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BODY COMPOSITION AND NUTRITION

SECTION VI
BODY COMPOSITION AND NUTRITION


Your weight and/or body fat was measured during your medical exam. Take a look at the weight allowed for your height as shown in Table 1. If you exceed the weight listed for your height, you may not be over fat. Some well-muscled individuals have body weights that far exceed the values for weight listed on the charts for their age, gender, and height. Yet, only a small percentage of their total body mass may be fat.


This standardized PT program meets the requirement to be physically active everyday. However, you will still need to make changes to your diet to so that you can report to IMT at an appropriate body composition. Losing one to two pounds per week is a realistic goal, which is best accomplished by a combination of eating less and exercising regularly.





Table 1. Screening table weight. Reproduced from AR 600-9, table 1.


People always want to know if a particular food is good or bad for them. No single food choice is necessarily a bad choice. Too many bad choices over time can accumulate into a poor diet. Poor
choices like a lunch of soda, chips, and a hamburger once in a while will be balanced out by a better choice like a turkey sandwich with low-fat dressing on whole wheat bread and fruit on a regular basis. Eating for performance and health doesn’t mean that you have to give up all of your favorite foods.


Build a healthy base by eating a variety of foods. Different foods contain different nutrients and other healthful substances. No single food can supply all the nutrients in the amounts you need. To make sure you get all the nutrients and other substances you need for health, build a healthy base by using the Food Guide Pyramid as a starting point. Choose the recommended number of daily servings from each of the five major food groups.


Breads, Cereals, Rice, and Pasta Group: Foods made from grains (wheat, rice, and oats) should form the foundation of a nutritious diet. They provide vitamins, minerals, carbohydrates



(starch and dietary fiber), and other substances that are important for good health. Grain products are low in fat, unless fat is added in processing, in preparation, or at the table. Whole grains differ from refined grains in the amount of fiber and nutrients they provide, and different whole grain foods differ in nutrient content, so choose a variety of whole and enriched grains. Eating plenty of whole grains, such as whole wheat bread or oatmeal may help protect you against many chronic diseases. You should consume at least 6-11 servings daily from the base of the pyramid.





Consuming the recommended daily intake is not difficult if you understand serving sizes. A ½ cup of cooked rice, cereal, or pasta is about the same size as your fist. The best choices from this food group are bran cereals, oat bran, low fat bagels (pumpernickel, rye, whole wheat), whole grain muffins (bran, corn and oat bran), whole grain breads and rice, and stoned wheat and whole grain crackers.


Vegetable Group: The vegetable group is one area where many people regularly fail to consume enough. Vegetables are nature’s vitamins. To ensure that you get essential vitamins and minerals, you should strive for 3-5 servings per day from this group. A serving size of raw or cooked vegetables is only ½ cup, and most people eat more. One cup of leafy raw vegetables is also a serving size, which is much smaller than the regular salad served with a restaurant dinner. A ½ cup of vegetables is about the size of a tennis ball. To maximize the vitamin and mineral content of your vegetables, don’t overcook. Cook in a microwave, steamer, or wok only until tender crisp. The lighter colored vegetables, such as cucumbers, iceberg lettuce, and celery are mostly fiber and water with very little calories, vitamins, or minerals. Choose dark green, orange, and yellow vegetables. The darker the vegetable, the more likely it is to have large amounts of vitamins and minerals. A variety of different vegetables should be consumed to ensure that you receive a variety of nutrients. Broccoli, spinach, green peppers, tomatoes, cauliflower, Brussels sprouts, collards, carrots, or winter squash are the best choices. A ¾ cup of vegetable juice also constitutes a serving from this group.


Fruit Group: The fruit group, in addition to providing vitamins and minerals, also provides fiber. Two to four servings of fruits are recommended each day. Breakfast is a good opportunity to eat some fruit. Drinking a glass of fruit juice for breakfast is a convenient way to get half of the minimum daily servings. Other good choices are citrus fruits, bananas, cantaloupe, kiwi, strawberries, and dried fruit. A serving size for the fruit group is one piece of medium sized fruit or melon wedge, or a ½ cup of chopped, canned, or cooked fruit. A ½ cup of fruit is about the same size as a tennis ball. If you choose fruit juice, make sure that it is not mostly sugar and contains a good amount of vitamins and minerals. A ¾ cup of fruit juice equals one serving. Juice that you can see through (apple, grape, or cranberry juice) usually contains more processed sugar than one that you cannot see through (orange juice, peach nectar, or prune juice).


Milk, Yogurt, and Cheese Group: These dairy products are a great source of protein, vitamins, and minerals (fortified by law) especially calcium and riboflavin. The milk group, however, can also contain a large amount of fat. Many no-fat or low-fat dairy products are available, including cheese, milk, sour cream, and yogurt. Top choices are 1% or skim milk, low-fat cheese, and yogurt. The recommended number of servings per day for this group is 2-3, and is easily attainable for most soldiers. One cup of milk or yogurt, a ½ cup of natural cheese (Cheddar or Swiss), or 2 ounces of processed cheese (American) is considered a serving size. 1 ounce of cheese is about the size of four dice.


Meat, Poultry, Fish, Dry Beans, Eggs, and Nuts Group: The Meat and Beans Group is very important for obtaining protein, vitamins, and minerals. Like the milk group, this group can contain large amounts of fat as well. Quick and easy choices include canned tuna, chicken, peanut butter, lentil soup, and beans. Two to three servings from this group are required each day. Most people are at one extreme or the other by consuming too much or not enough from this group. The serving sizes typically consumed greatly exceed the nutritional requirement. For example, a typical chicken breast (8 oz) equals 2 servings (and about 50 grams of protein) while the 16-ounce steak at your favorite restaurant equals 4 servings (and about 120 grams of protein) from this group. A serving size of cooked fish, poultry, or red meat is 2 to 3 ounces (the size of a regular deck of playing cards), a ½ cup of cooked dry beans, a 2 ½ ounce soyburger, 1 egg, 2 tablespoons of peanut butter, or 1/3 cup of nuts.


Fats, Oils, and Sweets Group: At the top of the food pyramid are the items that should be eaten in moderation. However, it does not mean that you should never eat these items. Most fats and sugars are nutrient poor. Foods from this group should be chosen in moderation because they often replace nutrient dense foods, so you may not get your daily requirement for the essential nutrients. For this reason, they are referred to as “empty” calories. This means that they provide nothing to the body except calories; no vitamins, minerals, fiber, water, or protein. Foods from this group are still an important part of a performance diet. Sweets add taste and flavor, while fat provides essential fatty acids like linoleic acid (part of every cell membrane), which can’t be made by the body. A better food preparation choice is baking, roasting, or grilling, however, frying food in fat (cooking oil) once in a while is all right. Top choices from this group include olive oil, walnuts, molasses, berry jams, or a favorite dessert. There are no suggested servings for the top of the pyramid because you always have plenty of opportunity to add these to their diet without even trying.


Choose natural or less processed foods whenever possible. An apple is a better choice than applesauce, which is a better choice than apple juice, which is a better choice than apple pie. A baked potato is a better choice than mashed potatoes, which is a better choice than potato chips. Whole grain (wheat) bread is usually a better choice nutritionally than white bread. Food processing tends to remove vitamins, minerals, and fiber and add undesirable or questionable additives.


Your pattern of eating is also important. Snacks and meals eaten away from home provide a large part of daily calories for many people. Choose them wisely. Try fruits, vegetables, whole grain foods, or a cup of low-fat milk or yogurt for a snack. When eating out, choose small portions of foods. If you choose fish, poultry, or lean meat, ask that it be grilled rather than fried. Also, notice that many of the meals and snacks you eat contain items from several food groups. For example, a sandwich may provide bread from the grains group, turkey from the meat and beans group, and cheese from the milk group.


CHOOSE SENSIBLY


The carbohydrates, fats, and proteins in food supply energy, which is measured in calories. High-fat foods contain more calories than the same amount of other foods, so they can make it difficult for you to avoid excess calories. However, low fat doesn't always mean low calorie. Sometimes extra sugars are added to low-fat muffins or desserts, for example, and they may be just as high in calories.


Fats supply energy and essential fatty acids, and they help absorb the fat-soluble vitamins A, D, E, and K, and carotenoids. You need some fat in the food you eat, but choose sensibly. Some


kinds of fat, especially saturated fats, increase the risk for coronary heart disease by raising the blood cholesterol. In contrast, unsaturated fats (found mainly in vegetable oils) do not increase blood cholesterol. Fat intake in the United States as a proportion of total calories is lower than it was many years ago, but most people still eat too much saturated fat. Eating lots of fat of any type can provide excess calories. The Nutrition Facts Label will state the number of grams of fat and sugar as well as protein, fiber, and sodium.


Saturated Fats: Foods high in saturated fats tend to raise blood cholesterol. These foods include high-fat dairy products (like cheese, whole milk, cream, butter, and regular ice cream), fatty fresh and processed meats, the skin and fat of poultry, lard, palm oil, and coconut oil. Keep your intake of these foods low.


Dietary Cholesterol: Foods that are high in cholesterol also tend to raise blood cholesterol. These foods include liver and other organ meats, egg yolks, and dairy fats.


Trans Fatty Acids: Foods high in trans fatty acids tend to raise blood cholesterol. These foods include those high in partially hydrogenated vegetable oils, such as many hard margarines and shortenings. Foods with a high amount of these ingredients include some commercially fried foods and some bakery goods.


Unsaturated Fats: Unsaturated fats (oils) do not raise blood cholesterol. Unsaturated fats occur in vegetable oils, most nuts, olives, avocados, and fatty fish like salmon. Unsaturated oils include both monounsaturated fats and polyunsaturated fats. Olive, canola, sunflower, and peanut oils are some of the oils high in monounsaturated fats. Vegetable oils such as soybean oil, corn oil, and cottonseed oil and many kinds of nuts are good sources of polyunsaturated fats. Some fish, such as salmon, tuna, and mackerel, contain omega-3 fatty acids that are being studied to determine if they offer protection against heart disease. Use moderate amounts of food high in unsaturated fats, taking care to avoid excess calories.


Following the tips listed below will help you keep your intake of saturated fat at less than 10 percent of your total calories:


Fats and Oils


· Choose vegetable oils rather than solid fats (meat and dairy fats, shortening).


· If you need fewer calories, decrease the amount of fat you use in cooking and at the table.


Meat, Poultry, Fish, Shellfish, Eggs, Beans, and Nuts


· Choose 2 to 3 servings of fish, shellfish, lean poultry, other lean meats, beans, or nuts daily. Trim fat from meat and take skin off poultry. Choose dry beans, peas, or lentils often.


· Limit your intake of high-fat processed meats such as bacon, sausages, salami, bologna, and other lunch meats. Try the lower fat varieties (check the Nutrition Facts Label).


· Limit your intake of liver and other organ meats.


· Use egg yolks and whole eggs in moderation. Use egg whites and egg substitutes freely when cooking since they contain no cholesterol and little or no fat.


Dairy Products


· Choose fat-free or low-fat milk, fat-free or low-fat yogurt, and low-fat cheese. Try switching from whole to fat-free or low-fat milk. This decreases the saturated fat and calories but keeps all other nutrients the same.


Prepared Foods


· Check the Nutrition Facts Label to see how much saturated fat and cholesterol are in a serving of prepared food. Choose foods lower in saturated fat and cholesterol.


Foods at Restaurants or Other Eating Establishments


· Choose fish or lean meats as suggested above. Limit ground meat and fatty processed meats, marbled steaks, and cheese.


· Limit your intake of foods with creamy sauces, and add little or no butter to your food.


· Choose fruits as desserts.


CHOOSE BEVERAGES AND FOODS THAT MODERATE YOUR INTAKE OF SUGARS


Sugars are carbohydrates and a source of energy (calories). Dietary carbohydrates also include the complex carbohydrates starch and dietary fiber. During digestion all carbohydrates except fiber break down into sugars. Sugars and starches occur naturally in many foods that also supply other nutrients. Examples of these foods include milk, fruits, some vegetables, breads, cereals, and grains.


Added sugars


Added sugars are sugars and syrups added to foods in processing or preparation, not the naturally occurring sugars in foods like fruit or milk. The body cannot tell the difference between naturally occurring and added sugars because they are identical chemically. Foods containing added sugars provide calories, but may have few vitamins and minerals. In the United States, the number one source of added sugars is non-diet soft drinks. Sweets and candies, cakes and cookies, and fruit drinks are also major sources of added sugars. Intake of a lot of foods high in added sugars, like soft drinks, is of concern. Consuming excess calories from these foods may contribute to weight gain or lower consumption of more nutritious foods. Some foods with added sugars, like chocolate milk, presweetened cereals, and sweetened canned fruits, also are high in vitamins and minerals. These foods may provide extra calories along with the nutrients and are fine if you need the extra calories.


Choose and prepare foods with less salt.


You may be able to reduce your chances of developing high blood pressure by consuming less salt. There is no way to tell who might develop high blood pressure from eating too much salt. However, consuming less salt or sodium is not harmful and can be recommended for the healthy, normal person. At present, the firmest link between salt intake and health relates to blood pressure. High salt intake also increases the amount of calcium excreted in the urine. Eating less salt may decrease the loss of calcium from bone. Loss of too much calcium from bone increases the risk of osteoporosis and bone fractures. Salt is found mainly in processed and prepared foods. Salt (sodium chloride) is the main source of sodium in foods. Only small amounts of salt occur naturally in foods. Most of the salt you eat comes from foods that have salt added during food processing or during preparation in a restaurant or at home. Some recipes include table salt or a salty broth or sauce, and some cooking styles call for adding a very salty seasoning such as soy sauce. Not all foods with added salt taste salty. Some people add salt or a salty seasoning to their food at the table. Your preference for salt may decrease if you gradually add smaller amounts of salt or salty seasonings to your food over a period of time.


IF YOU DRINK ALCOHOLIC BEVERAGES, DO SO IN MODERATION


Alcoholic beverages supply calories, but few nutrients. Alcoholic beverages are harmful when consumed in excess, and some people should not drink at all. Excess alcohol alters judgment and can lead to dependency and a great many other serious health problems. Taking more than one drink per day for women or two drinks per day for men can raise the risk for motor vehicle crashes, other injuries, high blood pressure, stroke, violence, suicide, and certain types of cancer. Even one drink per day can slightly raise the risk of breast cancer. Alcohol consumption during pregnancy increases risk of birth defects. Too much alcohol may cause social and psychological problems, cirrhosis of the liver, inflammation of the pancreas, and damage to the brain and heart. Heavy drinkers also are at risk of malnutrition because alcohol contains calories that may substitute for those in nutritious foods. If you choose to drink alcoholic beverages, you should consume them only in moderation and with meals to slow alcohol absorption.


Use of dietary supplements


Food supplementation is a multimillion-dollar business. There are thousands of supplements on the market, most of which are easily accessible. Supplements were traditionally defined as any product made of one or more of the essential nutrients such as vitamins or protein. That definition has to been broadened to include any product intended for ingestion as a supplement to the diet. Supplements include vitamins, minerals, herbs, amino acids, botanicals, as well as concentrates, metabolites, constituents, and extracts of these substances. Supplement product labels must include the words “dietary supplement”. Most products that meet this definition are not strictly regulated and are therefore not subject to any tight standards on ingredients or claims. Your primary goal should be to always strive to obtain the nutrients you need from the foods in your diet. Eating a variety of foods on a regular basis is the most important step toward this goal. Supplement powders and bars can be a convenient and portable method for busy people to ensure they are consuming adequate supplies of the essential nutrients. Variety is still important because bars and powders are not always low fat, inexpensive, or easily digested by all. Supplementation should be part of a larger plan for an optimal performance diet not a replacement for poor habits and choices. Nor are supplements a substitute for regular exercise.


There is no one magic pill or powder that you can take that will make you stronger, skinnier, or give you more energy. Information is key. If a product makes claims that sound too good to be true, the claims probably are too good to be true.


Additional benefits from CR training activities are the net caloric expenditure that impacts individual weight loss goals as a subset of the standardized physical training program. Each standardized physical training session expends approximately 300-400 kilocalories per session. Intensity and duration of exercise determine the total caloric expenditure during a training session, and are inversely related. For example, similar improvements in cardio-respiratory endurance may be achieved by a lower intensity longer duration regimen as with a higher intensity shorter duration program. However, the risk of overuse injury to the lower extremities is significantly higher in the former as opposed to the latter.
Healing Foods Pyramid

The University of Michigan Integrative Medicine’s Healing Foods Pyramid was conceived by Monica Myklebust, MD, and Jenna Wunder, MPH, RD, in their passion for food in all of its beauty, variety, and healing benefits. The foods we choose to eat are essential to how we care for ourselves. In choosing the healing foods on this pyramid, each one of us contributes to our own health.


Click on the categories in the pyramid to access highlights for each food group


Healing Foods Pyramid


We emphasize:


* Healing Foods
o Only foods known to have healing benefits or essential nutrients are included

* Plant-based choices
o Plant foods create the base and may be accented by animal foods

* Variety & balance
o Balance and variety of color, nutrients, and portion size celebrate abundance

* Support of a healthful environment
o Our food, and we in turn, reflect the health of our earth

* Mindful eating
o Truly savor, enjoy and focus on what you are eating




The pyramid shape was chosen due to its general familiarity. However, with the complexity of nutrition choices and concepts today, no two-dimensional model can fully convey all considerations. The categories and their placement on the pyramid generally support our intent, which is to emphasize the foundational role of Water, followed by the importance of a rainbow of Fruits and Vegetables. Grains emphasize whole grains and includes some starchy vegetables that act like grains in the body. Legumes are excellent sources of non-animal protein in this plant-based pyramid. Healthy Fats emphasizes monounsaturated oils and nuts. Eggs offer high quality protein and Dairy includes foods low in fat yet rich in calcium. Lean Meats complement other foods rather than playing the starring role. In Fish & Seafood, fish high in omega-3 fatty acids is emphasized. Seasonings include herbs, onions, garlic, pepper, salt and others that add flavor while contributing healing benefits. Dark Chocolate is a source of antioxidants and Alcohol, when used in moderation, has health benefits. Use of alcohol is to be guided by consideration of one’s personal health. Tea is recommended as a healthful beverage choice.

At the top of the pyramid is a personal space purposely left open. It is to be filled by you. What will make this Healing Foods Pyramid complete for you?

Facts About documents offer details of the recommendations. With the ever-changing ideas and research findings of food and nutrition, this Healing Foods Pyramid will be a continuous and dynamic work in progress.
High-fiber foods


Looking to add more fiber to your diet? Fiber moves quickly and relatively easily through your digestive tract and helps it function properly. A high-fiber diet may also help reduce the risk of heart disease and diabetes.


Here's a look at the fiber content of some common foods. Read nutrition labels to find out exactly how much fiber is in your favorite foods. Recommended fiber intake for women is 21 to 25 grams a day and for men is 30 to 38 grams a day.

Fruits Serving size Total fiber (grams)
Pear 1 medium 5.1
Figs, dried 2 medium 3.7
Blueberries 1 cup 3.5
Apple, with skin 1 medium 3.3
Strawberries 1 cup 3.3
Peaches, dried 3 halves 3.2
Orange 1 medium 3.1
Apricots, dried 10 halves 2.6
Raisins 1.5-ounce box 1.6
Grains, cereal & pasta Serving size Total fiber (grams)
Spaghetti, whole-wheat 1 cup 6.3
Bran flakes 3/4 cup 5.1
Oatmeal 1 cup 4.0
Bread, rye 1 slice 1.9
Bread, whole-wheat 1 slice 1.9
Bread, mixed-grain 1 slice 1.7
Bread, cracked-wheat 1 slice 1.4
Legumes, nuts & seeds Serving size Total fiber (grams)
Lentils 1 cup 15.6
Black beans 1 cup 15.0
Lima beans 1 cup 13.2
Baked beans, canned 1 cup 10.4
Almonds 24 nuts 3.3
Pistachio nuts 47 nuts 2.9
Peanuts 28 nuts 2.3
Cashews 18 nuts 0.9
Vegetables Serving size Total fiber (grams)
Peas 1 cup 8.8
Artichoke, cooked 1 medium 6.5
Brussels sprouts 1 cup 6.4
Turnip greens, boiled 1 cup 5.0
Potato, baked with skin 1 medium 4.4
Corn 1 cup 4.2
Popcorn, air-popped 3 cups 3.6
Tomato paste 1/4 cup 3.0
Carrot 1 medium 2.0




Grains and starchy vegetables

This Facts About explains and gives examples of grains and starchy vegetables. We list foods with a guide for selecting an appropriate portion size and provide recommendations for incorporating healthy changes into your diet.


What are the recommended servings of grains & starchy vegetables per day?


* 4 -11 servings per day. For optimal health, we recommend only whole grains versus milled, processed or refined grains.



What are whole grains?


Grains are the seeds of plants. Whole grains contain all parts of the grain, including the bran, endosperm and germ.


* Bran. Forming the outer layer of the seed, the bran is a rich source of niacin, thiamin, riboflavin, magnesium, phosphorus, iron and zinc. The bran also contains the majority of the seed's fiber.
* Germ. A concentrated source of niacin, thiamin, riboflavin, vitamin E, magnesium, phosphorus, iron and zinc. The germ also contains protein and fat.
* Endosperm. Also called the kernel, the endosperm makes up the bulk of the seed. It contains most of the grain's protein and carbohydrate and has small amounts of vitamins and minerals.



What are milled, processed and refined grains?


* Unlike whole grains that contain at least part of their bran and germ layers, milled, processed and refined grains have both the bran and germ removed during processing; therefore all of the nutrients in these layers are also removed.
* They are often “enriched” which means nutrients that were lost during food processing are added back. For example, B vitamins, lost when wheat is refined, are added back to white flour during processing. However, even after enrichment, milled grains do not have as many nutrients as whole grains, and they do not provide as much fiber, if any.
* While whole grains are preferred, adding fiber -rich foods to milled or processed grains can lower the glycemic impact and moderate fluctuations in blood sugar. Therefore, foods such as pasta and white rice can be part of a healthy diet when combined with high fiber foods such as vegetables or beans.
* Examples of milled grains are white rice and white flour.



What are starchy vegetables?


* Starchy vegetables include corn, potatoes (all kinds including sweet), winter squash, plantains, and yucca (cassava root)
* These vegetables are higher in starch than other vegetables and are metabolized in your body more like a grain
* They are often used as the central starchy part of a meal, for example: mashed potatoes or polenta (milled corn)
* When used whole, they provide ample fiber and nutrients
* Their primary function is to provide energy for the body, especially the brain and the nervous system. The body breaks down starches into glucose, which the body uses for energy.



Why choose whole grains and starchy vegetables?


* They are rich sources of fiber and naturally low in fat
* An important source of vitamins and minerals, such as B vitamins, Vitamin E, folate, selenium, zinc and iron
* They contain a variety of phytochemicals and antioxidants
* They help form the foundation of healthy eating
* There is a wide variety to choose from
* Tend to have a low glycemic index, which helps to regulate blood sugar levels
* Associated with reduced risk of type 2 diabetes, constipation, diverticulitis, obesity, heart disease and some tyepes of cancer



Try replacing refined, processed and milled grains with a whole grain alternative


Choose Less Often

Choose More Often


Milled/Refined Grains & Starchy Vegetables


Serving Size

Whole Grains and Starchy Vegetables

Serving Size

White / wheat bread
1 slice (1oz)
Whole wheat / whole grain bread
1 slice (1 oz)

White Rice
1/3 cup
Brown rice, millet, quinoa, barley or polenta
1/3 cup

Couscous
1/3 cup
Whole wheat couscous
1/3 cup

Pasta
1/3 cup
Whole wheat / multi grain pasta
1/3 cup

Crackers and Pretzels
3/4 oz
Whole grain crackers and pretzels
3/4 oz

Potato chips
3/4 oz
Tortilla chips
3/4 oz

Potato without skin
1 med
Potato with skin
1 med

Bagel, 4oz
1/4
Whole wheat / whole grain bagel, 4 oz
1/4

Pancake or waffle, 4 inches across
1
Whole grain pancake or waffle, 4 inches across
1

Pita bread, 6 inches across
1/2
Whole wheat pita, 6 inches across
1/2

Corn flakes, sugary breakfast cereal
3/4 cup
Oatmeal, cereal based on oats, barley or bran

3/4 cup




Specific Considerations


What is the glycemic index (GI)?


The glycemic index measures how different types of carbohydrate foods affect blood glucose (blood sugar) levels. The higher a food ranks on the glycemic index, the faster it increases glucose in the blood. Eating more than the recommended servings of foods high on the glycemic index can lead to loss of sensitivity to insulin, the hormone needed to allow blood sugar to enter cells for use as fuel. This "insulin resistance" promotes weight gain and type 2 diabetes.


* The glycemic index ranks carbohydrates on a scale from 0 to 100 according to the rate and extent that the sugars from these carbohydrates enter the blood and cause blood sugar levels to rise after eating
* Carbohydrates that breakdown quickly have the highest glycemic indexes
* Carbohydrates that breakdown slowly have low glycemic indexes



What is the glycemic load (GL)?


* GL builds on the glycemic index concept to provide a measure of total glycemic response to a food or meal based on serving size
* GL = GI (%) x grams of carbohydrate per serving



GI and GL Range Values

Glycemic Index (GI) Range Glycemic Load (GL) Range Glycemic Load per Day
Low GI = 55 or less Low GL = 10 or less Low GL <>
Medium GI = 56-69 Medium GL = 11-19 High GL > 120
High GI = 70 or more High GL = 20 or more




Milled Grains and GI


When the fiber is removed from grains during the milling process, the refined carbohydrate that remains is converted to glucose by the body much more quickly during digestion. Therefore the milling process increases the GI of a particular grain, for example:

Grain Glycemic Index (GI) Glycemic Load (GL)
Milled - White rice, instant, 1 c 87 - High 36 - High
Whole - Brown rice, 1 c 50 - Low 16 - Medium



Fiber in the prevention of chronic disease


Constipation
Fiber adds bulk, aiding the movement of food through the gut, thus preventing constipation


Diverticulitis
Fiber also helps reduce the risk of diverticulitis, a condition in which small pouches in the colon wall may become infected


Type 2 Diabetes
Foods with a low glycemic index and high fiber, like many whole grains and starchy vegetables, do not raise blood sugar levels as quickly as milled and processed choices. Therefore, they are associated with a lower risk of type 2 diabetes. Low glycemic index foods are often high in fiber and include legumes, whole fruits, oats, bran and whole grain cereals.


Heart Disease
Fiber reduces fat and cholesterol absorption leading to lower total and LDL (bad) cholesterol levels


Obesity
Because insoluble fiber is indigestible and passes through the body virtually intact, it provides few calories. Since the digestive tract can handle only so much bulk at a time, and since fiber-rich foods are more filling than other foods, people on high fiber diets tend to eat less. Insoluble fiber also may hamper the absorption of calorie-dense dietary fat.


Cancer
Whole grains contain phytochemicals and antioxidants that can help lower your risk for cancer. Also, the fiber in whole grains can help move potential cancer- causing compounds through the intestines faster, reducing their chances of being reabsorbed into the body.


What are the health concerns associated with grains?


Gluten Intolerance


Celiac disease (CD) is also known as gluten intolerance. Gluten is the common name for the proteins in specific cereal grains that are not tolerated in persons with CD. These proteins are found in all forms of wheat (including durum, semolina, spelt, kamut, einkorn, and faro), and related grains, rye, barley, and tritcale. When individuals with CD ingest gluten, the villi, tiny hair-like projections in the small intestine that absorb nutrients from food are damaged. This is due to an immune reaction to gluten. Damaged villi interfere with the body's ability to absorb basic nutrients - proteins, carbohydrates, fats, vitamins, minerals, and, in some cases, water and bile salts.


Pesticide Use


Pesticides are chemicals that are used to control pests that destroy crops. They are used in the production of most crops sold in the United States. These chemicals may increase your risk for cancer or other chronic diseases and should be limited in your diet.


Choose Organic


We recommend organic grains because they contain less pesticide residue. We believe they also provide better flavor and are a better nutritional choice than conventionally grown produce.


Organic food is produced by farmers who emphasize the use of renewable resources and the conservation of soil and water to enhance environmental quality for future generations. Organic food is produced without using most conventional pesticides, petroleum-based fertilizers, or sewage sludge-based fertilizers, bio-engineering, or ionizing radiation. Organic systems replenish and maintain soil fertility, eliminate the use of toxic and persistent pesticides and fertilizers, and build biologically diverse agriculture.


How can you get more fiber and whole grains into your diet?


1. Reduce the amount of refined grains you eat. A good way to be sure a food item contains whole grains is to look at the fiber content-3 or more grams of fiber per serving is recommended.
2. Use breakfast cereals based on oats, barley and bran for breakfast or a snack.
3. Use “grainy” breads made from whole seeds.
4. Eat brown rice instead of white rice.
5. Experiment with cooking various whole grains like quinoia, barley and millet.
6. When buying bread products, read the label. If you see the word enriched, the product probably does not contain whole grains.
7. Wheat flour and whole wheat flour are not the same! Look for whole grain, stone ground, whole ground, whole wheat flour, whole oat flour or whole barley flour.
8. When eating a milled or processed grain, add foods with plenty of fiber (fruits, vegetables, legumes or whole grains) to lower glycemic impact.
9. Many foods are now available in whole wheat / whole grain versions: pasta, couscous, frozen waffles, pancake mixes, crackers, bagels and pretzels.



This Facts About document is published by Monica Myklebust, MD, and Jenna Wunder, MPH, RD, at University of Michigan Integrative Medicine Clinical Services. Our mission is to care for people using an Integrative Medicine model that reaffirms the importance of relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.

Legumes

This Facts About reviews beans and lentils and gives examples of foods to choose from as well as foods to avoid. We provide a guide for selecting an appropriate portion size, and recommendations for incorporating healthy changes into your diet.


What are the recommended servings per day?


* 1-3 servings per day



Why choose legumes?


* Low in fat
* Excellent source of protein
* Good source of fiber
* Contain iron, zinc, calcium, selenium, and folate
* Rich in antioxidants
* Provide a low glycemic index (GI) / glycemic load (GL)
* May help reduce the risk of chronic diseases, such as, heart disease, diabetes mellitus,obesity and cancer



What are legumes?


