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Time-Delayed Eating Leads to Better Food Choices

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A study of online grocery orders found that people who order several days before delivery make better food choices than those who seek last-minute deliveries.

A study of online grocery orders found that people who order several days before delivery make better food choices than those who seek last-minute deliveries.Credit Yana Paskova for The New York Times

Want to improve your diet? Try time-delayed eating — ordering (or at least choosing) your food long before you plan to eat it.

A series of experiments at Carnegie Mellon University found that when there was a significant delay between the time a person ordered their food and the time they planned on eating it, they chose lower-calorie meals.

What was interesting, researchers said, was that the participants were not making a conscious choice to order less. Most didn’t even realize they were choosing lower-calorie options.

Being less hungry when they ordered the meal accounted for only a small part of the difference, said Eric M. VanEpps, a post-doctoral student at the University of Pennsylvania Center for Health Incentives and Behavioral Economics who led the research while at Carnegie Mellon. The research was published this summer in the journal American Marketing Association.

Dr. VanEpps believes people have what he calls a “bias toward the present,” that alters the calculations they make about something that is occurring momentarily.

“If a decision is going to be implemented immediately, we just care about the immediate consequences, and we discount the long-term costs and benefits,” Dr. VanEpps said. “In the case of food, we care about what’s happening right now – like how tasty it is – but discount the long-term costs of an unhealthy meal.”

On the other hand, when you order a meal in advance, “you’re more evenly weighing the short-term and the long-term costs and benefits,” he said. “You still care about the taste but you’re more able to exert self control.”

The finding is the latest to suggest that timing matters when it comes to healthful eating. When people order groceries online, they are more likely to choose healthier foods when they schedule a delivery date several days away, one study found..

Another study showed that people choosing a snack a week in advance were more likely to pick an apple or banana over a candy bar. When choosing a snack for immediate consumption, they were more likely to choose a candy bar.

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One study showed that people choosing a snack in advance were more likely to pick an apple or banana over a candy bar.

One study showed that people choosing a snack in advance were more likely to pick an apple or banana over a candy bar.Credit Tony Cenicola/The New York Times

The latest research, which focuses on three eating-delay experiments, offers a number of insights that can help us make better choices for eating out.

In the first experiment, 394 employees of a large health care company were asked to place their lunch orders at least 30 minutes before they wanted to pick up their meal. They had the option to place an order as early as 7 a.m. for lunches that were to be picked up between 11 a.m. and 2 p.m. Some people placed their order five hours in advance while others barely made the deadline, placing an order 31 minutes ahead of pickup.

The more hours people planned ahead, the fewer calories they ordered and ultimately consumed. For every hour in advance the participants ordered their meal, they ordered 38 fewer calories. The biggest effect of the time-delay was seen in women.

In another experiment, the Carnegie Mellon researchers recruited more than 1,100 workers and controlled the time delay between ordering and eating. One group of workers at the same company placed their food order before 10 a.m. and had to wait at least an hour before eating. Another group placed its lunch order after 11 a.m., and waited just 30 minutes before eating it. In one arm of the experiment, calorie labels were put on meals containing fewer than 500 calories.

The same pattern ensued: When people ordered lunch longer in advance, they were more likely to choose the meal with less than 500 calories. What was interesting was that they didn’t seem to think they were doing anything unusual and said they would have chosen the same option, regardless.

Did people order more calories later in the morning because they were hungrier? A third experiment attempted to answer this question. The researchers recruited about 200 university students who took classes that ended around lunchtime, and asked them to answer surveys in exchange for a free lunch.

Some students took the survey before their class, while others took it right before receiving their meal. The surveys asked about unrelated issues in order to mask the true purpose of the trial, and gave the students the opportunity to order their meal and also indicate how hungry they were.

Once again, the pattern held: Students who took the survey before their class (and thus placed their food order earlier) ordered lunches containing about 100 fewer calories. The sandwiches they chose were similar in type to those of the students who ordered later, but they were more likely to order bottled water instead of a soda and chose less caloric combinations of fruit and cookies.

Dr. VanEpps isn’t sure advance ordering will work the same way if you are going out for dinner or a celebratory meal. But if businesses or schools want to encourage employees and students to eat healthfully, he said “let them make decisions further in advance.”

But some researchers were skeptical about people’s ability to plan ahead like this on a regular basis.

“This requires a level of organization and forward planning that would be impossible for someone like me,” said Marion Nestle, a professor of nutrition, food studies and public health at New York University. But, she said, “More power to those who can do this!”

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Pretty Girls Are Supposed to Smile

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Credit Jon Krause

“There is no one who has not smiled at least once,” writes Marianne LaFrance, a Yale University psychology professor, in her 2011 book “Lip Service: Smiles in Life, Death, Trust, Lies, Work, Memory, Sex and Politics.” Her book explores how smiling unifies us. Like breath, the smile is universal. We smile to connect, to forgive, to love. A smile is beauty, human.

But I have never smiled. Not once.

I was born with Moebius syndrome — a rare form of facial paralysis that results from damage in the womb to the sixth and seventh cranial nerves, which control the muscles of the face. I was born in Britain, on the same day in 1982 the country’s first test-tube twins were born. But while science has created medical miracles like test-tube babies, there’s little that doctors can do for someone with Moebius syndrome.

Decades later, I still cannot smile. Or frown. Or do any of the infinite subtle and not-so-subtle things with my face that I see others in the world around me doing every day.

Doctors describe people with Moebius as having a “mask-like expression.” And that is what strangers must see. A frozen face, eyes unblinking. My mouth always open, motionless, the left corner of my lips slightly lower than the right. Walking down the street, I can feel the touch of casual observers’ eyes.

A child’s very first “social smile” usually occurs six to eight weeks after birth, eagerly awaited by new parents. Because, as an infant, my face remained so expressionless, when I began laughing it took my mother a while to realize that the sound I was making was laughter. At what point, I wonder, did I begin to compensate for the absence of my smile.

I am constantly touching my own face, making it move with my hands. I like the sensation of my fingertips shifting my otherwise motionless lips. It’s something I’ve done since I was very young.

I remember, age 5, kneeling at my grandmother’s dressing table, while my grandmother, without my noticing her, watched from around the doorjamb. Very quietly, I leaned toward her mirror, my elbows pressing into the cool granite top and, with two fingers, lifted the corners of my mouth into a tiny smile — a smile I only dared to share with my reflection.

This was the beginning of my understanding that I was different.

Not until I was 16 did Granny tell me that she had been watching me that day, saying, “It broke my heart.”

Through childhood and adolescence, I continued secretly “smiling” at myself in the mirror. Seeing the appearance, however awkward, of a smile on my own face helped me feel better about the day-to-day missed connections with others — schoolmates, girls in my ballet class, or adults on queue in the supermarket — who perhaps wanted to see me smile back at them.

Not smiling is about much more than surface image, though. It takes real stamina. To swallow a mouthful of food, for example, I use a few delicately placed fingers to press my lips closed. After swallowing, I try to lower the helping hand so that it looks as though I am merely brushing a stray crumb from my mouth, hoping no one notices that I do this many, many times more than a normal person would.

Going to sleep is another challenge. Because I can’t voluntarily close my eyelids fully, I have to either hold my eyelids closed with my right forefinger and thumb until they stay shut, or lie on my back with a cotton tank top laid over my eyes in such a way that their lids are sealed. Sometimes this gets exhausting. Sometimes I shed tears, and that speeds up the process.

I try to act around my disability. To pass. The one missing gesture I can never fully compensate for, though, is smiling. My body feels the smiles my face has never shown. When I explain to new friends why I don’t — can’t — smile, they say, Wow, that must be really hard. Not really, I lie, by now I’m used to it.

Still, there are moments when I feel the smile my face cannot physically make. It might be while I’m laughing over a shared joke with a friend, or when a child passing on the street smiles up at me. It translates as instantaneous pleasure throughout my whole body — a kind of minute awakening, both within and without. For a long time I wondered whether it showed. But close friends tell me my smile does come through, that they can see my smile.

Yet, recently, an elderly man passing me at a bus stop looked me up and down, caught my eye, and said, “Pretty girls are supposed to smile.”

I was speechless. I shook my head and laughed uncomfortably, hoping he wouldn’t pursue the subject. As he walked away, I remembered a high school photographer cheerily calling “Smile!” just before the blinding white flash. “Smile,” someone says, and again I’m 5 in the mirror, or 16, cringing, trying to do something I cannot do, and waiting for the uncomfortable moment to pass.

Effy Redman, a graduate of Hunter College’s creative writing M.F.A. program, lives in Saratoga Springs, N.Y.

What Are the Purple Dots on Michael Phelps? Cupping Has An Olympic Moment

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Michael Phelps competed in the final of the men’s 4x100-meter freestyle relay during the 2016 Summer Olympics with some strange purple dots on his arm and back.

Michael Phelps competed in the final of the men’s 4×100-meter freestyle relay during the 2016 Summer Olympics with some strange purple dots on his arm and back.Credit Matt Slocum/Associated Press

Have you been wondering why swimmer Michael Phelps and other Olympians are sporting deep-purple circles on their limbs and midsections?

