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In this issue we are pleased to bring you the exciting news that Dubai Healthcare City will launch a world-class tertiary care teaching hospital. This story has been developing for several months, as faculty from HMI, health care leaders in Dubai, a team of architects from a top firm, and clinical and administrative experts from throughout the Harvard medical community have worked together to design every component of the University Hospital.
Around Harvard
This article originally appeared in the December 2007 Harvard Men's Health Watch and is provided courtesy of Harvard Health Publications.
Gout: Joint pain and more
It starts with a bang, often in the dead of night. The pain is severe, almost unbearable, and fever may make you feel even worse. Lying still helps a bit, but even the touch of a sheet can be excruciating. And, worst of all, your distress may be greeted with a sly smile instead of supportive sympathy. You are suffering from gout, a common disease that’s often misunderstood.
Myths and realities
Gout is an old disease, and erroneous beliefs about it are almost just as old. The name, in fact, is based on a misconception It’s derived from a Latin word that means “a drop”; ancient physicians chose the name because they believed the pain resulted from a drop of “a bad humor.” Over the centuries, gout was considered a rich man’s disease, a product of overeating, excessive drinking, and corpulence. Modern research, however, shows that gout has no relationship to wealth or social status and little to diet and drink. But one traditional view has proved correct: Gout is a man’s disease, occurring seven to nine times more often in men than women. It’s also a common disease, striking an estimated 3.4 million American men annually. That makes gout the most prevalent form of inflammatory arthritis in men older than 40.
The chemical culprit
Gout is caused by an accumulation of uric acid. Uric acid has no useful function in the human body; it is simply a breakdown product of purines, a group of chemicals present in all body tissues and many foods. In normal circumstances, the body rids itself of uric acid by excreting it in the urine, keeping blood levels low. But some men have inherited a metabolic glitch that allows blood uric acids to rise; 90% of the time it’s because the kidneys don’t excrete enough uric acid, but sometimes the body just produces too much of the pesky chemical. Certain medications, such as low-dose aspirin, thiazide diuretics, and niacin, can also increase uric acid levels. Binge drinking, prolonged fasting, kidney disease, lead toxicity, extreme muscular exertion, and leukemia and lymphomas are much less frequent causes of high uric acid levels.
These high levels lead to gout — but not right away. In fact, uric acid levels are typically elevated for 20 to 30 years before they cause any trouble, which is why gout usually occurs in middle-aged and older men. Uric acid levels are normally below 7 milligrams per deciliter (mg/dL). The higher the level, the more likely an attack of gout; men with levels above 10 mg/dL have a 90% chance of developing gout. But gout can also be triggered by a rapid drop in uric acid levels, which is why up to 30% of men with gout have normal uric acid levels at the time of an attack.
An attack of gout occurs when excess uric acid is deposited in a joint and forms urate crystals that irritate the joint lining. White blood cells try to help; they gobble up the crystals, but they are not equal to the task. The white blood cells are themselves damaged, releasing chemicals that cause inflammation, swelling, and pain.
Ouch
Gout is painful, very painful.
The most common manifestation of gout is acute arthritis, severe pain in a joint. In most cases, it strikes one joint at a time; in half, it’s the first joint in the large toe. Other frequent sites include the forefoot, instep, heel, ankle, and knee. Gout is uncommon in the upper body, but it can strike fingers, wrists, and elbows. At any site, the attack usually begins abruptly, often at night. Within hours, the joint becomes red, swollen, hot, and painful. The pain and tenderness can be so severe that even gentle pressure from bedding is a problem. And even though only one small joint is affected, the inflammation can be intense enough to cause fever, muscle aches, and other flu-like symptoms.
Without treatment, gout can also cause long-term arthritis, with chronic swelling and permanent joint damage. Urate crystals can build up to a remarkable degree, producing large, even grotesque, deposits called tophi in joints and other tissues. Crystals may also be deposited in the kidneys, and they may precipitate in the urine, forming kidney stones.
