Cupping uses a vessel to create a vacuum as it is pressed to the skin, stretching the tissues and creating enhanced circulation in the area treated. These days, many practitioners use a glass “cup” which actually looks more like a miniature fish bowl. A vacuum is created by quickly flashing an open flame inside the cup, just before it is placed on the skin. As the air inside the cup cools, it reduces in volume. A modern variation makes use of plastic cups with built in check-valves. A hand pump is then used to suck out some air and create the vacuum. I find the glass cups to be more comfortable for the patient, especially if they will be used in a moving fashion to cover a large area. The plastic versions are superior for getting a strong suction in a very small cup, which can be ideal for working on small bony areas, such as an elbow or knee.

I find cupping therapy useful for a number of soft tissue problems, such as chronically tight muscles (especially on the back) and tendonitis (for example, with tennis elbow). I have used it on a couple of patients with back muscles so tight and sensitive they would actually spasm further when acupuncture needles were inserted. After a cupping treatment or two, I could use acupuncture normally. Cupping is sometimes superior to needling when a large area of muscle is involved, and in chronic conditions.

Traditionally, cupping is also used to stimulate almost any acupuncture point, similar to the way we might use needles. In other words, it can be used for internal medicine treatments, as well as musculoskeletal problems. I don’t do this often, but find it a very helpful treatment for chronic respiratory diseases such as asthma (in which case I treat points on the back of the neck and upper back). An ancient Chinese treatment for asthma was to use a small caustic poultice, including herbs like mustard seed, with the intent of creating a blister on the skin. Cupping is a much gentler way to achieve a similarly strong, long-lasting stimulation of a point.

Cupping is usually done with the expectation of causing some bruising. This comes from the suction that is created, rather than blunt trauma - most people find the sensation of cupping to be comfortable or even enjoyable. It seems to be the weak capillaries that break; as the tissue gets healthier, bruising is much reduced or eliminated. Cupping causes a strong stimulation at the time of the treatment. Afterwards, the stimulation continues, as the body flushes out the affected tissue and then builds new, healthier blood vessels. The result is a relatively strong and long lasting treatment, whether the intended target was specific acupuncture points or entire muscle groups.

People definitely report a variety of responses to acupuncture needles. There are a lot of factors that come into play. Believe it or not, a lot of people love the sensation of the treatment overall, and find the needling itself to be inconsequential. Here are some factors that can affect your experience.

All needles are not the same, and all needling techniques are not the same. Generally, acupuncture needles produce a lot less sensation than getting a shot - for several reasons: the needles are smaller, they are solid vs. hollow, they don’t have a cutting edge, and you are not injecting anything.

There is also a broad range of acupuncture needles. Not only is there a range of thicknesses, but there can be a big difference in quality, which relates to how sharp the needles are on a microscopic level, which in turn relates to how much sensation they produce. Some needles are even silicone coated, and really do slide in better.

Technique also comes into play. Even given equally skilled practitioners, some styles are more aggressive than others, and a stronger sensation may be actively sought after. Still the desired sensations are in such categories as heavy, or full, or warm. A sharp, stinging sensation usually means the needle is hitting a little blood vessel or hair follicle and is easily adjusted to a comfortable position.

Neither are all points created equal. While most acupuncture points are near a neural or vascular plexus, some are just plain more sensitive than others and are more likely to produce a stronger sensation.

And one more “point.”  Patients are different. Pain sensitivity varies hugely between people. I’ve seen patients who were sensitive to the tiniest needles and gentlest techniques. I’ve seen others with whom I might have used an ice pick without their noticing. Also, any given person may be more sensitive on one day than another.

In the end, most people are pleasantly surprised how comfortable and relaxing an acupuncture treatment is.

I remain skeptical. It’s not that I take a militant anti-vaccine stance in general. But my hubris alarm goes off when I see blanket recommendations for a vaccine (or anything else) with such mixed evidence of usefulness. Unlike polio or smallpox, for example, there is no suggestion that inoculating the entire population will eliminate the disease. In fact, because of mutations and variable prevalence of different strains of flu virus, manufacturers have a hard time predicting which vaccines to produce for the upcoming season. And inoculation is no guarantee you won’t catch the flu, although symptoms should be milder. Overall, the evidence of benefit from vaccines is muddy.

Influenza, and the bacterial pneumonia that may develop following a flu virus infection, can be deadly. The elderly, particularly those with prior respiratory conditions are at particularly high risk. Infants, young children and those with compromised immune systems also have higher mortality risk than others. Unfortunately, most statistics lump the flu and pneumonia mortality rates together, and most flu infections are probably never confirmed by lab tests - patients either don’t go in to see a doctor, or their doctor makes a diagnosis based on clinical observation.

While some studies seem to show a clear benefit from vaccination, others refute those apparent outcomes. For instance, asthmatic children are generally urged to get vaccinated, but a 2005 study of 696 children (aged 6-18 years) that covered the two previous flu seasons “did not find a beneficial effect of vaccination on the number, duration or severity of influenza-related asthma exacerbations.” Studies which have seemed to show a particularly strong benefit from vaccination in the elderly have also been brought into doubt: recent work suggests those results were confounded by the “healthy user effect.” That is, the healthiest, and most health-conscious people were getting the vaccinations in the first place, and thus would be expected to have the least adverse effect from influenza or pneumonia. Perhaps there was benefit from the vaccinations, but not nearly to the degree originally suggested.

Rather than just argue pros and cons of individual studies, I thought it would be interesting to see if there has been a clear change in mortality since flu vaccinations came into more widespread use. This does not look all that convincing, either. A graph compiled from CDC data at www.healthsentinel.com charts the flu vaccination rate against combined mortality rates of flu and pneumonia. It shows no obvious correlation between increased vaccination and lower mortality. There was actually a large decline the mortality rate in the late 1960’s - mid 1970’s before vaccination was prevalent. A recent leveling off of mortality rates could be due to better supportive care or less virulent strains of influenza. In any case, the combined (flu and pneumonia) mortality rate in 2004 was similar to that in 1964, despite the initiation and fairly rapid adoption of vaccines.

