One of the questions I ask each patient when she comes in for her check-up is whether she tales calcium and vitamin D. I know a lot of you have read media reports voicing concern about excess calcium intake. And indeed, many of my patients have simply stopped taking calcium supplements as a result of these reports, despite the fact that may not get adequate calcium in their diets. Unfortunately, the current typical answer that I seem to get regarding milk product consumption is “yes, I add milk to my coffee”…

I thought, therefore, it would be a good idea to summarize the recent article that appeared under the medical news and perspectives portion of JAMA. It reported on the latest data that has caused concern about excess calcium consumption. The authors noted that more than half of US women who are middle age or older take calcium supplements and that there are now concerns about potential cardiovascular disease risk with the supplements. A new study published in the British Medical Journal in 2013 may have added to this concern, but it came with some caveats. (As do all studies!)

The study comprised 61,433 women who were followed up for up to 19 years. The researchers used questionnaires to get information about the women’s diet and supplement use and followed their subsequent health. They found that women who consumed more than 1400 mg of calcium daily had a higher rate of death from all causes (about 40%) then women who consume between 600 mg and 1,000 mg daily. Women who consumed more than 1400 mg of calcium daily also had a higher risk of death from cardiovascular disease (49%) and ischemic heart disease (14%), but not stroke. The women who were at highest risk were those who had both a high dietary intake of calcium (more than 1400 mg)  and additionally took calcium supplements. They had an all cause- risk mortality increase of 2.57 ( two and a half times more) or, if want you want to use percentages, an increase of 257 %.

The authors tried to explain these findings by stating that excess intakes of calcium may impact physiologic control of calcium levels in the body and higher levels may increase the growth of fibroblast factors. Excess fibroblast activity can stimulate the thickening of the lining of blood vessels causing subsequent lack of pliability and an inability to dilate. This can then decrease the flow of blood to the heart and other vital organs hence, contributing to higher rates of cardiovascular and all cause mortality.

Remember you get calcium in many forms of food, both dairy and non-dairy. A cup of low-fat or nonfat yogurt has as much as 400 mg of calcium (once fruit is added however,  you lose about 100 mg) and a glass of nonfat milk has 300 mg. An ounce of sliced cheese averages 200 mg but surprisingly 1/2 cup of nonfat cottage cheese only has 80 mg. A cup of broccoli gives you 170 mg of calcium. Collards and dried beans do better at 270 mg per cup. Three ounces of canned sardines with bones (it’s “in dem bones”) has 370 mg and the same portion of canned salmon has 200 mg. It’s thought that the average diet without special high calcium foods or milk has about 200 to 250 mg of calcium.

We do utilize and excrete calcium on a daily basis and we need approximately 1000 mg “to keep on top of what we lose” as adults and 1200 mg in our later years. Low calcium intake has definitely been associated with low bone mass or osteopenia and then comes  menopause and age which compound this loss. Women have a greater than 40 % lifetime risk of developing an osteoporotic fracture. So ultimately we have to weigh your bone health together with your heart health. The evidence so far is that we need our calcium, but ultimately it’s best to get it through diet if at all possible and supplement only what is missing.

Read the label of contents on what you eat and drink. It will state the percent of calcium in a portion of the food that has been labeled (obviously you can’t do this with fresh veggies, but you can use the above reference or consult a nutrition chart.) Remember the percent is calculated on a daily total of 1000 mg so 30% is the equivalent of 300 mg.)  If you do not reach that 1000 mg goal through your food, then go ahead and supplement. The authors of the British Medical Journal article emphasize that calcium supplementation should be taken by “people with a low intake of calcium rather than increasing the intake of those already consuming satisfactory amounts.”

Sounds right.

No, I am not writing this while sipping a glass of wine. I may even forgo a glass later this evening. But why should I suffer alone! So, I am sharing a brief JAMA article published in the Medical News segment with the ominous title ” Even Low, Regular Alcohol Use Increases the Risk of Dying of Cancer”. Obviously, this caught my attention. This article was a summary based on new findings reported in the American Journal of Public Health.  Researchers from both the United States, Canada and France analyzed data that had already been published on alcohol use and cancer risk and combined this with 2009 US mortality data and national surveys of alcohol sales and consumption in United States. They searched for information on seven types of cancers that have been linked with alcohol use including cancers of the oral cavity and pharynx, larynx, esophagus, colon, rectum, liver, and female breast.

They found that alcohol use actually accounted for about 3.5% of US cancer deaths in 2009. And here is the scary part for women; they attributed between 48 and 60% of alcohol-related breast cancer deaths to having, on average, three or more drinks per day. OK, so most of us don’t drink that much…but about 30% of the  breast cancer deaths were attributed to having fewer than 1.5 drinks daily!  The researchers went on to calculate that alcohol consumption actually causes about 15% of breast breast cancer deaths among US women.

