MAYO CLINIC HEALTH LETTER

R E L I A B L E I N F O R M A T I O N F O R A H E A L T H I E R L I F E
VOLUME 23 NUMBER 2 FEBRUARY 2005

Inside this issue Diverticular sis). But, in a small percentage of peo-

HEALTH TIPS . . . . . . . . . . . . . 3
Altitude illness.
NEWS AND OUR VIEWS . . . . 4
Cardiac rehabilitation after heart
attack improves survival. A com-
bination treatment for localized
prostate cancer.
FATIGUE . . . . . . . . . . . . . . . . 4
A cue to rest, or a sign of
something more?
ADVANCE DIRECTIVES . . . . . 6
A plan for end of life.
BUNIONS . . . . . . . . . . . . . . . . 7
From shoe selection to surgery.
SECOND OPINION . . . . . . . . 8
Are certain types of chocolate
healthier than others? Why did my
doctor recommend metoprolol
before my surgery?
disease
The importance
of getting enough fiber
Good news — your colon screening
tests are over and not one precan-
cerous polyp was found. But your
doctor says you have several small
pouches along the colon wall.
With age, small bulging pouch-
es — called diverticula — common-
ly form in the large intestine. This is
especially so for people living in parts
of the world where foods are more
refined and fiber intake is low. The
result is diverticular disease.
Very often these small pouches
cause no problems and are referred
to as diverticulosis (di-vur-tik-u-LO-
Transverse colon
ple, they can become inflamed or
infected, resulting in a condition
called diverticulitis (di-vur-tik-u-LI-
tis). In most instances, diverticulitis
is treatable, but sometimes the con-
dition can become life-threatening.
The way things work
Your large intestine is a long cylin-
der ringed by a layer of circular mus-
cles and three long muscles that run
the length of the large intestine. The
widest portions of your intestine are
the first segments — the cecum and
ascending colon. Contents in these
segments are mostly liquid. Next is
the transverse section, which cross-
es from one side of the abdomen to
the other. This is followed by the
descending colon and the sigmoid
colon. The sigmoid ends at the rec-
tum. Waste in the sigmoid is main-

Coming in March

DEPRESSION Ascending
A definable medical disorder. Descending
colon colon
MEDITATION
Tuning the mind to help heal the Area of
body. diverticulosis

DELAYING DEMENTIA
Current evidence and future study. Cecum

PRESCRIBED VITAMINS
Sometimes the drug of choice.
Sigmoid
Rectum
colon

In most people with diverticulosis, there’s evidence of thickening of the muscle layers in the
sigmoid colon. This may lead to increased pressure in this region of the colon, which can cause
weak spots to balloon out, resulting in the formation of tiny pouches (diverticulosis).
2 M AYO C L I N I C H E A LT H L E T T E R
ly solid because much of the water
has been removed.
It’s not well understood why
some people develop diverticula,
but these factors may play a role:
■ Weak spots in the colon wall
— Blood vessels running through
your colon wall supply nutrients to
the inner layer of the colon wall. But
areas around these vessels are some-
what weaker than are areas without
blood vessels. In most people with
diverticulosis, there’s evidence of
thickening of the muscle layers in
the sigmoid colon. This may lead to
increased pressure in this region of
the colon, which can cause weak
spots to balloon out, resulting in the
formation of tiny pouches.
■ Aging — Risk of diverticular
disease increases with age, affect-
ing nearly half of Americans over 60.
■ Too little dietary fiber — Lack
of fiber contributes to small, hard
stools that are more difficult to pass,
increasing colon pressure. The high-
est pressure occurs in the sigmoid,
where most diverticula are found.
Recognizing the problem
Ordinarily, simple diverticulosis
— meaning the presence of pouch-
es — produces no symptoms. Most
people don’t even know they have
diverticula until they’re found dur-
ing a routine colon exam. Rarely,
some people with diverticulosis may
experience mild abdominal cramps,
bloating, gas, diarrhea or consti-
pation. However, if inflammation or
infection develops in a pouch, you
have diverticulitis.
