Are Older Women Receiving Too Much Calcium?

CalciumThe June issue of Menopause, a peer reviewed medical journal, carried an original research article by Margery Gass, MD and colleagues which indicated that older women are taking too much Vitamin D and Calcium. She conducted a randomized and placebo controlled trial of 163 women with low Vitamin D levels. The age range of the study group was 57 to 90. They were given Vitamin D and Calcium citrate tablets to reach the recommended daily amount of 400 to 4800 IU per day of Vitamin D and 1200 mg of calcium per day. Follow-up lab studies revealed that almost 10% of the women developed elevated blood calcium levels. More disturbing was the fact that 31% developed elevated levels of calcium in their urine predisposing them to kidney stones.

The lead author suggested that every patient calculate how much calcium they are getting daily in their normal diet before supplementing it with extra calcium. Her group pointed out the benefits of clinicians periodically measuring patients 24 hour urine calcium level. Those with a level > 132 mg were at much higher risk of developing hypercalcemia and its complications and need to reduce their supplemental calcium intake. We will begin suggesting 24 hour urine collection in our patients in the near future.

The Importance of the Physical Examination

Physical ExamMedical Schools and residency training programs are beginning to realize that they must devote more attention to training young physicians in the skills of physical examination. In recent years the tendency has been to concentrate on the technology rather than taking a thorough history and performing a comprehensive examination. Abraham Verghese M.D., a chairperson at Stanford’s medical program has been instrumental in creating the Stanford Medicine 25 program which emphasizes 25 physical exam skills that all students must learn, demonstrate and then teach. Prior to the program Verghese felt that ,” If you come to our hospital missing a finger, no one will believe you until we get a CT scan, an MRI and an orthopedic consult.” Steven McGee M.D., of the University Of Washington School Of Medicine is author of a book on evidence based diagnosis based on physical examination. He believes a physical exam can be as accurate as technology citing instances where evaluating patients’ eye movements are as accurate as an MRI scan in differentiating vertigo due to an inner ear problem as compared to dizziness from a stroke. W. Reid Thompson M.D. of the John Hopkins Pediatric Cardiology Division launched Murmurlab, a website containing the heart sounds of 1300 people to train his students how to distinguish which cardiac findings require further evaluation and an echocardiogram and which do not.

These physicians believe tests lead to tests and more tests and may obscure the diagnosis when a simple physical exam might provide the answer. They cite examples such as the 40 year old woman in a Northern California hospital who was being evaluated for a blood clot to her lungs with a CT scan because she had extremely high blood pressure and was confused. A simple examination of her breasts which had not previously been performed revealed bilateral hard non moveable malignant masses which were in fact the source of her problems.

Not all leaders in medical education feel the need to teach physical examination more effectively. Robert Wachter MD, the father of hospitalist medicine and former head of the American Board of Internal Medicine disagrees and feels more time should be spent on developing critical thinking skills than on physical diagnosis. Dr Wachter is part of a movement to shorten medical school education and shorten residency training. He believes in educating new physicians in a much narrower specialty oriented manner. Under his influence and leadership the Internal Medicine Board Examination is now a separate exam for doctors practicing in hospitals and those practicing outside hospitals.

I have been a faculty member teaching medical history taking and physical diagnosis to medical students for over a decade at the University Of Miami Miller School Of Medicine and the Charles E Schmidt College of Medicine at Florida Atlantic University. These two institutions have managed to teach both critical thinking skills and excellence in physical diagnosis without shortchanging either skill. There is no reason to narrowly train doctors when the fund of knowledge and technology is dramatically increasing. The goal to shorten medical school and residency seems to be an economic goal designed to reduce the costs of education and training a doctor and produce a class of physicians who can be compensated at a lower level. If anything today our future physicians need a broader more comprehensive training to improve understanding and communication regarding the increasingly complex and aging patient population they care for.

Extreme Intensity Exercise Good for the Ego But Maybe Not for the Heart

ExerciseHealth experts have encouraged regular moderate level exercise for adults 5-7 days a week lasting 30 – 60 minutes per session to stay heart healthy.  We talk about walking 15 – 20 minute miles while being able to comfortably carry on a conversation as your suggested goal. We all see other adults appearing far more fit and aggressive working out daily at a much quicker and much more strenuous pace. Experts have always wondered if they are healthier and if they fare better?

