I’ve previously written articles about the dangers of our overabundant salt consumption. But just to remind you about the sodium stats:  The Dietary Guidelines for Americans, 2005 state that persons with hypertension, all middle-aged and older adults and all blacks should limit their intake of sodium to 1,500 mg/day. These specific groups include nearly 70% of the US adult population!  The rest should be content with levels that are no higher than 2,300 mg/day.

(If we underwent a population-wide reduction in sodium to 1,500 mg a day, we could reduce the number of new cases of coronary heart disease by 60,00 to 120, 000 cases and stroke by 32,000 to 66,000!)

To estimate the proportion of adults whose sodium was within recommended limits, the CDC analyzed data from the National Health and Nutrition Examination Survey (NHAMES) for 2005-2006, the most recent data available. They found that only 5.5% of those who should be limited salt eaters followed the 1,500 mg/day guideline and when it came to those allowed more sodium,  only 18.8% were less-than- 2,300g/day-compliant. I and my husband certainly didn’t meet any of these guidelines this past weekend!

Aside from the obvious (soy sauce and salted edamame), where does all that sodium intake come from? Well, here are some salty tidbits from an editorial note on the CDC report in this week’s Journal of the American Medical Association: In the United States, an estimated 77% of dietary sodium intake comes from processed and restaurant foods and only 10% comes from table salt (1/2 a teaspoon contains 1200 mg of sodium) and cooking. The foods with much of the excessive sodium that we consume also have the most calories, even though they may not taste salty. The authors state that “Grains contribute the largest amount of sodium and calories followed by meats.” This sodium laden grain category includes frozen meals, soups and breads. The meats with the most sodium consist of lunch meats, sausages and hot dogs. Even when the vegetable category was analyzed, it too was found to contain way too much sodium, probably because it included vegetable based soups, sauces, white potatoes (those salty French fries and potato chips), salads with dressing as well as canned vegetables. In the NHAMES study, a more detailed look at the sodium containing culprits found that yeast breads, chicken, mixed chicken dinners, pizza, pasta dishes and cold cuts topped the list.

Because the NHAMES data was obtained though self-reported intake, many scientists feel that the population’s sodium consumption was actually higher. (We tend to make our previous meals sound smaller and healthier than they were; I know that when I wrote about my food intake I omitted the chocolate and tapioca pudding that I ate). And the sodium from salt added at the table was not calculated in the NHAMES questionnaire…. and we all know people who salt everything, even before they have tasted it.

It’s apparent that we have to become better sodium consumers if we want to confront our number one cause of death.  Since sodium intake largely comes from processed and restaurant foods, we have to start “deprocessing” and, if possible, (now I know I am entering dangerous culinary territory) cook for ourselves or at least know how our food is prepared and cooked. (I made this latter statement for all of you out there who rely on others to prepare the food you eat at home). Become a restaurant pest and ask what each dish is made from and how it’s prepared. Get your salad with dressing on the side and use very little. Sauces can also go on the side or be eliminated. Bread, french fries and pickles should not be an eating-out staple. Those quick take-out sandwiches with cold cuts (and/or the hotdogs) are not a terrific way to get your nutrients.

Oi …. so what’s left to eat? Well fruits are always fine, raw veggies are great and then “unsauced” and uncured fish, chicken (not plumped in salt water), meat, eggs (properly cooked and from non salmonella contaminated chickens) as well as dairy should all contain no or at least less sodium. Remember, whatever is pre-prepared and packaged to last long and taste sweet or salty, probably contains a lot of sodium. Read the label, it will tell you how many milligrams of sodium a portion contains. You might be surprised. Meanwhile, I’ll go take my blood pressure!

So here are some of the data that make you want to stop and take a deep breath of clean air.
•    Smoking causes 1 in 5 deaths in the United States.
•    435,000 people in the US die prematurely from smoking related diseases.
•    The chance that a lifelong smoker will die prematurely from a complication of smoking is approximately 50%.
•    Currently 45 million Americans smoke tobacco.
•    70% of smokers would like to quit and every year, 40% do….at least for 1 day.
•    More than 80% who attempt to quit on their own return to smoking in 1 month.
•    Each year only 3% of smokers quit successfully. (This blew me away!)