Diverticulitis can produce very
noticeable and often abrupt signs
and symptoms. These may include
severe cramping, pain in the lower
left abdomen, abdominal tender-
ness, fever, nausea, bleeding, and
constipation or diarrhea. Only a
small percentage of people who
have diverticulosis have an episode
FEBRUARY 2005
Rectal bleeding
A small percentage of people
with diverticulosis may
experience rectal bleeding.
It’s usually painless and
related to a weakened blood
vessel in a diverticulum.
Often, the bleeding stops
by itself. But any rectal
bleeding warrants seeing a
doctor to determine a cause.
of diverticulitis. And among those
who have an attack of diverticulitis,
only 20 percent to 30 percent will
eventually have a second.
It’s thought that diverticulitis
occurs when a small portion of stool
lodges in a pouch, causing pressure,
interrupting blood flow to that tis-
sue and creating microscopic holes.
These holes allow bacteria to pass
through the pouch wall to adjacent
tissue and cause infection. An ab-
scess may form. Rarely, a pouch rup-
tures, allowing intestinal waste to
spill into the abdominal area. The
result is peritonitis — a life-threat-
ening surgical emergency requiring
immediate attention.
See your doctor
If you suspect you have diverti-
culitis, see your doctor right away.
You’ll likely be checked for abdom-
inal tenderness and have a blood
test to check your white blood cell
count, which may indicate infec-
tion. You may also have a comput-
erized tomography (CT) scan to look
for inflammation or infection.
Treatment depends on your signs
and symptoms with a goal of min-
imizing internal colon pressure. In
the case of very mild diverticulitis,
you may be given a course of oral
antibiotics and told to give your
colon a rest by switching to a diet
of clear liquids for a couple of days.
In more severe cases, divertic-
ulitis may mean a stay in the hos-
pital. That’s especially true if you’re
older, are taking steroids or other
immune-suppressing medications,
have a weakened immune system,
or if you have a suspected bowel
obstruction or peritonitis. To let your
colon rest and allow any infection
to heal, you may be given intra-
venous (IV) fluids and IV antibiotics
for a few days, followed by a clear
liquid diet. As your colon’s health
improves, you’ll gradually build up
to a diet that includes plenty of fiber.
Fiber helps bulk up stools and de-
creases internal colon pressure.
Surgery is usually recommend-
ed if you’ve had a second or third
attack of diverticulitis or if you have
complications such as peritonitis,
MAYO CLINIC HEALTH LETTER
Managing Editor Medical Editor
Aleta Capelle Robert Sheeler, M.D.
Associate Editors Associate Medical Editor
Carol Gunderson David Williams, M.D.
Jennifer Jacobson
Editorial Research
Joey Keillor
Deirdre Herman
Medical Illustration Shelly Hewlett
Michael King
Proofreading
Customer Service Miranda Attlesey
Manager Donna Hanson
Ann Allen
Administrative Assistant
Jill Thompson-Riese
EDITORIAL BOARD
Shreyasee Amin, M.D., Rheumatology; Amindra
Arora, M.D., Gastroenterology and Hepatology; Brent
Bauer, M.D., Internal Medicine; Julie Bjoraker, M.D.,
Internal Medicine; Diane Dahm, M.D., Orthopedics;
Timothy Daley, M.D., Internal Medicine; Mark Davis,
M.D., Dermatology; Bobbie Gostout, M.D., Gyneco-
logic Surgery; Todd Johnson, Pharm.D., Pharmacy;
Frank Kennedy, M.D., Endocrinology and Metabolism;
Martha Lacy, M.D., Hematology; Suzanne Norby,
M.D., Nephrology; Steve Ommen, M.D., Cardiology;
Robert Sheeler, M.D., Family Medicine; Phillip
Sheridan, D.D.S., Periodontics; Peter Southorn, M.D.,
Anesthesiology; David Williams, M.D., Pulmonary
and Critical Care Medicine; Aleta Capelle, Health
Information. Ex-officio: Carol Gunderson, Jennifer
Jacobson and Joey Keillor.
Mayo Clinic Health Letter (ISSN 0741-6245) is published
monthly by Mayo Foundation for Medical Education and
Research, a subsidiary of Mayo Foundation, 200 First St.