Two articles addressing this issue appear in the journal Heart. Researcher Ute Mons, MA, of the German Cancer Research Institute found that men with known stable coronary artery disease who exercised strenuously daily had more than a two fold increase in cardiovascular mortality compared to men with CAD who exercised 2 -4 times per week at a moderate level. The study was the first of its kind to look at different levels of exercise and frequencies of exercise. Certainly more research is now required to verify these findings in studies which do not rely on patient self reporting of how often, how hard and how long you work out. It is also critical to remember that this study was conducted on individuals known to have heart disease.  The message to them should be clear to exercise moderately for the most benefit and least risk. The study says nothing about the benefits or risks of individuals without cardiovascular disease who exercise moderately versus strenuously.

In another related article men at age 30 who reported exercising 5 or more hours a week had an increased risk of developing the arrhythmia atrial fibrillation as compared to those who exercised more modestly. While these were both excellent preliminary works requiring further study, they both point toward moderation once again as the healthiest and best lifestyle path.

Skipping Breakfast May Be Fine For Weight Loss

Scale and foodEmily Dhurandhar, Ph.D, of the University of Alabama at Birmingham is a nutritionist who does not believe in following myths and dogma unless there is sufficient research and evidence to back it up. She recently led a team of researchers who looked at the question of whether skipping breakfast was a hindrance to weight loss. Her group conducted the first controlled randomized study on the topic looking at 309 overweight and obese patients over a 16 week period. Patients were assigned to one of three groups:

1.            An intervention group told to eat breakfast

2.            An intervention group told to skip breakfast

3.            A control group not specifically instructed to do eat or skip breakfast

They were all placed on a caloric restricted diet. The results of the study showed that the only thing that mattered in weight loss was whether your intake of calories was less than calories used during the day. The time of day we first eat had no effect on weight loss in this study.

Dr. Dhurandhar reasoned that none of us actually skip breakfast since our first meal of the day after a prolonged overnight fast is still breakfast. The study only looked at weight loss related to skipping or eating breakfast. It did not answer the other age old dietary question of whether eating a large calorie amount late at night and then retiring affects your weight. For those of you who enjoy sleeping in, this is excellent news.

New Diet Drugs Not Being Used

Diet DrugsA joint survey was conducted by the online medical news service MedPage Today, Everyday Health and The Daily Meal to evaluate physicians’ methods of treating obesity. They surveyed almost 1000 providers and found that the newer drugs such as Qsymia (phentermine/topiramate) are only being used by about 6% and Belviq (lorcaserin) in only 3.3%. Several of the survey respondents cited the high cost of the medications as barriers to use. One provider noted that “middle class (patients) and below cannot afford “these medications so he prescribes generic phentermine 37.5 mg one half tablet each morning with generic topiramate 25 mg twice a day with similar effectiveness.

Fat absorption blockers such as orlistat in it’s over the counter form “Alli” or its prescription form xenical were popular with over 20 % of respondents using those products. Generic phentermine was used alone by 16%. Other medications frequently mentioned included metformin the diabetic drug, and victoza another diabetic drug not yet approved for weight loss therapy.

The majority of the respondents prescribe diet and exercise to begin with. Weight Watchers is their favorite commercial diet with over 75% of those surveyed noting that it works steadily and safely. The South Beach Diet was the clear runner up. When the Atkins Diet was mentioned there was concern and controversy.

In our local clinical practice we are asked frequently about medication to lose weight. The survey did not look at the average age of the patients the respondents treated and their associated medical issues. Locally we have many elderly individuals using multiple medications for heart disease, elevated lipids, diabetes, heart rhythm control and other complex problems. It is much more difficult to find any oral medications for weight loss that do not adversely react with their prescribed medicines or that are not contraindicated due to their underlying medical problems.

Are Diet Sodas Unhealthy for Your Heart?

