I keep a mental dietary list which I review at the end of each day…”Let’s see, I had juice in the morning, salad at lunch, two vegetables at dinner and fruit for dessert. OK, now I’ve had my five or more fruits and vegetables and have done my nutritional duty to ward off cancer.” It turns out I am giving myself inadequately proven anti-cancer food advice.

The largest prospective study to date, the European Prospective Investigation into Cancer and Nutrition study (wisely acronymed the EPIC study), followed 478,478 individuals aged 25 to 70 years in 10 European countries for a median of 8.7 years. (How they got to a number that has those matching numerals is a mystery.) Unlike many large studies, women comprised the predominant gender (335,873 women vs. 142,605 men). The overall cancer incidence rates were 7.9 per 1000 person –years for men and 7.1 per thousand-person years for women. When the researchers analyzed the impact of daily veggies, they found that an increase of 100 grams (the equivalent of a serving of broccoli) reduced cancer risk by only 2% while a comparable intake of fruit (less than an apple) reduced cancer risk by just 1%. These were very low percentages…and were restricted to women; they didn’t even apply to men who gained no cancer protection.

I would like to remind you of a previous website article in which I cited articles that discourage women from drinking more than 10 grams (one drink) at any time. Well, the researchers that reviewed the EPIC data found that intake of fruit and vegetables did decrease cancer risk by 10% in heavy drinkers (more than 30 g daily for women and 60 grams for men). But considering all the damage that excessive alcohol consumption does to our health, proclaiming that the right foods will prevent certain cancers is not appropriate medical advice.

The American Cancer Society (ACS) still advises that we consume 5 servings of a variety of fruits and vegetables on a daily basis to help reduce cancer risk both directly as well as indirectly by helping maintain a healthy weight. In 2005, ACS made “the 5 rule” the third priority after healthy weight maintenance throughout life and adoption of a physically active lifestyle. The ACS meets to update its recommendations later this summer and will probably change them based on the EPIC study.

But before I encourage you to stop that “5-a-day” nutritional count let’s remember that cardiovascular disease is the number one cause of mortality in women (not cancer). There are many prospective studies that have shown that 5 servings of fruit and vegetables a day reduce cardiovascular risk by as much as 12%.  These foods contain nutrients and vitamins that are essential for all of our bodies’ functions. They most certainly help us maintain a healthy weight and a lower weight  (or more precisely, lack of obesity) will diminish our risk of diabetes, heart disease and many cancers. We have to eat something, and substitutions for fruits and/or veggies usually carry excess calories, sugar, salt and bad fats. (Think processed or junk food.)

I may stop computing those servings in the hope that I will reduce my risk of cancer, but I’ll keep up the count to maintain my heart, weight and future health and well being.

I routinely ask my new patients: “How much, on average, do you drink each week?” In order to make this question slightly less accusatory, I also add “do you usually have wine with dinner or a cocktail before?” If the answer is “yes, one or two glasses”, I then feel obligated to discuss the pros and cons of women’s alcohol consumption. I was therefore delighted to find an article under the heading of “Clinical  Crossroads” in last week’s JAMA which dealt with the question of whether a person (in this case, a 42 year old man) should drink for his health. The authors were kind enough to also consider the health implications of drinking for women. Here are some of the facts that they presented:

The estimated ethanol (alcohol) content per serving of various alcoholic beverages is similar, although their caloric content may vary. Twelve ounces of beer have 14 grams of ethanol and 150 calories, light beer contains 11 grams of ethanol but about 50 calories less; 5 ounces of wine contain 15 grams of ethanol and 120 -125 calories and finally 1.5 ounces of “hard alcohol” or spirits have 14 to 15 grams of ethanol and 100 calories.

Because women have a smaller volume of distribution in which to dilute the alcohol, overall smaller body size, and a different first –pass metabolism (alcohol is not as quickly metabolized by the liver), we experience the toxic effects of alcohol at approximately half the daily dose of alcohol as do men. One glass of  wine, serving of beer or “a drink” for a woman is like two for a man….so ( and I don’t meant to insult your intelligence, but  want to write this for emphasis)….two drinks at dinner would be the equivalent of four for a man. And that’s a number that would cause concern to most of their female companions.