S.W., Rochester, MN 55905. Subscription price is $27
a year, which includes a cumulative index published in
December. Periodicals postage paid at Rochester, Minn.,
and at additional mailing offices. POSTMASTER: Send
address changes to Mayo Clinic Health Letter,
Subscription Services, P.O. Box 9302, Big Sandy, TX
75755-9302.
 M AYO C L I N I C H E A LT H L E T T E R 3
FEBRUARY 2005

bowel obstruction, abscess or fistu- colon. In the past, it was thought

la. Surgery typically involves removal
(resection) of the colon where inflam-
mation occurred and then rejoining
healthy colon to restore function.
Recently, minimally invasive sur-
gical techniques involving smaller
incisions have become an option.
If surgery is done on an emer-
gency basis or because of compli-
cations, it may be necessary to cre-
ate a temporary colostomy to allow
for stool passage as the colon heals.
Lifestyle changes may help
Making a few changes may help
you avoid progression of divertic-
ulosis or a second attack of diver-
ticulitis. Start by gradually increas-
ing your dietary fiber intake. Plenty
of fresh fruits, vegetables and whole-
grain products help to soften and
bulk up stool, allowing it to pass
more quickly and easily through the
that foods such as nuts, corn and
seeds might contribute to divertic-
ulitis flare-ups. Although some doc-
tors may recommend avoiding such
foods, there’s little solid evidence to
support these recommendations.
If you find it difficult to get
enough fiber from your diet, a nat-
ural fiber supplement may be help-
ful (see “Fiber sources” in our Oc-
tober 2003 issue). In addition, drink
plenty of fluids, since fiber absorbs
water into the stool. Aim for at least
eight 8-ounce glasses of noncaf-
feinated liquids each day.
It’s also important to heed na-
ture’s call — putting off a bowel
movement makes for harder stools
that are difficult to pass and increas-
es colon pressure. Finally, aim for
30 to 60 minutes of exercise on most
days. Regular physical activity pro-
motes bowel function. ❒
Health tips
Altitude illness
If you live at a low altitude and
travel to an altitude higher than
6,000 to 8,000 feet, you may
experience altitude illness.
Signs and symptoms may
include headache, breathless-
ness with mild exertion, fa-
tigue, nausea, loss of appetite
and disturbed sleep. These usu-
ally develop within hours of
arriving at a high altitude and
may last for days. To avoid this:
■ Start slowly — If possi-
ble, begin below 6,000 feet.
■ Take time to adjust —
Rest at least a day after arriv-
ing. Slow down if you’re out
of breath or tired. Never go
higher if you have a headache.
■ Limit ascent — Don’t

Bulk up with fiber climb more than 3,000 feet a

Most Americans don’t get enough fiber in their diet. For adults 50 day, or 1,000 feet if you’re at
and younger, it’s recommended that men get 38 grams of fiber 12,000 feet or higher.
■ Sleep low — If you’re
daily and women 25 grams. For adults over 50, it’s 30 grams for
men and 21 for women. Nutrition Facts labels on food products list above 11,000 feet in the day,
fiber content. Here’s the fiber content of some common foods: sleep at 9,000 feet or lower.
■ Practice healthy habits
What’s on your plate? Grams of fiber — Avoid cigarettes and alco-
Beans, baked, homemade (1 cup) 13.9 hol, but drink plenty of fluids.
Kidney beans, red, boiled (1 cup) 13.1 ■ Consider medication —
Kellogg’s All-Bran Bran Buds (1/3 cup) 13.0 Ask your doctor about aceta-
Kellogg’s All-Bran (1/2 cup) 10.0 zolamide (Diamox Sequels) or
Avocado, raw/California (1 medium) 8.5 other prescription drugs to help
Post Premium Raisin Bran (1 cup) 8.0 prevent or lessen symptoms.
