Osteoporosis, a fall on an icy road, fractured hip, hospitalization, surgery, rehabilitation, nursing home……sounds tragic?

Yes. Falls among older adults, either at home or outside, have increased dramatically through out the world, says the British Medical Journal (BMJ). This is devastating to the patient and very expensive to our healthcare system.

In 1993, osteoporosis cost the Canadian health care system $465 million. This does not include the money spent on long term care ($563 million), and chronic care hospitals ($279 million).

The remodeling of bone (its formation and resorption) is a continuous process throughout life. When bone resorption exceeds bone formation, there is reduction in bone mass, density, and strength leading to osteoporosis.

In a review article in the Canadian Medical Association Journal, Dr. Brian Lentle says that a peak bone mass is achieved between the ages of 20 and 30 years. There after, men and women, lose bone at a rate of about 0.5 to 1 percent yearly. In fact, soon after menopause, a woman has 3 to 5 percent per year bone loss. The loss is less after the age of 65.

Can we prevent osteoporosis?

The Editorial in the BMJ says that regular exercise is probably the only method that may prevent osteoporotic fractures. Studies in animals and humans have shown that physical activity can increase bone mass, density, and strength.

The physical activity has to start early in life (before or at puberty) to have any beneficial effect in later life. The promotion of lifelong physical activity is essential, says the Editorial.

In one study, women aged 80 and over, strength and balance training reduced the rate of falling by more than 30 percent. Epidemiological studies have shown that both past and current physical activity does protect against hip fracture, reducing the risk by 50 percent.

Other studies have shown that estrogen deficiency plays a role in the loss of bone in post-menopausal women. Estrogen therapy reduces bone turnover. But many women are reluctant to go on this hormone because of side effects.

It has been shown that 50 percent of the women would prefer non-hormonal therapy (bisphosphonates). Some prefer to take Calcium, which helps sustain but not increase bone mass. Other medications used are: vitamin D and calcitonin.

How do you know you have osteoporosis?

There are number of methods, simple (x-rays and ultrasound) to sophisticated (dual energy x-ray absorptiometry) to measure bone density. Whether any of these methods should be used for screening or only for patients who are at risk of fracture remains controversial.

Osteoporosis continues to challenge the medical researchers. A literature search on the PUBMED revealed 17566 citations. This indicates that the last word is yet to come. If you think you have osteoporosis or are thinking of preventive measures then discuss this first with your family doctor. Do not consume large amount of Calcium or Vitamin D without medical advice. It can be hazardous to your health!

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Tamoxifen and Breast Cancer Prevention

“Dr. B, is there a pill to prevent breast cancer? You know my sister has had breast cancer and she takes Tamoxifen. Does the pill prevent cancer in women who have had no breast cancer?”

As always, Susan’s questions are right to the point. She has read recent reports about the benefits of Tamoxifen in women with a significantly elevated risk factors. She wants to know where she stands.

Susan, let’s look at the history of Tamoxifen – it’s usage, side effects – and then review the results of recent study undertaken by the Breast Cancer Prevention Trial (BCPT).

Breast cancer is usually hormone (estrogen) dependent. When indicated, women with breast cancer underwent surgery to remove organs which produced estrogen (e.g. ovaries) which helped control or regress the tumor.

Discovery of Tamoxifen reduced the need for these surgical procedures as the drug stopped the binding of estrogen to the tumor. In 1977, Tamoxifen was approved in the U.S. by the Food and Drug Administration for use in breast cancer. Thus began a new era in the treatment of this cancer.

“Dr. B, why did the researchers think that Tamoxifen would help prevent cancer in women who have no personal history of breast cancer?”

Tamoxifen has been used for 21years in the treatment of breast cancer. During this time, it clearly showed that it can reduce the risk of recurrent breast cancer and development of cancer in the other breast. The later finding encouraged researchers to start Breast Cancer Prevention Trial.

“Go on Dr. B, how did they do the study?”

Susan, BCPT enrolled 13,388 women at 300 sites in U.S. and Canada. These women were at a higher risk of developing breast cancer. They were randomly assigned to receive either placebo or Tamoxifen

The study – over 6 years – showed 45 per cent reduction of breast cancer in women who took Tamoxifen compared to the placebo group. It was also observed that these women have lower incidence of osteoporosis and coronary artery disease. Because of this significant finding the trial was discontinued earlier than expected due to ethical reasons.

“Doctor, what are the side-effects of Tamoxifen?”

Susan, some women developed cancer of the uterus, some had deep vein thrombosis (blood clot in the leg), and some had pulmonary embolism (blood clot in the lungs). About 15 percent of women suffer from: hot flushes, irregular menstrual periods, nausea, vomiting, light-headedness and dizziness.

One significant unanswered question is: For how long a woman can take Tamoxifen without increasing the chance of side-effects?

Women with breast cancer have been advised not to take Tamoxifen for more than 5 years as the risk of recurrent cancer and death were higher in women who took Tamoxifen for 10 years. The same cannot be said for women who take this pill for prevention. The study wasn’t long enough.

“So, Dr. B, can a woman take Tamoxifen for prevention if she is not part of a clinical trial?”

Last year, Susan, Editorials in the British Medical Journal and the Canadian Medical Association Journal discouraged women taking Tamoxifen outside clinical trials until further information was available on its risks and benefits.

But the authors, who reported the BCPT results in the Journal of National Cancer Institute said: Despite side effects resulting from administration of Tamoxifen, its use as a breast cancer preventive agent is appropriate in many women at increased risk for the disease.