Alcoholism has been ranked the third most important preventable cause of death in the United States. The National Institute on Alcohol Abuse and Alcoholism has issued the following guidelines for safe drinking:

* Up to 2 drinks for men younger than 65
* Up to one drink per drinking day (I’m not sure what constitutes a drinking day, but it’s their wording) for non-pregnant women and older adults

No alcohol for

* Women who are pregnant or trying to become pregnant
* Persons with medical conditions that could be made worse by drinking
* Persons who plan to engage in activities that require alertness and skill (such as driving a car)
* Persons taking certain over-the-counter or prescription medications (think sleeping medications, ant anxiety meds, antihistamines or anything that effects brazen chemistry)
* Persons recovering from alcoholism
*  Persons younger than 21

In order not to sound like an abolitionist, let me also proffer the data that was cited on the “biochemical effects of light to moderate alcohol consumption in short term feeding studies”. (Actually they were drinking studies). Researchers looked at certain biomarkers for cardiac disease and the effect of ethanol on these markers. HDL or high density lipoprotein (the good cholesterol) was minimally increased, but a lot of alcohol was needed to do this (60 grams per day in men and 35 grams in women). Alcohol seemed to work best on HDL if the levels were low to begin with. (Before menopause most women have fairly high HDL levels, perhaps due to their production of estrogen.) Triglycerides were increased in men who drank moderately but may have decreased in women (although beer with more carbohydrates seems to erase this phenomenon). Fibrinogen which is involved in clot production was lowered. Adiponectin which increases insulin sensitivity (a good thing) did minimally increase and as such may have lowered the risk of diabetes.

Now here is the concern for women: Light to moderate drinking increases the bodies own sex steroid hormones by 5% to 20% and can increase risk of breast cancer! This translates to an approximate 1% increase in the relative risk for each one gram a day of alcohol.   It also has an adverse effect on other cancers in men and women. Malignancies of the mouth, larynx and esophagus are increased in all moderate drinkers. The relative risk of developing these cancers (compared to nondrinkers) is approximately 1.4 to 1.7 with “just” 2 drinks a day.

So should we drink for our hearts or abstain for our breasts? Studies dating back at least 25 years have shown that 10 grams of ethanol per day among women (and 25 grams for men) lowered risk of coronary heart disease by 20 to 30%. The authors calculated that this conferred a 1% lower absolute 10 year risk for a 50 year old man who was deemed “average”, but remember our 10 year average risk at 50 is usually less than that of men.

It sounds like that one drink is a draw…but the authors go on to state that the typically high HDL levels in premenopausal women would appear to make any clinical benefit for alcohol limited at best, “and since the risk of breast cancer is increased, it is unlikely that premenopausal women would profit from drinking”.

There is so much more that we can do to prevent heart disease…not smoking, exercising, maintaining a reasonable body weight and if necessary treating elevated lipids (LDL cholesterol and triglyceride).

Alcohol is not a medicine. If you love it and want to drink a glass of wine with dinner or have that drink before….limit it to one.  Your choice to imbibe is similar to your desire for desert, but without the “nose”….it tastes good, you enjoy it and it adds to your meal. The toast “l’haim” (to life) that accompanies that drink is a wish, not a medical certainty.

Let me start with the scary and necessary-to-know statistics: Osteoporosis affects 10 to 12 million people in the US and forty million have low bone density (osteopenia). In 2005, over 2 million fractures were diagnosed. One in three Caucasian women over 50 will experience an osteoporotic fracture in her lifetime. (Whites and Asian women tend to have a lower bone mass than women of other ethnicities.) We also “out fracture” men (who have thicker bones) by a factor of 1.6.  And if a woman fractures her hip, she has a 20% chance of dying within a year. Osteoporosis is a very disabling, costly, and yes, mortal disease.

There has been a welcomed increase (both medically and financially) in pharmaceutical therapies that help avoid and/or treat osteoporosis. By now, you have all seen the ads and articles for the various bisphosphonates including oral alendronate (Fosomax), risedronate (Actonel) and ibandronate (Boniva) which can be used daily, weekly or monthly. There are also intravenous bisphosphonates that can be administered every 3 months or just once a year.

Then came the media outcry about potential side effects that these medications could cause….jaw necrosis, perhaps atrial fibrillation and more recently “atypical” fracture of the femoral shaft (long, upper leg bone), especially after long term use. I want to address the latter concern in this article.

Remember, these medications work by binding to the bone, preventing cells called osteoclasts from drilling minute cavities that make the bone porous. Cells called osteoblasts then do “their thing” and fill the cavities up. When stable, the drilling and filling are equal and thus maintain bone structure and strength. However if the drilling outpaces the filling, there is bone loss. This occurs with age (unfortunately after 30), and is accelerated by lack of estrogen (menopause) certain medications, especially steroids, diseases and the “wrong” genes. It is also aided and abetted by lack of proper nutrition.

Just to reiterate, bisphosphonates help stop the drilling and with time those minute cavities that made the bone porous get filled, diminishing the risk of fracture. We now know that these bisphosphonates attach and remain in the bone performing this job for years after being discontinued.