Beans, peas, lentils, and peanuts are collectively known as legumes, which are plants that have pods with tidy rows of seeds inside. Various foods in this category metabolize differently and provide different nutrients. For example, peanuts, which are usually consumed in ways similar to tree nuts are actually in thelegume family and grow underground. They contain more fat and fewer carbohydrates than other legumes. Sugar snap peas contain fewer calories, carbohydrates, and protein per serving than other legumes and are used in cooking as a vegetable. Soy beans are unique for their high isoflavone and essential amino content. They are also used to make such a wide variety of foods unlike other beans in this category. For these reasons, we have listed peanuts in Healthy Fats, fresh green peas in Vegetables, and soy beans in Soy. Please read these individual Facts About sheets for more information.


Legumes have many of the nutrients recognized as important in preventing heart disease, cancer, obesity, and other chronic diseases. They are a vegetarian source of protein for the diet. For non vegetarians, they offer an alternative source of protein with less fat and more fiber.


Selected Food Sources with Serving Sizes, Protein, and Fiber Content



Selected Food Sources of Legumes



Types


Serving Size


Protein and Fiber Content



Beans:
garbanzo beans (chickpeas), lima beans, fava beans, black beans, black-eyed peas, kidney beans, navy beans, great northern beans, pinto beans, adzuki beans, mung beans


1/2 cup canned or cooked


1/3 cup mashed


Provides approximately 8 grams of protein & 8 grams of fiber




Peas:
split, yellow or green




Lentils:
large or small; brown, green, red or black








Specific Considerations


Protein Complementation


Protein is made up of building blocks called amino acids and must be consumed in the diet for building new proteins in the body. Our bodies can make some amino acids from the protein we eat, but not others; the ones the body cannot make are considered essential amino acids because they must be consumed from the diet.


* Dairy and meat usually contain all of the essential amino acids and are considered to provide complete proteins. However, they often contain saturated fat and cholesterol.
* Grains, fruits and vegetables lack at least one of the essential amino acids and are considered to provide incomplete proteins. These items, when eaten in combination can fulfill requirements for essential amino acids in the diet.
* For the most benefit from complimentary protein foods, plant sources of protein such as legumes, seeds and whole grains should be eaten in combination and during the same day, but do not necessarily need to be eaten during the same meal as once thought.
* There are many examples of common plant-based dishes that contain adequate essential amino acids: brown rice and beans, peanut butter and whole wheat bread, cornbread and pinto beans and refried beans with wheat or corn tortillas.
* Dairy products can also be added to a meatless dish to enhance the protein content of a meal.



Canned versus Dried Beans


* Canned beans are fast and easy to use
* Many canned beans are high in sodium. To avoid this, buy “no added salt” products or rinse thoroughly.
* Dried beans have a fresher taste than canned beans and soaking times vary. Read product label for instruction.



Intestinal Gas


Many people who eat beans have a problem with intestinal gas. Humans are missing an enzyme required to break down raffinose sugars found in beans. The bacteria in our gut feast on these sugars, giving off hydrogen and carbon dioxide and causing intestinal gas. Some people avoid beans due to the intestinal gas or bloating they may produce. Gradually increasing the amount of beans you eat over several weeks can help in overcoming this.


Ideas to increase beans, peas & lentils


1. Choose beans as your protein choice instead of high fat meat or dairy products.
2. Keep pantry stocked with a variety of canned legumes for a quick meal or side dish.
3. If you're new to beans, start with a small amount and increase gradually.
4. Consider vegetarian days.
5. Change your favorite recipe by replacing half the meat with legumes.
6. Try a new legume each week.
7. Enjoy bean soups and a salad for lunch and / or dinner.



To decrease intestinal gas from beans, peas, & lentils


1. Mix 1/8 teaspoon of baking soda into the soaking water. It helps leach out raffinose sugars, reducing intestinal gas.
2. Drain and rinse canned beans. That will get rid of some of the gas-causing raffinose sugars (and almost half of the unwanted sodium).
3. Never cook beans in the water they've soaked in. It's loaded with the gas-causing raffinose sugars.



This Facts About document is published by Monica Myklebust, MD, and Jenna Wunder, MPH, RD, at University of Michigan Integrative Medicine Clinical Services. Our mission is to care for people using an Integrative Medicine model that reaffirms the importance of relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.


Fruits and Vegetables

This Facts About reviews fruits and vegetables and gives examples of foods to choose. We provide a guide for selecting an appropriate portion size, and recommendations for incorporating healthy changes into your diet.


What are the recommended servings per day?


* Overall: more than 7 servings
* Vegetables: unlimited (minimum 5 servings)
* Fruits: 2-4 servings



Why should you choose fruits & vegetables?


* Excellent source of fiber
* Rich in vitamins and minerals
* Low in calories and most are fat-free
* Provide a food source of water; fruits and vegetables are made up of more than 50% water
* Abundant in phytochemicals and antioxidants
* High consumption helps reduce risk of various diseases such as cancer, obesity, heart disease, arthritis, asthma, macular degeneration and diverticulosis



What is the threshold effect?


Research supports evidence of an inverse relationship of fruit and vegetable consumption with development of chronic disease. This means that the more fruits and vegetables you eat, the less likely you are to develop a chronic disease. The most significant reductions in risk of illness are seen when individuals consume 7-10 servings of fruits & vegetables per day (the threshold). Therefore, to get the most health benefits we recommend a minimum “threshold” of 7 servings of fruits & vegetables daily.

A limited selection of fruits and vegetables


Fruits

Vegetables

Apricots Oranges Asparagus Parsnips
Blackberries Papaya Bell peppers Radicchio
Blueberries Passion fruit Bok choy Radishes
Cantaloupe Peaches Broccoli Sorrel
Dates Plums Cabbage Spinach
Guava Pomegranate Carrots Swiss chard
Grapefruit Raspberries Cucumbers Tomato
Honeydew melon Star fruit Green beans Turnips
Kiwifruit Tangelos Kale Watercress
Mango Watermelon Kohlrabi Zucchini




Selected serving sizes of fruits & vegetables

Fruit or Vegetable Serving Size
Raw leafy greens 1 cup
Baby carrots 6-7
Apple/Orange Size of tennis ball
Banana Medium
Grapes 17
Berries ¾ cup
Melon chopped 1 cup
Raw, chopped fruit or vegetables ½ cup
Cooked vegetables ½ cup
Dried fruit ¼ cup




Specific Considerations


Phytochemicals


* Phytochemicals (‘phyto’means plant) are naturally occurring plant chemicals
* Phytochemicals are not yet classified as nutrients. Nutrients are substances necessary for sustaining life. Phytochemicals’ role in nutrition is still unfolding however, they have been identified as containing properties that aid in disease prevention
* In the human body, some phytochemicals act as antioxidants, some protect and regenerate essential nutrients, while others work to deactivate cancer-causing substances
* Thousands of phytochemicals have been identified in the plant foods we eat
* One serving of fruit or vegetables may contain 100 different phytochemicals. Some are available when the vegetable is raw, and others when the vegetable is cooked. It is important to eat a mix of raw and cooked vegetables to gain the most benefit from phytochemicals.
o Cooking method matters; steaming helps retain water soluble vitamins like B vitamins and vitamin C rather than boiling
o High cooking temperature and long cooking times also destroy heat sensitive nutrients such as B vitamins, vitamin C, and folate, so keep cooking times short



Antioxidants


The most well known phytochemicals are the antioxidants


* Antioxidants found in fruits and vegetables protect cells from damage caused by metabolic by-products (free radicals), as well as toxic substances from food and the environment. As our bodies use oxygen to produce energy, these free radicals are formed. They damage cells which may lead to cellular dysfunction and disease
* Colorful plant foods are loaded with antioxidants so eating a variety of fruits and vegetables is a great way to protect the body from oxidation, and therefore reduces the risk of numerous health conditions



Examples of antioxidants:


* Beta carotene - carrots, cantaloupe
* Vitamin C - citrus, cantaloupe, mango, and kiwi
* Vitamin E - dark leafy greens, broccoli
* Selenium – mushrooms, cabbage



Rainbow of Color


Phytochemicals contribute to the pigments of fruits and vegetables:


* Red - lycopene found in tomatoes, watermelon, & pink grapefruit
* Orange - beta carotene found in carrots, mangoes, & cantaloupe
* Yellow - beta cryptothanxin found in pineapple, oranges, & peaches
* Green - indoles found in broccoli, cabbage, & kale
* Purple - anthocyanins found in blueberries, grapes, & eggplant
* White – allicin found in garlic, onions, & chives





Research tells us that the more phytochemical-rich foods eaten, the lower the risk for diseases such as cancer and heart disease. Therefore we recommend eating a rainbow of fruits and vegetables daily.




Pesticide Use


Pesticides are chemicals that are used to control pests that destroy crops. They are used in the production of most crops sold in the United States. These chemicals may increase your risk for cancer or other chronic diseases and should be limited in your diet. To reduce consumption of pesticides, follow these tips:


* Wash all fruits and vegetables with water
* Before eating apples, cucumbers, potatoes or other produce in which the outer skin or peeling is consumed, scrub with a brush
* Throw away the outer leaves of leafy vegetables, such as lettuce and cabbage
* Peel and cook when appropriate, although some nutrients and fiber may be lost when produce is peeled



Choose Organic


We recommend organic fruits and vegetables because they contain less pesticide residue. We believe they also provide better flavor and are a better nutritional choice than conventionally grown produce.


Organic food is produced by farmers who emphasize the use of renewable resources and the conservation of soil and water to enhance environmental quality for future generations. Organic food is produced without using most conventional pesticides, petroleum-based fertilizers, or sewage sludge-based fertilizers, bio-engineering, or ionizing radiation. Organic systems replenish and maintain soil fertility, eliminate the use of toxic and persistent pesticides and fertilizers, and build biologically diverse agriculture.


According to the Consumers Union and The Environmental Working Group, the top fruits and vegetables to buy organic because of potential pesticide residue are:


* Peaches
* Apples
* Pears
* Green beans
* Grapes
* Strawberries
* Raspberries
* Spinach
* Tomatoes
* Cantaloupe



Ways to Transition to Organic Fruits and Vegetables


* Shop at farmers markets
* Buy a share in a community supported agriculture (CSA) program
o For more information, check out http://www.nal.usda.gov/afsic/csa/

* Join a food co-op
* Buy organic produce in-season and freeze/preserve
* Grow your own fruits and vegetables
* Ease into buying organic produce



Ideas to Increase Fruits and Vegetable Consumption


1. Do it gradually.
2. Snack on raw vegetables instead of chips and crackers. To keep it interesting, try dipping vegetables in hummus, salsa or low-fat dip.
3. Add fruit to your cereal or yogurt at breakfast.
4. Order salads as an appetizer when out to dinner.
5. Get creative. Add vegetables to dishes that don’t always include them, like scrambled eggs, rice or pasta dishes, pizza and casseroles.
6. Drink your fruit (including fruit just past it’s prime) in the form of a fruit smoothie.
7. Choose salads as your main course for lunch or dinner. For variety, top your salads with dried cranberries, sunflower seeds or other nuts.
8. In hot weather, frozen fruit such as grapes, sliced kiwis, sliced peaches and strawberries are a refreshing snack.
9. Enjoy salad bars at restaurants or grocery stores.
10. When craving a sweet treat, try dried fruit.
11. Buy fresh fruits and vegetables in season.
12. Frozen fruit and vegetables are frozen soon after harvest and can be eaten during the off season as a nutritious alternative to fresh produce.
13. Watch local grocery advertisements for reduced prices on your favorite fruits and vegetables.
14. Try fruit for dessert.
15. Prepare fruits and vegetables ahead of time in a way you like to eat them so they are readily available and desirable to you when you are hungry.
16. Fill half of your plate with fruits and/or vegetables.
17. Choose a rainbow of fruits and vegetables daily.



This Facts About document is published by Monica Myklebust, MD, and Jenna Wunder, MPH, RD, at University of Michigan Integrative Medicine Clinical Services. Our mission is to care for people using an Integrative Medicine model that reaffirms the importance of relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.

Diary

This Facts About reviews low-fat/non-fat dairy and gives examples of foods to choose from as well as foods to avoid. We provide a guide for selecting an appropriate portion size, and recommendations for incorporating healthy changes into your diet.


What are the recommended servings per day?


* Optional: 1-3 servings per day



Why choose low-fat/non-fat dairy products?


* Though many foods contain calcium, dairy foods are some of the richest sources of calcium
* They are high in protein, vitamin B12 and other minerals the body needs, such as selenium, zinc, phosphorus, potassium and magnesium
* Most milk is fortified with vitamin D, which helps the small intestine absorb calcium
* Low-fat and fat-free milk are also typically fortified with vitamin A, which is lost in the removal of milk fat
* Selecting low-fat/non-fat dairy products helps reduce total and saturated fat intake and calories
* While low-fat and non-fat dairy products are made using 1%, ½%, or non-fat milk instead of using whole milk or cream, artificial ingredients may be added to enhance color, shelf-life, and texture. Read labels and avoid products if the ingredients are chemicals or names too long to pronounce.
* Although recent research suggests that dairy product intake may be associated with lower body weight or body fat, definitive evidence is pending.



Why choose fermented/probiotic milk products such as yogurt?


Probiotic foods contain healthy living bacteria. Eating such foods can help re-establish a healthy bacteria balance in the digestive tract that may have been disrupted by poor diet or medications. Research has shown that the healthful bacteria in yogurt may provide many benefits, such as:


* Offering a safe and effective means of treating acute infectious diarrhea in children
* Preventing antibiotic-associated diarrhea
* Protecting against tumor formation in the colon
* Reducing intestinal transit time which helps prevent constipation
* Improving the digestion of lactose in persons with lactose intolerance
* Enhancing gut and systemic immune function by increasing IgA antibody production
* Preventing allergic reactions by reducing hypersensitivity reactions
* Helps reduce symptoms of inflammatory bowel disease (IBD) such as Crohn’s and ulcerative colitis
* Increasing HDL (good) cholesterol and decreasing the ratio of LDL (bad) to HDL cholesterol with long-term, daily intake of yogurt; this may be due to the fatty acid distribution and the type of fats in the milk



Other fermented milk products, such as low-fat/non-fat sour cream, cottage cheese, and cheeses (Swiss and Cheddar), may have similar benefits.


Selected Food Sources with Serving Sizes


Selected Low-fat Dairy Sources


1-3 servings per day
Select from the following with less than 3g fat per serving


Low-fat/non-fat yogurt (1 cup)


Low-fat/non-fat frozen yogurt (1 cup)


Low-fat/non-fat cottage cheese (1/2 cup)


Low-fat/non-fat cream cheese (1 tbsp)


Low-fat/non-fat sour cream (2 tbsp)


Part-skim ricotta cheese (1 oz or 1/8 cup)


Part-skim mozzarella (1 oz)


Skim milk (non-fat), 1/2%, or 1% (1 cup)




Specific Considerations

Choosing low-fat/non-fat dairy products


* Low-fat dairy products have less than 3 g of total fat per serving
* Check expiration date on containers
* Choose dairy products from "free-range", "grass-fed" or "organic" animals to minimize consumption of antibiotic residues and other toxins



Full-fat cheese




Although full-fat cheese is high in total fat and saturated fat, small amounts of natural, minimally processed cheese can be an important dietary component. The Mediterranean diet, known for its health benefits, includes small amounts of cheese almost daily. Full-fat cheese should be consumed in small portions.


Buy high-quality cheese made by local farmers or imported from reputable creameries. This decreases the chance of antibiotic and hormone residues and use of trans-fats/hydrogenated oils as a means of processing cheese to increase shelf-life. Avoid pre-packaged cheeses for the same reasons.




Examples of Full-fat Cheeses


Up to 1 serving per day
Serving size 1-2 oz

Soft Brie, Mascarpone
Semi-hard Blue, Feta
Hard Cheddar, Swiss
Very hard Parmesan, Romano



Lactose Intolerance




Many people are lactose intolerant, meaning that they lack the enzyme lactase that breaks down the natural sugar (lactose) found in dairy products. Around the world, various ethnic groups have different proportions of those who are lactose intolerant; approximately 90% of Asians, 70% of African and Native Americans and 50% of Hispanics are lactose intolerant, versus only about 15% of people of Northern European descent.


Lactose intolerance can cause bloating, gas, and stomach aches after intake of dairy products. Symptoms may be avoided by choosing fermented dairy products such as yogurt or lactose free milk.




Casein Sensitivity




The milk protein casein, found in dairy products, stimulates the production of mucus in some people and can potentially aggravate conditions like auto-immune disease, asthma, bronchitis or sinusitis. Some studies suggest that casein may irritate the immune system which should be considered by people who have “overactive immune systems” – often manifested by chronic allergies, lupus and rheumatoid arthritis, for example.




Choose Organic




We recommend organic, free-range animal products because they contain less antibiotic or hormone residue and have a higher omega-3 and vitamin E content. These qualities make organic animal products a better nutritional choice. We believe they generally provide better flavor than conventionally raised animals.


Organic food is produced by farmers who emphasize the use of renewable resources and the conservation of soil and water to enhance environmental quality for future generations. Organic meat, poultry, eggs, and dairy products come from animals that are given no antibiotics or growth hormones. With the increase in incidence of hormone-related diseases such as breast and prostate cancer, it may be prudent to consume only organic dairy products.




Hormones and Antibiotics


* Most commercial animal products contain residues from drugs, hormones, and chemicals used to keep modern dairy cows producing abundantly. These residues in food may increase the risk of breast cancer and other hormone-related cancers including prostate cancer.
* Most commercially-raised animals may have been exposed to antibiotics. This practice contributes to the escalating problem of antibiotic-resistant bacteria throughout the world.



Know Your Limits for Fat


* On a 2,000 calorie diet, about 30% or 600 calories (67g) should come from total fat per day
* A ratio of 1:2:1 of saturated: monounsaturated: polyunsaturated (such as Omega-3s) fat should be the goal. 1:2:1 in calories equals 150:300:150 - no more than 150 calories or 7.5% (17g) of total calories should come from saturated fat
* A low-fat dairy product has less than 3g of fat per serving



Ideas for your dairy consumption


* Freeze yogurt for a frozen dessert. Research shows that probiotic bacteria can survive the freezing process, so freezing yogurt will not diminish its health benefits.
* Plain yogurt, mixed with fresh fruit, makes a quick and easy snack. Since plain yogurt has no added sugars choosing it reduces your sugar and calorie intake. Additionally you get added fiber and antioxidants from the fresh fruit!
* Use cottage cheese like a dip for raw vegetables and whole grain pretzels or pita chips.
* Full-fat cheese has big flavor (and lots of fat). An ounce or two can be a satisfying treat.



This Facts About document is published by Monica Myklebust, MD, and Jenna Wunder, MPH, RD, at University of Michigan Integrative Medicine Clinical Services. Our mission is to care for people using an Integrative Medicine model that reaffirms the importance of relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.

Seasonings

This Facts About reviews spices and herbs and gives examples. We provide a guide for selecting an appropriate portion size, and recommendations for incorporating healthy changes into your diet.


What are the recommended servings per day?


* Use a variety of spices, herbs, and alliums in your daily food preparation. Experiment cautiously with hot peppers.



What are spices, herbs, alliums and hot peppers?


* Herbs refer to leaves of low-growing shrubs. They can be used fresh or dried.
* Spices may be the seeds, buds, berries, bark, root, or fruit of tropical plants and trees
* Alliums are bulbous plants that are used as flavoring for foods and for their medicinal properties. They are found in most regions of the world except the tropics, New Zealand and Australia.
* Hot peppers are edible, pungent fruits of the species Capsicum. They are used as spices and flavoring for foods and for their medicinal properties.



Why choose a variety of seasonings?


* Seasonings are grown for their culinary and medicinal properties
* They may be helpful in many medical conditions, such as:
o Nausea
o Infections
o Anti-inflammatory conditions
o Autoimmune disorders
o High blood pressure
o Cholesterol levels




Selected Food Sources - The following information is not meant to be an exhaustive list. Due to limited space, we have highlighted only a few of the many beneficial seasonings.


Selected Seasonings



Spices


curry, turmeric, cumin, chili pepper, fennel, cinnamon, ginger, cloves, nutmeg, allspice, mustard seed, black pepper, paprika, salt, cardamom, vanilla, horseradish, anise




Herbs


parsley, chives, thyme, sage, oregano, mint, rosemary, tarragon, basil, dill, cilantro, coriander, marjoram, caraway, savory



Alliums


green onions, onions, shallots, leeks, chives, garlic




Hot Peppers


cayenne, jalapeno, Anaheim , chipotle, habanero, Serrano, ancho





Special Considerations


Whole Turmeric in Powdered Form


* Tumeric is the yellow spice most familiar in Indian cooking and American prepared mustard
* Has antioxidant and anti-inflammatory properties
* May decrease symptoms of autoimmune disorders, arthritis, tendonitis, and other disorders with inflammation
* Curcumin is the part of turmeric that gives the yellow color



Fresh Ginger Root


* Ginger is an underground stem or rhizome which sprouts large pink and orange flowers that look as if they have been carved out of wax
* Has anti-inflammatory properties
* Helps with nausea and motion sickness
* Decreases symptoms of arthritis and bursitis
* Reduces platelet aggregation



Fresh Garlic Cloves


* Garlic cloves are the segments of a head or bulb of garlic
* Natural antibiotic and antiviral agent as a result of sulfur-containing compounds
* May help with infections: colds, sore throat, ear infections in children, fungal or yeast infections
* May slow development of atherosclerosis, improve high blood pressure and decrease total and LDL (bad) cholesterol by reducing blood platelet stickiness and artery spasms
* May decrease risk of developing colorectal, prostate, breast, liver, skin, and digestive tract cancers by inhibiting the growth of tumors and stimulating the immune system



Fresh or Dried Peppermint


* Fresh or dried peppermint are the leaves from the peppermint plant
* Used as a digestive remedy for relief of heartburn, indigestion, and nausea
* May soothe the lower GI tract by decreasing spasms and gas formation
* Contains antioxidants called flavonoids which stimulate bile and saliva production
* Its soothing effect results from the stimulation of salivation, which increases the swallowing reflex and suppresses cough



Cayenne Pepper


* A very pungent spice produced by drying and grinding the orange to deep-red fruits of small-fruited species of Capsicum
* Capsicum is used to stimulate digestion
* Eases toothache pain
* Improves peripheral circulation
* Reduces blood clotting tendencies
* Decreases cholesterol
* Helps to prevent arteriosclerosis and heart disease



Whole food vs. supplements


* Whole foods are the best sources of vitamins, minerals, and other plant compounds that help you stay healthy and fight disease
* We recommend these foods in their natural form. Taking them in supplement form may reduce their effectiveness and may increase the risk of side effects.



Interactions with medications and medical conditions




Because of their medicinal qualities, some spices and herbs may interact with medications. We advise individuals to contact their physician if taking medications.




How to use seasonings


1. Spices and herbs should be stored in a cool, dry place.
2. Green herbs should be protected against direct sunlight exposure.
3. Ground spices release flavor immediately, therefore add them at the end of the cooking period.
4. Whole spices should be added at the beginning of cooking so their full flavor can be extracted.
5. Crumbling whole herbs just before use helps to release their flavor.
6. Chopping or mashing garlic releases an active medicinal component, allicin.
7. To reduce the heat of hot peppers, remove the seeds.
8. Fresh herbs can be added to salads, soups and sauces.



This Facts About document is published by Monica Myklebust, MD, and Jenna Wunder, MPH, RD, at University of Michigan Integrative Medicine Clinical Services. Our mission is to care for people using an Integrative Medicine model that reaffirms the importance of relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.

Healthy Fats

This Facts About reviews healthy fats and gives examples of foods to choose from as well as foods to avoid. We provide a guide for selecting an appropriate portion size, and recommendations for incorporating healthy changes into your diet.


What are the recommended servings per day?


* 3-9 servings per day (see serving sizes below)



What are the different types of healthy fats and oils?


* Fats and oils are made up of basic units called fatty acids. Each type of fat or oil is a mixture of different fatty acids.
* Monounsaturated Fatty Acids (MUFA) are found mainly in vegetable oils, nuts, seeds and some plant foods. They are liquid at room temperature.
* Polyunsaturated Fatty Acids (PUFA) are found mainly in vegetable oils, fish and seafood. They are liquid or soft at room temperature. Omega-3 and omega-6 fatty acids are types of PUFA and are considered essential fatty acids because our bodies cannot make them, thus they must be obtained through the diet.
* Saturated Fatty Acids are usually solid at room temperature and are found mainly in foods from animal sources like meat, dairy products and butter. Some vegetable oils such as coconut, palm kernel and palm oil are saturated.
* Trans Fatty Acids are liquid vegetable oils that have been chemically processed to become solid at room temperature through the addition of hydrogen atoms. These hydrogenated and partially hydrogenated oils are used in some margarines and fried foods as well as to improve the flavor, texture and shelf-life of processed snack foods like cookies and crackers.



Which fats are recommended?


* Emphasize consumption of monounsaturated and omega-3 fatty acids
* Limit consumption of saturated and trans fats (listed as hydrogenated or partially hydrogenated vegetable oils on labels)
* All foods containing fat have a mixture of polyunsaturated, monounsaturated, and saturated fatty acids. It is not feasible or desirable to completely eliminate one type of fatty acid from your diet.



Why choose healthy fats like MUFA and omega-3s?


* They provide antioxidants such as vitamin E and selenium
* Small amounts of healthy fats help the body absorb the vital nutrients from fruits and vegetables
* Including healthy fatty acids in the diet in appropriate quantities can help prevent and treat: diabetes, heart disease, cancer, obesity, musculo-skeletal pain, inflammatory conditions
* Some research suggests that diets including MUFA can have a positive effect on cholesterol, blood pressure, blood clotting and inflammation.
* Omega-3 fatty acids are necessary for proper brain growth and development. They are anti-inflammatory and may be helpful in the prevention and treatment of heart disease, high blood pressure, inflammation, mental health disorders, diabetes, digestive disorders, autoimmune disease and cancer.



Why should I avoid saturated and trans fatty acids?


* Saturated fat eaten in excessive amounts is the main culprit in raising total and LDL “bad” cholesterol, which can increase risk of heart disease.
* Trans fatty acids may act like saturated fats in the body and raise LDL cholesterol levels. They may also lower HDL (“good”) cholesterol.
* A food item may contain less than 0.5 grams of trans fat per serving but still reflect “0” grams of trans fat on its food label. To ensure that the foods you eat are actually free of trans fat, check that hydrogenated and partially hydrogenated vegetable oils are not listed as ingredients.



Selected food sources of MUFA with serving sizes (listed highest to lowest MUFA content)




Oils
(serving size is 1 teaspoon)



Nuts (serving size)


Seeds (serving size)


Butters (serving size)


Other (serving size)



Olive oil


Canola oil


Peanut oil


Sesame oil


Walnut oil


Soybean oil


Flaxseed oil (should be consumed raw and not used in cooking)

Grape seed oil


Macadamias (2-3)


Hazelnuts (5)


Pecans (5 halves)


Almonds (7)


Cashews (6)


Pistachios (17)


Brazil nuts (2)


Peanuts (9)


Pine nuts (50)


Walnuts (4 halves)


Sesame seeds
(1 Tbsp)


Pumpkin seeds
(47 seeds)


Ground flaxseed
(1 Tbsp)


Sunflower seeds
(3 Tbsp)


Almond butter
(½ Tbsp)


Cashew butter
(½ Tbsp)


Peanut butter (½ Tbsp)


Tahini/sesame paste (2 tsp)


Sunflower seed butter (2 tsp)


Avocado
(2 Tbsp or 1 oz)


Black olives(8)


Green olives (10)




Selected Plant Sources of Omega-3 Fatty Acids (listed highest to lowest omega-3 content)
Please visit the Fish & Seafood sections for more information about animal sources of omega-3 fatty acids.



Oils
(serving size = 1 teaspoon)


Nuts and seeds (serving size)



Flaxseed oil*


Flaxseeds (1 Tbsp)



Walnut oil


Walnuts (4 halves)



Canola oil


Pecans (5 halves)



Soybean oil


Pine nuts (50)



*Should be consumed raw and not used in cooking.




Specific Considerations


Calorie-controlled high-MUFA diets:


* Do not promote weight gain
* Are more suitable than low-fat diets for weight loss in obese people
* Are a substitute for low-fat diets for medical nutrition therapy in diabetes



Flaxseed Facts


Flaxseeds are an oilseed just like canola and sunflower are oilseeds. The seeds that come from flax provide excellent health benefits:


* Rich source of omega-3 fatty acids, which are similar to the healthy fats found in fatty fish such as salmon
* Good source of fiber
* Contain other beneficial plant nutrients called lignans; research shows that a diet that contains lignans may reduce the risk of several types of cancer as well as heart disease and osteoporosis
* Using ground flax meal or grinding flaxseeds in a coffee grinder is necessary to make MUFA available to our bodies.



What is the daily recommended intake of omega-3 fatty acids?


There are currently no established guidelines regarding optimal omega-3 intake. According to the Institute of Medicine, the Adequate Intake (AI) is 1.1g daily for women and 1.6 g daily for men. However, some experts believe that these recommendations might be too low to obtain the health benefits associated with omega-3s. Research shows benefits associated with higher intake of 2-3 g per day.


Why is the fat ratio important?


Two types of fatty acids that are essential for human health are omega-3 and omega-6. Studies suggest that decreasing the ratio of omega-6 (in vegetable oils) to omega-3 fatty acids (in fatty fish and some vegetable oils) is important to reduce risk of cancer and heart disease, inflammatory conditions, and depression.


Most people consume too many omega-6 fatty acids and consume too little omega-3 fatty acids. To reduce your risk of chronic disease, reduce your intake of omega-6 fatty acids and increase your intake of omega-3 fatty acids.


* Avoid vegetable oils such as corn or safflower oil.
* Eliminate highly processed foods.
* Eat high omega-3 fish at least twice per week.



Know Your Limits for Fat


* On a 2,000 calorie diet, about 30% or 600 calories (67g) should come from total fat per day
* A ratio of 1:2:1 of saturated to monounsaturated to polyunsaturated (such as omega-3s) fat is recommended
* 1:2:1 in calories equals 150:300:150; no more than 150 calories or 7.5% (17g) of total calories from saturated fat
* Most people consume too much saturated fat and not enough monounsaturated or omega-3 fatty acids.



