I quickly glanced at the first 2014 issue of JAMA before I returned to the office on January 2. And there was the first article to deal with weight… It was titled ” New obesity guidelines: promise and potential”. As we go back to our regular lives after the nutritional and alcohol excesses of the holiday, it seems most appropriate that we consider the major contributor to chronic disease: obesity. One in three US adults are obese.

There are new obesity guidelines to help physicians manage obesity more effectively. They were formed by an expert panel which first started their ponderous work in September 2008 and finally at the end of 2013 published what is now termed “Obesity 2″ guidelines for the management of overweight and obesity in adults. Here is a brief summary of their recommendations:

Recommendation 1 – Identifying patients who need to lose weight.

They continued to use BMI and waist circumference to identify those who are overweight or obese. An adult who has a BMI between 25 and 29.9 is considered overweight and an adult who has a BMI of 30 or higher is considered obese. Individual waist circumference is also important because abdominal fat is a predictor of risk for obesity-related diseases. If your waist circumference is more than 35 inches this adds to your risks from excessive weight. In general the greater the BMI and waist circumference, the greater the risk of cardiovascular disease, type 2 diabetes, and all-cause mortality.

Recommendation 2 – Counseling about the benefits of weight loss.

The panel stated that sustained weight loss of as little as 3 to 5% is likely to result in clinically meaningful reductions in levels of triglycerides, blood glucose, and hemoglobin A-1 C and in the risk of developing type 2 diabetes. Greater amounts of weight loss will reduce blood pressure, improve levels of low density and high density lipoprotein cholesterol, and reduce the need for medications to control blood pressure, blood glucose levels, and lipid levels as well as further reduce levels of triglycerides and blood glucose. The panel states that weight-loss can provide benefit for obese and overweight patients with only one additional risk factor and that one factor can simply be an increased weight circumference.

Recommendation 3 – Dietary therapy for weight loss.

The panel’s recommendations emphasize that there is no ideal diet for weight loss and that there is no evidence of superiority for any of the myriad diets they reviewed. Their primary recommendation is that a diet should achieve reduced caloric intake as part of a comprehensive lifestyle intervention (that includes exercise)

Recommendation 4 -Lifestyle intervention and counseling.

Obese or overweight individuals should enroll in comprehensive lifestyle interventions for weight-loss that should be delivered for six months or longer. The gold standard of therapy is on-site and high-intensity sessions (14 sessions or more in six months) provided in individual or groups by a trained interventionist. And further therapy should continue for a year or more. (They hope that payers will recognize the value of well-run programs that use this approach. They did state that lesser intensity approaches delivered electronically have not shown the same amount of weight loss and health benefits.)

Recommendation 5 – Bariatric surgery.

The Obesity 2 panel has advised practitioners to suggest to patients who are either obese with a BMI at or over 40 or at or over 35 with additional obesity related health conditions that they consider undergoing bariatric surgery by experienced bariatric surgeons.

Oy, this is a lot to consider for one third of our population. I was overwhelmed when I read this. I also lost my appetite for my next meal… But I thought I should share this with my patients and readers. Hopefully this will help to exhort all of us to maintain a lifestyle with appropriate caloric intake, and exercise in this new year.

I searched this last week’s medical journals to find an article to write about. Unfortunately there was nothing I felt would be of interest to most of my patients. My fall back is usually JAMA, but the latest issue dealt with combat casualties, care for mass casualty events, treatment of post dramatic stress disorder and suicide… I pass. So I thought that this week I would write about the recommendations that were published in the Clinical Updates in Women’s Healthcare by the American College of Obstetricians and Gynecologists from April. There was a section dealing with physical activity for “older” adults and I, of course, wondered what their definition of older was… and as usual it encompassed anyone at or over the age of 65. Upon reviewing their recommendations, I realized that these are probably relevant to women and men of any age; so here they are:

AEROBIC ACTIVITIES

  • 30 to 60 minutes of moderate intensity exercise, performed on five days each week or more. This can include walking, jogging, running and bicycling.
  • 20 to 60 minutes a day of vigorous intensity exercise performed on three days a week or more. Higher endurance activities will include swimming, cross-country skiing and aerobic dancing. Team sports such as basketball, soccer and volleyball and racket-sports such as tennis and racquetball included. They obviously can be very vigorous but since they also include intermittent periods of exercise and rest their effectiveness for continuous aerobic activity makes the calculation of duration more difficult.