Another concern is the possibility of the flu viruses becoming resistant to treatments. After a mild 2006-2007 flu season, the 2007-2008 season was tougher. The Centers for Disease Control and Prevention (CDC) reports that evidence of resistance to the anti-flu drug Tamiflu was observed during that period.

Nonetheless, the CDC maintains that “Annual influenza vaccination remains the best method for preventing influenza infection and its potentially severe complications.”  Nor has the CDC made any changes in their recommendations for the use of the Tamiflu class of drugs (neuraminidase inhibitors), although they have instituted closer surveillance of the drug-resistant influenza viruses. CDC has in fact expanded its recommendations for influenza vaccination. They now to include all children from six months through 18 years old, all people with increased risk for influenza complications, adults aged 50 and over, those with suppressed immune systems or other chronic conditions that might put them at higher risk for complications, and those who reside in nursing homes or chronic care facilities, or who will be pregnant during the flu season. They also recommend that people who share a home or come in close contact with those who are at higher risk for influenza infection also be vaccinated. Whew! Apparently 19-49 year old recluses in perfect health don’t need a shot.

So, what to do?  As a pharmaceutical minimalist I’m disinclined to recommend putting substances into one’s body without clear benefit. I also worry about the overuse of medications that can lead to drug resistant diseases. We are well down that path with resistant strains of bacteria, yet antibiotics are still commonly overprescribed. One of the justifications for inoculating nearly everybody for influenza is the increased chance of developing an antibiotic-resistant form of pneumonia when weakened by a flu infection. But by giving anti-viral drugs to healthy adults who would likely just have a few days of discomfort from the flu, are we insuring that influenza strains become increasingly drug resistant?

Personally, pending better information, I would be inclined to get an influenza vaccine if only I were in one of the higher-risk population groups. Meanwhile, everybody should be more careful about hand washing (one of the best ways to prevent the spread of disease in general) and covering their mouth when coughing or sneezing. Avoiding close contact with those who are infected is great if you can do it, but a significant number of carriers won’t show symptoms anyway, so that one is tougher to accomplish. And to keep your immune system at its peak, getting a good night sleep, eating well and exercising regularly can help significantly. Oh, and do I have to say it? Stop smoking!

Clinically I see Chinese herbal medications providing a lot of benefit, but mostly if they are used early and aggressively; even a half day procrastination can make a difference for the worse. Most people will only have a day or two of discomfort if they start herbs right away. For early stage cold or flu I like the over-the-counter formulas called Gan Mao Ling combined with Chuan Xin Lian (andrographis). As always, I would recommend caution (meaning consultation with a board certified herbalist and/or your medical doctor) if you are already taking medications or have complicating health issues.

I have found that acupuncture can be very helpful with the cravings experienced when trying to quit. The calming effect and increased lung function can be immediate. Chinese herbal medicine formulas can also help with the anxiousness and irritability that many people experience.

The treatments can be the difference between success and failure, but acupuncture is no substitute for motivation. If a person lacks a real desire to quit, acupuncture isn’t going to make them suddenly loose interest in cigarettes.  Also, those with a long history of addictive behavior may find acupuncture to be an important part of their treatment, but this will likely need supplementation with other kinds of care.

The core treatment I use is the stimulation of points in the ears, which is known as auriculotherapy. I prefer to use tiny needles, but micro-current or laser light can be used to stimulate the points as well. I may use additional points in other parts of the body, depending on my overall evaluation of the patient, but the points in the ears seem particularly effective for this purpose.

Auriculotherapy can be  prolonged by applying semi-permanent needles (they look like tiny stud earrings, but don’t go all the way through) or non-penetrating magnets to the points in the ears. This can be a real advantage and greatly increase the likelihood of success.

If I use the semi-permanent approach, I find I only need to treat a motivated smoker once or twice. Some acupuncturists offer a flexible series of treatments for  a fixed price. This can also be a good way to go - it ensures a patient can come in as needed during the critical first couple of weeks.

Nicotine is such an addictive substance, that any one treatment technique may not be enough. I dislike the idea of using nicotine patches or gum. However, using negative reinforcement and/or relaxation techniques can be a big help in altering the mental and social aspects of the addiction. Combined with acupuncture, they can be enough to help you make the fabulous change into a non-smoker.

In TCM, the herbs, as well as the diseases, are classified according to their various characteristics. As a simple example, a patient whose illness causes signs of heat and dryness (such as fever, sore throat, dry mouth and dark urine) might be treated with herbs that are considered cooling and moistening. The “cooling” effects of an herb may be understood by modern medicine to be the result of its anti-infective properties, but there is less focus on biochemistry in the traditional concepts.

An herbal prescription or formula in TCM commonly contains 10 or 12 different herbs. These would not be simply a bunch of herbs with similar properties. Instead, herbs are chosen to play a particular role within the formula. Each herb would have a specific purpose, such as treatment of the primary complaint, treatment of secondary complaints, moderation of other harsh ingredients, “guiding” the formula to affect specific parts of the body, or harmonizing the actions if dissimilar herbs. The formula is also developed with one of eight traditional treatment methods in mind. For example it might be designed to tonify, reduce, warm, or clear away heat.

The following case study reviews the successful treatment of a Blastocystis hominis infection with Chinese herbs. Traditional Chinese names are given for the herbs, using the standard pinyin transliterations.

Blastocystis hominis is a common microscopic parasitic organism (a single-cell protazoan) found throughout the world. Infection is common; many infected people are asymptomatic. Symptoms can include loose stools, diarrhea, abdominal cramping or pain, anal itching, weight loss, and flatulence. It can remain in the intestines for years, and is typically not treated if there are no symptoms. Infection rates are higher in developing areas, and in places with inadequate sanitation and poor personal hygiene.

Standard treatments include the antibiotic metronidazole (Flagyl), a combination of sulfamethoxazole and trimethoprim (e.g. Bactrim, Septra) and the antiprotozoal iodoquinol (e.g. Yodoxin). Response to medication for blastocystosis varies greatly, and symptoms may not improve, even with elimination of the parasite.

