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Cardiovascular Disease and Stroke
Photo by Brenda Washington www.bjw-photo.com
Heart disease is by far the major cause of death for women in the United States. We've already noted that breast cancer is responsible for 40,000 deaths in the US each year. Consider this—heart disease is responsible for 489,000 deaths in the U.S. each year. Strokes, which have many of the same risk factors of heart disease, are responsible for another 100,000 deaths in women each year. The table below lists the major causes of death in the U.S. for year for the year 2000 – just in women.
- Heart Disease 489,000
- Strokes 110,000
- Lung Cancer 79,560
- Breast Cancer 40,410
- Ovarian Cancer 16,210
- Uterine Cancer 7,310
- Cervical Cancer 3,710
Most studies reveal that women have a far different perception. In one major U.S. Study published the Archives of Family Medicine (Volume 9, No. 6, June 2000) by Mosca L, Jones WK et al. only 8% of women identified heart disease and strokes as their greatest risk of mortality despite the fact that over 50% of women will die of heart disease and strokes.
According to the Department of Health and Human Services one in three women dies of heart disease alone while one in 30 women die of breast cancer. In an AHA (American Heart Association Study (2005) only 55% of women are aware that heart disease is the leading cause of death among women while only 20% of women identified heart disease as the greatest health problem facing women today.
For more information about this government study visit the following website:
www.nhlbi.nih.gov/health/hearttruth/press/nhlbi_04_women_disease.htm
Another excellent study by the Centers for Disease Control can be found at:www.cdc.gov/women/lcod.htm
So the bottom line is this—for most women visiting their gynecologist for a routine annual exam and are not having gynecologic problems it may be more worthwhile to discuss your risks for heart disease and strokes than your risk of cervical, uterine, breast and ovarian cancer. And the reason is simple—the average woman is at far great risk for heart disease and strokes than those 4 cancers combined!
What are the risk factors for heart disease and strokes?
Both heart disease and strokes are related inasmuch as both are diseases of small to medium sized blood vessels. With most forms of heart disease the coronary arteries that supply the heart muscle are narrowed. With most forms of "stroke" it is the small and medium sized blood vessels to the brain that are similarly affected. These vessels become clogged with plaque and don't allow blood to flow freely and carry oxygen to these vital organs.
We know that there are certain risk factors—some of them we can manage while others are beyond our control. We'll start with those factors that you can't modify or control:
·Advancing age—83% of people who die of coronary artery disease are over 65.
·Gender—women are at lower risk than men. You picked the right gender!
·Family history—if you have a strong family history of cardiovascular disease—first degree relatives (parents or siblings) who were younger than 50 when they were diagnosed—your risk is increased
·Race—African Americans have a higher risk of hypertension and diabetes compared to caucasians.
Now for the risks you can modify and control
·Hypertension—In addition to increasing your risk of heart disease and strokes, hypertension also increases your risk for congestive heart failure and renal failure.
·Abnormally high blood lipids (cholesterol and triglycerides)—this includes LDL cholesterol ("bad cholesterol") as well as another common lipid (or fat) call triglycerides.
·Obesity—Women who have excess weight, especially around their waist, are more likely to develop heart disease and strokes even if they have no other risk factors. Excess weight causes an increased work load on the heart, lowers good cholesterol and raises bad cholesterol and triglycerides. Being overweight also increases your blood pressure.
·Smoking—In general, smokers have 2-4 times the risk of cardiac disease compared with non-smokers.
·Physical inactivity—Regular moderate to intense exercise reduces your risk of heart disease, strokes and diabetes. Exercise also helps to lower your cholesterol.
·Diabetes—About 75% of diabetics will die of some form of blood vessel disease—heart attacks, strokes and kidney failure. Even well-controlled diabetics have a markedly increased risk for developing heart disease and strokes.
·Stress—Stress produces many deleterious effects on one's health. People under stress are more likely to sleep poorly, overeat and not exercise. The long term effects of stress are profound and beyond the scope of this brief discussion.
·Excessive alcohol consumption—Alcohol, in excess, can raise blood pressure, contribute to elevated triglycerides, obesity and abnormal heart rhythms.
Where can I read more about heart disease in women?
www.womans-health.net
familydoctor.org/287.xml
www.womenheart.org/
www.americanheart.org/
Hypertension
Hypertension (HT) is a largely silent disease until its late stages. Nearly 50,000 Americans died in 2002 as a result of HT and it was a major contributing cause of mortality to over 260,000 Americans that year.
As many as 65 Million Americans over the age of 60 have hypertension and one in three adults has the disease! Thirty percent of Americans with hypertension don't know they have it and 11% of those that have it (and know it) aren't on any form of therapy. Many women with hypertension are on inadequate therapy and only 1/3 Americans with hypertension are being adequately treated for it!
Hypertension, or blood pressure elevation, occurs in 30-40% of African American women and 20% of white women. The prevalence of this disease rises to over 90% of women after the age of 70.
Hypertension is truly a silent killer. Women may be hypertensive for many years until its cumulative effects are apparent—heart disease, strokes, kidney disease and blindness. Unfortunately most women in this country go untreated. Despite the fact that 90-95% of cases of hypertension are caused by unknown factors, it remains, in most cases, an easily treated condition and responds well to dietary changes, exercise and medications.
How do you diagnose hypertension?
A normal blood pressure reading contains two numbers: a diastolic and systolic reading. Normal diastolic blood pressures are 80 mm Hg or less, while normal systolic readings are 120 mm Hg or less. If you diastolic blood pressure is between 80-90 or if your systolic blood pressure is between 121-138 you are considered pre-hypertensive and you should get medical help to control this mild condition before it worsens. If your diastolic is consistently above 90 and your systolic is consistently above 140 you have hypertension. Many women balk at being told that they have hypertension and quickly point out that they are anxious in doctor's offices and that they have "white coat syndrome". Unfortunately, most of them are wrong. I usually point out that if they are hypertensive in a doctor's office that there are plenty of other aggravating events in their lives that likely make them hypertensive as well—waiting at an intersection for a light to change, arguing with their co-workers, husband and teen-age children are just a few examples. The point is this—no one likes to be told that they are hypertensive. But ignoring the issue only delays treatment and causes damage to one's heart, brain, kidneys and eyes.
Are all women with hypertension at equal risk for developing disease?
The simple answer is no. Hypertension is just one of many risk factors that can lead to heart attacks, strokes, congestive failure, kidney and retinal (eye) disease. If you have any other risk factors—smoking, obesity, diabetes, underlying kidney disease or elevated cholesterol you need to have any hypertension treated aggressively.
What causes hypertension?
The answer is a complex one. For the most part physicians don't understand the causes of most cases of hypertension. However we know that blood pressure elevation can be caused by the following:
- Diets high in salt
- Diets low in potassium
- Diets low in fruit, vegetables and dairy products
Diets high in fat and cholesterol
Moderate drinking (more than 2 beverages per day)
Genetic component
Lack of physical exercise
Kidney disorders
Sleep apnea
Hypo and hyperthyroidism
Adrenal tumors
Excessive serum calcium
If I have hypertension can I be helped?
Absolutely! We will ask you to be a partner in your own health care. That means purchasing a home blood pressure cuff , or other monitoring device, to track your own blood pressure and keep a log over an extended period of time. It also means committing to an exercise program, eliminating added salt to your diet, avoiding excess alcohol and well as making a variety of other life-style changes. Additionally, you may require medication to bring your blood pressure under control. Most of the medications that are available today have few if any significant side effects—and many of them are available in generic form which makes them more affordable. You will need to be monitored on a regular basis – every 3 or 4 months in most cases—so that we know that you are maintaining good blood pressure control
Elevated Lipids (cholesterol and triglycerides)
Cholesterol:
In 2006 the American Heart Association reported that 51 Million women in the U.S. had elevated cholesterol levels. In general, elevated cholesterol levels increase the risk for heart disease, strokes and kidney disease, which is exactly why we need to learn more about it.
