Curbing the Enthusiasm on Daily Multivitamins

Carl Wiens
Can you reduce your risk of cancer by taking a multivitamin every day?
Last week, Boston researchers announced that one of the largest long-term clinical trials of multivitamins in the United States — encompassing 14,000 male physicians 50 and older, and lasting over a decade — found that taking a common combination of essential vitamins and minerals every day decreased the incidence of cancer by 8 percent, compared with a placebo pill.
Men who had already had cancer earlier in life were most likely to benefit, the study found. Cancer deaths also were lower among those who took vitamins, though that may have been a chance finding. Curiously, the vitamin regimen did not reduce the rate of prostate cancer, the most common cancer affecting men.
The researchers also looked for side effects and found that daily vitamins caused only minor problems, like occasional skin rashes.
Even though an 8 percent reduction in the overall cancer rate is fairly modest, Dr. Demetrius Albanes, senior investigator at the National Cancer Institute, said the potential public health implications were vast. “If you think of the hundreds of thousands of new cases of cancer every year, 8 percent can add up quite a bit,” he said.
Yet no one is rushing out to urge more Americans to take multivitamins. Although half the population already takes some kind of supplement, previous studies have yielded decidedly mixed results. Some trials of high doses of nutrients believed to be cancer-fighters were shut down prematurely when they backfired, driving up cancer rates instead of reducing them.
Current federal dietary guidelines and American Cancer Society recommendations encourage people to eat a balanced diet rich in fruits and vegetables. Until now, the consensus has been that there is insufficient scientific evidence to justify taking a multivitamin to prevent cancer or other chronic diseases.
Though a large trial in Linxian, China, found decreases in stomach cancer in people randomly assigned to supplements including vitamin E, selenium and beta carotene, that population suffered from chronic nutritional deficiencies, and stomach cancer was more common than in the United States.
A review by the National Institutes of Health in 2006 concluded that evidence was “insufficient to prove the presence or absence of benefits from use of multivitamin and mineral supplements.” More recently, the Institute of Medicine cautioned people on vitamin D and calcium supplements, saying that most healthy adults do not need them and that high doses of calcium have been linked to kidney stones and heart disease and that high doses of vitamin D may also be harmful.
Dr. J. Michael Gaziano, a cardiologist at Brigham and Women’s Hospital and the V.A. Boston Healthcare System who is the lead author of the new multivitamin study, said the main reason to take a multivitamin was, and continues to be, to prevent nutritional deficiencies. He was reluctant to speculate about how a multivitamin might curb cancer. One of the dominant hypotheses, he noted, is that certain vitamins are antioxidants that protect aging cells against oxidative damage caused by free radicals, harmful molecules resulting from metabolic processes within cells.
The physicians study was a type of clinical trial considered highly reliable at determining cause and effect: participants were randomly assigned to take either a multivitamin or a placebo. But they were not representative of the population at large. The doctors were a fairly homogeneous, well-educated group, less racially and ethnically diverse than the population as a whole, with far fewer smokers. And, there were no women.
“The results are promising, but we want to make sure the effects would be similar and certainly not harmful across different populations,” said Marji McCullough, a nutritional epidemiologist with the American Cancer Society. “It’s worth trying to replicate these findings to see if they’re generalizable to women, smokers and others.”
Dr. McCullough also noted that there are different multivitamin combinations and the trial results would apply only to the specific formulation used in the study. Pfizer donated the multivitamins, called Centrum Silver, but the company has tinkered with the formula since the trial began — reducing the amount of vitamin A, for example, and adding the nutrients lutein and lycopene.
Generally speaking, people who take vitamins are a relatively healthy bunch to begin with, experts say. They tend to eat a varied and healthful diet, watch their weight and be physically active. It’s not always clear that the benefits they attribute to vitamins actually result from the pills.
“There’s a mystique about vitamins, that vitamins are some type of magical ingredient,” said David G. Schardt, senior nutritionist for the Center for Science in the Public Interest, an advocacy group in Washington. “There is a kernel of truth in that, because vitamins are essential to life. But that people will live longer or healthier lives if they take vitamins or eat foods fortified with vitamins — that’s difficult to prove.”
This year the center pressed Pfizer to change Centrum labels that said the multivitamins supported “breast health” and “colon health.” Such claims have to be approved in advance by the Food and Drug Administration, and even though the labels did not say explicitly that the supplements prevent cancer, the center alleged that was the implied message.
Experts are particularly concerned about letting the enthusiasm get ahead of the scientific evidence, because some vitamin trials have led to frighteningly paradoxical results. In two separate studies, smokers who were given supplements of high doses of beta carotene unexpectedly developed more lung cancers than those on placebos. Beta carotene was believed to protect against cancer, but it appears that in smokers’ lungs, the high doses actually caused DNA damage instead of protecting against it, Dr. McCullough said.
Another large study, involving 35,000 men who were given vitamin E and selenium in the hopes of reducing prostate cancers, also had disappointing results.
While deficiencies of certain nutrients can be harmful, an excess in some cases may also be bad, said Dr. Joel B. Mason, professor of medicine and nutrition at Tufts University. Like some medications, certain nutrients and vitamins may need to be delivered within a specific optimal range to confer benefit, he said, a concept he and others have termed a “Goldilocks phenomenon.”
“I think there is pretty compelling evidence that habitual underconsumption of folate does lead to an increase in colon cancer, and perhaps a few other types of cancer as well,” Dr. Mason said. “Folate is an essential factor in the synthesis and repair of DNA.”
But giving a well-nourished population folate supplements does not seem to decrease the risk further, Dr. Mason said, and some studies have indicated that “in some people who take extraordinarily large amounts of folate, there may be a paradoxical increase in colorectal cancer.”
One of the important observations of the new study is that a daily multivitamin appears to be fairly safe. That may also help shape the direction of future research, said Dr. Albanes, the senior investigator at the National Cancer Institute.
“The idea that ‘if a little is good, more is better’ led to trials with higher doses that didn’t necessarily come to fruition,” Dr. Albanes said. “This points us in the direction of the kinds of dosages that should be considered for prevention. It’s food for thought.”

