Well: Think Like a Doctor: Sugar-Free Solved!

Photo Credit Anna Kovecses

Think Like a Doctor

Solve a medical mystery with Dr. Lisa Sanders.

On Wednesday, we challenged Well readers to solve the case of a middle-aged woman who suddenly began to have episodes of confusion caused by low blood sugars. Her endocrinologist thought she might have an insulinoma, an insulin-producing tumor of the pancreas, but the testing he did seemed to rule out that diagnosis. Nearly 200 of you took on the challenge of trying to figure out what was causing her life-threatening drops in blood sugar level.

The correct diagnosis is…

Insulinoma

The first respondent to make the diagnosis was Karen Unkel of Kinder, La. She is not a doctor but has a longstanding interest in hypoglycemia that allowed her to recognize the disease even in the face of an apparently negative work-up. Well done, Ms. Unkel.

The Diagnosis

An insulinoma is a rare tumor of pancreatic tissue that makes and secretes insulin independently of blood glucose levels. This results in episodes of hypoglycemia that can be quite severe, even life-threatening. The diagnosis is suspected when a patient fulfills what is known as Whipple's triad: 1) symptoms of hypoglycemia 2) associated with low measured blood sugar and 3) which improve when blood sugar is raised to the normal range.

The diagnosis is made when doctors show that the patient is making too much insulin given his or her blood sugar level. Measuring insulin levels is not always accurate because insulin is processed rapidly in the body and because it is difficult to distinguish between insulin made naturally in the pancreas and any insulin that the patient might be injecting.

What is measured instead is something known as C-peptide. Insulin is first made as a larger molecule known as proinsulin. When blood sugar rises, an extra bit is shaved off the molecule; that extra bit is C-peptide, and both the resulting insulin and C-peptide are released into the bloodstream.

Surgical excision of the tumor is the usual treatment.

How the Diagnosis Was Made

When the endocrinologist heard about the second episode of life-threatening hypoglycemia, after the patient's hip replacement surgery, his understanding and his approach to the problem changed.

He hadn't been sure that the first low sugar measured by the emergency medical technicians had been right. No one is walking and talking with a sugar level that low, or at least not usually. And in his office the patient's sugar was always fine. But her second severely low sugar level was measured in the hospital. So he immediately began to consider a much more unusual cause of hypoglycemia – an insulinoma.

He sent off a blood test to look for high levels of C-peptide, evidence of high insulin levels. He expected the C-peptide to be as high as the patient's sugars were low. But it was normal.

Insulin was also measured. Also normal. When C-peptide was normal a second, then a third time, and a CT scan did not show the suspected tumor in her pancreas, both doctor and patient were puzzled and frustrated. That's when they decided to seek a second opinion.

He referred the patient to Dr. Ronald Tamler, the clinical director of the Mount Sinai Diabetes Center in New York.

A Second Opinion

Dr. Tamler had seen many patients who complained of postprandial hypoglycemia, or low blood sugar after meals. Like this patient, they appeared quite healthy. And like this patient, they reported a need to eat something sweet an hour or two after a meal.

But this patient had something that few of those patients had: a documented Whipple's triad. In the hospital she'd felt dizzy and was found to have an extremely low blood glucose, and she improved once she was given intravenous glucose and her blood sugar normalized.

Dr. Tamler knew that very few things will cause a sugar level to go this low. Patients who have been on steroids like prednisone can have low sugars for months afterward. This patient had once been on steroids for a diagnosis of lupus, but the disease had been quiet for decades and was unlikely to cause hypoglycemia this far out.

Occasionally alcohol can cause low blood sugars. Was she drinking more than she admitted to? Or could she be secretly using a diabetic medication to cause her own episodes of hypoglycemia? Again, it seemed unlikely, yet factitious disorders (like Münchausen syndrome) often seemed unlikely until proven to be true.

These diagnoses were possible and yet, even before performing the first test, Dr. Tamler suspected that the first endocrinologist had been right, that the patient had an insulin-producing tumor. Years of dealing with diseases of the pancreas had taught him that "normal" wasn't always normal.

Still, Dr. Tamler wanted to test the patient for all the possibilities. So, two weeks later she visited the lab.

Lab Testing

As instructed, the patient had eaten nothing that morning. Blood was drawn when she arrived, and then she was given a sugary drink. Her blood would be drawn at regular intervals for the next three hours, revealing how her body responded to sugar.

The results of the very first blood draw told Dr. Tamler what he needed to know. Her fasting blood glucose was 31 — extremely low. With a sugar that low, her C-peptide level should be zero. But it wasn't; it was 2.5. That is in the normal range, but definitely not normal in someone with such a low sugar. A normal pancreas would never do that.

The patient must have an insulin-secreting tumor, he thought. Now all they had to do was find it.

She'd already had a CT scan that didn't show anything. These tumors are often quite small. The doctor ordered an endoscopic ultrasound of the pancreas, which can pick up very small growths. A tiny ultrasound probe is inserted into the patient's mouth, through the stomach and into the small intestine where it can "see" the pancreas. They found a one-centimeter tumor, and it was removed a couple of weeks later.

Back to Normal

The first week after her surgery, the patient carried her juice boxes and candies with her, ready to dose herself if she started to feel odd. She never needed to. She felt great.

But she knew she was really cured a couple of weeks later when she heard her stomach growl, a sound which, because of her hourly snacks, she hadn't heard for years.

