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For a New Mom, Relentless Fatigue Could Signal a Thyroid Problem

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Credit Stuart Bradford

For six weeks after delivering my son, I had postpartum thyroiditis. Every afternoon around the same time, I would shake uncontrollably. Anxiety about night feedings and colic (which my son didn’t have) plagued my thoughts all evening. One night while my husband put our son, Jackson, to sleep, my sister put me to sleep. We watched “Romancing the Stone” and she rubbed my back until I drifted off — as if I were the baby.

Moreover, I lost all the baby weight within weeks. At my two-week checkup with my obstetrician, I had lost over 25 pounds. I left that appointment proud, feeling like I could be on the cover of Us Weekly. It must be the breast-feeding, pumping and healthy eating. But I was kidding myself. I breast-fed for all of three days. Sure, I pumped a few bottles, but Jackson got mostly formula. And I wasn’t eating healthfully. I was eating takeout.

About two months after Jackson’s birth, my thyroid burnt out. I didn’t know it at the time, but I later learned that mild hyperthyroidism had given way to Hashimoto’s disease, a potentially more serious, and chronic, thyroid condition in which the thyroid becomes underactive. Over the next few months, I gained about 30 pounds and became extremely lethargic. When I woke each morning, my first thought was: When can I take a nap today?

My body was just transitioning, I thought. And I had a baby now. Most new moms were tired, right? Still I sensed that something intense was happening: I was a different person.

My husband and I had some traumatic fights during those months. I feared that our marriage, the very foundation for loving this new child, was falling apart. He said things like “you’ve changed and “I can’t live like this anymore.” And the truth was that we really couldn’t live like this anymore.

To make matters worse, I felt that my internist largely dismissed my concerns. He ran my blood work for virtually everything except my thyroid hormone level. We spent the follow-up appointment discussing my elevated cholesterol (also a symptom of hypothyroidism). He offered me Xanax and suggested I talk to a therapist about postpartum depression. Even most friends and family members chalked up these physical changes to the stresses of being a new mom.

Finally, when Jackson was 6 months old, I saw my O.B. again. She, too, bet on postpartum depression but ran thyroid tests to rule it out. I vividly remember when the doctor called with the results, “I’m surprised you can get out of bed in the morning, much less work full-time and take care of a baby.” When I hung up, I wept. I wasn’t losing my mind. I wasn’t just having a hard time adjusting. My thyroid, this little butterfly-shaped gland in my throat that I last worried about in high school biology, was having a hard time keeping my body up and running.

The synthetic thyroid hormone Synthroid helped with losing weight and energy levels. And ever since, I’ve had routine blood work and sonograms to monitor my hormone levels and the small lumps on my thyroid. During my second pregnancy, I saw an endocrinologist and had blood taken every month. My endocrinologist told me that it was important that I have my medication adjusted every month during the pregnancy since the thyroid helps the body stay pregnant.

I was surprised to find that several of my women friends also turned out to have thyroid problems. They tell the same story about discovering their condition either later in life or surrounding a pregnancy. Toni had three miscarriages in one year because of a mismanaged thyroid. Lisa was diagnosed accidentally at 41 when she saw a doctor for a double ear infection and bronchitis. “He felt my neck and noticed that my thyroid was quite enlarged,” she writes.

All the women had weight troubles. Eat less carbs. Exercise more. Take the baby out for walks. You’re getting older so it’s harder. That was the advice I got, along with speeches about the American diet of processed foods and sedentary lifestyle. But I’ve never been sedentary, and becoming a mother certainly didn’t have me sitting on the couch eating potato chips. My friend Jen remembers being patronized at her doctor’s office. “I was literally patted on the leg and told it’s just going to be hard for you to lose weight, dear,” she said. Her endocrinologist prescribed her a medication for diabetes and told her to eat 1,100 calories a day.

My takeaway from those six months is this: Even amid the huge life change that is motherhood, I knew something was really wrong with my body. And if I had put my health first, I would’ve figured it out much faster and with much less heartache. But prioritizing yourself isn’t something many new moms do very well.

Of course the early weeks with a newborn are exhausting for all parents, but if you don’t start to feel normal once the baby’s sleep schedule stabilizes, it’s worth getting your thyroid checked. A simple blood test can make all the difference.