SodaI was eating lunch reading a report from the American College of Cardiology meetings stating that women who drank two or more diet sodas per day of 12 ounces or more were 29% more likely to have a cardiac event than those who consumed a lower quantity of no more than 3 diet drinks per month. The report was prepared by Ankur Vyas, MD, of the University of Iowa Hospitals and Clinics. The 5% of women with the highest consumption of diet beverages in the Women’s Health Initiative also had 26 % elevated all-cause mortality. Cardiac deaths were 52% more likely with two or more diet sodas or other diet drinks per day.

Jeffey Kuvin, MD, vice chair of the program committee for the ACC meeting, called the results “provocative” but not yet compelling. Clearly these results are convincing enough to plan another study with a larger group and stricter design to determine if it is the caffeine, the artificial sweetener or some other constituent causing this increased risk? Could it be that the individuals drinking two or more diet beverages are already practicing a relatively heart unhealthy lifestyle and are overweight, less active, diabetic, hypertensive and or smokers? This all needs to be determined before we condemn diet beverages. Dr. Kurvin pointed out that sugary non diet beverages are well known to cause weight gain, diabetes and eventually coronary artery disease.

What does one drink then? I chose to have an old fashioned unhealthy sugary soda with my heart healthy lunch. While I was sipping that sweet delicious beverage, but feeling extremely guilty about it, my computer sent me a medical alert, “Soda associated with increased heart attack and stroke risk.”. The soda came flying out of my mouth and nose instantly as if had coughed and it splattered everywhere moments before I read the full message closely and noted that they were referring to cocaine not soda.

This study will surely raise questions from my patients in my practice. I will advise them to avoid diet beverages if possible, just like I advise them to avoid sugary beverages in large quantities if possible. Drink water or drink diet beverages in extreme moderation until the data is clear. Moderation would mean no more than 36 ounces per week.

New Knees and Hips Cut Heart Risk

Heart DiseaseAt the annual meeting of the American Academy of Orthopedics in New Orleans, Bheeshma Ravi, M.D., an orthopedics resident at the University of Toronto, reported that patients who underwent knee and hip replacements were able to dramatically reduce their risk of a heart attack or stroke over a seven year period. He followed 153 patients who were high risk for cardiovascular disease and noted the major risk reduction.

Some of the improvement in risks were assumed to be due to the increased mobility and increased activity the recipients were able to enjoy. The increased physical activity improves cardiac health. While physical activity is one explanation, the reduction in pain, stress, use of painkillers and inflammation is another set of potential reasons. With pain comes use of more nonsteroidal anti-inflammatory medications which have been implicated in the development of acute heart attacks.

In our medical practice we often see senior citizens who are healthy enough to undergo a joint replacement but are too fearful to proceed with the surgery. This particular study provides additional evidence that replacing the inflamed joint and resuming activity is the correct choice to make.

Walking Reduces Stroke Risk

Walking signBarbara Jefferis, PhD, of University College London UK presented data in the journal Stroke that indicated that older men who added a long walk to their daily routine significantly reduced their risk of having a stroke.  The association was independent of activity level or walking pace. Men who walked 8 – 14 hours per week had about a one third lower risk of stroke compared to men who walked no more than three hours per week or at all. The risk was about 2/3 lower for men who walked more than 22 hours per week.  Walking is recognized to be the predominant form of physical activity in older adults and its impact in reducing stroke risk is important to understand.

The study looked at 3,435 men followed over a ten year period.  The lead researcher said there is no reason to believe that the protective effect does not apply to women as well.

This is one of several studies published over the last few months that extol the benefits of modest age related exercise to preserve function and independence.  We have seen the benefits of an after dinner walk on blood sugar levels documented in recent studies. In a recent British Medical Journal article (BMJ 2013, 347:f5555) researchers reviewing 60 research trials conclude that exercise benefits patients with arthritis rather than being sedentary. We have seen other studies linking seniors with active leisure activity life style exhibiting improved cognitive function compared to seniors with a more sedentary leisure life style.

From a doctor’s perspective the advice is simple. Find something you enjoy doing that is active and aerobic such as walking, running, cycling, swimming, dancing, roller skating or roller blading and engage in this activity regularly to protect your health and independence.