Let’s start with how smoking affects the brain. Inhalation of smoke from cigarettes gets nicotine to the brain in just seconds. (It’s a fabulously efficient route of drug administration!) Once in the brain it stimulates receptors (to be exact, they are called cholinergic receptors) causing them to release a variety of neurotransmitters. One of them, dopamine, signals a pleasurable experience. Other substances in cigarette smoke cause enzymes to activate neurotransmitters that feed our sense of well-being and emotions…dopamine, norepinephrine and serotonin. In addition, bi-products of acetaldehyde in cigarette smoke inhibit an enzyme called monamine oxidase and enhance the addictiveness of smoking by reducing the breakdown of dopamine.

And just to continue in this neurochemical explanation…. tolerance or “neuroadaptation” occurs with repeated exposure to nicotine though “self- multiplication”  of the number of binding sites on the nicotine receptors in the brain  . Unless these increasing number of receptors are bound by nicotine, they create craving and withdrawal symptoms of anxiety and stress. In order to sustain sufficient levels of nicotine to satisfy these receptors, the owner of the “nicotined” brain has to keep smoking!

Clinically, the authors of the article point out that “nicotine induces pleasure and reduces stress and anxiety” and that smokers use it to modulate levels of arousal and to control mood.  Most addicted smokers feel that inhalation of tobacco is necessary to improve their concentration, reaction time, and performance of certain tasks. They smoke to get relief from withdrawal symptoms (irritability, depressed mood, restlessness and anxiety) and this is probably what makes them feel better and able to perform.  Apparently, the intensity of the mood disturbances that occur from withdrawal from smoking is similar to that found in psychiatric outpatients.

So what about all those nicotine products that are supposed to aid smoking cessation? Although they supply nicotine to the body (and brain) they do so much more slowly than inhaled nicotine. And they don’t contain the other additives in cigarettes that have been designed to enhance their addictiveness. They help but, unfortunately, are not totally effective substitutes.

It’s felt that light smokers and occasional smokers smoke for the positive reinforcement and have minimal or no withdrawal symptoms. (And they are the ones that can most easily quit!)

Studies on twins have demonstrated that there is also a genetic propensity to cigarette dependence. Researchers have even found specific genes and gene regions that are associated with nicotine dependence. (This is interesting, but I would not suggest that a genetic study be done to see if a person has the dependence gene and if it’s not present, go ahead and smoke!)

So who is vulnerable? The answer is the young. Eighty percent of smokers begin smoking by the age of 18. Risk factors include peer and parental influences, behavioral problems (lack of scholastic and social success), personality characteristics such as rebelliousness, risk taking, depression and anxiety as well as genetics. Exposure to nicotine can then cause the brain changes that lead to addiction.

Women seem to be at a greater risk for smoking addiction than men. They are more strongly influenced by conditioned cues (eating, socializing and de-stressing), not to mention their desire to be thin, and have worse symptoms of withdrawal when they try to stop. Women also metabolize nicotine more quickly than men and this impacts their receptors more profoundly. Moreover as “rapid metabolizers” they need to take in more cigarette smoke per day than those who metabolize nicotine slowly. Rapid metabolism of nicotine is also associated with more severe withdrawal symptoms.

I know that all this information is pretty depressing and makes it sound as if women who smoke are destined to continue their addiction. By now, we all know that smoking leads to an unacceptably high risk for cancer, heart and pulmonary disease, osteoporosis, fertility problems, miscarriage, early menopause, wrinkles and a shortened life span. We need the type of call to action we have used in our fight to confront breast cancer. Our state and national public health departments are trying. Smoking has to become anathema to all. Supportive physicians, friends, family and medication can help those who smoke quit. This is not a “give up” situation. There are new medications; these and behavioral therapy, hypnosis and the right “instead of” nicotine products can be effective. We should be able to do a lot better than that 3% success rate.