Ideas to balance your fat consumption


1. Choose salad dressings that use olive, canola, or flaxseed oils as its base.
2. Add avocados, nuts, or olives to salads instead of high saturated fat animal foods like cheese, butter and meat.
3. For a snack, opt for a small handful of nuts/seeds each day in place of highly processed and high fat choices including chips, pastries, and cookies.
4. Use olive and canola oils for most cooking.
5. To increase plant sources of omega-3s, choose walnuts, ground flaxseed and uncooked flaxseed oil.
6. Never use oils, seeds or nuts after they begin to smell or taste rank or bitter. This is a sign that the oil has begun to turn rancid through a harmful oxidation process.
7. For high temperature sautéing or frying, use oils with a high smoke point, like canola or grape seed oils.
8. Limit/avoid consuming:
* Polyunsaturated vegetable oils like safflower, sunflower and corn oil
* Margarine, vegetable shortening, and all products made with partially hydrogenated oils
* Saturated vegetable oils such as coconut, palm kernel and palm oil

9. Use high-quality cold-pressed olive oil, flaxseed oil or sesame oil as an addition to cooked foods or salads before eating.
10. Add a tablespoon or two of ground flax seeds or flax meal to smoothies, muffins, bread or any other home-made baked item.
11. Choose white meat; in general, red meat (fatty beef, lamb, pork, ham, duck, and goose) has more saturated fat than white meat (turkey or chicken without skin) or fish
12. Be aware of any foods deep fried in restaurants. Deep fried foods may say “fried in vegetable oil”, but it is often hydrogenated vegetable oil.



This Facts About document is published by Monica Myklebust, MD, and Jenna Wunder, MPH, RD, at University of Michigan Integrative Medicine Clinical Services. Our mission is to care for people using an Integrative Medicine model that reaffirms the importance of relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.

Fish and Sea Food

This Facts About lists common fish & seafood with an emphasis on those choices with high omega-3 content. We make recommendations on how to avoid toxins and choose fish & seafood that support sustainable fisheries. We provide a guide for selecting appropriate portion sizes and recommendations for incorporating healthy choices into your diet.


What are the recommended servings of fish & seafood?


* Optional: 2-4 servings per week, including at least 2 servings of fish with high omega-3 content
o Serving size 4-6 ounces




Why should you choose fish & seafood?


* Low in saturated fat
* Rich source of protein and iron
* Contains B-12 vitamins
* Richest source of omega-3 fatty acids may be helpful in the prevention and treatment of: heart disease, high blood pressure, inflammation, mental health disorders, diabetes, digestive disorders, autoimmune disease, and cancer



Selected Food Sources with Serving Size*


Selected Fish and their Omega-3 Fatty Acid Content (2.0 g and above per serving)



Finfish High in Omega-3s


Average grams of omega-3 fatty acids
per 6 ounce portion



Anchovy, European, canned in oil


3.4 g



Wild Salmon


3.2 g



Pacific and Jack mackerel


3.2 g



Sable Fish


3.0 g



Whitefish


3.0 g



Pacific sardine


2.8 g



Bluefin tuna


2.8 g



Atlantic herring


2.4 g



Atlantic mackerel


2.0 g



Rainbow trout


2.0 g



*Note: We recommend eating fish listed in this table at least twice per week




Selected Fish and Seafood with Moderate-Low Omega-3 Fatty Acid Content (less than 2.0 g per serving)



Common Finfish





Grams of Omega-3's
per 6 oz. portion





Common Seafood








Grams of Omega-3's
per 6 oz. portion



Tuna, white albacore, canned in water


1.4 g


Mussel


1.4 g



Halibut


0.8 g


Wild Eastern Oyster


1.0 g



Pollock


0.8 g


Farmed Eastern Oyster


0.8 g



Ocean Perch


0.4 g


Blue crab or Alaska King crab


0.8 g



Tuna, light, canned in water


0.4 g


Shrimp


0.6 g



Yellowfin tuna


0.4 g


Scallop


0.6 g



Cod


0.2 g


Clam


0.4 g



.


.


Lobster


0.2 g



.


.


Crayfish


0.2 g



Note: While the fish and seafood above do contain some omega-3s, other fish are richer sources (see High Omega-3 table above)




* Omega-3 content of various fish and seafood sources are averages and may depend on factors such as time of year of harvest and body of water in which the animal resides. Values should be used for comparison of relative amounts in fish and seafood sources of omega-3 fatty acids.


Special Considerations


Choosing Fish & Seafood


* Seafood should not smell "fishy" but rather like a "fresh ocean breeze"
* Mollusks should always be alive when purchased with the shells. Shells should be tightly closed or close tightly when gently tapped.
* Use fresh fish no later than 2 days after purchase
* For long-term storage, fish must be frozen
* Fish is fully cooked when the flakes separate easily; about 10 minutes of cooking time per 1 inch of thickness



What are omega-3 fatty acids?


Omega-3 fatty acids are a type of polyunsaturated fatty acid (PUFA). They are an essential component of the human diet because our bodies can not make them. These fats are necessary for proper brain growth and development. Omega-3s are most abundant in deep-water fatty fish and some plant foods. They are anti-inflammatory and may be helpful in the prevention and treatment of numerous conditions.


Which fish should you eat to get the greatest benefits of omega-3 fatty acids?


Omega-3 fatty acid content varies greatly among different species of fish. Cold-water fatty fish have the highest content of omega-3 fatty acids because their physiology, environment and diet promote omega-3 fatty acid production in their flesh.
All fish contain some amount of omega-3s, however quantities vary among species and within a species according to the same factors mentioned above, i.e. environment and diet.


What is the daily recommended intake of omega-3 fatty acids?


There are currently no established guidelines regarding optimal omega-3 intake. According to the Institute of Medicine, the Adequate Intake (AI) is 1.1g daily for women and 1.6 g daily for men. Although some experts believe that these recommendations might be too low to obtain the health benefits associated with omega-3s. Research shows benefits associated with higher intake of 2-3 g per day.


Why is the fat ratio important?


Two types of fatty acids that are essential for human health are omega-3 and omega-6. Studies suggest that decreasing the ratio of omega-6 (in vegetable oils) to omega-3 fatty acids (in fatty fish) is important to reduce risk of cancer and heart disease, inflammatory conditions, and depression.


Most people consume too many omega-6 fatty acids and consume too little omega-3 fatty acids. To reduce your risk of chronic disease, reduce your intake of omega-6 fatty acids and increase your intake of omega-3 fatty acids.


* Avoid vegetable oils such as corn or safflower oil.
* Eliminate highly processed foods.
* Eat high omega-3 fish at least twice per week.



Know Your Limits for Fat


* On a 2,000 calorie diet, about 30% or 600 calories (67g) should come from total fat per day
* A ratio of 1:2:1 of saturated: monounsaturated: polyunsaturated (such as Omega-3s) fat is recommended
* 1:2:1 in calories equals 150:300:150; no more than 150 calories or 7.5% (17g) of total calories from saturated fat



Potential Chemical Contaminants


Risk of Mercury Poisoning


Mercury is a toxic heavy metal that can accumulate in fish. Eating fish with high levels of mercury can negatively impact brain development in children and can affect learning and memory function in adults. Certain fish species are known to have higher mercury concentrations than others, sometimes due to polluted waters. The highest levels of mercury and contaminants tend to accumulate in the large predatory fish at the top of the food chain.


Avoid in pregnancy and in young children*




Shark


Swordfish


King mackerel


Tilefish




Limit intake in children as well as pregnant and nursing women**




Albacore tuna
Bass (Sea and Largemouth)
Bluefish
Grouper
Halibut
Lobster
Marlin
Red snapper
Pike
Orange roughy
Spanish mackerel
Walleye




Low levels of mercury-containing fish**




Anchovies
Atlantic mackerel
Catfish
Cod
Canned light tuna
Haddock
Herring
Mahi mahi
Pollock
Salmon
Sardine
Shad
Shrimp
Trout
Whitefish




Advice from the EPA for women who are pregnant, planning to become pregnant or nursing:


* *Do not eat shark, swordfish, king mackerel, or tile fish because they contain high levels of mercury. Everyone else can eat up to 6 ounces of high-mercury fish per week.
* ** Eat up to 12 ounces per week (about 3 to 4 servings) of a variety of fish and shellfish that are lower in mercury
* Five of the most commonly eaten fish that are low in mercury are shrimp, canned light tuna, salmon, pollock, and catfish.
* A commonly eaten fish, albacore ("white") tuna contains higher levels of mercury than canned light tuna because these fish are larger. Limit consumption to 6 ounces of albacore tuna per week.
* For further information about the safety of locally caught fish and shellfish, visit the Environmental Protection Agency's Fish Advisory website www.epa.gov/ost/fish or contact your State or Local Health Department. A list of state or local health department contacts is available at www.epa.gov/ost/fish. If no advice is available, eat up to 6 ounces per week of fish you caught from local waters, but don't consume any other fish during that week.
* Follow these same recommendations when feeding fish and shellfish to your young children, but serve smaller portions



Risk of PCB Exposure


PCBs (polychlorinated biphenyls) are industrial pollutants that find their way into fresh waters and oceans where they are absorbed by fish. A recent study reported unacceptable levels of PCBs in fish feed given to farmed salmon. The study reported that PCB levels in farmed salmon, especially those in Europe, were about seven times higher than in wild salmon. PCBs are potential human carcinogens, known to promote cancer in animals. Other potential health effects include impaired memory and learning, and adverse effects on the immune, reproductive and nervous systems. Until more research results are available, it may be prudent to choose wild salmon over farmed salmon and eat a wide variety of fish, along with plant sources of omega-3s. You can reduce PCB exposure from fish by removing the skin and visible fat as well as baking, broiling or grilling fish instead of frying.


Farmed vs. Wild


The old adage “you are what you eat” applies even if you are a fish. The location and living conditions where fish and seafood live can affect what they eat and their exposure to chemicals. In some studies, farm-raised fish have been shown to contain higher levels of contaminants compared to fish caught from the wild. However, there are some ethical fish farms that take good care of their fish and limit contaminant exposure. Recommendations have not yet been established for farmed vs. wild fish and seafood sources although the EPA has limited fish consumption in vulnerable populations such as children and women of childbearing age. Talk to the person you buy your fish and seafood from to better understand this issue.


Incorporating High Omega-3 Fish into Your Diet


1. Order a variety of fish in restaurants and avoid fish that is fried or dipped in batter.
2. Experiment with fish recipes to replace red meat and other high fat choices.
3. Look for wild salmon at your local health food stores.
4. Mix canned sardines with your own combination of chopped red onion, avocado, hard-cooked eggs, lemon juice, salt and/or pepper.
5. Add chopped anchovies to pasta sauce just after you sauté your onions and garlic; the fish will melt away while leaving a mild, subtle fishy taste to your sauce.
6. When buying canned products, look for fish packed in water or olive oil (preferably, extra-virgin).
7. Cook with either dry or moist heat methods; poached, steamed, grilled, baked, or broiled are preferred.
8. Avoid fish that is battered and fried, slathered in butter, or blanketed in creamy sauces to reduce saturated fat and calorie intake.



This Facts About document is published by Monica Myklebust, MD, and Jenna Wunder, MPH, RD, at University of Michigan Integrative Medicine Clinical Services. Our mission is to care for people using an Integrative Medicine model that reaffirms the importance of relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.

Lean Meats

This Facts About reviews lean meats and gives examples of foods to choose from as well as foods to avoid. We provide a guide for selecting an appropriate portion size and recommendations for incorporating healthy changes into your diet.


What are the recommended servings per week?


* Optional* : 1-3 servings per week



*Optional - Those individuals choosing to not include animal foods in their diet need to be aware of important nutrients found in these foods. These nutrients can be obtained from a thoughtful and varied vegetarian diet. However, some individuals who avoid animal products may develop a vitamin B12 or iron deficiency and may also need to consider a calcium supplement. If you have questions regarding this, consult with your physician or registered dietitian regarding your individual needs.


Why choose lean meat?


* High protein source
* Rich iron source
* Contains B-12 vitamins



Selected Food Sources with Serving Sizes



Selected Lean Meat Sources
Lean Meat
Portion size: 2-3 oz

Poultry Beef Pork Lamb Wild Game
Chicken Flank steak Centerloin Chops Venison
Cornish hen Sirloin tip Tenderloin Leg roast Bison
Turkey Eye of Round Canadian bacon Tenderloin
Shank Elk

White meat, but not dark meat, without skin is considered lean.
Top Round

Ostrich
Tenderloin

Emu
Top Loin

Squab
Rump roast

Wild duck
Extra lean ground beef

Pheasant
Rabbit



Special Considerations?


Choosing lean meats


* Choose lean meat containing less than 3g of fat per 1 oz
* Generally, the leanest cuts of meat contain round or loin in their name
* Choose animal products that are labeled “organic,” “hormone-free,” “antibiotic-free,” “free-range,” “grass-fed, “ and / or “wild” whenever possible
* Choose lean meat over higher fat choices to reduce total fat intake
* Consume lean meat weekly rather than daily
* Look for poultry with USDA Select grading of A and B
* Look for beef with USDA Select or Choice grading
* To lower the fat content of poultry and other meat, cut off skin and fat before cooking and/or eating it
* While many grocery stores carry both ground chicken and ground turkey, it may contain as much fat as ground beef because it may include dark meat and skin. For lower fat, choose ground breast meat or look for low fat ground chicken or turkey.



Saturated Fat Content


* Lean meat contains less than 3g of fat per 1 oz , which is less than higher fat choices, but still contains some saturated fat
* The typical American diet is high in saturated fat, coming mostly from animal foods
* Eating too many foods with saturated fat may increase blood levels of LDL and total cholesterol. High blood levels of LDL and total cholesterol are risk factors for heart disease.
* Diets high in saturated fat promote obesity, cancer, heart disease, inflammatory arthritis, diabetes, and chronic pain



Use of Hormones and Antibiotics


* Most commercial animal products contain residues from drugs, hormones, and chemicals used to keep modern dairy cows producing abundantly. These residues in food may increase the risk of breast cancer and other hormone-related cancers including prostate cancer.
* Most commercially-raised animals may have been exposed to antibiotics. This practice contributes to the escalating problem of antibiotic-resistant bacteria throughout the world.



Choose Organic




We recommend organic, free-range animal products because they contain less antibiotic or hormone residue and have a higher omega-3 and vitamin E content. These qualities make organic animal products a better nutritional choice. We believe they generally provide better flavor than conventionally raised animals.


Organic food is produced by farmers who emphasize the use of renewable resources and the conservation of soil and water to enhance environmental quality for future generations. Organic meat, poultry, eggs, and dairy products come from animals that are given no antibiotics or growth hormones. Organic food is produced without using most conventional pesticides, petroleum-based fertilizers, or sewage sludge-based fertilizers, bio-engineering, or ionizing radiation. Organic systems replenish and maintain soil fertility, eliminate the use of toxic and persistent pesticides and fertilizers, and build biologically diverse agriculture.




Free-Range, Grass-fed, Pasture-raised




Some studies have shown that free-range, grass-fed and pasture-raised animals contain more omega-3 fatty acids and vitamin E. Free-range farming generally provides adequate room inside. To be certified by the USDA, producers must demonstrate to the Agency that the animal has been allowed access to the outside. These animals have fresh air, open space, and enjoy shelter. They also have the opportunity to forage for food.




Know Your Limits for Fat


* On a 2,000 calorie diet, about 30% or 600 calories (67g) should come from total fat per day
* A ratio of 1:2:1 of saturated: monounsaturated: polyunsaturated (such as Omega-3s) fat is recommended
* 1:2:1 in calories equals 150:300:150; no more than 150 calories or 7.5% (17g) of total calories from saturated fat



Ideas for your lean meat consumption


1. When ordering lean meat in restaurants make sure that it has been prepared with either dry or moist heat methods; poached, steamed, grilled, baked or broiled are preferred.
2. To reduce saturated fat and calorie intake, avoid meat that has been battered and fried, slathered in butter, or blanketed in creamy sauces.
3. Experiment with leaner cuts of meat in your favorite recipes to replace higher fat choices.
4. Choose lean meat up to 3 times per week rather than daily.
5. Use lean meat to flavor meals rather than as the main focus.
6. Be mindful of portion size for all meats – a 2-3 oz serving of lean meat is approximately the size of a deck of cards
7. To reduce the amount of meat in a recipe, replace half with beans, mushrooms or other vegetables.



This Facts About document is published by Monica Myklebust, MD, and Jenna Wunder, MPH, RD, at University of Michigan Integrative Medicine Clinical Services. Our mission is to care for people using an Integrative Medicine model that reaffirms the importance of relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.

Alcohol

This Facts About reviews the benefits and risks of alcohol consumption. It also provides a guide for selecting appropriate amounts.


What are the recommended servings per day?


* Optional: 1-2 servings per day depending on age, gender, and history



Optional - Although there are some documented health benefits to moderate alcohol consumption, we do not encourage people to start drinking. As with other categories listed in this pyramid, there are potential health risks that must be weighed (see health concerns section).


What is moderate drinking?


* One drink or less a day for women and people over 60
* Two drinks or less a day for men (no more than one an hour)



This limit is based on the differences between men and women both in weight and the way they metabolize alcohol.


Is the risk-benefit balance for an individual drinker favorable or unfavorable?


Risk-benefit balance depends on the individual's age, gender, and history. We do not recommend alcohol consumption for:


* Women who are pregnant or planning to become pregnant
* People who plan to drive or engage in other activities that require attention or skill
* People taking medications that interact with alcohol, including some over-the-counter medications
* Individuals with a history of alcoholism or alcohol abuse
* Those under the age of 21



Selected Alcohol Beverage Sources with Serving Sizes



Type of Drink


Serving Size


Typical % Alcohol


Total Amount of Alcohol



Beer


12 oz.


5 %


0.6 oz.



Wine


5 oz.


12 %


0.6 oz.



Hard liquor (whiskey, vodka, rum, gin, scotch)


1.5 oz.


40 %


0.6 oz.



The alcohol content of a beverage is dependent on its alcohol concentration, or % alcohol. The above examples contain approximately the same amount of alcohol.




What are the potential health benefits of moderate alcohol consumption?


* May lower risk of coronary artery disease and heart attack
* May decrease risk of stroke caused by blocked blood vessels
* Decreases tension, anxiety, and self-consciousness
* In the elderly, stimulates appetite and may promote regular bowel movement
* May be associated with a decreased risk of gall bladder surgery in women



Red Wine


* Moderate consumption may be associated with longevity
* Contains tannins, which may raise HDL (good) cholesterol levels and inhibit platelet cells in the blood from clumping together
* Contains resveratrol, an antioxidant compound found in grapes, which may decrease the development of some cancers
* Resveratrol affects the immune system and inflammation in the body; both immune and inflammatory components are thought to be important in the development of plaque buildup in blood vessels, which often leads to heart disease
* Significant source of saponins, antioxidants believed to promote heart health by binding to cholesterol in the blood and preventing its absorption
* Saponins may play a role in decreasing inflammation, which could have beneficial effects in reducing heart disease and cancer risks



Liquor and Beer


* Raises HDL (good) cholesterol levels
* Inhibits platelet cells in the blood from clumping together



What are the health concerns of alcohol consumption?


* Increases risk of accidents
* Often a trigger for migraine headaches
* Increases strokes caused by bleeding
* Higher risk of fetal alcohol effect (FAE), low birth weight, and stillbirth
* Increases physical, mental, and behavioral problems among the children of mothers who drink during pregnancy
* Medication interactions - including non-prescription drugs
* Increases the risk for cancers of the oral cavity, pharynx, esophagus, and larynx
* Increases the risk for cancers of the stomach, colon, rectum, liver, and ovaries
* Increases accumulation of fat in the liver, alcoholic hepatitis, and cirrhosis. This contributes to liver disease and sometimes liver failure.
* Increases estrogen levels, a risk for breast cancer
* Tobacco use enhances alcohol's effects on the risk for cancers of the upper digestive and respiratory tract
* Liquor consumption (not beer or wine) may be associated with higher homocysteine levels in the blood which is associated with an increased risk of heart disease



Specific Considerations


* Abstinent individuals should not begin to drink solely for health benefits
* Some benefits can be achieved from whole foods instead of alcohol. Resveratrol contained in grape skins is available in whole grapes, grape juice or wine.
* Ask your physician about potential benefit and harm of alcohol consumption in your individual case, considering your age, gender, medical history, and medications



This Facts About document is published by Monica Myklebust, MD, and Jenna Wunder, MPH, RD, at University of Michigan Integrative Medicine Clinical Services. Our mission is to care for people using an Integrative Medicine model that reaffirms the importance of relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.


Take a Second


Take a Second (Excerpts from toolstolife)

While we are postponing, life speeds by.
-Lucius Seneca (3BC–65AD)

Are you really telling me you don’t have a second? Come on, it’s me you’re talking to. Remember the rule: “I will not lie to myself.” Remember too, you’re training yourself to hear your inner voice. Out loud. Ready? Here we go: “Yes, I have a second.” That’s all it takes to improve the quality of your life. A second here, a second there.

You've trained yourself to be lazy. You trained yourself to ignore your inner voice. Now, as with everything else, we will use the Tools to stop being lazy. We will use these Tools to improve the quality of our everyday life. What’s funny is that, by taking a second, you will add time, not take time away, from your every day. You will feel lighter and happier overall. Hey, I can hear you! Be patient. I always tell you what I’m talking about, can’t you give me a second for my build up?

You’re already taking two to ten minutes a day, and now you will take a second as well. Let’s start easy. Your keys. How much time goes into looking for your keys? How come, when you come in through the door, you don’t take a second? How come you end up putting your keys anywhere and then have to take time and frustrate yourself looking for them? Then you feel late and pressured and annoyed before you even get to the door.

That’s not starting your day or any other time in the right frame of mind. Here’s what we will do. I like hooks for keys, but you pick. You find a place, a location where you’re going to put your keys. You will put them there every time you walk in the door. You will take that second and put the keys there. Again: you’re going to put the keys there. Take the second and make a mental note. Remember, Train Your Brain. Your inner voice will take care of it, and soon you’ll automatically put the keys there. Imagine no more looking for the keys. No more frustration! No more leaving the house feeling hassled. So take a second!

Action may not always bring happiness, but there is
no happiness without action.
-Benjamin Disraeli

Let’s hit some more easy ones:

(a) Put the cap right back on the toothpaste.

(b) Hey guys, put the toilet seat down.

(c) Put your CDs away! Again, this takes only a few seconds. You paid good money for them. You enjoy them. You want to be able to find them. You don’t want them scratched. You don’t want to fight with anyone who lives with you. Hey, it just takes a few seconds. You spend a lot more time going through the pile looking for them, than putting them away.

(d) Make your bed when you’re finished dressing. It takes a second. You’ll feel better about yourself. It’s nice to come home to a made bed. You actually function better at work or school knowing your bed is made. It builds self-esteem.

(e) Before you go to bed, put your clothes in the hamper, or hang them up.

(f) Do the dishes when you finish eating. Old dishes take longer to clean. Take a second and do them. I bet most of you have a dishwasher. How tough is it to put them in? Again, having a clean house builds self-esteem, and you perform better. Remember, we want all the odds on your side. Don’t lie to yourself; you have the time. You will spend less time by taking those seconds.

First say to yourself what you would be; and then do what you have to. -Epictetus

There are so many more examples I can give, so take a sec', and do the things you should. Life is not as tough as we make it on ourselves—from how to study to how to keep house to how to live. For now I would like to end with what will only take you a second. Ready? “TAKE A SEC'.”

So every time your inner voice says, “Do it now,” and your out-loud voice says, “I’ll do it later,” you do it now. You’re going to develop the habit of paying attention to your inner voice and doing the things you know you should, right there and then. No lost bills, no failing to find things or coming home to a mess. You’ll find your mind will function clearer and quicker without all these little things piling up and without constantly frustrating yourself.

I have always found that we are our own best friends and our own worse enemies. We can be both or just one. You can give yourself an edge out there.
Build your self-esteem, build positive habits and be successful. Everything builds
on itself. The better you feel, the better you can take advantage of life’s opportunities. The better you feel, the more positive momentum you have behind you.

It’s funny, but a simple thing like making your bed or leaving a clean sink gives you strength. Remember, the brain is a sponge and functions on many different levels. Your brain knows that you didn’t pay the bills even if you’re not thinking about them. Your brain knows that you’re coming home to a mess, even if you’re not thinking about it. Besides, you can’t invite someone over on the spur of the moment, and you never know what you might be missing. Seriously folks, your brain knows, and all the little things you don’t take a second for clutter your brain, and when you’re out there in the real world, you might be a split second behind the ball because of it. Your brain might wander, and one of those things you didn’t take a second for might take over right when you need to be paying attention to what’s going on. Just like when you’re driving and hit the car in front of you because your mind drifted for that split second.

Listen, we’re here to get all the odds in our favor, and all these little seconds end up costing not only more time; they also cost you peace of mind, whether you realize it or not. So we’re going to take a second. Remember, every time you say “later,” do it now. Pick a spot for your keys, pay attention to yourself when you come in through the door and take a second to put your keys there every time. Remember the inner voice that says not to lie to yourself. You know you can do it, and today we’re making the decision to do it.
Early Prostate Cancer: Questions and Answers
Early Prostate Cancer: Questions and Answers

Key Points

* The prostate is a gland in the male reproductive system that makes and stores a component of semen (see Question 1).
* The most common risk factor for prostate cancer is age (see Question 3).
* Prostate cancer often does not cause symptoms for many years. By the time symptoms occur, the disease may have spread beyond the prostate (see Question 4).
* The symptoms of prostate cancer can also be caused by noncancerous conditions (see Questions 4 and 5).
* Two tests can be used to detect prostate cancer in the absence of any symptoms: a digital rectal exam and a blood test to detect a substance made by the prostate called prostate-specific antigen (PSA) (see Questions 6 and 7).
* The diagnosis of prostate cancer can be confirmed only by a biopsy (see Question 8).
* Prostate cancer is described by both grade and stage (see Question 8).
* Three treatment options are generally accepted for men with localized prostate cancer: radical prostatectomy, radiation therapy, and surveillance (also called watchful waiting) (see Questions 9, 10, and 11).

1. What is the prostate?

The prostate is a gland in the male reproductive system. The prostate makes and stores a component of semen and is located in the pelvis, under the bladder and in front of the rectum. The prostate surrounds part of the urethra, the tube that empties urine from the bladder. A healthy prostate is about the size of a walnut. Because of the prostate’s location, the flow of urine can be slowed or stopped if the prostate grows too large.

2. What is prostate cancer?

Prostate cancer forms in the tissues of the prostate. Except for skin cancer, cancer of the prostate is the most common malignancy in American men. It is estimated that 218,890 men in the United States will be diagnosed with prostate cancer in 2007 (1). In most men with prostate cancer, the disease grows very slowly. The majority of men with low-grade, early prostate cancer (which means that cancer cells have been found only in the prostate gland) live a long time after their diagnosis. Even without treatment, many of these men will not die of the prostate cancer, but rather will live with it until they eventually die of some other, unrelated cause. Nevertheless, it is estimated that nearly 27,000 men will die from prostate cancer in 2007 (1).

3. Who is at risk for prostate cancer?

An important risk factor is age; more than 70 percent of men diagnosed with this disease are over the age of 65. African American men have a substantially higher risk of prostate cancer than white men, including Hispanic men. Dramatic differences in the incidence of prostate cancer are also seen in different populations around the world. There is some evidence that dietary factors are involved, such as vitamin E and selenium, which may have a protective effect. Genetic factors also appear to play a role, particularly for families in which the diagnosis is made in men under age 60. The risk of prostate cancer rises with the number of close relatives who have the disease.

4. What are the symptoms of prostate cancer?

Prostate cancer often does not cause symptoms for many years. By the time symptoms occur, the disease may have spread beyond the prostate. When symptoms do occur, they may include:
* Urinary problems:
o Not being able to urinate.
o Having a hard time starting or stopping the urine flow.
o Needing to urinate often, especially at night.
o Weak flow of urine.
o Urine flow that starts and stops.
o Pain or burning during urination.
* Difficulty having an erection.
* Blood in the urine or semen.
* Frequent pain in the lower back, hips, or upper thighs.

These can be symptoms of cancer, but more often they are symptoms of noncancerous conditions. It is important to check with a doctor.

5. What other prostate conditions can cause symptoms like these?

As men get older, their prostate may grow bigger and block the flow of urine or interfere with sexual function. This common condition, called benign prostatic hyperplasia (BPH), is not cancer, but can cause many of the same symptoms as prostate cancer. Although BPH may not be a threat to life, it may require treatment with medicine or surgery to relieve symptoms. An infection or inflammation of the prostate, called prostatitis, may also cause many of the same symptoms as prostate cancer. Again, it is important to check with a doctor.

6. Can prostate cancer be found before a man has symptoms?

Yes. Two tests can be used to detect prostate cancer in the absence of any symptoms. One is the digital rectal exam (DRE), in which a doctor feels the prostate through the rectum to find hard or lumpy areas. The other is a blood test used to detect a substance made by the prostate called prostate-specific antigen (PSA). Together, these tests can detect many "silent" prostate cancers that have not caused symptoms. Due to the widespread implementation of PSA testing in the United States, approximately 90 percent of all prostate cancers are currently diagnosed at an early stage, and, consequently, men are surviving longer after diagnosis.

At present, however, it is not known whether routine prostate screening saves lives. Screening is a term used to describe tests when they are done in individuals who are not experiencing any symptoms. The benefits of screening and local therapy (surgery or radiation) remain unclear for many patients. Because of this uncertainty, the National Cancer Institute (NCI), a part of the National Institutes of Health, is currently supporting research to learn more about screening men for prostate cancer. Currently, researchers are conducting a large study to determine whether screening men using a blood test for PSA and a DRE can help reduce the death rate from this disease. They are also assessing the risks of screening. Full results from this study, the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO), are expected by 2015.

7. How reliable are the screening tests for prostate cancer?

Neither of the screening tests for prostate cancer is perfect. Most men with mildly elevated PSA levels do not have prostate cancer, and many men with prostate cancer have normal levels of PSA. Also, the DRE can miss many prostate cancers. The DRE and PSA test together are better than either test alone in detecting prostate cancer.

A recent study examining the PSA histories of men enrolled in the Baltimore Longitudinal Study of Aging (BLSA) suggests that PSA velocity may be a better indicator of potentially life-threatening cancer than PSA level. PSA velocity is the rate at which serum PSA levels change over time. The study found that men who had a PSA velocity above 0.35 ng/ml per year had a higher relative risk of dying from prostate cancer than men who had a PSA velocity less than 0.35 ng/ml per year (2). More studies are needed to determine if PSA velocity more accurately detects potentially life-threatening prostate cancer early.

The NCI Early Detection Research Network (EDRN) has a Prostate Collaborative Group, which is applying a variety of strategies to find better ways to detect prostate cancer early. In addition, the NCI’s prostate cancer Specialized Program of Research Excellence (SPORE) program is funding projects to identify new biomarkers to detect prostate cancer.