Her first endocrinologist learned from the experience. Not long after his patient was cured of her tumor, he made the diagnosis of the same rare tumor in a man with persistent dangerously low sugars. One in a million, twice in one year.

Correction: July 6, 2014
An earlier version of this post misstated the patient's C-peptide level. It was 2.5, not 10.

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Well: Adopt a Bean and Cook With It

Photo Credit Andrew Scrivani for The New York Times

Eat Well

Recipe Finder

Are you searching for a new vegetarian or vegan recipe? Try our new Eat Well Recipe Finder, which offers hundreds of healthful soups, sides, main courses, salads and desserts.

John Ash, the renowned cooking teacher, chef and James Beard Award-winning author, sometimes assigns this wonderful exercise to his students: "adopt a bean" and cook with it.

I decided to do just that this week. I spent a lot of time perusing the website of Rancho Gordo, the purveyor of amazing heirloom beans in Napa, Calif. I ordered five varieties of beans, and I'll be bringing you recipes over the coming months. You don't have to use the heirlooms, which do average about $6 a pound (as opposed to supermarket varieties that usually sell for under $2). I'll give you alternative supermarket beans to use in the recipes. But the textures and colors of the heirloom varieties are extraordinary.

This week I cooked up two simple pots of beans using two varieties: a somewhat large, roundish dark reddish-brown mottled bean called Good Mother Stallard, and a gorgeous black and white mottled bean, a little larger than standard black beans, called vaqueros. All I did was add a quartered onion, a few minced cloves of garlic, and plenty of salt to the soaked beans; I didn't even sauté the onion and garlic first.

I cooked the beans in their soaking water, simmering them for about one and a half to two hours, and ended up with deeply flavored, plush beans that really could have stood alone. In fact, the following day – and beans are always better on the following day – I just snipped a little bit of cilantro into the broth and enjoyed them just so; they were even good cold.

Here's what Rancho Gordo has to say about the Good Mother Stallards: "Just this bean, some onion, some garlic and a splash of olive oil are all you need for cooking and the result is a luscious bean fiesta." But I couldn't help going ahead and using them in other dishes, summer dishes that don't require a lot of fuss.

About vaqueros, Rancho Gordo says: "A really lovely cousin to the Anasazi beans, vaqueros have intriguing black and white markings, not unlike an appaloosa horse might don. The flavor is somewhat like the Anasazi, but it's a little lighter. The real fun is the inky, black pot liquor."

There is a similar looking bean called the orca, but Rancho Gordo says many mottled black and white beans are called orcas, and that "vaqueros really look more like horses than whales." Rancho Gordo recommends as pot beans, for chili, and for stews. I used them for tostadas and pot beans. The pot liquor is indeed irresistible, especially with a handful of chopped cilantro added to it. The beans can break apart a little, but they don't break down the way starchy beans like large white limas and dried fava beans do.

Two-Bean and Tuna Salad: This is the most amazing version of tuna and bean salad I've ever tasted, thanks to Good Mother Stallard beans.

Big Bowl With Spicy Brown Bean, Squash and Corn Succotash: This version of succotash is lima-bean-free, with a kick that is a lively contrast to the sweet corn.

Tostadas With Smashed Black Beans or Vaqueros, Salsa Fresca and Avocado: Refried heirloom vaquero beans add a special touch to these tostadas, but black beans work, too.

Arugula and Corn Salad With Roasted Red Peppers and White Bean: Canned beans can also be used in this composed salad with a base of sweet corn and pungent arugula.

Orecchiette With Fresh and Dried Beans and Tomatoes: Once the beans are done, this pasta dish takes only 15 minutes.

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Well: Flame Retardants Are Everywhere

Photo Flame retardants have been found in Antarctic penguins and other unexpected animals and places.Credit L.A. Kelly Whybrow/Royal Navy Crown, via EPA

Just over 10 years ago, Dr. Arnold Schecter, a public health researcher in Texas, started finding traces of chemical flame retardants in the breast milk of American women. It appeared that the compounds were carried into the milk from fat in the mothers' bodies.

"The route wasn't a surprise," Dr. Schecter, a professor of environmental health at the University of Texas Health Science Center in Dallas, said in an interview. Breast milk is rich in fat, and the compounds he was looking at — polybrominated diphenyl ethers, or PBDEs — linger in fat.

The real question was how flame retardants were getting into women's bodies in the first place. One unexpected source turned out to be food. Dr. Schecter surveyed Dallas supermarkets and discovered flame retardants in lipid-heavy items including butter and peanut butter, bacon, salmon, chili with beans, sliced lunch meat and more.

They are present in tiny amounts, he emphasized. But that they are there at all raises questions that researchers find increasingly troubling. If flame retardants can be found even in peanut butter, then where else have they spread? And what health risks come with them?

Flame retardants are a family of chemical compounds that reduce flammability or inhibit the spread of fire in a range of ways — from interfering with fire's ability to consume oxygen, to forming a barrier, to acting as chemical coolants. Use of the chemicals rose greatly in the 1970s, as manufacturers increasingly put fast-burning synthetic materials and plastics in their products. Today, about 1.5 million tons of these compounds are used globally every year.

