Wax on, wax off
April 25, 2008

Dear Lucy: When I told my sister I'd had a hearing test, she asked if I'd had my ears cleaned first. I hadn't. She then wanted to know how I could have had an accurate hearing test if my ears were full of wax. So my question is this: Do you need to have your ears "cleaned" before you have a hearing test? —Can You Hear Me Now

Dear CYHMN: This question had Lucy running for the Q-tips, which, as MIT Medical audiologist Christine Rabinowitz later told her, was exactly the wrong thing to do. "Audiologists expect to see some earwax in people's ear canals," Rabinowitz emphasizes.

"Your body makes ear wax to lubricate the ear canal and to protect your ears from damage and infection," she continues. "It is created, sloughed off, and expelled from the ear in an ongoing cycle. This is a natural process that is helped along by typical washing or swimming."

Though ears are designed to be self-cleaning, ear wax can sometimes accumulate on its own, she notes. "Or sometimes people help it accumulate by using Q-tips or other devices inside their ears," she says. "And although it might look like some of the wax is coming out on the Q-tip, it's likely even more of it is being pushed in." In addition, the irritation caused by swabbing the ear canal with a Q-tip may stimulate the body to create excess new ear wax.

"There is no way to know if you have too much wax in your ears unless a healthcare provider examines your ear with an otoscope," Rabinowitz says. And, she adds, your audiologist probably looked into your ears before doing your hearing test. "I always take a look to see what is in the ear canal and to determine whether the patient is likely to have any problems using the earphones," Rabinowitz explains. "If I notice a problem, I'll send the patient to get an ear cleaning, typically done with irrigation by one of the nurses, before I perform the test."

You can inform your sister that Lucy says your hearing test was probably valid—and that your ears were probably not "full of wax." And Lucy encourages you, and all her other readers, to restrict Q-tip use to craft activities and belly-button cleaning. —Lucy

Dear Lucy: Do you recommend that college women who have not been sexually active take the three doses of the new Gardasil vaccine? My doctor mentioned that a more effective version of the vaccine may be released later this year, so I am wondering if I should wait for that one. —Hurry Up & Wait

Dear Unrated: Lucy hears from a lot of undergraduate woman with questions about the human papillomavirus (HPV) vaccine, so she's glad to have a chance to answer this one. You are probably not the only one who's heard that a new vaccine is currently being tested and has questions about it. For help in answering your question, Lucy turned to MIT Medical gynecologist Chana Wasserman, M.D.

According to Wasserman, the vaccine now being tested, Cervarix, varies from the currently available Gardasil vaccine in two ways. Both vaccinate against HPV strains 16 and 18, which cause 80 percent of all cervical cancers. Gardasil, however, also vaccinates against HPV strains 6 and 11, which cause 90 percent of the cases of genital warts and, according to recent research, it may also confer partial protection against 10 other HPV strains. But even though Cervarix doesn't protect against genital warts, it may have an advantage over Gardasil in the adjuvant, or vaccine enhancer, it uses, Wasserman notes. "Gardasil uses an aluminum salt adjuvant," she explains, "but Cervarix is using a novel adjuvant known as AS04, which leads to higher antibody levels and may provide longer-lasting protection."

As to recommendations for current action—or inaction, as the case may be—Wasserman says it depends on your level of sexual activity. "If you are currently sexually active or planning a new sexual partner, or partners, in the near future, it would be worth proceeding with the currently available vaccine in order to be protected right away," she says. On the other hand, Wasserman continues, "if you are currently in a stable relationship or not yet sexually active, it's probably worth waiting until the new vaccine completes its trials, and then see which one the CDC recommends."

In the meantime, Gardasil is currently available at MIT Medical (see http://web.mit.edu/medical/a-newsarchive.html#gardasil2), and elsewhere, and Lucy would like to remind everyone that most cases of cervical cancer can be prevented. Along with vaccination, that means regular Pap tests to detect treatable, precancerous cell changes. —Lucy

Dear Lucy: How do I figure out my basal metabolic rate (BMR)? When it comes to the number of calories I consume each day, should I aim for this number to maintain my weight? —Unrated

Dear Unrated: For help with this question, Lucy went straight to the source of all knowledge caloric and dietary: MIT Medical nutritionist Anna Jasonides, R.D.

"This is an easy question," Jasonides told Lucy happily, and immediately began scribbling mathematical formulas on a piece of scrap paper. "An individual's basal metabolic rate, or BMR, is the total number of calories required to keep the body functioning while at rest," she explained. "It's the minimum number of calories your body needs to keep your heart pumping, make new blood cells, and maintain respiration, body temperature, digestion, and other intrinsic metabolic processes and chemical reactions.

"But if you plan on getting out of bed for at least part of each day, you don't want to base your caloric intake on your BMR!" Jasonides exclaimed. "What you need to do is to figure out your BMR, and then multiply it by a number representing your level of physical activity. That result is your TDEE, or 'total daily energy expenditure'—and your TDEE is a pretty good estimate of the number of calories you should consume each day to maintain your current weight."

Jasonides explained how to figure BMR, using one of these formulas:

Women:
BMR = 655 + (4.35 x weight in pounds) + (4.7 x height in inches) – (4.7 x age in years)

Men:
BMR = 66 + (6.23 x weight in pounds) + (12.7 x height in inches) – (6.8 x age in years)

Then, she continued, to determine TDEE, simply multiply your BMR by the activity factor that most closely describes your level of daily exercise, as follows:

So, for example, a moderately active 35-year-old woman who weighs 140 pounds and is 5'5" inches tall would calculate her TDEE as follows:

BMR = 655 + (4.35 x 140) + (4.7 x 65) – (4.7 x 35)

= 655 + 609 + 305.5 – 164.5

= 1405

TDEE = 1405 x 1.55 = 2117.75

In other words, this woman should consume approximately 2118 calories per day to maintain her current weight.

Jasonides emphasizes that these calculations do not yield precisely accurate results. For example, a different calculation to achieve a more exact BMR estimation can be performed based on lean body mass as opposed to total weight (that formula, for both men and women, is BMR = 370 + (9.8 x lean body mass in pounds). Also, any estimation of one's activity level is just that—an estimation. But calculating your TDEE using either BMR formula will provide you with a baseline number that can be useful in dietary planning. —Lucy

Eyes wide shut
February 1, 2008

Dear Lucy: : I'm often seized by extreme sleepiness about one and half or two hours after lunch. I'm usually much sleepier at this time of day than I am at midnight. I think many people share this experience. Unfortunately, many classes at MIT are scheduled in the afternoon, just at this "sleepy time." Do you have any advice on how I can become more alert at this time of day? —Somnolent Sophomore

Dear S-squared: What a great question! You're correct that many people share your experience of mid-afternoon drowsiness, and that includes Lucy. A midday nap is part of the daily routine in many cultures, and many scientists now believe that this afternoon "downtime"—which tends to occur between 2 and 3 p.m. for most people—is hardwired as part of our circadian cycle. In fact, it even coincides with a slight drop in body temperature.

Unfortunately, says MIT Medical psychologist Xiaolu Hsi, Ph.D., this mid-day slump hits even harder if you're already overtired, and "chronically overtired" describes most college students. "Sleep deprivation is more pervasive than 'the freshman 15,'" she says emphatically. Hsi's first suggestion, therefore, is that students try to get enough sleep. "If possible, this means seven to eight hours a night," she emphasizes. "Try to peg your schedule to the hours of sunlight, especially as far as getting up in the morning," she adds. "Staying up past midnight, and then sleeping late the next day, is not the best way to be effective in any area."

