Tagged Columns

Rediscovering the Kitchen, and Other Tips for Heart Health

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Credit Paul Rogers

First the bad news: After decades of major progress in reducing deaths from diseases of the heart and blood vessels, the decline in cardiovascular mortality has slowed significantly, according to the latest report from the Centers for Disease Control and Prevention. The researchers called their findings alarming, suggesting that cardiovascular benefits from medical interventions may have reached a saturation point and that further improvements depend largely on changes in society and personal behavior.

The new data, published in June in JAMA Cardiology, covered the years from 2000 through 2014. From 2000 through 2010, the annual rates of decline for all cardiovascular deaths heart diseases and stroke averaged 3.69 percent for men and 3.98 percent for women. But since 2011, the rates of decline dropped to a mere 0.23 percent for men and 1.17 percent for women.

These findings point to near stagnation in controlling cardiovascular diseases and deaths, Dr. Stephen Sidney and colleagues wrote. And, they noted, the reasons are not difficult to discern. Based on data from the latest National Health and Nutrition Examination Survey in 2011-12, Americans did better in controlling three major risk factors smoking, high blood pressure and elevated cholesterol, often with the help of medication but many more people became obese and developed Type 2 diabetes.

According to data from the survey, the prevalence of adult obesity rose from 22.9 percent in 1988-1994 to 34.9 percent in 2011-12, and the C.D.C. found that the prevalence of diabetes nearly tripled, from 2.5 percent in 1990 to 7.2 percent in 2013.

Furthermore, the national survey showed, the percentage of adults who in 2012 were consuming an ideal diet that could minimize life-threatening damage to blood vessels was near zero.

Its not that these grim data were unexpected. Four years ago, Dr. Richard J. Jackson, a professor and former chairman of environmental health sciences at the University of California, Los Angeles, predicted that the current generation of young Americans (those born since 1980) may be the first to live shorter lives than their parents.

Even earlier, in 2007, Dr. Earl S. Ford of the C.D.C. and Dr. Simon Capewell of the University of Liverpool wrote that unless measures were taken to transform the abhorrent risk factor profile that currently characterizes much of the U.S. population and dangerous trends were reversed, mortality rates among younger adults may represent the leading edge of a brewing storm.

Now for the good news: Neither medical innovations nor genetic interventions are needed to turn the tide on cardiovascular diseases and deaths and restore their once-significant declines. And the very same changes needed to improve cardiovascular health may also help prevent many common cancers, diabetes, arthritis, cognitive decline, depression and osteoporosis.

Dr. Donald M. Lloyd-Jones, a chief architect of a 2010 strategic plan to improve cardiovascular health, said: The whole may be greater than the sum of the parts. We shouldnt assume that chronic diseases automatically occur with aging. Living healthfully until we die is an achievable goal.

Dr. Lloyd-Jones, a cardiologist and preventive medicine specialist at the Northwestern University Feinberg School of Medicine in Chicago, chaired an American Heart Association committee of experts that adopted the recommended changes. Instead of focusing on the negative, the plan aims to achieve ideal cardiovascular health through ideal health behaviors and ideal health factors.

Heres how the committee defined ideal: No smoking; maintaining a body mass index below 25; being physically active; following current dietary guidelines; and maintaining an untreated total cholesterol level of less than 200 milligrams, an untreated blood pressure level of less than 120 over 80, and a fasting blood glucose level of less than 100 milligrams.

The committee had hoped that fostering these seven health behaviors and targets would, by 2020, improve the cardiovascular health of all Americans by 20 percent while reducing deaths from cardiovascular diseases and stroke by 20 percent.

But current trends project at best a 6 percent improvement.

Although most of us are born with the potential for ideal cardiovascular health, fewer than half of all adolescents have retained five or more of the seven behaviors and factors at ideal levels, Dr. Lloyd-Jones wrote in 2014. And things get progressively worse with age until ideal cardiovascular health becomes rare above age 60, he said.

Still, he has not given up hope for a better result.

Now for the details. First and foremost, quit smoking or never start. Heart risks drop significantly within a year of quitting and eventually reach those of a nonsmoker.

Next, get regular physical exercise, at least 150 minutes a week of moderate physical activity or 75 minutes a week of vigorous activity, or a combination of the two. Keep in mind that this is the minimum amount of physical activity needed to glean health benefits. More is better.

Exercise should be part of your daily routine, like brushing your teeth. I do a combination of moderate and vigorous exercise every day. It energizes me and helps me control my weight without having to watch every calorie.

As for diet, the committee recommended focusing on foods, not nutrients. (As Dr. Lloyd-Jones put it, We dont eat nutrients.) It refrained from suggesting how many calories people should eat, since caloric needs vary tremendously based on an individuals basal metabolic rate, body size, lean body mass and physical activity.

Rather, it suggested a version of the DASH diet (for Dietary Approaches to Stop Hypertension) that was successfully tested by the National Heart, Lung and Blood Institute. It calls for four and a half or more cups of fruits and vegetables a day; two or more 3.5-ounce servings of fish each week; three ounces of fiber-rich whole grains a day; at most 36 ounces of sugar-sweetened drinks (less than 450 calories, or the equivalent in other sweets) a week; four or more weekly servings of nuts, legumes and seeds; and no more than two servings a week of processed meats.

At the same time, limit saturated fats to less than 7 percent of total calories and daily sodium to 1,500 milligrams for people with high blood pressure and no more than 2,300 milligrams (or one teaspoon of salt) for everyone else. Currently, Americans consume an average of 3,500 milligrams of sodium a day, most of it from processed and restaurant foods.

Which brings me to a final recommendation of my own: Rediscover your kitchen. No matter how busy you are, finding time to prepare healthy foods for yourself and your family should be a top priority.

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The Hazards of Ankle Sprains

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Credit Paul Rogers

Many fashion-conscious women wear high heels to show off their legs. But in truth, given the extraordinarily high incidence of ankle sprains, we’d probably all be better off if we had thick stumps like an elephant’s to connect our feet to our legs.

Every day in the United States, about 28,000 people sprain an ankle. Too often the injury is dismissed as “just a sprain,” with no specific treatment and a return to full activity before it has completely healed. Fully 45 percent of all athletic injuries are ankle sprains, and players often go back into the game with little or no treatment as soon as the pain subsides.

In fact, according to the International Ankle Consortium, a global group of researchers and clinicians who study ankle injuries, 55 percent of people who sprain an ankle never seek professional treatment in the aftermath of the injury.

Yet the majority of ankle sprains are doomed to recur. That’s because they often result in a chronically unstable joint that tends to “give way,” poor balance, a distorted gait, difficulty exercising, weight gain, diminished quality of life and early arthritis. Not to mention the expense of dealing with health problems that can result from being overweight and sedentary living.

Sound scary? It should, says Phillip A. Gribble, an athletic trainer at the University of Kentucky and co-director of the International Ankle Consortium, who hopes that knowing the potential consequences of ankle injuries will prompt more people to treat them with respect and seek proper treatment. Even better, he said, would be if more people took steps to prevent injury in the first place. And that, ladies, may include leaving those spike heels in the store.

Dr. Gribble was one of several experts who recently presented the latest technical information on ankle sprains to the National Athletic Trainers’ Association meeting in Baltimore. In a study of 3,526 adults who responded to a questionnaire, more than half, or 1,843, had previously sustained an ankle injury. Those who had injured their ankles tended to weigh more, had greater limitations in their daily activities and were more likely to have cardiovascular or respiratory conditions than those who remained injury free.

While ankle sprains are most common among physically active people, especially amateur and professional sports players and dancers, the general public is hardly immune. The injury can result from walking on an uneven surface (especially while wearing high heels or platform shoes), misstepping off a curb or staircase, being pulled erratically by a dog on a leash, even playing around in the yard with children or friends.

It doesn’t take much. I know — years ago, I sustained two bad sprains, one stepping on a stick while trimming a hedge and the other missing the last step while exiting a plane in the dark. I am now extremely careful about where I walk and what I put on my feet, especially when hiking in the woods (boots are de rigueur).

Most ankle sprains result when the foot abruptly turns in under the leg so that the sole of that foot faces the opposite leg, unduly stretching the ligament on the outside of the ankle. The extent of the injury can range from a minor strain to a complete tear, and the rate and extent of healing can vary greatly.

In one report to the athletic trainers’ convention, 12 college students who had sprained an ankle still had an incompletely healed, overstretched ligament a year after the injury, which “may explain the high percentage of patients that develop chronic ankle instability,” said Tricia Hubbard-Turner of the University of North Carolina at Charlotte.

Even though fewer than half of ankle sprains receive medical attention, the injury is so common (an estimated incidence of 2.06 ankle sprains per 1,000 people a year) that it is the leading lower extremity injury that results in an emergency room visit, according to data from the National Electronic Injury Surveillance System.

As with any injury, ankle sprains are best prevented. One of the best approaches is to improve one’s balance with exercises that train the body to stay upright and maintain control in all kinds of positions. Dr. Gribble recommends spending time standing on one foot, at first on a firm surface, then with eyes closed, then on a soft surface like a pillow. As a final challenge, practice balancing on a wobble board, he said.

Muscles surrounding the ankle can be strengthened by wrapping a towel around the foot for resistance, then moving the foot up, down, in and out. Do stretching exercises that increase the flexibility of the legs, hip and torso to guard against any unanticipated awkward movements.

When participating in sports like basketball, soccer and tennis — which involve jumps or quick changes in direction that can put ankles at risk — consider taping or bracing the ankles to increase their stability.

Finally, avoid being a weekend warrior who indulges in a sport full tilt without adequate preparation. Build up gradually, practice the skills involved and make sure to keep needed muscles strong.

Should you sprain an ankle, avoid the all too common layman’s advice to “walk it off.” At a minimum, leave the game or whatever you were doing and avoid putting weight on that foot to give the injured joint adequate rest. If the injury is severe, you may need to use crutches.

If you do sprain an ankle, apply ice wrapped in a cloth for 15 to 20 minutes every two or three hours for two days, then once a day until pain and swelling are gone. Sit or lie down as much as possible with the injured ankle elevated above the hip. To further minimize swelling, wrap the ankle in an elastic bandage, starting at the toes and working up to the leg.

Seriously consider a medical consultation, especially if pain and swelling persist for more than a few days. Although in most cases, an X-ray or M.R.I. is not needed to make an accurate diagnosis, the injury could be more serious than a simple sprain. Ask about physical therapy, which can strengthen the joint and help prevent reinjury.

Most important of all, don’t rush back into activity before healing is complete and normal, pain-free range of motion has been restored. Reinjuring the ankle can result in permanent pain and disability and the health consequences noted above.

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The Narcissist Next Door

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Credit Paul Rogers

Does this sound like anyone you know?

*Highly competitive in virtually all aspects of his life, believing he (or she) possesses special qualities and abilities that others lack; portrays himself as a winner and all others as losers.

*Displays a grandiose sense of self, violating social norms, throwing tantrums, even breaking laws with minimal consequences; generally behaves as if entitled to do whatever he wants regardless of how it affects others.

*Shames or humiliates those who disagree with him, and goes on the attack when hurt or frustrated, often exploding with rage.

*Arrogant, vain and haughty and exaggerates his accomplishments; bullies others to get his own way.

*Lies or distorts the truth for personal gain, blames others or makes excuses for his mistakes, ignores or rewrites facts that challenge his self-image, and won’t listen to arguments based on truth.

These are common characteristics of extreme narcissists as described by Joseph Burgo, a clinical psychologist, in his book “The Narcissist You Know.” While we now live in a culture that some would call narcissistic, with millions of people constantly taking selfies, spewing out tweets and posting everything they do on YouTube and Facebook, the extreme narcissists Dr. Burgo describes are a breed unto themselves. They may be highly successful in their chosen fields but extremely difficult to live with and work with.

Of course, nearly all of us possess one or more narcissistic trait without crossing the line of a diagnosable disorder. And it is certainly not narcissistic to have a strong sense of self-confidence based on one’s abilities.

“Narcissism exists in many shades and degrees of severity along a continuum,” Dr. Burgo said, and for well-known people he cites as extreme narcissists, he resists making an ad hoc diagnosis of narcissistic personality disorder, as defined by the American Psychiatric Association.

The association’s diagnostic manual lists a number of characteristics that describe narcissistic personality disorder, among them an impaired ability to recognize or identify with the feelings and needs of others, grandiosity and feelings of entitlement, and excessive attempts to attract attention.

Dr. Giancarlo Dimaggio of the Center for Metacognitive Interpersonal Therapy in Rome, wrote in Psychiatric Times that “persons with narcissistic personality disorder are aggressive and boastful, overrate their performance, and blame others for their setbacks.”

According to the Mayo Clinic, people with a narcissistic personality disorder think so highly of themselves that they put themselves on a pedestal and value themselves more than they value others. They may come across as conceited or pretentious. They tend to monopolize conversations, belittle those they consider inferior, insist on having the best of everything and become angry or impatient if they don’t get special treatment.

Underlying their overt behavior, however, may be “secret feelings of insecurity, shame, vulnerability and humiliation,” Mayo experts wrote. To ward off these feelings when criticized, they “may react with rage or contempt and try to belittle the other person.”

Dr. Burgo, who sees clients by Skype from his home in Grand Lake, Colo., noted that many “grandiose narcissists are drawn to politics, professional sports, and the entertainment industry because success in these fields allows them ample opportunity to demonstrate their winner status and to elicit admiration from others, confirming their defensive self-image as a superior being.”

The causes of extreme narcissism are not precisely known. Theories include parenting styles that overemphasize a child’s special abilities and criticize his fears and failures, prompting a need to appear perfect and command constant attention.

Although narcissism has not been traced to one kind of family background, Dr. Burgo wrote that “a surprising number of extreme narcissists have experienced some kind of early trauma or loss,” like parental abandonment. The family lives of several famous narcissists he describes, Lance Armstrong among them, are earmarked by “multiple failed marriages, extreme poverty and an atmosphere of physical and emotional violence.”

As a diagnosable personality disorder, narcissism occurs more often in males than females, often developing in the teenage years or early adulthood and becoming more extreme with age. It occurs in an estimated 0.5 percent of the general population, and 6 percent of people who have encounters with the law who have mental or emotional disorders. One study from Italy found that narcissistic personality traits were present in as many as 17 percent of first-year medical students.

As bosses and romantic partners, narcissists can be insufferable, demanding perfection, highly critical and quick to rip apart the strongest of egos. Employee turnover in companies run by narcissists and divorce rates in people married to them are high.

“The best defense for employees who choose to stay is to protect the bosses’ egos and avoid challenging them,” Dr. Burgo said in an interview. His general advice to those running up against extreme narcissists is to “remain sane and reasonable” rather than engaging them in “battles they’ll always win.”

Despite their braggadocio, extreme narcissists are prone to depression, substance abuse and suicide when unable to fulfill their expectations and proclamations of being the best or the brightest.

The disorder can be treated, though therapy is neither quick nor easy. It can take an insurmountable life crisis for those with the disorder to seek treatment. “They have to hit rock bottom, having ruined all their important relationships with their destructive behavior,” Dr. Burgo said. “However, this doesn’t happen very often.”

No drug can reverse a personality disorder. Rather, talk therapy can, over a period of years, help people better understand what underlies their feelings and behavior, accept their true competence and potential, learn to relate more effectively with other people and, as a result, experience more rewarding relationships.

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Keeping the Disruption of a Move in Perspective

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Credit Camilla Engman

At midnight, the ice cube dispenser on the refrigerator is not merely dripping. Water pours onto the floor. I drop down towels, empty the accumulated cubes from their plastic container and pop it back inside the freezer.

“Was that the right thing to do?” I ask my husband, who is trying to sleep. “For goodness sakes,” Don says, getting out of bed. We must leave for my monthly cancer blood test at 8 a.m. tomorrow.

Don pulls out the tray, puts it in the sink, and props up a little stick in the freezer, pushing up the ice maker’s metal wand in an attempt to stop the leak. Might work, might not… I’ll stay awake to see whether the deluge stops. When an unexpected disaster arises, I diminish its significance by comparing it to the worst of my cancer treatments a few years ago. I can do this because my current condition remains stable with an experimental drug.