Kristin Sample is a writer, teacher and dancer. Her novel “North Shore South Shore” is available on Kindle. Follow her on Twitter and Instagram @kristinsample or check out her blog, kristinsample.com.

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A Decades-Old Study, Rediscovered, Challenges Advice on Saturated Fat

A four-decades-old study — recently discovered in a dusty basement — has raised new questions about longstanding dietary advice and the perils of saturated fat in the American diet.

The research, known as the Minnesota Coronary Experiment, was a major controlled clinical trial conducted from 1968 to 1973, which studied the diets of more than 9,000 people at state mental hospitals and a nursing home.

During the study, which was paid for by the National Heart, Lung and Blood Institute and led by Dr. Ivan Frantz Jr. of the University of Minnesota Medical School, researchers were able to tightly regulate the diets of the institutionalized study subjects. Half of those subjects were fed meals rich in saturated fats from milk, cheese and beef. The remaining group ate a diet in which much of the saturated fat was removed and replaced with corn oil, an unsaturated fat that is common in many processed foods today. The study was intended to show that removing saturated fat from people’s diets and replacing it with polyunsaturated fat from vegetable oils would protect them against heart disease and lower their mortality.

So what was the result? Despite being one of the largest controlled clinical dietary trials of its kind ever conducted, the data were never fully analyzed.

Several years ago, Christopher E. Ramsden, a medical investigator at the National Institutes of Health, learned about the long-overlooked study. Intrigued, he contacted the University of Minnesota in hopes of reviewing the unpublished data. Dr. Frantz, who died in 2009, had been a prominent scientist at the university, where he studied the link between saturated fat and heart disease. One of his closest colleagues was Ancel Keys, an influential scientist whose research in the 1950s helped establish saturated fat as public health enemy No. 1, prompting the federal government to recommend low-fat diets to the entire nation.

“My father definitely believed in reducing saturated fats, and I grew up that way,” said Dr. Robert Frantz, the lead researcher’s son and a cardiologist at the Mayo Clinic. “We followed a relatively low-fat diet at home, and on Sundays or special occasions, we’d have bacon and eggs.”

The younger Dr. Frantz made three trips to the family home, finally discovering the dusty box marked “Minnesota Coronary Survey,” in his father’s basement. He turned it over to Dr. Ramsden for analysis.

The results were a surprise. Participants who ate a diet low in saturated fat and enriched with corn oil reduced their cholesterol by an average of 14 percent, compared with a change of just 1 percent in the control group. But the low-saturated fat diet did not reduce mortality. In fact, the study found that the greater the drop in cholesterol, the higher the risk of death during the trial.

The findings run counter to conventional dietary recommendations that advise a diet low in saturated fat to decrease heart risk. Current dietary guidelines call for Americans to replace saturated fat, which tends to raise cholesterol, with vegetable oils and other polyunsaturated fats, which lower cholesterol.

While it is unclear why the trial data had not previously been fully analyzed, one possibility is that Dr. Frantz and his colleagues faced resistance from medical journals at a time when questioning the link between saturated fat and disease was deeply unpopular.

“It could be that they tried to publish all of their results but had a hard time getting them published,” said Daisy Zamora, an author of the new study and a research scientist at the University of North Carolina at Chapel Hill.

The younger Dr. Frantz said his father was probably startled by what seemed to be no benefit in replacing saturated fat with vegetable oil.

“When it turned out that it didn’t reduce risk, it was quite puzzling,” he said. “And since it was effective in lowering cholesterol, it was weird.”

The new analysis, published on Tuesday in the journal BMJ, elicited a sharp response from top nutrition experts, who said the study was flawed. Walter Willett, the chairman of the nutrition department at the Harvard T.H. Chan School of Public Health, called the research “irrelevant to current dietary recommendations” that emphasize replacing saturated fat with polyunsaturated fat.

Frank Hu, a nutrition expert who served on the government’s 2015 dietary guidelines committee, said the Minnesota trial was not long enough to show the cardiovascular benefits of consuming vegetable oil because the patients on average were followed for only about 15 months. He pointed to a major 2010 meta-analysis that found that people had fewer heart attacks when they increased their intake of vegetable oils and other polyunsaturated fats over at least four years.