We know that many studies have linked alcohol consumption (in moderation) with cardiovascular benefits and this may in part explain why public-health efforts haven’t targeted limiting alcohol use as part of cancer prevention. It’s that old quandary: “Should I drink for my heart or abstain for my breasts?” ( …and pharynx, larynx and esophagus).  So here is the final quote from the writers of the article: ” When viewed in the broad context, alcohol results in 10 times as many deaths as it prevents in United States even after one considers possible beneficial effects of low level use for cardiovascular disease and diabetes.” I think I will forgo wine tonight…but maybe just a sip tomorrow.

I’ve heard them all. Every fall and winter I order the season’s flu shots and offer them to my patients. Some refuse and although I try to argue with their reasons not to get vaccinated, I often fail to convince those that I classify as the perennial “reluctant ones”. So when I read the recent viewpoint section of JAMA titled “Examining Common Arguments Against Influenza Vaccine,” I was delighted to see that the article made the same points I have used. And perhaps since they were published in this prestigious journal, they will be more official than mine. So here they are:

The vaccine does not work.

Yes it’s not as effective as other common vaccines but “not as effective” does not mean not effective. The Centers for Disease Control and Prevention’s midyear assessment of this season’s vaccine shows effectiveness of 62% for the prevention of significant respiratory illness. Sixty percent or better is still a noted achievement and not a failure.

The vaccine causes flu.

The shot contains an  inactivated vaccine, i.e. only killed virus and viral antigens that absolutely cannot cause influenza infection. There have been placebo-controlled, randomized trials that show that there is no higher frequency of systemic reactions in those who receive the vaccine when compared with those receiving placebo. If someone does get some sort of viral infection after-the-fact, it has to do with exposure to that virus before immunity from the vaccine had time to develop. Remember, it takes two weeks to build up antibodies that will fight off influenza after the vaccine.

I have an allergy to eggs.

Apparently all egg allergies are not equal. And now according to the Advisory Committee on Immunization Practices, those who only experience hives after egg exposure should receive the influenza vaccine and simply be observed for 30 minutes. However, egg-allergic patients with a history of swelling, breathing problems, nausea, vomiting or another major reactions that required use of an epinephrine or emergency medical attention should not get the current vaccine. Ah, but there is good news…the next round of flu vaccines approved by the FDA will be produced using a genetically engineered insect virus that infects cells grown in culture and doesn’t involve eggs. (It’s way complicated, so I will resist a 2 paragraph attempt to explain the vaccine biology here.) But the end result is that a non egg produced vaccine will provide a new option for people with egg allergies.

 I cannot get the vaccine because I am pregnant or have an underlying medical condition or because I live with an immune compromised person.

 You or your loved one are actually at the greatest risk of complications from influenza and the vaccine will not compromise your medical condition! If you get the flu and transmit it to a person who is at risk (or during pregnancy), you can cause them to suffer grave consequences. It’s your medical “duty” to diminish their exposure and risk.

I never get the flu, I am healthy.

Even if you don’t develop classic flu-like illness ( and you could get it with very minimal
symptoms and not know it), you can still transmit the virus to others. So do the ethical thing and get that shot.

So let’s stop procrastinating and protesting and make sure we protect ourselves and our loved ones. There are really no excuses. 

I was horrified to be told, while traveling in Mozambique, that life expectancy in that country was about 45. I attributed this statistic to the lack of healthcare resources, especially in rural communities where the closest health clinic requires a 20 to 40 km walk, as well as the hideously high maternal and neonatal death rates. And upon my return to the US, I felt somewhat smug as I went to my office and offered women, what I thought, was the best of health care. Apparently this is not a national attribute. This week, JAMA came out with an article titled “The US health disadvantage relative to other high income countries.”

The article is based on a report of the findings from the National Research Council Council/Institute of Medicine (NRC/IOM… yes there are initials for everything official) which documents the health of US females and males up to the age of 75. The Council compared our population to their counterparts in 16 other wealthy, developed nations including Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands, and the United Kingdom. Here are some of the facts that were presented:

• US children: Our newborns are less likely to reach the life expectancy of newborns in other wealthy countries. US infants are also less likely to reach their first birthday. They’re more likely to have low birth weights and their mortality rates up to age 5 are higher.

•  Adolescence: US adolescents die at higher rates from motor vehicle crashes and homicides than their counterparts in the other countries. They are also more likely to have unwanted pregnancies and sexually-transmitted infections. They have the second highest prevalence of HIV infection among 17 countries and the highest incidence of AIDS in their age group.

• Adults: The United States has the highest obesity rates. We also have the highest prevalence of diabetes among adults aged 20 years and older and the second highest death rate from ischemic heart disease. Lung disease and drug related deaths are more prevalent in the United States, and older US adults report higher rates of arthritis and activity limitations. The life expectancy at age 50 years is lower in the United States then in 16 other high-income countries.