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The Hunt for an Affordable Hearing Aid

Suzanne DeChillo/The New York Times
The crackling noises coming from my left ear weren’t a good sign.
Last year, when my decade-old analog hearing aid started making popping sounds, I knew I had to replace it. But because hearing aids are so costly and generally aren’t covered by insurance, I had put it off. I soon learned that in the last 10 years, purchasing a hearing aid had become even more difficult and confusing than buying a new car — and almost as expensive.
The first salesman I visited, in Los Angeles, looked at the hairline fracture on my wax-encrusted aid. He warned me that it could shatter in my ear and advised me to get a new one on the spot.
Alarmed, I visited Hearx, the national chain where I had bought my previous aids. There, a fastidious young man spread out a brochure for my preferred brand, Siemens, and showed me three models. The cheapest, a Siemens Motion 300, started at $1,600. The top-of-the-line model was more than $2,000 — for one ear. I gasped.
I’ve worn hearing aids for more than 30 years; I’ve had profound hearing loss in my right ear and moderate loss in the left ear, the one where I wear the aid, since I was 5. So I am probably savvier than most first-time customers, many of them elderly and scared of what might happen if they don’t buy an expensive aid.
A hearing aid is basically just a microphone and amplifier in your ear. It isn’t clear why it costs thousands of dollars.
But the digital era has ushered in new technology: Manufacturers boasted of Bluetooth, multiple settings, “channels” and “bands,” which processed sound and fine-tuned it like a stereo’s equalizer.
Perhaps that was why the Hearx salesman bristled when I asked what I could get for $1,000. He likened the expensive model with 16 channels to listening to an orchestra — and the eight-channel model to a car stereo. He didn’t show me any other options. It was as if I’d gone into a car lot and had been presented with only Mercedeses, Porsches and Ferraris, when I wanted to see a Honda.
Feeling pressured, I ordered the “cheap” aid. But I quickly canceled the order and started researching my options. I learned not only that now you can buy hearing aids online, but also that Costco — a place where you typically get toilet paper in bulk — has gotten into the hearing aid business.
Why have hearing aids become more expensive, while cellphones, computers and televisions have gotten cheaper? Russ Apfel, an engineer who designed a technology now found in all hearing aids, says there is no good reason for this.
“The hearing aid industry uses every new thing, like digital or a new algorithm, to raise prices,” said Mr. Apfel, whose company, Audiotoniq, aims to sell sophisticated but affordable devices. “The semiconductor industry traditionally reduces the cost of products by 10 to 15 percent a year,” he said, but “hearing aids go up 8 percent a year annually” and have for the last 20 years.
The microphones, speakers and processing chips aren’t that expensive. “Those devices in small volumes cost $10 to $15,” Mr. Apfel said. He estimated that most hearing aids cost no more than $100 to make.
Indeed, less expensive hearing aids are available online. At Audicus.com, prices run from $399 to $599, a discount made possible by eliminating the middleman — the hearing aid dispenser. “Retailers/audiologists account for up to 70 percent of the final price of a hearing aid, because they factor in a bundle of additional expensive services,” the site states.
“The big discussion right now in the industry is about unbundling,” said Audicus’s founder, Patrick Freuler. “The consumer has absolutely no idea how much is the cost of the device, how much is the cost of the service that went into testing, advising, programming, your after-sales support. All the customer sees at the end of it is one big fat price tag that says, ‘$2,000.’ ”
And all of those channels are mostly marketing. “For someone with mild to moderate hearing loss, the average hearing aid today is completely overengineered,” Mr. Freuler said. He cited studies showing that four or five channels improve speech intelligibility.
There is a downside to buying online: Hearing aids need to be mailed in for adjustments, an imperfect option.
Deborah Carlson, president of the American Academy of Audiology, said that the high prices included research and development, and pointed out that audiologists at private clinics provide customized service, including real ear measurements and repeated follow-up visits. “They’re going to understand your hearing loss better” than a Web site, she said.
Cindy Beyer, an audiologist and a senior vice president of HearUSA, the parent company of HearX, said in an e-mail that the company offers aids as low as $850 — but that the average cost of a hearing aid, according to a report from the Hearing Review and House Institute, is $3,000.
In other words, my shopping experience could have been much worse.
When I told a friend about the sticker shock, she said, “Why don’t you check out Costco?”
The chain started selling hearing aids in 1993, and now has 438 hearing aid centers. At Costco, a basic in-the-ear shell hearing aid costs $500, with the most advanced behind-the-ear models going for $1,300.
And unlike the Internet retailers, Costco offers face-to-face service with hearing aid dispensers and audiologists for custom fittings.
“As a company, we made a decision to go after this business,” said Richard Chavez, a Costco senior vice president. “I mean, to really try to become the best in the world.”
Costco’s prices are less than half than the industry standard, despite the fact that its hearing aids are produced by the same major companies, including Rexton (a brand made by Siemens) and GN ReSound. Its in-house brand of aids, Kirkland Signature, is also built by Siemens. And unlike many private hearing aid dispensers, Costco employees don’t work on commission.
Not surprisingly, Costco isn’t winning any popularity contests in the industry.
“Oh, they hate Costco,” Mr. Freuler said.
Sam Tanzer, a founder of an online store called Embrace Hearing (where prices run from $399 to $899), said that private retailers had to raise prices to cover fixed costs. “When you think about your typical independent audiologist charging $6,000 for a set of hearing aids, he’s not getting rich,” he said. “Costco just has much more efficient overheads. They don’t have to pay a receptionist; they don’t have to lease separate space.”
Admittedly, my experience at Costco was mixed. The inexperienced hearing aid dispenser suggested a brand, Bernafon, that I was not familiar with. The sound was compressed and tinny; it never sounded or fit right and had to be remade several times. After seven or so visits, I was beginning to believe the adage “You get what you pay for” (in this case, $950).
When I moved to Seattle last year, I went back to Costco and explained my situation. Though nearly a year had passed, the store accepted a complete return and gave me a new brand, which fit perfectly.
However, I may not have needed a new aid at all. Far into my Costco experience, I saw a nondescript sign in Culver City, Calif., for a hearing aid professional. I rang the doorbell, located discreetly inside an eyeglass shop, and an older man beckoned me to a small, windowless room with wood-paneled walls and shelves filled with odds and ends of the trade: hearing aid boxes, batteries, replacement parts, silicone molds.
I told him about my misadventures and he looked at my cracked, wax-encrusted aid — the one I was told was so dangerous it needed to be immediately replaced. He put a stethoscope in his ear and listened to it. He said that he could clean out the wax and have the shell repaired and that it would work just fine.
His price: $100.

