her idea of slow was certainly very different from mine.

The last thing I remember hearing before they began to pull ahead was something about how the woman's husband was annoyed about how much she'd been training. I tried to keep up with them, but no matter how fast I went, they were always several lengths ahead of me, and the gap kept widening.

That's cold, I thought. Only in running — or junior high school — is it acceptable to just "leave someone flat." I kept thinking if Tina turns around and sees how far behind I am, she'll never run with me again.

I'd done this run many times, but this time, as I trailed behind the other two runners in the pelting rain, it felt harder than ever. I finally caught up to them when I reached a drawbridge to a neighboring town. "They waited for me," I thought, relieved.

"We stopped to take a photo," Tina told me. "You going to keep going? We're heading back."

I followed their lead. The wind was now at our backs, propelling me forward and enabling me to keep up with them, though it was a struggle. I couldn't speak, and could barely keep up with the conversation. At one point, I thought they were talking about leukemia but realized they were discussing tattoos.

When we got back to the coffee shop, Tina asked if I was walking home, as we both live in town, but I said I took my car.

"You drove?" she asked.

"I was running late," I said.

We still run together, though not as much. Tina no doubt realized I was slowing her down. But I realized something as well. I never would have done it on my own. Even though I felt left out during our run, a little ashamed and embarrassed even, I kept going. Since then I've been running farther and faster, morning after morning, even in the rain. And when the little voice in my head tries to say, "Stop! I can't go any farther!" I can now say, "Um, actually, I can."

Caren Chesler is a New Jersey-based reporter who, with a little help from her friends, hopes to run a nine-minute-mile.

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Well: Practicing on Patients

"Who should do this case?" That was the question a senior surgeon posed to me outside a patient's room in the cardiac care unit. Judging by his expression, he already knew the answer.

The patient had a serious infection that had eroded her heart valve, rendering it "incompetent." Fluid was filling up in her lungs, making it difficult for her to breathe. A helium-filled balloon pump had been inserted into her aorta, the main artery coming out of the heart, to support her low blood pressure, but her condition was deteriorating.

The senior surgeon explained that the patient had been referred to a young surgeon in his practice who had just graduated a year before. "Ethically, I'm not comfortable with him doing the case," the senior surgeon said. "This lady's mortality is already high, probably close to 40 percent. In his hands, it's even higher."

The young surgeon was obviously going to have to learn to do such cases, but he wasn't going to start that day. The patient's condition was too unstable, and even a small mistake could have had devastating consequences. The senior surgeon obviously appreciated his young colleague's eagerness in seeking out referrals to build up his practice, but he and I knew that a junior surgeon wasn't the best man for the job.

Every doctor's expertise is earned on patients, but unfortunately, there is a learning curve.

How to protect patients while doctors learn is a conundrum faced in all areas of medicine. For example, studies have shown that surgeons' outcomes improve up to four years after their first hospital appointment. Some have argued that neophyte surgeons during this period should take on only the most straightforward cases. Yet every doctor eventually has to perform a procedure for the first time.

A few weeks ago, a second-year cardiology fellow told me that he had taught a first-year how to pull out a balloon pump. "When we went in the room, the patient said, 'You're not learning on me, are you?' And I had to lie and say: 'No! He's done this many times. We're going to do it together. You get two for the price of one.' That calmed him down. Then I had to talk the first-year through the entire procedure, pretending like I was explaining it to the patient."

It isn't only doctors who face this quandary. Hospitals too have their own learning curves. Medical teams work better together with practice. The first few cases of a new procedure frequently have subpar results.

In the early 1990s, a hospital in England introduced an innovative operation to correct transposition of the great arteries, a congenital heart abnormality in babies. Before this, newborns with this condition were treated with a palliative procedure that had poor long-term outcomes. Children at the hospital ultimately benefited from the innovation, but a heavy price was paid. The death rate for babies in the first few years was several-fold higher than with the palliative procedure. Commenting on the poor outcomes, a pediatric surgeon wrote that it was understood that "there would initially be a period of disappointing results."

The question of how to innovate without hurting patients comes up in my practice. For example, as a heart-failure specialist, I have long wanted to provide left ventricular assist devices (LVADs) to my terminally ill patients. LVADs, such as the one former Vice President Dick Cheney has, are tiny rotor pumps made of plastic and titanium that piggyback onto the heart, pumping blood directly out of it and into the aorta, which transports it to the rest of the body. Most of my patients who require an LVAD say they would prefer to have it implanted close to home on Long Island rather than at the more established centers in Manhattan.

So a couple of years ago, we started an LVAD program for patients with acute cardiac shock. As the cardiologist on the team, I received two days of classroom instruction. My surgical colleagues additionally received animal training (they implanted the device into a calf).