The ultimate goal will be the prevention of smoking by teenage girls so that they do not become addicted. Now we just have to get to them with the right message before the tobacco company does…

In the past, women were taught to look for “something” on the sexual member or their partner….i.e. a wart or an ulcer (a warning that herpes or syphilis was dwelling there). Unfortunately, the lack of a visible lesion does not mean that the Herpes virus or HPV is absent. Both types of viruses can be invisibly secreted and ready to jump right in (or on) any contacted skin or mucous membrane! And rarely is the examination at time of sexual activity performed with a microscope or special stains to detect microscopic lesions (Maybe this is where I mention the use of a vinegar solution which can help demonstrate small white areas that are often associated with certain HPV lesions. We call it acetic acid and it’s applied to the cervix (or penis) during a microscopic examination by the health practitioner when checking for HPV caused changes and/or dysplasia of the cervix or other genital tissue.)

This quadivalent (four type) human papillomavirus vaccine will not only protect from cervical cancer (and potentially cancers in other areas as stated above), but also genital warts. Let me emphasize….the warts we see (they feel granular and look like little pink or reddish growths and are often slightly uneven) are not from the types of HPV’s that cause cancer. They are due to HPV types 6 and 11. However since HPV’s may gather in groups, there is no reassurance that only one type is present.

Approximately 500, 000 cases of genital warts are estimated to occur each year in the Untied States. Hundreds of millions of dollars are spent treating them; they cause discomfort, embarrassment, as well as sexual and social isolation to those who are affected.

Clearly HPV infection has no gender preference….however cervical cancer has been a top priority for immunization and treatment. In the developing world (were PAP smears and screening are extremely limited or absent), cervical cancer is a major cause of death in women. When the Gardasil vaccine came out the FDA and the Advisory Committee on Immunization Practices (ACIP) recommended its use in young girls and women, preferably before they became sexually active and exposed to HPV infection.

But what about boys? I’m now happy to report that on October 16 2009 the FDA licensed Gardasil for males aged 9 to 26 for prevention of genital warts caused by HPV types 6 and 11. A week later the ACIP provided guidance stating that this vaccine may be given to males to reduce the likelihood of acquiring genital warts; however they don’t recommend its routine use among males. All this was recently reported in the section that contains reports from the Center for Disease Control in The Journal of the American Medical Association (JAMA).

So far the CDC feels that it’s most cost-effective to immunize girls because “the health burden is greater in females than males and numerous models have shown vaccination of adolescent girls to be a cost-effective use of public health resources; improving coverage of females aged 11 to 12 years could potentially be a more effective and cost-effective strategy than adding male vaccination”.

Having said this, the JAMA report adds that men who have sex with men (MSM is the medical term) are indeed particularly at risk for condition associated with HPV types 6,11,16 and 18; diseases that include anal cancers and genital warts, and that Gardasil could help prevent this. Now that’s a quandary for parents….how do you assess the future risks for your son at age 11? And even if you don’t feel he is at high risk….if his future sexual partners (be they female or male) are not immunized, then he will be, moreover once infected he can spread the HPV’s to others.

Social and sexual equality would suggest that we should immunize all of our children. That recommendation is still not public policy. But at least the availability of the vaccine for girls AND boys is now accepted. Discuss this amongst yourselves and your pediatrician. The series of 3 shots needed to giver immunity take 6 months….and may not be covered by insurance, especially when used in males.  This is yet another decision that now has to be considered as we raise our progeny.

First, let me address the fact that this was a “meta-analysis”. That means that they took a number of articles and studies, lumped them together and drew their own conclusions. So even if a study was poorly done, this type of analysis won’t question the results but simply adds them to the overall assessment. Small, short-term studies are counted together with larger and/or longer studies.

The research fellows (their title, not their gender) from the Department of Medicine at The University of Auckland who wrote the paper, searched several data bases and reference lists to find “randomized, placebo controlled trials with calcium supplements of at least 500 mg a day that included 100 or more participants of mean age more than 40”. None of the studies were conducted for the primary assessment of heart outcomes. What they found on their pooled analysis of around 12000 participants (from 11 studies) was that calcium supplements WITHOUT VITAMIN D were associated with a 30% increase in the incidence of heart attack. They excluded studies that compared calcium supplements with D or the co-administration of Vitamin D to subjects who received neither. Milk products that contain calcium were not included in their analysis.