MUSCLE-STRENGTHENING ACTIVITIES

  • Resistance exercise that involves each major muscle group should be performed on 2to 3 nonconsecutive days per week using a variety of exercise equipment or body weight resistance. This can be done with weight training machines, free weights, elastic resistance ( bands) or body weight resistance activities (push-ups, pull ups, sit ups, stair climbing and Pilates). Most individuals should aim for 10 to 15 repetitions of approximately 8 to 10 exercises to improve strength and power. The recommendations also includes correct breathing techniques… There should be exhalation during the effort phase and inhalation during the lengthening days.( All those exercise coaches were right!)

FLEXIBILITY

  • A series of flexibility exercises for each of the major muscle – tendon units, performed two days a week or more for at least 10 minutes is recommended to improve joint range of motion. This should include static stretches, performed by slowly stretching a muscle or tendon group and holding for a period of 10 to 30 seconds. Slow stretching allows greater stress relaxation and generates lower forces on the tendon. Holding the stretch at the point of tightness or mild discomfort for 10 to 30 seconds enhances joint range of motion. There is still a debate regarding the best time to stretch. Current evidence suggests that it is most effective when the muscle temperature is elevated after light to moderate exercise.

BALANCE

  • As we get older, coordinated actions become increasingly important in preventing falls and injuries. Walking on uneven or difficult terrain (try sand) is said to improve balance. The Chinese wellness practices such as can tai chi and qi gong which emphasize posture, breathing and meditation will increase our balance. Regular yoga practice can be quite amazing; it has been shown to be associated with improved gait, balance, flexibility, lower body strength and weight loss. To add to its increasing popularity, it also has been found to be effective in reducing blood pressure, glucose levels and cholesterol levels. Then we come to Pilates which is my favorite… It’s an exercise system focused on improving flexibility, strength and body awareness. It enables us to build core muscle strength and achieve better spinal alignment. One of the more fabulous benefits of Pilates is that it helps us become more aware of maintaining correct posture (I remembered to sit up straight as I wrote this) and activating core muscles in our every day activities.

So there you have it; it’s a fairly inclusive list and perhaps seems to be overly time intensive for many adults. But the impact of exercise (and it can be low-impact) on our health and longevity can be greater than many of the “preventive” medications that physicians prescribe. So I hope you’ll sit up, pay attention and get going.

Certain songs play over and over again in our minds…One that haunts me was written by Charles Fox and sung by Roberta Flack; “Killing Me Softly with His Song”. I was humming it while reading an article in the journal Menopause. (Please don’t laugh.) The article was a met- analysis  of studies that measured the mean difference in age of natural menopause between smokers and nonsmokers. Menopause occurred 1.12 years earlier in smokers than nonsmokers, and that difference was significant. Hence the heading for my article this week.

Menopause is defined as a permanent cessation of periods for 12 months. And if wis use this 12 month definition, the only way to date menopause is to do so retrospectively. Before our ovaries run out of the follicles that produce the estrogen and progesterone needed to instigate our periods, they “sputter”. The follicles that have not been used up during our teens through our mid forties are the rejects and they simply do not put out (hormonally) as they should. This period of approaching follicular extinction is termed the menopausal transition. On average it begins at age 47 and lasts 4 years. During this transition, even though periods may come and go, symptoms such as hot flashes, sleep disturbances, vaginal dryness and pain with intercourse can occur.

There are more than 3000 chemicals inhaled in cigarette smoke. Many of them are detrimental to the health and well being of the follicles and can contribute to their early demise. The concerns about early menopause do not solely relate to symptoms. Early menopause increases the risk of cardiovascular disease, venus thrombosis (clots) and osteoporosis. Overall it increases the risk of mortality by approximately 2% per year. And to add insult to smoke injury, the combination of earlier loss of estrogen and current smoking further increases a woman’s risk of cardiovascular disease and death!

For this and so many other reasons, quitting smoking is the best thing a smoker can do for her health. Now would putting a picture of ovaries with a big red X over them help to convince women to stop smoking? I’m not sure … But it can’t hurt to add this to all the other warnings.