“I don’t think the authors’ strong conclusions are supported by the data,” he said.

To investigate whether the new findings were a fluke, Dr. Zamora and her colleagues analyzed four similar, rigorous trials that tested the effects of replacing saturated fat with vegetable oils rich in linoleic acid. Those, too, failed to show any reduction in mortality from heart disease.

“One would expect that the more you lowered cholesterol, the better the outcome,” Dr. Ramsden said. “But in this case the opposite association was found. The greater degree of cholesterol-lowering was associated with a higher, rather than a lower, risk of death.”

One explanation for the surprise finding may be omega-6 fatty acids, which are found in high levels in corn, soybean, cottonseed and sunflower oils. While leading nutrition experts point to ample evidence that cooking with these vegetable oils instead of butter improves cholesterol and prevents heart disease, others argue that high levels of omega-6 can simultaneously promote inflammation. This inflammation could outweigh the benefits of cholesterol reduction, they say.

In 2013, Dr. Ramsden and his colleagues published a controversial paper about a large clinical trial that had been carried out in Australia in the 1960s but had never been fully analyzed. The trial found that men who replaced saturated fat with omega-6-rich polyunsaturated fats lowered their cholesterol. But they were also more likely to die from a heart attack than a control group of men who ate more saturated fat.

Ron Krauss, the former chairman of the American Heart Association’s dietary guidelines committee, said the new research was intriguing. But he said there was a vast body of research supporting polyunsaturated fats for heart health, and that the relationship between cholesterol-lowering and mortality could be deceiving.

People who have high LDL cholesterol, the so-called bad kind, typically experience greater drops in cholesterol in response to dietary changes than people with lower LDL. Perhaps people in the new study who had the greatest drop in cholesterol also had higher mortality rates because they had more underlying disease.

“It’s possible that the greater cholesterol response was in people who had more vascular risk related to their higher cholesterol levels,” he said.

Dr. Ramsden stressed that the findings by he and his colleagues should be interpreted cautiously. The research does not show that saturated fats are beneficial, he said: “But maybe they’re not as bad as people thought.”

The research underscores that the science behind dietary fat may be more complex than nutrition recommendations suggest. The body requires omega-6 fats like linoleic acid in small amounts. But emerging research suggests that in excess linoleic acid may play a role in a variety of disorders including liver disease and chronic pain.

A century ago, it was common for Americans to get about 2 percent of their daily calories from linoleic acid. Today, Americans on average consume more than triple that amount, much of it from processed foods like lunch meats, salad dressings, desserts, pizza, french fries and packaged snacks like potato chips. More natural sources of fat such as olive oil, butter and egg yolks contain linoleic acid as well but in smaller quantities.

Eating whole, unprocessed foods and plants may be one way to get all the linoleic acid your body needs, Dr. Ramsden said.

3 Things School Counselors Want You to Know About Their Jobs

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Credit Joyce Dopkeen/The New York Times

Over the years, this column has offered up “3 Things Students Wish Teachers Knew,” “3 Things Parents Wish Teachers Knew,” and “5 Things Teachers Wish Parents Knew.” Recently, it was called to my attention that I have never written about what school counselors might like readers to know about their profession.

I’ve spent a great deal of time this year meeting and talking with school counselors, and I can attest that they have a lot of wisdom to share about how to keep students healthy, happy and successful.

School counselors manage the intersection of multiple, disparate priorities: students’ academic performance and their mental health, parents’ dreams for their kids and teachers’ requirements for their students, decisions about the present and plans for the future. As challenging as this task is, daily life in this intersection is also increasingly demanding. According to the recommendation of the American School Counselor Association, the student-to-counselor ratio should go no higher than 250 to 1. According to the latest data, however, all but three states, New Hampshire, Vermont and Wyoming, exceed the recommended ratio. Nationally, the average student-to-school-counselor ratio is 491 to 1, but the ratio hits a high of 941 to 1 in Arizona.

The view from this intersection may be chaotic and crowded, but because counselors are concerned with the mental, emotional and physical health of students, it also affords counselors a glimpse of the whole child, one that teachers, parents and administrators can’t often discern from their more limited viewpoints. I asked three of these professionals to describe their work and share their unique perspective on what students need in order to succeed.