Recent cases have appeared in medical journals in which the femoral bone fractured in a horizontal fashion without prior significant trauma. In most instances, the patients were taking long term bisphosphonates.  How concerned should we be about this newly media reported “atypical” femur fracture?

An article in the May issue of The New England Medical Journal may help allay physician and patient concerns. It concludes that this type of fracture is truly rare. The authors used data from 3 randomized and placebo-controlled, prospective studies involving 14,195 women and 55,000 person years of observation. The risedronate data that they reviewed provided up to 10 years of study. All together, they found a total of 12 fractures in 10 patients that were classified as possible “atypical” femur fractures. (To be accurate, they were called subtrochanteric or diaphyseal fractures). The incidence came out to just 2.3 per 10,000 patient years. The authors also calculated that treating 1,000 women who had osteoporosis for 3 years would prevent about 100 fractures (including 11 hip fractures), a benefit that way exceeded the risk of “atypical” fracture, if indeed it was caused by the bisphosphonates.

So what does this mean? Well according to an editorial that followed the article, “physicians should not rush to judgment and stop prescribing bisphosphonates because of concern about atypical femoral fractures.” They should, however, reevaluate patients who have received long term therapy in the context of contemporary guidelines. (And for these please see my previous website article that discusses the use of FRAX to determine for whom and when to start therapy.)
I now review the FRAX indications for each patient who is at risk for osteoporosis. If she is a candidate for medication I will prescribe it, but carefully follow her with tests to check for bone loss. If she is stable for a number of years (usually 5 years) I suggest stopping the medication or at least taking a drug holiday. The good of the bisphosphonates still outweighs a possible bad, at least for those who need it.

Now, although I usually end my weekly newsletter with just one article, I have to mention another that just came out in JAMA. It also dealt with bone fractures. As we now all know, Vitamin D has become the vitamin “De jour”. The amount of D found in up to 70% of American is inadequate; low levels have been associated with osteoporosis, heart disease and a number of cancers. I ask all my patients about their Vitamin D intake (and exposure, remember you can get it though sun rays) and repeatedly advise them to take at least 1,000 international units (IU’s) daily.  I often check Vitamin D levels with a blood test, especially if there is a history of low bone density. For those whose level is found to be extremely low, I prescribe 50,000 units of Vitamin D-2 a week or every other week for several months, and then recheck their levels. If they have achieved a D level that is sufficiently high, I have them continue with an OTC supplement of up to 2,000 units daily.

Researches in Melbourne, Australia tried to maximize Vit D administration by giving elderly women considered to be at high risk of fracture  a dose of 500,000 IU of Vitamin D orally once a year.  They carried out a double-blind, placebo-controlled trial in 2256 women aged 70 or older. Half were given this very high yearly dose for 3 to 5 years; the others were given a placebo. There was no difference between the 2 groups with regard to calcium intake (indeed it increased for both). But contrary to expectations the group that received the high dose Vitamin D experienced 15% more falls and 26% more fractures than the placebo group. And the increase in falls was most apparent in the 3 months after they were given high dose Vit D! Frankly, the authors couldn’t explain this but went on to suggest that dosing should be more frequent and at lower doses. So far I (and most of my colleagues) will probably stick to advising daily 1,000 units or more of D and if your levels are low that you increase the dose (with a prescription) on a weekly or biweekly schedule. But I doubt we will prescribe that single oral dose once a year. So please continue to use D and calcium on a regular basis for better bones. And if necessary, go ahead and take that bisphosphonate that I or another doctor may have prescribed. The bones you strengthen will be there to stand you in good stead!

Recently, a mother brought her adolescent daughter to my office for advice about  menstrual migraine therapy. After I made my suggestions, I thought it might be timely to give a few “notes” (I sound like a producer) for the website regarding the causes of and treatments for this debilitating disorder. Migraine headaches are unfortunately very common; they affect nearly 28 million Americans including 18% of all women and 6 % of all men. A migraine is defined as a one sided, severe, pulsating headache aggravated by physical activity together with sensitivity to light (photophobia) and sound (photophonia). The true migraine usually manifests itself in 4 phases. (This is not a simple come and go headache).

The Premonitory Phase (Prodrome): This phase is due to neurochemical alterations in the brain and is most commonly associated with fatigue, difficulty concentrating, stiff neck and light sensitivity. It can also include mood swings, food cravings, yawning, change in vision, nausea and vomiting.

The Aura Phase: This occurs in 15% t 20% of migraine attacks. The ends of the 5th  facial nerve ( the trigeminal nerve) are activated causing symptoms that include scintillating lights, distorted vision and numbness and tingling in the hands or face. These sensations are usually followed within 60 minutes by the headache. Rarely an aura can occur and not be followed by pain; it’s then aptly called a migraine aura without headache. This may be a final neurological diagnosis (by exclusion) once a full work up for symptoms of stroke is negative.

