Blocks and Straps: Not Just for Yoga Beginners
How Basic Props Can Help Even Veterans Deepen Their Stretches and Maintain Alignment
The straps and foam blocks used in yoga classes are viewed by many as training wheels. But they can help even veterans get more out of their poses. Photo: Danny Ghitis for The Wall Street Journal
Many who practice yoga see the foam blocks and straps used in classes as crutches that they discard once they achieve a measure of proficiency. But those props also can help intermediate and advanced practitioners deepen their stretches, maintain proper alignment and challenge themselves, yoga instructors say.
The best function of blocks and straps lies in helping people fit a pose to their body "like a fine, tailored suit," says Bethany Lyons, founder of Lyons Den Power Yoga in New York City. People often are less flexible on one side of their body than the other, for instance.
Some yoga practices use props more often than others, but the tools are available for use without charge in most classes. Ms. Lyons (pictured) and Robin Armstrong, an instructor based in Vancouver, British Columbia, discuss several ways to benefit from props:
ENLARGE Standing triangle pose Danny Ghitis for The Wall Street Journal
The Triangle Test
Ms. Armstrong says when she teaches anatomy to yoga instructors, she pairs them up with someone of similar height. She has each pair compare the lengths of their legs, arms and torsos to illustrate the wide variability in bodies and illustrate the need for accommodation.
For instance, a person in standing triangle pose plants feet about 3 feet apart and holds out arms parallel to the floor, then tilts sideways toward the front foot until the arms are perpendicular to the floor. Someone with long legs and a short torso might be better off reaching down to touch a block, rather than straining to go all the way to the floor. "Then they can keep their form instead of trying to get those extra 2 inches," Ms. Armstrong says.
ENLARGE Standing leg raise Danny Ghitis for The Wall Street Journal
The Right Angle
Many people struggle to get the standing leg raise right. In that pose, someone stands on one leg and extends the other straight to the side, toes up, holding the foot in one hand. Many people hunch over to complete the pose, or jut out the opposite hip as a counterbalance, Ms. Armstrong says.
Looping a strap around the sole of the extended foot and pulling can give someone a few extra inches to better execute the pose.
ENLARGE Half-pigeon pose Danny Ghitis for The Wall Street Journal
Extend Your Pigeon
A popular hip-opening stretch is half-pigeon, in which you start on all fours and slide one knee toward the same-side wrist so the thigh is parallel to the mat, with the hips squared forward. The other leg slides straight back and the upper body folds forward.
Even people who practice yoga regularly can struggle to do this pose comfortably, Ms. Lyons says. So she recommends using three blocks: one under the rear end of the bent leg, another under the thigh of the straight leg and a third under the forehead. The blocks allow someone to go deeper into the pose and stay in it longer.
ENLARGE From left to right, dancer's pose, forearm stand and hero pose. Danny Ghitis for The Wall Street Journal
Get a Leg Up
Ms. Lyons, a former ballet dancer, has ample flexibility to perform dancer's pose. The position is typically done with a person balancing on one leg, bending the other knee behind and holding the foot of the bent leg while stretching the opposite hand forward.
But Ms. Lyons says using a strap helps her keep her hips squared to the front of the mat rather than opening to the side. She loops a strap under the foot of her bent-knee leg, kicks out and holds the strap behind her with both hands, her elbows above her ears.
Locked in Upside-Down
In forearm stand, Ms. Lyons cinches a strap around her upper arms to keep her forearms parallel on the mat as she raises her legs straight above her head. The strap keeps her elbows from splaying out.
Ms. Lyons recommends a yoga strap with a cinch buckle so the strap can be looped and cinched in place. (For other poses, she recommends firm foam blocks in the standard size—4 inches by 6 inches by 9 inches.)
We Can Be Heroes
A block can help even simple poses, Ms. Lyons says. She begins each practice with meditation while in hero pose, where she sits on her knees. A block under her rear end eliminates knee strain.