Whenever a study is published in a peer reviewed journal, there has to be a discussion of previous data. (Unfortunately this was not done in the LA Times article). The authors of the BMJ article did point out that in two prospective, observational studies of women in the US (they were followed to see how they fared with various levels of calcium intake), those with the highest fourth of calcium intake had a 30- 40% lower cardiovascular mortality than those in the lowest fourth, and those in the highest fifth (i.e. the most calcium selective) had a 30-40% lower risk of ischemic (non-hemorrhagic) stroke than those in the lower fifth. The well known Women’s Health Initiative (WHI) reported that calcium and Vitamin D had no effect on the risk of coronary heart disease or stroke. However, the WHI was conducted with relatively low doses of Vitamin D (400IU) and this might not have been enough to make a difference.

Vitamin D deficiency has been associated with cardiovascular disease. Moreover (in my ode to D), in order to get ingested calcium (either in food or supplements) into our bones in an appropriate fashion so that it can help prevent fractures, we need vitamin D. And since a majority of Americans have now been found to be Vitamin D deficient…I think what we can take one bit of important information away from that scary headline and that is: Calcium supplements in the absence of appropriate D may not sufficiently help our bones, moreover, much more research is needed to establish whether it can cause harm to our cardiovascular system.

I’ll finish with the current recommendations that have been issued by the National Osteoporosis Foundation: 1,200 mg of calcium a day AND Vitamin D 800 to 1,000 units should be the daily nutritional goal for women over the age of 50.

And, women under the age of 50 should get 1,000 mg of calcium every day (together with that all important Vitamin D).

Count the amount of calcium you consume in your food (especially milk products) then supplement what is missing. Read the labels on containers….they state the percent of calcium per serving based on a total daily requirement of 1,000 mg a day….so if the label states that a portion contains 30% of daily calcium, it contains 300 mg. The average diet without any milk products contains 250 mg of calcium. You can then figure out how much you should supplement….but remember the need for D Many physicians feel that higher than currently suggested amounts of Vitamin D are necessary for bone, heart, colon, breast and other organ health in adults. It’s hard to overdose on D, but don’t try to take daily doses of over 2,000 units on your own. If you are unsure how much you are absorbing from the sun, or getting with your food or supplements, your Vitamin D level can be measured with a blood test.

A calcium a day (or probably more depending on your food and the type of calcium you take) with that all important D helps keep the doctor away, or at least should help make your doctor less, not more worried about your health!

Some of this is probably due to the loss of circulating estrogen subsequent to menopause. Which then leads to the very complex question; does taking estrogen after menopause “fix” our cholesterol problem and help prevent CHD?  The prevailing opinion is that estrogen therapy can, to some extent, (I have to qualify statements like this) diminish the risk for CHD, but only if taken at the onset of menopause. Apparently hormone therapy won’t help and may actually do harm if given to a menopausal women who already has underlying CHD, nor will it necessarily help prevent CHD in a healthy women after many years of use or if started a decade after the onset of menopause.

But that is not what this article is about. The question that has been posed by many of my patients who do not want to take estrogen, have contra indications to estrogen or who simply want to follow the latest in nutritional health news is whether soy, as a food, will help lower their cholesterol levels and hence ward off CHD.

The aware consumers (hopefully those of you reading my newsletter) now know to look for a legitimate FDA health claim when a food (or supplement) is touted to prevent or treat disease. Well, in 1999 the FDA stated that “diets low in saturated fats and cholesterol that include 25 grams of soy protein a day may reduce the risk of heart disease”.

That statement may change…A recent article published in the journal Menopause tested the affects of soy ingestion in 87 postmenopausal women younger than 65 who were not using hormone therapy, prescription medications or herbal supplements, including soy, known to  influence cholesterol levels. Half the women were given a special snack bar, drink mix or cereal which contained 25 g of protein from soy, the other half were given similar looking (and tasting) products that were devoid of soy. The study was double blinded; neither the women tested nor the investigators following them knew what they were given until the study was completed after one year. Total cholesterol, high-density lipoprotein cholesterol HDL-C (the good kind), low-density lipoprotein or LDL-C (the kind that causes plaque) as well as triglycerides (also not good) were measured at the onset and completion of the study.

There was a slight weight advantage for the women who consumed the soy test foods; on average they gained 1.6% in body weight, whereas the control group of women gained 3.3%. But the cholesterol levels in the women who dutifully eat there soy foods did not improve. That 25 mg of soy just didn’t do it! Other similar studies have come to the same conclusion.  And the FDA is now reevaluating its previous claim about the cardiac benefits of soy protein.