8. How is prostate cancer diagnosed?

The diagnosis of prostate cancer can be confirmed only by a biopsy. During a biopsy, a urologist (a doctor who specializes in diseases of urinary and sex organs in men, and urinary organs in women) removes tissue samples, usually with a needle. This is generally done in the doctor’s office with local anesthesia. Then a pathologist (a doctor who identifies diseases by studying tissues under a microscope) checks for cancer cells.

Men may have blood tests to see if the cancer has spread. Some men also may need the following imaging tests:
* Bone scan: The doctor injects a small amount of a radioactive substance into a blood vessel. It travels through the bloodstream and collects in the bones. A machine called a scanner detects and measures the radiation. The scanner makes pictures of the bones on a computer screen or on film. The pictures may show cancer that has spread to the bones.

* CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of areas inside the body. Doctors often use CT scans to see the pelvis or abdomen .

* MRI: A strong magnet linked to a computer is used to make detailed pictures of areas inside the body.

Prostate cancer is described by both grade and stage.
* Grade describes how closely the tumor resembles normal prostate tissue. Based on the microscopic appearance of tumor tissue, pathologists may describe it as low-, medium-, or high-grade cancer. One way of grading prostate cancer, called the Gleason system, uses scores of 2 to 10. Another system uses G1 through G4. In both systems, the higher the score, the higher the grade of the tumor. High-grade tumors generally grow more quickly and are more likely to spread than low-grade tumors.

* Stage refers to the extent of the cancer. Early prostate cancer, stages I and II, is localized. It has not spread outside the gland. Stage III prostate cancer, often called locally advanced disease, extends outside the gland and may be in the seminal vesicles. Stage IV means the cancer has spread beyond the seminal vesicles to lymph nodes and/or to other tissues or organs.

9. How is localized prostate cancer treated?

Three treatment options are generally accepted for men with localized prostate cancer: radical prostatectomy, radiation therapy (with or without hormonal therapy), and surveillance (also called watchful waiting).
* Radical prostatectomy is a surgical procedure to remove the entire prostate gland and nearby tissues. Sometimes lymph nodes in the pelvic area (the lower part of the abdomen, located between the hip bones) are also removed. Radical prostatectomy may be performed using a technique called nerve-sparing surgery that may prevent damage to the nerves needed for an erection. However, nerve-sparing surgery is not always possible.

* Radiation therapy involves the delivery of radiation energy to the prostate. The energy is usually delivered in an outpatient setting using an external beam of radiation. The energy can also be delivered in a technique known as brachytherapy, which involves implanting radioactive seeds in the prostate using a needle. Patients with high-risk prostate cancer are candidates for adding hormonal therapy to standard radiation therapy.

* Active Surveillance (watchful waiting) may be an option recommended for patients with early-stage prostate cancer, particularly those who have low-grade tumors with only a small amount of cancer seen in the biopsy specimen. These patients have regular examinations, PSA testing, and sometimes scheduled biopsies. If there is evidence of cancer growth, active treatment may be recommended. Older patients and those with serious medical problems may also be good candidates for active surveillance.

10. How does a patient decide what is the best treatment option for localized prostate cancer?

Choosing a treatment option involves the patient, his family, and one or more doctors. They will need to consider the grade and stage of the cancer, the man’s age and health, and his values and feelings about the potential benefits and harm of each treatment option. Since both surgery and radiation therapy are options for localized disease, consultation with both a urologist and a radiation oncologist is recommended. Often it is useful to seek additional opinions—from the same type of doctor, an internist, a family practice physician, or a medical oncologist. Because there are several reasonable options for most patients, patients may hear different opinions and recommendations and the decision can be difficult. However, patients should try to get as much information as possible and allow themselves enough time to make a decision. There is rarely a need to make a decision without taking time to discuss and understand the pros and cons of the various approaches.

11. Where can a person find more information about prostate cancer and its treatment?

The NCI has several other resources that readers may find helpful, including the following:

* The Prostate Cancer home page provides links to NCI resources about prevention, screening, treatment, clinical trials, and supportive care for this type of cancer. This page can be found on the NCI’s Web site at http://www.cancer.gov/cancertopics/types/prostate on the Internet.

* Prostate Cancer (PDQ®): Treatment includes information about prostate cancer treatment, including surgery, chemotherapy, radiation therapy, and hormone therapy. This summary of information from PDQ, the NCI’s comprehensive cancer information database, is available at http://www.cancer.gov/cancertopics/pdq/treatment/prostate/patient/ on the Internet.

* Treatment Choices for Men With Early-Stage Prostate Cancer describes the treatment choices available to men diagnosed with early-stage prostate cancer and examines the pros and cons of each treatment. This NCI fact sheet is available at http://www.cancer.gov/cancertopics/prostate-cancer-treatment-choices on the Internet.



Selected References

1. Ries LAG, Melbert D, Krapcho M, et al. SEER Cancer Statistics Review, 1975–2004. Bethesda, MD: National Cancer Institute, 2007.

2. Carter HB, Ferrucci L, Kettermann A, et al. Detection of life-threatening prostate cancer with prostate-specific antigen velocity during a window of curability. Journal of the National Cancer Institute 2006; 98(21):1521–1527.

###

Related NCI materials and Web pages:

* National Cancer Institute Fact Sheet 5.29, The Prostate-Specific Antigen (PSA) Test: Questions and Answers
(http://www.cancer.gov/cancertopics/factsheet/Detection/PSA)
* Treatment Choices for Men With Early-Stage Prostate Cancer
(http://www.cancer.gov/cancertopics/prostate-cancer-treatment-choices)
* Understanding Prostate Changes: A Health Guide for Men
(http://www.cancer.gov/cancertopics/understanding-prostate-changes)
* What You Need To Know About™ Prostate Cancer
* (http://www.cancer.gov/cancertopics/wyntk/prostate)
* Prostate Cancer Home Page
(http://www.cancer.gov/cancertopics/types/prostate)
NCCN Prostate Cancer Notes


Clink on the above link for more notes
Management of Bone Metastases in Patients With Prostate Cancer
Introduction

Over 80% of patients with advanced prostate cancer are affected by bone metastasis, an incurable progression of the disease that accounts for a vast majority of disease-related mortality and is associated with significant morbidity. In addition, androgen deprivation therapy (ADT), the mainstay of treatment for advanced prostate cancer, increases fracture risk and may contribute to skeletal morbidity. The combination of these factors makes bone metastases one of the most wide-reaching and difficult processes to address in patients with prostate cancer.

Because the precise molecular and cellular mechanisms of the metastatic process in prostate cancer are still poorly understood, there remains an unmet need for effective strategies to prevent the progression of disease or, at the very least, to diminish the likelihood for development of additional metastases. Among the various, mostly palliative, treatments used to treat bone metastases, bone-targeted approaches using bisphosphonates, radiopharmaceuticals, or endothelin receptor antagonists currently appear to offer the most promise in terms of efficacy and tolerability.

This chapter of the Report to the Nation on Prostate Cancer will review the best-understood mechanisms behind the development of bone metastases and the latest research in the use of agents to combat the progression of and the complications associated with bone metastatic prostate cancer.
Mechanisms of Bone Metastasis

Bone metastases in patients with breast cancer and multiple myeloma are predominantly osteolytic in nature. By contrast, prostate bone lesions are mixed, containing both osteolytic and osteoblastic elements. Under normal conditions, the rates of bone formation and bone resorption are balanced. In patients with prostate cancer, however, the increase in osteoblast number and activity, coupled with an increase in osteoclastic activity adjacent to the osteoblastic lesions,[10,11] leads to an imbalance in remodeling and to more brittle bone tissue. Of note, urinary deoxypyridinoline, a marker of osteoclastic activity, has been shown to predict skeletal complications in patients with androgen-independent bone metastatic disease,[ indicating that bone resorption can directly affect clinical outcomes.

Transforming growth factor-beta (TGF-beta), epidermal growth factor (EGF), and other bone-derived growth factors that promote prostate cancer cell growth and differentiation have been shown to influence the preferential localization of prostate cancer in bone tissue. TGF-beta, which is expressed by prostate cancer cells and plays a role in osteoclastic maturation, facilitates cellular adhesion to the bone matrix, which, in turn, influences expression of androgen-independent cellular growth. Similarly, by promoting migration of prostate cancer cells to bone tissue, EGF facilitates development of metastases in bone.

Other tumor-derived factors that have been shown to influence development of bone metastases include endothelin-1, osteoprotegerin, bone morphogenic protein, and insulin-like growth factor. Discussion of their respective roles in the pathogenesis of bone metastases and of their potential utility as therapeutic targets is presented below.

The primary mechanisms of bone metastasis development in prostate cancer are illustrated in the Figure.
Figure 1

Figure. Interaction between tumor cells and bone in patients with bone metastatic prostate cancer.

TGFβ = transforming growth factor-beta; IGF = insulin-like growth factor; ET-1 = endothelin-1; BMPs = bone morphogenic proteins; OPG = osteoprotegerin; EGF = epidermal growth factor; bFGF = basic fibroblast growth factor.

Detection of Prostate Bone Metastases

Bone scintigraphy, or conventional bone scan, with Tc-99m MDP radiotracer is the current standard of care for detection of bone metastases. With this method, the entire skeleton is imaged, and uptake of the tracer is mediated by osteoblastic activity rather than the tumor itself. Bone scans are very sensitive, but not specific; other processes are associated with increased tracer accumulation in bone, including trauma, infection, and degenerative joint disease such as arthritis.

Studies with magnetic resonance imaging (MRI) indicate improved efficacy over bone scintigraphy due to its ability to detect metastatic cellular foci (ie, fatty and cellular tissue elements of bone marrow) before cortical bone destruction has occurred. In a series of 36 prostate cancer patients, MRI showed to be particularly useful in clarifying inconclusive radiographic tests in prostate cancer. Of 19 positive bone scans in 36 patients, MRI confirmed 8 equivocal cases and demonstrated additional metastatic lesions in 6 patients. MRI also indicated areas of spinal compression in 5 patients with spinal metastases, and altered the clinical stage in 2 patients. Only 1 false positive was noted. Results from a second trial in 19 men with prostate cancer concurred: Detection of metastatic disease was seen in 7% (1/13) of patients with a negative bone scan, and in 2 of 4 patients with indeterminate bone scans. Again, only 1 false positive was reported.

Given its demonstrable sensitivity over bone scintigraphy, MRI might also play a role in initial staging. In a retrospective review of staging skeletal scintigraphs in 200 patients with breast or prostate cancer, researchers determined that 7 of 100 breast cancer patients and 9 of 100 prostate cancer patients would be expected to have a negative MRI and abnormal bone scintigraphy. However, in the breast cancer patients, 1 of 7 abnormal scans represented metastatic disease, while in prostate cancer patients, only 1 of 3 represented metastatic disease. In addition, the high cost and difficulty in scanning all areas of interest limit the routine use of MRI. Thus, although data suggest that the addition of MRI to scintigraphy in initial staging may provide a more accurate basis for patient management, further study of MRI in this setting is clearly needed.

Because of its ability to detect tumors on the basis of metabolic activity rather than by simply demonstrating increased bone mineralization, the use of fluorine-18-deoxyglucose positron emission tomography (FDG-PET) has been examined as an alternative to bone scintigraphy. However, although it has proven effective in detecting other solid tumors, results in prostate cancer have been disappointing, possibly because prostate cancer tends to be metabolically quiescent. In one study, the technique underestimated the extent of osseous metastatic lesions in 4 of 5 patients, while in another it missed many of the osseous lesions found by bone scans.

By contrast, the use of 18-fluoride (18-F) as a tracer has shown greater promise. Early studies showed it to be more sensitive than bone scintigraphy, detecting twice as many prostate metastases in patients with established disease. Upon evaluation of patients with known metastatic lung cancer, two studies demonstrated that 18-F PET was more accurate and resulted in fewer false negatives compared with both bone scintigraphy and single photon emission computed tomography (SPECT). In a study of 26 patients with solid tumors and bone metastases, the integration of PET and computed tomography (CT) using the 18-F tracer had a 100% sensitivity and an 88% specificity vs 88% and 56%, respectively, with PET alone. Because these techniques are more expensive than the standard bone scintigraphy, additional studies with larger patient populations will be needed to confirm the benefits of 18-F PET and/or 18-F PET/CT.
Management of Bone Metastases

Bisphosphonates, synthetic analogues of inorganic phosphate that affect human bone metabolism through direct and indirect actions on osteolysis, have emerged as a key therapeutic strategy in the management of bone disease. Although they have demonstrable efficacy in treating osteoporosis, Paget's disease of bone, and hypercalcemia of malignancy, and have also proven beneficial in treating skeletal complications and pain in breast cancer, their application in the management of advanced prostate cancer is expanding, with more research being conducted to fully understand the potential of these agents.

Bisphosphonates are believed to act through several mechanisms: inhibition of cancer cells that bind to the bone matrix; osteoclast apoptosis through competitive inhibition of ATP/ADP translocase; inhibition of osteoclast formation, migration, and bone resorption; and inhibition of matrix metalloproteinases (MMPs). Recent in vitro data also suggest that bisphosphonates might act directly on osteoblasts by promoting preosteoblastic cell growth and differentiation. Their use in stemming bone loss seen with ADT has been well described, and is discussed in a separate chapter.

Variations in the molecular structure of each bisphosphonate determine its affinity for the bone mineral surface and its relative potency. Because the ability of bisphosphonates to inhibit cancer cell adhesion to cortical and trabecular bone has been shown to predict clinical efficacy, it has been suggested that use of more potent agents might improve outcomes in the management of bone metastases.
Zoledronic Acid

Of the available bisphosphonates, the third-generation zoledronic acid is the most potent. Like other agents in this class, its effects are mediated primarily through osteoclast proliferation and apoptosis.

In one of the largest phase 3 clinical trials with zoledronic acid, 643 patients with asymptomatic or minimally symptomatic bone metastatic androgen-independent prostate cancer (AIPC) were randomized to placebo or to 4 mg or 8 mg of zoledronic acid once every 3 weeks. To minimize renal complications, the protocol was amended to administration of the infusion over 15 minutes rather than over 5 minutes, and the infusate volume was increased from 50 to 100 mL. In addition, patients in the 8-mg arm were switched to the 4-mg dosage.

At study end, after 15 months of follow-up, fewer patients enrolled on the 4-mg zoledronic acid arm vs the placebo arm experienced at least one skeletal complication (33.2% with zoledronic acid vs 44.2% with placebo; P = .021), and the time to the first occurrence of any skeletal complication was shorter with placebo (median time to first event not reached in 4-mg group with zoledronic acid vs 321 days with placebo; P = .011). The skeletal morbidity rate, calculated as the number of skeletal complications divided by the time at risk in years, was significantly lower with 4-mg zoledronic acid (.80 vs 1.49; P = .006).[36] Significant reductions in biochemical markers of bone metabolism were also observed. The drug was well tolerated; the most commonly reported adverse events included fatigue, anemia, myalgia, fever, and lower-limb edema.

Updated results from this trial demonstrated continuing benefits at 24 months.[37] The proportion of patients experiencing at least one skeletal complication remained significantly lower with 4-mg zoledronic acid over placebo (38% vs 49%; P = .028), as did the median time to first event (488 days vs 321 days; P = .009). A significant delay was noted in the median time to a second event in patients on the zoledronic acid arm (median not reached for 4-mg zoledronic acid vs 449 days for placebo; P = .006), and a 32% relative reduction was noted in the percentage of patients on the zoledronic acid arm experiencing a second event vs those on placebo (P = .017).[38] Notably, a multiple-event analysis combining skeletal complication rate and timing suggested an overall 40% reduction in the risk for developing subsequent events with 4-mg zoledronic acid vs placebo (P = .011).

As a class, bisphosphonates have an analgesic effect on bone pain, which is often included as an endpoint in clinical studies on bone metastases. In this trial, although there was an increase in mean bone pain scores (as measured by the Bone Pain Inventory) from baseline in both treatment and control groups, bone pain was consistently lower in patients treated with zoledronic acid vs placebo at all time periods, reaching statistical significance at the 3-, 9-, 21-, and 24-month time points.

On the basis of results from this and other studies, zoledronic acid was approved for the management of bone metastases in patients with AIPC, and may be of particular value for patients at high risk for bone fractures or spinal cord compression. The effect of zoledronic acid on skeletal complications in patients with hormone-sensitive disease will be evaluated in the CALGB/CTSU 90202 trial that is currently recruiting patients. Additional studies are needed to assess the potential for bisphosphonates to prevent the development of bone metastases.
Pamidronate and Clodronate

Pamidronate disodium, a second-generation bisphosphonate, and clodronate, a first-generation bisphosphonate, are far less potent than zoledronic acid, and the evidence supporting the use of either agent in prostate bone metastases is less clear than that for zoledronic acid.

Pamidronate is approved in the United States for use in hypercalcemia of malignancy, as well as for the treatment of osteolytic bone metastases in patients with breast cancer and multiple myeloma. However, in patients with symptomatic bone metastatic AIPC, data from two trials pooled for analysis showed no significant benefit for pamidronate 90 mg every 3 weeks vs placebo. Of the 374 patients enrolled in the trials, no sustainable differences were noted between the two arms in the proportion of patients with a skeletal complication or in change from baseline in mobility at 9 weeks or at 27 weeks.[41] Of the 301 patients assessable for pain at 9 weeks and 218 patients assessable at 27 weeks, Brief Pain Inventory scores declined only minimally from baseline and were comparable between the treatment and control groups. The only significant difference was noted in a subset of pamidronate patients with decreasing or stable analgesic use, in whom the mean decrease in pain scores was significantly greater than placebo at 9 weeks (P = .008 for worst pain; P = .011 for average pain), but not at 27 weeks.

Data with clodronate, which remains investigational in the United States, are even less promising. Of the 209 patients with symptomatic bone metastatic AIPC receiving mitoxantrone and prednisone, no significant differences were noted between the addition of clodronate 1500 mg every 3 weeks or placebo in the primary study endpoint of palliation, defined as a reduction of 2 points on the pain scale or a 50% reduction in analgesic intake.[42] No differences were seen in other endpoints of median duration of response, progression-free survival, overall survival, and overall quality of life, although patients with more severe pain fared slightly better on subgroup analysis.

In patients with androgen-sensitive bone metastatic prostate cancer, investigators attempted to increase the dose of oral clodronate to more closely match that which would have been delivered intravenously. However, although the 2080-mg daily dose of clodronate resulted in a 21% reduction in the risk of symptomatic bone progression or prostate cancer death and a 20% reduction in the risk of death,[43] clodronate treatment was associated with significantly greater risk for gastrointestinal problems, leading to dose modification in approximately one third of patients (hazard ratio, 181% increase; P < .0001). The high rate of gastrointestinal toxicities suggests that the increased dose strategy is not feasible, and that the use of clodronate and other oral bisphosphonates in patients with prostate cancer is unlikely to be effective in management of bone metastases.

Although subgroup analysis in this study demonstrated a significant decrease in the time to first symptomatic skeletal complication, suggesting that there might be a benefit toward initiating bisphosphonate therapy at an earlier time point in the management of bone metastatic AIPC. Results from a similarly designed study ultimately found no significant benefit with clodronate in preventing symptomatic bone metastases or in improving overall survival. Clinical trials with agents more potent than clodronate might be better able to address this hypothesis.
Radiopharmaceutical Therapies

For patients with symptomatic bone metastases in whom bisphosphonates confer only moderate effects, radiation-based solutions can provide some palliative benefit. The use of local radiation therapy in this population as a single modality is well documented, and has been shown to provide symptomatic relief within a few weeks of administration. However, this approach is limited to patients with few sites of disease; hemibody radiotherapy, which targets the lower half of the body with a single dose of radiation, has been used in patients with more widespread disease. Both of these approaches have demonstrated significant improvements in pain scores and significant delays in the development of new sites of pain. Nevertheless, their lack of specificity for tumor bone sites can damage normal tissue, and the severe gastrointestinal toxicity seen with hemibody radiotherapy make these treatment modalities less than optimal.

By contrast, radioisotopes preferentially accumulate in tumor bone sites, minimizing the local tissue damage caused by standard radiotherapy. Studies with strontium-89, the most widely used radioisotope, demonstrated equivalence to local radiotherapy or hemibody radiotherapy in pain relief and in progression-free survival and time to disease progression. Response rates are above 70%, although about 20% experience pain flares 1-2 weeks after therapy. When added to consolidation therapy with doxorubicin, strontium-89 also showed activity, significantly increasing median survival time from 16.8 months to 27.7 months. However, hematologic toxicity with strontium-89, mainly transient dose-dependent thrombocytopenia, is frequent, with reports of patients developing acute myeloid leukemia following therapy.

A recent phase 3 trial of samarium-153 also demonstrated positive results, but with fewer side effects. By study end, significant improvements in analgesic consumption and pain were seen with the radioisotope vs placebo; changes in visual analog pain scores correlated with opiate use in the treatment arm but not in the placebo arm. Of note, hematologic toxicity was mainly mild transient myelosuppression, with nadirs observed 3-4 weeks after initiation of therapy and with recovery to normal levels observed by week 8.

Research with rhenium-188-HEDP, a radioisotope with a shorter physical half-life than strontium-89, is promising. In a phase 2 study in patients with hormone-refractory metastatic disease, palliation was achieved in 60% of patients receiving one dose of the isotope and in 92% receiving two doses; no grade 3 or grade 4 hematologic toxicities were seen in either group.

Continued research with these agents will explore their role in preventing bone metastasis and slowing disease progression; further attempts to enhance the efficacy of radiation-based therapies in combination with bisphosphonates and chemotherapy are also being explored.

Conclusions

Despite therapy, the prognosis for men with prostate cancer who develop bone metastases is poor. On average, median survival is currently estimated to be 30-35 months. Hence, therapeutic strategies that move beyond palliation to prevention of disease progression and development of bone metastases are essential, both in terms of prolonging life and in improving the prospects for better quality of life with fewer skeletal complications.

Although practicing clinicians have some ability to determine which patients are at risk for the development and progression of bone metastatic prostate cancer, the ability to extrapolate information about cellular or molecular mechanisms that potentially contribute to the metastatic cascade to assist with management is not as clear-cut.

Fortunately, researchers continue to define novel targets through which the skeletal metastatic process might be inhibited or interrupted. Some of the most compelling advances in this regard have been bone-targeting strategies using bisphosphonates to reestablish bone homeostasis, and ET-A antagonists to delay tumor progression in bone. Nevertheless, continued research in this arena is of paramount importance, and future clinical trials directed at novel targets such as RANKL, MMP, and OPG, which are currently in experimental development, are eagerly awaited.

These and other key issues regarding patients with bone metastatic prostate cancer are summarized in Table 1.

Optimal management of bone metastatic prostate cancer ultimately relies on discovering a means by which to halt disease progression altogether. As described in Table 2, future research and improvements in clinical practice in this and other areas will greatly contribute to our understanding of bone metastatic prostate cancer. In the interim, the challenge remains to diagnose bone metastatic prostate cancer at its earliest stages and as precisely as possible, so that skeletal complications can be adequately addressed and overall quality of life can be improved.
Table 1. Management of Bone Metastases in Patients With Prostate Cancer: Summary
1 The cross-talk among tumor cells, osteoclasts, and osteoblasts in the development of bone metastatic prostate cancer results in an imbalance in remodeling and subsequent fragile skeletal bone tissue as well as increased tumor growth in cells that have colonized bone tissue.
2 BMPs and RANK/RANKL mediate osteogenic activity, thereby making them attractive targets for disruption of bone disease progression.
3 Bone scintigraphy with Tc-99m tracer remains the standard of care for detection of bone metastases. Preliminary results with MRI, 18-F PET, and 18-F PET/CT have shown promise in improving sensitivity and specificity.
4 Administration of radiopharmaceuticals, such as strontium-89, samarium-153, and rhenium-188-HEDP, has demonstrated improvements in palliation and less damage to normal tissue compared with local radiation or hemibody radiation.
5 The potent bisphosphonate zoledronic acid has demonstrated an ability to reduce skeletal complications. Ongoing studies will address the role of earlier therapy.
Table 2. Future Research and Practice Opportunities: Calls to Action
1 Develop practice guidelines for the use of bisphosphonates in men initiating androgen deprivation therapy to prevent disruptions in bone metabolism and slow progression to bone metastatic disease.
2 Promote early diagnosis of bone metastatic disease by increased screening and thorough evaluations of patients with prostate cancer.
3 Encourage study of combination therapy with investigational and approved bone-targeted agents to stem the progression of bone metastases.
4 Develop criteria for conducting clinical trials in patients with bone metastatic disease with cytostatic agents, including clinically meaningful endpoints.
5 Promote enrollment in clinical trials by urologists, radiation oncologists, medical oncologists, and patients at all stages of prostate canc

Medications of prostate cancer
Calutide (Generic Casodex)



Bicalutamide is a man-made drug that is used in the treatment of prostate cancer. It is a type of hormonal therapy. Hormonal therapies interfere with the production or action of particular hormones in the body. Hormones are substances produced naturally in the body, where they act as chemical messengers and help control the activity of cells and organs.

How it is given


Bicalutamide is a tablet, which is taken once a day.

How it works


Most prostate cancers rely on supplies of the male hormone testosterone (which is produced by the testes and adrenal glands) to grow. On the surface of the prostate cancer cells are proteins called receptors. Bicalutamide has a structure similar to the male sex hormone testosterone. It works by blocking and preventing testosterone from attaching (binding) to the receptors on the surface of the prostate cancer cells.


The easiest way to understand the way bicalutamide works is to liken the process to that of a lock and key. The receptors are the lock and testosterone is the key. When testosterone comes into contact with the receptors it unlocks or activates the cancer cells to divide, and the tumour grows. Bicalutamide imitates the action of testosterone and fits into the lock but the key does not turn and the cells do not divide. The bicalutamide remains in place and prevents the testosterone from reaching the cancer cells so they either grow more slowly, or stop growing altogether. The cancer may shrink in size.


Bicalutamide may be used on its own to treat prostate cancer which is contained within the prostate gland, or the tissues around the prostate gland. In prostate cancer which has spread to other parts of the body, bicalutamide may be given on its own or together with injections of another type of hormonal therapy drug (goserelin, buserelin, triptorelin or leuprorelin). These drugs block the production of a hormone produced by the pituitary gland (luteinising hormone), which stimulates the production of testosterone.

Possible side effects


Each person's reaction to any medication is unique. Many people have very few side effects with bicalutamide while others may experience more. The side effects described here will not affect everyone and may be different if you are having more than one drug. We have outlined the most common side effects, so that you can be aware of them if they occur. However, we have not included those that are very rare and therefore extremely unlikely to affect you. If you do notice any effects which you think may be due to the drug but which are not listed here, please discuss these with your doctor or nurse.


You will see your doctor regularly while you have this treatment so that they can monitor the effects. This information should help you to discuss any queries about your treatment and its side effects with your doctor or nurse, as they are in the best position to help and advise you.


Some people may have some of the following side effects:

* Breast tenderness or fullness. Some men may notice slight breast swelling and tenderness. Your doctor can prescribe medicines to reduce any discomfort.
* Hot flushes. These are usually mild and may wear off after a period of time and become less of a problem. There are a number of ways to help reduce hot flushes and sweats. It can be useful to avoid or cut down on tea, coffee, nicotine and alcohol. Let your doctor know if hot flushes are causing you any problems as recent research suggests that progesterone or some anti-depressants may be very helpful in controlling this side effect.
* Some people find that complementary therapies help, and your GP may be able to give you details about obtaining these on the NHS. CancerBACUP has information on Cancer and complementary therapies.
* Itching and dryness of the skin. This is usually mild. Let your doctor know if it is a problem for you. Sometimes creams or medications reduce this effect.
* Nausea (feeling of sickness), vomiting and mild diarrhoea. These are usually mild and easily controlled. Nausea can sometimes be relieved by taking the tablet with food. Let your doctor know if you have any of these side effects as medication can be prescribed to help. CancerBACUP's information on Diet and the cancer patient discusses ways of coping with these effects and information is also available on managing nausea and vomiting.
* Lowering of libido (sex drive), and impotence (loss of ability to have an erection). If this occurs sexual function will return to normal after stopping the drug. Your doctor or nurse can discuss this with you.
* Drowsiness and weakness. Occasionally bicalutamide may cause feelings of weakness and drowsiness.


Length of treatment


Your doctor will discuss the length of treatment that they feel is appropriate for your situation. It is often given for several months or years.


If you forget to take your tablet don't panic levels of the drug in your blood will not change very much but try not to miss more than one or two tablets in a row. Remember to get a new prescription a couple of weeks before you run out of tablets and make sure you have plenty for holidays etc.

Things to remember about bicalutamide tablets


Keep the tablets in a safe place where children cannot reach them, as bicalutamide could harm them.


If your doctor decides to stop the treatment, return any remaining tablets to the pharmacist. Do not flush them down the toilet or throw them away.


If you are sick just after taking the tablet tell your doctor as you may need to take another one.


If you forget to take your tablet, do not take a double dose. Let your doctor or nurse know.

Bisphosphonates are a class of therapeutic agents originally designed to treat loss of bone density. It has been shown that the primary mechanism of action is inhibition of osteoclastic (Cell breakdown) activity. Accumulating data show that these drugs are useful in diseases with propensities toward osseous metastases (Spreading of cancer to other parts). In particular, they are effective in diseases in which there is clear upregulation of osteoclastic or osteolytic activity such as breast cancer and multiple myeloma. Despite the fact that osseous metastases in prostate cancer manifest as osteosclerosis rather than osteolysis, studies now show that bisphosphonates are useful in the management of this disease. In particular, they have demonstrated an impact on osteoporosis associated with hormonal therapy, bone pain from metastases, and skeleton-related events from prostatic adenocarcinoma. This review briefly summarizes the available clinical data on the utilization of bisphosphonates in the disease of prostate cancer.
Prostate Cancer terms and treatments- Things to know

It's important to remember that it can't be one-stop shopping for the treatment of prostate cancer. You've got to factor in the stage of the disease, the Gleason grade is a very important predictive factor, prostate -specific antigen (PSA) level, health status, and so forth, and then decide on surgery, radiation, brachytherapy, watchful waiting, or use bisphosphonates.

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Slide 5. Advanced Prostate Cancer-Classification Refinements Within the A-B-C-D Staging System

Several years ago, Dr. Blumenstein and I reported on a new stage of prostate cancer, which we called D1.5, which is a rising PSA after failed local therapy. This is biochemical failure. This is the most common way we're seeing advanced prostate cancer present. And it's a real challenge and a subject of a lot of debate -- what to do, when to do it, how long to do it, and so forth.
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Slide 6. Metastatic Disease: Goals of Treatment

Most of the patients live about 3 years. They go into a hormone-refractory state and the goal, when that happens, is prolonged survival if we can manage symptoms and maintain a quality of life. And that's what our patients want from us.