Acorn squash, baked (1/2 cup cubes) 4.5 Altitude illness usually im-
Popcorn, air-popped (3 1/2 cups) 4.2 proves as you adjust. Rarely, a
Raspberries, raw (1/2 cup) 4.2 severe form of altitude illness
Apple with skin (1 medium) 3.7 develops. Signs and symptoms
Brown rice, cooked (1 cup) 3.5 include shortness of breath at
Sweet potato, baked with skin (1) rest, chest tightness, coughing
3.4
Dates, dried (5) and confusion. These can be
3.1
fatal if not treated with supple-
Prunes, dried (5) 3.0
mentary oxygen and prompt
Pears, canned, juice-packed (1/2 cup) 2.0
removal to a lower altitude. ❒
Adapted from Bowes & Church’s Food Values of Portions Commonly Used, 1998
4 M AYO C L I N I C H E A LT H L E T T E R
FEBRUARY 2005

Fatigue
News and our views
A cue to rest, or a sign
Cardiac rehabilitation after heart attack improves survival
of something more?
A Mayo Clinic study found that people who participated in a med-
ically supervised exercise program after having had a heart attack Lately, you’ve been so exhausted
improved their chances of surviving at least three years by more than you can barely drag yourself out of
50 percent. bed in the morning. Throughout the
The study, published in the Sept. 1, 2004, issue of the Journal of day, you find yourself longing for a
the American College of Cardiology, involved more than 1,800 peo- good nap. Why are you so tired all
ple who’d had heart attacks between 1982 and 1998. In the three of the time?
years after their heart attacks, nearly half of the deaths were attributed There are a number of reasons
to not participating in cardiac rehabilitation. By comparison, those why fatigue may be dragging you
who did participate in cardiac rehabilitation had the same three-year down. Most often, it’s a result of
survival rate as would be expected among people of the same age lifestyle factors, including poor
and sex who’d never had a heart attack. The study also found that sleep, stress or a schedule that’s too
older adults and women of all ages were less likely to participate in full. But dramatic or prolonged
cardiac rehabilitation programs after a heart attack. fatigue may be a sign of an under-
Mayo Clinic cardiologists say their findings point to the poten- lying medical problem that requires
tial for improved survival among a large proportion of people who’ve a doctor’s care.
had heart attacks, especially among women and the elderly. ❒
The daily drag
A combination treatment for localized prostate cancer Fatigue — also referred to as
It’s estimated that over 230,000 new prostate cancer cases were diag- weariness, tiredness, exhaustion,
nosed in 2004. For some men, external radiation therapy is the treat- lethargy or lack of energy — is a
ment of choice for prostate cancer that hasn’t spread. This is espe- condition that challenges doctors.
cially true for older men and for those who can’t have surgery due It’s hard to define because it can feel
to other health problems. Radiation therapy allows for a good chance different for each individual.
of survival. However, a recent study shows that a combination of radi- Fatigue can accompany many
ation therapy and hormone therapy may provide even better results. physical ailments. It can also be
The study, in the Aug. 18, 2004, Journal of the American Medical related to everyday lifestyle. A lack
Association, followed 206 men who had been diagnosed with inter- of sleep may leave you drowsy and
mediate- or high-risk prostate cancer that hadn’t spread. Half the group unable to manage your daily rou-
was given radiation therapy alone. The other half was given a six- tine. Stress and anxiety may wear
month regimen of androgen suppressive hormone therapy, then radi- you down. Little physical activity
ation. This hormone therapy suppresses or blocks the male sex hor- may cause you to run on “low,”
mones that can stimulate the growth of prostate cancer cells. while too much physical activity can
Researchers found a significant survival advantage linked to the exhaust you. And poor eating habits
combination treatment. Almost five years after treatment, 88 per- deprive your body of the fuel it
cent of the men who received the combination treatment were still needs to make it through the day.
alive, with no deaths due to prostate cancer. Of those who had radi- Certain medications, including
ation alone, 78 percent survived, with six prostate-related deaths. many anti-anxiety drugs, antihista-
Combination treatment has become increasingly recognized as a mines, and some heart and blood
preferred choice for some men. Mayo Clinic doctors say that the study, pressure drugs such as beta block-
which shows improved outcomes, further supports the use of radia- ers, can also cause fatigue. Cold
tion and hormones together. However, data on this treatment over an medications and pain relievers that
extended number of years aren’t yet available. contain caffeine and other stimu-
If you have prostate cancer, your doctor can help determine which lants can interfere with sleep.
option may be best for you. ❒ Talk to your doctor if you’re
extremely tired or unable to regain
 M AYO C L I N I C H E A LT H L E T T E R
energy after several weeks of in-
creased rest. Virtually any illness can
cause fatigue. Because of this, your
doctor may wish to perform a gen-
eral exam. This may include a med-
ical history including the medica-
tions you’re taking, your stress level,
and other lifestyle habits. You may
also be asked to describe your
fatigue. How long have you expe-
rienced it? Did it come on sudden-
ly or gradually? Does it remain con-
stant throughout the day? What
other symptoms are bothering you?