Various formulations of flame retardants are linked to a variety of possible health effects, all still under study. Some seem to be fairly benign, but others are suspected carcinogens. Some appear to interfere with the normal operation of hormones, notably thyroid hormones, while some, such as PBDEs, appear to affect brain development.

But to understand and measure these health risks, researchers first must figure out the extent of the contamination in the environment. The answer is growing clearer: Flame retardants show a remarkable ability to spread everywhere.

"We're exposed in every known environment," said Heather Stapleton, an associate professor of environmental sciences at Duke who has been studying flame retardants for 15 years.

Some of the older chemicals, like PBDEs, are being phased out in the United States (and have been banned in Europe). But because they were designed to be durable, resistant compounds, they stubbornly persist in our surroundings. And some of their replacements, such as a new generation of organophosphate flame retardants, are also showing up in unwanted places.

Flame retardants have been found in Antarctic penguins and Arctic orcas; in North American kestrels and barn owls; in bird eggs in Spain, fish in Canada and, indirectly, in bees — honey from Brazil, Morocco, Spain and Portugal has been found tainted with flame retardants.

These chemicals also have been discovered in homes and offices, subways and trains, cars and airplanes. Dr. Stapleton worked on a recent study showing that airplane cabins contain startlingly high levels, leaching from seats, bins and even that curtain dividing first and coach class. She has found the compounds in baby products. Recently she published a study examining flame retardants in tents.

"If a camper sets up a tent in very hot area, it looks like the chemicals come off the fabric," Dr. Stapleton said. "We're worried that people are breathing them in."

Human activities help spread the flame retardants, but the larger drift of them across the planet derives from their longtime use in homes and businesses. The compounds are often sprayed into fabrics and foams used in furniture, bedding and clothing, rather than chemically bonded to the material. So they are gradually shed. Often they attach to dust particles, which not only settle onto floors and shelves, but also waft outside through open doors and windows and air-conditioning systems.

Once outside, they can be transported anywhere by water and winds. "We know this from other long-lasting materials, like DDT," Dr. Stapleton said. "It's called the grasshopper effect."

Of course, not all of it hops away — plenty stays right in the room. A 2012 study concluded that most American households contain dust tainted by flame retardants. A recent survey of 40 day care centers in California found a wide range of flame retardants, including PBDEs, in every one of the dust samples.

The dust may be especially risky for young children, because they crawl on the floors and often put their hands in their mouths, said the study's lead author, Asa Bradman, an associate director of the Center for Environmental Research and Children's Health at the University of California, Berkeley. It doesn't surprise him that the chemicals turn up in the children themselves.

An earlier study by Dr. Bradman, measuring flame retardant levels in children's blood, found they were highest in those who play indoors most often, notably in poor neighborhoods where parents hesitated for safety reasons to let them play outside.

Flame retardants are regulated in the United States primarily by the 1976 Toxic Substances Control Act, which does not require studies of toxicity or long-term health effects for most industrial compounds before they are marketed. Although several efforts have been made to update that legislation, so far none has gained enough Congressional support.

At the moment, there's not much you can do limit your exposure. Dr. Bradman recommends frequent hand washing and vacuuming, particularly in environments in which children may be exposed. He also suggests looking for products labeled as free of flame retardants.

More effective steps, he added, will require national policy changes, including laws that require better assessment of these chemicals and funding for studies of alternative strategies to protect against fire.

"Before we engage in the widespread use of chemicals with the potential to end up in everything, we should stop to ask if they're really necessary," said R. Thomas Zoeller, a professor of biology at the University of Massachusetts Amherst who has studied the effect of flame retardants on thyroid function.

He added, "We should do that, put some of those rules in place, before we put the next generation at any further risk."

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Well: Overweight and Pregnant

Photo Credit Sandra Dionisi

Personal Health

Jane Brody on health and aging.

Pregnancy, or the desire to become pregnant, often inspires women to take better care of themselves — quitting smoking, for example, or eating more nutritiously.

But now many women face an increasingly common problem: obesity, which affects 36 percent of women of childbearing age. In addition to hindering conception, obesity — defined as a body mass index above 30 — is linked to a host of difficulties during pregnancy, labor and delivery.

These range from gestational diabetes, hypertension and pre-eclampsia to miscarriage, premature birth, emergency cesarean delivery and stillbirth.

The infants of obese women are more likely to have congenital defects, and they are at greater risk of dying at or soon after birth. Babies who survive are more likely to develop hypertension and obesity as adults.

To be sure, most babies born to overweight and obese women are healthy. Yet a recently published analysis of 38 studies found that even modest increases in a woman's pre-pregnancy weight raised the risks of fetal death, stillbirth and infant death.

Personal biases and concerns about professional liability lead some obstetricians to avoid obese patients. But Dr. Sigal Klipstein, chairwoman of the committee on ethics of the American College of Obstetricians and Gynecologists, says it is time for doctors to push aside prejudice and fear. They must take more positive steps to treat obese women who are pregnant or want to become pregnant.

Dr. Klipstein and her colleagues recently issued a report on ethical issues in caring for obese women. Obesity is commonly viewed as a personal failing that can be prevented or reversed through motivation and willpower. But the facts suggest otherwise.

Although some people manage to shed as much as 100 pounds and keep them off without surgery, many obese patients say they've tried everything, and nothing has worked. "Most obese women are not intentionally overeating or eating the wrong foods," Dr. Klipstein said. "Obstetricians should address the problem, not abandon patients because they think they're doing something wrong."

