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Battle of the Buldge

Battle of the bulge continues for 50 percent of the Canadians!

Some months ago, I wrote about my own ever increasing girth and my struggle to lose few pounds. I received the following advice from one of the readers:

“It is my experience with ever increasing girth and the reduction of, to eliminate all things white, e.g. white flour, white rice, white fat (turns white when cold and solid), and white sugar (both refined and artificial). I quit sugar to eliminate my migraines (it worked) and lost 34 lbs. in a year. Hope it helps. Good luck, if you try it, that is.”

A good piece of advice.

Losing weight takes time. This point was driven home to me by a cartoon I saw in one of our humor magazines. A kid asks his friend, “How come your mom is so grumpy?” The friend replies, “She’s been on a diet for a month and all she’s lost is her patience.”

You probably remember the story of Melodie Garland published in The Medicine Hat News in May. The headline said: Determination and commitment leads to weight loss success. Garland lost 75 lbs in over a year with a strict diet and exercise. She also attended a local support group.

An article in the New England Journal of Medicine (NEJM) says, “Although 29 percent of the men in the U.S. and 44 percent of the women describe themselves as trying to lose weight, only about 20 percent report restricting caloric intake and increasing physical activity simultaneously, despite recommendation indicating that this combination is effective.” Well, Garland falls in that 20 percent group. She did the right thing.

What else?

In June, the Medicine Hat News wrote a story about the work done by my general surgical colleague, Dr. Carl Nohr. The article had a headline: Winning at the losing game. Nohr does gastric by-pass surgery. His patients lose more than 100 lbs rapidly and are extremely grateful to him for giving them their life back.

In the article, Nohr warns that surgery is not without risks. He says, “People who have a bypass have no protection against being overweight anymore than you and I. This is not a license for people to eat any amount or whatever they feel like. It is more a way of giving them a chance to be like an average person.”

What about pills? No magic pills to lose weight? None.

Obesity is a multi-factorial illness, says Nohr. It is a blend of genetic, metabolic and environmental factors. It is notoriously difficult to treat. There is no one magical solution to obesity. Which ever method or program you chose, you have to work hard for every pound you lose. And have to work harder to maintain the weight loss.

Losing weight isn’t easy but it can be done. Go on a diet (reduce income), exercise regularly (be a big spender), have determination and commitment, give it a good try and be patient. If it does not work then join a support group.

If that does not work then see a psychologist or psychiatrist for behavioral treatment. If that fails then see Nohr. If he accepts you then have bypass surgery and continue with diet, exercise, determination, commitment, patience, and try and try again………….. Winners never quit and quitters never win! The battle goes on!

Now, where is my mirror? And get me Dr. Nohr please!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Quitting HRT

Couple of weeks ago, we published a column on hormone replacement therapy (HRT). The column reported on Women’s Health Initiative (WHI) trial. The trial was suddenly stopped because it was found that HRT (estrogen and progestin) in post-menopausal women was responsible for:

-41 percent increase in stroke
-29 percent increase in heart attacks
-doubling of rates of blood clots in the legs and lungs
-26 percent increase in breast cancer
-22 percent increase in total cardiovascular disease.

But, it also said that HRT has benefits:

-37 percent reduction in cases of colorectal cancer
-33 percent reduction in hip fractures
-no difference in total death rate from all causes
-controls hot flashes

After reading that column, a lady wrote:

“I have been on HRT for around eight to 10 years, and after reading your column in the paper, I totally stopped using the HRT.”

This lady was scared that now she is off HRT she will get “emotional problems” and she had started to get hot flashes. She was worried because she could not get to see her doctor for three weeks!

My advice in the column was simple – DO NOT STOP TAKING HRT WITHOUT DISCUSSING FIRST WITH YOUR FAMILY PHYSICIAN OR GYNECOLOGIST. If one is on HRT for 10 years then waiting three weeks to see a doctor is not going to make anything worse.

I was also told by Dr. Robert Woolf that women who need HRT should look into natural hormone replacement therapy. Woolf is a family physician in Medicine Hat who also practices alternative or complementary medicine. The natural hormones are derived from plants.

What is the safety and efficacy of the natural hormones over a long period of time? NEWSEEK reports that the National Institutes of Health is now supporting a trial to test two herbs for post-menopausal symptoms. So far, researchers have found no side effects, but they will continue to monitor women for changes in the breast, uterus and bones. Results will be keenly awaited.

What should post-menopausal women do now?

Last week, the Canadian Society of Obstetricians and Gynecologists (SOGC) released guidelines for HRT use in response to WHI trial. Here are the main points:

-If you have been on HRT for more than five years then talk to your physician whether you should continue
-Do not be overly concerned if you have been on HRT for more than five years – danger to an individual woman is small
-If you need to be on HRT then take the lowest possible dose for the shortest possible time – probably not longer than four years
-97.5 per cent of women, out of 8000 in the WHI study, had no adverse outcomes
-If you have been off HRT for five years then the risk of cancer drops to zero
-These guidelines apply to women who are on combination therapy of estrogen and progestin.