Yet as I contemplate all the chairs and sofas and rugs that have to be donated to Goodwill, the mattresses and box springs to be given to the St. Vincent de Paul society, my late mother’s files and cabinets, Don’s late wife’s luggage and papers, his massive collection of 78 r.p.m. records, the yards of books on the shelves in the studies, our daughters’ stored memorabilia and their children’s baby equipment, the sheer volume of stuff seems daunting.

We are moving from a house of 4,000 square feet to an apartment less than half that size. One reason for our relocation: Don and I want to release our girls from the responsibility of dealing with the detritus accumulated over decades. We also have to leave because he cannot negotiate the stairs and both of us together cannot manage the upkeep.

Throughout the weeks and then the months when our beloved but aging house has to be repaired so we can sell it, workers arrive to shore up the porch, to fix the bowed ceiling supports in the garage, the cracks over the foyer doorway, a foundation that needs to be anchored to keep the structure from shifting, broken screen doors, mold in basement closets, chipped kitchen cabinets, and (oh!) a tree appears to be growing out of the chimney, and (yup!) an inspector found clogged drains — which suggest there might be trouble with the septic tank.

People tell me that moving ranks high up there on the stress index. But the commotion comes nowhere close to the terrifying havoc of cancer and its traditional treatments. Throughout the weeks and then the months of removals and renovations, the rhythms seem downright soothing, if measured against the ghastly tempos of surgeries, radiological interventions and chemotherapies.

The magnitude of cancer provides a scale against which everything else falls happily short. Cancer can be so bad that it imparts a sense of proportion. The poet Jane Kenyon once said that leukemia and a bone marrow transplant dispelled her fear of flying.

In the midst of all this chaos, I will postpone treating my recently diagnosed osteoporosis — I’m not clear yet about the efficacy of various remedies — but what about the cataract surgery? With or without glasses, I cannot see clearly and I have become the designated driver. Given the boxes mounting everywhere as well as the appointments of various people who are coming to take away the piano and the records and some paintings we won’t have room for, should I cancel? No way, I decide: a piece of cake, in contrast to cancer.

Ever shifting, the cancer terrain is treacherous to negotiate, its perilous landscape always unstable. There are roadmaps, but they often seem indecipherable. With surgeons, radiologists, and oncologists, I advance without a clear sense of how I will end up where and when.

As a cancer patient, I feel like an immigrant in a strange land. The customs of the country bewilder me. Dazed by unfamiliar sounds, sights, tastes, and touches, I had to learn a whole new language quite distinct from the idioms of every day discourse. I will never master it.

I speak of genetic mutations, chemicals and my anatomy in a grammar so simple that it resembles a 2-year-old’s. Terms must be adopted — debulking, PICC, port, PARP inhibitor — for processes I cannot really conceptualize. Frequently, physicians and nurses have to write down or spell out their prescriptions or directions. I mispronounce or stumble over words — anastomosis, extravasation, Gastrografin — that seem foreign.

So even this unsettling removal from a country house to an apartment strikes me as a change I can take in stride. After all, I know the address of my destination, the date of my prospective arrival, the route the truck will take and the neighbors speak my native tongue.

I’m staying up very late and can attest to the fact that the kitchen floor has remained dry. Don and I will travel to the hospital tomorrow and return. I will have cataract surgery and we will reside in a town whose byways may be easier to navigate with improved vision.

When you have cancer, you don’t just have cancer: You might have a broken refrigerator and cataracts and osteoporosis and loads of other issues. But you also have a unique perspective which, in a curious way, helps me keep on moving on.

Susan Gubar is the author of the new book “Reading and Writing Cancer: How Words Heal.”

To Stem Obesity, Start Before Birth

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Credit Paul Rogers

To stem the current epidemic of obesity, there’s no arguing with the adage that an ounce of prevention is worth a pound of cure. As every overweight adult knows too well, shedding excess pounds and keeping them off is far harder than putting them on in the first place.

But assuring a leaner, healthier younger generation may often require starting even before a baby is born.

The overwhelming majority of babies are lean at birth, but by the time they reach kindergarten, many have acquired excess body fat that sets the stage for a lifelong weight problem.

Recent studies indicate that the reason so many American children become overweight is far more complicated than consuming more calories than they burn, although this is certainly an important factor. Rather, preventing children from acquiring excess body fat may have to start even before their mothers become pregnant.

Researchers are tracing the origins of being overweight and obese as far back as the pre-pregnancy weight of a child’s mother and father, and their explanations go beyond simple genetic inheritance. Twenty-three genes are known to increase the risk of becoming obese. These genes can act very early in development to accelerate weight gain in infancy and during middle childhood.

In the usual weight trajectory, children are born lean, get chubby during infancy, then become lean again as toddlers when they grow taller and become more active. Then, at or before age 10 or so, body fat increases in preparation for puberty – a phenomenon called adiposity rebound.

In children with obesity genes, “adiposity rebound occurs earlier and higher,” said Dr. Daniel W. Belsky, an epidemiologist at Duke University School of Medicine. “They stop getting leaner sooner and start putting on fat earlier and put on more of it.”

Still, twin and family studies have shown that many children with these genes remain lean. Furthermore, these same genes were undoubtedly around in the 1960s and 1970s when the obesity rate in children was a fraction of what it is today.

So what is different about the 2000s? Children today are surrounded by a surfeit of unwholesome, easy-to-consume calorie-dense foods and snacks accompanied by a deficit of opportunities to expend those extra calories through regular physical activity. And countering a calorie-rich, sedentary environment is now harder than it should be, with the current heavy emphasis on academics, parental reluctance to let children play outside unattended, and intense competition from electronics. All these circumstances may give obesity genes a greater chance to express themselves.

“There is no going back to a world in which calories are scarce and obtaining them is physically demanding,” Dr. Belsky wrote in an editorial in JAMA Pediatrics. “And governments and their publics have shown little enthusiasm for regulations restricting access to palatable, calorie-dense foods.”

Curbing consumption of sugar-sweetened beverages and keeping calorie-dense junk food out of the house and other settings where young children spend time is crucial. This is especially important for infants and children with large appetites that are not easily satisfied.

It’s also essential that parents model good eating habits, experts agree. “If you do it, they’ll do it,” David S. Ludwig, an obesity specialist at Children’s Hospital Boston, said. “Young children are like ducklings, they want to do what their mothers do.”

Equally important, Dr. Belsky said, is “allowing children in institutional settings – in day care, preschool and elementary school – to be as active as they choose to be rather than forcing them to sit quietly in chairs most of the day. Being physically active encourages a healthy metabolism. Active children are not constantly hungry.”

He added, “In the face of the obesity epidemic, eliminating the handful of opportunities for kids to be active during the day is a shame. Sedentary behavior becomes a life pattern.”

Another critical issue is the vicious cycle of overweight that starts with future mothers and fathers who are overweight or obese. “If we want healthy kids, we need healthy moms before pregnancy and during pregnancy,” Dr. Belsky said. “There are multiple pathways by which unhealthy levels of weight before and during pregnancy can influence a child’s weight going forward.”

As Dr. Ludwig explained, “Although genes are not modifiable, the weight of the mother before and during pregnancy is. Excessive weight gain during pregnancy predicts not just the baby’s birth weight but also the likelihood of obesity in middle childhood.”

The father’s weight is also turning out to be important, Dr. Ludwig said. “Acquired factors influence gene expression,” he said. “Being heavy alters DNA in the father’s sperm that changes gene expression and can be passed down to the next generation.”

Most, though not all, studies have linked a longer duration of breast-feeding to a reduced risk of overweight in children. Although Dr. Ludwig said that the effect “is not dramatic,” a more important benefit of breast-feeding may be “exposing the baby to a wider range of tastes based on what a mother is eating. If a breast-feeding mom eats a large variety of nutritious foods, the child is more likely to like them.”

Antibiotics given early in life, however, may counter any potential benefits of breast-feeding for weight gain, a new study found. Researchers at the University of Helsinki in Finland reported that when breast-fed infants are treated with antibiotics, the antibiotics kill off health-promoting bacteria that live in the gut. “The protective effects of breast-feeding against infections and overweight were weakened or completely eliminated by early-life antibiotic use,” the team wrote in JAMA Pediatrics last month.

Even if children have already started on a path of poor eating habits and excess weight gain, Dr. Ludwig said it is not too late to make healthful changes. As founder of the Optimal Weight for Life program and author of “Ending the Food Fight: Guide Your Child to a Healthy Weight in a Fast Food/Fake Food World,” he advocates an authoritative, but not an authoritarian, parenting style that eliminates stress and conflict over what and when a child eats.

“Never force food on a child,” he insists. “Stand your ground in a gentle but firm way and be prepared to do a little negotiating. When a child refuses to eat the dinner that’s served, put it away in the fridge to be eaten later. If the child says ‘I’m not going to eat it,’ the response should be, ‘Fine, just go to bed,’ not ‘O.K., I’ll make you mac and cheese.’

“Children should be allowed to control their bodies, but parents have to provide the guidance and control the environment,” Dr. Ludwig said.

This is the second of two columns on childhood obesity. Read the first: “The Urgency in Fighting Childhood Obesity.”

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The Urgency in Fighting Childhood Obesity

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Credit Paul Rogers

Life-threatening ailments like heart disease, cancer, stroke and Type 2 diabetes most often afflict adults. But they are often consequences of childhood obesity.

Two new studies, conducted among more than half a million children in Denmark who were followed for many years, linked a high body mass index in children to an increased risk of developing colon cancer and suffering an early stroke as adults. The studies, presented at the European Obesity Summit in Gothenburg, Sweden, this spring, underscore the importance of preventing and reversing undue weight gain in young children and teenagers.

One study, of more than 257,623 people, by Dr. Britt Wang Jensen and colleagues at the Institute of Preventive Medicine, in Bispebjerg, Denmark, and Frederiksberg Hospital in Copenhagen, grouped children according to standard deviations from a mean B.M.I., adjusted for a child’s age and sex.

They found that each unit of increase in being overweight at age 13, generally corresponding to a two- to three-point increase in B.M.I., increased the risk of developing colon cancer by 9 percent and rectal cancer by 11 percent.

The second study, involving 307,677 Danish people born from 1930 to 1987, used a similar grouping of B.M.I. The risk of developing a clot-related stroke in early adult life increased by 26 percent in women and 21 percent in men for each unit of increase in being overweight at all stages of childhood, but especially at age 13.

Although neither study proves that excess weight in childhood itself, as opposed to being overweight as an adult, is responsible for the higher rates of cancer and stroke, overweight children are much more likely to become overweight adults — unless they adopt and maintain healthier patterns of eating and exercise.

According to the American Academy of Child and Adolescent Psychiatry, obesity most often develops from ages 5 to 6 or during the teen years, and “studies have shown that a child who is obese between the ages of 10 and 13 has an 80 percent chance of becoming an obese adult.”

In a study published in 2014 in The New England Journal of Medicine, Solveig A. Cunningham and colleagues at Emory University found that “overweight 5-year-olds were four times as likely as normal-weight children to become obese by age 14.” The study, which involved a representative sample of 7,738 kindergartners, found that the risk of becoming obese did not differ by socioeconomic status, race or ethnic group, or birth weight. Rather, it showed that excess weight gain early in life is a risk factor for obesity later in childhood across the entire population.

Children are generally considered obese when their B.M.I. is at or above the 95th percentile for others of the same age and sex. Currently, about one-third of American children are overweight or obese. By 2012, the Centers for Disease Control and Prevention reports, 18 percent of children and 21 percent of adolescents were obese.

The adverse effects of excess weight in childhood and adolescence don’t necessarily wait to show up later in life. In a review of complications resulting from youthful obesity, Dr. Stephen R. Daniels, a pediatrician at the University of Colorado School of Medicine and the Children’s Hospital in Denver, found that problems in many organ systems were often apparent long before adulthood. They include high blood pressure; insulin resistance and Type 2 diabetes; high blood levels of heart-damaging triglycerides and low levels of protective high-density lipoprotein (HDL) cholesterol; nonalcoholic fatty liver disease; obstructive sleep apnea; asthma; and excess stress on the musculoskeletal system resulting in abnormal bone development, knee and hip pain, and difficulty walking.

Problems of youthful obesity go beyond physical ones. Obese adolescents have higher rates of depression, which in itself may foster poor eating and exercise patterns that add to their weight problem and result in a poor quality of life that persists into adulthood.

In a study conducted in Singapore, researchers reported that “individuals who were obese in childhood are more likely to have poor body image and low self-esteem and confidence, even more so than those with adult onset obesity.”

Another study by Dr. Jeffrey B. Schwimmer of the University of California, San Diego, and colleagues found that obese children and adolescents reported a diminished quality of life that was comparable to that of children with cancer.

Taken together, the data speak to the critical importance of preventing undue weight gain in young children, a task that depends largely on parents, who are responsible for what and how much children eat and how much physical activity they engage in. As researchers from the University Medical Center Groningen in the Netherlands put it, “Early recognition of overweight or obesity in children by their parents is of utmost importance, allowing interventions to start at a young age.” Yet, they found in a study of the parents of 2,203 5-year-olds, “parents underestimated their overweight child in 85 percent of the cases.”

Though it seems logical that parents who think their children are overweight would make a special effort to assure they would “grow into” their weight as they get older, research has shown the opposite. Such children tend to get even fatter, according to findings from the Longitudinal Study of Australian Children reported in April in the journal Pediatrics by Eric Robinson of the University of Liverpool and Angelina R. Sutin of Florida State University College of Medicine.

Even being labeled overweight can itself be damaging and make it harder for children to avoid bad habits, the authors suggested. A 2014 study of girls aged 10 to 19 found that “regardless of actual weight, adolescents who reported having been labeled ‘too fat’ by a family member or peer were more likely to become obese nearly a decade later.”

“I encourage parents to change the environment at home,” Dr. Daniels of the University of Colorado said in an interview. “Without being authoritarian, they should limit high-calorie-dense foods, keep sugar-sweetened beverages out of the house and assure that kids eat the right amount of fruits and vegetables and fewer calorie-dense snacks. Parents also need to be tuned into opportunities for physical activity and set hard-and-fast rules about television and time spent on electronics.”

Following the “5210” daily program endorsed by the American Academy of Pediatrics can help: Aim for five fruits and vegetables a day; keep recreational screen time to two hours or less; include at least one hour of active play: and skip sugar-sweetened beverages and drink water.

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The Challenges of Male Friendships

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Credit Paul Rogers

Christopher Beemer, a 75-year-old Brooklynite, is impressed with how well his wife, Carol, maintains friendships with other women and wonders why this valuable benefit to health and longevity “doesn’t come so easily to men.”

Among various studies linking friendships to well-being in one’s later years, the 2005 Australian Longitudinal Study of Aging found that family relationships had little if any impact on longevity, but friendships boosted life expectancy by as much as 22 percent.

Mr. Beemer urged me to explore ways to promote male friendships, especially for retired men who often lose regular contact with colleagues who may have similar interests and experiences.

After Marla Paul, a Chicago-area writer, wrote a book, “The Friendship Crisis: Finding, Making, and Keeping Friends When You’re Not a Kid Anymore,” about establishing meaningful friendships with other women, she was inundated with requests from men to give equal treatment to male friendships.

“A lot of men were upset because I didn’t include them,” Ms. Paul told me. “They felt that making and keeping friends was a lot harder for men, that close friendships were not part of their culture. They pointed out that women have all kinds of clubs, that there’s more cultural support for friendships among women than there is for men.”

In a study in the 1980s about the effect on marriage of child care arrangements, two Boston-area psychiatrists, Dr. Jacqueline Olds and Dr. Richard Stanton Schwartz, found that, “almost to a man, the men were so caught up in working, building their careers and being more involved with their children than their own fathers had been, something had to give,” Dr. Schwartz said. “And what gave was connection with male friends. Their lives just didn’t allow time for friendships.”

In their book, “The Lonely American: Drifting Apart in the Twenty-First Century,” the doctors, who are a husband-and-wife team, noted a current tendency for men to foster stronger, more intimate marriages at the expense of nearly all other social connections.

When these men are older and work no longer defines their social contacts, “there’s a lot of rebuilding that has to be done” if they are to have meaningful friendships with other men, Dr. Schwartz said in an interview.