The patient in this case was a 51 year old female in overall good health, physically fit, with an athletic build. In the course of trying to discover the cause of her intermittent abdominal pain (particularly in the lower left quadrant) she was diagnosed with blastocystosis. She may have contracted the infection during a visit to India. As the patient was reluctant to take the course of Flagyl that was suggested by her medical doctor, she sought alternative treatment.

She was evaluated according to Traditional Chinese Medicine principles, but her positive diagnosis of B. hominis infection was also taken into consideration. A classic TCM herbal formula (Shao Yao Tang) was chosen as the basis of her prescription, but this was modified according to input from modern research. An important influence was the study In vitro response of Blastocystis hominis against traditional Chinese Medicine conducted by the Department of Parasitology, Shanghai University of Traditional Chinese Medicine, P.R.C.. In this study of 20 crude extracts of Chinese herbals, the extracts of Coptis chinensis [Huang Lian] and Brucea javanica [Ya Dan Zi] were found to be most active against B. hominis.

The patient was treated for one week with the following herbal formula. The quantities refer to grams of concentrated (5:1) powdered herbal extracts.

bai shao 14 g
dang gui 7 g
gan cao 7 g
haung lian 14 g
huang qin 7 g
da huang 3 g
mu xiang 4 g
zhi shi 3 g
rou gui 4 g
ya dan zi 14 g

Dosage was 3.5 g,  3 times daily  for one week. After one week, the patient reported improvement in the abdominal pain, but ongoing problems with constipation. The formula was modified slightly as follows:

bai shao 13 g
dang gui 6 g
gan cao 6 g
haung lian 13 g
huang qin 6 g
da huang 5 g
mu xiang 4 g
zhi shi 3 g
rou gui 3 g
ya dan zi 13 g
huo ma ren 5 g

Dosage for the second week was again 3.5 g, 3 times daily for one week.

About two weeks after completing the herbal treatment, the patient was retested and found completely clear of B. hominis. This concluded the successful treatment with Chinese herbs of a verifiable digestive tract infection. TCM is often noted for its usefulness against so-called functional diseases such as Irritable Bowel Syndrome, where there is no known organic cause of the dysfunction. This case offers an example of how effective Chinese herbal treatments can be against verifiable microbial infections as well.

Everyone knows coffee is evil, right? Drinking coffee is associated with groggy smokers, stained teeth and short life spans spent commuting to miserable jobs that require a dose of caffeine to get through. Well, perhaps. There has been a lot of interesting research about how coffee or caffeine (and they are not the same thing) affects our health. Despite concerns for certain people and conditions, the news is not all that bad. Since coffee remains the single most popular beverage in the world, that is good news.

Reviewing the evidence, a cautionary tale develops about how difficult it can be to construct a good study and interpret the results. Readers also need to remember that the information provided depends in part on who is delivering it, who is paying for it and what they want you to hear. Here are a few points to keep in mind:

• A study of caffeine is not the same as a study of coffee. This is a common problem with dietary studies: in an attempt to make the study more accurate, researchers might decide to isolate a single component from a food or beverage. The food itself, after all, will have variable quantities of that component. However, there can be very different results when consuming the whole food vs. an extracted part.

• A “cup” of coffee is typically assumed to be 6 oz. – not your 16 oz. travel mug!

• Caffeine levels are usually assumed to be about 100 mg per cup, but in fact vary significantly with the type of bean, brewing method, and even from batch to batch. Brewed coffee is estimated to range from 100-150 mg per cup, a similar volume of espresso having about 90 mg. Arabica beans have less caffeine than robusta beans.

Two health topics are commonly associated with coffee consumption – its effect on blood sugar and insulin resistance, and its effect on the adrenal glands. But there has also been considerable research on the consumption of coffee and the incidence of cancer,

Coffee and Diabetes Mellitus

When coffee drinkers over-indulge in sweets, many notice an immediate craving for coffee. The combination of coffee and dessert is common and traditional in many regions, as is the taking of bitter herbs (often in an alcoholic beverage) as a digestive aid. The desire to consume coffee together with sweet flavors could be due to coffee’s bitterness, but there may also be some beneficial effect on blood sugar levels that elicits a craving for coffee when blood sugar levels surge.

Some dieticians and researchers consider coffee detrimental to blood sugar levels because it (or the caffeine in it) stimulates the adrenal glands. This stimulation increases the production of hormones (adrenaline and glucagon) that cause the release of stored sugars into the blood. It is one of the ways a stimulant prepares the body for increased physical activity and higher energy demands.

There follows a supposition that sweetened coffee aggravates this effect by putting sugar into the blood, both via the digestive system and by releasing stored sugars through hormonal stimuli. When there is insufficient physical activity to consume the extra energy from the sugar, the pancreas responds by pumping out insulin. Insulin decreases sugar levels in the blood by driving it into the cells of the body – putting it back into storage. Physiologically, it’s like taking an “upper” and a “downer” at the same time, in a convoluted attempt to stay on an even keel.

There are concerns that the increased demand for insulin can lead to decreased sensitivity to it – as happens with Type 2 diabetes and metabolic syndrome. And there has been research indicating that caffeine (taken as an isolated drug) inhibits sugar metabolism.

However, a several studies in 2006 and 2004 indicate that coffee consumption is actually associated with a decreased incidence of Type 2 diabetes. Although any study has its weaknesses, these were conducted in different geographic areas, with different participants and different methodologies, and did their best to account for confounding factors such as obesity and smoking.

Coffee, Heart Health and the Adrenal Glands

The adrenal glands produce various hormones that are responsible for coordinating and monitoring a variety of physiological activities. These include cortisol, adrenaline, DHEA, estrogen and testosterone. There is concern that caffeine can cause the body to be flooded with excess adrenaline, resulting in an increased heart rate and higher blood pressure. Some authors even suggest that ongoing stimulation of the adrenal glands will eventually cause them “wear out.” Although there has been research into the stimulation caused by caffeine, an online search produced no study that addressed the “wearing out” theory.