While it may look like the athletes have been in a bar fight, the telltale purple dots actually are signs of “cupping,” an ancient Chinese healing practice that is experiencing an Olympic moment.

In cupping, practitioners of the healing technique — or sometimes the athletes themselves — place specialized, round circular cups on the skin. Then they use either heat or an air pump to create suction between the cup and the skin, pulling the skin slightly up and away from the underlying muscles.

The suction typically only lasts for a few minutes, but it’s enough time to cause the capillaries just beneath the surface to rupture, creating the circular, photogenic bruises that have been so visible on Mr. Phelps as well as members of the U.S. men’s gymnastics team. If the bruising effect looks oddly familiar, it’s because it’s the same thing that happens when someone sucks on your neck and leaves a hickey.

Thanks @arschmitty for my cupping today!!! #mpswim #mp @chasekalisz

A photo posted by Michael Phelps (@m_phelps00) on Sep 10, 2015 at 12:29pm PDT

Physiologically, cupping is thought to draw blood to the affected area, reducing soreness and speeding healing of overworked muscles. Athletes who use it swear by it, saying it keeps them injury free and speeds recovery. Mr. Phelps, whose shoulders were dotted with the purple marks as he powered his 4×100 freestyle relay team to a gold medal Sunday, featured a cupping treatment in a recent Under Armour video. He also posted an Instagram photo showing himself stretched on a table as his teammate, fellow Olympian swimmer Allison Schmitt, placed several pressurized cups along the back of his thighs. “Thanks for my cupping today!” he wrote.

While there’s no question athletes and many coaches and trainers believe in the treatment, there’s not much science to determine whether cupping offers a real physiological benefit or whether the athletes simply are enjoying a placebo effect.

One 2012 study of 61 people with chronic neck pain compared cupping to a technique called progressive muscle relaxation, or P.M.R., during which a patient deliberately tenses his muscles and then focuses on relaxing them. Half the patients used cupping while the other half used P.M.R. Both patient groups reported similar reductions in pain after 12 weeks of treatment. Notably, the patients who had used cupping scored higher on measurements of well-being and felt less pain when pressure was applied to the area. Even so, the researchers noted that more study is needed to determine the potential benefits of cupping.

Another experiment involving 40 patients who suffered from knee arthritis found that people who underwent cupping reported less pain after four months compared to arthritis sufferers in a control group who were not treated. But the cupped group knew they were being treated — it’s not easy to blind people about whether a suction cup is being attached to their leg or not — and so the benefits might have been due primarily to a placebo effect.

Still, a placebo effect can be beneficial, and for athletes at the Olympic level any legal edge, however tenuous, may be worth a few eye-catching bruises.

A few years ago Denver Broncos player DeMarcus Ware posted a photo on Instagram showing his back covered with 19 clear cups as a therapist held a flame used to heat the cup before placing it on the skin. Celebrities including Jennifer Aniston and Gwyneth Paltrow have also been photographed with cupping marks on their skin.

Last year, Swimming World magazine noted that some college programs had begun using cupping therapy as well as former Olympian Natalie Coughlin, who has posted a number of photos of herself undergoing the treatment.

U.S. gymnast Alexander Naddour was sporting the purple dots during the men’s qualifying rounds on Saturday in Rio. He told USA Today that he bought a do-it-yourself cupping kit from Amazon. “That’s been the secret that I have had through this year that keeps me healthy,” Mr. Naddour told USA Today. “It’s been better than any money I’ve spent on anything else.”

The Merits of Reading Real Books to Your Children

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Credit Getty Images

A new Harry Potter book and a new round of stories about midnight book release parties reminded me of the persistent power of words printed on a page to shape children’s lives.

How do we think about a distinct role for paper, for “book-books” in children’s lives? My own pediatric cause is literacy promotion for young children. I am the national medical director of the program Reach Out and Read, which follows a model of talking with the parents of babies, toddlers and preschoolers about the importance of reading aloud, and giving away a developmentally appropriate children’s book at every checkup.

We are talking about very young children here, and we begin by giving out board books which are designed to be chewed and drooled on by babies who are still exploring the world orally, or thrown down (repeatedly) off the high chair by young children who are just figuring out object permanence and experimenting with ways to train their parents to fetch and retrieve. But the most essential attribute of those board books, beyond their durability, is that they pull in the parent, not only to pick them up, but to ask and answer questions, name the pictures, make the animal noises.

I love book-books. I cannot imagine living in a house without them, or putting a child to bed in a room that doesn’t have shelves of books, some tattered and beloved, some new and waiting for their moment. It’s what I wanted for my own children, and what I want for my patients; I think it is part of what every child needs. There’s plenty that I read on the screen, from journal articles to breaking news, but I don’t want books to go away.

I would never argue that the child who loves to read is worse off because those “Harry Potter” chapters turn up on the screen of an ebook reader rather than in those matched sets of thick volumes that occupy my own children’s shelves. (Although I think there’s something wonderful about looking at the seven books of the series and remembering a midnight party in a bookstore or two, and sometimes coming home from high school or college and taking one — or all seven — to bed with you.)

But what about the younger children, the ones who are working to master spoken language while taking the early steps in their relationships with books and stories? There’s a lot of interest right now in pediatrics in figuring out how electronic media affect children’s brains and children’s learning styles and children’s habits.

In a 2014 review of studies on electronic storybooks, researchers outlined some of the ways that such stories could help young children learn, and some of the ways that they could hurt. They pointed out that especially for children with language delays, certain features of electronic books that reinforce the connection between image and word (for example, animated pictures) may help children integrate information, but that distracting features and games may cause “cognitive overload,” which gets in the way of learning. And they worried, of course, that screen time might displace parent-child time.

Dr. Jenny Radesky, a developmental behavioral pediatrician and assistant professor of pediatrics at the University of Michigan at Ann Arbor, is one of the authors of the coming American Academy of Pediatrics policy statement on media use for children from birth to age 5. “Preschool children learn better when there’s an adult involved,” she said. “They learn better when there are not distracting digital elements, especially when those elements are not relevant to the story line or the learning purpose.”

In a small study published in February in JAMA Pediatrics, researchers looked at the interactions between parents and their children, ages 10 to 16 months, and found that when they were playing with electronic toys, both parents and children used fewer words or vocalizations than they did with traditional toys. And picture books evoked even more language than traditional toys.

Words and pictures can do many things for the reader’s brain, as we know from the long and glorious and even occasionally inglorious history of the printed word. They can take you into someone else’s life and someone else’s adventure, stir your blood in any number of ways, arouse your outrage, your empathy, your sense of humor, your sense of suspense. But your brain has to take those words and run with them, in all those different directions. Brain imaging has suggested that hearing stories evokes visual images in children’s brains, and more strongly if those children are accustomed to being read to.

And a parent can offer questions and interpretations that take the experience beyond bells and whistles. “A parent can ask, ‘Oh, remember that duck we saw at the pond?’,” Dr. Radesky said. “When a parent relates what’s on the page to the child’s experience, the child will have a richer understanding.”

Story time can also be good for the grown-ups. “Parents have said to me, ‘I need that 30 minutes of reading, it’s the only time my child snuggles with me,’ ” Dr. Radesky said. “We shouldn’t only think about what the child is getting from it.”

Part of what makes paper a brilliant technology may be, in fact, that it offers us so much and no more. A small child cannot tap the duck and elicit a quack; for that, the child needs to turn to a parent. And when you cannot tap the picture of the horse and watch it gallop across the page, you learn that your brain can make the horse move as fast as you want it to, just as later on it will show you the young wizards on their broomsticks, and perhaps even sneak you in among them.

Reading and being read to open unlimited stories; worlds can be described and created for you, right there on the page, or yes, on the screen, if that is where you do your later reading. But as those early paper books offer you those unlimited stories, the pictures will move if you imagine the movement; the duck will quack if you know how to work your parent. It’s all about pushing the right buttons.

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Dementia Patients Hold On to Love Through Shared Stories

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Credit Paul Rogers

Can you keep the love light shining after your partner’s brain has begun to dim? Just ask Denise Tompkins of Naperville, Ill., married 36 years to John, now 69, who has Alzheimer’s disease.

The Tompkinses participated in an unusual eight-week storytelling workshop at Northwestern University that is helping to keep the spark of love alive in couples coping with the challenges of encroaching dementia.

Every week participants are given a specific assignment to write a brief story about events in their lives that they then share with others in the group. The program culminates with a moving, often funny, 20-minute written story read alternately by the partners in each couple in front of an audience.

Each couple’s story serves as a reminder of both the good and challenging times they have shared, experiences both poignant and humorous that reveal inner strength, resilience and love and appreciation for one another that can be easily forgotten when confronted by a frightening, progressive neurological disease like Alzheimer’s.

“It’s been an amazing experience for us,” Mrs. Tompkins said of the program. “Creating our story revealed such a richness in our life together and is helping us keep that front and center going forward.”

