I’m five foot nothing, and don’t weigh a hundred pounds soaking wet. I went into menopause on the early side, at 45, and when I did, I got my first bone scan. I know now that it showed I had a 17 percent loss of bone density in my spine and 15 percent in my hip, but my doctor at the time considered these results normal, and she never even called to give them to me.
So a whole year went by where I had no period, no estrogen, and no information. The next year, when my annual scan showed 23 percent bone loss in my spine and 16 percent in my hip, my doctor diagnosed me with osteopenia. She still said it was no big deal, and not to worry about it. She suggested I take calcium, but she didn’t breathe a word about vitamin D or magnesium or exercise or anything else I could do to help myself.
I’ve always been health-conscious. I’m a runner. I teach nutrition. So when I found out I wasn’t as healthy as I thought I was, I freaked out. I also knew there had to be a role for improved nutrition in keeping my bones strong. So I calmed down and got proactive. I started to get myself informed. I read every book I could find with sections on bone density. I searched the Internet. I checked out mainstream and alternative sources. The more I read, the more confused I got, and it started to seem that every new thing I read contradicted the last one. I went to a naturopath, and also to a mainstream doctor at a rehab center who specialized in exercise. That doctor asked for the results of both bone scans I’d had, and he was the one who told me about how much I had lost even at the time of my first scan. Then he told me I had the spine of an 81-year-old woman. I hit the roof. Of course, I’ve never gone back to my original doctor who neglected to alert me to the loss. But I can never get back that year when I could have been doing all the things I’ve since learned to do to prevent any further loss.
I really like my rehab doctor. He is a big believer in HRT, particularly for the first few years of menopause, but I have a knee-jerk reaction against the hormones even though I have no family history of breast cancer. So he listens to all my beefs and works with what I’m prepared to do. The naturopath, on the other hand, was hysterical at the mention of HRT. Even though I can relate to that, I wanted a more balanced, open-minded perspective. With all the information coming at you, in the end, you just have to go with your gut.
So 1 did start taking Fosamax. I increased my running to three times a week. I added in some exercises with hand weights. I take calcium supplements regularly, and other supplements—expensive trace minerals and extra vitamin D—with a bit less devotion. I have alfalfa and some Chinese herbs, and I started using a natural progesterone cream a year ago after I found out the “wild yam” stuff I was using doesn’t have enough active hormone to make any difference.
My diet is totally focused on calcium and my bones. I have a calcium chart stuck on my refrigerator, and I know spinach isn’t as good a source as kale, and so on. I eat tofu every single day. I buy extra-firm, not the jiggly, wiggly stuff, slice it thin, marinate it in soy sauce, ginger, and garlic, and pan-fry or grill it. It keeps in the fridge for a week, and I eat some plain for lunch every day. When my students make faces at the thought of tofu, this is what I bring in to let them try—anything marinated this way will taste good—and they always love it. I eat at least one can of salmon every week, bones and all, and broccoli, sesame seeds, fortified soymilk, leafy greens, and so on often enough that I get about half of the 1,500 mg of calcium I aim for each day in my food, without relying too heavily on dairy products.
It’s all paying off. It’s been a year since that second scan threw me into action, so I just had my third bone density scan. It shows I stopped the loss, and recovered everything I’d lost in the year between my first and second scans. I’m back down to 17 percent low from average peak density.
My doctor recommends staying on Fosamax indefinitely. But he knows I can’t stand taking all this stuff, even supplements, even though I haven’t had side effects from any of it. My goal is to maintain my bone density through diet and exercise. So our compromise is that after another year, assuming I’ll be pretty close to normal density by then, I’ll stop the Fosamax, keep up with my diet and weight lifting, and increase my running to five days a week. I’ll get another scan after a year of that to make sure I’m still on the right track.