Cholesterol is a soft, waxy substance found in your blood and in all of your body's cells. Cholesterol is important in forming the sheaths that surround nerves and also in the production of bile acids that are necessary for digestion. In addition to all that, cholesterol is a precursor to the production of estrogen, progesterone, and testosterone (yes, women need testosterone too!).
Cholesterol is normally made in the liver (about 1000 mg/day) and virtually all the cholesterol we require is made there. Unfortunately, we also get a lot of cholesterol from the foods we eat. In fact, the average American woman consumes over 200 mg/day in dietary cholesterol. Men generally consume more! Too much cholesterol is a major risk factor in the development of arterial narrowing—atherosclerosis—which leads to heart attacks, strokes, kidney disease and blindness.
Because cholesterol is a fat it can't dissolve in your blood (remember oil and water don't mix!). Cholesterol, therefore, gets transported through the bloodstream by attaching itself to a special "carrier" protein known as a lipoprotein. There are several kinds of lipoproteins, but for the purpose of our discussion we'll focus on two—LDL (low density lipoprotein) or "bad" cholesterol and HDL (high density lipoprotein) or "good" cholesterol.
We have known for many years that plaque, the fatty substance that narrows arteries, is composed of a variety of fatty substances, among which are LDL cholesterol and triglycerides.
LDL (Low density lipoprotein) cholesterol—"bad cholesterol"
Low density lipoprotein (LDL) is the major carrier of cholesterol in the blood stream. If too much of the LDL cholesterol circulates in the blood stream it can build up and cause narrowing of the small and medium sized arteries leading to heart disease, strokes, kidney disease and blindness. Together with other substances LDL cholesterol can form what is known as "plaque"—a thick hard deposit that narrows the blood vessels. Oftentimes, areas of plaque formation stimulate a thrombus (or clot) to form thereby completely cutting off blood supply to the affected tissue. If this happens in the heart it causes a "heart attack". The same process occurring in the brain is called a "stroke". In both cases the tissue being supplied by that artery is being blocked and starved of oxygen and nutrients.
HDL (High density lipoprotein) cholesterol—"good cholesterol"
About 25 – 35% of blood cholesterol is carried by high-density lipoprotein. This cholesterol seems to protect against heart attack. Researchers believe that HDL cholesterol carries cholesterol away from the arteries and back to the liver. For this reason some doctors have referred to HDL cholesterol as the "janitors" of the blood stream. High levels of HDL cholesterol have been shown to be protective against heart attacks and strokes.
The current status of medicine is such that we have more tools to lower bad cholesterol than to increase good cholesterol (HDL). Most of the medications available to us ("statins") lower LDL cholesterol with little effect on HDL cholesterol. There is some evidence that small quantities (one drink for women) of alcohol may be helpful. But be careful—large quantities of alcohol are definitely harmful! Hormone replacement therapy (HRT), if appropriate, can raise HDL cholesterol, but this may be offset by other disadvantages of HRT.
But the news here isn't bad. While we may not yet be able to raise HDL cholesterol significantly there's a great deal we can do, by working together, to sharply decrease your risk for a heart attack or stroke.
How does my diet affect my cholesterol?
Or 
?
We all get cholesterol from two different sources: our diet and what our liver makes. As I've mentioned earlier healthy livers make about 1000 mg of cholesterol a day. We also get cholesterol from the foods we eat. Most cholesterol comes from animal sources—egg yolks, meat, fish, poultry, seafood, and whole milk dairy products. Foods from plants (nuts, grains, seeds, fruits and vegetables) don't contain cholesterol. The average American man consumed about 337 mg of cholesterol per day while the average woman consumes a little more than 200 mg per day. The American Heart Association recommends that you limit your cholesterol intake to 300 mg/day. However, if you are at risk for heart disease for other reasons (smoking, hypertension, family history, etc) you might consider limiting your intake even further. For specific recommendations please discuss this with your health care provider at our office.
How does exercise affect my cholesterol?
Regular physical exercise increases HDL cholesterol in some people. Whether or not it will affect your cholesterol in particular will need to be determined. However, since the goal is to lower your risk of cardiovascular disease and stroke, exercise is an important component of avoiding atherosclerosis and the risks of heart disease and stroke.
What about cholesterol and smoking?
Smoking tends to lower good cholesterol. Apart from that smoking is one of the major independent risk factors for heart disease and strokes.
When should my cholesterol be checked?
The National Institute of Health (NIH) recommends that women have their first cholesterol screening test at age 20. We will generally screen women according to their overall risk factors for cardiovascular disease. Among the issues we consider in determining how often to check your serum cholesterol are:
- History of smoking
- Alcohol abuse
- Strong family history of cardiovascular disease and/or strokes
- Hypertension
- Obesity
Women at very low risk may be screened once in every 3-5 years. Women on cholesterol lowering medications will require more frequent screening.
What's a normal cholesterol level?
Generally speaking women at low risk for cardiovascular disease should keep their total cholesterol level below 200 mg/dL, their LDL cholesterol below 130 mg/dL and HDL cholesterol at least 50 mg/dL.
If women have one or more risk factors noted above we recommend that the LDL cholesterol remain below 100 mg/dL. For women with multiple risk factors for heart disease and strokes we often suggest that the LDL cholesterol be kept under 70 mg/dL.
If I have an elevated cholesterol level what can be done about it?
Fortunately, there are a great many things that can be done to improver your cholesterol level. The goal is more than getting your "numbers" in the proper range. The real goal, after all, is to lower your changes for heart disease, strokes, kidney disease, blindness and their effects of atherosclerotic plaques.
There are many ways, other than medication, to lower your cholesterol and overall risk of atherosclerotic plaque formation.
Exercise and weight loss!
The relationship between cholesterol and exercise has more to do with weight control than the exercise itself. However, it has been shown that in many individuals exercise itself raises HDL (good) cholesterol.
I see many women day in and day out that find theirselves at age 30 with a 5 or 10 pound weight gain since their last annual exam. They don't understand why. Many insist that it's their birth control pills. Others insist that they are probably hypothyroid. In most cases they're wrong. For the vast majority of us, the same level of eating and lifestyle after the age of 25 – 30 leads to weight gain. The truth is that we live in a very sedentary society. As residents of Western New York we don't get out much between November and April (almost half the year!). We have stressful jobs, but most of it involves sitting at a computer or standing in one place for long periods of time. The fact remains that as we age our metabolism slows down. At age 20 you may be able to "eat whatever I want" and get away with it—but for most of us that's a short-lived luxury. As we age, unless we modify our diet and establish a regular exercise routine, we find ourselves gaining weight. MAKE AN APPOINTMENT WITH YOURSELF! Just as you set aside time to shop, watch your favorite TV program or answer e-mails, set aside 45 minutes or more at least 5 times a week and work up a sweat. If you're 30 years old walking on a treadmill with a zero degree incline for 15 minutes is not exercise—its self-delusion. You need to get your heart rate up and break a sweat. Come in or call so we can specifically address this issue with you.
win.niddk.nih.gov/publications/for_life.htm
Dietary changes—Years ago researchers assumed that dietary cholesterol in such foods as meat, eggs, cheeses and whole milk was the main culprit in hypercholesterolemia. As our knowledge of cholesterol and heart disease improves we are beginning to understand that other dietary factors such as saturated and trans fats also play a key role in elevating one's cholesterol. Saturated fats are found in meats, whole-fat dairy products and eggs. Trans fats are frequently found in an artificial form contained in hydrogenated oils found in margarine and many commercial baked goods and processed foods. The New York City Board of Health voted unanimously in December 2006 to phase out the use of artificial trans fat from all NY city restaurants by July 2008.
www.nyc.gov/html/doh/html/pr2006/pr114-06.shtml
For a thorough discussion about what foods are rich in trans fat check the following website:
www.fda.gov/FDAC/features/2003/503_fats.html
The majority of Americans get their trans fats not from animal sources, but from cakes, cookies, crackers, pies and breads. It appears that high cholesterol levels are an unfortunate result of the luxuries of modern life
Stop smoking! Seriously….quit! It will not get easier than right now—except if you're in the midst of a major personal or family crisis. But unless you've just lost your job, a family member, find yourself in the midst of breaking up a long-term relationship or caring for a sick family member you need to ask yourself if there's really a better time to quit than right now. Life is stressful and smoking relieves that stress. Also, many women continue to smoke because they know it helps them control food cravings and allows them to keep their weight down. The problem is that smoking has devastating side effects. There are better ways to control your stress and your weight.