The Headache Phase: The trigeminal nerve that gives us our sensory perception from our face also provides a pain pathway from the meninges (the capsule around our brain). Though a complex system called the trigeminovascular system, the nerve can become activated by many triggers. This trigeminal activation then instigates the transmission of impulses in the brainstem and causes a release of substances called vasoactive neuropeptides. They, in turn, cause dilation of blood vessels and inflammation in the meninges. The activated trigeminal nerve fibers become abnormally sensitive and any stimulus, such as light, sound or even gentle touch can increase pain. (This explains why most migraine sufferers want to be left alone in a dark room without human contact once the migraine occurs.)

The Post Headache Phase (Postdrome): Migraine symptoms can last for up to 2 days. This “post” seems to go on forever!

More than half of the women who suffer from migraines have them in association with their menstrual cycles; moreover, the migraines that occur with their periods are worse than all others. There are 2 kinds of cycle associated migraines… (Medicine is chock full of nomenclature.) Pure menstrual migraines occur without aura 2 to 3 days after the start of menstruation but do not occur at any other time during the menstrual cycle. Menstrual related migraines include menstrual migraines but attacks can also occur at other times in the menstrual cycle (often days before the onset of the period, or right after ovulation). It is thought that change in hormones, especially the decline of estrogen before and during the period, play a role. Also as an added insult, when we menstruate, pain stimulating substances called prostaglandins are released and can trigger headache, nausea, vomiting and diarrhea even in women who do not have true migraines!

OK, now that I have given you a synopsis of Migraine 101, let me get to therapies. First … those that are nonphamacologic: This is where we try to limit migraine triggers, use relaxation training and biofeedback. Although I can’t teach you how to do the latter two in this summary, I can at least acquaint you with triggers that you can avoid. They fall into 4 categories:

• Diet: Alcohol, chocolate, aged cheese, monosodium glutamate artificial sweeteners, caffeine, nuts, nitrates and nitrites and citrus fruit. Not all these affect the same person and clearly there are other foods that can less frequently act as triggers.
• Changes: weather, seasons (maybe we should all live in San Diego or Hawaii), travel, altitude, schedule changes, sleeping patterns, diet changes, skipping meals.
• Sensory Stimuli: Strong lights, flickering lights, odors
• Stress: Let-down periods, intense activity, loss (death, separation, divorce); relationship difficulties, job loss/change and anything that causes emotional or physical crisis.

The above includes much of what we do or experience in life! But I would be remiss if I didn’t give you this list. (In case you want to know my reference it’s from The New England Center for Headaches… it should also be applicable to those of us residing in the West Coast).

Now let’s get to pharmacologic therapy:

• Nonsteroidal Anti-Inflammatory Drugs (NSAID’s): These interfere with those pain promulgating substances, the prostaglandins. They include ibuprophen, aspirin and naproxen. Some of these OTCs also include caffeine. If they don’t work after 4 to 6 hours or result in “bounce back” of the migraine once stopped and/or they need to be used continuously for several days, you are probably better off with a prescription medication.
• Triptans: These are prescription medications that bind to and activate specific receptors called 5-HT which are expressed on the smooth muscle cells in the walls of blood vessels. They induce constriction of those dilated vessels in the meninges of the brain that caused the migraine in the first place. The good news is that they usually work within 20 to 30 minutes and don’t cause sedation so you can continue your normal activities. There are at least seven triptans. One type is combined with an NSAID. The best way to use them is at the very onset of the migraine.
• Ergots: These have been used since the 1930’s. They constrict blood vessels and activate 5-HT. They are less “in vogue” for migraine therapy because of their potential side effects (such as an elevation of blood pressure).

Preventive Treatment: This requires daily use and includes medications that are used to treat hypertension (beta-blockers, calcium channel blockers), certain antidepressants that decrease the conduction of pain stimuli (tricyclics) as well as anticonvulsants. I would include hormonal therapy as a mode of migraine protection for many women. I frequently prescribe oral contraceptives to my younger patients who are migrainers in order to stop the ebb and flow of hormones during their cycle. (Remember that hormonal contraception signals the pituitary to NOT send signals to the ovaries to develop follicles and ovulate.)  I suggest using the active pills or a contraceptive vaginal ring continuously so that there in no break in the hormone level it provides. (No you don’t NEED to stop and get your period.) If there is a break in active contraceptive hormone use (some patients prefer to take it for  3 months at a time, or experience bleeding after a few months and “take a short break” from the Pill or ring), I prescribe an estrogen patch to “cover” the time off so that the decline of estrogen does not instigate a migraine.