From childhood on, Dr. Olds said, “men’s friendships are more often based on mutual activities like sports and work rather than what’s happening to them psychologically. Women are taught to draw one another out; men are not.”

Consciously or otherwise, many men believe that talking about personal matters with other men is not manly. The result is often less intimate, more casual friendships between men, making the connections more tenuous and harder to sustain.

Dr. Olds said, “I have a number of men in my practice who feel bad about having lost touch with old friends. Yet it turns out men are delighted when an old friend reaches out to revive the relationship. Men might need a stronger signal than women do to reconnect. It may not be enough to send an email to an old friend. It may be better to invite him to visit.”

Some married men consider their wives to be their best friend, and many depend on their wives to establish and maintain the couple’s social connections, which can all but disappear when a couple divorces or the wife dies.

Differences between male and female friendships start at an early age. Observing how his four young granddaughters interact socially, Mr. Beemer said, “They have way more of that kind of activity than boys have. It may explain why as adults they continue to do a much better job of it.”

In defense of his gender, he observed, “Men have a harder time reaching their emotions and are less likely than women to reveal their emotional side. But when you have a real friendship, it’s because you’ve done just that.”

He has found that “it’s important to expose yourself and be honest about what’s going on. If you reveal yourself in the right way to the right person, it will be just fine. There are risks, you can’t force it. Sometimes it doesn’t work — you get a don’t-burden-me-with-that kind of response and you know to back off. But more often men will respond in kind.”

Mr. Beemer has worked hard to establish and maintain valuable relationships with other men of a similar vintage. He joined a men’s book group that meets monthly, and after about two years, he said, “it became a group where the members really mean something to one another.”

He’s also in a men’s walking group that meets three times a week and gathers after each walk to share more conversation and a snack at a local cafe. When one member of the group had a heart attack, they visited him, cheering him up with the latest gossip and a favorite cafe snack.

“What sustains relationships over time is a regular rhythm of seeing each other,” Dr. Schwartz said. “It’s best to build a regular pattern of activities rather than having to make a special effort to see one another.”

He recalls “curing” a 70-year-old patient of his loneliness by encouraging him to join a bunch of guys who regularly dined and joked around at a neighborhood Panera Bread. “There are a lot of cafes in the Boston area where small groups of older men get together for breakfast everyday,” Dr. Schwartz said.

Dr. Olds said of her husband, “Richard has a regular group phone call with friends who live in different parts of the country. We program it into our schedule or it would disappear.”

Among other ways men can make new friends in their later years are participating in classes, activities, trips and meals at senior centers; taking continuing education courses at a local college; joining a gym or Y and taking classes with people you then see every week; volunteering at a local museum, hospital, school or animal shelter; attending worship services at a religious center; forming a group that plays cards or board games together; perhaps even getting a dog to walk in the neighborhood.

After my dentist’s wife died, he made several new friends and enjoyed lovely dinners with other men when he joined a group called Romeo, an acronym for retired old men eating out.

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No Such Thing as a Healthy Smoker

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Credit Paul Rogers

Smokers who think they are escaping the lung-damaging effects of inhaled tobacco smoke may have to think again, according to the findings of two major new studies, one of which the author originally titled “Myth of the Healthy Smoker.”

Chronic obstructive pulmonary disease, or C.O.P.D., may be among the best known dangers of smoking, and current and former smokers can be checked for that with a test called spirometry that measures how much air they can inhale and how much and how quickly they can exhale. Unfortunately, this simple test is often skipped during routine medical checkups of people with a history of smoking. But more important, even when spirometry is done, the new studies prove that the test often fails to detect serious lung abnormalities that cause chronic cough and sputum production and compromise a person’s breathing, energy level, risk of serious infections and quality of life.

“Current or former smokers without airflow obstruction may assume that they are disease-free,” but that’s not necessarily the case, one of the research teams pointed out. These researchers projected that there are 35 million current or former smokers older than 55 in the United States with unrecognized smoking-caused lung disease or impairments. Many, if not most, of these people could get worse with time, even if they have quit smoking. They are also unlikely to be referred for pulmonary rehabilitation, a treatment that can head off encroaching disability.

Perhaps most important, those currently smoking may be inclined to think they’ve dodged the bullet and so can continue to smoke with impunity. Doctors, who are often reluctant to urge patients with symptoms to quit smoking, may be even less likely to recommend smoking cessation to those with normal spirometry results.

Referring to C.O.P.D., one of the researchers, Dr. Elizabeth A. Regan, said, “Smoking is really taking a terrible toll on our society.” Dr. Regan, a clinical researcher at National Jewish Health in Denver, is the lead author of one of the new studies, published last year in JAMA Internal Medicine. “We live happily in the world thinking that only a small percentage of people who smoke get this devastating disease,” she said. “However, the lungs of millions of people in the United States are negatively impacted by smoking, and our methods for identifying their lung disease are relatively insensitive.”

Even when the results of spirometry are normal, Dr. Regan added, “a lot of smokers have respiratory symptoms. They get sick often, are more likely to be hospitalized with bronchitis or pneumonia, and have evidence on CT scans of thickened airway walls or emphysema that impair breathing.”

Dr. Prescott G. Woodruff, lead author of the other study, published May 12 in The New England Journal of Medicine, said in an interview, “Smokers have much more lung disease than we previously thought. The 15 to 20 percent who get C.O.P.D. is a gross underestimate.” Too often, Dr. Regan’s team pointed out, symptoms like shortness of breath and limits on exercise are “dismissed as normal aging.”

The multicenter study headed by Dr. Woodruff, a pulmonologist at the University of California, San Francisco, found that smokers with normal findings on spirometry nonetheless are likely to have chronic respiratory symptoms like cough, phlegm, wheezing, shortness of breath and chest tightness; lower than normal exercise tolerance; and evidence on a CT scan of chronically inflamed airways in the lungs. They also use more antibiotics to control respiratory infections and drugs called glucocorticoids to alleviate breathing difficulty. They pay more visits to doctors and emergency rooms and have more hospital admissions because of a flare-up of respiratory symptoms.

In other words, they are far more prone than nonsmokers to experiencing terrifying episodes of troubled breathing.

Of course, while lung disease is most prevalent, it is hardly the only adverse health effect of smoking, a source of noxious substances that can damage almost every organ system in the body. The list of smoking-related diseases has grown exponentially since smoking was labeled a probable cause of lung cancer 52 years ago in the first Surgeon General’s report on smoking and health. The decades since have added many other deadly cancers, heart disease, stroke, high blood pressure, blood clots, peripheral artery disease, Type 2 diabetes, rheumatoid arthritis, cataracts and macular degeneration, as well as C.O.P.D.

The new findings by the two investigative teams prompted Dr. Leonardo M. Fabbri of the University of Modena and Reggio Emilia in Italy to write an editorial accompanying the New England Journal study titled “Smoking, Not C.O.P.D., as the Disease.” He explained that the results of the two studies “suggest that smoking itself should be considered the disease and should be approached in all its complexity.”

The challenge ahead, Dr. Fabbri wrote, is to identify patients with smoking-related lung damage who do not yet have obstructive disease and devise ways to treat them to reduce their symptoms and prevent flare-ups.

A clinical trial to begin later this year, sponsored by the National Heart, Lung and Blood Institute, will examine whether treatments like use of a bronchodilator will help to alleviate symptoms in those without obstructive disease. Unfortunately, “the cost of bronchodilator medication has gone through the roof,” Dr. Woodruff said. Decades ago, people with breathing problems like asthma used aerosol bronchodilators that included chemicals called fluorocarbons. But these were banned for environmental reasons in the mid-1970s, and the replacements that drug manufacturers came up with are still not available in generic form, keeping prices high.

Dr. Woodruff said that rehabilitative exercise, one of the best treatments for C.O.P.D., should also help people with lung damage short of obstruction because it improves the ability of muscles to use available oxygen more efficiently.

To improve exercise tolerance, patients are encouraged to walk as fast as they can for as long as they can, rest, then walk some more. Most patients find this easiest to do on a treadmill, where speed and incline can be precisely regulated and the results measured. But if such equipment is unavailable or too costly to access, walking indoors or outdoors can be helpful if geared to a specific distance and speed that are gradually increased.

Most critical, of course, is for smokers with or without symptoms of lung disease to quit smoking, which can reduce the severity of respiratory symptoms and slow the decline in lung function, Dr. Regan’s team wrote. However, the team added, quitting smoking “does not eliminate the risk of progressive lung disease,” which means that the lungs of former smokers may need to be examined periodically.

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Being Transgender as a Fact of Nature

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After surgical and hormonal treatment, George Jorgensen, a Bronx-born G.I., became Christine Jorgensen, a nightclub entertainer and advocate for transsexual rights.

After surgical and hormonal treatment, George Jorgensen, a Bronx-born G.I., became Christine Jorgensen, a nightclub entertainer and advocate for transsexual rights.Credit Fred Morgan/NY Daily News Archive, via Getty Images

In 1952, George Jorgensen, a Bronx-born G.I., underwent surgical and hormonal treatment in Denmark to become Christine Jorgensen, a nightclub entertainer and advocate for gender identity rights. Ever since, health professionals and lay people alike have debated the origins of gender identity, the wisdom of altering one’s biologically determined sex, and whether society should accept the transgender community as a fact of nature.

There is even disagreement over whether the Civil Rights Act of 1964, which bars discrimination because of sex, also protects gender identity, a person’s inner sense of being male or female. Many more transgender people, whose identity does not match their biological sex, have come forward in recent years. Some seek sex change treatment. The Olympic gold-medalist Bruce Jenner made a high-profile announcement last year of his transition to Caitlyn Jenner, including a cover story in Vanity Fair.

This year, the Public Theater in New York presented the musical “Southern Comfort,” adapted from an award-winning 2001 documentary film about transgender people living in rural Georgia who came together to support a dying friend who developed ovarian cancer years after transitioning from female to male.

Yet the controversy now raging over the rights of transgender students to use bathroom and locker room facilities that match their gender identity rather than their birth sex reflects the persistence of widespread prejudice and misinformation about the nature and behavior of people who identify as transgender.

Those who insist that people should use only the facilities that match the sex on their birth certificates may not realize that most states allow those who change their sexual assignment to change the sex on their birth certificates. Furthermore, a transgender individual using a facility matched to his or her gender identity is no more of a sexual threat to others than anyone else using that bathroom might be. Psychosocial distress or embarrassment can be avoided simply by providing closed-door toilet and changing areas in public bathrooms and locker rooms. After all, we should be used to mixed-gender bathrooms by now: We’ve had them in our homes for years.

I recently read a most illuminating article, “Care of Transsexual Persons,” that answered many of the questions and concerns that have been raised about transsexualism, which is now more commonly referred to as being transgender. Written by Dr. Louis J. Gooren, an endocrinologist at VU University Medical Center in Amsterdam and a leading expert in the field, it was published in 2011 in The New England Journal of Medicine.

Perhaps the most important point Dr. Gooren and others make is that a mismatch between gender identity and biological sex is not something people choose. The most common description given by transgendered individuals is a persistent, painfully distressing belief that they are females trapped in a male body, or vice versa.

Although being transgender is classified in the psychiatric literature as “gender identity disorder,” Dr. Gooren pointed out that “a substantial proportion of the transgender population does not have a clinically significant coexisting psychiatric condition” other than chronic suffering from feeling they are not what their bodies tell them they are.

No chromosomal or hormonal causes of being transgender have been identified. Also lacking is convincing evidence that it is caused by some aberration of family dynamics — how a child is treated or dressed by mom, dad or anyone else.

Being transgender simply happens, possibly during brain development in the womb. All brains start out female; if the fetus is male, testosterone normally programs both the genitalia and the brain to develop as male. But autopsies of a small number of male-to-female transgender people found that two important areas of the brain had a typical female pattern, suggesting an alteration in the brain’s sexual differentiation.

In individuals who transition from female to male, it is possible that excessive production of androgens during pregnancy could have programmed the brain to be male.

Among adults, male-to-female transitions are nearly three times more common than female-to-male ones. It has not been unusual for people born male to first acknowledge and express their female gender identity in midlife, often after having married and fathered children.

In young children, girls who are tomboys and boys who act more like girls are quite common and should not be assumed to be transgender. Such behavior often changes by adolescence.

However, when bodily changes at puberty differ from a child’s gender identity, they are typically a source of extreme distress. Still, experts warn that at any age, and especially in adolescence, great caution must be taken before irreversible treatments are provided to induce changes that conform to a person’s discordant gender identity.

“Persons with gender identity disorder may have unrealistic expectations about what being a member of the opposite sex entails,” Dr. Gooren wrote. Therefore, he and others say that before starting hormone treatments, the person should live for at least a year as the desired sex. Only then should hormone treatments be used to induce the secondary sex characteristics of the new sex and suppress those of the birth sex.

Surgical sex reassignment may then follow to remove and reconstruct the genitalia, breasts and internal sex organs to more closely resemble the desired sex. Some people, especially transgender males, also undergo facial reconstruction. Even after surgery, hormone treatments must continue indefinitely to maintain the desired gender characteristics.

It is especially important for transgender individuals seeking treatment to know the risks involved. Long-term studies of people who underwent sex reassignment surgery have been conducted in Sweden and Denmark, where excellent population-wide medical records are kept.

A Swedish team from the Karolinska Institute and the University of Gothenberg followed 324 people who underwent sex reassignment surgery and compared them with matched controls in the general population. After an average follow-up of 11.4 years, men and women who had sex reassignments had death rates three times higher from all causes. Suicide rates were especially high, suggesting “the need for continued psychiatric follow-up” among those undergoing sex change, the authors wrote. Cancer deaths were doubled in the surgical group, though the cancers appeared to be unrelated to hormone treatments.

The recent Danish study, by researchers in Copenhagen, investigated postoperative diseases and deaths among 104 men and women representing 98 percent of those who underwent sex reassignment surgery in Denmark from 1978 through 2010. One person in three had developed an ailment, most often cardiovascular disease, and one in 10 had died, with deaths occurring at an average age of 53.5.

The authors suggested that a host of societal factors, including social exclusion, harassment and negative experiences in school and at work, could largely contribute to the patients’ health problems. The findings underscore the importance of better postoperative support and closer attention to injurious lifestyle issues like smoking and alcohol abuse.

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War Wounds That Time Alone Can’t Heal

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“Almost Sunrise”

A clip from “Almost Sunrise.”

By THOUGHTFUL ROBOT PRODUCTIONS on Publish Date June 5, 2016.

No doubt in the course of your life, you did something, or failed to do something, that left you feeling guilty or ashamed. What if that something was in such violation of your moral compass that you felt unable to forgive yourself, undeserving of happiness, perhaps even unfit to live?

That is the fate of an untold number of servicemen and women who served in Iraq, Afghanistan, Vietnam and other wars. Many participated in, witnessed or were unable to help in the face of atrocities, from failing to aid an injured person to killing a child, by accident or in self-defense.

For some veterans, this leaves emotional wounds that time refuses to heal. It radically changes them and how they deal with the world. It has a name: moral injury. Unlike a better known casualty of war, post-traumatic stress disorder, or PTSD, moral injury is not yet a recognized psychiatric diagnosis, although the harm it inflicts is as bad if not worse.

The problem is highlighted in a new documentary called “Almost Sunrise,” which will be shown next weekend at the Human Rights Watch Film Festival in New York and on June 23 and 24 at AFI Docs in Washington, D.C. The film depicts the emotional agony and self-destructive aftermath of moral injury and follows two sufferers along a path that alleviates their psychic distress and offers hope for eventual recovery.

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The new documentary “Almost Sunrise” follows Tom Voss and Anthony Anderson, two troubled Iraq war veterans, walking from Milwaukee to Los Angeles.

The new documentary “Almost Sunrise” follows Tom Voss and Anthony Anderson, two troubled Iraq war veterans, walking from Milwaukee to Los Angeles.Credit Courtesy of Thoughtful Robot Productions

Therapists both within and outside the Department of Veterans Affairs increasingly recognize moral injury as the reason so many returning vets are self-destructive and are not helped, or only partly helped, by established treatments for PTSD.

Moral injury has some of the symptoms of PTSD, especially anger, depression, anxiety, nightmares, insomnia and self-medication with drugs or alcohol. And it may benefit from some of the same treatments. But moral injury has an added burden of guilt, grief, shame, regret, sorrow and alienation that requires a very different approach to reach the core of a sufferer’s psyche.