Medications --Despite your best efforts you may find that you are unable to significantly lower your total or LDL cholesterol with diet and exercise alone. There are several situations when you might be asked to seriously consider the use of a medication to lower your cholesterol in order to reduce your overall risk of coronary heart disease and strokes. These circumstances include:
Age —Women 55 years or older.
Family history — You have a father, brother or son with a history of coronary heart disease before age 55, or a mother, sister or daughter with coronary heart disease before age 65.
Smoking — You smoke or live or work every day around people who smoke.
High blood pressure — Your blood pressure is 140/90 mm Hg or higher, measured on two or more occasions.
HDL cholesterol — Your HDL cholesterol level is less than 40 mg/dL.
Diabetes — Your fasting blood sugar is 126 mg/dL or higher.
There are many cholesterol-lowering medications available—you can't tune in to the evening news without stumbling onto the more heavily advertised ones.
Statins: These drugs work in the liver and are very effective in lowering LDL (bad) cholesterol. They have few short-time side effects and their long-term profile appears to be excellent. Despite their excellent safety, the decision to take any medication needs to be weighed against the potential harm of not taking that medication. Among the more common statins are Lovastatin (Mevacor), Simvistatin (Zocor), Atorvastatin (Lipitor), Fluvastatin (Lescol), Rosuvastatin Calcium (Crestor) and Pravastatin (Pravachol)
Clofibrate (Lopid): This drug raises HDL cholesterol and lowers triglycerides.
Nicotinic acid (Niacin): It's important to distinguish FDA-controlled nicotinic acid from that found in health food stores. Unfortunately, health food store preparations are unregulated and may contain more or less than the amount prescribed. Nicotinic acid is available in several prescription forms (Niaspan, Euduracin). The major indication for nicotinic acid lies in its ability to increase HDL cholesterol.
For more information please check the following websites.
www.americanheart.org/presenter.jhtml?identifier=4488
Triglycerides
What are triglycerides and what do I need to know about them?
Triglycerides are a type of fat. Most fat in foods, and in your body, takes the form of triglycerides. In summary, we "consume" triglycerides whenever we eat fat, store triglycerides (in fat cells) when we get "fat" and "burn" triglycerides (from fat cells) when we expend more calories than we ingest.
Triglycerides (TGs) are closely related to eating and the kinds of foods we eat. TGs rise dramatically after a simple-carbohydrate-rich meal—especially simple sugars and alcohol.. This is because sugars not used immediately for energy will be converted to triglycerides and stored as fat.
Some research has shown that people with above-normal triglyceride levels are at increased risk for heart disease. They're also likely to have high total cholesterol, high LDL, and low HDL--all risk factors for heart disease.
What's a normal level of triglycerides?
First of all, please remember that a triglyceride level is measured accurately only when you've been fasting for 8-12 hours.
- Normal triglycerides ≤ 150 mg/dL
- Borderline high 151 – 199 mg/dL
- High 200 – 499 mg/dL
- Very High ≥500 mg/dL
Do elevated triglycerides cause heart disease and strokes?
We do know that elevated triglycerides are linked to other abnormally elevated lipids and this may be responsible for the association between hypertriglyceridemia (elevated triglycerides) and coronary heart disease and strokes. We don't know with certainty that elevated triglycerides are an independent risk factor for coronary artery disease and strokes.
What are the causes of triglyceride elevation (hypertriglyceridemia)?
Triglycerides levels can rise to abnormally high levels when someone eats a diet rich in carbohydrates (starches, sugar and alcohol) and/or saturated fats. This is especially true in women who are obese and don't exercise. High triglyceride levels are also found in the following:
- Diabetes
- Kidney disease
- Familial dyslipidemias (genetic)
- Hypothyroidism
- Estrogen replacement therapy
- Tamoxifen
What are the recommendations if my triglycerides are elevated?
The answer is that it depends on your other risk factors for heart disease and strokes as well as how elevated.
With triglycerides in the 151-199 mg/dL range most experts emphasize weight reduction and increased physical activity.
When triglycerides are in the 200 – 499 mg/dL range emphasis is generally placed on lowering LDL cholesterol first, followed by the addition of nicotinic acid or fibrates, such as Lopid.
When triglycerides are over 500 mg/dL emphasis is placed in preventing pancreatitis by lowering triglycerides with a combination of non-drug therapy as well as the careful use of fibrates and nicotinic acid.
What are some ways I can lower my plasma triglycerides without medications?
- Reduce saturated fat
- Reduce the intake of simple carbohydrates (sugars and alcohol)
- Start a regular exercise program
- Control diabetes
- Control your blood pressure
- Control you "bad" (LD) cholesterol
- Fish oil
There is evidence from multiple large-scale studies that intake of recommended amounts of DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid) in the form of dietary fish or fish oil supplements lowers triglycerides, reduces the incidence of heart attacks and heart rhythm disturbances, slows the buildup of arterial plaques and lowers blood pressure. I often recommend fish oil supplements. Many brands are available at pharmacies, grocery and health food stores. I recommend 2-3 grams per day of fish oil supplements with omega-3 fatty acids.
Obesity
Two–thirds of American adults are overweight with one out of three considered obese. We are now witnessing a health care epidemic. Between 1976–1980 and 2003–2004, the prevalence of obesity among adults aged 20–74 years increased from 15.0% to 32.9%. The problem cannot be overstated. In my opinion we will soon witness the first decrease in life expectancy in the United States since 1900. If current trends are not reversed we can expect to see an increase in early deaths due to diabetes, hypertension, heart disease and strokes. Presently 300,000 deaths per year are linked to obesity.
Obesity is generally defined as having a body mass index (HMI) of 30 or greater. One is considered overweight with a BMI or 25-30.
Weight is largely determined by the balance we strike between the calories we take in from food and the energy we expend during our daily activities. If we take in more calories than we use the unused calories get stored as fat.
What are the risk factors?
Diet. The regular consumption of foods that are calorie-rich, frequently found in fast foods, fatty foods, soft drinks, candies, deserts are the general culprits. The average American skips breakfast and often eats the bulk of their calories late in the afternoon and evening. This provides a cycle of fasting and binging which is another problem with the average American's lifestyle.
Inactivity and lack of exercise. Sedentary people are more likely to gain weight because they don't burn calories through physical activities.
Psychological factors. A lot of women don't realize that they eat when they're not actually hungry. Many women overeat to cope with daily stresses or to deal with difficult emotions. Some women eat out of boredom.
Genetics. If one or both of your parents are obese, your chance of being overweight is greater. Your genes may affect your chances of becoming obese and even where fat is distributed. But a family history of obesity does not mean that you have no ability to control your weight.