Soy supplements and soy-rich foods may not be the answer to the rising levels of cholesterol that contribute to CHD us as we get older. But I still eat and enjoy my edamame; it has to be healthier than French fries!

There are several definitions for the descriptive and medical terms overweight, obese or morbidly obese…however, the models in magazines and popular actresses make most women feel that they fit into the overweight category. But the World Health Organization (WHO) has made it clear that obesity is the abnormal or excessive fat accumulation that presents a risk to health. They use body mass index (BMI) as an estimate of obesity:  a BMI of 25 to 29.9 kg/meter squared is defined as overweight, a BMI of 30 to 39.9 obese, and a BMI 40 or over morbidly obese. To figure out your BMI, go to www.nhlbisupport.com/bmi/bminojs.htm.

I receive a publication for continuing medical education in my specialty. (The State requires a certain number of CME credits to renew a medical license, and answering questions attached to the article is one way to get those accredited hours). A recent Postgraduate Obstetrics and Gynecology article dealt with bariatric surgery among reproductive-age women and upon reading it, I thought that its information would be of interest to many women.

We all know the health consequences of obesity: hypertension, coronary vascular disease (heart attack and stroke), diabetes, osteoarthritis and cancer (among them, breast, ovarian, colon, uterine and pancreatic). In the reproductive years, obesity can affect ovulation, periods, fertility, result in complications of pregnancy, higher C Section rates and immediate and long term health for newborns. Between 2002 and 2006 health care costs for treating obese adults increased by more than 81%, rising from $166.7 to $303.1 billion. Obesity weighs heavily on our economy.

The NIH has recommended guidelines for surgery (bariatric) as a treatment for morbid obesity. Potential candidates include anyone with a BMI over 40 or those whose BMI is 35 or over if they have other “co-morbid” conditions such as cardiopulmonary disease, diabetes, difficult ambulation and severe joint disorders as a result of their weight. More and more patients in these categories are undergoing bariatric procedures ….there has been an 800% rise between 1995 and 2005 and that percent keeps leaping (as do some of the now thinner post-op patients as well as the surgeons and surgery centers performing these procedures).

Bariatric surgeries work via restriction (limiting the food that gets to the stomach) and/or malabsorption (limiting food absorbed by the stomach as well as the intestine). There are two common methods performed in the US: the first, the banding procedure, which is restrictive. An adjustable gastric band is positioned around the upper portion of the stomach so that food comes into and is absorbed or propelled downward though a small stomach pouch. The band is usually placed by means of a laparoscope, avoiding the need for a large abdominal incision. The band can be adjusted to widen or narrow the opening of the stomach pouch via a port that is placed under the skin. (Fluid is used to fill and expand the band or conversely fluid can be removed to narrow it.)

The second type of procedure that is available is both malabsorptive and restrictive. It’s called a Roux-en-Y gastric bypass (RYGB). It involves dissecting the stomach to create a small pouch that empties into a portion of the intestine called the jejunum. Most of the stomach and 100 to 150 cm of the bowel are bypassed so that they do not come into contact with food. This procedure can also be done through a laparoscope; but in some cases, if there are complications (it’s more technically difficult than the banding surgery), may have to be completed via an open abdominal incision.

Complications do occur. According to the review article, band slippage occurs in up to 15% of patients; they then can develop nausea, inability to tolerate food and problems swallowing. Others have no overt symptoms but simply start gaining weight. Sometimes it’s hard to get to the port opening or the tube that leads to the band kinks or leaks and this may require re-operation. Most of these problems can be fixed, the real issue is the mortality rates following the procedure; and they are low: between 0.02% and 0.1%. (Remember that many of these patients have medical problems that make anesthesia difficult and aside from their operative risk they could succumb to their weight-caused diseases without the surgery).

