This week I’m going to diverge from my usual review and commentary of articles published in peer-reviewed journals and write about one that I read in the New York Times. The headline read “Younger Skin Through Exercise” and after I dutifully read the pages devoted to the conflicts in the Ukraine and Syria, I was delighted to find a good-news health article which pertained to aging skin.

The author cited a study which was presented this month at the American Medical Society for Sports Medicine. Having just returned from The Golden Door where, for a week, I exercised up to six hours a day with hikes, tai chi, yoga, dance, stretching, toning and Pilates I thought “wow not only did I get my body and mind in better shape, but I may have helped my skin!” So obviously I was intrigued, and unless you read the article in The New York Times, here is a summary:

The first part of the study was conducted on 29 male and female volunteers between the ages of 20 and 84. Half of the participants were active and exercised moderately or vigorously for at least three hours every week. The other half were sedentary, doing nothing or exercised for less than an hour per week. The scientists did skin biopsies from the volunteers buttocks. (They chose the tush area in order to examine skin that had not been exposed to sun… I assume the participants were not nudists.) The older volunteers had thicker outer layers of the skin and significantly thinner inner layers. But when they compared those who exercised and those who did not, they found that after age 40 the men and women who exercised frequently had markedly thinner, healthier outer layers and thicker inner layers in their skin. (Note, if for the top layer is thick it is also dryer, flakier and crocodile-like and when the underlying layer begins to thin it loses elasticity giving it a saggier appearance.)

The researchers understood that other factors, including diet, genes and lifestyles might have influenced the difference in the skin condition between the exercising and sedentary group. So they took a group of sedentary volunteers who were age 65 or older and who had normal skin for their age and had them begin an endurance training program. The volunteers worked out twice a week by jogging or cycling for 30 minutes for a period of three months. At the end of the three months, the researchers again biopsied the volunteers skin. (They were certainly brave volunteers.) Lo and behold, when viewed under the microscope, the volunteers’ skin looked like that of younger persons!

The researchers then analyzed the skin of those who had exercised and found elevated levels of a substance produced in working muscles, a myokin called IL-15. The skin samples contained almost 50% more IL-15 after exercising then at the start of the study. But before we start thinking we can just rub on some IL 15 or take a pill containing this myokin, the chief investigator specifically stated that it was unlikely that this would replicate the skin benefits of a work out.

This is a small study but I found it fascinating and felt it adds to our knowledge about the importance of exercise. Remember, the one intervention that has been found to prolong our lifespan and health span is exercise. Of course it helps to be in fabulous surroundings, focus one’s mind with meditation, get daily massages and eat great and nutritious foods… Last week was health week at The Golden Door and I was asked to give a talk on women’s health each day. I hope this was helpful to the other women there. But I have to admit that my personal health and well being significantly benefitted and perhaps it was also good for the layers of my skin! I’ll notify my dermatologist…

This week I’m going to give a lecture at the annual conference of the Academy for Anti-Aging in Las Vegas. They asked me to give a talk months ago, and hey, a weekend in Vegas sounded great. I will report on the conference and my talk next week. When I power-pointed my talk, I included some general dietary recommendations and one was “Eat your nuts”. So when I saw the article in the November 21 issue of the The New England Journal of Medicine titled “Association of nut consumption with total and cause-specific mortality” I looked for new data to support this recommendation. And it was there…

The authors examined the association between nut consumption and subsequent mortality among 76,464 women in the Nurses Health Study (all woman) which was conducted between 1980 and 2010 as well as 42,498 men in the Health Professional Follow-up Study (all men) that went on between 1986 and 2010. (In other words, 30 years of study on a huge number of women and men.)

