We have all seen articles and statistics about the ”graying population” and are euphemistically told that we can look forward to our “golden years”. Just to remind us of our aging status, we get AARP cards mailed to us in our 50′s and are sent reminders to register for Medicare the year we turn 65. (On the bright side, senior discounts follow.) How are we faring in our getting-older transition?

A new report titled “Old Americans 2012: Key Indicators of Well-being” was released by the US Federal Interagency Forum on Aging Related Statistics. (The government cares!) This report tracks the trends in the aging population in the US and compares our life expectancy with that of other countries. Among developed countries, the USA is relatively young. Only about 13% of our population was 65 years or older in 2010, compared with 23% in Japan and more than 15% in most European countries.

The percentage of US population age 65 years or older is, however, predicted to increase to nearly 20% in 2030. That graying portion of our population is increasing due to increased longevity and declining fertility. Life expectancy for Americans who survive to age 65 was 20.3 years for women and 17.6 years for men when last calculated in 2009. Before we congratulate ourselves, the report also compares our longevity to other developed countries whose numbers were better, especially the UK and Australia. Although years of existence may not indicate years of health, the report found that 76% of Americans age 65 years or older stated that their health was good, very good or excellent during the years 2008 – 2010.

All of this comprises a success story for medical science and our socioeconomic development. But there is no question that our longevity “laurels” come with a price, one that has to be addressed as we get to that 20% of the population. Many older Americans have developed extremely deleterious behaviors and health risks. The report states that death rates from chronic lower respiratory disease increased by 57% between 1981 and 2009 in the USA (the end result of smoking). The prevalence of obesity has risen significantly.  And adding insult to injury, older Americans who are in the poor or the near poor category continued to spend a high proportion of their income on health care services through 2009. (Health care reform should improve on this.)

Many clinical research studies under-represent older people. A study published in “The Journal of General Internal Medicine” in 2011 pointed out that out of 109 clinical trials published in high profile journals in 2007, about 20% excluded older patients. And these are the individuals who account for the major share of health-care and expenditures

So why am I relating all of this?  I, as well as all those who are Jewish, will observe Yom Kippur this week. It’s a day in which we atone for our sins, and request a blessing to be written in the “Book of Life” in the year to come. In order for this to happen, medical science and social programs need to consider the health and well-being of all of us as we get older. The World Health Program definition of what aging should be summarizes my Yom Kippur wish: that it become “the process of optimizing opportunities for health, participation and security in order to enhance the quality of life as people age”.

The scientist who headed the complementary medicine portion of the FDA was once asked which supplements he took. His answer: ” none”. Clearly a study consisting of one person, no matter how informed she or he may be, does not represent scientific evidence… but I have to admit that I took his advice to heart and to pill consumption. I try to rely on my diet to supply my nutrition (with the exception of calcium to supplement my insufficient consumption of milk products and Vitamin D since I try to avoid unnecessary sun exposure and lather on sunscreen.) So I felt a twinge of exultation and validation by the article that appeared in this last’s week JAMA . It was titled “Association between Omega- 3 Supplementation and Risk of Major Cardiac Disease Events”.

The authors analyzed a total of 20 studies that included 68,680 patients (a nice and large round number). They evaluated trials in which omega- 3 supplements were used for at least 1 year in doses that averaged 1.5 grams a day (g/d) and included 0.77 g/d of EDA and 0.6 g/d of DHA.The working hypothesis has been that these omega-3 unsaturated fatty acids lower triglycerides, help prevent serious arrythmias and might even lower platelet aggregation or stickiness (lessening clot formation) and diminish blood pressure. Indeed, the FDA has approved its use for lowering trigycerides in individuals who suffer from elevated triglycerides, and certain European countries have approved its use for diminishing cardiovascular risk..

 

I”ll bombard you with a few numbers just so you understand the size and scope of the study. Altogether there were 7044 deaths, 3933 were cardiac death, 1150 sudden deaths, 1837 myocardial infarctions, and 1490 strokes. The studies compared individuals who took omega-3 polyunsaturated acids (PUFA’s) supplements and those who did not.. And lo and behold, sophisticated statistical analysis demonstrated absolutely no significant difference in all-cause mortality, cardiac death, sudden death, heart attack or stroke for those who took omega-3 supplements and those who did not!

Bottom line: it’s not the supplement that will keep away cardiovascular disease or sudden death…it’s the right nutrition (with food), exercise and weight management…and if necessary the right medications prescribed by your physician.

The Jewish New Year began last Sunday evening. Our tradition is to begin the year with apples dipped in honey for a sweet, healthy and happy year to come. And so I wish this for all of you… Apparently you don’t need most supplements to achieve this goal.

This week I want to write about two subjects. The first affects all women, children and, of course, men. You all should get your flu shot for the 2012 – 2013 flu season. And now is the time to do it. There is no need to suffer with the debilitating fever/chills, cough, sore throat, headache, muscle aches (even your teeth seem to hurt) as well as fatigue and runny nose due to the most prevalent strains of influenza. And in some cases, especially women over 65, pregnant women, young children, individuals with chronic disease, and anyone with impaired immunity, flu can lead to pneumonia and even death! Thirty thousand Americans die yearly from the flu. In the past, we told you to make sure you were given your flu shot if you had a chronic disease, worked with children, had contact with babies, exposed adults or you were elderly or planned to get pregnant. Now the recommendation is that everyone over the age of 6 months get a flu shot.
And it is especially important for pregnant women. (Pregnancy decreases immunity to viral disease and if a pregnant women gets the flu she significantly endangers her health and that of her fetus). There are no contraindications to getting a flu shot during pregnancy, even in the first trimester. And remember, the flu shot you got last year will not protect you from the new strains of influenza that are coming to get you this year. It takes 2 weeks to build up the antibodies needed for your protection so the earlier you get your flu shot the sooner you will gain protection for the year to come.