There are higher complication rates with the RYGB procedure. These include hernias in the area of incision (15% -24%), fluid or blood collection in the area of incision (8%), infection (7%) and need for re-operation (1.6%). There are also reports in the literature of pulmonary embolism, lung problems, breakdown of the area of the stomach that has been sewn (or stapled) and bleeding. The mortality rates for the RYGB can vary depending on the severity of obesity, the multiple conditions that could already have impacted the health of the patient as well as the experience of the surgeon. It ranges from 0.3% to 7%. (Scores that can predict these rates have been formulated by various agencies.). Then because this procedure promotes weight loss by decreasing nutrient absorption (think malabsorption), it can lead to a deficiency in vitamins and minerals, especially vitamin A,D.E and K as well as the B’s, C, thiamine and calcium. So vitamin supplementation and tests to see “what’s missing” are important subsequent to the surgery….and should be continued, basically, forever.

I should mention a few more potential side effects…the most common is dumping syndrome which can occur at least initially in 25 to 50% of patients who undergo gastric bypass. The dumping can occur 30 minutes after eating and results in nausea, vomiting, fullness, diarrhea and/or palpitations or it can occur hours after eating with symptoms of dizziness and confusion. But before I dump on the procedure, let me quickly state that most patients learn how to control this problem by abstaining from rich carbohydrate laden food, eating small meals and taking additional fiber.

I feel like one of those TV commercials where I list so many possible side effects that, in the end, make the product sound horrendous. Well in the right conditions and appropriate patients, bariatric surgery can be amazing. Maximum weight loss often continues for 2 years and can range from 40 to over a hundred pounds. The procedure can result in complete resolution or improvement of conditions such as chronic hypertension, type 2 diabetes, obstructive sleep apnea and abnormal cholesterol (hyperlipidemia) and of course, the size of waist bands and clothes.  In women of reproductive age, there is an improvement in menstrual cycles, fertility, and maternal complications during pregnancy. There have been studies that also have shown lower rates of preterm deliveries and abnormal birth weight of the newborn. (However, the nutrition of the pregnant mother has to be followed carefully so that she has no vitamin deficiencies.) There on ongoing studies to see if there are less C Sections in women who have had the surgery before getting pregnant.

I don’t want anyone to come away embracing the thought that “well I’m fat, but never mind any attempts to lose weight; I can always have the surgery.” This is a procedure that should be considered only when diet with caloric restriction and exercise just don’t work. The decision to undergo lap banding or RYGB can only be made after all the pros and potential side effects are weighed by the patient and her physician.

The safety of tomography (CT scans) was discussed in a section called “Perspective” in the New England Journal of Medicine. The author (from the University of California at San Francisco) calculated that the risk of cancer from a single CT scan could be as high as 1 in 80!  She called for better standardization, monitoring and regulations as to how imaging equipment is used. In February 2010, the FDA did launch an initiative to reduce unnecessary medical imaging, but little has been done to implement their recommendations.

A second article in the same journal titled “The Uncritical Use of High -Tech Medical Imaging” continued an imaging critique. The authors pointed out that physicians often request imaging examinations in order to prevent future liability. We are sued if we don’t make a diagnosis but rarely are held accountable for overuse of testing. A recent survey of Massachusetts physicians showed that 28% of diagnostic imaging referrals were done as part of “defensive practice”. Moreover, the radiologists performing the imaging are often concerned about making a definitive interpretation with a single test and again, to avoid being sued, may suggest additional or follow-up CT scans. Patients expect an immediate and accurate diagnosis and often demand a scan; so excessive imaging is not entirely the fault of the physicians. The number of CT scans that are currently done is extraordinary high….we can’t all be that sick. Currently in the United States, approximately 10% of the population undergoes a CT scan every year adding up to a total of 75 million scans. (Obviously some patients receive multiple scans.) The authors also state that the use of CT continues to grow by more than 10% annually.

Everyone agrees that more has to be done to reduce the amount of radiation with each scan (it can be equal to 100 simple x-rays). Both physicians and patients should reconsider how often we have to look into our bodies to diagnose and treat a suspected or ongoing disease. The recommendations for getting a scan “just in case” or “to give the gift of good health” (the latter appears on ads for imaging centers) should be reevaluated. Non radiating tests such as ultrasound, MRI, as well as a good clinical examination and a thoughtful history can often be as helpful and less harmful to our health.