First, Phyllis Fagell, a licensed clinical professional counselor and school counselor in Bethesda, Md., told me: Don’t call them “guidance counselors.” The proper title is “school counselor,” she explained in an email. “School counselors chafe at the outdated term ‘guidance counselor,’ a relic from the past that no longer reflects our role,” she wrote. The profession was vocationally oriented and counselors had inconsistent educational backgrounds and levels of certification until the Association of School Counselors of America published “The ASCA National Model: A Foundation for School Counseling Programs” in 2003 in an effort to standardize the field.

“Today’s school counselors have master’s degrees. We use evidence-based practices and maintain data to ensure accountability; we work with teachers, parents and other community members to support our students,” wrote Ms. Fagell.

School counselors manage many roles, but the one role they do not own is that of disciplinarian. Students need to be able to confide in counselors without worry that they will be punished, Ms. Fagell explained. “The divide between administration and counseling is incredibly important to understand and maintain if students are going to trust us to act in their best interests.”

Those best interests, Brian Turcotte, a social worker and school counselor in Barrington, Ill., wrote in an email, are not always the same as the goals parents have for their children. When I asked Mr. Turcotte for his best school counselor advice to parents, he wrote,

We cannot make our kids live the life we wish we had lived. Parents’ aspirations and dreams for their children may not be the aspirations or dreams children have for themselves. It’s fine to try to encourage or inspire children to consider a future beyond what they see for themselves, but ultimately, every person needs to be in charge of his or her own life.

Kelly Wickham Hurst, counselor at Lincoln Magnet School in Springfield, Ill., said in a phone interview that she believes parents and teachers need to do a little less telling, a lot more listening and forgive children when they mess up.

Ms. Wickham Hurst said she left classroom teaching to become a school counselor because she felt she had an opportunity to multiply her influence for her students. She is black and said she thought she had particular impact among minority students. “Often, when a kid arrives in my office sad or angry about how he is being treated, my job is to give him back his humanity. I tell him that what he is feeling is normal,” and that he may be being treated differently than his white classmates. “I listen, help him manage his emotions and teach him how to move through the world we live in today, even when it’s not fair.”

“We have to forgive children when they get in trouble,” she added. “The most powerful relationships I have with kids develop when I forgive them, and validate their feelings. Kids need the respect and the space to be human.”

Finally, Ms. Fagell emphasized the role school counselors play in teaching “soft skills,” like negotiation, compromise and planning. “School counselors care deeply about educating children to be whole, happy people with the social-emotional skills needed to navigate life. It’s not enough to be good at math or history. Students need to be problem solvers and innovators. They need to be able to work in teams, to manage change, to take risks and to lead.”

Children learn these skills best when teachers, counselors and parents work cooperatively. Ms. Fagell concluded her email to me with this very sentiment. “When parents openly share their child’s stories and struggles, counselors can be effective advocates, helping build teachers’ empathy and desire to engage in problem solving with the student and her family.”

School counselors may be overburdened and misunderstood, but for most, there’s nowhere else they’d rather be.

“These are my people, my tribe,” Ms. Wickham Hurst said. “I get to work in the magic that is middle school.”


Jessica Lahey is an educator, writer and speaker and the author of “The Gift of Failure: How the Best Parents Learn to Let Go So Their Children Can Succeed.”

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Let Patients Read Their Medical Records

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Credit Reynaldo Leal for The Texas Tribune

Sometimes, before I interview new patients, while I’m waiting for them to be transported from the emergency department to the medical floor, I play a game.

I look through their lab tests. I peruse their imaging studies. I read other doctors’ notes and recent discharge summaries. Then I guess what the diagnosis is.

I know this is bad. It goes against most of what I learned about good doctoring in medical school — that the patient’s story is the core of medicine, that it’s essential for accurate diagnoses and therapeutic relationships.

It can also be dangerous. When I interview patients, I often find their medical charts are littered with inaccuracies. It’s one reason “read it in my chart” isn’t a good way for patients to communicate health information — or for doctors to learn it.

“I noticed you’re scheduled for surgery next week,” I say to one patient.

“I had that surgery three months ago,” he responds.

“So you don’t have diabetes?” I ask another, perplexed. I see “diabetes” clearly indicated in her chart.