At this point, I should add a warning: The occurrence of migraines without aura has been shown to increase the risk for stroke by a factor of 3, whereas if aura is present this increases to a factor of 6.  The use of oral contraceptives in women with stroke is considered an independent risk factor for stroke. So ACOG (the American College of Obstetricians and Gynecologists) discourages use of oral contraceptives in women who have migraines with aura.

Now, let’s consider migraines in menopausal women. They often improve. (Finally, something to look forward to as we age!) Once we stop the vacillations of our hormones in our reproductive years, the migraines may lessen. However (sorry, but there is often a “however” in medicine), some menopausal women begin to experience migraines once they no longer produce estrogen. If they want to reinstate their premenopausal estrogen status, I then prescribe transdermal estrogen….usually a patch so that they achieve a “steady state” of estrogen with no ups and downs.

This has been a longer website article than most. But since so many of my patients, friends, staff and relatives (my daughter) suffer from migraines; I felt I owed it to them to give a fairly complete summary. I hope it didn’t give you a headache!

We commonly use the adjective “sweet” to imply niceness….and of course the taste that has so domineered our palate. But the “added sugars” that help achieve the latter are anything but sweet to our hearts, brains or blood vessels. (I’ll refrain from using the word bittersweet.)  They are cloying together (my new term) to raise our bad cholesterol and enhance our demise from heart attack and stroke.

Our palate preferences have been fostered and exploited by the food industry. They know their market and have been happy to cater to our preferred taste for sweet by adding sugars in the form of refined beet or cane sugars and high-fructose corn syrup in processed or prepared food.

According to an article published in a recent Journal of the American Medical Association (JAMA), we ingest an average of 89.8 grams (21.4 teaspoons) or 359 calories of added sugar daily. This represents 15.8% of our total daily caloric intake and 31.7% of our total carbohydrate intake (as compared to just 10.6% in the late 70’s). These numbers were based on a study of adults who participated in the National Health and Nutrition Examination or NAHMES. (No, it wasn’t a pass-fail test and the subjects were not college students; as a matter of fact, they consisted of a “US civilian, noninstituitionalized population designed to obtain nationally representative estimates on diet and health indicators”). Individuals who were taking cholesterol- lowering medications and those with a diagnosis of diabetes were excluded. More than 6,000 adults were followed between 1999 and 2006; over half were women. (So we had due representation.) The participants were interviewed and gave a detailed 24 hour dietary recall. The nutrient content of the food they stated that they had consumed was determined by NAHMES from the US Department of Agriculture Nutritional Database as well as the MyPyramid Equivalents Database. (I guess a single source might have been questioned by the food industry.) The NAHMES investigators also collected fasting blood samples which they then tested for 3 lipid abnormalities: elevated triglyceride levels, elevated levels of small LDL-C particles and reduced HDL-C levels …all of which contribute to “dyslipidemia” (bad lipid levels that lead to coronary heart disease). So here is what they found:

• A mean weight gain in one year of 2.8 pounds among those “extra sugar eaters” who consumed 25% or greater total energy from added sugar compared to a mean loss of 0.3 pounds among those who consumed less than 5% total energy from sugar.
• In women who consumed more than 10% of their calories as added sugar, the odds that their good cholesterol or HDL-C  was low (think the stuff that acts as  a roto-rooter in your arteries) was 50 % to 300% greater than women who consumed less than 5% added sugar in their diets.
• A higher level of triglycerides and a higher ratio of triglycerides to HDL-C in those who consumed more than that 10% of calories though sugar.

I know I am giving a lot of “higher” and “lower” numbers, but alas, that is what statistics are all about. Put simply, the higher your intake of “added sugar” the more likely you will gain weight and ruin your good and bad lipid levels. It’s not enough to just eat low fat or abstain from the wrong fats in order to maintain an internal cholesterol and fat ratio that will protect your blood vessels, heart and brain. You have to abstain from ubiquitous “added sugars”. Check the labels on those sodas, coffee drinks, canned food, cookies, soups, cereals, breads or anything that is processed. (And the term “naturally sweetened” doesn’t mean that the sugar is exempt from the above.). Your overall “added sugar” should not be higher than 100 calories a day or 5% of your caloric intake. There is nothing sweet about the wrong fats that clog vessels and result in heart attack and stroke.

I know we have all heard the admonitions not to text or use hand-held cell phones while driving. Oprah even wrote an editorial in the New York Times. I installed a hands free device in my car several years ago in order to comply with California laws as well as to assume my role in assuring road safety to those in my car (mostly my dog) as well as on the road. A commentary in the April 15th issue of JAMA caught my attention and pointed out my inattention to the statistics that warn that even hands free devices result in accidents.