We have now successfully performed the procedure on several patients. A few months ago, I treated a young man who had had a heart attack. His blood pressure was so low that his kidneys had stopped working. I called one of my surgical colleagues to put in an LVAD. He agreed to do it, but he asked me whether my patient wouldn't be better off being transferred to a hospital that had more experience. "Do we have the best team in place to manage potential complications?" he asked. If it were your father, he said, what would you want?

And he was right. We have had good results with the few implants we've done. However, some centers in Manhattan do more than a hundred a year. Though our surgical teams are excellent, theirs are undoubtedly on a flatter portion of the learning curve.

I often wonder whether certain procedures should be "regionalized." There is a positive correlation between a hospital's surgical volume and its surgical mortality. For example, hospitals that do 200 or more coronary bypass operations annually have death rates nearly a third lower than hospitals with lower volumes.

But in American medicine, we believe in democracy. Any hospital can apply to be credentialed in a new procedure as long as it can demonstrate a need in the population it serves.

In the current economic climate, with ever-decreasing profit margins, many hospitals are trying to move into profitable surgical ventures. But we need to be careful. Hospitals have the right to innovate, but adequate protections such as expert supervision need to be put in place so patients are not harmed while doctors and institutions learn on them.

---

Sandeep Jauhar is a cardiologist and the author of the soon-to-be-published memoir "Doctored: The Disillusionment of an American Physician."

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Well: How Exercise Helps Us Tolerate Pain

Photo Credit Dominic Ebenbichler/Reuters

Phys Ed

Gretchen Reynolds on the science of fitness.

Regular exercise may alter how a person experiences pain, according to a new study. The longer we continue to work out, the new findings suggest, the greater our tolerance for discomfort can grow.

For some time, scientists have known that strenuous exercise briefly and acutely dulls pain. As muscles begin to ache during a prolonged workout, scientists have found, the body typically releases natural opiates, such as endorphins, and other substances that can slightly dampen the discomfort. This effect, which scientists refer to as exercise-induced hypoalgesia, usually begins during the workout and lingers for perhaps 20 or 30 minutes afterward.

But whether exercise alters the body's response to pain over the long term and, more pressing for most of us, whether such changes will develop if people engage in moderate, less draining workouts, have been unclear.

So for the new study, which was published this month in Medicine & Science in Sports & Exercise, researchers at the University of New South Wales and Neuroscience Research Australia, both in Sydney, recruited 12 young and healthy but inactive adults who expressed interest in exercising, and another 12 who were similar in age and activity levels but preferred not to exercise. They then brought all of them into the lab to determine how they reacted to pain.

Pain response is highly individual and depends on our pain threshold, which is the point at which we start to feel pain, and pain tolerance, or the amount of time that we can withstand the aching, before we cease doing whatever is causing it.

In the new study, the scientists measured pain thresholds by using a probe that, applied to a person's arm, exerts increasing pressure against the skin. The volunteers were told to say "stop" when that pressure segued from being unpleasant to painful, breaching their pain threshold.

The researchers determined pain tolerance more elaborately, by strapping a blood pressure cuff to volunteers' upper arms and progressively tightening it as the volunteers tightly gripped and squeezed a special testing device in their fists. This activity is not fun, as anyone who has worn a blood pressure cuff can imagine, but the volunteers were encouraged to continue squeezing the device for as long as possible, a period of time representing their baseline pain tolerance.

Then the volunteers who had said that they would like to begin exercising did so, undertaking a program of moderate stationary bicycling for 30 minutes, three times a week, for six weeks. In the process, the volunteers became more fit, with their aerobic capacity and cycling workloads increasing each week, although some improved more than others.

The other volunteers continued with their lives as they had before the study began.

After six weeks, all of the volunteers returned to the lab, and their pain thresholds and pain tolerances were retested. Unsurprisingly, the volunteers in the control group showed no changes in their responses to pain.

But the volunteers in the exercise group displayed substantially greater ability to withstand pain. Their pain thresholds had not changed; they began to feel pain at the same point they had before. But their tolerance had risen. They continued with the unpleasant gripping activity much longer than before. Those volunteers whose fitness had increased the most also showed the greatest increase in pain tolerance.

"To me," said Matthew Jones, a researcher at the University of New South Wales who led the study, the results "suggest that the participants who exercised had become more stoical and perhaps did not find the pain as threatening after exercise training, even though it still hurt as much," an idea that fits with entrenched, anecdotal beliefs about the physical fortitude of athletes.

Because it did not examine physiological effects apart from pain response, however, the study cannot explain just how exercise alters our experience of pain, although it contains hints. Pain thresholds and tolerances were tested using people's arms, Mr. Jones pointed out, while the exercisers trained primarily their legs. Because the changes in pain response were evident in the exercisers' upper bodies, the findings intimate that "something occurring in the brain was probably responsible for the change" in pain thresholds, Mr. Jones said.