Ideas about the cause of lung cancer have been so dominated by recognition of the effect of smoking for the last forty years that it is sometimes easy to forget that there may be other important causal factors and that lung cancer still occurs in non-smokers. The effect of smoking is so strong that it can be quite difficult to unravel other causes, because the presence of a few smokers in any group will so alter the statistics. However, there are undoubtedly other factors at work in the development of lung cancer and many of them can now be judged.
Once suspicion has been cast on an occupation it is a relatively straightforward, although laborious, task to examine the risk by comparing the incidence of lung cancer in workers in that occupation with that of the general population, and then doing more detailed work to look at the effect of the number of years spent in the occupation or the dose of the suspected agent to which the workers are exposed. Occupational hazard of lung cancer has been shown to be present for workers with asbestos, chrome, hydrocarbon chemicals in the old-style coke and gas industries, some chemicals used in the paint industry and for those who mine uranium (who are probably affected by radon gas from the rocks). New and effective regulations have been brought in to control these industries and the risks have been substantially reduced or eliminated. Careful monitoring remains necessary. Less certain risks have been suggested for workers with cadmium, nickel and vinyl chloride, and some fibres used in the textile industries, and precautions are now taken in industries based on these substances. Butchers appear to have a very small excess of lung cancer over the level which might be predicted. This is entirely unexplained and appears to be independent of smoking habits.


All the best intentions and plans for eating healthfully can be defeated in the kitchen unless you change some of the ways you prepare food. The most important change you can make is to learn to cook with little or no oils or other fats. Here are 10 tips to get you started.
1. Look for low-fat recipes in cookbooks or magazines that provide a nutrition analysis for each recipe.
2. Invest in nonstick cookware to be able to “fry” or brown foods in no added fat. If you would normally add a tablespoon of vegetable oil to a skillet, you save 120 calories and 14 grams of fat by using a nonstick skillet instead. Or use a 1-second spray of vegetable oil cooking spray, which adds about 1 gram of fat and few calories.
3. Add a few handy kitchen gadgets such as a garlic press, spice grater, lemon zester, egg separator, and vegetable steamer to expand or revamp your cooking habits.
4. Stock fat-free flavor enhancers such as onions, herbs and spices, colorful fresh peppers, fresh garlic, gingerroot, Dijon mustard: fresh lemons and limes, flavored vinegars, sherry or other wines, reduced-sodium soy sauce, bouillon granules, and plain, nonfat yogurt.
5. Saute onions, mushrooms, or celery in a small amount of wine broth, water, soy sauce, or Worcestershire sauce instead of butte oil.
6. Microwave or steam vegetables; then dress them up with flavored vinegars, herbs, spices, or butter flavored powders.
7. Cook fish in parchment paper (available at many supermarkets) or foil packets. This method seals in flavor and juices.
8. Poach fish or skinless poultry in broth, vegetable juice, flavored vinegars, dry wine, herbs, and spices. A covered roasting pan is an inexpensive alternative for a fish poacher.
9. Cut the amount of meat in casseroles and stews by one-third and add more vegetables, rice, pasta.
10. In recipes, substitute low-fat cream cheese, sour cream, or processed cheeses for their higher-fat, counterparts.


Bone has an amazing capacity to heal itself. After a bone breaks, the process of building new bone begins. Blood rushes to the wounded area, forming a fracture hematoma, or mass of blood that protects the injury. New, immature bone cells begin to form around the injury. In a process that can take between 6 weeks and 6 months, the immature bone cells mature and develop into solid bone, and the broken bones eventually knit back together.
At one time, we used to automatically put the injured limb in a cast to prevent overstressing the fracture while it heals. However, we have since learned that complete immobilization can seriously weaken the leg muscles; therefore, we now try to stress-relieve the wounded area with crutches and a functional cast made of fiberglass that allows for some movement. By doing this, we can prevent weight from being put on the broken bone, but the knee can still have some range of motion, which will prevent the muscles from atrophying.
Displaced fractures are surgical emergencies that can be treated by either closed reduction or open reduction, depending on the type of injury.


In the best of all possible worlds, clearly you should tell the school about the seizure. Unfortunately, this is not the best of worlds. Prejudice, misconceptions, overconcern, and fear of seizures still exist. Therefore, there is no simple correct answer to the question. In general, there is no need to tell the school about a single seizure. There is nothing school officials can do, or should do, about your child. They need not watch him more carefully unless he is participating in gymnastics that would place him at heights or is swimming unsupervised. They should not restrict him from playing on sports teams or at recess. He should be allowed to go on field trips and to do everything the other children do. Since there is nothing special school personnel need to do after a single seizure, it’s probably not necessary to let them know about it. What or whether you tell the school about the seizure may depend on your assessment of the teacher, the principal, and the school nurse and how you think they will react to the information. If your son or daughter does have another seizure, and if it occurs in school, you will wish that you had told them if you did not. After a second or third tonic-clonic seizure, or with epilepsy, it’s a different matter, to be discussed later.
This same philosophy applies to day care and to babysitters. Individuals acting as surrogate parents should have the same information and philosophy about overprotection as you have.