She added that the program provides “an opportunity to process what you’re going through and your relationship to each other. It helped me digest all the wonderful things about John and how well we relate as a couple, things that don’t go away with Alzheimer’s disease. John is so much more than his disease.”

Ditto for Robyn and Ben Ferguson of Chicago, married 42 years in 2012 when they learned that Ben, a psychologist, had Alzheimer’s disease. “The diagnosis was crushing,” said his wife, who is also a psychologist. “Telling people in the program about it helped us recognize the impact on our lives and relationship and really face that. It made things feel not quite so bad.”

The Fergusons have publicly presented their 20-minute story together 19 times so far, helping to enlighten medical students and those training in social work and pastoral care, as well as researchers and members of the general public. “It reinforces our relationship as a couple, rather than caregiver and patient, even though he is 85 percent dependent on me for the activities of daily living.”

Dr. Ben Ferguson, now 69, said, “I feel we’re giving people information that could be very valuable in their future. It’s helpful to them to see us smile, have a good time and give a good report – as well as a bad report – about what goes on with this disease. It’s helpful for people to hear it from someone who has it, and it’s helped us avoid getting so morose.”

As for their presentations, which they now give almost monthly, his wife said, “They help us stay positive and give us a sense of purpose. We both feel a real need to do advocacy work, and this is the best thing we can do right now. We know there’s a sell-by date on this – we won’t be able to do it forever. But we don’t think about that now. Now we’re focused on helping people understand that your life doesn’t stop with the diagnosis. We want people to hear that you go on with your life, even though you may need a lot of help.”

Another workshop participant, Sheila Nicholes, 76, of Chicago, said of her husband, Luther, who has vascular dementia, that the storytelling “brings him back to being funny again. Writing our story together gave us a way to talk about these things, to think about where we were then and where we are now.”

Noting that dementia is “a very hush-hush illness in our black community,” Ms. Nicholes said she hoped that telling their story would help others speak more openly about it and learn to “just roll with the flow.”

The storytelling workshop, which started in January of 2014, was the brainchild of Lauren Dowden, then an intern in social work at Northwestern’s Cognitive, Neurological and Alzheimer’s Disease Center. She quickly learned from family members in a support group that “their concerns were not being addressed about dealing with loss, not just of memory, jobs and independence, but also what they shared as a couple.”

During the group sessions, Ms. Dowden said, “there’s so much laughter in the room, so much joy and love of life as well as poignancy and tears. As they move forward, as the disease progresses, they can be reminded of who they are, their strength and resilience, what has made their relationship strong, what they loved about the person, as opposed to just being patient and caregiver.”

As the program moves week to week, Ms. Dowden said, “there’s more touching, affection, looking at one another and laughing. There are delightful moments of connection when one member of a couple reveals something the other didn’t know.”

The weekly story assignments require that the couple collaborates, “and they learn how to work together in new ways, how to make adjustments, because they’ll have to make thousands and thousands of adjustments throughout the course of the disease.”

In executing the workshop assignments, Dr. Ferguson said she would ask her husband questions, he would answer and she would write down what he said. “The workshop was really transformative,” she said. “It gave us hope for our future together in dealing with this disease.”

Ms. Dowden said the feedback from those in the audience for the 20-minute joint stories has been heartening. She explained, “Students learn about the biology of neurodegenerative conditions. These stories enable them to see the human side of the disease, what it’s like to live with it, and may help them develop programs that help these families live better. In addition to the stigma, there’s a tendency to write off people with dementia.”

Ms. Dowden said she is currently refining the workshop curriculum so that it can be used as a model for other institutions to replicate. She is also expanding it to include mother-daughter and sibling pairs.

She realizes, of course, that a storytelling workshop may not be suitable for every couple. “It’s not good if there’s a lot of behavioral issues, a lot of conflict, and no insight,” she said. “But for those it does fit, it’s an opportunity to tap into the core of relationships, to still grow and learn and be delighted by one another.”

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Think Like a Doctor: The Boy With Nighttime Fevers Solved!

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Credit Andreas Samuelsson

On Thursday we asked Well readers to take on the case of a 7-year-old boy who’d been having fevers and drenching sweats nightly for over a month. More than 300 of you wrote in, and although 20 of you came up with the right diagnosis, only three of you figured out both the diagnosis and the test needed to confirm it.

The correct diagnosis is…

Coccidioidomycosis, or valley fever.

The diagnosis was made based on a lymph node biopsy.

The first reader to suggest this diagnosis and the test was Dr. Malkhaz Jalagonia, an internist from Zugdidi, in the Republic of Georgia. He says he’s never seen a case like this, but he’s fascinated by zebras and so recognized the disease immediately. Well done, Dr. Jalagonia!

One of the reasons I chose this case was that, although this diagnosis is rare in life, it was the most frequently suggested diagnosis in my last column – the one about the middle-aged man with a cough for over a year. I thought it would be fun to show what valley fever really looks like. Hope you did too.

The Diagnosis

Coccidioidomycosis is a lung infection usually caused by inhaling the spores of a tiny fungus called coccidioides. This organism grows as a mold, a few inches below the surface of the soil in deserts in parts of the southwestern United States, Mexico and other countries of Central America.

In dry conditions, the fungus becomes fragile and is easily broken up into tiny single-celled spores that can be sent airborne with even the slightest disturbance. And once these single cells are aloft they can remain suspended there for prolonged periods of time.

Infection is usually acquired by inhaling the spores. Once lodged in the lung, the organism begins to reproduce almost immediately. The time course between exposure and disease depends on the inhaled dose and the patient’s immune system.

Symptoms, or No Symptoms

Disease severity varies considerably. Nearly half of those who breathe in these spores have no symptoms, or symptoms are so mild they never visit the doctor’s office.

More severe infection usually takes the form of a slowly progressive pneumonia known as coccidioidomycosis, or valley fever. This illness is characterized by a cough, fevers, chest pain, fatigue and sometimes joint pain. Indeed, because of the prominent joint pain, in some cases — though not this one — the disease is also known as desert rheumatism.

Rashes are also seen in many patients. Those who get a rash seem to have a more benign course of illness. The thinking is that the skin symptoms are the result of an aggressive immune response in the host to the pathogen.

Symptoms can last for months, and in many cases they resolve without treatment. But in some cases they get worse.

Hard to Diagnose

Those who seek medical attention are often not diagnosed — or not diagnosed quickly — because the symptoms of valley fever are not very specific, and few of the tests that doctors usually order have features that are unusual enough to suggest the diagnosis.

Chest X-rays are often normal. Blood tests may be normal as well, though some patients, like this child, have an unusually high number of a type of white blood cell known as eosinophils. These cells are usually seen in allergic responses or with infections due to parasites.

The most important clue to the possibility of this infection is travel to one of the areas where the fungus lives. In the United States, valley fever is endemic primarily in Arizona and southern California, as well as parts of southern New Mexico and West Texas. Indeed, the name valley fever is a shorter and more general term for an earlier name, San Joaquin Valley fever, because it was so common in that part of California.

A Dramatic Rise

There has been a significant increase in the number of cases of coccidioidomycosis in the past 15 years, with nearly 10 times as many in areas where the fungus is found. Development in areas where the fungus is endemic is thought to be the primary cause. Better diagnostic testing may also play a role.

While this infection may cause only a minor illness in many, there are some – like this child – for whom the disease can spread beyond the lungs into the rest of the body. Disseminated coccidioidomycosis is usually seen in those with some problem with the immune system – an underlying disorder such as H.I.V., for example, or because someone is taking immune suppressing medications such as prednisone.

Once out of the lungs, the bugs can go anywhere in the body, though they seem to prefer joints, skin or bones. Those with disseminated disease have to be treated for a long time – often up to a year, or occasionally for life.

How the Diagnosis Was Made

The little boy had been sick for nearly a month, and his parents were getting quite worried. He was pale, thin and really, really tired.

With their pediatrician’s encouragement, they had gone on a long planned, much anticipated vacation to the mountains of Colorado. But the child wasn’t getting better, and so his mother took him to yet another doctor – this one in a walk-in clinic.

The results of some simple blood tests done at that visit worried the doctor, who suggested that the boy be taken to a hematologist, a specialist in diseases and cancers of the blood.

Now the parents were terrified. The mother faxed copies of the lab results to her brother, a researcher in immunology. He wasn’t a physician but showed the results to friends who were. They agreed with the doctor at the walk-in clinic: The boy needed to be seen by a hematologist.

A Series of Specialists

The next morning the family headed home to Minneapolis. They took the boy to his regular pediatrician, who sent them to a hematologist. It wasn’t cancer, that specialist told them. Maybe some kind of severe food allergy, he suggested, and referred them to a gastroenterologist.

Not a GI thing, that specialist told them, and he referred the now nearly frantic family to an infectious disease specialist and a rheumatologist.

Nearly 10 days after getting the alarming blood test results, the couple and their child found themselves in the office of Dr. Bazak Sharon, a specialist in infectious diseases in adults and children at the University of Minnesota Masonic Children’s Hospital. After introducing himself, Dr. Sharon settled down to get a detailed history of the boy and the family.