Diagnosis
Gout is easy to recognize in the big toe, where it causes the characteristic inflammation called podagra. Doctors can often make the diagnosis over the phone, and most men with gout can diagnose themselves — particularly in their second or third attack of this recurring disease. But in other joints the diagnosis can be tricky. It’s simple to measure the level of uric acid in the blood; a high level supports a diagnosis of gout, but it’s not definitive, since many healthy men have high levels and some men with gout have normal levels. Other diseases can mimic gout, including rheumatoid arthritis, infections, and pseudogout, which is caused by crystals of another chemical (calcium pyrophosphate). If the diagnosis is in doubt, doctors can remove a small amount of fluid from the inflamed joint; in cases of gout, the fluid contains white blood cells and uric acid crystals, which can be seen through a special polarizing microscope.
Treatment
Gout responds very well to nonsteroidal anti-inflammatory drugs (NSAIDs) if two rules are observed. First, the NSAID should be started as promptly as possible, and second, it should be used at the maximum recommended dose. Many physicians prescribe indomethacin (Indocin) at a dose of 50 milligrams (mg) three or four times a day, but the other prescription and over-the-counter NSAIDs are also effective. One exception: Aspirin should not be used for gout because it can raise uric acid levels. After two to three days at full strength, the NSAID dose can be reduced by half, and in most cases, treatment can be stopped after just five to seven days.
Men who can’t take NSAIDs because of gastritis, peptic ulcers, or bleeding can get relief from a closely related drug, the selective COX-2 inhibitor, celecoxib (Celebrex). And if this new drug can’t be used, an old standby, colchicine, can help, though it’s fallen out of favor because it often produces vomiting or diarrhea in the high doses needed. Fortunately, a brief course of prednisone or a similar steroid will usually do the job for men who can’t take NSAIDs or celecoxib. Steroids can also be given intravenously to people who can’t take oral medications, and they can be injected directly into the inflamed joint to provide rapid relief.
Joints that are inflamed should be rested, but men can resume their normal activities as soon as their gouty attacks settle down.
Prevention
For centuries, diet was the mainstay of prevention, but since only about 10% of the body’s uric acid is derived from dietary sources, it didn’t work very well. Still, every little bit helps. Four reports from Harvard’s Health Professionals Follow-up Study show the best way to get that help. The first report implicates red meat and seafood as the villains and low-fat dairy products as the heroes. Although certain vegetables are also high in purines (see sidebar), the study did not confirm previous observations that linked veggies to gout.
The second Harvard report identifies beer as a culprit but exonerates wine; spirits were associated with a slight increase in risk. The third study tells us that men who lose 10 pounds of excess weight and keep it off reduce their risk of gout by 39%. And the newest study tells us that long-term coffee consumption appears to reduce the risk of gout. Even if coffee is not your cup of tea, a high fluid intake is important to help prevent uric acid kidney stones. But a 2007 study cautioned against a high consumption of sugary drinks, which were linked to high uric acid levels in men.
Although months or years can elapse between attacks, more than 75% of patients with gout have several episodes. Men whose attacks are infrequent don’t need any preventive medication, but they should have an NSAID on hand to use at the first sign of another attack. If episodes occur often, if they prove hard to treat, or if very high uric acid levels predict frequent attacks, medications can help.
There are three ways to prevent gout:
- Anti-inflammatory medication. Taken daily, low doses of NSAIDs (indomethacin, 25 mg twice a day, for example) or colchicine (0.6 mg once or twice a day) can prevent acute attacks.
- Medication to promote uric acid excretion. Probenecid (Benemid) is the traditional choice; the usual dose is 250 to 500 mg two or three times a day. A rash and intestinal upsets are the most common side effects. Since the drug increases uric acid in the urine, it can predispose a person to kidney stones, and it should be avoided in patients with kidney disease. Since it lowers blood uric acid levels, it can trigger gout early on, so men should always take an NSAID or colchicine during the first two to three months of probenecid therapy. Aspirin is a poor choice, however, because it blocks the activity of probenecid.
- Medication to reduce uric acid production. Allopurinol (Zyloprim) is the only currently available drug in this category, and it is the treatment of choice for men with chronic gouty arthritis or uric acid kidney stones. The typical dose is 300 mg per day, but some men need more, others less. The most common side effects are rash and intestinal upset; severe allergic reactions can occur, but they are rare. Because allopurinol produces such a rapid decrease in uric acid that it can precipitate gout, men should always take colchicine or an NSAID for the first two to three months of therapy. Febuxostat, a new drug to lower uric acid production, may soon be available.