Many researchers have reported over the years that there is a relationship between activity levels and weight loss. In general, our findings support their reports, yet we have also observed that a rigorous exercise regime is not essential to the success of the diet, and other scientists have supported our findings.
Do these findings seem odd? They aren’t, really.
The explanation lies in the distinction between exercise and physical activity. Today, the word exercise is usually used to mean a programmatic pattern of activity, a planned regimen of regular running or swimming or other vigorous workouts. On the other hand, physical activity is less well defined: a job that requires considerable walking, for example, involves what we would term physical activity.
Thus, while exercise may make you feel good, look good, and stay healthy, it is not an integral part of the weight-loss component of this diet. At the same time, we do emphasize that you need to maintain a moderate level of physical activity (not necessarily a rigorous exercise plan) to help make the diet work for you.
So run or swim if you wish: there are many health benefits, and it may make1 you look good and feel better. But don’t do it solely to advance your weight-loss goals. Recall that it is a return to normal insulin balance that eventually produces weight loss in the carbohydrate addict.
In short, you don’t have to be in training for the marathon to lose weight: but you also can’t expect reasonable weight loss when you never get out of your easy chair.
As always, follow your physician’s recommendations, too.


The question the reader will ask at this point is ‘Given all this epidemiological study, do we know the causes of cancer?’ Broadly the answer is ‘yes’ in many circumstances and for many cancers, and the opportunities for prevention that this understanding generates are there to be taken. We do not always know how the factors that have been identified by the epidemiological studies discussed in this chapter link up to what is being learned in the laboratories of the molecular biologists. This connection is being made rapidly and will be increasingly clear by the end of the century. Epidemiology has been very successful in discovering or confirming which features of our lives in the Western world can be now identified as causes of cancer.
Very few medicines have been implicated as causing cancers but there are three groups of drugs where cancer is probably an important and often unavoidable side effect. Hormones have already been mentioned. The very drugs that are used for treating cancers by chemotherapy include some (particularly those known as alkylating agents) which interfere with DNA and, hence, with some genes. Cases of leukaemia and other cancers are being discovered as a delayed after-effect of such drugs in patients who have been cured of their first cancer by such chemotherapy. Not all the drugs used in chemotherapy have this effect and modem treatments appear to have reduced the risks considerably. The third group which may put people at risk are those drugs which are used to suppress the body’s immune function. These are used for patients who have had transplants and in such patients, particularly those with kidney transplants, certain rare kinds of cancer, including those known as lymphoma, have been found. As a result of the risks, these patients have to be monitored very carefully.