Age. The older we get the less active we become. Muscle mass also declines with age (especially without exercise). Since muscle mass is related to calorie consumption, the loss of muscle mass also slows down our metabolism and increases our chances of gaining weight. Again, this doesn't mean that we're helpless. It does mean that in order to prevent weight gain we have to take a disciplined approach to exercise.
Cigarette smoking. Many women smoke in order to control their food cravings and maintain their weight. When you quit smoking you're at greater risk for gain weight. Why? Nicotine, apart from suppressing your appetite, increases your metabolic rate. With smoking cessation (unfortunately) your appetite may increase along with your slowing metabolic rate. The net result is that when smokers stop, they burn fewer calories and often gain weight. However, cigarette smoking is still considered a greater threat to your health than the extra weight.
Pregnancy. During pregnancy a woman's weight should and does increase. Some women find this weight difficult to lose after the baby is born. This weight gain may contribute to the development of obesity in women.
Medications. Corticosteroids and tricyclic antidepressants, in particular, can lead to weight gain. So can some high blood pressure and antipsychotic medications. Depo-Provera has been associated with some weight gain. Birth control pills, on the other hand, are not associated with significant weight gain. While this may have been true of oral contraceptives in the 1960s and 70s this argument doesn't pertain to today's very low dose pills, contraceptive patches and rings.
Medical problems. Uncommonly, obesity can be traced to a medical cause, such as low thyroid function, excess production of hormones by the adrenal glands (Cushing's syndrome) or other hormonal imbalances, such as polycystic ovary syndrome. A low metabolic rate is rarely a cause of obesity. A medical problem, such as arthritis, can also lead to decreased activity, which can result in weight gain.
Alcohol. Many women are surprised to learn that just one regular beer contains about 150 calories. Many people are unaware that the calories in 2 glasses of wine taken every day can add up to some serious weight gain over the course of time. Additionally, excessive drinking can stimulate your appetite and make you less likely to control portion sizes.
When should I seek medical advice?
BMI (Body Mass Index)
Unfortunately, few women actually seek medical advice regarding their weight and most have no idea what their BMI is. The BMI is not a perfect tool. It doesn't make allowances for women with a high muscle mass—unfortunately unless you're a weight lifter this probably doesn't apply to you.
If you're BMI is between 19 and 24 you're considered in a healthy weight range for your height. At a BMI between 25 and 29 you're considered overweight and with a BMI of 30 or greater you're considered obese. If you're in the latter two categories it's a least worthwhile getting some advice.
Waist Circumference
Weight distribution varies from one person to the next. Some women carry most of their weight around their hips, thighs and lower body and are "pear shaped". Others carry most of their weight in their upper body and waist and are "apple shaped". When it comes to your overall health it's better to be "pear shaped". Women with a waist over 35 inches have an increased incidence of various serious diseases including hypertension, diabetes, heart disease and the metabolic syndrome. So if you're apple shaped with a BMI over 25 you are even more compelled to lose weight!
Weight-related medical condition
A BMI over 25 increases your risk for hypertension, hypercholesterolemia, diabetes and arthritis. These conditions often improve (and even disappear) with weight loss.
Life-style issues
If you smoke, drink excessively and have a sedentary lifestyle coupled with a great deal of personal stress take action sooner rather than later. This is not a problem that gets better by itself.
Think about this
There are no magic pills or quick fixes to accomplish weight loss. Obesity, whether mild, moderate or severe is a national epidemic. Changing your weight is one of the most challenging things you can do and requires a tremendous commitment to an ongoing lifestyle change. Your weight is an important factor that will affect your risk of heart disease, strokes, diabetes, arthritis, sleep apnea, gall bladder disease, "fatty liver", gout and even cancers (breast, colon and uterine).
The good news is that even modest weight loss can fix a world of ills—lower your blood pressure, lower your cholesterol, improve your diabetes, sleep apnea and arthritis. It can even lower your risk for developing some cancers. For many people the loss of 10 lbs is the difference between taking blood pressure medications or statins for their hypercholesterolemia. The best weight loss happens, not with crash diets that are not sustainable, but with slow and steady lifestyle and dietary changes. Exercising is an invaluable part of a weight loss regime. Don't even start by saying you don't have the time. Make an appointment with yourself at least 4 times a week for an hour and exercise.
Getting started on a weight loss program
There are many ways to successfully lose weight and there are many ways to fail. The best way to get started, in most cases, is to get some help. Start with your health care provider to put this issue in its proper perspective. Some women who think they have a weight problem don't. Still others are quite naïve about the degree of the problem they do have and how it's affecting their overall quality (and quantity) of life. If you've tried losing weight on your own and have not succeeded call and schedule an appointment. We can get you pointed in the right direction. You might be interested in some of these websites:
www.consumer.gov/weightloss/setgoals.htm
www.cnn.com/HEALTH/library/HQ/01625.html
exercise.about.com/cs/weightloss/a/weightsuccess.htm
Smoking Cessation
Smoking increases your risk for heart disease, strokes, chronic obstructive pulmonary disease (emphysema or COPD), lung cancer, cataracts, macular degeneration (which causes blindness), Graves disease, thyroid cancer, cancers of the lips, mouth, throat and larynx (voice box). Smokers also have an increased risk of other cancers including esophageal, stomach, kidney, bladder, skin and pancreatic cancer. Apart from cancer smoking causes premature aging of the skin and increases your risk for peptic ulcer disease.
According to the CDC between the years 1997-2001 "The three leading specific causes of smoking-attributable death were lung cancer (123,836), chronic obstructive pulmonary disease (COPD) (90,582), and ischemic heart disease (86,801)."
www.cdc.gov/mmwr/preview/mmwrhtml/mm5425a1.htm
There are many, many other reasons to quit if you're a woman. Smoking has potentially devastating effects on fetal well-being for women who smoke during pregnancy. Smoking increases the likelihood of stillbirths, low birth weight infants, premature births and even sudden infant death syndrome (SIDS). Smoking is associated with an increased risk of cervical cancer, osteoporosis and urinary stress incontinence.
Smoking is deadly and is responsible for the deaths of nearly 430,000 people a year--more lethal than AIDS, automobile accidents, homicides, suicides, drug overdoses and fires combined!
Smoking diminishes the quantity and quality of life. On average, female smokers reduce their life from by 14.5 years! Apart from that, smoking also decreases the quality of life and is associated with many disabilities.
The smoke contained in cigarettes contains tar along with many other inhaled chemicals. Some of the chemicals are known carcinogens—cyanide, benzene, formaldehyde, methanol, ammonia and acetylene.
No wonder the U.S. Surgeon General has stated" Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of their lives."
No matter how old you are right now you can improve your life expectancy by quitting. Quitting before the age of 50 reduces by half your risk of dying in the next 15 years. Former smokers also have a reduced rate of bronchitis and pneumonia.
Why is quitting so tough?
The answer is nicotine. Nicotine is a drug naturally found in tobacco. It is highly addictive. Arguably, nicotine is more addictive than heroin and cocaine. Nicotine causes a real psychological and physical dependence in exchange for a temporary pleasant and calming sensation for most smokers. As the nervous system adapts to nicotine, smokers tend to increase the number of cigarettes they smoke in order to overcome to the tolerance they develop.
When smokers try to cut back or quit, the absence of nicotine leads to withdrawal symptoms. These include dizziness, depression, frustration, anger, irritability, sleeplessness, headaches, restlessness, fatigue, an increased appetite. No wonder Mark Twain once said "quitting smoking is easy. I've done it a thousand times."
Why should I quit?
The simple answer is "your health". The Centers for Disease Control (CDC) estimated that the average female smoker loses 14.5 years of life!
