Personal Health: A Valuable Medical Tell-All Can Be Found in Urine

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AppId is over the quota

I was tempted to ask her who is likely to know or care, except perhaps a stranger in a public restroom. Surely there are worse offenses.

As one of the four routes by which substances normally exit the body (the others being feces, breath and sweat), urine has a uniquely valuable role in medicine: It holds clues not just to what people eat and drink, but also to how well their bodies are functioning. The search for these telltale signs is why doctors routinely request urine samples from patients, whether they seem healthy or are obviously sick.

The color, clarity and other physical characteristics of urine, as well as substances dissolved in it, can provide clues to a wide range of problems, including infections, inherited metabolic disorders, kidney disease, bladder cancer, diabetes, substance abuse, exposure to toxins, inadequate or excessive fluid intake and, as many competing athletes know all too well, the use of performance-enhancing drugs.

Recently, in an eight-year European study, the sodium content of 24-hour urine samples from 3,681 adults was used to estimate the effect of daily sodium intake on the development of high blood pressure and illness and death from heart disease. The authors’ conclusion that too little dietary sodium was riskier than too much has been widely challenged, and until further notice most Americans would be wise to reduce significantly how much salt and other dietary sources of sodium they regularly consume.

Color and Odor

Urine can acquire off-odors from consumption of a few foods like asparagus (a genetic factor in some people is most likely responsible) and beverages like coffee, or as a consequence of health problems like a urinary tract infection or diabetes (a sweet smell from excess sugar). But the characteristic of urine most likely to be noted by a lay person is color.

If you are well hydrated, normal urine is clear and pale yellow, a color imparted by the pigment urochrome. Dehydration — which can be the consequence of drinking too little, sweating too much or suffering from repeated bouts of vomiting or diarrhea — results in dark urine with a smell of ammonia; it should be treated as a warning to drink more water or other plain fluids.

But consistently dark-colored urine can be a sign of hepatitis, a liver disease that requires prompt medical attention.

Less seriously, many foods and certain medications can impart an unusual and, to the unsuspecting, sometimes alarming color. For example, beets, which contain a betalain pigment that turns hands and cooking water red, can turn urine a color that may resemble blood. Likewise, blackberries and rhubarb can result in red or pink urine.

Tea-colored urine can follow the consumption of fava beans and sometimes rhubarb. The beta carotene in carrots, carrot juice and high doses of vitamin C can cause orange-colored urine, and B vitamins and asparagus may turn urine a greenish color.

Among medications that can affect urine color are the laxative senna, which can bring a red or reddish brown tinge; chlorpromazine (Thorazine) and thioridazine (Mellaril), which may add redness; indomethacin (Indocin), cimetidine (Tagamet) and promethazine (Phenergan), which can color urine blue or green; warfarin (Coumadin), phenazopyridine (Pyridium) and rifampin, which can add orange; and chloroquine (Aralen), metronidazole (Flagyl), nitrofurantoin (Furadantin) and primaquine, which can make urine brown. Of course, sometimes blood does appear in urine — for example, as a result of a urinary tract infection, a kidney or bladder stone, an enlarged prostate, or a jarring accident that injures the bladder or urethra. Or blood-tinged urine may follow strenuous exercise like a long run or triathlon.

If there is no obvious explanation for blood in the urine or if it persists, a visit to the doctor is mandatory to check for kidney disease or cancer. If no other explanation for red-tinged urine is uncovered, a test for toxic levels of lead and mercury should be done.

If urine is excreted very rapidly, it may appear foamy. But consistently foamy urine can be a sign that protein is being lost, a symptom of kidney disease, and that a medical exam is needed.

Cloudy urine is typically a result of a bladder or urinary tract infection, which is typically accompanied by a frequent urge to urinate and a burning sensation or pain when urinating.

Other Important Factors

The volume of urine produced can be an important indicator of hydration. Normally, a healthy person produces about 100 milliliters (about 3.4 ounces) of urine an hour, or about one cup in 2 ? hours. If the hourly output exceeds 300 milliliters, it could be a sign of excessive fluid intake; if the volume drops below 30 milliliters, it is probably a sign of dehydration.

Consuming lots of salty foods or carbohydrates can temporarily reduce urine output, because salt, sugar and starch hold more water in the body than, say, protein. And consuming foods or beverages that are diuretics — including caffeine-containing drinks (like coffee, tea and many soft drinks), alcoholic drinks (especially beer), and foods with a high water content, like watermelon or asparagus — can temporarily result in higher-than-average urine output.

