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 http://www.epa.gov/mercury/advisories.htm.)

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…

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!

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.

As a fellow of ACOG (The American College of Obstetricians and Gynecologist, the term “fellow” has no gender significance)….I recently received a survey to complete with questions about my age, number of hours I teach, see patients, percent of patients who are on Medicare, languages I speak, etc….the usual questions that one would expect them to ask in order to keep their census up to date. But this time they included a second page of questions that asked about my knowledge of a specific infection. When I realized my knowledge was minimal (actually I didn’t know anything about it), I quickly looked it up so that I could mark their queries in other than the column “I don’t know”. (The survey was multiple choice).

I’d like to share the information I learned with you….not because you too will be “tested” but because general knowledge about this water borne infection in not well known (even by doctors) and there are warnings that should be issued to help protect many of us.

The infection is due to a parasite called Cryptosporidium. It causes (you guessed it) cryptosporidiosis (nick name Crypto) …which usually manifests itself as diarrhea. It’s a fascinating organism. It thrives in cattle, sheep and pigs as well as wild animals such as deer, elk and moose, especially their young offspring (calves and lamb) and, unfortunately, in humans. Once a parasite gets to the small intestine (the gut) though ingestion, it can multiply and recycle indefinitely. In a fascinating process, once in the gut, this microscopic parasite actually undergoes a sort of fertilization to form a zygote, and this ends up having 4 offspring called sporozoites. (Sorry if I am getting too detailed, but it’s the biologist in me.) Some sporozoites remain in the gut and infect new cells. Others that get surrounded by a cyst wall become oocysts, and these are passed in the feces and into the environment. All this happens astoundingly quickly…each generation can develop and mature in 12 to 14 hours. During the last 2 decades, “Crypto” has become one of the most common causes of waterborne disease in humans in the US and through out the world!

The usual source of infection is water that has been contaminated by the feces of animals or infected humans. If a person drinks the water or involuntarily swallows it while swimming, they then “catch” cryptosporidiosis. Crypto has been found in swimming pools, hot tubs, Jacuzzis, fountains, lakes, springs, rivers, and ponds which can be contaminated with sewage or feces from humans or animals. It can be spread by eating uncooked food that is contaminated, by touching your mouth with contaminated hands…which could have “picked up” the parasite from touching surfaces (and this includes diapers) that have been contaminated by stool from an infected person or handling an infected cow or calf. (We do the latter infrequently in LA.)

Symptoms of the infection usually appear within 2 to 10 days of exposure and include diarrhea, abdominal cramping, nausea, vomiting, low grade fever and weight loss. In persons who are immunocompromised (due to diseases such as AIDS or cancer), the infection may become life threatening. The good news is that the immune system in healthy individuals is able to stop the infection, although symptoms may last for one to two weeks. But even after symptoms subside, sporozoites can be excreted in the feces and if that person swims, he or she can pass them into the water from spores that are present in the outer part of the anus or even on the thighs (ugh!). Here is where physician advice should include sanitary precautions to wash hands, use separate towels and not go swimming for 2 weeks after all the symptoms have resolved. The other rather concerning information that I discovered was that chlorine disinfection of the organism is ineffective; even one oocyst can withstand pure bleach for 24 hours and still cause infection .Most water filters today do remove small particles including cryptosporidium from our drinking water…but this may not occur in home wells (or swimming pools).

According to the CDC, the best way to protect yourself and others from this cause of diarrhea is to:

• Wash your hands after using the toilet and before handling food (especially for persons with diarrhea).
• Wash hands after every diaper change, especially if you work with diaper-aged children.
• Do not swim if you are experiencing diarrhea (essential for children in diapers) and stop for 2 weeks after diarrhea subsides
• Avoid water that might be contaminated.
• Do not swallow recreational water.
• Do not drink untreated water from shallow wells (or boil it first).
• Do not consume untreated ice or drinking water when traveling in countries where the water supply may not be safe.
• Use safe uncontaminated water to wash all food that is to be eaten raw (and if there is a chance that the food might be contaminated, peel it).
• Avoid eating uncooked foods while traveling in countries with poor water treatment and food sanitation
• You’ll love this one….avoid fecal exposure during sexual activity.

The diagnosis can only be made if stool samples are tested for the parasite, and frankly the test is not always positive the first time so several samples may be necessary.

The only FDA approved treatment is through a prescription of a medication called nitazoxanide (brand name Alinia). Most people with healthy immune systems will recover without treatment. Diarrhea should be managed with fluids to prevent dehydration.

So now you know and could “pass” the survey put out by ACOG. If I include a bottom line, as I usually do in my newsletter, it would probably include the phrase “Don’t swallow” (at least while swimming), know your drinking water source and wash your hands!