The saying that politics makes for strange bedfellows took on a new low when Michelle Bachman came out with her ridiculous statement against HPV vaccination. (In case you didn’t get the pun…HPV infection is most frequently transferred in a bed … or for that matter in any place that allows for sexual contact.)  So I’ll skip the part where we ask why a responsible parent would not want to help diminish the chance that her daughter would get cervical cancer or genital warts. (Yes, their may be parents out there who think that their daughter will not be sexually active with anyone but the man she marries, but what guarantees do they have that the young man she commits to did not have partners before or after he proposed to and married her.) Long-term large studies have shown negligible side effects from HPV vaccination. Sudden “mental retardation” which of course is a truly nonmedical and impolitic term, cannot suddenly occur from a vaccine given to an adolescent girl! (I have given hundreds of shots in my office and at most have seen a few “ouches” at the site of injection.) Okay, I have to stop now and become scientific. Here are the facts I promised in the heading of this week’s newsletter:

There are more than 40 types of human papilloma viruses or HPV’s that infect the general tract; approximately 15 types have been linked with cancers and are classified as carcinogenic or high risk. We now know (or at least the scientists who do the testing know) that 99.7%of cervical cancer specimens, as well as their precancerous predecessors, test positive for at least one of these high risk HPV’s. (Just in case you want to complete your viral numerical knowledge…they are HPV-16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, and 72.) The most common onset of infection occurs in the first years of sexually activity. Thankfully most of the infections in young women and men resolve within 2 years. In a small proportion of women however, HPV infection persists. If this happens, the virus may enter the DNA of cervical cells and cause mutations, which over time can result in precancerous lesions that progress to cancer.  HPV viral infections are extremely contagious. (Put bluntly, a touch of a penis harboring the virus will pass it on.) And there are usually no lesions that signify viral presence. It’s a “down there” scenario akin to that portrayed in the movie Contagion; but with HPV, the consequences of the viral infection occur years later. If a woman has sex with someone, she essentially has a viral contact with everyone he or she has had sex with and everyone those individuals have had sex with… etc., etc.

So it’s not surprising that at least 80% of women will, at some time in their lives, have an HPV infection…most commonly when they are young or when they are exposed to the virus through new or non monogamous partners. In most young women, the virus will clear. In the few in whom infection persists, it takes at least 2 to 3 years for potential progression to a precancerous lesion and more time until it can cause cancer. So adolescents and young adults have a very low risk of developing cervical cancer.

Obviously many young women will initially harbor one of the HPV viruses and as a result may also have some mild changes in a Pap smear screening. If these changes are found and pronounced abnormal, they (and their moms) will go through a lot of unnecessary anxiety over something that usually clears up… and even worse they may go through unwarranted surgical procedures that can scar the cervix and impact their future ability to conceive or have a normal vaginal delivery.

To help avoid unwarranted concern and cut down on unnecessary procedures, the American College of Obstetricians and Gynecologists (ACOG) has released guidelines that should make us all relax with regards to screening. They state that Pap smears should begin no earlier than age 21. And from 21 to 29 women should be screened every 2 years. (But this does not negate the need for annual pelvic exams and, if necessary Chlamydia and other STD testing should be done more frequently.) It’s recommended that by age 30 all women should undergo screening with HPV testing as well as a Pap smear. If both tests are negative and the woman has no new partners, she can then be tested every 3 years. (But again a yearly pelvis exam should be done, and if a woman has a new partner or if she is not sure of the monogamy of her current partner, testing should be more frequent.) All women in high-risk groups (women with HIV, those on immunosuppressive medications, women exposed to DES in utero and women who test positive for high risk HPV or who have been treated for cervical precancerous or cancer) should be screened frequently.

The current vaccines protect against 2 types of high-risk HPV infections that cause 70% of cervical cancers. These vaccines will not cure or get rid of HPV infections that are already present. Hence the best way to help prevent cervical cancer is to vaccinate young women (and ideally young men) before sexual activity occurs. In medical parlance this is when the young person is “sexually naïve”. Because other high-risk HPV’s, which are not covered by the vaccines, can still cause 30% of cervical cancers,  young women who receive the vaccine will still need to begin cervical cancer screening when they reach the age of 21. But when administered at the right time the vaccine will insure that the majority of cervical cancers won’t occur. What’s political about that!

This calls for a 101 on ovarian function: During our reproductive lives, the ovaries provide us with our essential female hormones… estrogen and progesterone which are taken up by receptors in every cell in our body. These hormones are produced through the development of primordial eggs or oocytes within the ovaries. The ovary of the female fetus is endowed with a huge number of oocytes… 6 to 7 million to be sort of exact. But by the time we are born, that number dwindles to “just” 1 million. And by the time we hit puberty, we have a paltry 400,000. Then during our reproductive years, thousands die each month (this is termed “atresia”) while one oocyte becomes a follicle that has the potential for ovulation. This dominant follicle develops for 2 weeks, producing more and more estrogen; it then extrudes an egg that can be fertilized.