If your doctor suspects that an
underlying medical condition may
be causing your fatigue, he or she
may order certain tests. Blood tests
and tests of organ function may help
determine the problem.
Medical causes
Some of the common medical
causes of fatigue include:
■ Anemia — This blood disor-
der results from a number of prob-
lems that reduce your blood’s abil-
ity to transport oxygen, contributing
to fatigue.
■ Cancer — On occasion, fa-
tigue is a symptom of cancer. A thor-
ough checkup, with routine cancer
screenings, can help diagnose it.
Fatigue may also be a side effect of
cancer treatments, such as radiation
therapy and chemotherapy.
■ Depression or other mood
disorder — Fatigue that’s accompa-
nied by sadness, loss of appetite,
loss of pleasure in activities, diffi-
culty concentrating or interrupted
sleep may be a sign of depression.
■ Diabetes — Extreme fatigue
can be a warning sign of diabetes.
Other symptoms may include exces-
sive thirst, frequent urination, blurred
vision and recurring infections.
■ Heart attack — A recent study
found that the most common early
warning sign that women experi-
ence before a heart attack is unusu-
FEBRUARY 2005
Chronic fatigue
Chronic fatigue syndrome is
a collection of symptoms
that may represent a group of
undefined illnesses.
It’s marked mainly by
fatigue, muscle aches and
difficulty concentrating. It
has no clear cause.
Unlike many of the other
medical causes of fatigue,
there’s no specific, reliable
test for chronic fatigue syn-
drome. Your doctor may use
a detailed medical history
and a broad series of tests to
determine a course of man-
agement. Treatment — which
is aimed to relieve symptoms
— may include exercise,
lifestyle changes to reduce
stress, and medications to
control related problems,
such as depression.
al fatigue. Fatigue, shortness of
breath and weakness may also indi-
cate congestive heart failure or a
heart attack in progress.
■ Infections — Persistent fatigue
may be a symptom of an infectious
illness — such as hepatitis — or of
a slow recovery from influenza or
pneumonia.
■ Sleep disorders — The symp-
toms of restless legs syndrome, such
as creeping or tingling sensations in
your limbs, can make it difficult to
sleep. These symptoms usually oc-
cur late in the day or before bed.
Sleep apnea is also a common but
often undiagnosed source of fatigue,
because it interferes with sound
sleep. Signs of this disorder may
include loud snoring, pauses be-
tween breaths and awakening fre-
quently while gasping for air.
■ Thyroid problems — Both de-
creased thyroid hormone produc-
5
tion (hypothyroidism) and increased
hormone production (hyperthyroid-
ism) can affect your metabolism and
cause fatigue.
■ Other health problems — Fa-
tigue has also been associated with
obesity, fibromyalgia, heart disease,
lung disease, muscle diseases, neu-
rological diseases and connective
tissue diseases such as lupus and
rheumatoid arthritis, as well as liver
and kidney disease and certain other
endocrine problems.
Fighting it
Fatigue is most often caused by
lifestyle factors. Because of this,
changes to your daily routine may
be enough to ease it. To fight fatigue:
■ Manage stress — Learn to say
no. Set priorities. Pace yourself. Take
time each day to simply relax.
■ Be active — Try to get at least
30 minutes of moderate physical
activity each day. Once you get
moving, you’ll likely notice more
stamina. But don’t overdo it — too
much exercise can also contribute
to fatigue.
■ Eat well — A low-fat, high-
fiber breakfast prepares your body
for the day’s demands. Limit high-
fat and high-sugar foods, which tend
to make you feel sluggish later.