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Thinking Twice About Health Checkups

In an analysis of studies including more than 180,000 subjects, researchers have found that general health checkups — like annual physicals or other visits to the doctor by asymptomatic people — are ineffective and possibly harmful.
The investigators found no evidence that an annual physical will prevent death by cancer, cardiovascular disease or any other cause. Nor did they find any effect on hospital admissions, disability, additional visits to the doctor or absences from work.
The researchers, writing in the October issue of The Cochrane Library, found that health checkups have no effect on clinical events or other measures of morbidity. But one trial found an increased rate of diagnoses of hypertension and high cholesterol, the scientists noted, and another found a 20 percent increase in the number of new diagnoses per patient.
One possible harm, the authors point out, is that the checkups can lead to unnecessary treatment of conditions that would not cause symptoms or death.
The authors acknowledge that most of the studies are old, which may make the findings less applicable to modern health settings.
“We’re not concluding that prevention is useless,” said the lead author, Dr. Lasse Krogsboll, a researcher at the Cochrane Center in Copenhagen. “One possible reason we couldn’t find an effect is that primary care physicians might be doing a good job in preventing illness, so that adding a systematic effort does not add anything except perhaps harms.”

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Are Doctors Too Wary of Drug Companies?

Not long ago, I asked a colleague for advice on a patient. He offered up a couple of treatment options, then stopped to show me a new medical app on his electronic tablet. With a few swipes of his finger, he summoned a compilation of research articles, synopses and even entire textbooks that, printed and bound, would have filled shelves in a library.
Dr. Pauline Chen on medical care.

“But do you know what the best part is?” he asked with a twinkle in his eye. I thought of the exhaustive reference material and the seemingly endless scroll of diagnoses that were all so easy to access on the small screen balanced on his knees.

“The best part is that none of this is sponsored by Pharma!” he said with a broad smile. “There’s no bias.”

My colleague is not the only doctor who feels that way, according to a recent study published in The New England Journal of Medicine.

For years, most doctors have had a predictable, if not close, relationship with the pharmaceutical industry. Companies handed out office tchotchkes, paid for staff lunches and distributed drug samples for patients. More significantly, drug companies were important sources of biomedical research money, particularly during periods when federal support wavered. It was understood that the companies providing funding would leave the researchers alone to design and conduct the study, analyze the data and write up the results.

That understanding began to fray about a decade ago when doctors, and patients, began to realize that drug companies were becoming too involved with the research they were supporting. For example, one major pharmaceutical firm manipulated data and underestimated the risk of heart attacks, strokes and deaths in a large study of a drug for arthritis. The drug was eventually withdrawn from the market, but not before 80 million patients had used it, with annual sales topping $2.5 billion.

The case highlighted the dangers of industry sponsorship of research into new drugs, and the public became eager to expose any potential conflict of interest, particularly for doctors. Within a few years, a new standard of transparency in medicine emerged. Brightly labeled drug company pens became an embarrassment; lunches on the drug company tab and sponsored conferences turned suspect; and editors at numerous medical journals published lengthy screeds detailing their disclosure requirements.

The new skepticism and transparency were no doubt good for patients and doctors, but this recent study reveals that in our zeal to single out the pharmaceutical industry’s biases, we may have become blind to our own.