Dr. Klipstein is a reproductive endocrinologist at InVia Fertility Specialists in Northbrook, Ill. In her experience, the women who manage to lose weight are usually highly motivated and use a commercial diet plan.

"But many fail even though they are very anxious to get pregnant and have a healthy pregnancy," she said. "This is the new reality, and obstetricians have to be aware of that and know how to treat patients with weight issues."

The committee report emphasizes that "obese patients should not be viewed differently from other patient populations that require additional care or who have increased risks of adverse medical outcomes." Obese patients should be cared for "in a nonjudgmental manner," it says, adding that it is unethical for doctors to refuse care within the scope of their expertise "solely because the patient is obese."

Obstetricians should discuss the medical risks associated with obesity with their patients and "avoid blaming the patient for her increased weight," the committee says. Any doctor who feels unable to provide effective care for an obese patient should seek a consultation or refer the woman to another doctor.

Obesity rates are highest among women "of lower socioeconomic status," the report notes, and many obese women lack "access to healthy food choices and opportunities for regular exercise that would help them maintain a normal weight."

Nonetheless, obese women who want to have a baby should not abandon all efforts to lose weight. Obstetricians who lack expertise in weight management can refer patients to dietitians who specialize in treating weight problems without relying on gimmicks or crash diets, which have their own health risks.

Weight loss is best attempted before a pregnancy. Last year, the college's committee on obstetric practice advised obstetricians to "provide education about possible complications and encourage obese patients to undertake a weight-reduction program, including diet, exercise, and behavior modification, before attempting pregnancy."

An obese woman who becomes pregnant should aim to gain less weight than would a normal-weight woman. The Institute of Medicine suggests a pregnancy weight gain of 15 to 25 pounds for overweight women and 11 to 20 pounds for obese women.

Although women should not to try to lose weight during pregnancy, "a woman who weighs 300 pounds shouldn't gain at all," Dr. Klipstein said. "This is not harmful to the fetus."

Dr. Klipstein also noted that obesity produces physiological changes that can affect pregnancy, starting with irregular ovulation that can result in infertility.

Obese women are more likely to have problems processing blood sugar, which raises the risk of birth defects and miscarriage. There is also a greater likelihood that their baby will be too large for a vaginal delivery, requiring a cesarean delivery that has its own risks involving anesthesia and surgery.

The babies of obese women are more likely to develop neural tube defects — spina bifida and anencephaly — and to suffer birth injuries like shoulder dystocia, which may occur when the infant is very large.

High blood pressure, more common in obesity, can result in pre-eclampsia during pregnancy, which can damage the mother's kidneys and cause fetal complications like low birth weight, prematurity and stillbirth.

It is also harder to obtain reliable images on a sonogram when the woman is obese. This can delay detection of fetal or pregnancy abnormalities that require careful monitoring or medical intervention.

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Well: Adopt a Bean and Cook With It

Photo Credit Andrew Scrivani for The New York Times

Eat Well

Recipe Finder

Are you searching for a new vegetarian or vegan recipe? Try our new Eat Well Recipe Finder, which offers hundreds of healthful soups, sides, main courses, salads and desserts.

John Ash, the renowned cooking teacher, chef and James Beard Award-winning author, sometimes assigns this wonderful exercise to his students: "adopt a bean" and cook with it.

I decided to do just that this week. I spent a lot of time perusing the website of Rancho Gordo, the purveyor of amazing heirloom beans in Napa, Calif. I ordered five varieties of beans, and I'll be bringing you recipes over the coming months. You don't have to use the heirlooms, which do average about $6 a pound (as opposed to supermarket varieties that usually sell for under $2). I'll give you alternative supermarket beans to use in the recipes. But the textures and colors of the heirloom varieties are extraordinary.

This week I cooked up two simple pots of beans using two varieties: a somewhat large, roundish dark reddish-brown mottled bean called Good Mother Stallard, and a gorgeous black and white mottled bean, a little larger than standard black beans, called vaqueros. All I did was add a quartered onion, a few minced cloves of garlic, and plenty of salt to the soaked beans; I didn't even sauté the onion and garlic first.

I cooked the beans in their soaking water, simmering them for about one and a half to two hours, and ended up with deeply flavored, plush beans that really could have stood alone. In fact, the following day – and beans are always better on the following day – I just snipped a little bit of cilantro into the broth and enjoyed them just so; they were even good cold.

Here's what Rancho Gordo has to say about the Good Mother Stallards: "Just this bean, some onion, some garlic and a splash of olive oil are all you need for cooking and the result is a luscious bean fiesta." But I couldn't help going ahead and using them in other dishes, summer dishes that don't require a lot of fuss.

About vaqueros, Rancho Gordo says: "A really lovely cousin to the Anasazi beans, vaqueros have intriguing black and white markings, not unlike an appaloosa horse might don. The flavor is somewhat like the Anasazi, but it's a little lighter. The real fun is the inky, black pot liquor."

There is a similar looking bean called the orca, but Rancho Gordo says many mottled black and white beans are called orcas, and that "vaqueros really look more like horses than whales." Rancho Gordo recommends as pot beans, for chili, and for stews. I used them for tostadas and pot beans. The pot liquor is indeed irresistible, especially with a handful of chopped cilantro added to it. The beans can break apart a little, but they don't break down the way starchy beans like large white limas and dried fava beans do.