■ Avoid alcohol — Alcohol de-
presses your central nervous system
and acts as a sedative, making you
tired for hours after consuming even
minimal amounts. It may also dis-
rupt sleep if you drink before bed.
■ Practice good sleep habits —
Avoid eating, reading or watching
TV in bed. Keep your bedroom cool,
dark and quiet. Set your alarm for
the same time each day — a routine
will help you establish a regular
schedule. Naps are OK, but keep
them short and early in the day. If
you can’t sleep, don’t toss and turn.
Instead, leave the bedroom and read
or relax until you feel drowsy. ❒
6 M AYO C L I N I C H E A LT H L E T T E R
Advance
directives
A plan for end of life
Planning takes the guesswork out of
life’s bigger moments. Imagine host-
ing a wedding without a plan.
Planning can also be an impor-
tant factor when it comes to end-of-
life care. In this era of high-tech
medicine, it’s increasingly possi-
ble to postpone death. If you’re seri-
ously ill or injured and no longer
able to communicate your wishes,
an advance directive — specifical-
ly a living will or a medical power
of attorney — can help guide those
who are caring for you.
Beyond the comfort zone
Discussing end-of-life issues may
make people uncomfortable. But
doing so in a timely fashion can
make a big difference for your loved
ones, who otherwise might be left
guessing what treatment you may or
may not want if you’re unable to
communicate. The key is knowing
your values and preferences and
communicating them to someone
who will act on your behalf.
An advance directive can be one
of many types of documents. These
either set out specific wishes or
name someone to make decisions
for you if your ability to communi-
cate is impaired by injury or disease.
It’s best if you consider and dis-
cuss an advance directive with your
loved ones well in advance of a sit-
uation that may call for its use. You
may wish to initiate the process on
your own. Some people prefer to
work with a lawyer.
Federal law requires most health
care settings that receive Medicare
funds to ask upon admitting you if
you have an advance directive.
FEBRUARY 2005
Getting the right form
Each state has its own laws
for advance directives.
The National Hospice
and Palliative Care Organ-
ization (NHPCO) can help
you obtain the documents
and information that pertains
specifically to your state.
You can reach the organi-
zation by calling (800) 658-
8898, or by writing to:
NHPCO Offices, 1700
Diagonal Road, Suite 625,
Alexandria, VA, 22314.
At your request, the
NHPCO can mail — without
charge — advance directive
forms specific to your state.
Common types of directives
A living will and a medical power
of attorney are the two most com-
mon types of advance directives.
Combined, they offer the maximum
opportunity for you to make known
your end-of-life medical wishes.
■ Living will — Also known as
a natural death declaration, this
describes the kind of care you do or
don’t want. It’s usually written in
general language reflecting the
unpredictable nature of death.
The extent to which your living
will can be followed is determined
by state living will laws. Most states
have these laws to interpret the ex-
tent of authority and legal force of
living wills. Before you set up a liv-
ing will, you may want to familiar-
ize yourself with your state’s laws or
have an attorney help you.
■ Medical power of attorney —
Sometimes called a durable power
of attorney for health care, this doc-
ument gives legal authority to the
person you choose to act on your
behalf in making health-related de-
cisions should you be unable to do
so. This person, also called a proxy
or agent, is usually a spouse, fami-
ly member or trusted friend. He or
she should clearly understand your
philosophy on medical care. As
such, your proxy will respond spe-
cifically to unique questions your
condition may create.
Clarifying your wishes
Deciding what to include in
your advance directive deserves
thoughtful consideration. Admitted-
ly, it’s impossible to predict exact-
ly what you may face. But common
considerations may include:
■ Discontinuing or withholding
lifesaving treatment — You may wish
to have treatment stopped if it’s de-
termined that further treatment only
prolongs the dying process. This may
include discontinuation of life-sus-
taining equipment such as respira-
tors and dialysis machines. It may
also include not starting more treat-
ments, such as an antibiotic to treat
infection. However, this doesn’t
mean you’ll receive no care. Quality
of life is still attended to with pain
control and other comfort measures.
■ Artificial feeding — This refers
to providing nourishment in a way
other than normal eating. Typically
it’s done either by a feeding tube
that’s inserted directly into the stom-
ach to provide a liquid diet or, occa-
sionally, by intravenous feedings
(parenteral nutrition).