The researchers created several hypothetical drug studies, then asked a group of practicing physicians to rate the “studies” and the likelihood they would prescribe the new “drug.” The researchers purposefully varied the quality of the studies and the disclosures – some of the made-up studies disclosed that they had received pharmaceutical company funding, others said they’d received support from the National Institutes of Health, and the rest listed no funding disclosures at all.

Most of the doctors were able to assess the quality of the research pretty accurately. After reading the less rigorous studies, the ones that weren’t designed, conducted or analyzed well, the doctors were hesitant to prescribe the new drugs under study; seeing the more rigorous studies, they were more willing to do so.

But the researchers also found that the doctors were also unduly swayed by any mention of industry funding. Regardless of the quality, if a study was supported by a pharmaceutical company, doctors were less willing to consider prescribing the studied drug and less likely to assess the quality of the research with accuracy.

“Some amount of skepticism is warranted,” said Dr. Aaron S. Kesselheim, lead author of the study and an assistant professor of medicine in the division of pharmacoepidemiology and pharmacoeconomics at the Brigham and Women’s Hospital in Boston. “But ultimately it should be the quality of the study and the impact of the results that determine your confidence about using a new drug, not who was funding it.”

Being overly skeptical has serious implications for patient care. The pharmaceutical industry, along with medical device and biotechnology firms, continues to finance a majority of current research. In 2007, for example, industry was responsible for nearly 60 percent of the more than $100 billion spent on research. Much industry-supported research focuses on the side effects of new drugs. By writing off such research, doctors risk overlooking findings that may have important treatment implications for their patients, like a new cholesterol-lowering drug that is found to have less of an effect on energy and blood sugar levels than other similar medications.

Dr. Kesselheim and his collaborators believe what is needed in biomedical research is even greater transparency. Such openness would include more independent third-party statistical reviews to ensure that data is not being manipulated or misleading and wider use of public Web sites like ClinicalTrials.gov, regardless of the source of funding.

ClinicalTrials.gov lists study details like objectives, design and data gathered, providing doctors and patients alike with a way to confirm that no data is being selectively reported or distorted. But participation on the site is voluntary, and pharmaceutical, medical device and biomedical companies are often hesitant to share what they consider proprietary data, choosing instead to list only selective details, or no information at all.

Until full transparency is achieved and such details are available to all on the Web or for independent statistical reviews, Dr. Kesselheim and his collaborators suggest that both doctors and patients remain alert to potential biases — Big Pharma’s, and also their own.

“Excessive skepticism,” Dr. Kesselheim observed, “is as much a bad thing as naïveté.”

Dr. Pauline Chen on medical care.

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Cholesterol Is Falling in Adults, Study Finds

Cholesterol levels in adults are falling, and changes in the amount of trans fats in the American diet may be part of the reason, new research suggests.

The findings, published Tuesday in The Journal of the American Medical Association, were celebrated as something of a triumph by health authorities, who said the data showed that the nation had reached its 2010 goal of getting the average total cholesterol level in adults below 200 milligrams per deciliter. Researchers examined a nationally representative sample of tens of thousands of Americans over the last two decades and recorded a decline of 10 points in average total cholesterol — to 196 mg/dL from 206 mg/dL.

While the so-called bad cholesterol decreased, there was a slight uptick in HDL cholesterol, higher levels of which are associated with a reduced risk of heart disease. Triglycerides, which are also linked to heart disease, initially rose 5 points to 123 mg/dL from 1994 to 2002, then dropped to 110 mg/dL by the end of 2010.

The study’s authors said they were buoyed by their observations, but could not provide a solid explanation for them.

The popularity of cholesterol-lowering drugs like statins was only part of the explanation, they said. Their use more than quadrupled among adults during the study period, to 15.5 percent from 3.4 percent. As many as 35 percent of men and women over 50 took them, the study found.

But the same improvements in cholesterol profiles were also seen in adults who were not taking them, said Margaret D. Carroll, the study’s lead author and a statistician with the National Health and Nutrition Examination Survey at the Centers for Disease Control and Prevention.

“It was somewhat of a surprise to us to see these favorable trends in people who were not on lipid-lowering medications,” she said.

The study was observational, which means it could not prove what caused the decline in cholesterol levels. Dr. Carroll and her colleagues said, however, that exercise, obesity and saturated fat intake were unlikely to have been significant factors. Average physical activity levels have not increased, more than a third of the adult population is obese, and the intake of saturated fat as a percentage of calories in the American diet is the same as it was over a decade ago.

Instead they suggested widespread public health campaigns to rid trans fats from foods might have had an impact.

Once widely found in fried and packaged foods, trans fats, which can raise LDL and lower HDL cholesterol, have been slowly stripped from the food supply as cities have banned their use in restaurants and pressed companies to remove them from cookies, soups, crackers and other processed foods. One C.D.C. study this year found that since 2000, levels of trans fats in Americans’ bloodstreams had fallen nearly 60 percent.

Two other trends in the last decade may have also been factors, the researchers said: declines in smoking and a drop in carbohydrate consumption.

Dr. David J. Frid, a cardiologist at the Cleveland Clinic, said the findings were unexpected given the high rates of obesity and Type II diabetes. He pointed to research showing a recent 30 percent drop in deaths from heart disease nationwide, and said the cholesterol data might be related.