We have the vaccine in our office… So if you would like to come, in my nurse, Judy, will be happy to give you your shot…and at the same time you can see our new office. (Which I must say looks great!) Or if you are due for an appointment in the next few weeks, we will be happy to give you your flu shot at that time. You can also get the influenza vaccine at most local pharmacies. Please just figure out the most convenient venue and take the time in the weeks to come to protect yourself and your family from the misery of influenza this year.

Now onto the second subject for this week’s newsletter: An interesting article from the American Journal of Gastoenterology caught my eye.. The Journal reported on a nationally representative survey of about 7800 people. Of these, one in 141 or 0.71% were found to have celiac disease or Sprue. This disease is a gastrointestinal disorder in which gluten, a protein found in wheat, rye and barley causes an immune response by damaging or destroying villi in the small intestine. Once those villi, which are small projections that increase the surface of the small intestine and allow for absorption of nutrients, are destroyed, malnutrition occurs. Celiac disease is thought to be genetic but can be triggered or become active after surgery, pregnancy, childbirth, viral infection or severe emotional stress.

The symptoms may be clearly gastrointestinal: bloating, abdominal pain, chronic diarrhea, vomiting and/or pale stool, but they also may be less digestive-tract-apparent: weight loss, anemia, fatigue, joint and bone pain, arthritis, osteoporosis, depression, anxiety and even gynecologic symptoms such as missed periods, infertility and miscarriage. Because of the vagueness of the many symptoms associated with celiac disease, diagnosis is often delayed by 1 to 2 decades. The authors of the article estimate that due to the vast under-appreciated disease burden, 83% of celiac disease cases in the USA remain undiagnosed. Diagnosis usually requires a blood test for specific antibodies: anti-tissue transglutaminase antibody (t TGA) and anti-endomysium antibody (EMA). If these are positive, an intestinal biopsy done via endoscopy will confirm the diagnosis by demonstrating the damaged villi.

This is not a test that is done routinely. But studies have shown that if an individual has celiac disease 4 to 12% of first-degree relatives will also have it.

So far, the only treatment for celiac disease is a strict and lifelong gluten-free diet, which involves avoiding foods containing wheat, rye and barley. The authors estimate that 1.6 million US citizens currently choose to abstain from gluten but many of them do not have celiac disease. (There was a cartoon in The New Yorker that showed 2 young people driving in a convertible. One said to the other “I don’t know what gluten is but I am staying away from it!”) And that is part of the issue; many individuals simply choose a gluten- free lifestyle for perceived health benefits. The authors of the article point out that more research is needed into the systemic effects of gluten abstinence in healthy people. It’s certainly not an easy diet to maintain.

Bottom-line: If you do have a first-degree family member who has been diagnosed with celiac disease, it might be worthwhile to request that the blood test be done. And if you have persistent symptoms included in those listed above, you might also request that your physician do appropriate antibody testing and if positive, discuss the results and your symptoms with a gastroenterologist.

Rarely do I become political in my weekly website articles. But as I watched and listened in horror as woman’s rights to abortion, even in cases of incest and rape, became part of a political platform and the rallying call of multiple candidates, I felt I had to protest. Why are so many women silent? We once burned our bras (even though some of us didn’t need them), we marched, we picketed; now let’s at least protest with our vote… So when I came across the “Current Commentary” in this September issue of The Journal Obstetrics and Gynecology, I was heartened by the authors’ medical opinion. (And I should point out they were not outraged women, nor we’re they professed members of any political party; although their MD titles might qualify them as “elites”… But this is a medical journal.)
The authors are physicians at Maimonides Medical Center in New York and Massachusetts General Hospital in Boston. The article is titled “When Legislators Play Doctor”. It begins with the fact that many state legislatures have proposed or enacted laws that mandate that women undergo ultrasonography before electing to have a pregnancy termination. And in some cases the law requires that the woman review the images before she decides on abortion. The authors then make a very poignant and horrifying comparison to the 1971 film Clockwork Orange..

Remember how Malcolm McDowell underwent aversion therapy?…. His eyes were pried open while he viewed films that the government hoped would cure him of his propensity to engage in criminal criminal behaviors. This, the authors argue, (and in truth there is no argument) is not the appropriate use of informed consent. It is a-shame-on-you admonition in which the state promotes guilt about a decision that a woman with an unplanned and perhaps violently coerced pregnancy has anguished about before coming to the physician. Informed consent should be a process in which the patient is familiarized with foreseeable risks and benefits of the procedure as well as those associated with alternative courses of action, in this case the option of continuing a pregnancy. (Which by the way, has been shown to be far more dangerous to a woman’s health than termination). The authors also ask us to ” imagine that rather than mandatory ultrasound examination, each woman who wanted a termination first had to be slapped and told that abortion was evil.” Not what physicians are taught to do in medical school!

The American College of Obstetricians and Gynecologists committee on ethics has noted that ” free consent is an intentional and voluntary choice that authorizes someone else to act in certain ways… Consenting freely is incompatible with the patient being coerced or unwillingly pressured by forces beyond herself.”

If we as physicians are forced under legal threats to give unwanted and adversarial information to patients, we have abdicated our professional obligations. As women, we should not be subordinated to decisions made by a state that denies our autonomy.

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