“No! Why does everyone keep asking me that?” she exclaims, exasperated.

When I read a patient’s electronic health record, I now assume what’s written there is as likely to be wrong or outdated as it is to be accurate. Sometimes these discrepancies are minor and inconsequential; sometimes they can be devastating. And unlike what happens in Vegas, what’s written in your medical record often stays with you forever.

One study found that there’s complete agreement between medications listed in the electronic health record and what patients actually take only in about 5 percent of patients. Another study found that 43 percent of medications listed in the electronic health record were inaccurate — with 29 percent having been stopped and 14 percent changed. Many allergies and adverse drug reactions aren’t recorded. Research from the Veterans Health Administration found that 60 percent of patient records had at least one error. From 2013 to 2014, the percentage of lawsuits related to electronic health record issues doubled and is expected to rise.

The ease with which doctors can copy and paste the information in a medical record can be one source of error — as well as a potent source of “note bloat”: notes so filled with extraneous information that you have to scroll through pages and pages of nonsense to find anything useful. Almost all doctors use the copy-paste function when writing notes, and by some estimates between half and three-quarters of daily notes are copied text. There are advantages: Forwarding text for stable patients can be safe and efficient — and a majority of doctors believe it doesn’t hurt patients. But, if not done carefully, it can perpetuate false or outdated material.

Another problem is that large amounts of patient information are now automatically imported into patient notes. Cognitively, it’s a very different experience searching for, confirming and personally recording aspects of a patient’s history than it is reviewing what’s auto-populated into your note. In some cases, one can “write” an entire note simply by clicking a few boxes to indicate the duration and frequency of a patient’s symptoms — essentially the same way you fill in a Mad Libs template

What can get lost in all this is the patient’s story.

Eliciting, distilling and communicating an account of what’s happened in a person’s life are skills that are vital for all doctors, but especially for doctors in training still learning to care for patients. Gathering and sharing a patient’s story offers the fullest sense of who a patient is as a human being, why he might have received this treatment, for example, and not that one, and what the best course of action might be going forward. We now spend two hours a day reporting quality measures, but what needs to be mandatory in the age of digitalization is the art of story gathering and storytelling.

One solution may be to encourage more patients to read their medical records. Doctors may be motivated to write more thoughtful and accurate notes if they know their patients will be reading them. While patients have had the right to access their medical records since 1996, when the Health Insurance Portability and Accountability Act was enacted, and the right to electronic copies since 2009, most patients never see their charts.

Research suggests that only about 40 percent of patients are offered online access to their medical records. Of those given access, only half choose to view them — but 80 percent of those who do find it useful. A quarter of patients remain unaware of their right to an electronic copy of their medical records. But patients who frequently access their medical records may be more motivated to take control of their health — and in a better position to correct outdated or erroneous information.

The federal government recently released guidelines making it easier for patients to access their records, requiring hospitals to provide electronic copies within 30 days of a request and prohibiting them from asking patients to state a reason for their requests. The government’s Blue Button Initiative also aims to empower patients, allowing them to directly download personal health data in an easy-to-read format.

The push to digitize health care has its upsides. But what’s too easily forgotten is the patient’s story, a coherent narrative of who a person is and what he or she has been through. As medicine continues to modernize, we can’t afford to lose this ancient art.

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Dhruv Khullar, M.D., M.P.P. is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.

Checking on Bullying at the Doctor’s Office

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Credit

I let out a huge sigh as I picked up the next chart in clinic. “Chief complaint: Behavioral concerns” was typed out on the top of a thick packet of papers. My young patient was sitting on the exam table comfortably. His parents sat stoically with furrowed brows in the chairs next to him. They were nervous, rigid, clearly concerned.

“What’s been going on?” I asked. Apparently he had been acting out at his elementary school. I sifted through the papers, chock full of documentation from teachers, detailing his behavior. He was on the verge of expulsion. His parents expressed understandable frustration to me given his remarkably normal behavior at home.

I gathered my history per usual, directing my questions toward him as he swung his legs back and forth on the exam table. I did not seem to be getting anywhere when I happened to ask, “Is anyone at school making fun of you?” Yes.

It turned out that another child at school was calling him names and telling him he was stupid. His parents looked shocked. They had no idea.