They found that for those who ate nuts as compared to those who did not there was a significant decrease in mortality during the 30 years of follow up. And this decrease in death rate was directly correlated with the number of times a week they ate nuts. Their risk of death was decreased by 7% with nut consumption once a week, 13% for 2 to 4 times a week, 15% for 5 to 6 times a week and a whopping 20% for those who ate nuts seven or more times a week. This inverse association was observed for most major causes of death, including heart disease, cancer and respiratory diseases. The results were similar for all tree nuts and peanuts. Not only that, the studies showed that the concern that frequent nut consumption can result in weight gain does not appear to be valid. In these two large studies, increased nut intake was associated with less weight gain and a decreased risk of obesity. So, how many nuts you should eat? In the study they considered a serving of nuts to be 28 grams or 1 ounce.

Why are nuts so healthy so healthy? They contain unsaturated fatty acids, high-quality protein, fiber, vitamins (folate, niacin and vitamin E), minerals (potassium, calcium and magnesium) as well as phytochemicals (flavonoids). These nutrients may have significant heart protective, cancer protective, anti-inflammatory and antioxidant properties.

Bottom line: I guess the advice to eat your nuts is appropriate. I’m off to eat eight almonds. (Yes, they are the salty kind.)

As you have heard from media reports and perhaps read on my website, there is conflicting advice as to how much calcium we should consume and how much we should strive to add on with supplements. The side effects of nutritional supplements are emphasized in many new studies but don’t necessarily impact the choices of consumers. We have a unique American sensibility…that more of a good thing is better! So how much calcium do we need, how can we get it in our food and when do we have to supplement? The New England Journal of Medicine very nicely summed up the data and recommendations in an article under the headline “Clinical Practice” this week. It was titled “Calcium Supplements and Fracture Prevention”. So here in a nutshell or should I say milk carton is a summary of the article….

More than 98% of calcium in the body is contained within the skeleton bone which acts as a reserve for calcium, storing it and releasing it when needed. Obviously if too much is released there is a diminution of calcium in the bone causing osteopenia and worse yet osteoporosis. We lose calcium on a daily basis in urine, sweat and stool and therefore insufficient calcium intake over a prolonged period may eventually lead to low bone calcium levels. Bone loss is accelerated with menopause, especially during the first seven years of this inevitable transition (estrogen keeps calcium in the bones) as well as with advanced aging. The Institute of Medicine (IOM) has issued guidelines regarding the recommendations for dietary intake of calcium according to sex and age.

  • Females (the gender I am most interested in) need 1000 mg a day between the ages of 19 and 50; the upper intake should not be more than 2500 mg. Above the age of 50 calcium intake should increase to 1200 mg and the upper intake level should be no more than 2000 mg.
  • Males (I’m including them here) also need 1000 milligrams a day between the ages of 19 and 70 and should not go above 2000 mg. Above the age of 70 they need 1200 mg with a maximum of 2000 mg

It’s estimated that in the United States dietary intake of elemental calcium varies between 750 to 850 mg in women. The lowest intake is observed in those over the age of 70. In order to estimate your dairy intake you should assume that, like most adults, you consume about 300 mg of calcium per day from nondairy sources (vegetables and grains). You should then calculate your additional daily intake of dairy products and if needed add on supplements to reach the goal of 1000 or 1200 mg of calcium.

Here’s a brief review of some of the well absorbed dietary sources of elemental calcium:

  • Plain low-fat yogurt, 8 ounces – 448 mg
  • Low-fat to yogurt with fruit, 8 ounces – 384 mg
  • Mozzarella, part skim milk, 1.5 ounces – 333 mg
  • Cheddar cheese, 1.5 ounces – 307 mg
  • 2% low-fat milk, 1 cup – 293 mg
  • Low-fat cottage cheese, 1 cup – 206 mg

When it comes to vegetables, those with the highest amount of calcium include that ubiquitous kale, one cup has 100 mg, bok choy which has 74 mg per cup and raw broccoli with 43 mg a cup.

And then we have fortified cereals in which one cup can have anything from a 100 to over 1300 mg of elemental calcium. (Look on the box!)