Gout is an old disease that has plagued men for centuries. Thomas Sydenham, a great 17th-century physician, wrote, “Gout, unlike any other disease, kills more rich men than poor, more wise men than simple.” But the modern era has witnessed major changes in gout. It never kills, and it rarely results from errant behavior. Moreover, wise men need not fear the disease; instead, they can learn to treat and prevent attacks themselves with just a little help from a physician wise to the ways of gout.
Noise-induced hearing loss
Call it acoustic trauma or noise-induced hearing loss. By any name, it’s not something the iPod generation wants to hear about. But since acoustic trauma is the most important preventable cause of permanent hearing loss, it’s a message that should ring out clear (if not loud).
Now hear this
Noise-induced hearing loss is a product of modern life. It first surfaced during the industrial revolution, when workers were exposed to loud machinery for hours on end. Occupational exposure is still the most common cause of acoustic trauma, but recreational noise threatens to catch up. When this problem was first recognized, it was called boilermakers’ disease because of the impaired hearing that plagued men who manufactured steam boilers. If present trends continue, though, it may someday be known as iPod Ear.
Although estimates vary, up to 28 million Americans have impaired hearing; for as many as a third, acoustic trauma is a significant contributor.
Normal hearing, abnormal sounds
The ear is divided into three parts. Sound waves first enter the outer ear, which is little more than a passive sound-collecting channel. Next, the waves strike the eardrum, the tympanic membrane, causing it to vibrate. The vibrations are transmitted through the middle ear along a short chain of three small bones, the hammer, anvil, and stirrup. Finally, in the inner ear these vibrations reach the cochlea, which is lined by tiny hair cells, the cilia. The vibrations caused by sound produce a shearing force on the cilia, which translate it into electrical impulses that are transmitted along the acoustic nerve to the brain. But the cilia are delicate structures. Excessively loud sound produces excessive force, which can damage the hair cells. The cells can recover from mild damage, but severe damage will kill nerve cells, producing permanent hearing loss.
Especially loud sounds will damage anyone’s ears, but some people are more susceptible than others. In addition to genetic differences, environmental factors such as smoking and exposure to heavy metals and solvents can play a role. Still, in the last analysis, it is the sound itself that in time damages the fragile hearing apparatus.
Noise and your heart
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How loud?
The intensity of sound is measured on the decibel (dB) scale; the higher the number of decibels, the louder the sound.
The table lists typical dB values for some common sounds. Note that this is a logarithmic scale. That means an increase of just 3 dB indicates a doubling of the sound intensity.
A sound’s potential to damage the ear depends on the duration of exposure as well as the intensity of the sound. For example, just four hours at 88 dB will deliver the same dose of sound as eight hours at 85 dB. And a single gunshot at 140 dB will be as damaging as 40 hours at 90 dB.
How much sound is dangerous to your hearing? The Occupational Safety and Health Administration (OSHA) has developed guides based on the intensity of sound and the duration of exposure. Sounds below 75 dB are safe, but eight hours at 85 dB can be harmful; OSHA regulations require hearing conservation programs for workers exposed to this level of sound. And you should take steps to conserve your own hearing as well.
The intensity of various sounds |
|
|
|
140 |
Gunshot, jet plane taking off, siren |
110 |
Sand blasting, rock concert, chain saw |
100 |
Snowmobile, personal stereo (high volume), car horn |
90 |
Lawn mower, motorcycle, heavy traffic |
60 |
Normal conversation |
50 |
Quiet room |
30 |
Whisper |
0 |
Softest audible sound |
Warning symptoms
Most often, noise-induced hearing loss begins with a subtle difficulty hearing high-frequency tones, then slowly begins to encompass lower tones as it becomes more severe. Both ears are usually equally involved, but if one ear is closer to the offending sound, the impairment may be asymmetric.
Once your hearing is lost, it can’t be restored; your only recourse is to wear a hearing aid, which amplifies whatever sound your acoustic nerve can still pick up. That’s why it’s very important to recognize early symptoms. If your ears ring or buzz after being exposed to noise, it’s loud enough to cause damage. And if noise exposure makes hearing painful, muffled, blurry, or distant for hours or days, your cilia are already in trouble. If you allow the noise exposure to continue, you’re likely to suffer permanent hearing loss.
Who is at risk?