So here are the distracting statistics:

• 5,870 persons died (16% of all fatalities) in crashes involving driver distraction due to texting or use of mobile phones in 2009
• 515,000 individuals were injured in what are now called “distracted crashes”.
• 21% of all reported injury crashes involved distracted driving
• While dialing a mobile phone, drivers of light vehicles (cars, vans and pickup trucks) were 2.8 times more likely to crash or near crash than non-distracted drivers. (If they were commercial truck drivers this number rose to 5.9.)
• Texting is a disaster waiting to happen….the average person who texts while driving takes her eyes off the road for 4.6 to 6 seconds and is 23.2 times as likely to have a serious vehicular crash compared to a non-texting driver.

And here is what really got my attention:

Analysis of 125 studies confirmed that cell phone conversations while driving were associated with impaired reaction time and that there was NO difference in risk between hands-free and handheld phones! And according to the Highway Loss Data Institute (yes there is an institute for everything) the benefits of banning the use of hand-free phones are outweighed by the increased use of similarly distracting hands-free devices. They found no decrease in crashes in states that enacted handheld cellular phone bans when compared to states that did not.

As I and my family update our cars, we are bestowed with more and more electronic gadgets. I can now do everything but write this column while driving… but I guess I won’t try. The good news is that using a GPS (with verbal instructions) is safer than trying to read a map. So I can tell my husband (who always gets lost) that his GPS is relatively safe. But the bad news is that I will not try to save time and answer patient queries while driving but instead will instruct you to call back once I have reached my destination.

Our cars should be declared no phone or messaging zones. For your sake, mine and all the other drivers and pedestrians on the road, I hope you will consider the above stats and turn your i-phones, blackberries, droids and i-pads off while driving.

As many of you know I travel abroad 3 or 4 times a year, mostly to visit family or go to conferences.  So many of us have gone global… there are 30 million travelers who fly from the US for destinations that are at least 5 or more time zones away from their home. Most suffer from jet lag upon arrival at their destination and then, alas, upon return. A recent review of jet lag appeared in the New England Journal of Medicine. I thought it appropriate (as I prepare to fly 7,000 miles in early April,) to share this pertinent information with you.

Jet lag is due to a temporary misalignment between your internal clock (termed the circadian clock) and local time. Your brain’s time and function follows a light-dark cycle set by the sun. And this internal clock does not readjust at the speed of jet travel. As a result, many travelers experience insomnia, daytime sleepiness, mood changes (I get grumpy) and fatigue. Fatigue may also be due to the fact that you are immobile, don’t eat right, become dehydrated and stressed with log-distant air travel. (And I am not even considering the stress that must have accompanied that recent “delayed flight” on Virgin Atlantic lasting 17 hours from LAX to JFK!)

There are a number of factors that contribute to jet lag:

• The number of time zones crossed: Obviously, the more the worse it gets, and if the trip is long, even if the number of crossed time zones are not great (i.e. the same latitude), travel fatigue can cause symptoms.
• Direction of travel: It is usually more difficult traveling east then west .Most people find it is easier to lengthen the day than to shorten it. (Unless like me you are a “morning type”, in which case the reverse can happen.) It’s estimated that the circadian clock resets an average of 92 minutes each day on a westward flight and 57 minutes earlier each day after an eastward flight.
• Sleep loss during travel: Chances are if you are in coach you will not be able to stretch out and go to sleep.
• Loss of light cues (exposure to natural light at your destination): If it’s the “wrong” time or if you arrive in non sunny weather, you don’t get the sun light that helps your brain adjust.
• Ability to tolerate circadian misalignment: Some people just can….hope it’s our politicians! Tolerance seems to decrease with age. Oi!

There are a few strategies that seem to somewhat mitigate jet lag:

• Optimize light exposure: Try to get  bright sun light in the evening if traveling Westward, not the early morning  and seek exposure to bright light in the morning if traveling Eastward (you get up much earlier so try to take a morning walk.)
• Take melatonin: Melatonin is the hormone that is secreted for about 10 to 12 hours at night and is a darkness signal. You can purchase melatonin without prescription. To promote shifting of the body clock to a later time when you travel westward take 0.5 mg during the second half of the night until you become adapted to local time. If you are traveling eastward take 0.5 to 3mgs at local bedtime nightly until becoming adapted.
• Schedule sleep changes ahead of time: Try to go to sleep 1-2 hours later than usual for a few days before your westbound trip and go to sleep 1-2 hours earlier for a few days before your trip east.
• Sleep medications. They help; you might try taking medications such as Ambien or Lunesta at bedtime for a few nights until you have adjusted to local time.
• Agents that promote alertness: Caffeine works, but avoid it after midday so it won’t adversely affect your sleep. Armodafi (Nuvigil)l and Modafinil (Provigil) which are drugs approved for narcolepsy and for shift workers (to improve alertness) have been show to reduce symptoms of jet lag if taken in the morning. They are not yet FDA approved for jet lag. Side effects include headache and nausea.
• On the plane: If possibly fly after you have had a good night’s sleep. Travel in business or first class (but know your health insurance won’t pay for this, even if your doctor recommends it). Drink lots of water, don’t consume caffeine if you expect to sleep on the flight, and don’t imbibe alcohol if you take a sleeping pill. You can try taking a short acting sleep medication such as Sonata. If the flight is more than 10 hours you can consider taking a longer acting sleeping pill such as Ambien or Lunesta.  (Make sure the flight takes off and is OK before taking any of these.)
• Exercise when you are at your destination…it can have an impact on your circadian rhythms.