Skeletal-Related Events: Definition and Impact
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Slide 7. Impact of Skeletal-Related Events (SREs)

SREs are skeletal-related events. These are debilitating, painful, and have an impact on the patient with prostate cancer's life and life expectancy. We know that prostate cancer has a predilection for bone. We're going to hear a little bit about that, why it is, and what you can do about it.
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Slide 8. Remember

This is just my way of remembering it, to prevent an SRE, get a Digital Rectal Exam (DRE).
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Slide 9. Summary

Bone metastases are common in prostate cancer. We know that. And indeed, if you look at most patients with the disease, when it progresses, 65% to 75% of them have significant bone disease.

SREs are important and they are debilitating.
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Slide 11. Strategies Would You Typically Attempt Before Administering Chemotherapy or Referring

We asked them what do you do when somebody fails hormonal therapy? And the answer, the first one, was withdraw anti-androgens, which obviously makes sense. A number of people will respond. The average time is 3 months.

Lots of other things happen. Adding an anti-androgen, ketoconazole, prednisone, and various other things. We all know that once somebody's hormone refractory, that in fact we're not prolonging their survival with quality of life. Hopefully, some of the new chemotherapy studies that are ongoing will be helpful. We have one with Taxotere (docetaxel) and M/Cip vs mitoxantrone and prednisone, which is considered the standard. We may see some improvement in survival rate, and that's going to be important to make that first step.

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Slide 2. Disease Stages

This slide is an attempt to introduce sort of what I think at least is the overview of the epidemiology of prostate cancer in the United States in the year 2002. So, this is specifically focused on patients who present with localized disease, which represent somewhere between 85% and 90% of cases of prostate cancer that are diagnosed today in the US.

A patient comes in and has several treatment options. They elect a treatment option. We won't get into how or why they do that. And if they fail that treatment option, how do they fail? About 90% of patients who fail either radiation or surgery will do so within the first 7 years of follow-up.

So then recurrent disease, the majority of cases is detected as a biochemical failure with a rising prostate-specific antigen (PSA). And the most common therapy, obviously, at that time, is androgen-deprivation therapy.

The average patient spends between 3 to 5 years in a hormone-sensitive state and then progresses to the androgen-resistant state. And what happens generally, again, the PSA is the marker that detects it and at that point, the patient is reevaluated and has a median survival of about 8 months.

Patients can enter at the metastatic state and progress more rapidly to androgen-resistance, but that's roughly the algorithm of how prostate cancer is managed today.
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Slide 3. Metastatic Disease: Treatment Options

What are the treatment options that currently exist? They're fairly well understood by most urologists. In the setting of advanced disease, the options include some form of androgen-deprivation, either medical or surgical castration, with or without the combination of an anti-androgen agent. For patients who fail androgen-deprivation, some form of systemic chemotherapy is used. Taxanes were mentioned, mitoxantrone. And then supportive care options, which include radiopharmaceuticals like strontium, treatment of local symptoms with either pain control, radiation, or surgery. And then a new category of medications that have been around for quite some time, but they really haven't shown efficacy in this setting, and that's intravenous bisphosphonates.
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Slide 4. Metastatic Disease: Goals of Treatment

The goals and treatment for the patient with metastatic prostate cancer are really 3-fold. One is to prolong quantity of life, survival. And that's the typical endpoint in most oncology trials: how much time is the patient offered by the treatment?

But more importantly perhaps is, the majority of patients have a median survival of roughly 8 months once failing hormone treatments, and the goal is to maintain a quality of life. So it's quantity and quality, and managing the symptoms that have been associated with advanced prostate cancer, particularly in reference to the bony symptoms.
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Slide 5. Metastatic Disease: Complications

The complications of metastatic disease, the way I, at least, think of them, are really in 2 major categories. One is the complications related to the disease itself, and the other is the complications that are related to us, the physicians, offering treatments.

The disease-related complications fall under a term called skeletal-related complications or SREs. A brief definition basically is a complication from the disease that affects the skeletal bone, including bone pain, which is the most common; fractures, often in terms of pathologic fractures; spinal cord compression from either vertebral body collapse or direct tumor impingement upon the spinal cord; and then radiation to the bone or an operation performed for one of these events.

Other non-skeletal-related complications of the disease itself include urinary tract obstruction, either hydronephrosis or bladder outlet obstruction, as well as cachexia, weight loss, and anemia.

Treatment-related complications are important. Medication may actually have an effect on both of these - disease-related and treatment-related. And the most common one, androgen-deprivation therapy, has some classic side effects, including osteoporosis, hot flashes, loss of libido and impotence, and anemia.



Advanced Prostate Cancer and Bone Metastases


Clinical Importance, Prognosis, and Diagnosis of Bone Metastases
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Slide 6. Clinical Importance and Prognosis of Bone Metastases

Today in the United States, the epidemiology of prostate cancer is fairly well understood. It's the most common malignancy in men. It accounts for roughly 185,000 new cases of cancer every year. It's the second most common cause of cancer death, second only to lung cancer.

What's a little bit less clear is what's called the prevalence of prostate cancer. And that basically is defined simply as how many people are walking around today in the United States with the diagnosis of prostate cancer? So that's accumulation of the incidence of prostate cancer. And at least in 1999, which is 3 years ago now, there were about 1.5 million patients in the US. Based on the incidence and the average life expectancy, that number's probably over 2 million.

So there are more than 2 million patients with prostate cancer today in the United States in all various forms of remission, treatment, or relapse. And probably somewhere on the order of 30% or 40% of these people are failing local therapy, and another 10% presenting with metastatic disease. So this is a large target audience. There are a lot of patients at risk for SREs and that's why this is probably a very significant population to be aware of and one that we're not quite comfortable with right now because we don't have a lot to offer them.
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Slide 7. Early Metastatic Disease

Here's the classic detection in metastatic disease. Here's a bone scan that shows a solitary vertebral metastasis.
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Slide 8. Advanced Metastatic Disease

Here's a slightly more advanced picture, oftentimes referred to as a super-scan. This is multi-focal bony metastasis in an androgen-resistant patient who presented with a rising PSA after medical castration.
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Slide 9. Diagnosis of Bone Metastases

How do we diagnose bone metastasis? This is just a typical state-of-the-art review. Right now, the most common way to diagnose a bone metastasis is a bone scan, radiopharmaceutical technetium scan. A plain x-ray is oftentimes used to detect osteoblastic lesions, and an MRI, particularly in the case of spinal cord compression, can also be used. When these fail, or if these are equivocal, a bone biopsy will be required, but that's not the standard.

Slightly more controversial is when to look for bone metastases. And depending on who you ask, these answers will be different, but in general, patients with PSA greater than 10, and that's a continuous numerical value. So the higher the PSA, the more likely they are to have bone metastases; patients with poorly differentiated cancers, Gleason 7, 8, 9 and 10; patients who have failed primary therapy and are presenting with a relapse in biochemical or otherwise; and those patients who have clinical suspicion, with or without any of these variables, such as bone pain or a new fracture.

PSA test results report the level of PSA detected in the blood. The test results are usually reported as nanograms of PSA per milliliter (ng/mL) of blood. In the past, most doctors considered PSA values below 4.0 ng/mL as normal. However, recent research found prostate cancer in men with PSA levels below 4.0 ng/mL . Many doctors are now using the following ranges with some variation:

* 0 to 2.5 ng/mL is low.
* 2.6 to 10 ng/mL is slightly to moderately elevated.
* 10 to 19.9 ng/mL is moderately elevated.
* 20 ng/mL or more is significantly elevated.

There is no specific normal or abnormal PSA level. The higher a man’s PSA level, the more likely it is that cancer is present. But because various factors (such as age) can cause PSA levels to fluctuate, one abnormal PSA test does not necessarily indicate a need for other diagnostic tests. When PSA levels continue to rise over time, other tests may be needed.

It should be noted that it is common for normal PSA ranges to vary somewhat from laboratory to laboratory.

The real question is why do we want to diagnose bone metastases? Because the standard of care for the androgen-naive patient is androgen-deprivation and for everyone else who's failed androgens, there's very little other than systemic chemotherapy to offer them. So, why does a urologist want to know about a new bone metastasis?
Skeletal-Related Events: Impact and Definition
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Slide 10. Impact of Skeletal-Related Events (SREs)

SREs are serious. They're debilitating, painful, and severely affect the quality of life for a patient with a significantly decreased quantity of life.
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Slide 11. Definition of SREs

The formal definition includes pathologic fractures, spinal cord compression, radiation to the bone or surgery to the bone for any reason, change of antineoplastic therapy if a patient fails a chemotherapy and goes back onto a new agent, and hypercalcemia of malignancy (HCM), which is rare in prostate cancer.

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Slide 3. The Impact of Bone Metastases in Advanced Prostate Cancer

For patients who have not been cured initially by their disease, about 65% to 75% of them will develop bone metastases and the prognosis is negatively affected by the presence of bone metastases. There's approximately a 25% 5-year survival and about a 40-month or 3-year median survival once there's evidence of bone metastases.

In general, cancer-related bone metastases can be osteoblastic, osteolytic, or mixed. And the classic teaching in urology has been that, in prostate cancer, there's a purely osteoblastic lesion, and I'm going to discuss with you that there's not only an osteoblastic reaction going on, but there's simultaneously an osteoclastic process that's going right along side of it, and that's what we're addressing with bisphosphonate therapy.

The etiology of the bone changes that occur when there are metastases include activation of osteoblasts and osteoclasts by substances that are released by the tumor cells once they're in the bone microenvironment.
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Slide 4. Osteoblasts

Here's a picture of osteoblasts. These are the cuboidal lining cells that you can see here. And on the bottom half of this screen is bone that's been formed. This is the bone marrow cavity. And the osteoblasts, as you know, are the bone forming cells that are derived from stem cells in the bone marrow. The osteoblasts are responsible for producing type 1 collagen, which is the main structural protein of bone, and also produce growth factors that influence other cells in the bone microenvironment.
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Slide 5. Osteoclasts and Howship's Lacunae

Osteoblasts are regulated by systemic hormones and local factors and as I said, in turn, secrete factors that act either by an autocrine or paracrine action in the bone to influence other cells, one of them being osteoclasts, which are shown here.

Osteoclasts are really specialized macrophages that, when they're mature, become multinucleated and they're responsible for digesting or resorbing bone. And as you can see here, Howship's lacunae are the excavated areas that have been taken away, removed by the osteoclasts, and they do their work by attaching firmly to the bone surface by secreting hydrogen ions into that space to dissolve the mineral part of bone and also by elaborating proteases like cathepsin B to digest the protein component of the bone matrix.

Impact of Bone Metastases in Prostate Cancer: From Pathogenesis to Treatment


Bone Remodeling
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Slide 6. Normal Bone Remodeling

I want you to have an appreciation of the normal process of bone remodeling. During childhood and adolescence, when we're developing new bone, it's called modeling. And in adults, the process is called remodeling where old bone is broken down, degraded, and replaced by new bone. And it's continuously happening in the skeleton. At any 1 point in time, there's approximately a million different sites within the skeleton in microscopic units, called bone structural units, where this process is actively occurring. And in a normal adult, in approximately 10 years, the entire skeleton is remodeled. So there's a process of replenishment in adults that goes on and is quite critical.

You can think of the process in the upper left-hand panel as beginning with resorption, where cells that are going to be the osteoclasts or mature osteoclasts are recruited to the site of resorption. They go in and do their work where they digest and excavate bone. As you can see in the upper right-hand panel, there's a bone resorption pit that's created. And then there's a process of reversal followed by formation. If you look in the lower right-hand panel, you see that osteoblasts are located there. They're recruited to the site and they form new bone. Initially they secrete proteins in the organic part of the matrix called osteoid, and that later becomes mineralized to form mature bone. And at the end, you're left with the same volume of bone, but it's been replenished. And this is also, by the way, trabecular bone, if you see the structure of it.
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Slide 7. Types of Bone Metastases

These are the types of bone metastases. There's osteoblastic, osteolytic, and mixed metastases. And prostate cancer is the main malignancy that has a prototypic osteoblastic reaction where there's excessive, new, but disorganized or woven bone that's formed. And this bone is being formed very rapidly and is structurally not as sound as healthy bone.

Osteolytic metastases occur, for example, in renal cell cancer, which is a tumor that you see as urologists. Also multiple myeloma and breast cancer have lytic lesions. And in this case, there's excessive bone resorption with pathologic destruction of bone. And then there are mixed lesions such as in breast cancer.

One of the key concepts that I would like to get across is that the classic teaching for prostate cancer is that the metastases are purely osteoblastic. And that is based primarily on the fact that on x-rays what you see is increased calcification. There's clearly a sclerotic process that's going on and the assumption has been that that's a purely osteoblastic type of reaction.

But in the past 10 years or so, we have different lines of evidence that indicate that there's simultaneously an osteolytic component going on right alongside the osteoblastic. Part of the evidence comes from bone biopsies taken from patients with prostate cancer where the bone metastases are, and it shows a very complicated picture that includes, obviously, the osteoblastic reaction where there's osteoblasts adjacent to tumor cells, but there's also osteolysis occurring.

Also, there are studies that show that markers of bone resorption, biochemical markers like urinary N-telopeptide and so on are increased in patients with prostate cancer who have bone metastases.

And finally, there's a common sense argument that's been put forward that, in order for bone metastasis within the skeleton to occupy an appreciable amount of space, that there has to be some destruction of normal bone in order for the cancer cells to proliferate and occupy space within the bone.
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Slide 8. Cancer Effects on Bone Remodeling

Here's a general diagram showing the different types of bone remodeling processes that may occur. In the upper left-hand panel, there's a healthy bone where the process of bone resorption and bone formation is both coupled and balanced, and it's a stable process.

And then on the upper right-hand panel, you can see that bone resorption exceeds bone formation and there's a loss of bone. This is the situation with osteolytic metastases or, in a more common disease, osteoporosis.

In the lower right-hand panel, I think this is a fairly good diagram to show what happens with prostate cancer where, in the 2 sites, you see that there's excessive osteoblastic or new bone being formed and at the same time, nearby, there's excessive bone resorption going on right alongside it. And that's the situation I think that most closely approximates what's going on with prostate cancer.

And then there's uncoupled but balanced process where there's excessive bone formation and resorption and they're balanced, but they're not coupled.
Prostate Cancer Hormone Therapy – Anti – androgen

Anti - androgens are another class hormone therapy drugs that are used in prostate cancer treatment. Anti – androgens affect the receptors of the prostate cells’ nuclei and prevent the reception of testosterone. These anti-hormone drugs are sometimes used as monotherapy for prostate cancer patients who are in early stages with low risk tumor features. Anti - androgens may also be used in conjunction with either surgical or medical castration to ablate 100 percent of the body’s testosterone.


Anti - androgens work by blocking the testosterone receptors in the prostate cells. Normally, testosterone would bind with these receptors and fuel the growth of prostate cancer cells. Some researchers believe that men with a higher number of hormone receptors will more quickly experience hormone refractory cancer, which occurs when the prostate cancer cells grow resistant to the hormone deprivation. With the receptors blocked, testosterone cannot “feed” the prostate. Anti - androgen therapy does not eliminate testosterone and therefore may have fewer or less severe side effects than those associated with surgical and medical castration.


When patients stop benefiting from the use of anti-androgens, some patients have found stopping hormone therapy to be effective for combating prostate cancer. This phenomenon is referred to as the “anti – androgen withdrawal effect.” For this reason, some doctors will use intermittent hormone therapy, where patients use the drugs until their levels drop then stop, then begin the drugs again when testosterone levels rise. Other doctors prescribe six months on and six months off as intermittent therapy.


The three most common anti - androgen drugs used for prostate cancer hormone therapy are flutamide, bicalutamide, and nilutamide. These drugs are taken orally as either a tablet or a pill. A single dose usually contains between 50 mg and 150 mg, depending on the patient’s needs and doctor’s prescription. Doctors encourage their patients to take the drug around the same time everyday to ensure a steady stream of therapy. Patients who forget to take a dose and are close to a time where they usually take the next dose, should not take a double dose. Taking a dose around the same time each day will decrease the incidence of some side effects, such as nausea or vomiting.


Hormone therapy can involve unpleasant and, in more rare cases, dangerous side effects. Because there are multiple anti - androgen drugs available in United States as well as Canada and the United Kingdom, patients with serious side effects should speak with their doctors about possibly changing drugs. Some doctors may change the form of hormone therapy, but in other cases doctors will encourage their patients to continue. In some cases, the side effects will dissipate as the body gets used to the drug and the androgen ablation.


The use of castration in addition to anti - androgens is called combined androgen blockade(CAB). The use of anti - androgens a few weeks before LHRH agonists are started has been shown to significantly reduce the incidence of hormone flare that can be painful dangerous for patients with distant bone metastasis. Anti – androgens can also be used after surgical or medical castration stops being effective. There are a few studies that indicate using anti - androgens as monotherapy may be slightly less effective than medical or surgical castration as monotherapy. Other studies found no difference in the survival rates of people who had used only one form of treatment.

The majority of men who are deprived of androgens, either by means of luteinizing hormone-releasing hormone (LHRH) agonists or bilateral orchiectomy, ultimately progress to an androgen-independent phase where the initial androgen deprivation regimen no longer controls the tumor. As a result, treatment strategies are needed for men with androgen-independent prostate cancer (AIPC). A minority of men who have progressive disease after initial androgen deprivation respond to additional hormonal treatments. Prostate cancer that no longer responds to any hormonal treatment is referred to as hormone-refractory prostate cancer (HRPC). Older estimates of median survival for patients with HRPC range from 7 to 12 months, but more recent studies report a median survival of 16 months.[5,6] This improvement may be the result of better treatments or may be explained by stage migration and prostate-specific antigen (PSA)-induced lead-time bias. Historically, cytotoxic chemotherapy for prostate cancer induced low response rates, with an average objective response rate of 8.7%. Prior to the use of taxanes, no survival benefit supporting the use of chemotherapy was demonstrated. More recent studies of chemotherapy in patients with HRPC report benefits including reduced pain, improved quality of life, and decreased need for narcotics.
Prostate Cancer Hormone Therapy – LHRH Antagonist


Because the growth of prostate cancer is fueled by the male sex hormone testosterone, doctors can use chemical castration to ablate 90 to 95 percent of the body’s supply. Chemical castration interferes with signals in the brain that tell the testicles to start testosterone production. The hypothalamus in the brain first detects that levels of testosterone are dropping and releases Luteinizing hormone-releasing hormone (LHRH) also called Gonadotropin (GnRH). LHRH or GnRH act as a messenger and fill in receptors of the pituitary gland to report the lowering levels of testosterone. The pituitary gland releases luteinizing hormones (LH) that travel to the testicles.


An antagonist inhibits the action of a cell by filling in receptors. A LHRH or GnRH antagonist mimics the shape of normal LHRH then fills in the receptors on the pituitary gland. Not receiving the message from the hypothalamus, the pituitary gland does not release LH. The testicles never produce testosterone and the body’s levels drop.


LHRH and GnRH antagonists should not be confused with agonists. LHRH antagonists are generally used only for advanced prostate cancer with bone metastasis. Unlike the agonists, LHRH or GnRH antagonists do not produce hormone flare. LHRH antagonists, however, have been known to cause severe allergic reactions with a small number of patients. Because of this risk, LHRH antagonists are used only for patients with advanced prostate cancer or who refuse any other type of hormone therapy due to preference or other side effects.


LHRH antagonist is injected through the buttocks at a doctor’s office. The injection will be made by either a doctor or a nurse. Two weeks after the initial injection, the patient receives his second injection. Two weeks after the second injection, the patient receives his third injection. After this first month, the patient receives the antagonist only once a month. Patients are strongly encouraged not to miss appointments, and to schedule those appointments as close to exactly four weeks later as they can. After an injection, a patient will also wait at his doctors office for another 30 minutes to ensure that he does not have an allergic reaction.


LHRH antagonists are usually not recommended for patients who have irregular heart beat, liver problems, or osteoporosis. Patients who weigh over 225 pounds are also not candidates for LHRH antagonists. Patients who have one or more of these physical criteria should speak with their doctors about whether LHRH antagonists are right for them. LHRH antagonists could exacerbate irregular heart beat and liver problems in addition to risking decreasing bone density. Researchers have found that weighing over 225 pounds could dramatically decrease the effectiveness of the antagonists.


After the first injection, patients should receive a blood test once every 8 weeks to ensure that his levels of testosterone have dropped to castrate level. Patients should also consider tests to monitor the functioning of the liver. Patients who undergo extensive LHRH antagonist hormone therapy run a higher risk of developing osteoporosis.


If patients experience a changing in the rhythm of their heartbeat or fainting, they should contact their doctor immediately.
Combined Androgen Blockade in Prostate Cancer Hormone Therapy


Combined androgen blockade is abbreviated as CAB and is a type of prostate cancer hormone therapy which combines an anti-androgen with either chemical castration or surgical castration. 90 to 95 percent testosterone is produced by the testicles while 5 to 10 percent is produced by the adrenal glands. Combined androgen blockade ablates 100 percent of the testosterone present in the blood stream. Combined androgen blockade is also known as total androgen blockade and combined hormone blockade.
















Gleason Score:

In developing his system, Dr Gleason discovered that by giving a combination of the grades of the two most common patterns he could see in any particular patient's specimens, he was better able to predict the likelihood that that particular patient would do well or badly. Therefore, even though it may seem confusing, the Gleason score which a physician usually gives to a patient is actually a combination or sum of two numbers. These combined Gleason sums or scores may be determined as follows:

* The lowest possible Gleason score is 2 (1 + 1), where both the primary and secondary patterns have a Gleason grade of 1 and therefore when added together their combined sum is 2.

* Very typical Gleason scores might be 5 (2 + 3), where the primary pattern has a Gleason grade of 2 and the secondary pattern has a grade of 3, or 6 (3 + 3), a pure pattern.

* Another typical Gleason score might be 7 (4 + 3), where the primary pattern has a Gleason grade of 4 and the secondary pattern has a grade of 3.

* Finally, the highest possible Gleason score is 10 (5 + 5), when the primary and secondary patterns both have the most disordered Gleason grades of 5.
Partin Coefficient Tables:
Introduction
The following four tables give data which allow you or you doctor to predict the probability that prostate cancer has spread out of your prostate into the lymph nodes on the basis of your Gleason score, your PSA value, and your clinical stage. Be careful to use the table which is based on your PSA value.


Example
Mike is a 62-year-old man with a PSA of 8.4 ng/ml and a Gleason score of 4 + 2 = 6. His doctor has categorized his clinical stage as T2b since he was able to feel a significant induration in one lobe of Mike's prostate on DRE and the biopsy and ultrasound indicated that the cancer had invaded more than half of that lobe but there was no sign of cancer in the other lobe.

Using the table for PSA values between 4.1 and 10.0 ng/ml, we find that Mike has an 4% likelihood of prostate cancer which has invaded his lymph nodes. In other words, there are about 19 chances in 20 that Mike's cancer has not invaded the lymph nodes.




Prediction of Probability of Lymph Node Involvement
PSA = 0.0-4.0 ng/ml Gleason score Stage T1a Stage T1b Stage T1c Stage T2a Stage T2b Stage T2c Stage T3a
2-4 0 0 0 0 0 0 ...
5 0 1 0 0 1 1 2
6 1 2 0 1 2 2 5
7 ... 6 1 2 5 5 9
8-10 ... 14 4 5 10 10 ...

All numbers represent percent predictive probabilities (95% confidence interval); ellipses indicate lack of sufficient data to calculate probability.





Prediction of Probability of Lymph Node Involvement
PSA = 4.1-10.0 ng/ml Gleason score Stage T1a Stage T1b Stage T1c Stage T2a Stage T2b Stage T2c Stage T3a
2-4 0 1 0 0 1 1 1
5 1 2 0 1 2 2 3
6 3 5 1 2 4 4 9
7 8 12 3 4 9 9 15
8-10 18 23 8 9 16 17 24

All numbers represent percent predictive probabilities (95% confidence interval); ellipses indicate lack of sufficient data to calculate probability.







Prediction of Probability of Lymph Node Involvement
PSA = 10.1-20.0 ng/ml Gleason score Stage T1a Stage T1b Stage T1c Stage T2a Stage T2b Stage T2c Stage T3a
2-4 0 2 0 1 1 1 ...
5 3 5 1 2 4 4 7
6 ... 13 3 4 10 10 18
7 18 24 8 9 17 18 26
8-10 ... 40 16 17 29 29 37

All numbers represent percent predictive probabilities (95% confidence interval); ellipses indicate lack of sufficient data to calculate probability.






Prediction of Probability of Lymph Node Involvement
PSA = > 20.0 ng/ml Gleason score Stage T1a Stage T1b Stage T1c Stage T2a Stage T2b Stage T2c Stage T3a
2-4 ... 4 1 1 3 ... ...
5 ... 10 3 3 7 7 11
6 ... 23 7 8 16 17 26
7 ... ... 14 14 25 25 32
8-10 ... 51 24 24 36 35 42

All numbers represent percent predictive probabilities (95% confidence interval); ellipses indicate lack of sufficient data to calculate probability.


adjuvant therapy (A-joo-vant THAYR-uh-pee) Treatment given after the primary treatment to increase the chances of a cure. Adjuvant therapy may include chemotherapy, radiation therapy, hormone therapy, or biological therapy.

neoadjuvant therapy (NEE-oh-A-joo-vant THAYR-uh-pee) Treatment given before the primary treatment. Examples of neoadjuvant therapy include chemotherapy, radiation therapy, and hormone therapy.
Working parent's guide to weekend fun
Working parent's guide to weekend fun (ages 5 to 8)
by Naomi Williams
Last updated: December 2005




Tackle some tasks during the week
Complete a few critical chores during the week, and come Saturday morning you'll both have breathing room and be grateful for it.

• Schedule certain tasks to occur on certain days every week. Jonathan Yackel, a computer science professor in Oshkosh, Wisconsin, and father to three young children, does the weekly grocery shopping for the family on his way home from work every Monday. "I do it by myself, so it's a lot faster than doing it with the kids," he says. He gets home later on Mondays as a result, but it frees him and his wife Lisa, a veterinarian, from having to fit this task into the weekend.

• Take advantage of delivery services. Consider having your groceries delivered to you during the week. It costs a bit more, but it may be worth it, depending on how much time grocery shopping takes each week. Many supermarkets have a Web site where you can place your order — some exclusively Web-based services are available. Also consider taking advantage of locally owned farms that deliver fresh, often organic produce to your doorstep each week or every other week.

• Work the Web. In addition to ordering groceries online, you can take care of a number of tasks and errands from the comfort of your desk chair, including consolidating and paying all your bills; banking; ordering drugstore items; and keeping an electronic calendar with e-mail reminders. Typing in a key word in a search engine will pull up a number of options.

Have a check-in toward the end of every week
Each week on a specific day (like Wednesday), check in with your spouse about the upcoming weekend to avoid miscommunications and unrealistic expectations, both of which can eat up precious time. Figure out what you're definitely doing (your haircut Saturday morning, the grown-ups-only dinner party Saturday night, and the birthday party your child will be attending on Sunday).

Talk about what else would be nice to fit in (a bike ride, cleaning out the garage, and going to the new exhibit on snakes at the science museum). Make sure you're both clear on details like confirming with the babysitter, directions to dinner, which of you is taking your child to the birthday party, and the museum's weekend hours.

Involve kids in weekend chores
Even young children can play a significant role in keeping the household running. In the San Francisco household of Debra Asher and John O'Hearn, their two kids, four years apart make their own beds, set the table for dinner, and are now learning how to make salad. If you have children of different ages, assign tasks that are age-appropriate, and gradually add additional chores as the kids get older.

"Doing chores together is important," says Joan Wenters, Ph.D., clinical and developmental psychologist with Children's Hospital in Oakland, California. "Children need to learn that this is part of life and need to grow up learning the skills to manage a household. As for the parents, if chores are joint projects with the kids, the weekend doesn't have to be so much of an either/or proposition."

Establish weekend family rituals
This is challenging, but the payoff is worth it. You'll not only develop an archive of family memories but you'll also raise cooperative kids.

"It's important to develop that expectation that you do things as a family," says Wenters. And part of family time involves a little compromise. "Kids also need to learn that you don't always get to do your first-choice thing."

Wenters recommends giving kids input on family activities. "Offer several different activities, or rotate who gets to choose — one child this time, the other child next time, then maybe Mom's or Dad's turn. Or sit down as a family and make a list of different things everyone wants to do, and use that as an activity pool to chose from."

Some suggestions:
• Attend religious services. Aside from the spiritual and community benefits of belonging to a church (or synagogue or mosque), you may also find that this becomes your principal and most reliable weekly activity as a family.

• Make mealtimes special. The Yackels rotate visits to inexpensive family-friendly eateries in their area for a weekly Friday dinner out. A leisurely Sunday morning breakfast of pancakes or waffles is a ritual at the Asher-O'Hearn household. After a week of rushed bowls of cereal or bagels wolfed down in the car, it's a special treat to be able to make and enjoy a hearty breakfast. Get your kids involved in measuring flour or cracking eggs, and preparation can be part of the ritual, too.

• Settle down for some screen time. A family movie-rental night is always a hit. Cut the lights, add popcorn, and you've got your own home theater.

Have a few fun activities at-the-ready
In addition to your weekend rituals, you'll want to add some surprising, new activities to the mix. Here are some options:

• Take advantage of local happenings. Memberships to your local zoo, science museum, or children's museum pay for themselves right here. Keep notes about special local events in a handy place like the kitchen bulletin board. "Hey, if we leave right now, we'll catch the penguin-feeding at the zoo!" can get even the grumpiest kid moving. Need ideas? Consider these options for great day trips.

• Do an art project. Begin shredding the already-read Sunday paper into hundreds of pieces; your child will eagerly join you in this "mischievous" act. Together, dump the paper shreds into a bucket and cover them with water. Now you have a bucketful of paper pulp — and an opportunity to make your own paper. Pour it onto a fine mesh screen. A small window screen works well. Make sure all the areas of the screen are covered evenly and you haven't left any holes. Put some bricks on the pulp-covered screen and leave it in the yard for a day or so to drain. Then take the bricks off (just before the paper is completely dry). Voila: A sheet of homemade paper, 100 percent post-consumer waste!