Everyone who is exposed to loud noise is vulnerable. If background noise makes it necessary for you to shout to make yourself understood by someone just an arm’s length away, that noise is loud enough to be damaging.
Occupational exposure is the most common cause of noise-induced hearing loss. Construction workers, factory workers, policemen, firefighters, military personnel, farmers, and truck drivers are especially at risk. Enthusiastic crowds at sporting events can also generate excessive sound, putting stadium workers and fans who attend many games at risk. Musicians are also at risk. Many classical performers wear ear plugs for protection during orchestral performances. Some rock musicians are less cautious; acoustic self-mutilation by the young seems to have become a tribal rite. Dr. Walter Brattain regrets “the use of solid-state electronics by rock musicians to raise the level of sound to where it is both painful and injurious.” Hardly a disinterested observer, Dr. Brattain won the 1956 Nobel Prize in Physics for inventing the transistor!
Personal stereos are a particular threat to the younger generation. Prolonged battery life means these devices can be played for hours on end, and iPods can store lots of music for continuous listening. Listeners are conditioned to like loud music, and since they often listen to their music in public, they are likely to turn the volume even higher to drown out competing environmental sounds. The trendy earbuds that are replacing earmuff-style headphones make the problem even worse by focusing the sound directly into the ear.
What to do?
First, turn down the volume wherever you can. You may have a hard time persuading your kids to keep their amplifiers and MP3 players set halfway between low and max, but you can set your own devices properly. And when you are at a loud concert or party, angle for a seat far from the band.
Even if you can’t get away from sound, you can keep it away from your ears. For occasional exposures, use disposable ear plugs — but if you’re frequently at risk, invest in custom-fitted ear plugs. For protection outdoors or at work, try acoustic earmuffs. And for maximum protection, wear both.
Used properly, plugs and muffs can provide 15 to 40 dB of sound attenuation. They may seem awkward, ungainly, or unsightly, but temporarily wearing protectors now is a lot better than wearing a hearing aid in the years ahead. It’s sound advice.
Supplements vs. exercise for nine health issues: The ‘‘vitamins’’ in your legs
Can you find good health in a bottle of supplements? Many people seem to think so, or at least have enough hope to spend billions of dollars a year on supplements. In view of the constant drumbeat for vitamins, minerals, and herbs — and the scant FDA oversight — you can hardly blame people for embracing supplements. Indeed, objective scientific studies are needed to learn which claims are valid and which are not. But while research goes forward, we should all look for other natural ways to improve our health. Good nutrition is one essential, exercise another.
When comparing the effects of supplements and exercise on heart disease and cancer, exercise comes out on top. Now, let’s see how the two compare on nine other health issues.
1. Muscles and bones. Strong muscles are important for health — and they are also important for athletic performance and for the muscular physique that is particularly valued by young men. Vitamins have no role in making muscles stronger or bigger, but vitamin D may help reduce falls by improving neuromuscular function. And other supplements may work, at least to some extent. Chemicals that are related to the male hormone testosterone are the best example, which is why androstenedione (Andro) and dehydroepiandrosterone (DHEA) have become best sellers. Trouble is, they can also have side effects; most experts strongly discourage their use, explaining that the potential harm far outweighs the possible gain. Creatine and various protein supplements have a less toxic potential, but they are also much less likely to enhance muscular function. All in all, there is little to recommend supplements for muscles.
Bones are different. Strong bones lack the sex appeal of bulging biceps, but the fractures and deformities caused by osteoporosis bespeak the importance of maintaining bone calcium in the face of age. About 34 million Americans have osteopenia, or low bone calcium, and another 10 million have the thin, brittle bones of osteoporosis. Virtually all authoritative medical groups recommend vitamin D (at least 200 international units, or IU, a day for adults younger than 50, 400 IU a day between 51 and 70, and 600 IU a day above age 70) and calcium (1,000 mg a day below age 50, 1,200 mg a day thereafter) to help prevent osteoporosis. An important 2007 meta-analysis of 29 trials involving over 63,000 subjects recommends 1,200 mg calcium and 800 IU of vitamin D a day. Most Americans will require supplements to reach these goals. Although osteoporosis is more prevalent in women, men are far from exempt.