The study's implications are considerable, Mr. Jones says. Most obviously, he said, the results remind us that the longer we stick with an exercise program, the less physically discomfiting it will feel, even if we increase our efforts, as did the cyclists here. The brain begins to accept that we are tougher than it had thought, and it allows us to continue longer although the pain itself has not lessened.

The study also could be meaningful for people struggling with chronic pain, Mr. Jones said. Although anyone in this situation should consult a doctor before starting to exercise, he said, the experiment suggests that moderate amounts of exercise can change people's perception of their pain and help them, he said "to be able to better perform activities of daily living."

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Hard Cases: Top Doctors, Dead or Alive

Hard Cases

Dr. Abigail Zuger on the everyday ethical issues doctors face.

The official letter is sitting on my desk, announcing that a relative of mine has just been named one of the world's top physicians in his area of expertise. Once he confirms his biographical details, he is guaranteed inclusion in online and print directories of similarly honored peers ("not only a tribute to your success, but also a valuable resource for potential patients").

I can clearly imagine his reaction had he opened the letter himself: a combination of amusement, dismay and just a small hint of pleasure. However, since he has been dead for 16 years, his widow passed the envelope over to me, and I got to experience all those emotions myself.

The amusement and dismay speak for themselves. The pleasure lay in this really superb demonstration that skepticism should attend all interactions with services promising to lead you through the thickets of subpar and merely average doctors directly to best of breed.

The methodology of these enterprises varies. Some, evidently, cull names and addresses from obsolete phone directories. Some poll doctors themselves for the biggest luminaries of their acquaintance. Some rely on patients' reviews, operating under the premise that a doctor who delivers a five-star health experience for one will do so for all.

It is easy to dismiss them all as just so much advertisement and avarice, contributing yet more buzzy white noise to the already crazy-making din of health care. But a more nuanced and charitable view is also possible. These services may simply be trying, valiantly if clumsily, to remedy the single biggest mystery in all of health care: that we do not have a clue what makes a top doctor, let alone how to find one.

Is it nature (unusual intelligence, compassion, common sense)? Nurture (diplomas from prestigious and pricey institutions)? Self-sufficiency? (Patients say proudly, "My doctor never has to send me anywhere.") A central location in a medical network? ("My doctor refers me to all the top people.") Is it speed or deliberation, ability to follow rules or ability to break them? Exuberant personal charisma or a peaceful office that runs like a Swiss watch?

No one has the slightest idea. Even the terms of the question are undefined. Is a top doctor one who keeps you in top shape, hauling you up when you plunge down? Or is it one who encourages you to remain in whatever shape feels right to you, even if some of your habits might give pause to less enlightened observers?

A sedentary, seriously overweight patient I know cannot walk a block. She adores the doctor who cheerfully tells her: "Who needs to walk? You should ride!" To her, he is unquestionably a top doctor. To the rest of her family, not so much.

I contemplate various listings of top doctors, recognizing the occasional name or face, often residents I knew long ago. Many of them, I think, are probably quite good. But why should I think that? Do I really know what goes on when they are closeted with a patient who drives them nuts, or when they are running late and have theater tickets, or when they completely miss the diagnostic boat and land on an atoll somewhere in the sea of wrong assumptions, many leagues from where they should be? Do they acquit themselves in top-doctor style then?

In fact, nobody knows who the top doctors are, not even the top doctors themselves. It is safe to say that the very topmost doctors, confusingly, are probably not top doctors: They have become news media stars and household names through efforts that presumably leave them little time to hone those top-doctor skills. But otherwise, all is smoke and mirrors.

Can the average consumer glean any information at all from the top doc lists? Here is one tip: Pay attention to the source of the information. Traits that doctors prize in their colleagues may be different from the ones patients rank high. Consultants who will see any patient at the drop of a hat — referring doctors love that — may have jam-packed waiting rooms and move with the speed of greased pigs. The rock stars of modern medicine, experts who publish widely and lecture all over the globe, may spend most of their workweeks in flight, inaccessible for humbler purposes.

Otherwise, I suspect we are left with only a single unarguable definition of a top doctor: one who is not on the bottom. Top doctors are, for instance, not in jail. They have valid licenses. They are presumably enthusiastic about taking new patients (although you can never be sure how enthusiastic they'll be about their insurance). I used to think that at least they were all living and breathing, but now I guess you can't be sure of that, either.

 

A version of this article appears in print on 08/12/2014, on page D4 of the NewYork edition with the headline: Top Doctors, Dead or Alive.

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Mind: Gene Strategy to Fight Alzheimer’s Clears a Hurdle

Photo Credit Stuart Bradford

The 40-year-old man showed up in Dr. Mary Malloy's clinic with sadly disfiguring symptoms.

His hands, elbows, ears and feet were blemished with protruding pustules and tuber-like welts, some so painful it was hard for him to walk. He suffered from a rare genetic condition called dysbetalipoproteinemia, which caused his cholesterol levels to soar so high that pools of fatty tissue seemed to bubble up under his skin.