A 2002 study from the Duke University Medical Center investigated the effects of moderate doses of caffeine on blood pressure and heart rate, urinary excretion of epinephrine, norepinephrine, and cortisol, and self-reported stress during normal activities. This study found that caffeine raised average blood pressure during the workday and evening by 4/3 mm Hg and increased average heart rate by 2 bpm. Caffeine also caused a 32% increase in the levels of epinephrine (a stimulating hormone). In addition, caffeine amplified the increases in blood pressure and heart rate associated with higher levels of stress from daily activities. These effects were undiminished through the evening until bedtime. An Australian study also found that while most data suggest very little excess risk of coronary heart disease among the general population of habitual coffee drinkers, the better controlled data suggest an excess risk on the order of 60% for people drinking five or more cups per day.

In another area of concern, a 2004 study linked moderate to high levels of coffee consumption to increased inflammatory markers. Inflammatory markers are important as predictors of coronary heart disease. Another study published in 2004 found that the combination of caffeine plus smoking cigarettes reduced the flexibility of the aorta more than either substance alone.

However, other work has suggested that response to coffee vs. isolated caffeine is minimal, particularly for habitual drinkers. In 2006, a study was reported in the April 24th Rapid Access issue of Circulation. The authors concluded that “coffee consumption was not associated with an increased risk of Coronary Heart Disease.” This study found that total cholesterol, low-density and high-density lipoprotein cholesterol levels in men and women coffee drinkers did not differ in those who drank caffeinated or decaffeinated coffee. CHD risk associated with drinking coffee did not differ in people with or without type 2 diabetes.

So are you off the hook? Er… not so fast. A 2006 study published in the Journal of the American Medical Association found that some people have a genetic mutation of the CYP1A2 enzyme that reduces the rate they metabolize caffeine. For those people, drinking four or more cups a day over for a year had a 64% increased risk of heart attack, compared to less than 1% increased risk for people without the gene mutation. Such genetic differences between participants in a study may explain why it has been hard to determine if there is a clear association between coffee consumption and heart attack risk.

Organ damage and cancer

This section will briefly list some research on coffee consumption and how it affects various organs and/or its association with different types of cancer.

• A study of cellular changes in the pancreas in 1986 found no changes due to coffee drinking. Most studies do not support an association between coffee consumption and pancreatic cancer.

• A study of gastric cancer conducted in Spain from 1987-1989 found no association with smoking, or with the consumption of coffee or tea.

• In a Polish study of stomach cancer published in 1999, no association was found with drinking regular coffee or herbal tea or using milk/cream in coffee or tea. (The findings did confirm an association with cigarette smoking, which is estimated to account for approximately 20% of stomach cancers.)

• A 2002 study published in the European Journal of Cancer Prevention found that coffee is associated only weakly or not at all with bladder cancer risk, inversely with colon cancer risk, and inconsistently with rectal cancer risk. Rectal cancer risk was not associated with either coffee or tea.

• A Harvard Medical School review of existing literature in 2002 found no convincing evidence has been presented to show that caffeine consumption increases the risk of any reproductive adversity in women.

• In 2002, an evaluation was conducted of several lifestyle factors influencing benign prostatic (prostate) enlargement and the severity of benign prostatic hyperplasia (BPH). There was a strong inverse association between alcohol intake and men treated surgically for BPH or in ‘watchful waiting’ for surgical intervention, but a positive correlation with coffee consumption. (That is, coffee seemed to make the conditions worse, alcohol was associated with improvements.) The authors concluded that “Given the opposite effects of coffee and moderate alcohol consumption, together with the increased risk for clinical BPH in men with coronary heart disease, coffee constituents, which increase the serum concentration of low-density lipoprotein cholesterol, may be involved in the pathophysiology of BPH.”

• The news is also not good for the urinary tract. A study in The Netherlands in 2002 concluded that, in accordance with earlier reviews, coffee consumption increases the risk of urinary tract cancer by approximately 20%. The consumption of tea seems not to be related to an increased risk of urinary tract cancer. There is also evidence that caffeine intake at a level equivalent to two or more cups of coffee daily produces increased calcium in the urine, which suggests a higher risk of kidney stones (a study that looked at coffee, rather than caffeine, consumption and calcium in the urine could not be found).

Coffee and Bone Mass

A 1991 study of 619 elderly men and women in Sweden concluded that coffee drinking was not a contributory independent risk factor for loss of bone mass and fractures.

Conclusions

There has been enough conflicting information and supposition published that individuals may be tempted to pick and choose data that supports the answer they were hoping for. Overall, it does seem that light to moderate coffee consumption (less than four 6 oz. cups a day) is not particularly bad for you. However, consumption should be limited for those particularly sensitive to caffeine (suggesting a reduced ability to metabolize it) and those concerned about urinary tract and/or prostrate health. As with so many things, moderation is definitely appropriate.

Also, there is little doubt that coffee/caffeine is addictive, and that’s never a good sign. Researchers at Johns Hopkins University in Baltimore found that as little as one cup of coffee a day can produce caffeine addiction. When you then try to do without it, you may suffer a range of withdrawal symptoms, including headache, fatigue and difficulty concentrating. Some may even feel as though they have the flu, with nausea and muscle pain. Simple caffeine withdrawal may explain much of the malaise associated with “cleansing diets.” To help reduce your coffee and/or caffeine intake it can be helpful to begin substituting decaffeinated versions (use products decaffeinated by the “Swiss” water method, which does not add chemicals to beans). Tea also seems to be less aggravating to the body’s systems, and has some benefits of its own; it may be worth switching over, and just saying goodbye to coffee.

Know the Risks
According to the American Academy of Dermatology, “Long-term overexposure can cause skin cancer, wrinkles, freckles, age spots, dilated blood vessels, and changes in the texture of the skin that make skin look older.” In fact, much of the visible signs of aging are the result of exposure to sunlight. Ultraviolet light has also been connected with cataracts and suppression of the immune system.