"The block takes away pain and keeps me from fidgeting," she says.
Write to Rachel Bachman at Rachel.Bachman@wsj.com
When Healthy Eating Calls For Treatment
A Desire to Eat 'Clean' Food Can Become an Obsession
Orthorexia nervosa is an eating disorder that involves obsessive healthy eating, sometimes to the point of malnutrition. WSJ's Sumathi Reddy discusses with Tanya Rivero. Photo: Getty
The growing interest in eating healthy can at times have unhealthy consequences.
Some doctors and registered dietitians say they are increasingly seeing people whose desire to eat pure or "clean" food—from raw vegans to those who cut out multiple major food sources such as gluten, dairy and sugar—becomes an all-consuming obsession and leads to ill health. In extreme cases, people will end up becoming malnourished.
Some experts refer to the condition as orthorexia nervosa, a little-researched disorder that doesn't have an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, or DSM, considered the bible of psychiatric illnesses. Often, individuals with orthorexia will exhibit symptoms of recognized conditions such as obsessive-compulsive disorder or end up losing unhealthy amounts of weight, similar to someone with anorexia.
Researchers in Colorado recently proposed a series of criteria they say could help clinicians diagnose orthorexia. The guidelines, published online in the journal Psychosomatics earlier this year, also could serve as a standard for future research of the disorder, they say.
Some Diets That Might Leave Out Nutrients
ENLARGE DAIRY-FREE: Pro: Some people feel better when avoiding dairy even if aren't truly allergic. Challenge: Make sure to get calcium, phosphorus and potassium from other foods. iStockphoto/Getty Images
ENLARGE RAW VEGAN: Pro: Plant-based diets are nutritious and are associated with lower rates of obesity and chronic disease. Challenge: Some vitamins, especially B12, are mostly in animal products. Cooking can make some nutrients more bio available. Getty Images
ENLARGE JUICING DIETS, CLEANSES: Pro: If used short term to kick start eating more fruits and vegetables, this diet can be acceptable. Challenge: Juices aren't nutritionally complete. And cleansing is a misnomer as your body is 'cleansed' by the kidneys, digestive tract and lungs. iStockphoto/Getty Images
ENLARGE GLUTEN-FREE: Pro: Gluten is a must avoid for people with an allergy. Those who are sensitive may find they feel much better. Challenge: A complete diet can be achieved with energy- and nutrient-rich foods such as non-wheat grains. Getty Images
Ryan Moroze, a psychiatry fellow at the University of Colorado Denver School of Medicine and senior author of the study, said more research needs to be done to develop a valid screening instrument for orthorexia, determine its prevalence and differentiate it from other more well-known eating disorders.
"There are people who become malnourished, not because they're restricting how much they eat, it's what they're choosing to eat," said Thomas Dunn, a psychologist and psychology professor at the University of Northern Colorado in Greeley, Colo., and a co-author of the article.
"It's not that they're doing it to get thin, they're doing it to get healthy. It's just sort of a mind-set where it gets taken to an extreme like what we see with other kinds of mental illness," Dr. Dunn said.
Among the proposed criteria: an obsession with the quality and composition of meals to the extent that people may spend excessive amounts of time, say three or more hours a day, reading about and preparing specific types of food; and having feelings of guilt after eating unhealthy food. The preoccupation with such eating would have to either lead to nutritional imbalances or interfere with daily functional living to be considered orthorexia.
Some orthorexia patients are receiving treatments similar to those for obsessive-compulsive disorder. "We're getting the people who aren't being treated well under an eating-disorder diagnosis and their disorder is better treated under the OCD dial," said Kimberley Quinlan, clinical director of the OCD Center of Los Angeles, an outpatient clinic.