But there was something else about this patient. He was missing a gene that, when present in one form, greatly increases the risk of developing Alzheimer's disease.

Dr. Malloy, who co-directs the Adult Lipid Clinic at the University of California, San Francisco, and her colleagues saw an opportunity to answer an important neurological riddle: Does the absence of the gene — named apolipoprotein E, or APOE, after the protein it encodes — hurt the brain?

If a person with this rare condition were found to be functioning normally, that would suggest support for a new direction in Alzheimer's treatment.

It would mean that efforts — already being explored by dementia experts — to prevent Alzheimer's by reducing, eliminating or neutralizing the effects of the most dangerous version of APOE might succeed without causing other problems in the brain.

The researchers, who reported their findings on Monday in the journal JAMA Neurology, discovered exactly that.

They ran a battery of tests, including cognitive assessments, brain imaging and cerebrospinal fluid analyses. The man's levels of beta-amyloid and tau proteins, which are markers of Alzheimer's, gave no indication of neurological disease. His brain size was unaffected, and the white matter was healthy. His thinking and memory skills were generally normal.

"This particular case tells us you can actually live without any APOE in the brain," said Dr. Joachim Herz, a neuroscientist and molecular geneticist at University of Texas Southwestern Medical Center, who was not involved in the research. "So if they were to develop anti-APOE therapies for Alzheimer's, we would not have to worry about serious neurological side effects."

Apolipoprotein E, the protein made by the APOE gene, helps transport cholesterol. In the blood, Dr. Malloy said, it guides different proteins containing cholesterol into the liver. In the brain, it chaperones cholesterol from neurons to a storage area while they are changing, she said, and then returns the cholesterol to neurons.

The APOE gene has several forms, and one of them, the APOE4 variant, is the biggest known genetic risk factor for the most common form of Alzheimer's. People with one copy of APOE4, about 20 percent of the population, have up to five times the risk of developing Alzheimer's, compared to people without that variant, and they develop the disease earlier.

People with two copies, about 2 percent of the population, have up to 15 times the risk. About 90 percent of people with two copies will develop Alzheimer's by the time they are age 80.

Another form of the APOE gene, E3, is very common but poses less risk. A third variant, E2, is rare and is the least dangerous.

Dr. Herz, who wrote an editorial about the study, said that the protein made by APOE4 slows the process of clearing beta-amyloid buildup in the brain, leading to the accumulation of the plaques associated with Alzheimer's.

Proteins made by the other gene variants, APOE3 and APOE2, clear amyloid more quickly, and "in the absence of any APOE, the turnover is fastest," he said.

So, it makes sense that a person with a fast-clearing form of APOE, or none at all, would have a very low risk of Alzheimer's. Several experts are working on ways to reduce APOE4 or increase APOE2 in the brain, and the results have been promising.

Dr. Steven Paul, a professor of neuroscience at Weill Cornell Medical College, has found that by using gene therapy to implant mice with APOE2, "we reduced plaque quite effectively and quite quickly," even in mice that also had APOE4, he said.

Dr. Paul, who is head of research and development at Voyager Therapeutics, said he is now studying the effect in monkeys. "If all goes well, in a year or so we could be thinking seriously about doing this in humans."

Research led by Dr. David Holtzman, chairman of the neurology department at Washington University School of Medicine in St. Louis, found that when mice with amyloid plaques were given a monoclonal antibody that reduces APOE, the mice developed fewer plaques and cleared some of them from their brains.

Decades ago, before the link to Alzheimer's was known, reports on a handful of people without APOE suggested that, aside from the physical side effects of astronomical cholesterol levels, they appeared otherwise normal.

But the 40-year-old man, a pipefitter who lives in California's Central Valley and is married with three children, is the first documented case of an APOE-less person whose brain health has been rigorously tested. He was not further identified to protect his privacy.

"This finding is important," Dr. Holtzman wrote in an email. It shows "that it is unlikely that APOE is key for normal brain development or function, as there are other proteins that can compensate in its absence."

The fact that Dr. Malloy's patient is relatively young makes the results a little less strong, because amyloid accumulation in people destined to get Alzheimer's may not begin until later in life.

But Dr. Herz said, "based on what we know now, I would say this patient will most likely never accumulate amyloid."

Dr. Malloy is working to treat the man's cholesterol problem, which has barely improved despite medication and a healthy diet.

Dr. Paul and others said anti-APOE therapies would have to target broad areas of the brain without crossing the blood-brain barrier and circulating to the liver. They consider that a quite realistic goal.

"Things are developing incredibly rapidly these days," said Dr. Herz, who is not involved in creating the new therapies. "I'm very confident that we will find approaches that address these issues."

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Well: Ask Well: Does Yoga Build Strength?

Photo Credit Damon Winter/The New York Times

A

In general, the few available experiments involving yoga suggest that it leads to measurable but limited and patchy strength gains.