Now a quick quick review of the most common over-the-counter calcium: The major type is calcium carbonate in which 40% of the tablet contains elemental calcium but requires acid in the stomach or food in order to be absorbed. My personal favorite is calcium citrate in which 21% of the tablet is elemental calcium (so you need more pills) however, this type of calcium can be taken between meals and it is absorbed even if you’re taking anti acid medication. Always look on the bottle, it will list how many pills you need to take to get the amount of elemental calcium you have decided to take. Don’t assume that one pill does it.

So how should we get our calcium and when is too much a good thing? There’s no question that individuals who are calcium depleted (those who do not include calcium in their diet i.e. those with milk intolerance or those who abstain from all milk products and don’t eat huge amounts of calcium rich vegetables) would benefit from supplemental calcium. However individuals with a normal diet and adequate calcium in their food may not need any. In pooled analyses of intake and fracture rates it’s been found that calcium plus vitamin D has only a modest protective affect on fractures, particularly among frail and elderly persons. A meta-analysis of 16 placebo-controlled trials of calcium and vitamin D supplements recently performed for the US Preventative Services Task Force showed an overall 12% reduction in the risk of any fracture.

The potential harms of calcium intake has received a recent media blitz. One set of studies that was quoted showed that calcium supplements without vitamin D was associated with an increased risk of myocardial infarction among persons randomly assigned to calcium. Statisticians however found problems with this study stating that it had marginal statistical significance. A more recent study in 2010 did not show any adverse coronary correlation when calcium was used with vitamin D. The authors of this article in the New England Journal stated in their summary that the evidence suggesting adverse cardiovascular effects of calcium supplementation is inconsistent. They go on to state that “pending further data a reasonable approach is to preferentially encourage dietary calcium intake and discourage the routine use of calcium supplements”.

And just to add to this information and perhaps confusion, a 2013 update by the US Preventative Services found insufficient evidence to assess the benefits and harms of daily supplementation with more than 1000 mg of calcium or more than 400 units of vitamin D for the prevention of fractures in non-institutionalized post menopausal women. They also found insufficient evidence to recommend for or against the use of calcium supplements in men and premenopausal women.

I will still try to assess calcium intake in the nutrition of my patients and obviously encourage those that are low to increase it to the 1000 or 1200 mg goal . But for those that are on a dairy free and kale free diet, I will continue to encourage calcium supplements in divided doses. (And for those who are not exposed to direct sunlight, especially in the winter…I do suggest Vitamin D supplements.)

Just thought it was important to share!

I just spent an amazing week at a spa near San Diego where I was able to hike, perform tai chi, yoga, dance, work out in a gym, meditate and even create art. It was a wonderful week of healing and renewal for my body and soul. Upon return, my state of “zen-hood” was altered when I discovered that only 20% of adult Americans meet federal recommendations for aerobic and muscle-strengthening activity.

Although during my spa week, I didn’t have the time nor the desire to read medical journals, once home on Sunday I felt a wee bit guilty (so much for being at peace with my zen-being) and quickly glanced at my favorite journal, JAMA. And there was an article titled “US Adults Are Lax On Meeting National Exercise Guidelines”. And in my current exercise euphoric state, I just had to read the article and feel a sense of exercise superiority as I unpacked. (It was a short article.) Here is what it reported:

Only 20% of adult Americans meet federal recommendations for both aerobic and muscle-strengthening activity. The federal government’s physical activity guidelines for Americans recommend two hours and 30 minutes of moderate intensity exercise or 75 minutes of vigorous aerobic exercise or an equivalent combination of both each week. Aerobic exercise can be walking, running, swimming and bicycling and should be in increments lasting at least 10 minutes spread throughout the week. They state that the health benefits of aerobic exercise include lowering the risk of coronary heart disease, stroke, hypertension, type 2 diabetes and depression. (We also know that it significantly increases longevity, perhaps more so then any medication!) Adults should also get at least two sessions a week of muscle strengthening exercise that works the body’s major muscle groups in the legs, hips, back, chest, abdomen, shoulders and arms. Working with a resistance band, lifting weights, doing push-ups and sit-ups or Pilates are a few of the recommended ways to increase bone strength and muscular fitness. Although the official physical activity guidelines don’t set a defined amount of time for this the exertion, they do state that it should be continued to the point that another repetition would be difficult. (We have all been there, after 10 or 15 reps, lifting that weight one more time or repeating that stretch is just too much of an effort.)