The same journal then had an article titled “Hunger and Socioeconomic Disparities in Chronic Disease.”  The number of US households whose members are at risk for hunger because of an inability to afford food (food insecurity) has risen. The rate was 32% in 2008 and is higher each year. In 2008, 21% of US households with children were classified as lacking food security. Because of their inability to afford healthy food, the members of these households had to resort to buying the cheapest calorie-dense products, i.e. food with added sugar, fats and sodium. The authors pointed out that $1 can purchase either 1200 calories of cookies or potato chips or 250 calories of carrots. As a result of these more affordable and abundantly advertised products, the parents and, of course, their children risk obesity, hypertension, diabetes and other diet–sensitive chronic diseases. Confronting food insecurity and making healthful food affordable will help prevent an enormous future burden of disease. The number of children and adults who may be destined to develop chronic disease in the US as a result of an inability to afford appropriate nutrition shames all of us!

Okay, I want to review just 2 more articles…

JAMA reported that proton pump inhibitors (PPI’s)  such as Prevasid, Nexium  and 6 other types that are currently on the market (and I have tried just about all of them) will carry revised labeling that warn that these stomach acid reducing medications can increase  patients’ risk of hip, wrist and spine fractures. The new warnings are based on 6 of 7 studies that showed a relationship between PPI use and an increase in fracture risk. Most of the patients in the studies were 50 years or older. The reason for this increase in risk is not known. Unfortunately, those of us who suffer from horrific “heartburn” (and let me take this opportunity to state that if it lasts for more than a few weeks and/or does not respond to a PPI you should have an endoscopy), there are no other terrific solutions. So if you need this type of medication, make sure you tell your physician, and she or he will probably order bone density tests.

Finally, the last article that I thought I should review dealt with the effect of glucosamine on chronic lower back pain caused by osteoarthritis (wear and thinning of the discs that separate the vertebrae). Glucosamine has been shown to help the body restore cartilage and seems to help knee and hip pain due to osteoarthritis. The current study on glucosamine’s affect on back pain was also published in JAMA. It was double blinded, randomized and placebo controlled (all the right things) and carried out in 250 Norwegian patients older than 25 who suffered from chronic back pain. (I can almost see a movies title here… “Back pain in Norway”). The patients were given 1500 mg of glucosamine or placebo for 6 months. And despite hopes that this over-the- counter product would help, there was no affect on their back pain. Twenty million individuals in the United States have chronic back pain from osteoarthritis, so this news was disappointing. I guess we’ll have to go back to Pilates and our orthopedists!

Yes, up to 80% of women have some cramps during their period but if they are severe enough to compromise lifestyle (missing days from school, work or usual activities), the pain may be due to endometriosis. Briefly, this is a disease characterized by abnormal endometrial-like cells (the ones that line the uterus) which seed onto tissues and organs outside the uterus. The current theory is that these cells get there through retrograde menstruation (during period bleeding downwards some of the blood and sloughed cells from the uterine lining go upward through the Fallopian tubes and implant on the surface of the tubes, ovaries, uterus, peritoneum and nearby bowel). These ectopic or misdirected cells then react to estrogen and progesterone as if they were in their right place, i.e. in the uterine lining. The cells enlarge, multiply, bleed and secrete inflammatory substances. The endometriotic implants also cause blood vessels to grow around them; all in all creating havoc to the surrounding tissue. Adhesions (scar tissue) may form and in some cases cysts filled with blood grow within the ovary….the latter are called endometriomas. In addition to the pain that endometriosis causes, this condition frequently contributes to infertility as a result of scarring of the tubes as well as production of substances that interfere with fertilization.

Endometriosis is unfortunately all too common. It affects 6 to 10 % of women in reproductive age, 50 to 60% of women and teenage girls with pelvic pain and up to 50% of women with infertility.

Because many internists and general practitioners will see patients with complaints that may be due to endometriosis, the New England Journal of Medicine recently featured a summary of this disorder in the section devoted to clinical practice.

The author of the summary pointed out that risk factors for endometriosis include any situation in which there is an obstruction to menstrual flow, for example a tightly closed cervix or imperforate hymen, prenatal exposure to DES, prolonged exposure to high levels of estrogen, (early onset of periods, late menopause or obesity), short menstrual cycles, low birth weight and (here is where the environmentalists start to shout) exposure to endocrine-disrupting chemicals.