At present, both genders should still follow the general guidelines, but men may be wise to limit their daily calcium to about 1,200 mg; some (but not all) studies suggest that a high intake may be linked to an increased risk of prostate cancer. And new evidence suggests that boosting vitamin D to 800 to 1,000 IU a day may help. But since high doses of vitamin A increase the risk of osteoporosis, men should keep any vitamin A supplements below 3,000 IU a day.
When it comes to musculoskeletal health, exercise has a crucial role. But not all forms of exercise are equally effective. Weight-bearing and resistance exercise are needed to enhance muscle mass and strength. It’s why strength training is important, particularly for older men and women. Fortunately, you don’t have to hit the gym to benefit. In fact, simple routines at home two to three times a week will do the trick.
2. Neurological and psychological disorders. Cognitive impairment, dementia, and Alzheimer’s disease are among the most feared diseases that can strike older people. Sad to say, the supplement industry preys on these fears, touting various products to keep the brain young. There is no credible evidence that any can help. One well-performed study did show that very high doses of vitamin E can slow the progression of Alzheimer’s disease slightly, but the benefits were very small, and there are no data to support any supplement’s ability to prevent, delay, or reverse cognitive decline.
Exercise is good for the body, but can it also help the mind? Animal studies show that exercise training can increase blood flow to the brain and enhance communication between nerve cells by promoting new connections (synapses) between brain cells. A study of mice even found that exercise increased the production and survival of new nerve cells in the aging rodents’ brains.
What’s good for mice also seems to be good for men. Ten recent studies of more than 53,000 older Americans, Canadians, and Europeans have all linked cognitive decline in seniors to a lack of exercise. Compared with the least active people, those who got the most exercise enjoyed a 15% to 52% lower risk of mental decline. In one study, for every mile a woman walked each day, her risk of cognitive dysfunction dropped by 13%. In another, regular exercise between the ages of 20 and 60 was linked to a nearly fourfold decrease in the risk of developing Alzheimer’s disease. In addition, researchers in Baltimore reported that people who carry a gene that increases the risk for Alzheimer’s obtain the greatest protection from exercise.
Psychological well-being is harder to quantify than physical health, but one supplement, St. John’s wort, does seem to help lift mild to moderate depression, at least in the short term. Exercise can also help fight depression, promote sleep, and dissipate stress.
3. Obesity and diabetes. Obesity is a big problem in America, and it’s a big market for the supplement industry. It would be nice if a supplement could help, but none has a meaningful or sustained effect on body fat, and some, such as ephedra, have proved very dangerous. Many of America’s 21 million cases of diabetes are spawned by obesity. Chromium is a mineral that is sold in various forms to promote weight loss. It can’t do that, but it may have a small role in improving glucose (sugar) metabolism. More study is needed.
Exercise burns calories. It is a necessary partner to dietary caloric restriction for sustained weight loss. Weight loss helps prevent and treat diabetes — but even without weight loss, exercise sensitizes the muscle cells to insulin, lowering blood sugar levels in both diabetics and others.
4. Arthritis. Supplements are praised and exercise is blamed for joint pains that plague millions of Americans. There is some truth to the former, little to the latter.
Although not all studies agree, there is a body of evidence that one supplement may help, at least to some degree. Glucosamine may partially reduce the pain of osteoarthritis for some patients. A companion supplement, chondroitin sulfate, does not seem to help. Although these supplements are expensive, they appear generally safe. There is much less evidence to support the claims of other supplements.
If exercise produces a major joint injury, it will increase the risk of osteoarthritis in later years. But aside from a slip on the ski slope or a hit on the gridiron, exercise is actually easy on joints. In fact, exercise helps cartilage cells get the nutrients they need from joint fluid. Even the steady pounding of long-distance running doesn’t cause symptomatic arthritis of the knees or hips, though it can produce minor abnormalities that will appear on x-rays.
5. Infections. In the “contest” between supplements and exercise, this one ends in a dead heat — not because both can help, but because neither lives up to hope and hype. Vitamin C, echinacea, and zinc have all been touted to prevent or treat upper respiratory infections, but none of their claims has stood up to the scrutiny of careful, objective scientific study. Vitamin E has fared even worse, actually increasing susceptibility to colds in one investigation. And, various claims notwithstanding, exercise does not have an important effect on infections for good or ill.