If you are on HRT then there is no need to panic. Discuss your options with your family doctor or gynecologist. There is more than one way to stay healthy and happy.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Rectal Prolapse

Dear Dr. B: Would you do a segment on prolapsed bowel in your “What’s Up Doc” column? The cause, the treatment, and how bad this should be before surgery should be done.

Yes, here is some information about prolapsed bowel – in other words rectal prolapse. If only the lining of the rectum prolapses then it is called incomplete or mucosal prolapse. If the entire wall of the rectum is protruding then it is a complete prolapse or procidentia.

Who gets it?

In children, it occurs most frequently in the first two years of life. Then the incidence declines. It is usually a mucosal prolapse, although occasionally a complete prolapse may be present. Boys are affected little bit more than girls.

There is developmental absence of curvature in the tail bone (sacral curve). The S-shaped rectum loses its curvatures and becomes straight. Thus it is prone to prolapse. Diarrhea, constipation and bad toilet habits can precipitate prolapse.

In adults, complete prolapse is more common than mucosal prolapse. Females are affected (in one series – 84 per cent) more often than males. It most commonly occurs in women 50 years-of-age and over. Quite often these women are in their 80s and 90s.

In a small percentage of women, prolapse of uterus and rectum can occur at the same time.

In younger adults, the prolapse may occur after some sort of rectal surgery. In older adults, the prolapse may occur due to weakness of anal sphincter and tone of muscles in the pelvis supporting the rectum. It is not related to pregnancy and delivery and the number of children a woman delivers. Quite often, prolapse develops in childless women.

Prolapse is like a hernia. The rectum slides in and out of the anal sphincter. Sometimes, it may fail to reduce and gangrene may set in. Urgent hospitalization is required if the prolapse fails to reduce.

How can we treat prolapse of the rectum?

In children, it is a self-limiting condition. Institution of proper bowel habit usually fixes the problem.

In adults, several surgical and non-surgical methods have been described. That means there is no single treatment (especially surgical treatment) which guarantees cure or that it is applicable to all patients.

There are different options for adults who are in good health and are a good surgical risk. Patients with multiple medical problems who are poor surgical risk have limited options.

Two commonly used surgical procedures used for patients who are good surgical risk are:

-removal of most of the rectum and redundant sigmoid colon and joining the colon to the residual small segment of the rectum near the anal sphincter or
-Fixing the rectum in the pelvis with prosthesis like a piece of mesh or sponge.

How bad this should be before surgery should be done?

This depends on how one feels about the problem. And whether the person is a good surgical risk.

If you have a prolapse then you should get a surgical opinion. Like a hernia, it will not go away. It may remain the same or get bigger. And there is a risk of complications, if not treated. This should be weighed against the risk of surgical procedure. Talk to your doctor or surgeon.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Risks of HRT

A month ago, it was announced that hormone replacement therapy (HRT) is causing more harm than good.

The Canadian Medical Association Journal (CMAJ) reports that the Women’s Health Initiative trial involving 16,608 women aged 50 to 79, was stopped because preliminary results showed statistically significant increases in coronary artery disease, invasive breast cancer, stroke and pulmonary embolism (clot in the lungs) in women treated with estrogen plus progestin (Prempro).

According to a report in the NEWSWEEK, last year U.S. pharmacists filled some 45 million prescriptions for Premarin and an additional 22 million for Prempro. There are more than 13 million American women on HRT.

Menopause is a natural event. But the event is very troublesome to the woman who is going through the menopause and also to the husband who has to show understanding and patience to help his wife get through these difficult years.

About 60 years ago, researchers discovered that a substance from pigs’ ovaries can put off old age and relieve menopausal symptoms.

In 1940s, pharmaceutical companies started producing estrogen from pregnant mare’s urine called Premarin. Twenty years later, the drug was being recommended for women who showed evidence of estrogen lack. Practically, all women over the age of 50.

HRT has several benefits. It was prescribed to menopausal women to relieve hot flashes, prevent heart disease and osteoporosis. There were other reasons such as improvement in quality of life.

But the risks and benefits of long-term postmenopausal HRT with estrogen alone or combined with progestin have long been a source of controversy.

This has now changed. The evidence is clear that women taking combination of estrogen and progestin have increased risk of breast cancer, heart disease, stroke and blood clots in the lungs. Potentially life threatening.

There were some benefits like reduction of hip fractures, decrease in the rates of osteoporosis and colon and rectal cancers. It also alleviates hot flashes after menopause.

What happens now?

HRT should not be used for preventative measures in healthy postmenopausal women without severe symptoms. It causes more harm than good. Other methods of prevention should be undertaken to prevent chronic illnesses.

Preventive measures for heart disease are: quit smoking, exercise, control blood pressure, control high cholesterol level, and eat a healthy diet (remember ELMOSS?).

Osteoporosis can be prevented by: exercise (starting early in life), calcium and vitamin D and in high risk women use bisphophonates.

Finally, this brief article does not cover all aspects of HRT. If you are on HRT and haven’t spoken with your family physician or gynecologist in the last one month then you better find out whether you should still be on HRT. A visit to your doctor may save your life.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!