These woeful statistics were gathered through The Behavioral Risk Factor Surveillance System, a telephone survey of adults aged 18 years or older conducted by state health departments. It showed that Colorado did best and 27% of residents met the guidelines for both aerobic and muscle-strengthening exercise. The lowest rate in the country was in Tennessee with about 13% meeting the guidelines.

Although I won’t have a chance to go back for a glorious spa week for another year, I do intend to keep up the daily walking and twice weekly muscle strengthening work out. Statistics are worrisome, but sensing how well one feels as a result of doing the “right thing” is convincing.

Imagine going through an entire pregnancy only to have your baby die at or within a month of birth. Nor do we expect to lose our lives during childbirth. Most American women would say that this is a tragic scenario that is far more likely to occur in developing countries. That’s correct, but a new report issued by Save the Children for Mother’s Day gives us pause for concern about our self satisfaction regarding our country’s maternal, newborn and child safety status. But before I report on America’s less than stellar statistics, let me give you some global ones:

Every year, nearly 7,000,000 children die before the age of five.
Every year, 40 million women give birth at home without the help of the skills birth attendant.
Every day, 100 women died during pregnancy or childbirth and 8,000 newborn babies die during the first month of life.
Newborn death accounts for 43% of all deaths among children under age 5.
3 million newborn babies die every year – mostly due to easily preventable or treatable causes such as infections, complications at birth and complications of prematurity.
60% of the infant deaths occur in the first months of life. Among those, nearly 3/4 die in their first week. And more than a third die on the date of birth.

Save the Children has compiled a yearly mother’s index that uses five indicators, definitions and data sources in order to rate the well-being of mothers and their children. These include: Lifetime risk of maternal death, under-five mortality rate, expected number of years of formal schooling, gross national income per capita and finally participation of women in national government. Now as underwhelming as this may be, our country ranks 30th on this mother’s index. Overall, the US performs quite well on educational and economic status (10th best in the world) but it lacks behind all other top ranked countries on maternal health (46th in the world) and children’s well-being (41st in the world) and performs poorly in political status (89th in the world!) And here is why:

In the US, women face a 1 in 2,400 risk of maternal death. Only five developing countries in the world – Albania, Latvia, Moldova, the Russian Federation and Ukraine – perform worse than in the United States on this indicator. A woman in the US is more than 10 times as likely as a woman in Estonia, Greece or Singapore to eventually die from a pregnancy related cause.
In the US, the under five mortality rate is 7..5 per 1,000 life births. This is roughly the same as the rates in Bosnia and Herzegovina, Qatar and Slovakia. At this rate, children in the US are three times as likely as children in Iceland to die before their fifth birthday.
Women hold only 18% of seats in the United States Congress. Half of all countries in the world perform better on this indicator. Sixteen countries have more than doubled this percentage of seats occupied by women. In Finland and Sweden, for example, women hold 43 and 45% of parliamentary seats respectively.

So who ranks first? Finland wins, followed by Iceland and the Netherlands and then Denmark. Ahead of us in the mother’s index is Estonia, followed by Canada, United Kingdom, Czech Republic, Israel, Belarus, Lithuania, Poland and Luxembourg. Then and only then we follow. The worst countries for mothers and their children are in sub-Saharan Africa and include Niger, Mali, Sierra Leone; last on the mother’s index is the Democratic Republic of the Congo.