Hsi also suggests eating a lighter lunch. Although the afternoon slump occurs whether or not one has eaten a midday meal, normal afternoon drowsiness may be exacerbated by a heavy noontime meal as the body's energy is diverted to the task of digestion. Hsi's colleague, psychologist Celene Barnes, Psy.D., further cautions against overdoing it with carbs at lunchtime. Studies have shown that a high-carbohydrate meal, especially one that is also low in protein, tends to elevate serotonin levels in the brain, which causes sleepiness. "Taking a brisk 10-minute walk before an afternoon class is another way to make sure you start the class as fully alert as possible," Hsi adds.

Finally, Lucy wants to remind you that you're never too old for a nap. Many studies have shown that the best way to deal with the mid-afternoon slump is not to fight it. In fact, even a 10- to 15-minute nap can lead to several hours of improved alertness and productivity. And short daytime naps have been shown to be especially useful when you're not getting enough sleep at night. Just keep naps to no more than 45 minutes—set an alarm—and don't nap after about 4 p.m. Lucy would also add that midday naps are best taken before an afternoon class, not during! —Lucy

Perimenopause?
January 8, 2008

Dear Lucy: : I assume I am in perimenopause. I just got my period after 10 months. Does that mean I am ovulating again? My energy level is very low, so I assume my iron is low. I do take Fergon iron supplements plus a multivitamin. This period has drained me. Is there anything I can take to feel energized? —Too tired

Dear TT: It's tough feeling tired all the time. Lucy is glad you are seeking solutions to make things better.

Perimenopause, the interval of transition into menopause, may last anywhere from two to eight years, MIT Medical gynecologist Annie Liau, M.D., tells Lucy, and according to studies, 95 percent of women enter perimenopause between the ages of 39 and 51. During this time, menstrual cycles may become irregular, and women may or may not ovulate during any particular cycle. "Without ovulation, the interval between menstrual cycles increases," Liau explains, "and bleeding can be excessive when the period resumes." In general, she continues, "clinical evaluation is recommended after a woman who has been menstruating regularly misses three periods."

According to Liau, there are many conditions that can cause amenorrhea, or absence of menstrual periods. "For example," she says, "underactive thyroid is a health condition other than perimenopause that can cause fatigue and amenorrhea. This woman should make an appointment with her clinician at MIT Medical—especially if she continues to have low energy despite adequate sleep."

Your clinician will probably want to take a history, do a physical exam, and order some laboratory tests to check iron reserve and thyroid function, Liau tells Lucy. "It is also important to observe the pattern of bleeding," she adds. "This information should be shared with your clinician, so he or she can decide if it would also be useful to check for abnormalities of the uterine lining, perform a hormonal evaluation, or do other clinical tests."

Lucy concurs with Liau's recommendation to make an appointment with your personal clinician for a check-up. Perimenopause is a natural transition in a woman's life, but that doesn't mean a clinician shouldn't be involved in helping you make this transition in the easiest, healthiest way possible. —Lucy

It's not the cough; it's the cover-up
December 7, 2007

Dear Lucy: I've seen the video that is making the rounds about the proper protocol for sneezing or coughing into your shirt sleeve rather than into your hands. I can certainly understand the importance of doing this if you have a cold or the flu. However, I am curious if it is as critical to follow this protocol when I sneeze because of allergies, or cough because cigarette smoke is bothering me, or if I need to use Kleenex because I just had a spicy dish or stepped out into the cold? —I saw it on the Internet, so it must be true

Dear Seeker of Truth: It's amazing what one can learn on YouTube.com. In just 15 minutes, Lucy's learned how to wash a cat (welder's gloves are a must, apparently), kill a ninja (not nearly as hard as bathing a cat), and place an order at a sushi bar. And, thanks to OtoRhinoLounsburgology Productions—and the aptly named "Why don't we do it in our sleeves?"—there's also a YouTube video that demonstrates the proper way to cough, or, more specifically, the proper way to cover one's cough in order to avoid spreading germs.

But, amazingly enough, Lucy couldn't find an answer to your question online, so she turned to MIT Medical nurse practitioner and infection control coordinator Jacqueline Sherry, A.P.R.N., B.C. Sherry tells Lucy that coughing or sneezing into one's sleeve is "generally good practice, no matter what has caused your cough or sneeze." It's also the case, she continues, that an individual cannot always know precisely what has caused a cough or sneeze. "There are several types of respiratory viruses," she notes, "and we may be unaware that we are infected. There's also an incubation period between the time of infection and the onset of symptoms, and practicing good respiratory etiquette is the only way to be sure you are not spreading germs before you are even aware that you are sick."

MIT Medical internist and infectious disease specialist Howard Heller, M.D., concurs, noting also that people around you won't know whether you're coughing due to illness, smoke, allergies, or some other benign cause, so covering any cough or sneeze appropriately will do much to enhance your reputation as a thoughtful and considerate person. "And," he adds, "it's easier to maintain good habits if you do something the same way every time. If you get into the habit of coughing or sneezing into your sleeve, no matter what, you'll do it automatically when it really counts."

Can we scrap the Pap?
November 16, 2007

Dear Lucy: Since we now have a vaccine for human papillomavirus (HPV), developing an HPV blood test would seem to be a simple matter. Why can't doctors do an HPV blood titer, which would be more accurate than a Pap smear in testing for cervical cancer? —Prefers a Needle

Dear Needle: Why not, indeed? With a vaccine in existence, a blood test seems only logical. Why must we be subjected to annual Pap tests if a simple needle prick would suffice? Lucy immediately called MIT Medical gynecologist Dawn Anderson, M.D., to register an official complaint.

Anderson quickly shot down Lucy's conspiracy theories. It's not that doctors enjoy doing Pap smears, Anderson said, but, she emphasized, regular Pap tests are still the only reliable way to diagnose precancerous cell changes before they become cancerous.

As for a clinically useful blood test, "it's not as simple as it might seem," Anderson continues. "For research purposes, epidemiologists and vaccine developers use tests that look for HPV antibodies in the blood, but a positive test only indicates exposure to the virus at some time in the past." Epidemiological studies have shown relatively high rates of exposure to the HPV subtypes implicated in cervical cancer, but since only a small percentage of the population ever develops cervical cancer, the presence of HPV antibodies alone would not be diagnostic of the disease.

But research continues, Anderson notes, so "although blood titers are not currently used in screening, managing, treating or preventing cervical cancer, perhaps there will be a clinically useful blood test in the future." However, she adds, "The Pap smear doesn't just screen for HPV-related cervical cancer. It includes a visual inspection of not only the cervix, but also the vagina and vulva. So, even if we had a blood test that could detect HPV and had good positive and negative predictive value for cervical dysplasia, a speculum exam with visual inspection would still be recommended."

For now, Lucy would like to remind everyone that most cases of cervical cancer can be prevented. For her female readers, that means regular Pap tests to detect treatable, precancerous cell changes. And for girls and women older than nine, the new HPV vaccine, Gardasil, is available at MIT Medical (see http://web.mit.edu/medical/a-pressreleases.html#gardasil2) and elsewhere. —Lucy

Dear Lucy: I know that an adult who had chicken pox as a child can get shingles from the dormant virus. Is there any medical consensus on how to prevent this? Do the experts at MIT Medical recommend, for example, getting the chicken pox vaccine? And if an adult has had one case of shingles, does that increase or decrease his chances of getting it again, thus making preventative measures more or less necessary? —Shingular Sensation

Dear Sensational: Though Lucy has been lucky enough to avoid shingles, several of her acquaintances have not been as fortunate. Shingles (also referred to as herpes zoster) is an outbreak of skin rash or blisters caused by the same virus that causes chicken pox—the varicella-zoster virus. The first symptom may be burning or tingling pain, or sometimes numbness or itch, in a specific location on one side of the body—most often in the trunk area, near the waistline. A few days or as much as a week later, a rash of fluid-filled blisters, similar to chicken pox, appears in the same spot. Shingles pain varies in intensity. Some people experience it mostly as itchiness; others feel excruciating pain from even a slight touch or breeze.