The urine of two-legged and four-legged athletes is now commonly tested for signs that performance-enhancing drugs were responsible for an unfair competitive advantage. Sometimes athletes who take medication for legitimate medical problems get caught in the net.

When you provide a urine sample as part of a routine medical checkup, it is likely to be tested for the presence of sugar (an indicator of diabetes) and protein (a sign of kidney disease), and perhaps for bile acids (an indicator of liver disease) or white blood cells (the result of an infection).

If symptoms of a urinary tract infection are present, the culprit organism — often the bacterium E. coli, a common resident of the lower digestive tract — can be isolated from urine and, if necessary, tested for antibiotic sensitivity.

Young girls who take bubble baths and sexually active women (especially those who are new or returning participants to the game of love) are especially prone to urinary tract infections. Doctors have a not-so-amusing name for this common plague of women in the throes of a new sexual relationship: They call it honeymoon cystitis.

In a healthy person, however, urine is sterile and contains neither infectious microorganisms nor white blood cells trying to fight them. Thus, in producing a urine sample for analysis, it is critically important that it be what doctors call a “clean-catch” specimen.

This entails first depositing some urine in the toilet before collecting the amount needed for testing. And be sure to cover the sample immediately to reduce the risk of contamination.

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Personal Health: High Sodium-to-Potassium Ratio in Diet Is a Major Heart Risk

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Well, think again. A major study, based on data from more than 12,000 American adults, took into account all those risk factors for death from heart disease. The researchers found that while a diet high in sodium — salt is the main source — increases your risk, even more important is the ratio of sodium (harmful) to potassium (protective) in one’s diet.

When people whose meals contained little sodium relative to potassium were compared with those whose diets had a high sodium-to-potassium ratio, the latter were nearly 50 percent more likely to die from any cause and more than twice as likely to die from ischemic heart disease during a follow-up period averaging 14.8 years.

Although there has been on-and-off controversy about the value of limiting dietary salt, there is no question that a high level of sodium in the diet raises blood pressure and the risk of chronic hypertension by stiffening arteries and blocking nitric oxide, which relaxes arteries. Hypertension, in turn, contributes to heart disease and stroke, leading causes of death.

Potassium, on the other hand, activates nitric oxide and thus reduces pressure in the arteries, lowering the risk of hypertension.

“We controlled for all the major cardiovascular risk factors and still found an association between the sodium-potassium ratio and deaths from heart disease,” said Dr. Elena V. Kuklina, a nutritional epidemiologist at the Centers for Disease Control and Prevention and an author of the study, published earlier this year in Archives of Internal Medicine. “With age, the risk of high blood pressure increases. The lifetime risk in this country is 90 percent. If you live long enough, you’re at risk.”

According to an Institute of Medicine report on sodium released last year, “No one is immune to the adverse health effects of excessive sodium intake.”

Our High-Salt Diet

Ninety percent of the sodium in the American diet comes from salt, three-fourths of which is consumed in processed and restaurant foods. Salt added in home cooking and at the table accounts for only a minor proportion of sodium intake.

The body’s requirement for sodium is very low — only 220 milligrams a day — but the average American consumes more than 3,400 milligrams daily. The current Dietary Guidelines for Americans recommend a maximum of 2,300 milligrams (about a teaspoon of salt) for people over age 2, but only 1,500 milligrams for the 70 percent of adults at high risk of sodium-induced illness: people older than 50, all African-Americans, and everyone with high blood pressure, diabetes or chronic kidney disease.

Despite widespread efforts to get people to consume less sodium, intake of this nutrient has increased significantly since the early 1970s as consumption has risen of processed and restaurant foods, which rely heavily on salt as a cheap way to enhance flavor and texture and preserve food. Because salt is categorized by the Food and Drug Administration as G.R.A.S., or “generally recognized as safe,” there is no limit to the amount food producers can use in a product.

To make matters worse, not only does the amount of sodium rise precipitously when foods like tomatoes and potatoes are processed, but the natural potassium in these foods declines significantly, worsening the sodium-potassium ratio.

The profligate use of salt in foods prepared outside the home has created an American preference for a salty taste, a preference that can be reversed with no loss of consumer pleasure if done slowly, said Dr. Thomas A. Farley, commissioner of New York City’s Department of Health and Mental Hygiene.