Skin cancer is the most common type of cancer in the United States. Although the mortality rates are relatively low, nearly 10,000 Americans die of skin cancer every year. Most of these are from the least common form, called melanoma. While different forms of skin cancer develop differently and have different risks, they do have one thing in common – the risks are greater with increased exposure to ultraviolet (UV) light, as from the sun and tanning beds.

Things aren’t getting better, despite the common use of sunscreens. According to the National Cancer Institute, it is not clear that using sunscreen reduces the risk of non-melanoma types of cancer, or that avoiding sunburns reduces the risk of melanoma. The incidence of skin cancer continues to rise each year. People with fair skin that tans poorly do seem to have a higher risk of developing any type of skin cancer, and those with many abnormal moles have an increased risk for melanoma. Twenty percent of Americans will develop some form of skin cancer. When diagnosed early, there is a nearly 100% chance of curing it, so have a doctor check out any unusual patches, bumps, scaly areas or moles that change shape, size or color.

Most of us get around 80% of our lifetime exposure to the sun by the time we’re 18. Adopting good habits about sun exposure and the use of sunscreen at an early age may result in significantly reduced incidence of skin cancer over a person’s lifetime. The Skin Cancer Foundation and the American Academy of Pediatrics recommend protecting kids from excessive sun exposure from an early age (but sunscreens should not be used on children under 6 months old).

Since dark-skinned people seem to be somewhat protected from the various kinds of sun damage, it is tempting to assume that staying tanned would give some protective benefit to those with fairer skin. So far, there does not seem to be evidence to support this. In fact, dermatologists consider a tan to be a form of skin damage.

Then again, there might be room for common sense and moderation. Some dermatologists and their professional organizations recommend avoiding sun and getting your vitamin D from a pill or “fortified foods” (generally foods which have had a lot of nutrition processed out of them, then had some chemical form of vitamins added back in). It’s hard to believe that hiding from the sun and taking supplements to replace normal physiological functions is a prescription for optimal health.

Sunscreens
Sunscreens may not be proven to be protective against skin cancer, but they can help prevent burns and reduce direct damage from UV radiation. (Possibly, sunscreens encourage additional exposure to UV rays, thus negating any protective effect from skin cancer.) To be effective, sunscreen should be applied at least a half hour before exposure, and reapplied every couple of hours, and after swimming or heavy perspiration.

The Sun Protection Factor or SPF rating of a sunscreen gives you an idea of the degree that UVB radiation is blocked out. An SPF rating of 15 means that, with the sunscreen, you’ll be protected for about 15 times longer than without it. For example, with an SPF 15 sunscreen it would take about 3 hours and 45 minutes to get the same amount of UVB exposure that you’d get in 15 minutes without it. A product with an SPF of 15 blocks 95% of the UVB rays. So, an SPF 30 does not block twice as much; it blocks about 98% of the UVB.

The shorter UVB rays are most responsible for causing sunburn. They are largely blocked by window glass (as well as by a good sunscreen). However, UVA rays also damage the skin, causing wrinkles and loss of elasticity. They are only partly blocked by window glass. There is no rating system for protection against UVA radiation. Choose a wide spectrum sunscreen that blocks both.

There are some concerns about the substances used in sunscreens. Most of the problems are related to skin irritation. Aminobenzoic acid and its esters (paba), oxybenzone and cinnamates can cause a rash or make your skin more sensitive to the sun. Fragrances, alcohol and preservatives can irritate the skin or eyes. The Environmental Working Group recommends avoiding sunscreens containing padimate-O and paba. Instead, use a product made with titanium dioxide or zinc oxide. These substances provide a physical, rather than chemical, radiation block. Unfortunately, both have been connected with environmental pollution related to their production.

To be any good, your sunscreen also has to stay on. Or, at least you have to re-apply frequently enough to get the rated benefit. These labeling guidelines have been recommended to give consumers an idea of a sunscreen’s ability to keep working:

• Sweat-resistant: protects up to 30 minutes of continuous heavy perspiration;
• Water-resistant: protects up to 40 minutes of continuous water exposure; and
• Waterproof: protects for up to 80 minutes of continuous water exposure.

Sunscreens are not to be used on children under six months old. That doesn’t instill a lot of confidence about their safety for adults, but there seems to be little evidence of serious side-effects from long term use in most of the population.

Prevention Guidelines
OK, so you’re going to get some fresh air or maybe play a little ball outside. It’s not a bad thing! Just be smart about it.

• Stop sunbathing and avoid other long baking sessions in the sun, especially between 10:00 a.m. and 2:00 p.m. when the rays are the strongest. Don’t count on the clouds to protect you – most of the UV light (60-80%) still comes through. Snow, sand and even concrete reflect up to 85% of UV radiation, so you can get more exposure than you bargained for on the beach or around the pool.
• Skip the tanning beds and sun lamps – they produce the same damaging rays as the sun, without any redeeming activity such as exercising or at least getting some fresh air.
• When you are out, minimize your exposure by seeking shade and covering up. Wear long sleeves and pants, and a broad brimmed hat. Even clothing does not give as much protection as you might think. A white cotton T-shirt has a SPF of only about 3. Tightly woven and darker clothes are the best. Unbleached cotton is a good material because it contains lignins, which do a good job of absorbing UV rays. Some clothing is made of specially treated cloth with protection factors over 40. It’s also possible to buy colorless dyes that you can launder into your own clothing, resulting in an SPF of about 30.
• Your sunscreen should have a minimum SPF of 15 and be applied 30 minutes before you go out. Reapply after swimming or heavy sweating, and every couple of hours, regardless.
• Be extra careful about sun exposure if you are taking antibiotics, tranquilizers or diuretics. Some of these make your skin more susceptible to sunburn. Check the package inserts or ask your pharmacist if you’re not sure of the precautions for the pharmaceuticals you are taking.
• Kids have other things on their minds, and teenagers feel invincible, so it’s our job to give them some guidance about sun protection. Sunscreens, however, are not considered safe for infants under 6 months old. Better to learn some good habits about using shade and protective clothing.
• Don’t forget to stay hydrated. If your activities have you worried about sun exposure, you’re probably loosing extra fluids, too.