 

New Weight Loss Drug on the Market

OverweightFor the last 13 years there have been no new medications designed specifically for weight reduction that have received FDA (Food and Drug Administration) approval. The long drought came on the heels of the reported adverse effects of the successful weight reduction combination of phentaramine and fenfluramine. While patients lost weight successfully on this combination of medications plus diet they additionally risked developing disease of the heart valves and its consequences. In July the FDA approved Belviq or lorcasrin HCl for weight reduction. Pharmaceutical manufacturer Vivus received approval for its weight reduction product Qsymia recently which is a combination of phentermine and topiramate. Topiramate has been on the market as a medicine to treat vascular and migraine type headaches and to treat seizures.

Vivus submitted data to the FDA involving 756 obese subjects, which showed that over seven months of treatment obese patients lost 10% or more of their body weight 38% of the time among those taking Qsymmia 7.5 /46 mg and 43% of the time when they used the higher dose of 15/92 mg. Patients taking placebo plus diet lost 10% of their body weight only 6.8%. The dose of topiramate in this combination drug is significantly lower than the starting dose for that drug when treating neurological issues. When the researchers looked at statistical significance the lower dose combination was actually more successful than the higher dose combination.

Adverse effects were more common in the higher dose group and included parasthesia (23%), dry mouth in 18.5%, headache and constipation. The drug was released to a limited number of pharmacies in April but has been slow to catch on. Its use is cautioned in individuals with existing heart, liver and kidney disease.

Obesity is epidemic in this country. Increased activity and dietary intervention are always our first line of therapy. Dietary counseling, organized diet programs with meal replacement therapy and bariatric surgery are available to help. Adding new medications to a difficult treatment problem is always a welcome step but will require that we closely watch their risk and side effect profile as the drugs become more popular and are used more frequently.

Do Probiotics Prevent Diarrhea and Antibiotic Related Colitis in Seniors?

ProbioticsProbiotics are medication containing bacteria that normally reside within a healthy intestinal tract and aid in digestion and the production of a solid stool.   Physicians and scientists have known for years that when a patient is given an antibiotic to treat a bacterial infection, that antibiotic works against the invading pathological bacteria as well as the bacteria that normally reside within us and keep us healthy. The theory for years is that by destroying the healthy normal flora of the intestine we are paving the way for virulent pathological and opportunistic bacteria such as clostridium difficile to invade the gut and produce antibiotic related colitis. The hope has been that by giving the intestine back the normal bacteria in the form of a pill containing normal gut flora, we can prevent diarrhea and even the more severe antibiotic related colitis when prescribing antibiotics appropriately to fight a bacterial infection.

Initial small Meta-analysis studies supported the notion. Based on these small studies private firms have produced over the counter probiotics such as Align and a series of prescription only probiotics for human consumption. Hospital and health systems have invested money in purchasing and prescribing probiotics to senior citizens given antibiotics to stave off diarrhea or antibiotic related colitis.  A new large study performed in South Wales and England looked at almost 3,000 patients aged 65 or older who were being treated with antibiotics while hospitalized.   Patients were treated with either a placebo pill or a probiotic pill containing two strains of Lactobacillus acidophilus, Bifidobaceterium bifidum and bifidobacterium lactis, for 21 days and between antibiotic doses.

Despite the probiotic administration, diarrhea occurred in 10.8% of the patients given probiotics and 10.4% of those given placebo. The researchers then went on to analyze the stool of half the diarrhea patients and found that Clostridia difficile was an uncommon finding in both groups. The probiotics did not produce any measurable adverse effects in the patients taking them.

The PLACIDE study was by far the largest study of the effectiveness of probiotics done to date. Its result speaks against the routine use of these agents to prevent antibiotic related diarrhea or colitis. There will be additional studies in the future.

The science of the composition of our intestinal flora is in its infancy. Studies have shown that genetically alike individuals have similar bacterial gut patterns. Studies have also shown that if you develop antibiotic related colitis and receive an enema containing stool from a genetically identical individual, your chances of recovering from previously resistant antibiotic related colitis are much better.   It could be that there will be different compositions of bacteria in future probiotics for genetically different individuals.  More research is needed.