A Desert Visit, but Other Possibilities

When Dr. Sharon heard that the family had spent a week at a ranch in the desert of Arizona, he immediately thought of coccidioidomycosis. The fungus isn’t found in Minnesota or Colorado – which is probably why other doctors hadn’t considered it. But it is all over the part of Arizona where they’d visited.

Still, there were other possibilities that had to be ruled out, including some types of cancer. After Dr. Sharon examined the boy, he sent the family to the lab for a chest X-ray and some blood tests.

The results of those tests were concerning. The child was getting worse. Dr. Sharon wasn’t going to be back in clinic for a week, and he was certain the child needed to be seen and diagnosed well before then. He called a friend and colleague who was taking care of patients in the hospital, Dr. Abraham Jacob, and asked if he would admit the child and coordinate the needed diagnostic workup for the boy.

First Some Answers, Then More Questions

Once in the hospital, the child had a chest CT scan. The results were frightening. The lymph nodes that surround the trachea, the tube that carries inspired air to the lungs, were hugely enlarged. They were so big that the trachea was almost completely blocked. The opening at one point was just two millimeters wide – basically the dimensions of a cocktail straw. Any worsening of his disease might cause the tube to close completely, making breathing impossible.

A pediatric surgeon was brought in immediately. The enlarged lymph nodes had to be removed. First in order to protect the child’s airways. And second because those nodes would reveal what the little boy had.

But trying to do surgery on a 7-year-old boy’s neck was complicated. Although the surgeon could easily feel the enlarged gland in his neck, it was close to many vital blood vessels, nerves and organs. The child had to lie perfectly still, and with most children that could only be guaranteed if they were under anesthesia.

Risky Surgery

When the anesthesiologist saw the CT scan, the doctors’ concern grew. They could put the child to sleep, but if anything went wrong during surgery and they had to put a tube down his throat into his lungs, they weren’t sure it would be able to fit.

The trachea was so small, there was no guarantee they could get the tube into place. In order to do this safely, they said they needed to use a technique known as ECMO, or extracorporeal membrane oxygenation – basically a machine that allows them to oxygenate blood without sending it to the lungs.

Rather than subject the child to this risky procedure, Dr. Jacob and the surgeon decided to just take a piece of the lymph node out in order to make the diagnosis. Treatment of whatever the boy had would bring the size of the lymph node down.

Don’t Make a Move

When the boy was brought to the procedure room, the surgeon explained that he was going to put numbing medicine all around the bump in the boy’s neck and take out a piece of it. The child listened calmly and agreed.

He wasn’t to move at all, the surgeon explained. The child nodded solemnly. He understood. The boy was remarkably mature and so brave throughout the entire process of anesthetizing the region that the surgeon thought he might be able to continue and get the entire node out.

He paused in his surgery and consulted the parents. Would they allow him to try this? Their son was doing so well he was sure he could get it. They agreed, and the surgeon returned to his task. The lymph node came out without difficulty.

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It was sent to the lab and the answer came back almost immediately. The swollen tissue was filled with the tiny coccidioides. You can see a picture of these little critters here.

A Year of Medicine

The boy was started on an intravenous medicine for fungal infections. Then after a week it was changed to one he could take by mouth.

Because the infection had spread beyond the lungs, the child will have to take this medication for a year. After starting the medication, the child began to look a little better. Slowly he was less tired. Slowly he started to eat the way he used to.

It was a long road to the diagnosis, and an even longer road to cure, but at least they were on the right one.

A Perfect Storm?

The mother called the ranch in Arizona where they stayed to let them know what had happened.
The owner told them that their son was not the only person visiting then who got sick. At least one other guest, there at the same time, had come down with the disease.

Apparently the conditions for spread were perfect. Their stay had started off with some rain, followed by heat and some brisk wind. The moisture helped the fungus grow; the heat dried it out so that it could become easily airborne and inhaled when lifted by the wind.

Although the family has loved their visits to this ranch – this was their second year – the child’s mother tells me that she’s not sure she’ll be going back, at least for a couple of years. Most people exposed to valley fever become immune forever, but because her little boy was so very sick, she’s planning to wait a while before they return.

My Brother, the Hospice Graduate

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Credit Giselle Potter

When I was a college sophomore living in a sorority house at the University of California at Santa Barbara, my parents called to tell me that my baby brother, Gavin, was dying. He had been given a diagnosis of a very rare disease, Aicardi–Goutieres Syndrome.

The doctors immediately placed him in hospice care.

He was 4 months old.

I hung up the phone and rode my red beach cruiser to class, trying to pretend that it was like any other day. I sat through Spanish class, but stared off into the distance, numb to what was happening. When I emerged, the sun seemed too bright. People were laughing, talking on their phones, surfing waves at sunset and meeting up with dates at coffee shops.

I thought back to Gavin’s birth in June. He looked like the rest of the babies in our family, with a thick pad of blond hair. A happy baby. Then at 6 weeks old he started having fevers of 104. They turned into weeklong affairs. And no one knew why.

My parents and Gavin’s doctors tried, for the next few months, to solve a seemingly unsolvable case. We just wanted to know what was wrong. But when we finally had the right diagnosis, it was awful. His disease had triggered brain calcifications, causing permanent brain damage. He was going to lose his motor skills and be unable to eat, so he would eventually die, we were told.

At first, I wanted to avoid dealing with the situation. The playground feeling of my oceanfront college campus was in stark contrast to the atmosphere at home, where my devastated family waited, heartbroken. My impulse was to stay away. I didn’t want to be crushed by the grief that was promised to me.

But I also knew I couldn’t live with myself if I never tried to face it. So I dropped out of college and spent every day with him and the rest of my family, including my sisters, who were 9 and 14 at the time.

Gavin’s disease showed up like Louisiana rainstorms — quick, strong and mean. Sometimes he was the handsome baby who smiled at me with his innocent blue eyes. Then, it was as if he was gone. Possessed. His fevers were now paired with jitters and vomiting. Gavin would shriek uncontrollably, turn a pasty gray and roll his eyes in different directions.

Mom called these visits from the Monster.

The hospice nurses stopped by every week to check Gavin’s temperature and weigh him. There was no handbook on learning to love your dying baby brother, but eventually, I did. Instead of hiding from the Monster — when his body shook, his lips turned jelly purple, and drool spilled from his mouth — I looked at him and said: You are worth it.

With his impending death sentence, Gavin was baptized in an oversize white gown. Mom wanted his soul to be protected.

After the ceremony, we played a slideshow of his short life. I saw a picture of me holding him and thought to myself, how could I not love you? We all loved him, the best way we knew how.

My parents did not give up on him, even though he was on hospice. A major change came when a friend of my mom’s who was an occupational therapist suggested the Haberman bottle, a baby bottle with an elongated nipple for children with special needs. Part of the reason Gavin was in hospice care was that he could no longer breast-feed and it was hard to get him nutrients. But he took pumped breast milk through that bottle.

And somehow his demise never came.

On Gavin’s first birthday he was taken off hospice: a hospice graduate.

The journey shifted. Instead of waiting for a baby to die, we were learning to love and live with a handicapped boy.

Now, Gavin is 9 years old. He is a quadriplegic; he cannot walk, talk or eat solid foods, but he is a survivor. He is joy.

That doesn’t mean his life is easy – for him or for the rest of the family.

Every morning one of my parents carries him downstairs around 7 a.m. They sit him in an egg-shape chair in front of the TV to watch cartoons, usually “SpongeBob” (he’s graduated from “Sesame Street”). His breakfast usually involves bran cereal for digestion, a fried egg, a couple of blueberries, maybe a waffle, sometimes crispy pork sausage. All of that is put into a coffee cup with whole milk and butter, and puréed with an immersion blender.

Gavin’s three epilepsy medications get pulled into plastic syringes. Then the hero of the morning carries a tray, with a handful of towels and a water cup, along with the delicious breakfast surprise and medicine into the TV room, and the real work begins.

Feeding Gavin can take up to an hour. And it can be messy. Sometimes he spits up his food, other times he is just not feeling well and he lets it roll down his chin, onto his neck.

Gavin’s life includes physical therapy, occupational therapy and speech therapy. But it also includes floating in the pool in a life vest, going to school and even gleefully crossing the finish line in a marathon – with my husband pushing him in a stroller.

Instead of dismantling our family, he has brought us closer together. We treasure Gavin’s small accomplishments, whether that is running down the driveway in his special gait-training walker or using an eye-gaze communication device or nodding to let us know that he wants to use the bathroom, play with his sister or bounce on the trampoline.

We don’t know what his future looks like. But we don’t know what the future looks like for any of us. The mystery of his life is no different from any of ours.

Courtney Lund is working on a memoir about her brother.


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Weight Has Greater Impact on Diabetes Than Heart Disease

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Carrying excess weight may have a greater impact on the risk for diabetes than it does on the risk for heart disease or early death, a new study has found.