If You Get Burned Anyway
There is no cure for sunburn, but there are some things you can do to ease the discomfort, and possibly speed the healing. Biomedical treatments include topical sprays like Solarcaine, and pain relievers such as aspirin and Advil. Here are some more natural treatments.

• A cool shower or bath will give some quick relief. Baking soda or chamomile can be added to the bathwater for a more soothing effect. Avoid warmer water as it strips away even more of the skin’s natural oils. It won’t feel good anyway!
• Similarly, cool milk compresses are quite soothing (use gauze or a soft cloth well-moistened with the milk). Use whole milk, as the milk fats contribute to the effect.
• Vinegar can be mixed half and half with water and applied as a compress or with a spray bottle. Vinegar is a traditional pain-relieving remedy – it’s good for sore throats and insect bites too. Avoid any broken skin and the eyes.
• After any of these treatments, it’s good to apply a moisturizing lotion or aloe vera gel. These may have some direct healing benefit, and act as a barrier that helps your skin stay hydrated.
• The Chinese herbal ointment Ching Wan Huang (also spelled Jing Wan Hong) can be used on mild to moderate burns. It helps relieve the pain, reduce inflammation and seems to speed healing of the tissues. It does have a pretty strong odor, and can stain clothes, but the relief it brings may be worth it.
• Honey is a traditional treatment for burns (and wounds) with an excellent history of success. It’s probably not very practical for treating a large area, though!

Remember when it didn’t take several manufacturing industries, a couple of government agencies and a watchdog group to prepare us for a walk? Well, perhaps it still doesn’t. But as our longevity increases, we’ll be wearing our skins longer, and the incidence of cancer will trend upward. This article may have armed you with some new information, but basic protection from the sun has been an age-old practice around the world. It has only been in recent times, and in industrialized countries, that a suntan has come to suggest wealth and leisure, rather than poverty and manual labor. Being more aware, you may find new respect for the power of the sun and traditional practices that moderated its effects. It’s not hard to develop habits that will allow you to work and play safely for years to come. So, go ahead and enjoy the summer – but don’t get burned!

Researchers found that people whose bodies produce relatively high levels of insulin in response to sugars lost more weight on a diet that was low in simple carbohydrates (a low-glycemic load diet). In the study, participants who produced more insulin lost almost five times as much on that type of diet, than on a low-fat regime. Those people also saw their body fat percentage decrease by 2 ½ times as much. By comparison, participants whose systems produced lower levels of insulin did about as well on either type of diet.

The study also looked at how the risk factors for heart disease were affected by the two different diets. Cholesterol and triglyceride counts were affected differently depending on which diet the participants followed. Unlike for weight loss, however, the amount of insulin produced by a person did not significantly affect the results in this area.

Rather than giving the dieters strictly controlled meals, the researchers relied on counseling and dietary guidance to help them chose the appropriate types and amounts of foods. This made the study particularly interesting, as it better replicated what a do-it-yourself dieter could expect to achieve. The study participants attended group workshops, and also received a private counseling session and 5 motivational telephone calls. These were more heavily concentrated near the beginning of the trial, which extended over a 6-month “intensive intervention period” and a 12-month follow-up.

The diet programs relied on the idea that they would make the participants feel more satisfied or satiated, and decrease their hunger. The presumptions were that the low-glycemic load diet would provide energy in an easily usable form, and the low-fat diet would provide foods that were filling and satisfying, but with more bulk and fewer calories. There was no calorie counting requirement, and the dieters were not told to go after specific nutritional targets. Instead, they were counseled on hunger and satiety cues, and told to “Eat when you are hungry, before you become famished. Stop eating when you are satisfied, before you become stuffed.” Physical exercise guidelines were also given based on common public health standards.

The low-fat diets in this study consisted of about 55% carbohydrates and 20% fats, while the low-glycemic load diet aimed for about 40% carbohydrates and 35% fats. Those on the low-fat program were told they should eat low-fat grains, vegetables, fruits, and legumes and to limit their consumption of added fats, sweets, and high-fat snacks. They were given lists of foods separated into high, medium and low fat categories, along with information and cooking demonstrations to help them prepare lower fat meals and use appropriate portions of higher fat foods.

The low-glycemic load group was advised to choose foods such as non-starchy vegetables, legumes, and temperate fruits, while avoiding high-glycemic load foods like refined grains, starchy vegetables, fruit juices, and sweets. Participants were also given guidance on selecting healthier fats, such as nuts, seeds and appropriate vegetable oils. As did the low-fat group, they received food choice lists, counseling and cooking demonstrations to encourage suitable choices and avoidance of inappropriate foods.

Overall, the final results showed that both diets were equally good for weight loss and reducing the percentage of body fat. The differences showed up only when looking at the amount of insulin a person produces in response to sugar consumption. When this was taken into consideration, those with higher than average insulin production did significantly better on the low-glycemic load diet. Such a diet, with fewer sugars, does not trigger as much insulin production.

When cardiovascular disease risk factors were checked, the amount of insulin produced did not make a significant difference. For both high and low insulin producers, those following the low-glycemic load diet had the most improvement in their HDL (high-density lipoprotein cholesterol) and triglyceride counts. On the other hand, those following the low-fat diet had the most improvement in their LDL (low density cholesterol). This is consistent with the results of other studies.

The researchers believe that the reduced levels of saturated fat in the low-fat diets could have been responsible for their better results with LDL. They speculate that if people on a low-glycemic load diet were careful about their saturated fat consumption, they would see bigger drops in their LDL concentrations, thus improving all three risk factors. In fact, another recent study found that women on a low-glycemic load diet that was high in vegetable fat and protein did reduce their risk of coronary heart disease.