Most of my patients, as well as readers of my website, know that I’m very involved with Save the Children and indeed serve as a trustee. I am particularly proud of our global newborn and child survival campaign. We are currently working on four fronts:

  • Increasing the awareness of the challenges and solutions to maternal, newborn and child survival. (as part of the campaign Save put out this year’s state of the world mothers report.
  • Encouraging action by mobilizing citizens around the world to support programs to reduce maternal, newborn and child mortality.
  • Working in partnership with national health ministries and local organizations and are supporting efforts to deliver high quality health services throughout the developing world. This means improving pregnancy and delivery care, vaccinating children, treating diarrhea, pneumonia and malaria as well as improving nutrition
  • The program Saving Newborn Lives launched in 2000 with the grant from Bill and Melinda Gates Foundation has helped deliver better care practices and improve health interventions to save newborn lives in 18 countries.At home we, the concerned women (and men) can help. Our votes and letters can have a huge impact…Congress should create a national commission on children to address the needs of 16 million children in the US now living in extreme poverty. Congress should also protect US global health funding and increase support for maternal and child health and nutrition. If every woman is afforded appropriate maternal health care (and hopefully the new health laws that go in effect in 2014 will help ensure this), we need not be ranked 30th in the world.

    So now I will do my trustee thing….If you want to learn more or help us make a difference in the lives of millions of children please go to

I sometimes think that half of the ads I see on TV (when I don’t rush through them with TIVO) show individuals clutching their chest after eating their favorite food or, more visually, chest cavity flames, which are subsequently doused with the right over-the-counter medicine or prescription drug. Having suffered from gastrointestinal reflux disease (GERD) and that sense of heartburn for many years, I am sympathetic. Most of the medications prescribed by physicians (often after suggesting an upper endoscopy to ensure that there are no ulcers or a precancerous condition called Barrett’s esophagitis) are Proton Pump Inhibitors (PPI’s). These reduce the production of acid in the wall of the stomach and assist in the healing of ulcers as well as treat GERD. These medicationss include omeprazole (Prilosec) (Zegerid), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium), (Zegarid) and dexlansoprazole (Dexilant). Some are by prescription; others are available as generics or even over-the- counter.
In the March 14 issue of JAMA, a recent announcement was made by the FDA; that reflux drugs were found to be linked to C difficile-related diarrhea.
Clostridium difficile is a bacteria that causes watery diarrhea, abdominal pain and fever, which when it does not resolve, may cause serious intestinal problems and even the need for resection of a portion of the colon. In some cases (rarely, thankfully), the infection can be fatal. C difficile has become more and more common in hospitals, nursing homes and in the general community. It often occurs after the normal flora of the intestine is wiped out by antibiotic therapy. (Even a short course of certain broad spectrum antibiotics can cause this, one of the reasons for our growing reluctance to use antibiotics unless they are absolutely required.) C difficile occurs more frequently in older adults. If a person has had an episode of C. difficile, she is more likely to experience it again, especially with antibiotic treatment. 
The FDA reviewed data from 28 observational studies, 23 of which found that PPI users had an elevated risk of C difficile associated diarrhea compared with those who didn’t use these medications. Their risk was 1.4 to 2.75 times greater. As a result of their review, the FDA has officially stated that “the weight of evidence suggests a positive association between the use of PPI’s and C difficile infection and disease”. The labels of these drugs will be updated to reflect this risk.
What this means is that if indeed you need a PPI medication, you should use the lowest dose for the shortest duration necessary. And if you do develop diarrhea that doesn’t go away while taking that PPI, see you doctor.

I thought I would start the New Year with a somewhat positive article that came out in the journal published by the North American Menopause Society. The journals’ name is appropriately, “Menopause”. Its cover is bright red…  I am not sure if this is meant to make it stand out or if the color represents hot flashes! I read the journal while trying to catch up on relevant articles during the holidays…these and my recent copies of the New Yorker have kept me mentally occupied. (I know that reading medical literature sounds boring, but actually I like it!)

So here is what caught my eye, and take a deep breath before reading the title; “Hip fracture in postmenopausal women after cessation of hormone therapy: results from a prospective study in a large health management organization”.