Unlike the soldiers who were drafted to serve in Vietnam, the members of the armed forces today chose to enlist. Those deployed to Iraq thought at first they were fighting to bring democracy to the country, then were told later it was to win hearts and minds. But to many of those in battle, the real effect was “to terrorize people,” as one veteran says in the film. Another said, “That’s not what we signed up for.”

That war can be morally compromising is not a new idea and has been true in every war. But the therapeutic community is only now becoming aware of the dimensions of moral injury and how it can be treated.

Father Thomas Keating, a founding member of Contemplative Outreach, says in the film, “Antidepressants don’t reach the depth of what these men are feeling,” that they did something terribly wrong and don’t know if they can be forgiven.

The first challenge, though, is to get emotionally damaged veterans to acknowledge their hidden agony and seek professional help instead of trying to suppress it, often by engaging in self-destructive behaviors.

“A lot of vets won’t seek help because what’s haunting them are not heroic acts, or they were betrayed, or they can’t live with themselves because they made a mistake,” said Brett Litz, a mental health specialist with the V.A. Boston Healthcare System and a leading expert on moral injury.

The second challenge is to win their trust, to reassure them that they will not be judged and are deserving of forgiveness.

Therapists who study and treat moral injury have found that no amount of medication can relieve the pain of trying to live with an unbearable moral burden. They say those suffering from moral injury contribute significantly to the horrific toll of suicide among returning vets — estimated as high as 18 to 22 a day in the United States, more than the number lost in combat.

The film features two very troubled veterans of the war in Iraq, Tom Voss and Anthony Anderson, who decide to walk from Milwaukee to Los Angeles — 2,700 miles taking 155 days — to help them heal from the combat experiences that haunt them and threaten to destroy their most valued relationships. Six years after returning from his second deployment in Iraq, Mr. Voss said of his mental state before taking the cross-country trek, “If anything, it’s worse now.”

Along the way, the two men raise awareness of the unrelenting pain of moral injury many vets face and encourage them to seek treatment. Mr. Voss and Mr. Anderson were helped by a number of counselors and treatments, including a Native American spiritual healer and a meditative technique called power breathing. They also found communing with nature to be restorative, enabling them to again recognize beauty in the world.

Shira Maguen, a research psychologist and clinician at the San Francisco V.A. Medical Center, who studies and treats vets suffering from moral injury, said, “We have a big focus on self-forgiveness. We have them write a letter to the person they killed or to a younger version of themselves. We focus on making amends, planning for their future and moving forward,” especially important since many think they have no future.

Dr. Maguen, who studied how killing during combat affects suicidal ideation in returning vets, found that “those who had killed were at much higher risk of suicide,” even when controlling for factors like PTSD, depression and alcohol and drug abuse. She said in an interview that decades after the Vietnam War “there was still an impact on veterans who killed enemy combatants, and an even stronger effect on those who killed women and children.”

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Tom Voss’ journey took 155 days, spanning 2,700 miles.

Tom Voss’ journey took 155 days, spanning 2,700 miles.Credit Courtesy of Thoughtful Robot Productions

To overcome veterans’ reluctance to seek help for moral injury, Dr. Maguen incorporates mental health care into routine clinical visits.

In Boston, Dr. Litz and colleagues are testing a related therapeutic approach called adaptive disclosure, a technique akin to confession. With eyes closed, the vets are asked to verbally share vivid details of their trauma with an imagined compassionate person who loves them, then imagine how that person would respond. The therapist guides the conversation along a path toward healing.

“Disclosing, sharing, confessing is fundamental to repair,” Dr. Litz said. “In doing so, the vets learn that what happened to them can be tolerated, they’re not rejected.” They are also encouraged to “engage in the world in a way that is repairing — for example, by helping children or writing letters.” The goal is to find forgiveness within themselves or from others.

One fact that all agree on: The process is a lengthy one. As Mr. Voss said, “I knew after the walk I still had a long road of healing ahead of me.” Now, however, he has some useful tools and he shares them freely.

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An Artist Takes On Cancer

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Susan Gubar

Susan GubarCredit Vivienne Flesher

In 2010, at age 29, the songwriter and performer Benjamin Scheuer was given a diagnosis of stage 4 Hodgkin lymphoma, a cancer of the lymph nodes. He recounted his experience, along with other family perplexities, when he played himself in his one-man autobiographical musical, “The Lion,” which opened Off Broadway last year. In the new video “Cure,” directed by Peter Baynton and premiered here on Well, Mr. Scheuer conveys the dread that brands cancer patients, whether or not their type of disease is treatable.

As sung by a self-proclaimed optimist who has been given the good odds of an 85 percent chance of full remission, “Cure” begins with a defenseless Mr. Scheuer, supine on a bed. The camera fragments him into body parts: a mouth, a limb, a trembling torso. From an area near his heart, where a port would have been implanted, rivulets of ink streak down his arms to the tip of his fingers, down his legs to cover the soles of his feet, branching over his quivering or convulsing midriff.

The chemotherapy Mr. Scheuer received was called A-B-V-D: Adriamycin, Bleomycin, Vinblastine and Dacarbazine. “Cure” depicts the chemicals striking like lightning, as if to shock the body or map it with bombed roadways, tracking a jagged terrain. The speed of the tattooing brings to mind the words “invasive” and “systemic.” We are looking at a representation of cancer treatment, but the video evokes terror at the disease’s malevolent capacity to spread quickly.

For viewers familiar with Franz Kafka’s story “In the Penal Colony,” the calligraphy on Mr. Scheuer’s skin may recall the sentences, etched by torture machinery, on a condemned prisoner’s body during the 12 hours it takes for him to die. Remarkably, though, the tone of the singer remains less shocked or shocking, more ruefully contemplative.

In a quiet voice, Mr. Scheuer sings about learning the results of testing done after 12 treatments. Although throughout the ordeal he has been fighting panic and fear, they threaten to engulf him as he worries about ending up like his father, with cancer in his brain and his spinal cord. Clothing starts to grow over him, covering his marked body. Does his being passively clothed mean that he is being costumed for a coffin?

After the doctor informs him that the treatment has worked, after his jacket is buttoned, Mr. Scheuer finally sits up, hearing the words “You’re cured.” But the sad final tones of his voice and guitar reflect his isolation in a room with bed sheets that remain indelibly imprinted with the sinister designs.

Although “Cure” seems quite distinct from the more amiable and upbeat folk tunes in his album, “Songs from the Lion,” its hermetic room with its isolated inmate raises issues that Mr. Scheuer addressed with the photographer Riya Lerner in their book, “Between Two Spaces,” namely the alienating landscapes of treatment. (Some of their collaborative work will be on exhibit at the Leslie-Lohman Prince Street Project Space on June 7.)

Cancer patients, who must shuttle between their homes and hospitals, frequently experience the clash between familiar, comfortable environments and strange, anxiety-producing settings. Mr. Lerner explores the disparity but also the blurring of these worlds in a book composed of portraits of Mr. Scheuer interspersed with snippets of texts from his journals. For me, as for Mr. Lerner and Mr. Scheuer, the contrast involves clothing: One of the humiliations of the hospital entails my flesh being exposed in cubicles where doctors, nurses and technicians are fully clothed.

“Between Two Spaces” opens with a picture of a suited but barefooted Mr. Scheuer bending over to choose between two pairs of shoes. It concludes with him sporting a coat and hat in a snowy park. Inside his recording studio or at home he appears blanketed or costumed: “I could control, to the tiniest detail, what I wore,” he explains in a reprinted journal entry, “so the worse I felt the more care I put into the shine of my shoes, the knot of my tie.” But in a PET scan or undergoing chemotherapy, he is only partly robed or completely undressed beneath or entering massive machinery.

The cover of “Between Two Spaces” features what looks to be a soothing picture of a naked Mr. Scheuer partly submerged in a bathtub. At least in my experience, bathing in a tub occurs only in the security of home, not in the hospital. Yet the journal entry, appended to this image within the book, mentions his watching a frightening video of Japan’s tsunami: “The land is now the sea, the churning, angry ocean. Black, filled with unwilling passengers, debris, creating clouds of mist, blindness, dust dirt smoke all grey and brown, all the houses and their red roofs are squeaking clean of their foundations like boats unmoored.”

What had at first seemed a serene portrait of the artist with his eyes closed, floating on the surface of the water, now portends drowning and death. Out of the hospital, as inside it, the patient endures an inexplicable natural disaster.

To my aging eyes, the youthful vulnerability of Benjamin Scheuer makes both the video and the photographs moving. Although, unlike me, he deals with a curable disease, he resembles all cancer patients who must come to terms with the term remission. The poignancy of Mr. Scheuer’s and Mr. Lerner’s images arises from the implacable effect that estranging clinical spaces impose on previously secure domestic places.

Even the cured must take their cancer experiences home with them where, paradoxically, remission — untrustworthy as a safe haven — continues to unmoor us.

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Computer Vision Syndrome Affects Millions

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Credit Paul Rogers

Joanne Reitano is a professor of history at LaGuardia Community College in Long Island City, Queens. She writes wonderful books about the history of the city and state, and has recently been spending many hours — sometimes all day — at her computer to revise her first book, “The Restless City.” But while sitting in front of the screen, she told me, “I developed burning in my eyes that made it very difficult to work.”

After resting her eyes for a while, the discomfort abates, but it quickly returns when she goes back to the computer. “If I was playing computer games, I’d turn off the computer, but I need it to work,” the frustrated professor said.

Dr. Reitano has a condition called computer vision syndrome. She is hardly alone. It can affect anyone who spends three or more hours a day in front of computer monitors, and the population at risk is potentially huge.

Worldwide, up to 70 million workers are at risk for computer vision syndrome, and those numbers are only likely to grow. In a report about the condition written by eye care specialists in Nigeria and Botswana and published in Medical Practice and Reviews, the authors detail an expanding list of professionals at risk — accountants, architects, bankers, engineers, flight controllers, graphic artists, journalists, academicians, secretaries and students — all of whom “cannot work without the help of computer.”

And that’s not counting the millions of children and adolescents who spend many hours a day playing computer games.

Studies have indicated 70 percent to 90 percent of people who use computers extensively, whether for work or play, have one or more symptoms of computer vision syndrome. The effects of prolonged computer use are not just vision-related. Complaints include neurological symptoms like chronic headaches and musculoskeletal problems like neck and back pain.

The report’s authors, Tope Raymond Akinbinu of Nigeria and Y. J. Mashalla of Botswana, cited four studies demonstrating that use of a computer for even three hours a day is likely to result in eye symptoms, low back pain, tension headache and psychosocial stress.

Still, the most common computer-related complaint involves the eyes, which can develop blurred or double vision as well as burning, itching, dryness and redness, all of which can interfere with work performance.

One reason the problem is so pervasive: Unlike words printed on a page that have sharply defined edges, electronic characters, which are made up of pixels, have blurred edges, making it more difficult for eyes to maintain focus. Unconsciously, the eyes repeatedly attempt to rest by shifting their focus to an area behind the screen, and this constant switch between screen and relaxation point creates eyestrain and fatigue.

Another unconscious effect is a greatly reduced frequency of blinking, which can result in dry, irritated eyes. Instead of a normal blink rate of 17 or more blinks a minute, while working on a computer the blink rate is often reduced to only about 12 to 15 blinks.

But there are additional problems. The head’s distance from the screen and position in relation to it are also important risk factors. To give the eyes a comfortable focusing distance, the screen should be about 20 to 26 inches away from the face. The closer the eyes are to the monitor, the harder they have to work to accommodate to it.

In addition, when looking straight ahead, the eyes should be at the level of the top of the monitor. The University of Pennsylvania’s ophthalmology department advises that the center of the monitor should be about four to eight inches lower than the eyes to minimize dryness and itching by lessening the exposed surface of the eyes because they are not opened wide. This distance also allows the neck to remain in a more relaxed position.

Yet, in a study in Iran of 642 pre-university students reported in Biotechnology and Health Sciences last year, 71 percent sat too close to the monitor for comfort, and two-thirds were improperly positioned directly opposite or below the monitor.

Improper lighting and glare are another problem. Contrast is critical, best achieved with black writing on a white screen. The screen should be brighter than the ambient light — overly bright overhead light and streaming daylight force the eyes to strain to see what is on the screen. A bright monitor also causes your pupils to constrict, giving the eyes a greater range of focus.

You might need to reposition the desk, use a dimmer switch on overhead lights, or lower window shades to keep out sunlight. In addition, using a flat screen with an antiglare cover, and wearing glare-reducing or tinted lenses can help to minimize glare.

Be sure to use a font size best suited to your visual acuity, and have your eyes examined regularly — at least once a year — to be sure your prescription is up-to-date. This is especially important for people older than 40 and for children who are heavy users of computers because visual acuity can change with age. Make sure, too, that your monitor has a high-resolution display that provides sharper type and crisper images. And clean the monitor often with an antistatic dust cloth.

Those who work from printed materials, moving back and forth from them to the screen, could minimize neck strain by mounting documents on a stand next to the monitor. If, like me, you use many different printed documents at the same time, consider getting special computer glasses — bifocal or progressive lenses with the upper portion ideal for screen reading and the lower designed for print distance.

While prevention is most important, if you already have symptoms of computer vision syndrome, there are ways to reduce or eliminate them. Ophthalmologists suggest adhering to the “20-20-20” rule: Every 20 minutes, take a 20-second break and look at something 20 feet away.

Consciously blink as often as possible to keep eye surfaces well lubricated. To further counter dryness, redness and painful irritation, use lubricating eye drops several times a day. My ophthalmologist recommends products free of preservatives sold in single-use dispensers.

You can also reduce the risk of dry eyes by keeping air from blowing in your face and by using a humidifier to add moisture to the air in the room. And Dr. Reitano said her eye doctor also suggested applying warm moist compresses to her eyes every morning.

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Supporting Children Who Serve as Caregivers

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Credit Paul Rogers

In the normal scheme of things, parents and grandparents take care of children when they’re sick or need help or sustenance. But in well over a million American families, this pattern is reversed, with children as young as 8, 9 or 10 partly or fully responsible for the welfare of adults or siblings they live with.

They may have to shop, prepare meals, clean house, do the laundry and tend to the hygienic needs of family members unable to care for themselves.

At the same time, these children must go to school, do their homework and attempt, but usually fail, to participate in nonacademic activities like sports and friendships widely recognized as important to well-rounded development.

Connie Siskowski, a registered nurse in Boca Raton, Fla., knows well the challenges these children face. As an 11-year-old with divorced parents, she began living with her grandparents in New Jersey. Her grandfather was, as she put it, “my hero, the only person I was close to, and it was my honor to help him with personal care issues.

“I slept in the living room so I could be near him in case he needed something during the night. One night I went into the bedroom to give him his medicine, and I found him dead of cardiac disease.”

There was no support system to help Connie, then 13, deal with the emotional fallout from this loss and put the pieces of her life back together. For years thereafter, she said she made poor personal choices, including three bad marriages. Her only good choice during this time: going straight from high school to nursing school, then getting advanced degrees in cardiac nursing and health care administration and a Ph.D. in educational leadership.

After her third marriage failed, she finally found her emotional equilibrium through counseling. She married a fourth time to a man who loves and respects her and, with his encouragement, felt compelled to do something to help caregiving children and “prevent some of the repercussions I experienced.”

In 2006, Dr. Siskowski started the Caregiving Youth Project, dedicated to helping young caregivers of ill, elderly or disabled family members. With support from grants and private donations her organization, now called the American Association of Caregiving Youth, works with school districts to identify children who need help navigating the competing demands of caregiving and school and still find some time to be a child.

Thus far, more than 1,000 children in Palm Beach County, Florida, have benefited from the support the organization offers to children 18 or younger who regularly help relatives with “physical or mental illness, disability, frailty associated with aging, substance misuse or other conditions.”

As many as 1.4 million American children from ages 8 to 18 care for a parent, grandparent or sibling with a disability or illness, the American Psychological Association says, but it remains largely a hidden problem. Parents are often too embarrassed to tell schools how much they depend on their children, and caregiving children fear being taken away from their parents.