Smoking is related to a long list of cancers (see above), progressive non-cancerous lung diseases (chronic obstructive pulmonary disease) and other diseases that dramatically shorten life expectancy. In all age groups smokers are twice as likely to die of a heart attack as non-smokers. Smoking also dramatically increases the risk of strokes and peripheral vascular disease. Just as smoking narrows medium and small blood vessels it also causes narrowing of the large blood vessels to the arms and legs.
There are plenty of other reasons to quit too. There are many workplace restrictions today on smoking. Some employers may not hire you if you're a smoker. Public buildings, hospitals, concerts and sporting events all have restrictions on smoking. New York State doesn't allow smoking in restaurants and bars. In the last 10 years smoking has gone from being socially acceptable to unacceptable. With evidence mounting against second-hand smoke you also have the health of others to consider—especially if those "others" are your children or loved ones. If you have children you need to think about setting a good example for them too. And if that isn't enough consider this—you'll pay twice as much for life insurance if you're a smoker.
Lastly, many work places from large corporations to small businesses are beginning to require not only smoke free environments on the job but that you lead a healthy lifestyle. Some businesses go so far as "drug testing" to see if you are "smoke-free". This issue is still working its way through the court system to determine whether or not it's legal for businesses to do so. In the meantime, business have fired smokers and refused to hire them.
Common reasons for not quitting
It's stressful—this may "lead the pack" in realistic reasons that women don't want to quit. Nicotine does cause psychological and physical dependence.
I'll gain weight—no question this happens in most cases. In every case the cigarettes are worse for you health than the weight gain. Deal with one problem at a time. Expect to gain some weight and then make sure that your next lifestyle change you will address are the issues of diet and exercise.
I worry about the side effects of medications—not all women who quit require medications. But even if you're taking medications remember that whatever side effects they may have (a) you're not going to taking them for the rest of your life and (b) they are far less risky to your health than cigarettes!
I can't afford the medications—that's ridiculous! Consider that a pack of cigarettes are now costing 5-7 dollars a pack. If you're smoking a pack a day that's $1800 – 2500 dollars per year! You can pay for your medications and still have a lot of money left over. Landlords may not rent to you and friends may not allow you to smoke in their homes.
Now is not a good time—perhaps you're right about this one. If you're in the midst of a divorce, a legal action, mourning over the loss of a loved one or dealing with an acutely sick family member or job loss it might be best to put this decision off for a few weeks or even a few months. But don't use this as a chronic excuse. In most cases there's never a better time than right now.
How do I get started?
There is no one right way to quit. Success has come from "going cold turkey", acupuncture, hypnosis, nicotine replacement (lozenges, patches, gum), bupropion (Zyban or Wellbutrin) and verenicline (Chantix). And all of these methods have failed.
The key elements of successfully quitting involve four crucial steps:
- Make a decision to quit
- Set a quit date, and choose a quit plan
Manage withdrawal
Maintain success
Learn more about ways to quit by visiting the American Cancer Society's "Kick the Habit" web page:
www.cancer.org/docroot/PED/ped_10_3.asp
Generally speaking smoking cessation requires a combination of approaches—behavioral and often medical. There is no single and simple approach for most people.
The American Cancer Society web-link above is a great resource. Additionally,
New York State has a great many resources available to its residents through the following link:
www.nysmokefree.com/newweb/default.aspx
If you need help here are some resources available in Monroe County
American Lung Association 1595 Elmwood Avenue 585-442-4260
Rochester NY 14620
Greater Rochester Area 220 Alexander St. Suite 409 585-530-2050
Tobacco Treatment Center Rochester NY 14607
Medications you should be aware of
We are not advocating the use of medications as a "one size fits all approach". However, many women have found medications very helpful for them while others experience no relief from nicotine withdrawal whatsoever. As of this writing Chantix has recently been approved by the FDA and we are just now getting more experience with this particular medication.
Some commonly used medications are:
Nicotine Replacement Therapy (NRT)—The AHA (American Heart Association) believes that nicotine replacement in the form of patches, lozenges, spray, inhaler and gum can help smokers quit as part of a comprehensive approach to smoking cessation. NRT almost doubles the chances of someone being able to successfully quit smoking. As already noted nicotine is a very addictive substance whose withdrawal leads to irritability, depression, food cravings and headaches. Learning the skills to quit smoking while dealing with nicotine withdrawal just makes it harder to successfully quit.
If you're planning on using NRT it's best to select a "quit time" for smoking cessation and plan the use nicotine replacement immediately. Remember that symptoms of nicotine withdrawal start in hours after smoking cessation. If you are using NRT use it consistently in the beginning and not just "every now and then". Some experts even advocate a combination approach to NRT such as using a patch as a form of baseline suppression along with lozenges, gum or spray when cravings become more acute.
If you're pregnant or have heart disease you should have a thorough discussion with your health care provider before using NRT.
What about smoking while taking NRT? It's not unusual, in the early stages of cessation for someone to smoke a few cigarettes while using a nicotine patch or other forms of NRT. If you're smoking only 2-3 cigarettes per day it's okay to use the NRT with the understanding that your goal is stop smoking completely in a short period of time. However, if you find yourself smoking as much as you did before attempting to quit you should stop taking NRT and consult your health care provider.
Bupropion (Wellbutrin, Zyban)
Buproprion has a long history as a very useful adjuvant to smoking cessation. It can be used with nicotine replacement therapy and is generally very well tolerated provided that one starts it at a very small dose. Some women are very sensitive to this medication's temporary side effects which include rapid heart rate, jitteriness, anxiety, headache, insomnia, nausea and dizziness. If you find that you're experiencing severe side effects stop the medication but ask to be re-started at half the dose. These side effects may last 2-4 days but improve quickly thereafter. Generally, this medication is started at 150 mg and increased to 300 mg per day after a week. Some women require only a minimal dose to appreciate profound improvement in the withdrawal cravings. It is recommended that you avoid excess alcohol with this medication especially if you have alcoholism or severe depressed. Ask your health care provider, however, about alcohol use while taking Bupropion.
Bupropion is an anti-depressant in a category of medications known as dopamine-reuptake inhibitors. These medications are not sedating and do not have the sexual side effects in selective serotonin reuptake inhibitors (SSRIs). Some women are able to take bupropion for a few months and then taper themselves off the medication. Other women require bupropion for long periods of time in order to stay smoke free. Just remember that the long term use of bupropion is safe—that's not true of cigarettes.
If you are taking bupropion you can minimize any sleep disturbance by taking it first thing in the morning.
Varenicline (Chantix)
Chantix was introduced by Pfizer in May of 2006 and is currently a less well known drug. As with any new drug its true effectiveness over a long period of time has not been studied on large populations. It has two mechanisms of action. First it mimics the effects of nicotine on the brain and helps stave off nicotine cravings. When used with nicotine it blocks some of the pleasurable effects of smoking. In clinical trials the main side effect was nausea (40%). Other significant side effects are insomnia (18-19%), headaches (15-19%) and abnormal dreams (9-13%). Many of the side effects can be reduced by starting at a low dose and gradually increasing the medication to a maintenance dose.
For the first week Chantix is taken at the dose of 0.5 mg per day for 3 days, followed by 0.5 mg twice a day for the next 4 days. That completes the first week on Chantix. Thereafter Chantix is taken at the dose of 1.0 mg twice daily for another 11 weeks. The total treatment program is 12 weeks though it has been approved for longer use in patients who have successfully quit.