• Come up with all-inclusive activities. For families with children of different ages, Wenters suggests developing projects that include age-specific tasks for everyone, like a family scrapbook: A preschooler can sort pictures, a grade-schooler can glue them on pages, and you can write the captions. Or make a family movie. "A 4-year-old can act, while a 9-year-old can direct," she says, while Mom or Dad runs the camera.

Schedule downtime
Having at least one weekend morning free of any scheduled activities is key to both relaxation and a young child's budding imagination. "If we try too hard to create the 'Disneyland phenomenon' every weekend, our kids come to expect that, and they don't learn how to create their own leisure activities," Wenters says.

Some of the most relaxing and enjoyable family moments are those in which each family member is home happily doing their own thing — Mom and Dad reading the newspaper next to a child contentedly drawing a picture, punctuated by chit-chat on the order of "Are you done with that section?" or "Mommy, look what I drew!"

Your children learn that weekends are great — not just because Mom and Dad are more available to them, but because they get unfettered time to create their own fun.
What's your discipline style?


Discipline is one of the toughest challenges of parenthood. It can frustrate, discourage, and humble you. When your toddler throws his 19th tantrum in a week, your preschooler hits her best friend in a fit of pique, or your grade-schooler is caught cheating on a test, you may look back on the gritty baby months with utter nostalgia and wonder why you ever thought feeding and sleeping dilemmas were so tough.

The good news is that you don't have to go it alone. There's a lot of helpful information out there.

The bad news is that there's almost too much information. A trip through the parenting section of your library or bookstore can be completely overwhelming. Dozens of books covered with photographs of smiling children and peaceful parents gleam from the shelves. "There's only one way to do it, and this is it!" they all seem to shout.

Some of the books are so similar that they're almost clones, while others appear to offer the opposite advice. The authors have widely different backgrounds and levels of expertise. Several of the discipline philosophies are well known and have large followings, while others are simply terms coined by a single writer. In short, the discipline field is one big, messy mishmash of information.





In addition, some parenting books contain veiled (and some not-so-veiled) threats that if you don't follow their advice, your kids will turn out badly. The anxiety this causes, combined with the dizzying array of conflicting and overlapping philosophies, is enough to make a parent want to throw her hands up in the air, conclude that none of these idiots know what they're talking about, and buy a juicy mystery novel instead.

This is too bad, because in truth, the right expert advice can be instructive and reassuring. It's a matter of finding a philosophy that fits your personal style. The question is, how do you find it?

First, realize that you don't have to pick just one. You may like certain aspects of several different discipline styles. It's OK to select the things you like and leave the rest.

Second, pay attention to how you feel when you read about a particular style. For example, Brooklyn mom Popi Pustilnik says, "One book made me feel like such a failure that I threw it across the room." She then turned to a book with a completely different approach and felt much more hopeful. "It was a much better fit for me," she says.

Third, learn about a few of the major "categories" of discipline philosophies. Once you get a handle on these, it will be easier to choose books that are a good fit for you.



What's the same in most theories
Although the discipline field is vast, it's not quite as overwhelming as it first appears. This is because many of the discipline books address similar themes. Here are some of the big ones:

1. Aim for the middle ground between being too punitive and too permissive.
2. Don't use physical punishments like spanking and slapping.
3. Don't use psychological punishments such as name-calling and insults.
4. When you or your child spiral out of control, take time to cool off.
5. Offer choices.
6. Learn how to manage your own anger.
7. Provide encouragement and positive feedback.
8. Let your child experience consequences to behavior.
9. Don't hold grudges. Once the behavior has been dealt with, give your child a clean slate.


What's different
One expert suggests that time-outs last a minute for each year of your child's age, while another says your child should decide how long the time-out lasts. One book instructs you to firmly tell your child, "No hitting," and another book cautions against using negative words like "no" and "don't." One author promotes the use of rewards, whereas another says rewards are nothing more than bribes.

The wide variety of advice can be frustrating and confusing, but it also proves that there's no one right way to discipline. You are the true expert on what works for you and for your children. While professional advice is helpful, it needs to match your own intuition and ideals.
Five basic philosophies
Take a look at these categories of discipline approaches and see what appeals to you:

1. Boundary-based discipline: Children need boundaries to feel safe. If they don't know where the boundaries are, they'll "test" until they find them. "What happens if I throw my spoon?" a toddler wonders, clanging his spoon noisily onto the floor. "Hmm ... not much of a reaction. How about if I throw my entire plate?" An older child might test limits by leaving her colored pencils in a glorious mess on the rug, or by taking several decades to get ready in the mornings.

Clearly communicate your boundaries (for example, "Please put my things back in my purse when you're done looking at them"). If this doesn't do the trick, follow through with a consequence. Try to make the consequence a logical fit for the behavior. For example, if your child leaves your wallet, hairbrush, and car keys strewn around the living room floor, she loses purse-inspection privileges for a while." Use "natural consequences," too. For example, if your child forgets his lunch box, don't rush it to school. Instead, let him experience the consequences.

Provide "limited choices" to give your child some wiggle room. Suppose your 5-year-old is loudly banging on her electronic toy piano, with the volume on maximum. Through your migraine, you respectfully ask her to turn it down. She ignores you. Offer a choice: "You can either turn the volume down now, or I'll put the piano away until tomorrow." This puts the responsibility in her hands.

2. Gentle discipline: A child can't learn much about behavior when she's screaming and crying. She (and you) can benefit greatly from daily preventive techniques — strategies that reduce opportunities for misbehavior. For example, create routines so that your child feels grounded. Offer choices to give her a sense of control, such as, "Would you like to wear the red pajamas or the blue?" Give warnings before transitions, as in, "We need to leave the playground in five minutes." Frame your requests positively. For example, say, "Please use your big girl voice," instead of, "Don't whine." When possible, use "when ... then" statements instead of outright no's, as in, "When we're done with dinner, then we can go outside."

When misbehavior occurs, turn to diffusion. First see if there's an underlying problem, such as tiredness, boredom, or hunger. Once you address this need, the misbehavior may magically disappear.

If not, turn to what author Elizabeth Pantley calls a "laundry bag" of tricks. This is a large collection, including silly games, distraction, redirection, validation, and self-soothing. You can pull a trick out of your hat — er, laundry bag — whenever it's time to derail your child from the misbehavior train. For example, if he refuses to take a bath, try making the washcloth "talk" to him in a playful voice. If this doesn't work, you can try something else, such as validation and redirection ("It's hard when you have to do something you don't want to do. How about if we see how quickly we can get it done? I'll get a clock.")

3. Positive discipline: Children behave well when they feel encouraged and have a sense of belonging. Misbehavior happens when children are feeling discouraged.

Talk with your child and try to find out what the underlying cause is for her misbehavior. For example, suppose your 3-year-old refuses to bring her plate to the sink. Is she afraid she'll break the plate? Is she trying to get attention? Perhaps it gives her a sense of power. Or maybe she's hurt about something else and is trying to "get you back." Once you know the reason, you give her the right kind of encouragement and work out a solution. For example, if she's struggling with powerlessness, you could encourage her by saying, "We need to get the table clean. Can you help me figure out how to do it?"

In positive discipline, misbehavior is seen as an opportunity for learning, and children are actively engaged in coming up with a solution. It's okay for a child to enjoy the solution — in fact, it's preferable. For example, if your 8-year-old spills soda on the couch and the two of you decide that the solution is for him to steam-clean the stain (using his allowance to pay for the steamer rental), he might enjoy this task. This doesn't mean he'll continue to spill soda on the couch in order to get to use the steamer. It means he's learning how to take responsibility for a mistake — and better yet, he's invested in his own learning.

4. Emotion-coaching: When children can recognize and understand their own feelings, they make better choices. You can teach your child to do this, and it will help strengthen the connection between the two of you.

Know your own standards for what is and is not acceptable behavior. Make sure you're up front with your child about these, and talk with him about some of the feelings he might experience in certain situations. For example, if he's been known to hit other kids and several friends are coming over, you might explain that it could get overwhelming for him. Suggest to him that if he starts to feel frustrated, he can spend some quiet time in his room — but hitting the other children is not acceptable.

Learn the skill of empathy. This means putting yourself in your child's shoes: What are the "real feelings" behind her misbehavior? Reflect these back to her, as in, "It's hard when we really want something and we can't have it. I bet you're feeling really disappointed right now." When your child feels that you understand her, she'll trust you. Within this context of trust, she'll be open to you when you teach her about responsible choices. ("We can't buy candy every time we see it. Too much candy isn't good for our bodies.")

5. Behavior modification: Positive reinforcement helps children increase good behavior and negative reinforcement helps them decrease misbehavior. This approach is similar to boundary-based discipline in that it emphasizes clear limits and backing them up with consequences. But in behavior modification, there's more emphasis on warnings and rewards.

Use warnings to help your child take responsibility for stopping the misbehavior on his own. For example, if your child is arguing with you because you told him he can't have a cookie before dinner, don't get caught up in the skirmish. Tell him to stop arguing about it, and that this is his first "warning." If he persists, give him a second warning, and if he doesn't stop, calmly tell him to take a time-out (these should be brief — just a few minutes long).

For more "serious offenses," come up with a consequence other than time-out. For example, if your child persistently teases the dog and is old enough to know better, you might take away her television privileges for a couple of days.

Rewards motivate your child to do well. This could be as simple as parental praise. In some cases you might want to set up a charting system with more tangible rewards. For example, for every morning that your child is ready on time to go to daycare, she gets a star in her chart. When she racks up five stars, she gets a treat.

These brief descriptions don't tell the whole story, of course. It's not as if boundary-based discipline doesn't include preventive techniques — it does. And gentle discipline includes the use of consequences. In fact, all of these styles overlap. The differences are more a matter of what they emphasize. Think about the primary colors — red, blue, and yellow. They contain no common elements. Discipline philosophies are more like secondary colors (orange, purple, green), which contain blends of more than one hue. Some may have a dash more red, and others may pour on the blue. What color will your discipline style be?
Negotiation Tips from a Professional Mediator
by Kim Lankford
Monster Contributing Writer
Negotiation Tips from a Professional Mediator







Good negotiation skills have a huge impact on your career -- whether you're a salesperson making deals or an entry-level employee trying to get good assignments or cube neighbors to quiet down.


"Most people think of negotiation only when they need to get something more," says Tammy Lenski, a professional mediator who helps universities and businesses nationwide with conflict management. "The reality is that at work, pretty much every conversation is a negotiation. You're negotiating deadlines, the quality level, what might be taken off your plate to make room for this priority project and what benefit you might get for taking on that project. The minute you walk into the workplace in the morning, you're negotiating."


Lenski says big negotiation mistakes are common -- people either are too confrontational or cave in because they're afraid to ask some basic questions. "If people think of a negotiation more as a conversation than something that needs to be won, they'll do much better," she adds.


Here are four of Lenski's tips on becoming a good negotiator -- and improving your situation at work:


1. Tactic Is Dictated by Situation


Playing hardball in the office can backfire when you need to work with your coworkers every day. "You have an ongoing relationship with these folks, and you're trying to not leave debris," Lenski says. "People need to stop thinking about negotiating as getting more of what I need, which means getting less of what you need."


Instead, find out the other person's needs, and try to come to a conclusion that helps both of you. "The best negotiating is using the really good human relation skills in an effective way," Lenski says. "It isn't about pushing or convincing or manipulating the other person. It's about having them figure out what they want and how you can help them get it."


2. Ask Good Questions


In negotiations, you know what you want. But you also need to find out what the other side wants in return. It's most efficient if you just ask openly.


When starting her private practice 10 years ago, Lenski presented her fee to provide conflict-management services to a company in turmoil. The department head asked her to slash her price 20 percent. Lenski said this was her bottom-line number, but the department head said everything is negotiable.


Lenski then asked the essential question: "Why do you believe everything is negotiable?" The department head explained the head of finance would ask if she bargained and got a good deal. At that point, Lenski crossed out the original fee and wrote a new one that was about 25 percent higher. "Will this work?" she asked.


The department head said, "Well, I'll have to offer you 20 percent less than that." And they had a deal.


You won't always get such a clear-cut answer, but it only strengthens your case if you can find out about the other person's goals.


3. Deal with Issues Up Front


Instead of keeping quiet and thus becoming resentful, "negotiating is figuring out how to raise the things that are bothering you so they can be sorted out," Lenski says.


There are gender-based differences in negotiation. "Many women are not very good at asking, or when they are made an offer, they tend to think that they have to say yes or no," Lenski says. "But men tend to think of it as the opening volley in a negotiating experience."


Instead of just thinking about what might make it difficult to accomplish your goal, talk with your boss about those issues right away. "It's much more helpful in general to think about under what conditions you might make it possible, and how can you help me do that," Lenski says.


Lenski was recently asked to speak at a conference, and the university offered to pay her travel expenses but not conference fees and hotel room. She discovered a colleague who was manning a nearby conference booth was getting all her expenses paid by another college department. Instead of having hard feelings, Lenski approached the dean. "Aren't I doing as much to get the college's name out there?" she asked. When she pointed out the discrepancy, he offered to pay her way as well.


People are too often afraid to have those difficult conversations, bottling up their resentment. "If I hadn't asked and would have gone home and fretted, I wouldn't have had the money," she says.


4. Do the Right Kind of Homework


Lenski says people tend to waste a lot of time worrying about scary negotiation scenarios. "They go into it thinking about all the ways it can go wrong," she says, even though the negotiation generally turns out much better than expected. "Instead, they should spend their time thinking of it from the perspective of the other person. What would make them want to join with you to figure things out? Not what will make them change their mind, but what will make them want to sort this out with me. Invite them into joint problem-solving."


Not only does this tactic lead to more successful negotiations, but your colleagues will also have a better opinion of you. "You have to keep seeing most of the folks in the workplace, and they can have a lot of input on whether you move up," Lenski says. "You want to approach them in ways that you're seen as a team player."

Step-by-Step Guide to Negotiating a Great Salary

by Kim Lankford
Monster Contributing Writer
Step-by-Step Guide to Negotiating a Great Salary




Related Articles

who negotiate generally earn much more than those who don't. And a well-thought-out negotiation makes you look like a stronger candidate -- and employee.


"We found that those people who attempted to negotiate their salary in a constructive way are perceived as more favorable than those who didn't negotiate at all, because they were demonstrating the skills the company wanted to hire them for," says Robin Pinkley, coauthor of Get Paid What You're Worth and an associate professor of strategy and entrepreneurship at Southern Methodist University's Cox School of Business.


You can start laying the groundwork for your salary negotiation even before the first interview. Here's a step-by-step guide:


During the Interview Process


*

Do Your Research: Before the interview, learn about the company's salary ranges and benefits as well as industry salary ranges. Also learn about the company, its competition and the industry. Then think about what you want from the job, both in terms of salary and benefits, as well as opportunity and upward mobility, Pinkley says. This information will become valuable during the interview and salary negotiation.

*

Don't Talk Turkey Too Early: "You never win by talking about money early on," says Lee Miller, author of UP: Influence, Power and the U Perspective -- The Art of Getting What You Want. "The time to talk about money is when they've fallen in love with you." Before that, you're just one of many easily dismissed candidates. But once the employer has decided you're right for the job, "it becomes an issue of, ‘how are we going to make this happen?'" Miller says.

*

Avoid the Salary Requirements Trap: Pinkley tells people to say: "I completely understand why this is an important issue -- you're trying to determine who you want to continue in this process, and it doesn't make much sense to pursue candidates you aren't going to get. Secondly, I know that the tendency is for people to lowball their salary range, because they don't want to get out of the pool. My preference is to figure out, independent of these issues, the degree to which there is a good fit here and the extent to which I can bring value to this organization and the extent to which I'm going to be fulfilled and involved and committed to this position. I suggest we wait to have the salary conversation until you're prepared to make an offer."


If they still want a number, leverage your research to talk industry-standard ranges, not specific numbers.




At Time of Offer


*

Strike First: Try to mention a specific salary before the employer does. This will start the negotiations in your ballpark. "The whole negotiation is based on that first offer," Pinkley says.

*

Don't Commit Too Quickly: The employer often offers the job and salary simultaneously. Never say yes right away -- even if you like the offer. "I would always come back and try to get more," Pinkley says. Tell them you'll give them an answer within a certain time frame.

*

Make Them Jealous: If you've been interviewing for other jobs, call those prospective employers, tell them about your offer, and see if they can speed up the interview process -- or make you an offer. Knowing you have another offer will make you more attractive to them.


When it's time to answer the first employer, mention the other employers' interest to help boost your value. But don't make up offers. It's easy to check, and the interest alone will help you look good.

*

Articulate Your Expectations: Tell the employer what you want from the job, both in terms of salary as well as benefits and opportunity. "It may be time off, flexibility about where you work, autonomy or ownership over a particular area, it may be your title -- whatever has a perceived value to you," says Joyce Gioia, president of the Herman Group, a think tank of management consultants and futurists.

*

Negotiate Extras: If the employer can't offer you the salary you want, think about other valuable options that might not cost as much. Miller always recommends asking for education, which can make a big difference in your long-term marketability.

*

Quantify Your Value and Performance: Mention your value in quantifiable terms, such as how much money you saved your company and how your projects increased revenues by X thousands of dollars, Gioia says. Then tell them specifically how valuable you expect to be in your new job.


You also can add a few contingencies showing your confidence in your performance. You could ask the employer to give you a salary review after six months rather than a year or for a year-end bonus if you make a certain amount of money. "It shows that you believe in yourself and are committed to bringing what you say you can do," Pinkley says. "You believe you are going to bring significant value to the organization.


Three Steps to Making Smarter Counteroffers

In every negotiation, the time comes when the other side puts an offer on the table. At that point, the ball is in your court. Unless you want to accept that offer or walk away from the table, you have to put forth a counteroffer.

You will hear all kinds of advice for doing this, and much of that advice is not particularly useful. For example, a friend might tell you, "Always ask for 20 percent more than you will settle for. You can always retreat." A colleague might say, "Always add 10 percent to what they offer. Employers are always trying to lowball you."


While these tactics may work a few times, they have significant flaws. Not only do they lead you to throw out arbitrary figures, but those figures may not be related to what you really want or need from the negotiation.


Here is some practical advice that can help you develop counteroffers that achieve your goals.


1. Get Prepared


Before the negotiation begins, take the time to research standard compensation for the position. Establish a reasonable range for salary, a typical benefits package and common additional compensation (e.g., stock options, annual bonus, performance bonus). This work makes it possible for you to know the range in which any satisfactory agreement has to fall.


Then, from those general points, determine the most favorable compensation package for you. You should be able to justify that package given your field, experience, expertise and credentials.


Make sure this package addresses your real needs -- you will likely have trouble asking for more later if you overlook something. This package is your counteroffer.


2. Be Firm


Most negotiators make the mistake of putting out an arbitrary position as their counteroffer, then having to retreat from it because they cannot justify it or because they face a hostile reaction. Avoid this pitfall by selecting a reasonable and appropriate counteroffer -- one based on the data you gathered in your research -- and staying there until the other side offers a persuasive reason for you to move.


By "persuasive," I mean an argument based on additional data or information that justifies a different figure or package than you had developed. For example, an employer might say, "I know that some of our competitors are offering higher salary figures. However, they are much larger than we are, and they expect you to work much longer hours for bigger clients. We offer a salary that allows you to have a reasonable work life and really have an impact on smaller companies."


An example of an unpersuasive argument would be, "Your figure is too high. We can't do that."


3. Be Wise


Keep the big picture in mind. Your goal in the negotiation is to reach an agreement that satisfies your interests, not to win a battle between positions. If your counteroffer is not moving you closer to an agreement, do not hunker down and defend it to the death.


Instead, think of another proposal that addresses your needs and concerns and is supported by data, and put that out as another offer. Use your energy to generate solutions, not to fight battles.


Negotiation is all about exchanging ideas, possible solutions and information. Offers and counteroffers are the typical steps in this dance. When you counteroffer, do so based on rigorous preparation and thinking. If you do, you will find yourself much more effective, and much more relaxed.
10 Relaxation Techniques To Reduce Stress On-the-Spot
Blissing Out: 10 Relaxation Techniques To Reduce Stress On-the-Spot

By Jenny Kovacs
WebMD Feature Reviewed by Jonathan Gelfand, MD




The kids need a ride to school, your husband can't find his shorts, your boss has just scheduled an online meeting, and your best friend desperately needs your help -- all at the same time.


Is it any wonder that you can't find a minute for relaxation? In fact, if you're like most women, you may have even forgotten how to relax.


And while experts say that some stress is good for you -- it can sharpen your senses and your mind -- too much stress is bad for your mental and physical health. At the same time, relaxation can do wonders to restore balance in your life -- and may even reduce some of the health risks associated with stress.


WebMD talked to the experts to learn more about relaxation -- and how to attain it. What follows are 10 on-the-spot techniques you can use -- any time and almost anywhere -- to reduce the tension in your life.


1. Meditate


If you're thinking meditation means twisting your body into an uncomfortable position and uttering "oohs" and "omms" for an hour, guess again. Any repetitive action can be a source of meditation, says Herbert Benson, MD, author of The Relaxation Response anddirector emeritus, Benson-Henry Institute for Mind Body Medicine in Chestnut Hill, Massachusetts. This includes walking, swimming, painting, knitting -- any activity that helps keep your attention calmly in the present moment.


When you catch yourself thinking about your job, your relationship or your lifelong to-do list, experts say to simply let the thought escape, and bring your mind back the repetition of the activity. Try it for just 5 to 10 minutes a day and watch stress levels drop.


2. Picture Yourself Relaxed


Is your mind too talkative to meditate? Try creating a peaceful visualization, or "dreamscape." To start, simply visualize anything that keeps your thoughts away from current tensions. It could be a favorite vacation spot, a fantasy island, that penthouse in New York City -- or something "touchable," like the feel of your favorite silk robe or cozy sweater.


The idea is to take your mind off your stress, and replace it with an image that evokes a sense of calm. The more realistic your daydream -- in terms of colors, sights, sounds; even touch and feel -- the more relaxation you'll experience.


3. Breathe Deeply


Feeling stressed evokes tense, shallow breathing, while calm is associated with relaxed breathing, says Michael Lee, author of Turn Stress into Bliss and founder of Phoenix Rising Yoga Therapy in Bristol, Vermont. So to turn tension into relaxation, he says, change the way you breathe.


Try this: Let out a big sigh, dropping your chest, and exhaling through gently pursed lips, says Joan Borysenko, PhD, director of Harvard's Mind-Body Clinical Programs. Now imagine your low belly, or center, as a deep, powerful place. Feel your breath coming and going as your mind stays focused there. Inhale, feeling your entire belly, sides and lower back expand. Exhale, sighing again as you drop your chest, and feeling your belly, back and sides contract. Repeat 10 times, relaxing more fully each time.


4. Look Around You


“Mindfulness is the here-and-now approach to living that makes daily life richer and more meaningful,” says Claire Michaels Wheeler, MD, PhD, author of 10 Simple Solutions to Stress. It’s approaching life like a child, without passing judgment on what occurs. Mindfulness means focusing on one activity at a time, so forget multi-tasking! Staying in the present-tense can help promote relaxation and provide a buffer against anxiety and depression.


Practice it by focusing on your immediate surroundings. If you're outdoors, enjoy the shape and colors of flowers, hear a bird’s call or consider a tree. In the mall, look at the details of a dress in the window, examine a piece of jewelry and focus on how it's made, or window-shop for furniture, checking out every detail of pattern and style. As long as you can keep your mind focused on something in the present, stress will take a back seat.


5. Drink Hot Tea




If you’re a coffee-guzzler, consider going green. Coffee raises levels of the notorious stress hormone, cortisol, while green tea offers health and beauty, says Nicholas Perricone, MD, author of 7 Secrets to Beauty, Health, and Longevity.


Chamomile tea is a traditional favorite for calming the mind and reducing stress. And black tea may be a stress-fighter, too, researchers from University College London report. Participants who drank regular black tea displayed lower levels of cortisol, and reported feeling calmer during six weeks of stressful situations than those who drank a placebo with the same amount of caffeine.


6. Show Some Love


Induce the relaxation response by cuddling your pet, giving an unexpected hug to a friend or family member, snuggling with your spouse, or talking to a friend about the good things in your lives, says psychologist Deborah Rozman, PhD, co-author of Transforming Stress. When you do, you'll be reducing your stress levels.


Why? Experts say social interaction helps your brain think better, encouraging you to see new solutions to situations that once seemed impossible, she says. Studies have also shown that physical contact -- like petting your dog or cat -- may actually help lower blood pressure and decrease stress hormones.


7. Try Self-Massage


When your muscles are tense and you’ve no time to visit a pro, try this simple self-massage technique from Darrin Zeer, author of Lover’s Massage and Office Yoga. Relax, and travel straight to Zen-land.


* Place both hands on your shoulders and neck.
* Squeeze with your fingers and palms.
* Rub vigorously, keeping shoulders relaxed.
* Wrap one hand around the other forearm.
* Squeeze the muscles with thumb and fingers.
* Move up and down from your elbow to fingertips and back again.
* Repeat with other arm.



8. Take a Time-Out


Adults need time-outs, too. So when you sense your temper is about to erupt, Jeff Brantley, MD, author of Five Good Minutes In the Evening, suggests finding a quiet place to sit or lie down and put the stressful situation on hold. Take a few deep breaths and concentrate on releasing tension and calming your heartbeat. Quiet your mind and remember: Time is always on your side, so relax. The stress can wait.


9. Try a Musical Detour


Music can calm the heartbeat and soothe the soul, the experts say. So, when the going gets rough, take a musical stress detour by aligning your heartbeat with the slow tempo of a relaxing song. And you might want to make that a classical tune. Research shows that listening to 30 minutes of classical music may produce calming effects equivalent to taking 10 mg of Valium.


10. Take an Attitude Break


Thirty seconds is enough time to shift your heart’s rhythm from stressed to relaxed, Rozman says. The way to do that: Engage your heart and your mind in positive thinking. Start by envisioning anything that triggers a positive feeling -- a vision of your child or spouse, the image of your pet, that great piece of jewelry you're saving up to buy, a memento from a vacation -- whatever it is, conjuring up the thought will help slow breathing, relax tense muscles and put a smile on your face. Rozman says that creating a positive emotional attitude can also calm and steady your heart rhythm, contributing to feelings of relaxation and peace.
8 ways to be a better boss

Great coaching boils down to 8 basic tips, she says. Here they are:

1. It's all in the relationship. "You can't coach if you haven't taken the time to build a strong relationship with your team," says Frankel. So take some time every day to get to know your team members - their likes and dislikes on the job, what they find frustrating and rewarding, their interests outside of work - and let them get to know you. "Trust me, the time you spend will pay dividends," Frankel says.

2. Always follow the 7:1 rule. "You must give seven pieces of positive feedback for every one piece of developmental feedback if you don't want to be perceived as overly critical," Frankel says. "Catch people in the act of doing things right and reinforce it with praise" - even if they're just doing the job they get paid for.

3. Be clear about your expectations. When you assign projects, discuss timelines, outcomes, and how success will be measured. Says Frankel, "Don't expect your team to be mind-readers."

4. Speak up when you see behavior that can be improved. Frankel notes that major league sports coaches don't wait until the end of the season or even the end of the game to coach their players. "They coach after plays and innings," she says. "If you offer guidance regularly and consistently, those dreaded performance reviews become pro forma, because you've already done the real work of developing employees throughout the year."

5. Coach people onto the playing field. "The workplace is a playing field with rules, boundaries, and strategies. Your job is to make sure players are on the field rather than out of bounds," Frankel says.

Let's say one of your salespeople is spending lots of time doing technical troubleshooting for clients, but isn't closing many sales as a result. You can remind him or her that, although the problem-solving side of things is essential, the ultimate goal here is to sell product, and suggest some techniques for getting to "yes" - or encourage him or her to tag along with a more proficient teammate to watch how it's done.

The point is "to focus on helping each person to succeed," Frankel says. "Framing it this way takes away the sting of judgment and allows you to focus on helping each person to succeed."

6. Focus on soft skills as well as hard skills. We've all stood by and cringed at one time or another, while a technically brilliant colleague put his or her foot in it politically. To be a good coach, you have to address that.

"Many times managers are hesitant to coach someone who is being too abrasive, too passive, not a problem-solver, or what have you, because they feel it's not tangible enough to talk about," Frankel observes. "But workplace success is contingent upon so much more than just doing the job."

Your role as a coach is to help people develop all the skills they need, not just (perhaps not even mainly) the technical ones.

7. Be a servant leader. The late management and business-ethics guru Robert Greenleaf coined the term "servant leadership," Frankel notes, "to describe the way in which leaders - and coaches - must serve their followers so the followers can be their most effective. If your team isn't serving you as well as you might like, the question to ask yourself is, 'How well am I serving them?' "

8. Prepare for each coaching session. "When it comes to coaching, winging it won't work," Frankel says. Instead, think about what you're going to say before you say it. If you need to criticize, she suggests, "try using the language 'where you seem to be getting stuck, and what you could do differently.' Again, it's not about judging the person, it's about getting them onto the playing field" - and helping them to do their best work.
And the 2007 Oscar goes to


List of winners at the 80th Academy Awards:





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Best Picture: No Country For Old Men










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Best Actress : Marion Cotillard in La Vie en Rose










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Best Actor: Daniel Day-Lewis in There Will Be Blood











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Costume : Elizabeth: The Golden Age










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Supporting Actor: Javier Bardem in No Country for Old Men










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Supporting Actress: Tilda Swinton in Michael Clayton











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Best Foreign Language Film : The Counterfeiters , Austria.










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Adapted Screenplay: Joel Coen and Ethan Coen for No Country for Old Men










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Original Screenplay: Diablo Cody for Juno











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Animated Feature Film : Ratatouille










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Art Direction: Sweeney Todd the Demon Barber of Fleet Street










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Cinematography: There Will Be Blood











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Sound Mixing : The Bourne Ultimatum











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Sound Editing : The Bourne Ultimatum










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Original Score : Atonement , Dario Marianelli.










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Original Song : Falling Slowly from Once ,' Glen Hansard and Marketa Irglova.









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Documentary Feature : Taxi to the Dark Side











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Documentary Short Subject: Freeheld











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Film Editing: The Bourne Ultimatum












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Makeup: La Vie en Rose











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Animated Short Film : Peter & the Wolf











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Live Action Short Film: Le Mozart des Pickpockets (The Mozart of Pickpockets)










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Visual Effects : The Golden Compass










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Directing: Joel Coen and Ethan Coen for No Country for Old Men




How to potty train your child?
No matter how frustrating they may be, accidents are best handled as matter of factly as possible. Calmly help your child out of his wet clothes and into dry ones. If he wets the bed at night, clean him up and change the sheets, then put him back to bed. Try to be very low key, just as you are when he spills his milk or drops a cookie on the carpet. Although the temptation to scold may be great, it won't help speed toilet training, and neither will punishing your child. These tactics can set up a power struggle or hurt his self-esteem, derailing potty training instead.