Many of these youngsters come from low-income, often single-parent households. They often fall behind in school, suffer from sleep deprivation and struggle with depression, anxiety and stress, said Gail G. Hunt of the National Alliance for Caregiving. She said 58 percent of these children “are too worried to concentrate on their schoolwork,” yet few tell their teachers about their responsibilities at home. A 2006 study by Civic Enterprises conducted for the Bill and Melinda Gates Foundation found that 22 percent of high school dropouts in this country leave school to care for a family member.

Dr. Siskowski’s Caregiving Youth project, now at eight middle schools and nine high schools in Florida, offers classes on topics like coping with stress and anger and managing finances. Along with home-care demonstrations and respite care, the project sponsors field trips, overnight camps and other recreational and social activities. They hope to expand the program to other schools throughout the country.

Schools are made aware that the children’s responsibilities may be reasons for incomplete homework, absenteeism and poor academic performance. The project offers in-home tutoring and study programs and even provides computers and printers for children who can’t get to a library. After four house fires resulted from youthful cooking attempts, the association began distributing slow cookers and fire extinguishers.

Perhaps most important, the children learn that they are not alone and that there is help available. “The kids feel valued; they learn what love is, and it flips the anger and frustration they may otherwise feel,” Dr. Siskowski said. The project stays in their corner until they graduate from high school.

One beneficiary was Nickolaus Dent, featured on CNN in 2012. When Nickolaus was 11, his father died and he became primary caregiver for his mother, sick with H.I.V. The boy was responsible for the grocery shopping and cooking, cleaning and laundry. He made sure his mother took her medication, got her dressed and sometimes even helped her bathe.

He said he considered caring for his mother “a bigger priority than going to school.” But with the organization’s help, he managed to do both, getting A’s and B’s. His mother died in December 2012, and Nickolaus expects to graduate from high school this year.

Others now being helped include Julianna Doran, a 14-year-old ninth grader, and Alecia Locke, a 13-year-old seventh grader, both in Boca Raton. Julianna helps to care for her 10-year-old brother who has cerebral palsy. “He can’t walk; he can’t control his muscles; he’s dead weight,” she said. Julianna’s parents have serious back problems, so it’s largely her job to lift and carry him.

Alecia, whose parents are divorced, spends weekends with her dad, whose mobility is seriously limited by multiple sclerosis. She does his laundry and dishes, cleans floors, assists with his scooter and fills the gas tank.

Dr. Siskowski knows much more help for young caregivers is needed now and in the years ahead. “With the increase in technology, more people are living longer and being cared for at home,” she said. “There are more multigenerational households, more women working and more gaps in the health care system that are being filled by children. We need to get these kids recognized as a vulnerable population at risk of dropping out of school.”

She added, “Society can benefit from investing in them. Children who graduate from high school have the potential of earning $10,000 more a year. And many of these kids want to get into health care, which needs all the help it can get.”

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Coloring Your Way Through Grief

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Credit Lisa Powell Braun

There is no disputing the adage that “into each life, a little rain must fall,” and the occasional need for a protective umbrella, but what do you do when the shower becomes a downpour that doesn’t seem to quit?

One shattering loss can be enough to derail a person for years, even for life. But tragedy seems to stalk some people, and it is reasonable to wonder how one goes on in the face of repeated painful losses.

Deborah S. Derman, a professional grief counselor in suburban Philadelphia, has clearly suffered more than her fair share. “The field of grief counseling sort of found me,” she said, “because I had such a long history of loss.”

She weathered her first devastating loss at age 27, when the boyfriend she had broken up with retrieved the vacuum cleaner she had borrowed, attached the vacuum’s hose to the exhaust pipe of his car and killed himself.

Fast-forward a decade: Now happily married and mother of a toddler, she was waiting at the airport for her parents to arrive when the private plane her father was piloting dropped from the sky and crashed in front of her, killing all four passengers aboard.

Four years later, while playing rugby, her husband died of a heart attack, leaving her a widow at age 39 with two young children and a third on the way. Then a few years later, she learned she had a rare form of breast cancer. “That’s when I felt I had a target on my back,” she told me. Her biggest fear, she said, was that if she died, her children would be orphans.

But she didn’t die. Instead, she managed to bring up the three children, marry again “a wonderful man” who adopted them, and earn a Ph.D., writing her dissertation on grief and attachment in young widowhood.

Dr. Derman has since been in private practice as a grief counselor, able to bring far more than professional training to the therapy she provides for those who have suffered losses. She has helped families on Staten Island who lost loved ones on 9/11, counseled breast cancer survivors, and conducted support groups for people weathering all manner of loss and grief.

She knows firsthand how important it is to say the right thing early on to someone who is hurting and vulnerable. When her former boyfriend committed suicide, “I felt like I was an accessory to his death,” she told me. Her mother helped to assuage her guilt by reassuring her that “this is not your fault.”

But when her husband died, her parents were no longer around with wise words. She recalled, “I was in so much pain, the grief felt physical. I was unable to concentrate on anything – I couldn’t read a book or hold a conversation. The only thing I could read were self-help books on loss and grief, looking for answers to how to get through the anguish I felt. I was so isolated and frustrated. No one knew what to do with me.”

She couldn’t even feel happy when two months after her husband died, she was accepted into a doctoral program in psychoeducational processes at Temple University. Advised to speak to another young widow, she was beaten down even further when the woman said, “Debby, do you know how you feel that your life is over? Well, it is,” which she said prompted her to take to her bed.

But she decided to get up and try a different approach after her sister said: “One day, Debby, this will be your past,” which made her realize that she might indeed have a future. She said she switched her field of study to grief and loss “because I never wanted another widow to feel as isolated as I did. I wanted to know how a person heals, so I can help others heal.

“Healing is a lifelong process, and elements of grief can occur at any time,” she said. “I’ve been widowed now for 24 years, but when my son got into medical school, I cried because my husband and parents weren’t there to see it. My daughter is about to graduate from college, and we will both cry because she never even knew her father. Her grief is different, but it’s not absent.”

Now Dr. Derman has produced an intriguing new tool – an adult coloring book intended to help others “get through tough times.” Called “Colors of Loss and Healing,” the book consists of 35 pages of lavish illustrations to color, each relating to a word or phrase, like “one day at a time,” “bitter and sweet” and “resilience,” meant to evoke thoughts and feelings that can help to promote healing.

Opposite each illustration, designed by Lisa Powell Braun, is a blank page with the heading “My palette … my words … my thoughts,” to prompt people to write down the feelings the words and phrases in the illustration evoke.

Dr. Derman said she had kept a journal after her husband died. “When you have to write something down, it really clarifies your thoughts and helps you know how to proceed,” she said. “In a journal, you can say whatever you want. No one else has to read it — it’s private.”

While art therapy has been used for decades to help people express what they can’t put into words, filling in the spaces of a coloring book has a different kind of benefit: enabling people to relax and be more focused. Marygrace Berberian, a clinical assistant professor in art therapy at New York University, said, “Research has shown that art making can have a profound impact on a person’s physical and psychological well-being. And coloring within an outlined structure can help to contain and organize feelings of distress and helplessness.”

In 2005, Nancy A. Curry and Tim Kasser of Knox College in Galesburg, Ill., reported in Art Therapy, Journal of the American Art Therapy Association, that coloring a mandala reduced anxiety in undergraduate students, a finding that has since been replicated and expanded. Today, there are adult coloring books to help alleviate stress and anxiety, release anger, induce calm and enhance mindfulness.

Dr. Derman’s idea for her book was prompted by a coloring book she received for her birthday last Christmas. “I colored one space, then another, and another, and realized this is how I proceeded through my life — one small step at a time. This is a good paradigm for how a person gets through loss, one day at a time. After my husband died, I didn’t think I could make it through a whole day. I looked at my watch — it said 10 a.m. — and made a deal with myself to make it to 11, then 12, then half a day.”

The book is meant to help people with losses of every kind, including illness, divorce, financial ruin, post-addiction — anything that might force people to redefine their identity.

Dr. Derman emphasized, “It’s not a recipe book. It doesn’t dictate how people should feel. We all go through grief and loss in very unique ways. One thing I’ve learned from my life and the hundreds of people I’ve counseled: Don’t try to pretend it didn’t happen and walk away fast.”

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Dehydration: Risks and Myths

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Credit Paul Rogers

Truth to tell, sometimes I don’t follow my own advice, and when I suffer the consequences, I rediscover why I offer it. I’ve long recommended drinking plenty of water, perhaps a glass with every meal and another glass or two between meals. If not plain water, which is best, then coffee or tea without sugar (but not alcoholic or sugary drinks) will do.

I dined out recently after an especially active day that included about five miles of walking, 40 minutes of lap swimming and a 90-minute museum visit. I drank only half a glass of water and no other beverage with my meal.

It did seem odd that I had no need to use the facilities afterward, not even after a long trip home. But I didn’t focus on why until the next day when, after a fitful night, I awoke exhausted, did another long walk and swim, and cycled to an appointment four miles away. I arrived parched, begging for water. After downing about 12 ounces, I was a new person. I no longer felt like a lead balloon.

It seems mild dehydration was my problem, and the experience prompted me to take a closer look at the body’s need for water under a variety of circumstances.

Although millions of Americans carry water bottles wherever they go and beverage companies like Coke and Pepsi would have you believe that every life can be improved by the drinks they sell, the truth is serious dehydration is not common among ordinary healthy people. But there are exceptions, and they include people like me in the Medicare generation, athletes who participate in particularly challenging events like marathons, and infants and small children with serious diarrhea.

Let’s start with some facts. Water is the single most important substance we consume. You can survive for about two months without food, but you would die in about seven days without water. Water makes up about 75 percent of an infant’s weight and 55 percent of an older person’s weight.

Human cells simply don’t function without water, and the body has evolved a finely tuned, complex system for making sure it has the water it needs under a wide range of conditions. In most cases, thirst is a reliable signal that more water is needed. A main job of the kidneys is to excrete just enough water to keep cells properly hydrated. However, contrary to myth, dark urine does not necessarily mean you’re dehydrated. Urine can be discolored by foods like asparagus, blackberries and beets.

Another popular myth: To moisturize skin, prevent wrinkles and produce a glowing complexion, you need to drink eight glasses of water a day. Drinking extra water doesn’t improve skin in people who are otherwise well hydrated. Better to use an emollient moisturizer to counter dry skin.

Good hydration definitely protects against kidney stones, and there is evidence that it counters constipation and exercise-induced asthma. It may also help protect against vascular diseases, like stroke, an elevated heart rate or sudden drop in blood pressure and is especially important for people with diabetes.

Despite the vital importance of water, there are relatively few good studies of how much is needed, by whom and under what circumstances, according to Barry M. Popkin, a professor of nutrition at the University of North Carolina at Chapel Hill. “We do not truly understand how hydration affects health and well-being, even the impact of water intakes on chronic diseases,” he and his colleagues wrote in Nutrition Reviews.

“Nearly all the funding of water research has been provided by industry,” Dr. Popkin said in an interview, referring to companies that sell all manner of beverages, including bottled water. “And most of the research on water has been organ-specific, done by people studying the kidneys or lungs. Whole body systems haven’t been well studied.”

There are no formal guidelines on how much water people need each day. The amount is affected by what people eat, their weight and activity level and even the environment in which they live.

The Institute of Medicine, which issues recommendations on the amounts of nutrients we need, states that an “adequate intake” of water ranges from 700 milliliters (about three cups) a day for newborns to 3.8 liters (16 cups) for lactating women. Still, the institute concluded that “individuals can be adequately hydrated at levels below as well as above the adequate intakes provided.”

Furthermore, the institute stated that all kinds of liquids can contribute to a person’s total water needs, including beverages like tea, coffee, juices, sodas and drinking water, as well as the moisture contained in foods like fruits, vegetables, soups and even meats. In fact, the institute estimates that the moisture in food accounts for about 20 percent of a typical person’s water intake.

Although the institute included juices and sodas as potential sources of hydration, these often sugar-laden beverages have become a serious nutritional problem in recent decades. The entire increase in fluid intake in the United States, from 79 ounces a day in 1989 to 100 ounces in 2002, came from caloric beverages, Dr. Popkin and colleagues reported. Studies have shown that people who drink these extra calories don’t compensate by consuming commensurately fewer calories from food, which has contributed mightily to the ballooning waistlines of Americans.

To be sure, it’s important for athletes to drink plenty of water, especially when high levels of activity, heat and humidity result in excessive sweating. But overdoing hydration has its own risks; marathon runners and other athletes have died after drinking more water than the kidneys are capable of processing in a timely manner, leading to swollen cells and dangerously low blood levels of sodium and other electrolytes.

At the same time, inadequate hydration can have debilitating effects. Studies by Lawrence B. Armstrong and colleagues at the University of Connecticut’s Human Performance Laboratory showed that dehydration can adversely affect vigilance, concentration, reaction time, learning, memory, mood and reasoning and can cause headaches, fatigue and anxiety.

Older people, especially the frail elderly, are among those at greatest risk of poor hydration, Dr. Popkin noted. The mechanism of thirst becomes less effective with age, and many older people cut back on how much they drink to limit how often they need to get to a bathroom.

“There’s a big problem with older people falling during the night and breaking bones when they get up to go to the bathroom,” Dr. Popkin said. “Many don’t drink because they’re afraid to fall, but instead they may die of the effects of dehydration.”

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A Shocking Way (Really) to Break Bad Habits

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Credit Kim Murton

Every January for the past decade, Jessica Irish of Saline, Mich., has made the same New Year’s Resolution: to “cut out late night snacking and lose 30 pounds.” Like millions of Americans, Ms. Irish, 31, usually makes it about two weeks.

But this year is different.

“I’ve already lost 18 pounds,” she said, “and maintained my diet more consistently than ever. Even more amazing — I rarely even think about snacking at night anymore.”

Ms. Irish credits a new wearable device called Pavlok for doing what years of diets, weight-loss programs, expensive gyms and her own willpower could not. Whenever she takes a bite of the foods she wants to avoid, like chocolate or Cheez-Its, she uses the Pavlok to give herself a lightning-quick electric shock.

“Every time I took a bite, I zapped myself,” she said. “I did it five times on the first night, two times on the second night, and by the third day I didn’t have any cravings anymore.”

As the name suggests, the $199 Pavlok, worn on the wrist, uses the classic theory of Pavlovian conditioning to create a negative association with a specific action. Next time you smoke, bite your nails or eat junk food, one tap of the device or a smartphone app will deliver a shock. The zap lasts only a fraction of a second, though the severity of the shock is up to you. It can be set between 50 volts, which feels like a strong vibration, and 450 volts, which feels like getting stung by a bee with a stinger the size of an ice pick. (By comparison, a police Taser typically releases about 50,000 volts.)

Other gadgets and apps dabble in behavioral change by way of aversion therapy, such as the $49 MotivAider that is worn like a pager, or the $99 RE-vibe wristband. Both can be set to vibrate at specific intervals as a reminder of a habit to break or a goal to reach. The $80 Lumo Lift posture coach is a wearable disk that vibrates when you slouch. The $150 Spire clip-on sensor tracks physical activity and state of mind by detecting users’ breathing patterns. If it detects you’re stressed or anxious, it vibrates or sends a notification to your smartphone to take a deep breath.

But the Pavlok takes things a step further, delivering a much stronger message.

To test the device, I wore it for a week, zapping myself every time I ate dessert. My goal was to curb my craving for sweets after dinner. First I zapped myself before and after I ate a square of dark chocolate, and did it again later in the week after eating ice cream, a red velvet cupcake and a chocolate chip cookie.

Set on low, it feels like a strong tickle. Set on high, it hurts. A lot.

It should be noted that the creator of Pavlok, Maneesh Sethi, once hired a woman to sit next to him and slap him on the face every time she saw him using Facebook, so he could increase his productivity. I called Mr. Sethi and told him that if we ever met, I’d try not to punch him in the face for creating such an awful torture device. “Yeah, I get that a lot,” Mr. Sethi said with a chuckle. “People either love it or hate it.”

“It’s not designed to be painful,” he added. “It’s instantaneous, a surprise sensation, a shock that knocks you out of automatic mode.”

But does this kind of self-imposed aversion therapy actually work?