So here’s hoping you have a safe and uneventful trip and that a few of these tips will help you enjoy the first few days of your arrival and return. I will be off trying all these jet lag preventions during the first 2 weeks of April. I’ll be back in the office and seeing patients after the 15th. I intend to be alert!

Most of us plan our medical appointment based on symptoms and complaints, need for check up, schedule and of course, the availability of our physician or health care practitioner. There are only so many early morning openings, and these may be further diminished when doctors make hospital rounds and/or perform surgeries before arriving at the office. If you don’t want to leave home without breakfast in the morning or you have to make a late afternoon appointment, you may not be willing or able to fast for blood tests. (I encourage everyone to eat their breakfast…I won’t leave home without it. This may be the time to mention that individuals who don’t eat breakfast have a shorter life span….fasting from dinner until lunch will result in an overly aggressive i.e., high, insulin response to the delayed meal. Elevated insulin levels can cause fat to accumulate in unwanted places and increase the risk of cardiovascular disease.)

So there you are at the doctor’s office, you have not fasted and you are told that the blood test for diabetes (and perhaps heart disease) can’t be done…Thus is no longer inaccurate. An article just published in the March 4 issue of The New England Journal of Medicine reported that a non fasting blood test called glycated hemoglobin (also known as hemoglobin A1c) will diagnose risk of diabetes just as well or better than a fasting blood sugar (glucose) test and can also strongly indicate risk of cardiovascular disease and death from any cause!

Until recently, the standard measure used for diagnosis of diabetes was a fasting blood sugar. Glycated hemoglobin is a test that reflects your previous 2 to 3 month exposure to glucose and will include spikes that occur after eating. It doesn’t vary from hour to hour or day to day and is not dependent on what you just ate. It is essentially the glucose “truth meter” for what you have consumed and your blood glucose response over the past few months. It has traditionally been used for the determination of glucose control among those who have already been diagnosed with diabetes and are on therapy. But this and other reports will eventually make glycated hemoglobin the test “of choice” for diagnosis and assessment of diabetic risk in everyone.

The Atherosclerosis Risk in Communities (ARIC) is a community -based prospective study of middle-aged adults from four U.S. centers. It was started in the late 80’s and continues to present time. During the study, the researchers measured the glycated hemoglobin in blood samples from 11,092 adults who did not have a history of diabetes or cardiovascular disease. More than 55% of those tested were women. Their ages ranged from the mid-forties to mid-sixties. For the individuals who were found to have glycated hemoglobin of 6.0 to 6.5%, the risk of diabetes (the technical term was multi-variable-adjusted hazard ratio) was 4.48. (Those who had values of 6% to 6.5% were 4.48 times more likely to develop diabetes then individuals used as a reference who had glycated hemoglobin of less than 5.5%). For those individuals who had a level greater than 6.5% the risk was 16.47. The researchers then checked to see who developed coronary disease and stroke. The hazard ratio for a value of 6 to 6.5% was 1.76 and over 6.5% was 1.95 (or a 95% increase over those with low glycated hemoglobin levels.) They also looked at death from any cause and found that the higher the glycated hemoglobin, the greater the risk of mortality. Moreover glycated hemoglobin levels were found to be more predictive of disease than fasting blood sugar levels.

Studies have show that among people in the United States who do not have a diagnosis of diabetes, over 2.4 million have a glycated hemoglobin higher than 6.5% and 7 million have a value higher than 6.0%. This is an ill inspiring number.

Bottom line: A non-fasting blood test for glycated hemoglobin can help determine whether you are at risk for development of diabetes, cardiovascular disease and even early death. Hopefully it will be less than 6.0%. Most of us now know our cholesterol and lipid levels; it may be just as important to know your glycated hemoglobin level. If it’s too high you and your doctor will need to discuss the necessary behavioral changes and therapies that will help you to maintain your health.