To look at the effect of obesity independent of genetics, Swedish researchers followed 4,046 pairs of identical twins whose average age was 58. One of the twins was overweight, and the other was not. Since identical twins have the same genes, their weight difference could not be attributed to genetics. The study is in JAMA Internal Medicine.

After accounting for physical activity, smoking and educational level, the researchers found that having a higher body mass index, or B.M.I. — even among those in the obese range of 30 or higher — was not associated with an increased risk for heart attack or death. But a high B.M.I. was associated with an increased risk for diabetes.

“Based on these results, the association between obesity and cardiovascular disease is explained by genetic, not environmental, factors,” said the lead author, Peter Nordstrom, a professor of geriatric medicine at Umea University. “Unfortunately, this also means that environmental factors that reduce obesity do not reduce the risk of cardiovascular disease or death. But they most certainly decrease the risk for diabetes.”

Think Like a Doctor: The Boy With Nighttime Fevers

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Credit

The challenge: A healthy 7-year-old boy suddenly starts having fevers and night sweats. Can you figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult medical case and solve a diagnostic riddle. This month we present the case of a boy who has fevers topping 102 degrees every night for over a month. His parents sought help from nearly a dozen doctors in two states before a diagnosis was made.

Below I’ve given you the information that was available to the doctors who figured out the cause of the boy’s fevers. It’s up to you to use this information to put his story together for yourself.

As usual, the first person to crack the case gets a copy of my book, “Every Patient Tells a Story,” and, of course, that fabulous feeling you get when you solve a really tough puzzle.

The Patient’s Story

“I think you need to take him back home.” Her brother’s voice was calm, but she could hear an undertone of anxiety even over the poor cellphone reception that was all she could get from rural Colorado. “He needs to see a hematologist. It could be a virus, but it could also be something else.” He didn’t say it, but she knew what he was thinking: cancer.

Her son, just 7 years old and always a little delicate, had been sick for nearly a month. He was fine during the day, but every night he’d spike a fever of 102 or 103.

Even before they’d come to the mountains for a much needed vacation, she’d taken him to see his pediatrician at home in Minneapolis several times. At each visit, the doctor or one of his partners had looked the boy over closely, and each time he’d seemed fine.

It was probably viral, she was told, time after time. But he seemed to be having one viral infection after another.

A Vacation Cut Short

The day before they left for Colorado, the boy’s father took him to the doctor’s office one more time.

Maybe it wasn’t viral, the pediatrician acknowledged, and prescribed a “Z-pak” — a five-day course of azithromycin. Don’t cancel the trip, the doctor reassured him. He’ll get better.

But he hadn’t. While on vacation, his mother took him to a walk-in clinic, where they’d checked his blood. A worried looking doctor told her that he didn’t know what was wrong with her boy. He should probably see a cancer specialist.

Now she was really worried. There weren’t any specialists anywhere near the bucolic town where they were staying. That’s when she’d sent the test results to her brother, a researcher in immunology. He wasn’t a doctor, but he passed the results to friends who were, and they were worried, too.

Thin and Pale

The family headed home right away, but the 4th of July was coming. They couldn’t get in to see a hematologist until Tuesday.

By now the boy was starting to look sick. He was pale and had dark circles under his eyes. Small for his age — consistently in the fifth percentile for height and weight — he now looked even smaller, thinner. He was a quiet child, always had been. Thoughtful and comfortable in the company of adults, as so many only children are. Even now he never complained.

Nothing hurt. He was simply tired. His fevers started coming a little earlier, peaking a little higher. His mother noticed a cough and wheezing sometimes. Always a picky eater, with these intermittent fevers, very few foods seemed appealing. She tried to hide the terror she felt when he seemed to be fading as she watched.

A Long Line of Specialists

The hematologist examined the boy and sent off more blood. Definitely not cancer, he said. He suggested seeing a gastroenterologist.

The gastroenterologist got an M.R.I. of the child’s digestive system. Nothing there. He noticed the boy’s wheezing and gave him an inhaler, then referred mother and child to a rheumatologist and an infectious disease specialist.

It seemed to the parents that this had to be an infection, but the earliest they could get in to see the infectious disease doctor was the following week. For the boy’s mother, the delay now seemed intolerable.

It had been five weeks since the fevers first started. In that time, the boy had lost nearly 10 pounds. They’d seen eight doctors in two states. They’d all been very nice, thorough, thoughtful, but had no answers.

By the weekend she was desperate. The boy needed to be in the hospital. Couldn’t they see how sick he was? She couldn’t wait for the specialist. She took him to the emergency room of the big university hospital.

The E.R. doctors, like all the doctors they’d seen so far, were kind and thoughtful, and so gentle with her delicate son. But like all the other doctors, they had no answers. They prescribed another inhaler for the boy’s wheezing, since the first hadn’t helped. They also urged her to see the infectious disease specialist. His appointment was just a couple of days away.

TB or not TB?

The boy was sitting quietly between his parents watching a video on his tablet when Dr. Bazak Sharon and the infectious disease fellow he was training entered the exam room. Dr. Sharon’s first thought was that the child looked as if he had tuberculosis.

He’d seen a lot of TB in this clinic, but it was usually among immigrant families who had traveled to Minneapolis from countries where the disease was common. Like this boy, kids with TB were usually thin, sickly looking, pale and quiet. But based on what his fellow told him, the child had no exposures that would put him at risk for this disease. He’d only been out of the country once – to Canada. He’d visited the beaches of South Carolina and the deserts of Arizona, and most recently the mountains of Colorado. But TB was rare in all these locales.

Dr. Sharon introduced himself to the child, who looked up immediately and smiled. How do you feel, he asked the boy? His temperature had been recorded at 103 degrees. I feel good, he’d answered pleasantly. Does anything hurt? No.

His heart was beating rapidly – nearly 140 beats per minute, but that was probably due to the fever. There were several enlarged lymph nodes in the child’s neck and his groin, though none under his arms. Otherwise his exam was unremarkable.

Getting Worse

Dr. Sharon had reviewed the blood tests that had already been done but wanted to see if anything had changed. And given that the only localized complaint was cough and wheezing, he wanted to get another chest X-ray.

Reviewing those studies that night, Dr. Sharon saw that the boy was slowly getting worse. He saw patients at that clinic only once a week and was reluctant to wait that long before having him seen again. He thought they needed an answer much sooner than that.

You can see the note from Dr. Sharon and his fellow here.

Dr. Sharon’s Note

The note from the patient’s visit to the hospital.

To the Hospital

Dr. Sharon called the family the next morning. He’d reached out to one of his friends and colleagues, Dr. Abraham Jacob, who could see them. They should go to the University of Minnesota Medical Center Fairview, where Dr. Jacob would orchestrate a thorough workup. That would be the fastest way to get an answer.

Based on the assessment by Dr. Jacob and his resident and the recommendations from Dr. Sharon, the team reached out to specialists in hematology-oncology and in rheumatology. And since his chest X-ray was abnormal and he had enlarged lymph nodes, they wanted to get a CT scan as well.

You can see the note from Dr. Jacob and his resident here.

Dr. Jacob’s Notes

Here are the notes from the pediatrics department.

Breathing Through a Straw

It was the results of the CT scan that really got things moving. It was the middle of the day when the resident was paged by the radiologist. The pictures showed that the lymph nodes in the boy’s chest were so swollen that they were pressing on the trachea – the breathing tube – so that it was almost completely cut off. Essentially he was breathing through the equivalent of a cocktail straw.

Any additional swelling could cut off the boy’s breath completely. You can see an image from the CT scan here.

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This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.

This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.Credit

A normal trachea in a child this age is four to six times the size seen in the scan. The image added even more pressure to make a diagnosis and treat the child before he got sicker.

Solving the Mystery

A diagnosis was made within the next 24 hours. Can you figure out what the boy had, and how the diagnosis was made?

The first person to offer the correct answers to these two questions will get a copy of my book and that sense of triumph that comes from nailing the right diagnosis when it really matters.

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

Running for Your Past and Future Self

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Speed Goggles: Someday

For professional runners, the time before a race is when you think about where you’ve come from and where you’re going.

By JEREMY TEICHER on Publish Date August 3, 2016.

Before a big race, I always feel more sensitive than usual. I feel as if I could cry any minute and also never cry again. I feel nervous. I notice the texture of the grass on the warm-up field more than I usually do — I also sense my heartbeat more than on a normal day when I don’t notice it at all. Stray frizzy hairs tickle the back of my neck. I try my best to keep the thoughts positive and productive and inspiring. Or at least distracting in a good way. When I step on the starting line, I will need to be razor-focused and entirely present – more so than any other time in my life. But on the warm-up field, it is perfectly fine — in fact, encouraged — to daydream.

“Speed Goggles” is a five-part series created by Alexi Pappas and Jeremy Teicher, who also created the feature film “Tracktown.” Ms. Pappas will be competing in the 2016 Olympics for Greece.

Watch: “The Elite Runner.” | “Normal People” | “Nightmares Mean You Care.” | “Group Run.”