The terms behavioral therapy and behavior modification have been bandied about by many folks, some of whom are poorly informed about them. Unfortunately, in too many facilities the terms have been used so casually and imprecisely that what is being discussed is not correctly termed behavior modification at all. Here we would like to give you a brief rundown of the pertinent factors, as well as point out some of the things that have muddied the waters.
Obviously, any therapy has as its goal the modification of behavior. However, behavioral therapy is the clinical application of the principles psychologists have discovered about how people learn. The basic idea is that if a behavior can be learned, it can also be changed. This can be done in several ways. To put it very simply, one way is to introduce new and competing behavior in place of the old or unwanted behavior. By using the principles by which people learn, the new behavior is reinforced (the person experiences positive results), and the old behavior is in effect “squeezed out.” Another technique is to negatively reinforce (punish) the unwanted behavior; therefore, it becomes less frequent. Recall the discussion of Johnson’s model for the development of drinking behavior in Chapter 6. That explanation was based on learning principles. People learn what alcohol can do; alcohol can be counted on in anyone’s early drinking career to have dependable consequences. Therefore, drinking is reinforced and the behavior continues.
Behavioral therapy is a field of psychology that developed rapidly over the past 20 years. In the course of this development, its techniques have been applied to the treatment of alcoholism. However, the early behavioral approaches fared no better than did other psychological approaches, which were unable to offer by themselves a full explanation of alcoholism, nor alone were sufficient to guide treatment.
Historically, one of the first behavioral methods to be used in alcohol treatment was aversion therapy. In this case, a form of punishment was used to modify behavior. The behavior was drinking and the goal was abstinence. Electric shock and chemicals were the things primarily used. The alcoholic would be given something to drink and as he swallowed the alcohol, the shock would be applied. Alternatively, a drug similar to disulfiram would induce sickness. The procedure was repeated periodically until it was felt that the drinking was so thoroughly associated with unpleasantness in the subject’s mind that the person would be unlikely to continue drinking alcohol. Although short-term success was assured, those results were not maintained over the long haul. Aversion therapy of this form is now used very rarely.
As one author noted in reviewing behavioral approaches toward alcoholism,
Historically there have been many fads in the treatment of alcoholism. … Behavioral therapists have also been guilty of this fad-dism in the form of aversion therapy. There is a recent awareness on the part of behavior therapists that this rather naive approach to a complex clinical problem such as alcoholism is unwarranted.
As the field became more sophisticated, it became clear that an effective behavioral treatment program could not be based on a single behavioral technique. One cannot expect all clients to be successfully treated by the routine application of the same procedure. Just as not all clients are given the same kind and dose of a medication, neither can they be given the same behavioral treatment. Thus, efforts were then made to devise total alcohol treatment programs based on a variety of behavioral techniques.
One such approach received considerable attention and generated much controversy. It centered on efforts by behavioral psychologists in the early 1970s to teach controlled drinking to alcoholics. The Sobells (Linda and Mark) are the researchers most closely identified with this. The initial reports were quite positive. Controlled drinking as an alternative to abstinence seemed to be further supported by several studies that followed up on individuals who had been treated for alcoholism. Though the programs the clients had been involved in were generally abstinence oriented, a portion of these clients (although nowhere near a majority) were found to have returned to moderate drinking without problems. The report that generated the most attention (in part because its findings were released at a news conference rather than being reported in a scientific journal) was the Rand study, funded by the federal government to explore the outcomes of clients in NIAAA-funded treatment programs.
The optimism about controlled drinking as an alternative to abstinence could not be sustained. Several researchers very painstakingly tracked down the subjects of the Sobells’ study to see how they had fared over the long haul. Of the original group, only one was described as continuing as a moderate drinker. All of the others had serious problems and relapses, and four had died of alcohol-related problems. Similarly, Vaillant’s work suggested that once an addictive state has been established, a return to moderate, controlled drinking is very rare. If one follows people over time as he did, the proportion who can maintain a controlled drinking pattern declines. It must also be noted that “controlled” drinking is not to be confused with “social” drinking. Most social drinkers do not need to invest considerable attention and energy to maintain a moderate level of alcohol use.
A recovering alcoholic is likely to face a multitude of problems. One of these is a high level of anxiety. It can be of a temporary nature, the initial discomfort with the nondrinking life, or more chronic if one is the “nervous” type. Whether temporary or chronic, it is a darned uncomfortable state, and the alcoholic has a very low tolerance for it. Many alcoholics have used alcohol for the temporary and quick relief of anxiety. What is now remembered (and longed for!) is the almost instant relief of a large swig of booze. When alcohol or drugs are no longer an option, the alcoholic has quite a problem: how to deal with anxiety. Many simply “sweat it out”; some relapse over it.
Some positive things can be done to alleviate their anxiety, or anyone’s, for that matter. One is relaxation therapy. It is based on the fact that if the body and breathing are relaxed, it is impossible to feel anxious. The mind rejects the paradox of a relaxed body and a “tense” mind. Working with this fact, some techniques have evolved to counter anxiety with relaxation. Generally, the therapist vocally guides a person through a progressive tensing and relaxing of the various body parts. The relaxing can start with the toes and work up, or with the scalp and work down. The process involves first tensing the muscles, then relaxing them at the direction of the therapist. These directions are generally given in a modulated, soft voice. When the client is quite relaxed, it is suggested a soothing picture be held in her mind. The client is then given a tape of the process to take home, with instructions on its use, as an aid in learning the relaxation. With practice, the relaxed state is achieved more easily and quickly. In some cases, the client may finally learn to totally relax with just the thought of the “picture.” Once thoroughly learned, the relaxation response can be substituted for anxiety at will. The response once learned can be used by the recovering alcoholic to deal with those situations in which taking a drink might be almost second nature.
Another behavioral approach to deal with anxiety, systematic desensitization, builds upon the relaxation response. This technique has been found quite useful in treating people with phobias. This is an appropriate approach for recovering alcoholics who may feel panic at the mere thought of a particular situation. We mean real panic, so that even the idea gets them so uptight that the temptation to drink may be overwhelming.
In this process, with the aid of a therapist the recovering alcoholic approaches the situation that leads to anxiety in his imagination. As the anxiety builds up, he is directed to use relaxation techniques he has been taught. Gradually, going step by step, he uses the relaxation to turn off the anxiety, and eventually the situation itself becomes much less anxiety provoking. In alcohol treatment, this approach has been used for persons whose drinking has been partially prompted by stressful, anxiety-producing situations. Given another option, they are better equipped to avoid drinking when such situations arise.
Record keeping is another tool borrowed from behavioral psychology. Not uncommonly, recovering alcoholics may report finding themselves with some regularity “suddenly” in the midst of some kind of troubling situation (e. g., an argument with a spouse), with no idea as to what led up to it. There may instead be periods of inexplicable despondency. Often there is a pattern, but the key elements may not be apparent. Record keeping, a personal log or diary, of one’s daily routine sometimes is used to help identify the precursors that lead up to difficult moments. Recovery requires all kinds of readjustments to routines. By keeping a. daily log, over time, one may have a far better sense of what areas need attention.