6. Vision. There’s no benefit for exercise here. But in one situation, a supplement can help. Age-related macular degeneration (AMD) is a distressingly common cause of visual loss in older people. The landmark Age-Related Eye Disease Study showed that a daily supplement containing 500 mg of vitamin C, 400 IU of vitamin E, 15 mg of beta carotene, 80 mg of zinc, and 2 mg of copper can reduce the risk of progression to severe AMD by about 25%. It’s one of the very few optimistic studies of antioxidants and health.
7. Anemia. There’s no role for exercise here, either. In fact, very high levels of exercise can actually reduce red blood cell counts (“marathoner’s anemia”). But with two exceptions, supplements don’t help, either. Older people can have trouble absorbing vitamin B12 from food; the crystalline form of B12 in supplements is much easier to absorb and can prevent anemia. Strict vegetarians and some people who have had gastrointestinal surgery need B12 supplements, and patients with pernicious anemia need high doses. Iron won’t help healthy men, but it can prevent iron-deficiency anemia in menstruating women. (And speaking of women, folic acid is vital to prevent birth defects during pregnancy.)
8. Energy and sexuality. This oft-repeated claim for supplements is another likely cause for disappointment. Vigor is hard to measure, but many people report that exercise boosts their energy, both mental and physical. It’s mostly anecdotal evidence, and like the testimonials for supplements, it may be subject to a strong placebo effect. But there is hard scientific evidence that regular exercise is linked to a reduced risk of erectile dysfunction (ED). A Harvard study linked walking for about 30 minutes a day to a 41% reduction in the risk of ED. And in 2004 a randomized clinical trial reported that moderate exercise can help restore sexual performance to obese middle-aged men with ED.
9. Aging and longevity. “Anti-aging” supplements have understandable appeal but no scientific merit. In this case, though, disappointment may take longer to set in.
Exercise can’t turn back the clock, either, but there are sound reasons to believe it can slow the tick of time. Bodily disuse contributes to many of the physiologic changes that accompany aging, and exercise can slow the rate of change.
Regular exercise prolongs life. According to the calculations of the University of Chicago’s Dr. Willard Manning and his colleagues, each mile you walk as part of a regular exercise program will extend your life by 21 minutes. The Harvard Alumni Health Study is even more optimistic; calculations based on its data say that you’ll gain about two hours of life expectancy for each hour of regular exercise, even if you don’t start until middle age.
Calculations are one thing, observations another. Scientists have gathered facts by evaluating elderly men in Hawaii, Seventh-Day Adventists in California, male and female residents of Framingham, Massachusetts, Harvard alumni, elderly American women, British joggers, middle-aged Englishmen, retired Dutchmen, and residents of Copenhagen — among others. Although the details vary, the conclusion is remarkably uniform: Regular exercise prolongs life and reduces the burden of disease and disability in old age. In reviewing the data, Dr. J. Michael McGinnis of the U.S. Office of Disease Prevention and Health Promotion concludes that regular physical activity appears to reduce the overall death rate by more than a quarter and seems to increase life expectancy by more than two years compared with the sedentary population’s average.
Exercise and longevity — it’s Darwin redux, the survival of the fittest.
Perspectives
Regular exercise is important, even essential, for optimal health. But it doesn’t have to be intense or prolonged; you don’t need mega-exercise any more than megavitamins. In fact, about 30 minutes of moderate exercise a day will yield an enormous benefit. Walking, taking the stairs, gardening, and biking are a few of the many ways to improve your health through physical activity. Add modest “doses” of strength training, stretching, and exercises for balance and you’ll have a complete prescription for health.
Except in a few special circumstances, exercise far outshines supplements for health. Among the supplements, vitamin D makes the most sense, and fish oil can help people at risk for heart disease. Extra amounts of B₁₂ are harmless and may help certain individuals, but extra amounts of other vitamins may do more harm than good.
Don’t waste your money on high potency, “all-natural,” or designer vitamins. Vitamin-mineral combinations are also unnecessary. Above all, remember that any supplement is just an insurance policy — a supplement, not a substitute, for a healthful lifestyle that incorporates moderate physical activity into the fabric of daily life.
When it comes to a supplement for exercise, though, the best choice is not a pill but a balanced, healthful diet. In fact, good nutrition is more than a supplement, it’s the natural partner of exercise. Together, they are the hand-and-glove of prevention and good health. Think of them, perhaps, as the unofficial “vitamins” E (exercise) and D (diet).