Susan was keen on exploring the idea further for preventive measures and was referred to a medical oncologist.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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Dangers of Winter

Winter is here! Some people have died. Some have exacerbation and/or complication of their pre-existing conditions. Some have broken bones. Some have flu. Some are depressed.

The lucky ones – if that is an appropriate word for them – are in Hawaii or Florida. Some are in Arizona or Palm Springs. Some are on a cruise in Bahamas or South America. Some are on the big mountains, gyrating down the slopes on their ultra super speed skis.

The big chill does create a new dynamics in peoples’ lives. As soon as the leaves start gathering on the ground, we are gripped with fear or joy depending on what we have planned for the snowy days.

But we carry on. Sometimes smiling, sometimes annoyed and sometimes angry. Each morning, we get ready for work in our best winter clothes. At work, the heating is on and the windows are shut. Your comfort level goes down. Your smile fades and your layers start coming off. You look out of the window for some inspiration and comfort. You see a pile of snow. You feel trapped

Do you find this stressful? Does this affect your health?

“It is well known that in all except equatorial regions, the death rate increases in winter,” says Dr Caralee Caplan, in the recent edition of Canadian Medical Association Journal.
About 50 percent of deaths in winter are related to coronary artery disease and blood clots in the brain.

Studies have shown that most deaths occur 24 hours after cold days. This appears to be due to brief rather than prolonged exposure to cold. Resulting in rapid changes in the blood viscosity, formation of blood clot and increase demand for oxygen by heart muscles.

Those who are already known to have coronary artery disease are prone to spasm of these vessels. This further aggravates the risk of heart attacks. Asthmatics run the risk of aggravating their condition by inhaling cold air especially during exercise.

The precise mechanism of cold-induced changes is being hotly debated by the experts. Engorgement of blood vessels and release of substances which produce spasm of lung vessels are responsible for asthmatic attacks.

Patients with Raynaud’s disease suffer significant spasm of blood vessels of hands and feet when exposed to cold. This occurs mainly in young healthy women. Their blood vessels are extremely sensitive to cold or emotions.

Dr Caplan says that no one is immune to the effects of hypothermia, frostbite and seasonal infections and injuries. In most of these conditions, the underlying mechanism appears to be the effect of cold on blood vessels.

Can we prevent heart attacks after shoveling snow and asthma attacks from winter sports? Yes. “The best prevention is, of course, avoidance,” says Dr Caplan.

Asthmatics, who want to enjoy winter sports, should keep inhalers (bronchodilators) handy at all times. People with heart problems should wear a light face mask to maintain a favorable air temperature and humidity during exertion. Warm clothings, mittens, gloves and socks should protect the rest of the body from the big chill.

Remember, better safe than sorry! We still have almost three months of winter to enjoy. Keep smiling!

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Miscellaneous Health Topics

Do you believe that “if it tastes that good, it can’t be healthy”? I do!

Do you believe in Benjamin Franklin’s maxim “early to bed and early to rise makes a man healthy, wealthy, and wise”? I do except for the “wealthy” part!

Well, if you think the way I do then we may need to change. Do you want to know why? Then read this and surprise yourself.

1. Life is sweet: candy consumption and longevity

This paper appeared in the British Medical Journal. It was picked up by Associated Press and published as a news item in the Medicine Hat News recently.

The authors are from the Harvard School of Public Health. They feel that since candy (sugar candy and chocolates) has existed for centuries, it cannot be totally unhealthy. They decided to investigate whether candy consumption was associated with longevity.

The authors note that an American consumes 5.4kg of sugar candy and 6.5kg of chocolates annually.

The subjects of the study were 7841 healthy men entering Harvard University as undergraduates between 1916 and 1950. In 1988, these men were surveyed about their health habits (smoking etc) and candy consumption. Death certificates for men who died up to the end of 1993 were obtained.

The authors found that a man who does not consume any candies is older, leaner and more likely to smoke. He drinks more, ate less red meat and vegetables or green salad, and is more likely to take vitamin or mineral supplements.

They also found that consumption of candy was associated with greater longevity. This could be due to the presence of antioxidant phenol (a substance known to decrease the risk of coronary heart disease) in the chocolates. A 41g piece of chocolate contains about the same amount of antioxidant phenol as a glass of red wine.

It is interesting to note that greater consumption of candy (3 or more times a week) did not progressively lower mortality. In fact, the lowest mortality was amongst those who consumed candy in moderation (1-3 times a month).

Of course, the authors had vested interest in the study. They confess to a weakness for chocolates and consume to an average of one bar a day each!

2. Larks and owls and health, wealth, and wisdom

This study was funded in the United Kingdom by the Department of Health and Social Services and published in the British Medical Journal. Object of the study was to test the validity of Benjamin Franklin’s maxim “early to bed and early to rise makes a man healthy, wealthy and wise”.

1229 men and women aged 65 and over took part in the survey. A lark was defined as a person who went to bed before 11pm and was up before 8am. An owl went to bed at or after 11pm and was up at or after 8am.

The authors, from Southampton University, looked at several outcome measures- income, standard of living, state of health and mortality during 23 years of follow up.

Their conclusions? The findings did not support Franklin’s claim. A “late to bed and late to rise” lifestyle has no adverse effect. What is interesting is that sleeping for more than 8 hours a night was associated with increased mortality.

Authors’ final comment: There is no justification for early risers to affect moral superiority.

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