Exercise May Ease Hot Flashes, Provided It’s Vigorous

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Credit Getty Images

Hot flashes are a lamentable part of reaching middle age for many women. While drug treatments may provide relief, two new studies suggest that the right type of exercise might lessen both the frequency and discomfiting severity of hot flashes by changing how the body regulates its internal temperature.

As estrogen levels drop with the onset of menopause, many women become less adept, physiologically, at dealing with changes to internal and external temperatures. The result, famously, is the hot flash (also known as a hot flush), during which women can feel sudden, overwhelming heat and experience copious sweating, a problem that in some cases can linger for years.

Hormone replacement therapy can effectively combat hot flashes, and antidepressants may also help, though drug treatments have well-established side effects. Weight loss also may lessen hot flashes, but losing weight after menopause is difficult.

So researchers at Liverpool John Moores University in England and other institutions recently began to consider whether exercise might help.

Endurance exercise, after all, improves the body’s ability to regulate temperature, the scientists knew. Athletes, especially those in strenuous sports like distance running and cycling, start to sweat at a lower body temperature than out-of-shape people. Athletes’ blood vessels also carry more blood to the skin surface to release unwanted heat, even when they aren’t exercising.

If exercise had a similar effect on older, out-of-shape women’s internal thermostats, the scientists speculated, it might also lessen the number or the intensity of their hot flashes.

Previous studies examining exercise as a treatment for hot flashes had shown mixed results, the scientists knew. However, many of those experiments had been short term and involved walking or similarly light exercise, which might be too gentle to cause the physiological changes needed to reduce hot flashes.

So for the two new studies, one of which was published in the Journal of Physiology and the other in Menopause (using the same data to examine different aspects of exercise and hot flashes), the researchers decided to look at the effects of slightly more strenuous workouts.

They first recruited 21 menopausal women who did not currently exercise but did experience hot flashes. According to diaries each woman kept for a week at the start of the study, some women were having 100 or more of them each week.

The scientists also measured each woman’s general health, fitness, blood flow to the brain (which affects heat responses) and, most elaborately, ability to respond to heat stress. For that test, researchers fitted the women with suits that almost completely covered their bodies. The suits contained tubes that could be filled with water. By raising the temperature of the water, the scientists could induce hot flashes — which typically occur if an affected woman’s skin grows hot — and also track her body’s general ability to deal with heat stress.

Fourteen of the women then began an exercise program, while seven, who served as controls, did not. (This was a small pilot study, and the researchers allowed the women to choose whether to exercise or not.)

The sessions, all of them supervised by trainers, at first consisted of 30 minutes of moderate jogging or bicycling three times a week. Gradually, the workouts became longer and more intense, until by the end of four months the women were jogging or pedaling four or five times per week for 45 minutes at a pace that definitely caused them to pant and sweat.

They also, in the last of those 16 weeks, kept another diary of their hot flashes.

Then they returned to the lab to repeat the original tests.

The results showed that the exercisers, unsurprisingly, were considerably more aerobically fit now, while the control group’s fitness was unchanged.

More striking, the women who had exercised showed much better ability to regulate their body heat. When they wore the suit filled with warm water, they began to sweat a little earlier and more heavily than they had before, showing that their bodies could generally dissipate heat better.

But at the same time, during an actual hot flash induced by the hot suit, the exercisers perspired less and showed a lower rise in skin temperature than the control group. Their hot flashes were less intense than those of the women who had not worked out.

Probably best of all from the standpoint of the volunteers who had exercised, they turned out to have experienced far fewer hot flashes near the end of the experiment, according to their diaries, with the average frequency declining by more than 60 percent.

These findings strongly suggest that “improvements in fitness with a regular exercise program will have potential benefits on hot flushes,” said Helen Jones, a professor of exercise science at Liverpool John Moores University, who oversaw the new studies.

Precisely how exercise might change a women’s susceptibility to hot flashes is still not completely clear, although the researchers noted that the women who exercised developed better blood flow to the surface of their skin and to their brains during heat stress. That heightened blood flow most likely aided the operations of portions of the brain that regulate body temperature, Dr. Jones said.

The cautionary subtext of this study, though, is that to be effective against hot flashes, exercise probably needs to be sustained and somewhat strenuous, she said. “A leisurely walk for 30 minutes once a week is not going to have the required impact.”

Are You Ready to Eat Your Natto?

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Ann Yonetani makes natto, a fermented soybean food popular in Japan, in Queens, N.Y.

Ann Yonetani makes natto, a fermented soybean food popular in Japan, in Queens, N.Y.Credit

Does a stinky, fermented soybean condiment belong on your plate? Ann Yonetani, a microbiologist turned food entrepreneur, thinks so.

The preparation, called natto, has a mild, earthy taste and looks like a mishmash of tiny brown jelly beans suspended in white goo. It is popular in many parts of Japan but has yet to catch on in most other places. Dr. Yonetani, who teaches food science at the New School, founded NYrture Food last year to introduce natto to New Yorkers, calling it one of the most potent sources of healthful bacteria there is.

Bacteria have not traditionally been something we wanted in our foods. Increasingly, though, researchers like Dr. Yonetani, a Columbia-trained specialist in cell reproduction, believe that in our quest to avoid germs, we have inadvertently eliminated many of the beneficial bugs that help to comprise a healthy human microbiome, the community of microbes that live in our gut.

“Food used to be fresh and dirty. We lived surrounded by nature,” said Dr. Yonetani. “Nowadays, we are exposed to too little microbial diversity.”

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Spaghetti with parmesan, black pepper and natto, garnished with broccoli rabe greens and flowers.

Spaghetti with parmesan, black pepper and natto, garnished with broccoli rabe greens and flowers.Credit Ann Yonetani

Dr. Yonetani, who calls herself a “microbe farmer,” says that each tablespoon of her finished product contains a billion of the healthful soil bacteria Bacillus subtilis, a count that is “orders of magnitude greater than what you would find in a typical probiotic food.” Because natto contains lots of dormant bacterial cysts, which Dr. Yonetani has observed under the microscope, she speculates that the bacteria can survive the high-acid environment of the stomach and “colonize the intestine, where conditions are more welcoming.”

It is a potent selling point given the growing interest in the microbiome and the booming market for probiotics, products that reputedly help replenish the healthful bacteria in our bodies.

“The microbiome is a hot issue right now, and proponents of probiotics are riding that wave,” said Marion Nestle, a nutrition expert at New York University. Still, she said, our knowledge of probiotics remains “in its infancy.” Most of the studies that demonstrate the efficacy of probiotics, she noted, are sponsored by yogurt companies that may report only positive outcomes.

“Are probiotics good for you? Sure, why not?” Dr. Nestle said. “Are they miracle foods? That would be nice, if true, but the science isn’t there yet.”

Fermented foods rich in living bacteria have long been popular in Japan as a way to promote health, said Dr. Yonetani, who was first introduced to natto as a child during visits to relatives there, where it is commonly consumed with rice for breakfast, and often mixed with chives and raw eggs. Just as children in America are urged to eat their spinach, in Japan they are told to eat their natto.

But for many of us who didn’t grow up on natto, there is a certain yuck factor. Natto’s slimy coating — reminiscent of okra — led one biologist collaborator of Dr. Yonetani’s at Harvard, where she did research, to call it “Klingon food.”

As with most probiotics, the science about natto is at an early stage. Dr. Ralph Holsworth, an emergency room supervisor and biomedical researcher in a rural hospital in Colorado who has coauthored several studies on the enzyme nattokinase, a byproduct of natto fermentation, said that the enzyme “breaks down fibrin in the blood, a protein aggregate involved in blood clotting, decreases the ‘stickiness’ of the red blood cells, and assists in the prevention of arterial plaque formation.” These blood-thinning actions, he said, may lessen the severity of heart attacks and strokes.

Dr. Holsworth uses the enzyme in his medical practice to help prevent blood clots and assist in healing from surgery. Nattokinase is not yet widely used in mainstream medical practice, although it has been gaining popularity as a food supplement with the public.

Natto may also be good for bone health, said Dr. Dennis Goodman, a clinical professor of medicine and director of integrative medicine at New York University. He cited a study that showed that in eastern Japan, where they eat more natto than in western parts of the country but otherwise have similar diets, there are significantly lower levels of osteoporosis. Dr. Goodman attributes this to natto’s high levels of vitamin K2, a form of vitamin K, which he said works like a theater usher by directing calcium to the bones.

“Most people are not getting nearly enough K2 in their diet,” said Dr. Goodman, who has written a book about the vitamin. “The only food that gives you a sufficient amount is natto.” Dr. Yonetani says that a single heaping tablespoon of natto contains approximately 300 micrograms of K2, about seven times the minimum daily requirement.

To make the product, Dr. Yonetani rents a room at the back of the Organic Food Incubator, a cooperative space for artisanal food producers in Long Island City, Queens. Her closet-narrow kitchen is fitted with pressure cookers, boxes full of glass jars and a microscope. A papier-mâché Daruma, a troll-like deity said to bestow good luck on fledgling businesses, oversees the operation.