The digestive system includes the mouth; the tube through which food passes after being swallowed, called the esophagus; the stomach; the small intestine, where food is broken down and absorbed; the large intestine or colon, where unabsorbed material is stored for elimination; and the anus. The whole system, taken together, is responsible for digestion of food and elimination of waste. This section will discuss all parts of the digestive system except the mouth: the mouth, which is a common site of problems, has been given its own section.
HIV infection can affect any part of the digestive system, and does so commonly in the later stages. The symptoms are often a clue to which part of digestive system is being affected. Painful or difficult swallowing is usually a symptom of problems with the esophagus. Pain in the abdomen, nausea, and vomiting are usually symptoms of problems with the stomach. Diarrhea, pain, and malnutrition from the failure to absorb nutrients are all symptoms of problems with the small intestine. And pain, diarrhea, or constipation are symptoms of problems with the colon.
Many of the problems in the digestive system also interfere with nutrition. Anything that interferes with nutrition is especially important to someone with HIV infection, because HIV infection itself causes weight loss and nutritional deficiencies. Severe malnutrition also seems to further weaken the immune system. Anyone with HIV infection and such problems with the digestive system should be under the care of a physician.


Wound healing
Elderly people often have very fragile skin which is easily injured. Healing may be slow, but, paradoxically, scars are often imperceptible because scar tissue is poorly formed in older people.
Leg ulcers
Leg ulcers frequently occur in older people with poor circulation, varicose veins, who smoke or who are diabetic. Ulcers can take a long time to heal, but the new biosynthetic dressings such as Duoderm aid healing and allow people to resume normal activities during the healing process.
Shingles is caused by the chicken pox virus and is painful and debilitating in older people. When chicken pox is contracted as a child, the virus continues to live in the spinal cord and is kept under control by the immune system. When the immune system deteriorates with age, the virus is able to re-emerge and produce shingles.
Acyclovir (Zovirax) is now used to treat shingles in the early stages. It makes the attack of shingles less severe and decreases the amount and severity of pain after the shingles episode.
Skin cancers
The risk of skin cancer increases as people get older. This is related mainly to cumulative sun exposure, but the deterioration of the immune system over time is a contributing factor. Skin cancers are often ignored in elderly people and so are treated far too late. If skin cancers are diagnosed early, treatment is very simple and is well tolerated by older people. The lesions are removed under local anesthetic in day procedure centers.
Although the skin cancer survival rate is generally improving, this has not been the case in elderly patients. This is probably because older people tend to neglect skin cancers until they become painful, bleed, ulcerate or become obvious to all their relatives. People, especially men, over the age of sixty need to be educated about skin cancer in the same way as all other age groups.