Osteopenia and Osteoporosis Screening
Photo by Brenda Washington www.bjw-photo.com
Osteoporosis, the most common bone disease in the U.S., is becoming more prevalent as an increasing number of women are living into their eighties and beyond. Currently there are 44 million Americans with osteoporosis—80% of them are women. Fifty percent of women will be affected by this disease and are at greater risk for a variety of fractures. Over 1.3 million osteoporosis-related fractures occur in the U.S. each year—some are asymptomatic and contribute 
only to loss of height. Other fractures (of the spinal column) are painful and disfiguring (Dowager's hump and kyphosis) causing some elderly women to appear stooped over. The distribution of osteoporosis-related fractures is as follows: half of them involve the spinal column (vertebral), a quarter of them involved the hip and the remaining quarter involve a bone in the arm called the radius (Colles' fracture).
Wrist and hip fractures are both painful and debilitating. Hip fractures, in particular, can be life-threatening, resulting in surgery, hospitalization and prolonged periods of recovery and rehabilitation. Unfortunately, many otherwise healthy women, after sustaining osteoporosis-related hip fractures, succumb to other diseases during the prolonged period of disability that follows. Deep vein thrombosis, pulmonary emboli and pneumonias are often the sequelae that befall women who had previously enjoyed excellent health. Those women who complete their recovery often suffer a loss of mobility and function once complete healing has occurred.
The incidence of fractures increases with age--the risk for white women at age 50 is about 16% (versus 5% for men). Osteoporosis and its precursor, osteopenia, are silent diseases that generally manifest themselves for the first time when someone has sustained a fracture that involved minimal trauma. Fortunately we are able to identify the early forms of osteoporosis on screening tests. Because these bone-thinning diseases can diminish the quantity and quality of life it's important for every woman to know about this silent disease, how to detect, prevent and treat it.
Osteoporosis and osteopenia can be detected with specialized scans and treated thereby preventing many of painful and debilitating sequelae to this disease.
Normal bone anatomy
Bones provide the structural support for muscles and also protect vital organs—heart, lungs, kidneys, spinal cord and pelvic organs. We often think of bones as inanimate or dead tissue because we know that archeologists have unearthed intact skeletons that are hundreds and even thousands of years old. But the truth is that bones are living, constantly changing structures made up of connective tissue (collagen) that provides a soft internal framework and calcium phosphate which provides bones with structural and weight-bearing strength.
There are 2 types of bone tissue: an outer shell called cortical bone and an inner "spongy" core called trabecular bone. These bones are constantly being injured—the result of day to day stresses that cause "micro-fractures"—and repaired. The process of injury and repair is called remodeling. In a normal adult 10-30% of the skeleton is remodeled every year.
The bone "breakdown" is caused by cells called osteoclasts which are formed from certain blood cells and are responsible for the breakdown or resorption of the skeleton. These cells dig holes in the bone and release the small amounts of calcium into the blood stream that are necessary for vital body functions. Other cells known as osteoblasts are produced by specialized bone cells and are the "bone builders". Their job is to lay down crystals of calcium and phosphates contributing the bone's strength and supportive structure. The balance of osteoclasts and osteoblasts is controlled by a complex mix of hormones and other chemical factors. Remodeling, which is the result of interplay between these two types of cells, requires calcium, vitamin D, estrogen, testosterone as well as other hormones. The repair process, in addition to requiring calcium and vitamin D, can be also be enhanced by exercise and diet. In young children and adults the rate of building is greater than the rate of resorption—the result is a net increase in bone mass. This process continues until women are in their early 30s and 40s at which point peak bone mass is achieved.
How and when does osteoporosis start?
Before you reach age 40, bone tissue breaks down and rebuilds in perfect unison. However, as we age this balance becomes out of sync, causing osteoclast cells to breakdown bone at a greater rate than the osteoblast cells can rebuild it. The breakdown of bone overtakes the buildup leading to a decrease in bone mass. Whether due to the onset of age (doctors aren't particularly sure why this occurs with aging) or the presence of certain conditions this system of remodeling (breakdown and buildup) becomes unbalanced. For some people this process is gradual and for others it's very quick--nevertheless the breakdown of bone eventually overtakes the buildup. Post-menopausal women see a greater rate of bone loss with a decrease in estrogen which helps the osteoblasts to keep working and form new bone. In some women the bone loss is mild and osteopenia results. In other women the loss of bone mass is so great that they develop osteoporosis. Left untreated bones become so weak that a sudden strain, bump, or fall causes fracture which wouldn't have happened to a person with "normal" bones.
In both osteopenia and osteoporosis outer cortical bone and inner trabecular bone is lost. The result is a thinner cortex and trabecular bone that contains larger "holes."
Understanding what it means to be "normal" or "average"
Before we can understand osteopenia and osteoporosis we need some basic knowledge of statistics. We first must understand that many human activities and features can be plotted and "averaged". For instances, we know that the "average" American man is 5'9" tall, that the average woman in this country is 5'4" and that Mr. "Average 40-year old white guy" weighs 183 pounds, while his "average" female counterpart weighs about 40 pounds less. We know that the life expectancy of the "average" male born in the year 2000 is about 74 years and is 79 years for the "average" woman. That said, we all know men and women who are very tall or short, very thin or massively obese as well as those that die young and live well into their nineties and beyond.
Even when we go to our doctor's office and have a simple blood test such as a "blood count" or a serum cholesterol we seek reassurance that we are "normal" and get very concerned about anything that falls outside the "normal range". We know, intuitively that being on one side of the "normal range"—taller than normal, stronger than normal, wealthier than normal or having a cholesterol lower than normal is (in most cases) good. We also know that having a blood pressure much higher than normal is likely to be harmful.
Many years of scientific work are often required to determine what "normal" means. It's easy to determine what "normal height" is for men and women and much more complicated to determine what a "normal" cholesterol value is. In fact, laboratories have drastically changed their definitions of "normal" over the past 30 years with respect to serum cholesterol. In the 1950s serum cholesterol under 300 mg/dL was considered "normal". Now we know that our doctor would like to see it below 200 mg/dL and lower still in men and women with hypertension or smoking. The new "normal" is based on what is harmful to your health and your life expectancy.
Because of the development of safe and inexpensive tests to determine bone density we have a means to measure the density of various bones that tend to break in the elderly –those in the wrist, hip and spinal column. By studying groups of men and women over time we also know that those men and women who are a certain percentile below normal have an increased risk of fractures.
In the case of bone density we derive our definition of "normal" by a statistical method. If you want to read more about who doctors use statistical analysis click on this link to learn more about the methods used to determine "normal"
How do we define osteopenia and osteoporosis?
Simply put we can measure a woman's bone density and then compare it to women of the same ethnic group who are young and healthy. If her bone density is better than average her T-score is on the positive side and there are no problems to worry about as far as bone thinning is concerned.
Since most women being tested are over the age of 50 and they're being compared to younger women (I know it doesn't sound fair!) they can expect to have bones that are less dense than "average" and therefore their T-scores will be on the negative side. Having a slightly negative T- score (-0.1 to – 1.0) is of little or not consequence. But having a T-score that is substantially below the average (-1.0 or less) requires a discussion with your health care provider on what your specific health risks are. Having a low T-score doesn't mean you will require medication but it does mean that it needs to be looked at as part of your overall health to determine what, if any effect it may have on the quality and quantity of your life.
For a more thorough discussion of how we define a T-score or a Z-score click on this link.
Taking the model of average women's height from the example above, we can substitute bone
What are the risk factors that I need to know about?
Despite the prevalence of osteoporosis, not all women are at risk for the disease. In fact, you can gauge your own individual risk by taking a look at yourself, your lifestyle and your family history.
- Age: In general, the older you get the greater your risk becomes to developing osteoporosis.
- Body Composition: Women with slender builds and low body weight are at greater risk because their bone mass is low to begin with and thus deterioration is faster.