Oy!  But the report did point out some of our health advantages, and these included better control of hypertension and serum lipids, lower cancer and stroke mortality rates and higher life expectancy after age 75 years. US adults are also less likely to smoke and drink less alcohol than adults in other countries but they have a greater propensity for other unhealthy behaviors such as high caloric intake, abuse of drugs, more motor vehicle crashes involving alcohol and finally own (and have injuries and deaths from) more firearms than those in the other high- income countries. US adolescents are also less likely to practice safe sex then adolescents in European countries.  We have the highest rate of child poverty of all the wealthy nations (what a “shanda”). We also rank below other countries in the ability of our children to achieve social and economic levels that are higher than their parents.

The authors (from the Department of Family Medicine and Center on Human Needs at the Virginia Commonwealth University and Center on Labor, Human Services and Population, Urban Institute in Washington, DC…just to be exact) went on to report on the reasons given by the NRC/IOM for our health disadvantages. And apparently, the chief reason is, unlike those other countries, we lack universal health insurance coverage!  Primary care is less available and there are greater barriers to access and affordable care. US patients are more likely than patients elsewhere to have lapses in care quality and safety outside of hospitals; moreover they are likely to require emergency department visits or even readmissions after hospital discharge, perhaps because of premature discharge (it’s expensive to stay in the hospital) or problems with ambulatory care.

So is all this because of a financial inability to get to the best doctors or hospitals? It’s not so simple; according to the NRC/IOM even non-Hispanic white adults or those with health insurance, a college education, high incomes, or healthy behaviors appear to be in worse health in the United States then in other high income countries.

So what should be done? The NRC/IMO recommends that the public be alerted to the scope of our US health disadvantages. Most individuals and even most doctors are not aware of these poor statistics. The Council suggests that these stats be used to stimulate the national discussion about the investments and trade-off the public is prepared to consider to attain the health status that other countries now enjoy. IN short, the message here it that we need affordable universal health care that starts with prevention, primary care and proven, best practice of medical care. I’m not sure that knowing all this will get sufficient attention from the public, physicians or our politicians. But they certainly should be informed. (And I am doing my small public service in reporting all this.)

I struggled to end this newsletter, I don’t have a reassuring message or effective personal advice. All I can say is that each of us has to try to maintain our own healthy behaviors and seek access to preventive and effective healthcare not just for ourselves, but for our children and our communities. We have a national health challenge that should not be insurmountable… Our research and major institutions are foremost in the world!  We should be able to do as well, and one would hope, even better than all those other countries!

So here is another website article written at 35,000 feet. I am on my way from LA to NY for a board meeting of Save the Children. (And I am excited to show the board members the pictures of the school the LA Associates of Save the Children built in Mozambique…pictures that I shared with you in my last newsletter.) I just purchased all the journals I missed in the last two weeks in order to find an article that I thought would be of interest to report.  Finally, I came upon one in the journal Menopause. (The journal with the bright red cover). The title: “Initiating therapy with antidepressants after discontinuation of hormone therapy.”

Just in case you don’t want to read further… the answer is yes, some women need to take anti-depressants when they stop their hormone therapy (HT).

Now for the study: Once more it comes from epidemiological data gathered by researchers at the Karolinska Institute in Sweden where there is an amazing drug and population register. These contain information on patients’ age, sex, and personal identification number for all medications prescribed and dispensed to the entire Swedish population of 9 million inhabitants. Data were obtained for women who had been dispensed systemic hormones, including natural and semisynthetic estrogens as well as progestogens and estrogen combinations. The researchers also obtained data on dispensed antidepressants. (I won’t list them by name but there were many classifications). The study included women between the ages of 45 and 70 who had used HT continuously for more than 6 months. The group included 101,911 women, 39.8% of whom discontinued HT during follow up. The drug register showed that discontinuation was associated with an increased risk of antidepressant use by 24%. Women who were 65 or older who had used HT for 3 years or more had the highest risk.

The authors noted in the conclusion of the article that “it is important to take into account that about 20% of all women will start HT and that 15% of them might avoid treatment with antidepressants if they continue HT.  The results suggest that clinicians should be aware of depressive symptoms, particularly in older women who discontinue HT. Therefore, the decision to continue or discontinue HT should be individualized based on the severity of symptoms and current benefit-risk ratio consideration.”

Since I, like most physicians, currently will tell patients who wish to continue their HT for many years, that long term use may increase their risk for breast cancer and that the positive impact of HT on coronary vascular disease decreases in later age… we are once more left with a depressing conundrum: To continue to take HT or stop, and possibly need “withdrawal” antidepressants.  So as usual, I will end my report with a ”discuss this with your doctor!”