According to MIT Medical internist Evelyn Picker, M.D., anyone who has had chicken pox is at risk for shingles, which occurs when the long-dormant varicella-zoster virus somehow reactivates. "A case of chicken pox in childhood confers immunity to the virus," Picker explains. "But as we get older, that immunity declines, which is why shingles is more common in adults over 50."

The chicken pox vaccine is now part of the standard childhood vaccination protocol. "It's also recommended for young adults if they don't already have immunity to varicella-zoster," Picker continues, "because the severity of the illness and complications are worse as an adult. Unfortunately, the chicken pox vaccine does not confer protection against shingles."

The good news is that there's now another vaccine that does. In May 2006, the FDA approved Zostavax, a vaccine that can prevent many cases of herpes zoster, or shingles. It's currently recommended for use in adults over 60. "The vaccine 're-exposes' you to the virus," Picker notes, " enabling your body to boost immunity." However, she adds, "People with normal or 'competent' immune systems who have had shingles once rarely experience a recurrence."

The Zostavax vaccine is available at MIT Medical and is covered under the MIT Student/Affiliate Health Plan and Traditional and Flexible MIT Health Plans with a $20 co-pay. MIT employees who do not have one of the MIT Health Plans but do have the Primary Care Benefit, pay nothing for vaccine administration but are charged full price for the vaccine itself. Unfortunately, the vaccine is not covered by Medicare, so retirees with Medicare coverage would be liable for the cost of the vaccine in addition to the administration fee. If you are interested in the vaccine, Lucy encourages you to discuss it with your primary care clinician. Shingles can be quite debilitating, so it's probably worth trying to avoid. —Lucy

Oh, deer [fly]
September 12, 2007

Dear Lucy: Can deer flies transmit West Nile virus or eastern equine encephalitis? I'm attacked by far more deer flies than mosquitoes on my morning walks. The deer flies certainly bite, and I've killed a few that have obviously had a blood meal. —Once Bitten

Dear Once: Lucy also seems to be accompanied by a number of nasty deer flies on her morning walks, and, yes, they definitely bite! They are not repelled by conventional insect repellents, nor are they put off by even the most vigorous swatting. Unlike stinging insects, deer flies have a mouth with razor-sharp "lips," which they use to slice the skin open, so they can feed on the resulting blood pool. Deer fly bites can be very painful, and some people also experience an allergic reaction to the salivary secretions released by the insects as they feed.

But the good news, says MIT Medical infectious disease specialist Howard Heller, M.D., is that deer flies can't transmit eastern equine encephalitis (EEE) or West Nile virus (WNV). "The viruses that cause EEE and WNV infect birds," Heller explains. "Mosquitoes become infected with these viruses after they feed on birds. Infected mosquitoes can then transmit those viruses to humans. Deer flies do not feed on birds and, therefore, do not become infected with these viruses."

Deer flies can transmit a bacterial infection known as tularemia, Heller adds, but this is fairly rare and, in any case, totally curable with antibiotics. Mosquitoes, which can transmit EEE and WNV, are more of a threat, so you should use insect repellent on your walks to ward off mosquitoes, even if they seem less numerous than deer flies this time of year. Of course, with winter rapidly approaching, neither mosquitoes nor deer flies will be a problem soon! —Lucy

Dear Lucy: I know you can lose fat if you run just about every day at a proficient speed. But can running help you lose fat in the upper-torso area—for example, in the stomach and chest—as well as in the lower body? —Running Off

Dear Running: Lots of people take up running or brisk walking as part of a weight-loss program, so you are probably not the only one with this question. For more information on how running can melt the pounds away, Lucy turned to MIT Medical health educator, Julie Banda, M.P.H.

According to Banda, when coupled with a balanced diet, cardiovascular activities like running, walking, swimming, or biking, are great ways to lose body fat. That said, Banda explains, we're all genetically programmed to gain or lose weight more readily in certain parts of our bodies. "So, although running will probably help you lose body fat in both your upper and lower body, you may not lose fat evenly in all parts of your body," she says.

Running can help build strength in your legs, Banda continues, but it's also a good idea to add a basic strength-training program that works all the major muscle groups. "This will help you build muscle mass, reduce injury and risk of osteoporosis, and aid in your weight-loss goals, Banda notes.

"For individuals who are trying to lose weight, the recommendation is to get 60 to 90 minutes of moderate-to-intense cardiovascular activity on most days," Banda adds. But she encourages people to start with what feels manageable. "Begin by setting small goals and working towards them, she says, "and then build on your successes."

Lucy commends you on your interest in becoming more active, but she wants to remind you, and all her other readers, that exercise is more than just a weight-loss strategy. While many people begin an exercise program as temporary means to an end, it's important to remember that exercise is part of a healthy lifestyle. While being more active can help you lose weight in the short term, keeping it up can also help you avoid other health problems—everything from heart disease to depression. So keep moving! —Lucy

Star Trek X: The Wrath of the Ear Khan-al
July 9, 2007

Dear Lucy: I had knee surgery a few months ago. I now swim four or five times a week for physical therapy and fun. I love it! However, I recently noticed that I have this weird sensation in my left ear. It feels like an alien bug that keeps crawling in and out of my ear all day long. I don't wear a swim cap, because my head is too big. In fact, my head is so big I can use it as a floatation device in time of need. Anyway, do I have swimmer's ear, or is it truly one of those critters from Star Trek: The Wrath of Khan? —Alien Abduction

Dear Abducted: What a choice! Swimmer's ear or an infestation by parasitic larvae of the green-blooded Ceti eel, which, as all Trekkies know, gain entrance to human cerebral cortexes through the ear canals of their hapless victims? Never one to hesitate when faced with the possibility that Earth has been invaded by extraterrestrials, Lucy wasted no time in obtaining the expert opinion of MIT otolaryngologist Robert Kiskaddon, M.D.

Though he hates to dash your hopes of a cameo appearance in the next Star Trek sequel, Kiskaddon puts creatures from planet Ceti Alpha V "lower on the list" of possible diagnoses. Nor does he think you have swimmer's ear. "Swimmer's ear is usually characterized by pain or itching," Kiskaddon says, "and sometimes a sensation that the ear is obstructed."

His conclusion? "The problem is most likely debris in the ear—wax and skin—which is getting moist during swims, and then gradually drying out," Kiskaddon says. He recommends an ear exam, which, he believes, "would probably clarify the problem and perhaps lead to alleviating the symptoms."

Lucy hopes you'll take Kiskaddon's advice and have your ear checked out by a clinician, as it sounds like an easily resolvable problem. Of course, should you start to exhibit symptoms of mind control or an overwhelming desire to betray Admiral Kirk to his enemies, it may be appropriate to reconsider the Ceti eel hypothesis. —Lucy

Dear Lucy: During parent meetings at my son's school, the school psychologist often discusses the issue of fabric softeners. She states that they can cause allergic reactions that may lead to anxiety, depression, mental retardation, attention deficit hyperactivity disorder, and other problems in children. I had never heard this before and have been trying to research the issue without much success. Is there reliable research out there that supports her statements? If so, what does the research actually say? —Soft Sell

Dear Soft Sell: This is the first Lucy's heard of a possible link between fabric softeners and developmental problems in childhood. Anxiety, depression, and ADD seem a high price to pay for soft tee shirts, so, like you, Lucy was anxious to get to the bottom of this story. For answers, she went straight to MIT's Office of Environment, Health, and Safety, where she posed your question to industrial hygiene officer Marilyn Hallock.