Once you’ve got your advance
directive in place, be sure to make
it accessible to those who may need
to use it. Give a dated and signed
copy to your primary care doctor for
your records.
Advance directives can be
updated or changed at any time,
even revoked if you desire. You lit-
erally have the last word on your
care as long as you are able to speak
or communicate. ❒
 M AYO C L I N I C H E A LT H L E T T E R
Bunions
From shoe selection
to surgery
Over the last few years, a large
bump has formed at the base of your
big toe. It’s so irritating, you dread
putting on shoes.
Fortunately, there are things you
can do that may help prevent these
protrusions — known as bunions —
from getting worse. Simply buying
the right shoes can help make being
on your feet more comfortable.
Surgery often isn’t necessary.
Crowded toes
A bunion is an abnormal, bony
protrusion that forms at the base of
your big toe. It occurs from a mis-
alignment or repositioning of the
bones of the feet, often forcing the
big toe to crowd against your other
toes. This can cause a bony bump
that looks like a growth on the side
of your foot at the big toe joint. You
may also develop a similar problem
— called a “bunionette” — at the
base of your little toe.
Bunions develop over years of
abnormal motion and pressure to
your big toe joint. Bunions may re-
sult from an inherited foot type, such
as flat feet or low arches, or from
shoes that fit improperly.
Bunions usually aren’t painful.
However, the cushioning sac of fluid
(bursa) over the affected joint can
become inflamed and cause pain.
This is called bursitis. Pressure from
shoes that fit tightly over the bunion
may also cause pain. Bunions can
also be accompanied by arthritis,
causing painful toe movement.
Finding footwear
Shoes that are wrong for your
feet can create problems and make
existing problems worse. Use these
FEBRUARY 2005
A bunion is an abnormal, bony protrusion
that forms at the base of your big toe.
guidelines to find shoes that won’t
irritate your feet:
■ Find the right fit — Make sure
your shoes don’t crowd or irritate
your toes. Choose shoes that have
a wide toe box, making sure that the
width of that part of the shoe mea-
sures equal to the ball of your foot.
Also be sure there’s a half-inch of
space between the tip of your
longest toe and the end of the shoe.
Don’t wear shoes that are too tight,
narrow or pointed.
■ Avoid high heels — These
force toes to the front of your shoes.
■ Give them a stretch — Shoe
stretching devices and sprays can
be used on tight shoes to give your
toes more room. Leather shoes tend
to be the most pliable. You can typ-
ically find these products and
devices in shoe repair shops and
orthopedic shoe stores.
Other treatments
You can’t make a bunion go a-
way on your own. But you may be
able to relieve pain and keep a bun-
ion from getting worse by removing
the source of irritation. Bunions can
often be successfully managed by
wearing proper shoes and using one
or more of these techniques:
■ Arch supports — Nonpre-
scription shoe inserts can help keep
7
your foot from leaning inward, and
alleviate pain. Prescription inserts
may eventually be required.
■ Padding — A self-adhesive
pad or nonprescription bunion pad
may minimize pain. However, these
generally work only for mild bun-
ions. Padding may actually contri-
bute to crowding with severe bun-
ions and make the problem worse.
■ Ice — If the bunion becomes
inflamed or painful, apply ice sev-
eral times a day to reduce swelling.
■ Medications — Nonprescrip-
tion drugs such as acetaminophen
(Tylenol, others) and nonsteroidal
anti-inflammatory drugs (NSAIDs)
such as ibuprofen or naproxen may
be recommended to control pain.
■ Physical therapy — Ultra-
sound therapy or whirlpool baths
can provide relief.
See your doctor if your bunion
causes persistent pain or impairs
your movement. Acute pain and
swelling in the big toe joint may sug-
gest other problems, such as gout.
Can surgery help?
Surgery generally isn’t necessary
to treat a bunion. However, it may
be your best option if you have
chronic, recurring pain that inter-
feres with your daily life, and other
treatments don’t help. A number of
procedures are performed for bun-
ions. No particular type of surgery
is best for every problem.