Most children will have accidents for up to six months after they're toilet trained. If you're seeing improvement, then things are probably progressing normally. If, however, your child has more accidents than he has successful experiences using the potty, he may not yet be ready to train. Try again in a few weeks or months when he seems more receptive. If your child is adjusting to a big change, such as moving to a new home or getting to know a new sibling, wait until things settle down before revisiting toilet training. If you're concerned that something else is causing your child to have trouble with toilet training, you may want to schedule an appointment with his pediatrician to discuss the situation.

If your child refuses to have a bowel movement on the potty, one of the first things to do is check the consistency of her stools. Most kids who refuse to use the toilet and have their bowel movements only in their diapers, training pants, or underwear, have had problems with constipation. Make sure your child has soft, formed stools. Hard stools, large stools, or small pebbly stools are all signs of constipation, and the most common reason for stool withholding or "toileting refusal" is that the child has had one or more bowel movements that were painful or uncomfortable.

The best way to soften the consistency of a child's stools is through her diet, by getting her to eat more fiber and by monitoring her intake of dairy products. To calculate the amount of dietary fiber your child is getting, check the nutritional information label on her food or a health book. A good rule of thumb: Children should eat enough grams of fiber to equal their age plus five. (For example, a 4-year-old needs 9 grams of fiber each day.) It's also best if the fiber is distributed equally among your preschooler's three meals, rather than eaten all at once.

It can take weeks, sometimes months, for a child to get over having a painful bowel movement. Parents often think their child has an accident because she is angry or resentful, but according to doctors, this is rarely the case. A child may have accidents because she holds back her painful stools until she can't hold them anymore.

Once your child is routinely having soft, formed bowel movements, keep track of when she has them to see if there is any pattern to them. If you can tell that it's about time for her to poop, encourage her to sit on the toilet.

I also recommend what I call toilet sits — encouraging your child to sit on the toilet or potty several times a day, without any pressure to have a bowel movement. These "sits" are more to get her accustomed to sitting on the toilet than to get her to use it. It's all right for her to do a dozen toilet sits each day without ever having a bowel movement there. Your goal is to help her learn to relax while sitting on the toilet.

Make certain that your child can place her feet firmly on the floor, if she's on a potty chair, or on a step stool if she's on the regular toilet. Being able to plant her feet on the floor means that she can get on and off the potty or toilet easily, that she feels stable and secure when seated, and that she can push with her feet to give her leverage. All of these are important to independent toilet use.

You probably know this by now, but it's hard to maintain your child's interest in anything unless she really wants to stay engaged — especially if it's taking her a while to learn a new skill or if she's had a few setbacks or frustrations. Some parents offer rewards such as stickers or treats when their child poops in the potty for the first time or stays dry for a certain number of days in a row. You can also reinforce your child's desire to leave babyhood behind by talking up the delights of wearing big-kid underpants all day long. Or celebrate a diaper-free day with a special privilege, such as staying up a bit later than usual to cuddle together and watch a video or read picture books. Sometimes a little excitement is all it takes to motivate your child. But if despite all your encouragement potty training is just not grabbing your child's attention the way you'd like it to, try to stay relaxed. If you push her too hard or she feels the pace is too fast, she may react to the pressure by slowing down rather than speeding up. She may even regress and start refusing to do whatever she has been doing up to that point. Let her feel that this is her big adventure, and that you're her biggest fan.
How to lower your cholestrol?
Your Lower Cholesterol Toolbox
Get the tools you need to help lower cholesterol -- and reduce your risk of disease -- starting now.

By Gina Shaw
WebMD Feature Reviewed by Charlotte Grayson Mathis, MD




Achieving lower cholesterol is one of the best ways to protect yourself from heart attack and stroke. A fat-like substance found in the blood, cholesterol can build up and form deposits in your arteries. These cholesterol deposits can clog -- or in some cases completely block -- the passage of blood and oxygen to the heart. The result, for hundreds of thousands of people every year, is chest pain, heart attack, or other cardiovascular problems.


There are two kinds of cholesterol: HDL (high-density lipoprotein) and LDL (low-density lipoprotein) cholesterol. HDL is often called the "good" kind of cholesterol because it helps remove unneeded cholesterol from the body. LDL is the "bad" cholesterol; it's made up primarily of fat and is a particular risk factor for heart disease.


So when you set out to lower cholesterol, you need to know your HDL number, your LDL number, and your total cholesterol number (which is not the total of your HDL and LDL cholesterol) too.



Total Cholesterol (mg/dL)


HDL (mg/dL)


LDL (mg/dL)



Best: Below 200


Men: 40-50


Best: Below 130



Borderline: 200–239


Women: 40-60


Borderline: 130-159



High risk: 240


High risk: Below 40


High: 160 or above




If any of your cholesterol numbers are in the high risk category, you're at an increased risk for heart disease -- which may lead to heart attack.


The good news is you have several options to help you get back in the cholesterol safety zone. These four options can all work separately -- or together -- to lower cholesterol, and keep it under control.


* Diet
* Exercise
* Weight loss
* Medications



Diet to Lower Cholesterol




The body gets cholesterol in two ways: by making it, and by what we eat. Most of the cholesterol we eat comes from dietary fats found in foods like butter, margarine, milk, and fish. One of the easiest ways to lower cholesterol is to lower your intake of certain kinds of fats.


Just as there is "good" cholesterol and "bad" cholesterol, there are "good" fats and "bad" fats. To keep your cholesterol low, your total fat intake shouldn't be more than 25% to 33% of your diet -- and most of those fats should be the good kind, like vegetable fats (monounsaturated fats and polyunsaturated fats), and omega-3 fatty acids, found mostly in fish.


To help lower cholesterol, you'll want to avoid or reduce saturated fats (usually found in animal products like meats, eggs, and dairy), and trans fats, which are formed when hydrogen is added to vegetable oil (think French fries and doughnuts).


"A quick way to tell the difference between animal fats and vegetable fats is that animal fats are usually solid at room temperature, while vegetable fats are liquid at room temperature," says Antonio Gotto, MD, the Stephen and Suzanne Weiss Dean at the Weill Medical College of Cornell University, in New York City.


So fill up on the healthy fats found in vegetable oils, nuts, avocados, and salmon, and cut back on higher-fat foods like red meat, whole milk, and of course, those tempting chips and pastries.


Exercise to Lower Cholesterol




Regular physical activity is key to keeping your cholesterol low. Studies have found that even moderate exercise is enough to boost HDL (good) cholesterol and lower LDL (bad) cholesterol. In a recent study of young and middle-aged women in Spain, researchers found that the more calories a woman burned through moderate exercise, the lower her LDL level and the higher her HDL level.


Exercise, in combination with a healthy diet, is also important because while a low-fat lower calorie diet helps lower total cholesterol and bad LDL cholesterol, one study showed it can also drop good HDL cholesterol by 7% over a year. That same study showed an increase in good HDL cholesterol (and a decrease in LDL and total cholesterol) for those who walked or jogged about 8 miles a week.


Weight Loss to Lower Cholesterol




Both a healthy diet and regular physical exercise can lead to another important tool in lower cholesterol: weight loss.


Excess weight tends to increase your LDL cholesterol level. If you are overweight and have high LDL cholesterol, losing weight may help you lower it. Weight loss also helps to lower triglycerides (another form of fat in your blood and one which you should aim to keep below 150 mg/dL) and raise HDL ("good") cholesterol levels.


Medications to Lower Cholesterol




Some people find they can't lower cholesterol enough with lifestyle changes alone. "There are genetic factors that affect cholesterol levels," says Gotto. "One person may be able to keep their cholesterol low without much effort at all, while someone else may eat right, exercise, keep their weight down, and still have high cholesterol."


That's where medications come in. There are several types of cholesterol-lowering medications, but the most commonly prescribed are statins. There's a good reason for that, says Gotto. "They are very effective in lowering LDL levels in the majority of patients." Studies have shown that statins can lower LDL cholesterol by 20% to 60%.


Other medications to lower cholesterol include:


* Bile acid sequestrants
* Nicotinic acid (niacin)
* Fibric acids
* Cholesterol absorption inhibitors



Each of these drugs act in slightly different ways. For example, some lower LDL cholesterol, while others treat high levels of triglycerides and/or raise HDL cholesterol. Your doctor will help you decide which medication -- or combination -- is best for you.


However, medication may not help you as much if you don't help yourself.


"It's been found that if you continue to eat a high-fat diet, the effects of cholesterol-lowering drugs like statins are diminished," Gotto says. So if you start taking a cholesterol-lowering medication and figure it's OK to load up on the Krispy Kremes -- it's not.


Diet, exercise, weight loss, and medication: Your cholesterol-lowering toolbox has all you need to help you lower cholesterol -- and keep it low.
Big Story: Ending the Chore Wars -- how to get your mate to help on the home front
Chore Wars: The great marital divide
By all accounts, I got lucky. My husband not only brings home his share of the bacon, but he also fries it up, scrubs the pan, and puts it away. If I'm as fortunate to have such an equitable partner as my friends say I am, then why after eight years together do we still argue over whose turn it is to take out the garbage? The short answer, it appears, is kids.

Before having children, most couples find it easier to maintain a neat house and to keep bickering about unmade beds at bay. But having kids means having more clutter to clear, loads of laundry to do, and more meals to make, and it's moms who bear most of the burden: Working women spend about twice as much time as working men on household chores and the care of the children, according to a recent time-use survey by the Bureau of Labor Statistics.

Not surprisingly, the housework gender gap is a common source of friction: A recent BabyCenter survey of more than 12,000 readers revealed that 63 percent of couples with children at home argue over cleaning. And nearly half of respondents say they resent having to do more housework, cooking, and laundry than their mates.

Not only do dust bunnies lead to marital dustups, but the responsibility for housework can also have harmful effects on women's health. A study by sociologist Chloe E. Bird published in the March 1999 issue of Journal of Health and Social Behavior found that women who do twice as much housework as their spouses have greater anxiety, depression, and worry. The least depressed people in Bird's study, both male and female, were those who split household duties down the middle.


Are men slackers?
If women are clearly doing more around the house, what are men doing? Guys don't appear to be totally slacking: American men in dual-income families handle a third of shopping and meal preparation. Men do roughly 15 percent of the laundry, and while that may not entitle them to bragging rights, it's an improvement over the measly 2 to 5 percent they did back in 1970. And men today are more involved parents: One in four preschoolers with working moms are watched by their fathers. "In general, men try to compare their contributions to their fathers, and compared they look very good, doing four or five times more than their fathers did," says sociologist Scott Coltrane, author of Family Man: Fatherhood, Housework and Gender Equity.

According to several studies, men with a higher education are more likely to pick up and pitch in. Coltrane suggests that more educated men may be more likely to put women on equal footing and assume a balanced role in the household. Interestingly, research also shows men who delay fathering children until their late 20s or early 30s, move away from the neighborhood they grew up in, and have less frequent contact with their parents, or who have been divorced and remarried, are more likely to do housework. Coltrane points out that these men have had to fend for themselves, so it makes sense that they'd continue to help out.

Still, "compared to their wives and partners, men do a lot less," says Coltrane. He points to a range of explanations for the battle of the sexes on the chore front — from cultural expectations about gender roles, to a greater emphasis on a husband's career if he's the primary breadwinner, to some women's difficulty delegating work. Practically speaking, though, the broom stops with whomever spends more time at home, says Coltrane, and that's usually Mom.

Psychologist Joshua Coleman, author of The Lazy Husband: How to Get Men to Do More Parenting and Housework, suggests that men's resistance to housework may start in childhood. From an early age, men are preoccupied with power and status (just look at any boy playing with an action-figure hero), and they may assert their independence by refusing to do something they've been asked to do. And while men feel they look pretty good compared with their fathers, they fail to factor in that their wives are also doing a lot more than their own mothers did, notes Coleman.

Men who do dishes do better in the bedroom
If only men knew what they were missing: Men who do more housework have better sex lives and happier marriages, according to a study by John Gottman, a psychologist who for more than three decades has been researching why relationships succeed or fail. Further research by Gottman suggests that harmony over housework may also yield happier children. His findings reveal that men who do housework frequently have kids who do better socially and academically.


Nine ways to get your partner to do his fair share

Talk to him.
While you may find it hard to believe that he can't see anything's amiss with the layer of dust covering your furniture or the mildew growing on the shower curtain, the truth is if your husband's not complaining, he's probably fine living that way. "The average guy feels like if it ain't broke, don't fix it," says psychologist Coleman, a self-described lazy husband in recovery. Take the time to let him know what you mean by a "clean" house.

Instead of quietly stewing with resentment or complaining to your girlfriends, tell your spouse you need more help keeping your place (relatively) clean. Be firm, but resist nagging. "Nagging isn't very assertive — it's humiliating to the person doing the nagging and annoying to the person being nagged," says Coleman. He suggests a friendly approach: Tell your husband that you've been feeling overwhelmed and that you really need and appreciate his help. Start by creating a short to-do list for him, suggests Coleman, and pick the tasks that have been bugging you the most. You might specify jobs such as cleaning up after dinner, making the bed on the weekends, and taking primary responsibility for the baby at least one weekend morning so you can sleep in.

Teach a man to fish and he'll eat for a lifetime.
This old adage can hold true for household chores too. "While some men feign incompetence, some genuinely have never learned how to do housework," notes sociologist Coltrane. Before your mate takes on a chore, demonstrate it for him, talking him through it as you go.

Don't be a control freak!
One of the reasons men don't help around the house as much as we'd like is that we can make them feel like they can't do anything right. So once you've shown him how to separate whites and colors, and to dust before running the vacuum, consider that his standards may never meet yours. Decide what you can live with: If the choice is to do every task yourself, or to live with his less-than-perfect housekeeping skills, you may more readily settle for adequate. A little restraint and a heaping of praise can go a long way in his wanting to be involved and useful.

Choose chores he'll want to do.
It's much easier to motivate someone to do something he likes, so if your mate's more inclined to cook than to clean up, ask him if he'll prepare more meals during the week. Of the "big five" household tasks — cooking preparation, meal cleanup, shopping, laundry, and housework — men are more likely to do the first three and least likely to do the last two, says sociologist Scott Coltrane. So strike some new deals with your spouse. If you've been doing all the shopping, cooking, and cleaning, let him troll the market aisles, cut up the vegetables, and toss the salad for dinner. He may even enjoy it. While it may seem unfair that he gets to choose jobs he wants to do, consider that it's better than the alternative — doing everything yourself!

Do a little at a time.
Splitting chores between you and your spouse over several days will keep weekends from turning into nonstop drudgery. "We used to jam all of the housework into Saturdays, but now my husband and I have designated weekdays for certain cleaning jobs," says Kate Richardson, mother of a 2-year-old. "By spreading chores out across the week, keeping a (fairly) clean house seems less overwhelming — plus we've freed up more weekend time for family fun," she says.

Appeal to his charitable side.
Show your husband that getting rid of the toys collecting cobwebs in your living room and the forgotten clothes in your closets is a great way to help a good cause and save your family money. Ask him to oversee a "giveaway box" to which he and the kids can contribute, and then put yourself on a calling list for a couple of charities and thrift stores. "They call every other month to see if we have anything to donate, and we gather up books we've finished, clothes and shoes the kids have outgrown, and toys they're bored with," says Ann Struckman, mother of three children, ages 13, 9, and 2. "The charity picks up the items and leaves a donation slip for tax write-off purposes."

Outsource!
If you can, make some cuts in your budget, and use the money to hire cleaning help. (Cost will vary depending on where you live and the size of your house, but the national average for someone to clean every week or every other week is around $75 to $110 per visit.) "We hired a housecleaning team after our daughter was born, and it's worth every penny, not just in time, but also arguments avoided," says Catherine Holecko, mother to a 3-year-old and a newborn. "Cleaning ranks way below family, work, and personal time in my order of priorities. Also, having cleaners come every two weeks forces us to do a round of picking up and de-cluttering on the day before they come."

And if he still doesn't pitch in...
"If you're still being ignored, it may be time to play hardball and say, 'I'm not going to keep doing all the things I'm doing,'" suggests psychologist Coleman. Take something off your plate that you know your mate relies on you to get done. For instance, if you usually pay the bills and your husband can't stand them to be late, tell him you're no longer paying the bills. Coleman points out that tough-love should be your last resort, but it can be surprisingly effective.

Take time to reconnect.
Finally, if you've been more irritated than usual by dishes collecting in the sink, consider whether it's merely the grimy plates that need attention. "In all my years of working with couples there seems to be this pattern: When men aren't paying attention to their wives, the housework issue becomes more of an issue," says marital therapist Michele Weiner-Davis, author of The Sex-Starved Marriage: Boosting Your Marriage Libido. "It becomes less of an issue if men are making an effort to be closer emotionally." Weiner-Davis frequently sees a vicious cycle: When women aren't getting help, they become less physically affectionate with their spouses, who in turn withdraw more emotionally. "It would ease tension if couples took the time to reconnect on a regular basis," says Weiner-Davis.

So at least once a month, do the things you used to enjoy together before you had children (and a messy house). Send the kids to Grandma's overnight so you can have a romantic evening in. Or hire a babysitter and go out for a relaxing dinner. Besides remembering what made you a good couple, the next-best part is that neither of you has to clean up the dishes afterward.
The BabyCenter Seven: Parent-tested tips for getting your child to pitch in
Now that you've learned how to get your mate to help out on the home front, read on for advice on getting your children to do their fair share. (If you're raising a boy, you'll also be doing the next generation of women a favor!)

Whistle while you work
Snow White's dwarfs had the right idea: My 3-year-old loves to sing the Barney cleanup song or make up tunes to go along with the task at hand. Singing really makes our jobs go faster. — April, mother of one going on two
Clean sweep
Here's a fun way to keep hardwood floors free of dust bunnies: My 4-year-old daughter and I put dry, dusting mitts on our feet and skate around the house. — Julie, mother of a 2-year old
Scavenger hunt
My son loves to help me clear the clutter around the house when I turn it into a seeking game. For instance, I'll ask him to find everything on the floor that has wheels on it in five minutes and have him put it in the appropriate storage basket. Or we'll go around the house on a dirty dish hunt. — Susan, mother of a 3-year-old
Mini me
My kids love to use miniature brooms, mops, and snow shovels to work alongside my husband and me. They have so much fun and we get such a kick out of watching them in action. — Jenn, mother of two
Beat the clock
I get my boys excited to pitch in by challenging them to the "ten minute tidy." I set a timer, and we race around the house picking up as much as we can before the buzzer goes off. My kids have so much fun that they don't even realize they're cleaning. — Melissa, mother of two
A clean house is in the stars
My son used to hate picking up his toys until we started the "star system." I bought colorful, star-shaped stickers and listed his responsibilities in a notebook. Now he gets a star for every task he accomplishes and exchanges them for ice cream, sweets, little toys, or stickers when we go grocery shopping. — Pauline, mother of a 4-year-old
Crank up the tunes and dance
My daughter and I play music and dance around while we're picking up toys and doing other housework. It's a great bonding time and we have so much fun that the chores whiz by. Plus, it's a great workout! — Elizabeth, mother of a 5-year-old


Top 10 Consulting Pitfalls
Top 10 Consulting Pitfalls

Excerpts from Monster career advise.



Contracting is the life, isn't it? You put your bare feet up on your desk, make a few phone calls to clients who eat up your advice like caviar, and then just count your money.


Not quite. There are lots of things that can go wrong when professionals go independent. So it's a good idea to survey the road for some of the most common potholes, and to consider making a pit stop before you blow a tire and lose control of your business.


1. You Stop Prospecting for New Business


Countless consultants get in a rut and work with the same small group of clients year after year. Stability is great, but if you don't regularly test the market for more challenging projects and prestigious clients, you could be missing stellar opportunities. Here are 5 steps to warn a client.

* Here are five additional tips for having effective and constructive conversations in difficult situations:
* Give Fair Warning: The element of surprise won't work in your favor, says Loren Ekroth, Las Vegas-based founder of National Better Conversation Week. "You don't want to blind-side the other person, so ask them to get together at another time in a private, confidential place to clear up some issues. Let them know what you see as the issues and give them some time to reflect and prepare their thoughts for when you get together."
* Have a Plan of Attack: "Consider what you want to say, write it down, and sit with it for awhile," says Suzanne Bates, author of Speak Like a CEO: Secrets for Commanding Attention and Getting Results and president of Bates Communications in Wellesley, Massachusetts. "Writing it down will help you act, instead of react. If you're not sure what you want to say, discuss it with someone you trust. Be sure that person can be trusted not to disclose it. Confidentiality is critical. You don't want to complicate the situation."
* Be Prepared for an Ongoing Process: Be ready to have to continue the conversation later, cautions Alexander Grashow, director of the consulting practice at Cambridge Leadership Associates in Cambridge, Massachusetts. "Difficult conversations are iterative and most often require the people involved to negotiate changes with their people, departments or communities."
* Call for a Mediator: If you think the conversation will become heated, ask that a mutual, trusted colleague be present to mediate and keep things civil, Ekroth suggests. "Often the simple presence of another puts antagonists on their best behavior so differences can be worked out with civility."
* Check Assumptions at the Door: Making too many assumptions is a common mistake, Bates says. "It's easy to assume we fully understand the other person's motivation. We are too quick to jump to conclusions about people's actions, behaviors and attitudes." To avoid that, forget about who is right and focus on understanding the other person. "Be genuinely curious. This will help you get clarity. Separating fact from assumptions is the key to arriving at real understanding. Questions also interrupt the blame game and create an atmosphere of trust instead of suspicion."
* Armed with these tips, you'll be ready the next time you have to have a tough talk with a colleague or client. And you'll be more likely to achieve a positive outcome for everyone.



2. Your Fees Don't Keep Pace with the Market


You have a longstanding relationship with a client and can't seem to find a way to move your fee up from $60 an hour. Rising expenses chip away at profits, and it's obvious that other potential clients would pay you $90 an hour, no questions asked.


3. You Enter Agreements Blindly


Work for hire, hold harmless, irrevocable assignment -- who knows the meaning of all that legal mumbo jumbo? You'd better find out -- with the help of a lawyer if necessary -- or you may end up in civil or bankruptcy court.


4. You Give Away Your Intellectual Property


Your client takes that ingenious little algorithm you wrote, turns around and licenses the code to five other companies for a cool $500,000. It's all perfectly legal, and what do you have to show for it? Resentment.


5. Your Home Office Gets Out of Control


Your office looks like an office supply store that got hit by a tsunami. You've actually lost business by misplacing contact information. Or maybe your toddler knows where to find that flash drive, and she's using it to test her new molars.


6. Bad Work Habits Lower Your Productivity


Billing by the hour can be profitable, but not if you keep clocking out to watch TV or shop online for stuff you can't afford because you're not billing enough hours. Even if you think you're spending time wisely, there's probably room for improvement.


7. Your Work Becomes Your Life


Do you work every weekend? Is your spouse preparing to hit you with a conjugal negligence suit? If so, you need to put work in a larger perspective and get a life. If you don't, your professional creativity and productivity will suffer.


8. You Fail to Ride the Technology Curve


Even if you don't work in the high tech arena, technology is key to your business productivity. Do you frequently rekey lots of data? Wait around while your PC completes tasks? Spend hours looking for basic information? If so, you're losing your competitive edge.


9. Your Professional Skills Stagnate


What's new in your field this year? What have you learned this month? If you don't have good answers, your stock value will drop like a dotcom's in spring 2000.


10. Your Grapevine Withers


What's the contractor's most valuable business property? The Rolodex. If you don't keep up with customers, colleagues, rivals, mentors and other players, you're toast.
US election - Few terms to know and learn
United States presidential election determines who serves as president and vice president of the United States for a four-year term, starting at midday on Inauguration Day, which is January 20 of the year after the election. The elections are conducted by the various states and not by the federal government. Constitutionally, the election is by United States Electoral College electors, who are chosen by methods each state individually establishes.

The United States Electoral College is a term used to describe the 538 Presidential Electors who meet every four years to cast the electoral votes for President and Vice President of the United States. The Presidential Electors of each state are elected by a vote of the people of that state on the day traditionally called election day. Presidential Electors meet in their respective state capitol buildings (or in the District of Columbia) on the first Monday after the second Wednesday in December , never as a national body. At the 51 meetings, held on the same day, the Electors cast the electoral votes. As such, the collectivity of the 51 groups is the technical definition of the college, despite never convening together. The electoral college system, like the national convention, is an indirect element in the process of electing the president. The Constitution does not require the Electors to vote as pledged, but many states do require their Electors to vote as pledged.[1]

Electors are chosen in a series of state elections held on the same day (election day). The number of electoral votes of each state is the sum of its number of U.S. Senators (always two) and its U.S. Representatives; the District of Columbia has the same number of votes it would if it had Senators and Representatives (currently three).[2] In each state, voters vote for a slate of pre-selected candidates for Presidential Elector, representing the various candidates for President. State ballots, however, are designed to suggest that the voters are voting for actual candidates for President. Usually states use what is termed the short ballot, in which a vote for one party (such as Democratic or Republican) is interpreted as a vote for the entire slate of Presidential Electors. [3] With rare exceptions, one party wins the entire electoral vote of the state (by either plurality or majority). Maine and Nebraska choose Presidential Electors using what is termed the District Method, which makes it possible for the voters to choose Electors of different political parties and split the electoral vote of these two states.

Electoral College mechanics


The election of the leader of the United States and the Vice President of the United States is indirect. Presidential electors are selected on a state by state basis as determined by the laws of each state. Currently each state uses the popular vote on Election Day to appoint electors. Although ballots list the names of the presidential candidates, voters within the 50 states and the District of Columbia are actually choosing Electors from their state when they vote for President and Vice President. These Presidential Electors in turn cast the official (electoral) votes for those two offices. Although the nationwide popular vote is calculated by official and media organizations, it does not determine the winner of the election.



Apportionment of electors


The present allotment of electors by state is shown in the article List of U.S. states by population.


The size of the electoral college has been set at 538 with 535 corresponding to the size of the United States Congress, plus 3 that represent D.C. since the election of 1964. Each state is allocated as many electors as it has Representatives and Senators in the United States Congress. Since the most populous states have the most seats in congress, they also have the most electors. The states with the most are California (55), followed by Texas (34) and New York (31). The smallest states by population, Alaska, Delaware, Montana, North Dakota, South Dakota, Vermont, and Wyoming, have three electors each. Because the number of representatives for each state is determined decennially by the United States Census, the electoral votes for each state are also determined by the Census every ten years. The number of electors is equal to the total membership of both Houses of Congress (100 Senators and 435 Representatives) plus the 3 electors allocated to the District of Columbia, totaling 538 electors. A candidate must receive a majority of votes from the electoral college (currently 270) to win the Presidency. If in either election for President or Vice-President no one receives a majority, the election is determined by Congress (the House votes for presidential candidates, and the Senate votes for vice presidential candidates).
Nomination of electors


Potential elector candidates are nominated by their state political parties in the summer before the Election Day. The U.S. Constitution allows each state to choose its own means for the nomination of electors. In some states, the Electors are nominated in primaries the same way that other candidates are nominated. Other states, such as Oklahoma, Virginia and North Carolina, nominate electors in party conventions. In Pennsylvania, the campaign committees of the candidates name their candidates for Presidential Elector (an attempt to discourage faithless Electors). All states require the names of all Electors to be filed with the Secretary of State (or equivalent) at least a month prior to election day.
One month following the casting of the electoral votes, the U.S. Congress meets in joint session to declare the winner of the election. If a candidate for President receives the vote of 270 or more Presidential Electors, the presiding officer (usually the sitting Vice President) declares that candidate to be the President-elect, and a candidate for vice president receiving 270 or more electoral votes is similarly declared to be the Vice President-elect.

The series of Presidential primary elections and caucuses is one of the first steps in the process of electing the President of the United States of America. The primary elections are run by state and local governments (where states do not have caucuses). A state primary election usually determines which candidates for president will be supported by that state at the national convention of each political party.

Both major political parties (Democratic and Republican) officially nominate their candidate for President at their respective national conventions, usually held during the summer before the federal election. Depending on state law and state party rules, when voters cast ballots for a candidate in a presidential caucus or primary, they may actually be voting to award delegates "bound" to vote for a candidate at the state or national convention, or they may simply be expressing an opinion that the state party is not bound to follow in selecting delegates to the national convention. In addition to delegates chosen during primaries and caucuses, state delegations to both the (Democratic and Republican) conventions also include "unpledged" delegates. For Republicans, these include top party officials. Democrats have a more expansive group of unpledged delegates called "superdelegates", who are party leaders and elected officials.

The Democratic National Convention is a series of presidential nominating conventions held every four years administered by the Democratic National Committee of the United States Democratic Party. As a national affair, the meeting is attended by delegates from all fifty U.S. states as well as delegates from American dependencies and territories such as Puerto Rico. Like the Republican National Convention, the Democratic National Convention marks the formal end of the primary election period and the start of the general election season.

The primary goal of the Democratic National Convention is to nominate and confirm a candidate for President and Vice President, adopt a comprehensive party platform and unify the party.
A precinct is generally the lowest-level minor civil division (MCD) in the United States. Precincts usually do not have separate governmental authorities, but for purposes of conducting elections, the next highest-level MCD, such as a county, township, etc., is subdivided into precincts and each address is assigned to a specific precinct. Each precinct has a specific location where its residents go to vote. Sometimes several precincts will use the same polling station. A 2004 survey by the United States Election Assistance Commission reported an average precinct size in the United States of approximately 1100 registered voters. Kansas had the smallest average precinct size with 437 voters per precinct, while the District of Columbia had the largest average size at 2704 voters per precinct [1].

Political parties often designate individuals, known by various titles such as "precinct captain" or "Precinct Committee Officer", to help them keep track of how the voters in a precinct feel about candidates and issues, and to encourage people to vote.
10 simple secrets to keeping her happy

I am the best husband in the world. If my wife were to read this, she'd fall to the floor, convulsed in laughter, and then gasp something about my "dazzling lack of self-knowledge." But no matter. I wear her ignorance of my excellence as a badge of honor. The best performers inhabit their roles--you never catch them acting.