So, how do you know if your body produces an above-average level of insulin? You could have a test done. For the study, insulin levels were checked 30 minutes after taking the standard 75g of oral glucose. But there may be no real advantage to having those results. If your insulin production is low to average, you will lose weight about as well on either diet. Meanwhile, the low-glycemic load diet seems to have the edge for improving cardiovascular health (provided you limit consumption of saturated fats) regardless of your insulin production. So being careful with sugar and starch intake will lead to better health for most people, with the bonus of faster weight loss for those who happen to produce higher levels of insulin.

CCCs aim to provide convenient, affordable care for a limited range of common ailments, such as colds or flu, minor burns or rashes, sprains, headache, ear infections, allergies and urinary tract infections. They also provide preventative care, including physicals, immunizations, and health screens. Besides the convenience of location, CCCs try to keep waiting times mercifully short and prices low. Treatment at one of these clinics costs from $40-70, plus any tests or immunizations. That can be half the price of a visit to the family doctor, and one-sixth the cost of going to an emergency room. Many insurance plans, as well as Medicare, will accept charges from a CCC, so that patients need only come up with their co-pay.

Costs are kept down in part by offering a streamlined menu of services, which in turn allows them to employ practitioners with less training (and lower salaries) than physicians. Most CCCs are staffed by Nurse Practitioners (NPs) or Physician Assistants (PAs). You may have noticed more of these around in traditional clinics and hospitals as well. An NP is a registered nurse who has advanced training and education (usually a master’s or doctoral degree in nursing), and is thus able to provide a broader range of health services. PAs are licensed to practice medicine under the supervision of a physician (who does not necessarily have to be on site). They typically have a bachelor’s degree in medicine. These health professionals are trained to deal with many ordinary health issues, and to refer to others with more advanced training when appropriate. They can diagnose and prescribe medications within the limits of their scope of practice. Patients seem to be pleased with the quality of service provided by these health care professionals.

If the expansion plans of the CCC chains are anything to go by, the clinics are a hit. The American College of Nurse Practitioners has registered its support of the convenient care industry. In fact, it seems remarkable that the pent-up demand for basic health services has not burst over the dam of limited availability before. But unsurprisingly, not everyone is pleased with the trend. Opposition to the CCCs is based on the possibility that their patients will receive lower quality care, or that the services rendered will not be integrated with the rest of the health care system (CCC patients are given a copy of their records when their visit is completed so that it is available to other providers). There is also concern that NPs are not qualified to work without direct supervision by a physician. The American Academy of Family Physicians, American Medical Association and American Academy of Pediatrics, are lobbying for increased regulation of the industry.

This is a common tactic of physician supported organizations to limit non-physician treatment options. Perhaps with enough regulation, CCCs can be made as inefficient and expensive as the physician-run clinics they are competing with. Clinicians need to have enough knowledge and training to know when referral to a more specialized expert is appropriate. One concern is that a less knowledgeable practitioner will miss a clue about a serious underlying disease. But that is true at any level in the medical field. Do we really need a physician with 6 years of training to treat an acute sprain? Does waiting several days to see the family doctor for a sore throat constitute quality care? When basic healthcare is provided more efficiently, the lower costs make it available to a wider range of patients, and can reduce insurance claims – the processing of which leads to even higher treatment costs.

Healthcare Economist author Jason Shafrin writes that “Many studies have claimed that Nurse Practitioners (NPs)–as well as Physician Assistants (PAs)–are adequate substitutes for primary care physicians. Researchers claim that NPs can perform a great majority of the tasks currently carried out by primary care physicians, and should be used more frequently since NP and PA salaries are usually half of primary care physicians.”

Despite the concerns of the traditional medical and insurance industries, it appears that CCCs do not increase the overall demand for services. Instead, they make appropriate care more easily available to more people at more affordable prices. This has been the model followed by chiropractors, acupuncturists, physical therapists and other independent health care professionals for years. There are shortages of family practitioners in America, especially in rural areas. Apparently, family practice holds little allure anymore for medical school graduates, compared to more prestigious and better paying specialties. So be it. But it is time then, to let other willing and qualified practitioners address the common health needs of patients in a way that is accessible and affordable.

Back pain that leads to surgery is often associated with a damaged intervertebral disc or spinal stenosis. The discs are the tough, flat cushions between the vertebrae. Imagine a disc as the warm toasted marshmallow sandwiched between two graham crackers in a s’more. If the crackers are pressed together evenly, the marshmallow will spread out evenly as well. If you squeeze just one side of the sandwich together, the marshmallow (or disc) will ooze out to the opposite side. That’s what happens with a “slipped” disc. The protruding part can irritate a nearby nerve. If it ruptures, there can be chemical irritation of the nerve as well. The discs also tend to degenerate, flatten and become less resilient over the years, so there is less space for the nerves where they come out of the spinal column.

Sciatica is an irritation of the sciatic nerve. It can cause radiating pain, burning sensations or cramping in the buttocks and down the leg. This may be caused by a nerve root problem in the lower part of the spine, but it can also be caused by impingement further down in the area of the buttocks. The piriformis muscle runs across the back of each hip joint, deep in the buttock, where it crosses paths with the sciatic nerve. Pressure from an overly tight piriformis muscle is believed to irritate the sciatic nerve causing buttock and/or radiating leg pain. This is known as piriformis syndrome. It can be addressed by releasing excess tension and any “trigger points” (knotted areas) in the piriformis and associated muscle groups.

Stenosis is a narrowing of the spinal canal that leads to compression of the enclosed spinal cord and nerves. Fractures of the spine can also result in unstable vertebral joints and irritation to the spinal nerves.

Treatment Options
Common surgical procedures for these conditions include discectomy, laminectomy, and fusion. In a discectomy, the part of the disc that is stressing the spinal cord or a nerve is removed. Removing or trimming part of the bony structure around the spinal cord (the lamina) is called a laminectomy. This may be done to widen the spinal canal when it has been restricted by stenosis, or to provide access for a discectomy. Spinal fusion fixes vertebrae together using bone grafts and screws or other hardware to prevent any movement between them.