The condition seems to start with an interest in living healthy and then, over time, people develop an increased anxiety about eating food that is contaminated or that they deem unhealthy, said Ms. Quinlan. Treatment often involves cognitive behavioral therapy, a type of psychotherapy aiming at behavior modification. "We've basically taken a model that we use to treat OCD and applied it to this disorder which is so similar," she said.
Experts say there is a gray area between striving to eat healthy and going to the extreme, which helps to spur skepticism about orthorexia. "People don't believe how eating healthy can be a disorder," said Ms. Quinlan.
Sometimes other illnesses can lead to orthorexia. David Rakel, director of integrative medicine at the University of Wisconsin School of Medicine and Public Health, estimated that 10% to 15% of the patients who come in with food allergies and related problems develop an unhealthy fear of particular foods.
Nutritional therapy often involves elimination diets—stopping to eat certain foods to check if they are contributing to an inflammatory condition, Dr. Rakel said. Under the program, the foods are later gradually reintroduced, but some people continue to avoid them. "People are getting so strict with their health choices that they're not getting the nutrients that they need," he said.
Some eating-disorder therapists say many of the orthorexia patients they treat also suffer from anorexia. But other experts say orthorexics often aren't underweight, which can make it difficult to identify them.
"Someone on paper may be perfectly healthy and their blood work is great and their weight is fine but their behavior has become obsessive with food," said Marjorie Nolan Cohn, a New York City-based dietitian and national spokeswoman for the Academy of Nutrition and Dietetics, a professional organization.
A red flag is when someone's eating habits are making them avoid social engagements, Ms. Cohn said. "They may not be able to go out to a restaurant with their friends because they don't know what's in the food or it's not cooked in a certain way or what if it's not organic olive oil?" she said.
Jordan Younger, 24, of Los Angeles, started a popular Instagram and blog last year to post recipes and pictures from her plant-based vegan diet. Then her daily diet became all-consuming.
"I would wake up in a panic thinking, 'What am I going to eat today?' " said Ms. Younger. "I would go to a juice place or Whole Foods or a natural grocery store and would spend so much time in there looking at everything trying to plan out the whole day. It just began to take over my mind in a way that I started to see was unhealthy," she said.
Ms. Younger, already slim, said she lost 25 pounds on her restrictive diet. Her skin turned orange and she stopped menstruating. In May, she started seeing an eating-disorder specialist and nutritionist who helped her recover.
Now, Ms. Younger said she doesn't restrict herself from eating anything except for processed food. Her skin has returned to its normal color, her hair has thickened and grown 5 inches and she has put back on her weight.
"With all these different dietary philosophies, there's a lot more room for orthorexia to develop," she said. "It makes it really hard to eat if you're listening to all these theories and it gives eating and food a ton of anxiety when really food should be enjoyable."
Some Cancer Experts See 'Overdiagnosis,' Question Emphasis on Early Detection
Debate Among Doctors Looks at Whether Zealous Screening Leads to Overtreatment
The surge of cancer screening in the U.S. has increased the detection of precancerous lesions that are often low-risk. Some experts now argue that cancer is being overdiagnosed. WSJ's Monika Auger reports.
Early detection has long been seen as a powerful weapon in the battle against cancer. But some experts now see it as double-edged sword.
While it's clear that early-stage cancers are more treatable than late-stage ones, some leading cancer experts say that zealous screening and advanced diagnostic tools are finding ever-smaller abnormalities in prostate, breast, thyroid and other tissues. Many are being labeled cancer or precancer and treated aggressively, even though they may never have caused harm.
As a result, these experts say, many people may be undergoing surgery, radiation, chemotherapy and other treatments unnecessarily, sometimes with lifelong side effects.
Meanwhile, an estimated 586,000 Americans will die of cancer this year—many from very aggressive, fast-moving cancers that develop between screenings and spread too quickly to stop.
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"We're not finding enough of the really lethal cancers, and we're finding too many of the slow-moving ones that probably don't need to be found," says Laura Esserman, a breast-cancer surgeon at the University of California, San Francisco.