This was a study of 80,955 postmenopausal women who were 60 years old or older and had filled hormone therapy (HT) prescriptions at least once between January 2002 and June 2002. They were then followed through December 2008. (It takes years to gather the statistics, so most large studies will have concluded a few years before all of the results are actually published.)  The data on whether the women used HT, for how long,  and whether any antiosteoporotic medication was used, as well as the occurrence of hip fractures were collected from an electronic medical record system. The women in the study population were followed through Kaiser Permanente Southern California, which included 11 Southern California medical centers. (Yes they are huge!)  Bone mineral density was assessed with a DEXA scan in 54,209 women at least once  during the study period.

The results demonstrated that  during the 6.5 years of follow-up   (and after accounting for age, race and other medications), the women who discontinued HT were at a 55% greater risk of hip fracture than the women who continued to use HT.  The use of hormone therapy helped prevent fracture as long as it was used. But, within 2 years of stopping HT, hip fracture increased and the risk of fracture rose incrementally the longer the women discontinued this therapy. Every year that the women stopped HT was associated with a lower BMD (The T score which compare BMD to a 30 year old decreased on average – 0.13 a year.)

The authors concluded that “the public health message to women and physicians is that discontinuation of HT is associated with increased hip fracture risk and lower BMD compared to women who continue to take HT.”

There are many reasons to consider hormone therapy at the onset of menopause. For most women it is prescribed to help them deal with severe hot flashes, night sweats, sleep problems, mood changes and for some a feeling of “walking around in a fog”. There are also reasons to consider stopping after several years…. these include risk of breast cancer as well as a potential decrease in cardiovascular benefits.  The pros and cons of continuing HT for decreased risk of bone fracture should now also be considered. Who said this was easy! But it’s a subject that reaches epidemic proportions as approximately 1 million women enter the menopause each year in the United States.

In the year to come I’ll try to keep you up-to-date on the most recent published articles and studies on this and many other topics.

Have a healthy 2012!

As you know when you come for your annual gynecologic visit, the receptionist requests that you update your information, sign a confidentiality form, and she checks on your insurance. The nurse then hands you a small plastic cup and asks you to give a urine sample. So there you are in a cramped bathroom trying to aim the stream into what now seems like an impossibly narrow container and thinking: (a) this is humiliating, (b) why is this necessary, I have no problems with my bladder? and possibly (c) I can’t go, so what am I supposed to do now?

A new article in the Journal Obstetrics and Gynecology aptly titled “In the Trenches” emphasizes the importance of checking your urine.

An immediate urine test can be performed with a “dipstick”, a strip of paper that is specially treated to check for white cells (often present if there is an infection) red blood cells or RBC’s (and the rest of this newsletter will deal with this… if blood is present in the urine, the medical term is hematuria), protein (if elevated, a sign of kidney or even systemic disease), glucose (present in urine if blood levels are high), ketones (elevated with kidney problems or dehydration), bilirubin (elevated in liver disease) and pH (acidity).

The journal article dealt specifically with microscopic hematuria in women. “Microscopic” simply means that there is blood (or red blood cells) in urine but the urine doesn’t look bloody to the naked eye or toilet paper…(I realize this is getting a bit gross!) According to the American Urological Association, “significant microscopic hematuria” means there are three or more red blood cells (RBC’s) per high power field (magnified 40 times) on microscopic examination from two to three properly collected urinalysis specimens. To get a proper sample, the first drops of urine should not be included, just the midstream…all the more difficult to get into that cup. If you have your period, recently exercised vigorously, just had sex or vaginal trauma, obviously blood cells in the urine will not count and the test should be repeated another time.

Once a dip stick test is positive for RBC’s …I (or any doctor) will probably send the urine out for a complete urinalysis. The urine is spun down and the sediment is examined for the number of RBC’s, white cells, and/or bacteria. Often we also do a urine culture to rule out infection. (Most women, however, do know when they have a bladder infection…. they have urinary urgency, frequency and burning.)