The notion of trans fat consumption contributing to the fall in cholesterol numbers, while intriguing, has not been proven, said Dr. James A. Underberg of the NYU Center for the Prevention of Cardiovascular Disease.

Dr. Underberg said that standard measures of cholesterol could be deceiving. People who are obese or have Type II diabetes can have seemingly normal levels of LDL, but also have high amounts of the small LDL particles that drive into artery walls and cause heart disease.

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Feeling the Pressure to Drink for Work

Béatrice de Géa for The New York Times COLD SHOULDER: Terry Lavin sipping seltzer water at the Pig ‘n’ Whistle in Manhattan.
As an ad-sales executive with Forbes magazine, Terry Lavin worked hard to earn his reputation as a dependable drinking buddy.
“I just basically rented space at P. J. Clarke’s,” he said, referring to the Midtown Manhattan watering hole. “I was always the last to leave, always had a cocktail in my hand.”
In a business built on likability, the role helped him succeed. Until 2010, when he decided to give his body a break and quit drinking for six months. His health got better; his business did not.
“I would call guys I was friendly with, guys who had their hands on big ad budgets, to see if they wanted to go to happy hour or get something to eat,” he recalled, “And they’d say: ‘Are you drinking? No? Don’t worry about it.’ ”
So much for the benefits of the sober life.
Even as three-martini lunches and whiskey-fueled staff meetings become harder to find outside of cable TV, plenty of American business rituals continue to revolve around alcohol. Whether it’s courting a client, sketching out a deal or simply proving you’re a team player, quaffing a round of beers is arguably more vital to many jobs than nailing a round of golf.
For professionals who abstain from alcohol — for health, religion, recovery or simple preference — it can sometimes seem harder to get ahead if you’re not willing to throw one back.
“You’re expected to drink, and drinking is part of what you do, and there’s a little bit of circumspection if you say you don’t do it,” said Link Christin, director of a special treatment program for legal professionals started last year by Hazelden, a network of alcohol- and drug-rehabilitation centers based in Minnesota. “If you say you don’t drink, you have to deal with the suspicion that you can’t play the game.”
To find that attitude in action, look no further than this year’s presidential campaign. As a part of his pitch to voters that Mitt Romney, a teetotaler Mormon, is different from most Americans, President Obama has made a conspicuous display of his own regular-guy fondness for beer.
“Yesterday I went to the State Fair, and I had a pork chop and a beer,” Mr. Obama boasted to an Iowa crowd in August the day after he closed down a beer kiosk so he could buy brews for himself and 10 other fairgoers. “And it was good. Today I just had a beer. I didn’t get the pork chop. But the beer was good, too.” The crowd rewarded him with chants of “Four more beers!”
When the public demanded that Mr. Obama release his recipes for home brews after he shared a bottle of one with a coffee shop patron in Knoxville, Iowa, the White House milked the moment by first demanding 25,000 signatures on a petition. (The White House eventually relented, releasing two recipes after just 12,000 signatures.)
It’s hardly a new tactic among politicians. Edward M. Kennedy complained about the lack of alcohol in Jimmy Carter’s White House as he prepared to challenge the president in the 1980 primaries. And it has become a pollsters’ truism in recent years that voters choose the candidate they’d rather have a beer with. (The most recent nondrinker to take the White House, George W. Bush, at least made sure he was occasionally photographed holding a nonalcoholic O’Doul’s.)
For less public figures, the notion that people who don’t drink can’t perform in business — or, worse, are somehow untrustworthy — can impede professional progress.
“There is a perception almost that you’re impotent,” said one nondrinker, an editor at a liquor-focused lifestyle magazine who asked not to be identified because many of his co-workers don’t know he recently entered a 12-step program.
Professional disadvantages to sobriety range from the literal — the editor had to decline a potential promotion because it would have involved wine tasting — to subtle.
“I regularly turn down lunches and dinners with industry people that I would have jumped at in the past,” the editor said. “I just can’t go to dinner with a winemaker and tell him: ‘No, thank you. I’m not tasting those.’ ”
One hardly has to work directly with alcohol to experience this. On Wall Street, where a “models and bottles” lifestyle prevails, those who don’t drink “complain that they can’t close a deal, can’t even get into early negotiations because they won’t engage in drinking behaviors,” said John Crepsac, a New York City therapist who counsels Wall Street workers in recovery.
Social scientists refer to it as “social capital,” the amount of economic potential to be harnessed from one’s capacity to fit in.
“There were times I knew the guys were going out with customers that could help advance my career,” said one nondrinking Wall Street trader who asked to remain anonymous because his employer doesn’t allow staff members to talk to the media, “but it was just unspoken: ‘Yeah, we won’t invite him ’cause we’ll probably get up to some drinking and he won’t partake, so what’s the point?’ ”
Of course, sobriety and success are not mutually exclusive. Warren Buffett, Donald Trump, Joseph R. Biden Jr. and Larry Ellison are all lifetime abstainers. Whether or not he wins, Mr. Romney hasn’t lacked for success, either.
And sober women might actually benefit from an old double standard. “Men are still expected to get together and go wild, but in some ways it’s frowned upon if the woman engages in it,” Dr. Crepsac said, noting that few of his female patients have complained that sobriety hurt their careers. “There are plenty of things for which women are discriminated against in the workplace, but this isn’t one of them.”
Still, research supports the idea that nondrinkers have a harder time climbing the corporate ladder. Multiple studies have shown that moderate drinkers earn more money than those who don’t drink, though heavy drinkers earn less than moderate drinkers.
That pressure to perform can sometimes cause professionals in recovery to backslide. This is one reason that Hazelden created a support group especially for lawyers who are trying to stay sober.
“The pressure to bring in business at legal firms, to be a rainmaker, is greater than ever,” said Mr. Christin, a former litigation lawyer and a recovered alcoholic. When someone must choose between supporting his or her family and having a glass of wine, it can be tough to stay the course, he said.
Teetotalers tend to develop strategies for socializing professionally without alcohol. Some will order a drink and simply leave it alone; others use humor to deflect unwanted attention. “I tell people I’m pregnant,” said the Wall Street trader (a man).
Mr. Lavin, who is on leave from ad sales to write a book, advises asking for your drink in deceiving glassware. “People are much calmer if you’re drinking a seltzer water out of a rocks glass,” he said.
And there is justice to be had. Joe McKinsey, a former mortgage executive who opened a rehab clinic for executives in East Hampton, N.Y., after his own recovery, said it had taken only a few months of being sober at his old job to go from a target of ridicule to a confidant for those in trouble.
“Eventually you get people buttonholing you, asking, ‘Do you think I have a problem?’ ” he said. “I became the go-to guy if you needed to have a private talk.”