According to Hallock, many consumer products, such as fabric softeners, cleaners, and detergents, release very low levels of organic vapors. "There has been some discussion in consumer and public-health circles that such chemicals may cause psychological or neurological conditions such as depression and attention deficit disorder," Hallock continues. "However, there have been no reliable scientific studies documenting that these health effects occur."

Hallock believes that these concerns began with studies conducted by the Environmental Protection Agency (EPA) in the early 1990s. In 1991, she explains, the EPA published a study showing that a variety of products found in the home—cigarette smoke, paints, pesticides, detergents, fabric softeners, and other materials—released low levels (in the part-per-billion range) of various, volatile organic compounds. "Related studies analyzed possible cancer risks from these compounds and found that organic vapors from second-hand smoke, gasoline products, solvent-based paints, moth repellents, and pesticides might contribute to cancer risk in the general population," Hallock reports. "However, organics released from detergents and fabric softeners were not associated with any increased cancer risk."

In advice to consumers, the EPA stresses that good air quality inside the home can be achieved by the reduction or elimination of cigarette smoke, solvent-based paints, pesticides, and other contaminants, such as lead and radon. For a complete list of EPA recommendations on indoor air quality, see The Inside Story: A Guide to Indoor Air Quality.

The EPA does not recommend a reduction in the use of detergents, fabric softeners or similar products, Hallock emphasizes. On the other hand, she notes, fragrances found in these products can cause allergy symptoms in some people and may also trigger asthma attacks in people with asthma. For these reasons, you may wish to use the fragrance-free versions.

Lucy hopes this answers your question, and she commends you for, in the best MIT tradition, looking into this issue for yourself, rather than simply accepting a story that struck you as dubious.—Lucy

Booster shots for adults?
May 23, 2007

Dear Lucy: I am not sure if I have had a booster for polio as an adult. If I have, what would be the consequence of getting a second polio booster (about 10 years after the first)? —Long Shot

Dear Long Shot: Unless we're planning travel to exotic destinations, most adults, Lucy included, spend very little time thinking about vaccinations. And when it comes to the polio vaccine, says MIT Medical nurse practitioner Janice McDonough, A.P.R.N., B.C., that's just fine. "Once fully immunized against polio in childhood, we do not need polio boosters as adults," McDonough explains. "Boosters would be recommended only for scientists working with the polio virus or individuals traveling to certain countries where health standards might place one at risk or where there have been recent outbreaks of the disease." Otherwise, McDonough says, although additional boosters won't hurt you, the polio vaccines you received in childhood should provide sufficient protection.

The long-term effectiveness of the polio vaccine and most others is good news indeed, but Lucy wants to take this opportunity to remind her readers that adults do continue to need boosters for tetanus and diphtheria. The tetanus/diphtheria booster is recommended every 10 years during adulthood, and it's 100 percent effective in preventing the oft-fatal disease caused by the environmentally ubiquitous tetanus bacteria. If you don't remember the date of your last tetanus booster, check with your primary care clinician; and if you need a booster, get one. —Lucy

Dear Lucy: My golf game seems to be suffering these days. Is it possible that going through the change (menopause) could have anything to do with the slump I'm in? —Teed Off

Dear Teed Off: Lucy's been known to hit the links from time to time, so she found your question quite intriguing. Slumps can be so frustrating, so inexplicable, and so hard to shake off. And as a woman of a certain age, Lucy had to wonder if you'd hit on an excuse she might borrow: Another double bogey? Blame it on the change!

Unfortunately, according to the specialists Lucy consulted, it may not be that simple. "Perhaps the real question is whether one's physical abilities, stamina, and coordination change at menopause," speculates MIT Medical gynecologist Dawn Anderson, M.D. "The answer to that question would be ‘maybe.'" Though menopause should not change your physical abilities, Anderson explains, it might have affected your sleep patterns. "A number of women experience sleep difficulties at the time of menopause," Anderson continues. "Many women find themselves waking much earlier than desired, and then they feel tired throughout the day. Some women also report memory and cognitive changes, in terms of attention." Tiredness or distractibility could certainly affect one's golf game on any given day, but, Anderson feels, it would be a bit of a stretch to blame a prolonged slump on menopause.

Weekend golfer and chief of MIT Medical's Mental Health Service, Psychologist Alan E. Siegel, Ed.D., concurs. "When people go through significant transitions in life, it is natural to feel a bit 'off,'" he notes. "In sports that require great concentration, small changes in one's attention can have a huge effect on performance. In golf, a small change in one's ability to concentrate could have a big influence on the subtleties of swing, resulting in hooks, slices, and less overall consistency."

Siegel's prescription would be to eat well, get plenty of sleep, do other types of exercise, and generally try to take good care of yourself. "And if things don't improve, any mental health clinician could talk with you about this important time in your life," Siegel says. However, he adds, it's important to realize that every athlete experiences slumps from time to time, and often there's no medical or psychological explanation. Speaking as a golfer, Siegel recommends spending some time analyzing your game to see if anything has changed. "You may not need a medical clinician or mental health professional to deal with your slump," Siegel comments. "Sometimes a golf pro will have the cure."

Lucy hopes this helps, and while she's disappointed to have lost a potential excuse for her next bad shot, the good news is that we women of a certain age should be able to keep enjoying this game and other kinds of physical activity for many years to come. Fore!—Lucy

Dear Lucy: I read a newspaper article about bird flu, in which a scientist from Harvard's School of Public Health noted that putting one's hand in bird excrement would be one way of contracting the disease. He seemed to scoff at the idea of anyone actually doing that, but another recent article in the same paper reported that many local playing fields are covered in goose doo. And just the other day, while eating a salad at one of the tables outside the Student Center, I caught myself picking up a piece of lettuce that had blown onto the grated table top and eating it. As I did, I noticed that the lettuce had picked up some residue of what may well have been bird droppings. (Yeah, not too smart, but it was done without thinking.) Anyway, lots of people eat outside at the Institute, and lots of us play sports, or have kids who play sports, on outdoor fields also used by geese. So how concerned should we really be about this mode of transmission? —Doos and Don'ts

Dear Doos: Lucy has never been a fan of what some people euphemistically refer to as "the five-second rule," nor has she ever considered salad a finger food. But etiquette issues aside, this is a great health-related question, and to address those concerns, Lucy turned to MIT internist and infectious disease specialist Howard Heller, M.D.

"There haven't been any cases of bird flu in North America," Heller notes, "but it is very appropriate to be cautious around bird droppings in areas of the world where avian influenza has been reported. Duck droppings are of the greatest concern, because ducks can be heavily infected with avian flu without getting sick. Fortunately, droppings from chickens and swans, the other two types of birds that have been primarily affected so far, are not commonly found in public areas in Boston." There have been no reports of affected pigeons, sparrows, robins, or similar birds common to this area, Heller adds.

As for geese, Heller tells Lucy that geese infected with avian flu have been reported in China. "If avian flu hits North America," Heller says, "and if it is found in geese, I would recommend that people avoid eating or participating in recreational activities in public areas that have a lot of goose droppings."