Consider the results of a 2012 study of premenopausal women who were randomly assigned to yoga or to a control group. The yoga group completed twice-weekly, 60-minute sessions of Ashtanga yoga (which consists of sequential, standardized postures), while the control group continued their normal activities. After eight months, the yoga practitioners had developed more powerful legs compared with at the study's start and with those of  the control group, but had not increased strength in other muscles or improved their cardiovascular fitness.

Similarly, in a 2013 study, 12 weeks of Bikram yoga (a variety that consists of other, specific poses done rapidly in a heated, saunalike space), enabled a group of young adults to dead-lift more weight on a barbell than they could at the start, but did not improve their hand-grip strength or any other measures of health and fitness.

Over all, yoga appears to be too gentle physically to be anyone's lone exercise. In one of the most interesting studies of the activity to date, experienced yoga enthusiasts performed their favorite type of yoga for an hour in a metabolic chamber that tracked their caloric usage and heart rate. The volunteers then sat quietly in the chamber and also walked on a treadmill there at a leisurely 2 miles per hour and a brisker 3 m.p.h. pace. In the end, the measurements showed that yoga was equivalent in energy cost to strolling at 2 m.p.h., an intensity of exercise that, the authors write, would "not meet recommendations for levels of physical activity for improving or maintaining health or cardiovascular fitness."

So if you downward dog, jog occasionally as well, and visit the gym to build full-body strength and wellness.

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Doctor and Patient: Throwing Money at the Past

Photo Credit Dario Lo Presti/Getty Images

Doctor and Patient

Dr. Pauline Chen on medical care.

The current physician training system, heavily subsidized by the federal government, has not produced doctors prepared to serve in a changing health care system and cannot account for billions of dollars in public funding each year, an exhaustive new report has concluded.

Compiled by a nonpartisan committee of 21 leading physicians, economists, health care administrators, nurses, physician assistants and a consumer representative, and published under the auspices of the Institute of Medicine, the report describes a remarkable lack of accountability and oversight that may be affecting patient care.

"Little is known," the committee writes, "about the management and effectiveness of the public's more than $15 billion annual investment in Graduate Medical Education" — the period of intensive clinical training physicians must undergo after medical school and before independent practice.

Among other remedies, the committee recommended freezing funding at current levels while siphoning off a portion to medical education research. That recommendation, among others, has roused fierce debate and high-minded harangues from medical and hospital organizations.

Although G.M.E. funding represents less than 2 percent of the Medicare budget, almost $10 billion was handed over to teaching hospitals in 2012, primarily in the Northeast. Some of them stand to lose significant amounts if the recommendations are adopted.

The American Medical Association, the American Hospital Association and the Association of American Medical Colleges have issued sharply critical statements, asserting that the recommendations will exacerbate what they predict will be a physician shortage. Other organizations, like the American Academy of Pediatrics and the American Academy of Family Physicians, contend that the report's recommendations may finally help bring medical education funding more in line with national health care needs.

The steady stream of official statements from these groups, with their varied and even contradictory takes, has created a Rashomon effect, obscuring the real issue at hand for all patients: a nearly complete absence of accountability and oversight in medical training programs that receive vast public funding.

Public financing of physician training began in 1965 with the creation of Medicare and Medicaid. Over the years, Medicare assumed responsibility for the bulk of funding, and lawmakers set the formulae determining who and how much should be paid.

Current G.M.E. funding is based on statutes enacted 20 or 30 years ago, when hospitals were the primary sites of physician training and patient care was centered on doctors. In the last decade, however, health care has shifted increasingly to ambulatory centers, outpatient clinics and team-based care that relies at least as heavily on nurses and physician assistants as it does on doctors.

The Institute of Medicine panel spent two years analyzing the extent to which the current financing system helps prepare physicians to provide "high-quality, patient-centered and affordable care." Ideally, the subsidies would be linked to how well trainees cared for patients and the extent to which they addressed not just a particular hospital's needs, but regional and national health care priorities.

Training programs that produced doctors who had better outcomes, eventually practiced in underserved areas or worked in specialties facing severe shortages would, for example, be eligible for more funding. But committee members were stymied in their efforts to answer even the most basic questions regarding the amount Medicare has contributed to individual G.M.E. programs and the effect of those contributions.

Teaching hospitals, the primary beneficiaries of Medicare G.M.E. funding over the years, have never had to account for anything more than the simple details necessary to calculate future funding. They routinely kept track of the total number of trainees in their programs, the trainees' salaries and benefits, and the percentage of Medicare patients cared for at their hospitals.

But the hospitals were under no obligation to Medicare to account for the quality of care provided by trainees, the places where their trainees eventually opened practices and the percentage of Medicare and Medicaid patients their graduates accepted into those practices.

Some of these training programs even lost track of how much Medicare money they received.

The committee tried to illuminate what it called "the black box of G.M.E. costs and benefits" by focusing on four representative academic medical centers and working closely with their G.M.E. officials. But they came up nearly empty-handed.