Subsequent to ovulation the follicle, now bereft of its egg, is called a corpus luteum. It produces, in addition to estrogen, progesterone and together they create a lush environment in the uterinelining for potential implantation of a fertilized egg (now called a blastocyst).

At what point does all this change? Do regular cycles mean that pregnancy will occur at the “touch” of a sperm (or thousands of them)? It turns out that reproductive menopause can occur years or even a decade before hormonal menopause. There is a national trend to delay childbearing. In my practice in LA, I practically never see women under 35 who are ready to conceive. A common question posed by my patients is “How long can I wait?” or “Is it too late?” So I thought it would be appropriate to share some of the information that was recently published in the “Postgraduate Obstetrics and Gynecology” publication that is sent to me and my colleagues biweekly for continuing education.

A woman’s fertility is definitely dependent on her age. The incidence of infertility in women 20 to 24 years old is 7%; this increases to 15% between ages 30 and 34 and then to 29% in women aged 40 to 44 years.  Not only does the quantity of oocytes dwindle, but so does their quality. The rate of spontaneous miscarriage is 10% before the age of 30; it almost doubles to 18% between ages of 35 and 39 years and then rises to 54% in those older than 45. It’s not the age of the uterus that counts, but that of the eggs. If donor eggs of younger women are used, the pregnancy and miscarriage rates are the same in women younger and older than 40.

IVF success with a woman’s own eggs is dependent on the age of her eggs. (This obviously means her own age, no matter how young she looks!) According to the Society for Assisted Reproductive Technology, women between the ages of 35 and 37 have a 37.3% live birth rate, women between 38 and 40 a 28.2% live birth rate and women between 41 and 42 a 16.7% live birth rate with their own eggs.

There are several ways to assess ovarian reserve and get some reassurance as to whether the oocytes are good enough for a successful pregnancy. (By success we mean a live birth, not whether the child can get into an Ivy League school.) Simply having regular periods is not sufficient evidence.

The first test that most doctors will run is a follicular stimulation hormone (FSH) blood test. FSH is the messenger hormone produced by the pituitary. It “commands” the ovaries’ oocytes to begin the steps towards ovulation. If the estrogen level is low (which is what happens with the onset of the period), the FSH revs up and oocytes’ development takes off. Once a dominant follicle develops and it produces its estrogen, the FSH level goes down (negative feedback). If there are not enough oocytes to pass “go” and the ovary’s reserves are low, the FSH continues to be secreted in a desperate attempt to get those oocytes to do their thing. High levels of FSH in the beginning of the cycle (we usually check around day 2 or 3 after the menstrual cycle has begun) indicate poor ovarian response. And FSH will stay up permanently once the ovaries have run out of oocytes, i.e. throughout menopause. In general, the FSH level should be between 4 and 10 mIU/mL during the early part of an “ovulatory” menstrual cycle. Levels higher than 10 to 15 are considered borderline and those higher than 16 mIU/mL are considered abnormally elevated, indicating poor reserves and predicting diminished success with fertility treatment.

There are other endocrine markers that may show low ovarian reserves. One is called antimullerian hormone or AMH. It is produced by ovarian cells from 36 weeks of gestation until menopause. With menopause it decreases to undetectable levels. AMH is not affected by pregnancy or birth control pills and may be the first ovarian reserve marker that declines. Another endocrine test that can predict potential fertility issues with age is a blood test for inhibin B, a growth factor in the ovary. It rises in the beginning of the cycle and then goes down during the second half. Low levels in the early cycle indicate diminished ovarian reserve.

Finally, ultrasound may help predict the ovaries’ reserve. The number of small “ready to go” follicles can be counted and if there are 10 or less that are seen in a scan, ovarian reserve may be compromised.

If you or a family member question whether you can wait or if it’s too late to try to conceive with your own eggs (especially if you are considering expensive and potentially invasive fertility procedures); screening for ovarian reserve should be done. The easiest test is an FSH level on day 2 of your cycle. It can be done in conjunction with these other tests, but it probably remains the simplest and least expensive method of reserve determination. The question, “How many eggs are left?”, is valid for all women who want to postpone pregnancy.