“The most clever thing about this gadget is the name,” said Dr. Peter Whybrow, a Los Angeles author, psychiatrist and neuroscientist. “It’s an expensive spin on the idea of wearing an elastic band that you snap on your wrist to stop a certain behavior.”

Dr. Marc Potenza, a professor of psychiatry at Yale, says researchers have questioned the ethical nature of shock intervention when more comfortable options like cognitive behavioral therapies, pharmaceutical interventions and 12-step programs are available.

The practice of aversion therapy has been around for 80 years. Schick Shadel Hospital, based in Seattle, reports that it has successfully treated more than 65,000 people for alcohol or drug addiction using counter-conditioning methods like emetic drugs, which make people feel nauseated if they drink alcohol, or supervised shock therapy. The hospital’s medical director, Dr. Kalyan Dandala, said that he was interested in using Pavlok to help people continue recovery once they finish the 10-day inpatient treatment, but added that the device should be professionally supervised.

“It’s better suited as a prescribed tool for behavior modification,” Dr. Dandala said. “The company needs to refine it, put more education in the tool, and have more oversight.”

Michelle Freedland, a psychiatric nurse practitioner in Manhattan, has worked with five patients who use the device for nail biting, addictions, compulsive behaviors and more.

“When one of my patients told me he was using it last year to help him get out of bed in the morning, I was skeptical at first,” she said. “I mean, the notion of being shocked — you can have a little reservation. But when you understand how to use it properly and people are more engaged in their own treatment, they tend to follow through with it more.”

Mr. Sethi, the founder, said the company had just begun to collect data on the long-term success of the device, and was planning a clinical trial later this spring. The Pavlok has been available since November, and he said about 10,000 people had used it.

Despite the potential for pain and the lack of science backing a long-term effect, user feedback on Facebook groups and message boards has been enthusiastic about the device, especially as a last resort for problems like overeating and binge drinking.

Bud Hennekes, 24, a blogger in St. Louis, said he had used Pavlok to kick a nearly two-pack-a-day cigarette habit. “When I tried to quit before, I still had the craving to smoke,” he said. “When I used Pavlok, the cravings completely went away. I don’t know if it’s science or a placebo effect or what, and I don’t really care because it worked.”

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Aging in Place

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Credit Paul Rogers

When I asked the other three members of my walking group, all of whom are in their mid to upper 70s, whether they had any concerns about future living arrangements, they each said they had none despite the fact that, like me, they live in multistory private homes without elevators and, in two cases, without bathrooms on every floor.

My Los Angeles son asked recently what I might do if I could no longer live in my house, and I flippantly replied, “I’m coming to live with you.” The advantages: I’d be surrounded by a loving and supportive family, and the warm weather is a benefit for someone like me who becomes increasingly intolerant of the cold with each passing year. The disadvantages: I’d lose a familiar community and a host of friends, and his house, unlike mine, is on a steep hill with no nearby stores; if I could no longer drive, I’d have to be chauffeured everywhere.

Probably my biggest deterrent would be relinquishing my independence and the incredible number of “treasures” I’ve amassed over the last half century. The junk would be easy, but parting with the works of art and mementos would be like cutting out my heart.

I suspect that most people are reluctant to think about changing where and how they live as long as they are managing well at the moment. Lisa Selin Davis reports in AARP magazine that “almost 90 percent of Americans 65 or older plan to stay in their homes as they age.” Yet for many, the design of their homes and communities does not suit older adults who lack the mobility, agility and swiftness of the young.

For those who wish to age in place, the authors of “70Candles: Women Thriving in Their 8th Decade,” Jane Giddan and Ellen Cole, list such often-needed home attributes as an absence of stairs, wide doorways to accommodate a walker or wheelchair, slip-resistant floors, lever-style door knobs, remotely controlled lighting, walk-in showers, railings, ramps and lifts. Add to these a 24-hour help system, mobile phone, surveillance cameras and GPS locaters that enable family members to monitor the well-being of their elders.

In many communities, volunteer organizations, like Good Neighbors of Park Slope in Brooklyn and Staying in Place in Woodstock, N.Y., help older residents remain in their homes and live easier and more fulfilling lives.

While many young adults chose to live and bring up children in the suburbs, a growing number of empty-nested retirees are now moving to city centers where they can access public transportation, shop on foot for food and household needs, and enjoy cultural offerings and friendly gatherings without depending unduly on others.

One reason my friends and I are unwilling to even consider leaving our Brooklyn community is our ability to walk to supermarkets, banks, food co-ops, hardware stores, worship and recreational facilities, and get virtually everywhere in the city with low-cost and usually highly efficient public transportation. No driving necessary.

We also wallow in the joys of near-daily walks in a big, beautiful urban park, remarking each time about some lovely vista — the moon, sunrise, visible planets, new plantings and resident wildlife.

Throughout the country, communities are being retrofitted to accommodate the tsunami of elders expected to live there as baby boomers age. Changes like altering traffic signals and street crossings to give pedestrians more time to cross enhance safety for people whose mobility is compromised. New York City, for example, has created Aging Improvement Districts, so far in East Harlem, the Upper West Side and Bedford-Stuyvesant, to help older people “live as independently and engaged in the city as possible,” Ms. Giddan and Ms. Cole wrote. In East Harlem, for example, merchants have made signs easier to read and provided folding chairs for seniors who wish to rest before and after shopping.

In Philadelphia, a nonprofit organization, Friends in the City, calls itself a “community without walls” designed to bring members closer to the city’s resources and to one another. It offers seniors a daily variety of programs to suit many cultural and recreational interests.

Also evolving is the concept of home sharing, in which several older people who did not necessarily know one another get together to buy a home in which to live and share responsibilities for shopping, cooking, cleaning and home repair. For example, in Oregon, Let’s Share Housing, and in Vermont, Home Share Now, have online services that connect people with similar needs, Ms. Giddan and Ms. Cole report. There’s also an online matching service — Roommates4Boomers.com — for women 50 and over looking for compatible living mates.

Of course, there are still many older adults, widows and widowers in particular, who for financial or personal reasons move in with a grown child’s family, sometimes in an attached apartment or separate floor. Host families may gain a built-in babysitter, and children can develop a more intimate relationship with grandma or grandpa.

For those with adequate finances, there is no shortage of for-profit retirement communities that help older people remain independent by providing supportive services and a host of amenities and activities. Some have extensive recreational and exercise facilities, as well as book and craft clubs, discussion groups and volunteer opportunities. Some take residents to theatrical productions and museums and on trips to nearby attractions.

I confess that retirement communities that house only older adults are not my style. I can’t imagine living in a place where I don’t see and interact with children on a daily basis. I find that nothing cheers me more than a smile or comment from a toddler. I guess I take after my father, who used to flirt with every child he noticed in a car near his. But I realize that, just as some people are averse to dogs, not everyone enjoys the companionship of a high-energy child.

For older people likely to require help with the activities of daily living, there are many assisted living facilities where residents can get more or less help, including aid with medications, feeding and ambulation, according to their changing needs.

And should I ever have to leave my home, Ms. Giddan and Ms. Cole point out that there is a new and growing cadre of professional organizers and moving managers to “help people sort through accumulated belongings, distribute and disperse what won’t be needed in the new setting, and assist with all stages of packing, moving and then unpacking, and staging the new home.”

This is the second of two columns about adjustments to aging. Read the first part: “Thriving at Age 70 and Beyond.”

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Thriving at Age 70 and Beyond

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Credit Paul Rogers

A recently published book, “70Candles! Women Thriving in Their 8th Decade,” inspired me to take a closer look at how I’m doing as I approach 75 and how I might make the most of the years to come. It would be a good idea for women in my age cohort to do likewise. With a quarter of American women age 65 expected to celebrate their 100th birthday, there could be quite a few years to think about.

It’s not the first time I’ve considered the implications of longevity. When one of my grandsons at age 8 asked, “Grandma, will you still be alive when I get married?” I replied, “I certainly hope so. I want to dance at your wedding.” But I followed up with a suggestion that he marry young!

Still, his innocent query reminded me to continue to pursue a healthy lifestyle of wholesome food, daily exercise and supportive social connections. While there are no guarantees, like many other women now in their 70s, I’ve already outlived both my parents, my mother having died at 49 and my father at 71.

If I have one fear as the years climb, it’s that I won’t be able to fit in all I want to see and do before my time is up, so I always plan activities while I can still do them.

I book cycling and hiking trips to parts of the world I want to visit and schedule visits to distant friends and family to be sure I make them happen. In a most pragmatic moment, I crocheted a gender-neutral blanket for my first great-grandchild, but attached a loving note in case I’m no longer around to give it in person.

Of course, advancing age has taken — and will continue to take — its incremental toll. I often wake up wobbly, my back hates rainy days, and I no longer walk, cycle or swim as fast as I used to. I wear sensible shoes and hold the handrail going up and down stairs.

I know too that, in contrast to the Energizer Bunny life I once led, I now have to husband my resources more carefully. While I’m happy to prepare a dish or two for someone else’s gathering, my energy for and interest in hosting dinner parties have greatly diminished. And though I love to go to the theater, concerts, movies and parties, I also relish spending quiet nights at home with my Havanese, Max, for company.

Jane Giddan and Ellen Cole, the authors of “70Candles!,” do not tout their work as definitive research. Rather, their effort involved scores of posts to an online blog, and eight gatherings in different cities with groups of women in or near their 70s, where participants were encouraged to share their stories and generate research questions that could be explored scientifically in more detail. Such studies are important: As baby boomers age, women in their 70s, already a large group, will represent an increasing proportion of the population, and how to best foster their well-being will be a growing challenge.

What are the most important issues facing these women as they age, and how might society help ease their way into the future? Leading topics the women chose to explore included work and retirement, ageism, coping with functional changes, caretaking, living arrangements, social connections, grandparenting and adjusting to loss and death.

As members of the first generation in which huge numbers of women had careers that defined who they were, deciding when to bow out can be a challenge. Some have no choice, others never want to, and still others like me continue to work part-time. However, sooner or later, most will need to find rewarding activities to fill their now-free time.

The authors reported that “the women seemed to fear retirement before the deed was done, and then to relish their newfound opportunities afterward.” Several warned against rushing into too many volunteer activities, suggesting instead that retirees take time to explore what might be most meaningful and interesting, from taking art classes or music lessons to mentoring students, becoming a docent or starting a new career.

As one woman said, “There are many places where you are needed and can make a difference.” Another said, “It’s more like putting new tires on a car… re-tiring!”

Still, many lamented society’s focus on youthfulness and its failure to value the wisdom and knowledge of elders like themselves. Ageism abounds, they agreed. As one woman wrote, “At my institution, there’s an unstated policy that anyone over 55 won’t get a job. We’re thought to be out of touch with the younger population and assumed to be lacking in the necessary technical skills.” A practicing attorney admitted, “People might not listen to me if they knew I was 71, so I keep it to myself.”

Adjusting to physical changes that accompany advancing years is often tough. Grandchildren, though a great joy to many, can be exhausting, necessitating a restorative nap. Adjustments are needed to reduce the risk of falls and fractures. Better lighting, hearing assists, a reliance on Post-it notes and lists as well as canes and walkers can become essential for safe and effective functioning.

As Ms. Giddan and Ms. Cole wrote, “Our bodies change as we age, even when we eat healthfully, exercise and try to take good care of ourselves. Sight, hearing, bones, joints, balance, mobility, memory, continence, strength and stamina — they will never be what they once were.”

There is also the matter of attending to or accommodating various aches and pains. As one physician reassured a woman of 70, “All my patients your age who are free of pains are dead.” I’m not one to run to the doctor the moment something hurts. Rather, I give it a few weeks — maybe a month — to see if it will go away on its own. Even if fully covered by Medicare, doctor visits cost time and effort, and tests that ensue may have side effects.

Also important as women age are social connections, especially with other women. Whether married, single, widowed or divorced, participants reported that women friends were their greatest source of support and comfort.

Perhaps most important, for men as well as women, is to think positively about aging. A 2002 study by epidemiologists at Yale found that “individuals with more positive self-perceptions of aging, measured up to 23 years earlier, lived 7.5 years longer than those with less positive perceptions.”

This is the first of two columns on adjustments to aging.

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School Athletes Often Lack Adequate Protection

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Credit Paul Rogers

With all the attention on national rules to prevent and properly treat injuries to professional and college athletes, it may surprise you to learn that there are no nationwide guidelines to protect high school athletes from crippling or fatal injuries.

Instead, it is up to individual states and the schools within them to adopt policies and practices that help to assure the safety of children who play organized school or league sports. But most states and schools have yet to enact needed safety measures, according to data from the National Athletic Trainers’ Association.

“Each state has its own high school athletic association, and each policy has to be individually approved,” said Douglas Casa, an athletic trainer and chief executive of the University of Connecticut’s Korey Stringer Institute, named for the former National Football League player who died from complications related to heatstroke in 2001.

“It’s a burdensome, grueling process,” Dr. Casa said, that he and others hope will yield to the efforts of a new program, the Collaborative Solutions for Safety in Sport created by the athletic trainers’ association and theAmerican Medical Society for Sports Medicine.

The program held its second meeting last month, attended by two high school representatives from each state, to provide them with road maps to establish safety rules and policies or laws for high school athletics.

Last year alone, about 50 high school athletes died, according to the association, and thousands suffered long-term complications from sports-related injuries, most of which could have been avoided had well-established safety practices been in place and observed.

The leading causes of sports-related deaths among high school students are sudden cardiac arrest, head and neck injuries, and exertion-induced heatstroke or sickling, which occurs in athletes who carry the sickle cell trait. Fatalities occur primarily because most schools lack four critical ingredients to assure sports safety: emergency action plans, policies for proper conditioning and safe exercise in high heat and humidity, the presence of trained health professionals at all practices and games, and immediate availability of automated external defibrillators, or A.E.D.s, to reset a stilled or erratically beating heart.

In July 2004, Laura Friend of Fort Worth, lost her 12-year-old daughter Sarah during a junior lifeguarding class because nobody recognized the child was in cardiac arrest and no one initiated CPR or used the A.E.D. on the premises. Not until after Sarah died was it known that she had been born with an enlarged heart.

Ms. Friend, who now coordinates a Texas cardiac emergency project, created a nonprofit foundation in her daughter’s memory that has donated 59 A.E.D.s and provided CPR and A.E.D. training for hundreds of youth and adults in Texas.

However, despite a 2007 law requiring an A.E.D. in every school in Texas, “many are locked up in an office and not accessible, or only the school nurse knows how to use it,” Ms. Friend said.

Knowing that sudden cardiac arrest is by far the leading cause of death among student- athletes, Dr. Casa owns an A.E.D. and takes it to every practice and game of soccer, lacrosse and swimming involving his three school-age children.

The Mallon family of Del Mar, Calif., knows all too well the importance of having a medically trained professional on hand during practices and games. Tommy Mallon owes his life and well-being to an athletic trainer and a quick-thinking teammate who refused to help him up when he landed hard after colliding with another lacrosse player when he was 17. Instead, a trainer was summoned who, noticing subtle neurological signs that suggested a catastrophic, potentially fatal injury, called immediately for an ambulance.

Tommy, 23, now a global risk analyst in Austin, Tex., had sustained a fractured vertebra in his neck and torn artery to the brain. Had he been moved incorrectly, he could have died or been paralyzed.

In the years since, Tommy’s mother, Beth Mallon, has been a relentless advocate for teaching athletes how to recognize basic signs and symptoms of trouble on the field or court. Some 5,000 students have already been through the program she developed, Athletes Saving Athletes, taught by athletic trainers.

“In just two hours, the kids learn all they need to know: This could be serious, when and how to get help,” Ms. Mallon said. “We’ve had three success stories so far: one involving a heatstroke, one with cardiac arrest and a third with a neck injury and concussion.”

“High schools spend tons of money on referees, but almost nothing on safety,” she said. “I’d like to see every high school in the country adopt a sports safety curriculum. You never think a catastrophic injury will happen to your kid, but if it does, you’d be so grateful that someone is there who knows what to do.”

Dr. Jonathan Drezner, director of the Center for Sports Cardiology at the University of Washington, outlined the key practices the collaborative project is trying to get every high school that sponsors athletic activities to adopt:

■ An athletic trainer at every practice and game;

■ An emergency action plan to respond appropriately to an athlete in distress;

■ A publicly accessible A.E.D. and school-based program in its use;

■ Climatization policies to prevent heat injury and heatstroke.