And, whether or not avian flu ever reaches these shores, Lucy further recommends abandoning any bits of food that fall from your fork to the tabletop, floor, or any other non-plate surface. While you may have avoided consuming bird droppings when snagging that piece of lettuce from the table outside the Student Center, that "residue" you ate probably wasn't anything terribly healthy or nutritious either. —Lucy

Into the drink
March 22, 2007

Dear Lucy: A friend just told me that sparkling water (seltzer) doesn't count towards the eight glasses of water we are supposed to drink each day. But I disagreed. It seems to me that water is water. Who is right? —Tiny Bubbles

Dear Bubbles: Lucy recruited MIT Medical nutritionist, Anna Jasonides, R.D., to be the arbiter in this disagreement, and she came down firmly on your side. "Water is water," Jasonides agrees, "and other fluids, like juice and milk, will also keep one adequately hydrated." In addition, she notes, even caffeinated drinks can add to one's daily fluid intake. Studies show that the average person retains between half and two-thirds of the fluid consumed by drinking caffeinated beverages, while individuals who regularly consume these kinds of drinks retain even more.

Furthermore, Jasonides continues, the recommendation to drink eight glasses of water per day "isn't as scientific as we might like to think." And don't just take her word for it; a fairly recent report from the Food and Nutrition Board of the Institute of Medicine concurs. The 2004 publication, Dietary Reference Intakes: Water, Potassium, Sodium, Chloride, and Sulfate, notes that while fluid needs vary depending on activity level, environment, diet, and other conditions, a significant amount of the fluid we need each day—approximately 20 percent—is obtained from the foods we eat. It concludes that, over the long run, for healthy individuals who simply drink when they are thirsty, "fluid consumption will match body water needs."

So, drink all the sparkling water you’d like—when you’d like—and if you’re thirsty, drink some more! —Lucy

Dear Lucy: For a month, I've been feeling blue and anxious and have had trouble sleeping. I am job hunting and struggling with a difficult project. About every third night, I can sleep only two to four hours. Someone suggested I take valerian to help me sleep. Is this a good idea? —Tossing and Turning

Dear T&T: Lucy gets lots of questions about herbal remedies such as valerian root. It's important to remember that in the United States, such "medicinal herbs" are sold as dietary supplements, which are regulated as food, not drugs, so they are not required to be tested for manufacturing consistency. This means that the composition, amount of herbal extract, and effectiveness may differ greatly between manufacturing lots.

"It probably isn't harmful to take valerian for sleep problems," MIT psychiatrist Simon Lejeune, M.D., tells Lucy, but he cautions that research has not yet demonstrated its clinical effectiveness as a sleep aid. For more information, Lejeune suggests reading the valerian fact sheet from the National Institutes of Health. "It would be a good idea to talk to a medical professional about sleep medications," he continues, "as there are many more effective options than valerian."

And, while Lejeune says that it's common to feel blue and have trouble sleeping for a few days during times of stress, insomnia that continues for more than a few days may indicate a more serious problem. "Given everything that's happening in your life, it might be helpful to talk to a mental health professional," he advises. "This kind of discussion may help you get some perspective on the situation," Lejeune explains, "and that could relieve some of the stress you are feeling."

Mental health consultations are available to all MIT students, staff, faculty, and affiliates. For appointments, call MIT Medical's Mental Health Service at 617-253-2916, or go to the walk-in clinic on the third floor of MIT Medical from 2–4 p.m., Monday through Friday, and be seen the same day. Lucy is glad you took the time to ask for advice, and she's sure that with the right help, you'll be sleeping better soon. —Lucy

Upstairs, Downstairs
February 7, 2007

Dear Lucy: I had a conversation with a friend who recently had knee surgery. She told me that one of her doctors told her that no one should use stairs, even for one flight—that in the long run, going up and down stairs does too much damage to your knees.

In contrast, I have been making a point of taking the stairs—often two at a time—for anything less than four floors. I don't have knee problems now, but am I putting those joints at risk by using stairs and not elevators? —Kneed Exercise

Dear Kneedy: Like you, Lucy's a stair-climber (albeit one who takes the stairs at a more sedate one-at-a-time pace), so your question raised her anxiety level just a bit. Though she briefly entertained the idea of running downstairs to MIT Medical's Orthopedic Service for an answer, she decided to play it safe, avoid the stairs, and send an email instead.

The prompt reply Lucy received from orthopedic surgeon Ronald Geiger, M.D., should put both our minds at ease. "Taking the stairs for two or three flights is excellent exercise for most people," Geiger writes. In fact, he adds, except for those with patella [kneecap] problems, he encourages stair climbing as exercise for his patients, as long as they don't have significant arthritis.

Weight-bearing exercise, like walking and stair-climbing, has many benefits, including maintaining bone mass and preventing osteoporosis. Although, like all joints, knees are subject to overuse injuries, it's safe to say that the risks of inactivity are much, much greater than the risks of injury during moderate exercise. The key to preventing exercise injuries is to follow a couple of common-sense rules:

1. Increase exercise gradually: For example, if you've been in the elevator habit for a long time, start with one flight of stairs at first, and
2. Listen to your body: In other words, if something's painful, stop doing it.

Assuming you're not experiencing any pain while taking the stairs, Lucy encourages you to continue your elevator-spurning habits; as will she. See you in the stairwells! —Lucy

Dear Lucy: I have never paid much attention to my calcium intake until recently. But now I am 26 and have the beginnings of osteoarthritis. I can only fault myself for not getting enough calcium over the years. Should I take more than the recommended dose of calcium now to make up for all those years when I didn’t get enough? Or should I just stick with the recommended 1000 mg. per day? —Making Up For Lost Time

Dear Making Up: Lucy is very sorry to hear that you are dealing with osteoarthritis at such a young age, but please stop blaming yourself for not doing enough to prevent it. According to MIT Medical rheumatologist Michael Kane, M.D., your previously insufficient calcium intake could not have contributed to your current problems.

"Osteoarthritis is a joint disease in which cartilage, the slippery tissue covering the ends of bones, wears away," Kane tells Lucy. "When cartilage degenerates, bones underneath the cartilage may rub together, causing pain and swelling in the joint." You may be thinking of osteoporosis, a condition in which bones become fragile and more likely to break. Since osteoporosis is a disease of the bones, its development may be affected by calcium intake, Kane says. But osteoarthritis is a very different disease, he emphasizes. "In osteoarthritis," Kane notes, "any changes to the bone are secondary, and calcium cannot prevent or affect its development."

Of course, calcium is still an important nutrient for women of all ages, and it’s great you are paying attention to your calcium intake now, says MIT Medical nutritionist Anna Jasonides, R.D. But, she says, you shouldn’t try to make up for lost time by taking extra supplements because, when it comes to calcium, more is not necessarily better. "The safe supplemental range for calcium is up to 1500 mg. per day," she explains, "but ingesting more than 2,000 mg. gets you into the toxicity range."

In addition, Jasonides reminds you not to forget other important nutrients, especially vitamin D, which stimulates calcium absorption. "Dividing the total daily supplemental dose is also helpful," Jasonides adds. "Your body will absorb more calcium with several small doses over the course of the day."

It might also be helpful to make an appointment with the clinician who diagnosed your osteoarthritis to discuss treatment options. There’s no cure for osteoarthritis, but proper treatment can reduce your pain and stiffness, allow for greater joint motion, and slow the progression of the disease. Good luck! —Lucy

Dear Lucy: I've been trying to shed some extra pounds by exercising regularly. Normally I do about 40 minutes of cardio on a treadmill or elliptical machine at the gym (in addition to some strength training). But about an hour after every workout, I end up with a pounding headache. I've tried drinking plenty of water ahead of time in case dehydration is the problem, but this doesn't seem to help. What could be causing this problem, and how can I prevent it? —Exercise in Frustration

Dear Frustrated: You're to be commended for embarking on an exercise and fitness program, but, according to MIT Medical nurse practitioner Janice McDonough, A.P.R.N., B.C., the headaches may be more than a simple annoyance. "It could be nothing, or it could be something," she tells Lucy, "but it is not normal."