Two-Bean and Tuna Salad: This is the most amazing version of tuna and bean salad I've ever tasted, thanks to Good Mother Stallard beans.

Big Bowl With Spicy Brown Bean, Squash and Corn Succotash: This version of succotash is lima-bean-free, with a kick that is a lively contrast to the sweet corn.

Tostadas With Smashed Black Beans or Vaqueros, Salsa Fresca and Avocado: Refried heirloom vaquero beans add a special touch to these tostadas, but black beans work, too.

Arugula and Corn Salad With Roasted Red Peppers and White Bean: Canned beans can also be used in this composed salad with a base of sweet corn and pungent arugula.

Orecchiette With Fresh and Dried Beans and Tomatoes: Once the beans are done, this pasta dish takes only 15 minutes.

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DealBook: Dimon’s Cancer and the Fine Line in Revealing Illness of a C.E.O.

Photo Jamie Dimon is the chief executive of JPMorgan Chase.Credit Richard Drew/Associated Press

The diagnosis came out of nowhere: It was leukemia.

Harry J. Pearce, then 56 and in line for the top job at General Motors, fainted at the news. But within hours, he had alerted his chief executive, John F. Smith Jr., about the sudden turn in his health.

"I felt strongly from Day 1 that when a senior executive is diagnosed with that kind of illness, especially one that is obviously more fatal than not, that the company and I had an absolute obligation to make disclosures about the disease and what the treatment would be and to lay it all out to the G.M. board of directors," Mr. Pearce, now 71 and in good health, recalled.

Like Mr. Pearce, corporate leaders from Steven P. Jobs to Warren E. Buffett and now Jamie Dimon have wrestled with how — or whether — to go public about health problems. How much to disclose, and when, involves delicate corporate and personal decisions for which there are few hard rules. Executives have no real legal obligation to tell the world they are sick.

Some, like Mr. Jobs, who died in 2011 of pancreatic cancer, tend toward secrecy. Others, like Mr. Dimon, the head of JPMorgan Chase, go public early, in the belief that board members, employees and the investing public should know. Mr. Dimon disclosed on Tuesday that he has been told he has throat cancer but said the prognosis was good.

Serious illness strikes boardrooms more often than you might think. Executives, after all, get sick like everyone else. Over the years, cancer, heart attacks and strokes have hit senior executives at companies ranging from McDonald's to Sara Lee to the American International Group. Handling the news is particularly difficult when it involves a leader who has become the face of the company.

That was the case with Mr. Jobs and, to a lesser degree, is also the case with Mr. Dimon, perhaps the nation's pre-eminent banker. Tuesday's news rekindled old concerns about whether the bank has moved quickly enough to groom potential successors given Mr. Dimon's long run as both chairman and chief executive. JPMorgan has said its bench is deep.

Still, employees inside JPMorgan's headquarters on Park Avenue were absorbing the news on Wednesday. The bank's share price fell 1 percent, even as the broad stock market clung near record highs.

But corporate governance experts generally praised the bank's timely disclosure given JPMorgan's importance to Wall Street and the nation's economy, as well as Mr. Dimon's bigger-than-life role inside the bank.

"JPMorgan hit the right note in its disclosure," said Gary Hewitt, the head of research at accounting and governance research firm GMI Ratings. "It's a difficult balance between the legitimate right to privacy on the part of the executive and the legitimate right to know when critical things might happen to an executive for shareholders."

No specific securities regulations compel companies to disclose health-related information about their executives. Experts say such rules would probably violate an individual's right to privacy under existing health care laws. A 2009 study of disclosures of chief executive illnesses found that many executives waited to go public until they believed their illness was manageable. Other companies made the disclosure only upon the executive's death.

"I think they either don't want to admit they are ill because it will cause concern for the company, or I think they don't disclose it because they don't have a succession plan in place," said Lex Perryman, the author of the study and an assistant professor of management at the Milgard School of Business at the University of Washington, Tacoma.

For corporations big and small, a crucial question is whether top executives alert their boards when they fall ill.

In April 2006, Frank C. Lanza, the chief executive of the military contractor L-3 Communications, announced he had undergone esophageal surgery to remove scar tissue caused by acid reflux. He died two months later, and an autopsy determined the cause of death was esophageal cancer. The revelation prompted questions about whether the board was aware of the severity of his illness.

But experts say it is important that well-known executives like Mr. Dimon, who have become closely linked to companies they oversee, disclose important information to investors.

There have been several prominent examples over the years of business greats providing rapid disclosure of illnesses.

In the spring of 2012, Mr. Buffett disclosed that he had prostate cancer. In 1996, Andy Grove, who built Intel into the world's most powerful chip company, went public through a startling first-person essay in Fortune magazine, detailing his discovery and treatment of prostate cancer.

But the company often given poor grades on such questions is Apple, which was widely criticized for providing limited information about the health of Mr. Jobs.

After months of speculation about Mr. Jobs's appearance, in early 2009 Apple went public, saying the executive was suffering from a "hormone imbalance." About a week later, Mr. Jobs took a medical leave of absence, stating that his health problems were "more complex" than first thought. He died in October 2011, at age 56.

For Mr. Dimon, who steered JPMorgan through the financial crisis of 2008-9 and into record profits, the decision to disclose his illness was a no-brainer, according to two people close to the executive. Mr. Dimon, who is 58 and regularly runs and plays tennis, noticed something was off-kilter with his health several weeks ago, these people said.