As she peels back the plastic wrapper from a freshly fermented tray, scores of sticky spider’s web thin strands of biofilm rise up from the batch, and a limburger cheese-like aroma pervades the air. Sampling the two-day-old natto with a plastic spoon, Dr. Yonetani pronounces it finished.

“It’s got some nice coffee notes,” she effuses, with the discernment of a wine connoisseur. She offers me a spoonful. The taste is not at all unpleasant, a cross between chopped liver and cottage cheese. “Every batch comes out a bit different,” Dr. Yonetani said. “That’s not something the food industry likes. But I think it’s beautiful, because that’s biology.”

Harry Potter’s a Dad: ‘Accio, Pacifier!’

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Harry Potter fans wait for the release for “Harry Potter and the Cursed Child.”

Harry Potter fans wait for the release for “Harry Potter and the Cursed Child.”Credit Yeong-Ung Yang for The New York Times

Our family is just home from the bookstore, with multiple copies of “Harry Potter and the Cursed Child” in hand, gamely reading in a new format — the book is the script of the play by the same name, and thus a different reading experience from the seven novels that came before it.

There will be no spoilers here, but the very title makes clear that “The Cursed Child” is a story about parents and children in a way that the original series never was. Harry Potter is a father now, and one question this book will answer is how the Boy Who Lived — when his parents didn’t — handles that role.

As an orphan, Harry himself could operate free of the burden a parent’s fears, love and expectation can place on a person. Now, as a parent, he has to confront it.

For readers who started reading these books when the first one came out nearly 20 years ago and grew up with Harry and friends, the scenes that reveal the characters as adults are the ones we’ve been waiting for. Though the story has serious themes, the sheer fun of returning to the familiar magical world is a delight.

And there are certainly moments when real-life parents can fantasize about the possibility of a magical assist. Imagine being able to use a spell like “Accio Binky!” to return a dropped pacifier to the sleeping baby, or “Expelliarmus Mobilio!” to expel a mobile phone right out of a teenager’s hand.

Molly Brennan, a mother of two attending a book release party on Saturday night at Watchung Booksellers in Montclair, N.J., suggested a spell called Behavioramus. “I would dodge it,” said her son, Logan Brown, 9. “I like my behavior how it is.”

Becky Middleton of Glen Ridge, N.J., who has four children ages 6, 9, 9 and 11, said her spell of choice would be volume control. Rob Fechner of Montclair, the father of two boys ages 7 and 10, asked for a spell “to pause time so I could get stuff done and take a nap.”

It’s giving nothing away to say that none of those abilities seem likely to make raising children any simpler for Harry, Ginny, Hermione and Ron. As Julia Miner, a mother of three who lives outside Washington, D.C., said Sunday, when she was up to page 70 of “The Cursed Child,” parenting teenagers has challenges no matter who you are. Magic has never helped much with relationships in the Harry Potter universe, and the fact that wizards face some of the same bitter limits that Muggles do has always been a part of the series’ appeal.

But for many parents and children in this universe, the books are conversation–starters that help connect us, engaging us in the same world. Now our conversations can go further.


In the comments or on Facebook, tell us what spell would help you most as a parent.

Attention, Teenagers: Nobody Really Looks Like That

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Credit Anna Parini

The universal truth of puberty and adolescence is body change, and relatively rapid body change. Teenagers have to cope with all kinds of comparisons, with their peers, with the childhood bodies they leave behind, and with the altered images used in advertising and in the self-advertising on social media.

It may be that the rapid way the body changes during these years can help adolescents believe in other kinds of change, including the false promises that various products can significantly modify their size and shape. A study published last month in the journal Pediatrics looked at two kinds of risky behavior that are increasingly common over adolescence: the use of laxatives for weight loss and the use of muscle-building products.

It used data from an ongoing study of more than 13,000 American children, the Growing Up Today Study (GUTS). The participants’ mothers took part in the Nurses’ Health Study II, and the children were recruited in 1996, when they were 9 to 14 years old, and surveyed about a variety of topics as they grew up.

By age 23 to 25, 10.5 percent of the women in this large sample reported using laxatives in the past year to lose weight; the practice increased over adolescence in the girls, but was virtually absent among the boys. Conversely, by young adulthood, about 12 percent of the men reported use of a muscle-building product in the past year, and again, this increased during adolescence.

So a lot of young women are taking laxatives to try to become very thin, and a lot of young men are using products to help them bulk up and become more muscular. The researchers were interested in how these practices were associated with traditional ideas of masculinity and femininity. They found that, regardless of sexual orientation, kids who described themselves as more gender conforming were more likely to use laxatives (the girls) or muscle-building products (the boys).

“The link is the perception that they are going to alter your weight, shape, appearance,” said Rachel Rodgers, a counseling psychology researcher who studies body image and eating concerns and is an associate professor of applied psychology at Northeastern University.

“The representations of ideal appearance in society are very restrictive and very unrealistic both for men and for women,” she said. “They portray bodies that are unattainable by healthy means.”

Jerel Calzo, a developmental psychologist who is an assistant professor at Harvard Medical School, and the lead author on the study, said that one important aspect of this research was the way it highlighted the vulnerability of those who identify with traditional gender ideals.

“Usually in research we tend to focus on youth who are nonconforming, who we might focus on as more at risk for negative health outcomes, depression, who might be ostracized or victimized,” he said. But there are risks as well for those who are trying to measure up to what they see as the conventional standard.

The GUTS participants were asked to describe themselves as children in terms of the games they liked and the movie and TV characters they imitated, and this was used to score them as more or less “gender conforming.”

The early patterns of gender conformity were significant, Dr. Calzo said, because they were linked to behaviors that lasted through adolescence and into young adulthood. “Laxative use increases with age, muscle-building product use increases with age,” he said. “There is a need for early intervention.”

Chronic use of laxatives can affect the motility of the bowel so that it can be hard to do without them, and overdoses can alter the body’s balance of electrolytes, to a really dangerous extent.

“There’s a lot of shame and guilt for laxative abuse,” said Sara Forman, an adolescent medicine specialist who is the director of the outpatient eating disorders program at Boston Children’s Hospital. And many products marketed as cleanses or herbal teas are not labeled as laxatives, though they contain strong laxative ingredients.

The muscle-building products in the study included steroids, creatine and several others. The risks of steroids are well known, from hormonal imbalances and shrinking testicles to acne and aggression. With other commercial muscle-building products, the risks may have more to do with the lack of regulation, Dr. Calzo said. The products can contain banned substances or analogues of banned substances, like the amphetamine analogue found in popular diet and workout supplements last year.

And of course, the muscle-building products won’t reshape you into the photoshopped model any more than the laxatives will.

As Dr. Calzo says, we need to worry about the vulnerabilities of children who are growing up with issues of gender identity and sexuality. But don’t assume that more “mainstream” or “conforming” kids have it easy when it comes to body image. Parents can help by keeping the lines of communication open and starting these conversations when children are young. We should be talking about the images that our children see, about how real people look and how images are altered.

And that conversation should extend to social media as well; in a review by Dr. Rodgers, increased social media use was correlated with body image worries. “Teenagers are looking at their friends on social media and seeing photos that have been modified and viewing them as something real.”

The other message for parents is about helping to model healthy eating, family meals, realistic moderation around eating and exercising, and to refrain from any kind of negative comments or teasing about a child’s body. “Research has shown people who have more body satisfaction actually take care of themselves better, which suggests that the approach of making them feel bad is actually not helpful,” Dr. Rodgers said.

Every adolescent, across gender, gender identity, gender conformity, and sexuality, lives with a changing body and the need to navigate body image and identity. There are a lot of unrealistic images out there to measure yourself against, and a lot of false promises about how you might get there.

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Watching TV Tied to Fatal Clot Risk

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Credit iStock

The more television you watch, the greater your risk for a fatal blood clot, according to a new study.

Japanese researchers studied 86,024 generally healthy people who filled out questionnaires with items about health and lifestyle, including time spent watching television.

During a follow-up of more than 19 years, there were 59 deaths from pulmonary embolism, a blood clot that travels from another part of the body to the lungs.

After adjusting for other factors, they found that compared with watching TV less than two and a half hours a day, watching for two and a half to five hours increased the risk for a fatal clot by 70 percent, and watching more than five hours increased the risk by 250 percent. For each extra two hours of watching, the risk of death rose 40 percent. The effect was independent of physical exercise.

“Television watching is likely to be uninterrupted,” said the lead author, Dr. Toru Shirakawa of Osaka University, and prolonged sitting increases the risk for embolism. “Take a break, stand up, walk around. Drinking water is also important.”

The study, in the journal Circulation, is observational, so it can’t determine cause and effect, Dr. Shirakawa said, but “the dose-response relationship between time spent watching and the risk of mortality from pulmonary embolism would be strong evidence for a causal relationship.”

Cancer in the Family: Compliments on Being Thin

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Credit The author with her daughter, Devon.

“I’m so jealous. You’ve lost so much weight, you look amazing,” a friend says to me. “I’d love to catch the stomach bug this year and lose a few pounds myself.”

I smile. I don’t know what to say.