McDonough suggests calling your primary care clinician for an evaluation. "Headaches after exercise could be caused by anything from low caloric and/or fluid intake to low glucose, high blood pressure, or some other condition causing increased intracranial pressure," she says. But whatever is causing the headaches, they are a symptom that should not be ignored, she emphasized.

There you have it. Call your doctor, and get this checked out before you climb back on the treadmill. Lucy hopes it's nothing serious, but she'll feel better knowing that you're getting an expert opinion on the matter. —Lucy

Dear Lucy: I have a pain in my lower back on the right side, and sometimes the pain travels to my right thigh. This only happens when I am walking briskly, and then I have to stop walking to stop the pain. Can you tell me what might be causing this? —Bad Back

Dear BB: Your problem sounds both painful and annoying. Fortunately, Lucy knew exactly where to turn for an answer: MIT Medical orthopedic nurse practitioner Anthony M. Pasqualone, MSN, NP-C.*

Although it's impossible to make a proper diagnosis without a physical examination, Pasqualone speculates that you may be suffering from a lumbar vertebral disc displacement. "The vertebrae in the lower back are separated by discs that act as 'shock absorbers,'" Pasqualone explains. "Discs have a hard outer layer and a gel-like center. As a person ages, it's common for the center of the disc to start losing water content, making its shock absorption less effective and causing the center of the disc to become displaced, which puts pressure on the nerves that come off the spine and protrude out between the vertebrae. Because the displaced disc presses on the nerves that go to the lower body, it can cause pain that extends to the thigh."

In extreme cases, Pasqualone says, the disc must be repaired surgically. "Fortunately, however, the vast majority of people with this problem can recover and resume their normal activities without surgery," Pasqualone notes. "Aggressive physical therapy works very well." Treatment goals include reducing inflammation and pain; improving flexibility, strength, and endurance through specific exercises; and learning new ways to perform activities of daily living while avoiding stress on the lower back.

Lucy suggests that you start by making an appointment with your primary care provider. From there, you may be referred to an orthopedic specialist or directly to physical therapy. But it's important to deal with this problem promptly in order to prevent further damage. Good luck! —Lucy

* Since helping Lucy answer this question, Pasqualone, a lieutenant colonel in the Army Reserve Nurse Corps, has been called up to active duty and is now serving in Iraq. He's slated to return to MIT Medical in the fall of 2007.

Dear Lucy: I was wondering if there are communicable diseases one can get from using a public toilet and if toilet seat covers actually reduce the chances of those diseases being transmitted. I'm all for being healthy and sanitary, but I'm also an environmentalist and don't see any point in wasting the paper if it's not doing any good. —Caught With My Pants Down

Dear Caught: What a great question! Lucy must confess some fondness for the idea of a barrier between her own derriere and all the derrieres that have previously occupied the same public toilet seat. But, like you, she's wondered what measure of protection a thin sheet of paper might actually afford and from what dangers she is being protected.

For answers, Lucy turned to MIT Medical internist and infectious disease specialist Howard Heller, M.D. Not surprisingly, Heller confirms our suspicions that as long as the seat is visibly clean, toilet seat covers provide little more than a reduction in the "ick factor" associated with using a public toilet. "It's very difficult to get sick from a toilet seat," Heller says adamantly. "This is especially true for sexually transmitted diseases (STDs)," he adds. (Hmmm… apparently, there's a reason they're referred to as sexually transmitted.) However, Heller notes, "a little extra caution might be warranted if one is traveling in an area where enteric infections like cholera are more common."

But for most diseases, Heller continues, "toilet seat transmission" would require the unlikely coincidence of two factors: 1) the presence of a sufficient number of germs to cause illness, and 2) a way for those germs on the seat to get into your urethra, genital tract, or blood stream. Interestingly enough, the first condition may be even more unlikely than the second. Microbiologists studying bacterial concentrations in offices found, in every case, that toilet seats were, by far, the cleanest surfaces of any sampled-a whopping 50 times cleaner than phone receivers, which were the filthiest. (High germ counts were also found on office desktops, the computer keyboard, and the mouse.)

But don't think public restrooms are without hazards. Just think about the number of unwashed hands that touch bathroom door handles, sinks, faucets, and towel dispensers in public restrooms. Now that's a source of germs worth worrying about. So, wash your hands correctly (see http://www.uhn.ca/patient/general/handwashing.asp for a video demonstration of correct hand-washing technique) and, to avoid recontamination of clean hands, use a paper towel to turn off the water tap and open the exit door. Lucy's "bottom" line? You may safely forgo the toilet seat cover, but put some paper between your hands and other bathroom surfaces. —Lucy

Tae Kwon Don't!
June 7, 2006

Dear Lucy: I compete in taekwondo. I am 5 ft., 4 in., and normally weigh 120 pounds, but after taking time off from my training due to a shoulder injury, I now weigh 130. Can you recommend a diet that will allow me to lose weight quickly and efficiently? I need to lose 18 pounds in six weeks to qualify for my weight division in an upcoming competition. I take a daily vitamin supplement, and I work out daily, so I can easily burn more calories than I take in. Please recommend a diet that will help me lose this weight in six weeks. —Side Kick

Dear Kick: Taekwondo is great exercise and great fun. But your plan to drop 18 pounds in six weeks set off alarm bells for Lucy, so she decided to run it by MIT Medical nutritionist Anna Jasonides, R.D.

Jasonides confirms Lucy's suspicions that when it comes to losing weight, your plan involves too much, too fast. "The maximum amount of weight one should lose is two pounds per week," she asserts. "You can do that by reducing your current intake by 1,000 calories a day, by expending some of those calories in exercise, or with a combination of the two. Any more than that is too extreme and would be considered unhealthy."

Jasonides also recommends that you take a multivitamin and make sure you are eating enough protein—at least 1.2 grams per killogram of your ideal weight. "For you, that is 65 grams per day," Jasonides says. She also warns against allowing your daily caloric intake to dip below 1,200 calories. "If you eat too little, your metabolism can slow down too much," she cautions. "And a slower metabolism will make weight loss slower."

The bottom line, Jasonides says, is that there is no quick and healthy way to lose weight. Take it slow, she recommends, and think about how you will maintain your target weight when you reach it. "As a serious athlete, you don't want to be in a position where you're constantly 'pulling tricks' to keep your weight low," she notes. "A healthy balance is the key to optimum athletic performance."

Hope this helps. Best of luck in future competition. —Lucy

Acupuncture coverage?
April 24, 2006

Dear Lucy: I have the MIT Traditional Plan. Does my medical coverage allow me to use acupuncture treatments? —On Pins and Needles

Dear Pins: For help in answering this question, Lucy contacted Leslie Patton, Claims and Member Services Administrator for the MIT Health Plans. According to Patton, the Traditional and Flexible MIT Health Plans cover acupuncture treatments only for pain management, and only with a referral from an MIT Medical provider. The benefit is limited to 18 visits per calendar year, and covered patients must receive their acupuncture treatments at MIT Medical, New England School of Acupuncture or the Massachusetts General Hospital Pain Clinic.