- Race: You're at greatest risk of osteoporosis if you're white (especially those with blonde hair and fair skin) or of Southeast Asian descent. African American and Hispanic women have a lower but still significant risk.
- Estrogen: Estrogen exposure also plays a role in protecting you from bone loss. The length of time between your first period (menarche) and last period (menopause) influences your likelihood to osteoporosis. The later you began menstruating or the earlier your menopause occurs the more likely you are to develop thinning of your bone mass. You can also understand why women who undergo early surgical removal of their ovaries (oophorectomy) are at increased risk for osteoporosis. Hysterectomy itself—which is the surgical removal of the uterus—does not predispose to osteoporosis. One of the reasons that physicians often prescribe hormone replacement therapy (HRT) to women who've undergo oophorectomies is to prevent osteoporosis.
- Family History: Osteoporosis runs in families. For that reason, having a parent or sibling with osteoporosis puts you at greater risk, especially if you also have a family history of fractures.
- Lifestyle: Living a sedentary lifestyle increases your risk of low bone density. Weight bearing activities and general exercise are beneficial to bone density. It's important to know that bone density can increase at any age. Tobacco and excessive drinking also diminish your bones ability to absorb calcium.
- Eating disorders: Anorexia and bulimia—left untreated--are often associated with the development of osteopenia/osteoporosis.
- Contraceptive choices: Although a wonderful method of contraception, Depo-Provera used over a period of many years also predisposes some women to develop osteoporosis.
- Cancer: Postmenopausal women who have had breast cancer are at increased risk of osteoporosis, especially if they were treated with a group of drugs known as aromatase inhibitors such as anastrozole, letrozole and exemestane, which suppress estrogen. This doesn't appear to be true of women treated with tamoxifen. Also women who've been exposed to long course of methotrexate (used for various cancers as well as rheumatoid arthritis) are at increased risk for osteoporosis.
Medications: There are many medications that adversely affect bone health. Some of there are:
- Corticosteroids-- (prednisone, cortisone, prednisolone, dexamethasone). Many of these medications are used to treat asthma, psoriasis, and rheumatoid arthritis.
- Coumadin--often used to treat thrombophlebitis or prevent pulmonary emboli
- Heparin--another "blood thinner" whose long-term use may cause loss of bone structure
- Cyclosporine--an anti-rejection drug used after organ transplants
- Vitamin A--high level of this vitamin have been associated with osteoporosis
- Thiazide Diuretics--Furosemide (Lasix), hydrochlorthiazide are some of the commonly used ones
- Methotrexate--sometimes used to treat osteosarcoma or acute lymphoblastic leukemia
- Antiepilectic--medications such as phenobarbital, phentoin and carbamazepine interfere with vitamin D activity and are associated with bone loss.
Medical Conditions
Crohn's Disease and Ulcerative Colitis
When should a woman be screened for osteoporosis?
Expert groups now recommend bone density screening for the following people:
- All women over age 65.
- Any postmenopausal women under 65 years with one or more risk factors for osteoporosis (e.g., being thin, being a smoker, having a family history of fractures, using corticosteroids for longer than three months, or any serious high-risk condition, such as hyperthyroidism or malabsorption).
- Any older woman who suffers a fracture. Unfortunately, studies suggest that only a minority of these patients are evaluated and treated for osteoporosis.
What is a DEXA Scan?
DEXA stands for Dual energy X-ray absorptiometry. This procedure is quick, simple and gives accurate results in two to four minute It measures the density of bones or BMD (bone mass density) in your spine, hip and wrist — the areas most likely to be affected by osteoporosis — and it's used to accurately follow changes in these bones over time. DEXA measures bone density by detecting the extent to which bones absorb photons that are generated by very low-level X-rays. (Photons are atomic particles with no charge.) Lower density bones at are greater risk for developing fractures. This, along with a patient's medical history, is a useful aid in evaluating the probability of a fracture and whether any preventative treatment is needed.
What are the risks of a low T-score result on DEXA Scan?
- A T-score of 0 to -1.0 indicates normal BMD. (This carries a lifetime chance for a hip fracture of up to about 20%, depending on age and other risk factors.)
- A T-score of -1.0 to -2.5 defines osteopenia, which is low bone density. This carries between a 20% and 50% lifetime risk for fracture.
- A T-score less than 2.5 (osteoporosis) carries a 60% chance for hip fracture. Additional risk factors increase the risk. They include low weight, smoking, and an increased risk for falling and history of previous fractures. For example, in women 65 years old with low bone density but no adverse factors, the risk for fracture is 4.3% in one year and 28.6% over five years. In similar women with a previous fracture, the probability of fracture at one year is 11% and at five years is 71.8%.
Should everyone with osteopenia or osteoporosis be treated?
It's not necessary for everyone to be treated. If you are a healthy post menopausal women with a T-score below the norm (osteopenia) this doesn't mean that you should automatically take medications to prevent osteoporosis. In fact, your chance of breaking your hip in the next five years would be 1%, and 20% in your lifetime--perhaps not worth the risk of certain side effects of the drugs. Calcium and exercise are always a good measure but unless a fracture is looming or already occurring such as seen in women in their 60's, medication may not be necessary in younger women.
What are the treatments for osteoporosis?
Hormone replacement treatment (HRT)
There are many good reasons for hormone replacement therapy. The subject has been confused by poor scientific studies, hysterical journalists, television reporters who sensationalize the news and even Suzanne Sommers. The issue of whether or not you should take HRT is an individual one that you should carefully discussion with your health care provider. But among several clear benefits of HRT is the alleviation of hot flashes unmatched by any other herb or medication and improvement in bone growth. More importantly the improvement of bone growth is directly related to the prevention of hip fractures.
In the Women's Health Initiative (WHI) Study, the combined use of estrogen-progestin replacement therapy was associated with a significant reduction in the number of hip fractures as depicted in the chart below.
Estrogen-progestin therapy reduces hip fracture
Calcium supplements
Every woman should take a minimum of 1200 mg per day of Calcium beginning at age 35. Calcium alone will not prevent bone loss but it is an essential part of the ingredients for bone health. There's even some evidence that calcium intake helps to decrease the risk of heart disease.
Vitamin D
Vitamin D should be taken along with calcium in a dose of 800 Units per day beginning at age 35.Women who have a malabsorption syndrome or take certain anti-seizure medication may need higher doses of vitamin D.
Exercise
The importance of exercise cannot be overstated. A prospective study in JAMA (November 2002) by Feskanich and Colditz that included 61,000 postmenopausal women found that those that walked 4 hours or more a week had a 41% lower risk of hip fracture than those who walked less than an hour a week.
Smoking Cessation
Smoking one pack per day throughout adult life decreases bone density by 5-10%!
Medications
There are many encouraging developments along the lines of medications that can prevent and treat osteoporosis and its precursor, osteopenia.
The available medications can be divided into two groups: (1) anabolic agents that stimulate bone formation (increasing the activity of the osteoblast) and, (2) anti-resorptive agents or those that decrease bone resorption (decreasing the activity of the osteoclast).
The vast majority of today's pharmaceuticals focus on the latter—decreasing bone resorption.
The medications that work by this mechanism of action are called anti-resorptive. They include:
- Bisphosphonates
- Estrogen
Calcitonin
SERMS (selective estrogen receptor modulators)
The other class of medication is one that increases bone formation by increasing osteoblast activity. The only pharmaceutical in this class is
- parathyroid hormone (PTH).
BISPHOSPHONATES (these drugs prevent bone resorption by osteoclasts). Although most women who take these medications take an oral form of the drug these agents are poorly absorbed orally and need to be taken on an empty stomach. In some women the combination of estrogen and a bisphosphate is appropriate.