I wasn't always a paragon. In my early years, I was a journeyman at best. In '88, I treated a precious marital secret as though it were the score of a Bulls game. And back in '96, there was a New Year's Eve kiss with our neighbor that probably should have been more perfunctory, less probing. But over the past decade, inch by inch, I've mastered the gig, and for the past few years, I've been locked in. I can see the seams on every chance to love, honor, and cherish.


I don't know how I got so good at this. As a kid, I had a front-row seat on my father's version of husband, which, at least according to my mother, was a star turn. And as a grown man, I've watched my father-in-law dazzle his sidekick of 53 years. But I have no formal credentials, and the only marriage counseling I ever got, from the rabbi the day before my wedding, amounted to, "A Catholic and a Jew? Don't bother. Cancel the wedding and save on the divorce." My only qualification? I've been a husband for a long time--24 years according to the state of Pennsylvania, over 30 by common-law count--and, fortunately for you, I've made many, many mistakes from which you are about to learn.


Will you ever be as great a husband as I am? Not likely. By now, I'm the gold standard. But you can do better, my brother. (And that's true for you unmarried guys, too: If you're with her, you can learn to be with her better.) I've condensed my wisdom into some guiding thoughts and tricks of the togetherness trade. Think of them as batting tips from Barry Bonds. Stash them in a part of your brain that guides your behavior, and two good things will happen: She'll get the partner she deserves, and you'll get the satisfaction and, oh yeah, the sex of which you dream.



No. 1 - Kill never and always

When you and Lucy argue, don't use either of these two words. First of all, they're not technically accurate. It's not true that she never wears the cheerleader skirt; you got some boolah-boolah on your birthday. But, more important, they're gas-on-the-fire words. Instead of these indicting adverbs, use ameliorative words and phrases, like sometimes or I feel or I wish.


Darn right they're soft, but guess what? The best husbands actually are a skosh more sensitive to their wives' feelings than your average brute of a mate is. By the way, the words never and always are great when you're complimenting her, as in, "You never fail to amaze me" or "I always enjoy reaching under your blouse."



No. 2 - Work the reunions

You come through the door tired, maybe distracted about something at work. You riffle through the mail, ask her a routine how-was-your-day question, and give her a pro forma kiss. But let's face it, you don't really focus on her, do you? She gets only a sliver of your attention. Not good enough.


Don't panic. I'm not about to suggest in-the-moment mindfulness. Men can't be "in" every moment. The secret is to "husband" your limited supply of attention, save it for deployment at pivotal times. Think like John McEnroe, who would occasionally tank a forsaken fourth set, saving his strength for the pivotal fifth. Your key moments are the reunions. Take a few seconds and resolve to be fully tuned-in during each come-together moment. You can do it. Trust me, if I can, you can.


Here's the plain truth: For all the habituation of marriage, all the erosions that come with familiarity, a link between a man and a woman is also instantly renewable in a momentary locked-on gaze. For just a beat, maybe two, claim her with your eyeballs. Look at her in a way that says, "I'm glad to be home, back in our powerful secret." This kind of subtle but daily maintenance keeps the engine thrumming.
No. 3 - Laugh at her

Among the most affirming things one person can do for another is to laugh at the other's attempts at humor. Lots of husbands, over time, forget this salute. What's that you say? Your wife isn't funny? So what? Neither is your dolt of a boss, but you laugh at his lame attempts. Why? Because you're trying to prove you respect him. Bingo!


One of the biggest dangers mature marriages face is that Homer and Marge stop trying to demonstrate their respect for each other. Laughter is tonic for a woman's woes. Keep it on display.



No. 4 Make the lion's roar

Describing his important role during World War II, Winston Churchill once remarked that though he was no lion, it had fallen to him to make the lion's roar. Every now and then, husbands have to get fierce, defiant on behalf of their team.


It won't happen often, but when you are in a confrontational situation, where reason and soft words have failed--a dispute with a teacher, a vendor, a bill collector, your neighbor, your mother--be prepared to bark in unambiguous defense of your family. Don't shrink from this obligation. Your wife's regard for you will shrink if you do.



No. 5 - Be a little lamblike, too

Yes, this contradicts the carnivorous idea above, but a husband is versatile: He can hammer the tee ball and feather the wedge. Softness and kindness and tenderness and all those traits that ain't much use in the marketplace are pure gold when it comes to being a husband.


A good husband relies on his wife, values her counsel, trusts her to love him even though he's not in command. We're most human when we're wounded or lost. Fred Rogers once said that the best gift you can give somebody is to gracefully receive his or her help. That enriches everybody, giver and getter alike. Now and then, wrap your arms around your wife and whisper that you're a mite confused. Let her help you find your way.



No. 6 - She needs closeness to feel sexual; you need sex to feel close
This is the fundamental impenetrable puzzle of love. I have no idea what to do about this. But great husbands have this reality in mind at all times.

No. 7 - Be touchy

Apparently, we touch our wives too infrequently--except, of course, when we are taxiing for takeoff. It pains me to cede any ground, but we're guilty as charged. I know one husband who when he's feeling conjugal actually touches his wife as though he cherishes her character. But in fact, he's hoping to cherish her caboose in a kitchen quickie. She sees through me every time. Did I say me? I meant him.


Nonsexual touch is a potent, underused endorsement of another soul. As you're heading out the door, give her upper arm a quick, affectionate double squeeze. As you're walking into a party or to your table, put a guiding hand, lightly but surely, on her lower back. Some nothing-special Tuesday night while she's standing at the sink doing the dishes, come up behind her and give her a kiss on the back of her head. It should be more than a peck--make it last 1.4 seconds.


Throw in a little grunt of gratitude; its message is only this: "I'm a lucky man." Don't linger behind her. No arms. No hint of pelvic urge. She'll get cranky if she suspects you're cruising for dessert while she's scraping chicken gunk off a baking dish. Just drop the husband kiss on her noggin and get out of there. She'll feel valued.



No. 8 - See the coffee cup

The perfect husband understands that women often get confused by stuff that doesn't matter, as in the unwashed coffee cup that's been sitting in the sink for days. Few wives understand that it isn't that we see the coffee cup and elect not to rinse it, but rather that the neural link between our eyeballs and brains actually keeps us from seeing the cup. The gender biology of why we don't see the cup comes down to this: We have a lot of more important things on our minds. Will the Bills cover? Any chance of sex today? I think my biceps really are getting bigger. Our minds are cauldrons of profound thoughts. Any wonder we occasionally overlook some stray dishware?


Charge: We don't help enough around the house. We're guilty. But here's the fix: Do more. Not a lot more--just a little more. One of the best things about women is that they really appreciate the smallest sign that you're trying. They're effort oriented.


Try walking into a room with a woman's mind. Imagine that your brain has space in it for trivialities like unwashed cups. Ask yourself, If I were a psycho neat freak, what would bother me in here? The coffee cup--which sometimes takes the form of the kids' sneakers under the table or the metro section crumpled on the couch--will suddenly reveal itself to you.



No. 9 - She ain't broke, so don't fix her
People rarely change unless they feel accepted as they are. Once folks feel they're not required to change, growth happens.




No. 10 - Play to win

You know the athletic wisdom that warns against playing not to lose, that argues you have to be loose to let your skills flow and maximize your game? Same goes for marriage. Oh, sure, you can have a perfectly fine little partnership by taking the cautious route. He & She Inc. may even hum along nicely if you companionably sidestep the briar patches. But that's no way to be a great husband. She's entitled to more, the full monty, the whole experience of being affiliated with, no, make that loved by, a man.


People often settle for accommodating coupledom because they're afraid some explosive issues will blow up the marriage. They fear ending their days alone, living under the bridge behind the high school. Set yourself free to play bravely by taking the big risk, divorce, off the table. Decide that you meant what you said at the wedding, that this woman, come what may, is your partner for life.


Older couples often report that once they've gone past the point where they might leave each other, their partnership gets an invigorating second wind. No longer afraid of being alone, they talk things through. In pursuit of something richer than mere amity, they explore regrets, grievances. Sure, it can be difficult, but it's full and human and adrenal and--hallelujah!--not dull. And it can lead to a more spacious marriage, a connection that is full hearted and well tempered instead of taped together.







The Power of Having a Vision for Your Business
Excerpts from CNBC Big Idea

For many years I heard that you had to start with a vision for your business or your life if you really wanted to succeed, but no one could explain to me why it was needed or how it worked from a practical or scientific standpoint.

When I was young and naïve, I was skeptical and wanted empirical evidence showing me why I should invest my thoughts and time into really thinking about a vision for my life and business, and why getting absolutely clear by writing it down was imperative to my achieving success.

Even though I couldn’t find adequate answers at the time, reluctantly, I did as others suggested purely because they were far more successful than I. As I was told “don’t ask so many questions” and “just do it,” I temporarily gave up my need for so many answers—but not for long.

At the ripe young age of 21, I created a grand vision for my life and my career. Even though I had only graduated from high school, and everyone told me that “you need a college degree to really succeed,” I took a different approach and got into business at a very young age.

For the next 26 years, I stayed on a healthy mental diet to train my brain, and followed the belief of allowing the universe to guide me and bring me whatever I needed to fulfill my visions of being financially free and living an extraordinary life.

After building four multi-million dollar businesses—one of which grosses more than $5 billion a year in sales—and having made millions of dollars for myself and others, I began to search for the answers to the question I’d had 25 years earlier—“Why is having a clear and precise vision so important?”

I couldn’t help wanting to know why. As a child I was very curious and my parents could not answer many of the questions I had about success. After all, they only had a total of 5 years of school between them and had never made more than $30 thousand in a year.

Since I wanted more for myself, I sought out the best minds, researchers, and teachers in the world to teach me how to have an abundant life in all areas.So, what did I learn that you can apply immediately and benefit from my lessons?

Simple: without a clear and precise vision of exactly what it is you want, you’ll never reach it or have it.

Now of course I will not leave you hanging without understanding why.

My research has taken me into the world of quantum physics and neuroscience for the answer to the question “why is it so important to start with a vision?”

Let’s start with the world of quantum physics. First and foremost, quantum physics is the study of how the very small world, one we cannot see with our eyes, operates. Since we live in two worlds—one that we can see—and one that we cannot, it’s important for us to know what these two worlds offer us. Scientifically we now know that even though we cannot see any connection, both worlds are totally interconnected at every level.

Newtonian physics helps us understand how to navigate the known physical world, and quantum physics helps us to understand the very intelligent non-physical world in which everything is connected to everything else, and from which and all known physical “things” are manifested.
What we’ve discovered in this new realm of quantum research is that whatever we focus on and emotionalize often, is what we will attract and actually see in the quantum field of all possibilities, or better yet, probabilities.

As weird as this may sound, this is now being proven without a shadow of a doubt. What this means is that the more clearly focused we are on exactly what we want, the easier and faster we’ll manifest everything we need to make it a physical reality.

Since all material things move from the non-physical to the physical reality, our vision and goals are paramount in the process of achievement. Our vision and focus acts like a magnet that attracts and connects the pieces together.

Another thing to keep in mind is that the universe operates by natural laws, exact precision, and perfect order. Our vision, then, must also be precise and exact in our mind in order for whatever we need to be attracted and shown to us by the intelligent forces that govern all of creation. When we focus our brain on what we want, we actually increase the amplitude of the cellular vibration and cause the “attraction” factor to really take shape.

Just like a magnifying glass can focus the sun’s rays and create a fire, focusing on our vision and goals keeps you in the right vibration and attraction field.

When we choose a vision or goal that is bigger than our current reality, we are in essence creating a gap or a vacuum between what we want and where we currently are. We know from natural law that nature fills a void or gap in the fastest and most efficient ways possible.

Now for the “brain and heart” part of the equation.

The latest research proves that when we’re fully engaged and emotionalized in our clear vision, we emit a frequency from our brain and heart that penetrates and permeates all space and time, and brings forth to us everything that’s in resonance with the image we’re holding.

The frequency we emit is our personal electromagnetic frequency. Just like a radio station that sends out a signal, we send ours out based on our dominating thoughts at a conscious and subconscious level.

Just imagine the way an apple seed attracts the nutrients it needs from the soil to grow its roots, and then once it sprouts above the ground the sun adds its magic and food through photosynthesis. Then, low and behold….the seed becomes an apple tree.

You, too, will attract exactly what you need to realize your dreams when you really start to believe and feel your vision becoming a reality. It’s the clear and consistent vibration of your vision that brings forth your needs. You provide the seed, the universe provides the resources.

Therefore, you must now make your “new vision” inside your brain more real than the current results in your outside world. Then, and only then, will the universe begin to present its riches to you in the most convenient and efficient ways possible.

Your clear vision is your seed. Choose it wisely and precisely, and riches beyond your imagination in every area of your life shall be yours.
General Travel Checklist
General Travel Checklist
========================
UNDERWEAR
SOCKS
SHIRTS
CASUAL PANTS
BELT
DRESS SHOES
SANDALS ( SO THAT YOU CAN WALK in BATHROOMS)
JEANS
SNEAKERS
T-SHIRTS

TOILET KIT
(Nail cutter)
GLASSES
SUNGLASSES
SPRAY


MUG - FOR BATHROOM
SPOON FOR SUGAR (YOU NEED SPOONS FOR FOOD AND TEA STIRRING)
TEA BAGS
SUGAR FOR TEA. (AS THE SUGAR SACHES WILL BE LESS IN HOTEL)
MILK FOR APPOOS AND FOR TEA.

ALARM CLOCK
UMBRELLA

BOTTLED WATER

RUNNING SHORTS
RUNNING SHIRTS
RUNNING SHOES
RUNNING SUIT
RUNNING GLOVES
EAR MUFFS
BATHING SUIT
SWIM GOGGLES

MOCCASINS
SANDALS

SLIPPERS
SHORTS

SUN LOTION
IRON
HANDKERCHIEFS
CLOTHES BAG

COMPUTER
MODEM LINES
T-CONNECT
AC CHARGER CORD

MOBILE AND CHARGER

CELL PHONE
PHONE BATTERIES
PHONE CHARGER

MP3 PLAYER
BATTERIES - AAs & AAAs
EARPHONES

BRIEFCASE
PACK
KEYS - SFO / UNION WHARF

TICKETS
CLIENT INFO
CITY INFO
UPGRADE CERTIFICATES
MAPS
MISC. READING
DISCOURSE

OVERHEADS
MARKER PENS
BUSINESS CARDS
PROMO MATERIALS
WRITING PAD
MODULE PADS (xtra?)
ENVELOPES
PETTY CASH ENVELOPE
IN-TRAY
COACHING SUPPLIES (LABELER, LAMINATES)
AIRLINE CARDS/UPGRADES

CAMERA - 35mm/Pocket
FILM
BINOCULARS

HANDLED?

PRINT OFF THE WEB
PHONE SILENCED
WEATHER checked
HERTZ CALLED
CAR P/U ARRANGED
COMPUTER BACKED UP
NOTES REPLICATED
PALM SYNCHED
TICKLER FILE FORWARDED

SPRINKLERS
CASH

International

PASSPORT
ADAPTER 110V
WASHRAG
Change announcement
Foreign language book
How to tickle your funny bone with your kid
You shouldn't overreact to your child's negative feelings. It's normal for kids to become oversensitive or clingy or nervous at times because of something in their environment, but it's not an unhappiness.

For better or worse, children pick up on their parents' moods. Even young babies imitate their parents' emotional style, which actually activates specific neural pathways.

In other words, when you smile, your child smiles and his brain becomes wired for smiling. But be genuine your child will sense if you're acting. If you make a point of enjoying small things and saying what you're grateful for, you'll be a positive role model for your child.

The first key to creating a happy child says Hallowell. Connect with them, play with them, he advises. If you're having fun with them, they're having fun. If you create what I call a 'connected childhood,' that is by far the best step to guarantee your child will be happy.

Unstructured play allows her to discover what she loves to do build cities out of blocks, teach counting to her stuffed animals which can point her toward a career that will seem like a lifetime of play. Play doesn't mean after-school lessons, organized sports, and other structured, enriching activities. Play is when children invent, create, and daydream.

Hallowell's prescription for creating lifelong happiness includes a surprising twist: Happy people are often those who have mastered a skill. For example, when your child practices catching a ball, he learns from his mistakes, he develops persistence and discipline, and then he experiences the joy of succeeding due to his own efforts.

He also reaps the reward of gaining recognition from others for his accomplishment. Most important, he discovers he has some control over his life: If he tries to do something, he has the satisfaction of finding that, with persistence, he can eventually do it. Research shows that this feeling of control through mastery is an important factor in determining adult happiness.

Hallowell agrees that allowing children a range of experiences, even the difficult or frustrating ones, helps build the reservoir of inner strength that leads to happiness. Whether a child's 7 months old and trying to crawl or 7 years old and struggling with subtraction, Hallowell tells parents, he'll get better at dealing with adversity simply by grappling with it successfully again and again.

Children need to know that it's okay to be unhappy sometimes it's simply part of life. And if we try to squelch any unhappiness, we may be sending the message that it's wrong to feel sad. We need to let them experience their feelings, including sadness.

They learn that no matter what happens, they can find a solution. This doesn't mean children shouldn't ask for help if they need it, but your role is to help them find a solution, not provide it for them. Learning to deal with life's inevitable frustrations and setbacks is critical to your child's future happiness.

Developmental experts who've studied humor say a childhood filled with laughter and fun has benefits that last a lifetime. A sense of humor offers a huge advantage in life, says Lawrence J. Cohen, author of Playful Parenting and a psychologist specializing in children's play. It's one of the best ways people have figured out how to cope with things that are difficult. A child who can easily tap his funny bone is more likely to make strong friendships, be well-liked by peers, and as an adult get along with colleagues at work, manage frustration, diffuse conflict, and suffer less from depression. A sense of humor is also linked to intelligence, self-esteem, creativity, and problem solving.

What's more, humor offers parents rare insight into their children's cognitive development. As humor expert Paul McGhee points out, humor is a form of intellectual play. In infants, laughter is initially stimulated by physical play (tickling, raspberries, and very gentle rough-and-tumble). But as early as 6 or 7 months, when babies start to gain a clearer sense of their world and how it works, they begin taking pleasure in seeing that known world turned on its head the very essence of humor.

Seeing your child get the joke is a sign that he's developing significant intellectual skills. So celebrate when your infant gurgles with glee over a game of peekaboo, your 1-year-old titters madly when you sing Mary Had a Little Lamb in a Tweety Bird voice, your preschooler giggles wildly when you hold a shoe to your ear and say, Hello?, or your 7-year-old pulls off his first pun.

Parents who laugh often and easily with their children understand that humor is an invaluable parenting tool, one that can be used to discipline without conflict. Moms and dads accustomed to yukking it up with their children also find it's a way to stay close.

The best part? Play and laughter, the foundations of humor, are part of our genetic makeup and preceded human language. Robert R. Provine, author of Laughter: A Scientific Investigation and professor of psychology and neuroscience at the University of Maryland, Baltimore County, says thepha-hamp sound of laughter evolved from the sound we make in physical childhood play the panting sound of our breathing when engaged in, say, tickling and rough-and-tumble activities.

The key, says Provine, is that a baby's earliest laughter, and most humor that follows in childhood and into adulthood, is an elemental form of social bonding. It could be said that humor, a more sophisticated means to evoke giggles and guffaws, is a way to re-create that unadulterated joy of childhood laughter when we're completely engaged with another person.

Funny like me
Can humor be taught, or is it an inherited trait like left-handedness and green eyes? While some children seem to be born with a bubbly, good-natured disposition, developmental psychologists say humor can be taught. Think of it as a muscle (one no doubt near the funny bone) that needs to be strengthened and worked regularly.

So what's the secret to teaching your child to get in touch with his inner comedian? Rush out to enroll your toddler in mommy and me stand-up classes? Happily, it's more straightforward than that. If you want to have a fun and funny child, there's no better role model than you.

Being funny shouldn't be another burden to add to an already hefty parenting to-do list (8 a.m.: Make clown pancakes; 1 p.m.: Tell an elephant joke; 5 p.m.: Slip on a banana peel). You don't need to be Ellen DeGeneres to get a laugh. All you need to do is tap into your silliest self.

Fortunately, you have years to develop your act, starting with your goofiest material for baby. Tickle her toes and sing Itsy Bitsy Spidermp in a ridiculous voice. To crack up your toddler, put a shoe on your head and a hat on your foot. Pick up your 4-year-old's favorite action hero and have him announce what's on the menu for dinner.

This isn't to suggest that your household has to be Comedy Central 24/7. But there's plenty of room for playfulness. In an age when parenting can feel like such serious business, with somber advice on the perils of toilet training too late and the importance of signing up for the best preschool on time, it's worth remembering that fun and games have their place.

Humor and fun make your household run more smoothly

Spencer and her kids yuk it up at the beach
says Paula Spencer, mother of four and author of Momfidence!: An Oreo Never Killed Anybody and Other Secrets of Happier Parenting. It helps kids feel more relaxed and confident and have more goodwill toward you.mp Plus, a funny thing happens on your way to making your child giggle. As scientists attest, laughter is indeed infectious. Once you get your child guffawing, you'll find yourself in stitches too.

And why not have fun? You're in the parenting gig for a good 18 years. Your family might as well have a few good laughs along the way.


10 ways to build your childs self esteem
Excerpts from baby center

Nurturing your preschooler's self-esteem may seem like a hefty responsibility. After all, a feeling of self-worth lays the foundation for your preschooler's future as he sets out to try new things on his own. "Self-esteem comes from having a sense of belonging, believing that we're capable, and knowing our contributions are valued and worthwhile," says California family therapist Jane Nelsen, co-author of the Positive Discipline series.

"As any parent knows, self-esteem is a fleeting experience," says Nelsen. "Sometimes we feel good about ourselves and sometimes we don't. What we're really trying to teach our kids are life skills like resiliency." Your goal as a person is to ensure that your child develops pride and self-respect — in himself and in his cultural roots — as well as faith in his ability to handle life's challenges (for a preschooler that may mean copying capital letters accurately). Here are ten simple strategies to help boost your child's self-esteem:

Give unconditional love. A child's self-esteem flourishes with the kind of no-strings-attached devotion that says, "I love you, no matter who you are or what you do." Your child benefits the most when you accept him for who he is regardless of his strengths, difficulties, temperament, or abilities. So lavish him with love. Give him plenty of cuddles, kisses, and pats on the shoulder. And don't forget to tell him how much you love him. When you do have to correct your child, make it clear that it's his behavior — not him — that's unacceptable. For instance, instead of saying, "You're a naughty boy! Why can't you be good?" say, "Pushing Gabriel isn't nice. It can hurt. Please don't push."

Pay attention. Carve out time to give your preschooler your undivided attention. That does wonders for your child's self-worth because it sends the message that you think he's important and valuable. It doesn't have to take a lot of time; it just means taking a moment to stop flicking through the mail if he's trying to talk with you or turning off the TV long enough to answer a question. Make eye contact so it's clear that you're really listening to what he's saying. When you're strapped for time, let your child know it without ignoring his needs. Say, "Tell me all about the picture you drew, and then when you're finished, I'll need to make our dinner."

Teach limits. Establish a few reasonable rules for your preschooler. For instance, if you tell your child he has to eat his snack in the kitchen, don't let him wander around the family room with his crackers and fruit the next day. Or if you tell him to put his dirty clothes in the laundry basket, don't say it's okay to pile them on the floor. Knowing that certain family rules are set in stone will help him feel more secure. It may take constant repetition on your part, but he'll start to live by your expectations soon enough. Just be clear and consistent and show him that you trust him to do the right thing.

Support healthy risks. Encourage your child to explore something new, such as trying a different food, finding a best pal, or riding a bike. Though there's always the possibility of failure, without risk there's little opportunity for success. So let your child safely experiment, and resist the urge to intervene. For instance, try not to "rescue" him if he's showing mild frustration at figuring out a new toy. Even jumping in to say, "I'll do it" can foster dependence and diminish your child's confidence. You'll build his self-esteem by balancing your need to protect him with his need to tackle new tasks.

Let mistakes happen. The flip side, of course, of having choices and taking risks is that sometimes your child is bound to make mistakes. These are valuable lessons for your child's confidence. So if your child puts his plate too close to the edge of the table and it tips, encourage him to think about what he might do differently next time. That way his self-esteem won't sag and he'll understand that it's okay to make mistakes sometimes. When you goof up yourself, admit it, says Daniel Meier, assistant professor of elementary education at San Francisco State University. Acknowledging and recovering from your mistakes sends a powerful message to your child — it makes it easier for your child to accept his own shortcomings.

Celebrate the positive. Everyone responds well to encouragement, so make an effort to acknowledge the good things your child does every day within his earshot. For instance, tell his dad, "Joshua washed all the vegetables for dinner." He'll get to bask in the glow of your praise and his dad's heartening response. And be specific. Instead of saying "Good job," say, "Thank you for waiting so patiently in line." This will enhance his sense of accomplishment and self-worth and let him know exactly what he did right.

Listen well. If your child needs to talk, stop and listen to what he has to say. He needs to know that his thoughts, feelings, desires, and opinions matter. Help him get comfortable with his emotions by labeling them. Say, "I understand you're sad because you have to say bye to your school pals." By accepting his emotions without judgment, you validate his feelings and show that you value what he has to say. If you share your own feelings ("I'm excited about going to the zoo"), he'll gain confidence expressing his own.

Resist comparisons. Comments such as "Why can't you be more like your sister?" or "Why can't you be nice like Peter?" will just remind your child of where he struggles in a way that fosters shame, envy, and competition. Even positive comparisons, such as "You're the best player" are potentially damaging because a child can find it hard to live up to this image. If you let your child know you appreciate him for the unique individual he is, he'll be more likely to value himself too.

Offer empathy. If your child compares himself unfavorably to his siblings or peers ("Why can't I catch a ball like Sophia?"), show him empathy and then emphasize one of his strengths. For instance, say, "You're right. Sophia is good at catching. And you're good at painting pictures." This can help your child learn that we all have strengths and weaknesses, and that he doesn't have to be perfect to feel good about himself.

Provide encouragement. Every child needs the kind of support from loved ones that signals, "I believe in you. I see your effort. Keep going!" Encouragement means acknowledging progress — not just rewarding achievement. So if your preschooler is struggling to fasten his snaps, say, "You're trying very hard and you almost have it!" instead of "Not like that. Let me do it."

There's a difference between praise and encouragement. One rewards the task while the other rewards the person ("You did it!" rather than "I'm proud of you!"). Praise can make a child feel that he's only "good" if he does something perfectly. Encouragement, on the other hand, acknowledges the effort. "Tell me about your drawing. I see that you like purple" is more helpful than saying, "That's the most beautiful picture I've ever seen." Too much praise can sap self-esteem because it can create pressure to perform and set up a continual need for approval from others. So dole out the praise judiciously and offer encouragement liberally; it will your child grow up to feel good about himself.
Fun activities to promote listening skills
Do you feel as if you spend more time talking at your child than to her? Many children have notoriously selective listening skills — they hear what they want and seem to tune out the rest. But listening is a skill that we can help our children improve. Like a muscle, it needs constant exercise to grow stronger.

Here are some games and activities to boost your child's listening skills. Because children learn in different ways, the games are arranged by learning style. If you're not sure what type of learner your child is, take our quiz. But any child can benefit from the suggestions in all three categories.


For auditory learners
Talk to your child all the time. Tell her about an interesting story you read in the newspaper. Describe a conversation you had at work with a friend. When you go shopping for clothes, tell her about the shopping trips that you used to take with your mom. Get in the habit of narrating everyday chores. If you're in the kitchen together while you're making dinner, for example, you can say, "I need to measure out two cups of water and then add one cup of rice..." It may not seem as if your child is paying attention — but she is. Don't be surprised if you hear her repeating something you said when she talks to someone else. And remember: Children are natural mimics, so watch your language!

Make reading an interactive activity. When reading a book to your child, stop before turning the page and say, "What do you think will happen next?" Ask her to explain her answer to see how well she's listened to what you've read so far. If she seems unsure about what happened, start again.

Ask your child to predict how a story will end. Read a book aloud to your child and stop just before the last page. Ask her to guess how the story will turn out, based on what she's already heard. Then finish the story and discuss the ending with your child. Was her prediction accurate, or was there a surprise ending? If the latter, were there any clues to the ending planted earlier in the story?

Revisit an old favorite. Bring out one of your child's most dog-eared, battered books and read it aloud yet again, only this time pause at key points to let her supply the words that come next. Or read the story and purposely change key details to see how well your child is paying attention. If she hears something that's not quite right, she'll be sure to correct you.

Listen to stories together. We never outgrow our delight at hearing stories told aloud. Libraries, bookstores, and community centers usually have read-aloud story times for young children. Go to fairs and community events at which professional storytellers will be performing. And borrow or buy books on tape for the car or the house.

Make up silly rhymes. The more absurd, the better. ("The fat cat ate the hat. Then the rat ate the fat cat who ate the hat...") This activity will teach your child to listen for words that sound the same and to identify rhyming patterns.

For physical learners
Listen to music tapes. Eve Ackert, an early-childhood education teacher in Connecticut, recommends the Kids in Motion creative-movement series. To learn the movements for each song, your child will have to listen closely to the lyrics. It's also great exercise!

Play listening games. You can rely on old favorites, like Simon Says, or make up your own simple listening games. For example, you can say, "I'm going to give you a mission. I want you to bring me the following items: a hairbrush from your bedroom and a slipper from your sister's room." Each round, you can add one item, and give her a prize at the end. For the rules to more great listening games, see telephone, rain and animal noises in our Activity Finder. You can also find games and worksheets that build listening skills at stores that sell teachers' supplies.

Cook together. Find a recipe, read the directions out loud, and let your child do the measuring, mixing, stirring, and pouring.

Use puppets or a tape recorder to relay instructions. Your preschooler may choose to ignore you when you ask her to tidy her room, but she may comply happily if the request comes from one of her favorite puppets. Or make cleanup a game by taping your instructions: "Pick up your dolls and put them on the shelf. Then put your clothes in the hamper."

Play "story chain." Everyone in the family will enjoy this. Have one person begin a story ("Once upon a time, there was a little boy who lived in a tree house in the woods"), and then have another contribute the next sentence, and so on. Because each person has to listen to what came before to advance the story, this game enhances listening skills. If your child is too young to extend a plot line, ask her to supply specific details: "What color was the tree house? Did any friends visit him there? What kind of animals lived near him in the woods?"

For visual learners
"Read" a song together. Buy a music tape and a corresponding book of lyrics, so you can follow the words along with the music. Even beginning readers can pretend to read a songbook.

Watch a child's video or television show together. Shows such as Arthur, Sesame Street, and Blue's Clues are designed for parent participation. Ask your child to tell you what the characters are saying and doing.