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Living With Cancer: We Are Seven

It is our luck that we are seven women grappling with various stages and types of gynecological cancer in a small group that no one in his or her right mind would want to join.
Susan Gubar writes about life with ovarian cancer.
We live in a town that boasts no program or facility to bring us together. Our group happened to happen. Patricia and Mary introduced themselves after a presentation I gave with my oncologist, who is also their doctor. Alison read a notice in the local newspaper and sent me an e-mail asking if we might correspond. Such was the start, as these three contacted three others — Diane, Judy and Sarah — and we began to meet every few weeks in a restaurant or at one of our homes. And oh the difference to me!
The elation of gathering with people who also confront the perplexities of cancer and its treatments has something to do with our being anomalies outside the group — but not inside it. Among my healthy colleagues and friends, I am the one singled out with a lethal disease. Inside the group, though, we are all normal, even though “normal” means dealing with a dire diagnosis and treatments, in the past or the present.
During the hour and a half we meet every few weeks, the (unspoken) promise we make involves not discussing our families, jobs, political affiliations, religions, entertainments or anything else except our relationship to cancer and its treatments. This might sound constraining, but for most of us the opposite rule holds true in all other social interactions. So when we are together, it feels like a relief to be able to ask a blunt question, to express a fear or a hope, to joke about mishaps. Without the supervision of a facilitator or an institution with its own agenda, no prescribed watchwords or goals confine our responses to cancer or each other.
Actually, there is another (unspoken) promise, namely that we perform acts of diligent attention when they are needed and without projecting our own watchwords or goals onto others. That means that if Judy must soon decide on whether or not to embark on a chemo-radiation “sandwich,” discussing her situation takes priority. If Alison’s doctor responds to a recurrence with surgery and Diane’s with a drug, we talk about it without formulating categorical rules about better and best. We strive for the condition of consciousness that the Romantic poet John Keats called “negative capability,” the psychological state of residing in “benign uncertainties, mysteries, doubts, without any irritable reaching after fact and reason.” We are as open to Patricia’s belief in healing hands as to Mary’s faith in CTs.
Because of cancer and its treatments, each of us has had to learn how to tolerate the painful confusion of uncertainty — not knowing why the cancer occurred, if or when or where it will recur, whether the treatment is working or how well. Since we don’t know ourselves, we certainly would not presume to judge the decisions or, for that matter, the lifestyles and values of others.
In other regards, of course, people with cancer are as different from each other as people without cancer. We need to make room for one person’s optimism, another’s fatalism. At times it is hard to keep the various case histories in mind. Which one was misdiagnosed for how long? Whose chemo resulted in kidney damage or neuropathies? What works for me might (or might not) work for you, we surmise.
“Can she drink scotch, doctor?” a relative is reported to have asked after a debulking operation. The answer — “If it’s good scotch” — cracks us up.
Sometimes, we take turns reciting our medical tales. Because these events were so traumatic and often complicated, the stories need to be recounted recurrently. Our language may sound less communicative than chirpy: not in the sense of cheerful, but rather like the phatic calls of birds, simply emphasizing that we are still here to do the telling.
This week, one in our group will be absent. To our surprise, we were informed by her friends that she had to undergo emergency surgery. Their e-mail brings to my mind the poet who Keats thought least capable of negative capability, William Wordsworth, and in particular his poem “We Are Seven.” In it, an adult questions a little country girl about her siblings, two of whom lie in the churchyard. If two are dead, he keeps on asking her like a tendentious math teacher, “how many are you?” But she insists, “We are seven.”
Keats may have been wrong about Wordsworth, for the reader’s sympathies reside not with the rational interlocutor but with the inscrutability of the little girl who, within the mysteries of mourning, resists the finality of death.
Even with Judy gone for the next session, we will be seven. I want to think that no matter what happens to any one of us, we will always be seven. The grace of the group provides us a setting in which what is awkward or unspeakable in other contexts can be heard or said. Within it, we can experience, if only briefly, the comfort of being linked to one another.
Susan Gubar is a distinguished emerita professor of English at Indiana University and the author of “Memoir of a Debulked Woman,” which explores her experience with ovarian cancer.