Oral agents:
- Fosamax (alendronate) -- 5 mg every day for prophylaxis; 10 mg per day for treatment of osteoporosis or 70 mg once a week
- Actonel (risedronate) -- 5 mg once a day for treatment or prophylaxis or 35 mg once a week
- Boniva (ibandronate) -- 150 mg once a month
Intravenous:
- Boniva (ibandronate) --3 mg every three months, appears to improve BMD to a similar or greater degree than the oral equivalent daily oral ibandronate (2.5 mg/day) and provides an alternative option for patients who cannot tolerate oral bisphosphates.
Effectiveness
Despite manageable side-effects, most women stop taking their medication after a year because the symptoms of osteoporosis are unnoticeable and therefore the benefits are not clearly recognized. However, many of these medications work over a period of time and do what they're meant to—prevent bone loss and fractures. No one should discontinue treatment if their medication is preserving bone density and there are no severe side effects. It should be noted that some women taking these agents actually lose bone density during the first year. Of interest in this regard was a 2000 study reporting that the women who lost the most bone during the first year of treatment experienced the greatest gains during subsequent years. Researchers recommend continuing treatment after the first year, even if a bone mass density (BMD) test is unpromising.
Side effects of oral agents
Bisphosphonates are poorly absorbed orally (less than one percent of the dose), and must be taken on an empty stomach for maximal absorption. About 5-10% of women do experience heartburn or some other gastric disturbance. Other less common side effects include muscular pain, joint pain, blurring of vision and a rare condition called ONJ (osteonecrosis of the jaw). Most ONJ complications have been in women undergoing cancer therapies. There is concern, however, in women undergoing invasive dental procedures such as extractions or implants. Many physicians and dentists suggest stopping bisphosphonates for 1-2 months before and after the procedure. One can also
expect women treated with bisphosphates to have a slight drop in serum calcium levels. This, however, does not appear to be significant.
Oral Regimen
In order to maximize absorption and minimize the esophageal and gastric side effects
· don't take this medication if you have an upper GI disease such as esophageal reflux, peptic ulcer or esophagitis.
· Stop the medication if you develop heartburn and consult your provider.
· Take the medication on an empty stomach, first thing in the morning with at least 8 ounces of water while sitting or standing. After taking
Monitoring the response
You will be asked to obtain serial bone mineral density scans (DEXA) to be certain that the medication is having the desired effect.
ESTROGEN -- Estrogen itself prevents bone resorption and therefore favors bone growth. The appropriateness of estrogen alone or in combination with another agent such as a bisphosphonates is a discussion you should have based on your individual needs and comfort level.
CALCITONIN -- Calcitonin is a small protein composed of 32 amino acids that binds to the osteoclasts and prevents bone resorption. In general, most studies suggest that calcitonin is less effective than the bisphosphonates for preventing fractures.
SERMS (SELECTIVE ESTROGEN RECEPTOR MODULATORS) --There are many women that cannot and should not take estrogen. However, there is a group of medications that has estrogenic effects on bone without estrogen's effect on the breast, uterus and blood vessels and other estrogen sensitive organs. These are selective estrogen compounds. In particular, these compounds are designed to have estrogen-like activity on the bone without the other undesirable estrogenic activity—including estrogen's possible adverse effect on cholesterol.
The commonly used medication in this class is Evista (Raloxifene). Raloxifene works by inhibiting bone resorption (similar to estrogen's effect on bone). Interestingly it's in a class similar to Tamoxifen (used to treat breast cancer). Like Tamoxifen, Raloxifene appears to protect against breast cancer.
The second group of medications are anabolic agents—ones that increase the activity of the bone- building (osteoblast) cells.
PTH (PARATHYROID HORMONE) This medication actually causes bone formation and stimulates the osteoblast precursor cell (pre-osteoblast) to mature. It is this cell that is responsible for new bone formation. If you require this medication we will refer you to an appropriate specialist.
SUMMARY AND CONCLUSIONS
Osteoporosis is a significant disease in women—particularly women of small stature, light skin with a history of smoking and certain medication use. It is a silent disease often manifesting itself for the first time with a fracture brought on by a relatively minor event. Women should undergo routine screening at age 65 though some women, particularly those with small, thin frames, a family history of osteoporosis and other risk factors should be screened earlier. There are many forms of prevention and treatment that women need to be aware of. Clearly this is a disease that requires more than taking supplemental calcium and is best managed by prevention.
Link 1-- Understanding the "bell curve"
Before we can understand osteopenia and osteoporosis we need some basic knowledge of statistics. Pictured below is a bell curve. We can plot many types of human behavior and attributes on a bell curve—salaries, reading scores, mathematics scores, serum cholesterol, exercise tolerance, height, weight and even bone mineral density.
In this example we'll examine a woman's height. In the U.S. the average height for a white 40 year old woman is 5'4". If we plot height on the vertical (y) axis and % of women at a given height on the horizontal (x) axis we note that the majority of women are somewhere in the middle (red) zone. The very middle of the red zone is the 50th percentile -- 5'4".
The right hand side of the red zone is one standard deviation, or +1.0 S.D, above the average woman's height and represents 34% of women. The left hand side of the red zone is also one standard deviation or -1.0 S.D. below the average woman's height and accounts for another 34% of women. Therefore, the entire red zone (which is plus or minus one standard deviation) accounts for 68% of all women.
Additionally, we are given another piece of information--that one standard deviation in women's height is approximately 3". Therefore 68% of all women are between 5'1" and 5'7" tall—one standard deviation above (34%) and one standard deviation below (34%) the 50th percentile value of 5'4" tall.
In a normal bell curve distribution, 2 standard deviations to the right and to the left (all of the red zone and green zones combined) account for 95% of women. Since 3" is a standard deviation and 5'4" is the 50th percentile, then it follows that 95% of women are between 4'10" tall (6 inches below the mean) and 5'10" tall (or 6 inches above the mean).
Link 2—Understanding T-scores and Z-scores
Taking the model of average women's height from the example above, we can substitute bone mineral density (BMD) on the vertical axis (y-axis) and the percentile of women on the horizontal (x) axis.
On the vertical axis we a plot measurement called the bone mineral density or BMD. This value is obtained from a specialized scan called a DEXA (Dual energy x-ray absorptiometry) Scan). Bone mineral density is nothing more than bone "concentration" expressed in grams of bone/square centimeter.
On the horizontal axis we substitute a derivative of the "standard deviation score" called a "T-score".
So the situation is parallel to the graph of height vs. percentile population. 68% of the population will fall between a T-score of +1.0 to -1.0 and 95% of the population will fall between a T-score of +2.0 to -2.0.
You must remember that when expressing a patient's bone density as a T-score she is being compared to a population of young women of the same race.
Some reports contain a Z-score which compares a woman's bone density to other women of her own age and race.
Osteopenia is a condition, defined by the World Health Organization (WHO) as follows:
If a woman's T-score is from -1.0 to -2.5 she is said to have osteopenia
If a woman's T-score is less than -2.5 she is said to have osteoporosis
Using this definition, osteoporosis is the disease and osteopenia (low bone mass) is its precursor
For the purposes of our discussion we will only consider the use of the T-score and not the Z-score—the reason being that the T-score is a better predictor of fracture risk.
For most women, the problem of osteopenia begins in middle age when the rate of new bone formation can't keep pace with the rate of bone resorption. During the early process of bone "thinning" bone minerals and "density" are lost leaving the woman more vulnerable to trauma that may result in fractures. As bone mass continues to decrease the condition is called osteoporosis. This process doesn't happen evenly in all bones. Some women develop mild osteopenia in their spine (vertebral column) accompanied by osteoporosis, in their hip (femoral neck).