I just returned from New York, so I am in “a talk about air travel” frame of mind.  (The reason for the trip was a board meeting for Save The Children. They are doing some amazing work to help children, mothers and families in Haiti as well as the USA and developing countries around the world….please go on their website http://www.savethechildren.org for more information.)

As usual, I felt that the flight was interminably long, the air was dry and the food….well, I won’t discuss it here, I already did a segment about microbes on the plane. But what I haven’t addressed in the past is whether it is safe for pregnant women to fly.  ACOG (the American College of Obstetricians and Gynecologists) issued a new committee opinion in October 2009. Here is a brief summary…

If there is a complication in pregnancy, it will usually occur in the first or last trimester (bleeding and miscarriage initially, premature labor and delivery the last trimester). Most commercial airlines allow pregnant women to fly up to 36 weeks. Some may be more restrictive when it comes to international flights. (I know my daughter was told she could not fly on El AL after 32 weeks and she had to bring a letter from her obstetrician to show that she was less than that on her last flight).

Air travel is certainly not recommended during pregnancy for women who have medical problems (especially cardiac) or obstetrical problems. (The latter would include bleeding, a possible impending miscarriage, pre-eclampsia, a history or risk of premature labor, a pregnancy complicated by hypertension, diabetes or failure of normal growth of the fetus). The airlines and your doctor do not want you to go into labor on a long flight, begin to hemorrhage, or rupture your membranes (even if you are the at-that time-Alaskan governor!)

All travelers should avoid dehydration and immobilization for long periods of time; we all know about the risk of deep vein thrombosis… this is even more of an issue if you are pregnant. So wear support stockings, drink plenty of water (my advice is a 6 ounces for every hour of flight), move your lower extremities (well, if you drink enough you’ll have to make frequent trips to the bathroom!), avoid restrictive clothing (no tights) and don’t consume gas-producing drinks (carbonated sodas) or foods before flying.

And remember, there is no way to predict sudden turbulence. So keep that seat belt fastened below your hipbones while seated.

Now, let’s consider radiation exposure which increases at high altitudes. The current recommendation is not to be exposed to more than 1mSv over the course of a 40-week pregnancy. Even the longest intercontinental flights will expose passengers to no more than 15% of this limit. (So round trip should be 30%.) For the “average” pregnant flier, this should not be a problem. But if you are a frequent flier or are a part of the air crew, you should check with your employer and the Federal Aviation Administration.

Final recommendation by ACOG: “In the absence of a reasonable expectation for obstetrical or medical complications, occasional air travel is safe for pregnant women.”

And I would like to add… especially if you don’t have to fly coach!

I have been mesmerized by the Winter Olympics. Each night, I eagerly tune into the NBC broadcast and watch with amazement as snowboarders and skiers race, soar and somersault in defiance of gravity, human speed and most probably their mothers. I know the latter are in the crowds cheering their progeny on…How do they do it? Do they have to avert their eyes as their progeny perform impossible feats? Needless to say, I am not the mother of an elite athlete. When my younger daughter competed in gymnastics, I would avoid watching her high beam practice and/or events. Indeed, I was not terribly unhappy when she decided to stop her training at the age of 12!

So while entertaining thoughts of injury, I was rather pleased to find a commentary titled “Skiers, Snowboarders, and Safety Helmets” in this week’s JAMA. The authors cited some statistics that A) verified my concern and B) addressed ways to appease them. Apparently there are 600,000 ski-and snowboard-related injuries each year. Of these, an estimated 15% to 20% are traumatic brain injuries and are the leading cause of hospitalization. Head and brain injuries account for 50% to 88% of total deaths in skiers and snowboarders. The US Consumer Product Safety Commission estimates that 44% of head injuries could be prevented by use of helmets and that 53% of these injuries in children would be reduced by strapping the appropriate helmet on their heads. Other studies have been even more “helmet praiseworthy” citing a 60% reduction in head injuries. They have also found that their use does not appear associated with an increase in spine or neck injury.

Despite this, the authors then give the rather astonishing stat that in a recent study at a western New York ski resort only 37% of 1472 children wore a helmet while skiing and snowboarding. Other studies have found that only 12% of the general ski and snowboard population wear them.

Fashion may have been the issue, but the Olympics will, I hope, change that. The helmets the competitors wore looked fabulous….remember the gold one, or how about the new fashion for women of “stick out” pigtails?
It would also help if ski patrols at resorts wore helmets regularly.

Bottom line: Having the wind in your hair may feel great, but not if you are attempting to traverse the surface of snow with skis or a snowboard at any speed. And as you pay those fees for ski and snowboarding lessons and equipment for your kids, make sure that a helmet (in any color they want) is included and always used.