Of course, without more details about your specific situation, it's impossible to know if you are a candidate for acupuncture coverage. In any case, Lucy recommends an appointment with your primary care clinician as a first step. Together, you can discuss various treatment possibilities and whether or not acupuncture may be a good option for you. Good luck! —Lucy

Dear Lucy: At my son's school, we've been asked not to send peanut butter sandwiches, or any food containing peanuts, for lunch or snack. I don't remember these restrictions when I was in school; in fact, peanut butter and jelly sandwiches were a staple of my childhood diet. Are peanut allergies more common these days, or are we just more sensitive to it? —Cracker Jack

Dear CJ: Lucy has many fond childhood memories involving peanut butter-though she must confess some preference for the fluffernutter, as opposed to the more pedestrian PB&J. Kids and peanut butter have long seemed a natural combination, so, like you, Lucy has wondered about the increasing number of restrictions on peanuts in public places. For answers, she turned to MIT pediatric nurse practitioner Pat Bartels, A.P.R.N., B.C., F.N.P.-C.

According to Bartels, although peanut allergy still affects less than one percent of the population (about 1.5 million Americans), recent studies do show that the problem is becoming more prevalent. In a five-year period, from 1997-2002, there was a two-fold increase in the incidence of peanut allergies in children. No one knows for sure why this is happening.

Peanut allergy is normally diagnosed in early childhood, Bartels explains, and only rarely develops later in life. "Peanut allergy is significant," Bartels continues, "because it is usually not outgrown, and because peanuts are such a common food in this country and so hard to avoid." Symptoms can affect the skin (swelling, hives/welts, itchiness, redness), the gut (itchy mouth, stomach ache, nausea, vomiting, diarrhea, odd taste), the respiratory system (hoarseness, difficulty swallowing, wheezing, repetitive coughing, throat closing, difficulty breathing), and circulation (paleness, dizziness, low blood pressure, loss of consciousness, loss of pulse). "In severe cases," Bartels notes, "life-threatening reactions can be triggered by even minute exposure."

MIT Medical's Pediatric Service considers an infant or young child to be at increased risk for peanut allergy if he or she has a family history of allergies or a personal history of skin problems, such as eczema or other types of rashes, Bartels explains. "Though it's not clear if peanut allergy can be prevented, we suggest that women avoid ingesting peanuts during the third trimester of pregnancy, as well as during breastfeeding. We also recommend not introducing peanuts into a child's diet before the age of two or three." Reading food labels is also important, Bartels adds. "If a person is allergic to peanuts, they must also avoid foods labeled as containing 'mixed nuts, ground nuts, mandelonas, peanut butter, peanut oil, goober nuts, goober peas, beer nuts, peanut flour, artificial nuts, and hydrolyzed peanut protein,'" Bartels says.

So, if your child has a classmate with a peanut allergy, it needs to be taken seriously. But for children who are not allergic-and Lucy is happy to hear that is still the vast majority-peanuts and peanut butter can still be healthy, nutritious snacks, at home if not in school. —Lucy

Caffeine addiction?
March 7, 2006

Dear Lucy: I think I might be addicted to caffeine. I usually have a cup or two of coffee and several diet cokes throughout the day. How can I tell if I'm addicted, and what can I do to quit without being unable to concentrate on my work? —Java Joe

Dear Joe: Addicted to caffeine? The very thought almost made Lucy spill her low-fat, lactose-free, double-shot, caramel latte macchiato on her computer keyboard! Just as quickly as her shaking hands could type, Lucy forwarded your question to MIT psychiatrist and addiction expert Adam Silk, M.D. According to Silk, the current edition of the psychiatric diagnostic manual-the Diagnostic and Statistical Manual of Mental Disorders, IV, commonly referred to as the DSM-4-does not include diagnoses of caffeine abuse or dependency. "The DSM-4 recognizes the disorders of 'caffeine intoxication,' 'caffeine-induced sleep disorder,' and 'caffeine-induced anxiety disorder,'" Silk explains. "It also provides a sort of catch-all category called 'caffeine-related disorder, not otherwise specified,' but none of these diagnoses would be considered an addiction by medical standards."

On the other hand, Silk continues, unless you're concerned with insurance coverage or billing, "maybe it's just semantics. After all, everyone knows that ingesting a lot of caffeine can make you feel bad, and that stopping it abruptly can make you uncomfortable for a while. Many lay people, and even some in the medical community, would call that 'addiction' or 'dependence.'"

The bottom line, Silk says, is that if you are concerned about your use of caffeine, you should try to do something about it. Researchers at the Johns Hopkins School of Medicine have identified a number of caffeine-withdrawal symptoms, ranging from headache and fatigue to, in rare cases, nausea and vomiting. They found that symptoms usually begin within 12-24 hours after stopping all caffeine ingestion, are at their worst in the first two days, and may continue for up to nine days. "Gradually reducing caffeine consumption over time, by substituting decaffeinated or non-caffeinated beverages for regular coffee and caffeinated soft drinks, is much easier than going 'cold turkey,'" Silk says. "And if you are having trouble stopping on your own, it may be helpful to talk with a mental health professional about behavioral techniques that are useful in breaking habits."

Lucy hopes this is helpful to you. It's inspired Lucy to put down the latte, at least for the moment, and take a hard look at her own caffeine consumption as well. Good luck kicking the habit —Lucy

Feel the Brrrrrrr.n!
February 13, 2006

Dear Lucy: Is it true that you burn more calories when the ambient temperature is lower? Should I quit exercising at the Z-Center and take up running along the river instead? —Calorie Conscious

Dear CC: According to MIT Medical health educator and certified personal trainer Deirdre Neylon, the idea that one burns more calories in cold weather is a myth-one that persists because, on the surface, it makes so much sense. The reasoning goes that since it takes more energy to maintain core body temperature in a cold environment, and since energy equals calories, the body will burn more calories in cold weather. But the truth is that, as long as you are dressed appropriately, cold temperatures alone won't cause you to burn more calories. You won't start using up additional calories unless your body temperature drops enough to induce shivering. And although intense shivering may burn 400 calories an hour, it also depletes muscle glycogen stores and drains energy, creating a potentially dangerous state of affairs, so Lucy does not recommend shivering as a form of winter exercise!

Of course, certain wintertime activities do offer the potential for burning more calories. For example, the resistance one encounters when walking in snow or running into the wind can provide a greater workout than the same activity done in more optimal conditions. And you'll also burn additional calories if you are wearing heavy clothes, like boots or a parka, or carrying the weight of extra equipment, like skis or snow shoes.

But while Neylon doesn't recommend abandoning the gym for outdoor exercise on the basis of caloric considerations, getting outside in the winter can add some variety and fun to your workout schedule, as long as you play it safe. With that in mind, Lucy offers the following tips for outdoor winter workouts:

• Drink sufficient fluids. According to experts, failing to drink enough fluids is one of the most common mistakes made by winter athletes. Since we tend to feel less thirsty when it's cold, winter athletes need to consciously consume fluids to replace the water that is lost through perspiration and breathing.
• Dress in layers: Start with a thin layer of one of the new synthetic materials that draw sweat away from the body, and build from there. Your outermost layer should be resistant to wind and water. But make sure every layer is made of a "breathable" material, so sweat doesn't get trapped near the skin, which can cause chilling.
• Warm up first. Cold muscles are tighter and more prone to injury, so warm up before beginning any intense physical activity. And make sure you dress for your workout; if you're perfectly warm at the start of your warm-up phase, you'll be too warm by the time you really get going.
• Head into the wind when you start out. Then, when you head home with the wind at your back, possibly sweaty, you'll be less likely to get chilled.
• Wear sunscreen. Sunscreen and lip balm are important protection all year round, and especially when the sun is reflecting off the snow.