His department is leading a national effort started in 2008 to get food producers and restaurants to gradually reduce the salt in their products. Thus far, 28 national food companies, retailers and supermarket chains, including Kraft, Subway, Target and Delhaize America, have made a commitment to the National Salt Reduction Initiative to cut sodium in their products by an average of 25 percent by 2014.

But Dr. Jane E. Henney, chairwoman of the committee that produced the Institute of Medicine report, said this is still just a voluntary effort, and to make a lasting nationwide difference in sodium intake, the government needs to push harder for change. The report said, “What is needed is a coordinated effort to reduce sodium in foods across the board by manufacturers and restaurants — that is, create a level playing field for the food industry.”

Dr. Henney, a public health specialist at the University of Cincinnati College of Medicine, said it is time to modify the G.R.A.S. status of salt because it can no longer be considered safe under current conditions of use. This would allow the Food and Drug Administration to place limits on the amounts of salt that can be used commercially in preparing various types of foods.

The report stated that “population-wide reductions in sodium could prevent more than 100,000 deaths annually.”

It can be done, if there is a will. Through decades of voluntary efforts and regulation, Finland managed to cut sodium intake by one-third, which has resulted in a decrease in hypertension and premature deaths from stroke and coronary heart disease.

What You Can Do

Dr. Kuklina recommends eating fewer processed foods, especially processed meats, and more fresh fruits and vegetables and dairy products that are low in sodium, like yogurt and milk. Increase your potassium intake not by taking supplements, but by eating more cantaloupe, bananas, oranges, grapes, grapefruit, blackberries, yogurt, dried beans, leafy greens, potatoes and sweet potatoes.

When ordering in a restaurant, she suggests, ask that your food be prepared without added salt and your vegetables steamed, and always request that salad dressings and sauces be served on the side, enabling you to use far less than the chef might. Consider splitting an order between two people, which would cut the salt intake in half. And if a dish arrives that is too salty, send it back to the kitchen.

Avoid fast-food restaurants, where a single meal can contain a day’s worth of sodium.

When shopping, Dr. Farley said, “read labels and compare products, then choose those with lower sodium.” He acknowledged that products labeled “low sodium” or “no added salt” can turn off consumers, who think they’ll be tasteless. But you can always add a modest amount of salt at the table.

He also suggested asking food companies to use less salt in your favorite products and supporting the government’s efforts to reduce sodium consumption by commenting on a proposal published on Sept. 15 in the Federal Register (Docket No. FDA-2011-N-0400 and Docket No. FSIS-2011-0014). The easiest way to comment is through the American Heart Association’s Web site: www.heart.org/sodium, then click on “Send your comment letter today.”

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Personal Health: The Twice-Victimized of Sexual Assault

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AppId is over the quota

Yet few told anyone about it at the time, or reported it to the police.

I have clear memories of three such episodes from my childhood, one of which involved a man who owned a store in my neighborhood. Not knowing at age 11 anything about reproduction (in 1952, expectant teachers had to take leave when they “showed”), I was terrified that I could become pregnant from having been forced to touch his penis.

I had trouble sleeping, and I avoided the block where the store was. Yet, fearing that the assault was somehow my fault, I said nothing to my parents.

Experts on sexual assault and rape report that even today, despite improvements in early sex education and widespread publicity about sexual assaults, the overwhelming majority of both felony and misdemeanor cases never come to public or legal attention.

It is all too easy to see why. More often than not, women who bring charges of sexual assault are victims twice over, treated by the legal system and sometimes by the news media as lying until proved truthful.

“There is no other crime I can think of where the victim is more victimized,” said Rebecca Campbell, a professor of psychology at Michigan State University who for 20 years has been studying what happens legally and medically to women who are raped. “The victim is always on trial. Rape is treated very differently than other felonies.”

So, too, are the victims of lesser sexual assaults. In 1991, when Anita Hill, a lawyer and academic, told Congress that the Supreme Court nominee Clarence Thomas had sexually harassed her repeatedly when she worked for him, Ms. Hill was vilified as a character assassin and liar acting on behalf of abortion-rights advocates.

Credibility became the issue, too, for Nafissatou Diallo, an immigrant chambermaid who accused the head of the International Monetary Fund, Dominique Strauss-Kahn, of forcing her to perform fellatio in a Manhattan hotel room. Prosecutors eventually dropped the case after concluding that Ms. Diallo had lied on her immigration form and about other matters, though not directly about the encounter with Mr. Strauss-Kahn.

When four women, two of whom identified themselves publicly, said they had been sexually harassed by Herman Cain, the Republican presidential hopeful, they, too, were called liars, perhaps hired by his opponents.