Before alerting employees or shareholders, Mr. Dimon went through a series of tests last week, including a biopsy and various scans. Doctors confirmed that the cancer had not spread beyond the "original site" and the adjacent lymph nodes on the right side of his neck, an assurance that Mr. Dimon relayed to employees and shareholders in a memo Tuesday night.

Mr. Dimon had also alerted Lee Raymond, the lead independent director on the bank's board, along with several other board members, after receiving a complete diagnosis on Monday. Mr. Dimon, in his memo, said his treatment was expected to last about eight weeks and restrict his travel. Nonetheless, he plans to remain immersed in his role at the bank.

While every person is different, Mr. Pearce, the former G.M. executive, said maintaining a full workload while being treated for a serious illness was not easy. Mr. Pearce had been told that the five-year survival rate for his form of leukemia was 14 percent. He subsequently underwent a stem cell transplant. After a four-month recovery, he returned to work.

"I was incredibly naïve to think I could go back and do what I was doing the way I was doing it before," said Mr. Pearce. He stepped aside in 2001.

"I told them they were paying me as if I was performing as I had before, and I didn't feel like I was at that time, and I didn't know whether I ever would again," he said.

A version of this article appears in print on 07/03/2014, on page B1 of the NewYork edition with the headline: A Fine Line in Revealing the Illness of the C.E.O..

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Well: Adopt a Bean and Cook With It

Photo Credit Andrew Scrivani for The New York Times

Eat Well

Recipe Finder

Are you searching for a new vegetarian or vegan recipe? Try our new Eat Well Recipe Finder, which offers hundreds of healthful soups, sides, main courses, salads and desserts.

John Ash, the renowned cooking teacher, chef and James Beard Award-winning author, sometimes assigns this wonderful exercise to his students: "adopt a bean" and cook with it.

I decided to do just that this week. I spent a lot of time perusing the website of Rancho Gordo, the purveyor of amazing heirloom beans in Napa, Calif. I ordered five varieties of beans, and I'll be bringing you recipes over the coming months. You don't have to use the heirlooms, which do average about $6 a pound (as opposed to supermarket varieties that usually sell for under $2). I'll give you alternative supermarket beans to use in the recipes. But the textures and colors of the heirloom varieties are extraordinary.

This week I cooked up two simple pots of beans using two varieties: a somewhat large, roundish dark reddish-brown mottled bean called Good Mother Stallard, and a gorgeous black and white mottled bean, a little larger than standard black beans, called vaqueros. All I did was add a quartered onion, a few minced cloves of garlic, and plenty of salt to the soaked beans; I didn't even sauté the onion and garlic first.

I cooked the beans in their soaking water, simmering them for about one and a half to two hours, and ended up with deeply flavored, plush beans that really could have stood alone. In fact, the following day – and beans are always better on the following day – I just snipped a little bit of cilantro into the broth and enjoyed them just so; they were even good cold.

Here's what Rancho Gordo has to say about the Good Mother Stallards: "Just this bean, some onion, some garlic and a splash of olive oil are all you need for cooking and the result is a luscious bean fiesta." But I couldn't help going ahead and using them in other dishes, summer dishes that don't require a lot of fuss.

About vaqueros, Rancho Gordo says: "A really lovely cousin to the Anasazi beans, vaqueros have intriguing black and white markings, not unlike an appaloosa horse might don. The flavor is somewhat like the Anasazi, but it's a little lighter. The real fun is the inky, black pot liquor."

There is a similar looking bean called the orca, but Rancho Gordo says many mottled black and white beans are called orcas, and that "vaqueros really look more like horses than whales." Rancho Gordo recommends as pot beans, for chili, and for stews. I used them for tostadas and pot beans. The pot liquor is indeed irresistible, especially with a handful of chopped cilantro added to it. The beans can break apart a little, but they don't break down the way starchy beans like large white limas and dried fava beans do.

Two-Bean and Tuna Salad: This is the most amazing version of tuna and bean salad I've ever tasted, thanks to Good Mother Stallard beans.

Big Bowl With Spicy Brown Bean, Squash and Corn Succotash: This version of succotash is lima-bean-free, with a kick that is a lively contrast to the sweet corn.

Tostadas With Smashed Black Beans or Vaqueros, Salsa Fresca and Avocado: Refried heirloom vaquero beans add a special touch to these tostadas, but black beans work, too.

Arugula and Corn Salad With Roasted Red Peppers and White Bean: Canned beans can also be used in this composed salad with a base of sweet corn and pungent arugula.

Orecchiette With Fresh and Dried Beans and Tomatoes: Once the beans are done, this pasta dish takes only 15 minutes.

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Well: Ask Well: Reapply Your Sunscreen

Photo Credit Hiroko Masuike/The New York Times

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The main reason to reapply a broad-spectrum sunscreen every two hours isn't that it breaks down; most of today's sunscreens are stable in sunlight. Rather, reapplication is crucial because most people don't apply enough sunscreen in the first place.

A full ounce — or the amount in a shot glass — should be slathered on 15 minutes before exposure, then reapplied. Use products that offer "broad-spectrum protection," meaning they protect against both UVA and burning UVB rays. Both kinds of radiation can lead to skin cancer.