So why is it so important to detect microscopic hematuria? Before I relate the possible causes and consequences listed in the journal article, I’ll tell the tale of a patient that I saw a few weeks ago. She was menopausal, had no signs of vaginal bleeding or urinary problems, but a routine urine dipstick test was positive for RBC’s. Her urine was sent out for culture (it was negative) and complete urinalysis. The latter confirmed the presence of a significant amount of RBC’s.. I asked her to repeat the test 2 weeks later and once more it showed RBC’s. I then referred her to a urologic specialist for a complete workup.. This ultimately consisted of cystoscopy and a CT scan of her pelvis and kidneys. She was found to have bladder cancer. It was resectable and curable.. This simple urine test probably saved her life.

The two most frequent causes of microscopic hematuria in non-pregnant women (46% of women do have hematuria during their pregnancy) are cystitis (bladder infection) and kidney stones. Additionally, some women seem to shed RBC’s in their urine without any pathology. But the cause that should be ruled out, especially in women over 40, is cancer. Bladder cancer is the 17th most common cancer in women worldwide. In the United States in 2008 there were 17,770 new cases of bladder cancer diagnosed and 4,270 deaths …that means that there were more deaths annually from bladder cancer in women than from cervical cancer! (A personal aside…. many years ago my paternal grandmother died from bladder cancer.)

The risk factors for urologic cancers in women include age over 40, smoking, a history of exposure to chemicals or dyes, a history of gross hematuria (the “gross” here is a medical term and means that urinary blood is visible), analgesic abuse and a history of pelvic radiation. And here is a fact that seems to appear whenever we discuss most cancers: up to 35% of female bladder cancer cases may be attributable to cigarette smoking!

The recommendations put forth in the article state that a complete work up of microscopic hematuria should include an evaluation of the lower urinary tract (the bladder) and upper urinary tract (the ureters and kidneys) in any “high-risk” patient. Once more, you are at risk if you are over 40, have smoked, have had chemical exposure (hair stylists), have a family history of bladder cancer (I guess that’s me) and/or recurrent urologic disease. The work up should include cystoscopy, x-rays with dye and CT scans.

We all know about the need for Pap smears. It turns out that a urine test is just as important. So please don’t bewail that request to pee in a cup.

I’ve written several newsletters about potential side effects of bisphosphonates medications used to treat osteopenia and osteoporosis (Fosomax, Boniva, and Actonel….just to remind you of some brand names). This time I want to share some potentially good news about this bone density enhancing class of medications. And I am especially happy to share the report because it comes from a study conducted in Israel. (As many of you know, I have taught and worked there and indeed will be in Tel Aviv when this article appears.)

The Israeli researchers conducted a study entitled The Molecular Epidemiology of Colorectal Cancer. It was supported by the National Cancer Institute and published in the February issue of the American Journal of Clinical Oncology. (I hope I haven’t lost most of my readers by this point…just bear with me. So many of you or your relatives take bisphosphonates so that your skeletons can successfully bear your weight without an osteoporetic fracture)

They found that postmenopausal women who had taken an oral bisphosphonates longer than one year had a 59% reduced risk of colorectal cancer. Like the Scandinavian countries, pharmaceutical records in Israel are extremely well documented. (All the citizens have health insurance and most of their prescription medications are covered…I wish I could say the same for us!) The researchers used computerized pharmacy records and identified almost 2000 women who had colorectal cancer.

They found that in these women, compared to controls who were matched for age, weight, and religion, the use of bisphosphonates longer than 1 year, but not less than 1 year, reduced the risk of colorectal cancer by half, even when they adjusted for other factors that could perhaps lower colorectal cancer risk. (Here is where I list these factors to remind you that they too count in our “war on colorectal cancer”…as does screening. They include vegetable consumption, physical activity, and weight control, use of low-dose aspirin, statins, vitamin D and postmenopausal hormones.)