On call
Chocolate and health
Q. I’ve been called a “chocoholic” because I love chocolate and eat a piece after dinner every night. My weight is fine and my cholesterol is, too. Is there any reason to change my ways?
A. Chocolate has long been viewed as a guilty pleasure. New research may help remove the guilt, but only if you understand America’s favorite confection.
To produce chocolate, cocoa beans are dried, roasted, and separated into cocoa butter and cocoa powder. The powder is low in fat and is used for baking or to make hot chocolate. The cocoa butter is the heart of chocolate.
Cocoa butter is high in saturated fat. But while most saturated fats will boost your blood cholesterol, the fat in cocoa butter won’t budge it. And cocoa butter is rich in antioxidants and chemicals called flavonoids, which protect arteries and lower blood pressure.
Cocoa butter tends to be bitter. To increase its appeal, confectioners process it, add sugar, and sometimes add milk solids. Unfortunately, processing removes the flavonoids, sugar adds calories, and milk adds a harmful variety of saturated fat.
Dark chocolate may improve health. People who eat about 3½ ounces a day have more supple arteries, lower blood pressures, and a lower tendency to form artery-blocking clots. White chocolate and milk chocolate do not have these benefits. Remember, too, that even 3 to 4 ounces of chocolate a day will provide enough calories for you to gain a pound a week. And chocolate may trigger migraines, heartburn, or kidney stones in some people.
Since you love chocolate, you should choose dark chocolate, limit yourself to a few ounces a day, and cut calories elsewhere to keep your weight in line. And don’t rely on chocolate to make up for a bad diet or insufficient exercise.
If you make dark chocolate part of a healthy lifestyle, you can have the pleasure without the guilt.
— Harvey B. Simon, M.D.
Editor, Harvard Men’s Health Watch
On call
Shy bladder syndrome
Q. I hope you can help me understand a troubling and embarrassing problem. I often find it difficult, sometimes even impossible, to pass my urine in a public men’s room. I’m 41 years old, and I’m very healthy. I have no problem urinating at home, and I rarely get up at night. But last week I couldn’t even urinate at a friend’s house, and I had to go home early just to use the bathroom. What can you suggest?
A. Although your problem doesn’t get much attention, it’s far from rare. In fact, it’s earned a medical name, paruresis, and a popular translation, the “shy bladder syndrome.”
Paruresis is not a urologic problem but a psychological one. It’s a variation on a common theme of social phobia disorders. Social phobias can take many forms. Perhaps the most obvious is performance anxiety or stage fright. Others can include fear of being seen eating or extreme shyness in personal encounters. In your case, the “performance” that triggers anxiety is urination. People with paruresis tense up when they think someone may see them urinating, hear them urinating, or even know they’re urinating, particularly when there is a line at the bathroom door. Anxiety tenses up the sphincter muscles at the bladder neck, and when these muscles won’t relax, urination is a no-go.
Since the problem is psychological, the best treatments are also psychological. Options include traditional counseling, cognitive-behavioral therapy, relaxation training, biofeedback with bladder training, and medication such as the antidepressant paroxetine (Paxil) or a similar drug. But if your problem is mild, you can try to manage it yourself by thinking positively (“What’s the worst thing that can happen if someone hears me?” “If I can’t void now, I will later”) and by practicing in restrooms.
Some tips may help tide you over. Be sure to empty your bladder in privacy before you set out. When you’ll be at the mercy of public facilities for some time, drink sparingly and avoid alcohol and caffeinated beverages. If possible, use a stall rather than a urinal. The time-honored trick of leaving the water running may help if it’s possible. Avoid decongestants like pseudoephedrine (Sudafed and other brands), which tighten the sphincter muscles. You can also ask your doctor about a trial of an alpha blocker, such as tamsulosin (Flomax), which relaxes the sphincter muscles.
It’s always best to get at the root of the problem, but people suffering from paruresis have another choice: they can learn to self-catheterize their bladders to let the urine out in emergency situations such as a long airplane trip. Although there is a small risk of bladder infection, it’s a surprisingly easy and safe technique.
All in all, if you have a shy bladder, don’t be shy about discussing it with your doctor. There are many ways he can help you go when you’re on the go.
— Harvey B. Simon, M.D.
Editor, Harvard Men’s Health Watch