What are the effects of bullying on children? A 2006 study showed that children who had been bullied have higher rates of both physical and mental illness, including abdominal pain, bed-wetting, poor appetite, sleeping problems, anxiety and depression. A 2007 2007 study in Denmark showed that bullied children also have higher rates of medication use associated with treating headaches, stomachaches, nervousness and difficulty sleeping.

In my young patient’s case, his bully had also been instructing other children at school to harass him. There is evidence showing that such indirect bullying actually has a higher association with depression and thoughts of suicide in children. Importantly, bullies are not immune to these negative effects. The same study showed that bullies more often report delinquent behavior. Moreover, among adolescents, both victims and perpetrators of bullying have higher rates of depression, suicidal thoughts and suicide attempts.

And what about parental and teacher awareness? I was surprised that my young patient’s parents and teachers knew nothing about the bullying. But, this is actually quite consistent with data from a 2004 study demonstrating that parents and teachers are often unaware that their children and students are victims of bullying. Furthermore, in this study, bullies were asked how often parents and teachers spoke to them about their behavior – only about 33 percent of parents and 50 percent of teachers spoke to regular bullies about their bullying activities.

As a physician, even more concerning to me is that some children face bullying because of chronic illnesses. For example, in a study of children with food allergies, 31.5 percent of children reported bullying specifically related to their allergies. Disturbingly, bullying included threats with foods the children were allergic to. Parents knew about the bullying in just over half of cases.

During my clinic visits, I am incredibly pressed for time. I check in on past medical history, family history updates, current medications, diet, sleep, exercise, vaccination records and more. But after meeting my young patient and hearing his story of being bullied, I now make it a point to ask my patients if they are being made fun of or bullied at school.

Ultimately, my responsibility as a pediatrician is to support the health and well-being of children. There is no special prescription I can write that will make bullying go away. Rather, the best remedy is communication between parents and their children.

Jessica W. Tsai, M.D., Ph.D., is a resident physician at Boston Children’s Hospital and Boston Medical Center. Follow her on Twitter: @jestsai.

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Running on Vacation

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Jen A. Miller in the mountains of North Carolina in May, 2015.

Jen A. Miller in the mountains of North Carolina in May, 2015.Credit

On the second day of a recent two-week road trip, I woke up at a Holiday Inn off Interstate 95 in Santee, S.C., and drove to a nearby state park. I was in my fifth week of marathon training and needed to complete three miles, so why not do so in a new place I might never see again? I’ve run in many unfamiliar towns and cities — Chicago; Minneapolis; Seattle; San Francisco; St. Pete Beach, Fla.; Freeport, Me.; Rome — and each jaunt has given me a unique look at a part of the world I might have missed otherwise.

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A warning sign at Santee State Park in South Carolina.

A warning sign at Santee State Park in South Carolina.Credit

By mile one, though, a light rain had gotten slightly heavier. By the time I reached a warning sign that read, “Do not approach alligators no matter how big or small. ‘Gators’ can move fast!” the rain had turned heavy and cold, and I thought that perhaps a treadmill would have been the way to go.

Running while traveling can be a challenge. You’re in a different climate, you don’t know where to go and sometimes, as I learned, wild beasts may be thrown into the mix. But with a little planning and an assist or two, running in a fresh location can give you a chance to experience something new.

“Every city has a feel to it,” said Chris Heuisler, head of the RunWestin concierge program at the Westin hotel chain, which, like a number of hotel chains, provides personal guidance to help visitors keep up with their fitness while traveling. One way to get a taste of a city’s feeling is to run there. “There are so many little details to a city that you would not see if you had not gone for a run,” he said.

The biggest hurdle, he said, is knowing where to go. Many hotels and resorts provide online or paper running maps. On a trip to San Francisco, for example, I stayed at a Kimpton hotel that provided a map with different routes through the city, with mileage marked. Free, ad-heavy paper tourism maps are also provided in many hotel lobbies and local tourism offices.

Another way to not get lost: join a group. “You can always hook up with local running clubs,” said Amy Begley, who ran the 10,000 meters for the United States in the 2008 Olympic Games and is a coach for the Atlanta Track Club. That’s how I got a running tour of Asheville, N.C., this spring. Specialty running stores often hold group runs that welcome visitors, too. You can find running clubs through the Road Runners Club of America and specialty running stores through the Independent Running Retailer Association.