Dr. Esserman chairs a National Cancer Institute advisory panel that is calling for major changes in how cancer is detected, treated and even talked about. Among its suggestions: devise new screening programs to target the deadliest cancers; create registries to track lower-risk cancers; and remove the term cancer from very slow-growing and precancerous tumors that are unlikely to progress. The panel suggests calling them "indolent lesions of epithelial origin," or IDLEs, instead.
"Unfortunately, when patients hear the word cancer, most assume they have a disease that will progress, metastasize and cause death," the group wrote in the journal Lancet Oncology in May. "Many physicians think so as well, and act or advise their patients accordingly."
ENLARGE The new thinking could bring radical changes to the vast world of cancer care, which accounts for more than $100 billion in medical costs in the U.S. annually. It is being embraced by a growing number of medical associations and major journals.
"The harm of overdiagnosis to individuals and the cost to health systems is becoming ever clearer," says Fiona Godlee, editor in chief of The BMJ, formerly the British Medical Journal, which is hosting a conference on the topic starting Monday at Oxford University.
The idea that not all cancers are deadly is already beginning to transform treatment for prostate cancer. As many as 60% of the tumors detected via screening grow so slowly that they pose little threat in a man's lifetime, experts say, and treating them with surgery or radiation carries a substantial risk of impotence or incontinence. About 15% of patients now opt to monitor them instead—and some experts say more could probably do so safely.
Some urologists even propose calling prostate tumors with a Gleason score of 6 or below "benign lesions"—although others note that that would mean half of the men treated for prostate cancer in the past 20 years didn't have cancer after all.
Overdiagnosis—the detection of tumors that aren't likely to cause harm—is now a hot topic in other cancers as well. A growing volume of studies estimate that as many as 30% of invasive breast cancers, 18% of lung cancers and 90% of papillary thyroid cancers may not pose a lethal threat.
ENLARGE Susan Merrell
'We want to figure out how to do less safely.'—Laura Esserman, a breast-cancer surgeon at the University of California, San Francisco
More than 2.5 million Americans are diagnosed with non-melanoma skin cancers each year—more than all other cancers combined. They are rarely fatal, and some experts say that removing the term "cancer" would encourage more doctors and patients to monitor the lesions rather than remove them surgically. A commentary in the Journal of the American Medical Association last week noted that more than 100,000 people are treated for basal-cell cancers annually even though they died of other causes within a year. "Clinicians need to take a step back from the microscope and take a look at the patient," the authors wrote.
Not So Fast
But such calls to rethink the C-word and slow the relentless drive for more and earlier treatments remain highly controversial.
Officials from five major dermatology societies have blasted the idea of calling non-melanoma skin cancers IDLEs, saying that deaths from squamous-cell cancers are rising and basal-cell carcinomas can invade surrounding tissues if untreated. "Renaming a destructive and sometimes fatal disease—to make it sound harmless—is a disservice to our patients," the doctors wrote in Lancet Oncology.
Brett Coldiron, president of the American Academy of Dermatology, says it's often the patients who want their skin cancers removed—"and sometimes you get surprised. These things that look like a basal-cell are a melanoma."
Dr. Esserman and other doctors warning about overdiagnosis have been harshly debated at cancer meetings and have received angry letters from people convinced that early detection saved their lives, or could have saved loved ones.
ENLARGE Some critics say that the whole premise that cancers are overdiagnosed comes from statistical guesses, based on old, flawed studies, and that even if some patients are treated unnecessarily, early detection still saves lives.
"There's no question that periodic screening doesn't catch fast-growing cancers, but you save lives by finding moderate and slow-growing cancers and finding them earlier," says Daniel Kopans, a senior radiologist at Massachusetts General Hospital.
Even doctors who accept the idea of overdiagnosis say it poses a dilemma when it comes to treating individual patients.