Since January, one of my 12-year-old twin daughters, Devon, has been in isolation in a Boise, Idaho, pediatric oncology unit receiving chemotherapy for acute myeloid leukemia. Her sister, Gracie, remains behind, in a little town south of Sun Valley. To cope, she has assigned herself as captain of Devo’s Fight Club, a band of peer supporters started with a sweatshirt she designed in the first 36 hours of her sister’s diagnosis.

Their dad and I have been driving the two and a half hours between home and hospital, splitting the week between our daughters, our jobs, middle school’s demands, puberty’s capriciousness, sports, music and running a household that includes cats, dogs, horses, cows and fish.

Devon’s cancer was as random as a dice roll. She had swollen gums for a week and then, a simple blood test to rule out mono instead declared that this sleek, athletic, freckle-faced cowgirl had a rare and often fatal leukemia.

My husband says he has gained weight since Devon’s diagnosis. I have lost weight. A lot. Neither one of us notices the other because we relate over phone or email mostly, and offer a country-style, four-finger half wave from the steering wheel as we blow past each other on the highway between towns.

Over the next 120-mile drive I am perplexed and obsessive.

“I’m so jealous. You look amazing.”

I’m nearly 51 years old and was prepared for the idea that menopause would keep me round despite my best efforts. How much weight have I lost? Was I really that fat before? Should I eat before I get to the hospital or after? The smell of food makes Devon sick. Eating in front of her seems torturous and unfair.

After I arrived at the hospital, a friend stopped by to visit. Before acknowledging Devon, she looked at me. With purrs of envy, she commented on how thin I looked. Again, I was at a loss for words. My daughter was not.

“My mom is not skinny because she worked at it,” Devon told our visitor. “It’s because I’m sick.”

The friend waved it off in the way that one deflects praise of a nice outfit with “this old thing,” and we all moved on. But every time someone notices my weight loss with a tinge of envy it makes me cringe.

Please, I want to tell them, do not admire how thin I have become since my daughter’s diagnosis — unless you are suggesting I look undernourished and want to give me a cupcake. My weight loss is not a goal you should aspire to, nor should it be confused with health and well-being. I was perfectly happy and fit in my pre-cancer-kid size, and a little hurt to hear that this shrinkage that could cost me a lot more than new pants makes me more beautiful than ever.

But what is most painful for me is the collateral damage to my daughters. When they hear that Mom is enviably thin, they hear that this is a reward, a take away for the suffering. That thin is best no matter the circumstances.

Gracie, a minute ahead of her twin, but always an inch and a pound behind, is now getting stretch marks from growing so fast. When her peers note how she “swims” in her choir dress, her mind begins the dance with body consciousness. Weight fluctuations are somewhat inevitable in adolescence and during menopause, but certainly magnified under the circumstances.

Devon’s physical changes are pushed to the bottom of most people’s thoughts now, because in this setting of a hospital room, she’s supposed to look wan and pale. Instead, her inner beauty and sense of humor are noted.

I’ve been sick and thin enough times to know I don’t want to be either. But my girls are facing this for the first time, and the ripple effects of this entire traumatic episode will surface the farther we get from the cancer. Hospital social workers are preparing us to watch for anxiety, regression, depression, eating disorders, apathy and sleeping issues. And signs of cancer returning, of course. And survivor’s guilt in Gracie, which could carve out a whole new emotional journey.

Devon, thankfully, is home now. But I’ve just been told that five months in the hospital have cost Devon nearly a third of her body mass. That her overall strength is that of a 90-year-old, and that after the chemo, her heart, which once pounded fearlessly, is in danger of failing. Her brain is wobbly from the lack of nutrition and her skin is translucent and cold where it once was earthy and warm.

When she returns to school next year, navigating the social riddle of middle school — now half a year behind her peers — and still mostly bald, and undoubtedly still thin, she will return with a self-consciousness she has never known.

Do not covet her thinness. Admire her resilience, and tenacity, and sheer will to live.

And, if you look into her eyes and you can see they are dim from the struggle, a happy-to-see-you smile or just saying nothing at all will do more than you know to help her find her way to loving herself as life has created her in this moment.

If you want to know how someone is, look in their eyes, because their size is not where the information is.

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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Why I Decided to Stop Writing About My Children

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Credit Giselle Potter

There is a hunger in our culture for true stories from the parenting trenches where life is lived mud-flecked and raw. I’ve written extensively, intimately, damningly, about my children for seven years without once thinking about it from the point of view of their feelings and their privacy. A few months ago I stopped.

I wish I could say that I deeply reflected on the ethics of writing about my children and heroically pivoted myself out of a concern for my character, but here’s what really happened: My father called.

He called me after reading a blog post I had written about my son’s first signs of puberty. It seems an obvious line-crossing that I wrote about such an intimate detail, but I did. At the time I didn’t pause for a split second; I was more than willing to go there. I had been writing and reading extensively about parenting tweens. I knew people might be mildly shocked, but mostly interested.

We live in a break-the-internet arms race of oversharing. And adolescent sexuality is an emergent, fascinating topic, especially for parents who are figuring out how to address difficult questions with their children. For example: I ate up Peggy Orenstein’s marvelous new book, “Girls & Sex,” with a spoon, shocked and upset the whole way through.

But when my dad said, “Elizabeth, are you pausing to deeply consider what you’re writing about?” I wanted to get defensive. I said, “Uh. I kinda perceive myself as a confessional poet, Dad,” I said, “Heir to Plath, Sexton and Sharon Olds. And the photographer Sally Mann, if I’m honest, Dad.”

But he said, “I’m not talking about art. I’m talking about my grandson.”

He was a lion for his grandson. I listened. I heard him. His words went to my heart, my maternal heart, which is in equal parts steel and cornmeal mush. I thanked him honestly for his feedback, got off the phone, and cried into my daughter’s stuffed animals, which are very soft and plush and forgiving.

So began my wrestling with my relationship with the Nora Ephron line, “Everything is copy.” Until now it has been my battle cry and artistic excuse for printing whatever I wanted whenever I wanted with very blinkered vision. Maybe, in fact, not everything is copy. Maybe it’s people’s lives, and we should be considerate and loving and respectful of their privacy. It’s a new point of view for me in our clickbait culture of confessionalism and parading nakedness.

When I started blogging, my kids were babes in arms, hardly people; they were creatures, mewling, milk-drunk, with eyes so deeply slate they were alien-denim blue.

I used the blog as a live journal to get me through postpartum depression and “the lost years” for me that were “the magic years” for them, when I felt overwhelmed by washing out sippy cups, lurking at the edges of the mommy wars, and co-sleeping and diapering.

Writing made the joys and the hardship of parenting into stories. Stories I could tell. Stories that I considered as one considers a diorama.

I was always the narrator, the main character, even if I was also the storm-tossed heroine, the hot mess in mom jeans who couldn’t get the overalls on her 2-year-old. Or figure out fourth-grade fractions homework. I was working out my issues. My kids were always satellites to the big round-faced moon of me.

I’ve shamed their eating habits in chat rooms. I have Facebooked the things they’ve said. I have skewered them horribly, but also with great interest and affection, as a collector might do to some butterflies.

I think Sally Mann’s photographs of her kids are luminous and transcendent, while others accuse her of child pornography. The lines between art and privacy are blurry. You have to consider what you are doing carefully. And previously I wasn’t.

Sally Mann and I don’t belong in the same sentence. I’ve been a Baltimore mommy-blogger writing about things like head lice. She is a world-class artist. But she and I have done the same thing: publicly disrobed our children.

My children didn’t give me their permission to tell their stories, or strike poses in a waterfall, naked, gorgeous as all get out, and human, with lives ahead of them, as Sally Mann posed hers. And now that I see that, I don’t want to mar my children’s glory and subvert their beginnings for my so-called art.

If I’m going to continue writing, I realize I need to find some new material, and for that I’m going to have to look more deeply within myself or entirely outside. For inspiration I have turned to writing about nature. The environment. The sea. Things that are bigger than me. I’ve been reading John Muir. I’ve been reading “Braiding Sweetgrass.” Nature is for all to see. Nurture is between me and my kids, off the record.


Elizabeth Bastos lives in Baltimore and writes about urban nature. Follow her at thenaturehood.blogspot.com and on Twitter @elizabethbastos.

Speed Goggles: Group Run

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Group Run

Sometimes, your running partners don’t show up.

Publish Date July 28, 2016.

I often make plans to meet companions for a run, but they may not always show up. This could be due to oversleeping, miscommunication or honest forgetfulness. When this happens, there is a rule of thumb among some runners to wait one minute for every five minutes the scheduled run was meant to last. Beyond that, it is considered acceptable to begin the run without the latecomers. Usually the rule is followed without a second thought. However, I find that the closer I am to a big race, the more important companionship is for me.

“Speed Goggles” is a five-part series created by Alexi Pappas and Jeremy Teicher, who also created the feature film “Tracktown.” Ms. Pappas will be competing in the 2016 Olympics for Greece.

Watch: “The Elite Runner.” | “Normal People” | “Nightmares Mean You Care.”.