If you’re worried you’ll get to your destination and lose your motivation, Mr. Heuisler suggests signing up for a race. “It holds you accountable but also immerses you into that culture,” he said.

In 2012, while training for my first marathon, I needed to do a 15-mile run while at a conference in Vancouver, British Columbia, so I signed up for and ran a half-marathon on Canadian Thanksgiving Day, then ran back to my hotel to complete the needed miles. I saw parts of the city I never would have otherwise — including a bridge I’ve seen used in movies shot in Vancouver — and have a medal with maple leaves on the ribbon as a souvenir.

Whether you are running to train or sightsee, make adjustments in pace and expectations, especially if the environment is very different from what you’re used to, and make do with what’s available. My first speedwork session of my latest cycle of marathon training lined up with the back end of my road trip, which took me to Jekyll Island, Ga. The island does not have a track, which I would have used to mark the start and finish of each sprint session, but it does have 22 miles of paved trails, so I did my 400-meter repeats there instead, using my GPS watch to tell me when to sprint and when to slow down. I also carried a water bottle because, even though it was cold enough that day for two locals to drop out of a planned afternoon kayak trip, the weather was still much warmer and more humid than I was used to in New Jersey.

And there’s nothing wrong with using the treadmill if you need to, Ms. Begley said, especially if you’re coming from a warm climate into a winter freeze. And don’t rely on pictures of a gym on a hotel website either. “Hotels may say they have a gym, but you don’t know what equipment they have,” she said. Call ahead to ask if they have treadmills and if they’re working.

My latest trip ended on a whimper: a 14-hour drive, with the last two hours in the dark through driving rain and the last 10 minutes through a fog so thick I turned on my flashers. When my gas tank warning sign went on just before I reached my hotel in Rehoboth Beach, Del., I thought, “Maybe you shouldn’t do your tempo run tomorrow,” then parked myself at the bar of Dogfish Head Brewing & Eats.

I did end up doing my run, but not in Rehoboth Beach, as originally intended. I slept in, then took the Cape May-Lewes Ferry to Cape May, N.J., a place I’ve visited too many times to count, and did a five-mile hard run through the meadows of West Cape May along Sunset Boulevard, a route I know well.

Then I had a sandwich, a cup of coffee and — finally — went home.

Jen A. Miller is the author of “Running: A Love Story.”

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When Is a Child Too Sick for School?

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Credit Getty Images

Sometimes, figuring out whether a child is too sick for school is an easy call. A vomiting child, or one with a fever or a raging case of pink eye, is clearly taking the day off. Some schools are even kind enough to spell out the parameters for a return to the classroom, asking that children stay home for 24 hours after the last symptoms or after starting a course of antibiotics.

Those are the easy cases. But at our house, which includes two adults and four kids, this year’s illnesses have not been so neatly categorized. Several of us have had nagging coughs of the deep, juicy, please-keep-that-away-from-me variety that dragged on for weeks. Others have complained of stomach misery, but never made use of the bucket next to the bed. We’ve had endless sniffles and endless debates about whether a child should just push through and go to school or stay home.

No one wants to infect an entire classroom. But we all know that there are times when even a child who isn’t feeling 100 percent really needs to grab the backpack and go.

The debate is complicated by the kind of child you have. Is your child a reluctant student at best, or a driven achiever who has to be forced to stay home? Unless it’s something readily detected, like a fever, “it’s very hard for me to tell if they’re just trying to get out of class,” said Kate Alexander, a school nurse in Saratoga Springs, N.Y. She has some “frequent flyers,” she says, who often just need a break from the classroom. But for those she doesn’t see often, she tries to work with the child to decide together whether he or she can go back to class.

As a parent, I find that a challenge as well. My kids are 9, 10, 11 and 14, with varying degrees of enthusiasm about school attendance. When one of my children didn’t get enough sleep and insists that he or she doesn’t feel well at the 6:20 Monday morning wake-up, it’s probably true, but is a “rest day” warranted?