Susan Gubar writes about life with ovarian cancer.

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When Doctors Stop Taking Insurance

Private health insurance used to be the ticket to a doctor’s appointment. But that’s no longer the case in some affluent metropolitan enclaves, where many physicians no longer accept insurance and require upfront payment from patients — cash, checks and credit cards accepted.
On Manhattan’s Upper East Side, it’s not unusual for a pregnant woman to pay $13,000 out of pocket in advance for childbirth and prenatal care to a physician who does not participate in any health plan. Some gynecologists are charging $650 for an annual checkup. And for pediatricians who shun insurance, parents on the Upper East Side are shelling out $150 to $250 whenever a child falls or runs a high fever.
Efforts by insurers to rein in health care costs by holding down physician fees — especially for primary care doctors, who play a critical role in health care though they are among the lowest paid doctors — appear to be accelerating the trend, and some patients say it’s getting harder to find an in-network physician.
Orlene Paxson, 33, a stay-at-home mom on Manhattan’s Upper East Side, was unable to find an obstetrician she liked who would accept her insurance. Many were not accepting new patients, and one highly recommended doctor did not return her call for five days and did not want to see her until 12 weeks into the pregnancy. It was Mrs. Paxson’s first pregnancy and she did not want to wait, so even though her policy does not cover any out-of-network services, she and her husband chose a doctor who doesn’t take insurance and paid the entire $13,000 fee themselves.
Once their daughter was born 20 months ago, Mrs. Paxson needed a pediatrician but could not find one who was in her plan, accepting new patients and within walking distance. So she again chose an out-of-network doctor.
“We stayed with her for a year and a half because we loved her,” Mrs. Paxson said. At her first scheduled visit after the baby was born, the doctor “talked to me for almost three hours. She knew it was our first baby.”
But three months ago, Mrs. Paxson switched to an in-network pediatrician, largely because of the cost of the vaccines. “They didn’t cover a dime of it,” Mrs. Paxson said of her insurance, adding that she was not complaining. “I made informed decisions.”
Though data on private practices is scanty, a new survey of 13,575 doctors from around the country by The Physicians Foundation found that over the next one to three years, more than 50 percent plan to take steps that reduce patient access to their services, and nearly 7 percent plan to switch to cash-only or concierge practices, in which patients pay an annual fee or retainer in addition to other fees.
When doctors stop taking regular insurance or drop a health plan, patients are free to take their business elsewhere. If they have health plans that cover out-of-network expenses, these patients may be reimbursed for fees they pay in cash, but probably not for the entire sum.
The cash-upfront trend raises an uncomfortable question. Can the Affordable Care Act, intended to widen access to health care, succeed by expanding insurance coverage if primary-care doctors are walking away from insurance?
“If all it means is that doctors who serve the wealthy are figuring out ways to avoid the hassles of insurance, I’m not sure it’s a public policy problem,” said Marsha Gold, a senior fellow at Mathematica Policy Research in Washington and an expert on health care financing. “The real problem comes in if it really restricts the choices people have and makes it worse than it is now. We don’t really have the data to know.”
The country is already facing a shortage of physicians, according to the Association of American Medical Colleges. By 2025, the nation will have 100,000 fewer doctors than needed, according to the association. With fewer medical students choosing to go into primary care, shortages in this area are expected to become especially acute.
Physicians are increasingly feeling shortchanged by insurance companies, said Dr. Bob Hughes, an otolaryngologist in Saratoga Springs who is president of the Medical Society of the State of New York. “Insurance companies do not negotiate with physicians. It’s all take-it-or-leave-it contracts,” he said.
A June report by the Medicare Payment Advisory Commission, which advises Congress and focuses primarily on the government plan for seniors, suggests adults ages 50 to 64 are having more trouble getting an appointment with a new physician. Some 30 percent of privately insured individuals who were looking for a new primary care doctor in 2011 reported problems finding one, compared with 26 percent in 2008. (Only 14 percent had a problem finding a specialist in 2011.)
Cash-only practices may exacerbate the access problem. Since her doctor stopped accepting her insurance, Kathryn Vanasek, 43, a mother of two in Manhattan, hasn’t been back for a checkup or preventive screenings, relying on a new walk-in clinic for urgent problems like an ear infection.
Her annual physical would cost at least $250 out of pocket, Ms. Vanasek said, but she would not get any money back from her insurer until she met the deductible.
“You are making a decision between preventive medicine and reactive medicine,” she said.
If you choose to see a physician who will not accept insurance, experts advise a few precautions:
¶Read the fine print on your health insurance policy. Though many plans provide out-of-network coverage, the reimbursement may cover only a fraction of your costs.
¶Try to estimate your out-of-pocket costs in advance so you can pay the physician with money saved in a flexible spending account, which is sheltered from taxes.
¶Ask yourself whether you really must see a doctor who does not take insurance. Is the care really better? Ask acquaintances outside your regular circle for references. If you are willing to travel, you may find a highly recommended physician who takes your insurance.
¶Keep track of your expenses and receipts, file out-of-network claims promptly and keep copies for yourself. Call your insurer to follow up; it is not unusual for an insurance company to lose paperwork.
¶Watch for expenses that will not be reimbursed. Children’s vaccines, for instance, may not be reimbursed even if you have out-of-network coverage. The global fee quoted by an obstetrician for childbirth should encompass all care required unless you have complications, need to see another specialist or require a last-minute Caesarean section.
¶Doctors who don’t take insurance are likely to refer to others who don’t. Make every effort to ensure that expensive services, such as hospitalizations and surgery, are with network providers and that you have the required approvals from your insurer.
The rising costs of the U.S. health care system.