The committee's report acknowledges that even without hard data, the financial stability that public funding provides has allowed training programs to improve physician training and therefore the medical work force over the last fifty years. Real progress has been made in increasing the diversity and numbers of practicing physicians, improving trainee working conditions and curtailing their duty hours.

With financial stability in mind, the committee's recommendations emphasize a slow transition to a "performance-based system" of payment and no changes in the overall amount of Medicare spending for the next decade.

But current beneficiaries would probably receive less support, as the Medicare fund would be divided. An "operational" portion would be distributed to training programs according to a single, national per-resident trainee sum, thus eliminating the current funding formula that favors hospitals in regions that had the highest number of trainees nearly two decades ago and relies on an institution's unaudited report of nonstandardized cost data.

The other portion, one the committee calls "the transformational fund," would be reserved for financing research on new approaches to training. The hope is that this research will provide the data necessary to create a reliable performance-based payment system.

Whether or not the committee's recommendations go into effect is now in the hands of lawmakers. But whatever the outcome, the truth regarding how wisely public money has been used to train our doctors may never be known.

Correction: August 7, 2014
An article on Tuesday about a report that was critical of the United States' physician training system, Graduate Medical Education, misstated part of the name of one of the organizations supporting the report's recommendations. It is the American Academy of Family Physicians, not the American Association of Family Physicians.

A version of this article appears in print on 08/05/2014, on page D4 of the NewYork edition with the headline: Throwing Money at the Past.

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Well: Think Like a Doctor: Losing It

Think Like a Doctor

Solve a medical mystery with Dr. Lisa Sanders.

Photo Credit Anna Kovecses

The Challenge: A 55-year-old man loses the hair on his legs, loses weight and then loses his strength. Can you figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a diagnostic riddle. Below you will find the details of a case involving a retired state trooper who starts wasting away. Over a few weeks, he drops 30 pounds and grows so weak he has to use a walker to get around.

As usual, the first person to figure out the diagnosis will receive a signed copy of my book "Every Patient Tells a Story" and the pleasure of figuring out a case that stumped a bunch of doctors.

The Patient's Story

"When did you start shaving your legs?" the woman asked her husband of 20 years.

The couple sat on the porch of their rural Pennsylvania home enjoying the end of a beautiful day. Her husband, a retired state trooper, laughingly replied that he shaved them every Tuesday. But when he took a good look at the limbs emerging from his pants legs, he was surprised to note that they were as smooth as a model's.

"Have you lost some weight?" she added. He always weighed 172, he told her. But he got up and weighed himself on the bathroom scale: he was 160 pounds. The man was not sure what to make of these two wifely observations, but a couple of months later, when his weight continued to drift downward, he made an appointment to see his internist, Dr. William Oleksak.

The Doctor Visit

The patient had not had an appointment with his doctor in nearly two years, so when the doctor saw him that June day, he was shocked by the man's appearance. The retired trooper had always been a slender, fit and vigorous man. Not any more.

The doctor could see that the patient had lost a significant amount of weight. His face looked almost skeletal – the cheek bones and bones around his eyes were prominent as the fat that gave his face a good-natured roundness had melted away. Looking at him, Dr. Oleksak first thought that the man had some kind of cancer.

Although the patient considered himself a pretty healthy guy, he had several medical problems. First, he was a smoker – a pack and a half a day for 40 years. Because of that, he had some early atherosclerotic changes, or hardening of the arteries, in the blood vessels leading to his legs. It got so bad that a few years ago, he had to have one of the big vessels in his leg reopened so he could walk more than a few steps.

And when he had his colonoscopy at 50, his doctor had to cut out a few polyps. He was due for another colonoscopy to make sure they hadn't come back. He had been found to have celiac disease a while back, but he had not had symptoms for years. His thyroid was not quite as cooperative. It stopped working a decade earlier, and he had to take a medication for that every day. Most days, it was the only medicine he took.

Other than the patient's weight and hair loss, Dr. Oleksak could find nothing wrong upon examination. He told the patient he was going to send him for a colonoscopy and a chest X-ray and to get a few blood tests.

"Are you looking for cancer," the man's wife asked. He was, he told the couple, ready to answer any additional questions. There weren't any. The wife just nodded as if that's what she'd been thinking as well.

You can see the results of the blood tests here.

You can see the results of the imaging tests here.

A Summer of Testing

Those tests were the first of many for the patient that summer. The chest X-ray was normal, except for the changes caused by his years of smoking cigarettes. The colonoscopy did not show cancer – just a couple of hemorrhoids. He had a CT scan of his chest, abdomen and pelvis. Normal.

Tube after tube of the blood he gave did not seem to show much. He had a low white blood cell count and mild anemia. When rechecked a couple of weeks later, the count of white blood cells – the warriors of our immune system – was even lower, so Dr. Oleksak sent the patient to a hematologist.