So a patient comes in to my office (sorry if this sounds like the beginning of one of those bar jokes) and as part of my due diligence I update her chart with her current medications. Upon enquiring as to what she is now taking, I may be given a container of various pills with the statement “I take these once a day”. Or I might get a description of the medication “I now take the pink pills that lower cholesterol; I’m not sure of the name…it’s a small dose; it used to be yellow”. Yes, this sounds ridiculously ambiguous but it’s not her fault. The names, colors and shapes of medications are no longer stable. (And this has nothing to do with their expiration date.) At least 70% of U.S. prescriptions are generic. The good news is that they are a lot less expensive than brand prescription drugs and indeed make up less than 20% of current prescription drug costs in the U.S..

An article about our lack of pill recognition titled “Why Do the Same Drugs Look Different? Pills, Trade Dress, and Public Health” was recently published in The New England Medical Journal. I thought I would share it with you in this week’s newsletter.

The clinical effects of brand and generic medications are supposed to be the same (or according to the authors “interchangeable”) but they often look very different. Whereas a brand medication will always appear identical with each refill, generic medications can vary in size, color and shape depending on the manufacturer supplying the pharmacy. (Need I say the cheapest brands will most likely be the ones that are supplied?) They all have to be approved by the FDA, so cheaper does not mean that quality or concentration of the medication has been compromised. An example that was given in the article (along with pictures) is fluoxetine (brand name Prozac). There are at least 10 generic versions that are pharmacologically equivalent to the original drug yet they vary in their color patterns.

No, this was not done on purpose to confuse the consumer or test the memory of her physician. It turns out that color and shape-shift has its basis in U.S. intellectual-property law. Drug manufacturers have had exclusive ownership of the physical aspects of their products, including their size, shape, color, texture, aroma and flavor. These properties are considered private property under a subset of trade law called “trade dress”.  (I immediately associated this title with words like designer, exclusive and whatever other branding adjectives makes “not-off-the-rack” fashion so unique.) To be fair…. the companies that do research and development of drugs should be compensated for the tremendous costs they assume. Often millions of dollars are spent on trials that have to be abandoned, because the medications that undergo testing are not significantly effective or are found to cause serious side effects in humans.  Without pharmaceutical company development of new drugs that meet the standards that are required for FDA approval, many diseases and conditions would remain untreated and we would all suffer. (Lack of special designer clothes would obviously not have the same effect!)

There were several reasons that pharmaceutical companies were granted broad based legal protections in the mid-20th century.  There was a valid concern that counterfeit drugs would be “palmed -off” to unsuspecting patients (and even their pharmacies) if they had the same appearance and packaging as brand-name drugs. At some point, the Third Circuit Court of Appeals upheld trade-dress protection because near-identical pills would facilitate the practice of “unscrupulous pharmacists” in “substituting less expensive generic drugs for the brand name drugs prescribed without informing their customers and without passing along the benefit of the lower price.” The courts also felt that allowing trade-dress protection served a public health function by preventing the substitution of one drug that was similar but not identical to another.

The 1997 FDA guidelines for expanding direct -to -consumer advertising of prescription drugs also made the images of pills more important to the drug companies. An example is sildenafil (you know it as Viagra, that diamond shaped light blue pill.) We all know about that “little blue pill”…it has become a stand up cultural phenomenon.

But now, that legal protection has begun to unravel. In 2003, there was a legal dispute about Adderall, a medication prescribed for children with attention deficit-hyperactivity disorder. The company that first produced it in 1996 stated that the color, shape and size of various doses helped children adhere to their prescribed regimens. When a generic company (Barr) tried to copy these color schemes the court agreed to let them; after all the original company (Shire) had claimed the importance of the color trade dress.  In the tradition of “if you can’t beat them join them” over the last 5 years, brand-name pharmaceutical companies have begun to license their trade dress to the manufacturers of authorized generics. And (for a price), some generics look the same as the name brand.

The suggestion offered by the authors of the article in NEJM seems to be truly appropriate: “Instituting a more consistent and organized system of pill appearance would increase patient adherence, reduce the complexity of medical regimens, reduce medication error, and encourage the rational use of bioequivalent generic drugs.”  I would also suggest that you bring in your bottle of current drugs so that your doctor or nurse can check the name, dosage and directions for use. None of us should rely on color, shape, aroma or flavor to identify a medication… No matter what it now looks like, it should be taken as directed.

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 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.

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.

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