Good luck with your winter workouts, and keep exercising! —Lucy

Dear Lucy: When working out, especially when doing anything that includes jumping, I end up tossing my cookies, and then I feel better right away. If I continue working out, I feel like throwing up again within 10 minutes or less. This happens whether my stomach is empty or full. If my stomach's empty, I vomit up a clear fluid at first, but after a few minutes, I get a bright yellow liquid material coming out. Can you help me determine why my stomach is so easily upset and what I can do to fix it? —(up)Chuck

Dear Chuck: Lucy sympathizes with your predicament. At the same time, she hopes not to find herself working out next to you at the gym before you get this problem under control. With some sense of urgency, Lucy brought your problem to MIT Medical gastroenterologist Richard Gardner, M.D.

Gardner tells Lucy he believes you may be suffering from exercise-induced acid reflux. "Vigorous exercise, especially if it includes jumping and bending over, may result in reflux of stomach contents—acid and sometimes bile—into the esophagus," Gardner explains. "Some individuals are more prone to reflux due to a weak sphincter muscle between the stomach and esophagus." This tendency may be increased when one exercises soon after eating, he adds.

Acid reflux is a potentially serious problem, Gardner emphasizes. "Individuals with significant acid reflux may irritate and damage the lining of the esophagus, resulting in heartburn and nausea," he notes. He recommends that you make an appointment to discuss this problem with your primary care physician, who can refer you to a gastrointestinal specialist for evaluation and appropriate treatment.

Lucy wishes you the best of luck in resolving this problem soon, so you can resume a healthy, active lifestyle—in other words, more stretching and less retching —Lucy

Craving cashmere
January 10, 2006

Dear Lucy:Clothing with wool (even a small amount) makes me itchy, and I've avoided lanolin products for years. But with all the lovely looking cashmere sweaters, I'm tempted to buy. Am I likely to have the same problem with cashmere as wool? —Itchy & Scratchy

Dear I&S: Lucy's with you and so many other people when it comes to wool-just thinking about it makes her itch! So it came as quite a surprise when MIT Medical dermatology nurse practitioner Barbara Starr, A.P.R.N., B.C., told her that wool allergies are actually quite rare.

"Though lots of people believe they are allergic to wool, we now know that it's the unique construction of the fiber itself that irritates the skin and causes the prickle and itch so many of us associate with wearing wool," Starr says. Under a microscope, a single fiber of wool looks like a strand of hair covered with coarse scales that overlap and curl outward. These fibers have a natural crimp that "springs back" after being stressed and permeable interiors that can absorb 30 percent of their weight in moisture without feeling damp. These characteristics make wool durable and warm, Starr explains, but for many people, they also trigger a reaction in the skin's pain receptors to cause a prickly, itchy feeling.

Interestingly, Starr adds, people who react to wool this way often have similar reactions to clothing that has been dried with fabric softener sheets. "While tumbling in the dryer, little particles from the fabric softener sheets get attached to clothes. Later, an individual wearing this clothing may feel itchy," Starr explains. "It's not an allergy to the fabric softener. It's these invisible particles that irritate the skin and trigger the itch response."

Starr thinks you and Lucy will probably be comfortable wearing cashmere-or even a higher-end (read "more expensive") wool fiber such as the fine or super-fine varieties of Merino wool. Cashmere and Merino wool are as warm as regular wool, but neither has the characteristics that cause prickle and itch in regular woolen garments. Cashmere, which is classified as a hair fiber, is made from the fine, soft undercoat of the Cashmere (or Kashmir) goat. Merino fibers, made from the fine wool of the Merino sheep, has overlapping scales that do not curl outward like those of regular wool fibers.

Lucy finds this information absolutely fascinating and believes some testing is in order. Fortunately, atmospheric conditions are now favorable for a controlled experiment (in other words, winter is here in full force). Will you and Lucy find cashmere and Merino wool non-irritating? Will we find it fashionable? In the interest of science, these questions must be answered. I don't know about you, but Lucy is off to the mall! —Lucy

Live long and perspire?

Dear Lucy: I've heard that aluminum deposits have been found in the brains of people who have died of Alzheimer's disease. Will using underarm deodorants or antiperspirants with aluminum compounds cause aluminum to enter the body? Also, will wearing pierced earrings made of silver introduce silver into the body? —Heavy Metal

Dear Metal: Lucy has long been an advocate of deodorant use, so she nearly broke a sweat at the suggestion that its use might be endangering the perspiring masses. Anxious for the best information she could find on this question, Lucy went straight to MIT Medical's chief of medicine, David Diamond, M.D., who is also a specialist in environmental medicine.

According to Diamond, while some studies have found higher-than-normal aluminum concentrations in brains from Alzheimer's patients, it isn't clear there is any causal relationship between these aluminum levels and the disease. In any case, he says, the aluminum compound in antiperspirants is not easily absorbed by the body. "One study found that less than 1/10,000th of a topical application labeled with a tracer was found internally," Diamond observes. "And in relative amounts, you absorb more aluminum from the foods you eat than from daily antiperspirant use."

Still, Diamond notes, for individuals who want to avoid aluminum whenever possible, there are alternatives to antiperspirants that include aluminum compounds as an active ingredient. Check out the personal care products at your local health food store, he suggests, or buy a conventional deodorant instead of an antiperspirant. Most deodorants that don't say "antiperspirant" on the label are aluminum free, though you should read the ingredient list to be sure.

As for your earrings, Diamond explains that elemental silver is relatively poorly absorbed through intact skin. "In fact," he notes, "silver is a main ingredient in one of the best anti-infective creams used extensively in treatment of burn patients. Several studies of these patients have failed to show systemic effects, even after many days of extensive exposure to damaged skin.

"The bottom line," Diamond concludes, "is that it's probably safe to go out wearing antiperspirant with your earrings." As relieved as she is by this news, Lucy feels compelled to add that, in the interest of decency, it's probably best to wear something else as well. —Lucy

Will they lettuce have some peas?

Dear Lucy: According to the new Dietary Guidelines for Americans, an individual on a 2000-calorie-per-day diet should be eating two cups of fruit and two and a half cups of vegetables per day. I happen to like veggies more than fruit. Can I substitute an additional cup of vegetables for one of the cups of fruit? —Age of Asparagus

Dear Asparagus: The fruit and vegetable recommendations in the new Dietary Guidelines have been the source of much discussion. However, most questions about substitution seem to be coming from people who, unlike you, prefer fruits to vegetables. But in either case, the real question is this: From the perspective of a balanced, healthy diet, what is the difference between fruits and vegetables?

Not much, answers MIT Medical nutritionist Anna Jasonides, R.D. "Fruits and vegetables provide many of the same nutrients, including vitamin A, vitamin C, potassium, folate, and dietary fiber," Jasonides tells Lucy. In fact, many foods that would be botanically classified as fruits (defined as "the mature ovary of a seed plant") are considered vegetables by most people—even people at the USDA, as it turns out. For example, in the vegetable section of "Inside the Pyramid" at MyPyramid.gov, the USDA's consumer website on the new dietary guidelines, four of the six "orange vegetables" listed—acorn squash, butternut squash, hubbard squash, and pumpkin—are technically "fruits." Other "fruits" on the government's vegetable list include cucumbers, eggplant, green or red peppers, tomatoes, and zucchini.

The bottom line, Jasonides concludes, is that as long as you are eating a variety of types and colors, fruit-vegetable substitution is fine, in either direction. Just watch your calories, she warns. "In general, fruits have about twice the number of calories as vegetables," she notes, so substituting veggies for fruits on the MyPyramid plan will mean making up the calorie difference by eating more, while substituting fruits for veggies will require borrowing calories from your discretionary allowance.

Happy veggie eating! And for more information on the new dietary guidelines, see the Summer 2005 issue of health@mit. —Lucy