That doctor was worried about cancer, too. She sent off several blood tests, and when they did not tell her what she needed to know, she took a piece of his bone marrow to make sure he did not have cancer there. He didn't.

She did find something that could account for the patient's symptoms. His vitamin B12 level was low. Was that why he felt so bad, he asked the doctor. Could be. The bone marrow needs B12 to make blood. And low B12 can cause weakness as well. It seemed the right answer, yet even taking huge doses of the vitamin did not seem to help.

You can see more of the patient's blood test results here.

And you can see the results of the bone marrow analysis here.

Falling Down

The patient continued to lose weight, drifting from the 160s down to the 140s. It seemed as if his strength was slipping away with the pounds. He was tired all the time; he needed to nap every afternoon.

And then he started falling. He knew he was in deep trouble one morning when he fell as he hurried out of his car to get into the grocery store during a rainstorm. His legs gave out, and he ended up face down on the wet pavement. He had to crawl back to the car to pull himself up.

This time, when he went back to Dr. Oleksak, his exam was not normal. The way doctors test for strength is pretty crude. We pit the strength of our arms against the strength of the patient's arms and legs. For a middle-aged man who keeps pretty active, there has to be significant weakness for the test to show anything at all. But when Dr. Oleksak held the patient's thigh down with one hand, the man could barely lift his leg off the table. And once he had raised it off the table, it was a struggle for him to keep it there.

Weakness can be caused by a problem with the muscles or a problem with the nerves that power them. And distinguishing between these two required a level of expertise that was not found in the rural Pennsylvania town where Dr. Oleksak practiced. He would have to send the patient some 50 miles away to the University of Pittsburgh Medical Center. Dr. Oleksak referred the patient to Dr. David Lacomis, a neurologist he had heard of who specialized in nerve and muscle diseases.

A Specialist Weighs In

The patient was sitting on the exam table in a flimsy cloth gown when Dr. Lacomis entered the room. He immediately made note of the wasted appearance of the patient and his hairless legs. He heard the patient's story and then examined him, focusing on the man's nerves and muscles. He was clearly quite weak. He could not get up from a chair unless he used his arms. He could not walk on his tiptoes or his heels.

Still, the patient's weakness and loss of muscle seemed to be everywhere.

Whatever the patient had, it had to be something that affected the whole body and not just one part or side. Was it a disease of the nervous system? Dr. Lacomis didn't think so, and subsequent testing of the man's nerves confirmed it.

Solving the Mystery

If not the nerves, then what?

That was the question Dr. Lacomis put to himself, and he eventually figured out what was causing this man's weakness and weight loss and why it had occurred. Can you?

Post your answers below in the comments section. The first person to answer both questions — What was the cause of this man's symptoms, and why did he get it? — will receive a copy of my book and that warm, wonderful feeling you get from solving a mystery.

Rules and Regulations: Post your questions and diagnosis in the comments section. The correct answer will appear on Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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Well: Why We Should Know the Price of Medical Tests

Photo Credit Stuart Bradford

One of the common arguments against mandating or providing upfront prices for medical tests and procedures is that American patients are not very skilled consumers of health care and will assume high prices mean high quality.

A study released Monday in the journal Health Affairs suggests we are smarter than that.

The insurer WellPoint provided members who had scheduled an appointment for an elective magnetic resonance imaging test with a list of other scanners in their area that could do the test at a lower price. The alternative providers had been vetted for quality, and patients were asked if they wanted help rescheduling the test somewhere that delivered "better value."

Fifteen percent of patients agreed to change their test to a cheaper center. "We shined a light on costs," said Dr. Sam Nussbaum, WellPoint's chief medical officer. "We acted as a concierge and engaged consumers giving them information about cost and quality."

The program resulted in a $220 cost reduction (18.7 percent) per test over the course of two years, said Andrea DeVries, the director of payer and provider research at HealthCore, a subsidiary of WellPoint, which conducted the study. It compared the costs of scanning people in the WellPoint program with those of people in plans that did not offer such services.

Better still, Dr. Nussbaum said, the exercise in price transparency had a ripple effect: Hospitals in areas with the program lowered their prices too, because "they were beginning to lose patient referrals."

Tests like M.R.I.s show some of the widest price variation in American medicine, studies show, often varying by a factor of 10 even in the same city. Hospital scanners tend to charge the highest prices, a practice that in part reflects higher overhead but also reflects hospitals' power in a market. Physicians affiliated with a hospital often refer to the hospital's radiology department. In some cases, this is because hospitals require them to do so; in others, it is a matter of familiarity and convenience because the results will turn up more rapidly on their office computers.

After two years of the price transparency program, price variation between hospital and nonhospital facilities was reduced by 30 percent in areas where it was implemented, the Health Affairs study found.