"I am confident that somewhere between 10% and 30% of women with localized invasive breast cancer would be just fine if we just watched them," says Otis Brawley, chief medical officer of the American Cancer Society. "But I cannot look into a patient's eyes and say, 'You're one of the 10% to 30% that should not be treated.' "
The conflicting messages have left many patients bewildered. After years of educational campaigns saying that early detection saves lives, it's no wonder that some people view recommendations to cut back on cancer screenings as dangerous, or veiled health-care rationing.
Bitter disputes still rage over a U.S. Preventive Services Task Force recommendation that men no longer use tests for prostate-specific antigen, or PSA, to screen for prostate cancer, and that women have mammograms every other year starting at age 50, rather than annually starting at 40, to reduce the likelihood of overdiagnosis. At Congress's insistence, the federal health law requires insurers to fully cover annual mammograms starting at 40 as part of "essential health benefits."
"Everyone says they'd be willing to be overtreated if it means not dying—but that's a big fallacy," says Dr. Esserman. "By treating 1,000 people who have low-risk disease, we're not going to save the one person with aggressive disease."
Sharks and Goldfish
What makes scientists think some cancers are indolent? One clue comes from autopsies that find a substantial number of breast, thyroid, lung and other tumors that never caused symptoms in people who died of other causes. Small, localized prostate cancers are so ubiquitous in older men that the risk is roughly equal to a man's age: a 70-year-old has a 70% chance of harboring the disease. Yet the average lifetime risk of dying of prostate cancer is less than 3% according to the American Cancer Society.
Most of the evidence for overdiagnosis comes from statistical analyses of long-term cancer trends. Theoretically, as screening efforts find more early cancers, the death rate from those cancers should decline. Widespread use of colonoscopies and Pap smears has cut the death rate from colon and cervical cancers roughly in half since 1975.
But death rates from thyroid, kidney and skin cancers have stayed flat or increased, despite many more being diagnosed at early stages, leading researchers to conclude that many of those caught early would never have progressed.
Death rates from breast and prostate cancers have fallen by about 30% and about 40%, respectively, in the past 30 years. But experts disagree on whether that is due to the rise of screening mammograms and PSA tests or improved treatments.
"We have thrown the net very, very widely and eliminated some of the sharks," says Ian Thompson, a urologist at University of Texas Health Science Center and co-chairman of the NCI advisory panel. "But we've also netted a lot of goldfish and assumed they'd behave the same way."
The New War on Cancer
Part of the problem, says Dr. Brawley, is that modern medicine is using a definition of cancer that hasn't changed since the 1850s, when German pathologists first described various types of the disease based on autopsy specimens. Tiny lesions that would never have been detected a few decades ago are now routinely biopsied and analyzed, he says, "and if it looks just like what killed that woman 160 years ago, we assume it will be deadly today."
But assuming cells that look the same will behave the same way is the biological equivalent of "racial profiling," Dr. Brawley adds. Many other factors—including the tumor's genetic profile and the patient's immune system, diet and overall health—could affect how fast those cancer cells grow, or conceivably regress. "We desperately need better tests to distinguish the things that will behave like traditional cancers versus the things that look like cancer but won't," Dr. Brawley says. "This is the beginning of the new war on cancer in the 21st century."
Prodigious efforts are under way to devise such tests. The National Cancer Institute's Early Detection Research Network is bringing together 300 investigators at 40 institutions to study how molecular patterns in screen-detected cancers differ from those that cause symptoms. Biotech firms and university labs are also racing to develop prognostic tools.
Much progress has been made in identifying subtypes of tumors and tailoring treatments to them. "It's a fallacy to throw up our hands and say we have no idea which patients are low risk," says breast surgeon Shelley Hwang at Duke University Medical Center, who is also on the NCI panel.
Tests such as Genomic Health Inc.'s Oncotype DX and Agendia Inc.'s MammaPrint analyze patterns of gene activity on breast tumors that have been removed and can help predict how likely the cancer is to recur and whether the patient would benefit from chemotherapy after surgery.