Although having a medically trained person readily available can be too costly for many schools, an A.E.D. costs only about $1,000 and can be used to save anyone — coaches, refs and spectators as well as athletes.

“I can’t believe we don’t have universal access to A.E.D.s in schools; they should be like fire extinguishers,” Dr. Drezner said. “There are 7.5 million high school athletes in this country. During the academic school year 2014-2015, there were 55 cases of cardiac arrest among them, and 57 percent died.”

Parents whose children want to play school sports often focus more on uniforms than on measures to protect them from serious or fatal injuries. Experts say that a pre-participation medical exam is critical and should include an EKG if there is any family history of heart trouble.

Coaches should know CPR, the location and use of an A.E.D., the signs of a possible concussion, and when to keep a player on the sidelines. Coaches should also monitor climate conditions and know when to postpone or suspend a practice or competitive event to avoid heat injuries. During hot weather and high humidity, a cooling tub should always be available. If school money is tight, parents might hold a fund-raiser to assure that an athletic trainer or sports medicine doctor attends every practice and game.

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Millions With Leg Pain Have Peripheral Artery Disease

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Credit Paul Rogers

More than eight million older Americans have a condition that can cause leg pain when they walk even short distances. Yet half of those who have the condition don’t know it and consequently don’t get treated for it, putting themselves at risk for a heart attack, stroke or worse.

The condition, called peripheral artery disease, or P.A.D., is marked by diseased or blocked arteries in the legs. More than half of those with such circulatory problems in the extremities also have coronary or cerebral artery disease, noted Dr. Iftikhar J. Kullo, a cardiovascular specialist at the Mayo Clinic, in The New England Journal of Medicine in March. Failure to diagnose and treat blocked arteries elsewhere in the body can result in more serious, or even fatal, problems if they affect the heart or brain.

It may seem odd that people who have serious difficulty walking normal distances would not know something is wrong and get checked out. Yet, as Dr. Kullo noted, P.A.D. is both underdiagnosed and undertreated. And the number of cases of P.A.D. is only likely to rise as the population ages, he said.

“A lot of people limit their activity for other reasons, like a hip problem, back pain or breathing difficulty, and may not push themselves hard enough to provoke symptoms of P.A.D.,” said Dr. Paul W. Wennberg, a cardiologist and specialist in vascular disease at the Mayo Clinic. Or they may think their limited ability to exercise is to be expected, given their advancing years. Still others, Dr. Wennberg said, “may have only minimal disease in their legs, or they adapt their lifestyle to where they don’t notice symptoms anymore.”

In other words, since walking brings on pain, people typically find myriad ways to avoid doing it.

But this very response — remaining sedentary — is counterproductive, Dr. Wennberg said, because the best treatment for P.A.D. is exercise: Walking up to the point of pain, then resting until the pain subsides, then walking again, repeating the sequence until you’ve walked for 20 to 30 minutes (not counting rests) every day.

With this approach, Dr. Wennberg explained, exercise tolerance gradually increases as collateral blood vessels form in the legs that can compensate for blockages in the main arteries.

Just as teachers often have star pupils, Dr. Wennberg talks fondly of a man who was his star patient. When first seen, the patient, a 76-year-old Minnesotan, was afflicted with such severe peripheral artery disease that he couldn’t walk much beyond his backyard. Although a nonsmoker, the man had chronic obstructive pulmonary disease, which also limited how far he could walk. Yet he desperately wanted to be able to hike the nature trail behind his house, which motivated him to follow the doctor’s prescription religiously: Walk until it hurts, rest, then walk some more. Repeat several times a day.

“He got a treadmill to use in his house, and he walked outside whenever he could,” Dr. Wennberg recalled. “In just three months, he had doubled his walking distance as measured on a treadmill in the lab, and before long he was able to walk the mile-long nature trail.” Not only did the exercise prescription reduce his leg pain, it also improved his breathing. Together, these benefits enabled him to walk the desired distance without pain or fatigue.

Another of Dr. Wennberg’s patients, Donovan Merseth, 76, of Zumbrota, Minn., said he walks his two dogs four or five times a day, accumulating daily walks of three to four miles. “The more active I am, the better I feel,” Mr. Merseth said in an interview. “I walk at a moderate pace,” he said, calling his exercise “a senior power walk.”

Variable symptoms present another stumbling block to getting a correct diagnosis of P.A.D. The discomfort P.A.D. causes “is more often atypical than typical,” Dr. Wennberg wrote in the journal Circulation. “Descriptions such as ‘tired,’ ‘giving way,’ ‘sore,’ and ‘hurts’ are offered more often than ‘cramp’,” which can challenge an examining physician’s ability to suspect P.A.D. as the cause of a patient’s discomfort.

He suggested that doctors ask, “What’s the most strenuous thing you do in a typical week? Do you do any routine exercise, like walking? Do you get pain when you walk?”

A simple noninvasive test that can be done in any doctor’s office, called the ankle-brachial index, or ABI, test, can reveal the likelihood of P.A.D. The test, which takes only a few minutes, compares blood pressure measured at the ankle with blood pressure measured in the arm. Lower pressure in the leg is an indication of P.A.D.

The index is calculated by dividing the systolic (top number) blood pressure in the arteries near the ankles by the systolic blood pressure in the arms. A low number strongly suggests a narrowing or blockage in the arteries that supply blood to the legs.

Follow-up tests, like an ultrasound exam of the arteries to the brain, may be done as well. “If there’s blockage in one area of the body, it’s likely also to be in another,” Dr. Wennberg noted.

Not surprisingly, the risk factors for P.A.D. closely match those for coronary heart disease: smoking (currently or formerly), diabetes, high blood pressure and high cholesterol. Consider asking your doctor to do the ABI test if you are 50 or older and have any of the above risk factors, even if you haven’t yet noticed a problem with walking (though insurance may not cover the cost if you lack symptoms).

However, Dr. Wennberg wrote, the ABI test done during rest may miss peripheral artery disease in nearly one-third of patients; they may require an ABI test following exercise on a treadmill to reveal the problem. The blood pressure measurements must be taken within a minute of stopping the exercise.

Given the same risk factors, African-Americans are more likely than Caucasians to develop P.A.D.

The average age at which people develop P.A.D. is 70, Dr. Wennberg said, adding that it occurs a decade earlier in people with diabetes and even earlier in people who both smoke and have diabetes.

Smoking increases the risk of developing P.A.D. fourfold, and more than 80 percent of people with the condition are current or former smokers.

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After Physical Therapy, Why Not Cancer Therapy?

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Susan Gubar

Susan GubarCredit Vivienne Flesher

In mid-January, after a fall on invisible ice, I was informed by an emergency room doctor that my fractured pelvis would heal in six to eight weeks. To help me recover from the injury, therapists started coming to my house. Their ministrations posed a question that nagged at me: why aren’t trained professionals made available to cancer outpatients in the way occupational and physical therapists are routinely assigned to orthopedic patients?

The occupational therapist appeared only a few times, when I was completely incapacitated. With extraordinary tact, she taught me how to unclothe in a narrow bathroom and then positioned me on a bench in the tub where I could use a hand-held shower.

Throughout February, my physical therapist, Sherry, rang the doorbell twice a week, entered as she heard me yell “Come in,” and placed a clean pad under the large bag she put on the floor near the blue couch on which I reclined. Out came the equipment she used to check and record my vital signs. The rituals that followed slowly raised my levels of mobility and confidence.

At the beginning, Sherry suggested ankle pumps and a few stretches. She would watch me rise to the walker and shorten its legs or tell me to change my gait. A week later, she had me move to the bedroom to show me the least painful way to get into or out of the bed. So I could sleep on my side, she propped a pillow between my legs.

Later in February, Sherry taught me the Clamshell: lying on my right side with my knees bent, feet together, I moved my left knee up a few inches. I could feel the muscles strengthening. In early March, she encouraged me to place my hands on the kitchen counter and raise my strong leg off the floor for 20 seconds in a pose I called the Flamingo. Putting weight on my weak leg gave me the sense that I might meet my goals: to graduate onto a cane, go up and down steps and become a functioning biped again.

Not one comparable sequence of instruction occurred during my eight years of cancer treatments, although I was much more incapacitated and traumatized at the start. Reeling with anxiety back in 2008, I never received any professional assistance at home for wounds, edema, neuropathies, fatigue, weakness, eating disorders, drains, elimination problems, rashes, insomnia, infections, a PICC line, and other complications that were especially shocking during the first year after diagnosis. I relied only on family and friends.

What escalated the injury of cancer for me was the passivity medical protocols produced or required. I was knocked out by anesthesiologists, cut up by surgeons, and infused with chemicals by nurses. “The very word ‘patient’ (Latin root, patior, ‘to suffer’) is a giveaway,” the columnist Max Lerner once explained. “Patients suffer things to be done to them, becoming thereby the acted upon, the diminished.”

Cancer patients like me would profit from supportive care aides who could spring us from this induced passivity and its accompanying fear. In my case, such a counselor would have allayed the bewilderment of treatment and also empowered me to exert a modicum of control over the broken rhythms of everyday existence.

Perhaps very wealthy people find and hire staff with the requisite expertise, but it never entered my mind. My new oncologist, Dr. Mina, assures me that breast cancer patients do receive physical therapy after mastectomy to prevent lymphedema. After a massive debulking operation for ovarian cancer, however, no physician or nurse ever hinted at the possibility of my obtaining outpatient therapy. Wouldn’t people with prostate or lung, throat or colorectal cancer prefer to receive help at home than go to the emregency room — a prospect that terrified me?

Sherry’s interventions persuade me that therapists could provide cancer patients a multitude of ideas — on pain management, nutrition options, personal hygiene strategies, psychological and sexual prompts, meditation and massage and workout routines — to ameliorate the harms cancer and its treatments typically cause.

Is this sort of therapy unavailable because insurance companies will not cover it? Or it is unavailable because it brings no profitable returns to hospitals? Yet paid therapists might be less expensive than recurrent E.R. visits as well as the psychic toll exacted by the depression that frequently burdens cancer patients.

Why not use the model of the occupational and physical therapist in orthopedics to create a central role for therapists in oncology, advisers who could help cancer patients help themselves in taking small, strengthening steps? After surgery and at the start of chemotherapy, my family and I would have given anything for the house calls of a creature we never imagined: an oncological therapist.

“What a comfort such a person would have been,” I said to Sherry after one of our sessions. “An oncological therapist might have given me what you give me — a sense of agency.”

Sherry said she had done extensive training in a host of proficiencies that would be useful for cancer patients, as have many of her peers. “Physical and occupational therapists with all sorts of skills pertinent to cancer treatment abound, but to enlist them, specialists in surgery, radiology, and chemotherapy need to think outside their specialization.”

Then she added, “Maybe the oncologists need to be educated.”

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A Teachable Moment on the Need for Colon Cancer Screening

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Credit Paul Rogers

As an alumna of Cornell who had been thrilled by the selection of the university’s first female president, Elizabeth Garrett, last fall, I was deeply pained to learn of her untimely deathfrom colon cancer at age 52 last month. May it be a teachable moment that could save many from a disease that will be diagnosed in an estimated 134,000 people and claim 49,000 lives in the United States this year.

Although colorectal cancer is the third most common cancer, it is the second leading cause of cancer deaths, after lung cancer. Detection guidelines call for screening to begin at 50 for most people, but colon cancer is now increasing in people under 50, and everyone should be aware of the risks and early warning signs.

While the circumstances that led to President Garrett’s diagnosis have not been publicly revealed, I do know that colon cancer can nearly always be prevented through detection and removal of its precursor lesions, commonly called adenomas or adenomatous polyps. I also know that it can most often be cured if one of several screening tests leads to early detection, before the cancer has spread beyond its point of origin.

Currently, a joint effort of the American Cancer Society and the Centers for Disease Control and Prevention is trying to make these screening methods available to the 40 percent of Americans who have yet to be tested. The goal of this National Colorectal Cancer Roundtable, as it is called, is to get 80 percent of Americans screened for colorectal cancer by 2018.

More than 690 organizations have joined the effort to remove barriers to screening that can include cost, transportation and resistance to what most people view as an unpleasant experience. Colonoscopy, the gold standard for detecting cancer and removing precancerous polyps, has the dubious distinction of being the least pleasant of all the available screening tests. But the other options, which involve collecting a sample of one’s stool for detection of possible cancer, are no one’s favorites either.

I’ve done both — in fact, I’ve had three colonoscopies, at ages 50, 60 and 70. The test itself is done under mild sedation, and I’ve never felt any pain, only slight pressure, while being scoped.

It’s the preparation for a colonoscopy — the need to clean out the contents of the colon to make its lining clearly visible — that I and many others find most taxing. The prep is not a walk in the park, but then again, neither is cancer.

The fact remains that being screened for colon cancer can save your life. Since 1975, death rates from colorectal cancer have dropped significantly and screening is responsible for slightly more than half that decline, the cancer society reports. The decline in deaths has accelerated in the last decade, dropping nearly 3 percent a year. This is primarily attributed to more people getting colonoscopies at appropriate ages.

For most people without a family history or symptoms, colonoscopy is generally recommended starting at age 50, then every 10 years if nothing untoward is found.

One adult in 20 in this country will develop colon cancer sooner or later, 85 percent of them after age 50. Among the remaining 15 percent whose cancers develop before 50, many have a family history of cancer that suggests it may be wise to start screening at 40. (There remain a heart-rending few in whom this cancer develops at an especially early age, say, at age 20 or 30, in people who had no indication that they needed to be screened.)

In the March 17 issue of The New England Journal of Medicine, Dr. Williamson B. Strum, a gastroenterologist at the Scripps Clinic Medical Group in La Jolla, Calif., points out between 20 percent and 50 percent of the American population has adenomas of the colon, the benign growths from which most colorectal cancers arise.

Screening with a traditional colonoscopy can find these growths and, at the same time, the doctor can remove them and head off a possible cancer.

A newer technique called computed tomographic colonography, or virtual colonoscopy, uses a CT scan instead of a scope to pick up these lesions. It, too, requires cleaning out the colon before the scan. And if polyps are detected, a traditional colonoscopy is needed to remove them.

The other tests that check the stool for signs of cancer are less invasive, safer and easier to do, but they are also less definitive and less likely to detect signs of hazardous polyps before a cancer arises in them. They involve stool samples enclosed in kits that are sent to a lab for analysis. If the test result is positive, a follow-up colonoscopy is then needed to find the reason.

One, called the guaiac-based fecal occult blood test, is based on a chemical reaction that can find hidden blood in the stool. Before doing the test, certain foods and drugs must be avoided. If blood is found, it could come from a source other than a colon cancer, like ulcers, hemorrhoids or diverticulitis, so a colonoscopy would then be needed.

Another option, the fecal immunological test, involves fewer pretest conditions but may require collecting stool samples from more than one bowel movement. A third, the stool DNA test, looks for telltale genetic material (mutations from a cancer or precancerous polyp) in the stool. The test currently available, Cologuard, also checks for blood in the stool and may prove to be the most effective of these noninvasive tests, Dr. Strum said.

Traditional colonoscopy is unequivocally best at finding cancer and precancer, but the best screening test is one that you will do as often as is recommended. So the message here is doing something is always better than doing nothing to avoid death from colon cancer.

Equally important is attending to known risk factors — and preventives — for colon cancer. Age is one: The prevalence of potentially dangerous polyps rises sharply after age 50, studies of tens of thousands of people have shown. However, colorectal cancer is now rising among people in their 40s, prompting Dr. Strum to suggest a thorough evaluation of any suspicious symptoms among people younger than 50.

Other known risk factors are smoking, excessive alcohol consumption, obesity and a diet rich in red meat. Protective factors include eating lots of fruits and vegetables, getting regular physical exercise, using menopausal hormone-replacement therapy, and taking a nonsteroidal anti-inflammatory drug (NSAID) at least twice a week for a year or longer. Drinking coffee, too, has been linked to a reduced risk — 54 percent lower among those who consume two-and-a-half cups a day or more.

Most promising, Dr. Strum wrote, is daily use of a baby aspirin (81 milligrams) for 10 or more years, which also helps protect against cardiovascular disease. However, the benefit of any NSAID must be balanced against an increased risk of gastrointestinal bleeding, he cautioned.