"In the past sunscreen broke down, but now technology has bypassed that," said Dr. Steven Q. Wang, the director of dermatology at Memorial Sloan-Kettering Cancer Center in Basking Ridge, N.J. "Unfortunately people's behavior hasn't changed, so that's why the two-hour rule is still a good principle."

Dr. Wang, who is a spokesman for the Skin Cancer Foundation, which gets funding from sunscreen manufacturers, tells his patients to apply sunscreen as if they were adding a second coat of paint to a house. First, he advises starting at the left ear, then methodically going from left arm to left trunk to left leg to left foot to right foot and back up. Reapply sooner than every two hours if you're sweating, swimming or exercising through a scorcher.

Remember there's no such thing as a complete sunblock. A sunscreen offers only some protection. "People have a false sense of security after they put sunscreen on," Dr. Wang said, "Then they stay in sun five or six hours."

It's a problem worsened, in a way, by sunscreen itself. Applied copiously, a cream with a high S.P.F. prevents a lobster-red burn, a hard-to-miss signal to head inside.

But don't be fooled. Even without a burn, your skin is still being damaged by the sun, Dr. Wang explained, "increasing your risk of developing skin cancer as well as signs of aging, like wrinkles."

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

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Well: Can Exercise Reduce Alzheimer’s Risk?

Phys Ed

Gretchen Reynolds on the science of fitness.

Photo Credit Karen Kasmauski/Getty Images

Exercise may help to keep the brain robust in people who have an increased risk of developing Alzheimer's disease, according to an inspiring new study. The findings suggests that even moderate amounts of physical activity may help to slow the progression of one of the most dreaded diseases of aging.

For the new study, which was published in May in Frontiers in Aging Neuroscience, researchers at the Cleveland Clinic in Ohio recruited almost 100 older men and women, aged 65 to 89, many of whom had a family history of Alzheimer's disease.

Alzheimer's disease, characterized by a gradual and then quickening loss of memory and cognitive functioning, can strike anyone. But scientists have discovered in recent years that people who harbor a specific variant of a gene, known as the APOE epsilon4 allele or the e4 gene for short, have a substantially increased risk of developing the disease.

Genetic testing among the volunteers in the new study determined that about half of the group carried the e4 gene, although, at the start of the study, none showed signs of memory loss beyond what would be normal for their age.

Then the scientists set out to more closely examine their volunteers' brains.

For some time, researchers have suspected that Alzheimer's disease begins altering the structure and function of the brain years or even decades before the first symptoms appear. In particular, it's been thought that the disease silently accelerates the atrophy of the hippocampus, a portion of the brain critical for memory processing. Brain scans of people who have Alzheimer's show that their hippocampi are considerably more shrunken than those of people of the same age without the disease.

There's been less study, though, of possible shrinkage in the brains of cognitively normal people at risk for Alzheimer's. One reason is that, until recently, few interventions, including drugs, had shown much promise in slowing or preventing the disease's progression, so researchers – and patients – have been reluctant to identify markers of its potential onset.

But then some studies began to suggest that exercise might affect the disease's progression. A 2011 brain scan study, for instance, conducted by some of the same researchers from the Cleveland Clinic, found that elderly people with the e4 gene who exercised regularly had significantly more brain activity during cognitive tests than people with the e4 gene who did not exercise, suggesting that the exercisers' brains were functioning better.

But that study looked at the function, not the structure of the brain. Could exercise also be affecting the physical shape of the brain, the researchers wondered, particularly in people with the e4 gene?

To find out, they asked the volunteers in their new experiment how often and intensely they exercised. About half, as it turned out, didn't move much at all. But the other half walked, jogged or otherwise exercised moderately a few times every week.

In the end, the scientists divided their volunteers into four groups, based on their e4 status and exercise habits. One group included those people with the e4 gene who did not exercise; another consisted of those with the e4 gene who did exercise; and the other two groups were composed of those without the gene who did or did not regularly exercise.

The scientists then scanned their volunteers' brains, with particular emphasis on their hippocampi. Eighteen months later, they repeated the scans.

In that brief interval, the members of the group carrying the e4 gene who did not exercise had undergone significant atrophy of their hippocampus. It had shrunk by about 3 percent, on average.

Those volunteers who carried the e4 gene but who regularly exercised, however, showed almost no shrinkage of their hippocampus. Likewise, both groups of volunteers who did not carry the e4 gene showed little change to their hippocampus.

In effect, the brains of physically active volunteers at high risk for Alzheimer's disease looked just like the brains of people at much lower risk for the disease, said Stephen M. Rao, an associate professor at the Schey Center for Cognitive Neuroimaging at the Cleveland Clinic, who oversaw the study. Exercise appeared to have been protective.

Meanwhile, the brains of sedentary people at high risk appeared to be slipping, structurally, toward dysfunction.

"This occurred in a very compressed time frame," said Dr. Rao, who described the differences in brain structure as "quite significant."

How exercise was guarding people's hippocampi remains unclear, he said, although the e4 gene is known to alter fat metabolism within the brain, he said, as does exercise, which could be counteracting some of the undesirable effects of the e4 gene.

More research needs to be done to better understand the interplay of exercise and Alzheimer's disease risk. But even so, Dr. Rao said, "there's good reason to tell people to exercise" to protect their memories. Many of us do not carry the e4 gene, but everyone has some chance of developing Alzheimer's disease.