Charges of sexual harassment often boil down to “she said-he said” with no tangible evidence of what really took place. But even when there is DNA evidence of a completed sexual act, as there was in the Strauss-Kahn case, the accused commonly claim that the sex was consensual, not a crime.

“DNA technology has not made a dramatic change in how victims are treated,” Dr. Campbell said in an interview. “We write off a lot of cases that could be successfully prosecuted. It’s bunk that these cases are too hard to prosecute.”

Victims must be better supported with better forensics, investigations and prosecutions, Dr. Campbell said. “This is a public safety issue. Most rapists are serial rapists, and they must be held accountable.”

In one study, published in 1987 in the Journal of Interpersonal Violence, 126 admitted rapists had committed 907 rapes involving 882 different victims.

Rapists are not the only serial sexual offenders. Witness the all-too-frequent revelations of sexual abuse of children involving multiple victims and persisting for decades even when others in positions of authority knew it was going on.

In the latest such scandal, an assistant football coach at Penn State University stands accused of molesting 10 boys. The charges led to the firing of a revered head coach, Joe Paterno, and forced the resignation of the university president for failing to take more immediate action.

The Risks

Last year, according to the Department of Justice, 188,280 Americans were victims of sexual violence.

Among female victims, nearly three-quarters are assaulted by men they know — friends, acquaintances or intimate partners, according to federal statistics.

But fewer than 40 percent of rapes and sexual assaults are reported to the police. Underreporting is more common among male victims and women raped by acquaintances or domestic partners. Only one-quarter of rapes are committed by strangers.

The result of underreporting and poor prosecution: 15 of 16 rapists will never spend a day in jail, according to the network. Dr. Judith A. Linden, associate professor of emergency medicine at the Boston University School of Medicine, reported in The New England Journal of Medicine in September that in the United States, “fewer than half of rape cases are successfully prosecuted.”

Victims may be reluctant to report a rape because they are embarrassed, fear reprisals and public disclosure, or think they won’t be believed. “Victims often think they somehow brought it on themselves,” said Callie Rennison, a criminologist at the University of Colorado in Denver. “Rape is the only crime in which victims have to explain that they didn’t want to be victimized.”

These feelings are especially common among college women who may have been drinking alcohol or taking illicit drugs when raped by a date or acquaintance.

Victims may not realize that any form of sexual behavior that is not consented to and that causes discomfort, fear or intimidation is considered sexual assault in most jurisdictions. That includes indecent exposure, unwanted physical contact (including kissing and fondling) and lascivious acts, as well as oral and anal sex and vaginal rape, whether with a body part or an instrument.

A minor — in general, 16 or 17, depending on the state — can legally consent to sexual activity. A person of any age who is forced or threatened, developmentally disabled, chronically mentally ill, incapacitated by drugs or alcohol, unconscious or preparing to undergo a medical procedure cannot legally consent to sexual activity.

Among young children, girls and boys are equally at risk of being sexually abused. But as they age, girls increasingly become targets; among adults, women represent about 90 percent of cases.

Experts have long debated whether rape should be seen as an act of aggression and control or the product of an irresistible sexual urge. To the victim, the distinction is moot.

The consequences can include pregnancy and sexually transmitted disease; feelings of helplessness, hopelessness and low self-esteem; self-blame and depression; substance abuse and eating disorders; fears of intimacy; numbness; post-traumatic stress disorder (nightmares, flashbacks, anxiety attacks, difficulty functioning); borderline personality disorder; unexplained physical problems; and even suicide.

Thus, even if rape victims choose not to report the attacks, prompt medical attention and psychological counseling can be critically important to their long-term well-being.

Next week: care for victims of sexual assault.

This article has been revised to reflect the following correction:

Correction: December 15, 2011

The Personal Health column on Tuesday, about factors that stifle the reporting of sexual assault, described the law on sexual activity involving minors incorrectly. The legal age of consent in many states is 16 or 17, so it is not the case that “a minor cannot legally consent to sexual activity.”

This article has been revised to reflect the following correction:

Correction: December 17, 2011

The Personal Health column on Tuesday , about factors that stifle the reporting of sexual assault, using outdated information from an advocacy group’s Web site, misstated the number of Americans who were victims of sexual violence last year, according to the Department of Justice. It is 188,830 — not 272,350, the corresponding figure from 2006. (The error was repeated on Thursday in an article about a survey by the Centers for Disease Control and Prevention on sexual violence and domestic abuse.)

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