Several new gene tests for prostate cancer have hit the market in the past year. Oncotype DX has a test that works at the biopsy stage and can help doctors assess how aggressive a particular tumor might be.
But clinicians say much more research needs to be done before they can say for certain how any individual cancer will behave. "I think we will get there. I just don't think we're there yet," says Clifford Hudis, chief of breast-cancer medicine at Memorial Sloan Kettering Cancer Center in New York and past president of the American Society of Clinical Oncology.
Peace of Mind
In the absence of certainty, many doctors and patients are opting for more aggressive treatment, not less.
In breast cancer, for example, nearly 20% of women with early-stage tumors now elect to have both breasts removed, up from 3% in 1998
"Patients do this for peace of mind, for symmetry—but there's no survival benefit for most of them," says Barbara Smith, director of the breast program at Massachusetts General Hospital.
About one-quarter of the breast cancers diagnosed each year aren't technically cancers, but abnormal cells confined to milk ducts called "ductal carcinoma in situ" that were seldom noticed before mammography. Experts think only about 20% of DCIS lesions might eventually progress to become invasive cancer. But they don't know for sure, because virtually all DCIS cases are treated as if they are stage-one cancers, with lumpectomy or mastectomy, often combined with radiation.
"We are picking up on these conditions way before we know whether they are dangerous or not," says Duke's Dr. Hwang. "In our ignorance, it's safest to assume they are all dangerous, but we're hurting some women in the process."
Few doctors dare leave DCIS untreated, but Dr. Hwang is leading a multicenter study treating patients who have small, estrogen-positive DCIS lesions with hormone therapy for six months in hopes they can avoid surgery. She hopes to start another study next year offering DCIS patients the option of hormone therapy or active surveillance alone. "We may identity a group of patients we could treat with just a pill rather than mastectomy," she says.
Risk-Based Screening
Dr. Esserman is embarking on a major study to test a new approach to breast-cancer screening. She hopes to enroll 100,000 women from all five University of California medical centers and Sanford Health in North Dakota. Those with average risk will have mammograms every other year, starting at age 50. Those at higher risk due to genetic variations, family history, dense breast tissue or other factors will be screened—with mammograms and other imaging tests—younger and more often.
"For some people, early detection does save lives—but we need to sort out who that might be," says Dr. Esserman, who theorizes that after five years, such "risk-based screening" will have netted more high-risk cancers, fewer indolent ones and fewer false positives.
Any breast cancers that are diagnosed will be treated and tracked in registries shared among the universities; women with low-risk DCIS will be offered active surveillance, with or without hormone therapy, as well as surgical options. The risks and benefits will be discussed in depth, and individual choices will be honored.
"For a woman with DCIS who has 6-year-old twins and a mother who died of breast cancer, the right option might be radical bilateral mastectomy," says Dr. Esserman. "For someone who is 86 years old and has multiple co-morbidities, surveillance may be."
Some critics, including Dr. Kopans, warn that risk-based screening could be risky, since about 75% of women diagnosed with breast cancers had no known risk factors.
Says Dr. Esserman: "We need to start testing some of these ideas, rather than just fighting over them. People are afraid to do less. We want to figure out how to do less safely."
Ms. Beck is a reporter and columnist for The Wall Street Journal in New York. Email: healthjournal@wsj.com
Corrections & Amplifications
More than 90% of all skin cancers are basal-cell carcinomas that are slow-growing and unlikely to be fatal, according to commentaries in the Journal of the American Medical Association and Lancet Oncology. An earlier version of the Fatal Retraction graphic appearing with this article incorrectly identified the source as the American Academy of Dermatology. And an estimated 18% of lung cancers diagnosed with low-dose CT scans are unlikely to be fatal, according to research published in JAMA Internal Medicine. The graphic incorrectly suggested that the 18% figure referred to all lung cancers.
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