Most surgical procedures in-
volve a bunionectomy. This gener-
ally involves realigning the affected
bones to a more normal position
and reducing the tightness of the sur-
rounding soft tissues that contribute
to the deformity. Recovery times
vary. To prevent a recurrence, wear
proper shoes after recovery.
Mayo Clinic doctors generally
discourage surgery unless your bun-
ion causes significant pain or inter-
feres with your mobility. ❒
8 M AYO C L I N I C H E A LT H L E T T E R
Second opinion
Questions and our answers
Q: Are certain types of chocolate
healthier than others?
A: Yes, recent studies have sug-
gested that there may be health ben-
efits to eating certain types of choco-
late in moderation.
Chocolate contains flavonoids.
These natural antioxidants — also
found in tea, red wine, and some
fruits and vegetables — help limit
the negative effects of lipoproteins,
which are components of the “bad”
type of cholesterol, low-density
lipoprotein (LDL) cholesterol. Flavo-
noids may protect arteries and pre-
vent heart disease, stroke and ath-
erosclerosis, a disease characterized
by clogged arteries.
The amount of flavonoids in
chocolate depends largely on pro-
cessing. Chocolate products are de-
rived from cocoa beans. To be made
into their final product, though, vary-
ing amounts of cocoa powder, co-
coa butter, milk (typically whole
milk), sugar and other ingredients
are added. This often adds fat and
reduces flavonoid content. The dark-
er the chocolate, the higher it’s like-
ly to be in flavonoids. For example,
a bar of dark chocolate contains an
average of 53.5 milligrams (mg) of
flavonoids. A milk chocolate bar
contains less than 14 mg. White
chocolate contains no flavonoids.
The type of fat is also key. Cocoa
butter is converted into an unsatu-
Copyright
© 2005 Mayo Foundation for Medical
Education and Research. All rights reserved.
MAYO, MAYO CLINIC, MAYO CLINIC
HEALTH INFORMATION, the triple-shield
Mayo logo, and RELIABLE INFORMATION
FOR A HEALTHIER LIFE are marks of Mayo
Foundation for Medical Education and
Research.
Recycled paper
FEBRUARY 2005
rated fat in the liver and has neutral
effects on cholesterol levels. Despite
this, if a chocolate’s ingredients list
includes milk or the words “hydrog-
enated” or “partially hydrogenated,”
it’s typically more likely to contribute
to higher cholesterol.
While chocolate may have some
benefits, it’s best to keep it as an
occasional snack. ❒
Q: I’m about to have elective sur-
gery. My doctor recommended that
I start taking a drug called metopro-
lol a few days before surgery to pro-
tect my heart. How does this work?
A: Metoprolol (Lopressor) is in a
drug class known as beta blockers.
Beta blockers are traditionally pre-
scribed to treat high blood pressure
(hypertension) and — more recent-
ly — coronary artery disease. They
block the effects of certain adrena-
line-related hormones, slowing the
heart rate and lowering blood pres-
sure. Other drugs in this class in-
clude atenolol (Tenormin), propran-
olol (Inderal) and others.
Studies show that those who
take beta blockers before coronary
artery bypass surgery have lower
death rates within 30 days than do
those who don’t. Beta blocker ther-
apy decreases the risk of major com-
plications, and may help control an
irregular heartbeat (atrial fibrillation)
— a common complication. Over-
all, outcomes tend to be improved
even for those at higher risk.
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Beta blockers also reduce car-
diovascular complications among
high-risk people undergoing major
surgeries that aren’t heart-related.
If you’re already taking a beta
blocker before surgery, your doctor
likely will have you continue taking
it. If you don’t normally take a beta
blocker, but have hypertension or
are at high risk of other complica-
tions, your doctor may prescribe
one. Although several factors may
affect when to start beta blocker
therapy, doctors typically recom-
mend starting a few days before
surgery. Therapy may continue while
you’re in the hospital, and may con-
tinue for a time after you’re home.
However, this therapy may not
be recommended if you have cer-
tain pre-existing conditions, includ-
ing asthma and significant low blood
pressure. Your doctor can determine
if the risks outweigh the benefits. ❒
Have a question or comment?
We appreciate every letter sent to Second
Opinion but cannot publish an answer to each
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on individual medical conditions. Editorial
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