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Healthy Hair Tips

Researchers warn of certain styles work when hair is wet because the hair is then extremely sensitive and very weak and easy to brittleness.

 Hair must be left until it is nearly dry and better to use the comb of wide teeth for easy combing and no embrittlement .

Must be a comb made ​​of wood because the plastic makes electrical discharges during the combing and lead to Trichorrhexis

You should start combing hair from its ends to rid the tangles , then from roots to ends but be sure to do that gently as dealing harshly causes hair loss .

 

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5 tips to get rid of stress

We live in a world filled with tension as result of the size of the burdens and responsibilities of everyday .. But do you know that 90% of the diseases and health crises we suffer from is the result of tension, stress, and nervous system, while only 10% due to organic causes ?
 As a result, some doctors suggested the establishment of medical centers for the treatment of raised tension and stress, and the most important tips provided by these centers to return to a healthy life again .


1 - the time for rest :
If you feel tired and fatigue you should "learn" that you take time to rest, but notice the word "learn" here which could take a rest period, but in the wrong way that may not return your activity again, For example, if you take long break this will make it difficult when coming back to work.


The advice here is that the average period of rest is 15 minutesit isn`t which to think about anything, even if simple, must be aware that as long as you're tired, you aren`t capable of production if you insist to continue working This is a waste of time and effort ,so you should stop immediately.


2 - should breathe well :
It is natural to think that all humans have the ability to breathe, it is true in theory but scientificaly 95% of them practice it wrong and superficially and the best way to breathe is to breathe "deeply" entering as many of the air into the lung filling it completely and not just breathing in and out , and that it is worth to write a sign in every place ( the home, office, car, etc. ...... ) to remind you of this and you will feel the difference.


3 - Make time for exercise :
Choose exercise that you wish. It is importantthat you do it regularly to break the daily routine, at first you will find it difficult not enjoy doing so, but continued this will take 21 days to become a habit in your life and you will feel pleasure and happiness.


4 - Make yourself a healthy food program :
Your food is directly related to your habits and often these are bad habits and not in your favor.You should change your habits to conform with the new health system. You should be aware that your health is the greatest and most important property which, if lost, is difficult to retrieve as before without losses.

5 - Try to find happiness to yourself :

The best one to please you, is yourself because you know it , and its wishes.

In a lot of times we are ready to be happy so take advantage of this opportunity and don`t waste it , just do what you love and what you wish with no restrictions to invest this feeling and become happier. this will give you a great energy to change and create a new life, do not forget that it is important to spend time with yourself to please it .

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Apple Uses For Your Skin

Apple is a great fruit widely used in cakes, pies and many health care products too. Everyone knows the context, "an apple a day keeps the doctor away", which is true enough. Because of its useful components it has received a new found respect. Features Apple is mind-boggling. It 'was increasingly used in shampoos, conditioners, washing face and much more. And 'true candidate for hair care and skin.
Home Based Recipes

Having Braeburn apples may protect against UV rays. It is one of the best qualities of the apple that the components of protection against UV rays.
Grind 1 apple cored and placed in a blender. Add 1 c. to tea. honey, sage to the mixture. Refrigerate for 10 minutes. Apply this mixture on your face. Hold for 30 minutes and later rinse it. This can be used for normal skin.
Mix 1 tablespoon cup apple juice with 5-6 drops of lemon juice. Apply this on your face. Hold for 15 minutes. Rinse with cold water. It's great for oily skin.
Grate an apple and refrigerate to cool. Apply this grated potato on your face for 15 minutes and then rinse with cold water. It works well for dry skin.

You can remove stains by dabbing the night of apple cider vinegar on your face before bedtime. Skin rejuvenated and radiant await you in the morning.

Age spots can be reduced by touching areas of apple cider vinegar before going to bed.
Take 1 / 2 cucumber, peeled, 1 egg white, 1 / 2 c. to tea. lemon juice, 1 / 2 c. to tea. lime juice 1 / 2 tsp. apple mint leaves and a drop of essential oil of lime. Mix the ingredients into a smooth paste, except the essential oil is added last and mix well again. Refrigerate for 10 minutes. Apply on your face. Leave it for 20 minutes. Wash with warm water in a large effect.

Cut an apple into small pieces and mix. Mix 1 teaspoon honey and sage to the apple wound and mix well. Apply on your face and relax for 15 minutes. Once done rinse and dry.
Take 1 / 2 apples, peeled and sliced, 1 tbsp. honey, one egg yolk, a tablespoon. ascorbic acid, vinegar and 2 tablespoons of oil. Mix these ingredients in the batter. Apply this paste on your face until dry and wash with warm water.
Warning: The reader of this article should exercise all precautions while following instructions on the recipes in this article. Avoid using any of these products if you are allergic to it. The responsibility lies with the reader and not with the site or author.

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