“Some kids say, ‘I have a cold,’ and I say, ‘that’s O.K., you can have a cold and still be here,’” said Ms. Alexander. Her response depends in part on age. “A kindergartner with a cold really can’t do anything. As they get older, that changes. By the time they get to fifth grade I’m trying to toughen them up. I have to say, in a very nice way, I know you don’t feel your best but you need to be here.”

How do we toughen up our children just enough that they become adults who can power through a cold, but aren’t putting everyone at risk of the flu in the mistaken belief that it’s never an option to stay home?

“I try to push, a little bit, in the sense that if the kid were just given their own choice, they probably wouldn’t go,” says Angela Duckworth, author of the forthcoming book “Grit: The Power of Passion and Perseverance” and a researcher and psychology professor at the University of Pennsylvania. “They need to learn to be comfortable being a little bit uncomfortable.”

Learning to find that space where a child is “a little uncomfortable” but not putting herself or others at risk helps a child learn to expand her “distress tolerance” in other areas, says Dr. Duckworth. “Most kids will not be able on their own to make the generalization, well, I went to school when I wasn’t feeling great, I can also struggle a little bit in my math class when I’m not feeling great. I can handle it. This isn’t just being sick, this is dealing with a challenge.”

Those choices don’t just affect our children, but the way others view them. Miss the first few days of class for illness, and you may find yourself struggling to overcome a reputation as a slacker for an entire semester. Show up and perform even though it’s tough, and you have a teacher (or, in later years, a boss) who knows that when you call in sick, it’s real. That’s a lesson children need to learn.

The initial choice to go to school or stay home, though, is still not an easy one. As a nurse, Ms. Alexander suggests setting parameters that are similar to those the school uses, and sticking to them. “Toe a tough line,” she says. “No fever, no vomiting, off you go.” Talk to the school nurse about your concerns, she says, and try to agree that the nurse will send the child back to class if at all possible. And when a child does stay home, “I wouldn’t make it fun,” she says. “They’re going to rest and not just watch TV or play games all day.”

Teachers, nurses and parents can disagree on when a child should stay at school. “I’ve encountered many situations where teachers want to send students home in fear of contaminating others,” said Bonnie Lee, a school nurse at an elementary school in Edenton, N.C. By doing “a thorough nursing assessment, and utilizing evidence-based practice guidelines,” she often finds that the student is able to remain in class. Adrian Wood, a parent in the same school district, says that keeping her elementary school-aged children home sometimes results in “a stern letter regarding the importance of attendance.”

Of course, for some families, being able to keep a child home is a luxury. Ms. Lee says she sometimes sees children come to school with a high fever, and is unable to reach an adult to come to take the child home, or has parents tell her that they can’t leave a work shift to pick up a child having an asthma attack. In her view — and mine — the children whose parents can afford to weigh the risks and benefits of coddling versus grit are the lucky ones.

Ask Well: The Best Exercises to Improve Balance

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Jarell Jones, 33, who served with the Marine Corps in Iraq, leads a yoga class at the Veterans of Foreign Wars Post 1 in Denver.

Jarell Jones, 33, who served with the Marine Corps in Iraq, leads a yoga class at the Veterans of Foreign Wars Post 1 in Denver.Credit Benjamin Rasmussen for The New York Times

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Big Health Benefits to Small Weight Loss

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Obese individuals who lose as little as 5 percent of their body weight can improve their metabolic function and reduce the risk of developing Type 2 diabetes and heart disease, a new study has found.

Many current treatment guidelines urge patients to lose between 5 percent and 10 percent of their body weight in order to experience health benefits, but the recommendations were based on earlier studies that didn’t distinguish between participants who lost only 5 percent of their weight and those who lost more.

The study, a clinical trial, randomized 40 obese individuals with signs of insulin resistance to either maintain their body weight or go on a low-calorie diet and lose 5 percent, 10 percent or 15 percent of their body weight.

It found that insulin sensitivity improved significantly after participants lost just 5 percent of their body weight, as did triglyceride concentrations, blood pressure and heart rate. There were no improvements in markers of inflammation at that level of weight loss, however.

“Losing 5 percent is much easier than losing 10 percent, so it was important to understand what the differences might be,” said Dr. Samuel Klein, a professor at Washington University School of Medicine and senior author of the study, published in the journal Cell Metabolism. “You get a big bang for your buck with 5 percent.”