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A Primer on Children’s Hernias

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Credit Paul Rogers

When my twin sons were 2½, their pediatrician detected a hernia in the right groin of one of the boys. The doctor minced no words: The hernia would not repair itself and surgery was necessary to avoid a serious, potentially life-threatening complication. But he added reassuringly that the operation was routine and the patient nearly always goes home the same day.

I selected a top-notch pediatric surgeon at a nearby hospital who found during surgery that my son had a second hernia on the left side that he also repaired. He was in recovery for an hour or so, where he was watched for possible complications while the anesthesia wore off. Then we took him home, put him in his crib, curled in a fetal position, and raised the crib’s bar to keep him safe.

Despite that precaution, during the night, he climbed out over the bar, went to the bathroom and climbed back into his crib, all without waking us. The next morning he saw a lot of snow outside the house, and after downing a hearty breakfast, went out to play with his brother. If only grown-ups recovered from surgery even half as quickly!

Because genetics can play a role in pediatric hernias, I fully expected that his identical twin brother might develop one too, but 44 years later this has yet to happen.

“Inguinal hernia correction is the most common elective surgery that pediatric surgeons perform,” said Dr. Shaun Steigman, a pediatric surgeon at Weill Cornell Medical College who also operates at New York Methodist Hospital in Brooklyn. The word “elective” distinguishes it from an emergency operation, which repairing a hernia is meant to avoid.

The two types of hernias that most often affect children are inguinal (the kind my son had), which occurs in the groin area, and umbilical, which occurs around the navel.

Pediatric hernias stem from a defect present at birth — a hole in the muscle wall of the abdomen. While not all such holes develop into hernias, in those that do, abdominal tissue, usually a portion of the small intestine, can protrude through.

Hernias in children are often detected during a routine pediatric checkup, or by a parent who notices a lump on one or both sides of the groin or around the navel while changing a diaper or bathing the baby. A telltale sign is a bulge in the groin when the baby is straining, crying or coughing.

In making the diagnosis, Dr. Steigman said he might try to get the hernia to pop out by making a young infant cry or an older baby laugh. He asks a toddler or older child to jump or cough.

In some cases the protruding tissue of a hernia can become trapped, an often painful condition called incarceration. This situation is especially dangerous if the intestine is pinched hard enough to cut off its blood flow, a condition called strangulation.

In addition to a lump, symptoms of incarceration or strangulation may include severe pain, fever, nausea and vomiting, or an inability to pass gas or produce a bowel movement.

An incarcerated or strangulated hernia can cause severe complications and even death. Emergency surgery is necessary if the doctor cannot push the intestine back through the hole by massaging the protrusion from outside the child’s abdomen.

Inguinal hernias affect from 3 percent to 5 percent of children born full-term, the vast majority of them boys. During fetal development, the testes have to pass from the abdominal cavity through the inguinal canal to reach the scrotum. Before birth, the opening to the canal is supposed to close. When it doesn’t, a hernia can result.

Children born prematurely are six times as likely to have an inguinal hernia as those born full-term. Up to 30 percent of premature infants develop an inguinal hernia, and in 60 percent of them tissue from the abdominal cavity gets trapped, according to Dr. Andre Hebra, chief of surgery at the Medical University of South Carolina Children’s Hospital.

Hernias are usually detected during the first year of life. In babies born prematurely they are often surgically corrected before the infants are discharged from the neonatal intensive care unit. But sometimes hernias do not become apparent until a child is much older, and occasionally not until adulthood.

Umbilical hernias, which affect about 10 percent of children, result when the hole in the abdominal muscles through which the umbilical cord passes in utero fails to close after birth. These too can ensnare a portion of the small intestine. However, unlike inguinal hernias, which always require surgical correction, “95 percent of umbilical hernias close on their own,” Dr. Steigman said. “They are less likely to get something trapped, so we wait until age 4 or 5 to repair them if they don’t self-correct.”

A third type, called a femoral hernia, is more common in girls. It usually shows up as a bulge in the groin, upper thigh or labia, the skin folds around the vaginal opening. It is associated with a high risk of strangulation and must always be surgically repaired.

Surgery to correct a hernia is straightforward and usually done as an outpatient procedure in children older than 3 months, Dr. Steigman said. In a majority of cases, the repair is done through open surgery, though Dr. Steigman said he prefers to operate laparoscopically, through two tiny incisions. But either way, the incision is very small and the child heals rapidly.

According to the American College of Surgeons, an open repair is needed by about 1 percent of children born full-term, 15 percent of those born prematurely and 20 percent of those who experienced an incarceration.

All that is required before surgery is a routine checkup — blood tests, urine analysis and a discussion of medications the child regularly takes. If the hernia is difficult to see or feel, an ultrasound exam may be done.

In preparing for surgery, the child should not eat for six to eight hours, consume breast milk for four hours or drink clear fluids for two hours before the scheduled operation to minimize the risk of aspirating stomach contents. The operation is most often done under general anesthesia, but even if local anesthesia is planned, there is always the possibility that general anesthesia will become needed during the operation.

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A New View of Appendicitis

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Credit Paul Rogers

Gwen Deely’s story is an example of how not to deal with a health crisis when traveling abroad. She realizes she’s lucky to be alive.

Ms. Deely, a 66-year-old living in Manhattan, was on an overnight flight from New York to Venice in October when she developed what she thought was food poisoning, perhaps from the tuna sandwich she had eaten at home that day. She weathered the night armed with more than a dozen airsickness bags and figured it would pass.

But it didn’t, and she spent the entire week in Venice in bed staring at the ceiling in the Airbnb apartment she and her partner had rented. She attributed her low-grade fever and chills to the flu shot she had received just before the trip.

“I would have had to take a boat to get to a doctor, and I couldn’t even stand up,” she said. Her decision not to go to a hospital that was a water taxi ride away was reinforced by a reluctance to seek medical help where she didn’t speak the language. “Had I been in a hotel, I would have asked to see a doctor who spoke English,” she said.

Ms. Deely somehow managed to fly home as scheduled, trying not to act sick on the plane, and went from the airport to the emergency room, where blood tests and a CT scan revealed a ruptured appendix.

Riddled with infection, she spent five days in a hospital on intravenous antibiotics, followed by months of antibiotic treatment and abdominal drainage at home. Finally, in mid-February, she was healthy enough for her ailing appendix to be removed with laparoscopic surgery, involving several tiny incisions in the abdomen.

A ruptured appendix is a life-threatening condition. Blindsided by atypical flulike symptoms rather than the stabbing abdominal pain one usually associates with a ruptured appendix, Ms. Deely failed to realize how close she came to dying. She now knows better than to try to “tough it out” when unexplained, debilitating symptoms occur.

Appendicitis, after all, is very treatable, and surgery is no longer the only option. Patients are now increasingly being offered a trial of antibiotics instead of being rushed into surgery to remove an inflamed appendix (the suffix “-itis” in appendicitis means inflamed). Without treatment, an inflamed appendix can rupture in two to three days after symptoms develop and can spill dangerous microorganisms throughout the abdomen. Thus, it is important to see a doctor as soon as possible.

Symptoms of appendicitis vary, and fewer than half of patients have them all. They often start with abdominal bloating and pain around the navel, which then moves to the lower right side of the abdomen and becomes sharp and continuous. The abdomen is likely to be tender to the touch, and a cough, sneeze, sudden movement or deep breath can intensify the pain. Mild fever, nausea and vomiting, diarrhea or constipation may occur.

Such symptoms are a clear warning that requires prompt medical attention. However, a third to a half of people with appendicitis do not have these typical symptoms, making cases like Ms. Deely’s especially challenging.

The appendix is a finger-shaped pouch attached to the large intestine (colon), usually on the lower right side of the abdomen. Long considered a vestigial organ with no known function, many people, young and old, have theirs removed in the course of another operation.

However, there are now indications that the appendix serves as a repository of healthy bacteria that can replenish the gut after an extreme attack of diarrhea. People who have had appendectomies, for example, are more likely to experience recurrent infections with the bacterium Clostridium difficile, a debilitating intestinal infection that causes severe, difficult-to-treat diarrhea.

Appendicitis occurs most often in children and young adults, and more often in men than women, but the risk of rupture is highest in older adults. The estimated lifetime chance of developing appendicitis ranges from 7 percent to 14 percent.

Acute appendicitis is the nation’s most common surgical emergency. It is most often performed laparoscopically, which is associated with faster recovery, less pain and lower risk of infection than an open operation. Some 300,000 people in the United States undergo an appendectomy each year, but sometimes, the appendix turns out not to have been inflamed, meaning the operation was not necessary.

The results of several recent studies suggest that patients with uncomplicated appendicitis should not be rushed into surgery and instead should be offered the option of a trial of antibiotics.

In a controlled study among 540 adult patients, 72.7 percent of 257 patients randomly assigned to take antibiotics in lieu of an operation did not require subsequent surgery a year later, and those who did need surgery had no bad effects from the delay.

In another nonrandomized study of 3,236 patients who were not operated on initially, the nonsurgical treatment failed to cure the appendicitis in 5.9 percent of cases, and the inflammation recurred in 4.4 percent.

Some patients may choose an operation so they won’t have to worry about developing another attack of appendicitis, but if they aren’t told they have a choice, they can hardly make one.

Writing in JAMA last month, Dr. Dana A. Telem, a surgeon at Stony Brook University Medical Center, noted that “the notion of nonoperative treatment of appendicitis has not been well-received by the majority of the surgical community.” This is hardly surprising, because doctors, like many of us, are creatures of habit, and surgeons who don’t operate miss out on a hefty fee.

But Dr. Telem pointed out that under the Affordable Care Act, it may soon become necessary for physicians to inform patients of nonsurgical options, which may include “watch and wait,” as some cases of appendicitis disappear without any treatment, and there may be nothing wrong with the appendix in others.

“Surgeons would be well served to take a leadership role in proactively developing decision aids to inform patients about the benefits and risks for both nonoperative antibiotic treatment and surgical treatment of appendicitis,” Dr. Telem said. She added, however, that the information should include the fact that data on the long-term outcome of nonsurgical treatment is currently lacking.

Also lacking is a large controlled trial in which patients with uncomplicated appendicitis are randomly assigned to antibiotic or surgical treatment and followed for perhaps five or more years. Such a study could define exactly which patients do best with nonoperative therapy and which require immediate surgery.

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In ‘Screenagers,’ What to Do About Too Much Screen Time

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In a scene from the film “Screenagers,” Dr. Delaney Ruston buys her daughter, Tessa, her first smartphone.

In a scene from the film “Screenagers,” Dr. Delaney Ruston buys her daughter, Tessa, her first smartphone.Credit

In the new documentary “Screenagers,” children can’t resist the pull of electronic devices, and parents don’t know what to do about it.

Sound familiar?

The average child in America spends more time consuming electronic media than going to school, with many teenagers going online “almost constantly.” And parents aren’t necessarily being good role models. A British study showed that while six in 10 parents worried that their children spend too much time in front of a screen, seven in 10 children worry that their parents are the ones who are plugged in and tuned out.

Dr. Delaney Ruston, the director of “Screenagers” and a physician serving as filmmaker in residence at Stony Brook Medicine in New York, says that screen time remains a topic that’s often contentious and downright confusing. I spoke with Dr. Ruston about her own family’s messy struggles with digital distractions, and about the surprising insights she learned making this film. Here’s an edited version of our conversation.

Q.

Where did the idea for this documentary come from?

A.

When I started the film, I was a mom having a hard time with my own teenage kids. My 14-year-old son wanted to play more video games, and my 12-year-old daughter was always on social media. I was at a loss. I would suddenly get mad and then feel guilty. I realized speaking with other parents that we all felt paralyzed about our kids and screen overload and that it’s only getting worse.

At the same time, I was seeing more of this issue with my patients. As a primary care doctor, I saw more and more kids of all ages and backgrounds glued to a screen. I felt a real need to understand the science around screen time and kids. And as a filmmaker who has worked on other movies for social change, I wanted to share my journey in order to help others who are struggling with these issues as well.

Q.

What’s the impact of modern technology on our children’s brains?

A.

Excessive use of screens could harm the physical development of young people’s brains. Studies show a correlation between too much screen time and worse attention spans, as well as negative effects on learning. We talk about two really important studies in the the film, one with mice and another with preschoolers.

In the first study, scientists found that when young mice are repeatedly exposed to flashing sounds and lights that mimic screen time, they develop fewer nerve cells in the parts of the brain that control learning and memory. The same stimulus doesn’t affect brains of adult mice. There’s something unique about the way screen time impacts the developing brain.

In the other study with preschoolers, researchers divided 60 kids into two groups. Half watched fast-paced images on screens for about 10 minutes, while the other half drew with crayons in another room. Then all the kids took the same test of cognitive skills. The kids who were exposed to the screens did significantly worse on the exams.

Our current fast-paced digital media, from flash games and online videos, to social media feeds and constant texting, seems to tire the brain. This has major implications for kids and how they reach their full academic potential.

Q.

The movie starts with your almost 13-year-old daughter trying to convince you she needs a smartphone. What’s the big lesson for other parents here?

A.

I want every parent to know two main scientific facts: The first is that the part of the brain responsible for things such as planning, decision-making and impulse control (the frontal cortex) grows slowly over the teen years and is not fully developed until our 20s. The second is that screen time releases the chemical dopamine in the reward centers of the brain, and there is no other time in life when you’re as susceptible to that pleasure-producing chemical than in adolescence.

The worst thing a parent can do is hand over a smartphone and hope for the best. But parents often feel like trying to set limits is pointless, that the cat is out of the bag, tech is everywhere. I hear all kinds of excuses. But kids’ brains aren’t wired to self-regulate. They can’t do it without you, and they shouldn’t have to.

Q.

What should parents do then?

A.

Given the right guidelines, kids can increase self-control over time. And that’s a more important indicator of success than even I.Q. I was really surprised, and you’ll see in the film, kids consistently told me that they want rules around their screen time.

So you have set guidelines. Two of our rules are: No phones in bedrooms at night, and no phone use in the car. We use alarm clocks and talk with each other instead. Those are the easy ones. For the rest of the “rules,” and what you’ll see after a few painful mistakes on my part in the film, is that it’s best to create a contract with your kids’ input.

Q.

It also helps if mom and dad aren’t checking their phone every five minutes.

A.

That’s right. Kids don’t want to be held to a higher standard than their parents, and that’s a big issue. You can’t punish your kids for breaking the rules when you can’t put your own devices down. Also, don’t make rules that don’t make sense, and remember that humans respond better to reward than punishment.

Q.

Speaking of punishment, there’s a part in the movie where a parent is scared of taking away video games because of the huge fights it causes.

A.

Whenever we try to enforce a screen limit there can be a tremendous backlash. Knowing the science behind this behavior helps to understand why kids respond so fiercely in the heat of the moment.

The dopamine we get from screen time is the same chemical released with activities such as drinking alcohol. The many hours of dopamine released with screen-based activities can affect the brain in serious ways. For example, research shows that those who play a lot of video games — about three hours a day — have M.R.I. brain scans that reveal similar patterns as people addicted to drugs.

Q.

You don’t sugarcoat the potential for disaster here.

A.

On any given day, 70 percent of boys are playing video games, and they play close to 2.5 hours a day, seven days a week, 52 weeks a year.

People like to rebut any negative talk about video games with the evidence that some games can improve visual acuity and problem solving. But are we, as parents, as a society, comfortable with kids giving up 15 plus hours of their lives every week for these video games they’re playing? Do you even know what games they’re playing?

Eighty percent of video games have violent content. With these games, the data shows an increased risk in aggressive thoughts and actions. It is not surprising that these games are not increasing thoughts of empathy and generosity — the traits that I would hope as a society we would want to promote.

The good news is that data also reveals that prosocial video games increase the chance that kids will be more helpful to others. Those are the games where you work to help someone, build a community or collaborate with others in a positive way. I just wish the industry would develop more “cool” prosocial games.

Q.

What do you hope happens now that the film is out and people are talking about it?

A.

I want to spark a movement to get everyone, from parents to policymakers, to watch the movie, then have a “town hall” style conversation afterward about how we can best help kids lead more balanced lives. I see this as the first step.