Determining when surgery is appropriate is not always easy. Most incidents of back pain resolve themselves over several weeks. Even cases of severe chronic back pain or sciatica may respond very well to more conservative treatments. Individuals with substantial disc degeneration and/or stenosis can return to an active pain-free life without surgery. Surgeons may have a skewed perspective because their patients who are diagnosed as needing surgery, but who go on to rehabilitate themselves through non-surgical means, are unlikely to report back to the surgeon.

Even when there is clear disc impingement upon a nerve, non-surgical remedies are possible. Experiments have shown that a healthy nerve root (where the nerve exits the spinal cord) can withstand substantial pressure without pain or paresthesia (tingling or burning). When a nerve root is injured, pressure on it can cause loss of feeling, reduced reflexes and eventually reduced strength and motor reflex. However, when a nerve root has a poor blood supply (ischemia), it becomes very sensitive to pressure. So, a healthy nerve root with a good blood supply can tolerate a fair amount of mechanical abuse. But once it has become irritated, swollen, inflamed or otherwise suffered decreased blood flow, it will be much more easily irritated. Therapy should therefore be aimed at reducing mechanical irritation, reducing inflammation, and improving blood perfusion.

“Conservative treatment” is a term that can be applied to anything from pain pills and bed rest to much more aggressive therapy that involves substantial patient participation. The latter requires more commitment but is likely to give better results. The patient can also learn some useful self-care techniques during treatment. Analgesics, muscle-relaxers and anti-inflammatory drugs (or herbal formulas) may also have their place in the therapy.

Seeing the Bigger Picture
The muscular, skeletal, neural, vascular and lymph systems of the body all affect one another. A good treatment plan works toward optimizing all of them. When there is pain, as from nerve impingement, a common protective reaction of the body is to tighten up and stabilize the area. Unfortunately, this tightening can exacerbate the problem by putting more pressure on the damaged structures. Also, chronic spasm of the muscles leads to decreased blood infusion (ischemia) and poor lymph movement. The muscles become poorly nourished, and the tissues are not properly cleansed of cellular waste products. A large component of patient’s pain can be from this muscular dysfunction, rather than from the direct nerve impingement itself.

Tight muscles, especially when their forces are not well balanced, are intimately involved with skeletal joint dysfunction. The skeletal system, after all, is aligned and controlled by the soft tissues around it (with limits set by the bony structures themselves and by the ligaments that surround the joints). When muscular action on one side of the spine is stronger and tighter than the other, it can significantly change the alignment between the vertebrae, and inhibit the natural smooth gliding at the joint surfaces. Besides nerve irritation (remember that squeezed marshmallow), this can accelerate arthritic changes in the joints.

Nerves are responsible not only for sending pain signals back to the brain, but also for sending motor control signals out to the muscles. Therapy should address the neural components of the problem. Neuromuscular reeducation refers to therapy that aims at normalizing the interaction between muscles and their nerve signals.

Many types of non-surgical therapies are available, and each has its strengths. Chiropractic adjustments can restore normal joint function, and thus release tension and inflammation in surrounding soft tissues. Unfortunately, some people do not respond well to this high-velocity approach, and normal muscular function often does not follow. Skilled massage, physical therapy, yoga, stretching, strengthening and other manual therapies can address the muscular components. Functional and postural habits that exacerbate the condition may need to be relearned. Acupuncture works via several pathways: it can release and balance muscle tensions, moderate nerve signals, decrease inflammation and increase local blood flow to the tissues.

The Benefits of Avoiding Surgery
Results from conservative therapy can be dramatic, but it typically takes weeks or months to effect lasting changes, and a combination of techniques may be needed. The reward for this effort is a reduction or elimination of pain, a better functioning body and more information about how to keep it that way, not to mention the avoidance of surgery, anesthesia, and post-surgical rehabilitation. This can save tens of thousands of dollars, and greatly decreases one’s exposure to pharmaceuticals. Even with a course of anti-inflammatory drugs, a patient will be subjected to a much lower pharmaceutical load that when undergoing surgery.

Besides, surgery often fails. The U.S. Agency for Healthcare Research and Quality states that “Patients considering lumbar spine surgery should be informed that the likelihood of having another spine operation later is substantial.” A study of 24,882 adults who had low back surgery for degenerative spinal problems in the early 1990’s found that about one out of five had another back surgery within 11 years. That’s about double the rate for hip or knee replacement. And one should not assume that the rest were living pain free.

Is Good Medicine Driving High Back Surgery Rates?
A study by the University of Washington’s Center for Cost and Outcomes Research looked at spinal surgeries in the U.S. and confirmed some disturbing trends. In 2001, approximately 122,000 lumbar fusions were performed, representing a 220% increase from 1990. Were those surgeries more successful than in the past? It seems not. Reoperation rates actually increased during the 1990’s, with a cumulative rate of about 12% just three years after the initial surgery.

The Department of Health Services at the University of Washington has noted that there are large variations in back surgery rates across different parts of the country. The Department also found that “The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country.” That sounds more like supply-side economics than evidence-based medicine.

Meanwhile, the New England Journal of Medicine has published a new study of 283 patients with severe sciatica. The participants were randomly selected to have surgery early on, or to have extended conservative treatment and undergo surgery at a later time, if needed. Only 39% of this second group actually ended up having surgery. After one year, the outcomes were similar for those with early surgery and the conservatively treated group, although those receiving early surgery had somewhat faster pain relief and self-perceived recovery rates.

The decision to have surgery for back pain or sciatica due to degenerative conditions will usually be left to the patient. Trauma resulting in fractures, cancer, and other conditions causing back pain may permit fewer options. But for patients who are willing to participate in their own recovery, conservative treatment holds a lot of promise with very low risk. Surgery, after all, will remain an option. They may need to be more proactive in seeking out treatment. Learning stretches and other exercises from a skilled therapist will give them some control over their recovery. A willingness to try appropriate therapies and actively engage in the treatment process can lead to much greater success than simpler treatments involving only rest and drugs. Those who choose such a treatment plan may well be rewarded with a strong, pain-free body, and new knowledge that can help keep it that way.