Ongoing research indicates that oral bisphosphonates may exert a cancer-protective effect (including breast and prostate cancer.)  Clearly this study is not large enough to persuade the FDA to approve any official indication that this class of medication will diminish colorectal cancer. So I’ll end with the phrase that is used in the conclusions of most medical articles: “Further studies are needed”. I felt , however, that a bit of good news about the medications that can lower the huge toll of osteoporotic fractures in women (and men) is welcome.

In the midst of our horror about the earthquake, tsunami and nuclear reactor disasters in Japan and concerns about the latter’s impact on the air, ocean and life forms, I thought that the timing of the article in the March issue of The New England Journal of Medicine was intriguing. It brought up another less immediate but valid concern, that of the effect of coal on our food and risk of disease.  (I hope that those of you reading this article acknowledge coal’s impact on climate change and the ecologic repercussions that are, in themselves, a disaster). The NEJM article was titled “Mercury Exposure and Risk of Cardiovascular Disease in Two U.S. Cohorts.”

A quick review: as we use coal for power, we contaminate our atmosphere with mercury. This then returns to the oceans of the earth and is incorporated into plankton where it is converted into organic methylmercury. The latter is stored in the fat of fish. As larger fish eat smaller fish, their levels of methylmercury go up. We then eat the fish and the methylmercury gets into our bodies (and is also stored in our fat). Chronic, low-level methylmercury exposure can cause neurodevelopment delay in infants. It’s currently recommended that women of childbearing age, pregnant or nursing mothers, and infants and young children eat no more than 2 servings of fish per week and also limit their intake of certain species of fish that are especially high in mercury. The worst culprits are the ones on the top of the fish eating food chain: shark, swordfish, king mackerel, and tilefish. Then to complicate matters, fish from streams and rivers in areas that have high mercury pollution may also be less than safe, especially if consumed regularly. (For information on mercury pollution check

For adults, the main health concern regarding chronic low levels of methylmercury (not high, toxic ones) is the risk for cardiovascular damage and disease. Government agencies, the Institute of Medicine and (I assume) the rest of us want to know if mercury exposure is correlated with cardiovascular disease.

There has been robust research that shows that fish consumption is heart healthy; indeed, fish intake has been shown to be inversely associated with the risk of coronary heart disease, especially fatal heart attack and stroke. So what is a fish eating person (like myself, who does not eat meat) to do?

Researchers from Harvard, the University of Washington, and the University of Missouri studied mercury exposure in 2 large groups of individuals. The first was comprised of male physicians followed from 1986 in the Health Professionals Follow-up Study (don’t get me started on my gender protests regarding this study) and the second was through the Nurses Health Study (as you may guess, all female) in which the nurses were followed from 1976. The two studies totaled 51,529 men and 121,700 women.
And here is where it gets really interesting… Their toenail clippings were stored! (I read this, believe it or not, while getting a pedicure and wondered if I should save my own toe nail clippings for research.) Apparently concentrations of mercury and selenium in toenails have been found to be excellent biomarkers of usual methylmercury and selenium exposure. The researchers wanted to check selenium (which we get from consuming plants grown on selenium –rich soil) because this trace element provides protection against mercury toxicity in some experimental studies.

They identified 3427 participants with cardiovascular disease and matched them to controls who were the same age, sex, race and smoking status. They also had information on their fish consumption and lifestyle habits. Their toenail mercury and selenium concentrations were assessed by (and I’m sure you will get this) the use of neutron-activation analysis. The usual complicated statistical analysis (actually called a multivariate analysis) was done and demonstrated that participants with higher mercury exposures did not have a higher risk of cardiovascular disease nor did selenium concentrations make a difference in the results.
The authors concluded that their findings “provide no support for clinically relevant adverse affects of typical levels of dietary methylmercury exposure on cardiovascular disease in U.S. adults”. They went on to state that the absence of an association “should not alter ongoing public health and policy efforts to reduce mercury contamination in fish and the environment.”

Bottom line: Most of us can continue to eat the “right” fish for our heart’s sake, but women who are pregnant or may become pregnant, or who are breast feeding should limit their fish consumption. Now, we can start worrying about the impact of radiation on those fish…