The diagnosis of endometriosis is not that easy to make. First, the physician has to rule out other pelvic causes of chronic pain such as ovarian cysts, uterine fibroids, infection and scar tissue from previous infection (pelvic inflammatory disease). And remember, that there are other organs “down there” that can hurt…including bowel (irritable bowel disease), the bladder (interstitial cystitis), muscles and abdominal tissues that can ache or burn. Women who have experienced sexual abuse may have pain with no anatomical cause.

Once all those other disorders have been ruled out, the next route that many physicians use to delineate the cause of the pain is via treatment. We try to make the ovaries “quiet” so that they don’t produce fluctuating levels of hormones that stimulate painful periods. First, most physicians try prescribing birth control pills on a monthly basis. If the withdrawal bleeding at the end of the pill pack “the period” still hurts, we will try to eliminate all bleeding by having the patient take the active pills continuously for months at a time. If this doesn’t work, it’s time to become more invasive in order to achieve a final diagnosis…This is when we suggest laparoscopy to see if there are endometriotic implants in the pelvis. If the diagnosis is confirmed, the surgeon will cauterize or excise the implants and any blood filled cysts on the ovary will be removed. Laparoscopy is the only way to make a final, definitive diagnosis and it also offers an important opportunity for treatment and pain relief. Unfortunately, the disease can recur and require additional surgery in the future.

Women who have infertility or recurrent disease may benefit from injections of GnRH agonists…the most common is a monthly or tri-monthly shot called Lupron. It fools the pituitary into “thinking” it doesn’t have to send messages to the ovaries to stimulate follicles and secrete hormones and thus prevents the care and feeding of the endometriotic implants (basically causing transient menopause). If menopausal symptoms become too severe, small amounts of hormone therapy can be prescribed to give back some progesterone or estrogen. The current recommendation for ongoing infertility in women who suffer from endometriosis is to then proceed with IVF (in vitro fertilization).

Sorry to give such a long and fairly complicated medical explanation about the recommendations for work up and treatment. Endometriosis is a very common disorder which is often ignored or misdiagnosed for years. I hope this information encourages you, your friends and family to seek help if your cramps are severe or “it really hurts down there”.

**We have changed the ‘from address’ on our newsletters so please be sure to add mail@reichmanmail.com to your safe senders list.  You can continue to contact us through info@judyreichman.com **

However, I’m already working on next week’s to be mailed July 9th.

You may want to take a moment to view the archives of my past articles. You can find them on my web site at: http://www.judithreichman.net See you next week,

Judith

**We have changed our mailing address so please be sure to add mail@reichmanmail.com to your safe senders list. You can continue to contact us through info@judyreichman.com**

The efforts I make to treat my patients and, yes, to write this web site seem miniscule compared to what health care workers sponsored by Save the Children do for the children, women and their families in rural and virtually inaccessible areas around the world. The “good goes” campaign supported by the Ad Council has just been launched. I have been honored to be a part of the communications committee and I would like to share the following with you:

Every 4 seconds a child survives thanks to the basic health care provided by local health workers.
Front line local health workers help children all over the world survive threats like newborn complications, pneumonia, diarrhea, malaria, and malnutrition. But global estimates suggest we need 4.2 million more health workers in developing countries. Sadly, one child dies every 3 seconds largely from preventable and treatable causes due to the lack of basic health care.

Of the children under the age of 5 who die each year, almost two thirds could be saved with the simple, low-cost interventions delivered by health workers in clinics and in their communities. With attention from developing country governments and donor nations, we can help them bring lifesaving care to more hard-to-reach communities and make the survival of children a reality worldwide.

There are some amazing videos and pictures that tell their story. They will appear on television next month. You can get a first hand look and appreciate what Save is doing by going to www.GoodGoes.org.

Health care workers walk hundreds of miles to save children. I sit in my office in Westwood and my patients come to me. We are all very lucky….and spoiled. As you read this, 15 children who would have died from preventable diseases and complications have survived, but many more are not so fortunate.

As you know, I write my weekly newsletter to keep you informed on matters of health. This week I am making a request: Please consider what you can do to help provide lifesaving care by contributing to Save the Children and its campaign for newborn and child survival. It’s less than what we pay for valet parking!