The study also suggests that patients are more vigilant custodians of cost than their doctors. Several years ago, WellPoint gave physicians similar price information on scanning providers in their practice area but did not see a change in referral patterns, Dr. Nussbaum said.

The newer study did not delve into patient motivations. Some patients probably chose the cheaper scans because their insurance plan required a 20 percent copay, so it made a huge different if the scan was billed at $300 or $3,000. But others had probably already met their annual out-of-pocket maximum, so choosing the cheaper site was merely a matter of principle, Dr. DeVries said.

From experience, I can say that shopping for scans is not always easy. When I learned the price a hospital was charging for an M.R.I. a neurologist had recommended for one of my children, I scheduled the test at an outside center that was two-thirds cheaper. The upside was much better value for my health care dollar. The downside: The hospital and the radiology center would not communicate with each other, though they could have easily done so electronically. I had to go to the center and pick up a disk with the scan and carry it to the hospital neurologist.

Join the Conversation: The New York Times's Paying Till it Hurts Facebook Group is a forum for conversation, analysis and insight into health care pricing and costs in the United States.

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Well: Women Pace Marathons Better Than Men Do

Photo Credit Ryan Pierse/Getty Images

Phys Ed

Gretchen Reynolds on the science of fitness.

During marathons, women pace themselves more evenly than male competitors do, according to a study of thousands of racers. The results provide unexpected insights into some of the physical and emotional differences between male and female runners, and also how both genders might improve their race times by noting how the other one runs.

Anyone who has competed in or seen a marathon knows that maintaining a steady speed throughout the 26.2 miles is advisable. People who start the race at a fast pace generally have to slow and even walk or zombie shuffle as the race goes on.

A few small studies and many anecdotal observations had suggested that men were more apt than women to wind up slowing. But no large-scale examination of marathon racers had confirmed that.

So for the new study, which was published last month in Medicine & Science in Sports & Exercise, researchers at Marquette University in Milwaukee; the Mayo Clinic in Rochester, Minn.; and other institutions began by gathering data about the finishers at 14 marathons. The races included prominent ones, such as the Chicago and Disney marathons, and smaller events. Some were conducted in warm weather, others in chilly conditions, with terrain ranging from hilly to pancake-flat.

The researchers wound up with information about 91,929 marathon participants, almost 42 percent of them women. The data covered all adult age groups and a wide range of finishing times.

They then compared each runner's time at the midpoint of his or her race with his or her time at the finish, a simple method of broadly determining pace. If someone covers the second half of a race in about the same time as the first, then his or her pace is relatively even, with little slowing. (Only rarely does someone speed up in the second half of a race, running what is known as a negative split.)

As it turned out, men slowed significantly more than women racers did. In aggregate, men covered the second half of the marathon almost 16 percent slower than they ran the first half. Women as a group were about 12 percent slower in the second half.

Burrowing deeper into the data, the scientists categorized runners as having slowed markedly if their second-half times were at least 30 percent slower than their first-half splits. In concrete terms, a racer covering the first half of the course in two hours and the second in 2 hours 36 minutes or more would have slowed markedly.

Far more men than women fell into the markedly slower category, with about 14 percent of the male finishers qualifying versus 5 percent of the women.

This disparity in race pacing held true in all age groups and finishing times, the researchers found, even among the fastest runners. The difference, however, was most pronounced at the back of the pack. There, female runners were much more likely than men to steadily maintain the same, less hurried pace throughout.

Wondering to what extent experience might affect the runners' pacing, the researchers next used a public database to gather the racing histories of 2,929 of the runners. Using this data to adjust for marathon experience, the researchers found that men, however many marathons they had completed, were still more likely than equally experienced women to slow during the second half of a race.

The study was not designed to determine why men more frequently fade during marathons. But the reasons are likely to be physiological and psychological, said Sandra Hunter, a professor of exercise science at Marquette University and the senior author of the study.

"We know that at any given exercise intensity, men will burn a greater percentage of carbohydrates for fuel than women," Dr. Hunter said, and women will use more fat. Our bodies, male and female, contain considerably more fat than stored carbohydrates. "So men typically run out of fuel and bonk or hit the wall earlier than women do," Dr. Hunter says.

They are also more prone psychologically to adopt what Dr. Hunter terms a "risky strategy" in their early pacing. "They start out fast and just hope they can hold on," she says.

Interestingly, she continues, that strategy can sometimes pay off in a swifter finishing time. "It's not necessarily a bad thing" to push yourself at the start of a marathon, she says, if you have not catastrophically overestimated your capabilities.

Similarly, she points, out, an evenly paced race is not a well-paced one, "if you run slower than you were capable of running."

The message of the study, then, would seem to be that an approach to marathon pacing that borrows something from men and women might be ideal.

"Maybe go a bit harder than you think you can" in training, Dr. Hunter said, aiming to calibrate what your actual fastest sustainable pace is. Then stick with it during the event, even if your training partners tear away like rabbits at the start. You'll reel them in.

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