And if exercise reduces that risk in any way, Dr. Rao said, "then why not get up and move?"

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Well: Flame Retardants Are Everywhere

Photo Flame retardants have been found in Antarctic penguins and other unexpected animals and places.Credit L.A. Kelly Whybrow/Royal Navy Crown, via EPA

Just over 10 years ago, Dr. Arnold Schecter, a public health researcher in Texas, started finding traces of chemical flame retardants in the breast milk of American women. It appeared that the compounds were carried into the milk from fat in the mothers' bodies.

"The route wasn't a surprise," Dr. Schecter, a professor of environmental health at the University of Texas Health Science Center in Dallas, said in an interview. Breast milk is rich in fat, and the compounds he was looking at — polybrominated diphenyl ethers, or PDBEs — linger in fat.

The real question was how flame retardants were getting into women's bodies in the first place. One unexpected source turned out to be food. Dr. Schecter surveyed Dallas supermarkets and discovered flame retardants in lipid-heavy items including butter and peanut butter, bacon, salmon, chili with beans, sliced lunch meat and more.

They are present in tiny amounts, he emphasized. But that they are there at all raises questions that researchers find increasingly troubling. If flame retardants can be found even in peanut butter, then where else have they spread? And what health risks come with them?

Flame retardants are a family of chemical compounds that reduce flammability or inhibit the spread of fire in a range of ways — from interfering with fire's ability to consume oxygen, to forming a barrier, to acting as chemical coolants. Use of the chemicals rose greatly in the 1970s, as manufacturers increasingly put fast-burning synthetic materials and plastics in their products. Today, about 1.5 million tons of these compounds are used globally every year.

Various formulations of flame retardants are linked to a variety of possible health effects, all still under study. Some seem to be fairly benign, but others are suspected carcinogens. Some appear to interfere with the normal operation of hormones, notably thyroid hormones, while some, such as PBDEs, appear to affect brain development.

But to understand and measure these health risks, researchers first must figure out the extent of the contamination in the environment. The answer is growing clearer: Flame retardants show a remarkable ability to spread everywhere.

"We're exposed in every known environment," said Heather Stapleton, an associate professor of environmental sciences at Duke who has been studying flame retardants for 15 years.

Some of the older chemicals, like PBDEs, are being phased out in the United States (and have been banned in Europe). But because they were designed to be durable, resistant compounds, they stubbornly persist in our surroundings. And some of their replacements, such as a new generation of organophosphate flame retardants, are also showing up in unwanted places.

Flame retardants have been found in Antarctic penguins and Arctic orcas; in North American kestrels and barn owls; in bird eggs in Spain, fish in Canada and, indirectly, in bees — honey from Brazil, Morocco, Spain and Portugal has been found tainted with flame retardants.

These chemicals also have been discovered in homes and offices, subways and trains, cars and airplanes. Dr. Stapleton worked on a recent study showing that airplane cabins contain startlingly high levels, leaching from seats, bins and even that curtain dividing first and coach class. She has found the compounds in baby products. Recently she published a study examining flame retardants in tents.

"If a camper sets up a tent in very hot area, it looks like the chemicals come off the fabric," Dr. Stapleton said. "We're worried that people are breathing them in."

Human activities help spread the flame retardants, but the larger drift of them across the planet derives from their longtime use in homes and businesses. The compounds are often sprayed into fabrics and foams used in furniture, bedding and clothing, rather than chemically bonded to the material. So they are gradually shed. Often they attach to dust particles, which not only settle onto floors and shelves, but also waft outside through open doors and windows and air-conditioning systems.

Once outside, they can be transported anywhere by water and winds. "We know this from other long-lasting materials, like DDT," Dr. Stapleton said. "It's called the grasshopper effect."

Of course, not all of it hops away — plenty stays right in the room. A 2012 study concluded that most American households contain dust tainted by flame retardants. A recent survey of 40 day care centers in California found a wide range of flame retardants, including PBDEs, in every one of the dust samples.

The dust may be especially risky for young children, because they crawl on the floors and often put their hands in their mouths, said the study's lead author, Asa Bradman, an associate director of the Center for Environmental Research and Children's Health at the University of California, Berkeley. It doesn't surprise him that the chemicals turn up in the children themselves.

An earlier study by Dr. Bradman, measuring flame retardant levels in children's blood, found they were highest in those who play indoors most often, notably in poor neighborhoods where parents hesitated for safety reasons to let them play outside.

Flame retardants are regulated in the United States primarily by the 1976 Toxic Substances Control Act, which does not require studies of toxicity or long-term health effects for most industrial compounds before they are marketed. Although several efforts have been made to update that legislation, so far none has gained enough Congressional support.

At the moment, there's not much you can do limit your exposure. Dr. Bradman recommends frequent hand washing and vacuuming, particularly in environments in which children may be exposed. He also suggests looking for products labeled as free of flame retardants.

More effective steps, he added, will require national policy changes, including laws that require better assessment of these chemicals and funding for studies of alternative strategies to protect against fire.

"Before we engage in the widespread use of chemicals with the potential to end up in everything, we should stop to ask if they're really necessary," said R. Thomas Zoeller, a professor of biology at the University of Massachusetts Amherst who has studied the effect of flame retardants on thyroid function.

He added, "We should do that, put some of those rules in place, before we put the next generation at any further risk."

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